SPECIAL TOPIC

The Diminishing Presence of Plastic Surgeons in Hand Surgery: A Critical Analysis

James P. Higgins, M.D.
Baltimore, Md.

Background: A growing trend of diminished presence of plastic surgery within the field of hand surgery has been observed in the membership of the American Society for Surgery of the Hand, applications for Certificate of Added Qualifications in Surgery of the Hand, and applications for hand surgery fellowships. Methods: The American Society for Surgery of the Hand resident education subcommittee has investigated this trend, collecting data from the Association of American Medical Colleges, the American Board of Orthopaedic Surgery, the American Board of Plastic Surgery, the National Residency Matching Program, the Accreditation Council for Graduate Medical Education, the American Society for Surgery of the Hand, the American Association of Hand Surgery, and the Certificate of Added Qualifications in Surgery of the Hand and from an online survey of plastic surgerytrained hand surgeons in the United States. Results: These data indicate that the subspecialty of hand surgery enjoys growing popularity with increasing fellowship applicants annually; uses an effective, fair, and multidisciplinary match; and demonstrates continued and healthy growth in its premier academic society. Despite these positive indicators, the percentage of new plastic surgery diplomates obtaining Certificate of Added Qualifications in Surgery of the Hand has decreased from 10 percent (20 applicants per year) to 4 percent (8 applicants per year), the percentage of examinees for the Certificate of Added Qualifications in Surgery of the Hand originating from plastic surgery training backgrounds has decreased from 30 percent to 15 percent, the percentage of the overall body of actively practicing plastic surgeons in the United States that hold Certificate of Added Qualifications in Surgery of the Hand qualifications is steadily decreasing (now to 10 percent), and the plastic surgery membership in the American Society for Surgery of the Hand is demonstrating negligible growth despite the overall expansion of the American Society for Surgery of the Hand. Conclusions: This report serves as a detailed and systematic account of these findings, a balanced interpretation, and a proposal of specific potential solutions. These include recommendations for changes in the structure and content of plastic surgery training programs and the National Residency Matching Program hand surgery fellowship designations. (Plast. Reconstr. Surg. 125: 248, 2010.)

he Curtis National Hand Center in Baltimore, Maryland, maintains a faculty of 14 full-time hand surgeons training five hand surgery fellows annually in an Accreditation Council for Graduate Medical Educationaccredited
From the Curtis National Hand Center and the Resident Education Subcommittee of the American Society for Surgery of the Hand. Received for publication January 12, 2009; accepted June 29, 2009. Presented in part at the November 1, 2008, meeting of the Association of Academic Chairmen of Plastic Surgery, in Chicago, Illinois. Copyright 2009 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0b013e3181c496a2c

fellowship program. Its founders represented the multidisciplinary crossroads that engendered the specialty of hand surgery, with backgrounds in orthopedic, general, and plastic surgery. The fellowship program has preserved this multidisciplinary approach since its inception in 1975. The belief that the field of hand surgery would best benefit by the cross-pollination of these disciplines represented the foundation of the Curtis National Hand Centers training model and contributed to

Disclosure: The author has no financial relationships or interests to disclose related to this project.

248

www.PRSJournal.com

Volume 125, Number 1 Plastic Surgery Presence in Hand Surgery

its success as a clinical center and academic training site. Over the past 10 years, the Curtis National Hand Center has experienced increasing difficulty finding high-quality fellowship applicants with plastic surgery backgrounds. The Center has seen a general increase in total number of candidates, and applications specifically from plastic surgery trainees have decreased (Table 1). A review of matriculated hand fellows over the past few decades demonstrated that the Curtis National Hand Center has enrolled a ratio of orthopedic to plastic surgery-trained hand fellows that was in keeping with a ratio of applications received (or demonstrating a slightly imbalanced ratio in favor of plastic surgery) (Table 2). This dispelled concerns that the Curtis National Hand Center may have been viewed as a fellowship that was unfriendly to plastic surgery applications. National Residency Matching Program data demonstrated that the Curtis National Hand Center received applications from roughly 50 percent of hand surgery fellowship applicants in the nationwide pool annually (Table 3).1 Furthermore, the Curtis National Hand Center received applications from 25 to 73 percent of the small annual number of hand fellowship applicants from plastic surgery residency programs, with the highest percentage being in 2006 (Table 4).2 This indicated that the decreasing number of plastic surgery applicants to the Curtis National Hand Center could be indicative of a nationwide trend whose origins, causal factors, and potential corrective solutions merited further investigation. Colleagues from other U.S. academic hand surgery training programs have voiced similar concerns. The specialtys premier academic body, the American Society for Surgery of the Hand, provided a springboard for an organized investigation of this issue. As a representative of the American Society for Surgery of the Hand resident education subcommittee, the author began this investigation in
Table 2. Curtis National Hand Center Fellows, by Specialty, 1998 to 2010*
Academic Year 19981999 19992000 20002001 20012002 20022003 20032004 20042005 20052006 20062007 20072008 20082009 20092010 Totals Plastic Surgery 1 1 2 2 1 1 1 1 2 12 (30%) Orthopedic Surgery 2 2 1 1 3 2 3 2 4 3 3 2 28 (70%)

*Data exclude U.S. Military Curtis National Hand Center fellows. Note that in 2006, civilian fellowship slots increased from three to four.

Table 3. Curtis National Hand Center Applicants among All Applicants Nationwide, 2002 to 2009
Training Year 2002 2003 2004 2005 2006 2007 2008 2009
CNHC, Curtis National Hand Center.

CNHC Applicants/All Applicants (%) 40/88 (45) 41/90 (46) 57/102 (56) 32/80 (40) 59/133 (44) 49/142 (35) 50/127 (39) 74/150 (49)

2007. Data were collected from the Association of American Medical Colleges, the American Board of Orthopaedic Surgery, the American Board of Plastic Surgery, the National Residency Matching Program, the Accreditation Council for Graduate Medical Education, the American Society for Surgery of the Hand, the American Association of Hand Surgery, the Certificate of Added Qualifications in Surgery of the Hand Examination Committee of the Joint Committee on Surgery of the Hand, and an online survey of plastic surgery

Table 1. Curtis National Hand Center Fellowship Applicants, 2001 to 2010

Academic Year 20012002 20022003 20032004 20042005 20052006 20062007 20072008 20082009 20092010 Totals Total Applicants 45 40 41 57 32 59 49 50 74 447 Orthopedic Surgery (%) 36 (80) 32 (80) 34 (82) 47 (82) 27 (84) 43 (72) 42 (85) 37 (74) 59 (80) 357 (80) Plastic Surgery (%) 7 (16) 6 (15) 6 (15) 7 (12) 3 (9) 11 (18) 4 (8) 5 (10) 5 (7) 54 (12) General Surgery (%) 2 (4) 2 (5) 1 (2.4) 3 (5) 2 (6) 5 (8) 3 (6) 8 (16) 10 (13.5) 36 (8)

249

Plastic and Reconstructive Surgery January 2010

Table 4. Curtis National Hand Center Plastic and Orthopedic Surgery Applicants among Fellows Trained Nationally, 2002 to 2006
Training Year 2002 2003 2004 2005 2006 Orthopedic Surgery Applicants (%) 32/61 (52) 34/73 (47) 47/83 (57) 27/77 (35) 43/104 (41) Plastic Surgery Applicants (%) 6/14 (43) 6/20 (30) 7/15 (47) 3/12 (25) 11/15 (73)

institutions in the United States maintain two hand fellowship training programs (2008 match) with separate designations of plastic surgery hand fellowship and orthopedic surgery hand fellowship: the University of Pittsburgh Medical Center, Massachusetts General Hospital, Washington University Medical Center, Beth Israel Deaconess Medical Center, and Baylor University Medical Center. The remaining majority of other U.S. institutions housing hand fellowships maintain only a single program.

trained hand surgeons in the United States. The following report serves as an account of these findings, a balanced interpretation, and a proposal of specific potential solutions. The purpose of this report is to stimulate discussion among the community of academic plastic surgery about this trend. An overview of the current pathway of a plastic surgery trainee through hand fellowship, certification, and academic society membership will provide a clear understanding of the subsequent data and assessment.

CURRENT STATUS OF THE FELLOWSHIP NATIONAL RESIDENCY MATCHING PROGRAM

Of the 70 Accreditation Council for Graduate Medical Educationaccredited hand surgery fellowships, 62 (89 percent) participate in the National Residency Matching Program encompassing 135 of the 143 Accreditation Council for Graduate Medical Educationaccredited positions (94 percent).3,4 Only eight of the Accreditation Council for Graduate Medical Education accredited programs do not participate in the National Residency Matching Program. The other subspecialty pathways of plastic surgery do not participate with the National Residency Matching Program, with the exception of ophthalmic plastic and reconstructive surgery (16 programs and 16 positions, not Accreditation Council for Graduate Medical Educationaccredited).1

THE STRUCTURE OF HAND SURGERY FELLOWSHIP TRAINING IN THE UNITED STATES

Hand surgery fellowships in the United States are of 1 years duration. Residents completing training programs in orthopedic surgery, plastic surgery, and general surgery are eligible for application to these training programs. Applications are due in December and interviews are held between February and April for matriculation in an academic year 18 months after the application due date. Thus, in a 5-year training program, a resident would apply for the position in December of their postgraduate year 4; in a 6-year program, residents would apply in December of their postgraduate year-5 training year, and so forth. There are 143 Accreditation Council for Graduate Medical Educationaccredited fellowship positions in 70 programs around the country.3 Of these 70 programs, 55 are designated orthopedic hand fellowship programs, 14 are designated plastic surgery hand fellowship programs, and one is designated general surgery hand fellowship program. These designations seem to have been assigned according to the board certification of the fellowship directors of each program. There exists no correlation between these designations and the eligibility requirements for applicants. There are no hand fellowship training programs of which the author is aware that officially or unofficially accept applications from only one discipline. Only five

ADDITIONAL QUALIFICATIONS AND SOCIETY MEMBERSHIP AFTER COMPLETION OF HAND SURGERY FELLOWSHIP
The Certificate of Added Qualifications in Surgery of the Hand began in 1986 when the American Board of Medical Specialties authorized its administration by the American Board of Surgery, the American Board of Orthopaedic Surgery, and the American Board of Plastic Surgery. (The American Board of Plastic Surgery refers to the Certificate of Added Qualifications in Surgery of the Hand as the Subspecialty of Surgery of the Hand Certification. The American Board of Surgery refers to it as Surgery of the Hand Certification. In this article, it is referred to as the Certificate of Added Qualifications in Surgery of the Hand, the certificates most widely recognized moniker.) Applicants must be diplomates of the American Board of Surgery/American Board of Orthopaedic Surgery/American Board of Plastic Surgery, maintain an active practice in hand surgery for at least 2 years, and have completed a

250

Volume 125, Number 1 Plastic Surgery Presence in Hand Surgery

1-year Accreditation Council for Graduate Medical Education hand surgery fellowship. This designation does not impart any legal privileges or license to practice hand surgery. It is intended as a means of recognition of additional training, commitment, and contribution to the field. There are two American academic societies for those specializing in hand surgery. The American Society for Surgery of the Hand is the larger society, with 2594 members (2007 data). This society requires that a hand surgeon hold a Certificate of Added Qualifications in Surgery of the Hand for eligibility for membership. The American Association of Hand Surgery has 533 members (2008 data) and does not require Certificate of Added Qualifications in Surgery of the Hand qualifications for membership. The relative makeup and membership of these two societies is shown in Figure 1.5 This framework provides a means of studying the decreasing presence of plastic surgery in hand surgery. The following data pertain to various stages of training and certification in hand surgery and are aimed at addressing possible causes for this trend. 193 graduates from 89 accredited programs. This orthopedic surgerytoplastic surgery ratio (3.2:1) of diplomates has been consistent for the past two decades (Fig. 2).6 This would indicate that the changes observed in hand surgery are not attributable to changes in their parent specialties.

POPULARITY OF HAND SURGERY AS A SUBSPECIALTY

National Residency Matching Program results from 1993 through academic year 2009 demonstrate increasing popularity of hand surgery as a subspecialty, with the most recent match witnessing a record high number of applications of 150 (Fig. 3).4 This indicates that the changes observed in hand surgery are not attributable to a general decline in interest in hand surgery as a subspecialty field.

TRENDS OBSERVED IN THE CERTIFICATE OF ADDED QUALIFICATIONS

The number of Certificate of Added Qualifications in Surgery of the Hand certificates awarded each year shows a decline in the plastic surgerytrained Certificate of Added Qualifications in Surgery of the Hand applicants, most recently dropping to less than 10 applicants in 2007 (Fig. 4).7 Figure 5 demonstrates each of the subspecialties in the overall pool of examinees for the Certificate of Added Qualifications in Surgery of the Hand by percentage, reflecting a decrease in the percentage of applicants from plastic surgery,

RELATIONSHIP IN NUMBER OF ORTHOPEDISTS TO PLASTIC SURGEONS PRODUCED ANNUALLY

Accreditation Council for Graduate Medical Education 2007 residency data demonstrate 617 graduates from 152 accredited U.S. orthopedic surgery programs, whereas plastic surgery created

Fig. 1. American Society for Surgery of the Hand and American Association of Hand Surgery membership, by specialty, for 2007 to 2008. Note that the number of hand surgeons holding membership in both societies is unknown.

251

Plastic and Reconstructive Surgery January 2010

Fig. 2. Orthopedic and plastic surgery diplomates from 1988 to 2007.

Fig. 3. Number of applicants to the National Residency Matching Program hand surgery match from 1993 to 2009.

Fig. 4. Certificate of Added Qualifications in Surgery of the Hand awarded from 1990 to 2007, by subspecialty training.

whereas the percentage of applicants from orthopedic surgery is steadily increasing.8 If the number of Certificate of Added Qualifications in Surgery of the Hand examinees is calculated as a percentage of new diplomates from each of the two major subspecialties, a concerning trend can be ob-

served. Figure 6 demonstrates this percentage of new diplomates from Accreditation Council for Graduate Medical Educationaccredited plastic surgery programs obtaining the Certificate of Added Qualifications in Surgery of the Hand declining to a record low of 4.05 percent in 2007, in

252

Volume 125, Number 1 Plastic Surgery Presence in Hand Surgery

Fig. 5. Certificate of Added Qualifications in Surgery of the Hand examinees, percentage by specialty from 1989 to 2006.

Fig. 6. New diplomates obtaining Certificate of Added Qualifications in Surgery of the Hand, percentage by specialty from 1995 to 2007.

contrast to the percentage of new diplomates from orthopedic surgery obtaining the Certificate of Added Qualifications in Surgery of the Hand remaining steady. The cumulative number of actively practicing plastic surgeons in the United States maintaining Certificate of Added Qualifications in Surgery of the Hand certification has effectively leveled off (Fig. 7). The percentage of active plastic surgeons holding a Certificate of Added Qualifications in Surgery of the Hand is now trending downward to 10.99 percent in 2007 (Fig. 8). This trend does not appear to be occurring in orthopedic surgery, where the cumulative number of active surgeons

holding a Certificate of Added Qualifications in Surgery of the Hand is steadily rising (Fig. 9).9

TRENDS OBSERVED IN ACADEMIC SOCIETIES

To thoroughly assess participation of hand surgeons in professional societies, the author attempted to obtain annual data from both the American Society for Surgery of the Hand and the American Association of Hand Surgery. The latter is thought by some to be more oriented toward the plastic surgery hand surgeon than the American Society for Surgery of the Hand. Indeed, the ratio of plastic surgeons to orthopedic surgeons in

253

Plastic and Reconstructive Surgery January 2010

Fig. 7. Cumulative numbers of plastic surgeons holding Certificate of Added Qualifications in Surgery of the Hand, from 1995 to 2007.

Fig. 8. Percentage of plastic surgeons holding Certificate of Added Qualifications in Surgery of the Hand, from 1995 to 2007.

American Association of Hand Surgery membership in 2008 was approximately 1.7:1. Unfortunately, no trends could be extracted because data on American Association of Hand Surgery membership over the past decade are not available. Furthermore, it is common practice for hand surgeons to hold membership in both societies, and the magnitude of this crossover is unknown. Therefore, calculating cumulative data on numbers of hand surgeons from each subspecialty as a sum of the two separate societies would be inaccurate and misleading. The American Society for Surgery of the Hand is approximately five times larger than the Amer-

ican Association of Hand Surgery. Although the ratio of orthopedic surgeon members to plastic surgeon members is higher in the American Society for Surgery of the Hand than in the American Association of Hand Surgery, the American Society for Surgery of the Hand maintains a larger number of plastic surgery members than the American Association of Hand Surgery. For these reasons, trends in the membership in the American Society for Surgery of the Hand are pertinent to the study of trends in the makeup of the field of hand surgery in the United States in general, and are indicators of the role of plastic surgery in the specialty.10

254

Volume 125, Number 1 Plastic Surgery Presence in Hand Surgery

Fig. 9. Cumulative number of orthopedic surgeons holding Certificate of Added Qualifications in Surgery of the Hand, from 1995 to 2007.

The American Society for Surgery of the Hand is a thriving society, with growing membership demonstrated annually for the past 10 years. However, this growth appears to be primarily because of growth in its orthopedic membership, whereas the number of plastic surgery members has grown only negligibly (Fig. 10). These data can be examined as a percentage of the overall membership, with the orthopedic surgery percentage increasing slowly and the plastic surgery percentage decreasing slowly (Fig. 11).11

DISCUSSION
These data indicate that the subspecialty of hand surgery enjoys growing popularity with in-

creasing applicants to hand surgery fellowships annually; uses an effective, fair, and multidisciplinary match through the National Residency Matching Program system; and demonstrates continued and healthy growth in its largest academic society. Because the past few decades have demonstrated a constant ratio of the production of new diplomates from orthopedic and plastic surgery annually, growth of the subspecialty of hand surgery should be reflected in increasing numbers of hand surgeons, Certificate of Added Qualifications in Surgery of the Hand awardees, and American Society for Surgery of the Hand members from both orthopedic and plastic surgery. However, the data demonstrate the following:

Fig. 10. Number of members of the American Society for Surgery of the Hand, by specialty, from 1997 to 2007.

255

Plastic and Reconstructive Surgery January 2010

Fig. 11. Percentage breakdown of the membership of the American Society for Surgery of the Hand, by specialty, from 1997 to 2007.

The percentage of new plastic surgery diplomates obtaining Certificate of Added Qualifications in Surgery of the Hand has decreased from 10 percent (20 applicants in 1999) to 4 percent (8 applicants in 2007). The percentage of examinees for Certificate of Added Qualifications in Surgery of the Hand from plastic surgery training backgrounds has decreased from 30 percent to 15 percent over the past decade. The percentage of the overall body of actively practicing plastic surgeons in the United States that hold Certificate of Added Qualifications in Surgery of the Hand qualifications is decreasing steadily (now to 10 percent). Plastic surgery membership in the American Society for Surgery of the Hand is demonstrating negligible growth despite the overall expansion of the American Society for Surgery of the Hand. Explanations for This Trend The resident education subcommittee of the American Society for Surgery of the Hand, as part of its investigation into this problem, performed an online survey of plastic surgerytrained members, focusing on potential causes of the decreased presence of plastic surgery in the field of hand surgery.12 Of 464 plastic surgeons in the American Society for Surgery of the Hand, 166 responded (36 percent response rate). The responses can be distilled into the three suggested contributing factors. Structure and Timing of Hand Surgery Rotations for Plastic Surgery Residents The application due date for hand surgery fellowships participating in the National Resi-

dency Matching Program match is 18 months before the start of the fellowship. In a 5-year program, plastic surgery residents have to submit applications in December of postgraduate year 4. In our current plastic surgery training structure, the timing of this match places plastic surgery residents in a much different position from their orthopedic counterparts applying for hand surgery fellowship positions. In a typical orthopedic residency program, trainees complete the prerequisite general surgical internship year and begin training rotations in orthopedic-specific subspecialties as early as the beginning of postgraduate year 2. Typical orthopedic surgical trainees are likely to have exposure to hand surgery and hand surgical mentors at this time, providing 2 years to identify hand surgery as an area of career interest; to pursue relationships with hand surgeons and obtain counseling, experience, and letters of recommendation; to pursue and complete hand surgeryrelated research projects; to explore hand surgery academia in meetings (such as the American Society for Surgery of the Hand and the American Association of Hand Surgery); and to complete and submit a high-quality application on time. If a plastic surgery trainee is in a 5- or 6-year program and completes prerequisite 2.5 or 3 years of general surgical training, he or she may begin rotations in subspecialties of plastic surgery at the midpoint of postgraduate year 3 or the beginning of postgraduate year 4. This provides the plastic surgery resident only 6 to 12 months (for the 5-year program) or 18 to 24 months (for the 6-year program) to complete these steps toward a hand surgery career. When a plastic surgery resident pursues a fellowship in hand surgery, it is unlikely

256

Volume 125, Number 1 Plastic Surgery Presence in Hand Surgery

that they will have the duration, quality, or depth of exposure that will enable them to submit an application of equal quality to their orthopedic colleagues. Thus, the organization of plastic surgerys training structure is not conducive to producing adequate numbers of applicants and adequate quality of applications for hand surgery fellowships. This makes it unlikely that plastic surgery can maintain a presence in the field of hand surgery commensurate with the relative number of plastic surgeons trained or the magnitude of its historical contributions to the discipline. One could identify this particular timing problem as being attributable to the early nature of the hand surgical match rather than the late exposure of plastic surgery residents to hand surgery. This argument would suggest that, rather than restructuring the timing of exposure of residents to hand surgery, the fellowship match should be restructured to occur during the final training year (similar to the informal process whereby plastic surgery residents are selected to other subspecialties without the use of a match). The fault in this argument is that the National Residency Matching Program for hand surgery has a long tradition of equity, participation, and success for both trainees and training programs. This is demonstrated by the 89 percent participation of Accreditation Council for Graduate Medical Educationaccredited fellowship training programs in the match, the growing (and recently record-high) number of applications for hand fellowship programs through the match, and the remarkably high match rate of the hand surgery fellowship National Residency Matching Program. The match rate is the often-cited indicator of the effectiveness of a particular specialty or subspecialty match. In 2008, of 127 applicants, 118 were successfully matched through the system, making the hand surgery specialty match rate 93 percent. Of 136 positions offered, 118 were filled, making 48 of the 63 programs filled.4 Any change initiated to improve the number and quality of plastic surgery applicants to hand surgery would best be undertaken by changing the structure of our training rather than disrupting a successful and effective match. Furthermore, simply changing the timing of the match would not address the underlying inequity between hand surgery exposure in the two specialties. Although this problem with our training programs structures may be a contributing factor to the inequality in orthopedic and plastic surgery applications, it is difficult to attribute the downward trend in plastic surgeons in fellowships/ Certificate of Added Qualifications in Surgery of the Hand/American Society for Surgery of the Hand to this issue. This inequality in training existed before the development of this trend. Earlier exposure of our trainees could, however, contribute to restoration of plastic surgerys presence in the field. Hand Surgery Role Models In the survey of the plastic surgerytrained, Certificate of Added Qualifications in Surgery of the Hand certified hand surgeons within the American Society for Surgery of the Hand (mentioned earlier),12 approximately 90 percent of the 166 survey participants stated that plastic surgery was underrepresented in the field of hand surgery. Eighty-seven percent felt that hand surgery was underrepresented in the subspecialty of plastic surgery. Among the issues cited, 75 to 80 percent of responders felt that the following were somewhat or very important factors explaining the relatively small presence of plastic surgery in the field of hand surgery. There are fewer hand surgery role models for trainees in plastic surgery training programs than in orthopedic training programs. There are fewer attendings of plastic surgery training program faculties with practices dedicated exclusively to hand surgery (compared with their orthopedic training program counterparts). There are relatively fewer attendings on plastic surgery training program faculties that are Certificate of Added Qualifications in Surgery of the Hand/American Society for Surgery of the Hand members (compared with their orthopedic training program counterparts). The influence of these factors on the low number of plastic surgery residents pursuing a career in hand surgery is difficult to quantify. The survey provides opinions of a large number of practicing hand surgeons but does not demonstrate the magnitude of these factors on the decision making of our trainees. Despite the growing trend toward subspecialization, the part-time hand surgeon model seems much more widely encountered and accepted in plastic surgery than it is in orthopedic surgery. In an increasingly complex and competitive hand surgical subspecialty, a practice only occasionally (i.e., 50 percent case load) encompassing hand surgery may be unlikely to thrive. Such a practice may be more likely to obtain its hand

257

Plastic and Reconstructive Surgery January 2010

surgical cases by means of trauma and emergency care and less apt to be identified as a referral source for elective cases, complex cases, or even cases involving common osseous abnormality of the hand and wrist. This practice model has also been demonstrated to be ineffective in achieving mastery of the discipline. Since its inception, the Certificate of Added Qualifications in Surgery of the Hand examination has demonstrated a significantly lower pass rate among plastic surgery applicants than orthopedic surgery applicants (69 percent and 97 percent, respectively). This was investigated by the Certificate of Added Qualifications in Surgery of the Hand Examination Committee of the Joint Committee on Surgery of the Hand (in which all three involved boards participated), and the most likely explanation for this observation was the presence of the part-time hand surgeon. Indeed, the failure rate was dramatically higher among those applicants whose practice in hand surgery represented 50 percent or less of their overall practice volume (Figs. 12 and 13).8 It is the authors opinion that the practice model of the part-time hand surgeon may also affect the exposure of our trainees. These trainees may be more likely to see a practice model where hand surgery cases (primarily emergency cases) represent the most inconvenient, difficult, and poorly reimbursed portion of the larger practice. They may also be less likely to be exposed to areas of superspecialization (such as congenital surgery, brachial plexus, microsurgical, and oncology) or even very common osseous problems of the hand and wrist. This training model may be less apt to ignite residents interests in hand surgery as a career. This model may also be less capable of providing trainees with career development and support, hand surgeryrelated research projects, or a sense of the gratification and satisfaction achievable from a practice dedicated primarily to hand surgery. Whether the number, quality, and practice models of our academic role models is an influence on our trainees diminished interest in hand surgery is speculative. It is also difficult to attribute the downward trend in plastic surgeons in fellowships/Certificate of Added Qualifications in Surgery of the Hand/American Society for Surgery of the Hand to this issue. This training model existed before the development of this trend. Further examination of hand surgery training role models and comparison with those in the orthopedic training programs is warranted. Financial Allure of Aesthetic Surgery The American Society for Surgery of the Hand survey indicated that many respondents felt the financial allure of aesthetic surgery was an important influence on the diminished role of plastic surgery in hand surgery. Three observations seem to indicate that this may be an overestimated factor in this trend: 1. Orthopedic surgery has a myriad of more lucrative specialties (e.g., spine surgery,

Fig. 12. The Certificate of Added Qualifications in Surgery of the Hand pass rate, by specialty, from 1989 to 2007 (average percentage pass rate by specialty in box).

258

Volume 125, Number 1 Plastic Surgery Presence in Hand Surgery

Fig. 13. The Certificate of Added Qualifications in Surgery of the Hand failure rate among plastic surgeons, by percentage of practice dedicated to hand surgery, from 2001 to 2005.

sports medicine, total joint reconstruction) yet continues to produce large and growing numbers of applicants for hand surgery fellowships annually based on interest in the technical and academic attributes of hand surgery itself. 2. Plastic surgery continues to populate less lucrative subspecialty fellowships (e.g., craniofacial, pediatric, microsurgery, major reconstruction) based on interest in the technical and academic attributes of those fields. 3. A recent study examining factors influencing plastic and orthopedic residents decisions to pursue hand surgery careers demonstrated intellectual issues (e.g., interest in and exposure to this field) to be more influential than lifestyle issues (e.g., reimbursement, work hours).13 Despite these realities, the American Society for Surgery of the Hand survey indicated that many respondents felt this was an important influence on the diminished role of plastic surgery in hand surgery. This perception may be perpetuated by a trend among some plastic surgeons to nurture an emergency room dominated hand surgery practice model before achieving an elective aesthetic surgery practice. Training programs that include full-time hand surgeons could demonstrate to trainees that the pursuit of hand surgery fellowship, Certificate of Added Qualifications in Surgery of the Hand, American Society for Surgery of the Hand/American Association of Hand Surgery membership, and a practice dedicated entirely to hand surgery is not only feasible and sustainable but often lucrative.

Proposals Changes in the structure and focus of our training programs can aim at addressing this problem. The Residency Review Committee for Plastic Surgery ratified a proposal to mandate changes in the duration and structure of U.S. plastic surgery training programs. This includes extension of all plastic surgeryintegrated programs to a minimum of 6 years of training enacted in 2009. The Association of Academic Chairmen of Plastic Surgery is diligently working to comply with these mandates with changes in structure, curriculum, and funding. This is an opportune time to address this disheartening trend of the decreasing presence of plastic surgery in the discipline of hand surgery. Given that the application for hand surgery fellowship positions has a deadline earlier than all other subspecialty fellowships of plastic surgery, this clinical experience should be provided at the earliest opportunity. As plastic surgery training programs are gaining increasingly more input into the curriculum of the prerequisite years (postgraduate years 1, 2, and 3), elective rotations during this period could be assigned to hand surgery rotations. Furthermore, with the mandated change to a minimum of 6 years of training, the years of requisite training would be lengthened, now totaling 3 to 3 years after prerequisite training completion. If feasible, the earliest months should focus on exposure and training in hand surgery so that residents can identify this as a career interest and have adequate time to explore the field and become competitive as fellowship applicants. Specifically, a goal would be to provide 4 months of hand surgery rotations before

259

Plastic and Reconstructive Surgery January 2010

the midpoint of postgraduate year 4 in a 6-year program. Plastic surgery training centers may benefit from having a quota of full-time hand surgeons to serve as role models for trainees. The definition of full-time hand surgeon could include the completion of a hand surgery fellowship, Certificate of Added Qualifications in Surgery of the Hand certification, membership in American Society for Surgery of the Hand/American Association of Hand Surgery, or a majority of overall case volumes dedicated to treatment of the upper extremity. If such faculty members cannot be secured within the plastic surgery faculty, it may be wise to use the mentorship of full-time hand surgeons from outside the confines of training programs. Outside sources could include orthopedic surgery departments in the same institution, community plastic/orthopedic private hand surgery practices, and regional centers of excellence in hand surgery. In Baltimore, the Curtis National Hand Center provides 4 months of hand surgery rotations for plastic surgery residents from the Johns Hopkins Division of Plastic Surgery and the Georgetown University Department of Plastic Surgery. These academic centers have prioritized obtaining highquality subspecialty exposure for their residents regardless of whether this can be achieved within the confines of their own institutions. The American Society for Surgery of the Hand could identify other regional hand centers interested in participating in such endeavors. Lastly, the National Residency Matching Program should abolish the meaningless designation of hand surgery fellowship programs as either plastic or orthopedic. This has no bearing on applicants eligibility to these programs and they all participate in the same match. These designations could be misleading to applicants or plastic surgery residency coordinators who provide career advice. Programs should simply be designated as hand surgery. field and discipline of hand surgery. Our specialty needs to continue to nurture this portion of our residency curriculum. The proposals submitted could do much to return plastic surgery to a vibrant and growing position in this specialty and maintain our historical tradition of innovation and leadership in the discipline of hand surgery.
James P. Higgins, M.D. Curtis National Hand Center 1400 Front Avenue, Suite 100 Lutherville, Md. 21093 jameshiggins10@hotmail.com

REFERENCES
1. NRMP Results and Data: Specialty Matching Service. 20022009 Appointment years. Available at: http://www.nrmp.org. Accessed December 15, 2008. 2. AAMC GME Track/National GME Census data for denominators in table. Data (1995-2006) obtained via electronic communication with AAMC central office. 3. Accreditation Council for Graduate Medical Education. List of programs by specialty. Available at: http://www.ACGME. org. Accessed December 15, 2008. 4. National Residency Matching Program. Available at: http:// www.NRMP.org. Accessed December 15, 2008. 5. Electronic communications with the central offices of ASSH and AAHS. 6. Data collected for ABOS graduates from 1988 to present via electronic communication with ABOS central office. ABPS data obtained from American Board of Plastic Surgery, Inc., Annual Newsletter to Diplomates. Available at: http://www. abplsurg.org. Accessed December 15, 2008. 7. American Board of Plastic Surgery, Inc. Annual Newsletter to Diplomates. Available at: http://www.abplsurg.org. Accessed December 15, 2008. 8. Chang B. The Plastic Surgeon Hand Surgeon: How to make it work successfully: CAQSH. Paper presented at: CAQSH Examination Committee of the Joint Committee on Surgery of the Hand, Northeastern Society of Plastic Surgeons, Boston, Mass, December 2006. 9. Data calculated as cumulative CAQSH awarded/cumulating specialty diplomas granted by each of respective boards of orthopedic and plastic surgery. 10. Data gathered via electronic communication with AAHS central office. 11. Data gathered via electronic communication with ASSH central office. 12. Plastic Surgerys Presence in Hand Surgery. ASSH resident education subcommittee on-line survey. 2008. 13. Chung KC, Lau FH, Kotsis SV, Kim HM. Factors influencing residents decisions to pursue a career in hand surgery: A national survey. J Hand Surg (Am.) 2004;29:738747.

CONCLUSIONS
This author believes that the trend observed represents a departure of plastic surgery from the

260