AMA Journal of Ethics^®

There are a variety of models of plastic surgery training: the traditional, integrative, combined, and alternative models. A superior training program can be developed in each. Training must focus on all areas and types of surgery, including breast, craniofacial, cosmetic, flaps and pedicles, microsurgery, reconstructive surgery, and upper extremity surgery. The linchpins of a thorough education include a solid foundation of the “prerequisite” general surgery experience, a graduated assumption of responsibility, incorporation of a didactic curriculum into training, use of simulation training, and proper oversight when performing procedures. A well-developed background in general surgery or completion of a full residency in one of the other surgical disciplines instills the basic principles necessary for specialist plastic surgeons. The surgeon-in-training emerges from his or her general surgery training with a level of comfort, independence, and confidence in the operating room and is ready to progress in the specialty.

Throughout residency training, faculty and colleagues play an integral role. Case-based learning, a didactic curriculum, and review of scientific literature via a journal club are essential to imparting knowledge in an ever-changing field. In addition to formal lectures, faculty can demonstrate commitment to professionalism, sensitivity, and ethics, as well as practicing evidence-based medicine when interacting with residents. Training at large multi-center facilities, smaller private centers, and in both the inpatient and outpatient settings helps residents develop an understanding of different patient populations and the different challenges that accompany working in such diverse facilities.

Training in the plastic surgery subspecialties provides the opportunity to acquire the clinical knowledge and the surgery experience specific to each and can help in choosing a professional future. In addition to learning from faculty and colleagues, simulations using mice, cadavers, or novel tools (e.g., microsurgical instruments) allow plastic surgeons-in-training to hone their skills in procedures for which they lack experience. Keeping a log or portfolio of experiences throughout training establishes a forum for self-reflection and elucidates areas of inexperience or weakness (e.g., trauma surgery or cosmetic procedures).

Although the plastic and reconstructive surgical field is constantly changing, a surgeon qualified and experienced in breast, craniofacial, cosmetic, flaps and pedicles, microsurgery, reconstructive surgery, and upper extremity surgery can be appropriately described as a plastic surgeon. Model plastic surgeons, in accordance with the program requirements developed by the Residency Review Committee in Plastic Surgery of the United States Accreditation Council for Graduate Medical Education (ACGME) master the specific specialty competencies in plastic surgery during their postgraduate training. Trainees must also achieve competency in the six core attributes common to all postgraduate training programs: (1) patient care, (2) medical knowledge, (3) professionalism, (4) systems-based practice, (5) practice-based learning and improvement, and (6) interpersonal and communication skills.

Characteristics of Excellence in Plastic Surgeons and Some Role Models

In combination with a comprehensive training program, certain characteristics are valuable in the making of excellent plastic and reconstructive surgeons. Most valuable of these are: integrity, compassion, commitment to excellence, humility, creativity, ingenuity, scientific curiosity, dedication, and humor. Although these intrinsic traits are developed in adolescence and young adulthood, their continued exercise is as imperative to the plastic and reconstructive surgeon as is the technical training. Rich Holt originally described these qualities as fundamental in ideal educators and role models in facial surgery [1], and they are equally critical in exemplary residents and fellows in plastic and reconstructive surgery. With guidance and appropriate mentoring, these attributes, combined with the knowledge and skills of a comprehensive training program, constitute the ideal paradigm for postgraduate training as a plastic and reconstructive surgeon.

The foundation of any healer must begin with integrity. Integrity, though developed early in life, is routinely tested and is influenced by friends, colleagues, and patients throughout our careers. Dr. Lloyd A. Hoffman, the former plastic surgeon in chief at New York-Presbyterian Hospital, continues to impress me as a true model of integrity for physicians across all fields of medicine. Dr. Hoffman consistently makes patients his top priority no matter the circumstances, refusing gratuities and financial inducements that might conflict with patients’ interests.

Compassion and empathy, important in every patient-physician encounter, take on a unique character when it comes to plastic and reconstructive surgery, particularly with trauma patients and those with congenital abnormalities. Sensitivity, support, and understanding of patients’ emotional states associated with their problems are integral to patient care. Although they are hard to teach formally, compassion and empathy are decidedly influenced during training, and, hence, must not be overlooked by residency program administrators and instructors. We can learn from plastic surgeons who have founded service organizations, like Dr. Bill Magee of Operation Smile. By caring for children who cannot gain access to or afford treatment, these surgeons demonstrate compassion on a daily basis. Their teams provide support and a sense of ease for patients and their families. Training in an environment that encourages patient-centered medicine will foster compassion and empathy.

Humility and commitment to excellence are essential in plastic and reconstructive surgeons. Recognizing that perfection is impossible both in life and in medicine, we nevertheless seek to achieve excellence in each individual case we undertake. At the same time, surgeons must understand the limits of their capabilities, hence humility goes hand-in-hand with the commitment to excellence; plastic and reconstructive surgeons must be realistic in their expectations. A lack of humility might lead the surgeon to apply his or her skills in a less-than-safe or inappropriate manner. The proper balance of humility and commitment to excellence creates pride in one’s craft. An example of a plastic surgeon who elevated the quality of plastic and reconstructive surgery while maintaining humility is Dr. Carl R. Hartrampf, Jr., the pioneer of TRAM flap surgery. TRAM flap uses the patient’s own excess abdominal tissue to reconstruct her breast following mastectomy. The TRAM flap transformed breast reconstruction, yet Dr. Hartrampf remains a model of humility for all who have the honor of learning from him.

The degree of creativity, ingenuity, and scientific curiosity that characterize the best plastic and reconstructive surgeons distinguish the subspecialty from others. The ability to approach a problem from a different perspective and to apply emerging science to medicine and surgery benefit patients as well as future physicians throughout all subspecialties. These traits make the plastic and reconstructive surgeon not only a better physician, but an inventor and researcher. The true plastic and reconstructive surgeon, irrespective of age, is constantly searching for a new or better approach to solving problems in life. Residency programs in plastic and reconstructive surgery look for creativity, ingenuity, and scientific application of knowledge in residents and fellows. Embodying these traits allows one’s education to last a lifetime. Dr. Michael Longaker, director of the surgical regeneration program at Stanford University, is an outstanding example; his innovation and creativity, combined with his own brand of ingenuity, have led to new concepts that revise traditional approaches to plastic and reconstructive challenges.

The inclusion of humor among the plastic surgeon’s attributes may sound strange at first. But humor can make an interaction more welcoming and less stressful and can establish a healthier working environment. “Although surgery is a serious business, there are times when it is very appropriate to use humor to put the patient at ease and provide an enjoyable experience for the trainee and the assistants in the office and operatory” [1]. As the stress of medical practice increases and patient expectations do likewise, a good sense of humor can often introduce the necessary “reality check” and help us get grounded. Aside from excellence in technical training, nothing is more satisfying than training with happy individuals.