Keywords
plastic and reconstructive surgery - medical students - teaching - medical school
- United Kingdom - curriculum
Introduction
Despite plastic and reconstructive surgery existing since 600 BC in India, it was
only since the work of Sir Harold Gillies in World War I that plastic surgery grew
as a specialty in the United Kingdom.[1] Initially, plastic surgery teaching began through case-based teaching, with techniques
being passed on from one individual to another, such as from Gillies to Archibald
McIndoe. Since World War II, however, there was a greater push for the introduction
of plastic surgery into the curriculum, with Gillies stating it should be a “a fully-fledged
and desirable medical school subject for educating undergraduate students.”[2]
However, little has been reported on medical students' exposure and teaching methods
regarding plastic surgery. Indeed, plastic surgery teaching has lagged behind other
major surgical specialties (such as urology, which is compulsory in 76% of medical
schools in Europe[3]), with some medical schools not including any plastic surgery teaching. The hypotheses
for this are variable: some state that the medical school curriculum is already too
intense to include plastic surgery in the curriculum,[4] while others feel that greater focus is being given toward preparing more general
practitioners (GPs). However, GPs also require a good grasp of plastic surgery in
managing skin cancers, reassuring parents of those with cleft lip/palate, and ensuring
adequate referrals. Furthermore, with adequate plastic surgery teaching, when medical
students qualify as future surgeons and GPs, they feel more adequately prepared to
deal with cases of hand injuries and burns, have better surgical skills,[5] and are more likely to pursue plastic surgery as a career.[6]
To date, no systematic review has been performed looking at the teaching of plastic
surgery to United Kingdom medical students. Thus, this systematic review will aim
to assess plastic surgery teaching for United Kingdom medical students, and answer
several key questions, namely the following:
-
To what extent is plastic surgery taught to medical students?
-
By which methods is plastic surgery taught?
-
What could be done to improve plastic surgery teaching in the undergraduate curriculum?
Methods
The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Checklist
was used to report the results.
Inclusion Criteria
Studies assessing plastic and reconstructive surgery teaching in the undergraduate
medical school curriculum were included. Letters to the editor, original articles,
editorials, technical notes, and cross-sectional surveys were all included. Only studies
conducted in the United Kingdom and published after 2011 were included. This was because
teaching methods may have changed since older studies were published.
Exclusion Criteria
The following exclusion criteria were applied:
-
Studies that involved qualified doctors, and not medical students.
-
Studies that looked at internships in plastic surgery after qualifying from medical
school.
-
Studies outside the United Kingdom.
-
Studies solely looking at the COVID-19 pandemic.
-
Studies that did not focus on plastic surgery training in the undergraduate curriculum.
-
Studies published before January 1, 2011.
Search Methods
PubMed, Medline, Embase, and Cochrane were searched from July 19 to 25, 2023. The
reference lists of articles were also searched. The search terms included “medical
students” AND “plastic and reconstructive surgery” AND “teaching” AND “UK.”
Data Collection
Initially, the titles of the articles were screened by reviewing the abstracts of
the articles. Following this, any duplicates that were present were removed from the
search. Then, the full texts of the studies were obtained, and any studies that did
not fulfil the inclusion/exclusion criteria were removed. This was performed by two
independent researchers (AK1 and SM), and following completion, the results were compared.
Any differences that arose between the two researchers were then settled. Where there
still existed any disagreement, a third researcher (AK2) decided whether the study
should be included. Once the studies were identified, they were screened for the risk
of bias. This was done by using the modified tool for screening nonrandomized trials
by Viswanathan et al.[7]
Search
Searches of PubMed, Embase, and Medline revealed 121 studies (PubMed = 63; Embase = 32;
Medline = 26). No additional studies were identified from the reference lists. Forty-one
abstracts were identified; following this, the full texts were screened, after which
15 studies were identified.[8]
[9]
[10]
[11]
[12]
[13]
[14]
[15]
[16]
[17]
[18]
[19]
[20]
[21]
[22] Any studies that did not fulfil the inclusion criteria or fulfilled the exclusion
criteria were removed from the search. See [Fig. 1] (the PRISMA flowchart) for a complete visual representation of how the 15 studies
were identified.
Fig. 1 PRISMA flowchart.
Of the 15 studies that were included in this systematic review, 11 were cross-sectional
studies,[8]
[9]
[10]
[11]
[12]
[13]
[14]
[15]
[16]
[17]
[18] 2 were letters to the editor,[19]
[20] 1 was a comparative study,[21] and 1 was a pilot study.[22] All the studies were published in English and were published after 2011.
Results
Current Exposure to Plastic Surgery
Across the studies, there were varying reports of medical students' current exposure
to plastic and reconstructive surgery (see [Fig. 2]), with some studies (n = 4) not reporting current exposure to plastic surgery.[9]
[14]
[18]
[20] There was a great deal of variance in exposure between the studies: for example,
at the University of Glasgow, Higgins and Thomson asserted that there was no current
exposure to plastic and reconstructive surgery,[22] whereas according to Khatib et al, 71% of medical students had received teaching
(either formal or informal) in plastic surgery.[11] Medical students' average exposure to plastic surgery was 29.44% across all the
studies; however, it has to be noted that there were varying sample sizes between
the studies, which may lead to bias.
Fig. 2 Bar chart showing current exposure to plastic surgery teaching.
What was thus needed was a study that aimed to assess all medical students' exposure
to plastic surgery, comparing different medical schools. Only the study by Wade et
al,[17] which collected its data between October 2010 and May 2011, did so. They reported
that only 16.5% of medical students had received formal teaching in plastic surgery,
and only 20.4% had clinical attachments to the specialty.
How Is Plastic Surgery Currently Being Taught?
Studies listed a variety of ways in which plastic surgery was being taught (see [Fig. 3]), and some studies mentioned more than one way in which plastic surgery was being
taught (when this was the case, equal weightage was given to each suggestion, e.g.,
if three methods of teaching were recommended in one study, each one was given one-third
weightage). The most common method of teaching plastic surgery was through lectures
(34%), followed by integrated clinical placements (19%). The lecture-based format
of teaching plastic surgery was largely in the earlier years of medical school (years
1 and 2), whereas clinical placements predominated years 3, 4, and 5. Other methods
of teaching were courses (15%), which were run by medical school surgical societies
and the British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS):
these were often over 1 day and had lectures by plastic surgeons and then some workshops
to practice practical skills. Some courses were free to attend, whereas others had
a cost associated with them. Other reported methods included the following: peer-assisted
learning (7%), where students were taught by fellow students; modules (11%), which
were delivered online and had information relating to plastic surgery; electives (4%),
which were self-organized; and national mentoring schemes (10%), where students collaborated
with plastic surgeons.
Fig. 3 Pie chart showing current methods of plastic surgery.
How Do Authors Recommend Plastic Surgery Be Taught?
There were varying suggestions as to how plastic surgery be taught, with some new,
innovative ideas. It is important to note that not all studies made recommendations
on how plastic surgery be taught, and some suggested that plastic surgery be taught
through all of the methods described in [Fig. 4] (when this was the case, such studies had their results evenly distributed).
Fig. 4 Pie chart showing how authors recommend plastic surgery to be taught.
Interestingly, the most common way of teaching plastic surgery was through voluntary
courses (40%), most of which had the format described in the previous section. However,
some courses incorporated newer techniques, such as a three-dimensional (3D) virtual
flap course. Lectures were the second most common way (20%) of plastic surgery being
taught; these were suggested in various guises, with some suggesting a 90-minute introductory
plastic surgery lecture, whereas others mentioned that plastic surgeons should educate
and examine medical students. Yoong et al suggested teaching through consultant led
peer-assisted learning[9] (10%): this would involve students learning surgical skills through a video developed
by a plastic surgeon, and then practicing this in person. Rodrigues et al suggested
a mentoring scheme[20] (10%): they emphasized that particular focus be given to having local mentors with
whom students can collaborate in multiple domains, such as teaching, attending theater,
and research. Finally, Smeeton et al made the innovative suggestion that plastic surgery
be taught through live surgery[18]: this would involve a surgeon doing a procedure that is being live-streamed to a
lecture hall of medical students and a prerecorded transcript being played. Students
would also have the opportunity to ask questions as the surgery proceeded. Further,
7 of the 15 studies recommended a voluntary form of teaching[9]
[11]
[12]
[13]
[14]
[16]2-, 5 recommended compulsory teaching,[10]
[15]
[17]
[18]
[22] and 3 suggested both.[8]
[19]
[21]
Risk of Bias
A drawback of this systematic review is that 12/15 of the studies[8]
[9]
[10]
[11]
[12]
[13]
[14]
[15]
[16]
[18]
[19]
[20] were deemed to have a high risk of bias. This is because two were letters to the
editor,[19]
[20] with no cross-sectional study performed and were thus viewed as being highly opinionated.
Most of the cross-sectional studies,[8]
[9]
[10]
[11]
[12]
[13]
[14]
[15]
[16]
[18] apart from the study by Wade et al,[17] were also deemed as being at high risk of bias: this is because they all had small
sample sizes and the data analysis was done with no blinding or control; for example,
the organizers of the intervention (such as a plastic surgery teaching course) did
the data analysis. The cross-sectional study by Wade et al[17] was deemed as being at low risk of bias as it was a nationwide study with a large
sample size. The study by Farid et al[21] was also rated as low bias. This was because it had a large sample size of 243 and
a control group. The study by Higgins and Thomson[22] was rated as medium bias. This was because despite a sample size of 160, there was
no blinding or control.
Discussion
Currently, plastic and reconstructive surgery is greatly under-represented in the
medical school curriculum, with 85% of medical students being unable to name five
conditions treated by a plastic surgeon.[23] Even if one does not want to pursue plastic surgery as a specialty, a thorough understanding
of plastic surgery is vital, in ensuring adequate referrals to plastic surgeons,[24] to ensure patients get the care that they need. Despite the comments of Walsh,[4] who suggested that the medical school curriculum is already too dense to facilitate
the learning of yet more information, teaching plastic surgery would have first-rate
dividends. Not only would it inspire the future generation of plastic surgeons,[7] but it would also ensure better patient care.[25]
It is interesting to note that there was a great degree of variance in the reported
exposure to plastic surgery, with estimates varying from 0 to 71%. One possible reason
for this may be varying definitions of plastic surgery. While some authors may have
defined plastic surgery teaching solely as teaching delivered by a plastic surgeon,
others may have had a looser definition, including preclinical teaching on the physiology
of burns and general surgery teaching on ulcer management.
Another possible reason for this may be local variance in teaching exposure due to
the setup of hospitals, as not all studies analyzed nationwide data. Generally, three
possibilities exist regarding plastic surgery setups at different hospitals:
-
Hospitals have a plastic surgery department.
-
Hospitals have a qualified plastic surgeon as a part of general surgery/trauma team.
-
Hospitals do not have a plastic surgery department.
As one progresses from option 1 to 3, plastic surgery teaching to medical students
is likely to decline considerably.
It is important that students who are placed at hospitals that have no plastic surgery
department receive some form of exposure to plastic surgery. One possible way of doing
this is to train a general surgeon, who has an interest in teaching and plastic surgery,
to a basic level in plastic surgery content and methods through a BAPRAS course. The
general surgeon can then deliver compulsory teaching to medical students who can then
be assessed to judge how much they have learnt. The general surgeon is an apt individual
to do so, since general surgery is the mother of all surgical specialties, thus being
an amalgamation of surgical specialties and super-specialties. Therefore, the general
surgery curriculum contains all the necessary parts of the surgical super-specialties
required to be an apt clinician and GP. Since GPs are increasingly coming into contact
with patients who have varicose ulcers, skin cancers, and cleft lip/palate, a thorough
understanding of plastic/general surgery is imperative to ensure that patients receive
optimal care from the GPs and clinicians of the future. This must be done through
appropriate methods, such as teaching by a plastic or general surgeon, such that biased
sources can be avoided.
Furthermore, it is imperative that the current exposure of medical students to plastic
surgery is studied once again, since the latest nationwide survey was conducted between
October 2010 and May 2011 by Wade et al,[17] which was over 12 years ago. Much can change in the span of 10 years in teaching,
and thus it is imperative that another study be conducted, reviewing the current exposure
of medical students to plastic surgery and teaching methods. We suggest that a nationwide
analysis be conducted every decade, surveying medical students, lecturers, and consultants.
This is to assess how exposure and teaching methods are evolving over time, allowing
for any trends to be tracked.
For those currently exposed to plastic surgery, the main method of teaching is through
lectures and clinical placements, accounting for 53% of current teaching methods.
However, there is little literature on what students are being taught in their lectures
and placements. It is highly important that this is also investigated every 10 years
through a nationwide analysis, such that the learning outcomes can be streamlined
across medical schools, to ensure standardization of curricula.
For those not exposed to plastic surgery, there are many ways to improve the exposure
of undergraduates to plastic surgery. Despite the most common suggestion being courses
for medical students (40%), care must be taken before these are prescribed as the
main method of teaching medical students. This is because running a compulsory course
for an entire year group of medical students (which can be in excess of 400) requires
lots of venue space and equipment, which is not always possible. Furthermore, external
courses, such as those run by the Association of Surgeons in Training (ASiT) and BAPRAS,
can be very expensive, especially when one accounts for registration fees, travel
costs, and accommodation costs. This may serve to further the notion that plastic
and reconstructive surgery is a specialty merely for the elite and rich,[26] thus barricading those from poorer backgrounds.
It is important that the method of teaching plastic surgery to undergraduates is one
that appeals to those without a prior interest in it and is also accessible to all.
This is such that plastic surgeons are recruited from all backgrounds and ethnicities.
The only successful way of doing so is through lectures and integrated clinical placements.
Once this foundation is achieved, voluntary forms of teaching, like mentorship schemes,
can be added for those in whom an interest has been sparked.
It is also interesting to compare these results on a broader international scale.
Studies show that lack of plastic surgery teaching to medical students is a global
phenomenon, with a similar dearth in teaching to medial students also being reported
in India,[27] Canada,[28] the United States,[29] and Saudi Arabia.[30] In India, as a result, the majority of plastic surgery teaching is delivered through
general surgery teaching. Due to the difficulty in incorporating surgical super-specialties
into the standard medical curriculum, more novel ways of teaching plastic surgery
have been developed. For example, where plastic surgery departments are not available
to medical students, online classes have been run by plastic surgeons from different
hospitals. These provide medical students with a vital insight into what plastic surgery
entails, and thus hope to spark a future interest in the specialty. Moreover, with
the recent change to the competency-based curriculum in 2020,[31] advances have been made in plastic surgery teaching. For example, as per the National
Medical Commission guidance, there are now voluntary electives at the end of the third
year of medical school, and students may choose to do this in plastic surgery (if
there is a local plastic surgery department). This aims to increase medical students'
interest in plastic surgery and to develop research opportunities. However, much like
the United Kingdom, this is optional and thus inevitably favors those with a prior
interest in plastic surgery. Therefore, it is important that there is a push globally
toward incorporating plastic surgery into the mandatory curriculum to ensure a baseline
level of competency and equitable access for all.
Conclusion
The BAPRAS logo incorporates a salamander, as it is able to marvelously adapt and
regenerate lost limbs, thus restoring form and function. Plastic surgery, in the past
100 years, has been metaphorically analogous to a salamander. It has marvelously adapted
to new innovations and methods. However, the proper teaching of plastic surgery to
medical students has been like a crocodile: prehistoric and slow to incorporate students.
This limited exposure to plastic surgery has meant that many incoming junior doctors
feel that they are unable to deal with plastic surgery emergencies, and has perhaps
meant many medical students have written off plastic surgery as a career due to inadequate
exposure.
It is now time for the teaching of plastic surgery to medical students to evolve and
change from a crocodile to a salamander for the better.
