The trouble with doing something right the first time is that nobody appreciates how difficult it was.
It has been more than 10 years since we became an independent Department of Plastic Surgery at the University of Texas Southwestern Medical Center.1 At that time, ours was only the fifth department of plastic surgery established in the United States (Table 1). It leveled the playing field with our competing specialties and truly allowed plastic surgery to grow autonomously and independently in an academic health center. The effect this has had on the positioning of plastic surgery as a separate specialty within the environment of the university has been truly remarkable. Our growth and development in an academic setting would not have been possible in any other venue; the end result is that this department has become one of the most productive in our academic health center by any measure, including educational, academic, and clinical expansion as well as financial success. The department has also seen an increase in publications and endowments. It is now overdue to have this occur in every medical center and every plastic surgery training program in the United States.
As I listen to and empathize with my colleagues and friends in academic plastic surgery around the country, I hear that academic plastic surgery is truly fledging and being hindered financially and educationally, with a diminished morale among academic plastic surgery faculty in the United States. I also have heard it discussed on numerous panels in our major society meetings and discussed at length in our Association of Academic Chairmen of Plastic Surgery meetings. Our experience at University of Texas Southwestern Medical Center is the exact opposite. Let me explain why.
The solution is clear and simple, but we must be steadfast and united if we are to succeed as a specialty, and we must do so. It is evident from our experience at University of Texas Southwestern Medical Center that plastic surgery must truly be allowed to blossom and grow as a unique and distinct specialty. It is long overdue (by several decades) that this should have occurred, similar to our change of training pathways and length. It is now no longer optional but essential that any and all new individuals taking or interviewing for chair positions in plastic surgery anywhere in the United States should not do it without having the short-term mandate of becoming a department that is autonomous financially, academically, educationally, and administratively from the department of surgery.
FROM DIVISION TO DEPARTMENT: NECESSARY ELEMENTS
How does one go about obtaining all of the criteria needed to succeed as a department? There is no pure or uniform template, as every situation, every institution, and every plastic surgery training program is different historically and according to how it is positioned within its academic health center. The common ground is that we must, not should, proceed toward independent department status for all plastic surgery training programs in this country. Often I am asked how we did it and what have we learned. What is the recipe? The following principles have worked for us at University of Texas Southwestern Medical Center. They are a mere footprint, a blueprint for all to use as they see fit in their journey to becoming a department.
Unify National Support for Mandatory Plastic Surgery Departments
Implementing change is truly something that is a “must,” not a “should.” It must be applauded and supported by all aspects of organized plastic surgery, including our major plastic surgery societies (and the subspecialty societies as well), the American Board of Plastic Surgery, and the Residency Review Committee in Plastic Surgery. In 2006, the Association of Academic Chairmen of Plastic Surgery voted and enthusiastically affirmed that any new faculty interviewed to take a position as chief of plastic surgery in the United States must have a commitment that plastic surgery become a department within a specific timeline in the near future. Change is always difficult, but acknowledging that plastic surgery is a separate and distinct specialty within all academic health centers in the United States is a bold yet important step in the right direction.
Autonomy: Establish Administrative and Financial Independence
Developing autonomy is the only way to establish the hallmark of a separate specialty, such as plastic surgery, especially within an academic health center. As a distinct specialty and entity, plastic surgery can establish a solid patient and financial base that will allow it to be recognized for its energy, efforts, and innovative accomplishments. We must be able to track financially the downstream effect of plastic surgery involvement in breast care, wound healing, trunk and extremity reconstruction, and other areas where other specialties and departments get primary credit (both financially and academically) in university hospitals and medical schools where plastic surgery is not a recognized as a separate department or entity.
Independent fiscal management and managed care decision making are also key elements in the growth and success of a department, as well as for expanding our patient volume, residencies, faculty, and facilities. This is essential, as no one knows plastic surgery better, both educationally and economically, than plastic surgeons. No matter how “friendly” we are with our surgical colleagues or the current chair of the department of surgery in our institutions, this element is a must for growth and prosperity in an academic health center.
Parity with our competing specialties, both academically and administratively, has helped plastic surgery grow tremendously in parallel and even sometimes exceed the growth of competing specialties and departments.
Advocate Selfless, Intense Involvement
All of our faculty members are involved with the institution and medical center. This involvement is manifested administratively at all clinical levels in the institution. Such involvement is very time consuming but worth the effort in the long term. As the chairs of numerous major committees or task forces at University of Texas Southwestern Medical Center, our involvement grows exponentially every year. We participate administratively not only to advance the strategic growth of our academic health center but also to enhance plastic surgery. The result is that the Department of Plastic Surgery's growth and success are unsurpassed. In addition, plastic surgery gains respect from our colleagues in the other specialties as well as the administration in the academic health center. Administrative immersion at all levels with the university has become a key element to our departmental growth; it has such an impact and such diffuse benefits that its value is difficult to measure.
Plastic surgery must become involved academically and administratively at all levels of the hospital, from peer review and quality assurance committees to medical records committees, from the executive committee of hospitals to chiefs of staff (including the executive committee of the university). You and your faculty must be involved internally and become integral and respected members of the hospital community. This is an essential part of our commitment to our academic health center. Plastic surgery needs to be considered a good citizen of the university and medical school/center. Serving on the so-called mundane committees at all levels, including the administrative, medical school, and hospital committees (especially the credentialing, operating room, and quality assurance committees), is a tremendous way to gain this type of respect.
Establish Respect and a Sense of Fairness and Duty to Your Academic Health Center or Medical School
First and foremost, you must establish the respect of what plastic surgery is in your institution. We must teach plastic surgery at all levels of medical school education, so the involved (medical school and the administration) understand what we do, from anatomy in the first year, to anatomic correlation in the second year, suturing techniques in the third year, and independent rotations in the fourth year. Plastic surgery needs direct contact with medical students each year if possible. It is essential that we have plastic surgery exposure each year in every medical school in the United States; yet today, more than one-third of medical schools do not have a plastic surgery experience or training program.
Develop Separate Residency Training Pathways
An important way to gain recognition and respect for the specialty is to develop separate residency training pathways. Plastic surgery needs to have separate training programs from year 1 to year 5 or 6, with an integrated or independent training pathway that has a core plastic surgery curriculum throughout. This allows plastic surgery to control the training process from the onset. Now we need to go to the next level and increase the overall training of true plastic surgery to at least 3 years or longer. No one can train plastic surgeons better than plastic surgeons. To do so requires more effort, coordination, and faculty.
We must have separate training pathways and we must lengthen plastic surgery training to at least 3 years, since we are the only country in the world with 2 years of training as a minimum. Adding an extra year will extend credibility to the specialty and confidence and competency to our residents.
Become the “Go-To” Clinical Department
We must also work daily both administratively and clinically to become respected in our various hospitals by becoming the “go-to” department for all specialties for complex reconstructive problems, and we must also develop an attitude of having excellence in everything we do. Develop a “yes” mantra in your residents and faculty. We say “yes” to every problem and solve complex patient problems that are not possible without our expertise. Basically, the Department of Plastic Surgery at University of Texas Southwestern Medical Center never says “no.” We always take patients internally and externally; when other groups or specialties falter or fail, we intervene and go forward to take care of the patient. Plastic surgery is and must be the “go-to” specialty for all aspects of difficult problems. After all, such care reflects our roots; we need to go back to them.
Develop Clinical/Basic Science Translational Research Focus and Expertise
Plastic surgery must participate at all levels, and it must also develop focused clinical and basic science research as well as clinical translational research. This is expounded upon by having clinically applicable National Institutes of Health, government, and industry grants that contribute to the overall support and strength of the academic institution. This requires significant organizational and long-term strategic planning and dedication to implementing a separate research division led by a talented M.D. or Ph.D. whose sole focus is the development of this area.
Plastic surgery must plan strategically. Nothing occurs in life, or medicine, without meticulous planning, focus, and unrelenting effort. Success is determined by being prepared for each opportunity despite failure and setbacks. I have had more failures than successes in my life, but I have learned much more from my failures and used them to engender success at the next opportunity. You can do the same. There needs to be overt, deliberate short- and long-term planning, so that there is a measurable annual template and matrix for growth and development. We conduct at least one clinical and research strategic planning meeting annually, with a separate research strategic planning session to set the benchmarks/matrix for each year's progress. There is no specific template, as it will be different for your institution, but you must do it. Success is measured by accomplishment, dedication, and perseverance, not just long-term years of service.
Establish Endowment Development and Planning
Critical to success is the development of endowments for research and clinical programs that are not usually well funded, such as congenital programs or other unique innovative clinical programs. Endowments provide consistent funding, a critical element that demonstrates long-term commitment to clinical and basic research.
Overcome Internal Inertia and Bureaucratic Hurdles
All of us have to overcome the internal inertia, apathy, persistent lack of a sense of urgency, and bureaucratic hurdles we encounter in our academic health centers. If we are focused, however, hurdles become the fuel for change and then the spark for igniting and sustaining the fire of interest and energy in the development of plastic surgery departments. Furthermore, the energy, synergy, and exuberance percolate from top to bottom in plastic surgery and must be perceived and appreciated by the academic administration specifically in the academic health center (i.e., by the dean or president of the university). I cannot overemphasize this as we go forward. Perception equates with reality. The corollary is true as well. Real and perceived energy and excitement are the recipe for success.
Achieve Critical Mass and Depth of Faculty
There is no specific number of faculty members that will determine success; that depends on the size of your academic health or medical center. Try to expand the size of the faculty as rapidly as you can to meet current and future clinical needs in all areas of reconstructive plastic surgery, from hand and microsurgery to craniofacial, pediatric, and breast surgery. Size helps you in so many ways: educationally, as you expand your research team; financially, as you create growth opportunities for expansion as revenues and earnings per faculty increase; and academically, as you increase the number of publications and research grants. When you have assembled that dedicated long-term faculty that covers all areas of plastic surgery (or the commitment from the academic health center to do so), then it is the time to move forward.
Develop Friends and Partners of Strength/Develop a Strong Plan
The above points will help you establish a base of power and powerful friends within the academic health center. In addition to these friendships and partnerships, develop a well-conceived intellectual basis for becoming a department. The intellectual underpinnings include the following:
- A clearly defined mission statement with your faculty. Repeat it often to the administration of your academic health center.
- A weighing of the alternatives. Is your division ready to make the move to department status? What are the foreseeable disadvantages of remaining a division?
- A poised, dispassionate, and reasonable communication of your thoughts. Ultimatums, arguments based on emotions, and poorly conceived rationale usually do not work.
- An ability to move forward rapidly with proper timing when there is a leadership transition or change in the department of surgery or a change of dean and/or president of the university.
These ideas represent only a start. We must finish together, for only together and united in this effort can we all succeed in establishing plastic surgery as a hallmark distinct and separate specialty, which is so long overdue! Our successes, setbacks, and failures can, it is hoped, help streamline the process. We do this not for ourselves but for the future of our specialty.
Because a thing seems difficult for you, do not think it impossible for anyone to accomplish.