Many plastic surgery training programs include a resident aesthetic clinic (RAC), in which trainees have increased autonomy in decision making and patients have improved access to aesthetic surgery, usually through reduced charges. Although many studies have demonstrated good outcomes,1–6 reasonable patient satisfaction,7,8 and an acceptable safety profile,9,10 few reports have rigorously evaluated the operational, financial, and medicolegal components of these programs.11–13
Even though most plastic surgery educators recognize the value of having a RAC, many different models for such a learning environment exist,14–18 and best practices for this teaching paradigm have not yet been defined. As the surgical trainee gains experience in aesthetic surgery, this learner must also become an autonomous practitioner, mastering key competencies of not only patient care and medical knowledge but also systems-based practice, communications, practice-based learning, and professionalism. The RAC, in which trainees evaluate patients, form an operative plan, execute the procedure, and provide follow-up care, represents an ideal setting for gaining increased independence, under the close observation of supervising faculty members.
This article attempts to move our educational framework “1-step closer” to knowing the optimal learning experience in aesthetic surgery. We hypothesize that RACs represent a valuable, unique paradigm for surgical education, provided that clinical results are acceptable, patient and provider satisfaction remains high, and patient safety is given highest priority. The authors will describe the current status of RACs in plastic surgery training and will provide best-practice guidelines to achieve superior outcomes.
MATERIALS AND METHODS
We conducted an anonymous, 41-question, internet-based survey of all members of the American Council of Academic Plastic Surgeons (ACAPS) (n = 399). Our questionnaire (designed by the first author and constructed by PRRI, Beverly, Mass.) focused on the following components: demographic information about the respondents, operational details of the clinic, resident training and supervision, patient safety, medicolegal history, financial considerations, and research opportunities.
The questionnaire was sent to ACAPS members 3 times, from October to December 2012 (See Appendix, Supplemental Digital Content 1, which displays the Resident Aesthetic Clinic: Best Practices Project, ACAPS National Survey, http://links.lww.com/PRSGO/A94) Overall response rate for ACAPS members was 24% (n = 96). Response rate for program directors was 56% (49 program directors from 87 institutions), representing over half of all training programs. Of the 96 respondents, 63 reported that their institution included a RAC (66%). It should be noted that some institutions had more than 1 respondent. Thus, this survey reflects the opinions of ACAPS members who are involved with resident education, not specific programs.
Using information obtained by this survey and combining these data with their own experience, the authors developed a list of best practices for RACs. These best practices were further refined, as a result of the discussion between panelists and attendees, at the 2013 ACAPS Annual Spring Retreat and further refined by the ACAPS Aesthetic Surgery Task Force at the 2014 Annual Winter retreat of ACAPS.
Demographics of Respondents
Overall response rate was 96 of 399 ACAPS members (24%). Of the 96 respondents, 49 were program directors and 31 were chiefs or chairs of plastic surgery (Fig. 1). Only 5 residency coordinators participated in the survey. Mean length of time in practice was 20 years, with a range of 0–40 years (Fig. 2). Regarding type of practice, the vast majority of respondents had mostly reconstructive practices (n = 76), compared with a minority of respondents who had mostly aesthetic practices (n = 9) (Fig. 3).
In terms of the training programs, respondents reported the following mix of residency programs: integrated, n = 35; independent, n = 34; integrated and independent, n = 27. The following organizational structure was reported for the plastic surgery practices: Division of Surgery at a Medical School (n = 72), Department of a Medical School (n = 19), and Private Practice (n = 5). Sixty-three of 96 respondents (66%) reported the presence of a RAC, in which “plastic surgery residents had a focused cosmetic experience with some degree of autonomy.”
RACs have been in practice for a mean of 19.6 years, with a range of 1–50 years (Fig. 4). In terms of clinical volume, respondents reported a median of 88 patients and an average of 243 patients treated each year, with a range of 2–2000 encounters per year (Fig. 5). When asked about procedures done at the RAC, respondents noted a median of 25 and an average of 53.9 procedures done each year, with a range of 0–300 cases per year (Fig. 6). Components of the RACs, specific to location of patient encounters, include a combination of examination rooms and surgical suites (Fig. 7), with 40 of the 63 clinics including access to a licensed operating room.
Thirty-five of 64 respondents (54%) who reported having a RAC indicated that RAC was a formal rotation in their residency program. Although respondents noted that chief residents represented the largest group of participants (n = 53), lower level residents also have some degree of participation in the RAC (Fig. 8). Nearly all residents (60 of 64) provide continuity of care for their patients. According to the respondents, residents receive supervision mostly by full-time core faculty (Fig. 9), who usually oversee all components of perioperative and intraoperative care (Fig. 10).
Although the majority of RACs have some type of accreditation, 18 of 63 respondents with RACs reported no accreditation (Fig. 11). Furthermore, 28 of 63 respondents with RACs reported a list of inclusion/exclusion criteria for cases, and only 17 respondents reported having a Life Safety Plan for the RAC. An anesthesiologist administers anesthesia in 31 of 38 RACs with operative capability, whereas other personnel are used for this function in the remaining RACs (certified registered nurse anesthetist, 3; nursing staff, 2; and surgeon, 2). Seventeen of the 35 clinics with operative capability reported the ability to recover patients overnight.
Of the 64 respondents who indicated that their institution had a RAC, 1 ACAPS member reported a patient death in the facility and 2 ACAPS members reported patient deaths within 30 days of the procedure. Our cohort of ACAPS members observed no cases of malignant hyperthermia. Sixteen of the 62 ACAPS members (26%) indicated that their RAC has been involved in a lawsuit. Regarding malpractice insurance models, most groups are self-insured and pay premiums to a group trust (Fig. 12). Three of the 63 respondents with RACs noted that patients must sign a waiver, releasing residents from malpractice liability or to limit award for damages.
Although 18 respondents did not know if their RACs were financially viable, 33 respondents indicated that their RACs were financially viable, compared with 13 respondents who reported that the RACs were not financially viable. The large majority of attending surgeons do not receive any financial remuneration, but some of the respondents do receive compensation from professional fees, teaching stipend, or a medial directorship (Fig. 13). Almost all RACs offer discounted fees (59 of 63, 94%), and most RACs charge for the initial consultation (39 of 63, 62%). The most effective method for patient recruitment was listed as “word of mouth” (61 of 63, 97%). Faculty practices contribute various types of resources to the RACs, in addition to resident supervision (Fig. 14), such as clinic space, scheduling, nursing support, and disposable supplies. If profitable, net income is primarily transferred to a residents’ education fund, but some of the gains are transferred back to the division or department, presumably to cover overhead costs (Fig. 15). Only a small fraction of the positive net income is directed toward incentive plans for the faculty, to the dean or the hospital, or toward an operating reserve.
Research and Outcomes Effectiveness
Respondents indicated that RACs use a number of different methodologies to measure the effectiveness of the educational experience, with review of resident case logs and morbidity and mortality conferences as the most popular techniques (Fig. 16). Fourteen of the 64 respondents with RACs have presented related data at national scientific meetings, and 12 respondents have published their research in peer-reviewed, scientific journals. The overwhelming perception is that RACs have a positive effect on plastic surgery training (Fig. 17). The majority of respondents were neutral when asked about the impact of the RAC on their practice (n = 36), but only a minority of respondents reported that the RAC was a liability for the practice (n = 7) (Fig. 18).
RACs serve as an important component of graduate medical education in plastic surgery. Most clinics are financially viable but carry a high malpractice risk and consume considerable resources. Best practices, to maximize patient safety and optimize resident education, include use of accredited procedural rooms, having anesthesiologists provide anesthesia, and providing appropriate faculty supervision at all stages of patient care.
Despite their tremendous potential educational importance, medicolegal issues limit the value of RACs, through increased exposure and liability of both the resident and attending physicians. Given the perioperative deaths reported in this survey, combined with a litigation rate of 25%, significant measures must be pursued to create a culture that stresses patient safety, in such a setting where graduate medical education occurs. Quality metrics, such as reporting of adverse events, use of standardized safety protocols and check lists, supervision that exceeds requirements of the Accreditation Council for Graduate Medical Education (ACGME), and longitudinal follow-up of patients, must be incorporated into the mission and operational structure of the RAC. We strongly recommend establishing a formal relationship with risk management, just as divisions and departments currently do, through the following modalities: morbidity and mortality conferences, peer review of cases, and preemptive reporting of complications and patient complaints.
The educational concept of a RACs is not new and has been implemented in various specialties, including plastic surgery, otolaryngology,19 and dermatology.20 In fact, the literature is replete with articles addressing the mechanics of administrating Plastic Surgery RACs, their educational benefit, and analyses of outcome data. According to Neaman et al3 in 2010, 71% of plastic surgery residencies had a cosmetic surgery clinic, with 44% of the respondents noted that 100% of the cases performed there were cosmetic in nature.
In 2006, the University of Kentucky group noted that the resident cosmetic surgery clinic contributed 82% of the resident’s total aesthetic procedures. This was completed with a 3.1% reoperative complication rate and no medicolegal litigation.4 Pyle et al10 at Wake Forest reported that not only do residents gain added experience as surgeon in a resident-driven clinic but also patients are able to receive cosmetic surgery that they might not otherwise be able to access. They had no major complications but did report a minor complication rate of 8% and a revision rate of 14.4%.10
Freiberg et al8 at the University of Toronto examined a retrospective survey of 265 patients with a 49% response rate, where 93% of patients said they would recommend the clinic (after a slightly lower rate the first year), and 93% would undergo the same procedure again if required. The highest patient satisfaction was seen in augmentation mammoplasty (9.1/10.0) and blepharoplasty (9.0/10.0), whereas rhytidectomy and rhinoplasty were lower at 7.8/10.00 and 6.9/10.0, respectively.8 At Georgetown University, Iorio et al7 evaluated satisfaction with resident injected fillers using a FACE-Q survey. They demonstrated a 91% rate of being satisfied or very satisfied with this evolving less invasive and highly popular injection in 10 patients.7
At the American Association of Plastic Surgeons meeting in 2012, a 2-year retrospective review of patient care from 2009 to 2011 at the Johns Hopkins Resident Cosmetic Surgery Clinic was presented. Rad et al9 noted complications rates consistent with the mainstream cosmetic surgery literature, breaking down the procedures by type and body location. Their study sample included 115 patients who underwent 132 primary body-contouring procedures and 53 patients who underwent 84 facial aesthetic procedures.9
Based on the published literature and the ACAPS national survey, it is clear that resident education in aesthetic surgery must be grounded in principles of informed consent, appropriate patient selection, patient safety, teamwork, and critical assessment of outcomes. Fortunately, qualitative and quantitative instruments have been recently developed to assess outcomes, in terms of patient satisfaction and objective measures.21–23 Furthermore, surgical educators are focusing on how to teach trainees aesthetic surgery—and reporting these results—within the framework of competency- and milestone-based graduate medical education.24–26 Additional efforts have been pursued to educate residents about the importance of strategic marketing, accounting and finance, economic forces of competition, the supply chain, and regulatory/legal considerations, in the context of office-based surgery and aesthetic services.27–32
The Aesthetic Surgery Task Force of the ACAPS endorses the concept a properly supervised RAC, provided that the following guidelines are considered and followed, to the greatest extent possible, within training programs accredited by the ACGME:
- The educational experience should maximize resident autonomy, appropriate to level of training, as permitted by ACGME guidelines.
Longitudinal, complete continuity of care is critical; no postrotation handoffs should occur.
The RAC must have a medical director who oversees the educational components of the program, to ensure that quality measures are met, that patient safety is optimized, and that operational logistics are well managed.
The RAC must establish screening processes to eliminate inappropriate patients, using such predefined parameters, such as body mass index, smoking status, uncontrolled diabetes, or hypertension.
The RAC must establish operative criteria, such as inclusion/exclusion lists and maximum length of case.
Surgery must be performed in accredited facilities only.
The RAC must have close faculty supervision in both the clinic and operating room, including presence at the key components of procedure.
The faculty must establish goals, objectives, and targets for residents; track outcomes; provide regular review; and offer timely feedback.
Real-time evaluation of competencies and milestones must be performed.
The program director should review operative logs to ensure diversity of cases, surgeons, and locations.
The RAC must combine a robust clinic and operative experience with strong educational modules focused on aesthetic surgery, including lectures, indications and outcomes conferences, and a journal club.
The medical director should moderate a formal Resident Clinic Outcomes Conference for the entire division/department, in association with risk management.
The division/department should reinvest net income back into the aesthetic curriculum/program.
The RAC can consider reduced fees to stimulate demand, by decreasing professional fees and charging facility fees high enough to cover overhead.
The RAC should involve residents with strategic marketing of the practice.
The RAC should have a dedicated administrative assistant to help run the program.
Although aesthetic education should begin early in the training program, the RAC should be limited to chief or senior residents in Plastic Surgery.
The educational curriculum should phase in the complexity of the cases as the resident skill set grows (eg, the trainee could start with breast and body procedures and then move to facial procedures).
Trainee experience at the RAC should occur after more traditional aesthetic surgery rotations have been completed and should be considered separate and distinct from faculty practices.
Residents should not be allowed to perform injection of neuromodulators, soft-tissue fillers, or chemical peels in the RAC, which instead should be used as an operative experience, for surgical procedures.
- a. Residents must obtain a complete history and physical examination, with preoperative evaluation to include patient photographs.
- b. Residents must discuss case with attending regarding operative plan.
- c. Attendings must be present for planning and execution of procedure.
- d. Residents must be involved with postoperative management, including complications.
- e. Residents must be available for 24–7 coverage, with adequate faculty backup.
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