Integrated versus Independent Pathway

[igap]

http://www.ncbi.nlm.nih.gov/pubmed/22743900

Anyone read this? Seems like the independent versus integrated debate continues....

Looks like faculty think that the independent guys are better technicians, but that the integrated guys have better fund of knowledge....

Any thoughts?

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[droliver]

the independent guys are better technicians, but that the integrated guys have better fund of knowledge....Any thoughts?

1. it's pretty intuitive the traditional model are more skilled operators as they're already significantly more experienced when they start residency. A fully trained general surgeon, ENT, or Orthopedic resident starting their 6th year of residency is going to run rings a 4th year integrated resident (who is essentially a junior level resident still) who very likely has never done a case independently at that point. I think this takes a couple years to even out.

2.I think the "fund of knowledge" thing might be true in terms of in-service exam scores and some familiarity on things you might not have seen much in your prior training (hand surgery, peds craniofacial, facial fractures). I think this evens out pretty quickly as you start to read all the time during residency.

In terms of general and applied knowledge, I actually think the integrated residency is significantly less then traditional as it's become more and more of an insular training model. The perspective and mindset of an orthopedist, ENT, or Surgeon is just different in the way they approach plastic surgery versus the superficial experience the integrated residents get in these specialties. (ENT background plastics know their way around the nose better and Orthopedic background guys get the whole hand/wrist/elbow mechanics then I ever will.) I'm afraid some of this traditional broad base of our specialty and the kind of benefits of it is going to be lost with the new models (I think the same of the new CTVS & vascular surgery fast track programs)

 

[igap]

Good points droliver. I think it's interesting that there was no consensus on what the better training pathway is. That would tend to conflict with your assessment that the independent route provided a better education.

Then again, I think that the independent route should, and most likely does, provide a deeper all-around surgical education. There is a lot to be said for completing an entire other surgical residency including a chief year, etc..

It doesn't appear that that the issue of training years was addressed. I have a friend who did a 7 year general surgery residency, and is in the final year of a 3 year plastics residency. He is so burned-out it is sad. No fellowship for him. I think that the length of the independent pathway is a major negative these days since the field has evolved tremendously over time, and fellowship training in plastic surgery is as important as any other surgical specialty. After 10 years of training, these guys just want out, and to get paid.

 

[maxheadroom]

I'm on faculty at a program that has residents in both pathways. The conclusions of the paper are pretty accurate with my experience. The Independent residents are more technically capable (although we frequently have to alter "General Surgery" habits). The Integrated residents definitely have a better fund of knowledge and "feel" for Plastics. Our experience has been that at the end of three years, the product is similar. I typically encourage our Integrated residents to do a fellowship of some sort, just to get more experience in a "niche" area of Plastics. Most of our recent Integrated residents have done one. None of the recent Independent residents have.

Overall, I think we produce competent Plastic Surgeons via both of the pathways.

 

[droliver]

Good points droliver. I think it's interesting that there was no consensus on what the better training pathway is. That would tend to conflict with your assessment that the independent route provided a better education.

Then again, I think that the independent route should, and most likely does, provide a deeper all-around surgical education. There is a lot to be said for completing an entire other surgical residency including a chief year, etc..

I think a lot of these assessments tend to depend on how the model works at any particular institution. It's a real train wreck at some programs for the junior years, where at others it seems to be OK.

Personally, I'm skeptical of the clinical value of junior level plastic surgery rotations, particularly the ones off service. You may get exposed to the "vocabulary" of our specialty sooner in an integrated program, but you really just aren't technically competent enough to do anything at that point in a specialty primarily defined by technique. It's much easier to train highly specialized technical skills to someone who's already trained rather then do it incrementally from a R-1. Particularly for reconstructive microsurgery, that is 1000x easier if you've already done a fair amount of vascular work and exposures rather then trying to learn on the smallest vessels 1st.

OTOH, the didactic parts of the specialty are easier to incorporate with integrated models. Most of this though (hand surgery excepted) is actually not very clinically useful on a day to day basis, as technique is more the defining feature for 99% of what we do and the didactic things we're tested on are disproportionately on obscure classifications of things and weird genetic anomalies. This actually is the opposite from general surgery where pathology, physiology, and patient care are much more important.

I think we can all agree on the fact that the integrated model is far more efficient (important in an era where we'll be paid less and every extra year is costly to lifetime earnings/savings) and the way all programs will be at some point in the future (due to funding issues). I bet there are almost no traditional spots left within 10 years

 

[PlastikeInfo]

I think a lot of these assessments tend to depend on how the model works at any particular institution. It's a real train wreck at some programs for the junior years, where at others it seems to be OK.

Personally, I'm skeptical of the clinical value of junior level plastic surgery rotations, particularly the ones off service. You may get exposed to the "vocabulary" of our specialty sooner in an integrated program, but you really just aren't technically competent enough to do anything at that point in a specialty primarily defined by technique. It's much easier to train highly specialized technical skills to someone who's already trained rather then do it incrementally from a R-1. Particularly for reconstructive microsurgery, that is 1000x easier if you've already done a fair amount of vascular work and exposures rather then trying to learn on the smallest vessels 1st

While it cannot be argued that it is easier to teach someone highly specialized technical skills who has already been consistently operating for several years, it would be strange for any integrated program to throw very junior residents into a flap dissection/vascular anastomosis without having a significant background in previous plastic surgical procedures, rat micro experience, and detailed knowledge of the procedure. In addition, plastics is the perfect place to learn how to sew with huge abdominoplasties, reductions, straight forward ventral hernia's, SOP's, and flap donor sites. What skin do you close nowadays in GenSurg? Port sites? Big open abdominal cases are fewer and fewer, and when they close they could give two cares about how it looks. The closures I have seen in Gen Surg would get the (literally, no joke) needle driver snatched from your hand in most of my attending rooms. Then they throw a couple of deep dermals and then staple the entire incision.

The other major problem with these type of comparisons is that how many PRS residents get a solid operating experience in the first three years on general surgery? I could be unaware of programs that are the exception, but after talking to many PRS residents from many programs across the country in both academic and community, everyone complains that GenSurg is top heavy... especially at the elite programs. So you take a PGY-4 plastics who has not been operating and compare them to General Surgery trained PRS resident that has just come off their heavily operative years. Seems like an unfair comparison.

In addition, Rod Rohrich has said repeatedly that his senior integrated plastic surgery resident's out operate his independent residents routinely and their knowledge base is vastly superior which makes their intra-operative judgement much better (probably because PRS at UTSW is heavy in the junior years). The problem is the bastardization of the integrated model and then people use those bastardized models as the water mark. Does that seem right? What if you placed a pgy4 prs guys who had been on prs for 4yrs against a gensurg resident of comparable training and then make a judgment. Which is why combined (disguised as integrated) programs should go, those 3 years of spending 95% of your time doin g-tube consults, lap chole's, SBO's, lap appy, trauma/colorectal rounding ect, ect, ect... As compared to the 5% of the time that you do a vascular case or open hernia case is so inefficient and a plain waste of time and should be changed. Does not appear to make any sense. The new reason for not breaking away seems to be that we need gensurg for referral and if we break away then we may upset them which would lead to the demise of plastic surgery as we know it. Well it is not happening in Dallas or Baltimore residency programs.

Lastly, here is a uselss n=1. We had a gsurg pgy-5 on chief trauma call interested in plastics when a forearm laceration came in with laceration of radial and ulnar artery. The pgy-3 (just off of rat micro) operated that guy under the table in vessel repair, that guy was so heavy handed it was hard to watch. The details that are important in plastics are just not important to many GenSurg guys. I recall several times being told, "don't do that, this is not general."

OTOH, the didactic parts of the specialty are easier to incorporate with integrated models. Most of this though (hand surgery excepted) is actually not very clinically useful on a day to day basis, as technique is more the defining feature for 99% of what we do and the didactic things we're tested on are disproportionately on obscure classifications of things and weird genetic anomalies. This actually is the opposite from general surgery where pathology, physiology, and patient care are much more important

I definitely do not have your experience, but I would think that experience and didactic knowledge makes you a good plastic surgeon. Not mention pass your boards.