NARRATIVE DESCRIPTION OF PROGRAM

PREAMBLE
The Residency Program in Plastic Surgery at The University of Texas Medical Branch was begun in 1949 under the direction of Truman G. Blocker, Jr., M.D. Dr. Blocker remained Chief of Plastic Surgery and Program Director until 1961, at which time the reins were passed to Steven R. Lewis, M.D. Dr. Lewis remained Chief of the Division and Program Director until 1980. During this time period, Galveston was the training program for many future teachers of plastic surgery. Steven Blackwell, M.D. served as interim chief until, after a national search, Martin Robson, M.D. was named chief and the first Truman G. Blocker Distinguished Professor. After his departure, Linda G. Phillips, M.D. was appointed as Chief of the Division of Plastic Surgery and Program Director in April 1994, as the Truman G. Blocker, Jr., M.D. Distinguished Professor of Surgery.

The Residency Review Committee for Plastic Surgery approved the UTMB program as an integrated plan. Six years of progressive responsibility rotate the residents through three years of basic surgical sciences followed by three years of core plastic surgery experience. An optional one to two-year research experience is available after the third clinical year. This would increase the time at Galveston, as the clinical experience must remain six years.

The Program originates in the Division of Plastic Surgery, Department of Surgery, of The University of Texas Medical Branch (Galveston). The three hospitals comprising the educational program are the John Sealy Hospital, Shriners Hospital for Children, and the Texas Department of Criminal Justice Hospital. These three are all closely organized under the University of Texas Medical Branch. They are separated for statistical purposes only. The entire campus is at one geographic location with only a crosswalk between the hospitals.

There is a two-week rotation during the fourth year of residency at the Baker and Stuzin practices in Miami, Florida. There is a 1-month rotation during the fourth year at the M.D. Anderson Hospital at the University of Texas Health Science Center in Houston.

The Program's administrative offices are located within the Department of Surgery area at The University of Texas Medical Branch. This is physically connected to the three hospitals, and is immediately adjacent to the University Hospital Clinics (UHC) where both the outpatients' clinics and ambulatory surgery suite are located. The Rebecca Sealy Hospital is recently acquired and now serves as the main private ambulatory care center with four operating rooms, and the full spectrum of anaesthesia available. It is located directly across the street from the UTMB complex.

PROGRAM ORGANIZATION
This is a six-year Graduate Educational Program with the Chief Residents delegated a high level of responsibility and authority for independent activity in an atmosphere where consultation and help are immediately available. There are five full-time clinicians overseeing the work of the residents and research programs.

The curriculum is an integrated program with the residents rotating through distinct educational experiences with progressive responsibility for surgery during their six-year program. Each of the clinical experiences requires pre-operative evaluation and post-operative management of the patients in addition to operative care. During the sixth year, the resident on the adult service takes on the additional responsibility of Chief Administrative Resident for the entire Program.

The Plastic Surgery Residency Review Committee has approved the UTMB program for three residents per year for a total of 18 residents.

All positions in this six-year program are currently filled. The resident applicants are screened by all faculty and invited for an interview. All clinical activity ceases for 2 days of a group interview with all faculty and residents. The faculty, residents, and staff meet to exchange information. Each resident and faculty member submits a rank list. Dr. Phillips submits the final list.

EDUCATIONAL GOALS/OBJECTIVES FOR EACH OF THE PARTICIPATING INSTITUTIONS
The educational goals and objectives for each institution, and each rotation at each institution, are outlined in the Plastic Surgery Residents Handbook. This is given to each new resident as he/she matriculates and is discussed in the orientation session held each July for all residents and faculty as well.

The chronological rotation of assignments for each year is as follows:

Year 1	General Surgery	3 months
	Trauma	1 month
	Vascular	1 month
	Cardiothoracic	1 month
	Transplant	1 month
	Acute Burns	1 month
	Pediatric Surgery	1 month
	Neurosurgery	1 month
	Urology	1 month
	Adult Plastic Surgery	1 month
Year 2	General Surgery	4 months
	Trauma	2 months
	Transplant	1 month
	Burns	1 month
	Orthopaedics	1 month
	Anaesthesia	1 month
	Otolaryngology	1 month
	Pediatric Plastic	1 month
Year 3	Dermatology	1 month
	Oral Surgery	1 month
	Plastic Surgery (Reconstructive Burn Service)	1 month
	General Surgery (A)	2 months
	Vascular	2 months
	Pediatric Surgery	2 months
	General Surgery (B)	3 months
Year 4	Adult Plastic Surgery	2 months
	Pediatric Plastic Surgery	2 months
	Burns	2 months
	Adult Plastic Surgery	2 months
	Pediatric Plastic Surgery	2 months
	Burns	2 months
Year 5	Adult Plastic Surgery	2 months
	Pediatric Burn Reconstruciton (SBI)	2 months
	Dr. Stuzin (Miami)	1/2 month
	M.D. Anderson (Houston)	1 month
	Adult Plastic	2 months
	Pediatric Burn Reconstruction (SBI)	2 months
	Research	2 1/2 months
Year 6	Adult Plastic - Administrative Chief	4 months
	Pediatric Plastic	4 months
	Texas Department of Corrections and Hand	4 months

An optional 1 or 2 year research block can be inserted between the third and fourth clinical year. This would make the Galveston experience 7 or 8 years, as each resident must have six clinical years.

The curriculum provides specific rotations as required by the Plastic surgery RRC to progress through an Integrated Program of 6 years' duration. The program will allow experiences of progressive responsibility as the resident begins with a broad exposure to surgical disciplines and advances into specific plastic surgery experiences. Early exposure to multiple surgical disciplines will provide experience with types of disease processes the plastic surgeon will encounter in practice and serve as a basis for plastic surgery experience.

The adult reconstructive service is rich with combined cases with other services. Here are the bulk of the cases for resident experiences with tissue transfers of complexities ranging from skin grafts to composite free tissue transfers. Patients with congenital and acquired truncal and genital defects are treated, often in conjunction with the general, urologic, or the gynecologic service. Benign and malignant neoplasms are part of this service. Patients with wound healing problems provide truncal reconstruction experience. Breast augmentation, reduction, and reconstruction is performed using tissue expansion, or flap reconstruction. Cranial and head and neck trauma are a part of this rotation, including facial fractures in rotation with oral surgery and otolaryngology. Neoplasms of the head and neck are referred to this service from Oral Surgery and the Mohs surgeon. Simple acquired and traumatic injuries of the hand are taken in rotation with Orthopedic surgery.

The pediatric service at John Sealy Hospital comprises the main experience in congenital defects of the head and neck, including cleft lip and palate, craniofacial, and other congenital anomalies such as myelomeningocele. Most of the complex cranial and facial trauma care is provided by this service. The Cleft Palate Project is run by Dr. Steven Blackwell from this service.

The Shriners Hospital rotation provides an experience rich in complex reconstructive dilemmas of pediatric burn victims. Tissue expansion, flap rotation, and skin graft release of severe burn scar contractures are daily experiences on this service. Recent expansion of services has allowed the development of a laser program for vascular malformation, and the use of osseo-integrated implants for those absent parts in patients without other reconstructive options. The superb resources in the rehabilitation facilities here offer the resident extensive opportunities of management in crippled extremities.

The M.D. Anderson rotation, begun 3 years ago, offers a heavy concentration in microvascular reconstructive cases, particularly of the head and neck region. The resident becomes an integral part of the reconstructive team while on this rotation. Housing is provided, as the hospital is 50 miles distant.

The rotation to the private practices of Drs. Baker and Stuzin is a long-standing rotation for this program. The resident assists in the care of the complete range of challenging aesthetic cases, primary and secondary. The vast video library is a significant addition to their education, as is the exposure to a well-run private office.

The chief resident in charge of the TDCJ for plastic surgery is responsible for coordinating all plastic surgical services for the 30,000 inmates who make up the state's prison population. This chief resident is afforded a broad exposure to all phases of reconstruction, cancer, hand, and congenital dysfunctions. The wealth of clinical material, administrative responsibilities, and follow-up opportunities are strong attributes of this rotation. Dr. Gould has brought more complex hand reconstruction as an integral component of this rotation.

The rotations in burn surgery allow a progression in responsibilities and duties for the integrated resident. The three progressive rotations on the burn service allow the resident repetitive exposure to burn victim evaluation, resuscitation, and the evaluation of concomitant injuries such as smoke inhalation, compartment syndrome, or additional injuries. The resident will have the opportunity to manage this service in the PGY-4 rotation and will supervise the PGY-1 through PGY-3 residents. The resident will have exposure to other traumatic acquired skin diseases such as Steven-Johnson syndrome. The resident will have opportunity to perfect endoscopic technique as suspected smoke inhalation victims are endoscoped and lavaged. As the burn ICU is included in this rotation, the resident will have progressive duties in critical care management.

With the exception of the two rotations at the M.D. Anderson Hospital and with the Baker-Stuzin practices, all of the rotations of the integrated resident, including those outside of plastic surgery itself, occur at the same geographic location. The Texas Department of Criminal Justice Hospital is on a separate floor of the main hospital. The Shriners Hospital is across the street from the main John Sealy Hospital.

The resident is afforded progressive rotations in general surgery in the first, second, and third years. In this time, the resident is expected to be able to correctly diagnose and manage an increasingly complex general surgical emergency patient. Fluid and electrolyte management and outpatient pre- and postoperative care are an integral part of these rotations. The resident will participate in the care of and perform as surgeon the less complex procedures on patients who have a full array of general surgical problems, including breast disease, gastrointestinal disease, endocrinologic disease, surgical oncology and hepatobiliary and pancreatic problems. A separate rotation on the vascular service will provide exposure to congenital and acquired, traumatic and atraumatic vascular diseases. The resident will become able to manage these patients pre- and postoperatively and learn to perform the appropriate examination in the outpatient setting.

The neurosurgical rotation is a 1-month rotation in the PGY-1 year. This will provide the resident exposure to neurosurgical emergency and outpatient evaluation, inpatient management and surgical care.

Separate rotations on the pediatric service in the PGY-1 year will familiarize the resident with evaluation of common pediatric congenital and acquired diseases. The resident will become familiar with dosing and fluid and electrolyte management in these patients and the surgical care of these disease entities.

PGY-1
Rotation on transplant surgery will expose the resident to the preoperative evaluation and preparation of transplant recipients, harvest of donor organs, and management of their postoperative care. Outpatient and inpatient management of rejection will familiarize the resident with transplant biology and immunology.

The PGY-1 rotation in urology will allow the resident the emergency evaluation and treatment of urologic problems as well as a separate component with pediatric urology with exposure to congenital urologic problems. The urology service works extensively with the plastic surgery service for their oncologic reconstructive needs. The resident will participate in the inpatient care and outpatient treatment of these patients.

Separate trauma rotations during the PGY-1 and -2 years provide concentrated experience in the evaluation and management of blunt and sharp trauma. All complex trauma of multiple system involvement is also admitted to this service. The resident will learn the management of all surgical trauma on this service.

There is a separate rotation in the PGY-2 year for anesthesiology. The resident will become familiar with general and regional anesthetic, possible risks and complications of particular agents and particular disease entities. The resident will learn monitoring techniques and line placement, including endoscopic placement.

Critical care techniques, monitoring, and management is provided in several separate settings. There is a Surgical Intensive Care unit (SICU) rotation in the PGY-2 year when the resident is responsible only for the treatment and management of those patients admitted to the SICU at John Sealy Hospital. In addition, the burn service provides surgical intensive care and fluid and electrolyte management of the burn victims. The cardiothoracic service provides its own intensive care setting as does the neurosurgical service.

A 1-month rotation on the orthopedic surgery service will allow the resident to rotate through the emergency room for evaluation and treatment of adult orthopedic problems such as fractures and dislocations. The resident will provide perioperative management and will also scrub into surgical procedures. This rotation allows the resident to become familiar with the concomitant injuries that can occur to the neurovascular bundles or compartment syndrome and hemorrhage.

A 1-month rotation on the otolaryngology service in the PGY-2 year provides two separate experiences. Half the time is spent on the pediatric service learning pediatric airway management and management of otologic diseases associated with the cleft lip and palate patients. The second half of the rotation is on the head and neck adult service which will allow an in-depth exposure to head and neck neoplasms including those of the oropharynx, and further experience with endoscopy.

As the resident rotates through the plastic surgical services, with repetition particularly through the services at John Sealy Hospital and the burn service, she/he has a progression of duties. With these repetitive rotations, the faculty are able to chart the progression of each resident. Due to the large number of cases on each service, and the range of their complexity on each service, the resident is able to act as independent surgeon in each of their years of postgraduate education, depending on their individual progression. Continuity of care is provided at each rotation with pre- and postoperative care during their allotted time in the outpatient areas to allow follow-up care. When they rotate back onto their respective services at more senior levels, they can follow patients they had cared for as junior residents. There is no emergency room rotation at the University of Texas Medical Branch. Each service provides evaluation, management and, if necessary, inpatient care or those patients who present with problems within the domain of each service. Thus, particularly at the junior resident levels, the rotation on each service, provides experience in the emergency evaluation and treatment of patients with a similar group of disease entities.

The Plastic Surgery full-time faculty sees all their outpatients within the University Hospital Clinics. The residents assigned to the Adult or Pediatric teams see their patients within the same facility; each team sees their outpatients' two days per week. Private patients and staff patients are seen at the same time, and their care is indistinguishable. Approximately 400 patients per month are seen in this way. Designated specialty clinics, which bring together the talents of multidisciplines, meet weekly; these include the Burn Rehabilitation Clinic, Cleft Palate and Craniofacial Clinic, and Wound Healing Clinic. These outpatient clinics are held in the University Hospital Clinics and are directed by the faculty.

In addition to this, some 1600 patients are seen in the Pediatric Reconstruction-Rehabilitation Clinic at the Shriners Burns Institute. These patients are seen on Tuesday afternoon by the plastic surgery resident assigned to that service. In addition to the plastic surgery faculty supervising, the entire rehabilitation team is available to give the resident a familiarity with the concept of total rehabilitation necessary for complex reconstructive problems.

Some 1300 patients are seen in the Texas Department of Corrections Outpatient Clinic by the plastic surgery resident and the designated attending faculty. The sterile minor operating room in that facility is reserved for plastic surgery one and one-half days every week. This offers the resident yet another opportunity to provide prompt operative service where local anesthesia and sedation are felt to suffice.

There are faculty members present in the outpatient clinics at all times. In addition to the outpatient clinics, 30 to 40 minor surgical procedures are performed monthly in the Plastic surgery Minor Operating Suite. The Ambulatory Operating Suites are immediately adjacent to the main hospital operating rooms. This allows staff cases being performed by the resident to be closely monitored by the attending faculty physician. The University of Texas system allows patients to choose resident physicians as their surgeons. This has been extremely useful in the teaching of aesthetic surgery to the residents.

Emergency Department responsibility is divided among the first, second, and third year residents on a rotating basis in their basic surgical science rotations. During rotations in plastic surgery, the PGY-1 is backed by the PGY-3; the PGY-2 is backed by the PGY-4. These residents serve as the primary physician or first call physician. In addition, they are at all times backed up by a fifth year resident and a faculty surgeon. The range of pathology seen in the Emergency Department includes head and neck trauma, including facial fractures, minor burns, problems of skin and soft tissue loss, upper extremity injuries, bite injuries, soft tissue infection, head and neck cancer, and lower extremity injuries. The average number of patients seen per day in the emergency department by a Plastic Surgery resident is six to eight. Approximately one-third of these are admitted for additional observation and treatment. Admissions from the Emergency Department are made to a faculty member.

Because of the unique integrated nature of the outpatient clinic facility in the University Hospital Clinics, no separate arrangements are made for residents to rotate through private offices outside the confines of the Institution. The private service patients are seen in the same facility, at the same time as the staff service patients. The only exception to this is a two-week rotation for each 5th year resident to the offices of Drs. Thomas Baker and James Stuzin in Miami, Florida.

All residents have full responsibility for pre-operative and follow-up care under the supervision of a faculty member. Since operating time and clinic time do not conflict with the service arrangement, all residents on a given team are either in the operating room or in the clinic. Residents are expected to identify, work-up, and follow patients on whom they operate.

Each resident develops research activities in either clinical reviews or actual laboratory work, or both. Fourth year residents serve a formal two-month rotation within the Wound Healing Laboratories. The laboratories are very well funded and staffed, allowing each resident to formulate a research plan and carry it out under the direction of basic scientists. The program is designed so that the resident will be allowed to continue his research interest throughout the remaining residency years. The two-month rotation is the only intensified time but because of the number of basic scientists and technicians available to help the resident, a continuum of research is encouraged.

During scheduled operating room time, a faculty member is in the operating room suite. In addition, the faculty is present at all times in the outpatient clinic area during their assigned times for pre- and post-operative outpatient care.