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Different models of training and certification in plastic surgery
L. Fodor, C. Ciuce, M. Fodor, C. Shrank, O. Lapid, M. Kon, Y. Ramon, Y. Ullmann (Chirurgia, 104 (5): 519-524)

Introduction
Becoming a specialist in one of the many fields in Medicine requires a period of training which, in many countries, is followed by a certifying examination. In this article, we describe how to become a certified Plastic Surgeon in five countries: Israel, Romania, USA, Germany and the Netherlands. In four of the five studied countries, passing board examinations after training is a pre-requisite for obtaining the desired license as a certified Plastic Surgeon. In the fifth country, USA, the examination is needed only to be acknowledged as “Board Certified”, and independent practice is started immediately after finishing training. Herein we describe five models of training and board certification. The information for this report was collected through the personal experience of the authors.

The models
The Romanian Model
The Residency program consists of six years of training, divided into four years and seven months in the Plastic Surgery Department and 17 months of complementary rotations in the following specialties:
· General Surgery – 6 months;
· Orthopedics – 4 months;
· Maxillofacial Surgery – 2 months;
· Otolaryngology – 1 month;
· Ophthalmology – 1 month;
· Pediatric Surgery – 2 months;
· Medical Management (optional) – 1 month.
Residents have a syllabus of surgeries they need to jconsists of three examiners, one acting as the head of the committee. The same committee examines the candidates in all three parts of the exam:
a. The written part consists of 10 small subjects chosen by the board from a list of 77 topics covering all fields of Plastic and Reconstructive Surgery. The maximum time allowed for the exam is two hours. According to a proof sample, the examiners follow the important points for each subject and give marks for each. The mark (from 0 to 10) is not eliminatory and represents 33% of the final exam mark.
b. The oral part is held on a different day and the candidate has to discuss two cases from a pool of cases pre-prepared by the board. The case topics are also part of the 77 subjects, as in the written part. The candidate has to complete the anamnesis and the physical examination for each case in 20 minutes. The next 20 minutes are for preparing the case. No matter how complex the case, the candidate has to present it in 20 minutes. The time period is a cardinal issue and any time extension results in a reduction of the final mark. No questions can be addressed to the candidate during his presentation. The board expects the examinee to discuss the case from the first contact with the patient through to evaluation of the data and imaging analysis, the surgery with its possible complications and their management. The mark obtained at this step represents 33% of the final mark.
c. The surgical skill assessment part, during which the candidate performs a surgical procedure. The cases are randomly selected from a pool of cases. This part is performed either on fresh cadavers or on live patients. During the procedure, the committee examines the candidate and has the right to question him. Marks are given by each of the examiners independently. The mark obtained at this step represents 33% of the final mark. An arithmetical formula is applied for the final score. The minimum mark to pass the exam is seven (out of ten).
At the present time, there is no requirement for re- certification.
The Israeli Model
The training period is six years with a plastic surgery core curriculum of four years and three months. Rotations needed to fulfill the program are:
· General Surgery – 6 months;
· Basic Science (research) – 6 months;
· Burn Unit (part of the Plastic Surgery Department) – 3 months;
· Hand Surgery – 3 months;
· One of the following options: Otolaryngology, Maxillofacial Surgery, Dermatology, Urology or Ophthalmology – 3 months.
The resident has to accomplish a syllabus of surgeries, acting as the first and principle surgeon, in order to obtain a license. Cosmetic surgeries are an obligatory part of this program.
The certification process starts in the middle of the Residency with a written examination.
a. Step I. The written examination can be taken only after completing half the Residency program. It has two parts which may be taken on the same day or a year apart:
- The General Surgery exam consists of about 150 multiple choice questions.
- The Plastic Surgery exam has about 100 multiple-choice questions. Results are analyzed by a computer.
- The minimum mark to pass each of these exams is 65 (out of 100).
b. Step II. The oral examination can be taken only in the last year of the Residency program. It is held twice a year in a single place for all the candidates in the country. Before the examination, board members who constitute the Examination Committee are given final instructions. They are specifically asked to avoid questions which are ambiguous, they need to be fair, and they do not know where the examinee completed his Residency.
Three committees consisting of two Plastic Surgeons in each act as the Examination Committee. Two of the three committees are based on cases that have been prepared by the examiners under the instructions of the head of the board, who is elected every 5 years by the Israeli Society of Plastic and Reconstructive Surgeons. Four photos of cases are introduced to the examinee, with a short story written underneath. The candidate is asked about these cases and is scored for his knowledge of how to deal with the case. He needs to plan the investigation and the surgery, and to know how to deal with complications introduced to him by the examiners. All the examinees are asked about the same cases, to establish the objectivity of the exam.
The third committee is a Case Report Committee. The examinee is given a list of 15 cases for which he performed the surgery, acting as the first surgeon. Of these, the chairman chooses four cases; the entire file of each of these four patients is the base of the questions in this part of the exam. The candidate needs to “defend” each case. Each case in the three committees is discussed exactly for 10 minutes.
If two of the six examiners consider that the candidate fails, it is discussed in the forum of all the examiners. This forum is chaired by the head of the examination board. If the forum considers that the candidate failure is on basic issues, he is failed and must repeat the examination. If three examiners fail the candidate, no discussion is needed. Each examiner has the same decisional power and rates the candidate independently without discussing the result with his co-board members.
There is no re-certification process in Israel at present.
The American Model
There are two main pathways for training in USA.
1. The independent model has two alternatives:
- The first alternative requires a minimum of three years of a general surgery residency program. There is an option to be enrolled in a general surgery training program in which, after completing three years of general surgery, the Resident continues with the Plastic Surgery program for two years.
- The second alternative is for Residents who have finished a formal training program in General Surgery, Neurosurgery, ENT, Orthopedics, Urology or Maxillofacial Surgery, after which they join a plastic surgery program for 2-3 years.
2. The integrated model requires no less than 5 years of residency under the authority of the Plastic Surgery program, with a minimum of two years focused on Plastic Surgery. During the last year, the resident needs to act as a senior resident.
The board examination is held at a minimum of one year after finishing residency. As soon as one has finished residency, one can act as an independent Plastic Surgeon, and no exam is needed to obtain a license. Exams are required only to become a Board Certified Plastic Surgeon. The exam has two parts:
a. The written examination is built up of about 400 multiple-choice questions. The examination is held on one day and at one place for the whole country, and the questions cover the entire field of plastic surgery.
b. The oral examination is held once a year, at one location, for candidates coming from all over the country. Each examinee rotates among three teams, each having two examiners, one of whom is a well experienced senior, and the other a guest examiner who needs to be a Board Certified Plastic Surgeon for 5 years at least. Two teams evaluate the candidate on six pre-prepared cases, the same for each candidate that year. The candidate spends 40 minutes with each team, being questioned about each case. The third team is a “case report team“. The candidates are asked for a “seven-month” case list, which includes all the surgical procedures performed by the candidate during that period, including emergency room procedures. There needs to be the whole file for every patient, including pre- and post- photographs and the coding of the case. The board analyzes the list before the exam and evaluates the complexity and diversity of the procedures. If it is not considered to be adequate, the candidate is not admissible for the oral examination and another list is required for the coming year. From the entire list, the board selects five cases which the candidate has to present and discuss at the exam. Economical and ethical aspects of the case are also discussed by the examiners.
Candidates receive six grades of pass or fail, one from each of the examiners, each making an independent decision. At least four passing grades are necessary to pass the oral examination.
After passing the board examination, certification is valid for 10 years. This type of time-limited certification was introduced in 1995. The re-certification examination consists of about 200 multiple-choice questions. Credits for re-certification are also given by active and passive participation in professional meetings.
The Dutch Model
The training period is six years. First the Resident must complete two years in General Surgery. Then there is a core curriculum of four years in Plastic Surgery. . Residents need to perform at least 100 in-patient surgeries and 50 office procedures every year. The procedures must cover the whole spectrum of Plastic Surgery: General, Hand, Reconstructive Microsurgery (Head and Neck, Extremity reconstructions), Congenital, Burns and Aesthetic surgery.
The Resident needs to work at least a half day a week in an Outpatient Clinic. Emphasis is placed on involvement in treating acute cases of facial and orthopedic trauma. The Resident needs to obtain experience in collaborative work with other surgical disciplines.
Twelve months of the four years in Plastic Surgery can be accomplished at another hospital in the Netherlands or for only six month in an authorized Plastic Surgery department in another country. The period of 12 month can also be dedicated entirely or partially to research, which is not mandatory. Residents are restricted to 48 hours of work per week. Residents need to pass three mandatory courses: Microsurgery, Flap Dissections, and Osteosynthesis (AO).
The certification process in the Netherlands is under the control of the Nederlandse Vereniging voor Plastische Chirurgie (NVPC - The Netherlands Society of Plastic Surgery), which is responsible for the training program of the certified departments. There are two steps in the examination:
a. The Written exam: On a four-year cycle, there is a teaching day twice a year dedicated to a specific topic. At the end of this day, there is a written exam. The exam is built of 15 open questions. The passing mark is 60. The Resident needs to pass at least six of eight exams in order to finish his residency.
b. The Oral exam is given in the last year of the residency. There are three examiners in each of two committees, all being chairmen of Plastic Surgery departments. For ten minutes each examiner discusses one case that is chosen from a “bank of cases”. The examination time for each committee lasts 30 minutes. The passing mark is 60. If the candidate fails, he has to be re-examined within three months. Passing the EBOPRAS (European Board of Plastic Reconstructive and Aesthetic Surgery) is equivalent to the national exam, and may substitute for it.
The German Model
The residency training in Germany is six years, the whole time being spent in an authorized Plastic Surgery Department. There is no mandatory need to go through a rotation period in General Surgery. The Resident must gain experience in Craniofacial Surgery, Hand Surgery, Burns, Aesthetic Surgery and Reconstructive Surgery, and has to perform a certain number of procedures in each of these branches of the profession as a prerequisite for finishing training.
At the end of the training, there is only an oral examination. Examination time is about one hour for every candidate. Two examiners evaluate each candidate and the questions cover the main fields in Plastic Surgery. Each examiner may ask the examinee to discuss 2-3 cases. A senior observer is present during examination and has the right to stop the examiner if the questions seem to be unfair or unrelated. The passing grade is 65. At present, there is no need for re-certification.

Discussion
Searching the English literature regarding residency training in Plastic Surgery, we found information only on the American model. Thirty years ago, there was only one way to get training in Plastic Surgery in the USA - the traditional model. Over time, other models developed, such as the “combined” model - integrated residency or alternate pathway (completing training first in another specialty, such as otolaryngology or orthopedic surgery, followed by a traditional Plastic Surgery residency) (1). According to Larson (2), the best “training program” for Residents must include:
a. Relating and interacting actions such as: open-door policy for Residents, interactions in clinical settings, and meetings on a regular basis.
b. Teaching focused on improving surgical skills in a laboratory (“hands-on” experience) which may be very useful mainly for microsurgery training.
c. Critiquing and providing feedback before and after completing the surgical procedures.
A number of plastic surgery programs in the USA have decreased the amount of traditional training in favor of short-track programs (3). Other subspecialties, such as Orthopedics and Otolaryngology, have also implemented a short-track system. In a survey on this system (3), 85% of chairmen in the integrated/combined residency program would recommend a short-track training program to medical students, while only 30% of traditional (independent) chairmen would recommend the short-track model.
In the USA, the pure time dedicated to Plastic Surgery training is the shortest as compared with the other countries mentioned in this review. The longest time seems to be in Germany where a full six years are needed. In Germany, no rotation in General Surgery is required, and training time is dedicated to Plastic Surgery and rotations in related sub- specialties which are within the mother department. It seems that the importance given to the experience needed for the Plastic Surgeon in General Surgery is being reduced in the USA.
The maximum number of work hours for Residents in the USA is now 80 hours per week4. In the Netherlands, there is a limitation of 48 working hours per week (not including the on calls). No such limitations are known for the other models. The 80-hour work week plan has pro and con opinions. The pros are: to reduce the number of medical errors due to tiredness and to allow Residents more time for self-learning, for educational activities, and for research. The con is: more time for training may be necessary to compensate for the “missing hours” of surgery and conferences (4). Recently, Residents in Israel are required to leave the department at 10:00 the next day after serving as “on-call” during the night. Limitations to the working hours of Residents in the surgical departments cause limitation of their surgical experience at the end of their residency period.
Research programs are better developed in the American, Israeli, German and Dutch models, but only in Israel are they an obligatory part of the residency; this may demonstrate the vision that a good physician needs to dedicate some of his time to research in order to fulfill himself.
Cosmetic surgery training is still a hot problem for some models. Although some Residents envision themselves as cosmetic surgeons (5), it is difficult to maintain interest in general plastic surgery. Cosmetic surgery training during residency seems to be limited in all the countries reviewed, mainly due to the fact that insurance companies do not fund pure cosmetic procedures, and patients who pay for the procedure will choose an experienced surgeon and not a Resident. The way to teach this field is by giving Residents the opportunity to perform these procedures at meaningfully reduced prices, under the control of an experienced senior surgeon, and by taking part in these procedures as assistants. This is how it is done in most countries.
It seems that the importance of evaluating Residents by examining them, as a means of maintaining a reasonable standard of quality, is well-established in most countries. In four of the five models described in this review, passing an exam at the end of the residency is a prerequisite to starting a career as a Plastic Surgeon. The American Board of Plastic Surgery (6) seems to be the oldest such organization, starting in 1937. Only in the USA is the exam held at least one year after finishing the residency. There, it is a sign of prestige and a marketing tool (7).
The written exam is a basic part of the requirements in four of the countries described, excluding Germany. In the USA, it is held after the residency period; in Israel it is held in the mid-period, in the Netherlands it is held throughout the residency period, and in Romania it is held at the end of the residency, evaluating the cognitive abilities of the candidate. In the USA and Israel, the exam is a multiple choice question type and in Romania and the Netherlands it is in an open question style. It is believed that the multiple choice style is more objective and can follow the textbook. In the Romanian model, the written part is restricted to only 10 subjects, thereby having less coverage compared with the other countries where all subjects are covered. The main differences between the models are shown in Table 1 .
The desired goals of the oral examination are to evaluate the ability of the candidate on his clinical applied knowledge, his ability to solve various clinical situations, to offer alternative possibilities, to confront the candidate with complications, and to assess his ethical attitudes (8). Nevertheless, at times the examination, especially the oral exam, is criticized for a lack of objectivity, reliability and validity (9). The subjectivity of the oral examination can be reduced by well-given instructions to the examiners through courses that instruct them how to ask questions, by giving the same cases to all the examinees, and by using pre-prepared questions that were discussed beforehand. In the USA and Israel, this model is well applied. Other models seem to be less objective. Presenting many cases that cover many fields can also contribute to the quality of the exam.
Knowledge is not enough to pass the examination. Communication behaviors, as well as other factors (10) can interfere with the success of the examination. It is hard to avoid the natural stress before and during the examination. Wade (11) emphasized the utility of in-training review courses as a tool for improving examination performance. Kearney (12) reported the importance of in-training examinations in predicting performance at board examinations. Communication can be improved by organizing special courses (13) which try to simulate examination settings; this has proved to be very efficient in raising the success rate up to 96%. Schubert (14) reported the importance of so called “mock oral” examinations as a tool of training and proved that they are well accepted as a part of training.
Finding the best method to evaluate surgical skills is not easy. This seems to be evaluated best in Romania, through performing surgery as part of the exam, either on real patients or on fresh cadavers. This has its merits, although emotional stress may significantly change performance. Also, only one or two types of procedures can be evaluated in this way, due to time and material restrictions. This method cannot be adopted in many other countries, due to legal and ethical problems when working with real patients. Operating on fresh cadavers is not the same, and may be less available in some countries. In the USA and Israel, an alternative method of evaluating the surgical skills of the candidate is used. Questioning the candidates on various aspects concerning the management of the cases that the candidates have operated on may give the examiners reasonable knowledge not only of the surgical performance but also about the candidate’s judgment and even his ethical attitudes. The diversity of the subjects is also greater in this way.
The training period in Romania, Germany, the Netherlands and Israel is longer than in the USA, but only in the USA is there a need for re-certification. There is no question that this is the correct way to keep physicians up-to-date in their professions, but such a change would need to be lead by the parliaments of the countries, and the other models seem to be retarded in this aspect as compared to the USA.
It is not easy to judge any specific model either for training or examining in any field of medicine, but particularly in fields that require surgical skills. It seems to the authors that six years of training in a Plastic Surgery Department that includes brief rotations in General Surgery and related surgical departments, such as Orthopedics, Otolaryngology and Maxillofacial Surgery, may give Residents good experience in general Plastic Surgery. More experience and specification can be completed by post-graduate fellowships. In our concept, it is better to make examinations mandatory. The exams should contain two parts: a written exam built of multiple choice questions, covering all the fields of the profession, and an oral part that should be objective and as wide as possible. Discussing case reports that have been performed by the candidate may give an idea about the candidate’s judgment, performance, and capabilities. Maintaining the standard of quality should be based on re-certification processes.

References
1. Ruberg, RL. - Plastic surgery training – past, present and future. Ann. Plast. Surg., 2003, 51:330.
2. Larson, DL. - Bridging the generation X gap in plastic
surgery training: Part 2. A proposed solution – Identifying a “Best Practice” in a Plastic Surgery Training Program. Plast Reconstr. Surg., 2003, 112:1662.
3. Karamanoukian, RL., Hurvitz, K., Evans, GR. - Short-Track training in plastic surgery. Ann. Plast. Surg., 2006, 56:369.
4. Rohrich, RJ., Persing, JA., Phillips, L. - Mandating shorter work hours and enhancing patient safety: A new
challenge for resident education. Plast. Reconstr. Surg., 2003, 111:395.
5. Larson, DL. - Bridging the generation X gap in plastic
surgery training: Part 1. Identifying the problem. Plast. Reconstr. Surg., 2003, 112:1656.
6. The American Board of Plastic Surgery. Booklet of information. July 1,2006 – June 30, 2007.
7. Rohrich, RJ. - So you are board-certified in plastic surgery: What it means in the new millennium. Plast. Reconstr. Surg., 2000, 105:1473.
8. Daugherty, SR., Baldwin, DC. Jr, Rowley, BD. - Learning, satisfaction and mistreatment during medical internship: a national survey of working conditions. JAMA, 1998, 279:1194.
9. Colliver, J.A., Vu, N.V., Markwell, S.J. - Reliability and efficiency of components of clinical competence assessed with five performance-based examinations using standardized patients. Med. Educ., 1991, 25:303.
10. Sako, EY., Petrusa, ER., Paukert, JL. - Factors influencing outcome of the American board of surgery certifying examination: an observational study. J. Surg. Res., 2002, 105:75.
11. Wade, TP., Kaminski, DL. - Comparative evaluation of educational methods in surgical resident education. Arch. Surg., 1995, 130:83.
12. Kearney, R.A., Sullivan, P., Skakun, E., - Performance on ABA-ASA in-training examination predicts success for RCPSC certification. American Board of Anesthesiology-American Society of Anesthesiologists. Royal College of Physicians and Surgeons of Canada. Can. J. Anaesth., 2000, 47:914.
13. Rowland-Morin, PA., Coe, NP., Greenburg, AG. - The effect of improving communication competency on the certifying examination of the American Board of Surgery. Am. J. Surg., 2002, 183:655.
14. Schubert, A., Tetzlaff, JE., Licina, M. - Organization of comprehensive anesthesiology oral practice examination program: planning, structure, startup, administration, growth and evaluation. J. Clin. Anesth., 1999, 11:504.


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