Patient Perspectives on Selecting an Academic Aesthetic Surgeon: A Qualitative Analysis.

BACKGROUND: Growth of the aesthetic surgery marketplace has increased patient choice in provider selection. This study aimed to characterize how patients choose an aesthetic surgeon, identify knowledge gaps in this decision-making process, and understand why patients select academic aesthetic surgeons. METHODS: A qualitative interview study of aesthetic surgery patients from an academic center was conducted. Purposive sampling maximized representation regarding surgeon, surgery type, and patient demographics. An interview guide was developed in collaboration with content and methodology experts, then refined through pilot testing. Emergent themes were identified using a codebook constructed by grounded theory. RESULTS: Thematic saturation was achieved with 24 patients. When selecting a surgeon, participants valued bedside manner (24 of 24) and past patients' satisfaction (18 of 24). Most participants (16 of 24) ascribed low importance to board certification. Reasons given for choosing an academic practice included the institution's reputation (13 of 24) and the availability of medical records and other specialties if complications arise (8 of 24). Participants demonstrated knowledge gaps regarding medical training and licensure. No participant (0 of 24) was aware that any licensed physician can offer aesthetic surgery, and nearly all participants (23 of 24) expressed discomfort with this. CONCLUSIONS: Patients prioritize subjective elements when selecting an aesthetic surgeon, relying less on objective and meaningful qualifications like board certification and training background. Academic aesthetic practice is valued because of reputation and ability to function as a medical home. Given the lack of public understanding regarding physician training, initiatives promoting transparency are needed to ensure that patients can make safe, informed decisions.

Perioperative Experiences of Transgender Adults Seeking Gender-Affirming Surgery: A Qualitative Interview Study.

Purpose: Transgender individuals have been systemically excluded from U.S. health care, creating barriers and disparities that other populations do not face. Gender-affirming surgery represents an emerging treatment modality for gender dysphoria, however, little is known about how transgender patients experience the perioperative pathway. This study sought to characterize the experiences of transgender patients seeking gender-affirming surgery and identify opportunities for improvement. Methods: A qualitative study was conducted at an academic medical center between July and December 2020. Semistructured interviews were conducted after a postoperative encounter with adult patients who had undergone gender-affirming surgery within the past year. A purposive sampling strategy was used to maximize representation across surgery types and surgeons. Recruitment continued until thematic saturation was reached. Results: All invited patients agreed to participate, yielding 36 interviews (response rate=100%). Four major themes emerged. First, gender-affirming surgery was described as a major life event, often reflecting years of personal decision making and research. Second, participants stressed the importance of surgeon investment, surgeon experience caring for transgender patients, and individualized care in developing a strong relationship with their care team. Third, self-advocacy was necessary to navigate the perioperative pathway and overcome barriers. Last, participants discussed a lack of equity and provider awareness regarding transgender health issues, including correct pronoun usage, terminology, and insurance coverage. Conclusion: Patients undergoing gender-affirming surgery encounter unique perioperative barriers to care, which would benefit from targeted interventions in the health care system. To improve the pathway, our findings support the creation of multidisciplinary gender-affirmation clinics, greater emphasis on transgender care in medical education, and insurance policy reforms aimed at promoting consistent and equitable coverage.

Otolaryngology Program Director, House-Staff, and Student Opinions: Step 1 Pass/Fail Score Reporting.

OBJECTIVE(S): To compare otolaryngology program director, house-staff, and medical student perspectives on the score reporting change of USMLE Step 1 to pass/fail. METHODS: Separate electronic surveys were sent to program directors of ACGME-accredited otolaryngology programs (Cronbach's alpha = .87), otolaryngology house-staff (Cronbach's alpha = .91), and medical students interested in otolaryngology (Cronbach's alpha = .76). RESULTS: Among the 51 otolaryngology program directors that completed the survey (response rate of 46.8%), 17.6% favored reporting USMLE Step 1 as pass/fail. A majority believed the reporting change would make it more difficult to screen (74.5%) and objectively compare applicants (82.4%). Step 2 CK scores will be more important to most program directors due to the reporting change (83.7%). Of the 93 house-staff that completed surveys, most did not favor the reporting change (61.3%). Over half (54.0%) of the 87 medical students that completed surveys did not support the scoring change, and most (65.5%) did not feel that it would decrease anxiety around residency applications (65.5%). Most house-staff and medical students felt that the scoring change would put non-U.S. MD students at a disadvantage (65.6% of house-staff, 69.8% of medical students). CONCLUSION: Most survey respondents do not agree with the decision to report Step 1 as pass/fail. Despite its intended goals, most do not believe pass/fail Step 1 reporting will improve medical student well-being and believe it will put certain student populations at a greater disadvantage.

Board Certification in Cosmetic Surgery: An Analysis of Punitive Actions.

BACKGROUND: American Board of Plastic Surgery (ABPS) diplomates complete training in aesthetic surgery through an Accreditation Council of Graduate Medical Education-accredited program. American Board of Cosmetic Surgery (ABCS) diplomates complete residency training in a "related" specialty, some historically nonsurgical, followed by an American Association of Cosmetic Surgery fellowship. Unlike the ABPS, the ABCS is not recognized by the American Board of Medical Specialties as an equivalent certifying board. This study evaluated differences in the rates of punitive action against diplomates of the ABPS and the ABCS. METHODS: Diplomates were accessed from their respective society's websites. Punitive action data were obtained by search of publicly available state medical board databases. A comparative analysis was performed between ABPS and ABCS. RESULTS: One thousand two hundred eight physicians were identified for comparative analysis. Two hundred sixty-six (22 percent) were members of the American Society of Plastic Surgeons, and 549 (49 percent) were members of The Aesthetic Society. ABCS diplomates had significantly higher rates of disciplinary administrative action by their respective state medical boards [ n = 31 (9.0 percent)] when compared with ABPS members [The Aesthetic Society, n = 26 (4.4 percent); ABPS, n = 8 (3.1 percent); p = 0.003], with a higher proportion of repeat offenders. In addition, ABCS diplomates had more public letters of reprimand [ABCS, n = 12 (3.5 percent); The Aesthetic Society, n = 6 (1.2 percent); and ABPS, n = 2 (0.8 percent); p = 0.015]. CONCLUSIONS: ABCS diplomates have significantly higher rates of punitive actions than ABPS diplomates. Although the reasons for this discrepancy warrant further investigation, punitive data should be transparently and publicly available to aid patients in informed decision-making.

Board Certification in Cosmetic Surgery: An Examination of Online Advertising Practices.

BACKGROUND: Aesthetic surgery patients commonly use online resources to select a surgeon. The American Board of Plastic Surgery is the American Board of Medical Specialties member board that certifies plastic surgeons. The American Board of Cosmetic Surgery (ABCS) provides aesthetic surgery credentials through a non-American Board of Medical Specialties-recognized process. This study examines use of the phrases "plastic surgery" and "plastic surgeon" by ABCS-certified surgeons when advertising online. METHODS: Diplomates of the ABCS were identified from the ABCS Web site. Professional Web sites, Facebook business pages, and Instagram profiles were located by online search. Use of the descriptor "plastic" and ABCS board certification on practice Web sites, Facebook business page categorization, and plastic surgery-related hashtag use on Instagram were recorded. RESULTS: A total of 298 non-American Board of Plastic Surgery-certified ABCS diplomates were included. One hundred eighty-nine (69.5%) categorized their Facebook business page as "plastic surgeon." Within Instagram posts, 123 (57.2%) used #plasticsurgeon, and 172 (80.0%) used #plasticsurgery. On professional Web sites, 90 (30.4%) identified themselves as a "plastic surgeon," 123 (41.6%) characterized their practice as "plastic surgery," and 196 (68.5%) used their ABCS credential to identify as a "board-certified" cosmetic surgeon. CONCLUSIONS: Diplomates of the ABCS frequently use "plastic surgeon" and "plastic surgery" in online advertisements despite a lack of accredited plastic surgery training or board certification. Furthermore, most ABCS diplomates use their ABCS credentials to market themselves as "board-certified" cosmetic surgeons, potentially violating American Medical Association-supported truth in advertising laws in some states and increasing public confusion regarding different board certifications.

Improving Gender-Affirming Surgery Terminology: A Multicenter Patient Survey.

BACKGROUND: To promote patient safety and build trust, plastic surgeons must use patient-centered language when discussing gender-affirming surgery. However, the existing terminology has not been evaluated from a patient perspective. This study sought to understand how gender-affirming surgery patients from 3 US geographic regions perceive common terminology. METHODS: An anonymous, 24-item electronic survey was distributed to gender-affirming surgery patients seen in Tennessee, Colorado, and California. After institutional review board exemption, the survey instrument was pretested and piloted with gender-affirming surgery patients. Internal consistency was assessed by computation of Cronbach α (0.87). RESULTS: A total of 306 participants completed the survey: 68 from a Tennessee academic center (response rate, 56%), 131 from a California private practice (response rate, 8%), and 107 from a Colorado academic center (response rate, 53%). A greater proportion of respondents felt the terms "top surgery" and "bottom surgery" were appropriate (83% and 82%, respectively) relative to "chest surgery" and "genital surgery" (41% and 30%, respectively). More respondents favored the phrase "gender-affirming surgery" than "gender-confirming surgery" (86% vs 67%). Nearly half (43%) perceived the phrase "sex reassignment surgery" as inappropriate. Most respondents (80%) preferred their surgeon ask for their pronouns. CONCLUSIONS: Optimizing communication is an actionable way for plastic surgeons to improve the healthcare experiences of gender-affirming surgery patients. "Top surgery" and "bottom surgery" are favored terms, and "gender-affirming surgery" is the preferred name for this discipline. Language preferences should be openly discussed with each patient to ensure professional communication.

Perspectives of Orthopedic Surgery Program Directors on the USMLE Step 1 Scoring Change.

The orthopedic surgery residency application process is highly competitive, and residency programs rely on objective measures, such as the United States Medical Licensing Examination (USMLE) Step 1 score, to assist in applicant selection. To deemphasize standardized test scores and improve student well-being, governing bodies have elected to change the Step 1 examination to a pass/fail grading system beginning in 2022. Given the utility of Step 1 in the orthopedic surgery residency application process, this change will significantly affect how applicants are assessed. To determine how this change will affect the process, we developed and validated a 19-item anonymous electronic survey and invited program directors (PDs) from orthopedic surgery residency programs accredited by the Accreditation Council for Graduate Medical Education to respond. The 86 surveys that were completed represented a 43.2% response rate (86 of 199). Only 4.7% of orthopedic surgery PDs believe that this change is a good idea, and 91.7% of PDs believe that the change will make it more difficult to compare applicants objectively. In addition, 90.7% of PDs report that they will increase emphasis on the Step 2 CK (clinical knowledge) examination in comparing residency applicants for their program, with 90.4% of PDs reporting that they will require students to submit their Step 2 scores via the Electronic Residency Application Service. These results indicate that changing the Step 1 scoring to pass/fail is unpopular among orthopedic surgery PDs. Further, losing the numeric Step 1 score will increase reliance on Step 2 scores and emphasis on less objective measures, such as where an applicant attended medical school. [Orthopedics. 2022;45(5):e257-e262.].

The Plastic Surgery Common Application: Improving Efficiency and Reducing Inequity in the Application Process.

The residency application process is expensive, costing an average of $2149 in application fees per applicant during the 2020-2021 cycle. Additionally, the number of applications per applicant continues to rise annually across all specialties. This considerable cost creates a financial barrier for students, particularly those from first-generation and underrepresented backgrounds. Moreover, the Electronic Residency Application Service (ERAS) application generates a lengthy, diluted output that hinders a holistic review. We developed the Plastic Surgery Common Application (PSCA), a focused, specialty-specific application external to ERAS with the goal of lessening the financial barrier for students and improving reviewer satisfaction. The PSCA was revised over a 5-month period after prepiloting with stakeholders. All integrated plastic surgery programs were invited to participate. Of the 86 plastic surgery programs, 20 agreed to participate in the pilot, accepting both ERAS and PSCA for direct comparison. A total of 181 completed applications were received through the PSCA. In a postparticipation survey, most applicants and reviewers felt that the PSCA offered a reasonable alternative to ERAS, despite minor technical difficulties. The PSCA pilot demonstrates that there is a reasonable alternative to applying to residency through ERAS and offers a template for developing a system that is not cost-prohibitive to applicants. The PSCA also demonstrates the benefit of a specialty-specific, customizable application for reviewer efficiency and satisfaction.

Comprehensive Reform and Greater Equity in Applying to Residency-Trainees' Mixed Responses to a Pass/Fail USMLE Step 1.

BACKGROUND: Pass/fail USMLE Step 1 score reporting may have varying implications for trainees of different demographic and training backgrounds. OBJECTIVE: To characterize the perspectives of a diverse cohort of trainees on the impact of pass/fail Step 1 score reporting. METHODS: In 2020, 197 US and international medical school deans and 822 designated institutional officials were invited to distribute anonymous electronic surveys among their trainees. Separate surveys for medical students and residents/fellows were developed based on the authors' prior work surveying program directors on this topic. Underrepresented in medicine (UiM) was defined in accordance with AAMC definitions. Descriptive and comparative analyses were performed, and results were considered statistically significant with P < .05. RESULTS: A total of 11 633 trainees responded (4379 medical students and 7254 residents/fellows; 3.3% of an estimated 285 000 US trainees). More students favored the score reporting change than residents/fellows (43% vs 31%; P < .001; 95% CI 0-24). Trainees identifying as UiM were more likely to favor the change (50% vs 34%; P < .001; 95% CI 0-32) and to agree it would decrease socioeconomic disparities (44% vs 25%; P < .001; 95% CI 0-38) relative to non-UiM trainees. Nearly twice as many osteopathic and international medical graduate students felt they would be disadvantaged compared to MD students because of pass/fail score reporting (61% vs 31%; P < .001; 95% CI 0-60). CONCLUSIONS: Trainee perspectives regarding USMLE Step 1 score reporting are mixed. UiM trainees were more likely to favor the score reporting change, while osteopathic and international medical students were less in favor of the change.

Actigraphy to Evaluate Changes in Physical Activity After Autologous Breast Reconstruction.

PURPOSE: Early ambulation and return to preoperative (baseline) ambulatory level is protective against postoperative venous thromboembolism. The duration of decreased physical activity after surgery is unknown for most procedures, as surgeons typically estimate physical recovery based on subjective patient reporting. This study aims to quantify the time it takes to return to baseline ambulatory status after breast reconstruction using actigraphy devices. METHODS: Actigraphy devices were used to evaluate preoperative and postoperative physical activity levels in patients undergoing autologous breast reconstruction at a single academic institution. Steps and resting heart rate (HR) were used as metrics of physical activity and physiological state. "Baseline" physical activity was defined by the average daily step count during the 14 days before surgery. "Return to baseline" occurred when the 7-day daily step average was greater than or equal to 95% of their baseline steps. Study participation was considered complete once a patient returned to baseline or surpassed 8 postoperative weeks. RESULTS: From May 2019 to April 2020, 17 patients were enrolled in the study before deep inferior epigastric perforator breast reconstruction. The mean age was 48.2 years and mean BMI was 27.6. This cohort averaged 7908 ± 3271 preoperative steps. Two patients returned to baseline activity by postoperative day 28. In total, 8 patients returned by postoperative week 8. Preoperative resting HR average was 73.5 ± 9.43 beats per minute. The average resting HR was elevated by 2.59%, 4.28%, and 2.31% at weeks 1, 2, and 3, respectively. The 7-day daily average resting HR had normalized by week 4. CONCLUSIONS: Return to baseline physical activity after surgery may take longer than previously perceived, particularly after physiologically demanding surgeries, such as free flap breast reconstruction. These findings indicate that surgeons may underestimate the impact of surgery on physical decline and, consequently, may undertreat with venous thromboembolism prophylaxis.