So You Want to Become a Plastic Surgeon? What You Need to Do and Know to Get into a Plastic Surgery Residency

PATHWAYS TO PLASTIC SURGERY It is a truth universally acknowledged that plastic surgery is the most elusive residency in the United States. Unlike most other major surgical subspecialties, there are two well-defined routes to becoming a plastic surgeon—the independent and integrated pathways.1 The integrated pathway consists of 6-year training programs that accept graduating medical students, whereas the independent pathway consists of 3-year training programs that accept graduates of general surgery, neurological surgery, orthopedic surgery, oral and maxillofacial surgery, otolaryngology, and urology residency programs. Both pathways are very competitive—in 2011, only 44 percent of U.S. seniors applying to integrated plastic surgery programs matched into the specialty.2 For comparison, the next lowest match rate belonged to orthopedic surgery, at 77 percent. The competitiveness of the independent pathway has diminished slightly since the training program was lengthened from 2 years to 3 years, but it remains in high demand, with the match rate ranging between 39 and 82 percent over the past 5 years.3,4 Clearly, plastic surgery program directors enjoy a buyer's market. Thus, the obvious question is, What do you need to do to maximize your chances of getting into a great plastic surgery residency? For the answers, we looked at the best available data in the context of the senior author's (R.J.R) 20-year experience chairing a large academic plastic surgery program, and our recent experience in the integrated pathway (P.N. and A.P.), and the independent pathway (B.P.) application process. THE INTEGRATED PATHWAY For a medical student applying through the integrated pathway, the first step to becoming a plastic surgeon is being invited for interviews. It goes almost without saying that applicants need to pass some minimum bar just to get their foot in the door. Data published by the National Resident Matching Program2 show that plastic surgery applicants to the integrated pathway (including the ones who did not match) are quite accomplished, with a mean United States Medical Licensing Examination Step 1 score above 240, approximately seven publications each, and a 35 percent Alpha Omega Alpha Honor Society membership rate. As a medical student, the first thing you need to do is to be honest with yourself: Do you have the basic prerequisites to be in the running for an integrated program position? If you are already a fourth-year medical student and you cannot clear this bar, there is likely not enough time to improve your grade point average and United States Medical Licensing Examination Step scores—or to compensate for them with more publications. You may be best served by pursuing the independent pathway. In fact, such a decision demonstrates commendable situational awareness. Remember, the integrated and independent pathways are designed to be equivalent, with the final 3 years of training in each pathway being generally identical. If you have been invited to some interviews, what do you do next? Many ask who the “ideal” candidate is.5–8 There is a consensus in the literature. The ideal candidate: Graduates at the top of his or her class. Has an excellent United States Medical Licensing Examination Step 1 score. Is a member of the Alpha Omega Alpha Honor Society. Has published prolifically. Is respected by his or her peers. Demonstrates maturity. Exhibits leadership qualities. Has letters of recommendation from giants in the field. Has completed rotations at every program with which he or she interviews. Unfortunately, there are probably only two candidates each year that fit this bill—everyone else is accomplished but not perfect. Fortunately, program directors know that for every Mozart (who composed his first piece at age 6) there is an Einstein (said to have had speech difficulties as a child). The “imperfect” applicant may end up being just as good a plastic surgeon or even better. For example, the senior author (R.J.R.) confesses that he was an imperfect applicant himself but somehow got into a great plastic surgery residency nevertheless. So how do you stand out in this crowd of excellent candidates? National Resident Matching Program data show that there are few objective variables that reliably differentiate plastic surgery applicants who match from those who do not.2 The best predictor of matching is the number of programs an applicant ranks (11 for those who match, compared with seven for those who do not). However, ranking more programs is the direct result of being invited to more interviews—which only indicates that an applicant was more appealing, without telling us why. Another possibly useful indicator is Alpha Omega Alpha Honor Society membership. Previous studies have found that membership was highly associated with an increased probability of matching.9 However, the most recent data show that for plastic surgery applicants, Alpha Omega Alpha Honor Society members have a match rate of nearly 60 percent, versus nearly 40 percent for non–Alpha Omega Alpha Honor Society members, suggesting that Alpha Omega Alpha Honor Society membership is not a reliable predictor of outcome.2 These data demonstrate that objective credentials are enough to get you in the door, but not enough to seal the deal. Two key subjective criteria are important. First, surveys of plastic surgery program directors show that “high-quality” letters of recommendation are a major differentiator between applicants.10 Specifically, the most persuasive components of your application are recommendations from plastic surgeons with whom you have had significant personal interactions (either through a subinternship or in a research capacity). Such close interactions are your opportunity to demonstrate the qualities that program directors are looking for: keen intellect, curiosity, an excellent work ethic, honesty, a deep commitment to plastic surgery, good humor, and empathy. Plastic surgery is a small community, with only approximately 500 academic plastic surgeons in the United States.11 When a respected plastic surgeon vouches that you possess the qualities of an excellent resident, program directors take notice. Some applicants fall into the trap of thinking that they need a letter—any letter—from a well-known plastic surgeon. The truth is that a letter from someone who does not know you well is the opposite of a high-quality letter—program directors can smell a generic letter of recommendation from a mile away. Second, it is worth noting that approximately 71 percent of plastic surgery residents match at either the program in their own medical school (28 percent; unpublished data) or a program where they completed an “away” subinternship (43 percent).12 Perhaps, then, the most important thing you can do as an applicant is to complete rotations at programs you are most interested in. Get to know the residents (who reliably pass on their impressions of rotating students to the faculty) and the faculty (who may be willing to write you a letter of recommendation). Everyone notices students who work hard, and word gets back to the program director and chairman. To summarize, then, the key points for medical student applicants are as follows: Start early13—some of the keys to success take planning, and years to achieve. Strive for top-flight objective academic credentials (top third of your medical school class, Alpha Omega Alpha Honor Society membership, good United States Medical Licensing Examination scores). Get involved in research and produce publications, abstracts, and presentations. Make sure the faculty and residents in your home institution's plastic surgery program know you well. Do several “away” rotations or subinternships at programs where you plan to apply for a residency position, and distinguish yourself by demonstrating your work ethic, intellect, and interpersonal and teamwork skills. Obtain letters of recommendation from well-respected surgeons (or other physicians) who know you well. THE INDEPENDENT PATHWAY Finally, what do you need to do if you are a surgical resident who has decided to pursue a career in plastic surgery? First, it is vital to focus on becoming a good doctor. As a surgical resident, you have a much longer track record of clinical and research work than the integrated pathway applicant. As such, your best chance of success stems from excellence in your residency, in terms of both clinical skills and raw knowledge acquisition (in-service examination scores are used as a minimum cutoff by 37 percent of programs).6 However, once again, personal interactions are the keystones of your application. If you happen to be at an institution with a plastic surgery residency program, it is imperative that you meet and interact with the faculty and residents in the program. Take advantage of your opportunity to demonstrate your work ethic, integrity, knowledge, clinical acumen, and (perhaps most important) social intelligence. A recent study found that applicants who have a plastic surgery program at their institution have a higher match rate than those who do not.3 If you are not fortunate enough to have this resource available to you, take a page out of the integrated applicant's playbook—visit other institutions for elective away rotations and build relationships with the faculty and residents there. Many independent applicants tend to have excellent research credentials, and approximately 30 percent of them have one or more years of dedicated research time under their belts.3 Applicants who stand out demonstrate productivity through publications, presentations, and the consistent ability to meet goals and deadlines. To summarize, the key points for independent applicants are: Remember the key points for integrated applicants; they apply to you as well. Do well on your annual in-service examinations (the most common cutoff used by program directors is the 50th percentile).6 Convey your clinical, technical, and social skills through direct interactions with faculty and residents at your own program and at other institutions if possible. Obtain letters of recommendation from your program director and other well-respected surgeons who know you well. CONCLUSIONS Plastic surgery is a great surgical subspecialty, combining technique and analysis to provide a wide variety of patients with innovative and life-changing medical care. All academic plastic surgeons are seeking the next generation of leaders, educators, and innovative thinkers who will continue to advance the field. However, they also want people who are honest, caring, compassionate, and amicable and who will function well as part of a team. If you have these traits, you have the potential to become a great plastic surgeon. Ralph Millard is said to have believed that he could train anyone to be a competent plastic surgeon,14 and we concur—any intelligent and honest person can be trained to be a good physician and a good plastic surgeon. So remember that every interaction with your patients, peers, and staff is an opportunity to demonstrate what makes you a good candidate. Actions speak louder than words, and no examination score or letter is as powerful as directly observing a person's character and qualities. We wish you good luck, and hope you are able to realize your goals of becoming a plastic surgeon. Enjoy the journey as much as we have in our own residencies, and as the senior author (R.J.R.) has in his years of training more than 100 plastic surgery residents and fellows. Rod J. Rohrich, M.D. 5959 Harry Hines Boulevard, POB 1, Suite 300 Dallas, Texas 75390-8820 email protected