Recently I read an editorial in the Plastic and Reconstructive Surgery (PRS) Journal by Dr. Thomas R Stevenson regarding the question of "What is Plastic Surgery and Who Decides?" It is a very thoughtful article. With his and Lippincott Williams & Wilkins permission, I am re-printing it here.
"What is Plastic Surgery and Who Decides?"
We are finishing a face lift consultation and my nurse puts away our mirror. Amy, rearranging her hair, asks a familiar question, “Why do they call it plastic surgery?” I fumble through an explanation of Carl von Graefe’s use of “plastic,” meaning “to mold,” and add something about having “nothing to do with a class of chemical compounds, but is a discipline that includes reconstructive and aesthetic surgery.” Amy’s eyes glaze over. Obviously confused but satisfied there is an answer, she walks into my manager’s office for a price quote. I am left with her question and my own interpretation of it. Amy really wants to know, “What is plastic surgery?” The answer depends on whom you ask.
Quiz a U.S. citizen about our specialty and chances are you’ll receive a response referencing movie stars and breast augmentation. A crude colloquial noun often will substitute for “breast.” You might get a script outline from last week’s plastic surgery reality television show. Press a little further and you may hear a reference to nose jobs and face lifts— occasionally cleft lip repairs or breast reconstructions. If you mention pressure sore closure or limb salvage, digital replantation, or hand surgery, the reply might be, “That’s plastic surgery?” Such is our specialty’s public perception.
Insurers have a clearer idea of surgery’s scope but limited concerns regarding plastic surgery’s future. Give them an ICD-9 and CPT code, and they will tell you if it is covered and what they will pay. Reimbursement is based on a negotiated fee-for-service scale. A plastic surgeon in private practice can decide if payment is sufficient, accepting only those insurance plans that pay enough and rejecting others. Plastic surgeons in large multispecialty groups or academic practice may not be allowed to turn down patients whose plans reimburse poorly. Thus, most private practitioners are pushed toward performing lucrative cosmetic procedures while other plastic surgeons are threatened with insolvency. Most of us do some cosmetic surgery. That part of our practice requires expertise, involves few emergency calls, and pays the bills. But who among us entered residency simply hoping to be a successful cosmetic surgeon? Unfortunately, if whittled down to a financially viable “chip,” plastic surgery would be one knife stroke away from disappearing. No, third-party payers and financial considerations should not circumscribe our specialty.
Plastic surgery’s accrediting and credentialing organizations are the Plastic Surgery Residency Review Committee and the American Board of Plastic Surgery. Each group has a slightly different view of what constitutes our specialty. The Plastic Surgery Residency Review Committee precisely delineates the variety and number of procedures each plastic surgery resident must perform in order for his or her program to stay accredited. Provide inadequate case volume and a training program risks loss of accreditation. Through written and oral examination processes, American Board of Plastic Surgery certification is granted only to those candidates who are familiar with a broad range of problems faced by plastic surgeons. The Residency Review Committee and American Board of Plastic Surgery determine what information a plastic surgery residency must impart and what a graduating resident must know to be board certified. These two organizations declare what a plastic surgeon starts out being, not what that surgeon will be doing in a mature practice.
Plastic surgeons are encouraged by the board to maintain certification. Board certification is time-limited. If a plastic surgeon wishes to maintain certification, that surgeon must regularly assess his or her patient management abilities, identify deficiencies, and objectively demonstrate an effort to improve. However, this Maintenance of Certification process will not force a plastic surgeon to master the same breadth of skills that surgeon possessed when he or she was initially certified. Plastic surgery’s scope cannot be defined by accrediting or certifying bodies.
Plastic surgery training programs develop curricula based on comprehensive didactic and clinical outlines. Program directors are required to educate residents across a wide spectrum. Still, no two programs are identical. Some programs are strong in microsurgery, others in aesthetic procedures. Newly graduated residents are as different as snowflakes. Those differences grow over years of practice. Principles of problem analysis and treatment planning, developed as a resident, should be retained and used to refine patient care techniques. However, specific procedures taught to a resident are supplanted by the discovery of superior ones or are shown to be ineffective, even dangerous. Who among us is still injecting liquid silicone? When a resident finishes training, his or her perspective interprets plastic surgery as that body of knowledge personally amassed to date—but there will be so much more.
Plastic surgery is defined by public opinion, reimbursement agencies, accreditation and certification bodies, training program curricula, and practice patterns. Is that the entire answer?
Back to Amy’s question, “What is plastic surgery?” She may never know, but we should. I believe plastic surgery is what plastic surgeons do. It is what we do collectively, and what this aggregate body does is what each of us individually entered plastic surgery to do. Yes, it is constrained by finances, limited by local availability of cases, and confined to its practitioners’ skills and training. Our scope may be narrowed by competing specialties, and certainly our practice will change. Still, we as a group fix clefts, treat pressure sore patients, reconstruct burn victims, repair mangled hands, and care for patients overseas.
As applicants to plastic surgery programs, we were picked because we were capable and promising in our program directors’ eyes. We were young surgeons who looked at things differently. Each of us vowed to be an innovator. We wanted to figure out a new and better way of doing something. Preserving that ideal and providing the chance for enthusiastic, creative young surgeons to flourish is plastic surgery’s essence. Each of us retains a portion of that spirit. Private practitioners, academicians, and researchers in plastic surgery must continue their commitment to variety and innovation. We must encourage the American Board of Plastic Surgery and Plastic Surgery Residency Review Committee to maintain breadth in plastic surgery training. Our membership organizations must be stimulated to provide varied educational offerings. We are obligated to ensure that those opportunities we enjoyed persist and are passed on to the next generation of plastic surgeons.
Thomas R. Stevenson, M.D.
Division of Plastic Surgery
University of California, Davis
Sacramento, Calif. 95817
What Is Plastic Surgery and Who Decides?; Plastic & Reconstr Surgery, 120(4):1079-1080, September 15, 2007; Stevenson, Thomas R. M.D.