The Scope Of Practice Of Hand Surgery Within Plastic Surgery: The ACAPS National Survey To Assess Current Practice And Develop Educational Guidelines
Scott D. Lifchez, M.D.1, Jeffrey B. Friedrich, MD2, C Scott Hultman, MD3.
1Johns Hopkins University, Baltimore, MD, USA, 2University of Washington, Seattle, WA, USA, 3University of North Carolina, Chapel Hill, NC, USA.
PURPOSE: There is no uniform agreement among plastic surgeons or institutions regarding what constitutes the scope of hand surgery practice. Due to this lack of an established consensus, many plastic surgeons may be limited or prevented from performing surgeries within the field of hand surgery. We set out to assess what faculty of plastic surgery training programs felt was contained within the scope of practice of hand surgery.
A survey was sent to all 351 members of the American Council of Academic Plastic Surgeons (ACAPS). Respondents were asked to provide information regarding size of department and composition of faculty (number of fellowship trained hand surgeons), coverage of hand surgery call, and amount of elective hand surgery within their training program. They were also asked open-ended questions regarding what areas/procedure types are they felt were within the scope of hand surgery.
93 survey responses were received (26% response rate). 65% of respondents do not have a hand surgery fellowship program within their department/division. 35 respondents were certified or eligible for the Surgery of the Hand (SOTH) examination. 25 respondents had zero or one SOTH surgeon among their faculty. 43 responders treat distal radius injuries. 87% reported they perform replants, including 31% who do not get any coverage of replants from orthopedics. Even with inclusion of upper extremity peripheral nerve within the tally, 15 departments/divisions performed 0-5 elective hand surgeries per week, and another 24 performed only 6-10 per week. Of 46 groups that take hand call, 36 reported that all faculty members took hand call regardless of if they had hand fellowship training. While more than 80% cover hand and wrist infections on call, only 46% cover distal radius fractures. In response to the free-response question “What does hand surgery include in its scope of practice,” 22% only listed trauma and emergencies as what is included in the scope of hand surgery practice.
Hand surgery is an integral part of plastic surgery training and practice but is variably represented in residency programs. In many programs, most or all hand surgery exposure is in the setting of trauma and emergencies, with elective hand surgery being minimal or absent in 42% of survey responders. Plastic surgeons with SOTH certification have the training to include a broader scope of hand surgery within their practices, including distal radius injuries and complex elective bony procedures. Plastic surgery resident participation in these cases in their training is equally critical to the diversity of their education as other plastic surgery subspecialty procedures such as cleft lip (most plastic surgeons do not treat cleft lip in their practice either). By supporting and promoting these plastic surgeons in their inclusion complex bony reconstruction (including distal radius fractures) within their scope of practice, we allow residents to see the full spectrum of hand surgery within plastic surgery. This allows them to make an informed decision regarding whether to seek subspecialty training and thus continue the participation of plastic surgeons in the full spectrum of hand surgery going forward.
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