Keywords
plastic surgery - medical students - general surgery - ophthalmology - orthopaedic
- ENT - neurosurgery - maxillofacial surgery
Introduction
Plastic surgery is a surgical discipline focused on reconstructing facial and body
tissue defects. The imaginative aspect of plastic surgery generates a distinctive
atmosphere in which the surgeon's creativity is the sole constraint. The surgeon's
creativity leaves individuals outside the area perplexed about what a plastic surgeon
accomplishes. There are several dimensions to cosmetic procedures—a progressive and
developing field not constrained by anatomical or organ systems. Not limited to breast
treatments, maxillofacial trauma, cleft lip procedures, skin cancer, burns, hand treatments,
trauma reconstruction, cosmetic operations, oncology transformation, ophthalmic eye
procedures, etc., are all subspecialties of cosmetic procedures.[1] Plastic surgery has developed to benefit in a variety of challenging areas formerly
handled by other disciplines.[2] In addition, general practitioners, nursing staff, medical trainees, and the general
public do not entirely understand plastic surgery as a clinical practice.[3] The general public and medical experts have misconceptions about the extent of reconstructive
and plastic surgery.[4]
Studies suggest that financial, professional possibilities, social status, ambitions,
personal traits, location advantages, and lifestyle benefits are among the most important
factors influencing medical students' decision to pursue a certain discipline. In
addition, in Saudi Arabia, lifestyle offered by any specialization has been the most
important element affecting medical students' decisions about their medical specialties.[5] A study showed that in Saudi Arabia, boys and girls tend to favor general surgery
and dermatology, respectively, in medicine.[6] Numerous studies have observed the variables that might affect a person's decision
to pursue a career in plastic surgery globally. Very often, plastic surgery is considered
a cosmetic treatment in the public. Major misunderstandings about plastic surgery
result from the public's point of view, ultimately affecting medical students' perception
with no access to this field during their clinical rotations. As a result, some medical
schools have included clinical rotations for plastic surgery in their medical curricula
to dispel this myth.[7]
According to a survey, the predominant association between cosmetic procedures and
financial benefits was a common reason for medical students' unfavorable perception
of plastic surgery.[8] These negative perceptions severely affect students enrolling in plastic surgery
as a career and professional referral practice. A survey shows that only 11% of medical
graduates at prestigious institutions in the United Kingdom considered plastic surgeons
were most inclined to conduct tendon surgery.[8] These medical students will eventually become professional doctors; thus, their
preconceptions regarding plastic surgery might impact the field as a whole, altering
referral trends, opinions, and if medical students decide to follow this as a career
choice.[3] In a large, comprehensive examination of 122 full-text source publications, three
key concepts—gender, surgical training characteristics, and student “fit” in the surgery
environment—were found to influence operational career choice.[9]
Literature reveals that several medical school courses undervalue plastic surgery,
a debatable topic. Lack of proper training and career counselling in plastic surgery
at the undergraduate level is a primary concern when medical students decide to choose
plastic surgery as a specialty. As cosmetic surgery and other areas of expertise like
maxillofacial surgery, orthopaedic procedures, dermatology, and otolaryngology frequently
share procedures, those who backed the involvement of cosmetic procedures in medical
programs claimed that this integration would enhance the referral trend among medical
providers.[10] Additionally, exposing undergraduate medical students to plastic surgery will enhance
their decision rates to specialize in this field. According to a survey, 30% of plastic
surgery residents chose their field while attending medical school.[11] As a result, how medical students view plastic surgery may be important in determining
whether they decide to pursue it as a profession after graduation. According to research,
the majority of medical experts, teachers, and students agree that reduced exposure
to plastic surgery curricula in medical school decreases students' professional proficiency
as prospective surgeons, doctors, and regular practitioners.[12] However, the availability of knowledge and the aforementioned beneficial consequences
strengthen the case for medical students' legitimate requirement of plastic surgery
rotation regarding the impact of medical practice and education variations on medical
graduates. The same regulations on medical procedures and specialization apply to
medical students enrolled in various programs. Thus, the sort of medical education
that graduate practitioners were exposed to might impact their inclinations for the
profession and, later on, how they carry out health care choices and choose which
patients to refer to plastic surgeons.[13]
In Kuwait, without mentioning specializations other than primary health care, physicians
were named as one of the resources and benchmarks for the growth of the health care
workforce in the Ministry of Health yearly report for 2019.[13] As a result, accurate monitoring of national surgical employee training is lacking,
which is crucial for strategic planning. Furthermore, the alarmingly low interest
in surgery among medical students in Kuwait makes their medical careers at risk, necessitating
an investigation of challenges and potential remedies, primarily since no prior local
research has addressed this topic.[14] Over 800 students are now enrolled in the faculty's 7-year medical program at Kuwait
University. The academic system is built on a problem-based teaching method, with
the first 3 years being devoted to basic sciences and the latter 3 years being medically
focused. Workshops and seminars on plastic surgery are 2 days long overall, focusing
on the fundamentals. The perception of medical students at Kuwait University about
plastic surgery is inadequate and does not sufficiently reflect the range of the profession.
However, with appropriate practical experience, this may improve.
Aim/Objective of Study
This study aimed to investigate Kuwaiti medical students' perception of plastic surgery
in terms of influence, passion, and career prospective. Additionally, to evaluate
the comprehension, competition, interest, and quality of education in plastic surgery
and devise approaches to increase undergraduate interest in the field.
Methods
Study Setting
The study was conducted in Kuwait Medical University.
Study Duration
The study was conducted over a period of 1 month.
Inclusion Criteria
Exclusion Criteria
-
First-Year medical students of Kuwait University
-
Medical students from other than Kuwait University
-
Medical students from Kuwait University who did not sign the consent form
Data Collection
Monkey Software formulated a questionnaire-based survey. Data of eligible participants
based on inclusion criteria were collected over 1 month via university emails of the
students in coordination with the Vice Dean of Student Affairs in the Faculty of Medicine.
A total of 244 responses were collected, 121 males and 123 females. Similarly, students
were categorized into preclinical (2nd, 3rd, and 4th Years) and clinical (5th, 6th,
and 7th Years), respectively.
Data Analysis
Data were analyzed using statistical package for the social sciences (SPSS) software
(version 25; SPSS Inc, Chicago, IL). They were presented as continuous variables,
that is, mean and standard deviation, and categorical variables were expressed as
count (n) and percentage (%). Pearson's chi-square test was used to calculate p-values for categorical variables. p < 0.05 was considered statistically significant.
Results
Demographic Characteristics
A total of 244 students participated in the study, including 121 males and 123 females,
respectively, with a mean age of 21 (±2) years. The number of students who participated
in the survey from the 2nd, 3rd, 4th, 5th, 6th, and 7th academic years were 37 (15.2%),
42 (17.2%), 39 (16%), 42 (17.2%), 42 (17.2%), and 42 (17.2%) respectively ([Table 1]). Similarly, categorically, 126 (51.6%) were clinical students (5th, 6th, and 7th
Years), while 118 (48.4%) were preclinical students (2nd, 3rd, and 4th Years).
Table 1
Background characteristics and perception of plastic surgery subspeciality of study
subjects by gender
|
Population background
|
Total
(N = 244)
|
Male
(N = 121)
|
Female
(N = 123)
|
|
Number (%)
|
|
Age (years, mean [±SD])
|
21 (±2)
|
21 (±2)
|
21 (±2)
|
|
Academic Year, (n [%])
|
|
7th
|
42 (17.2)
|
21 (17.4)
|
21 (17.1)
|
|
6th
|
42 (17.2)
|
21 (17.4)
|
21 (17.1)
|
|
5th
|
42 (17.2)
|
22 (18.2)
|
20 (16.3)
|
|
4th
|
39 (16)
|
19 (15.7)
|
20 (16.3)
|
|
3rd
|
42 (17.2)
|
20 (16.5)
|
22 (17.9)
|
|
2nd
|
37 (15.2)
|
18 (14.9)
|
19 (15.4)
|
|
Clinical academic year, (n [%])
|
|
Clinical students
|
126 (51.6)
|
64 (52.9)
|
62 (50.4)
|
|
Preclinical students
|
118 (48.4)
|
57 (47.1)
|
61 (49.6)
|
|
Plastic surgery perception, (n [%])
|
|
Do you think plastic surgery plays an essential role in trauma management?
|
|
Yes
|
190 (79.8)
|
104 (87.4)
|
86 (72.3)
|
|
No
|
22 (9.2)
|
7 (5.9)
|
15 (12.6)
|
|
I don't know
|
26 (10.9)
|
8 (6.7)
|
18 (15.1)
|
|
Are you considering to apply to plastic surgery residency after graduation?
|
|
Yes
|
37 (15.5)
|
13 (10.9)
|
24 (20.2)
|
|
No
|
112 (47.1)
|
62 (52.1)
|
50 (42)
|
|
Not decided yet
|
89 (37.4)
|
44 (37)
|
45 (37.8)
|
|
What are the two most influential factors that drive medical graduates to apply for
plastic surgery residency?
|
|
Variety of cases and operations
|
23 (9.7)
|
10 (8.4)
|
13 (10.9)
|
|
Positive personality traits
|
16 (6.7)
|
9 (7.6)
|
7 (5.9)
|
|
Expected income
|
147 (61.8)
|
84 (70.6)
|
63 (52.9)
|
|
Expected lifestyle
|
34 (14.3)
|
10 (8.4)
|
24 (20.2)
|
|
Media portrayal
|
18 (7.6)
|
6 (5)
|
12 (10.1)
|
Abbreviation: SD, standard deviation.
Medical Students' Perception of Plastic Surgery
The study reported that 79.8% of medical students believed that plastic surgery is
essential in trauma management, whereas 9.2% did not consider plastic surgery significant.
A total of 112 (47.1%) students did not consider applying for plastic surgery residency
after graduation. However, 89 (37.4%) were uncertain, and 37 (15.5%) were willing
to apply to this field after graduation.
The two most influential factors reported by the medical graduates expected to drive
them toward plastic surgery residency were expected income (61.8%) and lifestyle (14.3%).
On the other hand, media portrayal (7.6%) and positive personality traits (6.7%) were
reported as the least attractive factors ([Table 1]).
Responses of Clinical and Preclinical Medical Students Predicting the Most Suitable
Specialty to Refer the Stimulated Cases
Plastic surgery was selected as the most preferred option by the medical students
for clinical scenarios, including breast size reduction (96.4%), cosmetic nose reshaping
(85.25%), cosmetic contouring and liposuction (84.84%), facial fillers' injections
(65.57%), and abdominal chest burn experienced by firemen (58.26%). Despite the difference,
there is no significant relationship between students' preference for plastic surgery
and clinical scenarios; X
2 (396, N = 244) = 414, p > 0.05.
|
Clinical scenarios and plastic surgery preference
|
|
Value
|
df
|
p-Value
|
|
Pearson's chi-square
|
414.000
|
396
|
0.257
|
|
Likelihood ratio
|
133.142
|
396
|
1.000
|
Medical conditions where students optioned plastic surgery infrequently (by <10% of
the medical students) involved cases such as carpal tunnel syndrome (6.2%), fractured
jaw (3.69%), skull deformity in a newborn (8.61%), severed ulnar nerve (9.43%), drooping
eyelid affecting vision (6.56%), nasal septal deviation and breathing problems (8.61%),
total hip replacement in elderly (4.51%), lacerations in hand tendon (9.02%), excision
of a lipoma in the back (9.92%), brachial plexus injury due to motorcycle accident
(4.13%), decompression surgery for protruding eye (4.55%), bowel obstruction (2.07%),
cancer of the roof of the mouth (2.07%), and orbital fracture repair due to nail impinging
the lower lid (5.37%).
Scenarios, where maxillofacial surgery was the most frequently chosen specialty include
cleft palate syndrome (58.26%), fractured jaw (48.36%), and management of cancer in
the roof of the mouth (43.38%). However, there was no statistical significance in
clinical scenarios and choosing maxillofacial surgery as the speciality; X
2 (308, N = 244) = 322, p > 0.05.
|
Clinical scenarios and maxillofacial surgery preferences
|
|
Value
|
df
|
p-Value
|
|
Pearson's chi-square
|
322.000
|
308
|
0.280
|
|
Likelihood ratio
|
104.683
|
308
|
1.000
|
|
Number of valid cases
|
23
|
–
|
–
|
Students mentioned that neurosurgery was the most frequently chosen specialty in cases
involving carpal tunnel syndrome and tingling (41.32%), skull deformation in a child
(63.52%), severed ulnar nerve (57.38%), and brachial plexus injury (48.76%). Despite
the difference in choosing neurosurgery speciality by students due to various clinical
scenarios, the relationship was statistically insignificant; X
2 (286, N = 244) = 299, p > 0.05.
|
Neurosurgery speciality
|
|
Value
|
df
|
p-Value
|
|
Pearson's chi-square
|
299.000
|
286
|
0.287
|
|
Likelihood ratio
|
111.641
|
286
|
1.000
|
ENT was identified as the most suitable specialty for the management of cases including
broken nose (41.39%), nasal septal deviation (80.33%), and absence of an outer ear
during birth (51.64%); however, the selection was statistically insignificant; X
2 (286, N = 244) = 299, p > 0.05.
|
ENT
|
|
Value
|
df
|
p-Value
|
|
Pearson's chi-square
|
299.000
|
286
|
0.287
|
|
Likelihood ratio
|
114.275
|
286
|
1.000
|
On the other hand, students selected ophthalmology most frequently in scenarios that
involved drooping eyelid impacting vision (61.48%), decompression surgery for protruding
eyes (73.97%), and repair of the fractured orbital plate (50.83%). Orthopaedics was
selected in clinical scenarios that included muscle coverage for exposed tibia after
an accident (54.1%), total hip replacement (86.89%), hand tendon lacerations (55.33%),
and orbital fracture repair (9.92%).
The results of the present survey reveal that plastic surgery was selected as the
most preferred option by the medical students for clinical scenarios including breast
size reduction, cosmetic nose reshaping, cosmetic contouring and liposuction facial
fillers' injections, and abdominal chest burn experienced by firemen. Similarly, in
another study breast asymmetry and rhinoplasty were the most frequently recognized
“cosmetic” treatments of plastic surgery, with recognition rates of 96.4 and 91.2%,
respectively. These results are consistent with past surveys of medical students indicating
that there is still room for improvement in the way that medical students are taught
about the range of plastic surgery.[8]
[15]
Discussion
Study findings report a lack of adequate knowledge regarding the clinical aspect of
plastic surgery. Medical students from 2nd to 7th academic years were provided a clear
view of career prospective in plastic surgery. Unexpectedly, despite a presumed level
of clinical exposure in the field, neither the year of study nor gender was associated
with a future interest in a career in plastic surgery. Alarmingly, during the past
10 years, interest in pursuing a career in surgery has significantly decreased overall.
[Supplementary Table 1] summarizes that medical students consider plastic surgery a profession not associated
with trauma management and only mainly desirable for economical income; which is alarming
finding.[16]
Plastic surgery is acknowledged for its wide range of procedures as well as patient
variability deals by plastic surgeons during day-to-day practice.[5] This particular aspect propels 53.1% of the population to choose plastic surgery
as their future specialty.[5] Interestingly, 25% of the participants in the Pasha et al's study[17] rated it as the most alluring aspect. As [Table 1] demonstrated, desirable expected income was a main determinant in choosing plastic
surgery as future career in among 65.5% students. Similar results were supported by
Greene and May,[18] and it was also a significant predictor of job satisfaction among a cohort of Saudi-based
physicians, as reported by Aldrees et al.[19] Furthermore, as this study reports 112 (47.1%) students who did not consider to
enrol in plastic surgery residency after graduation. Studies report several factors
that could result a significant drop in adopting plastic surgery by medical students
such as, but not limited to, experience of undergraduate students, work–life harmony,
perceived competition, and a shortage of surgical mentors, and negative connotation
via media.[8] However, more concerningly, medical students, implying that the specialty and associated
treatments are not well covered in the medical curricula and medical care plans,[7] have also misunderstood plastic surgery.
Improving the quality of education of medical students, who stand-in for the future
of medicine, is one method to enhance their perception and awareness about plastic
surgery. A study conducted in University of Utah, about understanding of plastic surgery
as a career, allowing the medical educators to pinpoint particular areas in the curriculum
that require improvement. This approach can be used by different medical schools to
evaluate their students' understanding and develop novel strategies to improve medical
students' knowledge of plastic surgery.[15]
In this study, however, only 29.52% mentioned plastic surgery as primary surgery.
Medical students' knowledge of particular fields, such as cleft surgery, is significantly
improved by exposure to plastic surgery while in medical school.[20] Contrary to this study, plastic surgery was selected as the top specialty for treating
cleft lip and cleft palate (selected by 90.9% of students) in a previous study evaluating
perception of medical students on plastic surgery.[15] These findings contrast with those of Tanna et al, who found that oral and maxillofacial
surgery was chosen by 78% of primary care residents, whereas only 57% connected treatment
of this disorder with plastic surgeons.[21] Discrepancy in results can be attributed to different training patterns implemented
by medical schools. It was observed that as the training stage increased, the likelihood
of choosing plastic surgery for the treatment of cleft lip reduced. This observation
might be explained by the fact that senior students who are doing a rotation in ENT
consider cleft surgery as a part of only maxillofacial surgery. This underscores the
fact that it is critical to educate students about the field of plastic surgery rather
than relying on other specialties to do so.[15]
Additionally, similar to the present study, data in a study[15] suggest that more than half of these students believed that hand surgeons were not
plastic surgeons. This finding may be explained by several factors, such as the decreasing
number of plastic surgeons performing hand surgery, the existence of an “orthopaedic”
designated hand fellowship in several medical colleges, and limited training exposure,
that is, only 30% of students received exposure to plastic surgery during their 4
years of training.[15] Plastic surgeons should broaden the formal instruction of medical students about
hand and peripheral nerve surgery to improve their knowledge regarding these areas.
The breadth of plastic surgery training within the NHS remains unclear, even at a
higher level, especially concerning aesthetic surgery.[8] This study reveals that medical students still have a poor understanding of the
spectrum of operations. According to earlier research, students were far more inclined
to link cosmetic surgery with the field of plastic and reconstructive surgery.[22] This is probably impacted by how specialty is portrayed in the media. More than
most surgical subspecialties, this one has a public profile.[23] Some authors have suggested changing the name since they believe the title's use
of the word “plastic” contributes to the misconception.[24] These results are in-line with research done previously by Agarwal et al, who found
that among U.S. medical students, hand surgery was the operation least associated
with the specialty.[15]
The present study findings are rather unsettling. This lack of comprehension has implications
that go beyond the medical student. Previous research has demonstrated that beliefs
formed during medical school carry over into general practice.[22] This affects the plastic surgery specialty in a variety of ways, such as lost referrals,
deterring students from choosing plastic surgery as a specialization, losing the best
prospects to other specialties, and losing the trust of the medical profession. Exposure
to plastic surgery enhances a student's understanding of the field of study. Therefore,
it is important to work to increase this exposure. Rotations in the clinical years
would be the ideal way to accomplish this, but didactic lectures, career days, or
workshops may also be included in the learning process during the preclinical years.[23]
The present study has certain limitations. The design of a self-administered survey
might not produce the best dependability and result in recollection bias. Being a
single-center study, a nationwide study is required to provide a more generalizable
and comprehensive result. A small sample size with a limited demographic data. Selection
bias is a problem with voluntary online surveys because students interested in surgery
are more likely to participate. Hence, it is possible that students who were more
interested in surgery and, consequently, better educated about surgical subspecialties,
were more likely to complete the survey. Additionally, because the results are from
a single institution, local clinical and instructional experiences have an impact.
Despite these drawbacks, this study advances understanding of the matching procedure
for a competitive specialty and adds knowledge of the factors that influence medical
students' choice of a particular plastic surgery program. Academic residency programs
that might want to modify their elective or interview formats would obtain meaningful
insights from the present study. Future observational or cohort studies conducted
over several years with a wider population of candidates for plastic surgery or different
surgical specialties would be of great interest. Further research including numerous
university medical institutions, especially those where plastic surgery is taught
as a required course, will probably help us better understand how future doctors perceive
plastic surgery. Additionally, distributing this survey to family doctors and the
general public could help us gain a more comprehensive picture of current attitudes
on plastic and reconstructive surgery.
Conclusion
Medical students should be taught the broader scope of plastic surgery. In addition,
inclusion of formal training during undergraduation is essence of time and should
be added to or improved during plastic surgery rotations with more emphasis on the
improvement areas of students' in plastic surgery (such as hand/peripheral nerve surgery).
Teaching should concentrate on reconstructive and hand/peripheral nerve surgery. During
medical school, student-led interest groups can be a useful tool for educating students
about their specialty.
