Integrated vs GS Route

[Spinietzschon]

Unorthodox question here for people who're 'in the know' -

Integrated programs are typically desired over 'traditional' GS(3) and Plastics(3) programs, as far as my limited knowledge knows, because 1) people truly want plastics and don't want to a) deal with b) learn about other types of general surgery, 2) apparently GS for the first 3 years have less desirable hours/workload requirements...? Not sure on that one, and 3) the integrated programs are of greater prestige/stature on resume. Are these correct and pretty much complete reasonings, first of all, or am I mis/under-informed?

Now though, WHAT IF a candidate actually wants to learn GS techniques (i.e. idealistically wants to 'be able' to go to Ghana and do appendix removals and since they have no one else around to attempt it even basic tumor removals for a mission/charity, etc?) Will the candidate 1) learn the basics for a wide variety of surgical techniques to DO them if not actually be certified/licensed (at least not in US anyway) even in an integrated pathway? 2) ...lean enough about these in 3 years of GS before going to Plastics to do it that way (or are you still lacking so much GS knowledge that you STILL couldn't 'do both' even if you're not 'certified/licensed' in a pinch?)

Additionally, if anyone here knows that, (I'll keep to the numbered format) 1) Programs will never let you in b/c plastics in any case is so competitive that no one wants someone that's not actually 100% interested in only plastics in their future, 2) there's a great reason why the practical demands of medicine/life would make you say forGET THAT idealistic crap I don't want to bother with GS and I'm in too much dept etc etc and almost every candidate would be somehow VERY unlikely to actually do any surgery that is not plastic even if they do decide to volunteer abroad, etc etc; or 3) if absolutely necessary because someone is adamant they want to do GS/Surg Onc/other surgery later in life and they decide to change, is plastics so competitive that after you do that for a few years programs will more or less let you 'walk in' and change or is it hard not only personally but academically to get 'both'?

Any other comments/ideas would be great, thanks! Just probing for some early food for thought. Thank you!

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[rongeur]

Unorthodox question here for people who're 'in the know' - Integrated programs are typically desired over 'traditional' GS(3) and Plastics(3) programs, as far as my limited knowledge knows, because 1) people truly want plastics and don't want to a) deal with b) learn about other types of general surgery, 2) apparently GS for the first 3 years have less desirable hours/workload requirements...? Not sure on that one, and 3) the integrated programs are of greater prestige/stature on resume. Are these correct and pretty much complete reasonings, first of all, or am I mis/under-informed?

You're missing the other half of the most important one - people don't want to learn about general surgery... because they want to learn about plastic surgery. It takes four years of residency to learn urology, which is arguably a much narrower field than the full scope of plastic surgery. But 3 is supposed to be enough to teach you to do everything from rhinoplasty to clefts to breast free flaps to hand tendon transfers. People who want a minimal general surgery program think you're going to get a whole lot closer to that ideal skill set with an extra 2 years of experience, cases and reading.

 

[Stare Decisis]

Rongeur has hit the nail on the head. The amount time you spend doing endoscopy, taking the ABSITE, and learning colon cancer staging could be spent doing something that will actually have an impact on your career. Most Plastic Surgery residents do not have a disdain or disrespect for general surgery but just realize we would be better served learning a different skill set earlier on. I would be opposed to doing ACDF's for two-three years as well. Also, general surgery does not care about the plastics residents, they are mostly focused on whether they have enough people for the call pool or to staff undesirable rotations. I would suggest that if you truly want to become proficient at lap appy's, lap hernia's etc... then you should do a full Gensurg residency followed by plastics. This will give you the best educational experience IMHO. Most of the plastics residents that I have known from 3+3 programs admit that the OR experience is minimal and they were not expected to become proficient at any general surgical procedures. General Surgery will also teach you how to take care of patients should you have the need while doing surgery in developing nations. Surgeons with general surgery as their background tend to be much better at managing sick patients than any other surgical subspecialty.

 

[Spinietzschon]

Interesting - I had met up with several surgeons who told me (to effect) "I could teach you all there is to know about xyz surgery in a week and in a month you'd be as good as me, but it'll be 10 years of training before you're allowed to" (as a sort of wry joke)....

I know that one week for every technique is still a daunting amount of time/input and that you'd have to also learn all there is to know about pre/post surgical care and what to do in emergencies etc, but, I admit I'm surprised you all feel 3 years isn't enough to do more basic gen surg techniques (just the basics that are in dire need, remember, not the more challenging or less commonly practiced ones!) - it makes me wonder if 3 is enough for all of plastic surgery or if a fellowship is absolutely essential for responsible practice?

...Does anyone know of any really well reputed sources that clarify different specialization tracks/inter-specializaion? I know my questions may be pretty rudimentary as I've still got a ways to go but the field of plastic and reconstructive surgery is very interesting to me, I'm intimidated at its competitiveness though and really would like a better handle on the field before I try to go prepping for it (haha) or relying on the word of only one or two advisers and one faculty member, etc... Thank you! (PS all specialty literature welcome not only on plastics!)

 

[Valadi]

...Does anyone know of any really well reputed sources that clarify different specialization tracks/inter-specializaion? I know my questions may be pretty rudimentary as I've still got a ways to go but the field of plastic and reconstructive surgery is very interesting to me, I'm intimidated at its competitiveness though and really would like a better handle on the field before I try to go prepping for it (haha) or relying on the word of only one or two advisers and one faculty member, etc... Thank you! (PS all specialty literature welcome not only on plastics!)

Hey. Iserson's Getting into a Residency book does a decent job explaining all the different tracks available out of med school. As for competitiveness, you can google the NRMP's Charting Outcomes in the Match for statistics on who has gotten into what residencies. Otherwise, feel free to pm me as this is really more a pre-med/allo question than PS!

 

[Moravian]

Interesting thread. Here are some thoughts:

1. I can teach you an operation in a week but you'll never be as good as me unless you do that operation all the time. I've been in practice for 4 years now and I keep getting better every year.

2. I am general surgery trained (and boarded as well), but I do very little general surgery. I do mission trips every year and sometimes I help the local general surgeon with some complex cases, but my personal comfort level with doing some abdominal procedures on my own has dropped. I know it might sound a little funny, but I'm a lot more comfortable with taking of a skull and putting it back on again than I am with an appendectomy.

3. Not all plastic programs are created equal. There are some that are integrated and have rotations for plastic surgery residents during the GS years that the GS folks don't do (ophtho, derm, etc.) Some places actually treat the plastics people well and you get to do procedures/operations and some treat you like the redheaded step child. With all the minimally invasive stuff going on now, I'm not sure how valuable general surgery training is for plastic surgeons. As has been mentioned, you do get to learn the ICU and it is very valuable later on.

4. Even within the field of plastic surgery, most people will gravitate towards procedures that they enjoy. I think that mostly because I'm in an Academic practice, I still do a wide variety of operations, but I do way more of some things than others. I only do hand when on trauma call, I don't do any breast, I keep the micro to a minimum and I do no cosmetic. I have partners that do the other things which allows me to concentrate on what I like.

Again, just thoughts....

--M

 

[Stare Decisis]

Interesting thread. Here are some thoughts:

1. I can teach you an operation in a week but you'll never be as good as me unless you do that operation all the time. I've been in practice for 4 years now and I keep getting better every year.

2. As has been mentioned, you do get to learn the ICU and it is very valuable later on.

--M

Moravian,

In regards to teaching an operation within a week, a significant portion of plastic surgery appears to be complex soft tissue rearrangement. Do you think someone could really learn to do a decent complete bilateral cleft lip and palate in a week? Or a cleft rhinoplasty? I have known attending's that have admitted being humbled by some of these procedures. There are some simple procedures that could probably be taught in a week, but overall I think this is an overstatement.

Also, where do you feel the majority of your ICU experience comes into play? Do you manage many patients in the ICU? When I look at other specialties, such as ENT, urology, and even neurosurgery they appear to spend less time in the ICU than plastic surgery. While ICU time is critical (no pun intended), I wonder if it is a bit overkill.

Lastly, many plastic surgeons seem to be aware of the redundancy/limited utility of the amount of gensurg in the average PRS residency. Why is it taking so long to change it?

 

[Moravian]

Moravian,

In regards to teaching an operation within a week, a significant portion of plastic surgery appears to be complex soft tissue rearrangement. Do you think someone could really learn to do a decent complete bilateral cleft lip and palate in a week?

Maybe I should be clearer on my statement. Yes, I could teach a bilateral cleft repair in a week if it was a week filled with cleft repairs. The reality is that bilaterals are rare and challenging for anyone who does them. This does not mean you wouldn't be able to accomplish the repair....it means that it takes years to perfect your technique.

It took around 30 unilateral repairs (as an attending) before I figured out that operation. I teach my technique to my residents and they are able to do it on their own (of course, I'm in the OR assisting) during the second half of their time with me. However, when I go back and look at photos, the lips I do by myself (no resident available) are always better. And it's because it's what I do for a living. There are always little subtleties and nuances that are probably impossible to teach. Cleft rhinoplasties are the same.

For me, it's a lot like playing an instrument. I play classical guitar and it takes me a certain amount of time to learn a new piece depending not only complexity, but on how much time I have to devote to it. Once I "learn" it, it still takes a lot practice to get it up to tempo, with proper voicing, addition of my own interpretation, etc. There are times where it might be months before I pick up a guitar and I'll have trouble getting through a piece I knew fairly well a year ago. The operations I do all the time I'm best at, and the ones I do infrequently may turn out well, but they certainly take more time and are a bit of a struggle.

I had a teacher tell me the guitar is easy to learn how to play, but is very difficult to learn to play well. Surgery may not be as easy to learn as the guitar, but it takes time and devotion to become good at it.

The other big thing is judgment. It's a lifelong process and more important than just being technically proficient.

Also, where do you feel the majority of your ICU experience comes into play? Do you manage many patients in the ICU? While ICU time is critical (no pun intended), I wonder if it is a bit overkill.

I don't manage as many patients as I used to and my "critical acumen" is not as sharp as it once was. My hospital has Intensivists that manage the ICU patients, but you still need to be able to understand what is happening to your patient and contribute to their care. I had an incident last week that I won't go into where my PICU colleagues missed something I though was so obvious I didn't bring it to their intention. In the end, no one was hurt, but it made recovery of the patient more complicated than it should have been.

I have said this before and I will say it again. WHAT YOU DON'T KNOW CAN HURT YOUR PATIENTS. Even cosmetic plastic surgeons are still doctors (as one of the famous TV doctors was reminded a few years ago). We are not just closers of skin and rearrangers of tissue. It can be VERY easy early in your education to dismiss certain things because you don't know how it might be useful later. Learn as much as you can as I can guarantee your going to pull some little tidbit out of your pocket in a time of need that you were sure you didn't need to learn at the time it was taught to you.

Lastly, many plastic surgeons seem to be aware of the redundancy/limited utility of the amount of gensurg in the average PRS residency. Why is it taking so long to change it?

I don't have enough time to go into all the politics and personalities involved with this topic. Plastic surgery training already is different than it was 20 years ago. Change does come slowly and believe me, it's a good thing.

 

[Stare Decisis]

Moravian,

Thank you for your response, I truly took your words seriously. It may be my limited introspection and experience, but to me it seems the way to learn how to take care of plastic surgery patients and there issues, would be to take care of plastic surgery patients and their issues. Yes, some will be in the ICU, some on the floor, and some will be calls from patients discharged from same day surgery, but I would guess directly handling of those issues would best serve your "clinical acumen" for the plastic surgery patients you will be managing. It seems odd to try and convince myself that messing around with vent setting's, drawing ABG's, and doing ostomy care will give me the biggest bang for my educational buck when it comes to taking care of patient's in the future. As I always ask myself, if this were so essential then why are the other surgical specialties not involved in this heavy handed approach to getting abundant amounts of high acuity patient care on gensurg services?

From what I understand, the best ICU's with the BEST outcomes are closed units in which the ICU team is the "last word" on patient care and involvement of other services is not exactly encouraged. This plays out at my own institution where it is not a closed unit, and the ICU/critical care attending's constantly remark at how other services are just dabbling in an area they have no expertise in and it is in the worst interest of the patients. Too many amateur chef's in the kitchen. I agree that what you do not know can hurt your patient, but I wonder if it is what you think you know can actually be more damaging in the long run. It seems plastic surgery is at a breaking point, either the field decides to go all in and do 3-4 years of real critical care/gensurg/patient management and really learn the stuff or we become dedicated to our field of study like many other surgical specialties. Nothing wrong with calling our colleagues for help. It just seems that fence straddling is the least appealing and possibly the most dangerous.

 

[rongeur]

Lastly, many plastic surgeons seem to be aware of the redundancy/limited utility of the amount of gensurg in the average PRS residency. Why is it taking so long to change it?

Most plastic surgery places are still divisions under general surgery. Therefore, the general surgery chairman has final say in residency structure. They are not (to put it mildly) interested in losing the pgy2-3 plastic surgery residents from their current general surgery rotations, as they are invaluable in the pyramidal structure of gen surg residency. In ten years everything will be different. There are and will be more and more places where PRS is a department that answers to themselves, and that changes everything.

 

[maxheadroom]

Most plastic surgery places are still divisions under general surgery. Therefore, the general surgery chairman has final say in residency structure. They are not (to put it mildly) interested in losing the pgy2-3 plastic surgery residents from their current general surgery rotations, as they are invaluable in the pyramidal structure of gen surg residency. In ten years everything will be different. There are and will be more and more places where PRS is a department that answers to themselves, and that changes everything.

Completely wrong. If a program is Integrated, it is under the control of the Plastics Chair & PD. General Surgery has zero say in the administration of the program.

 

[Moravian]

Completely wrong. If a program is Integrated, it is under the control of the Plastics Chair & PD. General Surgery has zero say in the administration of the program.

Word.

Even some combined programs (depending on the program) have rotations set up specifically for plastic surgery residents. I continue to be amazed at some of the authoritarian posts by some of the members who are short of experience.

 

[Stare Decisis]

Completely wrong. If a program is Integrated, it is under the control of the Plastics Chair & PD. General Surgery has zero say in the administration of the program.

This is what initially thought, but from just after talking to several chiefs it appears that interaction between general surgery is more complex than this. When I was on the interview trail one of the Chairman emphatically stated that he did not want to move his residents around too much because his department was reliant upon gensurg for referrals. I don't know how true this is throughout the country. At least I respected his honesty, instead of the "gensurg is great for you in ways you will not appreciate until you older" line. Rohrich said that he would be one of the first programs to transition to 1+5 when it is available. Say what you will about UTSW, but I have never heard they produce lackluster plastic surgeons. During one of the interview dinners, Rohrich (who I would argue has adequate experience) made a great point that the single intern year is opposed without ever being tried in plastics but after having being successfully implemented in other surgical subspecialties. Just a thought.

 

[Moravian]

All programs are different. And you are correct in that the chairs of general surgery do not like to move their residents around. BUT, they have little choice in the integrated model. They can complain as much as they want (God know ours does), but our rotations are for our integrated residents. The negotiations happen above my pay grade, but our priority is our people.

Rod is certainly a big wig in the organization but he also has his detractors (as we all do). And he is certainly not the lone voice in the wilderness. There has been general disagreement about training plastic residents since I first interviewed in medical school. There are still those hold-outs that think there should be a full five years of general surgery training. My feeling is that it should be one way or the other. One being five years of general followed by three years of plastics (and I have my reasons for this that I'm not going into, but if you did 5 years of general, you'd know why), or go to 1 (at most 2) years of general followed by 4 years of plastics.

Please also understand that I'm not trying to belittle, but you don't know what you don't know. Every couple of years I seem to move up through another layer of crap that I never knew existed because I was swimming underneath it. After breaking the surface, there is stuff I never knew existed or didn't really understand how it worked until I got there. On this forum I try to be as honest as possible and share my experience, but some of this is like the matrix. You can't be told. You have to take the red pill.

 

[igap]

Most plastic surgery places are still divisions under general surgery. Therefore, the general surgery chairman has final say in residency structure.

As already noted by another poster, this is incorrect. In fact, divisional status has nothing to do with whether a program is "integrated", or "independent".

There used to be a "combined" model of residency where the training was split into general surgery years and plastic surgery years. This is what was called "3+3", or "4+2", and general surgery usually controlled the residents' training for the first 3 or 4 years and the resident was only under the control of plastics faculty for the last 2 or 3 years. This model no longer exists.

Integrated residencies are entirely run by the plastics program whether that program has divisional status, or departmental status. As an example, the University of Pittsburgh is an integrated plastic surgery residency program, and the entire residency is carefully controlled by the plastics division.

 

[Spinietzschon]

Moravian, sorry to break the thread and please everyone else feel free to ignore/continue as desired, did you get my PM? I might have sent it incorrectly I've not used SDN to contact people much/often...!

 

[maxheadroom]

This is what initially thought, but from just after talking to several chiefs it appears that interaction between general surgery is more complex than this. When I was on the interview trail one of the Chairman emphatically stated that he did not want to move his residents around too much because his department was reliant upon gensurg for referrals. I don't know how true this is throughout the country. At least I respected his honesty, instead of the "gensurg is great for you in ways you will not appreciate until you older" line. Rohrich said that he would be one of the first programs to transition to 1+5 when it is available. Say what you will about UTSW, but I have never heard they produce lackluster plastic surgeons. During one of the interview dinners, Rohrich (who I would argue has adequate experience) made a great point that the single intern year is opposed without ever being tried in plastics but after having being successfully implemented in other surgical subspecialties. Just a thought.

That Chair is a pansy. He needs to cowboy-up and take charge of his residents.

You learn Plastic Surgery by doing Plastic Surgery with Plastic Surgeons. You learn General Surgery by doing General Surgery with General Surgeons. We're getting close to having a true intern year and then four years of dedicated Plastics training.

 

[rongeur]

Even some combined programs (depending on the program) have rotations set up specifically for plastic surgery residents. I continue to be amazed at some of the authoritarian posts by some of the members who are short of experience.

I'm not sure why it's necessary to be rude. You're "correcting" me over things I didn't say.

Even in integrated programs, the plastics chief and program director are both faculty who are under the direct administrative control of the chairman of general surgery. The plastic surgery PD calls the shots on a day to day basis, but I have friends in programs where the PD says that gen surg won't allow them to pull them off more months of GS because they're shorthanded. There are certainly integrated divisional programs where GS is supportive of plastics and will allow them all the integrated rotations they want, but that isn't universal.

 

[maxheadroom]

I'm not sure why it's necessary to be rude. You're "correcting" me over things I didn't say.

Even in integrated programs, the plastics chief and program director are both faculty who are under the direct administrative control of the chairman of general surgery. The plastic surgery PD calls the shots on a day to day basis, but I have friends in programs where the PD says that gen surg won't allow them to pull them off more months of GS because they're shorthanded. There are certainly integrated divisional programs where GS is supportive of plastics and will allow them all the integrated rotations they want, but that isn't universal.

Again, this is total BS. I'm a faculty member at an integrated program. We call the shots on what our residents do. We tell General Surgery which rotations they will be on. When they run shorthanded, that's their problem. Our junior residents are not slaves for the General Surgery service to make sure there is someone to round on the Colorectal-Trauma patients. Any program that prostitutes their junior residents out like that is doing their residents a disservice.

I don't tell General Surgery what rotations their residents do. I don't tell General Surgery that they have to pony up their interns to take call on my service. They don't get to tell me what to do with my residents.

 

[Stare Decisis]

Max, you just became my hero! Seriously, a tear dropped. I am at a program that is integrated and we do 17 mos of gsurg and 90% of that is slavery. Kudos to your program for not using you junior residents as political pawns. Can you PM me what program that is, I am so curious. How much general surgery are PRS residents required to do? What rotations do your residents find useful?

At this point I am convinced that everyone just liked the way they trained and is unwilling to accept any alternative. The integrated guys would have liked less gensurg and the gensurg guys think PRS is beoming too much like Ortho.

 

[rongeur]

Again, this is total BS. I'm a faculty member at an integrated program. We call the shots on what our residents do. We tell General Surgery which rotations they will be on. When they run shorthanded, that's their problem. Our junior residents are not slaves for the General Surgery service to make sure there is someone to round on the Colorectal-Trauma patients. Any program that prostitutes their junior residents out like that is doing their residents a disservice.

The whole point of my post was explaining that I am NOT saying it is like that everywhere, only that it is possible for it to be like that if the head of plastics still answers to general surgery. It's good that your program runs their ship independently even if plastics still "under" GS, but as the last poster confirmed, there are still places where it isn't like that and it's one reason that "early integration" of rotations isn't more widespread. This is really not a controversial claim I'm making, it came up routinely from faculty members on the integrated interview trail.

 

[Bradieux]

Two things:

First, anyone who does full GS residency then plastics is considered one of the last "true general surgeons". A long road but a nice honor!

Second, be CERTAIN that if you go the GS route first, that the program you attend has a plastics program or at the very least a couple of plastic surgeons connected in the PRS community. It is very hard to match into a plastics fellowship otherwise. it's all about connections the future you go in your career.

Brian