Plastic Surgery Training Worldwide: Part 1. The United States and Europe

60 Years of Michigan Plastic Surgery

In 1964, the Section of Plastic and Reconstructive Surgery at the University of Michigan opened its doors to future surgeons and leaders in the field. Today, we are celebrating the 60-year history of the program and its significant contributions to the field. Beginning under the leadership of Reed O. Dingman, MD, DDS, the program began with three faculty members and two independent surgical residents. Since that time, it has expanded dramatically to include 24 faculty members and 28 integrated plastic surgery residents. The goals of the program have always been to achieve excellence in all three of our academic missions including clinical care, teaching, and research. Annually, the program sees an average of 35,000 outpatient clinic visits, 4,000 major operations, 200 peer-reviewed publications, $5,000,000 in research spending, and residents who are well trained and highly competitive for fellowships of their choosing every single year. Through scientific collaborations, academic exchanges, and medical missions, the program's influence has spread beyond Michigan, reaching the entire world. In addition to training world-renowned surgeons, Michigan's faculty and graduates have assumed leadership roles in prestigious professional organizations, scientific journals, and research foundations. In this article, we explore the roots of the program and reflect on six decades of impact, innovation, and inspiration.

Geographic Trends of International Medical Graduate Residents and Faculty in US Plastic Surgery Training Programs

BACKGROUND

Of the academic plastic surgeons in the United States, 13.6% are international medical graduates (IMGs). The objective of this study was to identify the countries from which IMGs obtained their medical degrees and the states they matched in. We sought to establish a correlation between IMG faculty and residents in plastic surgery programs.

METHODS

Plastic surgery program Web sites were reviewed. The primary outcome of interest was the country IMG residents had obtained their medical degrees from. Secondary outcomes of interest were program state location, IMG resident postgraduate year, and programs' number of IMG faculty.

RESULTS

One hundred one programs were screened. A total of 39 states were represented; there were 1262 current residents, of which 92 (7.3%) were IMGs. International medical graduate residents received their medical degrees from 46 different countries. The most common countries were England (n = 6 [6.5%]) for IMG residents and Canada (24.5%) for IMG faculty. The most common region represented for residents was South America (n = 44 [47.8%]). The highest proportions of IMGs per total state plastic surgery residents were found in West Virginia (33.3%) and Minnesota (25%); 13.5% and 15.6% of program directors and program chairs were IMGs, respectively. There was a statistically significant difference between the proportion of IMG residents in programs that had an IMG program director versus programs with no IMG program director (P = 0.016). No such statistically significant difference was found between the proportion of IMG residents in given programs with IMG chairs (P = 0.55). There were significantly more IMG faculty in programs with IMG chairs (P = 0.001). The number of IMG faculty was positively correlated to the number of IMG residents in a given program (P = 0.0001, r = 0.39).

CONCLUSION

International medical graduate residents constitute a small but appreciable portion of current plastic surgery residents; the majority have earned their degrees from the South America region. International medical graduate plastic surgery residents are more likely to be recruited to programs that have an IMG program director and a higher number of IMG faculty. International medical graduate faculty have a strong representation in academic plastic surgery, as evidenced by the percentage of IMG program directors and chairs. Programs with IMG chairs had a greater number of IMG faculty.

Evaluation of Research Opportunities and Limitations for Plastic Surgery Residents: An International Survey

BACKGROUND

Conducting research during specialty training provides an opportunity to develop critical thinking and leadership skills along with a better understanding of the scientific literature. However, trainees often find it difficult to undertake research, in the context of labor-intensive surgical training. The aim of this study is to evaluate the research output and limitations of plastic surgery residents in different countries.

METHODS

An international cross-sectional study involving plastic surgery trainees and recent postgraduates from Brazil, Chile, Germany, and the United Kingdom was conducted. A survey inquiring into academic productivity, limitations to conducting research, and working-hours patterns was distributed among eligible participants.

RESULTS

From September to December 2019, 106 surveys were retrieved. Most respondents declared having participated in at least 1 project that resulted in a presentation or publication during their training (90.6% in national presentations, 68% international presentations, 67% in national publications, and 66% international publications). Having completed a previous research fellowship was associated with a statistically higher academic output (P < 0.05). Seventy-nine percent of respondents felt that their participation in research activities would have been greater if limiting factors had been addressed, including lack of time (72.5%) and insufficient supervision and mentoring (55%).

CONCLUSIONS

Optimizing plastic surgery trainees' participation in scientific research is beneficial both for residents and their mentors. Research fellowships can provide an opportunity for academically oriented trainees to further develop their research skills. Protected time and adequate mentoring can help not only to increase residents' research output, but also to recruit the next generation of academic plastic surgeons.

Plastic Surgery Across Continents: A Comparison of Residency Training in Subsaharan Africa and the United States

ABSTRACT

There is a demonstrated need for access to plastic surgical care in low- and middle-income countries worldwide. Recently, there is increasing interest in promoting transcontinental partnerships between academic institutions to improve training opportunities for local surgeons while increasing access to care for patients. Before such programs can be established, it is crucial for US-based surgeons and educators to understand the existing training models in different countries. The aim of this study is to identify the current plastic surgery training model in the College of Surgeons of East, Central, and Southern Africa (COSECSA) group of African nations and compare this to training in the United States. The curricula of 2 accrediting bodies of plastic surgery, COSECSA and the Accreditation Council for Graduate Medical Education of the United States, were compared. Similarities included the length of dedicated plastic surgery training, curriculum content, and final evaluation structure. Differences include training pathways, assessment methodology, and regulation regarding specific competencies, program requirements, and resident benefits. These findings establish a baseline understanding of how plastic surgical training is organized, delivered, and evaluated in Africa, highlight opportunities for educational initiatives, and serve as a foundation for future efforts to develop collaborative partnerships in these communities. Future research will include a survey sent to program directors and plastic surgery attendings in the COSECSA regions to gather additional information.

Plastic surgery training in Ibero-Latin America: A cross-sectional survey study

Ibero-Latin American countries share a common background, similar cultures and historical experiences. Despite this, plastic surgery training presents striking differences among these countries. The aim of this survey-based study was to provide a general overview of plastic surgery training in this region. Results showed a great heterogeneity of training programs which confirms that plastic surgery education is very diverse in terms of requirements, programs content and duration, evaluations and certifying authorities. Standardization of these programs will surely improve the interaction between the different training centers, thus facilitating collaboration and academic exchange. Additionally, this will pave the way for the automatic recognition of degrees for those interested in working in other countries of the region.

Plastic surgery training in the UK: Results from a national survey of trainee experiences

Background

Plastic surgery training in the UK continues to evolve towards an outcome-based rather than time-served curriculum. UK plastic surgery trainees are appointed nationally, and are assessed according to national standards, but training is delivered regionally. This study sought opinion from current UK plastic surgery trainees in order to highlight strengths and shortcomings of the higher surgical training programme.

Method

A cross-sectional study was designed and administered by the UK Plastic Surgery Trainees Association (PLASTA). A questionnaire was distributed to all UK plastic surgery trainees holding a National Training Number, using the REDCap web-based application.

Results

Of the 320 UK plastic surgery trainees, 131 (41%) participated in this survey, with responses from all 12 UK training regions. The most common subspecialty career aspirations for trainees were hand surgery, cleft lip and palate, lower limb and oncoplastic breast reconstruction. The survey highlighted regional variation in teaching programmes, the ability to achieve indicative operative logbook numbers, and training in aesthetic surgery. Of the trainees, 82% expressed a desire to undertake a fellowship within their training, but most did not know whether their deanery would support this. Fifteen per cent of the respondents were currently training flexibly and the majority of these had experienced negative behaviours towards their less than full time working status. Of the respondents, 44% reported stress, 25% reported a lack of autonomy and 17% reported feeling burnt out at work at least once a week. A total of 85% perceived that they did not have access to a mentoring service.

Conclusions

Plastic surgery remains a popular and highly competitive surgical speciality in the UK, and many trainees reported high levels of satisfaction during their training. Aspects of training that could be improved have been highlighted and recommendations made accordingly.

Variation in training requirements within general surgery: comparison of 23 countries

Background

Many differences exist in postgraduate surgical training programmes worldwide. The aim of this study was to provide an overview of the training requirements in general surgery across 23 different countries.

Methods

A collaborator affiliated with each country collected data from the country's official training body website, where possible. The information collected included: management, teaching, academic and operative competencies, mandatory courses, years of postgraduate training (inclusive of intern years), working‐hours regulations, selection process into training and formal examination.

Results

Countries included were Australia, Belgium, Canada, Colombia, Denmark, Germany, Greece, Guatemala, India, Ireland, Italy, Kuwait, the Netherlands, New Zealand, Russia, Saudi Arabia, South Africa, South Korea, Sweden, Switzerland, UK, USA and Zambia. Frameworks for defining the outcomes of surgical training have been defined nationally in some countries, with some similarities to those in the UK and Ireland. However, some training programmes remain heterogeneous with regional variation, including those in many European countries. Some countries outline minimum operative case requirement (range 60–1600), mandatory courses, or operative, academic or management competencies. The length of postgraduate training ranges from 4 to 10 years. The maximum hours worked per week ranges from 38 to 88 h, but with no limit in some countries.

Conclusion

Countries have specific and often differing requirements of their medical profession. Equivalence in training is granted on political agreements, not healthcare need or competencies acquired during training.

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.

How Educational Theory Can Inform the Training and Practice of Plastic Surgeons

It is important to optimize our current learning and teaching models, particularly in a climate of decreased clinical exposure. With technical advancements and clinical care now more accountable, traditional methods of skill acquisition need to be revisited. The past decade has seen changes in plastic surgery curricula. There has also been a shift toward competency-based training programs reflecting the growing emphasis on outcomes-based surgical education. This review explores the role of educational theory in promoting effective learning in practical skills teaching. Key models of educational theory are presented and their application to plastic surgery training to an expert level are highlighted. These models include (1) learning within communities of practice (Lave and Wenger’s theory); (2) the role of the zone of proximal development and importance of the availability of expert assistance (Vygotsky’s theory); (3) skill acquisition and retention (Dreyfus’ and Dreyfus’, and Fitts’ and Posner’s theories); (4) development of expertise after repeated practice and regular reinforcement (Ericsson’s theory); and (5) the assessment of competence (Miller’s triangle). Future plastic surgeons need to possess a thorough understanding of the technical and nontechnical skills required to manage patients effectively. Surgical educators are therefore compelled to develop practical training programs that can teach each of these skills in a safe, learner-centric manner. It is hoped that new approaches to surgical skills training are designed in light of our understanding of educational theory to optimize the training of the next generation of plastic surgeons.

"Resident as teacher" in pediatric surgery: Innovation is overdue in Central Europe

PURPOSE

We set out to evaluate how residents in pediatric surgery learn and how they teach. We hypnotized that European residents learn as much from their peers and teach as much as their fellows worldwide, but that they receive comparably less educational training.

METHODS

An online questionnaire was distributed to the participants of the combined annual meeting for German, Swiss and Austrian residents in pediatric surgery. Participants were asked whom they learn from in different workplace environments (ward, operating room, emergency department), how, when and why they adopt the role of teacher and how they were prepared for this role.

RESULTS

Response rate was 48%. 65 questionnaires were analyzed. Residents stated that they predominantly learn from each other on wards and in the emergency department, less frequently in the operating room. They ranked fellow residents as first or second most important source of instruction. 53% of participants have never had any educational training, for another 33% the instruction was being done by fellow residents without any set curriculum. 93% of the participating residents had no or did not know about any resident as teacher training program available to them. Nevertheless, motivation to teach was stated to be high and interest in educational training was assured.

CONCLUSIONS

Our data delivers evidence that peer teaching during residency is the rule rather than the exception in Central Europe. Educational training however is scarce. Resident as teacher-training programs need to be introduced. Next to local initiatives, we strongly recommend national initiatives powered by regulatory authorities and surgical associations.

TYPE OF STUDY

Research paper.

LEVEL OF EVIDENCE

II.

Meta-analysis of operative experiences of general surgery trainees during training

BACKGROUND

General surgical training curricula around the world set defined operative numbers to be achieved before completion of training. However, there are few studies reporting total operative experience in training. This systematic review aimed to quantify the published global operative experience at completion of training in general surgery.

METHODS

Electronic databases were searched systematically for articles in any language relating to operative experience in trainees completing postgraduate general surgical training. Two reviewers independently assessed citations for inclusion using agreed criteria. Studies were assessed for quantitative data in addition to study design and purpose. A meta-analysis was performed using a random-effects model of studies with appropriate data.

RESULTS

The search resulted in 1979 titles for review. Of these, 24 studies were eligible for inclusion in the review and data from five studies were used in the meta-analysis. Studies with published data of operative experience at completion of surgical training originated from the USA (19), UK (2), the Netherlands (1), Spain (1) and Thailand (1). Mean total operative experience in training varied from 783 procedures in Thailand to 1915 in the UK. Meta-analysis produced a mean pooled estimate of 1366 (95 per cent c.i. 1026 to 1707) procedures per trainee at completion of training. There was marked heterogeneity between studies (I²  = 99·6 per cent).

CONCLUSION

There is a lack of robust data describing the operative experiences of general surgical trainees outside the USA. The number of surgical procedures performed by general surgeons in training varies considerably across the world.