I appreciate the comments of both Dr. Concannon1 and Dr. Taghinia2 on the issue of the diminishing presence of plastic surgeons in hand surgery. There seems to be no debate that this is a real and quantifiable phenomenon in our subspecialty. The purpose of the investigation and data presented was to provide a springboard for further discussion as to the importance of this trend and methods of correcting it. Drs. Concannon and Taghinia are among many society members providing feedback to this essay. It appears that many of us are concerned and have a wide range of opinions as to the causes.
Dr. Taghinia's observations about the relative paucity of job opportunities for the full-time hand surgeon in plastic surgery (as compared with orthopedic surgery) and the public perception of hand surgery as being the realm of orthopedics are certainly undeniable. These are commonly reported problems of new hand fellowship graduates with plastic surgery backgrounds. I would not consider this a cause of decreasing presence of plastic surgery in hand surgery. I see it as the end result of a long-neglected problem. Our training structure and model make it more difficult for plastic surgery trainees to gain interest in hand surgery as a career and become competitive for fellowships compared with their orthopedic counterparts. I believe that the reason orthopedics enjoys a growing dominance in this field is because it is a superior training model for nurturing hand surgeons, for the following reasons.
First, orthopedic training programs are more likely to expose their trainees to hand surgery earlier and provide them ample time to develop a competitive fellowship application (as discussed in the article).3
Second, orthopedics has embraced subspecialization. Their trainees see more examples of successful elective hand practices. The referral patterns Dr. Taghinia describes are perpetuated because difficult hand surgical problems are more likely to be sent to surgeons who devote their entire practice to the complexities of that subspecialty. Even if we are psychologically wed to the model of the “part-time hand surgeon,” we must critically assess its merit; objective data of Certificate of Added Qualifications in Surgery of the Hand pass rates clearly demonstrate inequities between “part-time” hand surgeons and those with hand surgery encompassing more than 50 percent of their practice (Fig. 13). Dr. Concannon points out that this part-time paradigm has historically been the “modus operandi” of the plastic surgeon.1 The data presented in the original article bring into question whether such a paradigm can be successful in the future.
Ultimately, our specialty needs to decide whether plastic surgery should embrace Dr. Concannon's approach of assuming that this trend is indicative of our specialty “discard[ing hand surgery] out of lack of interest” or entertain the possibility that fault may lie in our training structure and consider following the example of the more successful orthopedic model.
Dr. Taghinia suggested training more plastic surgeons to address this trend. The number of new graduates each year has remained constant in both plastic surgery and orthopedic surgery (Fig. 2). I do not believe that solely training more plastic surgeons without altering the training structure would correct this trend.
It is my belief that the proposals for modification in our training structures (see “Proposals” section of the original article) could reverse this trend and help repopulate the ranks of plastic surgery–trained hand surgeons. I believe this is the most realistic means of slowly correcting the social misperceptions and job market inequities observed by Dr. Taghinia.
I sincerely thank Drs. Taghinia and Concannon for their interest and insight into this subject. I look forward to our Society's continued discourse on this topic and collective efforts to address this problem.
James P. Higgins, M.D.
Curtis National Hand Center
1400 Front Avenue, Suite 100
Lutherville, Md. 21093
1.Concannon MJ. The diminishing presence of plastic surgeons in hand surgery: A critical analysis (Discussion). Plast Reconstr Surg
2.Taghinia AH. The diminishing presence of plastic surgeons in hand surgery: A critical analysis (Letter). Plast Reconstr Surg
3.Higgins JP. The diminishing presence of plastic surgeons in hand surgery: A critical analysis. Plast Reconstr Surg
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