Key words ESPRAS - Training - Specialization - Reconstructive Surgery - Aesthetic Surgery - Europe
Schlüsselwörter ESPRAS - Weiterbildung - Facharzt - Rekonstruktive Chirurgie - Ästhetische Chirurgie - Europa
Introduction
Specialty training is an integral part of becoming a plastic, reconstructive and
aesthetic surgeon. In European countries, it is organized by national training
programs with defined curricula and training pathways. Above all lies patient
safety: the aim of specialization is to provide patients with highly trained and
skilled board-certified Plastic Surgeons. The European Union of Medical Specialists
(UEMS) section of Plastic, Reconstructive and Aesthetic Surgery (PRAS) states that
Plastic, Reconstructive and Aesthetic Surgery is a specialty ”concerned with
acute and non-acute conditions which may be congenital or acquired as a result of
trauma, disease, degeneration or ageing in patients of both sexes and all ages. Its
aim is the restoration or improvement of function and the normalization of
appearance and well-being” [1 ]. The
section of PRAS has stipulated European training requirements for the specialty,
including reconstructive procedures of the entire body, burns and aesthetic surgery;
although the exact content of the speciality training varies somewhat between
different countries. The speciality is technical and non-organ specific. Many years
of training in the limitations and possibilities of tissue transfer and tissue
handling are fundamental to produce surgeons who are competent in plastic,
reconstructive, and aesthetic surgery. Adequate specialty training is a prerequisite
for both efficient and safe provision of care. In addition, it allows the
specialized surgeon to independently perform certain diagnostic and therapeutic
procedures that are limited to the specialty of plastic, reconstructive and
aesthetic surgery.
Unfortunately, specialties without basic training in plastic surgery have started to
perform advanced tissue transfers and aesthetic surgery. It is, however, a
misconception that specific procedures can be learned in isolation without a solid
foundation training in plastic, reconstructive, and aesthetic techniques. For
example, the field of aesthetic surgery, as a distinct part of the plastic,
reconstructive and aesthetic surgery specialty, is confronted by so called
“Beauty Doctors” who perform surgical, as well as minimally-invasive
aesthetic procedures without substantial training in the field. These practitioners
are not specialized within the field of plastic, reconstructive and aesthetic
surgery, and therefore have a limited skill set, and even more important a lack of
awareness of possible complications and complication management. Importantly, there
is currently no legal basis to prevent or regulate entry of non-surgical
specialists, medical doctors without appropriate specialization, nurses, and
paramedics into this field of medicine. Other examples include advanced tissue
transfers performed by surgical disciplines without comprehensive training in
plastic, reconstructive and aesthetic surgery, such as general surgeons,
gynecologists or otolaryngologists. This ultimately impacts patient safety
negatively and casts a bad light onto the specialty of plastic, reconstructive and
aesthetic surgery itself, as patients and the public are often not aware of these
circumstances.
The national societies of plastic surgery in Europe jointly face these challenges.
Therefore, the European Society of Plastic, Reconstructive and Aesthetic Surgery
(ESPRAS), which is the overarching European society for Plastic Surgery, has set out
to increase the awareness of these shortcomings and to highlight the relevance of
adequate training in plastic, reconstructive and aesthetic surgery for patient
safety. Therefore, as a first step, the aim of the presented study was to assess and
portray similarities and differences in the continuing education and specialization
in plastic surgery in Europe. The goal is to evaluate the standard of continuing
education and qualification of European plastic surgeons, and, as a next step, to
achieve European alignment and harmonization.
Materials and Methods
Study Design
A detailed questionnaire was designed and distributed utilizing an online survey
administration software (Google Forms, Google, California, U.S.). Questions
addressed core items regarding continuing education and specialization in
plastic surgery in Europe after full registration. These included items on
organization of entry into plastic surgical training, details about plastic
surgical training, such as core rotations and treatment spectrum, in addition to
requirements for board certification, such as examinations and proof of
performed procedures. The study was initiated in March 2022 and data entry was
discontinued in April 2022.
Sample
Participants were addressed directly via the European Leadership Forum (ELF).
These included members of the ESPRAS Executive committee (ExCo), delegates to
ESPRAS, as well as members of the board (presidents, vice presidents, secretary
generals) of national plastic surgery societies in Europe, other European
societies for subspecialties of plastic surgery and sole member societies. All
participants therefore had detailed knowledge of organization and management of
plastic surgical training in their respective country. One completed
questionnaire for each national society was included.
Data analysis
Data is presented as absolute and relative frequencies. Answers to free text
questions were clustered into groups and reported as absolute and relative
frequencies. All calculations were performed using Microsoft Excel (Microsoft,
Redmond, WA, USA). Graphical analysis was performed using Google Forms (Google,
California, U.S.) and Microsoft Excel (Microsoft, Redmond, WA, USA). A
color-code was generated ranking performance of individual European countries
with regard to the questioned items from red (worst) to green (best). Countries
were then highlighted on a publicly accessible Europe MapChart
(https://www.mapchart.net/europe.html).
Ethics
This study was conducted in accordance with the Declaration of Helsinki. Personal
data were treated in accordance with European General Data Protection
Regulation. Data was analyzed anonymously. Participants were informed in detail
regarding the scope of the study and provided informed consent prior to
initiation.
Results
The survey was completed by 29 participants from 23 European countries.
Training, core rotations and treatment spectrum
Entry into plastic surgery education is commonly controlled via two different
routes ([Fig. 1 ]). Firstly, 48%
of participants stated that applications are directly forwarded toward the
plastic surgery unit of choice by the medical doctor. Secondly, and according to
43% of respondents, entry into plastic surgery education is organized
via a centralized national program with allocation being based on an algorithm
considering grades and qualifications of the applicant. The total duration of
plastic surgical training continues for a mean of 5.7±1.0 years with a
range between 3 and 8 years within European countries ([Fig. 2 ]).
Fig. 1 Pie chart depicting participants response to item
addressing the levels of entry into plastic surgery education.
Fig. 2 Bar graph depicting the total duration (in years) and
structure of training required for board certification as a plastic
surgeon in European countries. *Undergraduate training,
foundation year before full registration, elective periods, or similar
are not included.
Core training and/or basic surgical training as part of plastic surgery
specialization were reported by 96% of respondents ([Fig. 2 ]). This can involve training in a
surgical emergency department (range<3 months to 24 months), as reported
by 91% of respondents ([Fig. 3 ]),
as well as training in an intensive care unit ([Fig. 4 ]), as reported by 70% of participants (range: 1 to 12
months). Treatment of severely burnt patients was compulsory for board
certification in 83% of respondents´ countries ([Fig. 5 ]).
Fig. 3 (a ) Map chart of European countries that
participated in the survey marked according to a color-code ranking
performance with regard to the questioned item. (b ) Pie chart
depicting participants response to item addressing rotation in emergency
medicine during plastic surgical specialization.; *yes, other:
Croatia: „5 years including general and plastic
surgery“; Austria: „module system“; Italy:
„3 to 6 months“; Finland: „Less than three
consecutive months. On call duty in emergency department during the
entire training“; Netherlands: „Variable on hospital and
experience out of training period“; Slovenia: „2 years,
followed by emergency department night shifts“.
Fig. 4 (a ) Map chart of European countries that
participated in the survey marked according to a color-code ranking
performance with regard to the questioned item. (b ) Pie chart
depicting participants response to item addressing rotation in intensive
care during plastic surgical specialization.; *yes, other:
Austria: „module system“; Portugal: „3
months“; Italy: „3 to 6 months“; Sweden:
„6 weeks“; Netherlands: „some
centers“.
Fig. 5 (a ) Map chart of European countries that
participated in the survey marked according to a color-code ranking
performance with regard to the questioned item. (b ) Pie chart
depicting participants response to item addressing the necessity of
treatment of severely burnt patients during plastic surgical
specialization.
Training is not limited to a hospital facility but can also be performed in a
plastic surgical practice, as reported by 41% of participants ([Fig. 6a ]). Thereby, the accepted
time-period varies between European countries, with a range of 3 months to 3
years of training being possible within a practice. In most countries, research
and teaching are important parts of plastic surgical training during residency
([Fig. 6b ]). This was claimed by
70% of respondents. An interim evaluation during training is performed
annually (65%), whereas no interim evaluations are performed according
to 35% of respondents ([Fig.
6c ]).
Fig. 6 Pie charts depicting participants response to items
addressing research and teaching in plastic surgical training across
European countries.
Requirements for board certification
According to 87% of participants, the fulfillment of a predefined plastic
surgical operation catalogue was required for board certification ([Fig. 7 ]). In addition, a high majority of
respondents report that final examination is required for board certification
(91%) ([Fig. 8 ]). In most cases,
this examination includes both oral and written assessments (65%).
Requirements for board certification include proof of surgical training in
procedures performed within the subspecialties of breast surgery (91%),
reconstructive surgery (91%), burn surgery (87%), hand surgery
(78%), cranio-facial surgery (65%) and various other disciplines
such as pediatrics, otorhinolaryngology and skin cancer (all 4%) ([Fig. 9a ]). Proof of training also included
procedures performed in all parts of the body, including the head- and neck
(91%), breast (91%), the trunk (91%), as well as upper-
and lower extremities (87%) ([Fig.
9b ]). Mandatory proof of procedures performed in aesthetic surgery was
reported by 87% of respondents.
Fig. 7 (a ) Map chart of European countries that
participated in the survey marked according to a color-code ranking
performance with regard to the questioned item. (b ) Pie chart
depicting the requirements for board certification in plastic surgery
across European countries.
Fig. 8 (a ) Map chart of European countries that
participated in the survey marked according to a color-code ranking
performance with regard to the questioned item. (b ) Pie chart
depicting the requirements for board certification in plastic surgery
across European countries.
Fig. 9 Bar charts depicting the requirements for board
certification in plastic surgery across European countries.
Board certification is issued either by a medical association (52%), an
assigned federal ministry (i. e., ministry of health, ministry of
education) or other government agencies (22%), the university or medical
school itself (17%), or the respective national society of plastic
surgery (9%) ([Fig. 10a ]). Most
European countries do not recognize the European Board Examination in Plastic
Surgery (EBOPRAS) as an equivalent to board certification in plastic surgery in
their respective country (65%) ([Fig.
10b ]).
Fig. 10 Pie charts depicting the national organizations
responsible for board certification across European countries.
Discussion
Specialization in plastic, reconstructive and aesthetic surgery continues to rank
amongst the most popular specialties in medicine, attracting high-potential
candidates [2 ]
[3 ]. Places for specialty training are limited, further propelling
competition. Optimization and adaptation of plastic surgical training curricula has
been ongoing for a considerable time, since plastic, reconstructive, and aesthetic
surgery emerged as an independent specialty in Europe in the 1940s [4 ]
[5 ]
[6 ]
[7 ].
Previously, the ExCo of ESPRAS shared solutions on relevant matters common to
national societies under the umbrella of ESPRAS in different survey-based studies
[8 ]
[9 ]
[10 ]
[11 ]. Following this example, this study aimed
at establishing the status quo of continuing education in plastic surgery in Europe.
Aim was to raise awareness of the importance of high-quality specialization in order
to perform safe, efficient and effective treatments for patients requiring care in
the field of plastic, reconstructive and aesthetic surgery.
While this study found some differences in the organization and practice of plastic
surgical training across European countries, the data show that the overall standard
of continuing education is high. During specialization, plastic surgeons in Europe
are trained in reconstructive and aesthetic techniques, including advanced tissue
transfer in all parts of the human body and several subspecialties, such as hand
surgery, burn surgery, and aesthetic surgery. Moreover, rotations in intensive, as
well as emergency care further elevate the skill set of a plastic surgeon to
treatment of critically ill patients.
Board certification in plastic, reconstructive and aesthetic surgery is only provided
for surgeons who have multiple years of training regulated by a national board, who
provide evidence of individually performed operative procedures in all
aforementioned anatomical regions and surgical fields, and who pass a final oral
and/or written examination. Board certified plastic surgeons therefore meet
the highest degree of qualification, are trained in all parts of the body and in the
management of complications ([Fig. 11 ]).
Fig. 11 Qualifications of a board-certified plastic and reconstructive
surgeon.
Many years of training in plastic, reconstructive, and aesthetic surgery are needed
to grasp the possibilities and limitations of tissue transfer and to avoid and
manage complications. The procedures cannot be isolated and learned as single
procedures without these years of fundamental training. Therefore, it is not safe
for surgeons and doctors without board certification in plastic surgery to perform
these procedures, neither aesthetic nor reconstructive. The phenomenon can be
described as a surgical Dunning-Kruger effect [12 ]
[13 ]
[14 ], where surgeons who do not have the proper
specialist training might not grasp the difficulty of performing reconstructive and
aesthetic surgery to a high standard and in a way that is safe for the patient.
Obtaining competence in both reconstructive and aesthetic surgery is key in the
process of training to be a plastic surgeon. The competencies are closely linked to
each other and both are necessary to perform plastic surgery. Given the popularity
of aesthetic procedures, both surgical and minimally invasive, patient safety and a
high standard are pressing issues [15 ]. In
this field of medicine, patient safety is of pivotal importance and it can be
endangered by underqualified practitioners from different specialties, or without
any medical specialty at all, entering the field foremost for financial reasons,
lacking adequate training in aesthetic surgery and complication management. Studies
have identified a paucity in academic aesthetic facilities, and it should be the aim
of plastic surgeons to establish these, in order to remain at the forefront of
aesthetic surgery [16 ], and guarantee a high
level of patient safety.
Patient care is strongly linked to science [17 ], and engaging in plastic surgery research lays the groundwork for being
at the cutting edge of innovation in the field, defining new treatment strategies,
expanding therapeutic options and improving patient outcomes [3 ]. Importantly, 70% of respondents in
this study claimed that research and teaching are tightly integrated into
specialization. Hence, plastic surgeons are also trained academically, driving
innovation in tissue engineering, regenerative medicine, transplantation,
microcirculation, basic science, surgical technique development, outcomes research
and more. A recent study showed that the highest publication volumes in the field of
aesthetic surgery and breast reconstruction were contributed by plastic surgeons
[18 ].
After having established the current structure and organization of plastic surgical
continuous training in European countries, aim should be to achieve international
harmonization. This will ascertain standards common to all European plastic surgeons
and increase comparability between the level of qualification. Interestingly, a
majority of approximately two out of three European countries do not accept the
EBOPRAS examination for board certification, which is by definition
“intended both as a quality mark, and to help in the harmonisation of
standards in EU (…) countries”
[19 ]. It is regarded more as a further
distinction of plastic surgeons that demonstrate high educational standards. As a
first step of European harmonization, and in order to increase European alignment,
including EBOPRAS examination as a requirement for board-certification could be an
important issue to pursue.
Overall, the data presented here demonstrate the high-level of training and
qualification required for board-certification within the field of plastic,
reconstructive and aesthetic surgery all over Europe. The standardized continuing
education ensures that board certified plastic surgeons can safely and effectively
perform state-of-the art procedures in all subspecialties of plastic surgery,
reconstructive, and aesthetic surgery, are aware of potential complications and
possess the skill-set to handle these. It is vital to continue to increase
patients´ awareness of the qualifications of medical professionals, in order
for them to make informed decisions on who they select to be treated by.
Limitations
The limitations of this study are mainly related to the study design and the use
of survey instruments. The data provided is merely descriptive and is
self-reported. The study sample is an extremely narrow population, addressed
specifically through channels of the ELF, which can be regarded both a weakness
and a strength of the study, as respondents were all experts in the field of
plastic surgery with detailed knowledge of organization and management of
plastic surgical training in their respective country. In addition, pie charts
depict results according to responses of individual European countries. These
responses were weighted equally, without taking into account the size of the
individual plastic surgical national societies and communities within these
countries, in addition to the number of specialized surgeons. Some of the
countries that participated in this study are not part of the European Union,
however their societies of plastic surgery are under the umbrella of ESPRAS
which is why they were not evaluated separately. In some European countries,
parts of training can be performed outside of a hospital facility and within a
practice. Unfortunately, the survey fails to further specify the nature of this
training and the requirements of these practices or offices, exemplary whether
they offer aesthetic training alone, or must include reconstructive surgery and
whether this is performed within a private or public insurance-based setting.
Last but not least, the study could be criticized as the included plastic
surgeons might be biased towards underlining the importance of their own
training. However, no other specialty comprises comprehensive skills in both
reconstructive and aesthetic techniques.
