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    Dr. Amanda Gosman & Dr. Sam Jejurikar: How to train a plastic surgeon

    Dr. Sal Pacella: Good morning, everybody. How are you today? I’m Dr. Sal Pacella from San Diego, California, @sandiegoplasticsurgeon, and I’m with Dr. Sam Rhee from Paramus, New Jersey, @bergencosmetic, and of course, Dr. Sam Jejurikar, @samjejurikar, from Dallas. How are you, gents doing this morning?

    Dr. Sam Jejurikar: Very well. 

    Dr. Sam Rhee: Great. 

    Dr. Sal Pacella: Awesome. It’s the first day of a time change, so we’re up bright and early. We have a special guest today, my good friend and colleague, Dr. Amanda Gosman, who is the Chair of Plastic Surgery at the UCSD Residency Program at UCSD Medical School. Amanda is a fantastic surgeon and a great person. I’ve known her since, I think, 1999. It’s been a long time. She and I were medical students the same at the medical school, and we were interviewing for the same residency jobs around the country. So, I’ve known her for a long time, and we’ve collaborated with some philanthropy and professional staff throughout the years. So, Amanda, welcome. 

    Dr. Amanda Gosman: Thank you so much. I really appreciate the invitation.  

    Dr. Sal Pacella: Fantastic. So, before we start, we just have a little housekeeping. We’re gonna be reading our disclaimer here. 

    Dr.Sam Jejurikar: I will happily do that. This show is not a substitute for professional medical advice, diagnosis, or treatment. This show is for informational purposes only. Treatment and results may vary based on the circumstances, situation, and medical judgment after appropriate discussion. Always seek the advice of your surgeon or another qualified healthcare provider with any questions you might have regarding medical care, and never disregard professional medical advice or delay seeking advice because of something you may have heard on this show. Back to you, Sal. 

    Amanda Gosman medical background

    Dr. Sal Pacella: Fantastic. So, Amanda, you did your training at UT Southwestern in Dallas, correct? 

    Dr. Amanda Gosman: I did indeed, yes. 

    Dr. Sal Pacella: So, after that, tell us about your training and fellowship. And I know you came to San Diego shortly afterward. 

    Dr. Amanda Gosman: So, San Diego is my first real job, but I did an integrated residency in Dallas, and then I stayed there and did my pediatric craniofacial fellowship. And then I did an additional year doing what was then the Webster Fellowship, which was a traveling fellowship which is not ReSurge, and it was really an amazing opportunity to travel around the and not just go on short mission trips, but also work with academic centers that have programs around the world, and that’s really what cinched it for me, in terms of going into an academic career. 

    Dr. Sal Pacella: As I should have mentioned earlier Amanda is a pediatric plastic surgeon who does a bit of adult plastic surgery. So, Amanda, I also know very well through our philanthropy organization Fresh Start Surgical Gifts. So, she’s one of the board and medical program committee members and one of the pivotal surgeons we continually work with for our children from from a charity standpoint. So, if you recall from one of our previous podcasts. Just a fantastic organization. So, Amanda, tell us a little bit about your practice and your role as the Chair of Plastic Surgery there. 

    Dr. Amanda Gosman: It’s very interesting. UCSD has a little bit of interesting geography, where we have two big busy hospitals that are separated from each other. So, I maintain an adult practice, which I enjoy, but it’s also important to think about keeping boots on the ground. But most of my clinical practice is at the children’s hospital, which is separate, and I am in charge of our division there too. So, it’s a little bit challenging to manage the reins at both institutions, but I think it’s also a great opportunity to develop longitudinal care for children who are in our community and find a landing pad for them to receive as an adult, and really try to work with them. It’s a really interesting cross-border health system we have, especially for pediatric care. 

    How a plastic surgeon is trained

    Dr. Sal Pacella: That’s fantastic. So, just a little bit about the landscape of San Diego. So, UCSD is located across Route 5, and on one side of Route 5 is my organization, Scripps Clinic, and UCSD is on the opposite side. So, to some extent, our two health systems are competitors from an organizational standpoint, but all of our surgeons and doctors collaborate extensively. And I know quite a few folks in the division at UCSD, and we’re a really tight professional group. So, obviously, as part of your job as the chairperson, you are responsible for training residents, correct? For our listeners who don’t necessarily know how a plastic surgeon is trained, could you maybe go a little bit into that how, from graduating medical school, one becomes a plastic surgeon and what your responsibility is in training? 

    Dr. Amanda Gosman: Absolutely. It’s a daunting responsibility. There are two pathways to becoming a plastic surgeon. The traditional pathway is to complete a full general surgery residency, and then it’s done essentially as a fellowship after that for an additional three years. At UCSD, we’ve had an independent pathway for approaching 50 years, so a very long time. In 2016 we started our integrated pathway, which means that we take students right out of medical school. They don’t do a formal general surgery program, but they go right into plastic surgery, and they do a lot of other rotations and clinical experiences in other specialties, but essentially they’re within plastic surgery training for a total of six years. And after that, there are a variety of different fellowship pathways that people can pursue, such as microsurgery.

    What I did was pediatric craniofacial. There’s aesthetic surgery; there’s gender-affirming surgery, and hand surgery. Those are the most common ones. And it is challenging to try to transition from training people who are fully-trained general surgeons to training medical students to not just surgeons but also to be physicians. That’s something that we’ve been evolving into, and it has been an iterative process in some ways. But definitely, we want to make sure that anyone that finishes the program is able to pass their board examination and is going to be safe to practice without supervision. So, it’s a little bit different. We’re actually taking a whole new generation of people into a surgical specialty, and I think it’s challenging for all of us. I always feel like an old person, where I’m like, ‘well, back in my day’… 

    Especially in Dallas, it’s a very different training. Before, we had the safeguards to protect ourselves while being residents, such as duty hours. So, a resident can only work 80 hours a week; they have mandatory time really for patient safety. But it hasn’t entirely evolved on the educational side, where that time period has transitioned into quite a defective way of skill attainment. All that time we spent operating and taking care of patients has mostly translated into us having to require a longer training period. So, it is a perpetual challenge to maintain the well-being of our physicians while they’re working in a really difficult environment. 

    Dr. Sal Pacella: Well, let’s go back to that for just a second. So, for our listeners, all four of us here have trained in an integrated program. The three of us gents at Michigan, and Amanda at UT Southwestern, arguably one of the best training programs in the country. All of us have done a fellowship. I myself have done two fellowships in aesthetic surgery, Dr. Jejurikar has done a full-year fellowship in aesthetic surgery, and Dr. Rhee has done a full craniofacial fellowship at UCLA. So, all four of us really see a tremendous value in the reputation of our training, as well as diving deep into the highest echelon of training, and that’s getting a fellowship. So, Samir, you train fellows now, correct? You’re a preceptor in the aesthetic surgery fellowship in Dallas. Tell us a little bit about your experience in training fellows. You are doing a little bit of a different job than Amanda is doing because you have had seasoned plastic surgeons finish the residency program that has a concentration in aesthetic surgery. 

    Dr. Sam Jejurikar: Yeah, I think I have a substantially easier job than Amanda has because I am getting plastic surgeons who have already finished their plastic surgery training and who have demonstrated an interest in being aesthetic surgeons. And this is what I was gonna ask Amanda about – there’s a clear delineation about whose patient it is. When we are in aesthetic surgery, and someone has to have a surgical procedure with me, it’s really clear that I’m doing their surgical procedure. And a fellow is there from one of my patients to basically watch, take notes, glean, and have a conversation. They’re not doing anything of any real value. Most fellow clinics have a very robust clinic where they have their own series of patients that they treat, and so there’s a clear delineation about whose patient it is.

    How to train plastic surgeons in residency

    When we trained, and I know when Amanda trained at UT Southwestern, which was a very different program than it is right now, we had a lot more autonomy as residents. So, my question for Amanda is: how do you balance that, knowing that the world is so different than it was when we were in residency? How do you train residents that are still learning how to operate but know that they need to be carefully and closely supervised? They maybe can’t have the degree of autonomy that you might have had when you were a resident. Do you find that there are challenges that you would have never anticipated that you’d face when you were a resident? 

    Dr. Amanda Gosman: That is an excellent question, and it is a tremendous challenge. You’re absolutely right. When I was in residency, there were two mindsets that were very different from what I see in trainees today. One is that if I didn’t know how to do it, there maybe was nobody who knew how to do it. So, that drive to learn. I mean, there was always some support, but really a lot of the independent decision-making was happening at a very early phase. So, you had to be competent. And then we also really wanted to learn. We hunted for opportunities to really engage in a learning space. I think there are probably some differences in the setting you’re working in, but it is very difficult to create situations where the resident is really independently taking care of patients, and one of the things that I think we’ve done well at UCSD, because we’ve had this independent longitudinal program at our resident aesthetic clinic, where now we have so many safeguards around it, but it still gives them an opportunity for patients to come in, they do the whole initial assessment, and then they have to present it at every phase, whereas that wasn’t the case in the past. 

    So, there’s always more faculty supervision than there has been historically, but it does give them that frontline, and they do identify to that patient that they are going to be taking care of them with this person who’s standing behind them. We used to have a little bit more ability to do that in the reconstructive space, but it’s not really allowed anymore because just this whole medical and legal environment, and people are very aware that they want to have someone who is licensed and board-certified in that specialty be their primary caretaker. So, it does make that more challenging. So, that’s really; I would say, our best opportunity to do that. And it’s hard because you’re not really seeing that full independence until very late in training. So, people can be very good at being part of a team or helping, but they may not actually be able to fly completely independently. 

    And I don’t know how we can do that better earlier, but it is a serious problem, just how we’re training within our healthcare system. So, definitely open to any suggestions. From a surgical skills standpoint, we definitely have a lot of amazing resources to train people on how to do surgery. So, the technical surgery, we have this whole center for the future of surgery. They can do the technical operations. I think the challenging part, as we all know, of taking care of patients is the assessment, coming up with a reasonable plan, and then managing expectations and complications, and not as much as them being the front line. 

    Dr. Sal Pacella: I’ve even noticed some of our fellows, they don’t even know how to talk to patients the way we do because they oftentimes- they haven’t had to do that. They’ve just been there watching surgeries or assisting in surgeries.

    Dr. Amanda Gosman: Especially cosmetic patients. I feel like that’s the most challenging patient population to really be able to communicate with effectively, where you have that appropriate balance of shared decision-making, but you’re still in charge of guiding them towards something that’s a safe solution. It’s interesting to see them start in that resident aesthetic clinic sometimes, and they’ll be like, ‘they don’t want this; they want this.’ Okay, but you’re the surgeon, and you need to be able to help them make a decision that is going to align with what their objectives are for their outcomes. I think it’s so challenging. 

    Dr. Sal Pacella: So, all of us trained at relatively high-intensity programs, where there was a tremendous amount of volume and a tremendous amount of responsibility. We did not have the benefit of an 80-hour work week, and it was very much the culture of…

    Dr. Sam Jejurikar: Just to be clear, we all actually technically did. I was on the RRC when that happened. And it actually all happened when we were residents; we just didn’t…

    Dr. Sal Pacella: I had no idea. 

    Dr. Sam Jejurikar: Yeah. I was at that meeting, where it got passed. 

    Dr. Amanda Gosman: I remember when that passed. I think I was in my third year. I was on my general surgery rotation. And there were so many complications, because during that transition it was so hard, because everybody previously took ownership for their patients, and then they were like, ‘you have to go home,’ and you weren’t longitudinally responsible for your patient. It was a horrible time of transition. 

    Dr. Sal Pacella: I distinctly remember the phrase, ‘well, if you go home for 12 hours, you miss half the cases’. But there clearly is a balance now. I think the positive memories outshine the negative memories of being tired, fatigued, cranky, etc., but I simply don’t know how you can train as a surgeon without pushing your mind and your body to the limits, to some extent. I think there has to be kind of a balance and a parachute for residents… I don’t necessarily know if the work hours are the answer, but the supervision clearly is part of the answer, at least. 

    Dr. Amanda Gosman: I think it’s hard, too, because I think there are so many guardrails around residency, and then when you get into practice, it’s totally different. There are no duty hours, and if your patient has a complication, you may miss some major life event for someone in your family or something like that. And that ownership it’s never completely conveyed when you’re in training. There’s so much that we need to do to align what we need to achieve during residency and these new restrictions, but for me, my approach has been really just trying to figure out what each individual resident is passionate about because I think that’s their only hope for pushing through and finding something that you’re really compelled to learn about and try to customize some of your training experience so that you keep that part of your life.

    Because being a plastic surgeon, or any type of medical professional, is very hard. With the Hippocratic Oath, you’re giving yourself up to some degree. And that’s a little bit contrary, especially to the younger generation, that you’re gonna sacrifice yourself in a time period where my wellbeing is in conflict with that. So, I don’t have any other magical structure to force them down other than just continually trying to find something that will drive them through a surgical career and help them strive toward excellence. 

    Amanda Gosman Leadership Style

    Dr. Sal Pacella: So, Amanda, for example, if you were a resident in your program, and you said to the chairman – yourself – that you were interested in cosmetic surgery, would your chairman say, ‘okay, not a good idea’? I’m gonna let you in on this joke. I’m sure you know Bill , who was our former chair. So, I think he took a slightly different approach to leadership than you did. 

    Dr. Sam Rhee: Well, I think what Sal is asking is really about the culture. Our culture as surgeons back then was very different. You could say charitably that it was more direct. That would be one way of saying it. There are some pretty negative aspects of it, but there are also some positives to it. And I think that when I talk to academicians who are training residents, that culture is very different. Maybe to the point where it might have swung the other way in some instances, I think. Do you feel, as the head of a training program, that that’s something that is a problem or not a problem for you when working with residents? 

    Dr. Amanda Gosman: I think there are still vestiges of both. I think there may be represented on the other side of the spectrum. I think it’s a lot of that bias against the private sector, which was a little different training in Dallas. For example, my plan was to really engage in global surgery as a major part of my career, which I have done. I have a non-profit that we work with a lot overseas and in academic collaboration, but I remember being told by one of my leaders, ‘why can’t you just be normal and go buy a BMW and go into practice like everyone else?’ So, I think there’s a little bias depending on where you train. But I think we do have flexibility in training. Six years is actually a long time. My residency was five years. 

    Dr. Sam Jejurikar: We’re all technically six, but… I had two, Sal got an MBA during his time, and Sam did two years in the lab too. 

    Dr. Sam Rhee: I did, yeah. 

    Dr. Sam Jejurikar: And then we all did fellowships. 

    Dr. Amanda Gosman: So, it’s almost like residency is almost a little bit too long. So, I think one of the opportunities now is becoming a little bit flexible; there’s a little bit more accommodation from the board. Because there used to be such a rigid timing requirement for training. Now there are weeks of leave that you can also do for electives, and also trying to accommodate family leave and things like that. So, I think there is some flexibility. So, for example, I have a resident who’s interested in cosmetics, going into private practice, and she’s a couple of years down the pike. And I was like, well, you need to learn you’re gonna run a small business since you’re gonna be an independent practice. 90% of people that go into group practice are gonna break up. 

    She was like, ‘I can’t do that.’ And I was like, okay, we have two years to figure it out. So, let’s create a program where we can customize your elective time so that you would be better prepared to go into independent practice. So I think we do have flexibility, and I think everybody acknowledges that. Just for the reference to and some of this old guard that has been alienated, this alienation of the private sector, that’s one of the things that I think is really important from an educator standpoint, that when we look at the board certification of our specialty, and what people are doing over time, the vast majority of our graduates are always going to go into the private sector, and they add tremendous value to our specialty, who are like, ‘why are you guys doing this on a Sunday?’ People are giving back all the time in a lot of different ways, and I think that this minority of academic plastic surgeons, which only represent 15% of us, have kind of driven this expectation that people need to give back in this way. 

    But in reality, when we look at a lot of the really innovative leadership and people who have demonstrated incredible value to their local, regional, national, and international communities, a lot of it comes from our private practice sector. And as plastic surgery faces a lot of threats from the outside, we have a common ground. We have a common ground for the scope of practice for all the things that we are battling with the FDA. And I think that coming from Dallas; I think that I received such a great aesthetic education as a resident, and part of it was because they thought I was gonna move to Africa, so I think they invested in me a lot because they knew for sure I wasn’t gonna set up shop down the street from them. I feel like that improves every single aspect of what I do as a reconstructive surgeon and that we have to stop this separation of ourselves. 

    We are one specialty. We are a principle-based, technique-based specialty that approaches things differently than other surgeons. And I think that if we could try to see where that common ground is more, then we would really help a lot of our trainees better. Because right now, we are in an arms race where people are trying to get into plastic surgery, with an average of ten peer-reviewed publications. The majority of those people will never publish a paper after they finish. So, why are we making them go through this crazy expensive process and selecting them on criteria that are never going to correlate with what they’re ultimately gonna do in practice? And that’s been one of my goals, not just as an educator but also being involved in our academics.

    We need to bring in the Aesthetic Society. Those are amazing educators and amazing educational resources for our residents. So, my resident who identifies is honest and has a safe place to say, ‘I wanna go into private practice.’ Okay, let me figure out how we can help you to be the best at that position instead of going out and winging it. It’s like somebody from business school going out and doing a facelift. You’re gonna be a small business owner. It’s not just the surgical skill. How do you manage your people so you don’t end up on the headlines or some social media blacklist? These are skills that people need to learn, business skills, as well as just how to be a good aesthetic surgeon.

    Dr. Sal Pacella: Well, Amanda, these are incredible insights. You and I have worked together a bit in professional societies such as the Aesthetic society. I know you’re involved with ASPS and the Association of Academic Chairmen. Your leadership is really paramount, and we love having you on to talk about some of your philosophies in training. It’s really admirable to see you joining the two ends of the spectrum, the private world, and the academic world. Any last questions for Amanda? 

    Dr. Sam Jejurikar: No, this has been incredibly insightful. It’s really encouraging to actually hear someone who’s prominent in academic plastic surgery having such a positive outlook toward plastic surgery. Just one slight comment. There are two of us that actually have MBAs and go out and do facelifts right now; that’s Pacella and me. But beyond that, I agree with everything you said. 

    Dr. Amanda Gosman: But you’re also a plastic surgeon, right? 

    Dr. Sal Pacella: Well, thank you so much. Thanks to our listeners. Amanda, have a great Sunday. We appreciate having you on.

    Dr. Amanda Gosman: Absolutely. Thanks so much. I really appreciated it.



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