by Safi Ali-Khan, BA and Jordan Frey, MD (@JordanFreyMD)
One of the principal characteristics of plastic surgery is its diversity, both technical and personal. Dubbed by some as “the surgeon’s surgeon,” plastic surgeons are known for their resourcefulness, expansive funds of knowledge, and willingness to challenge convention. As a result, they are privileged to be able to help both patients and fellow physicians in an enormous variety of situations.
Like the specialty, individual plastic surgeons are incredibly varied with respect to their career paths, interests, and stances on issues related to the practice and teaching of their craft. However, there are few forums in which plastic surgeons have opportunities to openly share these thoughts and experiences with their peers and with others who are interested in the field. In this series, we have interviewed several residents and attendings from the Hansjörg Wyss Department of Plastic Surgery at NYU Langone Medical Center, in an effort to create a space where stories, advice and ideas can be shared between past, present and prospective plastic surgeons.
Included in this first entry are excerpts from conversations with plastic surgery residents: Joshua Mirrer (PGY6), Sammy Sinno (PGY6), Brad Hill (PGY5), Jordan Frey (PGY4), Z-hye Lee (PGY3) and Ara Salibian (PGY2).
On What First Motivated Them to Pursue Plastic Surgery:
JM: I knew I wanted to be a surgeon, I knew I wanted to operate, I really enjoyed it, and it was sitting down with Court Cutting, my first time scrubbing in on cleft lip and palate, where he actually took the time to explain things in a way you can understand as a medical student, not in terms of referencing anatomy that is complex and over your head, but understanding it in terms of geometry, and I really took to that, and his patience in explaining it to me was incredible, as was the fact that he was able to do that and explain this in a complex way to the resident and fellow that were there…And I thought that I wanted to be a craniofacial surgeon, I liked the intricacies of the surgeries, the techniques, the anatomy, the fact that you had a patient essentially lifelong, from the time that they’re three months old to the time that they’re 21; there are very few surgical specialties where you get to have that, and along the way my path has led me in a different direction from craniofacial but I still appreciate all of those things just the same. Plastic surgery is very different from any other surgical subspecialty, outside of the fact that we operate from head to toe and the fact that we’re masters of anatomy, the real thing is that you develop a long-term relationship with your patients.
JF: Beginning in medical school, I really had no idea what plastic surgery even was. I was scheduled to do an elective in neonatology and, last minute, I changed it to a plastic surgery elective 2 or 3 days beforehand. The first day, I saw Dr. Girotto do a Furlow palatoplasty and I was sold. I thought it was amazing how you could move tissue to recreate normal anatomy. After that, I really dove in to all that plastic surgery entailed and fell in love with everything. I had incredible resident and attending mentors in medical school and now in residency that encouraged me and fostered that love. I think that’s the most important thing for prospective students interested in plastic surgery is to find good mentors. It’s as easy as just expressing your interest and showing that you mean it.
SS: What got me interested in plastic surgery was number one the ability to operate in different parts of the body because I loved anatomy so much – I was very curious about the opportunity to do surgeries not just in one limited area – and number two, to me it represented the only surgical subspecialty where a creative and artistic sense was valued and actually very important in almost every operation.
ZL: I kind of stumbled my way in accidentally – I thought I maybe wanted to go into psychiatry or pediatrics when I first came to medical school – but during my general surgery rotation I happened to see a few pretty standard, but at that time pretty novel procedures, like I saw a DIEP for example. But actually, it was the residents that I worked with at that time that really got me interested. They were the happiest, nicest, most intelligent and willing to teach, and I was like ‘Wow, I kinda want to be like one of them!’ Then I did a follow up rotation and realized that I actually liked doing all of the different procedures that are involved in plastics and what it’s about. But I would say what really got me interested was being introduced to the residents.
AS: I was also jumping around a little, but it really came down to what plastic surgeons do every day. I am obsessed with anatomy, and when I saw the meticulous detail in which plastic surgeons understood anatomy, probably more than any other surgical specialty, I was sold. Plastic surgery has a comprehensive and detailed understanding of anatomy, and even more so how to manipulate it; how to mold and alter it to treat the patient. I thought that was really amazing – not just cutting things out or removing things, but actually using the body’s anatomy in different ways to solve problems. I think that’s a very unique thing about plastic surgery, and you’re doing it from head to toe, you’re not operating in a small area the rest of your life and have the freedom to work on just about every part of the body. It’s an amazing specialty.
On Learning and Teaching Efficiently as a Plastic Surgery Resident:
ZL: The important thing as a resident for teaching is sometimes the time pressure can obviously be a factor, so both learning how to teach on the go – taking those 15-20 minutes before a case starts and you’re just hanging out, taking those moments to teach informally – but then on the flip-side, the residents that really made a difference are the ones who set aside half an hour or one hour, picked a topic and made a point so that everyone was familiar with the topic. So I think doing both the structured and unstructured is important and can be equally effective…One thing I didn’t really appreciate when I was a medical student was videos, because there are a lot of things that you can’t see and you’re not going to be exposed to, but videos are a good substitute in a lot of ways. You may not be actually doing it, but still it’s much more effective than just reading. Reading it and then seeing it is key. And then the best thing is if you can see it live the following day, that’s really the icing and when a lot of it starts to come together.
JM: Ultimately, when you’re going through your residency and as you get higher and higher up in your level of education there are certain things that just happen to click, and it’s a bit of a confluence of everything that you’ve done along the way – the combination of reading, the combination of seeing things repeatedly – and then one year after the next things begin to click into place and make more sense surgically. Everybody talks about this idea of surgical planes and you have no idea what anybody is talking about when you first start off as a medical student, you barely understand it as an intern, but once you reach your more senior years you’re like, ‘Oh yes, now I get it, now I completely understand what everyone is referring to,’ because your eyes are now exposed and experienced and so you can begin to parse out what everybody else was talking about. It’s almost like The Matrix you know, you have to see it for yourself, you can’t really believe it until you understand it…Surgery is a 3D mindset, and to read things in a two-dimensional setting makes things very difficult. When you have a text talking about landmarks, unless you know specifically where those landmarks are in reference to, to make that 3D image in your head becomes very difficult because you have no frame of reference, so that’s where videos come in handy because you can actually gain perspective and gain an understanding of what everything is in a three-dimensional space.
On What They Would Say to Medical Students Who are Considering Plastic Surgery:
SS: I would say that plastic surgery remains the most creative, exhilarating, and fun surgical subspecialty, and my advice would be that you have to be very versatile as a plastic surgeon and therefore it’s really important in medical school to do as well as you can in everything. It’s important to be as good as you can be in psychiatry, in pediatrics, in internal medicine and general surgery because our patient care will be better if we’ve mastered the concepts that you learn on those core rotations. I think a plastic surgeon has to be well rounded, so it’s really imperative that for each rotation in medical school you give your best effort.
JM: Get involved, and get involved early. Introduce yourself to the plastic surgery division, and really make an effort to getting to know the surgeons that are a part of that division. Not just the chief, but also the individuals. Also, there are likely residents that are passing through that program that are interested, or are applying to plastic surgery – introduce yourself to them, find out who they are and get involved in research…Be proactive. Go out and explore. Don’t hold yourself to a specific region unless you have to. Explore the West coast if you’re from the East coast, explore the East if you’re from the West, head down South, look at all these programs and don’t shy away from anyone in particular. [Sub-internships are] your chance to see not just where you want to practice and learn medicine for six years but also where you want to live, and that’s a huge thing that you may never have another chance at.
BH: When you’re thinking about specialties, as a medical student it’s so hard because you work so much with residents and you don’t really see the practice as a whole. When you’re thinking about a practice in general, you should first think, do you want to do something procedural or nonprocedural? And then the next question should be surgical or nonsurgical. If you think that you could be happy and fulfilled, and that you wouldn’t have regrets, doing something that’s nonprocedural, or at least nonsurgical, I think that that’s probably a safe bet, I really do. But if you have a drive and a desire and you’re never going to be satisfied or happy, or you’re going to have regrets – like when I talk to people in ER who are like, ‘Man I wish I had done surgery,’ or ‘I wish I had done plastics’ – if you feel like you’re going to have those regrets then I think you should go for it. There are people that say, ‘Oh I’m not at a top tier school,’ or etcetera – I wouldn’t let any of that get anybody down…Mentors are so important, even just identifying mentors. If you can get the right mentors you’ll succeed at anything. For that reason I think it’s so important to also be a mentor. It’s all about trying to help people make the right choice, help people succeed, that’s what medicine has always been about from the beginning. Look at the people that you identify with and you like, ask them why they like what they’re doing, and that’s a good way to make decisions.
On Major Factors They Considered When Choosing Residency Programs:
BH: With plastics we have the benefit that all accredited programs are really good. It’s so difficult to obtain accreditation as a plastic surgery training program that I really don’t think you can go wrong with any program. How I went into it was that I wanted to train somewhere that was really strong across the board – didn’t just meet minimums everywhere but was strong everywhere. I didn’t want to go into it saying, ‘Oh you know I really like lower extremity reconstruction, so I’m just going to go somewhere that really is good with lower extremity and trauma and I don’t really care if they’re good with head and neck or craniofacial.’ What I liked about NYU and a handful of other programs was that they were really all-around comprehensive programs.
SS: For me the biggest factor was technical training at that time, because for me as a medical student, I think like most medical students, your main objective and goal is to be at a program where you feel that your technical training can be superb. The other main factor for me was going to a program that was well rounded. I really wanted to go to a program that had strengths in all four of what I call pillars of plastic surgery, meaning reconstructive/microsurgery, hand surgery, craniofacial surgery, and aesthetic surgery. I think that that’s important because it’s very difficult as a medical student to know what subspecialty interests you’re going to have unless you actually see a lot in all four of those different spectrums.
Words of Advice for Junior Plastic Surgery Residents:
JM: For the interns, rising second years, you guys are almost done with your first year. It’s a huge accomplishment to finish your intern year with your head on straight. There’s a lack of sleep, lack of desire to do anything, you’ve sacrificed time with friends, time with family, and there’s a lot more to come, but remember where you came from and remember where you’re going.
The R2s – you guys have it made…There’s a lot in front of you, a lot’s changing, but changing for the better. Again, you’re still deep in a hole, you’ve got a long road ahead of you, another four years to go, but you guys are set.
For the R3s – fourth year is hard. It’s like drinking from a firehose, no matter who you are, no matter what program you’re coming from. There’s a lot of knowledge coming at you, faster than you’ve ever absorbed it, and not all of it will stick, and that’s okay. That is okay, and you should keep that in mind.
And for the new integrated junior classes, you guys are well ahead of the curve…Don’t lose sight, no matter what, do not lose sight of your goal, of the reason why you came into plastic surgery, the reason why you came into residency and the program that you’re a part of. Remember the feeling you had as a medical student exploring plastic surgery. Do not lose track of that in your own head, because it’s very easy to get bogged down by the roles, responsibilities, pressure, anxiety, etc. that comes with being a resident.
BH: Residency is fine, anyone can put in the work and do the hours and study, but the challenge is not just being a resident, but being a husband, being a father, and balancing those things without compromising…I knew it was going to be challenging, but it’s even more challenging than I thought it was going to be…it’s important to recognize that when you’re doing it, that you need to be present when you’re with your family, and when you’re in the hospital you need to be 100% focused on what’s in front of you, and I think that’s probably a guiding principle of maintaining sanity.