Giving thanks – Addressing the worldwide plastic surgeon shortage
2016; Elsevier BV; Volume: 69; Issue: 4 Linguagem: Inglês
10.1016/j.bjps.2015.12.002
ISSN1878-0539
Autores Tópico(s)Health and Medical Research Impacts
ResumoToday it is Thanksgiving, a national holiday here in America. Almost 500 hundred years ago, the Pilgrims sat down with their Native American neighbours to celebrate the harvest. Now Thanksgiving has multiple memes having morphed into a day for watching parades and American football on television, feasting on turkey with friends and family and preparing for Black Friday's shopping mania. Put simply, Thanksgiving is supposed to be a day of reflection and thanks for what we have. In the United States, we have approximately 6400 active board certified plastic surgeons, and according to ASPS, the average American plastic surgeon's practice is one half aesthetic. If the US population is approximately 320 million people, then there are but 3200 full-time equivalent plastic surgeons available to treat Americans' reconstructive needs. This yields a ratio of one plastic surgeon for every 100,000 Americans, or 0.00001. In 2010, BAPRAS′ UK Plastic Surgery workforce survey recommended a ratio of one plastic surgeon for every 100,000 of population. This “ideal” ratio matches the current estimate of what we are fortunate to have in America. India's population is 1.25 billion people. For India to have the same proportion of plastic surgeons as the United States would require India to have 12,250 plastic surgeons. Currently there are about 1400 members in the Association of Plastic Surgeons of India. What is the ratio of people to plastic surgeons in the rest of the world? Beginning in 2010, the cover banner of the now defunct IPRAS journal stated, “The e-magazine for 37,000 plastic surgeons”.1IPRAS Journal. Int Confed Plast Reconstr Aesthet Surg. 1st Issue July 2010. https://web.archive.org/web/20140726013157/http://www.ipras.org/sites/default/files/IPRAS_Journal_Issue_1_July2010_.pdf [accessed 27.11.15].Google Scholar This was not a typographical error. It was repeated until IPRAS′ demise.2IPRAS Journal. Int Confed Plast Reconstr Aesthet Surg. 10th Issue October 2010. 1 https://web.archive.org/web/20140726014447/http://www.ipras.org/sites/default/files/pdfs/IPRAS_14_Teliko-latest.pdf [accessed 27.11.15].Google Scholar The IPRAS website left no room for doubt by describing:“37,000 Plastic and Aesthetic Surgeons, 35,000 residents in training, 30,000 Hand Surgeons, 1000 Micro Surgeons and 1000 Burn Specialists from 99 nations are united in IPRAS.” Assume that 37,000 plastic surgeons is correct and that Planet Earth's human population is about 7.3 billion people, then this represents a distribution of approximately 197,000 people per “real” plastic surgeon. aIf the IPRAS number includes self-styled plastic surgeons, then conditions are worse, because I do not believe that self-styled plastic surgeons are clamoring to treat patients needing reconstructive surgery. If the number 37,000 is an overestimate, then there are even fewer plastic surgeons available to treat the world's 7.3 billion people. bIPRAS administration asserted that this was not a typographical error and that it was the total membership of the component national societies. One factual approach, that I find distasteful, is to limit the scope of plastic surgery. If plastic surgeons are constrained from treating certain problems, by either administrative fiat or restrictions on patient referrals, then the ratio of patients with plastic problems to plastic surgeons will be artificially decreased. Can the scope of plastic surgery be limited? Yes. When I was a fellow at Johns Hopkins in the mid-1970's, I saw this first hand because plastic surgery was a mere division of surgery in Johns Hopkins' political hierarchy, and plastic surgery's chief, though he had a national reputation as a head and neck cancer specialist, was relegated to cranking out cosmetic cases to generate revenue. Johns Hopkins had a shameful history of treating plastic surgeons as second-class citizens beginning with John Staige Davis, America's first plastic surgeon, never having been given any beds by William Halsted. I asked my fellow trainees the obvious question, “Why did Johns Hopkins need plastic surgery?” After all, the otolaryngologists could treat head and neck tumours, the orthopaedic surgeons could treat hands, the otolaryngologists and maxillofacial surgeons could treat clefts and facial trauma and general surgeons could treat burns. The only condition for which plastic surgeons were truly necessary at Johns Hopkins were the problem wounds, such as pressure sores, that no other service wanted to treat. When I moved to Miami, I learned that Ralph Millard, my plastic surgery chief, had abdicated responsibility for pressure sore treatment to the orthopaedic surgeons so the only place where pressure sores rested in our domain was at the Veterans Hospital where, by United States government regulation, pressure sores had to be treated by plastic surgeons. While we may find it difficult to accept, the world does not know that it needs plastic surgeons. If we were to disappear overnight, the vacuum would be filled, although the quality of the filling would leave much to be desired. Outsourcing is a practice in which a business function is transferred to another party. When your toll-free call for technical support is answered, “Hi, this is Bob” in barely intelligible English, that is outsourcing. In many parts of the world, the treatment of cleft-lips and palates is outsourced. In other words, while local plastic surgeons may exist, plastic surgeons from other countries fly in and provide free surgery. While our colleagues provide free surgery, the public charities that are involved in this effort are powerhouses whose fundraising efforts and financial resources dwarf other professional plastic surgery organizations in the United States, as can be seen in Table 1.Table 1Financial data of American plastic surgery organizations reported on tax forms.Name (Tax year)Funds RaisedExpensesAssetsAmerican Association of Plastic Surgeons (2014)$563,903$168,366$4,629,104American Society Plastic Surgeons (2013)$618,305$310,500$12,224,477Plastic Surgery Foundation (2013)$2,264,894$1,220,292$14,218,673Operation Smile (2013)$58,548,233$12,144,406$22,789,503Smile Train (2013)$91,184,210$47,899,791$250,709,500Financial data obtained from the latest “Form 990 Return of an Organization Exempt from Income Tax”that can be freely downloaded from http://foundationcenter.org.Funds raised are line 9 “Contributions and Grants”, line 13 Expenses are “Grants and similar amounts paid” Assets are line 22 “Net assets or fund balances”. Open table in a new tab Financial data obtained from the latest “Form 990 Return of an Organization Exempt from Income Tax”that can be freely downloaded from http://foundationcenter.org. Funds raised are line 9 “Contributions and Grants”, line 13 Expenses are “Grants and similar amounts paid” Assets are line 22 “Net assets or fund balances”. While there is a paucity of data on the quality of care that the outsourcers provide, these organizations do mitigate the global dearth of plastic surgeons by providing access to cleft care.3Fell M.J. Hoyle T. Abebe M.E. et al.The impact of a single surgical intervention for patients with a cleft lip living in rural Ethiopia.J Plast Reconstr Aesthet Surg. 2014; 67: 1194-2000Abstract Full Text Full Text PDF Scopus (11) Google Scholar Words cannot begin to express the admiration that I have for the British Foundation for International Reconstructive Surgery and Training's (BFIRST) practical and logical approach to provide plastic surgery to the developing world.4BFIRST British Foundation for International Reconstructive Surgery and Training http://bfirst.org.uk/what-we-do/.Google Scholar The concept is simple yet elegant. Rather than have trainees in the first world who are planning to practice in poor countries learn all of plastic surgery with the latest technology available, BFIRST focuses on training plastic surgeons in their own countries. This enables the trainees to learn more rapidly and to utilize the technology that is available to them. It makes little sense to train a plastic surgeon in staging Kienböck's disease with MRI, when the closest MRI machine is 2000 miles away. I previously have written about the value of the Internet in educating medical students and the public.5Freshwater M.F. Internet communication and education.J Plast Reconstr Aesthet Surg. 2009; 62: 1100-1101Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar However, the Internet has the potential to solve the plastic surgeon shortage. In 2008, I first became aware of this when I disembarked from a plane at Kennedy Airport in New York and found an e-mail message from a former resident in our military and stationed in Afghanistan. She was caring for an Afghan Special Forces soldier with a 3-week old 6-cm. median nerve gap in the proximal forearm from an AK-47, and she wrote for advice on the advisability of her doing tendon transfers in his insensate hand. After I overcame my initial shock of the fact that here I was communicating about a plastic surgery problem over 10,000 km away, I realized that our communication was a mechanism for solving the plastic surgeon shortage. How? My advice gave her the opportunity to treat her patient more promptly and properly. Asking me for advice saved her time that she would otherwise have had to spend searching the literature, if she even had access to the relevant literature and that she could trust the literature. Accepting my advice lessened the possibility of her having made a surgical mistake, which would have wasted resources, caused unnecessary patient suffering and increased the possibility that further surgery would have been necessary if her original plan was unsuccessful. Scaling up the dialogue from email correspondence between two plastic surgeons to a group discussion would produce even more efficiencies. Unbeknownst to me, this already had happened. Like plastic surgery itself, an Internet discussion group was first developed in India where the Yahoo group “plastic_surgery” was founded in 2001. It is a forum for discussing problem cases with members having the ability to upload images and obtain comments from other members.6Foong D. McGrouther D.A. An Internet-based discussion forum as a useful resource for the discussion of clinical cases and an educational tool.Indian J Plast Surg. 2010; 43: 195-197Crossref Scopus (11) Google Scholar Yahoo “plastic_surgery” now has over 1900 members who are primarily from India. Facebook too has a number of plastic groups. The largest was founded in 2013 by Italian plastic surgery residents, and, within a year, it had 1200 members. Now it is called the Interactive Plastic Surgery Network (IPSN) and has almost 2400 members, primarily from the Middle East, but in fact from every continent except Antarctica.7Taglialatela Scafati S. Lapalorcia L.M. Social networking and plastic surgery education: running international plastic surgery.Arch Plast Surg. 2014; 41: 446Crossref Scopus (5) Google Scholar, 8Interactive Plastic Surgery Network https://www.facebook.com/groups/internationalplasticsurgery/ [accessed 27.11.15].Google Scholar IPSN membership is restricted to plastic surgeons and plastic trainees who can prove their credentials. Because Facebook's algorithms suggest that any Facebook member with any interest in plastic surgery join the group, IPSN's 17 voluntary administrators have blocked almost 1600 applicants who were not verifiable as plastic surgeons or trainees. These administrators also serve as moderators to ensure that members refrain from prohibited posts of any commercial, political, religious or racist material. One of the beauties of science fiction is that it creates goals to which we can aspire. While there is no panacea for the worldwide manpower shortage, science fiction provides a host of solutions. Computers can replace surgeons in operating under the microscope.9Freshwater M.F. Hand 2061.Indian J Plast Surg. 2011; 44: 368-370Crossref Scopus (4) Google Scholar Topical medications will heal defects or regrow limbs, thereby creating a world that will no longer need the artistry and creativity that we plastic surgeons provide. We live in a world of fact not fiction, and we have to consider present day answers. Each solution that I offered has limitations, but each solution has the potential to grow, albeit incrementally. If you are thankful for the fact that you are a plastic surgeon, then consider how you too can contribute even more to providing patients worldwide with easier access to plastic surgery care. Clearly, you can contribute to any of the charities that I have named or to others, but please consider contributing the most precious and irreplaceable commodity of all — your time. The author is a pro bono administrator of IPSN. N/A.
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