Longitudinal Assessment of Aesthetic Plastic Surgery Training in the United States: The Effect of Increased ACGME Case Log Minimum Requirements

Comparing Graduating Plastic Surgery Residents' Case Logs With Accreditation Council for Graduate Medical Education Requirements, Content at National Meetings, and In-Service Examination Test Items

BACKGROUND

The importance of adaptable and up-to-date plastic surgery graduate medical education (GME) has taken on new meaning amidst accelerating surgical innovation and increasing calls for competency-based training standards. We aimed to examine the extent to which the procedures plastic surgery residents perform, as represented in case log data, align with 2 core standardized components of plastic surgery GME: ACGME (Accreditation Council for Graduate Medical Education) minimum procedure count requirements and the PSITE (Plastic Surgery In-Service Training Examination). We also examined their alignment with procedural representation at 2 major plastic surgery meetings.

METHODS

Nine categories of reconstructive and aesthetic procedures were identified. Three-year averages for the number of procedures completed in each category by residents graduating in 2019-2021 were calculated from ACGME national case log data reports. The ACGME procedure count minimum requirements were also ascertained. The titles and durations of medical programming sessions scheduled for Plastic Surgery The Meeting (PSTM) 2022 and the Plastic Surgery Research Council (PSRC) Annual Meeting 2022 were retrieved from online data. Finally, test items from the 2020 to 2022 administrations of the PSITE were retrieved. Conference sessions and test items were assigned to a single procedure category when possible. Percent differences were calculated for comparison.

RESULTS

The distribution of procedures on plastic surgery resident case logs differs from those of the major mechanisms of standardization in plastic surgery GME, in-service examination content more so than ACGME requirements. Meeting content at PSTM and PSRC had the largest percent differences with case log data, with PSTM being skewed toward aesthetics and PSRC toward reconstructive head and neck surgery.

DISCUSSION

The criteria and standards by which plastic surgery residents are evaluated and content at national meetings differ from the procedures they actually complete during their training. Although largely reflecting heterogeneity of the specialty, following these comparisons will likely prove useful in the continual evaluation of plastic surgery residency training, especially in the preparation of residents for the variety of training and practice settings they pursue.

A SWOT Analysis of Hot Topics in Plastic Surgery Resident Education: Consensus From the ACAPS 10th Annual Winter Meeting

Background

With the aim of facilitating a critical self-reflection on how to align plastic surgery education with making excellent plastic surgeons, a rotating small-group session followed by live interactive audience polling was used to perform a SWOT (strengths, weaknesses, opportunities, and threats) analysis at the 10th Annual American Council of Academic Plastic Surgeons Winter Meeting.

Methods

The final day of the conference included a 3-hour session of rotating small groups followed by live interactive audience polls discussing the following six relevant educational topics: the Plastic Surgery Common Application and resident selection, aesthetic surgery education, leadership development and business education, embedded fellowships and focused training, mentorship, and faculty retention.

Results

A total of 60 individuals participated in the activity. A SWOT analysis was successfully performed for each educational topic, and a minimum of four opportunities were identified per topic to help guide future endeavors. Examples of opportunities include releasing recommendations for the implementation of holistic review; developing formal guidelines for aesthetic surgery education in residency via collaboration between ACAPS, American Society of Plastic Surgeons, and The Aesthetic Society; creating extended focused elective rotations; integrating business education into formal curricula for all training levels; enforcing transparency regarding position expectations and offerings including salary, call schedule, and current challenges; and more.

Conclusion

The results of this study will help guide future initiatives by the ACAPS to improve resident education and academic retention.

Evaluation of a Plastic and Reconstructive Surgery Resident Non-surgical Cosmetic Clinic Experience

INTRODUCTION

An important component of plastic surgery residency training is independent cosmetic patient management. A resident cosmetic clinic was created at Oregon Health & Science University in 2007 to expand this experience. The cosmetic clinic has traditionally been most successful in offering nonsurgical facial rejuvenation with neuromodulators and soft tissue fillers. This study focuses on the demographics of the patient population and the treatments provided over a 5-year period and compares this experience to those of the same program's attending cosmetic clinics.

METHODS

A retrospective chart review of all patients seen at Oregon Health & Science University's Plastic and Reconstructive Surgery Resident Cosmetic Clinic between January 1, 2017, and December 31, 2021 was performed. Patient demographics, type of injectable received (neuromodulator versus soft tissue filler), location of injection, and additional cosmetic procedures were evaluated.

RESULTS

Two hundred patients met the study criteria, which included 114 seen in the resident clinic (RC), 31 seen in attending clinic (AC), and 55 patients seen in both. A primary analysis compared the two groups seen in the resident and attending only clinics. The average age of patients seen in the RC was younger, 45 versus 51.5 (P ≤ 0.05). There was a trend toward more patients in the RC being involved in healthcare as compared to those patients seen in the AC, but this difference was not found to be statistically significant. The median number of neuromodulator visits in the RC was 2 (1, 4) versus 1 (1, 2) in the AC (P ≤ 0.05) The most common location for neuromodulator injections in both clinics was the corrugators.

CONCLUSIONS

Patients in the resident cosmetic clinic were younger females, most receiving neuromodulator injections. No statistically significant differences were identified in patient population, injections received, and location of injections between the two clinics, indicating a similar trainee skill set and patient care plan between the two clinics.

Reviewing ACGME Plastic Surgery Fellowship Case Logs: Is Surgical Experience Increasing?

INTRODUCTION

Over the last decade, there has been a 32% decrease in independent plastic surgery fellowships. The growing prevalence of 6-year integrated plastic surgery residencies, duty hour restrictions, and new subspecialty training fellowships for general surgeons have changed the training experience of plastic surgery fellows.

METHODS

A retrospective review of the Accreditation Council for Graduate Medical Education (ACGME) case logs for graduating fellows of independent plastic surgery fellowships in the United States was conducted from 2011 to 2019. A linear regression analysis was conducted for each case log code and category, and a 95% level of confidence was assumed (α = 0.05).

RESULTS

In 2011, 141 residents from 69 programs graduated with an average of 1469.7 cases. In 2019, 84 residents from 47 programs graduated with an average of 1952 cases. Index procedures significantly increased overall during the 9 y (P < 0.001). Categorical cases increased in esthetics (P < 0.001), including facelift, browlift, blepharoplasty, and more. Categorical cases increased in reconstructive surgery (P < 0.001), including treatment of deformities of the skin, lower extremities, and trunk, nerve decompression, and hand reconstruction. In breast procedures, an increase was seen in the reduction of mammoplasty, reconstruction, and treatment of other breast deformities. In head and neck procedures, an increase was seen in resection of head and neck neoplasms and secondary cleft lip repair. Decreases in procedural numbers were seen in primary cleft lip repair and hand reconstruction by primary closure.

CONCLUSIONS

Despite a 32% decline in the number of independent plastic surgery fellowships over the last 9 y, plastic surgery fellows are obtaining significantly more surgical experience, both in esthetic and reconstructive surgery.

"Preparing for a Crowded Cosmetic Market: A Resident Training Model for Minimally Invasive Cosmetic Treatments"

SUMMARY

Patient demand for nonsurgical and minimally invasive cosmetic treatments has increased in recent years, resulting in a growing market that is particularly vulnerable to specialty creep. Despite this growing demand, nonsurgical cosmetic training for plastic surgery residents is often inconsistent and challenging. In order to ensure the continued safe and effective delivery of nonsurgical cosmetic care by board-certified plastic surgeons, it is critical to implement standardized training models for plastic surgery residents. In this Special Topic article, we describe our experience with a resident-run clinic training model that incorporates graduated autonomy, volunteer patient recruitment, and grant-based industry support, which has been successfully implemented at our institution for the last 6 years. The article provides a framework for a resident educational model and addresses common obstacles in resident cosmetic training. We additionally provide recommendations for patient recruitment, optimizing clinic workflow, and the management of patient complications.

A Systematic Review on the Implementation and Educational Value of Resident Aesthetic Clinics

BACKGROUND

Resident aesthetic clinics (RACs) provide plastic surgery residents with hands-on aesthetic surgery training. Although RACs have demonstrated successful surgical outcomes without compromising patient care, few studies have evaluated the efficacy or educational value of RACs to increase resident confidence and competence in procedures. In addition, clinic structures vary widely among institutions, with each clinic offering a unique patient volume, caseload, and degree of resident autonomy that impacts the clinic's educational value. This systematic review identifies existing RAC practices, compares clinic structures, and proposes a curriculum framework to maximize educational value for residents.

METHODS

Following PRISMA guidelines, we performed a systematic review of plastic surgery residency training program RACs. We queried PubMed, Embase, and Web of Science from January 2000 to April 2020. Eligible articles were original articles that discussed RAC structure and educational value. Data abstracted included details on clinic structure (eg, volume, location, cost, clinic operations) and trainee-perceived educational value (eg, resident satisfaction, resident confidence in procedures).

RESULTS

Of 1199 identified publications, 10 met the inclusion criteria: 6 single-site studies and 4 national survey studies. Among the single-site studies, annual volumes ranged from 22 to 68 patients/year and 35 to 81 cases/year. Resident aesthetic clinics were all staffed by full-time academic faculty (100%); one-third also were staffed by adjunct faculty and 17% also by community plastic surgeons. Resident involvement varied by hours in clinic and degree of autonomy. The survey studies found that RACs increase resident confidence and competence in performing aesthetic procedures and identified critical challenges to RAC implementation (eg, financial viability, continuity of care) that limited RAC educational value. Based on this review's findings, we propose a 6-step RAC curriculum framework for training programs seeking to establish an RAC and maximize the clinic's educational value.

CONCLUSIONS

Resident aesthetic clinics are increasingly important for providing plastic surgery residents with aesthetic training. Patient and case volume, degree of resident autonomy, and clinic attending physicians are critical determinants of the educational value of RACs. We hope our findings can aid plastic surgery training programs in better organizing educational and sustainable RACs.

A Systematic Review on the Current Trend In Nonsurgical Aesthetic Training for Knowledge, Skill, and Professional Identity Formation

BACKGROUND

Non-surgical aesthetics is a rapidly growing healthcare domain and lacks pedagogically sound education and training programs. The trainee physicians often participate in short courses which are outside of the scope of an existing postgraduate training program to acquire the necessary knowledge and procedural skills. However, such training programs lack values and interests that shape critical thinking and holistic decision-making, often referred to as professional identity.

OBJECTIVES

This systematic review aims to analyse current trends in non-surgical aesthetic clinical education to form knowledge, skills, and professional identity.

METHODS

A detailed literature search was conducted in nine databases; PubMed [United States National Library of Medicine (NLM), Bethesda, MD], Cochrane (Wiley, Hoboken, NJ), Centre for Reviews and Dissemination [(CRD) University of York, York, United Kingdom], and Google Scholar (Google, Mountain View, CA) for relevant studies published between January 2010 and December 2020, with an update in September 2021.

RESULTS

Fifty-five articles were identified through electronic searches, amongst which forty were selected following a review of the abstracts. Sixteen articles were identified as the best evidence for the detailed and iterative review based on their relevance and fit to the inclusion criteria. Unfortunately, none of the included studies designed their questionnaire based on the Kirkpatrick Model, which is best known for analysing and evaluating the results of training and educational programs.

CONCLUSIONS

This systematic review provides valuable insight into graduate professional identity formation and graduates' readiness for independent clinical practice. Therefore, particular consideration should be given to incorporating these triggers when developing evidence-based postgraduate curricula for non-surgical aesthetics.

A Systematic Review of Aesthetic Surgery Training Within Plastic Surgery Training Programs in the USA: An In-Depth Analysis and Practical Reference

BACKGROUND

The importance of aesthetic surgery exposure for plastic and reconstructive trainees has been recently validated by the expansion of case requirements for aesthetic procedures from 50 to 150, as well as resident-driven desire for increased cosmetic exposure throughout training. We aim to systematically review the literature at a national level to report on overall trends in aesthetic surgery training within PRS residencies.

METHODS

A literature search of PubMed, Embase, and Scopus identified all English articles published in the USA between 2000 and 2020, using a combination of "aesthetic surgery", "cosmetic surgery", "plastic surgery", "residency and internship", "education", and "training."

RESULTS

Our initial search resulted in 415 articles. After review of inclusion and exclusion criteria, in addition to cross-referencing, 41 studies remained, including 15 studies discussing resident and/or program director surveys, eight studies discussing teaching methods, sixteen studies discussing dedicated resident clinics, four studies discussing cosmetic/aesthetic fellowships, three studies discussing cosmetic practice patterns, and eleven studies discussing patient outcomes.

CONCLUSION

Current literature demonstrates that there are gaps in aesthetic surgery training for PRS residents in the USA, including facial and neck surgeries and non-surgical interventions. Resident clinics have clear benefits for resident education, without sacrificing patient outcomes. Residency programs should consider the development of a resident cosmetic clinic and/or dedicated cosmetic center to increase surgical exposure and increase trainee comfort in providing this subset of procedures. Published literature is limited in consistency of methods of evaluation, and further in-depth analysis of case volume and diversity at training programs within the USA and internationally is indicated.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

An ACGME-based comparison of neurosurgical and orthopedic resident training in adult spine surgery via a case volume and hours-based analysis

OBJECTIVE

In a 2014 analysis of orthopedic and neurological surgical case logs published by the Accreditation Council for Graduate Medical Education (ACGME), it was reported that graduating neurosurgery residents performed more than twice the number of spinal procedures in their training compared with graduating orthopedic residents. There has, however, been no follow-up assessment of this trend. Moreover, whether this gap in case volume equates to a similar gap in procedural hours has remained unstudied. Given the association between surgical volume and outcomes, evaluating the status of this disparity has value. Here, the authors assess trends in case volume and procedural hours in adult spine surgery for graduating orthopedic and neurological surgery residents from 2014 to 2019.

METHODS

A retrospective analysis of ACGME case logs from 2014 to 2019 for graduating orthopedic and neurological surgery residents was conducted for adult spine surgeries. Case volume was converted to operative hours by using periprocedural times from the 2019 Medicare/Medicaid Physician Fee Schedule. Graduating residents' spinal cases and hours, averaged over the study period, were compared between the two specialties by using 2-tailed Welch's unequal variances t-tests (α = 0.05). Longitudinal trends in each metric were assessed by linear regression followed by cross-specialty comparisons via tests for equality of slopes.

RESULTS

From 2014 to 2019, graduating neurosurgical residents logged 6.8 times as many spinal cases as their orthopedic counterparts, accruing 431.6 (95% CI 406.49-456.61) and 63.8 (95% CI 57.08-70.56) cases (p < 0.001), respectively. Accordingly, graduating neurosurgical residents logged 6.1 times as many spinal procedural hours as orthopedic surgery residents, accruing 1020.7 (95% CI 964.70-1076.64) and 166.6 (95% CI 147.76-185.35) hours (p < 0.001), respectively. Over these 5 years, both fields saw a linear increase in graduating residents' adult spinal case volumes and procedural hours, and these growth rates were higher for neurosurgery (+16.2 cases/year vs +4.4 cases/year, p < 0.001; +36.4 hours/year vs +12.4 hours/year, p < 0.001).

CONCLUSIONS

Graduating neurosurgical residents accumulated substantially greater adult spinal case volumes and procedural hours than their orthopedic counterparts from 2014 to 2019. This disparity has been widened by a higher rate of growth in adult spinal cases among neurosurgery residents. Accordingly, targeted efforts to increase spinal exposure for orthopedic surgery residents-such as using cross-specialty collaboration-should be explored.

Financial Analysis of Operating a Resident Aesthetic Clinic

BACKGROUND

Recent changes to the plastic surgery residency training requirements along with a general call for expanded education in cosmetic surgery have encouraged many institutions to incorporate resident aesthetic clinics into their curricula. Although the safety and satisfaction rates of resident aesthetic clinics have been well-studied, their financial viability has not. This study reviews the financial viability of the resident aesthetic clinic at the authors' institution through a cost analysis.

METHODS

Billing data were analyzed for all patient visits to the resident aesthetic clinic of the authors' institution during calendar year 2018. Data were extracted, including type and anatomical location of each procedure, charges collected, and supplies used. A financial analysis was performed based on fixed and variable costs and gross revenue.

RESULTS

A total of 100 unique patients were seen in the clinic over a 1-year period, resulting in 53 operations. This included 15 face, four breast, and 34 body contouring procedures. In addition, 160 cosmetic injections were performed. The gross revenue was $69,955 and the net revenue was $36,600.

CONCLUSIONS

The resident aesthetic clinic at the authors' institution proved to be financially viable. The authors encourage other institutions to more closely examine the financial state of their resident aesthetic clinics as well. Furthermore, the authors hope that this analysis demonstrates to other programs that, with certain practice models, cost should not be a barrier to initiating and maintaining this valuable training tool.

Consumer Awareness and Comfort with Resident-run Cosmetic Clinics: A Crowdsourcing Study

Background:

Resident cosmetic clinics (RCCs) are the training modality of choice among both residents and faculty and are a mainstay at most residency programs.^1–4 Despite this, knowledge of RCCs among plastic surgery consumers remains untested. We hypothesize that the public would be aware of and receptive to RCCs.

Methods:

Participants with prior cosmetic procedures or interest in future cosmetic procedures were recruited using Amazon Mechanical Turk and asked to complete a survey in September 2020. First, prior awareness of RCCs was assessed. After a brief description of RCCs, perceptions of safety and preferences for care were assessed.

Results:

After screening for quality, 815 responses were included. Forty-five percent of consumers were aware of RCCs. Seventy-six percent of consumers believed that RCCs were just as safe as attending clinics and 65% were comfortable receiving care from fourth-year residents or higher. Belief in RCC safety was associated with 4.8 times higher odds of feeling comfortable receiving care at an RCC [95% confidence interval (3.3–7.1), P < 0.001]. When given a hypothetical choice between residents and attendings in two scenarios, 46% of consumers chose residents for abdominoplasty and 60% chose residents for Botox injections. Belief in RCC safety was associated with choosing a resident or being indifferent in both scenarios.

Conclusions:

Consumer preference regarding RCCs has largely been untested. This study shows that belief in RCC safety influences consumers’ perceived comfort with receiving care at an RCC. This knowledge can help guide RCC practice and maximize learning opportunities for surgeons-in-training.

Global Needs-Assessment for a Postgraduate Program on Nonsurgical Facial Aesthetics

BACKGROUND

Standardizing training and education in nonsurgical facial aesthetic procedures during residency training has long been challenging because majority of the procedures are performed outside the usual teaching hospital settings. Several areas of refinement have been suggested and an increased need for more hands-on training identified in the available literature. Despite the growing demand for nonsurgical facial aesthetics (NSFA), it is yet to be fully integrated into standard postgraduate medical or surgical curriculum.

OBJECTIVES

The objective of this study was to explore the current state and the need for medical education and training of aesthetic clinicians across specialties in a formal postgraduate curriculum.

METHODS

A mixed-method, cross-sectional, online research was conducted among physicians involved in training and practicing NSFA between July 2018 and December 2018. Focus group discussion was conducted to ensure the face and content validity of the survey items.

RESULTS

The total responses collected in the trainer's group was 179 and 496 in the trainee's group. The majority of trainers (95%) and trainees (93.8%) across specialties expressed their opinion for the need of a standard postgraduate course in NSFA. Moreover, more than 55% of them felt that 12 months, with a work-based, blended learning approach, would be most suitable for training and education.

CONCLUSIONS

The survey results have underlined the need for specialized training in NSFA to enable clinicians to pursue independent practice with confidence. The authors recommend the inclusion of evidence-based postgraduate programs on NSFA in higher academic institutions as per their educational curriculum.

Perceptions of Preparedness in Plastic Surgery Residency Training

Supplemental Digital Content is available in the text.

Graduating competent surgical residents requires progressive independence during training. Recent studies in other surgical subspecialties have demonstrated overall fewer opportunities for resident independence due to changes in residency regulations, medical–legal concerns, and financial incentives. A survey study was conducted to assess perceived autonomy and preparedness during plastic surgery residency training and to assess factors affecting autonomy.

Aesthetic Training in Plastic Surgery Residency

Training in aesthetic surgery is a core element in a plastic surgery residency program. Nevertheless, in the past, many studies have shown the lack of resident confidence in aesthetic procedures upon graduation. In recent years, a number of efforts have been made to address this concern, including increasing the required residency aesthetic case requirements and the integration of resident aesthetic clinics to increase exposure and independence in this aspect of training. Numerous studies have been conducted to evaluate the efficacy of these resident-run clinics and have substantiated their value as an important educational tool in residency training and validated their safety in patient care. In fact, survey studies have shown that though residents today show a markedly increased confidence in their training when compared with the past, they still feel there is room for improvement in areas such as facial and minimally invasive surgeries, along with procedures that require higher patient volume to refine. In this article, we review the current state of aesthetic surgery training during plastic surgery residency and discuss future directions in the field.

The Role of Resident-Run Clinics for Aesthetic Surgery Training in the Context of Competency-based Plastic Surgery Education

Resident-run clinics (RRCs) have been suggested as a clinical teaching tool to improve resident exposure in aesthetic plastic surgery education. In exchange for reduced cost aesthetic services, RRCs offer trainees the opportunity to assess, plan, execute, and follow surgical procedures in an independent yet supervised manner. With the transition into a competency-based medical education model involving a switch away from a time-based into a milestones-based model, the role of RRCs, within the context of the evolving plastic surgery curriculum has yet to be determined. To that end, the present study summarizes current models of aesthetic surgery training and assesses RRCs as an adjunct to aesthetics education within the framework of competency-based medical education. Explored themes include advantages and issues of RRCs including surgical autonomy, feasibility, exposure, learners' perception, ethics, and quality improvement. In addition, attention is focused on their role in cognitive competency acquisition and exposure to non-surgical techniques. RRCs are considered an effective educational model that provides an autonomous learning platform with reasonable patient satisfaction and safety profiles.

Graduate perception of cosmetic surgery training in plastic surgery residency and fellowship programs

BACKGROUND

As the demand for cosmetic surgery continues to rise, plastic surgery programs and the training core curriculum have evolved to reflect these changes. This study aims to evaluate the perceived quality of current cosmetic surgery training in terms of case exposure and educational methods.

METHODS

A 16-question survey was sent to graduates who completed their training at a U.S. plastic surgery training program in 2017. The survey assessed graduates' exposure to cosmetic surgery, teaching modalities employed and their overall perceived competence. Case complexity was characterized by the minimum number of cases needed by the graduate to feel confident in performing the procedure.

RESULTS

There was a 25% response rate. The majority of respondents were residents (83%, n=92) and the remaining were fellows (17%, n=18). Almost three quarters of respondents were satisfied with their cosmetic training. Respondents rated virtual training as the most effective learning modality and observing attendings' patients/cases as least effective. Perceived competence was more closely aligned with core curriculum status than case complexity, i.e. graduates feel more prepared for core cosmetic procedures despite being more technically difficult than non-core procedures.

CONCLUSIONS

Despite the variability in cosmetic exposure during training, most plastic surgery graduates are satisfied with their aesthetic training. Incorporation of teaching modalities, such as virtual training, can increase case exposure and allow trainees more autonomy. The recommended core curriculum is adequately training plastic surgery graduates for common procedures and more specialized procedures should be consigned to aesthetic fellowship training.