Journal of Plastic, Reconstructive & Aesthetic Surgery
Volume 61, Issue 10 , Pages 1135-1138, October 2008

Reaching our successors: the trend for early specialisation and the potential effect on recruitment to our speciality☆

  • J.E. Rees-Lee

      Affiliations

    • Corresponding Author InformationCorresponding author. Address: Department of Plastic Surgery, Frenchay Hospital, Frenchay Park Road, Bristol BS16 1LE, United Kingdom Tel.: +44 1179 701212; fax: +44 1179753769.
    • ,
  • S. Lee

Department of Plastic Surgery, Frenchay Hospital, Bristol BS16 1LE, United Kingdom

published online 10 July 2008.

Article Outline

 

The implementation of earlier postgraduate specialisation, which is currently taking place in the United Kingdom (UK), will reduce the exposure of junior surgical trainees to surgical subspecialties prior to their final career choices. The teaching of our expanding specialty is contracting and this may have a significant effect on the recruitment of our successors to the speciality of plastic surgery.

Modernising Medical Careers (MMC),1 the restructuring initiative and vehicle for early specialisation in postgraduate medical education in the UK, was investigated after the first year due to the recruitment and organisational difficulties that occurred following its introduction. The resulting Tooke Inquiry2 concluded that early specialisation may be detrimental to training and suggested that medical training and education needs to be more co-ordinated and broad-based, especially in the early years. The UK government in it's response to the report have resolved to keep the current training structure for a further undefined period.3

Research shows that career choices are made as a result of preconceived ideas4, 5, 6 and positive exposure to a speciality.7, 8, 9 This includes exposure to good role models, positive time spent within the specialty and crucially the timing of that experience.10, 11, 12, 13

Some authors have looked at the effect of preconceived ideas. A 2006 study of 100 UK medical students5 revealed that 85% of undergraduates could not list 5 conditions treated by plastic surgeons, 93% felt that cosmetic surgery was the main component of the speciality and that plastic surgery as a speciality was not relevant to training thus giving it a score of only 226 out of 700 to reflect this view. After a plastic surgery teaching programme 100% could name five plastic surgery conditions, all realised cosmetic surgery only made up a small amount of the work of plastic surgeons and the relevance to training was rated at 613 out of 700. A 1979 study of 600 qualified doctors6 showed that 52% gave plastic surgery a low priority in the undergraduate curriculum and 41% thought it only warranted postgraduate study. 74% of the respondents had not had plastic surgery taught separately at medical school, and only 11% had experienced any postgraduate plastic surgery teaching. In 1970 Calnan,14 in his published essay on the future of plastic surgery, stated “undoubtedly the best way to encourage trainees to any speciality is to include, in the general undergraduate programme, lectures on the subject”. A wealth of discussion has followed5, 6, 10, 13, 15, 16, 17, 18, 19 and lends weight to the argument that the breadth of the subject and the interest that it generates amongst students5, 10, 20 justify its inclusion in the undergraduate curriculum.

Role models are “individuals admired for their ways of being and acting as professionals”.11 Burack et al12 used grounded theory to explain the process of speciality choice by medical students and the influence of role models in this process. They proposed that the process of speciality choices was a “socially constructed process of trying on possible selves (i.e. projecting oneself into hypothetical career and personal roles)”. They concluded that this explained the influence that role models have on career choices and their capacity to challenge negative stereotypes.

“We must acknowledge … that the most important, indeed the only, thing we have to offer our students is ourselves. Everything else they can read in a book.”21

A recently published study by Greene at el showed firstly that the most influential factor in an undergraduate's decision to choose a career in plastic surgery was exposure to plastic surgery as a medical student.13 In addition, the involvement of plastic surgeons with undergraduate training programmes is the strongest stimulus for the rising number of applicants to plastic surgery training in the United States. Such an involvement is most effective before the third year of medical school. The influence of future income was reported to be less important than the medical students perceived compatibility with the personality of plastic surgeons and lifestyle.

In 1986 a national survey of UK medical schools15 showed that 78% included plastic surgery in their undergraduate curriculum and that 77% of plastic surgery units in the country took part in this teaching. In 1992 an audit of the teaching of a third year undergraduate plastic surgery syllabus16 showed that undergraduates thought it was interesting and relevant to their training. At the time 11 of 51 (21%) plastic surgery centres were taking part in teaching undergraduates compared with the 77% quoted in the 1986 study. Our unpublished study using a simple questionnaire showed only 3 out of 23 medical schools (13%) in England and Wales taught plastic surgery in their core undergraduate curriculum in the academic year 2005/2006. This represents a significant fall from the 1986 figure of 78%. When questioned further it was found that the majority of medical schools did teach 8 of 9 plastic surgical areas in the core undergraduate curriculum, but these were not labelled as “plastic surgery” (Graph 1). The 9 areas were being taught in 21 different modules within different undergraduate curricula (Graph 2). 16 of the 23 medical schools ran special study modules in plastic surgery for a small number of undergraduates.

  • View full-size image.
  • Graph 1. 

    Which of the nine specified areas of plastic surgery were being taught elsewhere in the undergraduate curriculum but not under the title of “plastic surgery”.

Although many educationalists would argue that undergraduate medical education is for the teaching of generic skills and not “esoteric” surgical sub-specialties such as plastic surgery, Barnett and Coate suggest that,

“..an agenda of ‘generic skills’ may even be counter-productive, for such an agenda may diminish the possibilities of imaginatively creating curricula that are going to be likely to engender the kinds of human being appropriate to the twenty-first century.”22

Our recent unpublished study into plastic surgery jobs in Foundation Training programmes in England and Wales for 2006/2007 has shown that only 6 of the 15 foundation schools offer any jobs in plastic surgery, with only 0.6% of all foundation trainees in England and Wales getting an opportunity to experience plastic surgery. This is the same cohort of undergraduates who, according to the author's previous study, had little or no exposure to plastic surgery during medical school. So this ‘generic skills’ approach to the undergraduate medical curriculum along with a lack of plastic surgery jobs in Foundation training and early specialisation can only mean that far fewer individuals will be experiencing any plastic surgery before choosing their future career paths.

In 1949 Tyler23 laid out the questions that are still central to curriculum design today including, what is the purpose of an educational programme? We may ask: is it purely to give future doctors the generic skills for their professional practice or does it also need to plant seeds for the future by allowing trainees to “try on other selves” and obtain glimpses of their future career possibilities? Our knowledge of how individuals choose their careers and their need for speciality specific experience and inspiring role models strongly suggests that unless these seeds are sown and the glimpses acquired then undergraduates will not choose to specialise in areas such as plastic surgery.

The Dearing Report stated that one main purpose of higher education is,

“to inspire and enable individuals to develop their capabilities to the highest potential levels throughout life, so that they can grow intellectually, …….and achieve personal fulfilment.”24

So, not just about generic skills then? Barnett and Coate further suggest,

“..that the challenge of engaging students is twofold: first, to array before the students a wide range of experiences that draw them out in their understanding (their active knowing), in practical involvements (their acting) and in emotional and experieriential range that they have to offer (their being); second to give them space in those experiences so they can engage themselves fully and willingly. The hope must be then of any curriculum that it generates enthusiasm, optimism, self-belief, energy, fortitude, resilience (for when the going gets tough) and enduring commitment. But for such self-development to occur, spaces have to be provided into which a student's energies can flow.”22

Savin-Badens observes that within academic life: “currently there seems to be a lack of realisation that we are losing ground because we are losing space.”25 Whilst she means this in a general educational sense it is very apt for what is occurring in the undergraduate and post-graduate medical curriculum i.e. early specialisation does not allow the time, the experience or the opportunity for the necessary self development needed to “try on other selves” and so allow an educated, rather than a “best-guess”, career choice to be made.

We have shown from our studies that the majority of current undergraduate curricula in England and Wales do not contain plastic surgery in a recognisable form. Furthermore we have demonstrated it is not available in the foundation years of early postgraduate surgical training.

In the brave new world of post-MMC surgical training, with reduced training hours and early specialisation, we will no longer have the luxury of waiting to attract the best surgical trainees when they come to us as postgraduates. We need to engage with undergraduate programmes and take back the ownership of our speciality within the undergraduate curriculum so it is delivered in a recognisable form, create space for plastic surgery, to plant the seeds from which the future of our speciality will grow. The teaching of our specialty at undergraduate level is contracting and this has been translated into the foundation years. We must take the lead and stake our claim on the hearts and minds of each new graduating class. We must encourage those who are interested in looking further and provide them with worthy role models to inspire them as the likes of Mustarde and Kleinert have done for past and present generation.

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Acknowledgements 

To Gemma Cuff, a Bristol University Medical School third year student who helped contact a number of the medical schools and compile their data for the unpublished medical school study quoted in this paper.

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References 

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☆ Presented at summer 2006 BAPRAS meeting.Presented as a poster at Royal College of Surgeons Education Conference September 2007.

PII: S1748-6815(08)00507-X

doi:10.1016/j.bjps.2008.06.005

Journal of Plastic, Reconstructive & Aesthetic Surgery
Volume 61, Issue 10 , Pages 1135-1138, October 2008

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