Identification of Best Practices for Resident Aesthetic Clinics in Plastic Surgery Training:

The ACAPS National Survey

C. Scott Hultman, MD, MBA, FACS;1 Cindy Wu, MD;1 Michael L. Bentz, MD;2 Richard J. Redett, MD;3 Bruce R. Shack, MD4;

Lisa R. David, MD;5 Peter J. Taub,6 and Jeff E. Janis, MD7

From the Divisions and Departments of Plastic Surgery atUniversity Of North Carolina, Chapel Hill, NC1

University of Wisconsin, Madison, WI2

Johns Hopkins University, Baltimore, MD3

Vanderbilt University, Nashville, TN4

Wake Forest University, Winston-Salem, NC5

Icahn School of Medicine at Mt. Sinai, New York, NY6

The Ohio State University, Columbus, OH7

Presented in part at the Annual Scientific Meeting of the American Society of Plastic Surgeons, San Diego, CA, October 2013; and the Annual Winter Retreat of the American Council of Academic Plastic Surgeons, Chicago, IL, December 2014

Funding: The UNC Ethel and James Valone Plastic Surgery Research Endowment

Conflicts of Interest: no financial or commercial conflicts of interests

Key Words: surgical education, aesthetic surgery

Running Head: Best Practices for Resident Aesthetic Clinics

Correspondence/Proofs/Inquiries/Reprints:C. Scott Hultman, MD, MBA, FACSEthel and James Valone Distinguished Professor of SurgeryChief and Program Director, Division of Plastic SurgerySuite 7038, Burnett-Womack, CB#7195University of North CarolinaChapel Hill, NC 27599-7195Office: 919-966-2300; Fax: 919-966-3814

Email: cshult@med.unc.edu

2

ABSTRACT

Introduction: Resident aesthetic clinics (RACs) have demonstrated good outcomes, reasonable patient satisfaction, and acceptable safety profiles, but few studies have evaluated their educational, financial, or medico-legal components. We sought to determine RAC best practices.

Methods: We surveyed ACAPS Members (n=399), focusing on operational details, resident supervision, patient safety, medico-legal history, financial viability, and research opportunities. Of the 96 respondents, 63 reported having a RAC. 56% of plastic surgery residency Program Directors responded.

Results: RACs averaged 243 patient encounters and 53.9 procedures annually, over a mean period of 19.6 years. Full-time faculty (73%) supervised chief residents (84%) in all aspects of care (65%). Of the 63 RACs, 71% of facilities were accredited, 40 had a licensed procedural suite, 28 had inclusion/exclusion criteria, and 31 used anesthesiologists. 17 had overnight capability. 17 had a life safety plan. No cases of malignant hyperthermia occurred, but there was one facility death reported. 16 RACs (25%) had been involved in a lawsuit. 33 respondents reported financial viability of the RACs (52%). Net revenue was transferred to both the residents’ educational fund (41%) and divisional/departmental overhead (37%). Quality measures included: case logs (78%), morbidity/mortality conference (62%), resident surveys (52%), and patient satisfaction scores (46%). 14/63 (22%) of respondents have presented or published research specific to RACs. 80/96 (83.3%) of those surveyed believed RACs enhanced education.

Conclusion: RACs are an important component of plastic surgery education. Most clinics are financially viable, but carry high malpractice risk and consume significant resources. Best practices, to maximize patient safety and optimize resident education, include use of accredited procedural rooms and direct faculty supervision of all components of care.

word count: 268

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INTRODUCTION

Many plastic surgery training programs include a resident aesthetic clinic, in

which trainees have increased autonomy in decision-making and patients have

improved access to aesthetic surgery, through reduced charges. While many studies

have demonstrated good outcomes,1-6 reasonable patient satisfaction,7,8 and an

acceptable safety profile,9,10 few reports have rigorously evaluated the operational,

financial, and medico-legal components of these programs.11-13

Even though most plastic surgery educators recognize the value of having a

resident aesthetic clinic, many different models for such a learning environment

exist,14-18 and best practices for this teaching paradigm have not yet been defined.

As the surgical trainee gains experience in aesthetic surgery, this learner must also

become an autonomous practitioner, mastering key competencies of not only

patient care and medical knowledge, but also systems-based practice,

communications, practice-based learning, and professionalism. The resident

aesthetic clinic, in which trainees evaluate patients, form an operative plan, execute

the procedure, and provide follow-up care, represents an ideal setting for gaining

increased independence, under the close observation of supervising faculty

members.

This paper attempts to move our educational framework “one step closer” to

knowing the optimal learning experience in aesthetic surgery. We hypothesize that

resident aesthetic clinics represent a valuable, unique paradigm for surgical

education, provided that clinical results are acceptable, patient and provider

satisfaction remains high, and patient safety is given highest priority. The authors

4

will describe the current status of resident aesthetic clinics in plastic surgery

training and will provide best-practice guidelines to achieve superior outcomes.

MATERIALS AND METHODS

We conducted an anonymous, 41-question, internet-based survey of all

members of the American Council of Academic Plastic Surgeons (n=399). Our

questionnaire (designed by the first author and constructed by PRRI, Beverly, MA)

focused on the following components: demographic information about the

respondents, operational details of the clinic, resident training and supervision,

patient safety, medico-legal history, financial considerations, and research

opportunities.

The questionnaire was sent to ACAPS members three times, from October

through December 2012. Overall response rate for ACAPS members was 24%

(n=96). Response rate for Program Directors was 56% (49 PDs from 87

institutions), representing over half of all training programs. Of the 96 respondents,

63 reported that their institution included a resident aesthetic clinic (66%). It

should be noted that some institutions had more than one respondent. Thus, this

survey reflects the opinions of ACAPS members who are involved with resident

education, not specific programs.

Using information obtained by this survey, and combining these data with

their own experience, the authors developed a list of best practices for resident

aesthetic clinics. These best practices were further refined, as a result of the

discussion between panelists and attendees, at the 2013 ACAPS Annual Spring

5

Retreat, and further refined by the ACAPS Aesthetic Surgery Task Force at the 2014

Annual Winter retreat of ACAPS.

RESULTS

Demographics of Respondents. Overall response rate was 96 out of 399

ACAPS members, or 24%. Of the 96 respondents, 49 were program directors and 31

were chiefs or chairs of plastic surgery (Figure 1). Only 5 residency coordinators

participated in the survey. Mean length of time in practice was 20 years, with a

range of 0-40 years (Figure 2). Regarding type of practice, the vast majority of

respondents had mostly reconstructive practices (n=76), compared to a minority of

respondents who had mostly aesthetic practices (n=9) (Figure 3).

In terms of the training programs, respondents reported the following mix of

residency programs: integrated, n=35; independent, n=34; integrated and

independent, n=27. The following organizational structure was reported for the

plastic surgery practices: Division of Surgery at a Medical School, n=72; Department

of a Medical School, n=19; Private Practice, n=5. Sixty-three out of 96 respondents,

or 66%, reported the presence of a RAC, in which “plastic surgery residents had a

focused cosmetic experience with some degree of autonomy.”

Operational Details. RACs have been in practice for a mean of 19.6 years,

with a range of 1-50 years (Figure 4). In terms of clinical volume, respondents

reported a median of 88 patients and an average of 243 patients treated each year,

with a range of 2-2000 encounters per year (Figure 5). When asked about

procedures done at the RAC, respondents noted a median of 25 and an average of

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53.9 procedures done each year, with a range of 0-300 cases per year (Figure 6).

Components of the RACs, specific to location of patient encounters, include a

combination of examination rooms and surgical suites (Figure 7), with 40 of the 63

clinics including access to a licensed operating room.

Resident Supervision. Thirty-five out of 64 respondents (54%) who

reported having a RAC indicated that Resident Aesthetic Clinic was a formal rotation

in their residency program. Although respondents noted that chief residents

represented the largest group of participants (n=53), lower level residents also have

some degree of participation in the RAC (Figure 8). Nearly all residents (60 out of

64) provide continuity of care for their patients. According to the respondents,

residents receive supervision mostly by full-time core faculty (Figure 9), who

usually oversee all components of perioperative and intraoperative care (Figure 10).

Patient Safety. Although the majority of RACs have some type of

accreditation, 18 out of 63 respondents with RACS reported no accreditation (Figure

11). Furthermore, 28 out of 63 respondents with RACs reported a list of

inclusion/exclusion criteria for cases, and only 17 respondents having a Life Safety

Plan for the RAC. An anesthesiologist administers anesthesia in 31 out of 38 RACs

with operative capability, whereas other personnel are used for this function in the

remaining RACs (CRNA, 3; nursing staff, 2; surgeon, 2). Seventeen of the 35 clinics

with operative capability reported the ability to recover patients overnight.

Medico-legal History. Of the 64 respondents who indicated that their

institution had a RAC, one ACAPS member reported a patient death in the facility,

and two ACAPs members reported patient deaths within 30 days of the procedure.

7

Our cohort of ACAPS members observed no cases of malignant hyperthermia.

Sixteen of the 62 ACAPS members (26%) indicated that their RAC has been involved

in a lawsuit. Regarding malpractice insurance models, most groups are self-insured

and pay premiums to a group trust (Figure 12). Three of the 63 respondents with

RACs noted that patients must sign a waiver, releasing residents from malpractice

liability or to limit award for damages.

Financial Viability. Although 18 respondents did not know if their RACs

were financially viable, 33 respondents indicated that their RACs were, compared to

13 respondents who reported that the RACs were not financially viable. The large

majority of attending surgeons do not receive any financial remuneration, but some

of the respondents do receive compensation from professional fees, teaching

stipend, or a medial directorship. Almost all RACs offer discounted fees (59 out of

63, or 94%), and most RACs charge for the initial consultation (39 out of 63, or

62%). The most effective method for patient recruitment was listed as “word of

mouth” (61 out of 63, or 97%). Faculty practices contribute various types of

resources to the RACs, in addition to resident supervision (Figure 14), such as clinic

space, scheduling, nursing support, and disposable supplies. If profitable, net

income is primarily transferred to a residents’ education fund, but some of the gains

are transferred back to the Division or Department, presumably to cover overhead

costs (Figure 15). Only a small fraction of the positive net income is directed toward

incentive plans for the faculty, to the Dean or the hospital, or toward an operating

reserve.

8

Research and Outcomes Effectiveness. Respondents indicated that RACs

use a number of different methodologies to measure the effectiveness of the

educational experience, with review of resident case logs and morbidity and

mortality conferences as the most popular techniques (Figure 16). Fourteen of the

64 respondents with RACs have presented related data at national scientific

meetings, and 12 respondents have published their research in peer-reviewed,

scientific journals. The overwhelming perception is that RACs have a positive effect

on plastic surgery training (Figure 17). The majority of respondents were neutral

when asked about the impact of the RAC on their practice (n=36), but only a

minority of respondents reported that the RAC was a liability for the practice (n=7)

(Figure 18).

DISCUSSION

Resident aesthetic clinics serve as an important component of graduate

medical education in plastic surgery. Most clinics are financially viable but carry a

high malpractice risk and consume considerable resources. Best practices, to

maximize patient safety and optimize resident education, include use of accredited

procedural rooms, having anesthesiologists provide anesthesia, and providing

appropriate faculty supervision at all stages of patient care.

The educational concept and implementation of Resident Aesthetic Clinics is

not new, and has been implemented in various specialties including plastic surgery,

otolaryngology,19 and dermatology.20 In fact, the literature is replete with

manuscripts addressing the mechanics of administrating Plastic Surgery Resident

9

Aesthetic Clinics, their educational benefit, and analyses of outcomes data.

According to Neaman in 2010, 71% of plastic surgery residencies had a cosmetic

surgery clinic, with 44% of the respondents noted that 100% of the cases performed

there were cosmetic in nature.3

In 2006, the University of Kentucky group noted that the resident cosmetic

surgery clinic contributed 82% of the resident’s total aesthetic procedures. This was

completed with a 3.1% reoperative complication rate and no medicolegal litigation.4

Pyle and colleagues at Wake Forest reported that not only do residents gain added

experience as surgeon in a resident driven clinic, but that patients are able to

receive cosmetic surgery that they might not otherwise be able to access. They had

no major complications, but did report a minor complication rate of 8%, and a

revision rate of 14.4%.10

Freiburg and associates at the University of Toronto examined a

retrospective survey of 265 patients with a 49% response rate, where 93% of

patients said they would recommend the clinic (after a slightly lower rate the first

year), and 93% would undergo the same procedure again if required. The highest

patient satisfaction was seen in augmentation mammoplasty (9.1/10.0) and

blepharoplasty (9.0/10.0), while rhytidectomy and rhinoplasty were lower at

7.8/10.00 and 6.9/10.0, respectively.8 At Georgetown University, Baker and

colleagues evaluated satisfaction with resident injected fillers using a FACE-Q

survey. They demonstrated a 91% rate of being satisfied or very satisfied with this

evolving less invasive and highly popular injection in ten patients.7

10

At the American Association of Plastic Surgeons meeting in 2012, a two-year

retrospective review of patient care from 2009-2011 at the Johns Hopkins Resident

Cosmetic Surgery Clinic was presented. Rad and colleagues noted complications

rates consistent with the mainstream cosmetic surgery literature, breaking down

the procedures by type and body location. Their study sample included 115 patients

who underwent 132 primary body-contouring procedures, and 53 patients who

underwent 84 facial aesthetic procedures.9

Based on the published literature, as well as the ACAPS national survey, it is

clear that resident education in aesthetic surgery must be grounded in principles of

informed consent, appropriate patient selection, patient safety, teamwork, and

critical assessment of outcomes. Fortunately, qualitative and quantitative

instruments have been recently developed to assess outcomes, in terms of patient

satisfaction, as well as objective measures.21-23 Furthermore, surgical educators are

focusing on how to teach trainees aesthetic surgery—and reporting these results—

within the framework competency- and milestone-based graduate medical

education.24-26 Additional efforts have been pursued to educate residents about the

importance of strategic marketing, accounting and finance, economic forces of

competition, the supply chain, and regulatory/legal considerations, in the context of

office-based surgery and aesthetic services.27-31

The Aesthetic Surgery Task Force of the American Council of Academic

Plastic Surgeons endorses the concept a properly supervised Resident Aesthetic

Clinic, provided that the following guidelines are considered and followed, to the

greatest extent possible, within training programs accredited by the ACGME:

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1. The educational experience should maximize resident autonomy,

appropriate to level of training, as permitted by ACGME guidelines

a. Residents must obtain a complete history and physical examination,

with preoperative evaluation to include patient photographs

b. Residents must discuss case with attending regarding operative plan

c. Attendings must be present for planning and execution of procedure

d. Residents must be involved with postoperative management,

including complications

e. Residents must be available for 24-7 coverage, with adequate faculty

backup

2. Longitudinal, complete continuity of care is critical; no post-rotation

handoffs should occur

3. The RAC must have a medical director for the Resident Aesthetic Clinic

4. The RAC must establish screening processes to eliminate inappropriate

patients, using such pre-defined parameters as BMI, smoking status,

uncontrolled diabetes or hypertension

5. The RAC must establish operative criteria such as inclusion/exclusion lists,

length of case

6. Surgery must performed in accredited facilities only

7. The RAC must have close faculty supervision in both the clinic and operating

room, including presence at the key components of procedure

8. The faculty must establish goals, objectives, targets for residents, track

outcomes, provide regular review, and offer timely feedback

12

9. Real-time evaluation of competencies and milestones must be performed

10. The program director should review of operative logs to ensure diversity of

cases, surgeons, and locations

11. The RAC must combine a robust clinic and operative experience with strong

educational modules focused on aesthetic surgery, including lectures,

indications and outcomes conferences, and a journal club

12. The medical director should moderate a formal Resident Clinic Outcomes

Conference for entire division/department

13. The division/department should reinvest net income back into the aesthetic

curriculum/program

14. The RAC can consider reduced fees to stimulate demand, by decreasing

professional fees and charging facility fees high enough to cover overhead

15. The RAC should involve residents with strategic marketing of the practice

16. The RAC should have a dedicated administrative assistant to help run the

program

17. Although aesthetic education should begin early in the training program, the

RAC should be limited to Chief or Senior residents in Plastic Surgery

18. The educational curriculum should phase in the complexity of the cases as

the resident skill set grows (for example, the trainee could start with breast

and body procedures, then move to facial procedures)

19. Trainee experience at the RAC should occur after more traditional aesthetic

surgery rotations have been completed and should be considered separate

and distinct from faculty practices

13

20. Residents should not be allowed to perform botox, fillers, peels in the RAC,

which instead should be used as an operative experience, for surgical

procedures

14

REFERENCES

1. Morrison CM, Rotemberg SC, Moreira-Gonzalez A, Zinz JE. A survey of cosmetic surgery training in plastic surgery programs in the United States. Plast Reconstr Surg 2008;122:1570-8.

2. Oni G, Ahmad J, Zins JE, Kenkel JM. Cosmetic surgery training in the plastic surgery residency programs in the United States: How have we progressed in the last three years? Aesth Surg J 2011;31:445-55.

3. Neaman KC, Hill BC, Ebner Ford RD. Plastic surgery chief resident clinics: The current state of affairs. Plast Reconstr Surg 2010;126:626-633. Discussion 634-635.

4. Pu LLQ, Thornton BP, Vasconez HC. The educational value of a resident aesthetic surgery clinic: A 10-year review. Aesthetic Surg J 2006;26:41-4.

5. May JW Jr. Aesthetic surgery 101: resident education in aesthetic surgery, the MGH experience. Ann Plast Surg. 2003 Jun;50(6):561-6.

6. Momeni A, Goerke SM, Bannasch H, Arkudas A, Stark GB. The quality of aesthetic surgery training in plastic surgery residency: A survey among residents in Germany. Ann Plast Surg 2013 Jun;70(6):704-8

7. Iorio ML, Stolle E, Brown BJ, Christian CB, Baker SB. Plastic surgery training: Evaluating patient satisfaction with facial fillers in a resident clinic. Aesth Plast Surg 2012;36:1361-6.

8. Freiberg A, Giguère D, Ross DC, Taylor JR, Bell T, Kerluke LD. Are patients satisfied with results from residents performing aesthetic surgery? Plast Reconstr Surg. 1997 Dec;100(7):1824-31; discussion 1832-3.

9. Rad A, Burretta KJ, Im J, Manson PN. The chief resident aesthetic surgery clinic: A safe alternative for patients. Abstract presented at he 91st Annual Meeting of the American Society of Plastic Surgeons, April 2012, San Francisco, CA

10. Pyle JW, Angobaldo JO, Bryant AK, Marks MW, David LR. Outcomes analysis of a resident cosmetic clinic: Safety and feasibility after 7 years. Ann Plast Surg 2010;64:270-4.

11. Kreiger LM, Shaw WW. Pricing strategy for aesthetic surgery: Economic analysis of a resident clinic’s change in fees. Plast Reconstr Surg 1999;103:695-700.

12. Freiberg A. Challenges in developing resident training in aesthetic surgery. Ann Plast Surg 1989;22:184-7.

13. Bingham HG. Training in esthetic surgery: some problems encountered in a university program. Plast Reconstr Surg. 1980 Feb;65(2):227-8.

14. Schulman NH. Aesthetic surgery training: The Lenox Hill model. Ann Plast Surg 1997;38:309-14.

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15. Linder SA, Mele JA, Capozzi A. Teaching aesthetic surgery at the resident level. Aesth Plast Surg 1996;20:351-4.

16. Zweifer M, Glasberg SB. An outcome-based study of aesthetic surgery in a clinic setting. Ann Plast Surg 2000;44:355-60.

17. Rohrich RJ. The importance of cosmetic plastic surgery education: an evolution. Plast Reconstr Surg. 2000 Feb;105(2):741-2.

18. Rao VK, Schmid DB, Hanson SE, Bentz ML. Establishing a multidisciplinary academic cosmetic center. Plast Reconstr Surg 2011;128:741e-6e.

19. Sullivan CA, Masin J, Maniglia AJ, Stepnick DW. Complications of rhytidectomy in an otolaryngology training program. Laryngoscope 1999;109:198-203.

20. Alam M. Cosmetic surgery as a revenue engine for academic dermatology. Arch Dermatol. 2000 Sep;136(9):1096-8.

21. Pusic AL, Klassen AF, Scott AM, Cano SJ. Development and Psychometric Evaluation of the FACE-Q Satisfaction with Appearance Scale: A New Patient-Reported Outcome Instrument for Facial Aesthetics Patients. Clin Plast Surg. 2013 Apr;40(2):249-60.

22. Pusic AL, Lemaine V, Klassen AF, Scott AM, Cano SJ. Patient-reported outcome measures in plastic surgery: use and interpretation in evidence-based medicine. Plast Reconstr Surg. 2011 Mar;127(3):1361-7.

23. Klassen AF, Cano SJ, Scott A, Snell L, Pusic AL. Measuring patient-reported outcomes in facial aesthetic patients: development of the FACE-Q. Facial Plast Surg. 2010 Aug;26(4):303-9.

24. Kosowski TR, McCarthy C, Reavey PL, Scott AM, Wilkins EG, Cano SJ, Klassen AF, Carr N, Cordeiro PG, Pusic AL. A systematic review of patient-reported outcome measures after facial cosmetic surgery and/or nonsurgical facial rejuvenation. Plast Reconstr Surg. 2009 Jun;123(6):1819-27.

25. Ching S, Rockwell G, Thoma A, Antony MM. Clinical research in aesthetic surgery. Clin Plast Surg. 2008 Apr;35(2):269-73.

26. Ching S, Thoma A, McCabe RE, Antony MM. Measuring outcomes in aesthetic surgery: a comprehensive review of the literature. Plast Reconstr Surg. 2003 Jan;111(1):469-80; discussion 481-2.

27. Miller SH. Competitive forces and academic plastic surgery. Plast Reconstr Surg 1998;101:1389-99.

28. D'Amico RA, Saltz R, Rohrich RJ, Kinney B, Haeck P, Gold AH, Singer R, Jewell ML, Eaves F 3rd. Risks and opportunities for plastic surgeons in a widening cosmetic medicine market: future demand, consumer preferences, and trends in practitioners' services. Plast Reconstr Surg. 2008 May;121(5):1787-92.

29. Pacella SJ, Comstock MC, Kuzon WM Jr. Facility cost analysis in outpatient

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plastic surgery: implications for the academic health center. Plast Reconstr Surg. 2008 Apr;121(4):1479-88.

30. Pacella SJ. Exceptions to the Stark law: the ambulatory surgery center exemption. Plast Reconstr Surg. 2006 Sep;118(3):822-3; author reply 823.

31. Pacella SJ, Comstock M, Kuzon WM Jr. Certificate-of-Need regulation in outpatient surgery and specialty care: implications for plastic surgeons. Plast Reconstr Surg. 2005 Sep 15;116(4):1103-11; discussion 1112-3.

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FIGURES

Figure 1. Role of ACAPS member at parent institution.

05

101520253035

programdirector

core facultymember

chief/chairand

programdirector

chief/chair residencycoordinator

privatepractitioner

fellow

18

Figure 2. Distribution of years in practice for respondents. X-axis represents length of practice in years, Y-axis represents number of respondents for that time point.

0

1

2

3

4

5

6

7

0 2 5 7 10 12 14 16 18 20 22 24 26 28 31 35 38 41

19

Figure 3. Ratio of clinical practice, in terms of reconstructive vs. aesthetic.

0 10 20 30 40 50

<10% reconstructive: >90% aesthetic

25% reconstructive :75% aesthetic

50% reconstructive :50% aesthetic

75% reconstructive :25% aesthetic

>90% reconstructive: <10% aesthetic

20

Figure 4. Length of time that RACs have been in practice at institution. X-axis

represents length of practice in years, Y-axis represents number of respondents for

that time point.

21

0

2

4

6

8

10

12

14

1 2 6 7 9 10 12 15 19 20 22 25 28 30 33 45 50

Figure 5. Distribution of number of patients seen in the RAC each year. X-axis

represents number of patients seen per year, Y-axis represents number of

respondents for that number of patients.

0

2

4

6

8

10

12

2 7 14 15 20 30 35 40 48 50 60 75 80 85 100

120

150

180

200

225

250

300

500

1,50

02,

000

22

Figure 6. Distribution of number of procedures done in RAC each year. X-axis

represents number of procedures, Y-axis represents number of respondents for

each procedure number.

0

1

2

34

5

6

7

8

9

0 5 7 15

17

20

24

25

30

40

60

70

100

150

300

23

Figure 7. Components of RAC, in terms of locations for patient encounters.

0 10 20 30 40 50 60 70

non-licensed surgicalsuite

skin care center

minor procedure room

licensed operatingroom

examination rooms

24

Figure 8. Participation of plastic surgery residents in the RAC.

0 10 20 30 40 50 60

interns

fellows

junior residents

senior residents

chief residents

25

Figure 9. Responsible supervisor for trainees in RAC.

0 10 20 30 40 50

fellows

private practice paidfaculty

private practicevolunteer faculty

full-time core faculty

26

Figure 10. Type of resident supervision provided in RAC.

05

1015202530354045

preoperativeplanning,

surgical timeout, all

components,post-operative

care

preoperativeplanning,

surgical timeout, key

components

preoperativeplanning,

surgical timeout, all

components

none preoperativeplanning,

surgical timeout

preoperativeplanning only

27

Figure 11. Type of Accreditation for RAC.

0 5 10 15 20 25 30 35 40

AAAASF

Other

none

Joint Commission

28

Figure 12. Malpractice Insurance Model for RACs.

05

101520253035404550

we are self-insuredand pay premiums

to a group trust

we pay for standardmalpractice

insurance from acommercial carrier

we pay for standardand supplemental

malpracticeinsurance from a

commercial carrier

we do not havemalpracticeinsurance

29

Figure 13. Type of remuneration for attending surgeons who provide supervision of RACs.

05

101520253035

nothing professionalfee

teachingstipend

I don't know combinationof stipend,

professionalfee,

directorship

medicaldirectorship

30

Figure 14. Resources provided by practice to RAC.

0

10

20

30

40

50

60

clinic space scheduling nursing support disposablesupplies

capitalequipment

31

Figure 15. Transfer location of net income, if profit/loss statement positive

05

1015202530

resid

ents

'ed

ucat

ional

fund

back

to th

eDi

vision

/Dep

artm

ent

of P

lastic

Sur

gery

we a

re n

ot p

rofita

ble

incen

tive

plan

for

facu

lty to

par

ticipa

tein

the

Clini

cba

ck to

the

Depa

rtmen

t of

Surg

ery

back

to th

e Ho

spita

l

back

to th

e De

an o

fth

e M

edica

l Sch

ool

oper

ating

rese

rve

for

the

clinic

32

Figure 16. Mechanisms to assess effectiveness of RAC.

0

10

20

30

40

50

60re

siden

t cas

elog

s

mor

tality

and

mor

bidity

conf

eren

ce

resid

ent

satis

fact

ionsu

rvey

s

patie

ntsa

tisfa

ction

surv

eys

in-se

rvice

exm

inatio

nsc

ores

we d

o no

tas

sess

the

effe

ctive

ness

of th

e cli

nic

emplo

yee

satis

fact

ionsu

rvey

s

33

Figure 17. Effect of the RAC on plastic surgery training.

34

0102030405060708090

enhances resident education no effect on residenteducation

detracts from residenteducation

Figure 18. Impact of the RAC on the faculty practice.

0

5

10

15

20

25

30

35

40

neutral enhances the statureof our practice

we do not have sucha clinic

serves as a liabilityfor our practice

35

APPENDIX

Resident Aesthetic Clinic: Best Practices ProjectACAPS National Survey

Distributed October, November, December 2012

The American Council of Academic Plastic Surgeons (ACAPS) would like to develop a set of guidelines that 1) define best practices of Resident Aesthetic Clinics and 2) provide recommendations on how to start and maintain such clinic, for residency programs that are interested in pursuing such an endeavor. The goal of this project is to outline the principles and practices of a successful venture, focusing on the pillars of patient safety, clinical outcomes, financial viability, research opportunities, and resident education.

To help us with this important project, would you please answer the following questions? This survey should take you no longer than 10 minutes to complete. We will share the results of this project at the 2013 Spring Meeting of ACAPS.

Thank you.

GENERAL INFORMATION1. What is your role as an ACAPS member (please pick the single best answer)?

a. residency coordinatorb. fellowc. private practitionerd. core faculty membere. program directorf. chief/chairg. chief/chair and program director

2. How many years have you been in practice? _________________

3. What ratio best describes the mix of your personal clinical practice?a. >90% reconstructive : <10% aestheticb. 75% reconstructive : 25% aestheticc. 50% reconstructive : 50% aestheticd. 25% reconstructive : 75% aesthetice. <10% reconstructive : >90% aesthetic

4. What type of residency program do you have?a. independentb. integratedc. independent and integrated

5. What type of organizational structure does your practice have?a. Division of Surgery at a Medical Schoolb. Department of a Medical Schoolc. Private Practice

6. Do you have a Resident Aesthetic Clinic, in which plastic surgery residents have a focused cosmetic experience with some degree of autonomy?

YesNo (NOTE: if respondent answers “No” then go to survey end)

OPERATIONAL DETAILS

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7. How many years has the clinic been in practice? _____________________

8. How many patients are seen in the Resident Aesthetic Clinic each year? _________________

9. How many procedures are done in the Resident Aesthetic Clinic each year? _________________

10. What are the components of your Resident Aesthetic Clinic? Please check all that apply.a. examination roomsb. skin care centerc. minor procedure roomd. non-licensed surgical suitee. licensed operating room

EDUCATION11. Is the Resident Aesthetic Clinic a formal rotation for your residency program?

a. yesb. no

12. Which residents participate in the clinic? Please check all that apply.a. internsb. junior residentsc. senior residentsd. chief residentse. fellows

13. Do residents provide continuity of care for their patients?a. yesb. no

14. Who supervises your Resident Aesthetic Clinic?a. no oneb. fellowsc. private practice volunteer facultyd. private practice paid facultye. full-time core faculty

15. What type of resident supervision do you provide?a. noneb. preoperative planning onlyc. preoperative planning, surgical time outd. preoperative planning, surgical time out, key componentse. preoperative planning, surgical time out, all componentsf. preoperative planning, surgical time out, all components, post-operative care

PATIENT SAFETY16. What type of accreditation does your Resident Aesthetic Clinic have?

a. noneb. Joint Commissionc. AAASFd. AAAHCe. Other

17. Does the Resident Aesthetic Clinic have a list of inclusion/exclusion criteria for procedures done there?a. not applicable, because we do not do procedures at our center

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b. yesc. no

18. Who primarily provides anesthesia for the procedures done at the Resident Aesthetic Clinic?a. not applicable, because we do not do procedures at our centerb. the surgeonc. the nursing staffd. CRNAe. Anesthesiologist

19. For procedures done at the Resident Aesthetic Clinic, do patients ever stay overnight?a. not applicable, because we do not do procedures at our centerb. yesc. no

20. Does the Resident Aesthetic Clinic have a Life Safety Plan?a. yesb. noc. I am not sure what that is

21. Has the Resident Aesthetic Clinic ever had a patient death in the facility?a. yesb. no

22. Has the Resident Aesthetic Clinic ever had a patient death within 30 days of the procedure?a. yesb. no

23. Has the Resident Aesthetic Clinic ever had a case of malignant hyperthermia?a. yesb. no

24. Has the Resident Aesthetic Clinic or one of its surgeons ever been involved in a lawsuit, regarding a patient treated at the clinic?a. yesb. no

25. Please describe your malpractice insurance modela. we do not have malpractice insuranceb. we are self-insured and pay premiums to a group trustc. we pay for standard malpractice insurance from a commercial carrierd. we pay for standard and supplemental malpractice insurance from a commercial carrier

26. Do patients sign a waiver releasing the residents from malpractice liability or limiting damages that can be obtained?a. yesb. no

FINANCIAL CONSIDERATIONS27. Is your Resident Aesthetic Clinic financially viable?

a. yesb. noc. I don’t know

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28. What type of remuneration do the attending surgeons receive for providing oversight and supervision of the Resident Aesthetic Clinic?a. nothingb. teaching stipendc. professional feed. medical directorshipe. combination of stipend, professional fee, directorshipf. I don’t know

29. Which type of patients can receive discounted fees for services provided?a. noneb. employees onlyc. patients who respond to an advertisement or special promotional deald. all

30. Do you charge for the initial patient consultation?a. yesb. noc. I don’t know

31. The best method for patient recruitment at our Resident Aesthetic Clinic is:a. word of mouthb. advertisingc. employee discountsd. search–engine optimizatione. hospital marketingf. other

32. What resources does your practice commit to the Resident Aesthetic Clinic? Please check all that apply.a. nursing supportb. clinic spacec. schedulingd. disposable suppliese. capital equipment

33. If profitable, where do you transfer the net income? Please check all that apply.a. we are not profitableb. operating reserve for the clinicc. back to the Division/Department of Plastic Surgeryd. back to the Department of Surgery e. back to the Hospital f. back to the Dean of the Medical Schoolg. residents’ educational fundh. incentive plan for faculty to participate in the Clinic

RESEARCH AND OUTCOMES34. How do you assess the effectiveness of the Resident Aesthetic Clinic? Please check all that

apply.a. we do not assess the effectiveness of the clinicb. patient satisfaction surveysc. employee satisfaction surveysd. resident case logse. in-service exmination scoresf. resident satisfaction surveys

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g. mortality and morbidity conference

35. Have you ever presented research, derived from the Resident Aesthetic Clinic, at a national scientific meeting?a. yesb. no

36. Have you ever published research, derived from the Resident Aesthetic Clinic, in a peer-reviewed, scientific journal?a. yesb. no

OVERALL SUMMARY37. What is impact of a Resident Aesthetic Clinic on your practice?

a. enhances the stature of our practiceb. neutralc. serves as a liability for our practice

38. What is the effect of a Resident Aesthetic Clinic on surgical training?a. enhances resident educationb. no effect on resident educationc. detracts from resident education

39. If you do not have a Resident Aesthetic Clinic, are you interested in starting one?a. we already have a clinicb. yesc. nod. not sure

40. Please provide any additional comments regarding this project. _____________________________________________

41. If you would like to be contacted, to be interviewed as part of a focus group, please leave your email address._____________________________________________

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