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Integrated Programs: Teach across the Chasm

Park, Julie E. MD

Plastic and Reconstructive Surgery – Global Open: March 2015 - Volume 3 - Issue 3S-2 - p e350
doi: 10.1097/01.GOX.0000464844.36106.74
2014 ACAPS Congress: Abstracts
Open

From the Department of Surgery, Section of Plastic and Reconstructive Surgery, University of Chicago Medicine, Chicago, Ill.

Presented at the American Council of Academic Plastic Surgeons Winter Retreat, December 6–7, 2014, Chicago, Ill.

Disclosure: The author has no financial interest to declare in relation to the content of this article. The article processing charge for this abstract was paid for by the American Council of Academic Plastic Surgeons.

Julie E. Park, MD, Section of Plastic and Reconstructive Surgery, The University of Chicago Medicine, 5841 S. Maryland Avenue, Rm. J-641, MC6035, Chicago, IL 60637, E-mail: jpark@surgery.bsd.uchicago.edu

This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 3.0 License, where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially.

With the current trend of independent fellowships converting to integrated residency programs, many faculty are faced with the new challenge of teaching a junior resident rather than a fellow who has already been fully trained as a general surgeon. The lack of mastery of basic skills can lead to exasperation when the resident assistant does not have the expertise to which the attending is accustomed. This “chasm” exists due to the imbalance of faculty expectation and resident experience.

The most important factor to successfully “teach across the chasm” is simply awareness. Rather than assuming resident proficiency, faculty must recognize the PGY year of a resident assistant and scale expectations to the competencies concordant with that level. Take, for example, a simple reduction mammoplasty. A PGY 1 may retract and “hold hook” while teaching is focused on properly positioning and prepping the patient in the OR and perfecting suturing technique. The attending performs the majority of the surgery while teaching didactically on criteria for appropriate patient evaluation and selection and the differences between various pedicles and techniques. A midlevel PGY 4 may be shepherded through the procedure with close monitoring and be questioned in a Socratic method to probe and enhance understanding of the procedure. A PGY 6 would be expected to help with marking the patient and performing the reduction on 1 of the breasts. Programs are required by ACGME to outline competency-based goals and objectives and to delineate a progression in responsibility for patient care that is specific to each PGY year. Faculty should anticipate how to apply these guidelines to the particular procedures in which they specialize when working with individual residents.

With the implementation of integrated programs, faculty and senior residents also must assume the responsibilities of teaching basic surgical skills that were previously in the purview of general surgery. This includes fundamentals such as management of a service, with expectations to round on patients in both morning and evening, following up on laboratories and studies that were ordered, and properly writing H&Ps and consults. During the early years of a program’s transition from an independent to integrated pathway, the senior residents and the teaching faculty must be made of aware of the necessity to teach these skills.

As more fellowships become integrated residency programs, we have assumed the responsibility to teach not only the plastic surgery but also the commitment to develop the residents’ maturity and professionalism. Criticism or harsh feedback can be especially devastating to junior residents who are still developing confidence and resilience as surgeons. While junior residents enter residency with fewer skills compared with a first-year fellow, there is the benefit of not needing to restrain overconfident fellows who, while fully trained general surgeons, are just beginning their plastic surgery experience. An integrated resident presents more as a blank slate with fewer “bad habits” to unlearn. It is important to note that studies have not demonstrated a difference in overall final competency and abilities of graduating chief residents from either track.1,2

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REFERENCES

1. Guo L, Friend J, Kim E, et al. Comparison of quantitative educational metrics between integrated and independent plastic surgery residents. Plast Reconstr Surg. 2008;122:972–978; discussion 979
2. 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
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