S04E82 - Mentorship and Mastery: Plastic Surgeon Dr. Richard Winters on Surgical Excellence

Is mentorship the secret ingredient to surgical excellence? Join us as we explore this and much more in our conversation with Dr. Richard Winters, chairman of the Department of Plastic and Reconstructive Surgery at Hackensack University Medical Center. Renowned for his indefatigable work in microsurgery and significant leadership roles, Dr. Winters offers a unique perspective on the dynamic interplay between surgical proficiency and administrative acumen. He shares his journey from extensive training to a distinguished career, illuminating the evolution of medical practice and the intricate balance between patient care and leadership responsibilities.

In our discussion, we delve into the transformative power of mentorship in shaping the careers of surgeons. Reflecting on personal experiences with mentors like Dr. Harry Buncke, we uncover the essence of thorough preparation and the valor in pausing when faced with uncertainty. Dr. Winters emphasizes that the finest surgeons are those who are meticulously prepared and diligent, particularly in an era of shortened training programs. Our conversation touches on the selection of surgical partners, stressing the importance of kindness, compatibility, and collaborative spirit in achieving successful outcomes.

Navigating the complexities of hospital administration and the impact of private equity on medical practice, Dr. Winters provides valuable insights into modern healthcare challenges. From understanding the nuances of surgical routine, especially in rhinoplasty, to strategizing long-term career goals and legacy planning, this episode offers a comprehensive look at the multifaceted world of plastic surgery. Whether it's establishing a microsurgery center or creating a craniofacial clinic, Dr. Winters's dedication to advancing the field and supporting fellow surgeons is evident. Tune in to gain wisdom from a seasoned expert whose commitment to excellence and mentorship is truly inspiring.

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S04E82 - Mentorship and Mastery: Plastic Surgeon Dr. Richard Winters on Surgical Excellence

TRANSCRIPT

[00:00:04] Dr. Sam Rhee: When introducing my next guest, plastic surgeon, Dr. Richard Winters, two comparisons come to my mind. I would liken Rick to a battle sword or a fine bottle of wine.

Like swords, surgeons, especially the ones who are old school, like Dr. Richard Winters, are put through the forge and with tremendous heat and pressure, they are pounded into shape to become who they are.

And that experience Is their surgical residency. Now, after that experience, they go forth serving their purpose based on their strengths and skills. Just as there's never any doubt what a sword's function is, Dr. Rick Winters has always had a clear vision of his responsibilities as a surgeon. He trained in an era where the field of microsurgery revolutionized plastic surgery and he continues to be one of the leading experts in our field in microsurgery.

Rick has also taken an active interest in leadership. He is the Chairman of the Plastic Surgery Department at the Hackensack University Medical Center and he has served on nearly every committee at the institution, including Chief of Medical Staff, for over 20 years. If you think about true leaders in organized plastic surgery in the state of New Jersey, Rick is one of the few names that everyone could probably agree upon who is greatly respected.

Now, if surgeons are swords, Rick would be the sword wielded by General Maximus, played by Russell Crowe in the movie Gladiator. Efficient, multifunctional, gets the job done without glitz or glamour. I mean, come on. After breaking down a complex lower extremity trauma case in conference, I could imagine Rick saying, Are you not entertained?

Well maybe, maybe not.

On the other hand, surgeons are also like bottles of wine. Some, as they get older, mellow and become more complex and refined. Others become bitter and you can just hear the vinegar in their voice as they talk about anything new or different.

Now having known Rick for over 15 years, I have seen him go from a darker, bolder Cabernet Sauvignon, trending into a medium bodied Merlot. And now, you might think of Rick as a drier, silkier, Pinot Noir.

There's always still a trace of acidity, and you'll never mistake Rick for a sugary Riesling or Moscato when you speak to him. But I was struck how nuanced and thoughtful our conversation was about modern medicine and the sage advice that he gives to young surgeons joining our specialty.

In a world where most plastic surgeons beef like Kendrick Lamar and Drake, Rick has managed to bring the egocentric and self absorbed among us together.

He has harmoniously worked with his business partner and fellow surgeon Dr. Stephanie Cohen for well over 20 years. Plus, he has brought on new associates who actually seem to want to stay, as opposed to the typical revolving door scenario found at most private practices.

Rick does hold strong opinions and he is quick to express them, but as you'll hear, he likes breaking down problems into manageable steps.

He approaches every situation analytically, whether it's a rhinoplasty, or evaluating private equity's rise in our specialty. Now his solution may not, be the only right answer, but I don't think you'll ever go wrong if you follow his advice to a T.

Dr. Winters cares deeply about making life better for other surgeons, both at his home institution and beyond.

And he is one of the few surgeons who's putting the time and effort into addressing current issues that he sees in medicine and in plastic surgery.

Rick is obviously not afraid of hard work, and he is a true pragmatist.

He is honest and authentic, and unfortunately, we may never see another generation of plastic surgeons like Dr. Winters ever again.

I really enjoyed speaking with him, and I hope you enjoy listening to him, too. Thank you very much.

Welcome to another episode of Botox and Burpee's The Surgical Series. I have esteemed guest Dr. Richard Winters, who is the chair of the Department of Plastic and Reconstructive Surgery at Hackensack University Medical Center, which is the largest hospital in New Jersey. Dr. Winters is also the Chief of Facial Restoration and Reanimation.

at Hackensack. Uh, just to go through your bio, Rick, you, um, you've been at Hackensack since 1998 and you are probably one of the most, uh, prominent or stalwarts in New Jersey plastic surgery that I've known over the decades. Uh, you got your training, you went to your undergrad at Tufts University. And, uh, completed your medical degree at University of Connecticut.

And you also did your general surgery residency, full general surgery residency, so very old school at University of Connecticut, uh, and then your plastic surgery residency at Cornell, the New York hospital, uh, you followed with, uh, a fellowship training at one of the premier institutions at the time, the Bunke Clinic, Davies Medical Center in San Francisco in complex reconstructive microsurgery and hand surgery.

And, uh, so you've done a lot at Hackensack. You are also the vice chair of surgery. You are also an associate professor of surgery at Hackensack University, sorry, Hackensack Meridian School of Medicine. And you've played a lot of different roles there. You were president of the medical staff, chairman of the med, uh, med exec committee, medical executive committee, and, uh, you've served on numerous committees, so you've had a ton of leadership experience outside just being a surgeon and, uh, you currently.

do a lot of rhinoplasty, revision rhinoplasty, and cancer reconstruction. So, I just want to thank you, Rick, for coming on and talking a little bit about your experience and, uh, what you've done so far in your career.

[00:06:01] Dr. Rick Winters: Very kind words, Sam, and thank you. The road that we took was definitely a long one, and the landscape in medical care, medical education, and the practice of medicine has changed dramatically just since the time that I went into practice. And so I felt pretty strongly along the way That you can either just sort of put your head in the sand and grind away and just see patients and practice medicine, or you can get involved with the administrative side of it and the payment side of it and, and then in that way, make things hopefully better for everybody, the doctors and the patients.

[00:06:44] Dr. Sam Rhee: I want to definitely get into some of your leadership roles and what you've done on the administrative side of medicine, but let's delve into you as a surgeon first because, uh, that's what we trained as. That's, uh, I know you're an exceptional surgeon. I know you do amazing work. Uh, let's start with some of your early experiences.

Give me something that you remember memorably during training, uh, something that was really formative for you as a surgeon or becoming a surgeon, uh, coming up in the ranks. Anyone who

[00:07:13] Dr. Rick Winters: there, there really isn't any, any one thing and I've thought a lot about this actually and tailored my approach to the education of medical students and residents because of it. Since the training has been compressed now, which largely is a function of shrinking Medicare dollars to pay for postgraduate medical education, clearly the most important thing in surgery always has been mentorship.

But now, even more so, given the fact that most young surgeons finish an abbreviated program, and even if they've done fellowship training, they're kind of too young and haven't had enough independent decision making and operative experience to take care of complex patients. And what they really require is apprenticeship, so, which is an advanced form of mentorship.

So, Um, similar to most other medical subspecialties, but probably most importantly relies on mentorship to make you into a good surgeon. Anyone can really learn the skills and some of the most. Highly capable surgeons that I know now, clearly didn't start out as the ones with the best hands, or the ones that wowed everybody in the operating room.

So it's really mostly been about mentorship, and I can't name any one. I've had Wonderful mentors in general surgery. My chief of surgery at Hartford hospital went on to become the dean of the medical school and is a formidable surgical oncologist. And I had wonderful mentors in plastic surgery at New York hospital.

For different reasons, they were, you know, more kind and more generous than surgeons that people generally view the surgeons of old, because my general surgery training was quite brutal where, you know, a lot was expected and then more on top of that. But I would say my most formative mentor was Harry Bunke.

I was the last fellow. To be trained by him in San Francisco before he retired. And he was a remarkable guy because with all of the accolades and the international recognition that he had had achieved, he was a very humble man. And really, uh, always said the most important thing was that talk is cheap and results are priceless and really your results are not a function of how You are, but how diligent and how prepared you are.

And, um, and so I would say of all the mentors that I had, Harry Bunkie was probably first and foremost.

[00:09:57] Dr. Sam Rhee: Do you do anything that he still does or did or taught you like when you do your micro cases or anything in particular?

[00:10:06] Dr. Rick Winters: I think one of the remarkable things about surgery is even with the revolution in technology, look at robotics and you look at minimally, minimally invasive stuff. Um, what it really comes down to is always how well prepared that you are. And Harry Bunke and other mentors that I've had in the past are always in my ear because I never worry too much about the complications I'm going to face, even when they're life threatening, because I know that I'm always prepared, not only for that particular operation, but I've become such a student of anatomy and so comfortable dissecting out critical structures that I feel like I can either get out of trouble or avoid getting into it just by virtue of preparation.

And, and that's definitely a Harry Bunkie thing. And it is definitely a Peter Deckers from my general surgery training type of thing. And, you know, I'd say the most important element of that, and one of the things I really try to impart to younger surgeons, is that the mentality in surgery is always just to keep going, keep pushing, keep trying to find a solution where your most valuable tool actually is not that.

Your most valuable tool is actually just to stop. When you're in trouble or uncertain of where you are, you only make the situation worse by pressing forward when you are not certain of what the next step is. Best thing to do is whether it's bleeding that you get into or you're uncertain of of where a particular structure is that you're looking for.

You can stop an operation altogether and just go back to it another day with better help, patient will always understand. And if you're in a life threatening or a limb threatening situation, very few situations I can think of where you can't just stop and, and find somebody to come in and add an extra pair of eyes and hands.

So I think that like most surgeons, I'm not unique in this way, despite the fact that I trained for eight years and I've been in practice for 25. I think that, that you rely on the judgment that you have accumulated. And, and that didn't, that, that wasn't an original thought. I don't really do any operations, even if there's a little bit of a, of a progressive spin on it.

I think most surgeons would say that they're not doing anything original. They're, they're copying ideas from others. Trying to make them their own and in their own style and make them better. But the bottom line, uh, important elements of surgery, uh, have always been the same, you know, since Halstead.

[00:12:52] Dr. Sam Rhee: Well, so you talked about preparation being a hallmark for both your mentors and for you, but I would imagine your preparation and say someone who hasn't had your experience level would be different.

So let's suppose we see Rick Winters 10 or 15 years ago. How was your preparation for a complicated case then? And is it still the same now?

[00:13:18] Dr. Rick Winters: So I think that, um, as a, as a paradigm. The answer is it's about, it's about the same because I, I never go into a case unprepared, but you're right. There's a lot of operations I do now as a matter of routine where I don't have to go and look up the steps or, or something that's unique to this patient.

But I'll tell you the one thing in plastic surgery. That will never change. And I think that this has wide applicability for anybody who deals with disaster management or remediation of big problems, you have to very, for at the very outset of the operation, you have to take things apart and start over from the beginning.

So a lot of the patients that I operate on have had three, four, five previous operations, and you can't really tell what's been done. based on the previous operative reports or what the patient's telling you or even what a previous surgeon's telling you. So the, the most important part of my preparation now that I'm experienced and have judgment is just to start out by undoing the whole thing.

And once you've done that and laid bare what's missing, what's wrong, what needs to be changed, what needs to be added or deleted, That's probably the most important part of my preparation now as a more senior surgeon. And I watch younger surgeons, including my own partners, struggle with that a bit because sometimes they're afraid to take it apart.

There's scar tissue. You can't really find normal structures in a, in an operate, a previously operated on field. That, that's sort of my, my preparation gets done in the first half an hour, 45 minutes of the case where I just go back to zero. And take everything apart and then everything else sort of flows like a waterfall from there.

[00:15:04] Dr. Sam Rhee: That means, you know, one of the things I've talked to surgeons and they've mentioned was, oftentimes pre visualization. So they run through the case before they actually do the case. But it sounds like, especially with some of these cancer reconstruction cases or these multiple re operations that you're doing for limb salvage or other complicated cases, you can't really pre vis or pre visualize any of this stuff.

You have to Sort of decide once you get in there and like you said, open up the box and take it apart to decide what it is that you want to do.

[00:15:36] Dr. Rick Winters: So that's, that's an excellent point. And, uh, I remember vividly an article that came out in the New Yorker magazine. I believe it was 2010 or 2011 when a guy by the name of Atul Gawande coming, he's a neurosurgeon, was becoming

[00:15:52] Dr. Sam Rhee: Uh, no. Endocrine. He's a general surgeon. Endocrine.

[00:15:55] Dr. Rick Winters: Well, he, he wrote, um, an article in the New Yorker and I may be butchering the title, but it was something along the lines of surgeon as performance athlete.

And I thought about that and I circulated that article to pretty much every surgeon I know, because a lot of surgeons don't really prepare themselves in that way to go to work. And I think surgery is a very demanding way of making a living, not just intellectually and psychologically, but physically and emotionally.

And I think, That there are certain things that I, at 60 now, um, do routinely as preparation for the work that I'm going to be doing. And I think, you know, you have to live a reasonably healthy lifestyle. You have to do a certain degree of exercise. You have to take care of yourself with regard to getting enough sleep and that's changed for me now that I'm 60 from when I was 30.

And so I think as a very baseline, um, those are really good principles for anybody who does anything high intensity for a living. If you are not physically, mentally, emotionally, psychologically prepared to meet a challenge that may be coming your way, you, you get caught on your heels. And so I would say.

Now that there really isn't an operation that I haven't done multiple times, um, I may face circumstances that are different than others. I may face things that are more emergent than others that really require dealing with it in an expedient manner. But I always go into a case, I don't, I don't go out drinking and go on a bender the night before and stay up all night.

I don't carry baggage along with me. with regards to problems that my children might be having and all that stuff. You really have to be focused in that way. And if you are, then your experience in judgment takes over. But that, that's why mentorship and apprenticeship is so important because younger surgeons don't really have any of that.

And so most surgical training is still that way, uh, to some degree, but falls short of it compared to what we did back in the day, for example, When we were doing general surgery as fourth and fifth year residents, there were no attendings in the house at level one trauma centers. And, you know, every gunshot wound to the chest and every.

Emergency for cardiac surgery was being taken back to the operating room by a PGY 4. The, the, um, the curve gets shifted a little bit to the right now. You're, you're, you're probably familiar with Malcolm Gladwell, also from the New Yorker magazine, and he wrote a book called Outliers, and he cites a whole bunch of examples, whether it's, hockey players or the Shoal Dice Clinic for hernia repairs, but the most important tenet of the book is that you really need 10, 000 hours of being immersed in what you're doing, and that doesn't mean when you're training and you're watching or you're assisting, actually doing it before you really achieve Um, you know, a level of, of competence that allows you then to acquire judgment and ex and expertise.

So I, I, I think on the, the, the shift, the curve to that has been shifted a bit to the right. Because trainees don't get that kind of training in general surgery and plastic surgery like we did. But if they're not physically, mentally, and emotionally prepared to deal with it, then they'll never get the 10, 000 hours in.

And no knock against modern medical training, but it's sort of been softened up a bit. Maybe the pendulum has swung a little bit too far in the other direction. It used to be brutal and maybe now it's much kinder and much, you know, gentler, but somewhere in the middle is the right answer of how you train young people to take on big responsibility.

[00:19:54] Dr. Sam Rhee: I mean, I think one of the counter arguments would be, what was the level of care given, and what is the level of care given now in terms of experience? And I understand, I, listen, I, uh, I am all for independent, self directed care. Uh, experiential learning. Uh, I think there will be people that would argue that, you know, the patient comes first.

You can't leave it in inexperienced hands. You have to have people that are more experienced. It's a debate I think that you could go back and forth with, and I agree with you. There was a lot of compressed learning. Like you said, it was brutal in many cases.

[00:20:33] Dr. Rick Winters: That's why the pendulum has swung so far in the other direction now because I think, you know, people have recognized that often the results in community hospitals where an attending is doing the beginning, middle, and end of every operation. tend to be better with less complications than in academic medical centers where the fellow or the resident is doing it.

So I agree with those people who criticize my way of training, the way that we trained in the sense that there was not enough supervision, which is why I say somewhere in the middle is, is the right, is the right balance. And I think that's why apprenticeships are so important. And I think. Most early jobs that surgeons take, and I review all of the job offers that the residents in our program have, and what I really encourage them to look for is a situation where there are senior attendings with many more years of experience than they have who are going to be willing, not just to sort of send them out there to 10 different hospitals and churn as much work as they can, but take them under their wing and give them an apprenticeship.

And some, some young people will make it through that more quickly than others. But when it's you and a younger surgeon in the room, patient gets the best result. The younger surgeon gets. The experience and judgment that they need. It may not be quite independent operating, but it's, it's certainly operating the training wheels.

And, uh, and I think it's what works the best.

[00:22:00] Dr. Sam Rhee: It sounds like an ideal situation. What is your favorite procedure right now or one of your favorite procedures you really enjoy doing at this age?

[00:22:08] Dr. Rick Winters: So it's funny when I was in medical school, it was very easy for me to limit the things that eliminate the things that I absolutely knew I was not interested at all in. I won't mention them because it's not nice, but I have admiration for all the fields of medicine and surgery, even if it's not what I want to do.

But within plastic and reconstructive surgery, I spent a lot of time early in my career Pushing back against cosmetic surgery. And I have a very harsh stance towards that. Um, I don't, I understand that most people out there in the community don't really even know what plastic surgery is. They think it's Botox fillers and you know, the stuff they see on Hollywood shows, but in the end, I think if you are going to be an effective cosmetic surgeon.

You first really have to become an accomplished surgeon. And I think that, um, that when I hear residents going off to do cosmetic fellowships, especially after they haven't had the kind of training that we have, I view that largely as a waste of time. So in the first 10 years of my practice, I really worked hard at becoming an accomplished surgeon.

Doing what I considered were the hardest cases that nobody would touch, making sure that the transfer was not happening from our ER to another institution, that we were keeping the horrible extremity injuries and, and making sure that the, the oncology surgeons, whether they be head and neck or orthopedics or, or, or otherwise knew that we had the capability to reconstruct those.

And I found myself doing a lot of complex facial reanimation surgery, where You have to do all these nerve transfers and nerve grafts and muscle transplants to enable people with facial nerve injuries and facial nerve problems to smile again. And somehow out of that, a lot of the mothers of those kids and the grandmothers of those kids, would say things to me like, well, if you can do this, you must be able to do a facelift.

And so my, I, a cosmetic practice sort of began and I took a particular liking and became a student of complex rhinoplasty. And I, I think the area, the era in which we were trained rhinoplasty was largely a destructive, poorly done operation. It was not meticulous. It was not anatomically correct. And after Jack Gunter, at UT Southwestern first described the open rhinoplasty approach.

I became fascinated by it anatomically. And I couldn't understand why so many were still being done poorly. So I wound up in a, in a place where I am today, where I would say probably 60 percent of my practice is rhinoplasty. And of that 60%, two thirds of those are revisions and most require an autologous rib graft or something like that.

And, um, and, and I've, I've learned how to make lemonade out of lemons. And I, I, that to me is very rewarding. I don't really care. If someone comes to me with a D minus result and I can only bring them up to a B plus, my ego is not tied at all to the result. The only thing I care about is that that person is no longer self conscious over the appearance of their nose because it looks near normal, if not normal.

So I love doing revision rhinoplasty. There's no way I'm ever not going to love, that's a double negative. I'm always going to love microsurgery and I'm blessed now with two junior partners, one of whom is microsurgery trained. So when we do free tissue transfers, God bless them. Those two do all the heavy lifting.

They, they do the first three or four hours of the case where the positioning and repositioning the patient and dissecting the vessels in the flatbed. And then yours truly shows up. To try to add a little bit of color sometimes and sometimes shift the direction of the way they're going in a way that I know that it'll work out better, and then I get to participate to some degree in the microsurgery and the education of the residents and, um, And, uh, and I just absolutely love that.

So those are the two things I like to do the best.

[00:26:19] Dr. Sam Rhee: That sounds ideal. Let me ask you, how did you pick your surgical partners? What were some of the characteristics that you felt were important for them to be able to work with you?

[00:26:34] Dr. Rick Winters: So that's easy. And I, and I think you can talk to anybody in any business or we can be banking. It can be the insurance business. You know, I think that people can acquire skills if they have grit. And if they are willing to put the time in to learn those skills, then that's obviously the minimum standard.

And I think you'd be hard pressed to find many people in the field of surgery, let alone plastic surgery, that don't meet that bar. Honestly, what I really look for is I look for people who are kind and generous and compassionate. And I will tell you that the two, well, first I started with my. Senior partner, Stephanie, we met each other in our residency program and we were friends and, um, you know, neither one of us had much in the way of ego about, uh, about ourselves.

We both, people would argue that that was not true of me, particularly back then, and that's okay. There may be some truth to that, but we had very complimentary, um, skill sets and very complimentary personalities. And we were just friends. And so we began our practice. As a real partnership and, you know, we, we never really ever looked at who was making more money.

We never looked at who was getting to do this case versus that case. We helped each other all the time and we were fine for 17 years and thought, you know, until we find somebody who comes along, who kind of fits the, that personality mold that we want,

[00:28:03] Dr. Sam Rhee: move on

[00:28:04] Dr. Rick Winters: maybe we'll just, Right off into the sunset this way.

And then we met Janet who joined us first and she's just an incredibly hardworking, diligent person. Maybe a little bit too hard on herself, has a number of the characteristics of impatience that I have, but it's still a very kind person. And then after her, Paul, who both of them were residents in our program.

So we knew them for many years. Neither one of them. had extraordinary, extraordinary skill sets as residents. And I remember telling them when they were working with me to stop being so nervous. I really didn't care whether they were, you know, A plus good or A minus or B plus good, that they were going to get there eventually with repetition.

All I cared about is that they were outstanding human beings. And I was proud of that. proven to be right, because I would argue that both of them have skills now which exceed mine and Stephanie's. They just don't quite yet have the experience and judgment that we do, but they are extremely kind, generous people, and I would say those are the two most important characteristics.

Sometimes not necessarily the type of thing that, that surgeons try to instill or ingrain in their trainees, but, but I do and I'm pretty hard on the residents of medical students. I'm not a pushover and I'm not, you know, I'm not the one who's, you know, constantly lavishing them with compliments and telling them how wonderful they are.

But I never, I never act towards them. With anything less than, than kindness, even if they're not prepared, they're going to feel a sting. But those are really the most important, the most important elements, whether it's in a person that you're training or a person you take on as a partner.

[00:29:53] Dr. Sam Rhee: I think that's admirable, especially, I know you and Stephanie well in terms of your partnership. I don't think that that's, that's ever been, it's very rare to see that in plastic surgery and then to bring on two more, uh, people into your practice, all of whom, who mesh well, that is, That is not the norm in plastic surgery.

Let's just put it that way. It's usually the opposite where it's trying to herd cats together and it's quite, uh, contentious would be, um, one word I would use when I see people within, uh, like a multi group, like multi person practice, let's just put it that way.

[00:30:38] Dr. Rick Winters: that my group is at a bit of an advantage because We've managed to secure very reasonable contracts with payers and I've done that by demonstrating that our episode of care costs are quite low compared to people both in and out of network who do what we do because we don't play a lot of games with billing and collecting.

We don't, you know, um, ghost assist cases and do a lot of things that would jack up our, our earnings. And I think that because there's been so much downward pressure on reimbursement that sadly a lot of these senior people when they take junior people on are really looking to grind them up for three, four, five years or even longer largely to support their incomes while they are in a state of decline and we have not done that.

I can tell you that my junior partners, often in particular quarters, they out earn me, they work a lot harder than I do, and I take a lot of pride in that, actually, and I think you get what you give, and the level of commitment from your junior, your junior partners is going to be reflective of how they're treated, and sadly, in In all of surgery, in all of medicine, there's just too many outside forces that have sort of all kind of come together to put pressure on practices to behave in ways that don't wind up with the same vibe that our practice has.

[00:32:06] Dr. Sam Rhee: Who would have thought playing straight and caring about each other actually would have worked in business, huh? So, when you do a complex revision rhinoplasty, is there anything that you do as part of your particular setup or prep that you do every time to ensure that that case is going to go smoothly for you?

[00:32:30] Dr. Rick Winters: it's funny that you say that, you know, rhinoplasty, whether it's a primary or a complex revision is really just the same operation every single time. And, and the steps don't vary. It doesn't mean that you are looking to achieve the same result in every patient. The steps are the same. If you do a primary versus a revision, the first thing you have to do is take the nose apart.

You have to do a component separation. So you know what it is that you are missing. What's What's in excess, what the relationship between those structures are, and, and in a primary, it's easier because it's not all scarred and no one has gotten to it before you. But same thing in a revision. So I can tell you in complete honesty, my routine in every case is exactly the same with the, with the difference being, you know, if I have to do a rib cartilage graft, um, you know, I set time aside for that and I prepped for it, but that's not a material difference.

So every single time I set it up the same way. I have anesthesiologists who understand what the goal of the operation is. So they give, they give anesthesia in a particular way so that there's no narcotics and the patient is not, you know, um, waking up during the operation. I do them all under general.

with an endotracheal tube so I can pack the pharynx and, and make sure the airway is protected throughout the entire time. I, I, I, I give everybody the same preoperative routine. They swab their nose at home. They swab their nose the morning of. I prep it the same way by, you know, scrubbing out the face and the nostrils and irrigating the pharynx out.

I make the incision the same way, the approach is the same anatomically, and then once I've taken it apart, I just kind of get to work and either add, subtract, modify, and then I'm finished. I think, you know, one of the most important overlooked issues is in preventing post operative complications, in my practice, the most devastating of which, um, is an infection, particularly if I have cartilage grafts in.

So I always make sure to spend an extra 10 minutes at the end of the case to make sure that my mucosal approximation is as perfect as it can be. And unlike the way that I was taught, where the trans chiomellar incision gets closed first, I'm That makes it impossible to get up into the vestibule. I always start from the outs, from the inside and work my way out.

Some surgeons are fearful. If they do that, they'll wind up short when they close the chiamella, but it's. It's never that way, even in cases where you add significant projection. So I think I, I really do them all as a matter of routine. There's nothing special about the way I do that operation. I do it the same way every time.

I, I inject my local the same way every time, all that stuff. I

[00:35:28] Dr. Sam Rhee: Uh, I would love to talk to you about rhinoplasty only because I know a lot of people make it, like, they tell us there's an infinite variation of suture techniques, graft techniques to use, onlay or, you know, inlay, like, do you, how do you support the collumella, do you do it this way, that way, how do you, uh, you know, how do you do it?

Provide more tip projection. You know, there are like 15 different ways people will cite. So this isn't a rhinoplasty talk. I do like the fact that you break it down and you simplify a lot of these things because it can get so overwhelmingly complicated for someone who's who's trying to learn that as a business like for the first time. So

[00:36:11] Dr. Rick Winters: will say this, and this has broad applicability for all of surgery. It doesn't matter the procedure that you're doing. There's a couple things that are almost always true. When there's multiple ways to do something, it's more a matter of style. And there isn't one perfect way because if there was a perfect way, everybody would do it that way.

And secondly, when it comes to surgery of any type, and I don't care if you're doing, you know, a hepatico jejunostomy or you're doing a rhinoplasty, I think a structurally sound operation is the most important, and this is not my original thought. It goes back to Jack Gunter. If you read his rhinoplasty books.

It's all about providing structural support first. And then you start fooling around with onlay stuff, because onlay stuff isn't structural. It has a tendency to move, or warp, or, or sometimes resorb, and it's, it very rarely winds up perfect. But if you, you put graphs in that are the structural type, where they don't move, it's much more likely that you don't have You know, a lot of variegation and result afterwards.

So I think, you know, doing things anatomically correctly will never go out of style. You can't really camouflage, you know, a bad operation by throwing a whole bunch of onlay graphs on. You have to take it apart and fix the structure. And, and, and I think that those are really things about rhinoplasty that I utilize all the time that apply to all kinds of surgery, both complex and simple.

[00:37:42] Dr. Sam Rhee: What kind of music do you listen to in the O. R. now?

[00:37:45] Dr. Rick Winters: Well, only because I'm old. Um, if I'm in a case with my younger partners, they always have something on that hurts my ears that they know I'm coming, they usually will switch, they'll switch it. Um, it often doesn't matter that much to me, but if it's my case, I will listen to mostly seventies and eighties rock because.

The lyrics actually mattered back then. Um, but, but I can listen to just about anything that sort of set my mood. If the nurses or the techs in the room have something in particular that they really want to listen to, I'm all good with that.

[00:38:20] Dr. Sam Rhee: Now, let's talk about, now you, we talked about you as a surgeon, but you have spent an inordinate amount of time out of the operating room not being a surgeon. A lot of leadership, uh, roles within the medical center, um, within the medical school, within your department. What made you decide, you know, because like you said, a lot of us will just say, Operate.

That's what we originally trained to do. None of us were trained to become department heads necessarily, or this is what you're supposed to do in terms of joining committees and, and helping on the administrative side. Like, that was not something that was part of our curriculum. Explicitly as residents or as, uh, fellows.

So what made you decide to, and when did you start saying, listen, I need to spend less time in the operating room and more time doing things that are not involved with operating?

[00:39:15] Dr. Rick Winters: Well, look, it's not for everybody. And, um, and I, and I don't think it has to be for everybody, but I think there need to be people in leadership positions that understand the way the world works, otherwise, We wind up in a situation like we are today, where physicians have very little leverage in making the situation better.

So I realized, probably back in my general surgery residency, where I started reading the New York Times and the Wall Street Journal, Particularly the op ed pieces as they pertain to healthcare to try to understand, you know, in those days it was HMOs and PPOs and to try to understand the shifting landscape of medical education, how medicine is paid for, how it is consumed by patients.

And, and I think when you start to get a granular understanding of that, you realize that unless you are going to be part of the solution, you know, things are not going to change. And all you can do is keep your fingers crossed that You're going to run the clock out on your career and kind of get away with it.

And, you know, so much has changed. When I first really started becoming, uh, involved at the higher levels of medical leadership, it was about the time that hospital systems started achieving, uh, the Massive scale, you know, it used to be that, you know, hospitals were their own island and and then they started achieving scale and by way of doing that got huge leverage in the market were able to basically be on a par with the insurance companies.

And that left a lot of the doctors behind. And I sort of realized that, that if you weren't going to get left behind, you had to figure out how to partner with the institution where you make your living. And so I got to know the hospital leadership and now the network leadership. And, and, and I think that my viewpoint was not a Debbie Downer one.

My viewpoint has always been a very positive one. Um,

[00:41:14] Dr. Sam Rhee: positive kind

[00:41:15] Dr. Rick Winters: And I just thought it was extremely important. It was worth committing the extra time and energy to because it's not the kind of thing that you just show up to a meeting once in a while and your voice matters at all. And running a hospital is an extremely complex endeavor.

And if you don't have good leadership from surgeons and from medical doctors, the the wheels just completely come off. You know, a lot of the metrics whereby they, they, they measure hospital, um, quality are things that make no sense to a, to uh, a surgeon. Let alone any, any physician and they're important because if you don't have the health grades and you don't have the newest US News and World Report, you know, that's not more than just appearing in a magazine.

You, you, you lose your leverage with regard to payers. You can't borrow money the way that you'd like to, unless you have those accolades. But there has to be a completely other side to it. And when it comes to vetting problems with physicians on staff who have errors or behavioral problems, or God forbid, um, drug and alcohol problems, you need strong medical leadership to deal with that in a fair and just way.

And so that, that's kind of. The long answer to how I sort of got involved, and luckily, it's not just me. There are lots of other surgeons and non surgeons who participated high levels in hospital leadership and in network leadership that I think has Gone a long way towards sort of moving things in the direction of real quality, the way that we see it and, and protecting the, the good surgeons who do the right thing and the good doctors who do the right thing so that they can make a living.

[00:43:06] Dr. Sam Rhee: right thing. So the deeper you have gotten into this, do you feel like it's been worthwhile to take away from your surgical practice in order to spend that time?

Because how much time are you spending doing these administrative or, um, hospital or leadership type roles, and how much of that has sort of taken away from your surgical practice?

[00:43:27] Dr. Rick Winters: So it's been a progression. So when I was early in my career, I had the, I had the capacity. You know, to work 70 hours a week and it didn't matter. So, you know, I could still work a full surgical practice, including going to the emergency room and taking care of, you know, patients with complicated problems into the, throughout the night, and then show up at meetings the next day.

But I, I've been lucky because as I have. Uh, achieved higher levels of administrative leadership. I also have had more support in my practice. So for example, I don't take any call for the practice and I don't take call for the emergency room. So if somebody comes in with an injury that one of my junior partners wants me to help them with, then I'll go in and help them.

But that's pretty rare. So I'm able to dedicate a day and a half a week to helping And, you know, I only see patients one full day a week. Now, um, you know, from morning until night, just one day, and then I operate two days a week. And so it, it honestly, it hasn't been hard at all. And don't forget too, that a lot of the administrative positions that I've had have been volunteer, but the chair of a department gets paid a stipend.

So it's not as if I take away completely from my practice and I'm, you know, net negative on it. They compensate me for my time. It may not be, look, if I wanted to make as much money as I possibly could, I would just I wouldn't do anything administrative and I would just work because I make more money as a surgeon than I do as an administrator.

But the other is important enough to me that that doesn't figure into it.

[00:45:05] Dr. Sam Rhee: Now that you've gotten pretty deep into the hospital leadership, what do you think are the biggest challenges you see for us as surgeons dealing with hospitals, with payers, you know? It doesn't seem to me like it's getting better. Do you think it's going to get better?

[00:45:22] Dr. Rick Winters: Well, it's not a matter of getting better. I think that the problem is that the change doesn't get affected in medicine until there is a disastrous circumstance. So what we've seen over the last 10 to 15 years, Has been a gradual death by paper cut with regard to reimbursement, which has been painful, but not painful enough that surgeons have stopped doing what they're doing.

In fact, what many of them have done have gone to just working harder and working more. And so that doesn't displease the, the, the environment, right? The hospitals don't mind that. Um, the payers don't mind, the, the patients don't mind, provided that the quality is at a certain level, and they, they feel like they're being taken good care of.

So, the death by paper cut has gone on for a long time, but what it's allowed is, in addition to the hospitals achieving massive scale, and the insurance companies getting more leverage, private equity has, has taken an opportunity in medicine, because a lot of doctors had no ability to negotiate favorable in network contracts.

And so they were easy fodder for private equity backed groups to come in and say, Hey, listen, you don't want to struggle anymore. You come in and join us and, you know, we have better rates. And so you join us, you can do rates under our cases, under our tax ID. And so now we're in a situation where there really only are three camps of surgeons and medical doctors and the like.

There are academically oriented ones that work for a teaching institution. There are private equity backed groups that employ huge number of physicians, especially if they've gone through a couple of liquidity events and they're owned by somebody like Optum or Walgreens. And then you have a shrinking pool of people like me that have been able to survive in private practice.

That has put enormous downward pressure on, on the physicians and surgeons. And what I've seen happen at Hackensack, and I'd like to believe that me or And other surgeons like me have had a big role in kind of forming this. This is kind of a hybrid model now. You know, people were resisting working for a hospital because it was not really a terrific employment opportunity.

You know, the, your admin support was lousy. You weren't really enjoying the fruits of your labor. You were being asked to do more and more and more. And now there's a hybrid model that's moved in where the hospitals have kind of realized and the larger health systems have realized that if they're going to battle with the private equity backed groups, they're going to have to do it on the basis of quality, because it seems that most of the private equity backed groups, not all, But most have done a couple of things.

They've raised the cost, they've lowered the quality, and they've probably lowered the access. And I think that model eventually is going to, is going to come apart. So, but in order to compete with the generous salaries that are offered by those groups, If these people don't have private practice opportunities or don't want to become academic, there are hybrid models that the hospital offers where they have taken over full practices and they have a very complex reimbursement methodology whereby they use RVUs.

They sometimes will allow the physicians to partner in, in ancillaries like surgery centers and diagnostics. And they may not make the same income that they were making 15 years ago when they were practicing out of network. And getting paid arguably unfairly highly for what they were doing, but it's a sustainable model where you can make a really good living for a long time.

And in my practice, you know, I have, um, been, been in situations where, you know, private equity was a possibility and I decided not to go that route because I think particularly for my junior partners. A thriving private practice that continues to add value with more partners and does work in conjunction with our hospital and our network system.

Eventually, may not happen next year, may not happen in five years, who knows when, eventually is going to have to become aligned with the hospital. And I think that relationship has gotten much better than it was 10 or 15 years ago, and that's largely the result. of physicians and surgeons being involved in the process and doing the type of things that I've been doing at the administrative level.

[00:50:04] Dr. Sam Rhee: If I was a young plastic surgeon coming out of training now, what would be my best opportunity? What would you think I should be doing? Should I be looking at the hospital system? Should I be, like you said, the private practice groups are shrinking. Um, they're all sort of falling under the umbrella of PE in a lot of ways.

So, what is it that you would tell me I should be looking for to maximize my training? My best opportunity, economically, let's say.

[00:50:30] Dr. Rick Winters: So in economics, follow everything else. So if you're happy and productive and enjoying your work and enjoying your life, you make a good living. That, that has always been the case and is never going to change. I think because of how complex the marketplace is now with regard to what the job opportunities are.

It's difficult, and I review all the job offers and opportunities that our residents have, and I think there's one thing that I tell them to look for if they can get it. And that's not having to sign a restrictive covenant. It's really hard. If you look at restrictive covenants, And I think in the next few years will be largely unenforceable.

But the sad fact is, if you're a young person and you sign a contract with a group that has a restriction in it, It's going to be enforced, and even if it's not deemed legal or enforceable, you're going to spend a half a million dollars trying to get out from under it, and that's untenable to a young person beginning their practice, being told that they're going to have to move 50 miles away, 20 miles away, whatever it is.

So, the first thing I always tell them to look for, If they can get it is the absence of a restrictive covenant. The second thing and equally important is they have to look at a practice, whether it's PE backed or this or that or the other, they have to look at a practice and they have to ask themselves, what's the opportunity I want?

If you're going to go into an academic practice, Maybe you want the opportunity to operate independently, get your board cases, and you know, really establish yourself and be able to walk away and go wherever you want. But if you're going to join a private practice, you have to look really carefully at the senior partners and try to get a, a really granular understanding of where their heads are at.

Are they looking to ride you for five years and then ask you for a big Number for a buy in, or are these the type of individuals that are really interested in mentoring you and apprenticing you so that you can become as productive, if not more than they are. And I, and I realize it's not the most common, but it's out there.

And I've seen, I've seen jobs like that. And look, in my practice, it's simple. We just hired somebody who's coming to us from USC. He's going to start in the fall. He's going to be our fifth.

[00:52:52] Dr. Sam Rhee: paying him a

[00:52:53] Dr. Rick Winters: We're not paying him a lot of money. In fact, it's significantly below market rate, but he's not signing a restrictive covenant, and he knows if he follows the same path that Janet and Paul did, that he will be able to become a full partner.

After his second year, so in his third year, without a big buy in. And if I'm lying to him, or it doesn't work out, he can simply wipe his hands clean of me, and he can join any one of a number of groups in North Jersey, and he won't lose his privileges at Hackensack or anything. So, I actually think that's the ideal situation.

Coming in, In what is really an apprenticeship role helping you to develop the money you make in your first two years of practice really doesn't matter. I've seen terrible contracts where kids are offered. A lot of money, but those are structured as loans. So if they don't make back what they were paid, they either have it clawed back or they owe it the next year in their salary.

And so, you know, there's a lot of, um, opportunistic groups out there that are not really looking at the best interests of a young person, but if they look hard enough, they can find them. And the last thing I'll say is I really think that the, the kids coming out today that don't do fellowship training.

are really cutting out their own knees from underneath them. If they want to go to an underserved community or a place where there aren't a lot of plastic surgeons and they want to show up and do bread and butter plastic surgery, then God bless them. They can do it there, but you cannot go to any metropolitan, major metropolitan area in this country and come out of your five years, or a 5 plus 1 with a research year of plastic surgery training and make a name or a living for yourself.

If you haven't had the benefit of a fellowship where you will get some independent operating experience, some adult decision making, a chance to spread your wings when the environment is safe. You know, um, they all should be doing them. And when they come out of our residency program and they're not doing them, I question the advice that they're getting from, from, from their program directors and their chair and their chairman.

[00:55:04] Dr. Sam Rhee: What are you going to do as a future, like what are your future goals? You're only 60. That's very young. So what else are you going to be doing? What are your plans either as a surgeon or as a non surgeon in your career right now?

[00:55:17] Dr. Rick Winters: Well, I mean, I really, I really enjoy my work and I really enjoy my life because, you know, again, that, that wasn't by accident. My, my practice has evolved to the point where I think it's pretty easy to be me as a surgeon these days. I just have nothing but support and help. And I think if, if senior surgeons structure their practice that way, that they can practice for a very, very long time.

I can tell you that, that 10 years was added to my career by not taking call. Not running to the ER, not having to grind out these 14 hour cases, showing up for four hours of it. I mean, there's, there's real truth in that. So, I would like to continue working as long as I can be productive. If I lose my, my skills, I'm certainly not going to operate on human beings who are expecting a certain level of, of skill from me.

But, um, I, I'm in the process of establishing. certain programs at Hackensack that I think will be legacy programs where we're in the process of just putting the finishing touches on a center for microsurgery and complex reconstruction where we have our own set of rules and regulations and we're going to leverage the 17 hospital network and the two helicopters we have and try to make it convincing for the other hospitals in the network and then ultimately beyond to send their complex They're complex reconstructive problems to us, certainly the acute ones that come by helicopter.

And that's going to take me another, you know, 5, 6, 7 years before that really gets off the ground. We're also formalizing our craniofacial clinic. And our craniofacial program, finally, as you know, it's been many, many years where we have lacked a space to see patients along with the pediatric neurosurgeons and all the other supporting people, um, who, who help us with that endeavor, whether they be speech therapy or pediatrics or, um, So on and so forth.

So that that's getting close to being fruition to fruition. That's largely Frank Ciminello's doing. So those two projects will keep me busy for, for a bit. And, um, I don't imagine I will stay in the job of chair of surgery for, you know, the duration, because I don't think that these positions were, were meant to be held by a single individual for a lengthy period of time.

So I've always felt like I wanted to do this. Center for Microsurgery and Complex Reconstruction. And once that's off the ground, it'll be time for somebody younger with fresh ideas and more energy to take over. I would like to stay on, um, and continue practicing and continue being able to educate medical students and residents.

I think by then we'll be talking about having our own plastic surgery residency program. And possibly even a microsurgery fellowship. And the old guys can stay involved with that for very long periods of time. Even for example, teaching medical students how to do microsurgery on, on rats in a lab with a microscope.

So, but I do enjoy, um, I do enjoy my life. Both my children are grown. My daughter lives in the city and works in marketing and advertising. And my son is a sophomore in college. So my wife and I enjoy.

[00:58:33] Dr. Sam Rhee: wife and

[00:58:33] Dr. Rick Winters: And so we've taken a ton of these trips to all kinds of places with a travel company owned by the Trek Bicycle Company, which is really a great thing.

And so we have it in mind to, to go all over the world riding bicycles and that sort of thing doesn't necessarily, um, uh, uh, X out the opportunity that you can work to. It's just that I'll be needed a lot less. Where I am at work and I'll be able to do that stuff.

[00:59:02] Dr. Sam Rhee: Wow, you sound like you've really planned it out with a lot of forethought, which is not like the way a lot of surgeons necessarily plan their, uh, you know, their next stage after sort of, you know,

[00:59:17] Dr. Rick Winters: A lot of it, you fall into a lot of it, Sam, but I think one of the things that. I tell my children all the time, it doesn't matter if you are recognized as in the top 5 percent of your medical school class in your AOA. I mean, it's nice if you have it, but the more important thing is you have to have defined goals.

And one of the things that I tell all surgical trainees and medical students is that you have to play the long game. And when you play the long game, you have a perspective on things that allows you to make good decisions, So you can plan your career and you can plan your life. When you try to hockey stick things, you, you, you can go off in the wrong direction and it may not work out so well for you.

So even now, for the, for the med students that don't match into the surgical subspecialty of their choice, I tell them all to do general surgery. I didn't decide to be a plastic surgeon until after I had already done it. applied for cardiac surgery positions. I was going to be a cardiac surgeon. I had a job lined up and I pulled the plug on that in the 11th hour.

I don't know how these kids make up their mind this early, but if you have well defined goals, and my goal was never to be any of the things that I am now, I would never have known at the time, my goal was to play the long game, become an accomplished surgeon, and I knew if I did that, I'd have the ability to.

Kind of figure out what I was interested, maybe get pretty good at it. I don't have to be the best at it, but get good enough at it that, you know, you can make a living at it and enjoy what you're doing. And everything flows from there. You, you gain perspective by putting in.

[01:01:00] Dr. Sam Rhee: Would you say you've mellowed out over the years because talking to you now, I would say knowing you now and five years ago or another five years before that, I'd say you've, you've gained a lot of perspective and depth of, not that you weren't a deep thinker before, but you had a lot of emotion then and you, your emotion is still there, but it's tempered with a lot of perspective and thought at this point.

[01:01:24] Dr. Rick Winters: I think that happens to all, all people when they start to make enough of their own mistakes and they have to recover from enough of their own errors. Um, and, and you come to realize at a certain, it's not even a certain age, at a certain level of experience doing what you do. That everybody makes the same, you make the same, you have the same problems and you make the same errors and if you don't think about them in a sober humility type of way, then you're never going to learn from them.

And I think early on in my training, um, when we were general surgery residents, you know, we kind of ruled the hospital and, you know, if you couldn't do it, Nobody else could, and if you couldn't get the problem fixed, then the patient would, would probably not make it. And from that, when you're younger, comes a certain amount of hubris, and that never leads to a good place.

And I would say that in the first 10 years of my career, I probably suffered a little bit too much of that, and it just made it very easy to pick on me when I, when I didn't have a perfect outcome with something. And I, I realize now more than ever, you don't have to be the, the smartest or best in your class or this or that.

You, you need to be given an opportunity if you demonstrate grit. So I have a lot more patience now than, than I had back then. And I've also gotten over the fact that the training is different and, you know, kids are just not expected to suffer. Um, but just because they don't suffer, it doesn't mean that they don't have to make the same level of commitment if they want to get to a place where they're going to be happy and productive.

[01:03:09] Dr. Sam Rhee: Rick, it's been an honor talking to you. I've learned a lot and I think there's a lot of value in what you said and I hope that a lot of people will take that away. So thank you for taking the time with me today. And I really appreciate it.

[01:03:21] Dr. Rick Winters: Well, Sam, it's been an honor being on. It's been an honor to have known you for all these years. And, uh, and it certainly, I think is a great benefit to whatever the community is that, that, uh, watches your podcasts. Um, I think it's really helpful to hear other people talk about their experiences, whether they be good or bad, um, to grow and play a part in their own journey.

[01:03:46] Dr. Sam Rhee: Thank you very much.