A Qualitative Survey Study of United States Burn Units: Pathways to a Career in Burn Surgery

Plastic Surgery in Burn Care: A Call for Enhanced Burn Surgery Training Within Plastic Surgery Residency Programs

ABSTRACT

A 10 year cohort of patients admitted to a verified burn unit were analyzed to assess the role of plastic surgeons in the operative management of those patients. All 3843patients were admitted during this study period. Of these, 1509 of those patients underwent surgical procedures. Plastic surgeons performed 658 operations on these patients, including acute and delayed reconstruction of hand and facial burn injuries. In this population, plastic surgeons played a critical role in acute and reconstructive burn injuries in anatomically complex areas. This series illustrates the need for plastic surgery training in burn care.

Who manages burn injuries in children? A program director survey evaluating burn training during pediatric surgery fellowship

PURPOSE

Burn is one of the leading causes of injury and death in children. Currently, the Residency Review Committee does not require general surgery residents to rotate on a burn service. With many trainees no longer receiving burn training during residency, we sought to evaluate the exposure to burn management in pediatric surgery training programs.

MATERIAL AND METHODS

An electronic survey was sent to program directors at accredited pediatric surgery training programs (56) during the 2020 academic year. Case log reviews were performed for 2005-2019. Descriptive statistical analysis was performed.

RESULTS

Thirty-six program directors participated in the survey (64%), and 56% reported having an inpatient and outpatient component for burn management. Nearly 20% of program directors reported having no burn management at their institution. Fifty-four percent of responding programs had fellow participation in burn management. Over a fifteen-year period, case logs identified a median of 0-2 burn cases logged each year for graduating fellows. Logistically, 65% of burn centers relied on general pediatric surgeons for management.

CONCLUSION

Pediatric surgery trainee involvement in burn management varies with many programs offering no designated burn training. Increasing exposure to pediatric burn management during training is needed to provide improved care for this patient population.

LEVEL OF EVIDENCE

III, Retrospective Review.

The Impact of Plastic Surgery Volume on Inpatient Burn Outcomes

BACKGROUND

Acute burn care involves multiple types of physicians. Plastic surgery offers the full spectrum of acute burn care and reconstructive surgery. The authors hypothesize that access to plastic surgery will be associated with improved inpatient outcomes in the treatment of acute burns.

METHODS

Acute burn encounters with known percentage total body surface area were extracted from the National Inpatient Sample from 2012 to 2014 based on International Classification of Diseases, Ninth Edition, codes. Plastic surgery volume per facility was determined based on procedure codes for flaps, breast reconstruction, and complex hand reconstruction. Outcomes included odds of receiving a flap, patient safety indicators, and mortality. Regression models included the following variables: age, percentage total body surface area, gender, inhalation injury, comorbidities, hospital size, and urban/teaching status of hospital.

RESULTS

The weighted sample included 99,510 burn admissions with a mean percentage total body surface area of 15.5 percent. The weighted median plastic surgery volume by facility was 245 cases per year. Compared with the lowest quartile, the upper three quartiles of plastic surgery volume were associated with increased likelihood of undergoing flap procedures (p < 0.03). The top quartile of plastic surgery volume was also associated with decreased odds of patient safety indicator events (p < 0.001). Plastic surgery facility volume was not significantly associated with a difference in the likelihood of inpatient death.

CONCLUSIONS

Burn encounters treated at high-volume plastic surgery facilities were more likely to undergo flap operations. High-volume plastic surgery centers were also associated with a lower likelihood of inpatient complications. Therefore, where feasible, acute burn patients should be triaged to high-volume centers.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Plastic surgical trainees' perspectives toward burn surgery in Australia and New Zealand: Changes in the last 17 years?

INTRODUCTION

An emerging amount of literature emphasises the ever-growing shortage of burn surgeons worldwide. Despite burn surgery being a fundamental competency in the Australia and New Zealand plastic and reconstructive surgery training curriculum, a perceived lack of interest amongst trainees exists. The aim of this study was to investigate Australasian plastic surgery trainees' interest in burn surgery as a career and compare with the Brown and Mills survey in 2004.

METHODS

An electronic survey was distributed to all Australian and New Zealand plastic and reconstructive surgery trainees during the March 2021 registrar trainee conference. This anonymous survey was adapted from the original survey conducted by Brown and Mills in 2004, with additional questions to determine the perceived importance of burns surgery as a subspecialty of plastic and reconstructive surgery, and to elicit possible solutions to the issue of workforce shortage. A reminder email was sent one month following the conference to improve the response rate. The survey was hosted by Survey Monkey (San Mateo, California, USA).

RESULTS

The survey was distributed to all 121 trainees and 71 (58.7%) responded. An increase in interest amongst trainees in pursuing a career in burn surgery was found, with 34 trainees (48.6% of respondents) interested, mostly on a half time or sessional basis. The three most common barriers to practising burn surgery remain unchanged, and were nature of burn operations, nature of burn care and on-call commitments; inadequacy of exposure or training ranked fourth. We found a strong overall response that burn surgery and burn care remained an important component of plastic and reconstructive surgery.

DISCUSSION

Inadequate exposure or training has evolved to present a bigger barrier in this study compared to a similar study conducted 17 years ago. Burn units and training bodies may offer additional job placements to address these feelings of insufficient exposure. Facilitating employment of burn surgeons on a half-time or sessional capacity is a sustainable model, and will arguably improve clinical service provision. Strong and early mentorship and allocation of commensurate resources and funding will help to address the high workload.

CONCLUSIONS

Interest in burn surgery has improved over the last 17 years and the most common deterrents persist, namely nature of burn operations, nature of burn care and on-call commitments. However, many of these issues are modifiable or amenable to change. The opportunity exists for relevant stakeholders to address some of these concerns raised, and thereby addressing the issue of burn surgeon shortage.

The Impact of Fellowship Training in Academic Plastic Surgery

BACKGROUND

The competitive nature of an academic plastic surgery career has contributed to an increase in sub-specialization. The aim of this study is to assess the benefits of subspecialty fellowship training to pursue a career in academic plastic surgery.

METHODS

A cross-sectional study was conducted of all current academic plastic surgeons (APSs) participating in Accreditation Council for Graduate Medical Education-certified residency programs. Online faculty website listings were used to collect their demographics, training and practice characteristics, academic rank and leadership positions, and research productivity.

RESULTS

A total of 927 APSs met the inclusion criteria, of which 70.2% had undergone fellowship training, with an overall significant increase in fellowship-trained surgeons within the last 10 years (odds ratio [OR], 1.66; P = 0.0005). Hand training was the most common fellowship (35.6%), followed by craniofacial (32.0%) and microsurgery (28.1%). Fellowship training was more prevalent among younger (48.7 vs 53.5 years, P < 0.0001), White (67.8%), and non-White (77.4%, P = 0.0058) APSs who had received either integrated (67.1%) or independent (81.8%, P < 0.0001) plastic surgery training and are currently working in a department (OR, 1.44; P = 0.028). Fellowship training was shown to influence academic rank (associate professor: OR, 1.68 [P = 0.0073]; full professor: OR, 0.58 [P = 0.0008]), leadership position (fellowship director OR, 10.09; P < 0.0001) and research productivity (publications: 26 vs 16.5; P = 0.0009). In addition, fellowship attainment did not correlate with the size of the employing academic program, population of the city of practice, or being a residency director or chair.

CONCLUSION

The majority of APSs have undergone fellowship training, and there is very strong evidence supporting its impact in current entry and advancement in academic plastic surgery.

Practice Diversity and Burn Center Growth: A 10-Year Profile of a State's Only Burn Center

BACKGROUND

Growth and sustainability of burn practices can be impaired by irregular patterns of patient presentations, resulting in uneven utilization of facilities and staff. Burn care itself may not engage the full capacities of members of burn care teams. To address these problems, we organized a burn and reconstruction center to provide statewide acute care as Mississippi's only burn unit, to fully integrate reconstructive surgery into management of burn patients, and to diversify practice based on plastic surgery scope of practice. The first 10 years of this unit were reviewed to evaluate the performance of this scheme.

METHODS

Burn admissions to and surgical procedures at this unit between July 2009 and June 2019 were analyzed to quantify acute burn care, secondary reconstructive burn care, and categories of practice growth.

RESULTS

The unit admitted 5469 acute burn patients with a mortality rate of 1.49%. Comparing year 10 to year 1 of practice, acute burn admissions increased 58%. Total operations increased 276%. Acute burn procedures increased 176%. Secondary burn procedures increased 405%. Nonburn procedures increased 352%, with the subset of nonburn hand surgery increasing 1062%.

CONCLUSION

Acute burn admissions and procedures increased over this period, but greater growth was seen in secondary burn procedures and nonburn procedures, especially hand cases. Expansion of practice into areas within the overall skill sets of burn team members was an effective growth strategy.

Interdisciplinary Representation of Burn Surgery Journal and Society Leadership

Burn care is a complex craft that requires an interdisciplinary approach. It includes a diverse array of specialty providers to provide holistic, specialized care to burn victims. This study aims to evaluate the diverse array of subspecialties involved in burn surgery journal and society leadership. A cross-sectional study was conducted in July 2019 by examining the characteristics of society and journal leaders. Current governance and committee members of the American Burn Association (ABA) and International Society of Burn Injuries (ISBI) were determined, as well as the editors of five major burn journals. Information gathered included occupation, advanced degrees obtained, and type of residency training. Of 384 editorial board members identified, 76% were physicians (n = 291), with specialties including burn surgery (n = 208, 54%) and anesthesiology (n = 22, 6%). Among nonphysicians (n = 78, 20%), 76% were medical researchers (n = 59), 8% physical therapists (n = 6), and 5% nurses (n = 4). Looking at ABA and ISBI governance (n = 29), 82% were physicians (n = 24). Nonphysician ABA and ISBI leaders were nurses (n = 2, 7%) and occupational therapists (n = 2, 7%). Of 467 identified ABA and ISBI committee members, half were physicians (n = 244, 52%). There was a wide array of nonphysician occupations among committee members, from nurses (n = 99, 21%), to occupational therapists (n = 25, 5%), and even firefighters (n = 6, 1%). Burn surgery journal and society leadership reflect the interdisciplinary nature of burn care by including an array of subspecialties. Yet, physicians tend to dominate academic burn leadership in comparison to other disciplines, highlighting the need for more nonphysician representation in leadership positions.