Commentary on: Analysis of Cosmetic Topics on the Plastic Surgery In-Service Training Exam

Dr. Chang and his team should be congratulated for a thoughtful investigation. 1 They have compiled a statistical analysis comparing the cosmetic topic of each question on the In-Service Examination to the national procedural data of cosmetic operations performed. The structure of this paper is a retrospective review of published exams over the last six years—the anticipated training timeline of a new resident beginning out of medical school. The topic-specific question distribution is then compared against self-reported procedural data obtained via a survey of practicing surgeons. The assumption of this paper is that the topics covered in the cosmetic questions of the In-Service Examination should mirror national procedural volume and that, if this correlation were followed, the examination would be a better test for resident teaching. The subsequent statistical analysis demonstrates the In-Service Exam topic frequency does not mimic procedural volume. We disagree with this basic assumption. We do not believe that the number of questions on a specific topic should mimic the number of these procedures performed in practice. For example, we have purposefully written questions on the subject of anaplastic large cell lymphoma (ALCL) in both the cosmetic section and the comprehensive section of the exam. Every surgeon should suspect ALCL when a patient presents with a late seroma following breast implant surgery. However, ALCL is so rare that most surgeons will never encounter a case—the “practice volume” of ALCL is almost zero. Therefore, should this topic be omitted from the In-Service Exam? Certainly not.