What Attributes Make United States Plastic Surgery Programs Desirable? Perspectives from Medical Students and Residents

Plastic surgery is one of the most competitive specialties for residency application. In the 2021 Match cycle, integrated plastic surgery residency had the second-highest applicant-to-position ratio (1.57) and the lowest match rate of US MD seniors (72.1%).¹ As a result, plastic surgery attracts highly motivated applicants exhibiting strong United States Medical Licensing Examination® exam scores, a robust background in research, American Osteopathic Association (AOA) membership, and extensive subinternship experience.¹ In a 2016 survey conducted by Drolet et al, 91% of plastic surgery applicants believed an away rotation increased their likelihood to match to a program at which they rotated.² Consistent with this sentiment, applicants reported spending 13.7 weeks on plastic surgery rotations during medical school, including a mean of 9.2 weeks on away rotations.² Applicants and residency program directors agree that subinternships are mutually beneficial as an opportunity to make a good impression and find a “good fit.”^2,3 Therefore, the competitive residency application process places additional pressure on choosing programs for away rotations, application, and ranking. It is otherwise challenging for applicants to evaluate programs with which they have had little interaction.

Applicants routinely rely on online resources to learn about residency programs.⁴ With consideration of limited away rotation spots, residency programs are tasked with showcasing their assets and achievements online while anticipating applicant interests. Unfortunately, applicants often feel that program websites are incomplete and lack information that applicants use to stratify programs.⁵ In light of the COVID-19 pandemic, online resources have become increasingly important as a reference for applicants. Applicants in the 2021 Match had fewer opportunities to partake in away rotations and in-person interviews, thereby eliminating critical opportunities for subjective program assessment.⁶ Virtual interviews significantly limit an applicant’s interactions with a program and its residents,^7,8 and programs have addressed this need for engagement by increasing their accessibility online.⁹ Therefore, the criteria used by applicants to stratify residency programs should be of particular interest to residency program directors, faculty, and residents. Further, recent adaptations as a result of the COVID-19 pandemic may encourage a shift in applicant preferences to include specific virtual events.¹⁰

Currently, few studies exist that delineate the program attributes that factor into applicant preferences, particularly within plastic surgery. The National Resident Matching Program distributes a biennial survey to assess top considerations when choosing a residency program. Goodness of fit, interview day experience, and geographical location were the three most commonly cited factors for program ranking.¹¹ Atashroo et al reported that newly matched integrated plastic surgery interns highly valued the well-being of current residents, faculty mentorship, and strong research infrastructure.¹² A survey of Canadian final year medical students found that their interactions with specific mentors at a given plastic surgery program strongly impacted desire to train there.³ For independent plastic surgery applicants, however, overall operative training was prioritized above all else.¹³ This lack of consensus warrants further exploration. The aim of this study is to understand how prospective trainees choose and rank residency programs in plastic surgery. Further, desirable aspects of plastic surgery residency programs in the context of the COVID-19 pandemic were stratified in anticipation of a continually evolving application process.

An Institutional Review Board-approved cross-sectional analysis of data from an anonymous 7-question survey distributed via Qualtrics (Qualtrics, Provo, UT; Figure 1) was conducted. The survey was written to elucidate the desirable qualities of a plastic surgery resident training program. It was reviewed and refined by the plastic surgeon faculty, a statistician, and several current fourth-year medical students applying to plastic surgery residency as well as plastic surgery residents at the Tulane University School of Medicine. To quantify the relative value of various aspects of plastic surgery residency programs, the survey utilized a 3-point Likert scale in which items were categorized as “undesirable” (-1), neutral (0), or “desirable” (1). Sentiments were reported as mean ± standard error. Participants were additionally asked to reflect on which program characteristics were most important in their consideration of the program. The authors aimed to capture a convenience sample of plastic surgery-bound third- and fourth-year medical students and plastic surgery residents. Allopathic and osteopathic US medical students, international medical students, integrated-track residents, and independent-track residents were included. First- and second-year medical students, as well as trainees in a specialty other than plastic surgery, were excluded.

The survey was distributed to 103 program directors from 82 integrated and independent US plastic surgery residency programs via the American Council of Academic Plastic Surgeons (ACAPS). The survey was active from February 16th, 2021 through May 3rd, 2021. Respondents were permitted one-time access to the survey.

Data analysis consisted of both qualitative and quantitative results. Statistical analyses were processed with OpenMeta [Analyst]¹⁴ and STATA Statistical Software 16.0 (StataCorp, College Station, TX). Statistical significance was defined as a P-value <0.05. Chi-square tests were used to compare categorical outcomes and z-tests to compare population means.

A total of 50 surveys were completed and met criteria for inclusion in the final analysis. Most respondents identified as female (52%) and attended a US allopathic medical school (Table 1). Respondents included 32 current plastic surgery residents representing 28% of residency programs (n = 23 programs). The remaining 18 respondents were current third and fourth-year medical students applying to plastic surgery programs from 13 medical schools. The largest proportion of respondents were affiliated with institutions in the Midwest (32%; Figure 2).

Resident-reported happiness and well-being of residents was ranked the most desirable quality when choosing a program (1.00 ± 0.00, Figure 3). This was followed closely by resident autonomy (0.98 ± 0.02), large volume of operative and emergency room cases (0.96 ± 0.03), active faculty and peer mentorship (0.94 ± 0.3), and faculty responsiveness to feedback (0.92 ± 0.05). When asked to indicate which of the desirable program characteristics were most important, these five were also listed more frequently than the remaining choices (P <0.01, Figure 4).

Scores of program website quality and social media outreach were 0.58 ± 0.07 and 0.42 ± 0.08, respectively. There was no significant difference between their levels of desirability (P = 0.14).

In this study, the cohort exhibited mixed opinions with regards to research participation in residency.  Students felt that a mandatory research year during residency was the least desirable program quality (64% opposed; -0.50 ± 0.10), followed by the availability of a research year after medical school graduation (22% opposed; -0.12 ± 0.08). In a subgroup analysis of respondents with non-neutral responses (n = 39), 96% of current plastic surgery residents opposed a mandatory research year during residency, compared with 57% of medical students (P = 0.002). However, most respondents preferred to attend a residency program with a strong research reputation (60%; 0.54 ± 0.09), regardless of status as a resident or medical student (P = 0.91).

In the context of the COVID-19 pandemic, most respondents felt that virtual social events (i.e., meet-and-greets and happy hours) would most benefit current third- and fourth-year medical students (70%). Nearly half (46%) of respondents felt social media outreach was important (Figure 5).

With regard to non-academic and personal considerations, all six factors were deemed to be important when choosing a residency program (Figure 6). Location in a preferred geographical location was deemed the most desirable attribute (0.98 ± 0.02). Additionally, location was deemed “very desirable” more frequently than the other factors (P < 0.01) (Figure 7). 

Plastic surgery is a competitive specialty attracting highly qualified and competitive applicants. To maximize matching potential, it is essential that applicants prioritize programs at which they feel would be a “good fit.” In consideration of the COVID-19 pandemic and the development of compensatory virtual programming, applicant preferences regarding residency program attributes have evolved.¹⁵ This study gathered a regionally diverse sample of prospective plastic surgery applicants and current residents to provide an updated understanding of values associated with choosing a residency program for application. This study highlights attractive program characteristics with an aim to guide the development of more complete online resources for applicant appraisal. Further, programs are encouraged to consider these values to maximize the satisfaction for matched residents throughout their training.

Quality of Life

In recent years, the importance of residents’ physical and mental wellness has become a popular topic that may have a significant impact on patient care.^16,17 In this study, perceived resident wellbeing was the most desirable attribute for residency program consideration, with 100% of respondents noting its importance. This outcome echoes other studies in which plastic surgery resident happiness had a large positive influence on program ranking.^3,12 Also included among the top five factors were active faculty/peer mentorship and faculty responsiveness to feedback, which share a common theme of healthy interpersonal relationships and connectedness. Similarly, Zuo et al found that perceived collegiality and resident-staff relationships were the strongest factors attracting plastic surgery applicants.³ Atashroo et al also discussed “relationship-driven training” as the most significant factor influencing applicant perspectives of programs, which has historically not been exclusive to plastic surgery.^12,18

Resident autonomy and large case volume were ranked the second- and third-most positive factors. Autonomy has been cited elsewhere in the literature as a highly valued program attribute.³ This demonstrates applicants’ desire for opportunities to explore their interests, maximize clinical growth, and foster independence throughout their training. This desire to have more autonomy may increase as an individual moves to a higher level of training from medical student to chief resident. The two groups of respondents, medical students and residents, could represent a potential shift in perspective as trainees progress in their careers. In addition to attracting top applicants, interpersonal connection and resident happiness are crucial for preventing burnout. For plastic surgery residents, weekly ward rounds by senior surgeons and regular staff meetings have both been found to be protective against burnout as these program features limited depersonalization.¹⁹

Online Program Presence

In the context of a growing online community of programs and providers, it will be prudent for programs to showcase examples of resident happiness and wellness on their official websites and public social media. According to a 2021 study by Steele et al, 73% of surveyed applicants followed a plastic surgery residency social media account. As of October 2019, 73% of integrated programs had active Instagram accounts and this number has likely since increased.²⁰ Social media has evolved from personal to professional use, serving as an efficient and accessible avenue by which to reach prospective applicants. In contrast, 67% of surveyed applicants in the 2015 Match felt that program websites did not influence their program choice.¹² In this study, program website quality and social media outreach had a moderate influence on program interest, however these scores did not differ significantly. Although online presence itself may not be a critical consideration for applying to a program, the information conveyed online may be. Therefore, the authors encourage programs to update official websites and utilize social media as an informative recruitment tool.

In the 2021 Match, programs were obligated to adapt applicant interviews and season-long applicant outreach to an online format. Much of these virtual events were based around social events that took place in person in past cycles. The majority (70%) of the cohort in this study strongly valued virtual meet-and-greets and resident happy hours, which aligns with their interest in resident happiness. These types of events were some of the few ways applicants could have conversations with faculty and residents outside of formal interviews this past year. With consideration of long work hours in a 6- to 7-year-long program, plastic surgery applicants want to ensure that most of their waking hours are spent with a team that suits their personalities. Social events, therefore, serve to showcase the culture within a program in a way that cannot be communicated in text or during an interview. Social media similarly offers an insider look at a program, indicating why 46% of respondents felt that strong social media outreach was desirable in the context of the pandemic. However, the format of social media may be limiting, providing a selective portrayal of a program with a “highlight reel” rather than the day-to-day reality.

Respondents demonstrated strong preference for events that would showcase a program’s personality and culture. The authors recommend that programs allocate more time and funding towards resident well-being, team relationship building, and applicant outreach. Notably, online representation of programs was integral for shaping medical students’ opinions this past cycle, while residents who had already matched had no need to follow multiple residency social media accounts and websites.

Conditional Interest in Research

The cohort in this study exhibited mixed opinions regarding research participation in residency.  Sixty percent of respondents favored a program with a strong research reputation, whereas 64% reported disinterest in a mandatory research year within the residency curriculum. Respondents preferred to have the option to contribute to research, rather than dedicate a year of training to it. Interestingly, current medical students were less averse to a dedicated research year, possibly due to a previous positive research experience, a productivity-centered mindset formed in the application process, or interest in the flexibility offered within a year away from clinical duties. This may also suggest a change in mindset once the rigor of residency begins, although this assertion warrants further investigation.

The overall negative opinion of mandatory research years was likely due to the subsequent delay in residency graduation. After six years of residency, almost half of trainees opt to complete one or more clinical fellowships.²¹ Additionally, many residents have already committed significant time to research in medical school and/or residency. Mehta et al found that 25% of applicants to plastic surgery programs from 2013 to 2016 had participated in a dedicated research year.²² As research is becoming an increasingly important component of the residency application, upward trends in applicant publications or dedicated research years, or to have dedicated years for research before starting residency, have been noted.²³ Currently, there are five integrated programs that require a dedicated research year, and one that requires a research year for one resident per class. A research year may be viewed as a hurdle, rather than a goal, causing applicants to lose interest once clinical training starts.

An Ever-Changing Application Landscape and the Post-Pandemic Match

Virtual interviews are more convenient and less expensive than in-person interviews, eliminating travel-associated costs of time and money amid a busy fourth-year schedule. As a result, the authors question whether interviews will remain virtual following the lift of social distancing mandates. Although much of the interviewee etiquette and strategy for the two styles remain comparable, other qualities may be lost behind the screen.^24,25

Virtual interviews may limit opportunity for meaningful rapport with faculty and residents – a clear impairment considering respondents’ interest in interpersonal relationships and resident happiness. Applicants may also be challenged to appraise the interpersonal skills, professionalism, and culture of the residents and staff at a given program, making it difficult to identify a “good fit.”⁸ In a recent study of independent plastic surgery residents, 88.9% of respondents preferred to interview in-person than online.⁷ Programs should strongly consider ways to personalize applicant interactions in virtual contexts. Applicants’ strong preferences toward in-person interviews, however, may sway programs to resume the traditional interview process once feasible.

Program Environment

Geographical program location was strongly considered by participants in this study when choosing residency programs within plastic surgery, despite the competitive nature of the specialty. Previous studies have also described geographical location to be a key factor in program choice.^3,11 However, results of a study by Hashmi et al have suggested that an individual’s home region may impact their decision to stay there.²⁶ Compared with other regions within the United States, individuals from the northeast were most likely to match to plastic surgery programs in their home region, despite the widespread availability of programs.²⁶ Similarly, respondents expressed interest in a program within their preferred climate. This suggests that both programs and applicants may benefit from regional social events, thereby encouraging early communication with realistic program choices. However, geographic location may be subjective and involve multiple factors such as weather, safety, ease of access, cost of living, recreation, social support, and patient population. Further studies are needed to elicit the geographical considerations that may influence an applicant’s decision.

Unsurprisingly, at least 80% of respondents in this study also strongly valued ease of transportation and low cost of living, although these descriptions may be too subjective to evaluate cost-of-living cutoffs or the value of public transportation. Interest in a large city population may relate to respondents’ preference for a potentially large volume of operative and emergency cases reflecting their self-motivated interest in clinical growth.

Although the demographics of the respondent pool in this report are comparable to similar studies, the sample size in this report may be limited, representing only 28% of plastic surgery residency programs and thirteen medical schools.^12,27 This study depended on program directors to distribute the survey to residents and medical students. Therefore, the response rate cannot be elicited from this data. A re-distribution of this survey to program directors was not allowed by ACAPS due to new policies and guidelines from the research committee. Additionally, when combining data for analysis from residents and medical students, there may be a generalizability of the outcomes to what residents prefer versus what medical students think they value. The authors acknowledge the risks of nonresponse bias, as well as recall bias, in this study. An additional limitation is the use of weighted averages as a rating system, designed using a limited 3-point Likert scale. A 3-point Likert scale was used in this study to provide easier consolidation of the data collected from the surveys and allow respondents to respond in a timely manner.

In a survey of plastic surgery residents and prospective medical students, resident happiness and well-being was the single most desirable attribute of residency programs. Other desirable qualities included, but were not limited to, greater resident autonomy, high operative caseload, active faculty mentorship, and preferred geographical location. Although most respondents highly value programs with a strong research reputation, program-mandated research years were reported as undesirable by both residents and medical students. Among the novel outreach modalities introduced by plastic surgery residency programs during the COVID-19 pandemic, virtual meet-and-greets and resident happy hours were the most desirable. Moving forward, plastic surgery residency programs may seek to better integrate the preferences of residents and prospective students into their curriculum to attract high-quality applicants and continually improve the training experience.

Affiliations: Tulane University School of Medicine, New Orleans, LA

Correspondence: Magnus Chun, BS; mchun@tulane.edu

Disclosure: The authors report no financial or other conflicts of interest. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.