The Diminishing Presence of Plastic Surgeons in Hand Surgery: A Critical Analysis

Sir: I read the January 2010 article by Dr. Higgins (Plast Reconstr Surg. 2010;125:248–260)1 with great interest as a hand surgeon and plastic surgeon. By way of disclosure, I am a member of the American Society for Surgery of the Hand and a member of the resident education committee, so I have been aware of the work on this topic before its publication. Dr. Higgins does an excellent job of outlining a problem: the diminishing presence of plastic surgeons in the subspeciality of hand surgery. Over the years, the definition and scope of hand surgery has changed significantly. Now, hand surgery includes the wrist and distal forearm, and our understanding of carpal kinematics and pathology has expanded significantly since 1993. In addition, specialization is more common in all surgical disciplines, and I believe the role of a “part-time hand surgeon” will be the exception rather than the rule in the future. Dr. Concannon has mentioned several “hand surgery leaders in plastic surgery” that fall in the category of “part time.” Although all of these surgeons have been leaders in the past and served a vital role in the education of residents, most of them are in the latter part of their careers, and when browsing the Web sites of those mentioned, more than half do not mention hand surgery as an area of interest. There will be some surgeons who are able to maintain a general plastic surgery practice and be leaders in hand surgery, but not the majority. Although it may be rare for plastic surgeons to have a practice where the significant majority or all is hand surgery, the current leaders in hand surgery with a plastic surgery background do have this scope of practice. Andy Lee, M.D., Kevin Chung, M.D., Jim Chang, M.D., Neil Jones, M.D., Nick Vedder, M.D., and Chris Pederson, M.D., just to name a few, are all current leaders in hand surgery, active members in the American Society for Surgery of the Hand, and involved with educating residents and fellows. Most of us would probably not choose a cardiac surgeon, neurosurgeon, or oncologic surgeon who practices something else more than half of the time, and hand surgery should not be any different. We can all speculate on the reasons residents have not chosen to pursue hand surgery fellowships and a career in this subspeciality. Residents often choose a subspecialty because of an influential person or mentor,2 and a decreasing number of hand surgeons with a plastic surgery background will result in fewer mentors. This is a critical time for the subspeciality of hand surgery within plastic surgery. Currently, the inservice examination is 25 percent hand and extremity; however, 25 percent of the didactic programs are rarely dedicated to hand surgery. As residency programs are transitioning from 2 to 3 years, this is the optimal time to address this issue of hand surgery, so that it will remain an integral part of plastic surgery. Plastic surgeons have always been great innovators, but we are at risk of hand surgery following the same path as burn surgery and head and neck cancer/reconstruction. Warren C. Hammert, M.D. University of Rochester Medical Center 601 Elmwood Avenue, Box 665 Rochester, N.Y.