Providing adequate training in plastic and reconstructive surgery is fraught with several challenges and this survey was performed to investigate the various shortcomings in training perceived by the trainees.
First, we attempted to define the demographics of the population under study and change in the behavior with certain demographic characteristics including education debt. One of the findings that stood out was that educational debt exceeded $100,000 in more than half of the trainees. Upon analyzing senior residents (PGY 4–9) separately educational debt still exceeded 100,000 in more than half of senior residents. Imahara et al. reported that outstanding educational debt does not influence career plans of trainees [8]. However, that study was limited by a small sample size; the highest amount of debt that they looked at was 100,000 and authors of that study neglected to further categorize the group with a debt of >100,000. We analyzed the population with a debt ranging from <100,000 to >250,000 and divided them in increments of 50,000 and then compared them based on type of training and career goals. In our study independent residents had a higher debt compared to the integrated group of residents. We also noticed a trend towards declining interest in fellowship training and academic career with incremental amount of educational debt. However, there was a statistically significant enhanced interest in pursuing private practice among those reporting higher amount of debt. Moreover in subgroup analysis, upon comparison of residents with debt of <100,000 to residents with a debt of >250,000, residents with higher debt were significantly less interested in fellowship training (p value 0.05) and were found to be more interested in private practice (p value <0.01) at the conclusion of their training.
Second, we found that career plans and goals do not vary by gender. As the number of women pursuing a medical career in surgery continues to increase [9, 10], it is interesting to note that that women’s goals and aspirations do not significantly differ from men. In our study interest in fellowship training as well as academic, private or hospital-based practice were similar between men and women.
Our third interesting observation was related to quality of training. Our findings validate the common perception that comfort level in subspecialty training is a product of experience and therefore time spent in the respective specialty. For all specialties combined, in our study this averaged out to be 6.4 months for the residents who felt comfortable with their training versus 3 months for the residents who felt that they were least trained in the respective specialty. We looked at craniofacial, burn, hand, aesthetic and microsurgery. Statistical significance was reached for all specialties except microsurgery training (Table 1). Some minor observations related to quality of training that also deserve attention are as follows: 45% of responders of our survey did not have a microsurgery rotation. A plausible explanation of this finding maybe that some programs are structured such that microsurgical cases are simply mixed into the daily caseload without offering a specific rotation. For the programs that are indeed deficient in microsurgical training, simulator training maybe a useful alternative [11, 12]. 33% responders also indicated that they lacked an aesthetic rotation in their training program, which also explains the observation that 53.7% trainees felt that they were least trained in aesthetic surgery. Momeni et al. analyzed the quality of aesthetic surgery training in Germany to investigate how these challenges were met abroad [5]. Their study revealed that problems in providing adequate cosmetic surgery training were a product of three factors i.e., lack of curriculum, private patient population demanding to be operated upon by attending physicians only, dearth of cosmetic surgical procedures at major academic centers. Oni et al. suggested some steps to improve quality of aesthetic surgery training. Authors recommended establishment of senior resident cosmetic clinic, cosmetic surgery rotation including outreach programs to include community plastic surgeons for programs weak in cosmetic surgery, inclusion of online education modules and encouragement to attend national meetings [13].
Fourth, we found that that most residents who are interested in fellowship training are from integrated programs (p value <0.01). In retrospect it may be related to higher educational debt that independent residents carry compared to integrated residents. Residents who reported interest in subspecialty training spent an average of 6, 5, 10 and 5 months in craniofacial, aesthetic, microsurgery and hand surgery respectively during the course of their training. This averages out to be 6.5 months for all specialties combined. Moreover residents with an interest in fellowship training spent an average of 14 weeks in research during the course of their training. Despite the extensive amount of time spent in research we noticed a declining interest in academia. We observed that even though nearly half of the graduates intended to pursue a subspecialty fellowship only one-fifth intended to enter academic career, which is consistent with prior smaller studies [4]. Grewal et al. observed that even though a majority of fellowship applicants indicated an aspiration to practice academic medicine, only one-third remained in full-time academics 5 years after the completion of their subspecialty training [14]. Economic constraints developing as a result of rising health care costs in the United States pose significant challenges for and threats to the survival of academic plastic surgery [15].
Fifth, majority of graduating plastic surgery trainees’ complete residency with inadequate business skills as evidenced by this survey. The ever increasing complexity of the United States healthcare system in conjunction with the competitiveness of the plastic surgery marketplace, demand that residencies begin to address practice development in their training of residents.
Findings of this study should be considered in light of potential study limitations, which are as follows: our online survey did not go through vigorous validation process but rather was based on group consensus. However, we used ‘alternate form’ questions in the questionnaire to ensure reliability. Second, there is a potential for response bias in our study because of nature of the topics addressed in our study and also data was subjectively reported.
The study has several strengths that support the validity of findings and suggest potential for future analyses. First, while there have been surveys of graduating residents [8], to our knowledge data regarding demographics that lead to change in behavior pattern including career plans has not been studied. Second, the survey was structured so that most responses were obtained in the last month of academic cycle 2013 giving junior residents an opportunity to gain experience in plastic surgery prior to responding to the survey. Third, scope of our study including representation from all types and years of training as well as from programs all across US offers a comprehensive national picture of plastic surgery residency training.