I read with great interest the article by Dr. Higgins1 and the discussion Dr. Concannon2 exploring the diminishing presence of plastic surgeons in hand surgery. As a young hand surgeon entering practice recently, I have encountered another major explanation for this trend: developing an “elective” hand practice is difficult for plastic surgeons.
This difficulty begins at the time of the initial job search and continues into the early years of practice. Most advertised hand surgery positions, such as those found in the Journal of Hand Surgery or the American Society for Surgery of the Hand Web site, cater to orthopedic surgeons. Typically, the new recruit joins an established practice and provides care to patients who are referred to the group, thus forming a starting point for an elective practice. By contrast, a hand surgery position advertised in this Journal or in Plastic Surgery News is more likely to be a general plastic surgery position with emergency-based hand call as the primary source of hand cases.
Perhaps a more ominous reason for the difficulty in establishing an elective hand practice is that most referring physicians have learned to associate hand surgery with orthopedics. Strong relationships and referral patterns with orthopedic practices have evolved over many years and provide a major barrier for a hand surgeon who joins a plastic surgery practice. Although the new hire may have the credentials and interest to perform hand surgery, he or she is much more likely to see general plastic surgery referrals than hand referrals.
Why has this occurred? Surely, part of it is the public perception that plastic surgeons only perform cosmetic surgery. Another potential reason is that we are not training enough plastic surgeons in total. This has been proposed as a potential reason for increasing competition in all fields of plastic surgery, including cosmetic surgery, eyelid surgery, facial reconstructive surgery, and hand surgery.3–5 Although other specialists such as facial plastic surgeons, dermatologists, and orthopedic hand surgeons continue to grow in numbers, ours have remained unchanged. We are losing market share. Over the past 10 years in Harvard-affiliated hospitals, I have seen the number of orthopedic hand surgeons double (from seven to 14), whereas the number of plastic hand surgeons (who perform mostly hand surgery) has remained unchanged (at three). Given these barriers, is it so surprising that fewer trainees choose hand surgery as a career path?
Although current economic conditions may cause a temporary increase in hand fellowship applications from plastic surgery trainees, this spike is unlikely to be sustained unless we address the underlying issues. We need to increase the overall number of plastic surgeons, educate referring physicians, and develop an infrastructure for young hand surgeons to flourish—all while continuing to deliver high-quality hand care.
Amir H. Taghinia, M.D.
Department of Plastic and Oral Surgery
300 Longwood Avenue
Boston, Mass. 02115
1.Higgins JP. The diminishing presence of plastic surgeons in hand surgery: A critical analysis. Plast Reconstr Surg
2.Concannon MJ. The diminishing presence of plastic surgeons in hand surgery: A critical analysis (Discussion). Plast Reconstr Surg
3.Noone RB, Goldwyn RM, McGrath M, Spear S, Evans GR. 50th Anniversary Plastic Surgery Research Council Panel on the Future of Academic Plastic Surgery. Plast Reconstr Surg
4.McGrath MH. Workforce issues. Plast Reconstr Surg
5.Rohrich RJ, McGrath MH, Lawrence WT, Ahmad J; American Society of Plastic Surgeons Plastic Surgery Workforce Task Force. Assessing the plastic surgery workforce: A template for the future of plastic surgery. Plast Reconstr Surg.
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