Integrated/Combined programs

[zealous]

Hey guys,
I was wondering if someone could help out and post a list of the combined/integrated programs. I can't seem to find them here or anywhere! I know there are a lot of people with the same question so, can someone help out?

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[Pir8DeacDoc]

I can't guarantee that this is all of them. But this is a pretty darn good start. Hope that this helps!

Albany
Baylor
Brown
Cincinnati
Cornell
Georgetown
Grand rapids
Harvard
Johns Hopkins
Kentucky
Lahey
Lehigh Valley
Loma Linda
MCV
Medical College of Wisconsin
Missouri-Columbia
Mount Sinai
Northwestern
NYU
Ohio State
Oklahoma
Penn
Penn State
Rochester
SLU
Southern Illinois
Stanford
Texas A&M Scott White
UC Irvine
UC-Davis
UCSF
UCLA
UMDNJ-Newark
Umich
Univ of Washington
University of Chicago
University of Kansas
University of Nevada
University of Pittsburgh
University of Southern California
USF
Utah
UTMB
UT Southwestern
University of Virginia
Wake Forest
WashU
Wisconsin Madison

 

[drvechman]

i found a somewhat shorter list when I was looking into this. I am sure your list is more accurate than mine. A couple of questions - Are some of these programs new? Does it seem that more and more programs are moving to an integrated model? Can we hope for more in the near future? Also, does anyone know how many applicants there were this past year for integrated programs? What's the competition look like? How many overall spots are there? Answers to any or all of these questions would be very helpful. thanks

 

[DukeDoc08]

I have always known about the integrated plastics programs, but when reading on the AACPS website I came across the "combined" programs. They made it sound like the two types are programs are different or at least different avenues into a plastics fellowship. When you apply to the combined programs are they interviewing/ matching based on going into plastic? or are they interviewing you for gen surg + / - plastics? is it the same match process (system) as the integrated programs?
Maybe it's late and I'm not thinking clearly but I really have tried to find the info on the net....any help will be appreciated!
Regardless, I am meeting with some upperclassmen and whatever info I gain I will post here for the rest of the newbies!

 

[Pir8DeacDoc]

Really as I understand it the difference is who controls your GS years. In the integrated model you are "owned" by the Plastics Department right from the start. They can model your GS years so they might let you have a bit more time in plastics, ENT, etc. I.e. things a bit more relevant to your career as a plastic surgeon.

In the combined model you are "owned" by the GS department during your GS years. You follow the same schedule as the the other GS residents. You are just like any other intern. Plenty of CT, Colorectal, vascular,etc.

Hope this clears some stuff up for you. Some will tell you that there really isn't much difference between the two models. However other people will say it's nice to be integrated from a stability standpoint. Good luck.

 

[drvechman]

bump

 

[mcindoe]

Really as I understand it the difference is who controls your GS years. In the integrated model you are "owned" by the Plastics Department right from the start. They can model your GS years so they might let you have a bit more time in plastics, ENT, etc. I.e. things a bit more relevant to your career as a plastic surgeon.

This is correct, but it's also an oversimplification. It's more than just a matter of "ownership"--it's about who your boss is and what implications that has on your training experience.

Here are a few specific differences between the two:

Integrated programs:
-you report to the plastics department. they are your boss from day 1, and if you're caught in a turf battle with gen surg ordering you to do one thing and plastics ordering you to do another, you answer to plastics.
-your gen surg years are customized so that you do rotations that aren't usually included in the curriculum for gen surg residents (e.g. ortho, ent, OMFS, anesthesia, ER, etc.) and many programs have you rotate on the plastics service for as much time allowed by law during your gen surg years. They keep the rotations as relevant to your career interests as possible; as such, you don't spend month after month on transplant, trauma, vascular, etc., at least not nearly as much as categorical gen surg residents.
-many integrated programs are set up such that you go to the weekly plastics conferences and plastics grand rounds. this is "protected" time, in that even if you're scrubbed into a lap chole case or in the middle of rounding with the gen surg team, you stop what you're doing and go to conference. if you have some pain in the ass power-hungry attending who insists that you stay and hold the retractor even though conference is about to start, it doesn't matter cause he's not your boss. you answer to plastics, end of story. THAT is why it matters who "owns" you during your first three years.
-by going to weekly conference/grand rounds for the entire course of your residency, you stay involved with plastics all the time even when you're not on the service, and you establish a relationship with them early on rather than just showing up 3-4 years later and saying "remember me?" when it's time to start your plastics years.

Combined programs:
-everything is the same as far as the plastics years are concerned. during the gen surg years, you deal with the gen surg dept when it comes to schedules, grievances, rotations, educational conferences, etc.

Summary:
In some ways it works like an airline code-share agreement, like when you buy a ticket on United but find out that the outbound flight is operated by USAir...even though you bought a ticket from United, when you're flying on the USAir segment you are being served by USAir, and if your bags are lost or your flight is delayed, you deal with USAir to handle it, not United. A lot of it is just logistics, but it's also an issue of management. There are many places that have very organized, efficient, well-managed plastics departments, and there are gen surg programs that seem like they're managed by the DMV. It's not easy to discern this as an applicant, but at least when you're in an integrated program you know that your entire flight will be operated by the airline printed on your ticket, so to speak, rather than the proverbial code-share carrier that you might not know much about but will nevertheless have to fly with them for the first half of your trip.

Hope this helps.

 

[navysurgeon]

its was my understanding that 'combined' and 'integrated' PRS programs were one in the same...basically a six year gig that leads to board certification in PRS...the 'ownership' issue is non-sense. you belong to the gen surg program director until you're handed off to the PRS program director after your third year of training...

the other training model is the 'traditional' system, in which one does gen surg or ent or ortho (very rarely) and then does an additional two or three years of PRS after completing residency...

there are lots of arguments about the benefits of either training model...frankly, the 'independant' model is a more effecient way to start PRS practice...doing the basics..i think people that have completed an ENT or gen surg residency are more technically competent and likely can handle more challening cases that demand some mature clinical judgement. that's just my opinion.

i matched this year into a great 'traditional' program after doing three years of gen surg practice in the navy..i can't tell you all how freaking stoked i am to be done with the gen surg nightmare.

TNS

 

[Pir8DeacDoc]

You are confusing a few things. There are actually three models to get into plastic surgery..The first two are guaranteed right out of med school.


1. Integrated. As mentioned above you are under the direction of the PRS dept the entire time. They help schedule out your 3 GS years.

2. Combined: This is as mentioned above where your first three years are managed by GS. Once you are done with these three years you are rolled right over into the Plastics dept.

3. Traditional: This is the old faithful fellowship match. Here you do GS wherever you want. Then apply for the fellowship after 3,4,5+ years of Gen surg.


Glad to hear that two of our board "regulars" TNS and GS matched in the fellowship this year. Congrats guys!

 

[navysurgeon]

combined vs integrated...

its the same 'match', correct?

frankly, who really cares who 'owns' you during your first three years?

the point of residency, any residency, is to develop sound clinical judgement and get some technical training...your first three years of training should be stenuous, IMO.

TNS

 

[Harrie]

combined vs integrated...

its the same 'match', correct?

frankly, who really cares who 'owns' you during your first three years?

the point of residency, any residency, is to develop sound clinical judgement and get some technical training...your first three years of training should be stenuous, IMO.

TNS

I agree! Everyone tries to make a big deal about this combined/integrated thing. After rotating through both and talking to a lot of people, I agree that there is virtually no difference. It is the same match and same number of years, some combined programs have just as many months of plastics in the first 3 years as integrated - really no difference.

 

[Ergo]

As I understand it:One big difference is to whom you are ultimately accountable. For the combined probrams you interview with one set of people, then if you match there you go work for god knows who in their GS department with whoever else is a resident there. So, they are all people you never meet until your first day of internship. The program director of GS is your boss until you begin the PS years. Three years can be a long time....

In the integrated programs you are accountable to the PS program director who interviewed and ranked you personally. I think that sounds slightly nicer than option 1, given the chance to express a preference in my match list.

 

[mcindoe]

combined vs integrated...

its the same 'match', correct?

It's the same match for people looking to match right out of med school. It has nothing to do with the fellowship match, since you've already completed your g-surg requirement.

frankly, who really cares who 'owns' you during your first three years?

I do. Why? Because I don't want to be told that I have to do several months of transplant surgery, for instance, when I would rather spend that time doing rotations that are more relevant to my interest in plastics. Integrated residents get to spend 1-2 months per year on the plastics service during the first three years, and they also rotate on services like ortho, ENT, anesthesia, neurosurg, ER, etc., which is not part of the typical g-surg curriculum. People in combined programs are effectively gen surg residents for the first three years.

Furthermore, I want to go to plastics grand rounds every week, as well as all the plastics weekly conferences, and I can...because my boss says so. And if anyone has a problem with that, take it up with my boss. This keeps you involved in plastics from day 1, and you're not a stranger to the department during the first three years because you work with them or see them every week for the duration of your residency.

So yeah, I care, and since it sounds like you're going to sorely miss being a g-surg resident, I'm sure you would too if you had to do it all over again.

the point of residency, any residency, is to develop sound clinical judgement and get some technical training...your first three years of training should be stenuous, IMO.

Agreed, and they are. But if you can make those years a little more relevant to plastic surgery, it makes for a more interesting experience. Ortho, ENT, and neurosurg figured that out a while ago...isn't it time for plastics to do the same?

 

[JudoKing01]

All this doesn't matter to me, because I'd love to be a PRS, but I'll be an IMG and I probably have as much chance as matching into a PRS res as a hotdog making it past michael moore's mouth w/o being eaten.

 

[droliver]

Agreed, and they are. But if you can make those years a little more relevant to plastic surgery, it makes for a more interesting experience. Ortho, ENT, and neurosurg figured that out a while ago...isn't it time for plastics to do the same?

I'm going to have to call bull**** on that. When you get down to brass tacks, the move to take over the curriculum by the various surgical specialties has come down to two things.

1) most of the subspecialties feel less and less in common with General Surgery, and its kind of an ego thing at this point. The distinction b/w combined and integrated is more a selling point for students then much of an advantage . They both short you on the important preliminary skills, the integrated has the theoretical advatage of streamlining the didactic program over 5-6 years but I think a lot of that is probably lost on junior residents.

2) MANPOWER issues!!!!!!!!!! Which is the horse driving the cart for this at most programs. The 80 hr. work week rules have only exagerated this. What's more is that in many specialty divisions (and almost all Plastic Surgery divisions) the # of full-time academic faculty has dropped signifigantly while the patient load at teaching programs continue to swell with non or under-insured populations. This is effectively squeezing programs at both ends, with picking up a few more residents to throw on the pile is the lower lying fruit versus coming up with funding for faculty positions.


I'd also caution you on trying to limit what exactly is relavent to Plastic Surgery. Short of GI endoscopy & hepatobilliary surgery, I've used elements of just about every part of my Surgical background during my training. As a Plastics Fellow I've had to do everything from carotid endarterectomies, esophagostomy creations, mediastinal trachs, jejunal harvest and bowel resection, incarcerated hernias, fem-distal bypasses, critical care medicine (out the yin-yang), and retro-peritoneal hematoma drainage (don't ask!). Junior level rotations on those subspecialty services are pretty marginal to your education. You have to learn how to be a surgeon before you learn how to be a Plastic Surgeon, and I think that's the intellectual fallacy behind some of the arguments for the integrateds. The most attractive feature of the integrated curriculum is clearly the prolonged didactic exposure, NOT the abbreviated surgical exposure. You can easily be well trained in Plastic Surgery without 5 years of a preliminary specialty, but I think the pendulum has gone too far the other way.

 

[JudoKing01]

droliver, I take it that you did a GS res and a PRS fellowship... Being that I am going to a foreign school and probably wouldn't be able to match into an integrated PRS program, do you think it'd be relatively possible to match into a GS program and then do a PRS fellowship afterwards (i'd be happy "stuck" in GS...I love surgery, so there isn't really a risk for me)? Or is GS just as hard to match as far as IMGs are concerned? What do you think?

 

[mcindoe]

I'm going to have to call bull**** on that.

I'm not in a position to challenge a lot of what you said because you have a lot more experience with this than I do, and you may be correct. However, it seems like it's always the fellows who offer this opinion and do so with a bit of anger/frustration (e.g. "I'm going to have to call bull**** on that") or righteousness (e.g. "you have to learn how to be a surgeon before you learn how to be a Plastic Surgeon"). I don't think I need to have those extra two years in general surgery to become a competent surgeon, and let's not forget that integrated residents have three full years of plastics training whereas the fellowship is only two years. Regardless, unless you have some proof to show that integrated residents are less competent than their colleagues who did a full gen surg residency, this argument comes across as a bitter diatribe against integrated residents for having to spend an extra two years doing g-surg to get to the same endpoint, and I doubt that cataloguing the list of procedures you've done will convince any prospective applicant that they should forsake an integrated or combined plastics program for a traditional g-surg program because of concerns about possibly not developing the skills that only an extra two years of jejunal harvesting or colon resections may provide. If anything, it sounds like an attempt to justify those extra years of gen surg by portraying them as necessary rather than profligate experiences. You may have used elements of your surgical background in your plastics training, but there are many skills from my background that I've incorporated into my work in the hospital which probably make me a better physician, but does that mean that everyone else has to have that same background in order to do an equal or better job than me? I don't think so.

I interviewed at both general and plastic surgery programs, and I got a pretty good sense of what both offer. I can't comment on the skill of integrated residents because I don't know how one determines that, but if they have lousy skills I would imagine it has less to do with the training they received in their junior years and more to do with the fact that the programs only know the med school applicants on paper and in person but have no sense of their manual dexterity, since medical students don't operate. All I know is that at several gen surg programs I was able to see how the five years are structured, and to use my earlier example, many had several consecutive months on the transplant service. You can make any argument you want about what it takes to learn how to be a surgeon, but how can you honestly tell me that anyone interested in plastics would be eager to spend three months doing liver transplants knowing that they could be spending those three months doing ENT, ortho, or...plastics!

I'm not the one who conceived of the integrated/combined model for training, nor am I the one who deems one specialty more relevant to plastics than another. All I know is that several of the leaders in the field believe in this model, so much so that they've gone to great lengths to change the system at their respective programs. If they felt the "traditional" system worked best(and they know that system well, as they themselves were trained that way), they wouldn't feel the need to fix it. They believe that certain rotations are more relevant than others, and unless you somehow know something that they don't, I trust that they know what they're doing, particularly in consideration of the greater level of experience and perspective that they have and we don't. To dismiss this as a battle of egos or to suggest that integrated residents are shortchanged in prelim skills is your opinion, not fact, and I know plenty of chief residents in g-surg at my home program who have always been lousy surgeons and the 4th and 5th years did little to change that.

In the end it doesn't really matter anyway. I matched at an integrated program and chose that program after seeking the advice of several plastics chiefs, residents, fellows, deans, and even a few professors of general surgery. Not one of them advised me to go the "traditional" route, especially the general surgeons, and I don't think they're all full of bull****. Do you?

 

[doc05]

...transplants knowing that they could be spending those three months doing ENT, ortho, or...plastics!

pardon my ignorance, but where would you expect the plastics rotators to get any significant OR time during ortho or ENT months??

 

[mcindoe]

pardon my ignorance, but where would you expect the plastics rotators to get any significant OR time during ortho or ENT months??

Ask me next year when I'm actually doing the rotations.

To follow up on your question: if not doing ortho or ENT rotations, what would plastics rotators be doing instead? And where would you expect the plastics rotators on those services to get any significant OR time as well? You think that spending time on "classic" g-surg services means you'll be ushered into the OR every day to do cases? No way...if you're the intern, you're on the floor doing scut.

The interns at my home hospital hardly ever see the OR no matter what they're doing. But if I'm learning to take care of patients, I'd rather learn how to manage ENT patients than liver transplant patients.

 

[JudoKing01]

pardon my ignorance, but where would you expect the plastics rotators to get any significant OR time during ortho or ENT months??

I can see how you'd question ortho, but ENT? A lot of plastics involves facial surgery, both aesthetic and reconstructive. Sure, a PRS wouldn't be doing BMTs and T&As, but ENTs do more than that.

 

[Harrie]

Okay, don't assume that if you're integrated you'll go to plastics conferences, grand rounds, etc. I know my home program is integrated and the R1-3's do NOT go to plastics conference (unless they are on service that month) but they are required to go to ALL general surgery conferences.

Also, there are some combined programs that have a lot of plastics time in the first three years.

I guess my point is, although the combined and integrated MODELS are very different, in practice the line grays quite a bit.

 

[mcindoe]

Okay, don't assume that if you're integrated you'll go to plastics conferences, grand rounds, etc. I know my home program is integrated and the R1-3's do NOT go to plastics conference (unless they are on service that month) but they are required to go to ALL general surgery conferences.

All I know is that at the program I matched, it's not an assumption but a fact. The integrated residents attend the weekly conferences and grand rounds. This may not be the case for other integrated programs, but at mine this was one of the things that the senior level residents loved about their experience at this program.

 

[navysurgeon]

I think your view is short-sighted....

""""I do. Why? Because I don't want to be told that I have to do several months of transplant surgery, for instance, when I would rather spend that time doing rotations that are more relevant to my interest in plastics.""""

I gained more technical experience during my transplant rotation than any other rotation in my Gen Surg training. It was phenomenal...sewing in a liver? there is absolutely no bigger case then that....those skills, and the stamina required to do a 6 hour liver tx...that's all directly transferrable to plastics...to not do transplant would be an incredible detriment to your training.

On the 'ownership' issue...politics are important in a hospital. As an intern, your plastics PD does not give a crap about your nascent 'career'...if you piss off a General Surgeon, blow off transplant because you don't think its relevant to your plastics 'career'...your plastics PD is going to come down heavy on you. What the **** does an intern know about anything, let alone plastic surgery. Your job as an intern is to learn to be a good doctor, period.

My advice to you...pretent you are interested in EVERY rotation you are place on, and by happy you're there. That attitude will get you far in life, as a plastic surgeon, once you become one, because you are not one yet.

 

[mcindoe]

I think your view is short-sighted....

I gained more technical experience during my transplant rotation than any other rotation in my Gen Surg training. It was phenomenal...sewing in a liver? there is absolutely no bigger case then that....those skills, and the stamina required to do a 6 hour liver tx...that's all directly transferrable to plastics...to not do transplant would be an incredible detriment to your training.

On the 'ownership' issue...politics are important in a hospital. As an intern, your plastics PD does not give a crap about your nascent 'career'...if you piss off a General Surgeon, blow off transplant because you don't think its relevant to your plastics 'career'...your plastics PD is going to come down heavy on you. What the **** does an intern know about anything, let alone plastic surgery. Your job as an intern is to learn to be a good doctor, period.

My advice to you...pretent you are interested in EVERY rotation you are place on, and by happy you're there. That attitude will get you far in life, as a plastic surgeon, once you become one, because you are not one yet.

Thanks for the lecture.

In my opinion, the person who believes that one must do month after month of liver transplantation in order to master the skills and stamina necessary to become a surgeon is the shortsighted one. There are other ways to acquire these skills, and either you know it deep down but don't want to admit it because you don't want to feel like you've wasted two years of your life, or you're just ignorant.

Don't tell me what will or will not be a detriment to my training as a future plastic surgeon. You wouldn't know, as you haven't even started your plastic surgery training. Why don't you share your thoughts on this with the folks at Harvard, UTSW, Pitt, NYU, NW, etc. and let me know if any of them agree with you. I would love to watch some general surgery resident lecture them about how detrimental it is that 3 months of transplant surgery are no longer part of their curriculum. Better yet, talk to the attendings who just finished the 8 hour joint ortho/plastics flap case and tell them and their plastics residents that they need that six hour liver transplant case in order to develop enough stamina to become a surgeon.

I don't need to be told how to act on every service, like I'm some med student who is asking for tips on how to do well on a surgery rotation. I love surgery and I won't have to pretend I'm enjoying it, no matter which service I'm on. But I'm glad I at least get to do rotations that general surgery residents do not. It makes the experience more diverse and I'll be exposed to much more than what I'd encounter as a gen surg resident. If you were starting all over again, I seriously doubt you would have wanted to do 5 long years of g-surg when you could have done only 3.

 

[navysurgeon]

well, you're a resident, and i'm an attending with a few years of experience...you sound like you're a bit of wanker and cry-baby, i'm glad i won't be training with you...

 

[navysurgeon]

well, you're a resident, and i'm an attending with a few years of experience...you sound like you're a bit of self-possesed wanker and a definite cry-baby, i'm glad i won't be training with you...

 

[maxheadroom]

Wow, this thread has really degenerated into some fun . . .

It's always the same. The GenSurg trained guys come down hard on us integrated-wimps because we'll never experience the full force of general surgery training. I'll never be a trauma chief (darn). I'll never do some big, horrible liver resection (shucks). I'll never do some god-awful colorectal pouch procedure or an APR (oh well). I'll never do a laparoscopic gastric bypass (but I've done a couple of opens, ugh). My only Whipple exposure will probably be the one that I took back one night for a leak (oh the horrible pain). Of course, I've still got my third year to go, but next year I've got 2 months of PRS, a month of lab time, two months of ENT/H&N Onc, and a month on the Ortho Hand service. The ENTs are short residents, so their faculty often operate without a resident, so there's always plenty of cases for the PRS rotators. The Ortho residents aren't very interested in the hand cases, so I'll get plenty of upper extremity cases.

All of my past chiefs whom I talk to feel very comfortable in their practices. Nobody seems to be short on technical skill or deficient in clinical judgment. Maybe we're special, but I don't think so.

The current ASPS President (Scott Spear) says that PRS training should have less general surgery (Georgetown's PRS program is pretty darn good). The immediate past President (Rod Rohrich) wants to move the ABPS and RRC to reduce the requirement. My chairman (ASPS President several years ago) was one of the chairmen who helped drive the official development of the integrated pathway -- before that there were lots of places that were combined in an under the table sort of way.

OK, that was longer than expected. The fact is, it's a debate that's been around since training in PRS started. Remember Joe Murray, the Nobel Prize winner? He only did two years of general surgery training, yet he helped pioneer renal transplantation . . . as a plastic surgeon.

 

[toofache32]

well, you're a resident, and i'm an attending with a few years of experience...you sound like you're a bit of self-possesed wanker and a definite cry-baby, i'm glad i won't be training with you...

Wow. Spoken like a true Gen Surg attending..."I'm up here, you're down there, don't whine because I had to go through it too."

 

[GSresident]

Wow the rhetoric has certainly gotten strong on this thread. I won't add any badness to what is already seeping through the computer screen.

I would like to make two points. First, if given the opportunity to do it all over, I would still do all five years of general surgery. The extra two years at least at my program are spent operating like a madman with plenty of protection from BS afforded by junior residents. Where I am training, I would feel cheated if I only got to do the first three years of scutwork and didn't get any of the benefits of being chief, but hey that is just me. Also, I may be a little strange but I chose to go this route. Suffice it to say that it was not an issue of qualifications that kept me from applying to combined/integrated programs. As a medical student I was very impressed by the capabilities of a chief resident in general surgery and I wanted that for myself and my future patients. There is no doubt who I would want managing me if I came in to a hospital extremely sick. The one thing I would change is the fact that I was never sure that I would be able to become a plastic surgeon until I matched. So basically I went through 3 years of stress capped off by a year of unbelievable expense, effort and ulcer generating madness because I was worried that I put in all the effort and still might not get the reward. Now having matched all is bliss.

Second, I have to tell you a story about my life. When I was in college I knew exactly what I wanted to do with my life and exactly how I was going to get there. I wanted to be a plastic surgeon. I went to a liberal arts college and I had to take a lot of classes that had nothing to do with my ultimate goal. I used to hate sitting through European history classes, film classes etc. I was miserable because I thought that I wasn't getting anything out of those classes and it was a waste of my time. I would have preferred to have been studying for my 'important' classes. Ten years later, I look back and see that I was wrong. The things I learned in Survey of Film (and other classes like that) have added an enormous amount of enjoyment to my life and exposed me to many different ideas and people. I can't imagine how boring my life would be now and how shallow my worldview and experience pool would be without those 'worthless' classes. In fact, if I had it to do over again, I would have majored in something not related at all to medicine. Take it for what it is worth. I will get back to you in 10 years to see if my 'worthless' general surgery experience paid off for me in the same way.

There are a lot of different ways to become a plastic surgeon. The important thing is that you do it the way that makes you a happy and competent physician. Best of luck to all of you and I truly hope that I get to meet some of you at PRS meetings.

 

[traumasurgeon]

Thanks for the lecture.

In my opinion, the person who believes that one must do month after month of liver transplantation in order to master the skills and stamina necessary to become a surgeon is the shortsighted one. There are other ways to acquire these skills, and either you know it deep down but don't want to admit it because you don't want to feel like you've wasted two years of your life, or you're just ignorant.

Don't tell me what will or will not be a detriment to my training as a future plastic surgeon. You wouldn't know, as you haven't even started your plastic surgery training. Why don't you share your thoughts on this with the folks at Harvard, UTSW, Pitt, NYU, NW, etc. and let me know if any of them agree with you. I would love to ....QUOTE]
This seems as good a discussion as any to start off in. I agree with navysurgeon in that I am glad that I am not a general surgery or plastic attending at your program trying to teach you and with the attitude you have. The truth is there are advantages and disadvantages to both pathways. The advantages of the combined/integrated route is a) its shorter and b) when you start your plastic years you have a head start on the didactics of PRS. However, in the skills, judgment and experience sector they are way behind the independent pathway fellows. Eventually they catch up, but it is after several years of practice. The five year general surgery trained fellows usually start off behind on the didactics because of their limited exposure to plastic surgery however, they are usually caught up six months into it. Why don’t you share your thoughts with the folks at Harvard, UTSW, Pitt, NYU, NW, etc. Ask them who they prefer to work with them in difficult cases and who they trust more with their patients, the general surgery trained fellows or the combined pathway residents. Get them in private and they ALL prefer the general surgeon trained surgeons. Your statement of about combined pathway being more diverse is a joke, the whole point of the integrated/combined program is to narrow down and concentrate your experience. So which is better? I don’t know, probably the one that best fits your own preferences. Some people go into general surgery because they couldn’t get into a plastic residency. If that’s the case then your general surgery time will probably be miserable and might not get much more out of the ordeal. Others go into general surgery because they like it and want the broad experience and excellent training. They choose to do plastic surgery later. For them, their general surgery time only makes them better surgeons overall.

 

[mcindoe]

Note to future plastics applicants who are going to apply in g-surg as a backup yet fear not knowing what to say when asked on a g-surg interview about your long term goals without having to lie....here's your answer:

First, if given the opportunity to do it all over, I would still do all five years of general surgery. The extra two years at least at my program are spent operating like a madman with plenty of protection from BS afforded by junior residents. Where I am training, I would feel cheated if I only got to do the first three years of scutwork and didn't get any of the benefits of being chief, but hey that is just me. Also, I may be a little strange but I chose to go this route. Suffice it to say that it was not an issue of qualifications that kept me from applying to combined/integrated programs. As a medical student I was very impressed by the capabilities of a chief resident in general surgery and I wanted that for myself and my future patients. There is no doubt who I would want managing me if I came in to a hospital extremely sick. The one thing I would change is the fact that I was never sure that I would be able to become a plastic surgeon until I matched. So basically I went through 3 years of stress capped off by a year of unbelievable expense, effort and ulcer generating madness because I was worried that I put in all the effort and still might not get the reward. Now having matched all is bliss.

Second, I have to tell you a story about my life. When I was in college I knew exactly what I wanted to do with my life and exactly how I was going to get there. I wanted to be a plastic surgeon. I went to a liberal arts college and I had to take a lot of classes that had nothing to do with my ultimate goal. I used to hate sitting through European history classes, film classes etc. I was miserable because I thought that I wasn't getting anything out of those classes and it was a waste of my time. I would have preferred to have been studying for my 'important' classes. Ten years later, I look back and see that I was wrong. The things I learned in Survey of Film (and other classes like that) have added an enormous amount of enjoyment to my life and exposed me to many different ideas and people. I can't imagine how boring my life would be now and how shallow my worldview and experience pool would be without those 'worthless' classes. In fact, if I had it to do over again, I would have majored in something not related at all to medicine. Take it for what it is worth. I will get back to you in 10 years to see if my 'worthless' general surgery experience paid off for me in the same way.

There are a lot of different ways to become a plastic surgeon. The important thing is that you do it the way that makes you a happy and competent physician. Best of luck to all of you and I truly hope that I get to meet some of you at PRS meetings.

 

[mcindoe]

This seems as good a discussion as any to start off in. I agree with navysurgeon in that I am glad that I am not a general surgery or plastic attending at your program trying to teach you and with the attitude you have. The truth is there are advantages and disadvantages to both pathways. The advantages of the combined/integrated route is a) its shorter and b) when you start your plastic years you have a head start on the didactics of PRS. However, in the skills, judgment and experience sector they are way behind the independent pathway fellows. Eventually they catch up, but it is after several years of practice. The five year general surgery trained fellows usually start off behind on the didactics because of their limited exposure to plastic surgery however, they are usually caught up six months into it. Why don’t you share your thoughts with the folks at Harvard, UTSW, Pitt, NYU, NW, etc. Ask them who they prefer to work with them in difficult cases and who they trust more with their patients, the general surgery trained fellows or the combined pathway residents. Get them in private and they ALL prefer the general surgeon trained surgeons. Your statement of about combined pathway being more diverse is a joke, the whole point of the integrated/combined program is to narrow down and concentrate your experience. For them, their general surgery time only makes them better surgeons overall.

Obviously there's no perfect system. If the attendings would prefer to work with the g-surg trained fellows over the integrated residents, so be it. They have two extra years of experience, so are you surprised? I would hope that after two extra years of surgical training that you'd be a better surgeon. I'm sure I'd be a better cook too if I spent an extra two years working in a restaurant. Regardless, this isn't about what's best for the attendings...this is about what's best for us as residents or future residents and what sort of training experience we believe is in our best professional interest.

You can criticize the integrated programs all you want, but it's like listening to those who say they turned down Harvard Med or Hopkins to go to U Mass or U Maryland, respectively, because the latter schools were less expensive. That may sound callous but it's honest, and we can all see through it. I'll pass on the extra two years of hepatobiliary, transplant, GI, endocrine, and lap chole cases, enjoy the extra year of plastics I'll get, and relax knowing that I don't have to spend my time and money years from now going through the stressful, protracted nail-biting application process hoping to match in a plastics fellowship when we all know it's getting more and more competitive every year. GSresident sounds like he had a wonderful time trying to get a spot, and he's fortunate that it worked out for him. Many others had no such luck. If you know you want to do plastics, you'd be a sucker (or a sadist) if you chose to do a full g-surg residency over a combined/integrated one. At least you'd have five years to improve your judgment while perfecting your surgical skills.

 

[mcindoe]

one last post for today...

I find it interesting that the person who wrote this:

I think your view is short-sighted....

I gained more technical experience during my transplant rotation than any other rotation in my Gen Surg training. It was phenomenal...sewing in a liver? there is absolutely no bigger case then that....those skills, and the stamina required to do a 6 hour liver tx...that's all directly transferrable to plastics...to not do transplant would be an incredible detriment to your training.

also wrote this in another thread:

but if i was a med student today, i would have done a rotation with the plastic surgeons and spent some time on ortho, and derm....i'm almost certain i'd be a PRS or an orthopod right now, rather than my current career path which was gen surg residency.....my point is is that I was ignorant about a lot of fields while i was making some important decision in life. dumb.

Sounds like you loved all those years in g-surg. I might be a wanker, but I'm certainly not ignorant. At least everyone can learn from your dumb mistake (hey, you said it yourself).

 

[Pikevillemedstudent]

Mcindoe is only reacting to the comments you guys threw at him. I would have the same attitude if I was in his position. He is only sticking up for himself. I definitely agree with mcindoe in that only those completing the tradional route are against the integrated/combined route. Seems fishy. Mcindoe's program sounds like a great fit for him. Everyone seems to be attacking him and his future plastic surgery training.

How would any of you react to that?

Imagine Droliver, if I said you need to stop doing all these other procedures like carotids and bowel resections during your short two year fellowship and start doing full time plastics work since you didn't get much during your GS years like mcindoe's integrated program. I think that would make you a little defensive. BTW I mean no disrespect. I am sure your program is excellent. Just making a point.

His program has obviously been training plastic surgeons longer than anyone on SDN, so I think they know what's best.

Bottomline: I call bull**** on everyone attacking the integrated/combined route. I think your motives are suspect.

Disclaimer: I don't know mcindoe and I am not interested in plastics.

 

[GSresident]

Let me reiterate: I am not attacking or even criticizing the combined/integrated route. Frankly it isn't my battle. Like I said there are many paths to becoming a plastic surgeon and you should choose the one that will make you happy and competent. There are benefits and drawbacks to each path.

I'll pass on the extra two years of hepatobiliary, transplant, GI, endocrine, and lap chole cases, enjoy the extra year of plastics I'll get, and relax knowing that I don't have to spend my time and money years from now going through the stressful, protracted nail-biting application process hoping to match in a plastics fellowship when we all know it's getting more and more competitive every year. GSresident sounds like he had a wonderful time trying to get a spot, and he's fortunate that it worked out for him. Many others had no such luck. If you know you want to do plastics, you'd be a sucker (or a sadist) if you chose to do a full g-surg residency over a combined/integrated one. At least you'd have five years to improve your judgment while perfecting your surgical skills.

The uncertainty involved with regards to matching in the traditional/independent pathway is a serious drawback. I have consistently mentioned this drawback to medical students looking at the various pathways. I don't mind being called a sadist although masochist is probably the term you were looking for. I tried to explain a few of the reasons that I chose this path versus the integrated/combined route in my above post. There are other reasons as well including family tradition etc. Another potential drawback, depending on how you look at it, is you are 'loosing' a year of practice. I don't see this as a drawback for me personally because the year I am 'loosing' is occupied by a cushy chief year of operating and great satisfaction. I will take only 12 calls next year and operate like a madman. If you want to be a Jedi, you have to go to Dagobah.

There are numerous benefits to taking the combined/integrated route and they have been discussed ad nauseum on this forum. The chief benefit, as I see it, is that you are sure from day one that you will become a plastic surgeon. The traditional/independent spots are going away slowly but surely. Combine the drop in the number of spots with the continually soaring number of applicants and you've got a real problem if you are on the traditional path. I was incredibly fortunate to match this year. In the combined/integrated route you get plastic surgery didactics from day one of your residency. I would love to have had didactics in plastic surgery during my general surgery training. There are a few drawbacks to the combined/integrated route as well. You can figure those out for yourself. One that is probably fairly evident on this forum is that some of my more bitter general surgery colleagues will chide you for taking the 'easy route'. Oh well, don't listen to them. Do what you think is right for you.

 

[navysurgeon]

good discussions...

i think one thing my GS training has done for me is ignited an interest in clinical problems in PRS that have a GS 'root cause'....

For example, swinging a flap into the pelvis of someone with a non healing APR wound...or a comlex abdominal wall reconstruction....or harvesting a jejunal free flap with the laparoscope...

These are the types of problems I'd like to tackle as a PRS, and I'm glad I got to see a lot of GS during my career...i think it will help with insight into these problems...

in truth, it has cost society a lot of money to train me...5 years of gen surg, and then 2 years of PRS coming up in 2006...its certainly more effecient to train PRS docs with the integrated model...

is the product the same?

 

[toofache32]

...If you want to be a Jedi, you have to go to Dagobah.