Portal de Periódicos da CAPES

???If You???ve Got the Money, Honey, I???ve Got the Time???If You???ve Got No More Money, Honey, I???ve Got No More Time???

2006; Lippincott Williams & Wilkins; Volume: 118; Issue: 2 Linguagem: Inglês

10.1097/01.prs.0000227622.12204.99

1529-4242

Frederick J. Menick,

If you’ve got the money, honey, I’ve got the time If you’ve got no more money, honey, I’ve got no more time —Willie Nelson My father was a general surgeon. I am a surgeon’s son. When I was a child, surgeons seemed to be important, special. However, the world is changing. When I completed my general surgery residency, a relative asked me when I was going to “specialize.” I was confused and frustrated. I was glad I was starting a plastic surgery residency. I would finally get some respect. Lately, when I am asked what kind of doctor I am, I hesitate. I flinch. I am embarrassed to say “I am a plastic surgeon” without qualifying that I do reconstruction. Are my concerns real or imagined? In the public’s perception, plastic surgery seems pretentious and a community joke—logos, “Trump”-like office, tailored scrubs, augmented wives, kisses, hugs, and “hello, darling.” It’s all Doctor 90210. Reality television may not be reality, but is it perception? A mother recently brought in her 9-year-old daughter, who had suffered a nasal dog bite about a week earlier. They had, according to the mother and grandmother, called multiple plastic surgeons in Tucson and Phoenix (even the Mayo Clinic!) and were told that “they don’t do trauma.” In the past, we completed residency, did reconstructive surgery, took emergency room call, developed a practice, and later slid over into cosmetic surgery as we aged. Certainly “paying dues” was not the issue. It was a natural progression. Older surgeons did it all. Because of their experience, they were sources of information and guidance and could help their patients and other younger surgeons within the complete scope of plastic surgery. My old professor, Garry Brody, once told me that it took 5 to 10 years to become confident and develop judgment. He was right. Many recent graduates never develop the requisite experience to mold their wide but shallow reconstructive training into high-level skills and surgical judgment. A modest residency experience in cosmetic surgery and weekend courses are all that is required to create another “cosmetic surgeon.” With this emphasis on cosmetic surgery comes the “need” for advertising. As Ralph Millard once said, “Reputation used to be earned; now it is bought.” Competition based on inconsequential, nonscientific procedures (barbed sutures, dubious lasers, and a desire to be the first with the questionable) follows right along. Is this to the patient’s or the surgeon’s profit? Or is the primary benefactor the cosmetic industry, which will sell anything to you or any nonplastic surgeon or nurse who will pay for it, emphasizing little of the science but all of the Wharton economics required to see so many patients per month to pay the lease and cover your cost (with plenty left over in your pocket)? You will remind me of the cost of malpractice, overhead, and poor insurance reimbursement for reconstruction cases, but I do not remember ever seeing a plastic surgeon on a street corner with a sign reading “I’ll work for food.” Certainly, we are not reimbursed within the scheme of life’s important things. Perhaps some “special” surgeons deserve “special” fees, but greed, conceit, and ego sometimes seem to be the overriding concern. Emergency room coverage is often inconvenient and exhausting and certainly interferes with elective cases. Often our skills are underappreciated and summoned inappropriately. Believe me, I hate emergency room call, but I do enjoy reconstructive surgery. It serves a useful purpose. It is intellectual, highly complex, and a source of great satisfaction. On my death bed, I may be thinking about a nasal reconstruction, but I certainly won’t be reliving my “best” face lift. With cosmetic surgery comes office operating rooms. No longer practicing in a hospital setting, we don’t meet, mix, gossip, seek help from other specialties, or gain the respect of hospital-based physicians. Other physicians may envy our wealth, but little else. Their image of us (as with the public) is that of a fancy car, big fees, and unimportant skills. I do not mean to suggest that cosmetic surgery is easy or nonintellectual. It is complex surgery requiring great skill. A few of the great cosmetic surgeons exude enthusiasm, interest, artistic skill, and problem solving to the highest level, but most plastic surgeons see it as “cash.” I know many surgeons who would perform a reconstructive case for charity, but I never met one who would do a breast augmentation or a face lift for free! We profess that plastic surgeons are the only specialists skilled enough to do cosmetic surgery, but realistically, how much of our training is required to lift a face flap or push an implant into a breast? Other specialties are capable and certainly able to learn through symposiums and by trial and error, just as we do. Yes, our best is better than their best, but our average is very average. Are we honest with ourselves? Over 2 hours, the opening ceremonies of our 2005 American Society of Plastic Surgeons’ annual meeting presented the specialty through the triumphs of reconstructive surgery. Our public (and private) image emphasized skills, caring, and the effect on our patients. In reality, all the lights and action over the next few days were in “session A” highlighting cosmetic surgery. “Session B” seemed to be a forgotten orphan! What can we do about it? What will be our future? Some of us will continue to do both reconstructive and cosmetic surgery and maintain perhaps the best of both worlds. A few senior surgeons who have done it all will continue to be available to younger surgeons as sources of reconstructive experience. A few others will specialize and teach truly intellectual and artistic approaches to cosmetic surgery. But will we be able to find a skilled and interested surgeon to fix our child’s or grandchild’s facial fracture, abdominal wall defect, or skin cancer ablation? I am not so sure. Will the field of plastic surgery be “special”-ized any more? I am in serious doubt.