If you ask most people (medics included!) what they think of when you say plastic surgery, most people will say it’s about nose jobs, boob jobs and making people look like a Kardashian! We have a reputation of being focused on private practice and earning lots of money doing purely cosmetic procedures. In reality, cosmetic procedures are a tiny part of what plastic surgery is all about.
Why do plastic surgery?
It is an ancient specialty which developed during the first and second world wars, reconstructing soldiers with devastating injuries. Plastic surgery is a specialty of techniques rather than procedures and it gives you the chance to operate on any part of the body, on patients from new-born babies to elderly adults and everyone in between.
Plastic surgeons may choose to specialise in a particular area such as cleft lip and palate, hand surgery, breast reconstruction, head and neck cancer, burns, lower limb trauma, skin oncology, facial palsy, paediatric and congenital conditions, skin and soft tissue loss, gender reassignment, chronic wounds, LASER and many others, as well as the cosmetic procedures often read about in the press and social media.
It is a specialty with a strong background in research and academia with many new and emerging techniques such as tissue engineering, scar-free healing and face transplants.
Plastic surgery at its heart is about restoring form and function and whilst we may not necessarily always be saving lives, we can certainly improve them. It is an incredibly varied, challenging and satisfying specialty and I would recommend it to anyone with an artistic flair and an appetite for solving problems.
Your training pathway will begin as a Foundation Doctor before you spend 2 years as a Core Surgical Trainee (CST), usually in a plastic surgery themed programme. You will complete your MRCS exam during this time. You then have a further round of interviews before obtaining a National Training Number (NTN, “number”) which allows you to enter a higher surgical training programme. This usually lasts for 6 years although a new surgical curriculum was introduced in 2021 which is moving towards a “competence based” rather than “time based” programme meaning some people may take more or less time to complete it. After completing your FRCS (Plast) exam, many trainees take the opportunity to complete a fellowship to undertake further training in a narrow subspecialist area in another region or even overseas. Throughout your training you will be assessed by a series of assessments of your clinical and surgical skills and professional behaviours. Once you have met all of the curriculum requirements you will be awarded your Certificate of Completion of Training (CCT) which enables you to apply for a consultant post where the fun really begins!
Day in the life of a plastic surgery doctor (theatre days and non-theatre days)
As a trainee your working week will be spent carrying out a mix of elective work and on call or emergency commitments. A typical working day usually begins at 8am with a ward round and a review of any patients who will be going to theatre, making sure they have been prepared adequately for their procedure. If it is a theatre day then you will usually spend the day in the operating theatre with your consultant and the rest of the team carrying out operations. The varied nature of plastic surgery means that a single operating list may contain several different types of operations, rather than a whole list of varicose veins or hernias for example. Some operations will be very complex and performed mainly by the consultant but every procedure should have at least part that can be done by a trainee and this is your chance to develop the key skills of tissue handling, dissection, wound closure and utilising the “reconstructive ladder” to choose the most appropriate way to reconstruct a given wound. Theatre days also give the chance to have some one on one teaching with the consultant, discussing aspects of the cases being performed. At the end of the day is the time for a post-op ward round before heading home, perhaps doing some reading to prepare for the cases the following day.
On non-theatre days you might attend a clinic or MDT. These are often seen as less “exciting” than theatre lists but they are still an essential part of your work as a plastic surgeon and they are where you meet your patients and follow them up after you have operated on them. You will see patients in clinic and be able to develop skills in history taking, forming a clinical diagnosis, breaking bad news and formulating a management plan. MDTs are common in all areas of oncology as well as other specialties such as burns and cleft surgery. This is the chance to interact with the whole team and realise that surgery is only a small part of the treatment that our patients receive. You may be able to present some cases and join in with the discussions with the rest of the team to plan treatment.
Being on call is also an important part of your training although it can be busy and stressful. When you are on call you will receive referrals for patients with acute injuries including burns, hand injuries, lower limb trauma, soft tissue infections etc. You will need to prioritise cases and learn to make focused assessments of patients to decide who requires admission or potentially surgery. Although your consultant will be available, you often have more independence during the time on call and learn valuable skills about communicating and team working as well as developing surgical skills to manage a range of emergency conditions.
Life as a consultant
As a consultant my working week is also very varied and contains surprisingly little operating! I have one whole day adult operating theatre list and one half-day paediatric list each week. The rest of my time is spent doing ward rounds, clinics, MDTs and teaching, as well as a fair amount of admin! I am on call for adult and paediatric burns around 1 week in 6 and this can be very busy and unpredictable. As well as my main job as a plastic surgeon, I have other roles in training and education and Clinical Ethics which I find very interesting and challenging. I really enjoy the variety of my week and as a consultant I have more control over my weekly timetable which makes it easier to manage my work-life balance.
Working as a plastic surgeon is demanding but enjoyable. There will be work required outside of main working hours to develop your portfolio and keep up to date with the literature etc and this is still the case when you become a consultant. It is not a 9-5 job and you will need to have some degree of flexibility to work hard when it is busy and then perhaps relax a little when it is less busy. Times around exams are always stressful, particularly trying to juggle revision with your usual work. It is possible to manage good work life balance and also to have a family whilst working as a plastic surgeon but it does require you to work hard and be organised.
How to build your portfolio
Plastic surgery is a highly competitive specialty and it is never too early to start developing a portfolio to make you a strong candidate for job applications. It is important to try and achieve something in all the various areas of the portfolio rather than focusing on just one thing. The national selection process relies on allocating points to achievements in different areas such as audit, publications, presentations and surgical experience so it is best to try and get something in each “box” rather than for example focusing on surgical procedures at the expense of audits and publications.
Prizes and higher degrees will also score more points on the application form but it is perfectly possible to be a strong candidate without them so don’t be too disheartened if that doesn’t work out for you.
Anything that shows your commitment to specialty will help so think about “taster weeks” or shadowing some of the members of the plastic surgery team where you work. Think about joining online meetings or webinars to learn more about the specialty or maybe join surgical societies at university depending on your stage of training. Take every opportunity to get plastic surgery related experience.
The application process
The application process is similar for both core and higher training and involves submitting a summary of your experience so far including operative skills and non-surgical things like audits and presentations. If you are successfully shortlisted then you will be invited to an interview which currently all take place virtually on MS Teams. The interview is very structured and usually consists of questions about clinical scenarios and various management or quality improvement questions. Depending on your score you will be ranked and potentially offered a job – those with a higher ranking will get their first choice of job and naturally some jobs/regions are more popular than others. Wherever you end up working you will get the same opportunities to acquire the skills and experience you need to be a successful plastic surgeon.
Good luck in your applications and your future careers!
Consultant Burns and Plastic Surgeon, University Hospital Birmingham
Training Programme Director for Plastic Surgery West Midlands
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