Pathways to Plastic and Reconstructive Surgery in the United States: Should the Independent Model be Abandoned?

by Efstathios Karamanos, MD
PGY 6 Independent Resident
UT Health San Antonio, San Antonio, TX


There are currently two pathways in the United States for a residency in plastic and reconstructive surgery. One is the integrated pathway, which involves a 6 year- long training immediately after graduation from medical school and the other is the independent pathway, which involves a 3 year ‘fellowship’ following a five year residency in another surgical specialty, most commonly general surgery. There has recently been a trend for many programs to switch from the independent model to the integrated one. This trend has been observed as well in other surgical specialties over the country, such as cardiothoracic surgery, vascular surgery, etc. While many advocate for the superiority of the integrated model, others argue the opposite. But, is one model better than the other? Here are some of the arguments of the proponents and the adversaries of the independent model:

THE INTEGRATED PATHWAY ATTRACTS BETTER APPLICANTS 

Advocates of the integrated model argue that the pool of applicants has usually a better academic record: higher USMLE Step 1 and 2 scores, more likely to be AOA, better research experience and academic achievements overall. This might be true in recent years, after the advent of the integrated pathway since good, qualified applicants prefer to concentrate on the specialty they are more interested in, rather than going through another tedious and demanding surgical residency prior to plastic surgery. In addition, candidates that pursue an independent training model, may sometimes have tried but failed to match into an integrated residency in the past. 

THE INTEGRATED MODEL GIVES YOU THE ABILITY TO ‘MOLD’ THE RESIDENT TO YOUR LIKING

Certainly, training a resident to become a plastic surgeon straight from medical school, provides a tabula rasa, that teachers can formulate and mold into the ‘ideal’ plastic surgeon. That may not hold true for the independent model, where five years of training has already molded a mature surgeon who might experience difficulties erasing ‘old ways’ for the sake of new techniques that are more in alignment with the plastic surgery mentality.

THE INDEPENDENT PATHWAY ATTRACTS MORE MATURE SURGEONS

Proponents of the independent pathway argue that independent residents are more aware of the surgical life, have a better understanding of what being a surgical resident means and are less likely to drop out of residency. Independent residents have gone through a very demanding surgical residency before and are less likely to be surprised by the workload of a plastic surgery residency. 

THE INDEPENDENT PATHWAY HAS MORE TECHNICALLY SKILLED RESIDENTS

As expected, independent residents are fully trained surgeons and have already a good understanding of basic and advanced surgical techniques. This might be a major advantage for some program directors since they may be more interested in creating a ‘seasoned’ plastic surgeon by modifying or further expanding the surgical skills of the trainees, rather than teaching them basic skills from scratch. 

INDEPENDENT RESIDENTS HAVE MORE CONFIDENCE IN TREATING PATIENTS 

While people may argue that a chief year in another surgical specialty creates a plastic and reconstructive surgery resident that is able to deal with complex surgical issues in a more effective way, others may argue that this may result in a less enthusiastic junior resident. Independent residents, depending on their previous surgical training background are more likely to be able to treat life threatening conditions with confidence and experience compared to their integrated counterparts.

INTEGRATED RESIDENTS ARE MORE LIKELY TO PURSUE A FELLOWSHIP

Integrated residents are more likely to pursue an academic career and/or pursue a fellowship after the completion of their plastic and reconstructive surgery residency. This may be attractive to program directors, especially if they are interested in promoting academic surgery. 

INDEPENDENT RESIDENTS ARE MORE LIKELY TO PICK PLASTIC SURGERY FOR THE RIGHT REASONS 

Integrated applicants are often immature and do not have adequate exposure in the field of plastic and reconstructive surgery; they might show interest in the specialty for the wrong reasons. This might result in a higher attrition rate. Independent applicants on the other hand, have a deep understanding of surgery and often have been exposed as residents in the field of plastic surgery beforehand. 

In conclusion, while there are pros and cons in both models, most programs are switching over to the integrated pathway. This might become a missed opportunity both for applicants and programs alike, when a well – qualified independent applicant realizes his/her passion for plastic and reconstructive surgery later during training. A combination of both models may still remain the most viable option for the future. 

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