Expanding Eligibility Pathways to Plastic Surgery Training and Its Considerations

The National Medical Commission (NMC) has proposed a new Postgraduate Medical Education Regulations, 2023 that expands feeder broad specialties for super specialities.[1] For MCh/DNB Plastic and Reconstructive Surgery (PRS) courses, MS Otorhinolaryngology (ear, nose, and throat [ENT]) will now be eligible, along with the existing MS General Surgery, once adopted.

The proposal is a welcome addition and has many potential benefits. Interestingly, this is not a novel proposal. This model already exists in premier institutes in India. For more than two decades, MS-ENT postgraduates have been permitted to pursue plastic surgery residency at Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh. Furthermore, the Institute of National Importance Super Specialty (INI-SS) entrance test allows MS Orthopaedics along with MS General Surgery and ENT for plastic surgery courses.[2] MS Orthopaedics is expected to be included in the list of eligible feeder specialties by the NMC in the near future. For those interested in pursuing reconstructive, hand and microsurgery, plastic surgery courses offer higher chances of admission than limited seats in M Ch Hand Surgery.

Three years of residency in general surgery is expected to provide a sound foundation in surgical principles and techniques for pursuing super-specialty courses. This foundation is crucial as we do not have integrated 6-year courses to offer a comprehensive training model, unlike many other countries.[3] Completing a general surgery residency remains a common pathway to entering plastic surgery. However, the specific eligibility requirements for plastic surgery residency programs vary widely in different regions. In the United States, other than a 6-year integrated course pathway, candidates are required to complete a residency in either general surgery or alternative sub-specialties such as otolaryngology (ENT), orthopaedic surgery, urology, or maxillofacial surgery to enter an independent 3-year pathway in PRS residency.[4] In many European countries, general surgery, orthopaedic surgery, and other sub-specialties remain a part of the integrated course after graduation.[3] Even within Europe, training program remains heterogeneous.[4] Each country has unique training pathways and requirements and flexible eligibility criteria.

Having a diverse background in plastic surgery courses can be beneficial for the speciality. One of the worthy examples enriching our association is legendary Prof. K S Goleria, who trained under Sir Harold Gillies, and both had formal training in the ENT specialty. Dr. Venkata Ramana, known for his expertise in rhinoplasty, is another shining example among the younger generation. Nonetheless, the advantages should be weighed against their own considerations.

Advantages

The advantages include the following.

• Large applicants: Several institutions currently face seat vacancies due to lack of eligible applicants, higher course fees, or lack of motivated candidates.[5] Expanding the eligibility criteria can potentially attract a larger pool of candidates, making the selection process more competitive. This could lead to motivated and higher-quality residents entering the field.

• Diverse skillsets: Candidates from ENT and orthopedics may bring a unique set of skills that can complement and enrich their training in plastic surgery. For example, ENT postgraduates are well versed in facial anatomy, and a better understanding of pathophysiology could be very useful. Similarly, orthopaedic surgery applicants have good exposure to trauma, hand, and skeletal procedures.

• Broader knowledge base: Residents with varied surgical backgrounds may have a wider knowledge base, which can be beneficial when dealing with complex and multidisciplinary cases. This can promote interdisciplinary collaboration and cooperation within the field of surgical specialties.

• Strengthening subspecialties with a dedicated faculty pool: The teaching departments benefit from a unique faculty pool after PRS residency with their expertise. The subspecialties of plastic surgery are strengthened by a dedicated pool of talents who become experts in the fields, particularly in the areas of facial plastic surgery and hand surgery.

While diversity is valuable, it is important to ensure that the core training in plastic surgery remains consistent and comprehensive.

Considerations

The considerations include the following.

Knowledge gaps and adaptation: The plastic surgery program may need to adapt to accommodate residents from different backgrounds. This may involve tailoring the curriculum to address specific gaps in knowledge or experience. Certain unique forms of didactic education such as cadaver courses, microsurgery laboratories, and hands-on workshops are valuable.

Fair selection criteria: Develop transparent and fair selection criteria to evaluate candidates from various specialties based on their curriculum. Eligible candidates should not have to face disadvantages during the entrance test.

Uniformity in eligibility: Ensure that the expanded eligibility criteria align with the uniform requirements of different institutes. For example, Jawaharlal Institute of Postgraduate Medical Education & Research (JIPMER), Pondicherry, does not accept MS ENT postgraduates for PRS courses, unlike other premier institutes of INI.

Competition and selection: While increased competition can be an advantage, it can also make it more difficult for some good candidates to secure admission, particularly for applicants from a general surgery background. This could potentially discourage highly motivated individuals.

The decision to expand the eligibility criteria needs to be carefully considered and take into account the specific needs and goals of the uniform PRS training program. It is crucial to find a balance between expanding the applicant pool and ensuring the quality and adequacy of training. Additional courses, hands-on training, or rotations may be required in training programs to bridge any gap in knowledge and skills for candidates from ENT and orthopedics backgrounds.

The plastic surgery specialty can reap the benefits of broadening the eligibility criteria, but it should be done with care and a focus on maintaining the quality and consistency of training. The objective should be to produce plastic surgeons proficient in providing patients with high-quality care, regardless of their previous surgical training.

Conflict of Interest

None declared.

• References

• 1 Post Graduate Medical Education Regulations-2023 draft. Accessed September 26, 2023 at: https://www.nmc.org.in/MCIRest/open/getDocument?path=/Documents/Public/Portal/LatestNews/MER.pdf
• 2 Institute of National Importance-INI-SS Prospectus July 2023. Available at: https://iniss.aiimsexams.ac.in/Data/INISS%20Prospectus%20Part%20A%20JULY-2023.pdf
• 3 Kamali P, van Paridon MW, Ibrahim AM. et al. Plastic surgery training worldwide: part 1. The United States and Europe. Plast Reconstr Surg Glob Open 2016; 4 (03) e641
• 4 American Board of Plastic Surgeons. 2023-BOI-Training-requirements.pdf (abplasticsurgery.org). 2023. Accessed September 23, 2023 at https://www.abplasticsurgery.org/media/21144/2023-BOI-Training-requirements.pdf
• 5 Kadam D. NEET super-specialty intake: a paradox of demand and supply or the eligibility?. Indian J Plast Surg 2021; 54 (01) 1-3

Publication History

Article published online:
03 November 2023