Special Topic Craniofacial Fellowship Training: Where Are We Now? Niyant Patel, M.D. Kanlaya Dittakasem, R.N. Jeffrey A. Fearon, M.D. Akron, Ohio; and Dallas, Texas
Background: The authors sought to evaluate current craniofacial training in the United States to achieve perspective on changes over time and to gain insights into possible process improvements. Methods: Following a review of the San Francisco Match listings and an Internet search, an anonymous online survey invitation was sent to all fellows finishing in 2013. Results: Thirty-three fellows were identified in 29 listed programs and 30 responded (91 percent). All had completed plastic surgery training. A mean caseload of 380 cases (95 percent CI, 307 to 452) was reported. Case analyses permitted subclassification of fellowships into five areas of relative strengths: cleft/intracranial/midface, 35 percent; cleft/general pediatrics, 20 percent; cleft/adult plastics, 20 percent; cleft/facial trauma, 15 percent; and adult plastics/facial trauma, 10 percent of programs. Eighty-six percent were residencytype programs, whereas only 14 percent remained apprenticeships. Fellows cited confidence in any procedure following participation in more than 12 cases, but 20 percent reported not feeling adequately trained following fellowship. Over half (52 percent) thought training could be improved by establishing core areas of exposure and case category minimums. Conclusions: Fellowships identified as “craniofacial” are actually fairly heterogeneous, offering diverse clinical experiences. Currently, only a minority emphasize traditional cleft, intracranial, and midfacial procedures, with the majority focused more on cleft care, general pediatric plastic surgery, and trauma. Concomitant with an increase in fellowship-trained surgeons has come a change in program structure from apprenticeships to residency-type models. Prospective fellows should consider matching their individual training goals with each program’s unique clinical strengths. (Plast. Reconstr. Surg. 135: 1454, 2015.)
Tell me, I may listen. Teach me, I may remember. Involve me, I will understand. —Chinese proverb
T
he field of craniofacial surgery has arisen from a foundation built by numerous remarkable contributors. However, the earliest roots of modern craniofacial surgical training can be traced back to a single individual, Paul Tessier, who in 1967 presented his early results with Le Fort III osteotomies and intracranial hypertelorism From the Craniofacial Clinic and Plastic and Reconstructive Surgery Center at Akron Children’s Hospital; the Medical City Children’s Hospital; and The Craniofacial Center. Received for publication September 6, 2014; accepted October 21, 2014.
Presented at the 2014 Annual Meeting of the American Society of Craniofacial Surgery, in Indianapolis, Indiana, March 28 through 29, 2014.
Copyright © 2015 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0000000000001061
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corrections at the Fourth Congress of the International Confederation for Plastic and Reconstructive Surgery in Rome.1 The feedback he received following this presentation spurred Tessier to organize a weeklong conference in Paris, during which time he presented past cases and performed live surgery on four patients.2 In the years that followed, plastic surgeons from around the world traveled to Paris to watch Tessier operate and, thus inspired, would bring these innovative techniques back to their respective countries. This preliminary core of international plastic surgeons went on to further collaborate, refine these new procedures, and eventually begin formal fellowship training, and a new subspecialty of plastic surgery was born. These early fellowships were mostly structured as yearlong apprenticeships. As the number of newly Disclosure: The authors have no financial interest to declare in relation to the content of this article.
www.PRSJournal.com
Volume 135, Number 5 • Craniofacial Fellowship Training trained surgeons increased, professional organizations that were focused on craniofacial surgery were formed, further facilitating the interchange of knowledge. Almost 50 years later, we sought to evaluate the current status of craniofacial training in the United States to achieve some perspective on the changes that have occurred as this specialty has matured and to gain insights into possible ways of improving the educational process.
Table 1. Determinations of Case Groupings by Case Types Case Groupings
Case Types
Cleft/orthognathic
Intracranial/orbital/ midface
METHODS A search for current craniofacial fellowships was performed through a review of all listings posted in the San Francisco Match directory, and the American Society of Craniofacial Surgery Fellowship Directory, and these results were augmented by an open Internet search. We reduced this preliminary list of identified programs to either those based in the United States or those international programs previously sought by U.S. trainees (based on known prior fellow demographics), with the presumption that trainees attending these programs would be mostly likely to return to practice in the United States. An anonymous online survey (SurveyMonkey, Palo Alto, Calif.) was sent by e-mail in June of 2013 to all 33 fellows participating in one of these programs over the 2012 to 2013 academic year. After sending an initial e-mail, follow up e-mails were sent, and finally telephone solicitations were made requesting survey completion. Demographic data were solicited and questions were structured to ascertain the breadth of acquired surgical experience and a fellows’ future plans. Finally, suggestions were solicited concerning ways of improving the fellowship training. To appreciate both differences and similarities between different programs, we analyzed case types and volumes reported. Categories of similar case types were developed from an analysis of all cases reported and then we grouped similar case types into general categories as depicted in Table 1. By combining case types, we were able to subdivide each program into one of five general types to highlight each program’s unique strengths. This categorization into program types was achieved by examining all of the cases performed at each program, grouping them into one of the above case types, and then describing the program based on each center’s primary and secondary highest volume case experiences.
Adult/reconstructive/ aesthetic
Facial trauma General pediatric plastic
Primary cleft lip–cleft palate repairs, secondary cleft lip– cleft palate repairs, cleft nasal deformity corrections, orthognathic procedures (mandibular and maxillary) Nonsyndromic craniosynostosis repairs, syndromic craniosynostosis repairs, hypertelorism/ facial clefting repairs, monobloc/Le Fort III/bipartition osteotomies Microvascular reconstructions, skull base, head and neck tumor resections/reconstructions, oculoplastic procedures, aesthetic procedures Primary facial trauma reconstructions, secondary facial trauma reconstructions Microtia repairs, vascular malformations/hemangioma treatments, congenital hand repairs, miscellaneous pediatric plastic surgical cases
RESULTS We identified 29 programs located in the United States and five international programs in three countries (Australia, Canada, and Taiwan) that fulfilled our criterion for identifying all trainees who were likely to eventually practice in the United States. We were able to obtain fellow contact information from 31 of these programs (United States, n = 27; Canada, n = 2; Australia, n = 2). Two of these programs had two fellows, whereas the remainder had one, for a total of 33 fellows. Thirty of 33 craniofacial fellows from 29 programs (United States, n = 26; Canada, n = 1; Australia, n = 2) responded to our survey, yielding a 91 percent response rate. Of the 27 United States–based programs, 25 participated in the San Francisco Match and eight of these were Accreditation Council for Graduate Medical Education accredited. Of those responding to our survey, only one U.S.-trained plastic surgeon chose to pursue craniofacial training at a program outside the United States over the 2012 to 2013 academic year and five internationally trained plastic surgeons had accepted U.S. fellowships. Seventy-seven percent of responding fellows were male and 23 percent were female, and all had previously completed plastic surgery training, with 13 coming from independent and 17 coming from integrated/combined programs (Table 2). Six fellows (20 percent) had undergone supplementary subspecialty training following
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Plastic and Reconstructive Surgery • May 2015 Table 2. Fellow Demographics Characteristic
No. (%)
No. Sex Female Male Previous plastic surgery residency Integrated/combined Independent General surgery Otolaryngology U.S. surgeons training internationally International surgeons training domestically Previous subspecialty training Microsurgery Burn
30 7 (23.3) 23 (76.7) 30 (100) 17 (56.7) 13 (43.3) 12 1 1 (3.3) 5 (16.7) 6 (20) 5 1
their plastic surgery residency training, before beginning a craniofacial fellowship (one burn fellowship and five microsurgery fellowships). An analysis of listed program faculty revealed that only four of 29 programs (14 percent) were structured along the traditional apprenticeship model, with a single senior surgeon responsible for all training. The majority of programs [25 of 29 (86 percent)] were structured following a residency-type model, with multiple surgeons (typically one senior surgeon, with multiple junior faculty) sharing responsibility for training. Over half of the programs (55 percent) included some type of international surgical experience, and 19 percent of the fellows attending these programs believed that their international experience was designed to address a case-type deficiency (Table 3). The mean estimated total number of cases reported was 380 (95 percent CI, 307 to 452). Based on actual case volume supplied by the majority of respondents, five general areas of case types were identified (Fig. 1): Table 3. Program Characteristics No. (%) Total Country United States Australia Canada San Francisco Match participant ACGME accredited Residency model Apprenticeship Monthly didactics Lectures Journal club Research activities International experience Necessary for case-type deficiency
29 26 (89.7) 2 (6.9) 1 (3.4) 25 (86.2) 8 (27.6) 25 (86.2) 4 (13.8) 24 (82.8) 16 (55.2) 14 (48.3) 17 (58.6) 16 (55.2) 3 (10.3)
ACGME, Accreditation Council for Graduate Medical Education.
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1. Cleft/orthognathic, 44 percent. 2. Intracranial/orbital/midface, 18 percent. 3. Adult/reconstructive/aesthetic, 15 percent. 4. Facial trauma, 13 percent. 5. General pediatric plastics, 10 percent. From this analysis, we were able to obtain an overview of the distribution of the various craniofacial fellowships types (Fig. 2), as follows: 1. Cleft/intracranial/midface, 35 percent. 2. Cleft/general pediatrics, 20 percent. 3. Cleft/adult plastics, 20 percent. 4. Cleft/facial trauma, 15 percent. 5. Adult plastics/facial trauma, 10 percent A further analysis revealed that fellows were more likely to score confidence in a particular technique if greater than 12 cases has been experienced in that category. Overall, 80 percent of all fellows reported feeling well prepared for a career in craniofacial surgery at the end of their fellowships, whereas 20 percent indicated that they did not feel sufficiently prepared. When queried about their perception of an ideal practice, only 20 percent (six of 30) cited an ideal future practice as having a case mix consisting of more than 80 percent pediatric reconstructive procedures. Only 17 percent of respondents suggested that their ideal practice would not include any aesthetic surgery. The combined aggregate of responses suggested an ideal practice ratio of 53 percent pediatric reconstructive surgery, 29 percent adult reconstructive, and 18 percent cosmetic surgery. When asked about an ideal program’s relative strengths, the operative experience was cited to be most desirable factor, followed by the faculty, a significant clinical diversity, some surgical autonomy, and (lastly) individual mentoring. Fifteen of 29 respondents (52 percent) believed craniofacial training could be improved by establishing core areas of exposure and case category minimums. All but one fellow had formal plans following their fellowship training: 13 trainees (43 percent) were entering academic jobs, 10 (33 percent) were going into some type of private practice (only one was going solo; the rest were joining a group, a few of which had some formal association with an academic institution), and six (21 percent) were beginning another subspecialty fellowship.
DISCUSSION We sought to acquire an overview of the type of training experiences that craniofacial surgeons
Volume 135, Number 5 • Craniofacial Fellowship Training
Fig. 1. Five general areas of case types were identified, based on combined reported case volumes by craniofacial fellows at the end of their training.
Fig. 2. An examination of case frequencies permitted subclassification of the various offered fellowship experiences into one of five different fellowship types to highlight each program’s unique strengths. Gen Peds, general pediatrics; Cranio, craniofacial.
likely to practice in the United States are currently receiving. This survey of recent craniofacial fellowship–trained surgeons is notable for a relatively high survey response rate of 91 percent, which we believe supports the likelihood that these findings provide a fairly accurate representation of the current state of training. The combined responses suggest a number of interesting trends. To begin with, although there may be non–plastic surgery– trained specialists currently treating children with craniofacial anomalies, the observation that 100 percent of trainees reported having first completed plastic surgery residency training would appear to confirm the general perception that craniofacial surgery is a true subspecialty of plastic surgery. Although we recognize that this observation is subject to search methodology bias (not capturing fellowships outside of the fellowship
match program and without an Internet listing), we believe it is reasonable to assume that any program “falling under the radar” would be less likely to offer comprehensive training. Another identified trend relates to program structure. Earliest craniofacial training involved experienced plastic surgeons traveling to watch a single surgeon (Paul Tessier) performing new surgical techniques. Soon after, a more structured craniofacial education was developed through the creation of 1-year fellowships immediately following plastic surgery residency training. These early fellowships all began as apprenticeships, with a single mentor taking full responsibility for training. However, today only 14 percent of programs still follow this paradigm, with most now structured more along a residency-type model. Around the time that the senior author began his craniofacial training, it
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Plastic and Reconstructive Surgery • May 2015 was not uncommon to hear established surgeons remark that there were already too many craniofacial surgeons. As the number of fellowships has grown, there has been a corresponding increase in the number of craniofacially trained surgeons. Over the past decade, over 300 new craniofacially trained surgeons have entered the U.S. work force, which has allowed academic programs the opportunity to have more than one craniofacial surgeon on their faculty. This “deeper bench” may explain the gradual shift in craniofacial training from apprenticeships with a single mentor to more of a residency-type experience, working with multiple surgeons. Concomitant with this increase in the numbers of active craniofacial surgeons has been an expansion of the scope of this subspecialty, which has grown to encompass general pediatric plastic surgery, improved cleft care, refined facial trauma, fostered the development of skull base surgery, and even contributed to aesthetic surgery. This expansion in scope has resulted in a shift in focus away from treating the types of cases that originally defined this specialty toward a more broader clinical experience. Only 18 percent of all reported cases involved intracranial or orbital osteotomies, which are those procedures that reflect the traditional definition of “craniofacial” surgery. Interestingly, a review of all the various fellowship experiences showed that only approximately one-third of all programs appeared to offer a significant experience in those procedures falling under this classic definition. Most of the remaining two-thirds of craniofacial fellowships offer cleft care as the predominant case type, followed by general pediatric plastic surgery, facial trauma, and general plastic surgery, in decreasing order. The findings that the majority of fellowships (65 percent) are not offering a classic craniofacial experience; that just over 20 percent of fellows choose to pursue different subspecialty fellowships following their “craniofacial” training; and that the ideal practice suggested by graduating fellows is 53 percent pediatric reconstructive surgery, 29 percent adult reconstructive, and 18 percent cosmetic surgery, all would seem to indicate that a significant percentage of residents are seeking craniofacial training without a focused interest in performing these classic procedures (i.e., intracranial, orbital, and midface). Another possibility is that a majority of fellows have either been shaped by their broader training to seek more diversified practice goals, or are not optimistic about finding job opportunities that would offer a concentrated traditional craniofacial practice. However, it is also important to recognize
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potential biases within this study design, especially with respect to how these data were obtained. Selfreported data are susceptible to social desirability bias, which describes the tendency to overreport desirable behavior and underreport negative outcomes because of embarrassment or the desire to be viewed favorably by others. It is our hope that by ensuring anonymity, we may have accomplished some reduction in this particular bias. Another potential bias that needs to be considered is choice-supportive bias, which describes the tendency to distort prior self-chosen experiences in a more positive light—for example, in this series through the inflation of case volumes, or the high percentage (80 percent) of the fellows reporting feeling well-prepared for a future career in craniofacial surgery. Lastly, aside from asking fellows to estimate hours spent pursuing various research endeavors, our questionnaire did not delve deeper into the types of either clinical, experimental, or research components of fellowship training, which are aspects of training that might be particularly germane for those considering a career in academia. In addition to obtaining a snapshot of current craniofacial training, it was also our intention to spur a debate as to how to improve the training process. How successful are craniofacial educators at providing a quality educational experience? When we analyzed the fellows’ stated confidence levels in performing a particular procedure and correlated these with the number of cases actually performed in training, we found that when exposed to 12 cases of a particular type, fellows were most likely to report being confident in their ability to perform these cases. However, it is reasonable to ask the question: Might there be some disconnect between confidence and performance?3 Is feeling confident in one’s ability to perform a procedure while in the presence of an experienced surgeon in a tightly supervised setting different from one’s actual surgical ability working independently? The goals of craniofacial fellowship training should be to produce surgeons capable of safely, efficiently, and effectively caring for those affected with craniofacial anomalies. An objective assessment of how successful current training programs are at achieving these goals is a noteworthy endeavor but would require an examination of outcomes of practicing craniofacial surgeons after they had finished their training, which is something that was not done with this survey. With respect to program structure, has the shift in training from an apprenticeship to a specialized residency model been a positive step for
Volume 135, Number 5 • Craniofacial Fellowship Training craniofacial training? There are numerous potential advantages to the residency training model. Through exposure to different faculty members, trainees gain broader insights into variations on treatment approaches and attain experience with more diverse types of surgical cases. However, it is also reasonable to ask the question: Is the experience gained from junior faculty a quality experience? Moreover, the benefits of spending a greater percentage of time with different staff surgeons in the operating room must come at the expense of less time spent on what educators believe are the equally important experiences that take place outside of the operating, such as patient evaluations, the operative decision-making process (if, when, and how), and the ability to track surgical outcomes. Quality in-training initiatives have been recently introduced into general surgical training to address the need for residents to track their patient outcomes.4 These reciprocal goals (time spent in the operating room versus time spent in the clinic experiencing preoperative and postoperative care) suggest the need for surgical educators to structure an appropriate balance. The apprenticeship model would seem to offer one solution for achieving this balance in that it approximates the ratio of operative and clinical experiences normally found in an average practice. In addition, there are potential advantages to having a single individual focus on a trainee’s education, and assuming some responsibility for the development of a young surgeon’s subsequent career. Interestingly, the fellow responses seem to possibly indicate a different priority in selecting fellowships. Their combined responses ranked the operative experience as being the most important trait, followed by faculty, clinical diversity, autonomy, and mentorship. We suspect that by ranking a program’s faculty as a more favorable program characteristic than mentorship, fellows might be considering qualities such as reputation, experience, and skill sets being more desirable than traits such as a potential role model, personal supporter, or advocate; however, our survey was not designed to specifically differentiate these qualities. Intuitively, if multiple craniofacial surgeons share a single institution’s patient population, then, unless cases are distributed among attending physicians by type, each faculty member is likely to have a lesser experience level compared with a single faculty member at a similar institution handling the entire case volume. What is better for trainees, a more concentrated exposure with a single surgeon with greater experience, or a more diversified exposure with multiple
surgeons, albeit with somewhat less experience? It is unlikely that anyone who has emerged from surgical training in the United States has not heard the aphorism: “see one, do one, teach one.” Ericsson and Lehmann have shown that it takes approximately 10 years to achieve superior expert performance (a finding popularized in Malcolm Gladwell’s Outliers, suggesting a 10,000-hour threshold).5,6 If the average craniofacial fellowship year provides 60 hours of on-site training per week, this would translate to a little over 3000 hours of training over a 1-year period. Considering that most fellowships are not 100 percent pure craniofacial experiences (at least by the traditional definition), then for most, the yearlong fellowship is clearly just the first small step in this important educational process. We believe that a case can be made for both types of fellowship experience. The apprenticeship model may be better suited for those residents who wish to pursue a more focused experience in craniofacial surgery, whereas the residency-type model might be a better choice for those who seek a broader training experience, with goals set on a more diverse future practice. In light of the significant diversity noted among the reported surgical experiences across the various fellowship programs, what type of clinical and operative experiences should qualify as providing adequate craniofacial training and is there a need for minimum caseloads? The Accreditation Council for Graduate Medical Education initiated an outcome project based on “core competencies” almost 10 years ago, and specific evaluation tools have been designed for plastic surgery training programs to assess whether these competences are being achieved.7,8 However, others have questioned the validity of these proposed competencies and the ability for the assessment tools to accurately measure the impact of theses guidelines on surgical training, especially for larger programs containing many residents and faculty.9 There are no data showing that the current training of craniofacial surgeons has been idealized and cannot be further improved; however, before one can design metrics to gauge the quality and success of any teaching methodologies, the goals of training need to be carefully defined. When asked for suggestions for improving the craniofacial fellowship experience, 52 percent of fellows believed core areas of exposure and case category minimums would be helpful, although almost an equal number of respondents did not share this belief. Confounding these fellows’ opinions is the observation that there was a fair amount of diversity in the graduating fellows’
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Plastic and Reconstructive Surgery • May 2015 imagined ideal practice types. Given the observed disparity of clinical experiences offered by the different programs, the variability in training models (apprenticeship versus residency type), and the finding that 20 percent of fellows stated that they did not feel adequately prepared for becoming craniofacial surgeons, it would seem prudent that residents seek to ascertain the unique type of clinical experience being offered at each different fellowship opportunity, to best match their desired career paths with the appropriate program. Although it might seem intuitive that establishing caseload minimums would be a beneficial step in improving craniofacial education, most craniofacial anomalies are fairly uncommon, making it difficult or impossible for many programs to achieve certain minimal caseload requirements. This survey revealed that some programs sought to correct this deficiency by offering international clinical experiences as partial compensation. Another solution might be the establishment of minimum caseloads that vary with program type. The final unanswered question by this survey is: Are we training too many craniofacial surgeons? Without guidelines dictating exactly what constitutes a craniofacial fellowship, and without any minimum caseload standards, there has been a concomitant unrestrained growth of training opportunities in the United States occurring over the past 50 years. A different model for subspecialty training can be seen within the national health care system in the United Kingdom. This program limits the number of craniofacial centers, which in turn limits the number of available craniofacial training positions. This type of system creates the potential for more plastic surgery residents desirous of craniofacial training than there are available positions, and potentially for more craniofacially trained surgeons than there are job opportunities. Having a health care delivery system that focuses on specialty care can provide significant benefits to patients by creating an experience advantage among that system’s surgeons. However, there is also a theoretical downside to a pyramidal system in that young gifted surgeons, potentially capable of achieving marked advances in care, might go unrecognized in the training selection process, rendering them unable to ever fulfill this potential. With our current system in the United States, almost all individuals interested in pursuing a career in craniofacial surgery are able to obtain craniofacial training. This open system has resulted in a large increase in craniofacially trained plastic surgeons. Although it is likely that one unintended result of this plethora of new
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trainees is that patients may be more likely to receive suboptimal care as a result of less focused and less experienced practitioners, our system has possibly allowed a number of talented individuals the opportunity to flourish here, where they might otherwise not been able to do in other medical systems, further propelling this rewarding surgical subspecialty.
CONCLUSIONS A review of recent fellowship graduates shows that current craniofacial training opportunities offer very diverse clinical experiences. Only a minority of fellowships today offer substantial exposure to classic craniofacial procedures, with most showing relative strengths in cleft care, general pediatric plastic surgery, and trauma. There has been a gradual shift in craniofacial fellowship training structure away from the apprenticeship model toward the residency model, with fellows now working with a larger faculty. Given the diversity of clinical experiences identified, prospective fellows should consider matching their training goals with the program type best suited to their needs. Jeffrey A. Fearon, M.D. 7777 Forest Lane, Suite C-700 Dallas, Texas 75230 [email protected]
references 1. Jones BM. Paul Louis Tessier: Plastic surgeon who revolutionised the treatment of facial deformity. J Plast Reconstr Aesthet Surg. 2008;61:1005–1007. 2. Jackson IT. Atlas of Craniomaxillofacial Surgery. St. Louis: Mosby; 1982. 3. Friedell ML, VanderMeer TJ, Cheatham ML, et al. Perceptions of graduating general surgery chief residents: Are they confident in their training? J Am Coll Surg. 2014;218:695–703. 4. Kelz RR, Sellers MM, Reinke CE, Medbery RL, Morris J, Ko C. Quality in-training initiative: A solution to the need for education in quality improvement. Results from a survey of program directors. J Am Coll Surg. 2013;217:1126–1132.e1. 5. Ericsson KA, Lehmann AC. Expert and exceptional performance: Evidence of maximal adaptation to task constraints. Annu Rev Psychol. 1996;47:273–305. 6. Gladwell M. Outliers: The Story of Success. Large type large print ed. New York: Little, Brown; 2008. 7. Bancroft GN, Basu CB, Leong M, Mateo C, Hollier LH Jr, Stal S. Outcome-based residency education: Teaching and evaluating the core competencies in plastic surgery. Plast Reconstr Surg. 2008;121:441e–448e. 8. Knox AD, Gilardino MS, Kasten SJ, Warren RJ, Anastakis DJ. Competency-based medical education for plastic surgery: Where do we begin? Plast Reconstr Surg. 2014;133:702e–710e. 9. Dumanian GA. The emperor has no clothes. Plast Reconstr Surg. 2009;123:1137–1138.
Background: The authors sought to evaluate current craniofacial training in the United States to achieve perspective on changes over time and to gain insights into possible process improvements. Methods: Following a review of the San Francisco Match listings and an Internet search, an anonymous online survey invitation was sent to all fellows finishing in 2013. Results: Thirty-three fellows were identified in 29 listed programs and 30 responded (91 percent). All had completed plastic surgery training. A mean caseload of 380 cases (95 percent CI, 307 to 452) was reported. Case analyses permitted subclassification of fellowships into five areas of relative strengths: cleft/intracranial/midface, 35 percent; cleft/general pediatrics, 20 percent; cleft/adult plastics, 20 percent; cleft/facial trauma, 15 percent; and adult plastics/facial trauma, 10 percent of programs. Eighty-six percent were residencytype programs, whereas only 14 percent remained apprenticeships. Fellows cited confidence in any procedure following participation in more than 12 cases, but 20 percent reported not feeling adequately trained following fellowship. Over half (52 percent) thought training could be improved by establishing core areas of exposure and case category minimums. Conclusions: Fellowships identified as “craniofacial” are actually fairly heterogeneous, offering diverse clinical experiences. Currently, only a minority emphasize traditional cleft, intracranial, and midfacial procedures, with the majority focused more on cleft care, general pediatric plastic surgery, and trauma. Concomitant with an increase in fellowship-trained surgeons has come a change in program structure from apprenticeships to residency-type models. Prospective fellows should consider matching their individual training goals with each program’s unique clinical strengths. (Plast. Reconstr. Surg. 135: 1454, 2015.)
Tell me, I may listen. Teach me, I may remember. Involve me, I will understand. —Chinese proverb
T
he field of craniofacial surgery has arisen from a foundation built by numerous remarkable contributors. However, the earliest roots of modern craniofacial surgical training can be traced back to a single individual, Paul Tessier, who in 1967 presented his early results with Le Fort III osteotomies and intracranial hypertelorism From the Craniofacial Clinic and Plastic and Reconstructive Surgery Center at Akron Children’s Hospital; the Medical City Children’s Hospital; and The Craniofacial Center. Received for publication September 6, 2014; accepted October 21, 2014.
Presented at the 2014 Annual Meeting of the American Society of Craniofacial Surgery, in Indianapolis, Indiana, March 28 through 29, 2014.
Copyright © 2015 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0000000000001061
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corrections at the Fourth Congress of the International Confederation for Plastic and Reconstructive Surgery in Rome.1 The feedback he received following this presentation spurred Tessier to organize a weeklong conference in Paris, during which time he presented past cases and performed live surgery on four patients.2 In the years that followed, plastic surgeons from around the world traveled to Paris to watch Tessier operate and, thus inspired, would bring these innovative techniques back to their respective countries. This preliminary core of international plastic surgeons went on to further collaborate, refine these new procedures, and eventually begin formal fellowship training, and a new subspecialty of plastic surgery was born. These early fellowships were mostly structured as yearlong apprenticeships. As the number of newly Disclosure: The authors have no financial interest to declare in relation to the content of this article.
www.PRSJournal.com
Volume 135, Number 5 • Craniofacial Fellowship Training trained surgeons increased, professional organizations that were focused on craniofacial surgery were formed, further facilitating the interchange of knowledge. Almost 50 years later, we sought to evaluate the current status of craniofacial training in the United States to achieve some perspective on the changes that have occurred as this specialty has matured and to gain insights into possible ways of improving the educational process.
Table 1. Determinations of Case Groupings by Case Types Case Groupings
Case Types
Cleft/orthognathic
Intracranial/orbital/ midface
METHODS A search for current craniofacial fellowships was performed through a review of all listings posted in the San Francisco Match directory, and the American Society of Craniofacial Surgery Fellowship Directory, and these results were augmented by an open Internet search. We reduced this preliminary list of identified programs to either those based in the United States or those international programs previously sought by U.S. trainees (based on known prior fellow demographics), with the presumption that trainees attending these programs would be mostly likely to return to practice in the United States. An anonymous online survey (SurveyMonkey, Palo Alto, Calif.) was sent by e-mail in June of 2013 to all 33 fellows participating in one of these programs over the 2012 to 2013 academic year. After sending an initial e-mail, follow up e-mails were sent, and finally telephone solicitations were made requesting survey completion. Demographic data were solicited and questions were structured to ascertain the breadth of acquired surgical experience and a fellows’ future plans. Finally, suggestions were solicited concerning ways of improving the fellowship training. To appreciate both differences and similarities between different programs, we analyzed case types and volumes reported. Categories of similar case types were developed from an analysis of all cases reported and then we grouped similar case types into general categories as depicted in Table 1. By combining case types, we were able to subdivide each program into one of five general types to highlight each program’s unique strengths. This categorization into program types was achieved by examining all of the cases performed at each program, grouping them into one of the above case types, and then describing the program based on each center’s primary and secondary highest volume case experiences.
Adult/reconstructive/ aesthetic
Facial trauma General pediatric plastic
Primary cleft lip–cleft palate repairs, secondary cleft lip– cleft palate repairs, cleft nasal deformity corrections, orthognathic procedures (mandibular and maxillary) Nonsyndromic craniosynostosis repairs, syndromic craniosynostosis repairs, hypertelorism/ facial clefting repairs, monobloc/Le Fort III/bipartition osteotomies Microvascular reconstructions, skull base, head and neck tumor resections/reconstructions, oculoplastic procedures, aesthetic procedures Primary facial trauma reconstructions, secondary facial trauma reconstructions Microtia repairs, vascular malformations/hemangioma treatments, congenital hand repairs, miscellaneous pediatric plastic surgical cases
RESULTS We identified 29 programs located in the United States and five international programs in three countries (Australia, Canada, and Taiwan) that fulfilled our criterion for identifying all trainees who were likely to eventually practice in the United States. We were able to obtain fellow contact information from 31 of these programs (United States, n = 27; Canada, n = 2; Australia, n = 2). Two of these programs had two fellows, whereas the remainder had one, for a total of 33 fellows. Thirty of 33 craniofacial fellows from 29 programs (United States, n = 26; Canada, n = 1; Australia, n = 2) responded to our survey, yielding a 91 percent response rate. Of the 27 United States–based programs, 25 participated in the San Francisco Match and eight of these were Accreditation Council for Graduate Medical Education accredited. Of those responding to our survey, only one U.S.-trained plastic surgeon chose to pursue craniofacial training at a program outside the United States over the 2012 to 2013 academic year and five internationally trained plastic surgeons had accepted U.S. fellowships. Seventy-seven percent of responding fellows were male and 23 percent were female, and all had previously completed plastic surgery training, with 13 coming from independent and 17 coming from integrated/combined programs (Table 2). Six fellows (20 percent) had undergone supplementary subspecialty training following
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Plastic and Reconstructive Surgery • May 2015 Table 2. Fellow Demographics Characteristic
No. (%)
No. Sex Female Male Previous plastic surgery residency Integrated/combined Independent General surgery Otolaryngology U.S. surgeons training internationally International surgeons training domestically Previous subspecialty training Microsurgery Burn
30 7 (23.3) 23 (76.7) 30 (100) 17 (56.7) 13 (43.3) 12 1 1 (3.3) 5 (16.7) 6 (20) 5 1
their plastic surgery residency training, before beginning a craniofacial fellowship (one burn fellowship and five microsurgery fellowships). An analysis of listed program faculty revealed that only four of 29 programs (14 percent) were structured along the traditional apprenticeship model, with a single senior surgeon responsible for all training. The majority of programs [25 of 29 (86 percent)] were structured following a residency-type model, with multiple surgeons (typically one senior surgeon, with multiple junior faculty) sharing responsibility for training. Over half of the programs (55 percent) included some type of international surgical experience, and 19 percent of the fellows attending these programs believed that their international experience was designed to address a case-type deficiency (Table 3). The mean estimated total number of cases reported was 380 (95 percent CI, 307 to 452). Based on actual case volume supplied by the majority of respondents, five general areas of case types were identified (Fig. 1): Table 3. Program Characteristics No. (%) Total Country United States Australia Canada San Francisco Match participant ACGME accredited Residency model Apprenticeship Monthly didactics Lectures Journal club Research activities International experience Necessary for case-type deficiency
29 26 (89.7) 2 (6.9) 1 (3.4) 25 (86.2) 8 (27.6) 25 (86.2) 4 (13.8) 24 (82.8) 16 (55.2) 14 (48.3) 17 (58.6) 16 (55.2) 3 (10.3)
ACGME, Accreditation Council for Graduate Medical Education.
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1. Cleft/orthognathic, 44 percent. 2. Intracranial/orbital/midface, 18 percent. 3. Adult/reconstructive/aesthetic, 15 percent. 4. Facial trauma, 13 percent. 5. General pediatric plastics, 10 percent. From this analysis, we were able to obtain an overview of the distribution of the various craniofacial fellowships types (Fig. 2), as follows: 1. Cleft/intracranial/midface, 35 percent. 2. Cleft/general pediatrics, 20 percent. 3. Cleft/adult plastics, 20 percent. 4. Cleft/facial trauma, 15 percent. 5. Adult plastics/facial trauma, 10 percent A further analysis revealed that fellows were more likely to score confidence in a particular technique if greater than 12 cases has been experienced in that category. Overall, 80 percent of all fellows reported feeling well prepared for a career in craniofacial surgery at the end of their fellowships, whereas 20 percent indicated that they did not feel sufficiently prepared. When queried about their perception of an ideal practice, only 20 percent (six of 30) cited an ideal future practice as having a case mix consisting of more than 80 percent pediatric reconstructive procedures. Only 17 percent of respondents suggested that their ideal practice would not include any aesthetic surgery. The combined aggregate of responses suggested an ideal practice ratio of 53 percent pediatric reconstructive surgery, 29 percent adult reconstructive, and 18 percent cosmetic surgery. When asked about an ideal program’s relative strengths, the operative experience was cited to be most desirable factor, followed by the faculty, a significant clinical diversity, some surgical autonomy, and (lastly) individual mentoring. Fifteen of 29 respondents (52 percent) believed craniofacial training could be improved by establishing core areas of exposure and case category minimums. All but one fellow had formal plans following their fellowship training: 13 trainees (43 percent) were entering academic jobs, 10 (33 percent) were going into some type of private practice (only one was going solo; the rest were joining a group, a few of which had some formal association with an academic institution), and six (21 percent) were beginning another subspecialty fellowship.
DISCUSSION We sought to acquire an overview of the type of training experiences that craniofacial surgeons
Volume 135, Number 5 • Craniofacial Fellowship Training
Fig. 1. Five general areas of case types were identified, based on combined reported case volumes by craniofacial fellows at the end of their training.
Fig. 2. An examination of case frequencies permitted subclassification of the various offered fellowship experiences into one of five different fellowship types to highlight each program’s unique strengths. Gen Peds, general pediatrics; Cranio, craniofacial.
likely to practice in the United States are currently receiving. This survey of recent craniofacial fellowship–trained surgeons is notable for a relatively high survey response rate of 91 percent, which we believe supports the likelihood that these findings provide a fairly accurate representation of the current state of training. The combined responses suggest a number of interesting trends. To begin with, although there may be non–plastic surgery– trained specialists currently treating children with craniofacial anomalies, the observation that 100 percent of trainees reported having first completed plastic surgery residency training would appear to confirm the general perception that craniofacial surgery is a true subspecialty of plastic surgery. Although we recognize that this observation is subject to search methodology bias (not capturing fellowships outside of the fellowship
match program and without an Internet listing), we believe it is reasonable to assume that any program “falling under the radar” would be less likely to offer comprehensive training. Another identified trend relates to program structure. Earliest craniofacial training involved experienced plastic surgeons traveling to watch a single surgeon (Paul Tessier) performing new surgical techniques. Soon after, a more structured craniofacial education was developed through the creation of 1-year fellowships immediately following plastic surgery residency training. These early fellowships all began as apprenticeships, with a single mentor taking full responsibility for training. However, today only 14 percent of programs still follow this paradigm, with most now structured more along a residency-type model. Around the time that the senior author began his craniofacial training, it
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Plastic and Reconstructive Surgery • May 2015 was not uncommon to hear established surgeons remark that there were already too many craniofacial surgeons. As the number of fellowships has grown, there has been a corresponding increase in the number of craniofacially trained surgeons. Over the past decade, over 300 new craniofacially trained surgeons have entered the U.S. work force, which has allowed academic programs the opportunity to have more than one craniofacial surgeon on their faculty. This “deeper bench” may explain the gradual shift in craniofacial training from apprenticeships with a single mentor to more of a residency-type experience, working with multiple surgeons. Concomitant with this increase in the numbers of active craniofacial surgeons has been an expansion of the scope of this subspecialty, which has grown to encompass general pediatric plastic surgery, improved cleft care, refined facial trauma, fostered the development of skull base surgery, and even contributed to aesthetic surgery. This expansion in scope has resulted in a shift in focus away from treating the types of cases that originally defined this specialty toward a more broader clinical experience. Only 18 percent of all reported cases involved intracranial or orbital osteotomies, which are those procedures that reflect the traditional definition of “craniofacial” surgery. Interestingly, a review of all the various fellowship experiences showed that only approximately one-third of all programs appeared to offer a significant experience in those procedures falling under this classic definition. Most of the remaining two-thirds of craniofacial fellowships offer cleft care as the predominant case type, followed by general pediatric plastic surgery, facial trauma, and general plastic surgery, in decreasing order. The findings that the majority of fellowships (65 percent) are not offering a classic craniofacial experience; that just over 20 percent of fellows choose to pursue different subspecialty fellowships following their “craniofacial” training; and that the ideal practice suggested by graduating fellows is 53 percent pediatric reconstructive surgery, 29 percent adult reconstructive, and 18 percent cosmetic surgery, all would seem to indicate that a significant percentage of residents are seeking craniofacial training without a focused interest in performing these classic procedures (i.e., intracranial, orbital, and midface). Another possibility is that a majority of fellows have either been shaped by their broader training to seek more diversified practice goals, or are not optimistic about finding job opportunities that would offer a concentrated traditional craniofacial practice. However, it is also important to recognize
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potential biases within this study design, especially with respect to how these data were obtained. Selfreported data are susceptible to social desirability bias, which describes the tendency to overreport desirable behavior and underreport negative outcomes because of embarrassment or the desire to be viewed favorably by others. It is our hope that by ensuring anonymity, we may have accomplished some reduction in this particular bias. Another potential bias that needs to be considered is choice-supportive bias, which describes the tendency to distort prior self-chosen experiences in a more positive light—for example, in this series through the inflation of case volumes, or the high percentage (80 percent) of the fellows reporting feeling well-prepared for a future career in craniofacial surgery. Lastly, aside from asking fellows to estimate hours spent pursuing various research endeavors, our questionnaire did not delve deeper into the types of either clinical, experimental, or research components of fellowship training, which are aspects of training that might be particularly germane for those considering a career in academia. In addition to obtaining a snapshot of current craniofacial training, it was also our intention to spur a debate as to how to improve the training process. How successful are craniofacial educators at providing a quality educational experience? When we analyzed the fellows’ stated confidence levels in performing a particular procedure and correlated these with the number of cases actually performed in training, we found that when exposed to 12 cases of a particular type, fellows were most likely to report being confident in their ability to perform these cases. However, it is reasonable to ask the question: Might there be some disconnect between confidence and performance?3 Is feeling confident in one’s ability to perform a procedure while in the presence of an experienced surgeon in a tightly supervised setting different from one’s actual surgical ability working independently? The goals of craniofacial fellowship training should be to produce surgeons capable of safely, efficiently, and effectively caring for those affected with craniofacial anomalies. An objective assessment of how successful current training programs are at achieving these goals is a noteworthy endeavor but would require an examination of outcomes of practicing craniofacial surgeons after they had finished their training, which is something that was not done with this survey. With respect to program structure, has the shift in training from an apprenticeship to a specialized residency model been a positive step for
Volume 135, Number 5 • Craniofacial Fellowship Training craniofacial training? There are numerous potential advantages to the residency training model. Through exposure to different faculty members, trainees gain broader insights into variations on treatment approaches and attain experience with more diverse types of surgical cases. However, it is also reasonable to ask the question: Is the experience gained from junior faculty a quality experience? Moreover, the benefits of spending a greater percentage of time with different staff surgeons in the operating room must come at the expense of less time spent on what educators believe are the equally important experiences that take place outside of the operating, such as patient evaluations, the operative decision-making process (if, when, and how), and the ability to track surgical outcomes. Quality in-training initiatives have been recently introduced into general surgical training to address the need for residents to track their patient outcomes.4 These reciprocal goals (time spent in the operating room versus time spent in the clinic experiencing preoperative and postoperative care) suggest the need for surgical educators to structure an appropriate balance. The apprenticeship model would seem to offer one solution for achieving this balance in that it approximates the ratio of operative and clinical experiences normally found in an average practice. In addition, there are potential advantages to having a single individual focus on a trainee’s education, and assuming some responsibility for the development of a young surgeon’s subsequent career. Interestingly, the fellow responses seem to possibly indicate a different priority in selecting fellowships. Their combined responses ranked the operative experience as being the most important trait, followed by faculty, clinical diversity, autonomy, and mentorship. We suspect that by ranking a program’s faculty as a more favorable program characteristic than mentorship, fellows might be considering qualities such as reputation, experience, and skill sets being more desirable than traits such as a potential role model, personal supporter, or advocate; however, our survey was not designed to specifically differentiate these qualities. Intuitively, if multiple craniofacial surgeons share a single institution’s patient population, then, unless cases are distributed among attending physicians by type, each faculty member is likely to have a lesser experience level compared with a single faculty member at a similar institution handling the entire case volume. What is better for trainees, a more concentrated exposure with a single surgeon with greater experience, or a more diversified exposure with multiple
surgeons, albeit with somewhat less experience? It is unlikely that anyone who has emerged from surgical training in the United States has not heard the aphorism: “see one, do one, teach one.” Ericsson and Lehmann have shown that it takes approximately 10 years to achieve superior expert performance (a finding popularized in Malcolm Gladwell’s Outliers, suggesting a 10,000-hour threshold).5,6 If the average craniofacial fellowship year provides 60 hours of on-site training per week, this would translate to a little over 3000 hours of training over a 1-year period. Considering that most fellowships are not 100 percent pure craniofacial experiences (at least by the traditional definition), then for most, the yearlong fellowship is clearly just the first small step in this important educational process. We believe that a case can be made for both types of fellowship experience. The apprenticeship model may be better suited for those residents who wish to pursue a more focused experience in craniofacial surgery, whereas the residency-type model might be a better choice for those who seek a broader training experience, with goals set on a more diverse future practice. In light of the significant diversity noted among the reported surgical experiences across the various fellowship programs, what type of clinical and operative experiences should qualify as providing adequate craniofacial training and is there a need for minimum caseloads? The Accreditation Council for Graduate Medical Education initiated an outcome project based on “core competencies” almost 10 years ago, and specific evaluation tools have been designed for plastic surgery training programs to assess whether these competences are being achieved.7,8 However, others have questioned the validity of these proposed competencies and the ability for the assessment tools to accurately measure the impact of theses guidelines on surgical training, especially for larger programs containing many residents and faculty.9 There are no data showing that the current training of craniofacial surgeons has been idealized and cannot be further improved; however, before one can design metrics to gauge the quality and success of any teaching methodologies, the goals of training need to be carefully defined. When asked for suggestions for improving the craniofacial fellowship experience, 52 percent of fellows believed core areas of exposure and case category minimums would be helpful, although almost an equal number of respondents did not share this belief. Confounding these fellows’ opinions is the observation that there was a fair amount of diversity in the graduating fellows’
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Plastic and Reconstructive Surgery • May 2015 imagined ideal practice types. Given the observed disparity of clinical experiences offered by the different programs, the variability in training models (apprenticeship versus residency type), and the finding that 20 percent of fellows stated that they did not feel adequately prepared for becoming craniofacial surgeons, it would seem prudent that residents seek to ascertain the unique type of clinical experience being offered at each different fellowship opportunity, to best match their desired career paths with the appropriate program. Although it might seem intuitive that establishing caseload minimums would be a beneficial step in improving craniofacial education, most craniofacial anomalies are fairly uncommon, making it difficult or impossible for many programs to achieve certain minimal caseload requirements. This survey revealed that some programs sought to correct this deficiency by offering international clinical experiences as partial compensation. Another solution might be the establishment of minimum caseloads that vary with program type. The final unanswered question by this survey is: Are we training too many craniofacial surgeons? Without guidelines dictating exactly what constitutes a craniofacial fellowship, and without any minimum caseload standards, there has been a concomitant unrestrained growth of training opportunities in the United States occurring over the past 50 years. A different model for subspecialty training can be seen within the national health care system in the United Kingdom. This program limits the number of craniofacial centers, which in turn limits the number of available craniofacial training positions. This type of system creates the potential for more plastic surgery residents desirous of craniofacial training than there are available positions, and potentially for more craniofacially trained surgeons than there are job opportunities. Having a health care delivery system that focuses on specialty care can provide significant benefits to patients by creating an experience advantage among that system’s surgeons. However, there is also a theoretical downside to a pyramidal system in that young gifted surgeons, potentially capable of achieving marked advances in care, might go unrecognized in the training selection process, rendering them unable to ever fulfill this potential. With our current system in the United States, almost all individuals interested in pursuing a career in craniofacial surgery are able to obtain craniofacial training. This open system has resulted in a large increase in craniofacially trained plastic surgeons. Although it is likely that one unintended result of this plethora of new
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trainees is that patients may be more likely to receive suboptimal care as a result of less focused and less experienced practitioners, our system has possibly allowed a number of talented individuals the opportunity to flourish here, where they might otherwise not been able to do in other medical systems, further propelling this rewarding surgical subspecialty.
CONCLUSIONS A review of recent fellowship graduates shows that current craniofacial training opportunities offer very diverse clinical experiences. Only a minority of fellowships today offer substantial exposure to classic craniofacial procedures, with most showing relative strengths in cleft care, general pediatric plastic surgery, and trauma. There has been a gradual shift in craniofacial fellowship training structure away from the apprenticeship model toward the residency model, with fellows now working with a larger faculty. Given the diversity of clinical experiences identified, prospective fellows should consider matching their training goals with the program type best suited to their needs. Jeffrey A. Fearon, M.D. 7777 Forest Lane, Suite C-700 Dallas, Texas 75230 [email protected]
references 1. Jones BM. Paul Louis Tessier: Plastic surgeon who revolutionised the treatment of facial deformity. J Plast Reconstr Aesthet Surg. 2008;61:1005–1007. 2. Jackson IT. Atlas of Craniomaxillofacial Surgery. St. Louis: Mosby; 1982. 3. Friedell ML, VanderMeer TJ, Cheatham ML, et al. Perceptions of graduating general surgery chief residents: Are they confident in their training? J Am Coll Surg. 2014;218:695–703. 4. Kelz RR, Sellers MM, Reinke CE, Medbery RL, Morris J, Ko C. Quality in-training initiative: A solution to the need for education in quality improvement. Results from a survey of program directors. J Am Coll Surg. 2013;217:1126–1132.e1. 5. Ericsson KA, Lehmann AC. Expert and exceptional performance: Evidence of maximal adaptation to task constraints. Annu Rev Psychol. 1996;47:273–305. 6. Gladwell M. Outliers: The Story of Success. Large type large print ed. New York: Little, Brown; 2008. 7. Bancroft GN, Basu CB, Leong M, Mateo C, Hollier LH Jr, Stal S. Outcome-based residency education: Teaching and evaluating the core competencies in plastic surgery. Plast Reconstr Surg. 2008;121:441e–448e. 8. Knox AD, Gilardino MS, Kasten SJ, Warren RJ, Anastakis DJ. Competency-based medical education for plastic surgery: Where do we begin? Plast Reconstr Surg. 2014;133:702e–710e. 9. Dumanian GA. The emperor has no clothes. Plast Reconstr Surg. 2009;123:1137–1138.
