by Jordan Frey & Stelios Wilson
Plastic surgery is based on problem solving and innovation. As such, research is not merely an adjunct, but rather a pillar, to what we do and how we evolve as a discipline. It is important, then, to be introspective in examining how we as a specialty are performing academically. Duquette et al. do just this in their article, “Do Plastic Surgery Programs with Integrated Residencies or Subspecialty Fellowships Have Increased Academic Productivity?” The authors therein examine the academic productivity of plastic surgery departments and divisions in the United States while comparing them to other surgical disciplines. They also determine factors that are associated with increased productivity using publications, citations, h-indices, and NIH funding as metrics of academic contribution.
In all, the authors find that plastic surgeons had less publications and citations than their general surgery or sub-specialty colleagues. When productivity was stratified by the presence or absence of NIH-funding, there was a greater percentage of non-NIH-funded plastic surgeons that diminished the median academic productivity of overall plastic surgeons. The authors offer multiple possible explanations for the decreased academic output of plastic surgeons. They cite the decreased number of academic plastic surgeons compared to other surgical specialties and increased economic pressure that may influence surgeons to focus more on clinical duties, eschewing research activity.
While these findings are concerning for budding academic plastic surgeons, perhaps a more important discourse is then undertaken. The authors show that integrated residency programs tend to be more productive than their traditional counterparts. Likewise, departments with craniofacial and hand fellowships were more productive than those without these fellowships. Faculty plastic surgeons with an integrated residency program were also more likely to have procured NIH funding.
A simple explanation for this discrepancy is offered: candidates entering an integrated residency program are intrinsically more academically motivated and that is why they are seeking an integrated program in the first place. Therefore, they are likely to have already partaken in significant academic pursuits in an effort to appear attractive to top residency programs and are apt to continue these endeavors. Unfortunately, there is no way to definitively delineate this causation over the correlation established by the authors. There are noteworthy limitations in the study that are acknowledged by the authors, such as the inability to determine the number of residents in a program, to evaluate the influence of microsurgery or aesthetic fellowships, or to quantitate funding from sources other than the NIH. The quality of the academic output utilized for the study was likewise unable to be evaluated. Lastly, the authors look for productivity only in academic plastic surgery departments, which eliminates the sometimes significant contributions from plastic surgeons in non-academic practices.
The findings described in this article are important for members of all levels of the plastic surgery community. The goal of all plastic surgeons, regardless of affiliation with an academic institution or not, is to advance the field and curate a younger generation of plastic surgeons. Duquette et al. highlight gaps both between plastic surgery and other surgical specialties as well as within the plastic surgery community. Once identified, the logical next step becomes: what can be done to ameliorate these disparities and advance our field into the future?
While most programs have converted to an integrated pathway for training residents, there are still a large number of programs that have yet to make the transition. Meaningful research takes time to perform. In addition, meaningful relationships between residents and their mentors also take time to develop. As mentioned by the authors, transitioning from a 3-year fellowship to a 6- or 7-year integrated residency facilitates both of these processes. Moreover, a previous study has demonstrated the differing goals and outlooks of residents and their attending mentors1. The importance of establishing symbiotic mentor-mentee relationships is imperative in resident education but also in maximizing academic productivity. A hard-working, ambitious resident can learn to be academically productive from an established attending in an association that will benefit both parties. Working to craft and enhance these relationships should be a goal of all residency programs.
This study also shows that there is a clear difference in academic productivity among plastic surgery faculty. Specifically, there is a positive association between mean publication/citations from assistant professor, to associate professor, and finally to professor. This finding is not surprising as academic promotion is based on multiple factors – one of which is academic productivity. Therefore, residents seeking employment in an academic practice, or even current faculty pursuing eventual promotion, should surmise that publications and citations are paramount for future success. While this notion is likely intuitive for most, its confirmation in this study emphasizes the importance of pursuing academic activity early in one’s career.
Programs also need to focus on matching compatible residency candidates into their residencies. This is easier said than done with a variety of parameters such as test scores, clerkship grades, and letters of recommendations serving as proxies for future success as a clinical resident. While previous publications may foreshadow research inclination, perhaps the best indicator of a candidate’s future academic productivity is the “eye test” performed by an experienced department chair, program director, or faculty member. The importance of refining this imperfect process is again highlighted in the article. Medical students with ambitions for academic productivity will be best suited in residency programs committed to training the future leaders in plastic surgery. By maximizing these matches, the academic productivity of the entire specialty can flourish.
Academic performance in plastic surgery departments can also be advanced through research funding with a focus on higher level funding. Interestingly, the authors found that, of all surgical faculty with low-level NIH grants, plastic surgeons faired worst. In contrast, plastic surgery faculty who obtained large NIH grants (R01/U01/P01) had the highest level of academic productivity. It has been previous reported that the median priority score and funding rates for RO1 applications were less favorable for clinical research than for nonclinical research2. Taken together, plastic surgery divisions/departments should continue to promote basic science research as part of their comprehensive academic mission.
Lastly, this study serves an importance notice to residency candidates, especially those interested in pursuing a career in academic plastic surgery. As noted by the authors, a previous study found that residents in traditional plastic surgery fellowships are less likely to pursue additional fellowship training, which in turn, makes them less likely to pursue a career in academic plastic surgery3. Taken together, individuals who may be interested in academic plastic surgery should work hard to match into an integrated residency program, especially one with fellowship programs.
Overall, Duquette et al. should be commended for their thought-provoking article. The information presented can help residency and fellowship candidates to more objectively rank programs. Conversely, faculty members who ultimately choose their residents and fellows have an incentive to choose those with strong potential for academic output in an effort to maximize their joint productivity during a relatively short training period. It is incumbent on the entire plastic surgery community to continue advancing our specialty into the future with high-quality research focused equally on self-assessment and innovation.
- Koltz PF, Frey JD, Sbitany H, Bell DE, Iannuzzi JC, Song DH, Langstein HN. Employment Satisfaction in Plastic and Reconstructive Surgery and Its Influence on Graduating Residents in an Evolving Health Care Climate. Plast Reconstr Surg. 2015 Jul;136(1):96e-105e.
- Imahara, S. D., Scott, J. R., Neligan, P. C. Career Plans of Graduating Plastic Surgery Trainees in 2009: The Impact of an Uncertain Economic Climate. Plastic and Reconstructive Surgery 2009;124:2173-2178.
- Kotchen, T. A., Lindquist, T., Malik, K., Ehrenfeld, E. NIH peer review of grant applications for clinical research. JAMA 2004;291:836-843.