Refusing to do cosmetic surgeries as a resident

[StillChoosing]

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[Leforte]

I suppose one could ask to not assist in cosmetic cases if you have a moral or religious basis for doing so - I would approach your Chief Resident first with the issue (as the Chief usually assigns the cases), then the facial plastic surgeon, program director, and chairman in that order if your request is denied. I do not think there would be any implications from anyone involved, to be honest. Quite frankly, facial plastics is a weakness in many programs and your fellow residents would likely jump at the chance to be involved in the cases in your absence.

There may be issues with you meeting RRC targets for your facial plastics numbers, however. You may also be disadvantaged when it comes to both written and oral boards. There is always a cosmetic question in the orals, and they will ask you how would you approach the patient - if you have had reasons to not be involved in residency with these cases, I would assume the only moral thing to do in your orals, then, would to tell the examiner that you would do nothing to the patient due to your moral standards.

Of course, this leads to further questions. What about otoplasty? It is a cosmetic procedure, but for the kid who is getting ridiculed relentlessly at school, this can be a socially changing operation. Would you choose to not participate in this procedure? What about microtia repair? Scar revision? Dermabrasion for unsightly hypertrophic scars? What about the functional rhinoplasty and the request to "bring my hump down a little?" - would you scrub only for the functional part, and excuse yourself while the attending rasps the hump? What about the kid with a disfiguring hemangioma that is growing, but does not have airway or visual complications - they sometimes are given steroids, would you refuse to prescribe? What about keloids on ears in African Americans - they are often removed solely for cosmetic reasons. What about ear lobes that have been ripped in the past from kids grabbing earrings - I've closed many of these years later to make a better appearing ear. Would you remove skin tags? What about removing tonsils for halitosis/tonsiloliths? What would you say to your attending who does small incisions for thyroids (some people are doing then in crazy small incisions) - why not make a 10 cm incision so you can see the anatomy better? The small incision adds much more time, potential complications in the less experienced hands and is solely for cosmetic purposes. Would you refuse to participate in the opening and closing portion of the case?

At the end of the day - you can choose what you want to practice when you finish residency and can refer the rest. I am not sure it would benefit you to miss any opportunity in residency to gain technical knowledge. Let's face it - this is in no way similar to an OB/GYN resident electing to not participate in terminations/abortions in their residency.

Cosmetic patients are free to choose what type of procedure they desire in consultation with their surgeon. As long as they are away of the risks, complications, and alternatives - we live in a free society where people can choose their health care. Just as you are free to choose what type of operations that you want to perform. No one can force you to operate.

BTW - are you the one who was curious about work hours and not wanting to spend a lot of time learning ENT in residency? I am starting to see a pattern here.

 

[StillChoosing]

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[resxn]

LeForte's response was exceptional. I'd add snoring and transaxillary thyroidectomy to that list of "cosmetic" procedures he mentions.

So I have a question based on ignorance, I guess. I'm interested in knowing why someone would not want to at least learn cosmetics even if you choose not to do it in practice. Is there a religious reason, or is it just philosophical opposition to the idea of it? I may be too ignorant to know if there is a religion which has strong opposition to it.

As far as it being a philosophical, moral, or other value I would only mention that some of the surgical techniques I learned in plastics (particularly in wound closure, care, and skin manipulation) have had a profound impact on how I practice medicine to this day. I would argue that in terms of high-yield, the relatively brief exposure I had in cosmetic plastics had one of the biggest overall impacts on my surgical skill.

Perhaps, if there's not a personal value that would be irreparably violated, proceeding with at least the training would be worthy to help those patients you'll see in the future who would benefit from those skills. I can definitively say my patients have even though I don't do classic non-reconstructive cosmetic plastics anymore.

 

[neutropeniaboy]

Can a resident refuse to assist in rhinoplasty or other cosmetic surgeries done purely for aesthetic reasons (no medical indications) ?

What would the implications be of such actions?

Why?

Your program is required to have each resident complete and be competent in a specified number of cosmetic/functional plastics procedures. To refuse to do them will reduce your plastics key procedures and put your residency program at risk.

This is decidedly bad.

Do you have some ethical dilemma here? It's not like you're being asked to perform an abortion out something "morally controversial."

And LeFort is right. What if it is mostly functional and a minor amount is cosmetic?

You can't learn everything about ENT before residency. It is a life of learning, but again it sounds like this field is something you should stay away from.

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[StillChoosing]

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[Apollyon]

you guys have been very helpful and I'm quite impressed that 3 attendings found the time to provide input. Thank you.


As for the reasons, I don't want to discuss why i wouldn't want to perform "classic non-reconstructive cosmetic plastics." However I agree with Resxn that acquiring such skills in residency will benefit my non-cosmetic patients. After all, once I'm out of residency I choose my cases.

Neutropeniaboy, i see you have no faith in me, you never know i may be your best resident one day . I hope.

Oh, spare me, please. I'm not oto, but I've dealt with many, many residents at several hospital systems, and I can tell you that there are quite enough well-qualified applicants that become residents that don't have such extreme hangups that they stay out of the OR. You never know, but I may end up with Jennifer Love Hewitt, despite my moving from Hawai'i to upstate New York. Likely? Hell, no.

And, as for your "reasons", your cryptic style makes me, at least, think that there's something really, really weird behind your desire to not do any cosmetic procedures - without information, I, like many, assume the worst. The more it's assessed, the more florid become the stories. Since you specifically won't say why, then I shall stand solidly with neutropeniaboy (and he and I are not brothers in lockstep - I once referred to him as "insufferable"). Were you to yield your reasons for this extreme position, you would likely get advice that could help you. However, if you just say "I do not want to learn or perform ANY cosmetic only procedures, and that is that. No discussion, and I won't tell you why", then PDs can easily just pass your application by otherwise unread, because, as I said, there's more than enough other highly qualified applicants.

 

[StillChoosing]

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[pong]

Here's some advice for you: go hang out in the pathology forum. You'll find your 40-hour work week there. You'll also find patients who could care less about cosmetics.

It's such a travesty that you may very well end up becoming an otolaryngologist, while there are many others who will fall short, despite being much more driven and in love with this incredible field.

 

[StillChoosing]

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[Apollyon]

Apollyon, I was looking for answers and others have kindly provided them for me. Of course I would discuss it with my supervisors and let them know my reasons (as recommended by Leforte). I'd appreciate if you have anything to add.

I'll say it again (as I do not know what you posted before you edited it): be open. You would discuss it with your supervisors? When? After you matched? How do you think that would go? If your reasons are specious, you could easily be out of a job. I am having difficulty, and I would hazard a guess that others are, too, trying to guess what would cause such an ethical crisis for you. When I was a med student, rotating on Ob/Gyn, I had a fellow student that refused to be in any elective abortions. He clearly stated his preference, and that is a known issue, and he didn't have to do it. I just wasn't scheduled for any elective TOPs. Yours does not seem to fall in the same place. LeForte did mention some steps, but, also, sensed a pattern in you. It's one thing to do your training, but, then, when you're on your own, to do no cosmetics. You sound like, though, the whole think is "haraam" or not kosher, and you would stay out of the room as a resident. Unless your reasoning is deemed legitimate, you would be in violation of your contract. And what is "legitimate"? You can't even say it, so, as I say, speculation runs wild. And, if you can't say it, how much do you believe in it? Do you have the courage of your convictions? Or are you prepared to NOT get an oto spot, or a plastic sx spot because of what you believe?

 

[StillChoosing]

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[pong]

Why would "many others despite being much more driven and in love with this incredible field," fall short?

People have circumstances surrounding their residency match, or are just plain unlucky. But every year I see well-qualified candidates, and admittedly less-qualified candidates but with a relentless passion for this field, go unmatched. I would rather have any of them over someone like you, who questions the time commitment and does not seem to demonstrate a desire for comprehensive training and a willingness to learn.

My advice for you: go get a life and love outside of hospital, you'll be a happier doctor.

I wake up every morning for a job that I love and continually challenges me. I come home everyday to people and activities that I love and continually challenge me. I am quite happy in my life, but thank you for your concern.

 

[Apollyon]

So let it run....

I didn't come here to ask if my reasons are legitimate. I know they're for me.

I'm sensing you're just curious and not here to help. Like I said I would appreciate any advice or information, if you have any.

"Sensing"? I'm asking you outright - are you OK with not getting a spot for your beliefs? And, as I said, even if legitimate to you, that doesn't mean they are to the people in charge. That is the second time I've given you that advice. I have indeed tried to help, but you are not hearing it. That is on you.

But, others have also told you that wanting to work less, and not do everything, seems like a pattern.

And, as I said before, if someone has to bend over backwards to accommodate you, if it is not legally required, why should they? There are enough riches around that any "buyer" can pass on your ducat and not even care.

 

[StillChoosing]

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[neutropeniaboy]

Since you specifically won't say why, then I shall stand solidly with neutropeniaboy (and he and I are not brothers in lockstep - I once referred to him as "insufferable").

Heh. I remember that now. Had to search for the post, though....

Those lawyers will kill you, Apollyon....

 

[neutropeniaboy]

I'll throw in my final word here on this issue.

It's interesting (reviewing the old exchanges between me and Apollyon) that in the end the seasoned physicians (surgeons in our forum) here all recognize that success in residency depends on being an individual of certain character.

StillChoosing: I don't know if you have those characteristics since, honestly, I don't know you well enough. However, if I am to go on the questions you've posed and the responses alone, I would wage money that you do not. You may end up being a good resident; I'm just not sure you'd be a good surgical resident -- in any surgical residency program.

 

[StillChoosing]

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[Apollyon]

Heh. I remember that now. Had to search for the post, though....

Those lawyers will kill you, Apollyon....

What 8 years will do to you...

First, to read that exchange today, I would not call you "insufferable". So that one is on me. Apologies.

Second, had to do a criminal trial last year. I saw a pt who was shot in the head by her husband (just grazed her). I was sworn in as an expert. What I learned was, no matter what happens, do NOT use the public defender* - unless you want to be convicted. I came off as smart but kind of snotty (which is OK). I looked at each member of the jury, and looked authoritative.

(* as a caveat, though - if you know anyone who knows anyone who is likely to be arrested, tell them to demand a trial. About 10% - maybe - of criminal cases go to trial. 90%+ are plead out. The "Man" threatens "You'll get 20 years if you are convicted, but we'll put you in for 10". If everybody asks for a trial, the courts won't be able to handle it, and the defendants will be deprived of their 6th Amendment rights (to a speedy trial), and will be released free and clear. Tell EVERYBODY.)

 

[resxn]

Obviously, we can't force you to tell us why the objection to cosmetic surgery. I personally don't do it because I got tired of the hand holding, butt-kissing, schmoozing, and constant positive reinforcement those patients required. The straw that broke the camel's back for me was when a 23yo model came to see me and brought a picture of her model friend's nose and wanted hers to look like that. She was gorgeous. I told her, "There is no way that I can surgically make you more beautiful than you are." I went on to tell her that if she saw enough surgeons, someone would take her money and do her surgery, but even with a perfect result (which was unlikely) she couldn't possibly be more attractive. She left and I don't know if she ever had a rhinoplasty. However, I didn't want to be the guy that was the 3rd opinion on someone like that and decided to do that surgery. I stopped cosmetics shortly thereafter. I do love reconstructive plastics, however, and still do that regularly for my Mohs colleagues and others with facial lesions, trauma, etc.

The reason I bring this up is that I do agree that there are valid personal reasons for someone to not want to do cosmetics. I admit I'm very curious as to why you wouldn't share, especially on an anonymous forum. I doubt anyone here could care less who you are or where you're from so to not say why certainly strikes me as odd.

Nevertheless, if you don't share, there's nothing more I can offer in terms of advice other than this. You ABSOLUTELY must share this conviction during your interview. If you do not, you are being dishonest. Many programs who have feeble plastics exposure won't care, but those that do will care. They would feel violated if they brought you on and you refused to participate.

You should also decide now if you'll participate in otoplasties, minimally invasive thyroids, lipoma excisions, snoring surgery, pre-auricular pits/tag excision, benign facial cyst excision, and other things that are purely cosmetic but can greatly benefit a patient. You'll be cheating the program and other potential residents if you fail to disclose what you are and what you are not willing to participate in.

This is probably the oddest string I've ever seen in this forum. I'm so morbidly curious that you won't disclose anonymously what the basis for the objection is, I don't know what to say. I'll say this, stillchoosing, if nothing else, you create a lot of participation in the forum for someone who is not an obvious troll.

 

[maxheadroom]

It seems as though someone who is so dead-set against participating in ANY cosmetic surgery at all during training would be better off in another surgical specialty where that kind of thing isn't an issue. Ortho/GenSurg/NeuroSurg/Urology -- none of them have any cosmetic component.

 

[Leforte]

It seems as though someone who is so dead-set against participating in ANY cosmetic surgery at all during training would be better off in another surgical specialty where that kind of thing isn't an issue. Ortho/GenSurg/NeuroSurg/Urology -- none of them have any cosmetic component.

You mean I can no longer get that penis implant I've been saving up for?

 

[Apollyon]

You mean I can no longer get that penis implant I've been saving up for?

Don't urologists do penis cosmesis, though? And who does the "phalloplasty" for SRS? "If you need the junk, we will build it!"

And GSx does thyroidectomies, right? Those can be split between general and oto, so they have to be concerned with cosmetics. And does NSx consider anything like that when they're cracking a crani?

But, yeah - ortho, I got nothing.

 

[Germanada]

But, yeah - ortho, I got nothing.

How about bunions?

http://www.hss.edu/conditions_cosmetic-foot-surgery.asp

 

[Apollyon]

Good eye there, kid!

I guess they all, after a sort, do something that has to do with the phenotype of humans.

 

[StillChoosing]

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[Fah-Q]

Just to clarify, I'm more than willing to perform surgical procedures to:
improve quality of life

Great. So you will participate in cosmetic surgery because the standard you have listed above includes all cosmetic procedures. Problem solved. Nothing to worry about.

Thank goodness too. It might become burdensome to personally review all surgery requests in your training program so that it may or may not be approved and possibly blessed with your presence.

The earth can continue to rotate now.

 

[OtoHNS]

Just to clarify, I'm more than willing to perform surgical procedures to:

improve quality of life

Why do you think most people get cosmetic surgery? To look and feel better about themselves, thus improving their quality of life. Lots of studies out there that show improved QOL outcomes after cosmetic procedures as well- do a pubmed search. Yes, it's wishy-washy science, but pretty much any QOL "measurement" is going to be very subjective and non-scientific.

However as of now I don't think I'd be comfortable to operate on a 23 yo model who wants to have a nose looking like her friend's.

I'm interested in surgery for those who really need it , not interested in , what I would call, surgical psychiatry.

I agree with your statements here. However, an important part (maybe THE most important part) of being a good cosmetic surgeon is weeding these types of patients out and educating all your patients on what they can realistically expect. The majority of facial cosmetic patients are going to be older women (some men too) who want to "turn back the clock" or people with ugly noses who want to improve their appearance with a rhinoplasty. You can decide for yourself whether you think this is reasonable or not. I also think it's bizarre that you're so opposed to any cosmetic procedures that you wouldn't even assist on them as a resident (and this is all you'll be doing anyway, not doing the surgery yourself).

I don't do any cosmetics in my practice either aside from the occasional botox or filler injection. My reasons are pretty similar to the post above by resxn.

 

[Hoju]

It seems as though someone who is so dead-set against participating in ANY cosmetic surgery at all during training would be better off in another surgical specialty where that kind of thing isn't an issue. Ortho/GenSurg/NeuroSurg/Urology -- none of them have any cosmetic component.

Agree mostly, but who is OK with some messed up looking junk? Uro definitely has some cosmetic aspects.