The Role of Senior Resident Clinics in Plastic Surgery Education in Canada

Abstract

Background:

Senior resident clinics are a means to encourage independent practice and problem solving and enhance surgical skills. The objective of this study is to investigate senior resident clinics across Canada and their utility in providing comprehensive plastic surgery training.

Methods:

A web-based survey was sent to all plastic surgery program directors (PDs) and senior residents (SRs; postgraduate years 3, 4, and 5) across Canada. The surveys focused on demographics, clinic structure, procedures commonly performed, perceived autonomy, educational benefit, competency-based design considerations, and areas for improvement. Chi-square tests were used to compare responses between PDs and SRs.

Results:

A total of 10 PDs (100% response rate) and 26 SRs (41% response rate) responded. Half of the training programs across Canada currently have senior clinics, and the format varies between institutions. Clinics generally focus on hand trauma and aesthetics. Both PDs and SRs felt that there is considerable autonomy for resident care in both the pre/post-operative and operative setting. Common barriers to implementing a senior clinic include not enough staff, not enough time, and the medicolegal risk. Most core competencies are felt to be addressed through the use of senior clinics. Methods to improve senior clinics could include more regular and higher volume clinics, enhanced equipment, and separation of hand and aesthetics clinics.

Conclusions:

Senior clinics are a useful method to improve plastic surgery education and address many core aspects of plastic surgery training. Implementation of supported clinics focused on hand and aesthetics surgery separately may be useful for training programs that currently lack a senior clinic.

Introduction

In recent years, concerns surrounding resident well-being and patient safety have prompted the enforcement of mandated resident work-hour restrictions.¹ Due to work-hour restrictions, concerns have been raised surrounding the potential for a negative impact on surgical training and patient care resulting from fewer hours spent in the clinic and operating room.^2-4 In contrast, reducing time spent in hospital allows for more independent study time, thus enriching residency training in certain domains.⁵ In an era of mandated resident work-hour restrictions, postgraduate medical education must evolve to optimize resident training, without sacrificing quality.⁶

In the past 30 years, plastic surgery residency programs across North America have implemented senior resident (SR) clinics as a way to increase resident autonomy and enrich the resident learning environment.^7,8 Senior clinics, or “chief clinics,” were first described by Freiberg in 1989 where residents at the University of Toronto served as the surgeon in charge of performing various aesthetic procedures.⁹ Research specifically investigating senior clinics has shown that not only are they safe for patients, they also have the ability to substantially improve technical skills and surgical judgment.⁴ A descriptive study in the United States found that 57 of the 80 surveyed plastic surgery training programs (71.3%) had a senior clinic and that approximately half of the clinics focused solely on the aesthetic aspect of plastic surgery.⁷ While research has largely focused on aesthetic-specific plastic surgery training^10-14 and describing the format of clinics in the United States, no study has formally evaluated the current state of senior clinics as a whole across Canada.

The variation in senior clinic metrics related to their role within the new model of competency-based residency education, types of procedures performed, areas for improvement, and barriers to initial implementation has not been reported. Therefore, the goal of this study is to investigate senior clinics across Canada and their utility in providing comprehensive training during plastic surgery residency.

Methods

A web-based survey was sent to all plastic surgery program directors (PDs) and SRs (postgraduate years 3, 4, and 5) across Canada. The surveys focused on demographics, clinic structure, procedures commonly performed, perceived autonomy, educational benefit, competency-based medical education (CBME) considerations, and potential areas of concern or opportunities for improvement among senior clinics. The surveys administered to PDs and SRs were similar; however, SRs were also asked about whether the presence of a senior clinic influenced their decision to rank their current program during residency selection and the frequency at which certain procedures are performed. Participants were initially given 2 weeks to complete the survey, and a reminder e-mail was then sent after 2 and 4 weeks from dissemination. Informed consent was obtained electronically for all participants after having read the study background, goals, along with risks and benefits. In order to calculate SR response rate, online data from the Canadian Resident Matching Service (CaRMS) was used to calculate the number of plastic surgery residents in postgraduate years 3 to 5.¹⁵

Data were analysed with SPSS, version 24 (SPSS Inc). Descriptive statistics were generated for all variables. The chi-square test was used to compare answers between PDs and SRs. Responses from PDs and SRs at programs that have senior clinics were compared. Differences were considered statistically significant if P values were lesser than or equal to .05.

Results

A total of 10 PDs (100% response rate) and 26 SRs (41% response rate) completed the surveys (Table 1). Most PDs were from Quebec (30%) or Ontario (30%), while most SRs were from Ontario (38.5%) or Alberta (26.9%). Program directors were typically within the first 10 years of practice (70%), while there was an even distribution of SRs between all 3 residency years. As each PD represents a single plastic surgery training program in Canada, it was determined that 5 of the 10 (50%) plastic surgery training programs across Canada currently have senior clinics (Table 1).

Table 1.

Demographic Characteristics of Program Directors (N = 10) and Senior Residents (N = 26).

Variable	Program directors (%)	Senior residents (%)
Province of practice
Quebec	3 (30)	6 (23.1)
Ontario	2 (20)	10 (38.5)
Alberta	2 (20)	7 (26.9)
Manitoba	1 (10)	0
British Columbia	1 (10)	0
Nova Scotia	1 (10)	3 (11.5)
Years practicing
0-5 years	4 (40)	-
6-10 years	3 (30)	-
11-15 years	2 (20)	-
>16 years	1 (10)	-
Year of training
PGY-3	-	8 (30.7)
PGY-4	-	7 (26.9)
PGY-5	-	11 (42.3)
Presence of senior clinic
Yes	5 (50)	11 (42.3)
No	5 (50)	15 (57.7)

Abbreviation: PGY, postgraduate year.

Responses from programs that had senior clinics were compared between PDs and SRs to determine consensus. Clinics generally run half a day per week (40% PDs and 45.5% SRs; P > .05), focus on hand trauma and aesthetics (60% and 20% PDs, and 63.6% and 27.3% SRs, respectively; P > .05 for both), are supervised (100% PDs and 90.9% SRs, P > .05), and have appropriate support from nurses, procedural equipment, transcription services, and electronic medical records (Table 2). Referrals come from a wide variety of sources, including staff plastic surgeons (60% PDs and 54.5% SRs; p > .05), community plastic surgeons (40% PDs and 0% SRs; P < .05), emergency physicians (40% PDs and 54.5% SRs; P > .05), and resident referrals (40% PDs and 63.6% SRs; P > .05). Both PDs and SRs disagreed on whether patients were screened prior to being assessed in senior clinics (P < .05). Common reasons for not accepting referrals included the procedure being out of scope (60% PDs and 36.4% SRs; P < .05), too challenging of a procedure (60% PDs and 27.3% SRs; P < .05), and the procedure not being offered (20% PDs and 27.3% SRs; P > .05; Table 2). Figure 1 details the group average of procedures performed in senior clinics, indicating that hand trauma and common aesthetics procedures are frequently performed. Senior residents were largely unsure of where funds from the clinic were used; however, PDs indicated that funds were most commonly used for resident education (60%). Program directors felt that the risk to patients in senior clinics was similar to the risk in attending clinics (80%). Both PDs and SRs agreed that SRs had partial autonomy for pre- and post-operative care (80% for PDs and 72.7% for SRs; P > .05), while for procedures, SRs felt that they generally had complete autonomy (72.7%) while PDs felt they had partial autonomy (100%; P < .05). Feedback for senior clinic performance is generally in the form of daily or random unstructured oral feedback. Senior residents felt that the complexity of cases seen in senior clinics was appropriate for their level of training (72.8%). Senior residents indicated that the presence of a senior clinic was influential in their decision to rank a current program during the CaRMS selection process (63.6%).

Table 2.

General Questions Regarding Senior Clinics Based on Program Director (N = 5) and Senior Resident (N = 11) Responses.

Variable	Program directors (%)	Senior residents (%)
Frequency of clinic
Half day per week	2 (40)	5 (45.5)
No set time	1 (20)	1 (9.1)
Dedicated rotation	0	1 (9.1)
Other	2 (40)	4 (26.4)
Focus of clinic
Hand trauma	3 (60)	7 (63.6)
Aesthetics	1 (20)	3 (27.3)
Other	1 (20)	1 (9.1)
Is the clinic supervised?
Yes	5 (100)	10 (90.9)
No	0	1 (9.1)
Available support staff and equipment
Nurse	5 (100)	7 (63.6)
Procedure trays and instruments	5 (100)	11 (100)
Transcription services	3 (60)	4 (36.4)
Electronic medical records	3 (60)	4 (36.4)
Occupational and physiotherapy	1 (20)	4 (36.4)
Photography equipment	0	1 (9.1)
Portable fluoroscopy	0	3 (27.3)
Source of referrals
Staff plastic surgeon	3 (60)	6 (54.5)
Community plastic surgeon	2 (40)	0
Emergency physician	2 (40)	6 (54.5)
Resident referral	2 (40)	7 (63.6)
Other physicians	1 (20)	4 (36.4)
Patients screened prior to clinic
Yes	1 (20)	9 (81.8)
No	3 (60)	2 (18.2)
Unsure	1 (20)	0
Reasons for not accepting referral
Out-of-scope procedure	3 (60)	4 (36.4)
Too difficult of a procedure	3 (60)	3 (27.3)
Comorbid conditions	2 (40)	1 (9.1)
Patient BMI too high or low	1 (20)	1 (9.1)
Request for procedure not offered	1 (20)	3 (27.3)
Usage of funds from clinic
Resident education	3 (60)	2 (18.2)
Faculty salary	1 (20)	0
Departmental budgets	1 (20)	1 (9.1)
Travel	1 (20)	1 (9.1)
Clinic overhead	1 (20)	0
Unsure	0	7 (63.6)
Impression of risk to patients in senior clinic relative to attending clinic
Same risk	4 (80)	-
Higher risk	1 (20)	-
Resident autonomy for pre-/post-operative care
Complete autonomy	1 (20)	3 (27.3)
Partial autonomy	4 (80)	8 (72.7)
Resident autonomy for procedures
Complete autonomy	0	8 (72.7)
Partial autonomy	5 (100)	3 (27.3)
How is performance in the clinic assessed?
Unstructured oral feedback	3 (60)	6 (54.5)
Structured written feedback	2 (40)	1 (9.1)
Multisource feedback	1 (20)	2 (18.2)
No feedback	0	2 (18.2)
How often is feedback received from staff?
Daily	3 (60)	0
Quarterly	1 (20)	3 (27.3)
Never	1 (20)	2 (18.2)
Weekly	0	2 (18.2)
Randomly	0	4 (36.4)
I feel the complexity of cases is appropriate for my level of training
Strongly agree	-	4 (36.4)
Agree	-	4 (36.4)
Neither agree nor disagree	-	2 (18.2)
Disagree	-	1 (9.1)
Was the presence of a senior resident clinic influential in your decision to rank your current program during CaRMS?
Yes	-	7 (63.6)
No	-	3 (27.3)
Unsure	-	1 (9.1)

Abbreviations: BMI, body mass index; CaRMS, Canadian Resident Matching Service.

Figure 1.

Group average of the percentage of procedures performed in senior resident plastic surgery clinics across Canada based on senior resident response (N = 11).

Common barriers to implementing a senior clinic include not enough staff (40% for PDs and 46.2% for SRs; P > .05), medicolegal risk (40% for PDs and 15.4% for SRs; P < .05), not enough time (40% for PDs and 30.8% for SRs; P > .05), and not enough money (20% for PDs and 34.6% for SRs; P < .05; Table 3). The majority of PDs (80%) and SRs (69.2%; P > .05) felt that senior clinics should be mandatory and have had discussions regarding the implementation of senior clinics (90% for PDs and 50% for SRs; P < .05). Program directors felt that the implementation of CBME will increase the number of senior clinics (80%) and that senior clinics are an important part of CBME (80%), while there was no consensus among SRs. There was no consensus from PDs whether residents will be more interested in senior clinics once CBME is implemented; however, the majority of PDs felt that senior clinics will improve the ability of programs to evaluate residents in core plastic surgery competencies (60%; Table 3).

Table 3.

Variables Related to Implementation and Competence by Design (CBD) for Senior Resident Clinics Based on Program Director (N = 10) and Senior Resident (N = 26) Responses.

Variable	Program directors (%)	Senior residents (%)
Barriers to implementing a senior clinic (absolute percentage)
Not enough staff	4 (40)	12 (46.2)
Medicolegal risk	4 (40)	4 (15.4)
Not enough time	4 (40)	8 (30.8)
Not enough money	2 (20)	9 (34.6)
Other	2 (20)	2 (7.7)
Not educationally valid	0	2 (7.7)
Not an efficient method of training	0	1 (3.8)
Should senior clinics be mandatory?
Yes	8 (80)	18 (69.2)
No	2 (20)	4 (15.4)
Unsure	0	4 (15.4)
Has there been a discussion at your institution about implementing a senior clinic?
Yes	9 (90)	13 (50)
No	1 (10)	7 (26.9)
Unsure	0	6 (23.1)
Do you feel staff would be receptive to changes you suggest about a senior clinic?
Yes	-	8 (30.8)
No	-	4 (15.4)
Unsure	-	4 (15.4)
Not answered	-	10 (38.5)
How do you feel the implementation of CBD will impact the number of senior clinics?	8 (80)	7 (26.9)
Increase	0	1 (3.8)
Decrease	2 (20)	6 (23.1)
No change	0	5 (19.2)
Unsure	0	7 (26.9)
I feel that senior clinics are an important part of CBD
Strongly agree	7 (70)	7 (26.9)
Agree	1 (10)	5 (19.2)
Neither agree nor disagree	1 (10)	4 (15.4)
Disagree	1 (10)	1 (3.8)
Strongly disagree	0	2 (7.7)
Not answered	0	7 (26.9)
I feel that residents will be more interested in senior clinics when CBD is implemented
Strongly agree	3 (30)	-
Agree	3 (30)	-
Neither agree nor disagree	3 (30)	-
Disagree	1 (10)	-
Strongly disagree	0	-
I feel that senior clinics will improve program directors’ abilities to evaluate resident outcomes in core competencies
Strongly agree	5 (50)	-
Agree	1 (10)	-
Neither agree nor disagree	2 (20)	-
Disagree	2 (20)	-
Strongly disagree	0	-

Figures 2 and 3 indicate that both PDs and SRs felt that senior clinics are strongly associated with preparing for independent practice, improving patient communication, managing complications, providing pre- and post-operative care, and facilitating operative training. Interestingly, a portion of SRs (30%) did not agree that senior clinics addressed operative training. To a lesser degree, SRs also felt that senior clinics did not address training in providing post-operative care (15%; Figure 3).

Figure 2.

Program directors’ responses to Likert scale questions indicating their agreement with how senior clinics will address the following knowledge areas of plastic surgery education (N = 5).

Figure 3.

Senior residents’ responses to Likert scale questions indicating their agreement with how senior clinics will address the following knowledge areas of plastic surgery education (N = 11).

When asked how to improve senior clinics, both PDs and SRs had interesting viewpoints. Program directors indicated that having higher volume, more regular clinics, and acquiring more sophisticated equipment (eg, fluoroscopy) would be helpful. Senior residents felt that having increased support from allied health care professionals for clinics (eg, physiotherapy and occupational therapy) and separating hand specific from aesthetic senior clinics is crucial. The majority of comments from SRs focused on the need for a dedicated aesthetic clinic to enhance and practice skills in an independent manner prior to entering the workforce.

Discussion

Both PDs and SRs from programs that had senior clinics disagreed on a number of points including whether patients were screened prior to clinic, reasons for not accepting referrals, and the amount of autonomy for completing procedures. From our experience, it is likely that for many senior clinics, PDs actually pre-screened patients, thereby limiting resident exposure to potentially difficulty cases or ones that represented low-yield learning. It is unclear exactly why SRs feel they have more autonomy during procedures. However, it is possible that during senior clinics they often operate independently due to their level of experience and the implicit trust from supervising surgeon leads to a greater sense of autonomy.

Senior resident aesthetic clinics are popular in the United States, with studies indicating that between 63% and 71% of training programs have a dedicated resident aesthetic clinic.^7,16 These clinics are similar in format to what we found in the current study. They typically run one half-day per week, are supervised, receive referrals from a variety of sources, and do not screen patients prior to clinic.⁷ By contrast, SR hand clinics are not well described in the US plastic surgery literature, likely due to the lack of popularity when comparing hand to aesthetic procedures and the fact that hand surgery can be performed by other specialities in the United States. While resident aesthetic clinics in the United States are similar to those in Canada, they differ in that a common reason for not accepting patients in the United States is due to insurance reimbursement issues and that over half of the clinics are primarily fee for service.⁷ Interestingly, a US study found that a higher number of SRs felt that they had complete autonomy in pre- and post-operative care (60%) compared to Canadian SRs (27.3%). However, operative autonomy results between US and Canadian cohorts were the opposite, with more Canadian SRs in general indicating that they have complete autonomy (27.4% in the United States and 72.7% in Canada).⁷ In terms of resident assessment, US SR clinics use written evaluations in 68.9% of programs, while in Canada, the more common method of feedback is unstructured oral feedback (60%). With respect to that feedback, it is challenging to compare feedback timing between the United States and Canada as PDs and SRs disagree in terms of feedback timing based on our survey. Within the United States, approximately 40% of programs provide feedback daily,⁷ whereas in Canada, 60% of PDs and 0% of SRs indicated that this was the case. As expected, both Canadian and American residents indicated that senior clinics are essential to plastic surgery training.

A common critique of senior clinics is their potential for higher complication rates and revision surgeries compared to a staff surgeons’ clinic. However, literature from the United States suggests that surgical outcomes performed in SR clinics are not significantly different than staff performed procedures.^11,14 When comparing 3 years of procedures performed by SRs at the Washington University plastic surgery program to a large aesthetic surgery database, rates of major complications were 1.7% compared to 2.0%, respectively (P = .45).¹⁴ Similarly, a study completed at Wake Forest University over a 7-year period found that rates of minor complications, major complications, and revision surgeries of senior clinics were well within normal limits compared to what was reported in the literature.¹¹ Our study and studies completed in the United States^7,16 indicate that PDs feel that the risk to patients in senior clinics is generally the same risk as patients presenting for treatment at a staff surgeons’ clinics. Objective evidence from the literature and the sentiments described by the PDs in our study indicate that SR clinics have appropriate risk profiles but still warrant supervision and input from a staff plastic surgeon for educational purposes and medicolegal oversight.

One of the goals of CBME is to implement a higher frequency of low stakes assessments of resident progress continuously throughout training as opposed to few high stakes assessments typically done only at the conclusion of time-based training.^17,18 As CBME has yet to be fully implemented in plastic surgery training programs across Canada, it is challenging to predict how the role of senior clinics will be affected. As senior clinics are varied in terms of case presentations, it may be possible for residents to select for certain cases to achieve their core competencies. An example being a resident who has not assessed, treated, and followed a certain type of facial fracture. If this is recognized by the resident and their PD, then perhaps their respective senior clinic could flag craniofacial cases for that individual to help address their specific knowledge gap and provide the opportunity for that clinical experience and staff observation. The flexibility for programs to develop individualized learning plans for resident trainees is also an important component of CBME.¹⁸ If the number of clinics per rotation and the volume of patients assessed per clinic is increased as suggested by numerous PDs who completed our survey, senior clinics could play a more prominent role in CBME. For the model of CBME specific to Canada, the Royal College of Physicians and Surgeons of Canada has developed Competence By Design which involves a step-wise progression of training through phases that outlines an individual’s competence and ability to practice independently.¹⁹ Given the structure and objectives of SR clinics, they would likely be most beneficial to residents during the Transition to Practice phase of training. Additionally, senior clinics serve as a medium to reinforce all the knowledge accumulated over residency and allow SRs to improve their managerial skills of running an independent clinic. Figures 4 and 5 indicate how PDs and SRs predict senior clinics will address plastic surgery core competencies in CBD.

Figure 4.

Program director responses to Likert scale questions indicating their agreement with statements concerning how senior clinics will address core competencies as outlined in Competence by Design (N = 10).

Figure 5.

Senior resident responses to Likert scale questions indicating their agreement with statements concerning how senior clinics will address core competencies as outlined in Competence by Design (N = 17).

Addressing the perceived barriers to implementing a senior clinic is challenging. The medicolegal risk of a senior clinic compared to a staff clinic is similar as demonstrated above and therefore should not represent a significant issue. Adequate time and staffing were the most common barriers brought up by both SRs and PDs but do not present insurmountable hurdles. One effective model involves pre-scheduled senior clinics with a transparent and evenly distributed rota of staff coverage. Allowing supervising staff to concurrently schedule other academic or clinical tasks at the same physical site can help facilitate faculty buy-in but also ensure that they are available to field questions, provide educational input, and maintain medicolegal responsibility. This model serves as a safety net for the SR, allows for the necessary degree of independent practice, and ensures that there is scheduled coverage on a fair basis.

The strengths of this study include the strong overall response rate, geographic diversity of responses, generalizability of results in Canada, and the utility of the research findings to plastic surgery training programs across Canada. Limitations of the study include low response rate for select questions, inability to generalize results outside of Canada, and the potential for response bias that is inherent in all survey studies.

We believe the results of this study are important for a number of reasons. No study has examined the state of plastic surgery SR clinics in Canada, while there is extensive research on US-based senior clinics. Describing this aspect of training is crucial to not only improve upon current senior clinics, but it also serves as a means to showcase the utility of senior clinics to training programs that do not currently have one. Our results indicate that senior clinics have substantial benefits in most realms of plastic surgery training including satisfying the newly proposed core competencies of competency-based training. With all plastic surgery training programs in Canada implementing CBME in July 2020, it is important that senior clinics fit this educational model.

Conclusions

Senior resident clinics are numerous across Canada and serve as an opportunity for residents to assimilate all that is learned during a 5-year residency program. While senior clinics are generally well received and address the majority of core competencies in plastic surgery, there are always methods to evaluate and improve training methods. Having more regular clinics, ensuring proper access to equipment and staff, and having distinct hand and aesthetic clinics are some ways to progress the senior clinic experience going forward. It is our hope that this manuscript can be used by all plastic surgery programs across Canada to improve or implement an SR clinic.