Highlights
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Plastic surgeons with large metropolitan-based practices were more likely to have trained in large urban areas for residency and fellowship.
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52% of subspecialty fellows and 46% of residents went on to establish practices over 500 miles apart from their respective training locations.
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Approximately 20% of residents and fellows established practices within 20 miles of their respective training institutions.
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There was no significant difference for average distance between fellowship and practice location or between residency and practice location when differentiating based on education background.
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The year of ABPS certification and gender also had no significant effect on the average distance between training location and current practice.
Keywords: Graduate, Geography, Trends, Practice location
Abstract
Background
The geographic proclivities of plastic surgery trainees have important ramifications for the field of plastic surgery.
Methods
Names of American Society of Plastic Surgeons (ASPS) members who were board-certified in 2000, 2005, 2010, 2015, and 2019 were compiled for a cross-sectional analysis of geographic trends.
Results
A total of 811 practitioners were reviewed, and 31 lacked sufficient data for further analysis. Plastic surgeons with large metropolitan-based practices were more likely to have trained in large urban areas for residency and fellowship (odds ratio of 4.06; 95% CI, 2.94 to 5.60, and odds ratio of 3.61; 95% CI, 1.90 to 6.85, respectively). 52% of subspecialty fellows and 46% of residents went on to establish practices over 500 miles apart from their respective training locations. Approximately 20% of residents and fellows established practices within 20 miles of their respective training institutions, and there was no significant difference for average distance between fellowship and practice location or between residency and practice location when differentiating based on education background (p = 0.16 and p = 0.22, respectively). The year of ABPS certification and gender also had no significant effect on the average distance between training location and current practice (p > 0.05).
Conclusions
Data showed some persistent geographic tendencies that inform future practice location. A small minority of trainees chose to establish practices in the immediate vicinity of training locations, and geographic trends were largely independent of subspecialty fellowship type, gender, and career length.
Introduction
In the United States, the growth of residency and fellowship training opportunities has enabled and educated increasing numbers of specialized practitioners within plastic and reconstructive surgery. There are vast differences in training programs with regard to mentorship models, caseloads, research experience and professional development [1], [2], [3]. Despite the dissimilarities, there is limited longitudinal study of the practice trends of these graduates as they join the wider workforce.
In the current literature, attention has been paid mostly to tracking the decision of graduates to pursue academic or private practice. While some trainees have aspirations to remain at academic institutions, others choose to branch out. In one study, roughly a third of craniofacial sub-specialists were found to remain in academic craniofacial roles following graduation, while another third assumed private practice positions [4]. A UCLA study found that fellowship graduates in the fields of craniofacial, hand and microsurgery pursued full-time academic positions in 48%, 27% and 20% of cases, respectively [5]. While these studies highlight and quantify a particular career-related tendency, they also miss out on other details to better clarify practice trends of plastic surgery trainees. Given the shortage of available positions for highly-trained specialists, further research is warranted to both track existing patterns and anticipate future developments. It is hypothesized that geographic proclivities portend future career decisions.
Geography is of relevant import considering the regional disparities in the job market. States with greater median per capita income have correspondingly higher densities of hand surgeons [6]. Similar trends are apparent in most if not all medical specialties and account for differences in health outcomes [7]. Specialized care is often clustered, thereby creating geographic restrictions. Women seeking implant-based breast reconstruction following mastectomy are required to travel farther on average for care than those desiring mastectomy alone, and those opting for autologous reconstruction travel the most, by comparison [8].
Large academic hospitals capable of delivering this kind of high-level care are typically concentrated in urban areas with a large patient volume to support such institutions. These medical centers are also, by definition, teaching centers. Early graduates who go on to practice at or near their training hospitals may be biased by a reluctance to stray too far from the nest. In many cases, trainees initially seek out programs on the basis of geography and identify location as a critical factor in forming a rank list [9,10]. At the same time, a desire by fellowship applicants to practice in the same city is seen as a negative or neutral factor for an applicant [11], [12], [13], [14]. Many fellowship programs look more favorably on applicants who already have secured employment in a distant location or intend to do so. In light of the significance of practice geography and the current lack of data in the literature, the authors sought to elaborate on these trends in a broad cross-sectional analysis and through stratification by education background, gender and year of American Board of Plastic Surgery (ABPS) certification. Various metrics related to geography were collected to form a more comprehensive summary of these trends.
Methods
Data collection
The ASPS maintains a roster with names and basic demographic information for its members. The society estimates that its membership includes 93% of board-certified plastic surgeons in the United States. Searches based on the year of board certification were conducted to compile a thorough list of American-based plastic surgeons starting their careers in the years 2000, 2005, 2010, 2015, and 2019. The decision was made to collect from a range of time points in order to capture possible differences in geographic tendencies based on career length. Since the present study was cross-sectional in nature, the ability to longitudinally track surgeons who may have transitioned between practices was lost. The inclusion of practitioners both new and seasoned in practice would therefore help to clarify theoretical differences in geographic trends that may develop over the span of a career.
Online searches using the names from the roster helped to uncover information related to education background, fellowship experience, training location and current practice location. Locations were recorded based on zip code to assist with further analysis. Those with multiple fellowships were considered individually within the cohort for each fellowship type. Training outside the United States was not included for further analysis as the study was designed to focus specifically on local and national trends. The addition of international movements was theorized to sway trends through significant outliers. Collectively, 1.9% of residents and 7.0% of fellows underwent their respective training abroad, and this data was thereafter excluded from further analysis. All information collected was from publicly available sources online.
Data analysis
For those with multiple practice locations, the first listed on the website was used for comparison. Distances between locations were calculated as a straight-line measure based on zip code coordinates. Measures of proximity were made by stratification into pre-determined groups of less than 20 miles, between 20 and 100 miles, between 100 and 500 miles, and over 500 miles. The determination of metropolitan-based versus non-metropolitan-based locations was done through cross-referencing data from the Department of Agriculture rural urban continuum codes. Zipcodes were determined to be part of a specific county if most of the region falls within that county. Counties with an urban influence code of 1 have a population of over 1 million people, while the remaining codes belong to less populated locales.
Descriptive statistical analyses were used to draw conclusions and inform comparisons between practitioners. For comparisons of the means between more than two cohorts, a single-factor ANOVA test was used. For comparisons between two cohorts, a Student's t-test was used to compare means, and associated p values below 0.05 were deemed significant. Calculations of odds ratios and 95% confidence intervals for the study population were used to compare the association between metropolitan training location and metropolitan practice location.
Results
The total number of ASPS members who achieved board certification in the years 2000, 2005, 2010, 2015 and 2019 was 811. Due to insufficient online data regarding education background or practice location, 31 plastic surgeons were excluded from further study, leaving a total cohort of 780 American-based plastic surgeons. This group included 324 subspecialty fellows (41.5% of total cohort) in the fields of esthetic surgery, craniofacial surgery, hand surgery and microsurgery. 24.0% of the study cohort was female. 69.1% of clinicians had practices in large metropolitan centers.
Graduate geography by education background
On average, fellowship graduates established practices 750.1 miles from fellowship training grounds, and residency graduates established practices 658.7 miles from residency institutions, though this difference was not significant (p = 0.06). Across all cohorts, there was no significant difference in the average distances between fellowship and current practice or between residency and current practice with respect to subspecialty training or lack thereof (p = 0.16 and p = 0.22, respectively). Table 1 displays the average distances between training location and practice location based on education background.
Table 1.
Graduate geographic patterns in current practice. Summary of average distances between current practice location and training location. Cohorts were divided by subspecialty training. The group termed “other” represents those with another form of subspecialty fellowship training or no subspecialty fellowship training.
| Average Distance Between Fellowship and Current Practice | |
|---|---|
| Sub-specialty Fellowship Type | Average (miles) |
| esthetic | 758.4 |
| Craniofacial | 912.8 |
| Hand | 760.1 |
| Microsurgery | 612.3 |
| Average Distance Between Residency and Current Practice | |
|---|---|
| Sub-specialty Fellowship Type | Average (Miles) |
| esthetic | 645.2 |
| Craniofacial | 870.8 |
| Hand | 662.9 |
| Microsurgery | 665.6 |
| Other | 631.6 |
In order to further clarify differences in geographic spread based on education background, distances were stratified into distance categories of under 20 miles, between 20 and 100 miles, between 100 and 500 miles and over 500 miles. Craniofacial fellows were most likely to establish practices over 500 miles apart from their fellowship training location. Additionally, microsurgery fellows were most likely to remain within 20 miles of fellowship training locations, and this may explain a comparatively shorter average distance between fellowship location and current practice location for the cohort. Graphic representations for the breakdowns of relative distances between training location and current practice are summarized in Figs. 1 and 2. For the entire study population, approximately 20% of trainees were found to remain within 20 miles of their respective training institutions. Figs. 3 and 4 are map plot representations of the geographic spread from education location to current practice.
Fig. 1.
Proportion of relative distances between fellowship and current practice location based on education background.
Fig. 2.
Proportion of relative distances between residency and current practice location based on education background.
Fig. 3.
Map plot showing the geographic spread from residency location to current practice.
Fig. 4.
Map plot showing the geographic spread from fellowship location to current practice with colors connoting differences in fellowship type.
Effect of career length on geographic spread
Overall, there was no significant difference in the average distance from fellowship or residency training to current practice when cohorts were grouped by year of board certification (p = 0.68 and p = 0.27, respectively). Table 2 displays the average distances between training location and practice location based on year of board certification. Cohorts were then subdivided to determine the relative proportions for distance categories between training and current practice as was performed earlier. These breakdowns are summarized in Figs. 5 and 6. In this analysis as well, there was a consistent finding whereby approximately 20% of trainees remained within 20 miles of their training institution.
Table 2.
Geographic patterns in current practice with respect to career length. Summary of average distances between current practice location and training location. Cohorts were divided by year of board certification.
| Average Distance Between Fellowship and Current Practice | |
|---|---|
| Year of Board Certification | Average (miles) |
| 2000 | 733.6 |
| 2005 | 715.7 |
| 2010 | 639.6 |
| 2015 | 782.5 |
| 2019 | 851.6 |
| Average Distance Between Residency and Current Practice | |
|---|---|
| Year of Board Certification | Average (Miles) |
| 2000 | 678.0 |
| 2005 | 631.3 |
| 2010 | 732.9 |
| 2015 | 683.1 |
| 2019 | 551.4 |
Fig. 5.
Proportion of relative distances between fellowship and current practice location based on year of certification.
Fig. 6.
Proportion of relative distances between residency and current practice location based on year of certification.
Comparison of geographic spread by gender
Data showed no statistical difference for the average distance between current practice and residency or fellowship locations when female plastic surgeons were compared to their male counterparts (p = 0.29 and 0.10, respectively). Similar to previous cohort groupings, roughly a fifth of residents and fellows remained within 20 miles of their training location regardless of gender. Table 3 summarizes these findings.
Table 3.
Comparison of geographic spread based on gender. Summary of geographic trends based on gender.
| Proportion of Total Cohort | |
|---|---|
| Female | 187/780 |
| Male | 593/780 |
| Average Distance from Residency to Current Practice Location (miles) | |
| Female | 612.0 |
| Male | 674.2 |
| Average Distance from Fellowship to Current Practice Location (miles) | |
| Female | 643.2 |
| Male | 788.8 |
| Proportion of Plastic Surgeons Remaining within 20 Miles of Residency Location | |
| Female | 23.4% |
| Male | 19.4% |
| Proportion of Plastic Surgeons Remaining within 20 Miles of Fellowship Location | |
| Female | 17.6% |
| Male | 19.8% |
Effect of metropolitan training location on future metropolitan practice location
A large majority of the study cohort both trained and established practices in large metropolitan areas. For those with a history of training in a large metropolitan area, nearly 80% went on to establish practices in similar locales. By contrast, those with training experience in less populated regions went on to establish practices in large metropolitan centers only about half of the time. These findings are summarized in Table 4. Collectively, clinicians with large metropolitan-based practices were much more likely to have trained in large urban areas for residency and fellowship (odds ratio of 4.06; 95% CI, 2.94 to 5.60, and odds ratio of 3.61; 95% CI, 1.90 to 6.85, respectively).
Table 4.
Effect of metropolitan training location on metropolitan practice location. Summary of geographic trends based on metropolitan influence.
| Proportion of Cohort in Large Metropolitan Area | |
|---|---|
| During Residency | 68.0% |
| During Fellowship | 86.5% |
| For Current Practice | 69.5% |
| Fraction with Practice Location in Large Metropolitan Area | |
| With Residency Training in Large Metropolitan Area | 79.3% |
| With Residency Training in Less Populated Area | 48.6% |
| Fraction with Practice Location in Large Metropolitan Area | |
| With Fellowship Training in Large Metropolitan Area | 78.3% |
| With Fellowship Training in Less Populated Area | 50.0% |
Discussion
Fellowship and residency directors may express concerns about training their future competition. Particularly in the case of fellowship, there is a risk that graduates who learn selective subspecialty skills and practice secrets will establish practices ‘in their backyard.’ Fellowship directors attempt to match the best candidates but may preferentially rank candidates who they feel will leave the area after graduating [11], [12], [13], [14]. Contrary to that concern, we found that fellowship graduates infrequently remained within a close distance of fellowship locations. Microsurgery fellows were most likely to remain in close proximity. Even for these graduates, roughly three out of four chose to establish careers at a distance from their fellowship institutions. While there were subtle differences with respect to average distances traveled between the cohorts, no significant difference was uncovered.
Similarly, the amount of time in practice did not seem to appreciably affect geographic spread or the relative proportions establishing practices either in close proximity or very far away from their training grounds. A major limitation of the study is that it is a cross-sectional and not a longitudinal analysis. Other studies have highlighted the frequent career shifts common within medicine whereby roughly 50% of physicians change positions within the first couple of years of practice [15]. Despite these shifts, there is no evidence in the current study that practitioners either migrate away from or towards their training institutions over time. Among the common reasons cited for changing practices, 42% of doctors mentioned transitioning in order to be closer to family [16].
Gender similarly had no significant effect regarding geographic spread or proclivity to remain within close proximity of one's training location. No matter the cohort grouping, there seemed to be a relatively consistent range of 15–25% of trainees who went on to establish practices in the closest proximity to their training location. In fact, the majority appeared to establish practices over 500 miles away from their training institutions. This is in contrast to previously reported data demonstrating that most residents practice within 90 miles of their graduating program [17]. Perhaps the greatest strength of the paper then is to more clearly establish the true nature of the geographic spread of graduates within the field of plastic surgery.
Along these lines, the study uncovered a strong metropolitan influence with respect to future practice location. It was found that those training in large metropolitan areas were more likely to establish practices in similar urban areas as compared to those who had trained in less populated centers. Most of those studied trained in larger urban areas, and this is invariably because such institutions are found in larger regional centers. Establishing training programs in underserved communities may be a way to combat some local physician shortages.
There were some limitations to note for the current study. Missing information on practice websites led to the exclusion of some practitioners from the studies involved in the paper. Additionally, despite the large number of plastic surgeons included, some analyses appeared to be insufficiently powered to highlight significant findings. Nevertheless, with the numbers included in the present study, many of the analyses helped to provide broad findings that shed light on the current landscape of graduate geography within the field of plastic surgery. It is important to note that data on the hometowns of the plastic surgeons is not included in the dataset as this could not be gleaned from publicly available data. As such, there is a missing piece of information on the front end that may clarify why trainees sought to train in certain centers and in the same vein why they may have been selected to train in those centers based on regional biases of training programs. In other cases where trainees match into residency or fellowship programs across the country, they may nevertheless choose to set up practices close to their hometowns and not out of an inability to find employment in the vicinity of their training hubs. In essence, the data presented can help to answer the question as to what extent trainees remain near their training institutions but not as to what extent they are geographically tied to their hometowns or surrounding regions.
In conclusion, our data showed that the vast majority of graduates established practices at great distances from their training centers, and relatively few chose to stay in close proximity to residency or fellowship locations. Education background, gender and length of career all had no significant effect on these findings. Those with training in a large urban center were more likely to go on to establish practices in similarly populated regions, and this latter finding should prompt further discussion regarding the current state of training program geography.
Declaration of Competing Interest
The authors have no conflicts of interest to disclose.
Footnotes
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. We would like to acknowlegde the work and support of Mr. Christopher Rooney for his creation of the map plots presented in the article.
References
- 1.Silvestre J., Upton J., Chang B., Steinberg D.R. The impact of specialty on cases performed during hand surgery fellowship training. J Bone Jt Surg Am. 2018;100(5):e29. doi: 10.2106/JBJS.17.00176. [DOI] [PubMed] [Google Scholar]
- 2.Patel N., Dittakasem K., Fearon J.A. Craniofacial fellowship training: where are we now? Plast Reconstr Surg. 2015;135(5):1454–1460. doi: 10.1097/PRS.0000000000001061. [DOI] [PubMed] [Google Scholar]
- 3.Ngaage L.M., Kim C.J., Harris C., et al. Graduate perception of cosmetic surgery training in plastic surgery residency and fellowship programs. Arch Plast Surg. 2020;47(1):70–77. doi: 10.5999/aps.2019.00409. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Silvestre J., Runyan C., Taylor J.A. Analysis of practice settings for craniofacial surgery fellowship graduates in North America. J Surg Educ. 2017;74(2):181–186. doi: 10.1016/j.jsurg.2016.08.014. [DOI] [PubMed] [Google Scholar]
- 5.Grewal N.S., Spoon D.B., Kawamoto H.K., et al. Predictive factors in identifying subspecialty fellowship applicants who will have academic practices. Plast Reconstr Surg. 2008;122(4):1264–1271. doi: 10.1097/PRS.0b013e3181858f8d. [DOI] [PubMed] [Google Scholar]
- 6.Rios-diaz A.J., Metcalfe D., Singh M., et al. Inequalities in specialist hand surgeon distribution across the United States. Plast Reconstr Surg. 2016;137(5):1516–1522. doi: 10.1097/PRS.0000000000002103. [DOI] [PubMed] [Google Scholar]
- 7.Singh G.K., Daus G.P., Allender M., et al. Social determinants of health in the United States: addressing major health inequality trends for the nation, 1935–2016. Int J MCH AIDS. 2017;6(2):139–164. doi: 10.21106/ijma.236. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Albornoz C.R., Cohen W.A., Razdan S.N., et al. The impact of travel distance on breast reconstruction in the United States. Plast Reconstr Surg. 2016;137(1):12–18. doi: 10.1097/PRS.0000000000001847. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Lozada K.N., Bloom J.D. Factors important in facial plastic and reconstructive surgery fellowship program selection. Facial Plast Surg. 2019;35(5):534–539. doi: 10.1055/s-0039-1695723. [DOI] [PubMed] [Google Scholar]
- 10.Brunworth L.S., Chintalapani S.R., Gray R.R., Cardoso R., Owens P.W. Resident selection of hand surgery fellowships: a survey of the 2011, 2012, and 2013 hand fellowship graduates. Hand. 2013;8(2):164–171. doi: 10.1007/s11552-013-9504-y. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Egro F.M., Saliu O.T., Nahai F., Nguyen V.T. Aesthetic surgery fellowship selection criteria: a national fellowship director survey. Aesthet Surg J. 2017;37(8):961–966. doi: 10.1093/asj/sjx020. [DOI] [PubMed] [Google Scholar]
- 12.Egro F.M., Vangala S.K., Nguyen V.T., Spiess A.M. Hand surgery fellowship selection criteria: a national fellowship director survey. Arch Plast Surg. 2017;44(5):428–433. doi: 10.5999/aps.2017.44.5.428. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Egro F.M., Blecher N.A., Losee J.E., Nguyen V.T., Goldstein J. Craniofacial surgery fellowship selection criteria: a national program director survey. J Craniofac Surg. 2017;28(5):1132–1135. doi: 10.1097/SCS.0000000000003695. [DOI] [PubMed] [Google Scholar]
- 14.Egro F.M., Blecher N.A., Gimbel M.L., Nguyen V.T. Microsurgery fellowship selection criteria: a national program director survey. J Reconstr Microsurg. 2017;33(3):206–210. doi: 10.1055/s-0036-1597569. [DOI] [PubMed] [Google Scholar]
- 15.United States Department of Labor. Occupational outlook handbook. 2008 -09 ed. Available at: http://www.bls.gov.
- 16.Gildea A. Primary care. Physician Recruit Publ. 2007;15:2–4. [Google Scholar]
- 17.Davison S.P., Clemens M.W. Career evaluation and the decision process for plastic surgery graduates. Plast Reconstr Surg. 2011;128(2):559–565. doi: 10.1097/PRS.0b013e31821b62bd. [DOI] [PubMed] [Google Scholar]