<< back to UW Plastic Surgery Residency Basic Info

Plastic Surgery Residency Program - Full Description

Faculty

The following are the full time academic faculty of the Division of Plastic Surgery, Department Surgery. Each faculty has an area of clinical and scientific expertise and many are nationally and/or internationally-renowned experts in their fields, representing all of the clinical areas of plastic surgery. As a result, residents in the program are learning from the experts in any given field. All have chosen to be part of the program because of their commitment to educating the next generation of leaders in the field. All of these faculty are university-based and fully committed to the educational program of this residency. None of our faculty have private practices. All of their clinical activities, including inpatient and outpatient, clinics, and O.R. are centered on resident education. Most of our faculty have regular activities at two of the four primary institutions.

Craig Birgfeld, MD, Assistant Professor

Dr. Birgfeld joined the faculty in 2007. He completed his plastic surgery training at the University of Pennsylvania and a craniofacial surgery fellowship at the University of Washington. Dr. Birgfeld is assistant professor of surgery and his area of specialty is adult and pediatric craniofacial surgery. Dr. Birgfeld practices at both Children’s Hospital and Harborview Medical Center.

Loren Engrav, MD, Professor

Dr. Engrav is a Professor and was the Chief of the division since its founding in 1977 and program director from the inception of the residency in 1988 until Dr. Vedder assumed these roles in 2001. He is internationally recognized for his expertise in the areas of burn and burn reconstruction and general reconstructive surgery. He is formerly Associate Director of the Harborview Burn Unit and was one of the pioneers in the area of early excision and grafting of burns and of facial grafting. He has an active NIH-funded basic science lab, investigating the molecular and cellular basis of hypertrophic scarring as well as federally funded research in burn and burn reconstruction outcome studies. His clinical practice is at Harborview and includes burns and burn reconstruction as well as general reconstructive plastic surgery.

Jeffrey Freidrich, MD, Assistant Professor

Dr. Friedrich joined the faculty in 2007. He completed his plastic surgery training at the University of Washington and a fellowship in hand surgery at the Mayo Clinic. Dr. Friedrich’s practice focuses on adult and pediatric upper extremity surgery as well as microvascular reconstruction. Dr. Friedrich, along with Dr. Doug Hanel in Orthopaedic surgery, will run the pediatric hand center at Children’s Hospital. In addition, Dr. Friedrich has developed a research program in hand injury outcomes.

Joseph Gruss, MD, Professor

Dr. Gruss is an internationally recognized pioneer in maxillofacial surgery and was the first surgeon in North America to use rigid internal fixation in the craniomaxillofacial skeleton. He was already a respected figure in 1990 when he joined the faculty, moving from the University of Toronto. Since that time, he has built the craniofacial program at Children’s Hospital into the highest volume congenital craniofacial program in the nation. His practice includes congenital craniofacial and pediatric plastic Surgery at Children’s Hospital as well as maxillofacial trauma and facial reconstructive surgery at Harborview. He is the Chief of Pediatric Plastic Surgery at Children’s Hospital. His clinical educational abilities and commitment are outstanding.

Richard Hopper, MD, Associate Professor

Dr. Hopper trained at the University of Toronto and was a craniofacial fellow at NYU before joining the faculty in 2001. He is internationally recognized for his expertise in congenital craniofacial reconstruction, especially distraction osteogenesis. He has a basic science research program, focusing on the molecular basis of craniosynostosis, and he serves as an important research mentor to the residents. His practice includes congenital craniofacial and pediatric plastic Surgery at Children’s Hospital as well as maxillofacial trauma and facial reconstructive surgery at Harborview. He is the Surgical Director of Craniofacial Center at Children’s Hospital and is the residency site director at Children’s Hospital. He is highly regarded for his teaching abilities and has been a leading force in expanding the didactic teaching program for the division and is a leading force in the craniofacial education program. He is also the director of the UW’s craniofacial surgery fellowship.

Matthew Klein, MD, Associate Professor, Program Director

Dr. Klein was appointed Program Director of the residency program in 2008. He trained at Stanford, then was the UW’s Burn Fellow and joined the faculty in 2004. He is the Associate Director of the UW Burn Center. In addition, he holds and adjunct appointment in the Department of Epidemiology in the School of Public Health. He is an expert in acute burn care and burn reconstruction, as well as general reconstructive surgery. His clinical practice is at Harborview and includes burns and burn reconstruction as well as general reconstructive plastic surgery. His research focuses on outcomes following burn injury and his research program is supported by a research training grant from the NIH.

OTWAY LOUIE, MD, Assistant Professor

Dr. Louie joined the faculty this August. He received his plastic surgery training at New York University and then completed a fellowship in microsurgery at the University of California, Los Angeles. His clinical practice will be at the University of Washington Medical Center and focus on reconstructive microsurgery.

David Mathes, MD, Assistant Professor

Dr. Mathes joined the faculty in August, 2006. He completed a full categorical residency in Surgery at New York Presbyterian/Cornell and spent 3 very productive years as a research fellow in the Department of Surgery at Harvard/Massachusetts General Hospital where he made a number of seminal contributions to the field of composite tissue allotransplantation. He recently completed his Plastic Surgery training at the University of Texas Southwestern Medical Center. Dr. Mathes is based clinically at the Puget Sound Health Care System/Veteran’s Administration Hospital, where he is the Chief of Plastic Surgery and residency site director. In addition, he devotes part of his clinical time at the University of Washington Medical Center. His research focus is in the area of transplantation immune tolerance and he is a Research Affiliate at the Fred Hutchinson Cancer Research Center.

Peter Neligan, MD, Professor

Dr. Neligan joined the faculty in 2007. Dr. Neligan is well regarded as an international leader in the field of microvascular reconstruction and facial reanimation and co-authored the definitive text on perforator flap reconstruction. Prior to coming to the University of Washington, Dr. Neligan was chief of plastic surgery at the University of Toronto. Dr. Neligan is the Chief of Plastic Surgery and the site director at the University of Washington Medical Center and is the Director of the new UWMC Center for Reconstructive Surgery, a regional complex reconstruction center akin to the regional programs that currently exist within UW Medicine for burn and hand surgery.

Hakim Said, MD, Assistant Professor

Dr. Said joined the faculty in August, 2006. He completed his Plastic Surgery training at Northwestern in 2005 and recently completed the prestigious reconstructive microsurgery fellowship at MD Anderson Cancer. He is based clinically at the University of Washington Medical Center and is the residency site director there. With his excellent reconstructive microsurgery training, he is a vital addition to the UWMC service. With his computer science and engineering background, his research focus will continue in the area of 3-D modeling of tissue flap reconstruction as well as clinical outcomes research in reconstructive surgery.

Nicholas Vedder, MD, Professor and Chief, Division of Plastic Surgery, ASSOCIATE PROGRAM DIRECTOR

Dr. Vedder’s role is Chief of the Division and associate program director. He is an internationally recognized expert in the area of hand and extremity reconstruction and in the basic science of ischemia-reperfusion injury. His primary practice is in hand, upper, and lower extremity reconstruction at Harborview and also practices at the UW Medical Center’s Bone & Joint Center and at the Puget Sound Health Care System/Veteran’s Administration Hospital. In addition, he is primarily responsible for the hand surgery education program, along with the adjunct Orthopædic faculty members of the Combined Hand Service.

Adjunct Faculty:

Thomas Trumble, MD, Douglas Hanel, MD, Christopher Allan and John Sack, MD are adjunct faculty in the Division and are the Orthopædic members of the UW’s Combined Hand Surgery Service that was formed by Drs. Trumble and Vedder in 1990. Drs. Trumble and Hanel are internationally recognized experts in hand surgery and all of these faculty are strongly committed to the joint education of Plastic Surgery and Orthopædic residents through the Combined Hand Surgery Service.

Mark Engelstad, MD, DDS and Mark Egbert, MD, DDS are adjunct faculty in the Department of Oral and Maxillofacial Surgery. Dr. Englestad is a key member of the interdisciplinary craniomaxillofacial trauma service at Harborview and Dr. Egbert is a key member of the interdisciplinary craniofacial program at Children’s Hospital.

Neal Futran, MD, DMD is an adjunct faculty in the Department of Otolaryngology/Head & Neck Surgery is a nationally-recognized leader in head & neck cancer and microsurgical reconstruction and is the Director of Head & Neck Reconstruction within the UWMC Center for Reconstructive Surgery.

Active Clinical Faculty:

Wallace Chang, MD, David Barker, MD, Patty Briscoe, MD, and Jonathan Hutter, MD are the clinical faculty in the Renton Plastic Surgery group. Dr. Chang is the site director there, and is the former Chief and Program Director at the University of Massachusetts program. Dr. Hutter is a recent graduate of this program. Drs. Michael Leff and Joseph Welch are active clinical faculty at the Puget Sound Health Care System/Veteran’s Administration Hospital. All of these faculty are outstanding clinicians and dedicated educators and play a vital role in the educational program, especially in the areas of aesthetic surgery, elective hand surgery, general reconstruction, and outpatient surgery.

Faculty scholarly activities

As noted above, all of the full-time academic faculty are university-based and fully committed to the educational program of this residency. None of the full time faculty have private practices. All of their clinical activities, including inpatient and outpatient, clinics, and O.R. are centered on resident education. Each faculty has an area of clinical and scientific expertise and many are nationally or internationally-renowned experts in their fields, representing all of the clinical areas of plastic surgery, such that residents are learning from the experts in any given field. All have chosen to be part of the program because of their commitment to educating the next generation of leaders in the field. All of these faculty are regularly involved in research and in national professional organizations. All of the faculty actively participate in the various scholarly and didactic educational activities in the program, and as mentors to the residents in their research and scholarly activities.

Program Organization

1. Description of the program format. This is a three-year “independent” or “coordinated” program that is typically entered by matching out of medical school into a special three-year preliminary residency position in the UW Surgery Residency Program and successfully completing that preliminary residency. After successfully completing the three-year Preliminary Residency in Surgery, the coordinated plastic surgery residents enter the three-year Plastic Surgery Residency at the R4 level. The goal of the UW Plastic Surgery Residency is to train Plastic Surgeons in all four components of academic medicine: patient care, medical education, medical research and administration. Since it is not possible to teach all four topics in two years, the residency program in Plastic Surgery is three years, allowing time for the latter three subjects. The program is accredited for three residents per year.

Because of the program’s commitment to fostering the development of future academic plastic surgeons, dedicated research time is provided for residents in their 2nd year of plastic surgery training. This combined research rotation, though brief, allows the residents to gain an important insight into research and provides them a valuable education in how to properly evaluate research and scientific contributions. The opportunities at the University of Washington to learn to do and to do research are excellent. The clinical and basic science faculty are outstanding and the University is the top ranked public institution in NIH support, and consistently in the top few of all institutions nationwide. At the completion of this program, it is expected that the resident will have an understanding of sound and relevant research and will be capable of designing and executing case reports, case series reports, prospective clinical protocols, and applied surgical laboratory studies.

Institutions

The program utilizes four University affiliated hospitals and one private office. The hospitals include the University of Washington Medical Center (UWMC), Harborview Medical Center (HMC), the Veteran's Administration Puget Sound Health Care System (VAPSHCS), and Seattle Children's Hospital (SCH). These institutions represent the only level 1 trauma center, only major children’s hospital, only academic VA hospital, and only university-based tertiary referral hospital for a 5-state region, Washington, Alaska, Montana, Idaho, and Wyoming, representing nearly ¼ of the U.S. land mass. The clinical experience for our residents, therefore, is outstanding, and in our opinion, unparalleled. Because of the integral nature of academic administration of UWMC and HMC with the UW School of Medicine, these two institutions are now considered a single ACGME-accredited institution, though they are physically separate and have unique areas of clinical emphasis. The private office is that of Drs. David Barker, Patricia Briscoe, Jonathan Hutter, and Wallace Chang. These physicians admit patients to Valley Medical Center (VMC). The University of Washington Burn Center is located at Harborview Medical Center and is intimately involved in the residency. In addition, the plastic surgery residency is an integral part of the UW Hand Surgery Institute that is coordinated between the Division of Plastic Surgery and the Department of Orthopaedics.

The University of Washington Medical Center, located on the campus of the University of Washington and contiguous with the School of Medicine, is a 450-bed teaching hospital. It is a tertiary referral center for WWAMI (Washington, Wyoming, Alaska, Montana and Idaho). In addition to the main UW Medical Center Campus, the UW Medical Center also includes clinic and operating room facilities approximately 1 mile northwest of the main campus and a clinic in Bellevue, a city located across

Lake Washington approximate 2 miles from the main campus.
Harborview Medical Center is located approximately three miles from the University of Washington campus. It is a 413-bed hospital owned by King County and operated under a management contract by the University of Washington School of Medicine. It is the primary Seattle metropolitan receiving hospital for trauma and emergency medicine and surgery as well as a health resource for urban and inner-city inhabitants. It is the only Level I Trauma Center and Burn Center for the five-state WWAMI region.

The Veteran's Administration Puget Sound Health Care System is a Dean's Committee Hospital, and all of the medical staff are UW faculty. The 450-bed hospital opened in 1985. It is located approximately five miles from Harborview and includes a Spinal Cord Injury Center.
Seattle Children’s Hospital is a 200-bed hospital with a substantial referral base throughout the WWAMI region. It includes a well-developed and very busy craniofacial program and is located approximately two miles from the University of Washington Medical Center.
The office of Drs. Barker, Briscoe, Hutter, and Chang is one of the premier private practices in the metropolitan area and is located in Renton, Washington, adjacent to Valley Medical Center, approximately twenty miles from the University. Their practice is quite general, including most aspects of Plastic Surgery. These physicians see approximately 9000 outpatient visits annually and admit approximately 250 patients to Valley Medical Center.

The University of Washington Burn Center is located at Harborview Medical Center and is one of the largest in the country. It admits over 700 acute burn patients per year, and is one of the original burn centers that focused on early excision and grafting of acute burns. In addition, most of the patients are followed long term in the Burn Center, undergoing secondary reconstruction. Plastic surgery residents participate in both the acute and reconstructive care of burn patients during both the first three and final three years of training.

The University of Washington Hand Surgery Institute manages all hand surgery for all of the medical centers and consists of hand surgery attendings, residents, and fellows from both Plastic Surgery and Orthopaedics, working together in shared clinics, on-call responsibilities, teaching conferences, and many procedures involving faculty, fellows and residents from diverse training backgrounds and primary specialties. As an integral member of this service, the Plastic Surgery Resident gains a broad, diverse, and comprehensive exposure to hand surgery that is available in very few other Plastic Surgery programs.

Educational goals and objectives for resident assignments to each of the participating institutions.

The goals and objectives for the various rotations and components of the residency program are appended to this section and are distributed to the residents at the beginning of the program.

Resident responsibilities when assigned to the plastic surgery service

These are described in detail for every rotation in the documents attached to this section. Since all Plastic Surgery services except CHRMC are well supported with in-house Surgery residents and since it is a goal of the program to keep Surgery residents intimately involved, it is possible and desirable for the Plastic Surgery residents to work at two hospitals on some of the rotations, though on any given day of the week, the resident is generally at just one institution.

The current practice of Plastic Surgery at each of the hospitals and the private office provides exposure to general Plastic Surgery. In addition, the practice at each provides unique clinical exposure. Plastic Surgeons at the University of Washington Medical Center are involved primarily in aesthetic, breast, and truncal surgery. Clinical care at Harborview includes maxillofacial trauma, hand surgery, reconstruction of lower extremities and the trunk, burns, and microsurgery. The practice at the VAPSHCS is very general and includes H&N cancer reconstruction and most aspects of Plastic Surgery except pediatric surgery and trauma. Activities at Childrens' include congenital anomalies of the head and neck and other aspects of pediatric Plastic Surgery. The practice of Drs. Barker, Briscoe, Hutter, and Chang includes aesthetic, maxillofacial and hand trauma, and microsurgery.

The rotations are all four months in duration and are as follows:

Year 1

Harborview Burns/Plastic Surgery
Harborview Hand & Craniofacial
University of Washington Medical Center

Year 2

VA Puget Sound/ Research
Community Plastic Surgery (Renton Practice with Drs. Barker, Briscoe, Chang, and Hutter)/ Research
UW Medical Center/Childrens Hospital

Year 3

Childrens Hospital/Pediatric Plastic Surgery
Harborview Hand & Craniofacial
University of Washington Medical Center

Every effort has been made to minimize scheduling conflicts and to allow time for nonclinical activities, as well as to minimize covering more than one institution on a given day of the week. The schedules at the various institutions have been carefully integrated. In addition, since each service is staffed with Surgery housestaff as well as Plastic Surgery housestaff, the Plastic Surgery resident has some flexibility.

The first year resident spends 4 months at Harborview Burns/Plastic Surgery, 4 months on the Harborview Hand/Craniofacial service and 4 months at the University of Washington Medical Center. The resident is exposed to general Plastic Surgery and trauma and will become familiar with the principles and techniques of wound care, grafts, flaps, microsurgery, and trauma. As the resident's knowledge and technical skills mature, the educational needs of the surgery housestaff are integrated into clinical activities so as to provide the educational objectives of both. This is accomplished by a case distribution that directs more complex procedures to the Plastic Surgery resident and standard wound care, grafts and flaps to the Surgery housestaff. Further, as his/her abilities increase, the resident is allowed more independent clinical activity, but always functions with the supervision and participation of the faculty.

In the second year, the residents rotate on the VA service, the Renton Plastic Surgery service and on a combined UWMC/Childrens rotation. Given the clinical schedules at the VA and in Renton, there is ample time for residents to participate in a research project. This research time extends over 8 of the 12 months of the second year. While there is not sufficient time for a resident to conceive, initiate and ultimately complete a sophisticated project of their own, there are several opportunities to complete a basic science or clinical research project with one of the core plastic surgery or other University faculty. During the UWMC/Childrens rotation the resident spends a part of the week participating in microvascular surgery cases at the UWMC and in craniofacial and pediatric hand clinic and surgery cases at Childrens hospital. During, the Renton rotation, the house officer participates in the practice of a four-physician group that includes the broad spectrum of Plastic Surgery—including both reconstructive and aesthetic cases. These physicians supervise the resident who carries out those procedures and makes those decisions in keeping with his/her level of development.

In the third year, the Chief resident again spends 4 months on the Harborview Hand/Craniofacial sevice, the University of Washington Medical Center service and 4 months at Childrens hospital doing pediatric plastic surgery. On these services, the house officer will be exposed to the clinical activities of those institutions, i.e. aesthetic, breast and pediatric Plastic Surgery, as well as advanced aspects of general reconstruction, head & neck reconstruction, hand, and microsurgery. The resident becomes more familiar and facile with the principles and techniques of all aspects of Plastic Surgery. As he/she develops in these areas, the resident assumes greater responsibility and independence but is always working with the supervision and participation of the faculty. It is expected that the chief resident will take an increasingly greater role in the evaluation of patients, formulation of treatment plan and operative cases commensurate with the advanced level of training. When the third year resident is on the UWMC/CHRMC rotation, they also have a special “resident-oriented” cosmetic clinic at UWMC that is staffed and supervised by faculty, but allows the resident to assume greater responsibility in the preoperative, operative, and postoperative care of these patients. In addition, the resident participates actively in the education of the Surgery housestaff, assisting them in procedures of wound care, grafts and flaps at these institutions.

Continuity of care is achieved at all of the institutions through resident participation in the various clinics. There are no “private” clinics nor “resident” clinics. Faculty and residents will usually participate in all clinics together.

During all three years and on all rotations the educational philosophy is the same. It is that of the Department of Surgery, i.e. “wide latitude in intellectual inquiry but very close supervision of specific patient care with gradual assumption of clinical decision-making and operative responsibility.” Two training methods are fundamental to this philosophy, one for cognitive activities and one for technical matters. The first is that in all cognitive activities the resident is required to “make a plan” prior to discussing the problem with the attending. Attendings do not dictate diagnostic or therapeutic plans. The resident “makes a plan” which is then discussed with the attending and together a combined plan is made. This method of “making a plan” and then defending it against the critique of the attending physician trains the resident and permits him to assume increasing levels of independence. It is the goal that at the completion of his/her training the resident will have made sufficient independent decisions (under faculty supervision) that he/she can easily assume the position of an independent physician. This philosophy holds for all patients on the wards, in the clinics, pre- and postoperatively, and throughout the program. There are no “private” cases in which this philosophy does not apply. Regarding technical skills, the resident is expected to master the less complex procedures before proceeding to the more complex. Furthermore, he/she is expected to first assist until he/she understands the principles and methods, at which time the resident becomes the operating surgeon with faculty supervision, and eventually moves to teaching others. In virtually all instances there is an attending in the operating room. However, as the residents experience grows, the attending plays an increasingly supervisory role.

Regular, scheduled participation during every week in the clinics, ie. the pre- and postoperative care of patients, is mandatory and is an integral part of every rotation. In the clinic setting, the resident usually sees the patient first, performs an evaluation, formulates a plan, then discusses the findings and plan with the attending, who then examines the patient with the resident and modifies/implements the plan.

Resident responsibilities when assigned to other services:

Residents are not assigned to other services.

Resident assignments outside the United States:

Residents are not assigned outside the United States.

Didactic component

The didactic component is planned and modified at the beginning of each year in a meeting that includes all of the faculty and residents of the program. The structure and schedule of the plastic surgery didactic program is attached to this section and encompasses all required sections IA and V B&C of the program requirements over a 3-year period. Implementation is coordinated by the associate program director along with the administrative Chief Resident (the three switch after each rotation). Attendance by faculty and residents is mandatory and attendance is documented. All faculty and all residents participate at one point or another throughout the year. Visiting faculty participate in giving lectures 1-2 times per year.

Ethics, professionalism, systems based practice and the optimal conduct of an interdisciplinary medical team, as well as medicolegal issues are regularly discussed on rounds and at the Wednesday morning conferences. The M&M conferences are actually termed “M&M&X” with the “X” representing cases involving ethics, professionalism, systems based practice and the optimal orchestration of a complex, integrated interdisciplinary medical team, as well as medicolegal issues- potential or real.

In addition to the main Wednesday morning 0630-0800 plastic surgery teaching conference and the preceding evening teaching conferences, the following are also part of the didactic curriculum:

Monday

7:00 Hand Conference UWMC- Ortho/PS (2x/month)
8:00 CHRMC Craniofacial Conference
10:00 HMC Wound Rounds
12:00 HMC Burn/Plastic Surgery Teaching Rounds

Tuesday
6:30 Hand Conference (HMC);
7:30: Burn Teaching Conference (HMC)
10:00 HMC Wound Rounds

Wednesday
6:30-0800 Plastic Surgery Conferences

Thursday
10:00 HMC Wound Rounds
12:00 HMC Burn/Plastic Surgery Teaching Rounds

Friday 10:00 HMC Wound Rounds

The subspecialty (hand and craniofacial) conferences are attended by the resident(s) rotating on that service, with the exception of the Monday morning hand lecture series, which is attended by all residents. The Divisional conferences are held at Harborview Medical Center and are attended by all Plastic Surgery residents. The Divisional conferences include preop case discussion, M&M (statistics are recorded), Selected Readings reviews, literature reviews, topic oriented resident questioning, and formal presentations by faculty, residents, and students. During the preop discussions the residents present the cases, including history, physical exam, analysis and plan. During the M&M conferences the residents present the cases and then all participate in the discussion. The Selected Reading reviews are presented by the residents, as are the literature reviews. In all conferences the faculty comment and lead the discussions. The topic oriented resident questioning sessions are based on regular, monthly evening teaching sessions, held by one of the faculty.

Resident scholarly activity

Residents are taught to understand and apply the scientific method to clinical medicine throughout the training program. This includes reviews of journal articles as part of the didactic program, presentation of topics based on the literature, and participation with the faculty in clinical and basic science research. Each resident completes one clinical research study and one surgical laboratory study during his/her three year training and one grant application is recommended (the manuscripts are required for successful completion of the program). Some residents generate and prepare their own clinical and surgical laboratory research ideas and complete the studies during their three years. Others assume responsibility for studies partially underway.

The clinical studies are conducted with the faculty of the Division of Plastic Surgery. The topics are those related to the practices of the faculty of the Division.

As noted previously, because of the program’s commitment to fostering the development of future academic plastic surgeons, there is dedicated research time during the VA and Renton community plastic surgery rotations during the second year. This research rotation, though brief, allows the residents to gain an important insight into research and provides them a valuable education in how to properly evaluate research and scientific contributions. The opportunities at the University of Washington to learn to do and to do research are excellent. The laboratory studies are generally conducted with a faculty person of the Division of Plastic Surgery utilizing laboratory space and equipment of the Department of Surgery and the Division of Plastic Surgery. Such studies are prepared during the first year, executed during the second, and completed during the third. With this experience, UW plastic surgery residents have won the resident research award at the national Plastic Surgery Research Council meeting more than any other program.

Program Policies

1. Supervision. As noted previously, during all three years and on all rotations the educational philosophy is the same, i.e. “wide latitude in intellectual inquiry but very close supervision of specific patient care with gradual assumption of clinical decision-making and operative responsibility.”

Two training methods are fundamental to this philosophy, one for cognitive activities and one for technical matters. The first is that in all cognitive activities the resident is required to “make a plan” prior to discussing the problem with the attending. Attendings do not dictate diagnostic or therapeutic plans. The resident “makes a plan” which is then discussed with the attending and together a combined plan is made. This method of “making a plan” and then defending it against the critique of the attending physician trains the resident and permits him to assume increasing levels of independence. It is the goal that at the completion of his/her training the resident will have made sufficient independent decisions (under faculty supervision) that he/she can easily assume the position of an independent physician. This philosophy holds for all patients on the wards, in the clinics, pre- and postoperatively, and throughout the program. There are no “private” cases in which this philosophy does not apply.

Regarding technical skills, the resident is expected to master the less complex procedures before proceeding to the more complex. Furthermore, he/she is expected to first assist until he/she understands the principles and methods, at which time the resident becomes the operating surgeon with faculty supervision, and eventually moves to teaching others. In virtually all instances there is an attending in the operating room. However, as the residents experience grows, the attending plays an increasingly supervisory role.

Residents will evaluate and treat patients in the emergency rooms and on the wards of the hospitals where they are on call and will involve the faculty depending on the severity, complexity, and urgency of the problem. Some minor procedures such as laceration repairs, fracture reductions, extensor tendon repairs, I&D, amputation revisions, etc. can be performed by the resident without supervision, once they have achieved competence under supervision. At all times an attending is assigned, available, and ultimately responsible, however.

In the clinic setting, the resident usually sees the patient first, performs an evaluation, formulates a plan, then discusses the findings and plan with the attending, who then examines the patient with the resident and modifies/implements the plan.

2. Duty Hours

The program director monitors compliance with the resident duty hours requirements by having the residents keep a running log of their daily, weekly, and monthly duty hours and submitting them weekly to the program coordinator. These are presented, reviewed, and discussed by all faculty and residents monthly at the Wednesday morning conference. The residents are clearly instructed to notify faculty at any time when they are approaching any of the duty hours limits. The schedule is arranged such that there is always a backup resident available.

Evaluation

1. Resident evaluation

Each resident is evaluated every four months by all faculty on their current rotation with online evaluation forms that are based on the core competencies, as well as face-to face interviews with the residents during the last week of their 4 month rotation. In addition, each resident receives a “midrotation” face to face evaluation with the appropriate service chief to monitor progress and identify areas for improvement for the remainder of the rotation. Any problems are discussed directly with the resident and are discussed amongst the faculty and remedial/corrective action is taken. In 2005, for the first time, one of our 1st year residents (PG4) was not reappointed to an R2 (PG5) position. A temporary increase in resident complement to address was been granted by the RRC. The primary change that has been made as a result of this incident has been a restructuring of the R1-3 experience in the Preliminary Surgery Program in cooperation with that program such that coordinated plastic surgery residents in the coordinated track rotate on plastic surgery earlier during their preliminary years so that fundamental problems with patient care and innate technical ability can be identified and addressed earlier. In addition, each year the residents take the Plastic Surgery In-Service Training Exam. The results of this exam are not be used to determine promotion but rather as another measure of progress. In addition, every six months, each resident meets with the program director and associate program director to review his/her progress in the program. During these meetings, resident case logs are reviewed, rotation evaluations are reviewed and there is discussion of the resident’s career plans. In addition, the residents are given an opportunity to discuss issues with the program structure and conduct.

2. Faculty evaluation by the program director and residents.

Each resident confidentially evaluates faculty with online evaluations every 4 months. Confidentiality is achieved through the blinded online evaluation system. Any documented difficulties are addressed and plans promptly made to correct the problem. In addition, the program director meets with the residents face-to-face every six months to receive feedback regarding the faculty. The program director also meets annually with the junior faculty and biannually with the senior faculty to discuss academic performance. Teaching performance is part of this evaluation.

3. Program evaluation.

Each resident confidentially evaluates each rotation with online evaluations every 4 months. Confidentiality is achieved through the blinded online evaluation system. These are discussed with the faculty at regular faculty meetings and improvements are discussed and implemented. In addition, the program director meets with the residents face-to-face every six months to receive feedback regarding the program and to discuss potential changes to the educational program to improve it. In addition, the educational, research, and clinical aspects of the program are discussed in a meeting with all residents and faculty 1-2 times per year. A number of improvements have come from the combination of these evaluations, including reassignment of residents within the overall rotation structure to improve workflow, allow better continuity of care, and facilitate emergency coverage so that it does not disrupt key educational activities. Redeployment to different activities within the same service and changing the structure of backup coverage in certain cases has also resulted in an improved educational experience. In addition, time is taken at the beginning of Wednesday conference to discuss any problems with the current residency operation and to make necessary interim adjustments.

^ top

reviewed 10/08