What Am I Going to Do with All of These Appendectomies?!: A Plastic Surgery Resident’s Reflections on General Surgery Training

by Jordan D. Frey, MD (@JordanFreyMD)

Plastic surgeons are the ultimate interdisciplinary surgeons, frequently called upon to collaborate with other specialties while addressing innumerable surgical entities covering the entirety of human anatomy. As such, training in plastic surgery requires each resident to gain sufficient knowledge related to nearly every surgical specialty. The ACGME currently mandates that plastic surgery residents be exposed to “clinical experiences appropriate to plastic surgery education … in alimentary tract surgery, abdominal surgery, breast surgery, emergency medicine, pediatric surgery, surgical critical care, surgical oncology, transplant, trauma management, and vascular surgery1.” As plastic surgery residencies have evolved from independent to combined and now to integrated models, the paradigm for experience in general surgery and its sub-specialties has transitioned as well2. In the majority of integrated plastic surgery training programs, approximately 18 months are spent on general surgery rotations compared to the 3 and 5 years dedicated to general surgery in the combined and independent models, respectively. Similar to many training programs, my institution recently transitioned from a combined to an integrated model. As one of the last combined residents in the program, I currently stand firmly in the middle of my training. Looking forward to my next three years of dedicated plastic surgery training, I cannot help but to reflect on the past three years during which I primarily trained as a general surgery resident.

I must admit that I was unsure what to expect when I began residency knowing it would be three years before I would begin my full-blown plastic surgery training. I was so eager to start learning about anterolateral thigh flaps, cleft palate repair, and tendon transfers, but innumerable appendectomies, cholecystectomies, and bowel resections stood in my way. Sure, I would have plenty of plastic surgery rotations during each of my first three years, but I wanted more. Would all of this be worthwhile? What would I take away from my general surgery time? These along with so many other questions floated in my head as I walked into the hospital for the first time to cover the surgical intensive care unit.

Plastic surgery residencies first transitioned from being a fellowship completed after a full general surgery residency to the combined/integrated model due to recognition of the disparity between the training required for a plastic surgery resident and a general surgery resident3. This is most definitely valid. Plastic surgery as a field has evolved exponentially since the American Board of Plastic Surgery first formed in 19374. More and more specialized knowledge and skills are required of plastic surgery residents before we can graduate and act independently as attendings. This requires as much dedicated plastic surgery training as possible; the integrated format is the most effective model through which this can be achieved. However, spending time on general surgery rotations is still valuable.

During my three years spent primarily as a plastic surgery resident learning general surgery, I have progressed from being an intern learning the surgical basics to a third-year resident who has served as chief of multiple general surgery services. It is true that not all of the knowledge I have gained will be directly applicable in my future training. However, so much of what I have experienced will serve me immeasurably in my career as a plastic surgeon. In performing a component separation abdominal wall reconstruction after an exploratory laparotomy, it is undoubtedly helpful to fully understand what your general surgery colleague has encountered. Comprehension of the typical neoadjuvant and adjuvant treatment regimens for breast cancer patients is necessary to safely plan a successful breast reconstruction. Even the skills necessary to tie intracorporeal knots during laparoscopic procedures is remarkably translatable to tying 9-0 suture under the microscope. Myriad other such analogous skills and symbiotic practices abound. Above all, the leadership, time management, and interpersonal skills developed during the experience of serving as chief resident of surgical services are invaluable.

This is certainly not to say that one should devote all of their time to general surgery despite their ultimate goal of becoming a plastic surgeon. Quite the contrary, extra time and effort must be dedicated to laying the foundations to support your future plastic surgery career. The habits developed as a junior resident will set the stage for future success. From intern year onwards, one should strive to attend every weekly plastic surgery Grand Rounds conference, read each monthly volume of  Plastic & Reconstructive Surgery (all of it!), and progress through the Plastic Surgery Education Network curriculum. Studying for the In-Service Examination is intrinsically important in order to score well, but will also advance one’s knowledge of plastic surgery greatly. Recommended resources for In-Service Exam studying, as well as plastic surgery studying in general, is discussed in a separate PRS Resident Chronicles blog post. Lastly, attending select plastic surgery conferences, such as Plastic Surgery: The Meeting, is extremely advantageous early in training (Tips for attending such conferences also found here). This is recommended regardless of residency training organization, no matter if you are a combined resident scrubbing in on a Whipple or an integrated resident about to begin an Oculoplastics rotation.

So, to answer my original question…yes, this all was worthwhile. As nascent plastic surgeons, we must continue to recognize and honor our roots in general surgery while preparing for our futures as interdisciplinary surgeons. Non-plastic surgery services, regardless of how much time is spent on them, are still an important component of our early training of which full advantage should be taken. And with that, I could not be more excited and ready to dedicate 100% of my time to plastic surgery!

References:

  1. Accreditation Council for Graduate Medical Education. “ACGME Program Requirements for Graduate Medical Education in Plastic Surgery.” 10 May 2016.
  2. American Council of Academic Plastic Surgeons. “Pathways to Plastic Surgery.” 10 May 2016.
  3. Pace E, Mast B, Pierson JM, Leavitt A, Reintgen C. Evolving Perceptions of the Plastic Surgery Integrated Residency Training Program. J Surg Educ. 2016 Apr 29.
  4. American Board of Plastic Surgery, Inc. “History of ABPS.” 10 May 2016.
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