Trends in Leadership at Pediatric Orthopaedic Fellowships.

BACKGROUND: Pediatric orthopaedic fellowship directors (FDs) have a valuable impact on the education of trainees and future leaders in the field. There is currently no research on the characteristics of pediatric orthopaedic FDs. METHODS: Programs were identified using the Pediatric Orthopaedic Society of North America fellowship directory. Operative, nonoperative, and specialty programs were included. Data was collected through Qualtrics survey, e-mail, telephone, and online searches. Variables included demographics (age, sex, race/ethnicity), Hirsch index (h-index) as a measure of research productivity, graduate education, residency and fellowship training, years of hire at current institution and as FD, and leadership roles. RESULTS: Fifty-five FDs were identified. The majority (49/55, 89%) were male and 77% (27/35) were Caucasian. The mean age at survey was 51.1±8.2 years. The mean h-index was 17.2. Older age correlated with higher h-index (r=0.48, P=0.0002). The average duration from fellowship graduation to FD appointment was 9.6±6.7 and 6.9±6.1 years from institutional hire. Sixteen FDs (29%) had additional graduate level degrees. Almost all (52/55, 95%) FDs completed orthopaedic surgery residencies and all graduated fellowship training. Twenty-nine percent (16/55) completed more than 1 fellowship. Most FDs (51/55, 93%) completed a fellowship in pediatric orthopaedic surgery. Ten FDs (18%) completed pediatric orthopaedic surgery fellowships that included spine-specific training. One-third of all current FDs were fellowship-trained at either Boston Children's Hospital (9/55, 16%) or Texas Scottish Rite Hospital for Children (9/55, 16%). CONCLUSIONS: Pediatric orthopaedic FDs are typically early-career to mid-career when appointed, with a strong research background. Nearly a third completed additional graduate degrees or multiple fellowships. Although male dominated, there are more female FDs leading pediatric orthopaedic programs compared with adult reconstruction, trauma, and spine fellowships. As fellowships continue to grow and diversify, this research will provide a baseline to determine changes in FD leadership.

Gender and ethnic diversity in academic general surgery department leadership.

BACKGROUND: Diversity in surgery has been shown to improve mentorship and patient care. Diversity has improved among general surgery (GS) trainees but is not the case for departmental leadership. We analyzed the race and gender distributions across leadership positions at academic GS programs. METHODS: Academic GS programs (n = 118) listed by the Fellowship and Residency Electronic Interactive Database Access system were included. Leadership positions were ascertained from department websites. Gender and race were determined through publicly provided data. RESULTS: Ninety-two (79.3%) department chairs were white and 99 (85.3%) were men. Additionally, 88 (74.6%) program directors and 34 (77.3%) vice-chairs of education were men. A higher proportion of associate program directors were women (38.5%). Of 787 division-chiefs, 73.4% were white. Only trauma had >10% representation from minority surgeons. Women represented >10% of division chiefs in colorectal, thoracic, pediatric, and plastic/burn surgery. CONCLUSION: Diversity among GS trainees is not yet reflected in departmental leadership. Effort is needed to improve disparities in representation across leadership roles.

Prevalence and extent of industry support for program directors of surgical fellowships in the United States.

BACKGROUND: Fellowship program directors have a considerable influence on the future practice patterns of their trainees. Multiple studies have demonstrated that industry can also exert substantial influence on the practice patterns of physicians as a whole. The purpose of this study is to quantify industry support of fellowship program directors across surgical subspecialties and to assess the prevalence of this support within specific subspecialties. METHODS: Fellowship program directors for acute care, breast, burn, cardio-thoracic, critical care, colon and rectal, endocrine, hepato-pancreato-biliary, minimally invasive, plastic, oncologic, pediatric, and vascular surgery for 2017 were identified using a previously described database. The Open Payments Database for 2017 was queried and data regarding general payments, research, associated research payments, and ownership were obtained. The national mean and median payouts to nonfellowship program director surgeons were used to determine subspecialties with substantial industry support. RESULTS: Five hundred and seventy-six fellowship program directors were identified. Of these, 77% of the fellowship program directors had a presence on the Open Payments Database. The subspecialties with the most fellowship program directors receiving any industry payment, regardless of amount, included vascular (93.5%), cardio-thoracic (92.8%), minimally invasive surgery (90.5%), plastics (85.3%), and colon and rectal (81.0%). The subspecialty with the greatest mean payment was minimally invasive surgery (21,175 US dollars); the greatest median payment was vascular (1,871 US dollars). The 3 most common types of payments were for general compensation (31.4%), consulting fees (28.7%), and travel and lodging (14.7%). Vascular surgery had the greatest percentage of fellowship program directors receiving research payments (48%). The greatest amount paid to any individual fellowship program director was 382,368 US dollars. Excluding outliers, fellowship program directors received substantially more payments than those received on average by general surgeons. CONCLUSION: The majority of fellowship program directors receive some industry support. Most payments are for compensation for noncontinuing medical education related services and consulting fees. Certain specialties were more likely to have industry payments than others. Overall, only a minority of fellowship program directors received research support from industry. We advocate for transparent discussions between fellowship program directors and their trainees to help foster healthy academic-industry collaborations.

Training Residents in High-Value, Cost-Effective Care: a National Survey of Psychiatry Program Directors.

OBJECTIVE: The goal of this study was to explore how prepared psychiatry programs are to teach residents to practice resource management and high-value, cost-effective care. METHODS: An anonymous online survey was sent to 187 psychiatry training directors between July and September 2015. RESULTS: Forty-four percent of training directors responded to the survey. While most training directors who responded (88%) agreed that that graduate medical education has a responsibility to respond to the rising cost of health care, fewer than half agreed that that their faculty members consistently model cost-effective care (48%), that residents have access to information regarding the cost of tests and procedures (32%), and that residents are prepared to integrate the cost of care with available evidence when making medical decisions (44%). Only 11% reported providing training in resource management. Barriers cited to teaching cost-effective care included a lack of information regarding health care costs (45%), a lack of time (24%), a lack of faculty with relevant skills (19%), and competing training demands and priorities (18%). Training directors also noted a lack of available curricular resources and assessment tools (21%). Another 12% cited concerns about cost containment overriding treatment guidelines. Ninety percent of training directors agreed that they would be interested in resources to help teach high-value, cost-effective care. CONCLUSIONS: Most psychiatry programs do not provide formal training in resource management but are interested in resources to teach high-value, cost-effective care. Curricula for residents and faculty may help meet this need.

Gender disparities in academic vascular surgeons.

OBJECTIVE: Previous studies have identified significant gender discrepancies in grant funding, leadership positions, and publication impact in surgical subspecialties. We investigated whether these discrepancies were also present in academic vascular surgery. METHODS: Academic websites from institutions with vascular surgery training programs were queried to identify academic faculty, and leadership positions were noted. H-index, number of citations, and total number of publications were obtained from Scopus and PubMed. Grant funding amounts and awards data were obtained from the National Institutes of Health (NIH) and Society for Vascular Surgery websites. Industry funding amount was obtained from the Centers for Medicare and Medicaid Services website. Nonsurgical physicians and support staff were excluded from this analysis. RESULTS: We identified 177 female faculty (18.6%) and 774 male faculty (81.4%). A total of 41 (23.2%) female surgeons held leadership positions within their institutions compared with 254 (32.9%) male surgeons (P = .009). Female surgeons held the rank of assistant professor 50.3% of the time in contrast to 33.9% of men (P < .001). The rank of associate professor was held at similar rates, 25.4% vs 20.7% (P = .187), respectively. Fewer women than men held the full professor rank, 10.7% compared with 26.2% (P < .001). Similarly, women held leadership positions less often than men, including division chief (6.8% vs 13.7%; P < .012) and vice chair of surgery (0% vs 2.2%; P < .047), but held more positions as vice dean of surgery (0.6% vs 0%; P < .037) and chief executive officer (0.6% vs 0%; P < .037). Scientific contributions based on the number of each surgeon's publications were found to be statistically different between men and women. Women had an average of 42.3 publications compared with 64.8 for men (P < .001). Female vascular surgeons were cited an average of 655.2 times, less than half the average citations of their male counterparts with 1387 citations (P < .001). The average H-index was 9.5 for female vascular surgeons compared with 13.7 for male vascular surgeons (P < .001). Correcting for years since initial board certification, women had a higher H-index per year in practice (1.32 vs 1.02; P = .005). Female vascular surgeons were more likely to have received NIH grants than their male colleagues (9.6% vs 4.0%; P = .017). Although substantial, the average value of NIH grants awarded was not statistically significant between men and women, with men on average receiving $915,590.74 ($199,119.00-$2,910,600.00) and women receiving $707,205.35 ($61,612.00-$4,857,220.00; P = .416). There was no difference in the distribution of Society for Vascular Surgery seed grants to women and men since 2007. Industry payments made publicly available according to the Sunshine Act for the year 2018 were also compared, and female vascular surgeons received an average of $2155.28 compared with their male counterparts, who received almost four times as much at $8452.43 (P < .001). CONCLUSIONS: Although there is certainly improved representation of women in vascular surgery compared with several decades ago, a discrepancy still persists. Women tend to have more grants than men and receive less in industry payments, but they hold fewer leadership positions, do not publish as frequently, and are cited less than their male counterparts. Further investigation should be aimed at identifying the causes of gender disparity and systemic barriers to gender equity in academic vascular surgery.

Gender equality in Rheumatology.

Not available.

Residency Program Directors of United States Ophthalmology Programs: A Descriptive Analysis.

PURPOSE: To analyze the academic background, scholarly achievements, and demographic characteristics of all US ophthalmology residency program directors (PDs). DESIGN: Cross-sectional study. METHODS: Online search of publicly available resources conducted from February 16, 2019, to February 26, 2019. STUDY POPULATION: 116 ophthalmology residency PDs. Main outcome measurements were demographic and academic data. RESULTS: A total of 116 program directors were analyzed. Eighty-four of 116 (72%) PDs were male. The average age was 50.0 years old. The mean age at appointment was 42.9 years old. Ninety-three percent graduated from an American medical school, and 97% received an MD degree. Twenty percent of PDs completed an additional graduate degree, most commonly a master's degree (7 of 23) and doctor of philosophy (7 of 23). Seventy-eight percent completed a fellowship, with the most frequent in glaucoma (24%), cornea and external diseases (22%), and neuroophthalmology (21%). The mean number of publications according to PubMed was 17.6 (range, 0-92). There were no significant differences between the average number of publications by male PDs and those by female PDs (19.2 ± 20.5 vs. 13.5 ± 23.1, respectively; P = 0.21). On average, the H-index was 8.7 (range, 0-35) and was higher in male than in female PDs (9.8 ± 8.3 vs. 5.4 ± 4.0, respectively; P = 0.01). CONCLUSIONS: Ophthalmology PDs are predominantly male with fellowship training in glaucoma, cornea, or neuro-ophthalmology. Women remain underrepresented, and future efforts should be aimed at addressing this disparity.

Gender-Based Salary Inequities Among Pediatric Rehabilitation Medicine Physicians in the United States.

OBJECTIVE: To assess whether gender inequities exist for pediatric physiatrists and, if affirmative, what factors account for this difference. DESIGN: Cohort study. SETTING: Online REDCap survey administered via e-mail. PARTICIPANTS: Pediatric physiatrists practicing in the United States in 2017. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Respondents reported on their gender, training, practice type and location, leadership positions, years in practice and years at their current location, salary, research, and clinical productivity. RESULTS: Of the 307 surveys sent, 235 individuals responded, yielding a response rate of 76.5%. Pediatric physiatrists who identified as women were more likely to work part-time but were demographically similar to their colleagues who identified as men. The odds of having no leadership role were higher for women (odds ratio=2.17; P=.02) than men. Pediatric physiatrists who identified as men made on average (in US dollars ± SD) 244,798±52,906 annually compared with those who identified as women 224,497±60,756. The average annual difference in full-time salary was $20,311 in favor of those who identified as men (95% confidence interval, $3135-$37,486). The set of predictors in the multivariable model explained about 40% of the total variability in annual full-time salary (R2=0.389; adjusted R2=0.339; F15,197=7.734; P<.001). Gender was not a significant predictor in the model, but model prediction of the salaries of pediatric physiatrists who identified as men was better than model prediction of the salaries of those who identified as women. CONCLUSIONS: Despite representing a majority of the field, pediatric physiatrists who identified as women were paid less than their counterparts who identified as men. The traditional predictors associated with the salaries of men were not enough to explain salary variation among those who identified as women, thereby providing evidence of the importance of intangible and unmeasured aspects of a women's career, such as bias and institutional culture.

Residency and Fellowship Program Administrator Burnout: Measuring Its Magnitude.

BACKGROUND: Little is known about the level of burnout among program administrators (PAs) working in graduate medical education. OBJECTIVE: We created a national database with baseline burnout data for PAs from residency and fellowship programs, including intention to leave their current positions. METHODS: A cross-sectional study was conducted in July 2017 to assess levels of burnout in a national cohort of PAs, who were largely members of online specialty forums. The Copenhagen Burnout Inventory (CBI) was used to measure burnout. Univariate analysis produced descriptive statistics for CBI. We performed a 2-sample t test to measure differences in average burnout scores for those who had thoughts of resigning from their positions and those who had not. RESULTS: Of the approximately 10 205 national PAs, we sampled 1126 (11%). Of the 1126 individuals who received the study information, 931 (83%) completed the baseline survey. Total mean scores for all subscales were elevated (personal: 53.7, SD 21.4; work-related: 52.0, SD 22; and client-related: 30.6, SD 20.8; each scale ranged from 0, low, to 100, high). Burnout scores differed between those contemplating leaving their jobs and those who were not, across all subscales of CBI, including personal (64.2 versus 42.4, -24.18 to -19.44 confidence interval [CI]), work-related (63.5 versus 39.7, -26.12 to -21.35 CI), and client-related (36.6 versus 24.2, -14.95 to -9.84 CI; P < .0001 for all). CONCLUSIONS: In this national survey of PAs, burnout scores measured by the CBI were higher among those who had considered leaving their positions.

Perceptions of Residents and Their Training Directors Regarding Wellness Education, Program Support, and Access to Depression Treatment: the DEPRESS-Ohio Study.

OBJECTIVE: This study determines the extent to which residents and their program directors have discordant perceptions regarding wellness, support, and treatment opportunities for trainees. In addition, the authors examined whether psychiatry residents differed in their perceptions compared with residents in other specialties. METHODS: Residents and their program directors from each of 10 specialties were electronically surveyed after IRB approval and giving informed consent. RESULTS: Of 42 program directors responding, over 92% indicated they provided wellness education and programming; however, a significantly lower percentage of 822 trainees were aware of this (81.2% and 74.9%, respectively). A similar disparity existed between program directors (PDs) who knew where to refer depressed residents for help (92.9%) and residents who knew where to seek help (71%). Moreover, 83.3% of program directors believed they could comfortably discuss depression with a depressed resident, but a lower percentage of their trainees (69.1%) felt their training directors would be supportive. A significantly greater percentage of program directors (40.5%) believed seeking treatment for depression might compromise medical licensure than did residents (13.0%). Psychiatry residents were significantly more aware of wellness, support, and access than were residents from other specialties. CONCLUSIONS: The availability of wellness education, programming, program director accessibility, and knowing where to ask for help if depressed does not seem to be adequately communicated to many residents. Moreover, program directors disproportionately see depression treatment as a risk to medical licensure compared with their residents. Psychiatry residents seem to be more aware of program director support and access to care than their colleagues.

A survey of Heads of Surgery and Residents on accessibility and employment in liver transplant teams in Spain. / Encuesta a los jefes de Unidad y residentes de Cirugía sobre la accesibilidad y el trabajo en los equipos de trasplante hepático en España.

INTRODUCTION: The access of surgeons to liver transplant teams in Spain is heterogeneous. This study aims to portray the current human resources of Spanish transplant teams, distribution of transplant duties among team members, how transplant team members acquire their skills, their leaders' view of their future, as well the motivations of Spanish General Surgery residents to choose transplantation as their future career choice. METHODS: Two different surveys were created, one for head surgeons and one for residents, about the number of team members and their training, recruitment, organization of tasks and motivation to work in transplantation. The questionnaires were e-mailed to both the transplant program directors and the surgical residents. RESULTS: There are on average 8 surgeons in each transplant unit. More than four surgeons perform the hepatectomy in 54.2% of the groups, while the graft implantation is performed by more than 4 surgeons at just 25% of the centers. Forty-two percent of the transplant chiefs advocated a fellowship training system, and 87.5% believe that generational turnover is guaranteed. Out of 525 residents, 101 responded. Regarding training, 12.8% had no interest in transplantation. Concerning their work preferences, 37.6% were not interested in transplantation because it is excessively demanding, and 52.5% would not like to be part of a liver transplant team in the future. CONCLUSIONS: The generational turnover seems to be guaranteed according to liver transplant program directors. The new generations of surgeons generally opt for other areas of surgery other than transplantation. Studies with a greater number of responses are necessary to validate these results.

State of the Unit: Physician Gender Diversity in Pediatric Critical Care Medicine Leadership.

Gender disparities in leadership are receiving increased attention throughout medicine and medical subspecialties. Little is known about the disparities in Pediatric Critical Care Medicine. In this piece, we explore gender disparities in Pediatric Critical Care Medicine physician leadership. We examine physician leadership in the Accreditation Council for Graduate Medical Education fellowship programs, as well as a limited sample of major Pediatric Critical Care Medicine textbooks and societies. Overall, the gender composition of division directors is not significantly different from that of workforce composition, although regional differences exist. More women than men lead fellowship programs, at a higher ratio compared with workforce composition. However, greater gender disparities are present in editorial leadership in this limited analysis. We conclude by recommending potential paths forward for further study and intervention, such as tracking gender diversity and being cognizant of the unique challenges that women currently experience in professional advancement.

The Current State of Advanced Practice Provider Fellowships in Hospital Medicine: A Survey of Program Directors.

BACKGROUND: Postgraduate training for advanced practice providers (APPs) is a growing field in hospital medicine. As hospital programs continue to benefit from highly trained physician assistants (PAs) and nurse practitioners (NPs), fellowship programs have become more prevalent. However, little is known about the number of active programs or how they prepare trainees. OBJECTIVES: To describe the existing APP fellowships in hospital medicine, with a focus on program characteristics, rationale, curricula, and learner assessment. METHODS: An electronic survey was distributed by e-mail to hospital medicine program directors in May 2018. The survey consisted of 25 multiple choice and short answer questions. Descriptive statistics were calculated utilizing Stata 13 for data analysis. RESULTS: Of the 11 fellowships identified, 10 (91%) of directors responded to the survey. Eighty percent of programs accept both NPs and PAs and 80% are between 12 and 13 months long. All programs cite "training and retaining" as the main driver for their creation and 90% were founded in institutions with existing physician residencies. Ninety percent of program curricula are informed by Society of Hospital Medicine resources. Despite these similarities, there was wide variation in both curricular content and APP fellow assessment. CONCLUSION: APP fellowships in hospital medicine are quickly growing as a means to train and retain nonphysician hospitalists. While most programs accept similar types of applicants and share a common rationale for program development, there is little standardization in terms of curriculum or assessment. Further research may be valuable to characterize the best practices to guide the future of these fellowships.

Child Psychotherapy Training in the United States: A National Survey of Child and Adolescent Psychiatry Fellowship Program Directors.

OBJECTIVES: Training in child and adolescent psychotherapy continues to be emphasized by accrediting organizations (ACGME and ABPN) but it is not known how these skills are taught and what types of therapy are highlighted in fellowships across the United States. METHODS: A 16-question anonymous online survey was developed by the authors and covered six main areas: demographics, the priority of psychotherapy in training, the competency goals for different psychotherapy modalities, training strategies, types of supervision, and program directors' satisfaction of their training implementation and assessment of trainees. The survey was sent to every identified CAP program director during a three-month period in early 2017. RESULTS: Data was gathered from 53 of the 131 program directors surveyed, giving a 40% response rate. Ninety percent of CAP program directors strongly agree or agree that it is important to preserve and promote training and practice of psychotherapy. Most (83%) program directors indicated competence or expertise as a training goal for CBT with more variability among programs for other psychotherapies. Seventy percent of program directors agree that their program provides adequate time for learning and practicing psychotherapy but the allotted time for psychotherapy is low across majority of programs over both years of training. CONCLUSIONS: These results indicate that there is a gap between the goals of providing optimal training in psychotherapy with the low amount of protected time for the practice of psychotherapy. These results should provide a foundation for program directors to learn from each other about developing, improving, and implementing effective psychotherapy training.

Moonlighting by Psychiatry Residents: a Survey of Residents and Training Directors.

OBJECTIVE: This study sought to assess the prevalence of moonlighting among psychiatry residents; the perceived effects of moonlighting on resident recruitment, education, and liability; and policies and practices governing oversight. METHODS: In 2013, surveys were emailed to all general psychiatry residency programs that were accredited by the Accreditation Council for Graduate Medical Education and had available contact information (n = 183). Resident surveys were emailed to program coordinators with a request to forward the survey link to their residents. RESULTS: Responses were received from 63 program directors (34% response rate) and 238 residents (about 5% of total general psychiatry residents). Most psychiatry program directors (95%) indicated that their programs permit moonlighting. Moonlighting participation increased with each year of training, culminating with 67% of fourth year residents. Most residents and faculty (87%) agreed that moonlighting enhanced resident education. Thirty-seven percent of program directors reported having no oversight procedures in place to monitor moonlighting activities. Thirty-nine percent of resident survey responders reported having no supervision for at least one of their moonlighting activities and only 9% reported always having access to on-site supervision. CONCLUSION: Though limited by a low response rate, this study found that moonlighting seems to remain prevalent among psychiatry residents and widely accepted by psychiatry residency training programs. There appears to be relatively limited program oversight for moonlighting activities, many of which seem to lack close supervision.

Surgery program directors' knowledge of opioid prescribing regulations: a survey study.

BACKGROUND: Opioid misuse is a public health crisis that stems in part from overprescribing by health-care providers. Surgical residents are commonly responsible for prescribing opioids at patient discharge, and residency program directors (PDs) are charged with their residents' education. Because each hospital and state has different opioid prescribing policies, we sought to assess PDs' knowledge about local controlled substance prescribing polices. METHODS: A survey was emailed to surgery PDs that included questions regarding residency characteristics and knowledge of state regulations. RESULTS: A total of 247 PDs were emailed with 110 (44.5%) completed responses. One hundred and four (94.5%) allow residents to prescribe outpatient opioids; one was unsure. Sixty-three (57.3%) respondents correctly answered if their state required opioid prescribing education for full licensure. Twenty-two (20.0%) were unsure if their state required opioid prescribing education for licensure. Sixty-four (58.2%) respondents answered correctly if a prescription monitor programs use is required in their state. Twenty-nine (26.4%) were unsure if a state prescription monitor programs existed. Seventy-six (69.1%) PDs answered correctly about their state's requirement for an additional registration to prescribe controlled substances; 10 (9.1%) did not know if this was required. Twenty-nine (27.9%) programs require residents to obtain individual drug enforcement agency registration; 5 (4.8%) were unsure if this was required. CONCLUSIONS: Most programs allow residents to prescribe outpatient opioids. However, this survey demonstrated a considerable gap in PDs' knowledge about controlled substance regulations. Because they oversee surgical residents' education, PDs should be versed about their local policies in this matter.

Plastic Surgery Resident-Run Cosmetic Clinics: A Survey of Current Practices.

BACKGROUND: The recently increased minimum aesthetic surgery requirements set by the Plastic Surgery Residency Review Committee of the Accreditation Council for Graduate Medical Education highlight the importance of aesthetic surgery training for plastic surgery residents. Participation in resident aesthetic surgery clinics has become an important tool to achieve this goal. Yet, there is little literature on the current structure of these clinics. OBJECTIVES: The authors sought to evaluate current practices of aesthetic resident-run clinics in the United States. METHODS: A survey examining specific aspects of chief resident clinics was distributed to 70 plastic surgery resident program directors in the United States. Thirty-five questions sought to delineate clinic structure, procedures and services offered, financial cost to the patient, and satisfaction and educational benefit derived from the experience. RESULTS: Fifty-two questionnaires were returned, representing 74.2% of programs surveyed. Thirty-two (63%) reported having a dedicated resident aesthetic surgery clinic at their institution. The most common procedures performed were abdominoplasty (n = 20), breast augmentation (n = 19), and liposuction (n = 16). Most clinics offered neuromodulators (n = 29) and injectable fillers (n = 29). The most common billing method used was a 50% discount on surgeon fee, with the patient being responsible for the entirety of hospital and anesthesia fees. Twenty-six respondents reported feeling satisfied or very satisfied with their resident aesthetic clinic. CONCLUSIONS: The authors found aesthetic chief resident clinics to differ greatly in their structure. Yet the variety of procedures and services offered makes participation in these clinics an effective training method for the development of both aesthetic surgical technique and resident autonomy.