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

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1 Research Analysis of Cosmetic Topics on the Plastic Surgery In-Service Training Exam Aesthetic Surgery Journal 2015, Vol 35(6) The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: DOI: /asj/sju151 Jason Silvestre, BS; Anthony J. Taglienti, MD; Joseph M. Serletti, MD; and Benjamin Chang, MD Abstract Background: The Plastic Surgery In-Service Training Exam (PSITE) is a multiple-choice examination taken by plastic surgery trainees to provide an assessment of plastic surgery knowledge. Objective: The purpose of this study was to evaluate cosmetic questions and determine overlap with national procedural data. Methods: Digital syllabi of six consecutive PSITE administrations ( ) were analyzed for cosmetic surgery topics. Questions were classified by taxonomy, focus, anatomy, and procedure. Answer references were tabulated by source. Relationships between tested material and national procedural volume were assessed via Pearson correlation. Results: 301 questions addressed cosmetic topics (26% of all questions) and 20 required image interpretations (7%). Question-stem taxonomy favored decision-making (40%) and recall (37%) skills over interpretation (23%, P <.001). Answers focused on treatments/outcomes (67%) over pathology/ anatomy (20%) and diagnoses (13%, P <.001). Tested procedures were largely surgical (85%) and focused on the breast (25%), body (18%), nose (13%), and eye (10%). The most common surgeries were breast augmentation (12%), rhinoplasty (11%), blepharoplasty (10%), and body contouring (6%). Minimally invasive procedures were lasers (5%), neuromodulators (4%), and fillers (3%). Plastic and Reconstructive Surgery (58%), Clinics in Plastic Surgery (7%), and Aesthetic Surgery Journal (6%) were the most cited journals, with a median 5-year publication lag. There was poor correlation between PSITE content and procedural volume data (r 2 = 0.138, P =.539). Conclusions: Plastic surgeons receive routine evaluation of cosmetic surgery knowledge. These data may help optimize clinical and didactic experiences for training in cosmetic surgery. Accepted for publication December 8, The Accreditation Council for Graduate Medical Education defines medical knowledge as one of six clinical care domains in which residents should receive instruction and display competency. 1 One tool commonly used in plastic surgery to assess this domain is the Plastic Surgery In-Service Training Exam (PSITE). Given the breadth of medical knowledge covered during a plastic surgery residency, great interest has emerged to optimize resident education during training. This interest is reflected in the near tripling of studies in plastic surgery literature concerning resident education in the past 5 years (n = 131) compared with the preceding 5-year period (n = 46) (Figure 1). Additional widespread adoption of the integrated model 2 and restrictions on the resident work week 3 will challenge residency program directors to optimize residency curricula. Among its principle objectives, the PSITE allows residents to measure their knowledge against a national norm, establishes a core plastic surgery curriculum, and provides critical feedback on the teaching quality of a residency program. The PSITE is composed of 200 questions divided into four equal categories: comprehensive, hand and lower extremity, craniomaxillofacial, and breast and cosmetic. Principles in cosmetic surgery are tested in all domains, but From the Perelman School of Medicine, The University of Pennsylvania, Philadelphia, PA, USA. Corresponding Author: Mr. Jason Silvestre, Clinical Research Fellow, Division of Plastic Surgery, 3400 Spruce Street, 10 Penn Tower, Philadelphia, PA 19104, USA. jason.silvestre@uphs.upenn.edu

2 740 Aesthetic Surgery Journal 35(6) Figure 1. Proliferation of publications on plastic surgery residency training. it is unclear whether its broad scope is consistently tested on each PSITE administration, and whether tested topics adequately reflect the most commonly performed cosmetic surgeries. Additionally, literature is often recommended as a teaching aid during residency, but its utility for PSITE preparation remains unknown. Thus, we sought to: (1) determine the most commonly tested cosmetic topics during plastic surgery residency, (2) quantify the most commonly cited literature sources used as references for correct responses, and (3) correlate PSITE content with national procedural volume data. To accomplish these objectives, this study evaluates questions testing cosmetic topics over six consecutive PSITE administrations for: (1) the percentage of dedicated questions, (2) distribution of question taxonomy, (3) focus of tested material, (4) anatomical locations, (5) most common procedures, and (6) most cited reference titles. METHODS Digital syllabi for each PSITE administration were obtained for years 2008 through This 6-year period was selected as it reflects the typical exam experience of an integrated plastic surgeon resident. A database was developed that included variables for each question obtained after a thorough review and consensus among authors. Questions were included if they tested a cosmetic procedure. To help minimize selection bias, classifications were consulted from password-protected content of the American Council of Academic Plastic Surgeons webpage. 4 The number of questions pertaining to cosmetic topics was recorded for each major section of the exam: comprehensive, hand and lower extremity, craniomaxillofacial, and breast and cosmetic. The presence of associated images was recorded. Using an established educational taxonomy model, 5 question stems were classified into one of three levels: (I) recall, (II) interpretation, and (III) decision-making. Level I questions require basic recall of knowledge and facts. Level II questions require interpretation of clinical parameters to establish a diagnosis. Level III questions require the development of an appropriate next step in management. For simplicity of analysis, questions spanning more than one level were categorized into the higher order, as the hierarchical nature of this classification system implies that objectives in one level require the cognitive processes in preceding levels. The tested domain of each question was determined by analyzing the answer choices. Each item was categorized into one of three focus domains: (A) anatomy/pathology, (B) diagnoses, and (C) treatments/outcomes. In cases where answer choices spanned multiple categories, the primary focus was selected based on the correct answer. Clinical vignettes were analyzed to determine the primary anatomical locations, as well as the tested procedures. Questions addressing multiple procedures were categorized according to knowledge of the procedure that would lead to the right answer. The breakdown of surgical versus minimally invasive procedures was recorded. Categories for these procedures were selected based on frequency of appearance and were organized by anatomical location. Suggested answer references were reviewed to determine the most frequently cited literature sources. We noted the average number of primary literature sources referenced per question as well as the relative year of publication for each referenced journal article. The most referenced textbooks were also recorded. Question characteristics were summarized and presented descriptively with means. Trends in the proportion of cosmetic questions tested over time were analyzed via a chi-square goodness of fit test. Differences in variables were evaluated by category via chi-square analysis. Post-hoc analyses were performed via Fisher exact test. Pearson correlation was used to assess the relationship between tested cosmetic surgery topics and the most common cosmetic surgeries performed in the United States in All statistical tests were two-tailed, performed on STATA 13 (StataCorp, College Station, TX), and considered significant if P <.05. RESULTS The number of questions addressing cosmetic topics was 301 (26% of all questions), giving an average of 50 questions per year (range = 43-55). The proportion of dedicated questions each year was stable throughout the study period (P >.05). On average, 3 questions per year required image interpretation (range = 1-5). A minority of cosmetic questions was found in the craniomaxillofacial (6%) section compared with the comprehensive (15%) and breast and cosmetic (79%) sections of the PSITE (P <.01). Cosmetic topics were absent in the hand and lower extremity section. Questions favored decision-making (40%) and general recall (37%) skills over interpretation (23%) skills (P <.001). Furthermore, questions focused on treatments/

3 Silvestre et al 741 outcomes (67%) over pathology/anatomy (20%) and diagnoses (13%, P <.001). This breakdown is presented in Table 1. Most questions tested cosmetic surgery (85%) over minimally invasive procedures (15%, P <.001). When counting the nose (13%) and eyes (10%) with the face (8%), facial aesthetics accounted for the majority of surgical procedures (31%). Otherwise, the breast (25%) and body (18%) were more common. Augmentation mammoplasty (n = 36), rhinoplasty (n = 34) and blepharoplasty (n = 29) had the greatest number of dedicated questions (Table 2). For minimally invasive procedures, lasers (n = 16), neuromodulators (n = 13), and fillers (n = 10) constituted the majority (Table 3). 693 answer references to 98 unique journals gave an average of 2.3 journal publications per question (Table 4). Plastic and Reconstructive Surgery (PRS) had the greatest total number of citations (58%), followed by Clinics in Plastic Surgery (7%) and Aesthetic Surgery Journal (6%). A reference to PRS was used in support of 209 questions (69%). The median time from publication to PSITE administration was 5 years. Answer keys also contained 119 references to 51 unique textbooks. The two most referenced textbooks were The Art of Aesthetic Surgery: Principles and Techniques by Nahai 7 and Plastic Surgery by Mathes 8 (Table 5). Table 1. Cosmetic Topics on the Plastic Surgery In-Service Training Exam (PSITE) Table 6 shows the most commonly performed cosmetic surgeries in the United States in 2013 and the corresponding testing frequency during the study period (Table 6). There was poor correlation between PSITE content and procedural volume (r 2 = 0.138, P =.539). DISCUSSION In-service exams are used among diverse medical specialties to objectively assess clinical knowledge. These exams serve to simulate the respective board examination of a medical specialty and provide feedback to program directors regarding the effectiveness of a residency program s curriculum. The Plastic Surgery In-Service Training Exam (PSITE) is administered yearly to plastic surgeons. Given its widespread use, the PSITE has an important role in plastic surgery education in the United States, yet remains understudied. For this reason, it is worthwhile to exam the PSITE to determine the topics plastic surgery residents are expected to master. Training in cosmetic surgery offers unique challenges to plastic surgeons, 15 and recent economic trends have revived an interest for cosmetic surgery training during residency. Declining third-party reimbursements, reduced academic budgets, and evolving healthcare reforms have led many plastic surgeons to gravitate toward cosmetic Total Average (%) for Cosmetic questions (26) Images (2) Total questions (100) Section Comprehensive (15) Hand and Lower Extremity Craniomaxillofacial (6) Breast and Cosmetic (79) Taxonomy I (recall) (37) II (interpretation) (23) III (decision-making) (40) Focus Category Pathology/anatomy (20) Diagnoses/diagnostic- modalities (13) Treatments/outcomes (67)

4 742 Aesthetic Surgery Journal 35(6) Table 2. Tested Cosmetic Surgeries by Anatomical Location Cosmetic Topic Total % of Questions Breast Augmentation 36 Reduction 15 Gynecomastia 10 Congenital deformities 6 Mastopexy 4 Mastopexy + implant 3 Tuberous deformity 2 Fat injection 1 Body Body contouring, multiple 19 Abdominoplasty 17 Liposuction 10 Brachioplasty 6 Thigh lift 2 Nose Rhinoplasty 34 Rhinoplasty, tip 3 Rhinophyma 2 Eye Blepharoplasty 29 Thyroid ophthalmopathy 1 Face 25 8 Rhytidectomy 13 Brow lift 4 Fat injection 4 Chin implant 3 Jaw line implant 1 Ear 12 4 Otoplasty 12 Genitalia 3 1 Gender reassignment 2 Labioplasty 1 Hair Transplant 2 1 Other 12 5 Total Table 3. Minimally Invasive Cosmetic Procedures Cosmetic Topic Total % of Questions Injectables 23 8 Neuromodulator 13 Fillers 10 Lasers 16 5 Wrinkles 9 Birthmark 4 Tattoo 2 Hair 1 Chemical Peel 7 2 Dermabrasion 1 0 Total surgery. 16,17 Because of these trends, residents are increasingly interested in gaining adequate exposure to cosmetic surgery during residency. 18 In response to this pressure, many residency programs are offering more autonomous clinical experiences in cosmetic surgery. Still, only half of graduating plastic surgeons feel adequately trained to integrate cosmetic surgery into their practice. 19 With regard to competency, graduating residents feel most comfortable performing cosmetic breast surgery. 19 In our study, this domain was heavily tested. Overall, however, cosmetic questions comprise a quarter of all PSITE questions. This finding highlights a focus on reconstructive surgery during plastic surgery residency training. We found that minimally invasive procedures were tested in only 4% of all PSITE questions, a finding that may reflect the desire for increased exposure to these procedures among plastic surgery residents. 19 There was ultimately poor correlation between tested cosmetic topics and national procedural volume data. It is important to point out that these data were derived from a sample of aesthetic surgeons including plastic surgeons, otolaryngologists, and dermatologists. 6 Thus, while indicative of the supply and demand for cosmetic surgeries in the United States, these data may be less reflective of the teaching objectives during plastic surgery residency. Ultimately, however, plastic surgeon trainees may be served by better training in cosmetic surgeries of highest demand. 19 This systematic review of cosmetic topics on the PSITE may be used to improve the educational utility of journal clubs, resident conferences, and other modes of instruction. These sessions could prove most valuable when directly correlated with cosmetic questions on the PSITE. The preponderance of answers to cosmetic questions was

5 Silvestre et al 743 Table 4. Journals Cited for Correct Responses Journal Title No. of Citations % of All Citations Published, No. (%) Median Lag 1 y 2-5 y 6-10 y >10 y Plastic and Reconstructive Surgery (4) 180 (45) 123 (31) 80 (20) Clinics in Plastic Surgery (13) 20 (43) 8 (17) 13 (28) Aesthetic Surgery Journal (71) 11 (26) 1 (2) Annals of Plastic Surgery (22) 7 (39) 7 (39) Aesthetic Plastic Surgery (6) 11 (65) 2 (12) 3 (18) Journal of Plastic, Reconstructive & Aesthetic Surgery/ British Journal of Plastic Surgery Journal of the American Academy of Dermatology (46) 2 (15) 5 (38) (13) 2 (25) 1 (13) 4 (50) Facial Plastic Surgery (57) 2 (29) 1 (14) Other* (6) 62 (44) 37 (26) 34 (24) Total (5) 319 (46) 193 (28) 148 (21) *Less than 1% of journal citations. Table 5. Textbooks Cited for Correct Responses Textbook Author No. of References %of References The Art of Aesthetic Surgery: Nahai Principles and Techniques 7 Plastic Surgery 8 Mathes Grabb and Smith 0 s Plastic Surgery 9 Thorne 9 8 Plastic Surgery: Indications, Achauer 8 7 Operations, and Outcomes 10 Surgery of the Breast: Principles Spear 6 5 and Art 11 Aesthetic Plastic Surgery 12 Aston 4 3 Surgical Anatomy of the Orbit 13 Zide 3 2 The Unfavorable Result in Plastic Goldwyn 3 2 Surgery 14 Other* Total Table 6. Top Cosmetic Surgeries Performed by Plastic Surgeons and Associated Questions Cosmetic Surgery No. (Thousands) No. of Questions Total Liposuction Breast Augmentation Blepharoplasty Abdominoplasty Rhinoplasty *Pearson correlation testing shows P >.05 *Less than 2% of textbook references. found in only three journals and the majority of citations were published in the preceding 2-5 years (Table 4). This observation may warrant further investigation to assess the utility of these resources in improving PSITE performance. Ultimately, early exposure to the clinical management of cosmetic surgery patients will improve resident confidence in performing aesthetic surgery. 20 The PSITE can assist in this goal by adequately preparing residents with the requisite knowledge for treating such patients. The Orthopedic In-Training Examination (OITE) was the first specialty-specific exam for residents 21 and its early success led to the development of similar exams in

6 744 Aesthetic Surgery Journal 35(6) other surgical specialties. Systematic evaluations of OITE questions and correlations with other metrics have benefited orthopedic training. Results from similar studies analyzing the PSITE may likewise facilitate plastic surgery training. Future correlation between PSITE performance and the American Board of Plastic Surgery examination would be an important area of research. Studies in the orthopedic and general surgery 25 literature suggest the utility of in-service exams in identifying underperforming trainees. Furthermore, resident selection criteria such as United States Medical Licensing Examination scores can be correlated with PSITE scores and other performance metrics during residency to help predict successful applicants. 26 There are limitations to the present study. First, this review covers PSITE questions over a six year period and places emphasis on current topics at the expense of previously tested topics. While concepts on the PSITE are unlikely to change from year to year, it is impossible to predict how closely future iterations will reflect results from this study. Furthermore, a journal s impact may change over time and become more or less frequently cited. Secondly, we employed classification schemes and categories based on previous studies to characterize PSITE questions. The ASPS does not readily provide these data and this was a motivation for the present study. Lastly, performance on standardized exams is not the purpose of residency training. Instead, educators should apply these tools to improve clinical and operative experiences as a means of adequately preparing residents for the care of future patients. Despite these limitations, our study identifies the most frequently tested cosmetic procedures during plastic surgery residency training. Trainees and educators alike may harness these data to ensure adequate exposure to cosmetic surgery during plastic surgery training. CONCLUSIONS Plastic surgeons are routinely evaluated on cosmetic surgery knowledge. This curriculum is consistently tested each year allowing plastic surgery trainees the opportunity to effectively anticipate future topics. Cosmetic surgeries are tested in roughly a quarter of all questions and adequately reflect procedural statistics in the United States. Disclosures The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article. Funding The authors received no financial support for the research, authorship, and publication of this article. REFERENCES 1. Swing SR, Clyman SG, Holmboe ES, Williams RG. Advancing resident assessment in graduate medical education. J Grad Med Educ. 2009;1: ACGME. Plastic Surgery Program Requirement Changes. ProgramResources/360_Plastic_Surgery_Program_ Requirement_Changes.pdf. Accessed August 1, Nasca TJ, Day SH, Amis ES Jr. The new recommendations on duty hours from the ACGME Task Force. N Engl J Med. 2010;363:e3. 4. American Council of Academic Plastic Surgeons. InService Exams. Exams. Accessed August 1, Buckwalter JA, Schumacher R, Albright JP, Cooper RR. Use of an educational taxonomy for evaluation of cognitive performance. J Med Educ. 1981;56: Cosmetic Surgery National Data Bank: Statistics Aesthet Surg J. 2014;34(1 suppl):1s-22s. 7. Nahai F. The art of aesthetic surgery: principles & techniques. Quality Medical Pub., Mathes SJ, Hentz VR. Plastic surgery. Saunders, Thorne CH. Grabb and Smith s plastic surgery. Lippincott Williams & Wilkins, Coleman JJ, Russell RC, Guyuron B. Plastic surgery: indications, operations, and outcomes. Mosby, Spear SL, Willey SC, Robb GL, Hammond DC, Nahabedian MY. Surgery of the Breast: Principles and Art. Lippincott Williams & Wilkins, Aston SJ, Steinbrech DS, Walden JL. Aesthetic Plastic Surgery. Saunders, Zide BM. Surgical Anatomy of the Orbit. Lippincott Williams & Wilkins, Goldwyn RN. The Unfavorable Result in Plastic Surgery. Lippincott Williams & Wilkins, Bingham HG. Training in esthetic surgery: some problems encountered in a university program. Plast Reconstr Surg. 1980;65: Krieger LM, Lee GK. The economics of plastic surgery practices: trends in income, procedure mix, and volume. Plast Reconstr Surg. 2004;114: Silvestre J, Bess CR, Nguyen JT, Ibrahim AM, Patel PP, Lee BT. Evaluation of wait times for patients seeking cosmetic and reconstructive breast surgery. Ann Plast Surg. 2014;73: Neaman KC, Hill BC, Ebner B, Ford RD. Plastic surgery chief resident clinics: the current state of affairs. Plast Reconstr Surg. 2010;126: Morrison CM, Rotemberg SC, Moreira-Gonzalez A, Zins JE. A survey of cosmetic surgery training in plastic surgery programs in the United States. Plast Reconstr Surg. 2008;122: Sterodimas A, Boriani F, Bogetti P, Radwanski HN, Bruschi S, Pitanguy I. Junior plastic surgeon s confidence in aesthetic surgery practice: a comparison of two didactic systems. J Plast Reconstr Aesthet Surg. 2010;63:

7 Silvestre et al Mankin HJ. The Orthopaedic In-Training Examination (OITE). Clin Orthop Relat Res. 1971;75: Dougherty PJ, Walter N, Schilling P, Najibi S, Herkowitz H. Do scores of the USMLE Step 1 and OITE correlate with the ABOS Part I certifying examination?: a multicenter study. Clin Orthop Relat Res. 2010;468: Klein GR, Austin MS, Randolph S, Sharkey PF, Hilibrand AS. Passing the Boards: can USMLE and Orthopaedic in-training Examination scores predict passage of the ABOS Part-I examination? J Bone Joint Surg Am. 2004; 86-A: Swanson D, Marsh JL, Hurwitz S, et al. Utility of AAOS OITE scores in predicting ABOS Part I outcomes: AAOS exhibit selection. J Bone Joint Surg Am. 2013;95:e de Virgilio C, Yaghoubian A, Kaji A, et al. Predicting performance on the American Board of Surgery qualifying and certifying examinations: a multi-institutional study. Arch Surg. 2010;145: Nagarkar P, Pulikkottil B, Patel A, Rohrich RJ. So you want to become a plastic surgeon? What you need to do and know to get into a plastic surgery residency. Plast Reconstr Surg. 2013;131: