Introduction

The fellowship or boards of plastic surgery equivalent exams are the final trial by ordeal for most trainees, who will have faced exams over a large portion of their adult lives. Their respective examining boards put together the general structure of all four exams with the aim of presenting a safe surgeon who has adequately covered the entire plastic surgery curriculum. This is perhaps the most stressful academic period in a prospective surgeon’s training career. All exams have their own unique quirks of technique and reflect examiners’ habits or favorite topics. In recent years the various boards have attempted to provide a more standardized format to ensure reproducibility and fairness. As they begin to prepare for the final exam each candidate finds their favored study modality. Group study with a long-term timetable, regular tutorials from recently passed surgeons and more experienced senior surgeons together form the basis of most trainees’ approach to the exams. The structure of the FRACS(Plast), FRCS(Plast), FRCSC, the American Board of Plastic Surgery, and the European Board of Plastic Reconstructive and Aesthetic Surgery (EBOPRAS) exams is described below, with reflections by the authors on their personal experiences of their individual examination process.

FRACS(Plast)/EBOPRAS Exams

The Australasian College of Surgeons invites final year trainees from a 5-year specialist training program conducted by the Royal Australasian College of Surgeons to sit the fellowship exams. All candidates must have passed a PRSSPE (PRS Science and Principle Examination) multiple-choice exam usually as a SET 2 candidate. The final fellowship has the following components:

• (I)
  

  Two written papers: each of 2 hours’ duration, 2 questions in each paper and multiple parts in each question

  
  
• (II)
  

  Clinical – long cases: 2 cases, each of 30 minutes

  
  
• (III)
  

  Clinical – short cases: 6 cases, each of 5 minutes

  
  
• (IV)
  

  Surgical Pathology and Operative Surgery (SPOS) 1 – viva: 2 scenarios, each of 12.5 minutes

  
  
• (V)
  

  SPOS 2 – viva: 6 slides, each of 5 minutes

  
  
• (VI)
  

  Anatomy – viva: 25 minutes.

The scoring is a Closed Marking system – 8, 8.5, 9, 9.5. Support can be given in each of the marks: 9 is a clear pass, 8.5 is borderline fail, 8 is a clear fail. Any candidate can be failed on one critical error irrespective of the marks. Critical errors are considered those decisions that may be life- or limb-threatening. Although all seven segments are considered equal in value, during court of examiner discussions more emphasis is placed on clinical components, in particular long cases. These exams are held twice a year.

The EBOPRAS exam is divided into written and viva components. The written exam is a multiple-choice exam covering clinical as well as basic sciences. The viva component is divided into two 25-minute sections; clinical scenarios covering congenital, trauma, tumor management, esthetic and general reconstruction are conducted by two examiners.

As a candidate, I (Rostam D. Farhadieh) had the dubious pleasure of sitting three of the five exams discussed in this chapter (FRACS(Plast), FRCS(Plast), EBOPRAS). Each had its own strengths and weaknesses, however the common theme is that the examiners were not intent on failing the candidates, but to discover what their knowledge limits and more critically where their clinical limits lay. The FRACS is the most rigorous of these exams in terms of expected depth of knowledge, however it is not necessarily the broadest exam. The written form is significantly more detailed and in my opinion more in line with expectations of a specialist surgeon. The FRCS exam is the broadest exam; each candidate is assured that a series of congenital, trauma, esthetic and general reconstructive viva questions will be asked. The arrays of short cases were undoubtedly the best outpatients clinic not only I but also all candidates are likely ever to attend. The EBOPRAS exams similarly seek to cover the same broad base. The candidates are often, however, qualified surgeons and as such the exam format may seem more like a semi-formal discussion amongst colleagues than tutor to pupil format of the FRACS and FRCS exams.

The most pertinent advice for a prospective candidate is a broad formal clinical experience. This experience is best gathered in the trenches of interminable dressings and initial consultation clinics. Formal long case, short case practice and presentation is essential not only to success but also to a crisp and succinct decision-making process. This will become less formal, but nevertheless form the crux of your clinical practice for years to come. The examiners are destined to have more clinical experience than the candidates and this is where the candidate can compensate by depth and breadth of knowledge. The more a candidate reads and knows around a topic, the more confident and systematic they will become in replying to questions and putting clinical scenarios into a correct perspective. Review CME articles from the journals Plastic and Reconstructive Surgery , Clinics in Plastic Surgery , and Hand Clinics formed the basis of my own reading, in addition to the standard single-volume texts, although the latter I often found inadequate. Revision and complete command of surgical anatomy is mandatory in clinical practice of plastic surgery. Unfortunately, neither the FRCS nor the EBOPRAS exam stresses this component. This results in what is often perceived to be a deficit in many of the British and European candidates’ knowledge base.

FRACS(Plast): The IMG (International Medical Graduate) Perspective

The common theme from an IMG perspective with recent experiences of FRACS(Plast) and FRCS(Plast) is that in both exams the examiners were not intent on failing the candidates, but to discover what their knowledge limits were and, more critically, where their clinical limits lay. The FRACS significantly differs from the FRCS in having a written component. The written form is significantly more detailed and requires careful tactful organization in addition to knowledge. It helps to practice answer-writing and the previous question papers may be obtained from RACS itself. During practice runs, one must stay within the allotted time. The time allotted to each component of a question is clearly mentioned and serves as a useful guide to the detail required. It was easier to utilize bullet point answers to lend a structure to replies, whilst reducing the size. The most pertinent advice for a prospective candidate is broad formal clinical experience. This experience is best gathered in review and initial consultation clinics. Formal long case, short case practice and presentation is essential not only to success but also to a crisp and succinct decision-making process. At the same time, it is better to have concise but clear, rather than extensive but haphazard, knowledge. Every candidate has their own way of covering the syllabus and gaining requisite knowledge. This could be in the form of personal notes, standard textbooks, concise revision books, selected review articles or a combination of these.

My personal feeling after the exams was that failure is rarely from lack of sufficient knowledge. The Australian exam in being drawn out over 3 days is good at testing the examinee’s stamina and resolve. A good night’s sleep is much better than last minute cramming. Being part of a cohort of examinees is very useful. Revision and complete command of surgical anatomy is mandatory in clinical practice of plastic surgery. Although the common feeling was that Last’s Anatomy is the reference text, it is best to use a text whose figures make the most sense. Regular practice sessions with fellows and especially past examiners are very useful. Several opportunities are available in Australia and New Zealand to attend mock exams and one of these is readily available at the SET conference. Practicing with a cohort of examinees provides good opportunity to improve upon presentation skills.

FRCS(Plast) Exams

UK plastic surgery trainees are required to complete the FRCS(Plast) examination as part of the portfolio of evidence required to be awarded a Certificate of Completion of Training (CCT). The examination is administered and regulated by the Joint Committee on Intercollegiate Examinations ( www.jcie.org.uk ) on the behalf of the four Royal Colleges of Surgeons within the British Isles (England, Edinburgh, and Ireland, and the Royal College of Physicians and Surgeons, Glasgow).

Trainees should aim to complete the examination within the last two years of training. This allows adequate exposure to the breadth of the plastic surgery curriculum during the earlier years of training. There are two sittings for each section of the examination per year, which gives some flexibility in planning the optimal time to sit the exam.

The FRCS(Plast) is composed of two sections. Both aim to cover the full breadth of the syllabus and therefore cover clinical, basic science, ethics, consent, and statistics relevant to plastic surgery.

Section 1 consists of two written papers: Single Best Answer paper (2 hours) and Extended Matching Question paper (2.5 hours). Both papers are completed on the same day at a Pearson VUE computer-based examination center. In the past few years there has been a move to make the examination more clinically-focused. As a result, basic science and ethical topics are often incorporated into a clinical scenario. This has the benefit of making the examination more relevant to the candidate’s day-to-day practice, but it becomes more important to identify the theme being assessed to help determine the correct answer. The pass mark is determined by a standard-setting exercise completed by experienced FRCS(Plast) examiners. This varies with each exam sitting but is typically between 60% and 70%.

Section 2 is the verbal component and consists of both a clinical and oral exam. These are held over two days at a single hospital in the UK. The clinical examination comprises both short and long cases with the candidate being taken through the exam by three different pairs of examiners. The short cases are completed in two 30-minute periods with candidates examining five patients within each block. Examiners will guide the candidate on which aspect(s) of history, examination, and diagnostic study interpretation they want to focus upon. Following this, a discussion on the management of the patient typically follows. The long cases involve assessing two patients with each lasting 15 minutes. This allows ample time for a detailed evaluation of the patient, interpretation of relevant diagnostic investigations, and in-depth discussion of subsequent management.

The oral exam is viva-based and involves the candidate sitting with two examiners at each station to discuss a broad spectrum of clinical cases. No patients are present for this part of the exam. There are three viva stations each of which contain three core subject areas:

• 1.
  

  Hand trauma, other trauma (lower limb, maxillofacial), and wounds (pressure sores, wound care), burns.

  
  
• 2.
  

  Head and neck tumors, cleft and craniofacial, trunk, and urogenital.

  
  
• 3.
  

  Basic sciences, ethics and consent, esthetics.

At each viva station the candidate will be asked questions relating to six cases with at least one question from each core subject area. Clinical questions are usually based around a brief history and clinical photograph. Typical follow-on questions may relate to the results of diagnostic tests, drawing a diagram or explaining the reasoning behind the management proposed.

Performance in Section 2 of the exam is judged against the standard expected of a newly-appointed consultant in the National Health Service (NHS).

The marking is structured. Each constituent part of Section 2, the short cases, the long cases, and the oral exam, contains a certain number of marking events which are each given a score between 4 and 8 (6 is a pass). At each marking event, two examiners will score the candidate. It should also be noted that the long cases are weighted in such a way that each case, scored by two examiners, contributes six marking events. An average score of 6 is required to pass and, therefore, an overall score of at least 408 is required. No one score is able to result in an immediate fail, instead, the overall performance throughout Section 2 of the examination is considered.

Weighting of scores for the different parts is as follows:

• 
  

  Long cases: 2 cases, 12 marking events (pass mark = 72)

  
  
• 
  

  Short cases A: 5 cases, 10 marking events (pass mark = 60)

  
  
• 
  

  Short cases B: 5 cases, 10 marking events (pass mark = 60)

  
  
• 
  

  Viva 1: 6 scenarios, 12 marking events (pass mark = 72)

  
  
• 
  

  Viva 2: 6 scenarios, 12 marking events (pass mark = 72)

  
  
• 
  

  Viva 3: 6 scenarios, 12 marking events (pass mark = 72)

When attributing a score, the examiners take the following areas of a candidate’s performance into consideration:

• 1.
  

  Overall professional capability/patient care

  
  
• 2.
  

  Knowledge and judgement

  
  
• 3.
  

  Quality of response and ‘bedside manner’.

A copy of the marking descriptors that will be used by the examiners is sent to candidates in advance with their examination pack and there is also an up-to-date copy on the JCIE website ( http://www.jcie.org.uk ). It is advisable for candidates to check this for any changes to the marking scheme that may subsequently occur.

Each candidate has a maximum of four attempts over a 2-year period for Section 1 and four attempts at Section 2. The whole exam process must be completed within 7 years. Once Section 1 is complete, the candidate is not required to complete this part again should they fail Section 2.

Preparation is a personal approach, however general principles apply. At this stage of medical training, every candidate will have their own particular way of preparing for an examination. To ensure an adequate depth of knowledge is acquired, a detailed text such as this textbook should be used from the outset. This will also help guide further reading of appropriate journal articles, as single-volume textbooks often do not provide adequate detail in the core topics of hands, breast, burns, and head and neck. As the exam approaches, a more succinct textbook allows for quick revision of the key topics. Specific to Section 1 is the need to practice both Single Best Answer and Extended Matching Questions and a number of books are available that facilitate this. The JCIE also provide a small selection of past questions to help demonstrate the standard required.

The candidates should be familiar with the current UK guidelines, especially for skin cancers (produced jointly by the British Association of Dermatologists (BAD) and the British Association of Plastic Reconstructive and Aesthetic Surgeons (BAPRAS)) and lower limb trauma (produced jointly by the BAPRAS and the British Orthopaedic Association). The latter can be downloaded from the BAPRAS website. The National Institute for Health and Care Excellence (NICE; www.nice.org.uk ) also produces a range of clinical guidelines (in addition to evaluating new interventions or technologies and cost/benefit analysis), some of which are particularly relevant to plastic surgery (e.g., pressure sore management, fat grafting, venous thromboembolism prophylaxis), and candidates should be familiar with these. It is helpful to go through summaries of guidance on consent and ethics from the General Medical Council website ( www.gmc%2duk.org ) under the section entitled Good Medical Practice.

When preparing for Section 2 it is essential to practice discussing clinical cases and evaluating patients. Although day-to-day clinical activities provide ample exposure, a modified technique is required for the exam to allow for the time constraints and format. Practice should ideally be undertaken with others sitting the exam as well as both newly-appointed and senior consultants. Another very useful resource are senior trainees who have recently sat the examination and are, therefore, familiar with the examination format and standard. Although the main emphasis should be on the candidate answering questions, the value of watching others answer questions should not be ignored.

Here are my tips for the exams. Exam technique is an essential component when preparing for Section 2. The following are some pointers that were of particular help.

• •
  

  Speak like a consultant. The FRCS(Plast) is the first time the majority of candidates will be completing an examination that expects them to interact with the examiners in the role of a fellow consultant. An answer should, therefore, focus on succinctly describing the key aspects in the history and examination and follow-on with a clear management plan that describes what will be done rather than what options are available. The examiners will critique your proposed management, so be prepared to explain the reasoning behind the decisions made.

  
  
• •
  

  Prepare an opening statement. This is particularly relevant to the viva where the breadth of topics covered allows for preparation prior to the exam. A focused opening statement allows the candidate to demonstrate a good understanding of the key aspects of the case and its initial management. Further time can then be spent demonstrating higher-order thinking and, hopefully, scoring beyond the pass mark. An example for a head and neck cancer case would be: “My initial management will comprise obtaining a tissue diagnosis with HPV status, determining the local and distant extent of the disease and identifying the patient factors that will impact on any treatment proposed to allow me to generate a plan I can take to the head and neck oncology MDT.”

  
  
• •
  

  Say what you would do in real life. It can be tempting to pick a treatment option or procedure that might demonstrate a high level of knowledge. This is a risky strategy, as the examiners may press you to explain the details of this intervention. A safer approach is to keep the treatment chosen simple and in line with things you have directly experienced. Allow the examiners to push you for further treatment options later in the case discussion.

  
  
• •
  

  Show good clinical judgment before quoting papers. A concern of many candidates preparing for the exam relates to the level of knowledge of the existing evidence base required. Although being able to reference a relevant paper supporting the management pathway chosen is one aspect of demonstrating higher-order thinking, candidates should first aim to demonstrate robust clinical judgment grounded upon their own clinical experience. The reality of the exam is that there is often little time to discuss the evidence base and so it is often best to be guided by the examiners’ questioning to decide if quoting a paper would be appropriate (e.g., “What is the evidence for that?”).

  
  
• •
  

  Keep going. No one score is able to cause an automatic fail, so aim to avoid lingering on cases gone before and instead keep motivated and focused on the present topic.

  
  
• •
  

  Don’t forget the importance of a succinct, focused history. This is of particular importance in the long cases. Done well, these are easy to score on given the additional weighting they carry. History-taking should be quick and with some patients it may be necessary to take control. Some omissions can be a fail, for example skipping family history in breast cancer, and it is wise to remember these. It is important to reach a definitive plan in the long case with at least a backup plan. The examiner may try to streamline the examination in order to reach the discussion stage and it is important to take hints and yet not skip on important things.

  
  
• •
  

  Focus on the case in hand. Short cases can be compromised if the candidate starts thinking about the previous short cases. Evaluating five short cases in 30 minutes requires alertness and full concentration on the present case. Many of the short cases may have complex problems but the evaluation may be on only one of the components. Always answer exactly what the examiner is asking without second guessing.

  
  
• •
  

  It is acceptable to say “I don’t know” when asked a difficult question. It is better to take a hint and accept a wrong answer early rather than proceed along the wrong path.

  
  
• •
  

  Answers should be succinct and to the point. This way the candidate gets to move on to the next question. It is good to aim high and answer well as this can compensate for a borderline poor performance elsewhere. Sometimes if a scenario is not going well, the examiner may ask a standard default question like stages of graft take. These questions have almost standardized answers with buzzwords and these questions have to be answered well.

  
  
• •
  

  If you feel comfortable with a technique that differs from an examiner’s, do not change. This scenario is common when asked for cleft lip marking in which examiners rarely are comfortable with a repair other than Millard’s. Be prepared to mark and explain your technique well. Trying to change marking technique for exams may end badly.

  
  
• •
  

  Just as the focus of any clinical encounter is the patient, the exams are no different. It is important to put the patient at ease and treat them with dignity and respect. Always ask for tenderness before palpation, ensure you have a chaperone and thank the patient at the end. These are things we do in our daily lives and exams are no different.

FRCSC Exams

At the end of plastic surgery training in Canada, candidates are invited to sit the Canadian Plastic Surgery Royal College examination. The title Fellow of the Royal College of Surgeons of Canada (FRCSC) – Plastic and Reconstructive Surgery is awarded following successful completion of this examination. The FRCSC is a renowned designation recognized worldwide and is usually a requirement for specialty licensure in Canadian jurisdictions. This final certification exam consists of two components: a written section and an oral examination approximately 2 weeks later. Candidates are required to pass both the written and the oral components in order to successfully complete the exam. The examination addresses all facets of plastic and reconstructive surgery, including basic science, basic principles and techniques, pediatric plastic surgery, craniofacial surgery, burns and wound care, head and neck reconstruction, esthetic surgery, trunk and lower extremity reconstruction, breast and hand surgery. A more detailed description of the plastic surgery curriculum can be found at www.royalcollege.ca .

Although this examination is stressful and comes at the end of a long and arduous residency training, it is considered to be a fair exam. There is an enormous quantity of information to master (as evidenced by the content of this book), but in the end, review and critical appraisal of the material while preparing for the exam will make any potential candidate a better plastic surgeon.

Failure is usually a function of two primary deficiencies: lack of knowledge and lack of examination-taking skills. The former shortcoming, a lack of knowledge, occurs simply because candidates did not read enough. Some may be more proficient at memorizing the material, but ultimately, with weeks, months and years of commitment, everyone should be able to learn the required knowledge. There are no excuses. Preparation for the Plastic Surgery Royal College exam does not begin a few weeks or months before the exam, it starts at the beginning of the candidate’s residency. The latter point cannot be emphasized enough. It is of the utmost importance that early on residents read around their cases and on the topics relevant to their current rotation. Consistent and continued acquisition of information throughout residency is key. A strong knowledge base is a function of discipline and dedication to acquisition of the material. It is simple: if one does not have sufficient knowledge, one will not pass this exam. So, the secret to success? Read, read, and re-read.

It remains an unfortunate truth that even when armed with the knowledge required to pass the exam, failure may ensue due to a lack of examination-taking skills. However, as the word “skill” implies, this can be gained through experience and training. With regard to the oral examination, very often anxiety can overshadow one’s ability to relay information in a proficient and succinct fashion. In like manner, for the written component, failure to pace oneself can often result in falling short of completing the entire series of questions. The latter limitations can be improved with continued practice. Indeed, preparation for the exam can be likened to training for a marathon, and as any seasoned runner can attest, in order to achieve the objective of a long run, one must first devise a practice plan of shorter runs. Likewise, at the outset of one’s final year of residency, formulation of a good reading and oral exam practice plan is essential. Training is always easier in a group, and organizing a study group of 3–4 residents with whom one can review the material, questions, cases and articles is recommended. Each member is likely to have a particular strength, which would assist the other residents in the group in gaining a better understanding on that topic.

Remember, the objective of the exam is not to impress the examiners nor is it a platform to exhibit innovative solutions to common clinical problems. Rather, it is to demonstrate that once in practice, without the direct guidance and supervision of senior colleagues, one has the necessary competence and will exercise the safety requisite to independent practice.

The written examination, which can be taken in French or English, consists of two 3-hour sessions of short answer questions (approximately 40 questions per session). The questions cover the entire breadth of plastic and reconstructive surgery, including basic science, embryology, anatomy, classifications, etc. The questions are prepared by plastic surgeons across Canada and submitted to the Examination Board of Plastic Surgery. Following a rigorous review process, a final set of questions is selected to appropriately assess candidates’ competence. These questions vary in complexity, from listing a series of answers to completing a number of questions relating to a specific clinical scenario or particular pathology.

Here are my tips for the exam:

• 1.
  

  Do not be late.

  
  
• 2.
  

  Pay attention to the instructions provided by the invigilators and outlined in the booklet.

  
  
• 3.
  

  In order to answer all the questions, manage the allotted time thoughtfully. For instance, if there are 40 questions worth 10 marks each to be completed in 3 hours, approximately 5 minutes should be allocated to each question.

  
  
• 4.
  

  Answer the question in a clear and concise manner. If, for example, the question is to “list three risk factors,” then provide three, not four or five. Extra credit is not given for any additional answers provided.

  
  
• 
  

  5.Make an effort to write legibly. If the examiner cannot read the answer, then credit will not be granted.

  
  
• 6.
  

  Answer all the questions to accumulate the maximum number of points.

As an adjunct to point 6, it is highly recommended not to linger on those questions where the answers are not straightforward. Rather, mark these more difficult questions with sticky notes so that they can easily be identified and come back to answer them once the rest of the exam is completed.

The oral examination can also be taken in French or English. It consists of two 1-hour sessions, each session consisting of nine clinical scenarios with associated questions. The objective of the oral component of the exam is to assess the candidate’s application of theoretical knowledge and clinical judgment. More importantly, the examiner seeks to ascertain that the candidate is safe with regard to clinical decision-making.

The examinee is permitted 15 minutes prior to the start of the examination to review the series of clinical scenarios. Typically, two examiners will independently evaluate each candidate. Upon entering the room, the examiners will introduce themselves and give the candidate a short explanation about the oral exam. The clinical vignettes, illustrated with photographs, radiological imaging, etc., cover all areas of plastic and reconstructive surgery and with questions related to each. The aim of a scenario may be to evaluate a clinical problem, design a treatment plan, manage a complication, etc. Ultimately, it is important to understand that the examiners want candidates to pass the exam, and as such, they will guide you through the scenarios when necessary in an effort to elicit all information critical to passing the question. Examiners are instructed to not lead the candidate, so one should not expect any positive or negative reinforcement for responses given. Examiners may, however, redirect the candidate if responses are completely erroneous. At the end of each session, the candidate is allotted time for so-called sober second thoughts, where modifications or clarifications of any answers can be made.

My tips for the oral exam are as follows:

• 1.
  

  Practice, practice, and practice oral examinations. Whereas the written component of the exam is a reflection of knowledge acquired, the oral exam is, in principle, a skill that requires much practice to master. The latter also pertains to drawings and/or markings.

  
  
• 2.
  

  Answers are an indication of the candidate’s thought process, and so structured and succinct answers demonstrate that the candidate’s approach to a clinical problem is organized. It exhibits experience and preparedness for clinical practice.

  
  
• 3.
  

  As a corollary to point 2, it is important to listen carefully to the question and answer the question specifically. For instance, if asked for a specific investigation, do not elaborate on history and physical exam. Likewise, if asked about “your preferred flap option for the given defect,” do not list a number of potential reconstructive options. Instead, state your surgical plan.

  
  
• 4.
  

  Show confidence, but avoid arrogance.

  
  
• 5.
  

  In the event you do not know the answer, it is acceptable to state it, rather than present a guess. In like manner, pausing (briefly) to reflect and properly formulate a response is appropriate.

  
  
• 6.
  

  Pertinent and selective consultation of other subspecialties is advisable. However, referral of every problem and/or every patient is inappropriate and demonstrates a lack of knowledge, judgment and/or confidence.

  
  
• 7.
  

  The Royal College exam is not the time to conceive of a new treatment option or suggest an innovative operation. Be safe and provide a well-established solution for the clinical problem at hand, and preferably, one seen or done during your training. If presented with a controversial topic, begin by explaining that this is an area of controversy and exercise caution when stating your response. Remember, ultimately, the examiners want to ensure you are a safe surgeon.

  
  
• 8.
  

  Stay positive and focused. If one question/scenario did not go well, do not dwell on it and instead concentrate on the next question. Do not let one question disturb your focus or confidence for the following questions. Keep in mind that at the end of the session, there will be time for any sober second thoughts.

  
  
• 9.
  

  Remember, the examiners ask the questions, not the examinee. By asking for more than the occasional clarification, the candidate may give the examiner the impression that they lack knowledge or confidence. Moreover, this is a waste of time, time which should be maximized to answer the question.

  
  
• 10.
  

  Formulating a standard template for each potential topic is useful as the type of cases tend to be repeated.

  
  
• 11.
  

  Finally, approach each case as though confronted with the clinical scenario in actual practice.

To conclude, it is indeed a difficult process, but with the right approach and adequate preparation, a passing result is an achievable task. Ultimately, review and critical appraisal of the material while preparing for the exam will make any potential candidate a better plastic surgeon. These are all fair exams, and most graduating residents are well prepared to pass. Candidates would do well to remember that the objective is not to impress the examiners, but to demonstrate that once in practice, without the direct guidance and supervision of senior colleagues, one has the necessary competence and will exercise the safety requisite to independent practice.

Plastic Surgery Fellowships in the United States

Many plastic surgery residents elect to augment their surgical training by completing additional time in a subspecialty focus area of interest following their residency training experiences. While most of these fellowship training programs are completed following graduation from residency, some residents may elect to complete research-related fellowships at various time points during their residencies.

Fellowship programs in the United States are available in nearly every possible subspecialty focus area within the full spectrum of plastic surgery, including burn/critical care, microsurgery, esthetic surgery, hand surgery, breast surgery, peripheral nerve surgery, craniofacial surgery, pediatric plastic surgery, oculoplastic surgery, and body contouring. Most fellowship programs are 1 year in length, although there may be some that offer supplemental training in the 3–6-month range.

Many of the fellowship programs in major subspecialty focus areas, such as microsurgery, hand surgery, esthetic surgery, and craniofacial surgery, require a formal application, interview, and match process that is not too different from the process graduating medical students must endure prior to beginning their residency training. Some of these programs will also be recognized and accredited by the Accreditation Council for Graduate Medical Education (ACGME), which will affect the formality of the process, the timing of the application, interview, and residency matching period, as well as certain program requirements surrounding educational and training aspects.

While some fellowships may not be formal ACGME accredited programs, in general they all require some form of an application, interview, and selection process. For this reason, it is imperative that trainees interested in pursuing fellowship training meet regularly, and early, with their Program Director and faculty mentors to discuss their interests so they will meet application deadlines. Although many programs will conduct their interview and match in the PGY-5 and/or PGY-6 years, beginning this process early, as soon as a specialty area of focus is identified, cannot be underscored as some fellowship programs can be filled nearly 2 years in advance (e.g., esthetic surgery).

For a detailed listing of available fellowship programs, including updated contact information, residents are encouraged to review the fellowship clearinghouse page located on the American Council of Academic Plastic Surgeons (ACAPS) website ( http://acaplasticsurgeons.org/fellowship-listing/ ). Although this list may not contain every possible fellowship program, it is updated annually and is generally thought to be the most detailed list of programs available. Additional fellowship program information may also be found on individual institutional, or program, websites and through specialty societies, such as the American Society of Reconstructive Microsurgery (ASRM) fellowship page ( https://www.microsurg.org/fellowships/match/ ).

The American Board of Plastic Surgery (ABPS) was first organized in 1937 by Vilray Blair, and other surgical colleagues across the United States, who were interested in a new subspecialty of surgery that focused on the repair, reconstruction, or replacement of physical deficits in human form or function. Prior to this establishment, Plastic Surgery was not recognized as its own major specialty within the field of American surgery. In 1938 the American Board of Surgery (ABS) recognized the ABPS as a subsidiary of General Surgery. And in 1941, the ABPS was awarded status as an independent major specialty board within the United States.

As stated in the annual ABPS booklet of information, the mission of the ABPS is to “promote safe, ethical, efficacious plastic surgery to the public by maintaining high standards for the education, examination, certification, and maintenance of certification of plastic surgeons as specialists and subspecialists.” In an effort to fulfil this mission, the Board has established several requirements for the qualifications of applicants requesting certification. Once all applicant qualifications have been met, the board then conducts examinations for certification. The examination process, which will be discussed in more depth below, occurs in two phases – a written examination, followed by an oral examination once the written portion is completed successfully.

In addition to the above objective criteria for obtaining board certification, the ABPS also encourages a culture of ethics within plastic surgery that begins in residency training and extends throughout the professional career of the surgeon. For instance, the Board does not allow fraudulent, or unethical, advertising or marketing practices. They also prohibit marketing events where injectables, procedures, or operations are provided in a social or educational setting where alcohol is served. Such practices, if brought to the attention of the board, can result in inadmissibility to examinations, disciplinary action, and/or revocation of a certification. Likewise, the Board is strict in preventing surgeons in training from conducting themselves in any manner that could be misrepresentative of their trainee status to the public (i.e., personal practice websites, etc.).

Once certification is obtained, the ABPS certified surgeon must continue to maintain an ethical practice as well as complete various maintenance of certification (MOC) milestones, to be eligible for re-certification every 10 years.

To be eligible for ABPS certification, applicants must have graduated from a medical school in the United States that is accredited by the Liaison Committee for Medical Education (LCME), a Canadian Medical School accredited by the Committee on Accreditation of Canadian Medical Schools (CACMS), or from a United States school of osteopathic medicine accredited by the American Osteopathic Association (AOA). Graduates of schools outside of the above, and accepted into an ACGME approved plastic surgery residency program, must have a valid certificate from the Educational Commission for Foreign Medical Graduates (ECFMG) or have completed a Fifth Pathway program in an accredited school of medicine in the United States. Graduates of schools outside of the above who have been accepted into a Canadian Plastic Surgery residency program must match through the Canadian Resident Matching Service (CaRMS).

There are two approved residency training models for plastic surgery that must be completed prior to admissibility to the board examination phase by the ABPS: the Integrated Model and the Independent Model. Regardless of the model, the board requires that residents acquire basic surgical science knowledge in 10 essential content areas, and advance knowledge in plastic surgery principles and practice. A list of the critical content areas can be found on the ABPS website and within the ABPS booklet of information ( https://www.abplasticsurgery.org/ ).

While residents may be accepted into plastic surgery residency training programs directly from medical school, there are two alternative pathways which are considered to be acceptable prerequisite training experiences prior to plastic surgery residency: completion of an American Board of Medical Specialties (ABMS) training program in General Surgery, Vascular Surgery, Neurological Surgery, Orthopedic Surgery, Otolaryngology, Thoracic Surgery, or Urology; completion of a residency program in Oral and Maxillofacial Surgery approved by the American Dental Association (ADA).

For requisite training, the ABPS requires a minimum of 3 years of plastic surgery training in an Independent program or 6 years of plastic surgery training in an Integrated program. To be eligible for certification, the training in plastic surgery must be obtained in either the United States or Canada. For US training programs, the board will only accept training which has been completed in a program that is accredited by the ACGME. Likewise, for Canadian programs, training must be completed in a program accredited by the Royal College of Physicians and Surgeons of Canada (RCPSC).

Upon completion of the above requisite education and training in Plastic Surgery, graduates may apply for admissibility to complete the official board examination process. Candidates for ABPS certification have 8 years to complete certification following the completion of training. If certification is not obtained after the first 5 years of admissibility, the candidate will be required to submit additional reapplication materials.

Candidates who have successfully met the above requirements and passed both the written and oral examination will be issued official ABPS certificates attesting to their qualifications in plastic surgery. The certificate is valid for 10 years. Per the ABPS, the certification process is a “lifelong commitment to continued education, professionalism, and ethical behavior.”

The purpose of the written examination is to evaluate the knowledge base and overall training of the candidate. The written exam is completed via a computer-based test offered at a specific testing center. The examination is given on only one day annually throughout the United States and Canada.

To sit for the written examination, candidates must have a current, valid medical license to practice medicine, and hold admitting privileges in plastic surgery in the United States or Canada unless the candidate is a graduating resident or in fellowship training. All candidates take the entire written examination on the same date. Beginning in 2020, the written exam is planned to be administered in June, immediately prior to graduation for residents in their final year of training. Prior to this date, the written exam was typically administered in the fall.

The examination consists of 350 multiple-choice questions formatted in three blocks of 100 questions and one block of 50 questions. Candidates are allowed a total, optional, break-time of 60 minutes. The candidates have 7 hours to complete the 350 questions. Each test item consists of a case history or situation, a question, followed by a list of possible answers. Subjects covered can be found on the ABPS website, or in the ABPS booklet of information, and include anatomy, embryology, basic pathology, basic techniques, trauma/resuscitation, preoperative and postoperative care, anesthesia, cosmetic and reconstructive surgery, hand surgery, craniofacial surgery, congenital anomalies and pediatric plastic surgery, and psychiatry and legal medicine.

The examination is graded on a pass/fail system. Candidates who pass the written examination are eligible to sit for the oral examination. Candidates who fail the written exam are eligible to re-take the examination the following year.

For the oral exam, once the candidate has successfully passed the written examination, they may submit a 9-month case list for admissibility to the oral examination. The case collection period normally begins on July 1 and continues until March 31. Case lists of less than 9-months are allowed if they meet the board criteria regarding quality, complexity, and variety of cases. Case collection cannot occur during fellowship training.

Candidates must perform a minimum of 50 major operative cases to be considered admissible for the oral boards. The cast list must include all operative procedures performed by the candidate, including those in the inpatient, outpatient, or office setting, all patients hospitalized by the candidate as the admitting physician, all emergency room patients who require an operation, co-surgeon cases if the candidate is the surgeon of record, cases performed by a resident with the candidate as the responsible attending surgeon, skin resurfacing laser procedures of the head and neck, laser ablation of congenital malformations greater than 5 cm ² , and any office-based procedures.

Each case submitted must include specific patient information, the healthcare setting, admission status, date of the procedure, duration of the procedure, anesthesia type, diagnosis, procedure description, CPT codes plus modifiers used for billing, outcome information including adverse events/complications, and case classification including category and anatomy. The category classification includes congenital, cosmetic, general reconstructive, hand, skin, and trauma. The anatomy classification includes breast, hand/upper extremity, head and neck, lower extremity, and trunk/genitalia.

In addition to case submission, all candidates eligible for the oral exam must submit one copy of all advertising and marketing materials, as well as pertinent website content including the candidate’s homepage, profile page, any page with candidate qualifications/credentials, and any page that includes any board or society emblem.

Once finalized, the board will review the candidate’s case list to determine if the list has an acceptable diversity and complexity to allow admission to the oral examination. If the candidate is deemed to have an inadequate case list, they will not be allowed to take the oral examination and must submit another case list for the following year. If the case list is acceptable, the Board will select five cases from the list and the candidate must prepare detailed case reports for these “known” or selected cases.

The case reports for the five selected cases will be uploaded online and must include a narrative summary of the case and outcome, all pertinent preoperative, operative, and postoperative documentation, anesthetic reports, laboratory data, pathology reports, radiology reports, consent forms, billing information, as well as one preoperative and postoperative photograph.

Once the cases are uploaded and submitted online, the board will review each case for completeness. If a case report is deemed incomplete, the candidate will have a limited opportunity to provide additional requested, or missing, information. If the board request is not satisfied, the candidate will not be admissible to the exam.

The oral exam consists of three exam sessions, each 45 minutes in length, spread out over 2 days. It is typically administered in the fall. Candidates are graded by trained, certified board examiners within each of these sessions, however, the overall pass/fail grade is dependent upon the combined performance on all three sessions. The three sessions are split up into two theory and practice sessions (also called the “unknown” sessions), and one case report session (also called the “known” session). The “unknown” sessions consist of general discussion of 6 “cases” or clinical scenarios that span the spectrum of plastic surgery. The “known” session consists of a discussion about the candidate’s five selected cases.

Performance in each of the exam sessions follows the following standardized guidelines: diagnosis/planning, management/treatment, complications/outcome, clinical judgment/limitations. In the known examination/case report session, candidates will also be scored on safety (practicing within the acceptable standard of care and avoiding excessive risk), and ethics/professionalism (honest, ethical, and professional in practice).

Per the ABPS booklet of information, a passing performance on the oral exam requires the following criteria:

• 1.
  

  A reasonable analysis of the problem.

  
  
• 2.
  

  An acceptable plan of treatment that has a reasonable chance for success.

  
  
• 3.
  

  Recognition of possible complications of the initial plan with understanding of methods to avoid and/or manage these complications.

  
  
• 4.
  

  Knowledge of a “back-up” plan in the event the first plan fails.

The oral examination is also graded on a pass/fail system. Candidates who pass the oral examination will be issued an official board certification, and recognized as a diplomate of the ABPS. Candidates who fail the oral exam are eligible to re-submit cases the following year, so long as they are within the 8-year window.

Here is my advice for examination preparation. It is imperative that candidates for board certification have an accurate understanding of how they best prepare for an examination, and follow these techniques during test preparation. While the individual preparation techniques for the written exam and oral exam may differ, they both share a common denominator: time. There is no substitute for adequate time spent preparing for each exam. Candidates must put in the time to prepare for each step in the certification process if they wish to be successful; after all, these examinations are, without question, the most important examinations of the candidate’s career. Therefore, they must be taken seriously and approached with adequate and thorough preparation. In addition, the booklet of information published directly by the ABPS and the ABPS website have detailed information on the common, or important testing topics covered in the examination process. A review of these topics should guide the candidate’s study focus.

The written examination is designed to test the candidate’s general fund of knowledge regarding the full spectrum of plastic surgery. Like any standardized test, there will be certain test nuances, which require good testmanship to overcome. Familiarizing oneself with the computer-based exam by completing the tutorial is a great way to understand and be comfortable with the electronic format of the exam. Likewise, tests such as these will often cover general concepts as well as the minutiae. Therefore, review of an adequate depth of knowledge of general plastic surgery is required. To obtain this fund of knowledge, review of several sources should be considered. It is good to utilize a general, detailed, plastic surgery textbook, such as this one, to establish a baseline fundamental knowledge. In addition, utilizing review books and/or high-yield focused textbooks, such as Core Procedures in Plastic Surgery or Review of Plastic Surgery, will help to drive home key concepts in a quick, bulleted fashion. Lastly, completion of practice exams, review of past in-service examinations, and review of frequent questions will help the candidate familiarize themselves with the test environment and overall format of clinical scenario and multiple-choice answers.

The oral exam is quite different from the written exam, thus it is no surprise that it requires a different type of preparation. While the oral exam will also test knowledge, more importantly, it will test the candidate’s ability to communicate effectively, think on their toes, and communicate under pressure. Similar to an actor preparing for a play or scene, candidates preparing for the oral exam must prepare out loud, that is to say they should either practice discussing plastic surgery topics and cases by speaking to themselves in a mirror, or more commonly, practicing with a colleague so they can improve the effectiveness and efficiency of their communication. Due to the recent standardization of the oral exam, a candidate’s performance is graded more as a collection of checkboxes and buzzwords, rather than based on the subjective feeling of the examiner regarding the candidate’s competence. As such, if the candidate is not talking during the exam, or cannot communicate efficiently and effectively, then they are not likely orating the critical buzzwords required to check the boxes, receive credit, and ultimately score points; thus the oral exam is more of a performance, and requires practice, rather than rote memorization of facts.

One key difference between the oral exam and the written exam, is that one-third of the oral exam is “open book.” By that I mean the case report session should be the easiest session for which to prepare (although it is often the most common session that results in failure of the exam). Candidates should know their cases inside and out. They must be able to communicate the indication and justification for their surgical intervention, the steps taken during their operation, and the plausible reasons for their outcome. Likewise, having an understanding of how one could have, or should have, done things differently is helpful.

For the unknown sessions, the best way to prepare is to review as many cases as possible. Again, the ABPS website and booklet of information will detail common topics tested during these sessions. However, utilizing review books such as Core Procedures in Plastic Surgery and Review of Plastic Surgery , are helpful in understanding all of the nuances for the most common plastic surgery conditions and operations. Likewise, working with colleagues, peers, and partners to review as many cases as possible will not only improve your knowledge, but will also help you generate a script to effectively communicate the diagnosis, preoperative considerations, operative plans and details, and postoperative care and considerations for these topics. Adequate preparation and practice cannot be overstated. Additional tips listed in this chapter will also help you prepare for the oral examination.