Surgical Subspecialty Wrap-up Part 1 of 3: Plastic Surgery

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“Pardon my English, I am a French” – My plastic surgery attending physician

My first rotation of my third year of medical school is over. In true fashion of the last few years, it seems that the 5 weeks I spent on that rotation sat somewhere between a compressed and stretched version of the space-time continuum. In that failed attempt at sounding intelligent, what I mean is that I thought the rotation lasted both 5 years and 5 days. I’m officially in the thick of my life as a student of clinical medicine, no longer bound by the cockroach-infested chains of basement lecture halls. I would like to say that I’d been gracefully guided out of this student “net of safety” that I have been hiding in for the better part of 18 years, and got my “training wings” and shown how to fly. In reality, I think I got a boot to the gluteus maximus that sent me reeling out of my safety net into the open air. As I’ve been falling, my first thought was, “I think I got a lecture about flying once”, but a lot of good that does when the ground is rushing up to meet my face.

The contrast between the first two years of my education and the second two is blinding; it’s like walking out of a movie theater into the blazing sunlight. It’s shocking, disorienting, and I’ve found myself in a whole different world. It wasn’t like it was a gradual transition either, we had 4 days of orientation that did little to actually prepare us for the light-switch flip into the clinical side of medicine. Sure, they taught us how to scrub in to surgery, some basic suturing techniques, and gave us a few lectures on how to log clinical encounters (which was incredibly painful. We got to watch someone who was supposed to be one of their “computer technicians” struggle with the basic functionality of a website. Click the “X” to close your window! No, over to the right!), but they also lectured us on some fluffy philosophical things, some session about interpreters, and a lot of things that weren’t even close to being immediately applicable. Honestly, I don’t think anything they could have done would have adequately prepared us. We have no idea how to swim, and all of the lecturing about the techniques of swimming or giving us cute little floaty wings was not going to help us. We just had to jump in.

This is a series of posts that I’m going to make after every rotation, partially to expose you all to the insanity that is third year of medical school, but also to log my feelings about each of the specialties I rotate through. In one short year, I’m going to have to make the decision of what I want to be when I grow up, aka what specialty I want to be trained in. Having my thoughts and ideas written down will help me decipher what circle of docs I want to run with when it comes time to make that decision. With that, let’s be off.

My first rotation encompassed Surgical Subspecialty, in which we got to rotate through 2 surgical subspecialties and anesthesia. We got to preference 3 of the subspecialties (now that word looks funny to me because I’ve typed it too many times in a row. Chair. Chair chair chair chair. Okay, it’s fixed) in preference order, they included: cardiothoracic surgery, orthopedic surgery, ophthalmology, otolaryngology (commonly known as ear, nose, and throat or ENT), transplant, vascular surgery, urology, pediatric surgery, or plastic surgery. I wanted cardiothoracic and transplant as my top two choices, with vascular as my third just for curiosity’s sake. In true fashion of my third year, I ended up not getting my top two preferences, and got vascular and plastics. Sorry for putting the spoiler in the title. Kidding, no I’m not. I swear, the tagline for my medical school is that Whose Line is it Anyway? meme with Drew Carey “IU School of medicine, where your schedules are made up and your preferences don’t matter!”. My rant about that will come another time, but it marked the third time this year that my preferences were pretty much completely disregarded.

I’m going to split each of the 3 parts of this rotation into its own separate post, because they are too long when they are lumped together. I hit almost 8,000 words between the 3, which are already written, so there should be little delay between the release of the next two parts. That being said, let’s get off to the first of the three parts of this rotation: plastic surgery.


Plastic Surgery – Riley Hospital for Children

My first foray into clinical medicine came in the world of boobs, butts, face lifts, and people obsessing over cosmetic surgery. Well, at least that’s what my idea of plastic surgery was. Turns out, a lot of things in medicine are not what they seem. I had tabloid covers running through my head, like “Celebrity X now has breasts bigger than her head!” “Too much Botox, or not enough?” and pictures of people who look worse after becoming completely plastic. Ew, gross. Here’s a gif of a corgi trying to get a baby to chase him to cleanse your eyes. I was wondering what children were going to do with breast implants, but I figured I should just shut up and see what my rotation had in store for me. I wandered up to the second floor of Riley Children’s Hospital, and I got there before any of the clinic’s office staff that day. Organization isn’t the best thing here at IUSM, so I was just happy I got to the right place; whether I was over an hour early was a minor point. My attending physician, a young guy with dark hair and a slick French accent (he later was quoted as saying “I am a French” after apologizing for his English, which was otherwise spotless) rolled in soon after, and we had a flurry of patients to see. My fellow and resident were both incredible, hilarious human beings as well. I felt like part of the family with the plastics team.

Short interlude here, an attending,or “staff”, physician is a doctor that is done with their residency and can practice on their own. In teaching hospitals, they are the head honchos, the big burritos, the top dogs, the King Kongs of the hospital. Fellows have completed their standard residency and are doing additional training that is still supervised. Residents are still very much in training, and must be supervised by staff, at least loosely, at all times. Interns are first year residents. And then there’s 4th and 3rd year medical students. I’m on the bottom of the totem pole.

The clinic was a joint one with neurosurgery, and we saw a variety of children from mere weeks old to teenagers. This clinic specialized in craniofacial surgery, and we saw a lot of kids with cleft lip/cleft palate (where the lip or palate fails to fuse, which leaves a gap in the upper lip or a hole in the top of the mouth), craniosynostosis (your skull starts as a bunch of pieces that fuse at certain times to become a completely solid sphere-ish shape, these kids skulls fused too early), and a variety of dog bites, other injuries, and more. I was my attending’s shadow, and didn’t do much but take it all in and ask a few questions. Before I knew it, we were running off for outpatient surgical procedures before calling it a day. What a Friday that was.

I wasn’t sure what to make of the rotation as a whole until I walked into the operating room for our first real case of the next week. My attending goes in, hooks up his phone to the speaker system, and Mac Miller’s “Donald Trump” came on. My jaw dropped as my attending proceeded to sing the words, walk with a bit of bounce in his step, then go scrub for surgery. I was speechless. I later found out that he was actually under 30 years old, but he proceeded to have an absolutely killer surgery playlist. I was impressed. With that, it was off on the journey of plastic surgery.

As it turns out, plastic surgery is really, really cool. It can come as a standalone specialty through a five year integrated program, or as a three year fellowship after doing general surgery (for a total of eight years of training). There are a lot of different facets of the specialty, where only one of which is pure cosmetics. The majority of it is actually reconstructive surgery, whether that be from injury, birth defect, or any number of causes. They are specialists in burn surgery, hand surgery, wound healing, cosmetics, skin defects, birth defects, grafting, and putting things back together much prettier than they were to start. The bottom line: these surgeons are artists. Very few of the techniques are 100% standardized, and they have the freedom to choose and do the type of repair they want. They take pride in their own style, techniques, and incredible results. We had a conversation about our attending’s technique of cleft palate repair versus other surgeons, and his technique is much faster. This hammers home the point of a great quote I heard:

“Medicine is an art based on a science”

Watching them repair a cleft lip and have it barely be noticeable in 3 months is incredible. Or they do techniques such as a facial bipartition for a repair of hypertelorism (eyes being too far apart, which is found in a number of disabling syndromes) that is nothing short of incredible. You can Google that more at your own risk, I just linked to a basic picture of the general idea. They can even take a muscle, clamp off its blood supply, transplant it to another part of the body, and then suture the blood vessels to other blood vessels by hand, AND PLACE THE MUSCLE THERE TO FILL MISSING TISSUE FROM AN INJURY! Plastic surgery is NUTS.

While I didn’t get to necessarily participate too much short of holding a retractor or suturing a little (yes!), I was grateful for this fact. I was a noob. My big achievements were not getting lost on the way from the locker room to the operating room (henceforth OR), finding my way to the bathroom and back, and not contaminating myself while scrubbing in. I didn’t accomplish a single one of those correctly on the first try. Medical students at Riley don’t get to do as much considering kids are a lot higher stakes when it comes to medicine, but it was an amazing rotation. It was hard enough for me to walk and wear my white coat at the same time, let alone not lose sight of my residents. Because if I did, I would be lost forever. I swear they make hospitals to intentionally trap people inside. Now that I’m on the other side of the white coat, I find hospitals just as confusing as I did before.

I did manage to somewhat learn to navigate Cerner, our electronic medical record (EMR) used at the IU Health system. I can’t imagine what charting was like before the wonders of the almighty 1’s and 0’s, but I bet it must have been ugly. Let’s just say I’m more than glad that I’m learning to practice medicine in this decade. If I had to go out on a hunt to find a patient’s lab results in one random folder halfway across the hospital, and bring snacks in order to make the journey, I’d be pretty annoyed. Also, one thing I quickly learned about third year is that dedicating an entire white coat pocket (we have 5) to snacks is a necessity. I’m pretty much constantly eating, and having to go superhuman hours without eating is just not a pleasant experience. On that note…

Surgeons don’t eat. Or at least not very often. It disgusts me. I’d have no problem working for 12, 18, or 24+ hours as long as I was adequately fed. That’s pretty much the one variable (besides being sick) that throws my body off so bad that everything is unbearable. And I swear there is something about the activity of running around a hospital that makes sure I burn calories faster than the US government burns money. Ooooh, burn. Take that, fiscal responsibility of our lawmakers. Back on topic, it seems as if surgeons delay eating until it becomes purely biological necessity. I think there must be some kind of evolution as one goes through the years of medical training that allows for photosynthesis from surgical lights or something. I was eating pretty much constantly, whether that be between cases (which is what surgeries are called, i.e. “we have 4 cases today”), walking through the hallway, or scarfing down a sandwich in our team room. Residents seemed to eat a lot less frequently, getting food maybe once in our 12 hour shift. Never did I ever on my entire surgical subspecialty rotation see an attending physician eat. It’s magic. Or Voodoo. Or something.

The thing about plastic surgeons, even in this reconstructive context, is they were still very concerned with aesthetics. We would talk with a teenager or older child about removing a mole, and focused on how they felt about it from an appearance standpoint. My residents made sure all of their incisions were sutured up nicely; my attending was always talking about scars, shape, symmetry, and all sorts of aspects of good aesthetics and beauty. We made sure that our fat grafting made an area look full and even. It was an interesting aspect of medicine for me to see, one that very few other specialties are so concerned with. I’d bet lots of money that your average general surgeon isn’t nearly as concerned about the profile of a scar or surgical incision, beyond wanting them small just to make recovery easy.

The last aspect that I’m going to mention before I do a pros/cons/wrap-up of plastic surgery as a specialty is that….I actually liked working with kids. Which comes as a bit of a shock, despite how well I think I know myself. I never thought I’d enjoy working with those little hellions we call children. My joke is that I think I could one day handle my own children, but I could care less about anyone else’s. Especially in large groups. My mother teaches kindergarten. I have no idea how she does it. The kids were, for the most part, wonderful. The babies were cute, the smaller kids were happy (in general) and it just felt good to be helping those that are so young, helpless, and defenseless. Their parents were always so grateful, and the kids were too. There was just a sort of joy at a children’s hospital that I haven’t quite found at any of my other hospitals. Although in my context, it wasn’t like I had kids with terminal cancer or anything (man, that must be rough), so that partially plays into my perspective here.

Now, it’s time to grade the specialty, using Lego’s/10 as a scale. Because, plastic…surgery. Lego’s are plastic. Get it? Also, I don’t think I’m using Lego’s properly, it should probably be Legos because it’s not possessive. But it looks weird as Legos, so I’m leaving it as Lego’s. These are my own perspective here, so don’t take this as “this is how all plastic surgery is/how everyone should feel about it.” Remember, I’m doing this to figure out what I want to be when I grow up.


Plastic Surgery, Graded:

Cool factor: 9/10 Lego’s. It’s just an amazing specialty, provided it’s in the reconstructive sense. How much artistry goes into it is truly incredible regardless.

Type of work: 7/10 Lego’s. Plastic surgeons get to do a lot of surgery, which has so far been what interests me the most about medicine. They get a lot of freedom in their work, get to be “artists”, cover a wide range of conditions, use some cool equipment, and get to generally make peoples’ lives better. In my book, it gets knocked down in score because not all plastic surgery is created equal, and a fair amount of it can be purely cosmetic. I would get little satisfaction out of doing breast augmentations, face lifts, liposuction, and the like. While I don’t doubt that improves quality of life for people, I personally wouldn’t find it very fulfilling. Even in the context of what I saw in a reconstructive sense, it was a little too cosmetically oriented for my own tastes. Other than that, it’s basically like a suped up version of general surgery with an expanded scope.

Lifestyle: 5/10 Lego’s. It’s a surgical specialty, so that automatically makes it a 7/10 tops as far as lifestyle goes. These doctors work…a lot. The fact that there are so few of them per hospital/area necessitates higher workloads and close proximity to academic centers. My fellow (now graduated) is likely heading off to be the only plastic surgeon in a 5 county radius. Why this score isn’t lower is that there are (relatively) fewer “plastic surgery emergencies”, but they are called into trauma cases with some frequency. Anything doing with burns or skin grafts, or even loss of limbs will eventually see a plastic surgeon. They aren’t the most worked of surgeons per se, but they put in some serious hours that puts them near the top.

Ease of attaining residency: 2/10 Lego’s. Plastic surgery is notoriously competitive, especially considering the limited number of spots. It requires a high board score, a wide net of applications, and some divine intervention. This would be about a 1/10 if not for the fact that it is possible to do general surgery and then plastics (making it a bit easier) instead of a straight integrated plastics residency. However, that’s 8 years of residency instead of 5. Woof.

Bonus category – Working with kids: 7/10 Lego’s. While I couldn’t do exclusively pediatrics, I actually wouldn’t mind having children in my practice one day. However, I would still be fine with only adults. Kids are just so much more…fun. And generally they didn’t do anything to get themselves into their healthcare debacle, unlike the obese/smoking/diabetic/non-exercising adults that often find themselves on the receiving end of surgery or a hospital stay.

Pros: Awesome procedures, mainly surgical field, artistry and creativity, generally great patient outcomes, not life-or-death, very well-compensated, wide depth and breadth of procedures, procedures generally completely fix or eliminate a problem, no “half” results.

Cons: Hard to attain residency, a fair portion of cases are cosmetic procedures, relatively small field, potentially long hours/high case load, less exposure with life-or-death cases (this is both a pro and a con), and slightly different criteria for success than other specialties.

Overall likelihood of me choosing this specialty: 7/10 Lego’s. I honestly could see myself doing plastic surgery, which isn’t something I thought I’d say. With my board score and position in life, an integrated residency is a bit of a long shot. However, if my practice was mainly cosmetic (as I don’t believe I could completely choose my case type in such a small field), I really wouldn’t like it. That is the main part of plastics I don’t care for too much. Regardless, it has a lot of things I like in a specialty, so maybe if I’m interested in it down the line (or do general surgery), I might consider specializing in plastics. Only time will tell.

I hope this gave you a good perspective on what my first part of this rotation was like, as well as given you an initial perspective on 3rd year of medical school. I’ll probably dedicate an entire post to what it’s like to be a third year in general after I get some more experience, but I think this did a good job of chronicling my feelings. When I need to choose what I want to be when I grow up, I’m going to come back here to see what I thought at the time. Thanks for reading about my journey, look forward to my next piece on vascular surgery.

-Brandon

In honor of my plastic surgery attending’s great taste in music, here is the song he got stuck in my head from the OR:

Maroon 5 – This Summer’s Gonna Hurt

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