Cosmetic Surgery Training in Canadian Plastic Surgery Residencies: Are We Training Competent Surgeons?

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1 INTERNATIONAL CONTRIBUTION Special Topic Cosmetic Surgery Training in Canadian Plastic Surgery Residencies: Are We Training Competent Surgeons? Aesthetic Surgery Journal 33(1) The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journalspermissions.nav DOI: / X Quinton J. Chivers, MD; Jamil Ahmad, MD, FRCSC; Frank Lista, MD, FRCSC; Richard J. Warren, MD, FRCSC; Amr Y. Arkoubi, MBBS, FRCSC; Raman C. Mahabir, MD, MSc, FRCSC; Kenneth A. Murray, MD, FRCSC; and Avinash Islur, MD, FRCSC Abstract Background: With the demand for cosmetic surgery continuing to rise, it is necessary to reevaluate the current state of cosmetic surgery training during plastic surgery residency. An evaluation of cosmetic surgery training in US plastic surgery residency programs in 2006 identified several areas for improvement, resulting in changes to both the duration and content of training. Objectives: The authors assess the current state of cosmetic surgery training in Canadian plastic surgery residency programs. Methods: A paper survey of all graduating Canadian plastic surgery residents eligible to complete the 2009 Royal College of Physicians and Surgeons of Canada fellowship examinations was performed (N = 29). The survey was conducted primarily at the Canadian Plastic Surgery Review Course in February 2009, with surveys collected from absent residents by within 1 month after the course. The survey covered 2 broad areas: (1) specifics regarding resident cosmetic surgery training and (2) confidence and satisfaction associated with this experience. Results: Of the 29 residents surveyed, 28 responded (96%). The majority of Canadian plastic surgery residency programs (75%) have a designated cosmetic surgery rotation, but 90% of respondents felt it has become increasingly difficult to gain exposure to cosmetic procedures as most are performed at private surgery centers. Elective rotations at cosmetic surgery practices and resident cosmetic clinics were considered the most beneficial for cosmetic surgery education. Residents considered cosmetic surgery procedures of the face (such as rhinoplasty and facelift) more challenging, but they had more confidence with breast and body contouring procedures. Conclusions: Canadian plastic surgery residency programs need to ensure that residents continue to receive comprehensive exposure to both surgical and nonsurgical cosmetic procedures to ensure our specialty s continued leadership in this evolving and highly competitive field. A multidimensional approach utilizing a variety of readily available resources will ensure that the current and future cosmetic surgery educational needs of Canadian plastic surgery residents are met. Keywords aesthetic surgery training, cosmetic surgery training, residency training, education, Canada Accepted for publication November 3, With the demand for cosmetic surgery continuing to rise and the rapid increase in nonsurgical cosmetic procedures, it is necessary to reevaluate the current state of cosmetic surgery training during plastic surgery residency. 1 An evaluation of cosmetic surgery training in US plastic surgery residency programs by Morrison et al 2 in 2008 identified several areas for improvement, including facial cosmetic surgery, minimally-invasive procedures, and newer body contouring techniques. These concerns were echoed by the Accreditation Council for Graduate Medical Education (ACGME) Residency Review Committee for Plastic Surgery, resulting in numerous recommendations and changes made to both the duration and content of US plastic surgery curriculums. 3 In addition, the American Society for Aesthetic Plastic Surgery (ASAPS) has recently Dr Chivers and Dr Arkoubi are residents, Dr Murray is Professor, and Dr Islur is Assistant Professor in the Section of Plastic Surgery, Department of Surgery, University of Manitoba, Winnipeg, Manitoba, Canada. Dr Ahmad and Dr Lista are plastic surgeons in private practice in Mississauga, Ontario, Canada. Dr Warren is Clinical Professor, Division of Plastic Surgery, Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada. Dr Mahabir is Associate Professor, Division of Plastic and Reconstructive Surgery, Department of Surgery, Scott & White Healthcare, Temple, Texas, United States. Corresponding Author: Dr Avinash Islur, St Boniface General Hospital, Z Tache Ave, Winnipeg, MB R2H 2A6, Canada. aislur@gmail.com

2 Chivers et al 161 produced guidelines for aesthetic plastic surgery fellowships. Five years after the Morrison et al 2 study, Oni et al 4 showed significant improvements to cosmetic surgery training in US plastic surgery residency programs, particularly with regard to increased instruction and confidence of graduates with minimally-invasive procedures and advanced body contouring techniques. A similar situation to that which existed in the United States prior to 2006 is thought to exist in Canadian plastic surgery residency programs. Despite cosmetic surgery representing a significant portion of the Royal College of Physicians and Surgeons of Canada (RCPSC) objectives of training 5 and exams for certification as a specialist in plastic surgery, no changes have yet been made to the duration of training or standardization of content across Canadian plastic surgery residency programs. Currently, plastic surgery residency training in Canada involves a 5-year integrated program leading to eligibility for the RCPSC specialist certification in plastic surgery. The RCPSC Objectives of Training outline professional competencies, the type and duration of each rotation, and the type of procedures to which the resident should be exposed. In contrast to ACGME-accredited plastic surgery residency training programs in the United States, there are no specified minimum case requirements in Canada. Instead, evaluating the competence of residents in specific procedures is left to the discretion of the residency program, recognizing that each resident develops at a different pace. The objective of this study is to assess the current state of cosmetic surgery training in Canadian plastic surgery residency programs. Methods A written survey of all graduating Canadian plastic surgery residents eligible to complete the 2009 RCPSC fellowship examinations was performed (N = 29). The survey was conducted primarily at the Canadian Plastic Surgery Review Course in February 2009, with surveys collected from absent residents by within 1 month after the course. Two broad categories were investigated: (1) specifics of cosmetic surgery training in Canadian plastic surgery residency programs and (2) self-reported competence and satisfaction of graduating plastic surgery residents with their cosmetic surgery abilities. Future training and practice plans were also evaluated. Questionnaires comprised a total of 21 open- and closed-ended questions and typically required 15 minutes to complete (Appendix; available online at No incentives were provided to any of the participants. Data were tabulated and placed into graphical form. Data from incomplete surveys were included to the greatest extent possible. Results A total of 28 of the 29 graduating Canadian plastic surgery residents completed the questionnaire, for an overall response rate of greater than 96%. All plastic surgery residencies in Canada are presently 5-year integrated programs. All training programs with graduating residents were represented in this survey (n = 12). The majority (75%) of residency programs have a designated cosmetic surgery rotation, with most (88%) of those rotations being in the penultimate or final years of training. The average duration for cosmetic surgery rotations is 1 to 4 months. In the programs without designated cosmetic surgery rotations, less than 5% of the cases overall are felt to be cosmetic in nature, and these are dispersed throughout training. In general, residents typically reported that they felt they performed less than 20% of any individual cosmetic surgery case. The greater part (70%) of cosmetic surgery training was felt to come from staff without a significant cosmetic surgery practice. Some (17%) of the training programs have a designated resident cosmetic clinic in which the resident performs an estimated 30 cosmetic cases over the course of training. Most (75%) programs allow for elective rotations outside of their institutions over the course of training; between 2004 and 2009, only 31% of these electives had a cosmetic surgery focus. When asked to rank the utility of various sources of cosmetic surgery education, residents reported that designated electives in cosmetic surgery practices were the most beneficial, followed by resident-run cosmetic clinics, university-based staff cases, and independent learning/ courses. The majority (90%) of respondents felt moderately satisfied with their training but also felt that it was difficult to gain exposure to cosmetic procedures, as the majority of them are being performed at private surgery centers. Less than half (42%) of residents said this training could be improved by performing more cosmetic surgery procedures at major teaching hospitals. Less than 20% of graduating residents felt adequately prepared to integrate cosmetic surgery into their future practice. The perceived surgical confidence of graduating residents and the estimated number of cases required to feel comfortable performing specific cosmetic procedures are illustrated in Figures 1 and 2. On the topic of pursuing further training after residency, 76% of respondents planned on completing fellowship training, although the majority did not plan to undertake fellowships focused on cosmetic surgery (Figure 3). Anticipated practice patterns of graduating residents are displayed in Figure 4. Discussion Although 58% of graduating residents surveyed in this study indicated a preference to work in an academic setting, the perception is that academic employment opportunities in Canada are in fact becoming limited. 6 Although a 2007 study of the Canadian plastic surgery workforce 7 did not specifically examine the type of practice environment and scope of practice of Canadian plastic surgeons, data

3 162 Aesthetic Surgery Journal 33(1) Figure 1. Canadian residents self-reported perceived level of confidence performing cosmetic surgery procedures (1 = not at all confident, 5 = very confident). from a 2010 American Society of Plastic Surgeons (ASPS) Workforce Task Force 8 study revealed that 94% of US plastic surgeons were in nonacademic practice and 94% performed cosmetic surgery as part of their practices. In addition, this study forecasted a doubling of cosmetic surgery demand for at least the next 2 generations, 8 underscoring the integral role of cosmetic surgery in plastic surgery practice. Barriers to cosmetic surgery training in Canadian plastic surgery residency programs have been discussed for decades The results of our study again highlight the important role of comprehensive cosmetic surgery training within the plastic surgery core curriculum. Many graduating residents still lacked confidence in performing several cosmetic procedures and felt that additional training would be necessary prior to incorporating cosmetic surgery into their future practices. In line with the experience of US plastic surgery residents, Canadian plastic surgery residents tended to consider cosmetic surgery procedures of the face (such as rhinoplasty and facelift) more challenging, whereas they had more confidence with breast and body contouring procedures. In addition, residents also expressed less confidence with minimally-invasive cosmetic procedures. However, they reported that only small increases in exposure to many minimally-invasive cosmetic procedures could instill significant confidence, enabling them to incorporate such procedures into a practice. 2,4 Despite a move toward making significant improvements in the quality and comprehensiveness of cosmetic surgery training in the United States, the approach to cosmetic surgery training in Canada has changed little over the past 30 years. Resident knowledge is still acquired in the majority of programs through observation of staff and review of

4 Chivers et al 163 Figure 2. Estimated number of cosmetic surgery procedures required to perform in order to enhance confidence. Figure 4. Practice preferences of graduating residents. Figure 3. Future fellowship training plans. journals and textbooks With an increased number of plastic surgery residents, a shift in the demands being placed on our specialty, and numerous changes to the cosmetic surgery landscape over the past decade, it would seem logical that the breadth of cosmetic training in Canadian plastic surgery residencies should continue to grow and evolve.

5 164 Aesthetic Surgery Journal 33(1) The importance of resident cosmetic clinics was underscored at the Canadian Society for Aesthetic Plastic Surgery annual meeting, during a panel discussion led by Williams and Graham at the 1994 Carlsen Lectureship. 10 Both the University of British Columbia and the University of Toronto plastic surgery residency programs have integrated resident cosmetic clinics into their curriculum in an effort to improve cosmetic surgery training. Clinics such as these are generally felt by residents to be highly beneficial in helping to increase the hands-on experience needed to mature surgically. 15,16 This impression was confirmed in the current survey, with plastic surgery residents ranking a resident cosmetic clinic as the second most important experience in their cosmetic surgery education after designated cosmetic surgery rotations. As the practice of cosmetic surgery shifts away from hospitals to more private surgical centers, potentially so too should some aspects of plastic surgery resident education. Many academic plastic surgeons are now salaried or alternatively funded with restrictions placed on the use of their time and any cosmetic surgery they perform. Outreach to nonacademic, community-based plastic surgeons through designated rotations or visiting electives is incredibly valuable. The focus of these practices, the practice environment, and the unique surgical and business expertise of the staff represent an underutilized resource. In fact, when pursued, these types of educational experiences are considered the most beneficial source of learning by residents in this survey. Both the ASAPS and ASPS have taken proactive steps to encourage resident education in cosmetic surgery by offering free meeting attendance, subscriptions to journals, access to online content, web-based seminars, and traveling professorships. 4,16 These resources are open to Canadian and American plastic surgery residents. Residents should be encouraged to take advantage of these opportunities to enhance their cosmetic surgery training. The Canadian Society of Plastic Surgeons (CSPS) already provides similar benefits to residents and is working on updating its resident programs to help address these educational needs through the Young Plastic Surgeons Committee. Although the response rate of this survey was 96%, the results presented here reflect the feelings of only 28 graduating Canadian plastic surgery residents and have limited statistical value. However, many of the responses from this survey are similar to those reported in a recent study by Oni et al. 4 In particular, Canadian plastic surgery residents feelings regarding procedures that they could perform very confidently, procedures that were perceived as more challenging, and educational resources that residents felt were most useful paralleled the findings of Oni et al. 4 We feel that the results presented in this study probably reflect the feelings of most North American plastic surgery residents. On the basis of the findings of this study, our recommendations to improve cosmetic surgery training in Canadian plastic surgery residency programs echo those of Oni et al 4 : 1. Each program should endeavor to establish a resident cosmetic clinic, allowing independent planning and operating by trainees with direct staff oversight, and administrative advice should be sought from programs that have already instituted such clinics. 2. The 2008 RCPSC plastic surgery objectives of training are now outdated, with significant effort currently being put into updating them. Once available, training programs should adhere to the new 2011 RCPSC objectives that specify cosmetic procedures in which competence should be obtained by the completion of resident training. Increased experience is warranted for areas deemed more challenging by residents, such as cosmetic surgical procedures of the face. Furthermore, residents should be exposed to a broad range of minimally-invasive cosmetic procedures. 3. For programs deficient in any given cosmetic surgery area, outreach to nonacademic plastic surgeons with the required experience should be sought locally or nationally. 4. For residents desiring further training, program directors should encourage and facilitate opportunities such as visiting electives and fellowships in cosmetic surgery. 5. Residents should be encouraged to make use of the many cosmetic surgery resources available to them through the ASAPS, ASPS, and CSPS, including web-based education, journal subscriptions, and attendance at national meetings. Conclusions Canadian plastic surgery residency programs need to make certain that residents continue to receive comprehensive exposure to both surgical and nonsurgical cosmetic procedures if we wish to ensure our specialty s continued leadership in this evolving and highly competitive field. A multidimensional approach utilizing a variety of readily available resources will ensure that the current and future educational needs of Canadian plastic surgery residents are met. Disclosures The authors declared no conflicts of interest with respect to the authorship and publication of this article. Funding The authors received no financial support for the research and authorship of this article. References 1. American Society for Aesthetic Surgery. Cosmetic Surgery National Data Bank statistics. sites/default/files/stats2010_1.pdf. Accessed August 1, 2011.

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