Any NP's working in plastic surgery?

core0 · Oct 16, 2007

Hello all. I have recently applied to an MSN-FNP program and thinking of my options for the future. I am most interested in teaching and would like to do a post-masters teaching certificate and teach at our local hospital program. However, I am looking into clinical practice options as well.
I currently work for a privately owned ambulatory plastic surgery center where we see patients in the office setting as well as perform the surgery! I have been here for so long and have a lot of great benefits that I hate to think of giving up. So...I am wondering if there is any place for an NP in this setting. I can think of a # of areas where it would be useful but...I feel they will argue that they can have the RN's do the same thing for less (w/ the exception of RX's and perhaps some minor suturing...).
Anyone out there with experience in this or similiar settings? How about PA's?
Anyone know about reimbursement for NP's in this setting? My administrator thought that 'no reimbursement' would be an issue.
Thanks for reading.

There are a lot of PAs working in Plastics. There are a few issues that are unique to plastics. One that you have already run into is the reimbursement. Because this is cash pay, there is no reason that you need to be able to bill for the encounter. Therefore there is no reason that an RN or even an MA cannot do a wound check or other visit.

If you are speaking purely of cosmetic plastics - the kind most often done in an outpatient center there is a strong incentive to use the cheapest provider since every dime comes out of the surgeons fee.

The other model where you are talking about reconstructive plastics then you are talking about being credentialed for inpatient work which is unlikely with an FNP. These are big cases usually covered by insurance.

There are PAs that work in cosmetics. The model here is that you have good enough surgical skills to do the surgery. They either do the contralateral side in breast implants or follow the surgeon and do the closure. You need meticulous surgical and suturing skills. These are usually experienced vascular PAs who are sick of call.

That being said, a lot of CSTs and MAs are working alongside Plastic surgeons in ambulatory centers having been trained by the surgeons. The beauty (and problem) of an ambulatory center is the surgeon can credential whomever they want. If they are willing to train you then there is no reason that you can't assist. The issue that you have already encountered is that why should they pay a NP salary when they can get someone else to do it for less. The other issue that you should consider in the "with the exception of Rx" is that if there is an untoward event, depending on the state, you would be well outside your scope of practice working in plastics as an FNP.

David Carpenter, PA-C

amberfnp · Oct 17, 2007

Thanks for your reply core0. I know of one plastic surgeon in our area that utilizes a PA. I do know that they do a lot of the post-op follow up appt's in place of the surgeon, as well as take ER call in his place for some treatments. I'm not sure of the extent of use in the OR.

We do not have PA's in our office. We have a few CST's and 1 RN (can't remember if she is a RNFA but she does have additional OR training) that do assist with sewing under direct supervision of the surgeon. We primarily staff with RNs and surgical techs and have 2 OR's, 8 bed PACU and see patients in the office setting. When one of our surgeons wants to, they will pick one of the staff as their "private scrub" and give them extra training.

In our practice, we do a good mix of reconstructive/insurance cases as well as cosmetic. We do a fair amount of what we call "nurse only" appts where the nurse or tech will see a patient in the surgeons absence to evaulate post-op complaints/problems etc. Often times, there are issues that I think could be addressed by an NP without having to bring the doc on call back into the office to evaulate such as infections that don't need immediate surgical intervention, wound dehisence, re-suturing when stitches come out unexpectantly after lac repair or minor procedure...etc...We do a # of history and physicals where the doc is not present. The nurses or techs do the paper work part but do not do the actual physical exam. The techs in many instances, and some of the nurses depending on their background, do not know what to look for when taking info from patients and determining surgical risks and needs. There has also been talk of docs wanting nurses to field their "calls" when they are on call. After being with this practice for many years, these are just a few things that I feel could be better served by utilizing an NP, with structured guidelines of course. I have just begun trying to think in an advanced practice direction and have no clue about reimbursements. I'm just looking for different insights as to how or if an NP would be useful. Money of course will always be the deciding factor!

Your insight was helpful. Thanks again.

core0 · Oct 17, 2007

thanks for your reply core0. i know of one plastic surgeon in our area that utilizes a pa. i do know that they do a lot of the post-op follow up appt's in place of the surgeon, as well as take er call in his place for some treatments. i'm not sure of the extent of use in the or.
this is pretty common. in a surgical practice almost all your "income" comes from the or. some surgeons will value either the lifestyle help that a pa brings or recognize the downstream revenue. the er call is one of the lifestyle issues. there are a number of very good pas that will do plastics closures in the er when on call but it really depends on the local physician practice environment.
we do not have pa's in our office. we have a few cst's and 1 rn (can't remember if she is a rnfa but she does have additional or training) that do assist with sewing under direct supervision of the surgeon. we primarily staff with rns and surgical techs and have 2 or's, 8 bed pacu and see patients in the office setting. when one of our surgeons wants to, they will pick one of the staff as their "private scrub" and give them extra training.
this is pretty common in office based plastics. since a lot of this is cash based any salaries essentially come out of the surgeons income. mostly they will use the cheapest providers.
in our practice, we do a good mix of reconstructive/insurance cases as well as cosmetic. we do a fair amount of what we call "nurse only" appts where the nurse or tech will see a patient in the surgeons absence to evaulate post-op complaints/problems etc. often times, there are issues that i think could be addressed by an np without having to bring the doc on call back into the office to evaulate such as infections that don't need immediate surgical intervention, wound dehisence, re-suturing when stitches come out unexpectantly after lac repair or minor procedure...etc...we do a # of history and physicals where the doc is not present. the nurses or techs do the paper work part but do not do the actual physical exam. the techs in many instances, and some of the nurses depending on their background, do not know what to look for when taking info from patients and determining surgical risks and needs. there has also been talk of docs wanting nurses to field their "calls" when they are on call. after being with this practice for many years, these are just a few things that i feel could be better served by utilizing an np, with structured guidelines of course. i have just begun trying to think in an advanced practice direction and have no clue about reimbursements. i'm just looking for different insights as to how or if an np would be useful. money of course will always be the deciding factor!
you have to be very careful here. where i work big ugly scars are considered part of the package. in plastics the appearance is a large part of the outcome. you have to have meticulous technique. its not just a matter of dropping in a stitch. its a matter of having good cosmesis. people that have paid $10-20k for their new body part tend to be very vocal when the outcome is not to their satisfaction. h&ps could easily be part of an nps job here, but again there is no reimbursement for this so a lot of plastics do this as cheaply as possible. in a lot of ways this is different from other surgical practices.
your insight was helpful. thanks again.

no problem. you just have to understand how the system works. plastics has a different entry point. people show up and pretty much have decided that they want surgery. there is not testing or medical decision making for the most part. what they want is to sit with the surgeon and talk about the options/results they can expect. this really can only be done well by the surgeon.

this is very different from a typical surgery practice. take ortho (the largest pa surgical specialty). the typical patient is referred to the practice for a problem (say knee pain). they see any provider (most likely a pa). the pa assesses the problem and makes out a plan for testing. they may need injections, additional testing or other therapies. when the decision is made that the problem needs a surgical solution they will have an appointment with the surgeon and go over the procedure and available options. the surgeon will then schedule the surgery.

now look at how the pa generates money (i am using the term pa since 35% of pas are employed in surgery and 1% of nps are). the pa generates a consult which pays nicely. several follow up visits that don't:madface:. it may also generate procedures such as injections that pay very well;). when the patient is scheduled for surgery the pa can get the assist fee which for medicare which is around 13% of the surgeons fee. after the surgery the pa can follow the patient on the floor. they can also see the patient in the clinic. neither of the last two visits generate billing but since they don't have to be done by the physician generate more time for the physician to do more surgery or see more patients to schedule surgery.

now look at the plastics model. the patient usually self refers for a problem (i don't like my nose for example). even in the case of restoration the course is generally defined. the patient is scheduled for surgery. the only income here is for the assist fee. in the case of cash pay it comes out of the surgeons pocket and therefore most use the cheapest provider that they can. follow ups are the same issue. there is very little opportunity for an npp to bring in income here. the one place that i have seen nps here is in cosmetics such as derm abrasion or lasers. some nursing practice acts prohibit rns from doing these creating opportunity. personally not my cup of tea.

hope this helps

david carpenter, pa-c

odinhoub2422 · Feb 27, 2010

So you have seen np in cosmetic derm? I am very interested in this area. I am trying to decide to go to np or pa school, my ultimate goal is cosmetic derm doing using laser and doing botox.

efy2178 · Mar 3, 2010

"The other model where you are talking about reconstructive plastics then you are talking about being credentialed for inpatient work which is unlikely with an FNP. These are big cases usually covered by insurance."

An NP either family or adult can just as easily work in inpatient areas as a PA. I don't know why you think they would not be able to.

:confused:

core0 · Mar 3, 2010

"The other model where you are talking about reconstructive plastics then you are talking about being credentialed for inpatient work which is unlikely with an FNP. These are big cases usually covered by insurance."
An NP either family or adult can just as easily work in inpatient areas as a PA. I don't know why you think they would not be able to.

Depends on where you are. I worked with an ACNP student today who was an FNP returning for a post grad certificate. Our hospital won't hire anyone without an ACNP for critical care positions. Other hospitals won't hire/credential FNPs for inpatient positions. Depends on your state and local.

David Carpenter, PA-C

core0 · Mar 3, 2010

So you have seen np in cosmetic derm? I am very interested in this area. I am trying to decide to go to np or pa school, my ultimate goal is cosmetic derm doing using laser and doing botox.

Its hard to tell how prevalent this is. It really depends on what the state nursing practice acts will allow RNs to do. If the nursing board will let RNs do Botox and laser then the jobs will usually flow there. If they define it as a medical act/advanced nursing act then NPs will be more common.