Plastics possible after GSurg Residency?

[Blitz2006]

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Just curious,

I definitely want to do GSurg for residency, but I also am interested in Plastics. Are there many fellowships in Plastics for GSurg residents? How many years is the fellowship, 1 or 2? Is the Plastics fellowship ridiculously competitive?

And if there are Plastic fellowships for GSurg residents, how is it different than going straight into a Plastic surgery residency? I'm assuming those residents are more competent as Plastic surgeons?

I would consider going straight into Plastics for residency, but given that I'm IMG, I know that is pretty much impossible, hence my inquiry on the GSurg pathway into Plastics....thx

 

[Winged Scapula]

Just curious,

I definitely want to do GSurg for residency, but I also am interested in Plastics. Are there many fellowships in Plastics for GSurg residents?

Yes, this is the traditional and still the most common route to PRS.

How many years is the fellowship, 1 or 2?

At least 2, some are 3. There are also some fellowships (ie, Hand, Burn, Craniofacial, Aesthetics, etc.). See http://www.sfmatch.org

Is the Plastics fellowship ridiculously competitive?

Yes, it is widely considered to be one of the most competitive.

And if there are Plastic fellowships for GSurg residents, how is it different than going straight into a Plastic surgery residency?

You do more general surgery.

I'm assuming those residents are more competent as Plastic surgeons?

That is the million dollar question. Some have questioned the Integrated programs in which medical students match straight out of medical school as the candidates have not learned basic surgical techniques and are somewhat an untested surgeon. It has led some programs to revert back to the traditional Independent model. This is an area of controversy.

I would consider going straight into Plastics for residency, but given that I'm IMG, I know that is pretty much impossible, hence my inquiry on the GSurg pathway into Plastics....thx

I would venture that Integrated plastics as an IMG is pretty much impossible (I interviewed at several places but didn't match - doesn't mean you won't but its very competitive) but its probably worth trying all the same.

 

[tsip]

It has led some programs to revert back to the traditional Independent model. This is an area of controversy.

Really? Do you know which specific programs have done so? I was under the impression that the trend was in the opposite direction-that more and more programs were going the integrated route and becoming either 6 or 7 year programs.

 

[rongeur]

Yes, this is the traditional and still the most common route to PRS.



At least 2, some are 3. There are also some fellowships (ie, Hand, Burn, Craniofacial, Aesthetics, etc.). See http://www.sfmatch.org



Yes, it is widely considered to be one of the most competitive.



You do more general surgery.



That is the million dollar question. Some have questioned the Integrated programs in which medical students match straight out of medical school as the candidates have not learned basic surgical techniques and are somewhat an untested surgeon. It has led some programs to revert back to the traditional Independent model. This is an area of controversy.

1) After this year all PRS fellowships must be 3 years.

2) I haven't heard of any programs that have gone from integrated to independent lately. But I know of a number of programs have or are in the process of replacing their independent spots with integrated, including several of the biggest programs and even smaller programs like Irvine.

Also, many programs are reducing the number of general surgery years. Some top programs (UPitt, UMichigan, Hopkins) now have a year or less. There are definitely old school general surgery people who think that if you haven't done ten whipples you can't operate, but the people who actually train plastics residents seem to think it's better.

 

[Winged Scapula]

Really? Do you know which specific programs have done so? I was under the impression that the trend was in the opposite direction-that more and more programs were going the integrated route and becoming either 6 or 7 year programs.

1) After this year all PRS fellowships must be 3 years.

Yep...that is true.

2) I haven't heard of any programs that have gone from integrated to independent lately. But I know of a number of programs have or are in the process of replacing their independent spots with integrated, including several of the biggest programs and even smaller programs like Irvine.

Also true. However, my point was that in the early days of these programs several programs did give up their Integrated tracks as they were not happy with the candidates they were receiving.

Furthermore, the drive toward *more* Integrated programs may be at least in part, financially based. Programs will receive full CMS funding for these as opposed to the reduction in IME funds for the Independent programs.

Also, many programs are reducing the number of general surgery years. Some top programs (UPitt, UMichigan, Hopkins) now have a year or less. There are definitely old school general surgery people who think that if you haven't done ten whipples you can't operate, but the people who actually train plastics residents seem to think it's better.

Its not about the number of Whipples/AAAs/etc that you do that makes the extended training a good idea. This is a common argument that all that general surgery training is "wasted" on the PRS bound.

The fact remains that whether you are doing Whipples or other general surgery cases, you are learning tissue handling techniques, pre and post- operative management and general patient care. I did twice the national average number of Whipples during my residency - I'll never do one again but that isn't important. What is important is that doing those cases and taking care of those patients gave me insight and skills that are transferable to any surgical practice.

Frankly, I may be old school but I've worked with both and I think the Independent trained plastic surgeons are just better all around physician-surgeons. Are they better plastic surgeons? I can't tell the difference but they are more likely, at least in my experience, to be able and willing to manage the sicker patients and the global patient "picture" for all of their patients. That may not be important and at the end of the day, the PRS skills may be identical between the different tracks.

There's no doubt that the Integrated programs are here to stay and that they produce some fine plastic surgeons. There's also no doubt that perhaps a lot of the general surgery training is superfluous and not necessarily for the subspecialty surgeon. But to say there aren't problems with the Integrated training models is a bit sort sighted - and IMHO, it isn't fair to ask the PDs and faculty in such programs (who likely have a biased view) whether that's the case. Not *all* of them, even the younger ones, think that the Integrated programs are necessarily better - even if that's what they tell you on the interview trail.

 

[Stare Decisis]

I was under the impression that during some of the general surgery years, even at reputable plastic surgery programs, the PRS resident may be ignored and not given the attention required. This is not everywhere but it seems to be fairly prevalent. A chairmen who switched back to the independent model stated that the only way he would only consider integrated again was if he had full control of the residents and could place them rotations where they received surgical training. I know this has been stated before, but I fail to understand why the other surgical subspecialites only require a limited GS exposure but plastic surgery residents should get 3 years of general surgery. It would seem that excessive general surgery years would make any surgical subspecialist a better over all physician but if it is not required to excel in your area of interest then why do it. It also seems that the average integrated PRS applicant may possess qualities that the average general surgery applicant does not, just based on the charactersitcs of the applicant pool. This may permit training to be "tweaked" and still produce capable plastic surgeons. While I have extreme respect for general surgery I do wonder that when the PRS training model is more polished if those years will be required.

 

[Guile]

I did twice the national average number of Whipples during my residency - I'll never do one again but that isn't important.

How many Whipples did you do, out of curiosity? More than half of graduating surgical residents do ZERO during residency, so I'm not sure about the average, but that would make the median zero.

 

[Winged Scapula]

How many Whipples did you do, out of curiosity? More than half of graduating surgical residents do ZERO during residency, so I'm not sure about the average, but that would make the median zero.

For some reason I remembered the average as 9; I did 20.

 

[skiz knot]

but I fail to understand why the other surgical subspecialites only require a limited GS exposure but plastic surgery residents should get 3 years of general surgery. It would seem that excessive general surgery years would make any surgical subspecialist a better over all physician but if it is not required to excel in your area of interest then why do it.

As an orthopod (eligible for PRS) I definitely see the benefit of having a 3 year General surgery education prior to starting formal PRS training. Having done some basic thyroids and thyroglossal ducts etc... prior to the radical neck cancer excision and reconstruction would be beneficial. Knowing how to properly fix an abdominal hernia 1st revision would be helpful when it comes time to fix the 6th attempt at one. Even vascular surgery work will help when learning extremity rotational or free flaps.

ENT, Ortho, and GS all bring different skill sets to the PRS world. Even though pure general surgery is not as general as it once was, it still gives those candidates a breadth of operative experience to make excellent PRS surgeons that probably isn't matched by ortho and ENT. Take note, I don't often give props to GS.😉

 

[ESU_MD]

A whipple isnt a good metric, cause they arent that hard to do.....

however, you can make it really hard if you try to resect unresectable tumors

 

[Winged Scapula]

As an orthopod (eligible for PRS) I definitely see the benefit of having a 3 year General surgery education prior to starting formal PRS training. Having done some basic thyroids and thyroglossal ducts etc... prior to the radical neck cancer excision and reconstruction would be beneficial. Knowing how to properly fix an abdominal hernia 1st revision would be helpful when it comes time to fix the 6th attempt at one. Even vascular surgery work will help when learning extremity rotational or free flaps.

ENT, Ortho, and GS all bring different skill sets to the PRS world. Even though pure general surgery is not as general as it once was, it still gives those candidates a breadth of operative experience to make excellent PRS surgeons that probably isn't matched by ortho and ENT. Take note, I don't often give props to GS.😉

I was having dinner with a plastic surgeon friend of mine tonight and she made these exact points.

While doing a TRAM recently, she found an abdominal hernia and repaired it. Not a difficult skill set to be sure, but one that she obtained during her general surgery residency. And today when she did a flap repair to cover an ulcer, she said her vascular surgery experience helped.

And yes, Whipples are not a great measure - they are not difficult (although one can make them so), just time consuming. I brought it up because it was mentioned before (and has become somewhat of a stereotype drone about why subspecialists shouldn't do GS) as a reason not to do GS.

 

[Fah-Q]

ENT, Ortho, and GS all bring different skill sets to the PRS world. Even though pure general surgery is not as general as it once was, it still gives those candidates a breadth of operative experience to make excellent PRS surgeons that probably isn't matched by ortho and ENT.

Ooooh, yeah...I'm going to go ahead and disagree with you a little bit there.

I'm slightly biased but I don't think there is a more technically complete surgical training program than an good ENT program and I think they are probably best prepared for a plastics training program. The breadth and depth of an otolaryngology residency's operative experience is outstanding: everything from microscopic ear and larynx surgery to massive head and neck cancer resections; endoscopic procedures of the sinuses and upper aerodigestive tract; microvascular cases; intracranial and skull base cases; bony trauma; soft tissue techniques; delicate cranial nerve dissections; neck dissections; skin grafts, local flaps, regional flaps. We learn to operate on virtually every tissue type in the body.

There is no question that a general surgeon is a better "overall" physician compared to a subspecialist, but I think the variety of technical training offered in ENT translates into graduates who are better suited to move on to plastics.

I expect a good beating from the general surgeons here. I'm not trying to tear g surg down, just trying to stick up for my specialty.

 

[Winged Scapula]

Ooooh, yeah...I'm going to go ahead and disagree with you a little bit there.

I'm slightly biased but I don't think there is a more technically complete surgical training program than an good ENT program and I think they are probably best prepared for a plastics training program. The breadth and depth of an otolaryngology residency's operative experience is outstanding: everything from microscopic ear and larynx surgery to massive head and neck cancer resections; endoscopic procedures of the sinuses and upper aerodigestive tract; microvascular cases; intracranial and skull base cases; bony trauma; soft tissue techniques; delicate cranial nerve dissections; neck dissections; skin grafts, local flaps, regional flaps. We learn to operate on virtually every tissue type in the body.

There is no question that a general surgeon is a better "overall" physician compared to a subspecialist, but I think the variety of technical training offered in ENT translates into graduates who are better suited to move on to plastics.

I expect a good beating from the general surgeons here. I'm not trying to tear g surg down, just trying to stick up for my specialty.

Well this general surgeon actually agrees with you (except for the part about ENT being the most technically complete - although I'm not sure what that even means 😉 ).

I think ENTs are excellent candidates for PRS training and some of the best facial plastics guys I know are ENT trained.

 

[Stare Decisis]

I was having dinner with a plastic surgeon friend of mine tonight and she made these exact points.

While doing a TRAM recently, she found an abdominal hernia and repaired it. Not a difficult skill set to be sure, but one that she obtained during her general surgery residency. And today when she did a flap repair to cover an ulcer, she said her vascular surgery experience helped.

Why can't those skills be taught within the plastic surgery residency by Plastic surgeons who regularly use them? Is it a better educational experience iF they are taught by general surgeons over a 3-5 year period? I only asks because after speaking with some integrated surgeons who trained at a well respected breast heavy program with very limited general surgery experience but felt comfortable repairing hernias and handling vessels. They felt they were only at a disadvantage if they wanted to do an omental flap or something like that. My point being, it seems that improved plastic surgery education could possibly negate the need for 3 years of general surgery and possibly 1.5 years of gen surg related subspecialties would be adequate.

 

[Fah-Q]

Well this general surgeon actually agrees with you (except for the part about ENT being the most technically complete - although I'm not sure what that even means 😉 ).

I really don't know what that means either. I was trying to draw attention to the huge variety of different tissue types operated on and techniques an otolaryngologist must employ to operate on all of the various structures within the head and neck.

 

[bottombracket]

To SD:

Another shift in the training paradigm (at least at my program) is that now plastic surgeons are responsible for teaching basic surgical principles, patient management, etc. instead of the general surgeons.

Six years ago, we did a pretty standard 3+2 (which became 3+3) in which we did exactly what the categorical general surgery residents did. We were not treated differently as far as I can tell; at least I was not. I did the same cases and had the same opportunities as my categorical friends, and I had a pretty good time and a broad exposure to general surgery. That has changed somewhat today at my institution - as we have decreased gen surg time and increased plastic surgery time, I think that the general surgery dept has taken more of an attitude of "they're not worth training because they're plastics". This has seemed to reduce the rigor of their experiences. What happened with my class and others before me is that we were trained mostly by general surgeons for three years, and then came to plastics with decent operative skills from gen surg and with a decent education.

Now, however, we as residents are responsible for teaching our own juniors in an organized fashion and instructing them basic in operative skills that we had picked up in our general surgery time - how to bovie, hold a knife, etc. - essentially from square one.

Whether or not this makes a difference is yet to be seen. We will see if our younger residents become good doctors as well as plastic surgeons.

 

[Winged Scapula]

Why can't those skills be taught within the plastic surgery residency by Plastic surgeons who regularly use them?

Because I don't think you'll find a plastic surgeon who "regularly" uses those techniques.

Is it a better educational experience iF they are taught by general surgeons over a 3-5 year period?

That remains to be seen, but in general, one learns more from those with greater experience. I would venture that doing macrovascular anastomoses with a vascular surgeon can only better prepare you for the microvascular work. And learning hernia repair with a general surgeon who does them everyday is probably better than from someone who learned them at some point in time but hasn't done one in a long time or kept up with any new techniques/advances.

I only asks because after speaking with some integrated surgeons who trained at a well respected breast heavy program with very limited general surgery experience but felt comfortable repairing hernias and handling vessels. They felt they were only at a disadvantage if they wanted to do an omental flap or something like that.

IMHO its probably not fair to ask them what they are missing in their education because they don't know what they are missing.

I know a lot of surgeons who are "comfortable" doing certain procedures - that doesn't always mean they have good outcomes or are doing the procedure in the best/most efficient/standard of care fashion.

My point being, it seems that improved plastic surgery education could possibly negate the need for 3 years of general surgery and possibly 1.5 years of gen surg related subspecialties would be adequate.

Perhaps but I think bottombracket has touched on the exact concerns: Integrated residents are coming in with little to no skills and valuable time is being taken away from PRS training to teach them how to suture, Bovie, handle tissues, manage patients pre, intra and post-operatively. This IS a concern of PRS faculty - they might not mention it to you on the interview trail but they talk about it in the physician's lounge.

This doesn't mean that Integrated programs don't produce quality PRS, nor does it mean you necessarily need 3+ years of general surgery but if you are in a good program like bottombracket was, you will come to realize those years of GS are valuable. We all have things to learn from each other.

 

[Green Grass]

I have searched the SF match website and cannot find a listing of fellowship programs. anyone have a link?

 

[Guile]

I have searched the SF match website and cannot find a listing of fellowship programs. anyone have a link?

You're an M3 looking at listings of post-surgery residency fellowships? If you are looking for categorical plastics programs, then that match is through ERAS. Just Google FREIDA to get program info.

 

[JackADeli]

Why can't those skills be taught within the plastic surgery residency by Plastic surgeons who regularly use them? Is it a better educational experience iF they are taught by general surgeons over a 3-5 year period? ...

Because I don't think you'll find a plastic surgeon who "regularly" uses those techniques.

... in general, one learns more from those with greater experience. I would venture that doing macrovascular anastomoses with a vascular surgeon can only better prepare you for the microvascular work. And learning hernia repair with a general surgeon who does them everyday is probably better than from someone who learned them at some point in time but hasn't done one in a long time or kept up with any new techniques/advances...

I think WS has pretty much nailed it. In general, you can find plenty of examples of specialties in which the actual practice may involve specific skills sporadicly. You need those skills but shouldn't learn them from a sporadic practitioner of these skills. For example, most FM residents, I have spoken with, learn high risk OB from OB/Gyns and not from FM attendings (yes, FM teaches and participates in the process). They also will often get their greatest volume of deliveries with OB's to include csxns, etc. On the flip side, I know a good deal of EM/ER residents that talk about learning most ortho including tendon repair from.... ER/EM attendings. I am not sure I think that is the best idea but leave that discussion to them & their board.

...IMHO its probably not fair to ask them what they are missing in their education because they don't know what they are missing...

I agree. We already have too much of a trend of undergrads whining about how unfair a particular college course is because they "won't need it as a physician". We have med-students trying to auto select/subspecialize during clinicals cause ~they know what is best. We have residents planning a specific practice and as early as PGY1/2 avoiding tasks cause they won't be doing that procedure in practice. In the end, someone really needs to have a bigger picture and be the adult.

 

[Green Grass]

You're an M3 looking at listings of post-surgery residency fellowships? If you are looking for categorical plastics programs, then that match is through ERAS. Just Google FREIDA to get program info.

The only reason I ask is because it might be beneficial to match at a general surgery program where there is an independent PRS fellowship, as well. I don't think FRIEDA offers information about fellowships, so I was trying to find it on SF match.

 

[Stare Decisis]

I think WS has pretty much nailed it. In general, you can find plenty of examples of specialties in which the actual practice may involve specific skills sporadicly. You need those skills but shouldn't learn them from a sporadic practitioner of these skills. For example, most FM residents, I have spoken with, learn high risk OB from OB/Gyns and not from FM attendings (yes, FM teaches and participates in the process). They also will often get their greatest volume of deliveries with OB's to include csxns, etc. On the flip side, I know a good deal of EM/ER residents that talk about learning most ortho including tendon repair from.... ER/EM attendings. I am not sure I think that is the best idea but leave that discussion to them & their board.

While I appreciate and respect the surgical experience of both the OBGYN and ER/ED docs and what appears to work for them; I would still wonder if a tailored plastic surgery education is the answer and not necessarily just more general surgery. Take UPitt. for example, the graduates seem very comfortable with abdominal reconstruction. This is according to physicians that have worked with graduates of the program and residents within the program itself. I had the opportunity to sit down with a chairman after clinic and walked me through how he would organize the "perfect" residency if he had complete control of his residents from day one and limitless funding. He did not think 3 or 5 years of GSurg was the answer but specific targeted rotations in the first 2 years to maximize resident experience.

I agree. We already have too much of a trend of undergrads whining about how unfair a particular college course is because they "won't need it as a physician". We have med-students trying to auto select/subspecialize during clinicals cause ~they know what is best. We have residents planning a specific practice and as early as PGY1/2 avoiding tasks cause they won't be doing that procedure in practice. In the end, someone really needs to have a bigger picture and be the adult.[/QUOTE]

While this is a fair statement, the individuals commenting on their training were attendings, albeit within their first 5 years, but attendings nonetheless. The quote I hear often is: "More gsurg will make you a better doctor in regard to managing patients, but do you need that intense experience to be a better plastic surgeon." Maybe that makes you more of a technician and not a physician, but I will leave those philosophical musings for others.

JAD, I agree that medical students have started to auto select and I too have committed this sin. It was because I wanted to make myself competitive for plastic surgery with high board scores, publications, grants etc... It is not that I had any less respect for other specialties but I was just trying to put myself into a comfortable position to match. Plastic surgery, although a broad specialty, seems to auto select within the program because of your limited exposure to all areas within the field. At a national meeting I was chatting up a community plastic surgeon who told me he does mostly cosmetic because that is what he did mostly during residency, as opposed to the high volume recon you see at most places. Recently I rotated through an independent program, just for kicks, and the residents pretty much just scrubbed the cases they wanted to because those were the procedures they wanted to do in practice. My point is, that it aside from a few places, such as UTSW, were you get your hands into some of everything it appears factors out of your hands (such as where you match) may "auto select" for you. Why not try to drive the process instead of always being driven. Theoretically if you make a mistake and become an incompetent surgeon/practitioner then the program will recognize this and either remediate or discharge you.

 

[JackADeli]

While I appreciate and respect the surgical experience of ...what appears to work for them; I would still wonder if a tailored plastic surgery education is the answer and not necessarily just more...

I agree that medical students have started to auto select and I too have committed this sin...

It seems like this will just continue as a philisophical debate... As our points of references are too far distanced from each other over numerous years of training and long nights of conversations with residents, fellows, and attendings, I don't see us at eye to eye level for quite some years. I defer back to WS's comments and my own.

You will just have to figure it out on your own through time and additional experience.

 

[Stare Decisis]

It seems like this will just continue as a philisophical debate... As our points of references are too far distanced from each other over numerous years of training and long nights of conversations with residents, fellows, and attendings, I don't see us at eye to eye level for quite some years. I defer back to WS's comments and my own.

You will just have to figure it out on your own through time and additional experience.

I agree. This is why I did not respond to WS last coment because it appeared to be futile. I just wanted to show your thought out response to my previous statements the respect of a reply. Your perspective is appreciated, and although I am biased by my mentors and their decades of training/experience, I will continue to reflect on your thoughts.

SD

 

[JackADeli]

I agree. This is why I did not respond to WS last coment because it appeared to be futile. I just wanted to show your thought out response to my previous statements the respect of a reply. Your perspective is appreciated, and although I am biased by my mentors and their decades of training/experience, I will continue to reflect on your thoughts.

SD

The maturity of that response, from a medical student, is surprisingly refreshing.👍

I absolutely encourage you to continue to think of ways to improve your training/learning and subsequent practice. While easy to do, try to not get bogged down in dogma. Continue to question... even if just to yourself. That approach will ultimately end with you in the front of the pack. Best of luck 🙂

 

[maxheadroom]

At a national meeting I was chatting up a community plastic surgeon who told me he does mostly cosmetic because that is what he did mostly during residency, as opposed to the high volume recon you see at most places. Recently I rotated through an independent program, just for kicks, and the residents pretty much just scrubbed the cases they wanted to because those were the procedures they wanted to do in practice. My point is, that it aside from a few places, such as UTSW, were you get your hands into some of everything it appears factors out of your hands (such as where you match) may "auto select" for you. Why not try to drive the process instead of always being driven. Theoretically if you make a mistake and become an incompetent surgeon/practitioner then the program will recognize this and either remediate or discharge you.

That's a bogus excuse for being a dedicated cosmetic surgeon. He needs to man up and tell the truth that he likes more money and less call as a cosmetic guy. An accredited Plastic Surgery residency will more than adequately train a graduate in a wide variety of reconstructive surgery. More importantly, you don't learn particular surgeries as much as techniques and principles. I've been an attending for all of a week and I've already done two operations that I didn't do in residency or fellowship.

 

[droliver]

Why can't those skills be taught within the plastic surgery residency by Plastic surgeons who regularly use them? Is it a better educational experience iF they are taught by general surgeons over a 3-5 year period? ....... My point being, it seems that improved plastic surgery education could possibly negate the need for 3 years of general surgery and possibly 1.5 years of gen surg related subspecialties would be adequate.

There's just no way to recapture what you traditionally learned over 5 years of surgery by trying to cram it into junior level rotations of an integrated plastics program. It just doesn't work. You never get the experience and knowledge base to ever be fluent in it. It's a traditionally vital part of our specialty that's going to be lost as we become more and more of a sub-specialized insular group of technicians. Your ability to communicate with other surgical specialties about things is on another level when you've actually had to perform their procedures and take care of those patients post-op.

I see this with my partner and one of my good friends(who both came from some of the pioneer integrated programs and are excellent surgeon) who looks at me with blank stares when I talk about some of the kinds of cases I get involved in. They are clearly much less comfortable with complex patients and surgeries as they were largely peripheral consultants rather then in the trenches of patient care during their training. I remember seeing that mindset change myself (literally overnight, as I was a plastics resident 2 days after finishing my general surgery at the same institution)

Coming up with training programs that balance these things is hard. I don't think you need 5 years of surgery to get the most out of it, but considering clipping it to 1 - 1.5 years as some programs are is the worst of all worlds as you get none of the technical training, none of the management skill, and all of the low man on the totem pole service duties. I personally think 4+3 (with several months a year at the junior levels on plastics and hand) is the sweet spot but funding, politics, and manpower issues make that unlikely to emerge.