Routes to Residency: A National Survey Demonstrating the Pathways to Become a Plastic Surgeon.

Plastic and reconstructive surgery (PRS) residency training can be completed through multiple pathways. Current residents' experiences regarding these different routes have not been previously described. The objective of the present study was to describe the educational pathways taken by current PRS residents in the United States. We hypothesized that there would be a small cohort of current PRS residents who were initially unsuccessful in matching into an integrated residency.
METHODS: An online survey was sent to PRS residents across all training years from October 2020 to January 2021. The survey collected information about residents' match history, experience after not matching, and narrative comments on their route to residency. Public match data from the past 20 years (2001-2021) were also summarized with descriptive statistics.
RESULTS: One hundred seventy-four residents responded (response rate 15%; 174/1158). Of these, 133 applied to integrated programs as senior medical students, and 15 (11%) did not match after applying as a senior medical student. Unmatched applicants took multiple different routes to PRS, including participating in the Supplemental Offer and Acceptance Program, reapplying, transferring after some general surgery training, and completing an independent PRS residency. Three-fourths (76%) of independent program residents did not originally apply to the integrated match.
CONCLUSIONS: An initial unsuccessful match result does not portend that one will not be able to train for a career in PRS. Our findings illustrate the potential routes to successful completion of PRS residency training, both for unmatched applicants and residents who develop later interest in PRS.

Takeaways

Question: How many current plastic surgery residents did not match through the integrated route, and what routes did they take?

Findings: Eleven percent of surveyed residents that applied to the integrated match did not initially match, and they were able to enter training through other routes, such as reapplying or transferring. Three-fourths of surveyed independent program residents did not apply to the integrated match.

Meaning: Alternate training routes allow unmatched applicants and residents who develop later interest to become plastic surgeons.

INTRODUCTION

Integrated plastic and reconstructive surgery (PRS) residency is the most competitive route for American medical students who wish to become plastic surgeons. In 2021, the National Resident Matching Program (NRMP) reported that 329 candidates applied to integrated PRS residency programs, for which 187 positions were available, resulting in a 57% match rate for all applicants and a 70% match rate for US MD applicants.[1] This competitiveness has been consistent since the development of the integrated PRS training pathway, which has been formally recognized by the American Board of Plastic Surgery since 1995.[2] Consequently, there are many applicants who do not match into integrated PRS programs, and both these applicants and their educational advisors need to be aware of alternative options available to achieve the applicants’ goals of becoming a plastic surgeon.

Prior studies have investigated the topic of reapplication in other competitive surgical specialties, such as cardiothoracic (CT) surgery, orthopedic surgery, and otolaryngology.[3-5] One study surveyed 250 CT residents, and based on their responses and NRMP data, the authors estimated that only 14% of unmatched CT applicants ended up in independent CT fellowships, implying that they lost interest in the field after their unsuccessful match attempt.[3] In the orthopedic literature, Amin et al[6] surveyed 91 orthopedic program directors and chairpersons about their approach to evaluating reapplicants. They found that the majority would favor reapplicants who completed a general surgery (GS) internship over time spent doing research, but respondents from academic programs looked more favorably upon dedicated research time. A survey of 82 otolaryngology program directors and chairpersons also reported a preference towards completing a surgery internship over research.[5] However, three studies (with cohorts of 141 orthopedic surgery reapplicants, 81 orthopedic surgery reapplicants, and 23 otolaryngology reapplicants, respectively) have not shown an advantage to completing a surgical internship or a research year.[4,7,8]

One recent article by Patel et al.[9] surveyed a small cohort of PRS reapplicants about their match outcomes. For integrated applicants, they received 18 responses (33% response rate) and reported a 50% successful rematch rate. For independent reapplicants, they received seven responses (16.7% response rate) and reported a 43% successful rematch rate. The authors did not find a significant advantage between pursuing a research year or an internship.[9] However, no studies have described the current number of formerly unmatched PRS applicants who eventually successfully obtained a PRS residency position or the different routes they undertook to achieve that goal.

The purpose of this study is to describe the training pathways taken by current PRS residents in the United States, with a focus on the routes taken by those residents who were unsuccessful in their initial efforts to match. These results may enable us to draw conclusions about how residents who were unsuccessful in their initial application to integrated PRS residency were subsequently able to accomplish their goal of training in plastic surgery. We hypothesized that while most current residents would have entered training through a direct match into integrated plastic surgery, a minority would have not initially matched and found different routes to become plastic surgeons.

METHODS

A survey of current PRS residents in the United States was conducted from October 2020 to January 2021. (See survey, Supplemental Digital Content 1, which displays the survey study in detail, http://links.lww.com/PRSGO/B944.) The survey was designed by the authors to elicit specific information of interest. It was distributed through a listserv of integrated and independent PRS program directors and coordinators via the American Council of Academic Plastic Surgeons, who were asked to forward it to residents in their programs. Reminders were sent three times at monthly intervals. Individuals were included in the study if they were current plastic surgery residents at a US-based integrated or independent plastic surgery training program.

The survey elicited information about the resident’s medical school type (MD, DO, and international medical graduate [IMG]) and ranking (according to the US News & World Report rankings), current residency program, and integrated PRS match history (such as initial match participation year, number of programs to which they applied, accepted interviews, and included in their final rank list, and their initial match results). If they did not match, branching logic led to questions about their experience after not matching (such as when they reapplied, to what specialty they reapplied, and what they did with their time before reapplying). If the resident did not originally apply to integrated PRS, different questions gathered information about why they did not apply to integrated programs and what training they completed instead. At the conclusion of the survey, free-text questions included: (1) “What were the most significant factors that led to your successful match into PRS?”; (2) “What were the factors that contributed to your initial unsuccessful match into an integrated PRS program?” (If applicable); and (3) “Any comments or thoughts on the route you took to PRS residency? (eg, positives, negatives, regrets, advice for medical students).”

Quantitative data was summarized with descriptive statistics, Fisher exact test, and two-sample t tests. Application data, medical school ranking, and medical school type were compared between matched and unmatched applicants. Narrative responses from free-text questions underwent thematic analysis with Atlas.ti, a qualitative research tool. The thematic analysis included (1) complete data review; (2) code generation; (3) theme generation; (4) theme review; (5) theme definition; and (6) analysis.[10] To contextualize the results of the survey, publicly available NRMP match data from the past 20 years (2001–2021) were summarized with descriptive statistics and presented as tables. This study protocol was reviewed by the Northwestern University Institutional Review Board and found to be exempt (IRB ID: STU00213316).

RESULTS

One hundred seventy-four residents completed the survey (Table 1). Residents were represented from 67 independent and integrated plastic surgery programs. For response rates by program and region, see table 1, Supplemental Digital Content 2, which displays the survey response rates by region. Program response rate is calculated based on 67 total programs. Resident response rate is calculated based on 174 total resident respondents, http://links.lww.com/PRSGO/B945; see table 2, Supplemental Digital Content 3, which displays the survey response rates by program. Total number of integrated and independent residents per program was sourced from the Doximity Residency Navigator (https://www.doximity.com/residency/) and the FREIDA AMA Residency & Fellowship Programs Database (https://freida.ama-assn.org/), http://links.lww.com/PRSGO/B946.

Table 1.

Medical School and Residency Program Characteristics of Survey Respondents (n = 174)

Type of Medical School	n	%
Allopathic/MD (United States)	154	89
Osteopathic/DO (United States)	7	4
Medical school outside of the United States	13	7
Medical school ranking
1–20	37	23
21–40	27	17
41–60	35	22
61–80	23	14
81–100	15	9
101+	24	15
Type of residency
Integrated	140	80.46
Independent	34	19.54
Year
PGY1	17	10
PGY2	17	10
PGY3	32	18
PGY4	31	18
PGY5	24	14
PGY6	18	10
Independent year 1	11	6
Independent year 2	13	7
Independent year 3	10	6
Research year	1	1
Applied for integrated PRS
Yes	133	76
No	41	24
Matched in integrated PRS
Yes	118	89
No	15	11

The estimated total number of active PRS residents at the time was 1158 (based on NRMP and SF Match data from 2015 to 2020),[11,12] thus achieving a response rate of 15%. The medical school graduation year of the residents ranged from 2006 to 2020, and 86% graduated in the past 7 years (Fig. 1). Residents who finished medical school in 2006–2008 were all IMGs, some of whom completed residency training in other countries. An outlier medical school graduation date (2005) was excluded for one resident, as it did not correspond with the rest of that resident’s responses. Most residents graduated from an allopathic (MD) program (89%) and were currently in an integrated residency program (80%). Nine of 13 (69%) IMGs and two of seven (29%) osteopathic graduates (DOs) were in integrated programs.

Fig. 1.

Graduation year of survey residents (n = 173).

For applicants who applied to the integrated plastic surgery match as fourth-year medical students, the mean numbers of applications, interviews, and ranks during their initial application cycle were 59.5 (SD 19.2), 13.7 (SD 6.0), and 13.1 (SD 5.7), respectively (Table 2). Applicants who matched successfully as fourth-year medical students applied to, interviewed at, and ranked more programs than applicants who did not match (P = 0.009, 0.022, and 0.010, respectively). Medical school ranking and medical school type were not associated with likelihood of matching. However, it is noted that this data are likely limited due to the small cohort studied and the fact that the survey only captured unmatched applicants who eventually became plastic surgery residents, not all unmatched applicants.

Table 2.

Integrated Plastic Surgery Applicant Factors and Match Results

No.	Total		Matched		Unmatched		P
	Mean	SD	Mean	SD	Mean	SD
Applications	59.5	19.2	62.3	15.7	39.1	29.6	0.009*
Interviews	13.7	6.0	14.4	5.2	8.6	8.6	0.022*
Ranks	13.1	5.7	13.8	5.1	7.9	7.5	0.010*
Medical school ranking	n	%	N	%	n	%	P
1–20	36	27	34	94	2	6	0.541
21–40	22	17	19	86	3	14
41–60	30	23	27	90	3	10
61–80	15	11	13	87	2	13
81–100	12	9	9	75	3	25
101+	17	13	15	88	2	12
Medical school type	n	%	n	%	n	%	P
Allopathic/MD (United States)	131	98	116	89	15	11	1.000
Osteopathic/DO (United States)	1	1	1	100	0	0
Medical school outside of the United States	1	1	1	100	0	0

One hundred thirty-three residents (76% of all residents) applied to integrated PRS programs as senior medical students. Fifteen residents (11%) did not match to integrated plastic surgery after applying as a senior medical student. Of the residents who did not match, eight residents dual-applied and matched into categorical GS positions, three matched into integrated PRS positions through the Supplemental Offer and Acceptance Program (SOAP), and four matched into preliminary GS (prelim) positions (Fig. 2). Of the residents who matched into prelim positions, three went on to reapply and match into categorical GS positions, while one transferred into an integrated PRS program. After matching into categorical GS (n = 11), nine residents matched into independent PRS residency programs, one transferred into an integrated PRS position at the same institution without completing GS residency, and one left their categorical GS program after completing multiple years and rematched as a PGY1 in integrated PRS.

Fig. 2.

Visual representation of the routes applicants who did not match into integrated PRS residency took to become plastic surgeons.

Forty-one residents did not apply to integrated PRS programs as fourth-year medical students (MS4s) (Fig. 3). Most residents who did not apply as MS4s started training as categorical (n = 36) or preliminary (n = 1) GS residents. Two residents did not specify their original match outcome, but they were currently in integrated PRS programs, so it was assumed that they transferred. Of the residents who matched into GS training programs, 26 completed their categorical GS training and then went on to complete an independent PRS residency. Thus, 76% (26/34) of current independent PRS residents did not originally apply to plastic surgery as MS4s. Eleven residents transferred into integrated PRS (eight from categorical GS, one from preliminary GS, and two from unspecified specialties). Most (56%, n = 5) transferred to institutions outside of the geographic region of their initial residency position. Two residents left their categorical GS programs and rematched as integrated PGY1s.

Fig. 3.

Visual representation of the routes applicants who did not initially apply to integrated PRS residency as fourth-year medical students took to become plastic surgeons.

For residents who did not apply to integrated PRS programs as MS4s, the most common reason was not being interested in PRS at the time (46%) (Table 3). Two residents did not apply as MS4s due to military obligations to train in GS, and two did not apply as MS4s because they completed training in other countries first; one did PRS training, and the other did preliminary GS training. Both residents who completed surgical training in other countries first worked in PRS research labs in the United States and then matched into integrated PGY1 positions.

Table 3.

Summary of Survey Responses from Respondents Who Did Not Apply to Integrated Plastic Surgery Programs as a Senior Medical Student (n = 39)

Reason for Not Applying to Integrated PRS as an MS4	n	%
Not interested in PRS at that time	18	46
Wanted a broader training experience before specializing in PRS	9	23
Not competitive enough to match at that time	8	21
Military obligation	2	5
Residency in other country	2	5
First residency specialty	n	%
Categorical GS (US)	36	92
Prelim GS (US)	1	3
Core surgical training (UK)	1	3
PRS (Europe)	1	3
Interest in PRS	n	%
Before PGY1	11	28
PGY1	9	23
PGY2	10	26
PGY3	8	21
PGY4	1	3
Training after GS	n	%
Completed GS, proceeded directly into an independent residency program	23	59
Transferred into an integrated residency as a PGY2 or higher	9	23
Left first residency and rematched as a PGY1 in integrated PRS	3	8
Completed GS, practiced as an attending before independent residency	2	5
Completed GS and another fellowship before independent residency	1	3
Completed GS, did research before applying to a PGY1 integrated position	1	3
Transfer location	n	%
Institution in different geographic region than first residency	5	56
Institution in same geographic region as first residency	2	22
Home institution (same as first residency)	2	22

From 2001 to 2021, the overall match rate into integrated or combined PRS programs ranged from 36% to 74% (Table 4).[11] The match rate for USMD seniors ranged from 36% to 84%, and the match rate for non-USMD seniors ranged from 12% to 47%. From 2007 to 2021, USMD seniors filled 88%–97% of positions, whereas USMD graduates filled 1%–9%, IMGs filled 0%–7%, and DOs filled 0%–2% of positions (Table 5).

Table 4.

Integrated Plastic Surgery Match Results, 2001–2021

Year	Programs	Total Match	Total Applicants	Unmatched	Total Rate (%)	USS Match	USS	USS Rate (%)	Other Match	Other Applicants	Other
							Applicants				Rate (%)
2021	85	187	329	142	57	167	239	70	20	90	22
2020	84	180	291	111	62	165	236	70	15	55	27
2019	78	172	234	62	74	158	188	84	14	46	30
2018	77	167	229	62	71	156	185	84	11	44	25
2017	73	157	246	89	69	148	200	74	9	46	20
2016	69	151	216	65	61	133	178	75	18	38	47
2015	67	144	206	62	67	136	168	81	8	38	21
2014	60	130	215	85	63	120	181	66	10	34	29
2013	53	115	203	88	53	111	179	62	4	24	17
2012	45	97	177	80	48	87	141	62	10	36	28
2011	31	70	194	124	40	65	166	39	5	28	18
2010	31	69	200	131	36	61	168	36	8	32	25
2009	49	99	212	113	50	87	177	49	12	35	34
2008	49	92	182	90	43	86	153	56	6	29	21
2007	46	93	193	100	51	88	161	55	5	32	16
2006	44	88	217	129	46	84	183	46	4	34	12
2005	40	80	198	118	37	73	172	42	7	26	27
2004	40	77	176	99	39	73	151	48	4	25	16
2003	39	76	172	96	43	71	150	47	5	22	23
2002	39	77	157	80	45	72	134	54	5	23	22
2001	28	58	134	76	37	56	121	46	2	13	15
Mean	54	113	209	95	52	105	173	1	36	9	24
Total	-	2379	4381	2002	—	2197	3631		750	182	—

Other, any applicant who is not a current senior at a US MD program (eg, US MD graduates, DO applicants, international medical graduates); USS, US MD senior applicants.

Adapted with permission from National Resident Matching Program, https://www.nrmp.org/report-archives/.

Table 5.

Integrated Plastic Surgery Match Results by Applicant Type, 2007–2021

Year	Positions	Filled	MD Senior		MD Grad		DO		IMG				Unfilled
			n	%	n	%	n	%	US	Non-US	n	%	n	%
2021	187	187	167	89	9	5	3	2	2	6	8	4	0	0
2020	180	180	165	92	5	3	1	1	3	6	9	5	0	0
2019	172	172	158	92	8	5	2	1	2	2	4	2	0	0
2018	168	167	156	93	5	3	2	1	1	3	4	2	1	1
2017	159	157	148	94	5	3	1	1	1	2	3	2	2	1
2016	152	151	133	88	11	7	1	1	3	3	6	4	1	1
2015	148	144	136	94	3	2	1	1	1	3	4	3	4	3
2014	130	130	120	92	1	1	0	0	2	7	9	7	0	0
2013	116	115	111	97	2	2	0	0	0	2	2	2	1	1
2012	101	97	87	90	9	9	0	0	1	0	1	1	4	4
2011	70	70	65	93	4	6	1	1	0	0	0	0	0	0
2010	69	69	61	88	5	7	0	0	0	3	3	4	0	0
2009	101	99	87	88	7	7	1	1	1	3	4	4	2	2
2008	92	92	86	93	2	2	0	0	2	2	4	4	0	0
2007	93	93	88	95	4	4	0	0	1*		1	1	0	0
Mean	129	128	118	92	5	4	1	1	—		4	3	1	1
Total	1938	1923	1768	-	80	-	13		—		62	—	15	—

DO, applicant from DO/osteopathic medicine program; MD, applicant from MD/allopathic medicine program; Non-US IMG, non-US applicant from international medical school; US IMG, US applicant from international medical school.

*The 2007 report did not split IMG applicants into US and Non-US IMGs.[30]

Adapted with permission from National Resident Matching Program, https://www.nrmp.org/report-archives/.

Qualitative Analysis

One hundred twenty-two residents provided subjective narrative responses (Table 6). Themes of the narrative responses included positive applicant characteristics (11 codes), barriers to success (eight codes), interpersonal relationships (seven codes), application logistics (four codes), and research (four codes). Residents also shared their general opinions (five codes) on their training pathways.

Table 6.

Thematic Analysis of Narrative Responses

Theme	Code (No. Quotations)	Representative Quote
Applicant characteristics	Scores/grades (44)	If interested in PRS, focus 100% on boards/grades first, then if those are good, you can focus on research/letters after. I think too many medical students focus on clubs, publications, and extracurriculars, which can hurt grades/boards, which one does not get to repeat
	Personality (12)	I think I fit in with the group dynamic and got along with everyone. I was able to demonstrate my interpersonal skills as I spent a great deal of time with the residents and faculty members before applying
	Medical school/home program reputation (12)	The connections from mentors and reputation of the PRS program I was coming from
	Interview skills (11)	Good grades/scores/AOA which got me great interviews, and then being a personable interviewee
	AOA (9)	—
	Work ethic (8)	I believe that being an honest, hardworking, humble applicant ultimately led me to match into PRS. Specifically, by working hard on away rotations and subinternships at my home institution, I demonstrated these characteristics which led to strong recommendation letters and, when combined with my application, led me to multiple interviews and then a match. I think people stress out about PRS being “impossible” to match into when in fact it takes diligence, decent-strong test scores, and most importantly showing up and working hard
	Early involvement in PRS (8)	Coming from a small medical school, it was very beneficial to know going into medical school that [I was interested in] PRS, find mentors right away, and become a part of the PRS group there
	Nonmedical achievements (5)	I would strongly recommend pursuing additional interests rather than rushing from college, medical school, and into residency with no pauses to enjoy/pursue other interests. Each unique experience only helps your ability to care for patients in the future
	Operative skills (3)	Try to practice as much as possible with technical skills, as this does ultimately become important and something that people will notice
	Leadership skills (3)	Demonstrated maturity, independence
	Expressing clear intentions (2)	Reaching out to program coordinators before interview invitations being sent to express specific interest.
Barriers to a successful match	Lack of a home institution residency program (9)	It is very, very difficult if you do not come from a place with a home program and well-recognized mentors
	Lack of exposure to PRS in medical school (7)	Most medical schools are not geared to helping medical students early on in terms of getting into competitive subspecialties, and often there is not enough exposure to PRS, so even practicing physicians have no idea what we do
	Competition with other medical students (5)	I felt I had to outperform/outwork my peers at every step of the process
	Stress (4)	The 4th year of medical school and the interview process are extraordinarily stressful. If you are overwhelmed or struggling do not wait to reach out to counselors/PCP/mentor, etc., for help
	Poor support from home institution (4)	My medical school PRS department did not see the need to make a single phone call or email on my behalf or that of any of my classmates when we applied for residency—only two of us matched in PRS, and only into the home program
	Geographic bias (3)	There is a lot of geographical bias based on your previous school history
	Financial burden (3)	I would like to note that doing away rotations was very advantageous for me, but it cost quite a bit of money. I am thankful that my parents had the financial means by which to support me during these three months; however, I do not think that all students have the same financial means, which may limit people of different socioeconomic classes from exploring and ultimately matching into PRS
	Couples match (2)	I couples matched and there was very little communication between program directors regarding that fact, which I think puts all couples match applicants at a disadvantage
Relationships	Letters of recommendation (general) (51)	Recommendation letters and interactions with residents on away rotations are paramount to matching
	Mentorship (general) (20)	In addition to having a well-rounded application, it is important to be able to build positive relationships throughout PRS for both mentorship and to have people advocate for you
	Networking (14)	If you are interested definitely start early—reach out to plastic surgeons in the area and past medical students who have matched into PRS, so you have someone to help guide you through the process
	Mentor reputation (11)	Having connections in PRS from a prominent institution and letters of recommendation from nationally recognized academic plastic surgeons that I collected from away rotations. In this small specialty, name recognition is huge
	Engagement with home institution residency program (8)	Early and frequent involvement in home department is essential
	Personal communication from mentors (6)	After working with an incredibly talented plastic surgeon, it took him one phone call to make sure I had a plan at the program where I needed to be [for family reasons]. Now, of course, I had to be highly qualified for that spot, but having someone in his position both guide me and “vouch” for me sealed the deal when it mattered
	Letter writer selection (2)	Be very cognizant of who your advocates are and ask those people for letters of recommendation. People who have big names but don’t seem particularly enthralled by you will be asked to write letters for several other students they may like 1000× more, so make sure your letter writers are the people you trust and who seem to think you’re the greatest thing since sliced bread
Application logistics	Away rotation performance (37)	Once I knew I liked plastics, I aggressively applied for away rotations and did 3. I worked very hard on subinternships and got strong letters to boost my application
	Away rotation selection (9)	I wish I were more informed about selecting which subinternships to apply to and select. Subinternships are very deterministic of where you end up or which programs you would be eligible to go to
	Applying and interviewing broadly (7)	Apply to every PRS program and take every interview
	Dual applying (2)	Dual apply to plastics and another specialty
Research	Research (general) (39)	Always being positive, available, helpful, and getting involved in projects and research as a medical student
	Proresearch year (12)	My research year made it possible to develop close relationships with my mentors and to complete research I would not have been able to otherwise, given that I decided on plastics at the end of my third year
	Regret about not doing enough research (8)	I wish I would have done more research as a medical student to make myself more competitive
	Antiresearch year (3)	Many students who take a year off to do research during medical school are probably increasing their chance of matching, but unless you want to become a “scientist-surgeon” and run your own lab, I do not feel it is necessary. There are plenty of strong PRS programs that will make you an excellent surgeon and clinician where you can match without a research year
Opinion	Positive GS experience (17)	I believe my training in general surgery really prepared me to be a strong surgeon clinically and technically. I feel better knowing that I know how to take care of sick patients if need be, and I am comfortable with most surgical problems pertaining to and not pertaining to PRS
	Prointegrated pathway (8)	The experience is much simpler and less convoluted for integrated trainees straight out of medical school than for anyone else.
	Regret about long length of training (7)	My pathway was too long… Had I been more competitive as a med student (I was a DO graduate), I would have done an integrated program. I do believe I’m generally more confident in managing complex patients and appreciate my general surgery background; however, I lost several productive money-making years taking the long road
	No regrets (6)	I have NO regrets about doing what I needed to do for my family - those accomplishments are infinitely more important to me than my profession or the route that I took to get here professionally. I do wish others would have more respect for those decisions, but they often lack the perspective that these life experiences bring to do so. I would advise students or residents interested in PRS to do whatever they need to for themselves and not worry about the “right” way or the “best” way - as long as it aligns with their personal and professional goals. Some of my favorite residents and attendings are “nontraditional” in some way - and I very much appreciate the diverse perspectives that they each bring to our teams
	Proindependent pathway (5)	I hope the independent track never goes away and continues to provide a pathway into PRS for those without early exposure or interest

Residents who initially did not match in integrated PRS cited multiple factors that they thought contributed to their unsuccessful match, including the disadvantage of couples matching, poor interview skills, low board scores, poor home institution support, weak letters of recommendation from faculty who did not know them well, and lacking or poor caliber research. Residents who went through the independent pathway generally expressed satisfaction with their GS training, emphasizing benefits such as a broad fundamental knowledge base, excellent judgment and decision-making skills, and comfort with taking care of sick and complex patients.

DISCUSSION

There are multiple routes to PRS residency beyond the match as a senior medical student. Survey respondents proceeded through multiple paths, including participating in the SOAP to obtain an integrated position, re-entering the match for a PGY1 position, and transferring into an integrated position as a PGY2 or higher. As new integrated PRS programs open each year, this finding highlights the trend of “backfilling” these programs with residents who want to transfer from other specialties. In accordance with national trends described in the NRMP match results, a small minority of residents were integrated residents that trained at international medical schools or osteopathic schools. It has been estimated that less than 1% of PRS residents are IMGs.[13] In the present study, one IMG directly matched into integrated PRS as an MS4; two matched after completing surgical training abroad and research in the United States; and four IMGs transferred into integrated spots from categorical GS. For DO candidates, there have been historically low successful match rates in PRS, which have been further compounded by the recent elimination of the American Osteopathic Association match.[14,15] In our study, one DO matched into an integrated position as a PGY1, and the other initially matched into categorical GS, then left their program and rematched as a PGY1 in integrated PRS. These findings emphasize the difficulty of directly matching integrated as an IMG or DO, but they also demonstrate the multiple other options available to achieve a training position.

Studies of applicant characteristics between matched and unmatched applicants in competitive fields such as orthopedic surgery,[4,6,16] ophthalmology,[17] dermatology,[18,19] neurosurgery,[20] otolarygnology,[5,6,21] and obstetrics and gynecology fellowships[22] have either focused on specific applicant factors that were associated with matching or discussed immediate postgraduation strategies. Few have discussed the long-term outcomes of unmatched applicants or offered guidance on how unmatched applicants should proceed. In our study, successful PRS reapplicants or transfers elected to complete GS training rather than research years. This finding is consistent with the recommendations of program directors in orthopedic surgery and otolaryngology.[5,6] Research years have been found to be associated with a successful initial match into integrated PRS residency, but a survey of 51 attending plastic surgeons found that a minority (37.3%) recommend that their mentees take research years.[23] Program directors and chairpersons in plastic surgery have not yet been surveyed about their recommendations specifically for reapplicants, which provides direction for additional research.

In the PRS literature, application characteristics that are associated with a successful match or rematch into integrated PRS include Alpha Omega Alpha status and graduating from a top-ranked allopathic medical school.[9,24-27] Of note, the aforementioned studies in PRS and other specialties either do not mention or only minimally discuss the phenomenon of transferring into the specialty or participating in the SOAP to match the specialty. Although these routes cannot be guaranteed or officially recommended, we found that 33% of initially unmatched applicants in the present study used such routes to successfully obtain integrated PRS positions. This finding may provide some comfort to unmatched applicants who are committed to pursuing a career in plastic surgery and inform advisors on how to counsel their advisees.

The narrative responses of independent PRS residents demonstrated high levels of satisfaction with the independent pathway, a finding which was similarly described for independent CT residents in a different study.[3] Whereas those residents who fail to match into an integrated CT or PRS residency may view the independent pathway to be a “salvage route,” we demonstrated in our study that three-fourths of the surveyed independent residents chose this as their primary route by which to train in PRS. Many independent plastic surgery training programs have been converted to the integrated pathway. From 2010 to 2018, the number of independent positions declined by 32%, and a national survey of 16 plastic surgery program directors indicated that this trend is likely to continue into the future.[28,29] Thus, our results reaffirm that the independent training model is a valuable option that allows individuals who do not initially choose the integrated pathway to still have the opportunity to train in plastic surgery. Further research, discussion, and advocacy may be needed to ensure that the independent training model is maintained in perpetuity.

The current study had multiple limitations. As a survey study, it was inherently subject to self-reporting, recall, and nonresponse bias. As we were only able to survey a small cohort of reapplicants who successfully matched, we recognize that our results are limited in generalizability. Only 15 of the 174 (8.6%) residents to our survey did not initially match into an integrated PRS residency program. Since 2001, approximately 2000 applicants have applied and not matched into integrated PRS programs. Many of those individuals likely ended up in other specialties, so they would not have been captured in this survey. To study the routes of those applicants, one would need to identify all applicants to integrated PRS residency programs and survey them at multiple timepoints after not matching, which was not feasible. The study findings were predominantly descriptive and did not objectively analyze or draw conclusions about applicant demographics, such as gender, race, or ethnicity, or academic characteristics, such as USMLE score or AOA status, which should be explored in future research. Finally, of the reapplicants captured in the survey, none completed a research fellowship before reapplication. This was surprising, considering the emphasis on research in the PRS application process. Further study of unmatched applicants via national surveys is warranted to clarify the optimal route to a successful match.

CONCLUSIONS

Our study illustrates the various routes taken by plastic surgeons to complete their training. By shedding light on nontraditional routes to PRS, our findings may reduce stigma and bias surrounding not matching and reapplying, provide guidance and reassurance to applicants, inform graduate medical educators and plastic surgery mentors on how to prepare and advise applicants, and normalize alternate routes to becoming a plastic surgeon.