We thank Mr. Al Omran for his insightful letter and questions surrounding our study1 and the ensuing Discussion by Drs. Greives and Losee.2 It is our hope that we can adequately address his inquiries, or at least provide opinions on these subjective topics.
First, Mr. Al Omran mentions the Discussion by Drs. Greives and Losee and their concept of “early differentiators” being those students who commit before residency to a career in academics.2 This model suggests that the correlation observed between eventual pursuit of academics and academic accomplishments during residency is the result of a causal relationship that begins with academic differentiation. This relationship is likely valid, but we would addend the model by incorporating the other observation mentioned by Drs. Greives and Losee: that most applicants pledge dedication to a future career in academics, and yet the majority of graduating plastic surgeons pursue private practice. We, like Drs. Greives and Losee, feel that this inconsistency is not the result of intentional deceitfulness, but is rather a product of changing perspectives during plastic surgery residency. Our suggestion would be the expansion of the early differentiator group to include two distinct subsets: those that eventually pursue academic careers, and those that are initially committed to academics but change career plans as a result of the influences of residency (e.g., rigorous hours, birth of children, loss of interest in research).
Next, Mr. Al Omran posits the question that perhaps research-oriented programs requiring 7 years may not be successful in achieving their goals given that students must have already differentiated before matriculation. Although this may be the case, we could also consider the following points. First, it is possible that early differentiation is not definitive, and that there is a continued role for research mentorship and academic nurturing. Second, we feel that the goals of an added research year extend beyond simply enhancing research aptitude among a select group of academic “hardcores.” The field of plastic surgery is constantly changing, and the refined ability to critically judge new publications requires exposure to research. However, given that integrated programs are correlated with academic careers1,3,4 and academically minded applicants likely self-select for these research-oriented programs, the research year is likely benefiting the intended residents.
Mr. Al Omran then comments on the process of assigning relative value to applicant publications, specifically, regarding the importance of position within an author list. The quantification of an applicant’s aggregate research experiences for comparison with other applicants presents a challenging task. First, not all publications are created equally. It is unlikely that any program director would place the same weight on a clinical study in a journal with a low impact factor as on a graduate thesis in basic science. In addition, even for equivalent publications, author position may not always serve as a reliable metric for the commitment and aptitude of an individual student. Clearly, various departments will differ with respect to the level of involvement and thus authorship on publications. For example, students working with more senior authors may be encouraged to take more responsibility and place their names first more often, whereas some institutions may subscribe to a culture that prefers relying on residents or more senior authors first.
The weight placed on these various research accomplishments for applicant selection is typically specific to each institution based on the preferences of the program directors and other involved faculty members. As suggested by Mr. Al Omran, it would have been interesting to investigate whether applicants with few first-author publications differ in eventual career trajectory from those with multiple publications with less involvement. However, given our retrospective survey methodology, these data would likely have been subject to additional recall bias; future studies will be needed to address this question through accurate means, but until that time, we are left with anecdotal evidence and speculation.
Lastly, Mr. Al Omran questions whether a difference exists between traditional M.D. graduates and those with dual degrees. The tendency for graduates with combined M.D./Ph.D. degrees to gravitate toward research-oriented careers has been demonstrated in other fields5; however, our study was inadequately powered to detect any significant impact of this variable on our conclusions.
Ultimately, selecting a career after graduation can be a difficult decision for plastic surgeons and is influenced by many factors, both internal and external. The process of prioritizing activities in medical school and choosing the residency with the “right fit” can be challenging. Residency programs have evolved over the past decades with the introduction and adoption of the integrated training model, and have continued to change; the integrated program today is not the same as the integrated program 20 years ago. Location, affiliated hospitals, specific strengths and weaknesses, research opportunities, faculty, and fellow residents are all factors that should be considered.
The authors have no financial interest to declare in relation to the content of this communication.
Michael R. DeLong, M.D.
Duncan B. Hughes, M.D.
Bryan D. Choi, M.D., Ph.D.
Michael R. Zenn, M.D.
Division of Plastic and Reconstructive Surgery
Department of Surgery
Duke University Medical Center
1. DeLong MR, Hughes DB, Tandon VJ, Choi BD, Zenn MR. Factors influencing fellowship selection, career trajectory, and academic productivity among plastic surgeons. Plast Reconstr Surg. 2014;133:730–736
2. Greives MR, Losee JE. Discussion: Factors influencing fellowship selection, career trajectory, and academic productivity among plastic surgeons. Plast Reconstr Surg. 2014;133:737–739
3. Roostaeian J, Fan KL, Sorice S, et al. Evaluation of plastic surgery training programs: Integrated/combined versus independent. Plast Reconstr Surg. 2012;130:157e–167e
4. Herrera FA, Chang EI, Suliman A, Tseng CY, Bradley JP. Recent trends in resident career choices after plastic surgery training. Ann Plast Surg. 2013;70:694–697
5. Choi BD, DeLong MR, DeLong DM, Friedman AH, Sampson JH. Impact of PhD training on scholarship in a neurosurgical career. J Neurosurg. 2014;120:730–735
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