Episode 58: Thursday November 03
Have you ever wondered how someone graduating from medical school becomes a plastic surgeon? Today we talk to special guest Dr. Amanda Gosman @aagosman, who trains plastic surgeons for a living. Dr. Amanda Gosman is a board certified plastic surgeon who is chief of the Division of Plastic Surgery at UC San Diego School of Medicine and Director of the Plastic Surgery Residency Program and the Craniofacial Fellowship Program. She is also the director of the Fresh Start Clinic for Craniofacial Anomalies at Rady Children’s Hospital-San Diego.
Dr. Salvatore Pacella @sandiegoplasticsurgeon, Dr. Sam Jejurikar @samjejurikar, and Dr. Sam Rhee @bergencosmetic discuss how plastic surgery training has changed over the years, how to safely incorporate aesthetic surgery in residency training, and the challenges facing newly trained plastic surgeons.
Dr. Gosman completed her fellowship in craniofacial and pediatric plastic surgery and her residency training at the University of Texas Southwestern. She also completed a one-year fellowship in international plastic surgery with ReSurge International (formerly Interplast). She earned her medical degree from Case Western Reserve University.
As a board-certified plastic surgeon, Dr. Gosman’s clinical interests include cleft lip and palate surgery, pediatric and adult craniofacial surgery, microsurgical facial reanimation, breast reconstruction and aesthetic surgery. Her research is focused on cleft lip and palate surgeries, plastic surgery outcomes, telemedicine and international health.
#podcast #plasticsurgery #cosmeticsurgery #plasticsurgeon #beauty #boardcertified #aesthetic #3plasticsurgeonsandamicrophone #bergencosmetic #bestplasticsurgeon #beforeafter #aesthetics #realpatientrealresult #boardcertifiedplasticsurgeon #njplasticsurgeon #njplasticsurgery #nyplasticsurgeon #nyplasticsurgery
#ucsdplasticsurgery #diversifyplasticsurgery #globalsurgery #craniofacial
2022.11.10 S03E58 DR AMANDA GOSMAN HOW TO TRAIN A PLASTIC SURGEON
[00:00:03] Dr. Salvatore Pacella: Good morning everybody. How are you today? I'm Dr. Sal Pacella from San Diego, California at San Diego Plastic Surgeon. And I'm with Dr. Sam Ree from Paramus, New Jersey at Bergen Cosmetic, and of course, Dr. Sam Jejurikar at Sam Jejurikar from Dallas. How are you just doing this morning? Very well.
Great. Awesome. Good morning. It's a first day of a time change, so we're upright and early. We have a very special.
Today my good friend and colleague, Dr. Amanda Gossman, who is the chair of plastic surgery at U C S D residency program at U C S D Medical School. Amanda's a fantastic surgeon, a great person. I've, I've known her actually since I think about 1999, I believe. It's been a long time. Her and I were medical students the same year at.
Medical schools and we were interviewing for the same residency jobs around the country. So I've known her for, for a long, long time, and we've collaborated throughout the years with some philanthropy and, and some professional stuff. So, Amanda,
[00:01:03] Dr. Amanda Gosman: welcome. Thank you. Thank you so much. I really appreciate the invitation.
[00:01:08] Dr. Salvatore Pacella: Oh, fantastic. So, before we get started, we just have a little bit of housekeeping. So, who's gonna be reading our disclaimer here?
[00:01:14] Dr. Sam Jejurikar: I will. How do we do it? This show is not a substitute for professional medical advice, diagnosis, or treatment. This show is for informational purposes only, treatment and.
May vary based upon the circumstances, situation, and medical judgment. After appropriate discussion, always seek the advice of your surgeon or other qualified healthcare provider with any questions you may have regarding medical care and never disregard professional medical advice or delay seeking advice because it's something you may have heard in the show.
Back to you, Sal.
[00:01:40] Dr. Salvatore Pacella: All right, fantastic. So, Amanda, you, you did your training at UT Southwestern in Dallas, correct?
[00:01:46] Dr. Amanda Gosman: I did. I did indeed, yes. .
[00:01:49] Dr. Salvatore Pacella: And then after that tell us a little bit about kind of what your training was and your fellowship. And I know you came to San Diego shortly afterwards.
[00:01:56] Dr. Amanda Gosman: Yeah, San Diego is my first real job, but I did integrated residency in Dallas and then I stayed there.
I did my pediatric community facial fellowship. And then I did an additional year doing the, what was then the Interclass Webster Fellowship, which was a traveling fellowship with Interclass, which is now research. And it was really an amazing opportunity to travel around the world and not just go on short term mission trips, but also work with academic centers that hesitancy programs around the world.
And that's kind of really what cinched it for me in terms of going into an academic career.
[00:02:33] Dr. Salvatore Pacella: So, so Amanda I, I should have mentioned earlier, Amanda is a pediatric plastic surgeon that also does a bit of adult plastic surgery. So Amanda, I know also very well through our philanthropy organization, Fresh Start Surgical Gifts.
So she's one of the Board members and medical program committee members and one of the, the pivotal surgeons that we, we continually work with for our children in a charity standpoint. So, if you recall from one of our previous podcasts, we had Sherry Bra who was the ceo and just just fantastic organization.
So, so Amanda, tell us a little bit about kind of your practice and, and kind of your, your role as the, the chair of plastic surgery.
[00:03:13] Dr. Amanda Gosman: Yeah, it's been very interesting. I you know, our U C S D is has a little bit of a interesting geography where we have like two big busy hospitals that are separated from themselves.
So I do maintain an adult practice, which I enjoy, but it's also important, I think, in terms of kind of keeping boots on the ground. The majority of my clinical practice is at the Children's Hospital, which is separate, and I am in charge of our division over there too. So it is a little bit challenging to kind of, manage the res at, at both institutions.
But you know, I think it's also a great opportunity to develop longitudinal care for children who are in our community and, and find a landing pad for them to, you know, receive care as an adult and really try to. Work within. What's really interesting cross-border healthcare system we have, especially for, for pediatric care.
[00:04:06] Dr. Salvatore Pacella: That's fantastic. So, and you know, just a little bit about the landscape of San Diego. So, U C S D is located across Route five, and on one side of Route five is my organization, Scripps and Scripps Clinic, Scripps Health and U C S D is on the opposite side, so to. To some extent our two health systems are competitors from the organizational standpoint.
But clearly all of our surgeons and doctors collaborate pretty extensively. And you know, I know quite a few folks in the division at U C S D and RA Children's and, and you know, we really are are a really tight professional group. I think so. And obviously as part of your job as the chairperson, you, you, you were responsible for training residents?
Correct. And tell for our visitors or for our listeners who don't necessarily know how a plastic surgeon is trained, could you maybe go a little bit into that as to how from graduating medical school, one becomes a plastic surgeon and kind of what your responsibility is and, and training.
[00:05:04] Dr. Amanda Gosman: Yeah, absolutely it is definitely a daunting responsibility there.
There are two pathways to become a plastic surgeon. So the traditional pathway is to complete a full general surgery residency, and then it's done essentially as a fellowship after that for an additional, now three years. So at U C S D, we've actually had an inde that's called an independent pathway.
We've had a pathway independent pathway. We're approaching 50 years actually, so a very long time. In 2016, we started our integrated pathway, and that means that we take students right outta medical school. They don't do a formal general surgery program, but they go right into plastic surgery and they do a lot of other rotations and clinical experiences and other specialties, but essentially they're within plastic surgery training for a total of six.
And then after that there are a variety of different fellowship pathways that people can pursue, such as microsurgery. What I did was pediatric cra facial, there's aesthetic surgery, there's gender affirming surgery, hand surgery. So those are the most common ones and is challenging to try to transition from training people who are fully.
Train general surgeons who training medical students to not just be surgeons, but to also be physicians. And that's something that, you know, we've been, you know, kind of, evolving into and has been an iterative process in, in some ways, but definitely we want to make sure that, you know, anyone that finishes the program is able to pass their board examination is gonna be safe to practice without supervision.
So it's a little bit different learner where we're taking, you know, actually a whole new generation of. Of people into a surgical specialty. And I think it's, it's challenging for all of us to kind of, you know, I, I always feel like the old person, whereas like, well back in my day, well, especially like in Dallas was very different training.
That was before we had these safeguards to protect wellbeing of, of residents such as duty hours. So a resident can only work 80 hours a week. They have man mandatory time. Really for patient safety. But it hasn't entirely evolved on the educational side where that time period has transitioned into a.
Quite as effective a way of skills obtainment. So, you know, all of that time that we spent operating and taking care of patients has mostly translated into us having to require longer training periods. So it, it is like a perpetual challenge to maintain the wellbeing of our physicians while they're working in a really difficult environ.
[00:07:46] Dr. Salvatore Pacella: Well, let's come to that, Come back to that in just a second. So, just for our listeners all four of us here have trained in an integrated program. The three of us gents at Michigan, and Amanda of course at ut u UT Southwestern, arguably one of the best training programs in the country. And all of us actually have done a fellowship.
I myself have done two fellowships. Aesthetic surgery. Dr. Jejurikar has done a full year fellowship in aesthetic surgery, and Dr. Bree has done a full cranium facial fellowship at ucla. So, you know, we, we really, I think all four of us really see that a tremendous value in, in the reputation of our training as well as diving deep into the, the highest echelon of, of training.
And that's getting a fellowship. So, Samir, you you train fellows now, correct? You do a you're a preceptor in the the aesthetic surgery fellowship in Dallas. So, tell us a little bit about your experiencing. Your experience in training fellows. Now you are, you are doing a little bit of a different job than Amanda's doing because you have had seasoned plastic surgeons who finished the residency program that have a concentration in aesthetic surgery.
[00:09:01] Dr. Sam Jejurikar: Yeah, I think I have a substantially easier job than Amanda has because I am getting plastic surgeons who have already finished their plastic surgery training, who have demonstrated an interest to be aesthetic surgeons. And there's also, and this is what I was gonna ask Amanda about there's a clear delineation about whose patient it is.
You know, when, when we are in aesthetic surgery and someone's coming to have a surgical procedure with me, It's really clear that I'm doing their surgical procedure and a fellow is there from a, from one of my patients to basically watch, take notes, glean, have a conversation, but they're not doing anything of any real value.
You know, in most fellow clinics, they have a very robust clinic where they have their own series of patients that they treat. And so there's a clear delineation about whose patients who's patient that it's when we trained, and I know when Amanda trained at UT Southwestern, which was a very different program than it is right now just in terms.
You know, we had a lot more autonomy as residents and so, that's not my dog ,
[00:10:02] Dr. Salvatore Pacella: but
[00:10:03] Dr. Sam Jejurikar: so I, so I was gonna say, so, so my question for Amanda is how do you balance that and, and knowing that the world is so different than it was when we were in residency? How do you train residents that are so learning how to operate?
But knowing, you know, that, that they need to be carefully, closely supervised. They maybe can't have the degree of autonomy that you might have had when you were a resident. You find that there's challenges that you would've never anticipated that you face when you were a
[00:10:28] Dr. Amanda Gosman: resident. Yeah, It, that is an excellent question and it is a tremendous challenge because you're absolutely right.
I, I, you know, I felt, when I was in residency, there were like two kind of mindsets that were very different than what I see in trainees today. One, That if I didn't know how to do it, there maybe was nobody who knew how to do it. So like that was that like drive to learn. I mean there always was like some support, but like you really, a lot of the, you know, independent decision making was happening at a very early phase.
So like you had to be competent. And then we also like really wanted to learn like we haunted for opportunities to really engage in a learning space. You know, especially, and I think there's probably some differences in kind of the setting that you're working in, but it is very difficult to create situations where the resident is really independently taking care of patients.
And one of the things that I think we've done well and at U C S D because we've had this longitudinal and independent program, is our resident aesthetic clinic. Where now we have so many safeguards around it, but it still gives them an opportunity for patients to come in. They do the whole initial assessment and then they have to present it at every phase, whereas that wasn't the case in the past.
So there's always more more faculty supervision. Then they're, you know, maybe historically has been, but it does give them kind of that frontline and they do identify to that patient that they are going to be taking care of them with this person who's kind of standing behind them. We used to have a little bit more ability to do that in a reconstructive space, but it's just like, It's not really allowed anymore because, you know, just this whole kind of medical legal environment and you know, it's, people are, are, are very aware that you know, they want to have somebody who is, you know, a licensed and board certified in that specialty, be their primary caretaker.
So it does make that more challenging. So that's really, I would say, our best opportunity to do that. And it's hard because you're not really seeing that full independence still very late in. So, you know, people can be very good at being part of a team or helping, but they may not actually be able to completely fly in independence.
And I don't, you know, I don't know how we can do that better earlier, but it is, I think, you know, a serious problem with just how we're training within our healthcare system. So definitely open to any suggestions. I think from surgical skills standpoint, we definitely have a. Amazing resources to train people how to do surgery.
So like the technical surgery, we have this whole center for the future of surgery. They have a micro lab, they can do the technical operations. I think the challenging part, as we all know for taking care of patients is the assessment and like coming up with a reasonable plan and then managing expectations and complications.
And that is much hard to do as them being the frontline.
[00:13:27] Dr. Sam Jejurikar: Yeah, I mean, I, I've even noticed in some of our fellows, they don't even know how to talk to patients the way we did because they oftentimes un, you know, they, they haven't had to do that. They've just sort of been there watching surgeries or helping or assisting in surgeries.
So, yeah, it is,
[00:13:40] Dr. Amanda Gosman: especially cosmetic patients, right? I mean, like, that is like a whole, I feel like that's like one of the most challenging patient populations to really be able to communicate with effectively. You have that appropriate balance of shared decision making, but like you're still in charge of guiding them towards something that's a safe solution.
You know, it's, it's interesting to see them, you know, start in that reson aesthetic clinic sometimes, and they'll be like, Well, they don't want this. They want this. I'm like, Okay, well you're, you're, you know, you're the surgeon and you, you need to be able to kind of help them make a decision that is going to align with what their objectives are for their outcomes.
And he's so challenging. Yeah.
[00:14:21] Dr. Sam Jejurikar: I think Sal's talking, but he's muted.
[00:14:24] Dr. Salvatore Pacella: There we go. My dog had a few things to say about this topic. So, so I, what I was saying was you know, we I think the, all of us trained at relatively how do I say this high intensity programs. Where , Well, there was a, there was a tremendous, tremendous amount of volume and a tremendous amount of responsibility.
We did not have the benefit of an 80 hour, hour work week, and it was very much the culture of,
[00:14:53] Dr. Sam Jejurikar: just to be clear, we all actually technically did, I was on the RRC when that happened and it actually all happened where residents, we just didn't enforce it.
[00:15:03] Dr. Salvatore Pacella: I had no idea.
[00:15:04] Dr. Sam Jejurikar: Yeah. Yeah. I was at that meeting where it got passed.
Just to,
[00:15:08] Dr. Salvatore Pacella: I
[00:15:08] Dr. Amanda Gosman: forgot. I remember when that, when that pass, I was like, I think it was a third year and I was still, I was on like a general surgery rotation and there were like, there was so many complications because during that transition was so hard cuz everybody previously took ownership for their patients and then where they're like, you have to go home and you weren't like longitudinally responsible for your patient, it was like it was a horrible time of
[00:15:31] Dr. Salvatore Pacella: transition.
And I, I distinctly remember the phrase, Well, if you, if you go home for 12 hours, you miss half the cases. Right? So it's like, Exactly. But yes, there, there clearly is a balance now, and I, you know, we, we all have, I, I think the, the positive memories sort of outshine the negative memories of being tired and fatigued and cranky, et cetera.
And, and, but I, I just simply don't know how you could train as a surgeon without. Pushing your mind and your body to the limits to some extent. And I mean, I think there has to be kind of a balance and a you know, parachute for residents and, and that's where the kind of attending steps in, you know, I, I don't necessarily know if the, the work hours or the answer, but the, the supervision clearly is, is part of the answer at least.
[00:16:21] Dr. Amanda Gosman: Yeah, I think it's hard too, because I think that there's, there are so many guardrails around residency and then like when you get into practice, It's totally different, right? There's no like duty hours and you know, if your patient has a complication, like you may miss some major life event for someone in your family or something like that, and you, that ownership it never, you know, is completely conveyed when you're in training.
I think you know, the only. There's so much that we need to do to kind of align what we need to achieve during residency and these new restrictions. But for me, my approach has been really just trying to figure out what they, each individual resident's passionate about, because I think that's like their only hope for like pushing through.
And can you find something that you're really compelled to learn about and. And try to create, you know, and customize some of your training experience so that you like keep that fire alive. Because being a plastic surgeon or any type of medical professional is very hard. You're like with a Hippocratic Oath.
Giving up yourself to some degree. And that's a little bit contrary, especially to like a younger generation that you're gonna sacrifice yourself in a, in a time period where like my wellbeing, I don't, you know, is in conflict with that. So I, I don't, I don't have any other kind of magical structure to force them down that, other than just continually trying to find something that will drive you through a surgical career and help you strive toward.
[00:17:53] Dr. Salvatore Pacella: So, Amanda, for example, if, if say you were a, a resident in your, in your program and you said to the chairman yourself that you were interested in, in cosmetic surgery, would your chairman say, Okay.
Not good. Good idea. . We'll let you on this little, let you on this little joke here. So, I'm sure you know Bill Kuzon, who was our former, former chair. Yeah. So that was, he was I think he took a slightly different approach to leadership than. So ?
[00:18:32] Dr. Sam Rhee: Well, I think what Sal's asking is really about the culture because our culture as surgeons back then was very different.
It was, you know, you could say charitably, it was more direct or
[00:18:44] Dr. Salvatore Pacella: you know, more could be,
[00:18:46] Dr. Sam Rhee: that would be one way of saying it. And there were some pretty negative aspects to it, but there were also some positives to it. And, and I think that when I talk to academicians who are training residents, that culture.
Is very, very different. Maybe to the point where it might have swung the other way in some instances, I think. And do you feel as the head of a training program that that's something that is a problem or not a problem for you when working with residents?
[00:19:16] Dr. Amanda Gosman: Yeah, I mean, I think there's still vestiges of, of both.
I think there it may, there may be representation on the other side of the spectrum. I think there is a lot of. You know, that's bias against the private sector, which, you know, was a little different. Grow, you know, training in Dallas. They, for example, like I was told, like, you know, my plan was to really like, engage in global surgery, like as a major part of my career, which I have done in, you know, in addition to fresher, have a nonprofit that we work with a lot overseas and in academic collaboration.
But I mean, I remember being told by one of my leadership, Why can't you just be normal and go buy a BMW and like go into practice like everyone else? So, so I, that was like their mold. So I think there was like always like a little bit of like a different bias depending on, on where you trained. But I, I think, you know, we do have flexibility in training.
Six years is actually a long time. I don't know. How long was your trade? Cause my residency was five years. We were
[00:20:19] Dr. Sam Jejurikar: we were all technically six, but You had a research. Yeah, we, I had two. Sal got an MBA during his, his research time. And Sam you did two years in the lab too, so I
[00:20:30] Dr. Salvatore Pacella: did, Yeah. Yes. So we were all eight years then.
Huh? And then we all did fellowships after
[00:20:34] Dr. Sam Jejurikar: fellowships too, right? Yeah.
[00:20:36] Dr. Amanda Gosman: So I think there's like, it's almost like residencies. Almost a little bit too long. So I think one of the opportunities now is that it is becoming a little more flexible. There's a little more accommodation from the board because you have, there used to be such a rigid timing requirement for training.
Now there is like a 12 weeks of leave that you can also do for like elective and Wow. You know, also, you know, tragedy trying to accommodate family leave and things like that. So I think there is some flexibility. So for example, I have a resident who's interested in cosmetics in going into private practice, and she's a couple of years down the pike.
And I was like, Okay, well you know, you need to like learn how. You're gonna run like a small businesses, you're probably gonna be in independent practices. 90% of people go into a group practice, aren't gonna like break up. Is there like the statistics, like I can't do that. I'm like, okay, we have like two years to figure it out.
So let's create a program where we can kind of customize your elective time so that you would be better prepared to go into independent practice. So I think we do have flexibility and I think everybody acknowledges that, you know, Just for like the reference to, to Koon and just some of this old guard that has been like, I kind of alienated, you know, kind of this alienation of the private sector.
That's one of the things that I think is really important from an educators standpoint is that when we look at the board certification of our specialty, And what people are doing over time. The vast majority of our graduates are always going to go into the private sector and they add tremendous value to our specialty people who are, you know, like, Why are you guys doing this on a Sunday?
People are giving back all the time in a lot of different ways, and I think that this. Minority of academic plastic surgeons, which only represent 15% of us have kind of driven this expectation that people need to give back in this way. But in reality, when we look at a lot of the really innovative leadership and people who have demonstrated incredible value to their local, regional, national, and international communities, that a lot of it comes from our private practice sector and.
Plastic surgery faces a lot of threats from the outside. We have a common ground. We have a common ground for scope of practice for all things that we are battling with the fda. And I think that coming from Dallas, I feel like I received such a great aesthetic education as a resident and part of it was cuz they thought I was like, gonna go move to Africa.
So I think they invested in me a. Because they knew for sure I was not gonna like set up shopped on the street from them. But like, you know, I feel like that improved every single aspect of what I do as a reconstructive surgeon and that we have to stop this separation of ourselves. Like we are one specialty, We are a principal based, technique based specialty that approaches things differently than other surgeons.
And I think if we. Tried to see where that common ground is more that we would really help a lot of our trainees better because right now we are in an arms race for people trying to get into plastic surgery. The average is like 10 peer review publication. The majority of those people will never publish a paper after they finish.
So why are we making them go through this crazy expensive process in selecting them on criteria that are never going to correlate with what they're ultimately gonna do in practice? Been one of, kind of my goals is not just as an educator, but also being involved in our academics as the acap. So try to see like we need to bring in the aesthetic society.
Those are amazing educators and amazing, amazing educational resources to our residents so that, like my resident who identifies and is honest and has a safe place to. I wanna go in private practice. Okay, let me figure out how we can help you to be the best at that position. Instead of like just going out and winging it.
It's like somebody from business school going out and doing a facelift, like you're gonna be a small business owner. It's not just the surgical skill, like how do you manage your people so you don't end up on the headlines or in some like social media, you know, blacklist there. These are like skills that people need to learn.
Business skills as well as, you know. Just how to be an good aesthetic surgeon.
[00:24:55] Dr. Salvatore Pacella: Well, Amanda, that's these are incredible insights and, you know, you and I have, have worked together a bit in, in the professional society such as the Aesthetic Society. I know you're involved with as p and the Association of Academic Chairman and, you know, your leadership is, is really paramount and it's you know, we love having you on to kind of talk about Some of the, your philosophies and training, and it's really, you know, it's really admirable to see you joining the two ends of the spectrum, the private world and the the academic world.
Jens, any, any last questions for Amanda? .
[00:25:28] Dr. Sam Jejurikar: Now that this has been incredibly insightful and it's really encouraging to actually hear someone who's prominent in academic plastic surgery having such a positive outlook towards plastic surgery. Just one slight comment. There's two of us that actually have MBAs and go out and do facelifts right now.
That's me, Pacella. So . But beyond that, I agree with everything You said ,
[00:25:48] Dr. Amanda Gosman: but you're also a platinum,
[00:25:50] Dr. Sam Jejurikar: right? I know, I, Yeah, that's exactly.
[00:25:55] Dr. Salvatore Pacella: Great. Well, thank you so much. Thanks to our listeners at Amanda. Have a great Sunday. We appreciate you having having yon.
[00:26:00] Dr. Amanda Gosman: Absolutely. Thanks so much. I really appreciated it.
