Independent vs. Combined/Integrated Programs Future??

[GRABBnSMITH]

I was just wondering what will happen in the future between these training modules. Will the combined programs be shut down and convert to the integrated models or just start acting as independent programs (take trained surgeons instead of med students)?

In other words, what is the number of programs a 4th year medical student can apply to next year- fewer or the same number of programs as this year?



My understanding of the training programs so far, correct me if Im wrong:
Combined: you Match as a 4th year medical student, with a handshake agreement that if you complete 3 years in the General Surgery Dept-(they pay your salary and they can dictate your schedule), you will be allowed to continue in plastics from PGY-4 to PGY-6

Integrated: you match as a 4th year medical student, the plastics program has to pay your salary for the 6 years and also can determine your schedule earlier in your training, incorporating more plastics associated/non Gen-Surg core rotations (ophtho/ENT/Derm/PRS/Burns/Ortho/Hand, etc...) in PGY1-3.

Not to be confused with,
Independent: after completing a full 5 years of GS/ENT/Ortho/Uro/Neuro.... (or a minimum of 3yrs GSurg at the same institution if you are lucky???), you can apply for a plastics fellowship and essentially start as a PGY-4 level plastics resident.

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[Stare Decisis]

My mentor seems to be certain that within 1-2 years the RRC will force programs to either collapse into the integrated or independent training model, with the coordinated programs being eliminated. Not certain how far along this is in the process. Plastic surgery seems to be still searching for the most appropriate way to train future plastic surgeons. Although I do not think this switch will dramatically alter the competitive nature of the plastic surgery match, there seems to be more than enough people interested in PRS to contribute to the trend.

As far the integrated training model goes. Some of the integrated programs are 2+4(the last 4 are all PRS), some programs are pretty close to a 1+5,and others have the 3 years of affiliated rotations then 3 years of PRS. Some integrated programs seem to only be integrated mostly in name without as much thought going into the curriculum.

On another note. Some coordinated programs have stated there is a better operative experience when you spend the entire first 3 years with GS instead of jumping through different "PRS relevant" specialites which lack continuity. Just something to think about.

 

[GRABBnSMITH]

Also, are there any plans that you know of to shut down any of the independent programs in the future?

(I hope not)

 

[CSMORR02]

I think this debate will go on for a while. I think the important thing for applicants to understand is that if for whatever reason the RRC decides to endorse the integrated over the combined route, that it won't "shut" programs down, the programs would just adapt towards compliance.

The PRS RRC is a very strong group, and quite strict, so nearly every PRS program is solid in training by the books or else they wouldn't maintain approval. Most programs CHOOSE to be either integrated or combined. Integration is not necessarily an elite club to which all programs seek to belong. I found most programs "integrated" themselves if they felt that their residents weren't receiving the training they wanted in the first several years of training, or programs with weaker departments of GS, in essence pulling their own back into the control of the PRS dept. I feel most combined programs remain as such if they feel that the junior PRS residents are receiving good GS/subspecialty training and have a good working relationship with the GS folks.

There are positives and negatives to each. Integration likely allows more flexibility in the junior years with more subspecialty rotations and more time on PRS earlier. Combined programs likely allow stronger GS basics training since you are "one of their own" for 3 or so years and really get incorporated into their training model. I think most combined programs also have relationships with GS allowing rotations on PRS and subspecialties as well. I am biased because I am at a combined program, but I found the 3 years of solid GS training invaluable in learning the fundamentals of patient management, surgical skills, and comfort operating in the abdomen, chest, etc (that being said, we also rotated on PRS each year and some subspecialties as well during the first 3 years). I found that since I was essentially a GS resident, for 3 years, that I had much more responsibility and hence privilege than say a rotator from another service, and therefor was taught and allowed to operate as a midlevel GS resident. Because the GS team knew me and trusted me, I was doing mastectomies, colons, lung resections, oncologic cases, bypasses,etc, that were invaluable in preparing for the reconstructive part of our training. That being said, I can imagine that in an integrated model I would have much earlier comfort and knowledge about PRS specifically.

I think you just have to balance the pluses and minuses to each, and largely pick based on the feel for the program and the education you think you want to receive. I think the sexy thing when you are applying is to think about how much PRS you will receive, and superficially doing 5 years sounds great because that is what you are interested in, but also pause to balance the bigger picture and the other aspects of your training. Which path is better remains to be seen. It will be interesting to see how the 1+5 products emerge, not in terms of PRS education (clearly they will be well trained), but also in terms of comfort in terms of management of the sick patient, comfort with intraabdominal and intrathoracic cases, etc. Maybe the GS component of our education is overemphasized, however I think many practicing PRS guys will argue as I do that it would be a shame to move too far away from our roots.

 

[shaunmend]

Nearly every program I've interviewed at so far (I'm currently a 4th year med student on the trail) has quoted that the Plastic Surgery Educational Foundation (or RRC, not sure which) unanimously voted and mandated that all combined/coordinated programs switch to the integrated model by 2012.

From my discussions with program directors, the independent model will never go away because 1) it's a funding issue (only have to pay for 3 years of resident salary instead of 6) and 2) some program directors feel VERY strongly about getting a full general surgery education before moving on.

 

[rongeur]

Integration is not necessarily an elite club to which all programs seek to belong. I found most programs "integrated" themselves if they felt that their residents weren't receiving the training they wanted in the first several years of training, or programs with weaker departments of GS, in essence pulling their own back into the control of the PRS dept. I feel most combined programs remain as such if they feel that the junior PRS residents are receiving good GS/subspecialty training and have a good working relationship with the GS folks.

I don't think this is at all true. The first 1 year GS programs were UMichigan/UPitt then UTSW/Hopkins. It's safe to say those residents weren't getting low grade general surgery education. Conversely it may be true to say that there are some 3+3 programs where the plastic surgery part of the training is not strong enough to merit 1 or 2 more years on service, I suppose.

In most places, plastics decisions are still ultimately subject to the chair of general surgery's approval. It's not surprising that they are not supportive of the idea of losing a bunch of their low-mid level residents as bodies to fill rotation slots.

 

[Stare Decisis]

It is also interesting that many of combined programs where I have interviewed seem to emphasize movement toward an integrated model, while at the same time praising the benefits of the combined model. Has anyone else noticed this?

The smaller programs that move toward integrated could also have a problem with the amount of cases available after you throw several more residents into the mix.I remember visiting a very well known program that appeared to be overflowing with residents to the point of having senior residents just standing or retracting. My initial thought was this could really dilute your operative experience, especially when the attending is also very hands on.

 

[Moravian]

Just a couple of comments.

1. There are some combined programs that have managed to set up a custom curriculum for the GS part of the training but Integrated models have an advantage in that there is more control over the rotation schedule. Personally, I think the GS training, with more emphasis on minimally invasive, and a built in prejudice against plastic residents, does not prepare anyone surgically for the plastic years in either model.

2. Funding can be an issue for either model. There are integrated programs who have general surgery department funding part of the slots for GS years. this probably has something to do with plastics being its own department in some places and a division of surgery in others. Either way, the number of federally funded spots is capped and in order to pay for residents (if one wishes to increase the number of spots or change from one model to another) can be an issue.

3. There is always discussion about the best way to train residents. Changes have been proposed since I started general surgery 11 years ago. The biggest issue I have seen is the advent of the 80 work week. It really has hurt more than helped. Then there is the whole argument of integrated/combined vs independent. And some have proposed models similar to orthopedic surgery or urology. The bottom line is that it doesn't really matter at this point. Integrated or combined, if you match, you match and you make the most out of it.