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Transition from the Independent to Integrated Program: Changing All Those Changes

Hultman, C. Scott MD, MBA, FACS

Plastic and Reconstructive Surgery – Global Open: March 2015 - Volume 3 - Issue 3S-2 - p e352
doi: 10.1097/01.GOX.0000464846.13236.d2
2014 ACAPS Congress: Abstracts

From the Division of Plastic Surgery, University of North Carolina, Chapel Hill, N.C.

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.

C. Scott Hultman, MD, MBA, FACS, Division of Plastic Surgery, University of North Carolina, Suite 7038, Burnett-Womack Building, Chapel Hill, NC 27599-7195, E-mail:

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.

As a mid-career academic plastic surgeon who survived a 20th century categorical general surgery residency, 3 years of a basic science fellowship, every other night in-house call, and work weeks never less than 100 hours in length, my formal education culminated in 2 glorious years of training with some of the legends (and 1 rising star) in our field: Jurkiewicz, Bostwick, Nahai, and a very young Bert Losken. Thankfully, paradigms change.

Although I defended the independent training model publicly,1,2 I privately questioned: what is the best way to train our residents to become not only competent surgeons but also leaders and innovators? Certainly, if neurosurgery, orthopedics, and otolaryngology could train outstanding physicians in 5–6 years, why would plastic surgery be so self-righteous to think that our residents had to be fully-trained surgeons before we would let them hold a scalpel? Were we afraid of failure?

Incrementally, over many years, I concluded that the value created by integrated programs was too large to ignore. Evidence from other programs appeared in the form of increased resident research productivity, more fulfilled faculty members, and conversion of many divisions into departments. The tipping point, for me, was crystal clear: one of our star residents, having also completed 10 years of training, just ran out of energy. He was done, burned out. No fellowship, no academic career. Time to cash in.

Once our division made the decision to convert from an independent to an integrated program, we have never looked back. In fact, the transition has been less traumatic and far more exciting than when we expanded from a 2-year to a 3-year program. Although our conversion is not yet complete (that occurs in the symbolic year of 2020), it already feels like a different program. We must confront many known knowns (milestones) and known unknowns (graduate medical education funding), plus the unknown unknowns that lurk over the horizon. However, the collective collegiality, academic enrichment, and re-innervation of our program are palpable. Coming to work every day is exciting (disclaimer: almost every day).

What I have learned is this:

  • Explore, develop, and articulate your vision.
  • Select a great Associate Program Director.
  • Delegate well.
  • The residents can and should manage a large bulk of their program.
  • Figure out early on what details you need to pay attention to and which ones you can ignore.
  • Develop your faculty as educators.
  • Nurture your important relationships, with the Designated Institutional Official, Chief Financial Officer, General Surgery Program Director, Chair of Surgery, and Vice President of Surgical Services.
  • Network with your colleagues in American Council of Academic Plastic Surgeons and national leaders in the Residency Review Council, American Society of Plastic Surgeons, and American Board of Plastic Surgery. chances are highly likely that your problem has been solved before.
  • Fake it until you make it.
  • Protect your integrity, which in the end is your most valuable asset.
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1. Hultman CS.. Efficacy of training pathways for residency education: results of the YPS National Survey. Plast Surg News. 2006;17:23
2. Hultman CS, Song D.. Point/counterpoint: the survival of independent pathways: time to change our approach? Plast Surg News. 2006;17:38
© 2015 American Society of Plastic Surgeons