the diminishing presence of plastic surgeons

7/29/2019 The Diminishing Presence of Plastic Surgeons

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SPECIAL TOPIC

The Diminishing Presence of Plastic Surgeonsin Hand Surgery: A Critical Analysis

James P. Higgins, M.D.Baltimore, Md.

Background: A growing trend of diminished presence of plastic surgery withinthe field of hand surgery has been observed in the membership of the AmericanSociety for Surgery of the Hand, applications for Certificate of Added Quali-fications in Surgery of the Hand, and applications for hand surgery fellowships.Methods: The American Society for Surgery of the Hand resident educationsubcommittee has investigated this trend, collecting data from the Associationof American Medical Colleges, the American Board of Orthopaedic Surgery, the

American Board of Plastic Surgery, the National Residency Matching Program,the Accreditation Council for Graduate Medical Education, the American So-ciety for Surgery of the Hand, the American Association of Hand Surgery, andthe Certificate of Added Qualifications in Surgery of the Hand and from anonline survey of plastic surgerytrained hand surgeons in the United States.

Results: These data indicate that the subspecialty of hand surgery enjoys grow-ing popularity with increasing fellowship applicants annually; uses an effective,fair, and multidisciplinary match; and demonstrates continued and healthygrowth in its premier academic society. Despite these positive indicators, thepercentage of new plastic surgery diplomates obtaining Certificate of AddedQualifications in Surgery of the Hand has decreased from 10 percent (20applicants per year) to 4 percent (8 applicants per year), the percentage ofexaminees for the Certificate of Added Qualifications in Surgery of the Handoriginating from plastic surgery training backgrounds has decreased from 30percent to 15 percent, the percentage of the overall body of actively practicingplastic surgeons in the United States that hold Certificate of Added Qualifica-tions in Surgery of the Hand qualifications is steadily decreasing (now to 10percent), and the plastic surgery membership in the American Society for

Surgery of the Hand is demonstrating negligible growth despite the overallexpansion of the American Society for Surgery of the Hand.Conclusions: This report serves as a detailed and systematic account of thesefindings, a balanced interpretation, and a proposal of specific potential solutions.These include recommendations forchanges in thestructure and content of plasticsurgery training programs and the National Residency Matching Program handsurgery fellowship designations. (Plast. Reconstr. Surg. 125: 248, 2010.)

T

he Curtis National Hand Center in Balti-more, Maryland, maintains a faculty of 14full-time hand surgeons training five hand

surgery fellows annually in an Accreditation Coun-cil for Graduate Medical Educationaccredited

fellowship program. Its founders represented themultidisciplinary crossroads that engendered thespecialty of hand surgery, with backgrounds in

orthopedic, general, and plastic surgery. The fel-lowship program has preserved this multidisci-plinary approach since its inception in 1975. Thebelief that the field of hand surgery would bestbenefit by the cross-pollination of these disciplinesrepresented the foundation of the Curtis NationalHand Centers training model and contributed to

From the Curtis National Hand Center and the ResidentEducation Subcommittee of the American Society for Surgeryof the Hand.Received for publication January 12, 2009; accepted June29, 2009.Presented in part at the November 1, 2008, meeting of theAssociation of Academic Chairmen of Plastic Surgery, inChicago, Illinois.Copyright 2009 by the American Society of Plastic Surgeons

DOI: 10.1097/PRS.0b013e3181c496a2c

Disclosure: The author has no financial relation-ships or interests to disclose related to this project.

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its success as a clinical center and academic train-ing site.

Over the past 10 years, the Curtis NationalHand Center has experienced increasing diffi-culty finding high-quality fellowship applicantswith plastic surgery backgrounds. The Center has

seen a general increase in total number of candi-dates, and applications specifically from plasticsurgery trainees have decreased (Table 1).

A review of matriculated hand fellows over thepast few decades demonstrated that the CurtisNational Hand Center has enrolled a ratio of or-thopedic to plastic surgery-trained hand fellowsthat was in keeping with a ratio of applicationsreceived (or demonstrating a slightly imbalancedratio in favor of plastic surgery) (Table 2). Thisdispelled concerns that the Curtis National HandCenter may have been viewed as a fellowship that

was unfriendly to plastic surgery applications.National Residency Matching Program data

demonstrated that the Curtis National Hand Cen-ter received applications from roughly 50 percentof hand surgery fellowship applicants in the na-tionwide pool annually (Table 3).1 Furthermore,the Curtis National Hand Center received appli-cations from 25 to 73 percent of the small annualnumber of hand fellowship applicants from plasticsurgery residency programs, with the highest per-centage being in 2006 (Table 4).2 This indicatedthat the decreasing number of plastic surgery ap-

plicants to the Curtis National Hand Center couldbe indicative of a nationwide trend whose origins,causal factors, and potential corrective solutionsmerited further investigation.

Colleagues from other U.S. academic handsurgery training programs have voiced similar con-cerns. The specialtys premier academic body, theAmerican Society for Surgery of the Hand, pro-vided a springboard for an organized investigationof this issue. As a representative of the AmericanSociety for Surgery of the Hand resident educationsubcommittee,theauthorbegan this investigation in

2007. Data were collected from the Association ofAmerican Medical Colleges, the American Boardof Orthopaedic Surgery, the American Board ofPlastic Surgery, the National Residency MatchingProgram, the Accreditation Council for GraduateMedical Education, the American Society for Sur-gery of the Hand, the American Association ofHand Surgery, the Certificate of Added Qualifi-cations in Surgery of the Hand Examination Com-mittee of the Joint Committee on Surgery of theHand, and an online survey of plastic surgery

Table 1. Curtis National Hand Center Fellowship Applicants, 2001 to 2010

Academic YearTotal

ApplicantsOrthopedicSurgery (%)

PlasticSurgery (%)

GeneralSurgery (%)

20012002 45 36 (80) 7 (16) 2 (4)20022003 40 32 (80) 6 (15) 2 (5)20032004 41 34 (82) 6 (15) 1 (2.4)20042005 57 47 (82) 7 (12) 3 (5)20052006 32 27 (84) 3 (9) 2 (6)20062007 59 43 (72) 11 (18) 5 (8)20072008 49 42 (85) 4 (8) 3 (6)20082009 50 37 (74) 5 (10) 8 (16)20092010 74 59 (80) 5 (7) 10 (13.5)Totals 447 357 (80) 54 (12) 36 (8)

Table 2. Curtis National Hand Center Fellows, bySpecialty, 1998 to 2010*

AcademicYear

PlasticSurgery

OrthopedicSurgery

19981999 1 219992000 1 2

20002001 2 120012002 2 120022003 320032004 1 220042005 320052006 1 220062007 420072008 1 320082009 1 320092010 2 2Totals 12 (30%) 28 (70%)

*Data exclude U.S. Military Curtis National Hand Center fellows.Note that in 2006, civilian fellowship slots increased from three tofour.

Table 3. Curtis National Hand Center Applicantsamong All Applicants Nationwide, 2002 to 2009

Training Year CNHC Applicants/All Applicants (%)

2002 40/88 (45)2003 41/90 (46)2004 57/102 (56)2005 32/80 (40)2006 59/133 (44)2007 49/142 (35)2008 50/127 (39)2009 74/150 (49)

CNHC, Curtis National Hand Center.

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trained hand surgeons in the United States. Thefollowing report serves as an account of these find-ings, a balanced interpretation, and a proposal ofspecific potential solutions.

The purpose of this report is to stimulate dis-cussion among the community of academic plasticsurgery about this trend. An overview of the cur-

rent pathway of a plastic surgery trainee throughhand fellowship, certification, and academic soci-ety membership will provide a clear understand-ing of the subsequent data and assessment.

THE STRUCTURE OF HAND SURGERYFELLOWSHIP TRAINING IN THE

UNITED STATESHand surgery fellowships in the United States

are of 1 years duration. Residents completingtraining programs in orthopedic surgery, plastic

surgery, and general surgery are eligible for ap-plication to these training programs. Applicationsare due in December and interviews are held be-tween February and April for matriculation in anacademic year 18 months after the application duedate. Thus, in a 5-year training program, a residentwould apply for the position in December of theirpostgraduate year 4; in a 6-year program, residentswould apply in December of their postgraduateyear-5 training year, and so forth. There are 143Accreditation Council for Graduate Medical Edu-cationaccredited fellowship positions in 70 pro-

grams around the country.3

Of these 70 programs,55 are designated orthopedic hand fellowshipprograms, 14 are designated plastic surgeryhand fellowship programs, and one is designatedgeneral surgery hand fellowship program. Thesedesignations seem to have been assigned accord-ing to the board certification of the fellowshipdirectors of each program. There exists no corre-lation between these designations and the eligi-bility requirements for applicants. There are nohand fellowship training programs of which theauthor is aware that officially or unofficially accept

applications from only one discipline. Only five

institutions in the United States maintain twohand fellowship training programs (2008 match)with separate designations of plastic surgery handfellowship and orthopedic surgery hand fellow-ship: the University of Pittsburgh Medical Center,Massachusetts General Hospital, Washington Uni-

versity Medical Center, Beth Israel DeaconessMedical Center, and Baylor University MedicalCenter. The remaining majority of other U.S. in-stitutions housing hand fellowships maintain onlya single program.

CURRENT STATUS OF THEFELLOWSHIP NATIONAL RESIDENCY

MATCHING PROGRAMOf the 70 Accreditation Council for Graduate

Medical Educationaccredited hand surgery fel-lowships, 62 (89 percent) participate in the Na-

tional Residency Matching Program encompass-ing 135 of the 143 Accreditation Council forGraduate Medical Educationaccredited posi-tions (94 percent).3,4 Only eight of the Accredita-tion Council for Graduate Medical Educationaccredited programs do not participate in theNational Residency Matching Program. The othersubspecialty pathways of plastic surgery do notparticipate with the National Residency MatchingProgram, with the exception of ophthalmic plasticand reconstructive surgery (16 programs and 16positions, not Accreditation Council for Graduate

Medical Educationaccredited).1

ADDITIONAL QUALIFICATIONS ANDSOCIETY MEMBERSHIP AFTER

COMPLETION OF HAND SURGERYFELLOWSHIP

The Certificate of Added Qualifications in Sur-gery of the Hand began in 1986 when the Amer-ican Board of Medical Specialties authorized itsadministration by the American Board of Surgery,the American Board of Orthopaedic Surgery, andthe American Board of Plastic Surgery. (The

American Board of Plastic Surgery refers to theCertificate of Added Qualifications in Surgery ofthe Hand as the Subspecialty of Surgery of theHand Certification. The American Board of Sur-gery refers to it as Surgery of the Hand Certifica-tion. In this article, it is referred to as the Certif-icate of Added Qualifications in Surgery of theHand, the certificates most widely recognizedmoniker.) Applicants must be diplomates of theAmerican Board of Surgery/American Board ofOrthopaedic Surgery/American Board of PlasticSurgery, maintain an active practice in hand sur-

gery for at least 2 years, and have completed a

Table 4. Curtis National Hand Center Plastic andOrthopedic Surgery Applicants among FellowsTrained Nationally, 2002 to 2006

Training YearOrthopedic Surgery

Applicants (%)Plastic Surgery

Applicants (%)

2002 32/61 (52) 6/14 (43)

2003 34/73 (47) 6/20 (30)2004 47/83 (57) 7/15 (47)2005 27/77 (35) 3/12 (25)2006 43/104 (41) 11/15 (73)

Plastic and Reconstructive Surgery January 2010

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1-year Accreditation Council for Graduate Medi-cal Education hand surgery fellowship. This des-ignation does not impart any legal privileges orlicense to practice hand surgery. It is intended asa means of recognition of additional training,commitment, and contribution to the field.

There are two American academic societies forthose specializing in hand surgery. The AmericanSociety for Surgery of the Hand is the larger so-ciety, with 2594 members (2007 data). This societyrequires that a hand surgeon hold a Certificate ofAdded Qualifications in Surgery of the Hand foreligibility for membership. The American Associ-ation of Hand Surgery has 533 members (2008data) and does not require Certificate of AddedQualifications in Surgery of the Hand qualifica-tions for membership. The relative makeup andmembership of these two societies is shown in

Figure 1.5This framework provides a means of studying

the decreasing presence of plastic surgery in handsurgery. The following data pertain to variousstages of training and certification in hand surgeryand are aimed at addressing possible causes forthis trend.

RELATIONSHIP IN NUMBER OFORTHOPEDISTS TO PLASTIC

SURGEONS PRODUCED ANNUALLYAccreditation Council for Graduate Medical

Education 2007 residency data demonstrate 617graduates from 152 accredited U.S. orthopedicsurgery programs, whereas plastic surgery created

193 graduates from 89 accredited programs. Thisorthopedic surgerytoplastic surgery ratio(3.2:1) of diplomates has been consistent for thepast two decades (Fig. 2).6 This would indicate thatthe changes observed in hand surgery are notattributable to changes in their parent specialties.

POPULARITY OF HAND SURGERY AS ASUBSPECIALTY

National Residency Matching Program resultsfrom 1993 through academic year 2009 demon-strate increasing popularity of hand surgery as asubspecialty, with the most recent match witness-ing a record high number of applications of 150(Fig. 3).4 This indicates that the changes observedin hand surgery are not attributable to a generaldecline in interest in hand surgery as a subspe-cialty field.

TRENDS OBSERVED IN THECERTIFICATE OF ADDED

QUALIFICATIONSThe number of Certificate of Added Qualifi-

cations in Surgery of the Hand certificatesawarded each year shows a decline in the plasticsurgerytrained Certificate of Added Qualifica-tions in Surgery of the Hand applicants, most re-cently dropping to less than 10 applicants in 2007(Fig. 4).7 Figure 5 demonstrates each of the sub-specialties in the overall pool of examinees for theCertificate of Added Qualifications in Surgery ofthe Hand by percentage, reflecting a decrease inthe percentage of applicants from plastic surgery,

Fig. 1. American Society for Surgery of the Hand and American Association of Hand

Surgery membership, by specialty, for 2007 to 2008. Note that the number of hand sur-

geons holding membership in both societies is unknown.


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whereas the percentage of applicants from ortho-pedic surgery is steadily increasing.8 If the numberof Certificate of Added Qualifications in Surgeryof the Hand examinees is calculated as a percent-age of new diplomates from each of the two major

subspecialties, a concerning trend can be ob-

served. Figure 6 demonstrates this percentage ofnew diplomates from Accreditation Council forGraduate Medical Educationaccredited plasticsurgery programs obtaining the Certificate ofAdded Qualifications in Surgery of the Hand de-

clining to a record low of 4.05 percent in 2007, in

Fig. 2. Orthopedic and plastic surgery diplomates from 1988 to 2007.

Fig. 3. Number of applicants to the National Residency Matching Program hand surgery match from 1993 to 2009.

Fig. 4. Certificate of Added Qualifications in Surgery of the Hand awarded from 1990 to 2007, by subspecialty training.


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contrast to the percentage of new diplomates from

orthopedic surgery obtaining the Certificate ofAdded Qualifications in Surgery of the Hand re-maining steady.

The cumulative number of actively practicingplastic surgeons in the United States maintainingCertificate of Added Qualifications in Surgery ofthe Hand certification has effectively leveled off(Fig. 7). The percentage of active plastic surgeonsholding a Certificate of Added Qualifications inSurgery of the Hand is now trending downward to10.99 percent in 2007 (Fig. 8). This trend does notappear to be occurring in orthopedic surgery,

where the cumulative number of active surgeons

holding a Certificate of Added Qualifications in

Surgery of the Hand is steadily rising (Fig. 9).9

TRENDS OBSERVED IN ACADEMICSOCIETIES

To thoroughly assessparticipation of hand sur-geons in professional societies, the author at-tempted to obtain annual data from both theAmerican Society for Surgery of the Hand and theAmerican Association of Hand Surgery. The latteris thought by some to be more oriented toward theplastic surgery hand surgeon than the AmericanSociety for Surgery of the Hand. Indeed, the ratio

of plastic surgeons to orthopedic surgeons in

Fig. 5. Certificate of Added Qualifications in Surgery of the Hand examinees, percentage by specialty from

1989 to 2006.

Fig. 6. Newdiplomates obtaining Certificate of Added Qualifications in Surgery of theHand,percentage by specialty from 1995 to

2007.


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American Association of Hand Surgery member-

ship in 2008 was approximately 1.7:1. Unfortu-nately, no trends could be extracted becausedata on American Association of Hand Surgerymembership over the past decade are not avail-able. Furthermore, it is common practice forhand surgeons to hold membership in both so-cieties, and the magnitude of this crossover isunknown. Therefore, calculating cumulativedata on numbers of hand surgeons from eachsubspecialty as a sum of the two separate soci-eties would be inaccurate and misleading. TheAmerican Society for Surgery of the Hand is

approximately five times larger than the Amer-

ican Association of Hand Surgery. Although the

ratio of orthopedic surgeon members to plasticsurgeon members is higher in the AmericanSociety for Surgery of the Hand than in theAmerican Association of Hand Surgery, theAmerican Society for Surgery of the Hand main-tains a larger number of plastic surgery mem-bers than the American Association of HandSurgery. For these reasons, trends in the mem-bership in the American Society for Surgery ofthe Hand are pertinent to the study of trends inthe makeup of the field of hand surgery in theUnited States in general, and are indicators of

the role of plastic surgery in the specialty.10

Fig. 7. Cumulative numbers of plastic surgeons holding Certificate of Added Qualifications in Surgery of the Hand, from1995 to 2007.

Fig. 8. Percentage of plastic surgeons holding Certificate of Added Qualifications in Surgery of the Hand, from 1995 to 2007.


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The American Society for Surgery of the Handis a thriving society, with growing membershipdemonstrated annually for the past 10 years. How-ever, this growth appears to be primarily becauseof growth in its orthopedic membership, whereasthe number of plastic surgery members has grownonly negligibly (Fig. 10). These data can be ex-amined as a percentage of the overall member-ship, with the orthopedic surgery percentage in-

creasing slowly and the plastic surgery percentagedecreasing slowly (Fig. 11).11

DISCUSSIONThese data indicate that the subspecialty of

hand surgery enjoys growing popularity with in-

creasing applicants to hand surgery fellowshipsannually; uses an effective, fair, and multidisci-plinary match through the National ResidencyMatching Program system; and demonstrates con-tinued and healthy growth in its largest academicsociety. Because the past few decades have dem-onstrated a constant ratio of the production ofnew diplomates from orthopedic and plastic sur-

gery annually, growth of the subspecialty of handsurgery should be reflected in increasing numbersof hand surgeons, Certificate of Added Qualifica-tions in Surgery of the Hand awardees, and Amer-ican Society for Surgery of the Hand membersfrom both orthopedic and plastic surgery. How-ever, the data demonstrate the following:

Fig. 9. Cumulative number of orthopedic surgeons holding Certificate of Added Qualifications in Surgery of the Hand,from 1995 to 2007.

Fig. 10. Number of members of the American Society for Surgery of the Hand, by specialty, from 1997 to 2007.


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The percentage of new plastic surgery diplo-mates obtaining Certificate of Added Qualifi-cations in Surgery of the Hand has decreasedfrom 10 percent (20 applicants in 1999) to 4percent (8 applicants in 2007).

The percentage of examinees for Certificate ofAdded Qualifications in Surgery of the Handfrom plastic surgery training backgrounds hasdecreased from 30 percent to 15 percent overthe past decade.

The percentage of the overall body of activelypracticing plastic surgeons in the United States

that hold Certificate of Added Qualificationsin Surgery of the Hand qualifications is de-creasing steadily (now to 10 percent).

Plastic surgery membership in the AmericanSociety for Surgery of the Hand is demonstrat-ing negligible growth despite the overall ex-pansion of the American Society for Surgery ofthe Hand.

Explanations for This TrendThe resident education subcommittee of the

American Society for Surgery of the Hand, as part

of its investigation into this problem, performedan online survey of plastic surgerytrained mem-bers, focusing on potential causes of the decreasedpresence of plastic surgery in the field of handsurgery.12 Of 464 plastic surgeons in the AmericanSociety for Surgery of the Hand, 166 responded (36percent response rate). The responses can be dis-tilled into the three suggested contributing factors.

Structure and Timing of Hand SurgeryRotations for Plastic Surgery Residents

The application due date for hand surgery

fellowships participating in the National Resi-

dency Matching Program match is 18 months be-fore the start of the fellowship. In a 5-year pro-gram, plastic surgery residents have to submitapplications in December of postgraduate year 4.In our current plastic surgery training structure,the timing of this match places plastic surgeryresidents in a much different position from theirorthopedic counterparts applying for hand sur-gery fellowship positions. In a typical orthopedicresidency program, trainees complete the prereq-uisite general surgical internship year and begintraining rotations in orthopedic-specific subspe-

cialties as early as the beginning of postgraduateyear 2. Typical orthopedic surgical trainees arelikely to have exposure to hand surgery and handsurgical mentors at this time, providing 2 yearsto identify hand surgery as an area of career in-terest; to pursue relationships with hand surgeonsand obtain counseling, experience, and letters ofrecommendation; to pursue and complete handsurgeryrelated research projects; to explorehand surgery academia in meetings (such as theAmerican Society for Surgery of the Hand andthe American Association of Hand Surgery);

and to complete and submit a high-quality ap-plication on time.If a plastic surgery trainee is in a 5- or 6-year

program and completes prerequisite 2.5 or 3 yearsof general surgical training, he or she may beginrotations in subspecialties of plastic surgery at themidpoint of postgraduate year 3 or the beginningof postgraduate year 4. This provides the plasticsurgery resident only 6 to 12 months (for the5-year program) or 18 to 24 months (for the 6-yearprogram) to complete these steps toward a handsurgery career. When a plastic surgery resident

pursues a fellowship in hand surgery, it is unlikely

Fig.11. PercentagebreakdownofthemembershipoftheAmericanSocietyforSurgeryoftheHand,byspecialty,from1997to2007.


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that they will have the duration, quality, or depthof exposure that will enable them to submit anapplication of equal quality to their orthopediccolleagues. Thus, the organization of plastic sur-gerys training structure is not conducive to pro-ducing adequate numbers of applicants and ade-

quate quality of applications for hand surgeryfellowships. This makes it unlikely that plastic sur-gery can maintain a presence in the field of handsurgery commensurate with the relative numberof plastic surgeons trained or the magnitude of itshistorical contributions to the discipline.

One could identify this particular timing prob-lem as being attributable to the early nature of thehand surgical match rather than the late exposureof plastic surgery residents to hand surgery. Thisargument would suggest that, rather than restruc-turing the timing of exposure of residents to hand

surgery, the fellowship match should be restruc-tured to occur during the final training year (sim-ilar to the informal process whereby plastic sur-gery residents are selected to other subspecialtieswithout the use of a match). The fault in thisargument is that the National Residency MatchingProgram for hand surgery has a long tradition ofequity, participation, and success for both traineesand training programs. This is demonstrated bythe 89 percent participation of AccreditationCouncil for Graduate Medical Educationaccred-ited fellowship training programs in the match,

the growing (and recently record-high) numberof applications for hand fellowship programsthrough the match, and the remarkably highmatch rate of the hand surgery fellowship Na-tional Residency Matching Program. The matchrate is the often-cited indicator of the effectivenessof a particular specialty or subspecialty match. In2008, of 127 applicants, 118 were successfullymatched through the system, making the handsurgery specialty match rate 93 percent. Of 136positions offered, 118 were filled, making 48 of the63 programs filled.4 Any change initiated to im-

prove the number and quality of plastic surgeryapplicants to hand surgery would best be under-taken by changing the structure of our trainingrather than disrupting a successful and effectivematch. Furthermore, simply changing the timingof the match would not address the underlyinginequity between hand surgery exposure in thetwo specialties.

Although this problem with our training pro-grams structures may be a contributing factor tothe inequality in orthopedic and plastic surgeryapplications, it is difficult to attribute the down-

ward trend in plastic surgeons in fellowships/

Certificate of Added Qualifications in Surgery ofthe Hand/American Society for Surgery of theHand to this issue. This inequality in training ex-isted before the development of this trend. Earlierexposure of our trainees could, however, contrib-ute to restoration of plastic surgerys presence in

the field.

Hand Surgery Role ModelsIn the survey of the plastic surgerytrained,

Certificate of Added Qualifications in Surgery ofthe Handcertified hand surgeons within theAmerican Society for Surgery of the Hand (men-tioned earlier),12 approximately 90 percent of the166 survey participants stated that plastic surgerywas underrepresented in the field of hand surgery.Eighty-seven percent felt that hand surgery was

underrepresented in the subspecialty of plasticsurgery. Among the issues cited, 75 to 80 percentof responders felt that the following were some-what or very important factors explaining the rel-atively small presence of plastic surgery in the fieldof hand surgery.

There are fewer hand surgery role models fortrainees in plastic surgery training programsthan in orthopedic training programs.

There are fewer attendings of plastic surgerytraining program faculties with practices dedi-cated exclusively to hand surgery (comparedwith their orthopedic training program coun-terparts).

There are relatively fewer attendings on plasticsurgery training program faculties that are Cer-tificate of Added Qualifications in Surgery ofthe Hand/American Society for Surgery of theHand members (compared with their orthope-dic training program counterparts).

The influence of these factors on the low num-ber of plastic surgery residents pursuing a careerin hand surgery is difficult to quantify. The survey

provides opinions of a large number of practicinghand surgeons but does not demonstrate the mag-nitude of these factors on the decision making ofour trainees. Despite the growing trend towardsubspecialization, the part-time hand surgeonmodel seems much more widely encountered andaccepted in plastic surgery than it is in orthopedicsurgery.

In an increasingly complex and competitivehand surgical subspecialty, a practice only occa-sionally (i.e., 50 percent case load) encompass-ing hand surgery may be unlikely to thrive. Such

a practice may be more likely to obtain its hand


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surgical cases by means of trauma and emergencycare and less apt to be identified as a referralsource for elective cases, complex cases, or evencases involving common osseous abnormality ofthe hand and wrist.

This practice model has also been demon-

strated to be ineffective in achieving mastery of thediscipline. Since its inception, the Certificate ofAdded Qualifications in Surgery of the Hand ex-amination has demonstrated a significantly lowerpass rate among plastic surgery applicants thanorthopedic surgery applicants (69 percent and 97percent, respectively). This was investigated by theCertificate of Added Qualifications in Surgery ofthe Hand Examination Committee of the JointCommittee on Surgery of the Hand (in which allthree involved boards participated), and the mostlikely explanation for this observation was the

presence of the part-time hand surgeon. Indeed,the failure rate was dramatically higher amongthose applicants whose practice in hand surgeryrepresented 50 percent or less of their overallpractice volume (Figs. 12 and 13).8

It is the authors opinion that the practicemodel of the part-time hand surgeon may alsoaffect the exposure of our trainees. These traineesmay be more likely to see a practice model wherehand surgery cases (primarily emergency cases)represent the most inconvenient, difficult, andpoorly reimbursed portion of the larger practice.

They may also be less likely to be exposed to areasof superspecialization (such as congenital surgery,brachial plexus, microsurgical, and oncology) or

even very common osseous problems of the handand wrist. This training model may be less apt toignite residents interests in hand surgery as acareer. This model may also be less capable ofproviding trainees with career development andsupport, hand surgeryrelated research projects,

or a sense of the gratification and satisfactionachievable from a practice dedicated primarily tohand surgery.

Whether the number, quality, and practicemodels of our academic role models is an influ-ence on our trainees diminished interest in handsurgery is speculative. It is also difficult to attributethe downward trend in plastic surgeons in fellow-ships/Certificate of Added Qualifications in Sur-gery of the Hand/American Society for Surgery ofthe Hand to this issue. This training model existedbefore the development of this trend. Further ex-

amination of hand surgery training role modelsand comparison with those in the orthopedictraining programs is warranted.

Financial Allure of Aesthetic SurgeryThe American Society for Surgery of the Hand

survey indicated that many respondents felt thefinancial allure of aesthetic surgery was an impor-tant influence on the diminished role of plasticsurgery in hand surgery. Three observations seemto indicate that this may be an overestimated fac-tor in this trend:

1. Orthopedic surgery has a myriad of morelucrative specialties (e.g., spine surgery,

Fig. 12. The Certificate of Added Qualifications in Surgery of the Hand pass rate, by specialty, from 1989

to 2007 (average percentage pass rate by specialty in box).


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sports medicine, total joint reconstruction)yet continues to produce large and growingnumbers of applicants for hand surgery fel-lowships annually based on interest in thetechnical and academic attributes of handsurgery itself.

2. Plastic surgery continues to populate lesslucrative subspecialty fellowships (e.g.,craniofacial, pediatric, microsurgery, majorreconstruction) based on interest in thetechnical and academic attributes of those

fields.3. A recent study examining factors influenc-ing plastic and orthopedic residents deci-sions to pursue hand surgery careers dem-onstrated intellectual issues (e.g., interestin and exposure to this field) to be moreinfluential than lifestyle issues (e.g., reim-bursement, work hours).13

Despite these realities, the American Societyfor Surgery of the Hand survey indicated thatmany respondents felt this was an important in-fluence on the diminished role of plastic surgery

in hand surgery. This perception may be perpet-uated by a trend among some plastic surgeons tonurture an emergency roomdominated handsurgery practice model before achieving an elec-tive aesthetic surgery practice. Training programsthat include full-time hand surgeons could dem-onstrate to trainees that the pursuit of hand sur-gery fellowship, Certificate of Added Qualifica-tions in Surgery of the Hand, American Society forSurgery of the Hand/American Association ofHand Surgery membership, and a practice dedi-cated entirely to hand surgery is not only feasible

and sustainable but often lucrative.

Proposals

Changes in the structure and focus of ourtraining programs can aim at addressing this prob-lem. The Residency Review Committee for PlasticSurgery ratified a proposal to mandate changes inthe duration and structure of U.S. plastic surgerytraining programs. This includes extension of allplastic surgeryintegrated programs to a mini-mum of 6 years of training enacted in 2009. TheAssociation of Academic Chairmen of Plastic Sur-gery is diligently working to comply with these

mandates with changes in structure, curriculum,and funding. This is an opportune time to addressthis disheartening trend of the decreasing pres-ence of plastic surgery in the discipline of handsurgery.

Given that the application for hand surgeryfellowship positions has a deadline earlier than allother subspecialty fellowships of plastic surgery,this clinical experience should be provided at theearliest opportunity. As plastic surgery trainingprograms are gaining increasingly more input intothe curriculum of the prerequisite years (post-

graduate years 1, 2, and 3), elective rotationsduring this period could be assigned to hand sur-gery rotations. Furthermore, with the mandatedchange to a minimum of 6 years of training, theyears of requisite training would be lengthened,now totaling 3 to 3 years after prerequisitetraining completion. If feasible, the earliestmonths should focus on exposure and training inhand surgery so that residents can identify this asa career interest and have adequate time to ex-plore the field and become competitive as fellow-ship applicants. Specifically, a goal would be to

provide 4 months of hand surgery rotations before

Fig. 13. The Certificate of AddedQualifications in Surgery of the Hand fail-

ure rate among plastic surgeons, by percentage of practice dedicated to

hand surgery, from 2001 to 2005.


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the midpoint of postgraduate year 4 in a 6-yearprogram.

Plastic surgery training centers may benefitfrom having a quota of full-time hand surgeons toserve as role models for trainees. The definition offull-time hand surgeon could include the com-

pletion of a hand surgery fellowship, Certificate ofAdded Qualifications in Surgery of the Hand cer-tification, membership in American Society forSurgery of the Hand/American Association ofHand Surgery, or a majority of overall case vol-umes dedicated to treatment of the upper extrem-ity. If such faculty members cannot be securedwithin the plastic surgery faculty, it may be wise touse the mentorship of full-time hand surgeonsfrom outside the confines of training programs.Outside sources could include orthopedic surgerydepartments in the same institution, community

plastic/orthopedic private hand surgery practices,and regional centers of excellence in hand surgery.

In Baltimore, the Curtis National Hand Centerprovides 4 months of hand surgery rotations forplastic surgery residents from the Johns HopkinsDivision of Plastic Surgery and the GeorgetownUniversity Department of Plastic Surgery. Theseacademic centers have prioritized obtaining high-quality subspecialty exposure for their residentsregardless of whether this can be achieved withinthe confines of their own institutions. The Amer-ican Society for Surgery of the Hand could identify

other regional hand centers interested in partic-ipating in such endeavors.Lastly, the National Residency Matching Pro-

gram should abolish the meaningless designationof hand surgery fellowship programs as eitherplastic or orthopedic. This has no bearing onapplicants eligibility to these programs and theyall participate in the same match. These designa-tions could be misleading to applicants or plasticsurgery residency coordinators who provide ca-reer advice. Programs should simply be desig-nated as hand surgery.

CONCLUSIONSThis author believes that the trend observed

represents a departure of plastic surgery from the

field and discipline of hand surgery. Our specialtyneeds to continue to nurture this portion of ourresidency curriculum. The proposals submittedcould do much to return plastic surgery to a vi-brant and growing position in this specialty andmaintain our historical tradition of innovation

and leadership in the discipline of hand surgery.

James P. Higgins, M.D.Curtis National Hand Center

1400 Front Avenue, Suite 100Lutherville, Md. 21093

[email protected]

REFERENCES

1. NRMP Results and Data: Specialty Matching Service. 2002-2009 Appointment years. Available at: http://www.nrmp.org.Accessed December 15, 2008.

2. AAMC GME Track/National GME Census data for denom-inators in table. Data (1995-2006) obtained via electroniccommunication with AAMC central office.

3. Accreditation Council for Graduate Medical Education. Listof programs by specialty. Available at: http://www.ACGME.org. Accessed December 15, 2008.

4. National Residency Matching Program. Available at: http://www.NRMP.org. Accessed December 15, 2008.

5. Electronic communications with the central offices of ASSHand AAHS.

6. Data collected for ABOS graduates from 1988 to present viaelectronic communication with ABOS central office. ABPSdata obtained from American Board of Plastic Surgery, Inc.,Annual Newsletter to Diplomates. Available at: http://www.abplsurg.org. Accessed December 15, 2008.

7. American Board of Plastic Surgery, Inc. Annual Newsletter to Dip-

lomates. Available at: http://www.abplsurg.org. Accessed De-cember 15, 2008.

8. Chang B. The Plastic Surgeon Hand Surgeon: How to makeit work successfully: CAQSH. Paper presented at: CAQSHExamination Committee of the Joint Committee on Surgeryof the Hand, Northeastern Society of Plastic Surgeons, Bos-ton, Mass, December 2006.

9. Data calculated as cumulative CAQSH awarded/cumulatingspecialty diplomas granted by each of respective boards oforthopedic and plastic surgery.

10. Data gathered via electroniccommunication withAAHS cen-tral office.

11. Data gathered via electronic communication with ASSH cen-tral office.

12. Plastic Surgerys Presence in Hand Surgery. ASSH resident

education subcommittee on-line survey. 2008.13. Chung KC, Lau FH, Kotsis SV, Kim HM. Factors influencing

residents decisions to pursue a career in hand surgery: Anational survey. J Hand Surg (Am.) 2004;29:738747.


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the diminishing presence of plastic surgeons

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