independent pathway

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Anyone know if the independent plastics pathway is going to be phased out or if the amount of fellowship spots will drop precipitously in the near future?

I have no inside knowledge, but doesn't seem likely. In fact, one of the california programs recently dropped its integrated program and became independent-only. In my view, there will always be opportunities for those in general surgery/ENT/orthopedics/etc to do 3 years of plastic surgery training. They may also consider just doing hand/aesthetic/micro fellowships, though these may be difficult to get without prior plastic surgery training (except hand in the case of ortho residents or aesthetics for those with ENT training). It may take longer than the integrated route, but plenty of surgeons still opt for the dual-residency pathway.

That's good to know. I wasn't sure with all the talk of the increase in integrated residency programs in vascular, thoracic, etc.

Originally Posted by XCdude

Anyone know if the independent plastics pathway is going to be phased out or if the amount of fellowship spots will drop precipitously in the near future?

For a few reasons I think that the long-term trend will be to decrease the number of independent training positions.

The biggest reason imo is the transition to 3 years for all plastic surgery residencies. That means for the independent pathway, trainees are in the pipeline for up to 10 years before doing any fellowship training. Applicants from the best general surgery programs typically have research years built in to their training and the overall length of training is just getting too long. There was a drastic reduction in the number of independent applicants, and the quality of independent applicants immediately following the implementation of the 3 year pathway.

If you look at the most recent data for the independent match on the sfmatch website, the most telling stat imo is the total number of positions offerred in the independent match. It is an all-time low even as the number of programs participating remains relatively stable. I suspect that this number will decrease at an accelerating rate, and we will see a reduction in the number of programs participating in the independent match. Once an independent program decides to make the switch, there can be a lag time of 2-3 years as all of the administrative ducks are lined up. Since going to a 3 year residency in 2010, we are just seeing the beginning of an accelerating reduction in independent training positions.

There has traditionally been a belief that independent residents are better managers, better technically, and are more likely to pursue a career in academics than integrated trainees. All of these things may be true but its an apples to oranges comparison. An apples to apples comparison is comparing today's quality/profile of independent applicants with those of 10 years ago. With all of the work-hours changes, the incredible reduction in autonomy, the emphasis on laparoscopy, and ever evolving specialization of general surgery, the perceived traditional strengths of the independent pathway applicants are just not there anymore. 10 years ago general surgery chief residents were essentially junior attendings who did major cases on their own without any attending present. Now we are seeing chief general surgery residents who are doing more training, not because they are necessarily interested, but because they don't feel comfortable going out on their own yet. This represents an incredible evolution in the general surgery "product". The advantages that we once had with independent applicants are simply not there anymore.

Cost is a factor in this discussion as well. It does not make any sense from a systems standpoint to train someone in 2 full residencies to get essentially the same end product. With the focus in healthcare on spending reduction, why are we still paying out for this pathway? There really is no justification for it. Both pathways produce the same product, but one pathway costs 30-60% more.

I do think that the independent pathway will persist for another 10-15 years albeit in an increasingly reduced capacity. The reasons are many for this, but I think the most important one is that there are many people in academic plastic surgery who trained in this pathway and believe strongly in it. There are very real disadvantages of an integrated pathway, and those who believe in the indep. pway are quick to point them out. I won't go into those here as this post is already verbose. But I think that there wil continue to be an accelerating reduction in the number of programs with an independent pathway. The future is undoubtedly an integrated one, and we will continue to see that trend.

What an enlightening post igap, thank you for taking the time to write it!!

I think we're starting to see the dam burst. Several programs that were either early Integrated failures (Duke) or longtime holdouts (Indiana) have Integrated programs. I expect to see a substantial number of Independent programs make the switch in the next 3 years. I've heard several "old-school" Plastics chairs say that they're working on changing their institutional funding format now in order to switch (not a quick process). While I don't think the Independent track is going to be gone in ten years, I expect there to be substantially fewer spots.

Originally Posted by maxheadroom

While I don't think the Independent track is going to be gone in ten years, I expect there to be substantially fewer spots.

I get the same feeling at the ACAPS meeting. There will be fewer spots, but I think there will always be some independent programs.