Political Advocacy from Plastic Surgery Trainees in the United States.

Legislature directly impacts the practice of physicians across multiple specialties. The goal of our study is to investigate the political engagement and opinions of plastic surgery trainees, and how they perceive legislation impacts future practice.
METHODS: A 24-question survey was designed and distributed to all program directors and Resident Council members within the American Society of Plastic Surgeons. This initiative was driven by the board and directors and supported by the Resident Council. The Resident Council is a trainee-driven committee within the American Society of Plastic Surgeons that communicates with the Board of Directors.
RESULTS: This survey generated a 10.3% response rate with 118 responses out of 1143 trainees in ACGME accredited institutions. When asked in an open-ended fashion to list the most important reason why one planned to vote in the 2020 election, only 6.8% listed healthcare as a factor. Eighty-four percent of respondents believe that their vote impacts future legislation and regulation. Ninety-four percent strongly agree or agree that political legislation affects reimbursement.
CONCLUSIONS: With only 10.3% of trainees responding, there is a concern that political activity is not a priority for plastic surgery trainees. Plastic surgery trainees are attending summits, meeting with politicians, writing letters, and attending fundraisers. Respondents are overwhelmingly voting and planning to vote in elections, though few list healthcare as a reason. A future goal must be to motivate trainees to consider the intersection between healthcare and plastic surgery.

INTRODUCTION

The past decade, with its evolving political environment, has made plastic surgeons not only caregivers but also political advocates.[1-5] Plastic surgeons are advocates for insurance coverage for procedures, mitigating inappropriate encroachment into specialty procedures, promoting funding for residency training, and arguing for appropriate reimbursement to name a few examples. This advocacy includes addressing the Affordable Care Act, surprise billing legislation, breast cancer awareness, and initiatives to address projected physician shortages.[6-8] Congress and politics in general influence the landscape of physician practices in plastic and reconstructive surgery.[9] The authors of this study believe advocacy will become an important part of many plastic surgeons’ careers.

Plastic surgeons have organized their advocacy goals with the creation of the ASPS political action committee, the PlastyPAC. Members of the Young Plastic Surgeons (YPS) forum[10] and ASPS meet with Congress to discuss policy and how it impacts patients and practice. Politicians who receive support have platforms that improve health care, patient care, and the future of plastic surgery. The aims of the PlastyPAC include raising awareness of insurance coverage, protecting patient safety by promoting policies that prevent nonphysicians from performing procedures, increasing the cap on graduate medical education positions funding, and promoting insurance for reconstructive procedures. Plastic surgeons are currently advocating for insurance coverage in gender dysphoria[1] while challenging the low reimbursement rates for breast reconstruction patients with Medicaid[2] and bringing awareness to the average decline in reimbursement by 14% from 2000 to 2019.[3]

The aim of this work was to study the opinions regarding political advocacy in plastic surgery trainees, in a manner similar to that of the prior assessment of attending plastic surgeons.[11] The purpose was to understand trainees’ perspective on politics, advocacy, legislature, and how these issues may or may not influence the specialty and their ability to practice plastic surgery when they finish training. This is the first survey the ASPS has initiated, with the sole purpose of eliciting a response from trainees only, regarding political engagement. The importance of this study is to bring focus on the evolving political legislation that may affect the future practice of current plastic surgery trainees.

This study is an initiative of the Resident Council of the ASPS. The Resident Council is a resident-led national initiative to bring together trainees from all programs to share ideas and engage the ASPS at the highest level. The council allows the residents to work together on projects, engage the YPS, implement local and national change, and develop leadership skills. Consisting of 1 resident from each program in the nation, the Resident Council is a diverse entity with a strong voice at the resident level.

MATERIALS AND METHODS

This survey was designed by the Resident Council, PlastyPAC, and the ASPS Vice President of Health Policy and Advocacy with the assistance of the ASPS administrative support staff. This study is based on the pilot study completed by the general surgery residency in the department of surgery at the Monmouth Medical Center in Long Branch, New Jersey. Institutional review board approval was granted for this survey study. After receiving approval, a 24-question survey was designed to collect information on plastic surgery trainees’ (integrated track, independent track, and fellows) political engagement. Demographics, voting habits, interest in advocacy, and the intersection of legislation and practice are assessed in the survey as outlined in the attached flowsheet (Fig. 1).

Fig. 1.

Political engagement flowchart.

The survey was administered via electronic mail on 3 occasions, each separated by a 2-week interval. After the first communication, the Resident Council president contacted all Resident Council leaders in a group message. Following the second communication, each Resident Council leader was contacted individually in a private communication. The PlastyPAC resident representatives also participated in communications to bring awareness to the survey. Three separate emails were sent to the 1143 plastic and reconstructive surgery trainees listed in the ASPS database. The survey was closed 2 weeks after the third email, with a 10.3% response rate. This is commensurate with previous ASPS surveys. Each question was evaluated for percentage responses and the information tabulated.

Once the survey was created, it was then constructed digitally, using the ASPS account on the Survey Monkey website (Table 1). Access to the survey was strictly limited to trainees. The ASPS generated a unique link to each trainee using IP filtering to prevent multiple submissions from the same individual. All data were maintained in a database without identifying features. Each question had specific data recorded and this was evaluated after the survey was closed. Questions were designed in multiple-choice, Likert scale, and open-ended fashion. The ASPS performed a statistical analysis using chi square, denoting statistical significance with a P < 0.05 as well as a non-responder analysis. (See table, Supplemental Digital Content 2, which displays a statistical analysis using chi square, denoting statistical significance with P < 0.05. )

Table 1.

Plastic Surgery Political Engagement Survey

Question	Answer Choices
1. What is your age?	Grouped by 10 years
2. What is your gender?	Man, woman, nonbinary, prefer not to identify, prefer to self-describe
3. Are you in the integrated track, independent track, or fellowship?	Integrated, independent, fellowship
4. What is your postgraduate year of training?	PGY-1 through PGY-10
5. In which state is your program located?	Drop down selection of each state
6. Are you a registered voter?	Yes or no
7. Are you aware that ASPS has a political action committee (PlastyPAC)?	Yes or no
8. Have you ever donated to the American Society of Plastic Surgeon’s Political Action Committee (PlastyPAC) or another PAC?	Yes or no
9. Have you ever donated to a political party?	Yes, no, or I prefer not to answer
10. Are you a member of a political party?	Yes, no, or I prefer not to answer
11. Select all of the following you have participated in:	Attend summit, met with representative, wrote letter, fundraiser, met with congress, PlastyPAC event, or none of the above
12. In what state do you vote?	Drop down selection of each state
13. Have you previously voted in a presidential election?	Yes, no, or I prefer not to answer
14. Did you vote in the 2016 presidential election?	Yes, no, or I prefer not to answer
15. Please specify what motivated you to vote in the 2016 presidential election?	Open ended
16. Please specify why you decided not to vote in the 2016 presidential election	Open ended
17. Are you planning on voting in the 2020 presidential election?	Yes, no, or I prefer not to answer
18. What is the most important reason why you are voting in the 2020 presidential election?	Open ended
19. What is the factor(s) influencing your decision not to vote in the 2020 election?	Open ended
20. Have you utilized an absentee ballot in the past?	Yes, no, or I prefer not to answer
21. Do you believe your vote impacts future legislation and regulation?	Yes, no, or I prefer not to answer
22. Do you believe current legislation impacts your ability to practice plastic surgery?	Yes, no, or I prefer not to answer
23. How much do you agree or disagree with the following statement: political legislation affects reimbursement for plastic surgeons?	Likertscale from strongly agree to strongly disagree
24. In what practice model do you see yourself practicing?	Academic, private, employed, military, undecided

RESULTS

Three separate emails were sent to the 1143 plastic and reconstructive surgery trainees at ACGME accredited institutions listed in the ASPS database. The survey was closed 2 weeks after the third email, with a 10.3% response rate from 118 respondents. This is commensurate with previous ASPS surveys. A flow chart is provided that summarizes the themes of the survey, which include demographics, voting habits, interest in advocacy, and opinions on the intersection of legislation and practice. (See appendix, Supplemental Digital Content 1, which displays the full analysis of data tables with P values. )

Demographics

The majority of trainees (85%) are between the ages of 25 and 34. Sixty-two percent of trainees who responded are men, and 38% are women. Most trainees (80%) are in the integrated model, whereas 15% are in the independent track. There is a well-balanced variety in the postgraduate year of respondents, with the highest percentage (21%) noted in PGY-2 and PGY-6. Ninety percent of trainees are registered voters. Ninety-two percent of respondents are aware that the ASPS has a PlastyPAC. Only 25% of respondents have ever donated to a PAC, including PlastyPAC. Even fewer (22%) have donated to a political party. Though, 56% of respondents belong to a political party. Plastic surgery trainees are for the most part registered voters, but many have not contributed to the PlastyPAC or a political party.

Engagement

Fifty-seven percent of respondents are politically active. Thirteen percent have attended an advocacy summit. Twenty-four percent have met with a local or state representative and 15% met with a member of congress. Thirty-one percent have written a letter to a representative. Fourteen percent have attended a fundraiser and 12% have attended a PlastyPAC event. Fourty-three percent of respondents are not politically active. Half of plastic surgery trainees are currently engaged in advocacy, which is a good foundation on which to build.

Voting Habits

Ninety percent of respondents voted in the 2016 presidential election and 92% plan to in the 2020 election. When asked in an open-ended fashion the motivation to vote in the 2016 and 2020 election, only 2.5% and 6.8%, respectively, listed healthcare as a reason. Barriers to voting included missing the absentee ballot deadline, living in a different state than the state in which one votes, and clinical obligations. Whether or not trainees voted or planned to vote in the 2016 and 2020 elections was statistically significant (p < 0.0014). Plastic surgery trainees are engaged in voting but do not readily list health care as the primary motivating factor.

Voting Impact

In regard to voting impact, 84% of respondents believe that their vote impacts future legislation and regulation. Ninety-three percent state that current legislation impacts their ability to practice plastic surgery. Ninety-four percent strongly agree or agree that political legislation affects reimbursement for plastic surgeons. Plastic surgery trainees are aware of the impact of their vote has on legislation and regulation.

Legislation

Three specific questions were used to evaluate trainees’ opinions regarding the intersection of legislation and plastic surgery. Question 21 asked “Do you believe your vote impacts future legislation and regulation?” Eighty-four percent answer yes (114 answered). Question 22 asked “Do you believe current legislation impacts your ability to practice plastic surgery?” Ninety-three percent answered yes (118 responded). Question 23 asked, using a Likert scale, the respondent to agree or disagree with the statement “Political legislation affects reimbursement for plastic surgeons.” Ninety-four percent answered either agree or strongly agree (114 answered). Plastic surgery trainees are aware of the impact of legislation on their specialty and future practice.

DISCUSSION

Plastic surgeon involvement in advocacy has resulted in major changes over the years. One of the monumental achievements was the Women’s Health and Cancer Rights Act, mandating coverage for breast reconstruction after mastectomy.[6] The ASPS helped advocate for the Breast Cancer Patient Education Act of 2015, which increases patient awareness and education of reconstructive options after mastectomy.[7] Funding for graduate medical education positions to address the state of the plastic surgery trainee workforce is another aim of ASPS.[12,13] The society also supported the Ensuring Lasting Smiles Act, requiring coverage of congenital craniofacial defects.[14] New Jersey plastic surgeons helped advocate to sunset the 6% cosmetic surgery tax.[15] Recently, plastic surgeons have advocated for patient awareness of nonsurgeons attempting to perform procedures requiring extensive reconstructive training.[16]

The degree of involvement from plastic surgery attendings has previously been evaluated.[11] Over 2000 plastic surgeons offered insight into attitudes and engagement. Scope-of-practice issues and specialty encroachment were top concerns of these surgeons. Additionally, most report no formal training on policy education during residency. Many YPS members are not active in the ASPS advocacy efforts. The YPS struggled with membership awareness of the PlastyPAC, donation to the PlastyPAC, limitation in engagement, and barriers to engagement. We have designed this study in a similar fashion, with a goal of ascertaining information on trainee demographics, voting habits, interest in advocacy, and opinions on the intersection of legislation and practice.

This study offers insights into the current culture of political awareness and advocacy amongst plastic and reconstructive surgery trainees. Resident and fellow participation in the society’s advocacy initiatives may foster more active career long involvement. First, this will motivate trainees to be involved in the society, as their voices will be heard. Second, it fosters a commitment to advocating for policy and legislation that protects patients and plastic surgeons. Third, resident involvement is a stepping stone for joining the YPS and contributing to PlastyPAC.

This is the first and largest survey analysis of trainee attitudes in the specialty. The authors are the first to focus on the resident and fellow level, addressing political interests, advocacy, voting habits, and perceptions related to plastic surgery. The results are important to build a foundation on which to increase awareness and exposure to political advocacy during training. The trainees of the specialty are the voices that will carry forward in the coming years, and including them in the discussion before joining YPS should be an aim of ASPS.

The data in this study show that there is room for increasing resident engagement. Respondents are overwhelmingly voting and planning to vote in elections, though few list healthcare as a reason. There is a concern that political activity is not a priority for plastic surgery trainees. This is an area for growth within the specialty. More than 80% of respondents see their vote impacting legislation and this legislation affecting reimbursement for plastic surgeons. This is a positive sign, as these trainees are looking forward into their professional career and how political practice may affect it.

Other specialties are grappling with the same issue, and there are blueprints available to build upon for trainees interested in political advocacy. One study conducted with dermatology residents notes that legislation may negatively impact dermatology patient care and practice.[17] Their results show that 99.3% of respondents found advocacy important and 98.6% believe it will affect their career. Fourteen percent of the trainees participate in their PAC, SkinPAC. The neurosurgical specialty also faces the same challenges pertaining to physician engagement. Complacency, disdain for politics, and lack of information of what societies are legally allowed to do may explain this.[18] Advocacy issues facing their specialty include Medicare advantage prior authorization practices, graduate medical education funding, and surprise medical billing legislation.

A compelling piece from The New England Journal of Medicine offers a roadmap for effective legislative advocacy.[19] Collaboration is essential for a trainee to have an effect in legislative advocacy. The PlastyPAC and ASPS should lead a collaborative effort at the trainee level to achieve this step. Trainees may have the strongest voice at a local level. The PlastyPAC and ASPS can focus on creating opportunities for residents to meet locally and regionally with politicians. Thirdly, trainees need to work with professionals. Again, the PlastyPAC and ASPS can function as the liaison here. Lastly, focus on incremental change. Opportunities should build as the trainee progresses. Goals should be longitudinal. The physician’s armamentarium must include advocacy.[20]

This study is not without its limitations. First, there may be a response bias favoring those with interests in political advocacy. This is evidenced by the face that almost a quarter of the respondents have met with a local or state representative. Thus, the results should be viewed in that light, understanding that those with advocacy interests were more likely to complete the survey. Lastly, the open-ended nature of some survey questions may have inadvertently missed motivating factors for the respondent. Many more may consider health care an important issue, but without a prompt, it was not included in the answer to the question.

CONCLUSIONS

To effect change going forward, the ASPS should aim to increase engagement and voting percentages amongst trainees. A future goal must be to motivate trainees to consider the intersection between healthcare and plastic surgery. It is important that our specialty invest in itself at a legislative advocacy level before decisions are made on our behalf.

ACKNOWLEDGMENTS

The authors of this study would like to acknowledge the efforts of Christopher Simmons, Katie Sommers, and Keith Hume at the American Society of Plastic Surgeons administrative offices for their assistance with designing, administrating, and analyzing the survey. Their efforts were instrumental in acquiring the data for this article.