The Training Program Problem
Until recently, many training programs properly fulfilled their
mission. But, today's training programs differ significantly from the
programs we enjoyed a generation ago. As a trainee at the University
of Illinois in the early 1970s, I had access to a generous stream of
patients seeking cosmetic surgery. The university made it very
affordable for patients to have surgery performed by surgeonsin-
training because the hospital had a plump
budget, which included funds for noninsured
training cases.
Patients paid between $50 and
$250 for a single or multiple procedures. This
inflow of patients seeking our services allowed
many of us to become quite accomplished
during our residencies. We graduated both
competent and confident in our skills. Our
professors felt comfortable sending us out to
do cosmetic facial surgery.
William P. Graham III, MD, former chairman of the American Board of
Plastic Surgery, stated in his Carlson Lectureship in 1994 that "Although
aesthetic (cosmetic) surgery is absolutely integral to a basic plastic
surgery education, it is the fact that the quality of aesthetic training
varies greatly among residencies. Training opportunities in aesthetic
surgery are not as accessible to the large superspecialized university
center as they are to the freestanding facility or small, private hospital.
How do we ensure the availability of appropriate aesthetic surgical
training to all plastic surgery residents, and what minimum standard
should be set for resident experience in aesthetic surgery?"
-from an editorial entitled "Aesthetic Surgical
Education: A Personal Perspective" by Stanley A. Klatsky, MD
Editor-in-Chief, Aesthetic Surgery Journal, November/ December 1999
By contrast, today's residency training programs often work
against the aspiring young cosmetic surgeon. First, there is the time
constraint of the training period itself. Consider this: The minimum
residency requirement for plastic surgeons is only two years. For the
entire body. Is this adequate time to master the 137 head-to-toe procedures that the American Board of Plastic and Reconstructive
Surgery recognizes as within that specialty's province?
In fact, the
training focuses on the reconstructive procedures required by
accident and tumor victims, not cosmetic surgery patients.
Furthermore, since most residency training is held in hospitals, rather
than boutique clinics or dedicated cosmetic surgery centers, residents
aspiring to be cosmetic surgeons have inadequate training and little
access to the cosmetic wing of plastic surgery.
The dilemma is the same for opthalmologists aspiring to perform
cosmetic surgery on the eyelid and brow; for head and neck surgeons
interested in face and neck cosmetic surgery; and for dermatologists
seeking training in cosmetic procedures. Residency focus is on
reconstructive not cosmetic surgery.
What other barriers exist to proper training and experience before
a doctor starts performing cosmetic procedures in practice? One is
that today's more sophisticated and well-informed patients are
reluctant to have the procedures performed by novice surgeonsin-
training. They realize that regardless of the amount of
supervision, if a doctor-in-training is performing the procedure, his
inexperience may negatively influence their result.
Cosmetic Surgery Is Not a Hospital-Based Subspecialty
Like other subspecialties of plastic surgery, dermatology, head
and neck and ophthalmic surgery, cosmetic surgery lives in an
outpatient world. It is not hospital based because the patients do not
require hospitalization before or after surgery.
This has great
significance for trainees who are generally hospital bound. How
difficult must it be for a hospital bound cosmetic surgery resident to
gain experience in a specialty that is not hospital based? Most highly
specialized, full time cosmetic surgeons are found in larger cities,
practicing apart from university hospital settings. They practice in
either office or outpatient surgery centers. Not in hospitals. Contrary
to reconstructive cases, the cosmetic surgeon does not see the patient
preoperatively or postoperatively in the hospital. This is a major
disadvantage for doctors in training.
Neophytes need to learn the entire menu of the surgical
experience. The operating room is only one course. They need
exposure on how to interview patients. They must learn "when to
operate, and when not to operate." Medical photography and computer imaging are rarely available in an
all-purpose university hospital. Learning how to
manage patients postoperatively is imperative.
Dealing with patient dissatisfaction, post-operative
problems and complications mean care is often given
for months after surgery.
Jordan Cohen, MD,
President of American
Association of Medical
Colleges, has been involved
in medical education for
over forty years. In Modern
Physician, January 15, 2001,
Dr. Cohen stated:
"One of
the consequences of
managed care . . . is that
there has been an erosion
of many of the funding
streams that have been
depended on to maintain a
high quality medical
education" Trainees often change
services every two to three months and never get the
full benefit of having their work evaluated on a
long-term basis. Thus, we must conclude, the
university training setting is not a replica of the
actual practice world for the cosmetic surgeon.
Ironically, the typical cosmetic surgery patient is
not anxious to go to a teaching hospital, but that's
where the trainees are based. It offers little privacy,
no anonymity, and hospital charges are often
prohibitive.
The Uncomfortable Truth About Teaching
By traditional ethics and public insistence (not to mention court
rulings), a patient's right to the best care possible must trump the
objective of training novices. We want perfection without practice. Yet
everyone is harmed if no one is trained for the future. So learning is
hidden, behind drapes and anesthesia and the elisions of language. And
the dilemma doesn't apply to just residents, physicians in training. The
process of learning goes on longer than most people know.'
-from "Annals of Medicine
The Learning Curve. Like everyone else, surgeons
need to practice. That's where you come in."
by Atul Gawande, MD
New Yorker, January 28, 2002 Cosmetic surgeons are even less excited about a hospital
stay for their patients. The threat of antibiotic-resistant bacteria is a
concern with elective surgery, which should be done in a low risk
environment. And, overworked hospital nurses are not ideal service
providers for the special needs of cosmetic clients; their inherent
allegiance is to the sick, not to the vain. |
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