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Maintaining standards of aesthetic practice

in trainees subject to NHS restrictions*

P. Paterson*, K. Allison

McIndoe Surgical Centre, East Grinstead, West Sussex, UK

Received 11 September 2004; accepted 16 October 2005

KEYWORDSAesthetic training;Fellowshipprogrammes

Summary The Specialist Advisory Committee (SAC) in plastic surgery within theUnited Kingdom (UK) recommends a modular training programme to includeaesthetic surgery. The intercollegiate board examinations test candidates on allaspects of aesthetic practice yet there is no formal, national aesthetic training in theUK. Closure of National Health Service (NHS) private patient facilities has reducedtraining opportunity [Nicolle FV. Sir Harold Gillies Memorial Lecture; Aestheticplastic surgery and the future plastic surgeon. Br J Plast Surg 1998;51:41924.]Calmanisation [Hospital doctors: training for the future. The Report of the WorkingGroup on Specialist Medical Training (The Calman Report). London: HMSO; 1993.],the European Working Time Directive (EWTD) [www.rcseng.ac.uk/ewtd/consul-tants_html; Phillips H, Fleet Z, Bowman K. The European Working time Directive

interim report and guidance from The Royal College of Surgeons of England workingparty chaired by Mr Hugh Phillips; 2003 [http://www.rcseng.ac.uk/services/publications/publications/index_html?pub_idZ68]; Chesser S, Bowman K, PhillipsH. The European Working Time Directive and the training of surgeons. BMJ CareersFocus 2002;s697.], and more importantly the implementation of local aestheticguidelines have placed further pressures on training. Reductions of NHS case mix willultimately lead to a reduction in trainee experience. With increasing regulatorypressure from the Commission for Healthcare Improvement, standards of aestheticpractice can only be maintained by increasing private/independent sectorinvolvement. At present a disparity exists between the demand and provision ofaesthetic surgery training in the UK. Aesthetic surgery forms part of the trainingcurriculum for plastic surgery and as such remains a training issue. A review ofaesthetic surgery training is needed in the UK through consultation with trainers andtrainee representatives.q 2005 The British Association of Plastic Surgeons. Published by Elsevier Ltd. Allrights reserved.

Journal of Plastic, Reconstructive & Aesthetic Surgery (2006) 59, 856859

S0007-1226/$ - see front matter q 2005 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights reserved.doi:10.1016/j.bjps.2005.10.006

*Poster presentation summer BAPS. Presentation BAAPS.* Corresponding author. Address: Department of Plastic

Surgery, Royal Preston Hospital, Sharoe Green Lane, Preston,Lancs, UK.

E-mail address: ppaterson1@btconnect.com (P. Paterson).

http://www.rcseng.ac.uk/ewtd/consultants_htmlhttp://www.rcseng.ac.uk/ewtd/consultants_htmlhttp://www.rcseng.ac.uk/services/publications/publications/index_html?pub_id=68http://www.rcseng.ac.uk/services/publications/publications/index_html?pub_id=68http://www.rcseng.ac.uk/services/publications/publications/index_html?pub_id=68http://www.rcseng.ac.uk/services/publications/publications/index_html?pub_id=68http://www.rcseng.ac.uk/services/publications/publications/index_html?pub_id=68http://www.rcseng.ac.uk/services/publications/publications/index_html?pub_id=68http://www.rcseng.ac.uk/ewtd/consultants_htmlhttp://www.rcseng.ac.uk/ewtd/consultants_html

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Method

Using an e-mail database and the British Associationof Plastic Surgeons (BAPS) handbook, 70 UKSpecialist Registrars (SPR) in plastic surgery wereidentified and contacted throughout the UK. Theywere asked to complete a questionnaire on their

experience of several index aesthetic proceduresand exposure to private patient clinics. To identifywhich factors of NHS modernisation threatenedtrainee experience, the aesthetic experience ofCalman and pre-Calman registrars (nZ10) withinthe West Midlands were compared. To establish theimpact of locally arranged aesthetic guidelines,trainees prior to implementation were comparedwith those subject to NHS restrictions.

Results

Fifty-one of 70 questionnaires were completed, with41 within the target training years of 46 (Chart 1).Although 35 senior trainees expressed an interest inprivate practice only four felt prepared (Chart 2).Senior trainee operative experience is shown in(Chart 3). Closer analysis demonstrates that out of41 trainees nine had no experience of a browlift(Chart 4), four had never seen a blepharoplasty(Chart 5) and five had never seen a rhinoplasty(Chart 6). When asked about private sector trainingopportunities; 11 trainees were invited to privateoperating sessions, eight indicated that these ses-sions were timetabled and only seven had attended aprivate consultation (Chart 7). Twenty-eight traineeswere considering an aesthetic fellowship but allagreed that aesthetic training should be formallyincluded in the training programme (Chart 8). When

looking at the impact of Calmanisation; Calman andpre-Calman log books showed no difference in

experience. However, trainees prior to the introduc-tion of aesthetic guidelines (nZ8) had greaterexperience and more confidence than those subjectto restrictions.

Discussion

Aesthetic surgery is considered a major componentof plastic surgical training like skin oncology,paediatric or burns surgery. Like most countries,healthcare in UK is provided by the state through

taxation and also by the private/independentsector where patients choose to pay. The NHS hasresponsibilities for healthcare and the training ofdoctors within a tight financial budget. Rationalis-ation of these finances within the NHS has meantthat a large number of plastic surgical procedureshave been withdrawn and with it trainee experi-ence. Reduced NHS training opportunities havebeen compounded by limited exposure of trainees

Chart 1

Chart 2

Chart 3

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to the private/independent sector. Thirty five outof 41 trainees were interested in private practiceyet only 11 were invited to attend private theatresessions and only seven had any experience of aprivate consultation. The consultation sets up the

relationship between doctor and patient and inaesthetic surgery is fundamentally different to mostconsultations within the NHS, which are based onclinical need. It is only by clinic attendance thattrainees will begin to identify that subgroup ofpatients with unrealistic expectations of surgery.Low clinic attendance may be explained byconcerns that private patients might object to thepresence of a registrar/fellow in clinic. Theexperience of the aesthetic fellows at the McIndoeSurgical Centre has been different. It is commend-able that out of the 11 trainees who were able to

attend private operating sessions eight had it builtinto their training timetable. Like Mr F.V. Nicolle,1

we have seen a fundamental change in the way thatPlastic Surgical Services are provided. Calmanisa-tion2 and the EWTD35 have streamlined andshortened training programmes. Within the West-Midlands region Calmanisation appears to have hadlittle impact on aesthetic training with pre-Calmanand post-Calman trainees having similar log bookexperience. The implementation of local purchas-ing agreements and aesthetic guidelines appears tohave impacted on plastic surgical trainees the

most. Established consultants, i.e. those whowere trainees prior to the implementation ofpurchasing contracts were questioned on theiraesthetic experience. Unlike trainees subject tolocal aesthetic guidelines they had performed large

numbers of mastopexies, augmentations and rhino-plasties and felt more confident about theirpractice. Although the study group is small itrepresents the current situation in one region.Continued reductions of NHS case mix and trainingtime will undoubtedly have an impact on the levelof experience that future consultant plastic sur-geons possess. Reduced training opportunities arenot confined to the UK, several papers from the USAand Canada demonstrate a similar lack of trainingopportunity and propose models for setting upaesthetic programmes.68 At a time of increasing

litigation, private hospitals need to limit theirliability by ensuring that consultants are properlytrained. This responsibility falls on the MedicalAdvisory Committee whose responsibility it is togive admitting rights to those who can provecompetency. This study shows that although mosttrainees have logbooks showing experience, ninesenior trainees had never seen a browlift, four hadnever seen a blepharoplasty and five had noexperience of a rhinoplasty. Given that privatesector opportunities were limited it can be assumedthat most experience was gained within the NHS.

Chart 4

Chart 5

Chart 6

Chart 7

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Aesthetic techniques may benefit patients withinstate run hospitals as well as the independantsector although the indications may differ. Withinthe NHS treatment is based on clinical need, i.e.blepharoplasty for blepharochalasis; rhinoplasty

following trauma; breast augmentations for asym-metry or absence. Mastopexies help correct tubularbreast deformities and facelifts provide staticimprovement following facial palsy and faceliftflaps may be raised during parotidectomy. Withincreasing financial pressure from fund holderssome Primary Care Trusts (PCTs) are beginning toquestion the benefits of what remaining nononco-logical or trauma based plastic surgical proceduresexist. With a reduction in case mix and movementof what were once routine plastic procedures tothe private/independent sector; future traineeswill need to look outside the NHS for their

experience. Twenty-eight senior trainees wereconsidering a fellowship but all respondents agreedthat aesthetic training should be formalised withinthe training timetable. The current situation isthat; eight trainees have aesthetic modules builtinto their training timetable, 12 fellowships arerecognised by the SAC9 but only a small number areadvertised nationally. As self-directed adult lear-ners the onus remains with trainees to seek outaesthetic experience as an integral part of theireducational needs. However, aesthetic surgeryforms part of the training curriculum and as such

remains the responsibility of those for training toensure that opportunities are readily available andthat minimum standards are achieved. Trainingopportunities can be provided on a regional ornational level. Eight trainees were benefiting fromthe successful incorporation of aesthetic traininginto regional training timetables. This may be the

way forward and deserves further investigation.Fellowship programmes are another option forthose that are unable or unwilling to employ localtraining schemes. Like any industry, the private/independent sector in partnership with the BritishAssociation of Plastic Surgeons and the BritishAssociation of Aesthetic Plastic Surgeons will needto invest in the future by facilitating more fellow-ship programmes. For it is only by investing in futuretraining that standards of good practice will bemaintained and survival guaranteed.

References

1. Nicolle FV. Sir Harold Gillies Memorial Lecture; Aestheticplastic surgery and the future plastic surgeon. Br J Plast Surg1998;51:41924.

2. Hospital doctors: training for the future. The Report of theWorking Group on Specialist Medical Training (The CalmanReport). London: HMSO; 1993.

3. www.rcseng.ac.uk/ewtd/consultants_html.4. Phillips H, Fleet Z, Bowman K. The European Working time

Directiveinterim report and guidance from The RoyalCollege of Surgeons of England working party chaired by MrHugh Phillips; 2003 [http://www.rcseng.ac.uk/services/pub-

lications/publications/index_html?pub_idZ68].5. Chesser S, Bowman K, Phillips H. The European Working Time

Directive and the training of surgeons. BMJ Careers Focus2002;s69s70.

6. Schulman NH. Aesthetic surgical training: the Lennox HillModel. Ann Plast Surg 1997;38:30913.

7. Frieberg A. Challenges in developing resident training inaesthetic surgery. Ann Plast Surg 1989;22:1847.

8. Linder SA, Mele 3rd JA, Capozzi A. Teaching aesthetic surgeryat the resident level. Aesthetic Plast Surg 1996;20:3514.

9. Duncan CO, Ho-Asjoe M, Hittinger R, Nishikawa H,Waterhouse N, Coghlan B, et al. Demographics and macro-economic effects in aesthetic surgery in the UK. Br J PlastSurg 2004;57:5616.

Chart 8

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