Perspectives on Application and Interview Capping in Residency Selection of Surgical Subspecialties

OBJECTIVE

With the advent of virtual interviews, the potential for interview hoarding by applicants became of greater concern due to lack of financial constraints associated with in-person interviewing. Simultaneously, the average number of applications submitted each year is rising. Currently there is no cap to the number of applications or interviews an applicant may complete when applying to residency, with the exception of ophthalmology with a cap of 15 interviews. No studies have assessed the applicants' perspectives on an application or interview cap. We assessed the attitudes of surgical subspecialty applicants towards capping, which may be useful when considering innovations in residency selection.

DESIGN/SETTING/PARTICIPANTS

About 1841 applicants to the Johns Hopkins' ophthalmology, urology, plastic surgery, and orthopedic surgery residency programs from the 2022-2023 cycle were invited to respond to a 22-item questionnaire. Statistical analyses of aggregate data were conducted using R.

RESULTS

Of the 776/1841 (42%) responses, 288 (40%) were in support of an application cap, while 455 (63%) were in support of an interview cap. Specialty (p < 0.001), gender (p < 0.001), taking a gap year (p = 0.02), medical school region (p = 0.04), and number of interviews accepted off of a waitlist (p = 0.01) were all significantly associated with a difference in opinion regarding an application cap. Specialty (p < 0.001), USMLE Step 1 score (p = 0.004), number of interviews (p < 0.001), and number of programs ranked (p < 0.001) were all significantly associated with a difference in opinion regarding an interview cap. Of those applicants who were in support of the respective caps they believed that on average a cap should consist of 48.1 (16.1) applications and 16.0 (8.0) interviews.

CONCLUSIONS

Our findings highlight the desire for interview caps among the majority of applicants to surgical subspecialties and thus this innovation may be considered by other specialties in the era of virtual interviews.

Game Changers: Plastic and Reconstructive Surgery Innovations of the Last 100 Years

Background

Innovation is an essential aspect of plastic and reconstructive surgery (PRS), whether it involves improving current processes or implementing radical change that disrupts the status quo. Collaborating and sharing innovations help advance the field of PRS as a whole.

Methods

An anonymous survey was administered to members of the American Association of Plastic Surgeons on their opinions of the top five innovations in PRS of the last 100 years.

Results

A list of 69 unique innovations were compiled; the top five innovations overall were microsurgery, myocutaneous flaps, craniofacial surgery, negative pressure wound therapy, and organ transplantation. This list was reviewed by the American Association of Plastic Surgeons Technology Committee, and expanded to 100 unique innovations.

Conclusions

We discuss why the above innovations were essential to the development of PRS, as well as the unique factors that can make a new product or procedure into something that remodels the field of PRS.

81 Post-operative Self-adherent Compression Wrapping of the Hand and Its Impact on Skin-graft Viability

Introduction

Potential complications of autografting for burn wound coverage of the hand include edema, hematoma formation, and bleeding; all of which can lead to graft failure. Self-adherent elastic wraps are commonly used by burn rehabilitation clinicians to minimize complications by providing graft protection and decreasing edema post-operatively; however, there is a lack of evidence on its impact on graft healing. The purpose of this study was to determine if the application of self-adherent elastic wraps to the hand in the operating room after autografting improves the percentage of graft viability.

Methods

A retrospective chart review was performed for 37 patients with burned hands who underwent autografting from January 2017 to July 2021. Grafted hands were categorized into 2 groups: post-operative dressings with and without self-adherent elastic wraps. Post-operative day 4 pictures for both groups were collected from the medical record and a blinded digital photograph analysis of graft viability was performed by 5 expert raters including 3 Burn Surgery Fellows,1 Burn Attending Surgeon and 1 Hand Attending Surgeon. A rating system was developed based on percentage of graft take as seen in Table 1 and presence of hematomas were assessed.

Results

Patients who received self-adherent elastic wraps suffered burns with significantly larger TBSA (p=0.007) and were admitted for a longer duration (p=0.009) than patients who did not. Patients with elastic wrap had a higher percentage of grafts with >95% take (64.0% vs 41.7%, p=0.227) and a lower rate of hematoma formation (24.0% vs. 41.7%, p=0.443). Intra-class correlation coefficient across raters was 0.90 for graft take and 0.87 for determining presence of hematomas, indicating excellent interrater reliability.

Conclusions

Despite suffering larger burns requiring longer hospitalizations, patients who received elastic wrap had a higher rate of >95% graft take than those without. This study is limited by a relatively small sample size, however these findings warrant continued research in the use of self-adherent elastic wrap to maximize graft take in hand burns.

International Medical Graduates in the US Plastic Surgery Residency: Characteristics of Successful Applicants

Objectives: Within the United States, plastic surgery is a difficult field to match into for both US and international medical graduates. While the number of available residency positions has grown in recent years, this has not been mirrored by an equal increase in the number of international medical graduates who match. Furthermore, there are few reliable resources to guide international medical graduates who are interested in matching into US-based programs, so the process is often even more difficult and unpredictable than for US applicants. Methods: An anonymous survey was distributed electronically to international medical graduates who successfully matched into independent and integrated US plastic surgery residency programs. The survey assessed qualities such as medical school performance, test scores, research experience, and other relevant applicant information, and χ² analysis was done to compare the survey results for integrated and independent track international medical graduates. Results: International medical graduates who successfully match tend to rank high and score well in their medical school classes, score between 230 and 250 on USMLE step 1 and 2CK tests, and have a mean of 2 years of research experience before applying to the match. International medical graduates in the independent track tend to have higher step 1 scores, whereas international medical graduates in the integrated track tend to have more research experience and additional nonmedical degrees. Conclusions: This is a survey-based overview that describes the characteristics of successfully matched international medical graduates. Limitations of this study include the inability to identify and survey the unsuccessful applicants as well as poor response rate of the successful candidates in the independent pathway who successfully matched.

Cosmetic Surgery Training in Plastic Surgery Residency Programs

BACKGROUND

Over the past decade, plastic surgery programs have continued to evolve with the addition of 1 year of training, increase in the minimum number of required aesthetic cases, and the gradual replacement of independent positions with integrated ones. To evaluate the impact of these changes on aesthetic training, a survey was sent to residents and program directors.

METHODS

A 37 question survey was sent to plastic surgery residents at all Accreditation Council for Graduate Medical Education-approved plastic surgery training programs in the United States. A 13 question survey was sent to the program directors at the same institutions. Both surveys were analyzed to determine the duration of training and comfort level with cosmetic procedures.

RESULTS

Eighty-three residents (10%) and 11 program directors (11%) completed the survey. Ninety-four percentage of residents had a dedicated cosmetic surgery rotation (an increase from 68% in 2015) in addition to a resident cosmetic clinic. Twenty percentage of senior residents felt they would need an aesthetic surgery fellowship to practice cosmetic surgery compared with 31% in 2015. Integrated chief residents were more comfortable performing cosmetic surgery cases compared with independent chief residents. Senior residents continue to have poor confidence with facial aesthetic and body contouring procedures.

CONCLUSIONS

There is an increase in dedicated cosmetic surgery rotations and fewer residents believe they need a fellowship to practice cosmetic surgery. However, the comfort level of performing facial aesthetic and body contouring procedures remains low particularly among independent residents.

Dorsal and Volar Surgical Approaches to the Metacarpophalangeal Joint: A Comparative Anatomic Study

BACKGROUND

We compared 3 surgical approaches to the MP joint: a dorsal extensor tendon-splitting approach, a dorsal extensor tendon-reflecting parasagittal approach, and the volar A1 pulley approach. We quantitatively compared each of these approaches by measuring the amount of articular cartilage exposed on the base of the proximal phalanx. We hypothesize that visualization of the articular cartilage of the proximal phalangeal base is enhanced with the volar approach.

METHODS

The MP joints of the 32 available digits were randomly assigned to 1 of 3 surgical approaches: extensor tendon splitting (A), extensor tendon reflecting (B), or volar approach (C). After each approach, the visible articular surface of the base of the proximal phalanx was stained with methylene blue. The MP joints were then disarticulated, and the proximal phalanges were digitally mapped using a 3-dimensional digitizer. Three-dimensional computer software was used to analyze and calculate the dyed exposed surface area and total surface area of each specimen.

RESULTS

The mean % exposed joint surface area for the dorsal extensor splitting, dorsal extensor reflecting and volar approaches were 62%, 67% (over the dorsal side of the proximal phalanx) and 54% (over the volar side of the proximal phalanx), respectively. Multiple linear regression showed statistical significance for a smaller percentage of articular surface area exposed with the volar approach. However, this was not clinically significant. A significant association was found between location in the small finger and greater % exposed joint surface, compared to approaches in the index finger. In all volar approach specimens, the collateral insertion site was visible, but not in the dorsal approach specimens.

CONCLUSIONS

Knowledge of the limits of each exposure is essential for planning the most appropriate surgical approach. The A1 pulley approach provided greater access to the volar 50% of the joint and collateral ligament insertion without violating the extensor mechanism. The amount of joint surface visualized through all 3 approaches was not significantly different. However, based on the accessibility to the collateral ligament insertion site among three different approaches, we recommend the volar A1 pulley approach for treatment of avulsion fractures of the base of the proximal phalanx. For other injuries of the MP joint, including the intra-articular proximal phalanx base fractures, and metacarpal head fractures, the dorsal approaches are still indicated.

Increased immunoreactive rat lung ICAM-1 in oleic acid-induced lung injury

Levels of immunoreactive ICAM-1 in rat lung were followed during the kinetic development of acute oleic acid-induced lung injury in the rat by the ELISA assay. Significant increases in ICAM-1 immunoreactivity were found on rat lung membranes within 30 min of oleic acid injection. The increased immunoreactive ICAM-1 persisted for the duration of the study (4 h) and paralleled lung injury as measured by decreased lung compliance. Enhanced ICAM-1 immunofluorescence was also observed on cryostat sections of lungs from oleic acid-treated rats. No direct effect of oleic acid on ICAM-1 levels of cultured human umbilical vein endothelial cells or rat lung microvascular endothelial cells was observed. This suggests that either oleic acid raises rat lung ICAM-1 levels on endothelial cells by an indirect mechanism or that oleic acid increases ICAM-1 levels on other cell types, such as fibroblasts or lung epithelial cells, by direct or indirect mechanisms. Some of the increased ICAM-1 may also be due to the accumulation of ICAM-1 containing circulating leukocytes in the lung. The role of ICAM-1 in the pathophysiology of oleic acid-induced lung injury and the mechanism by which oleic acid increases ICAM-1 expression in the lung therefore remain to be defined by future experimentation.