A new surgeon shares an alternative postgraduate experience
Who knew that 5 days after having a facelift and an upper–lower blepharoplasty, a patient could look like this? Maybe those half-days during clinic in residency were looking better after all. The patient, with ther red hair and pale, freckled skin, stared at me from across the room. Why had Dr Hunstad picked this week to leave the country? What was I going to say to her?
“Well, Mrs Smith, you look good,” I said. “I look good?” she responded, incredulously. “Yes, you do,” I lied. It was difficult, but I found the words. In reality, she didn’t look bad. I could see the makings of an early ectropion, but even as a fellow of Joseph Hunstad, MD, FACS, I knew this was just due to swelling. So I reassured her and asked her to be patient, to rest, and to have confidence that it would get better. Of this, I was sure.
What I hadn’t expected was the onslaught of calls and visits she made thereafter. Every day I saw her, and every day she expected to be miraculously healed. But she was a slow healer, and I continued to tell her that she looked good—and continued to worry about the small pools of tears I saw forming at the lateral aspect of each lower lid. A little too much sclera showing. When is Joe getting back?
One week felt like 10, but even after Hunstad returned, I continued to see Mrs Smith. After all, we had developed a relationship. In reality, she had grown dependent on me telling her she looked “gooooooood,” with my awkward northern accent on a southern expression. With time, she did well, and finally agreed: “I do look gooooooood!” When pronounced correctly, it became the humorous phrase by which Hunstad’s terrific office staff will always remember me.
My Graduation Decision
Six months of traveling flashed by in an instant, and suddenly I was home. I’m not a stranger to travel, but my decision after graduating from plastic surgery residency to visit various plastic surgery practices was atypical, although not unique. Inspired by a good Chicago friend, Julius Few, MD, I knew that this was a once-in-a-lifetime opportunity. About 30% of plastic surgery graduates go on to additional training, but most of these stints are 6- or 12-month positions, and the formality, work experience, and availability are variable. After investigating my options, I made the easy decision to embark on this experience.
As a medical student at Northwestern University in Chicago, I had also been labeled atypical or “nontraditional,” having worked for several years before beginning medical school. My life’s goal was to be a medical illustrator; I had no expectation of becoming a physician. After I earned a bachelor’s degree in fine arts at the University of Michigan, Ann Arbor, I entered the School of Medical and Biological Illustration (also at Michigan) to study for a master’s degree.
During orientation in anatomy class, I stood side by side in the laboratory with the incoming medical students. We were all horrified by the overwhelming stench in the room as the guide presented the cadavers to us. When he pulled back the white drape, at first I was shocked at how motionless the body appeared. My medical student neighbor gasped too, but he was shocked by the nakedness of the cadaver. My years of figure drawing had softened that blow for me, but the entire experience defined what would be many years of searching for contemporaries similar to me.
I moved to Chicago, and my first job was at the Anatomical Chart Company, where for 2 years I researched, drew, and painted anatomy charts, created educational games, and trained other illustrators. In my spare time, I illustrated pediatric orthopedic surgical textbooks. I was living my dream, but the gross anatomy experience had stung me with the surgery bug.
A Eureka Moment
During this time, Bruce Bauer, MD, at Northwestern Memorial Children’s Hospi-tal asked me to create illustrations for a congenital ear reconstruction. While sketching his case in the operating room (OR) and watching him harvest, shape, and transform the cartilage framework into a new ear, I had a eureka moment—I realized that this was my future. No surgical field other than plastic surgery would allow me to weave my anatomical interests with my creative skills.
To stay focused on the goal throughout medical school and residency, and to learn the information you need to know, it’s not uncommon to lose sight of the forest. This becomes obvious during the last stages of residency as you prepare to enter the “real world.” Decisions regarding a fellowship loom over you as a junior chief, and fielding questions like, “What are you going to do next year?” becomes daunting. A certain amount of introspection and self-exploration are needed to make decisions regarding the future. The questions can be as simple as, “Where do I want to live?” or, “Will I work in a group or solo?” Or, they can be as difficult as, “Am I intellectually prepared to work on my own?” or, “Do I have what it takes to care for my own patients?” or the big one: “Will I fail miserably?”
Of course, a good residency program, with a variety and volume of cases, should prepare a graduate for the task ahead—be it a fellowship or a full-time practice. Some residents are just better equipped. Much like a well-rounded fitness program, there are several components to preparing for life in the real world. These include education, the knowledge passed on by predecessors in the field; maturity, the ability to make decisions regarding the care of patients; and confidence, that sometimes elusive trait that comes with time and experience.
I planned to work in the community where I trained, and I was fortunate that my future partners not only accepted my plan but encouraged me to pursue these interests. My goals for this 6-month fellowship experience were to clarify and reinforce information taught to me in residency, to meet and work with people I admired and respected, and to learn procedures not taught in my training program to evaluate whether I would use them in my practice.
Leaving my black mutt behind with my parents, I set off for Nashville, Tenn. One of my partners encouraged me to take a serious look at a two-woman group previously featured in Plastic Surgery Products,1 so I called on Mary Gingrass, MD, and Melinda Haws, MD, for their expertise in breast surgery and their input on being female plastic surgeons in a female-driven market.
I discovered that they have delicately balanced the smooth delivery of comprehensive plastic surgery with busy personal and family lives, apparently without difficulty. “A pair of lady docs,” I thought. “This must be special.” But to my surprise, like me, they don’t consider themselves different from anyone else. They work hard every day to provide excellent care, and they are only reminded that they are women by other people.
Gingrass and Haws worked at Baptist Hospital in Nashville, and so, conveniently, did Patrick Maxwell, MD. I was acquainted with Maxwell through his mentoring of one of my attending surgeons in residency, Dennis Hammond, MD, and through his contributions to the Inamed Academy. I observed Maxwell making his impact not only surgically, but also on the local community through his efforts to provide focused, patient-oriented hospital services outside the megahospital setting.
The next stop was Paces Plastic Surgery, nestled atop a rise in the tree-studded north side of Atlanta. Previous graduates from my training program had passed through its doors for 6-month fellowship positions, and they had glowing comments. One of them was still living down the street and offered me a place to stay for a month.
My attendance at several conferences gave me the opportunity to hear many well-known plastic surgeons speak, and what I most appreciated about this group was their ability to teach with a clear vision. Foad Nahai, MD, Rod Hester, MD, Clint McCord, MD, and Mark Codner, MD, are the core of this practice, an honorable group of gentlemen who also have residents from Emory University in Atlanta rotating in and out of their OR and office.
Although my visit with them was purely observational, their volume of facial cosmetic and revision surgery for their patients and referrals from all over the country made this experience valuable and unforgettable. The ongoing academic pursuit of books, publications, and conferences offered many opportunities for learning and critiquing, and their genuine hospitality and polite humility made them uniquely approachable.
Fellows and visitors came regularly, and the physicians were well-prepared for my stopover. The office was elegant, and the exceptional staff gave me, a northerner, an inside look at life in the South.
Upon my arrival one morning, they were talking about a fire and all the destruction it caused. I listened quietly as they spoke about the landmarks that had burned and the loss Atlanta suffered. Finally, I broke in and asked naively if the residents would be taking care of the patients. They turned ever so slowly and looked toward me like my dog—one ear up, one ear down, and head tilted to his left—and said, “Darlin’, now you know, we were talkin’ about the fire [pronounced ‘far’]. You know, Thee Far!” Suddenly, it occurred to me that they were talking about Sherman’s Fire, which burned Atlanta in 1864! I suddenly felt very northern.
A Surgeon Abroad
My next visit would take me even farther from my roots, to Ghent, Belgium. I made the decision to visit this charming city easily after hearing presentations at a Virgin Islands workshop by Patrick Tonnard, MD, Moustapha Hamdi, MD, and Koen Van Landuyt, MD, nearly 11¼2 years earlier. Their group, which also included program chairman Professor Stan Monstrey, MD, and Philip Blondeel, MD, had vast experience in developing and promoting perforator flaps for elective breast reconstruction and trauma cases, articles about which were evident in almost every issue of Plastic and Reconstructive Surgery.
The experience was nothing short of exhilarating. One morning, the sun rose over the canal adjacent to my flat, filling the sky with red and orange and matching the turning leaves. There were jet paths above me that crisscrossed the clear blue September sky. The weather was starting to grow chilly, and I hadn’t packed gloves. I could see my breath as I warmed up along my ride. I was getting a little tired of the bike ride to the hospital, and I looked forward to getting home to my car. Midwesterners all drive to work, like a religion, especially in the state of the Motor City. At least I had finally found a reasonable route to the hospital, one that had the fewest cobblestones, a pronounceable street name, and a low density of other biking commuters.
Cases were performed at the University of Ghent Hospital, a massive modern center in which the buildings were numbered rather than named. Every day there was a perforator flap case, and there were some cases for elective breast reconstruction, as well as for traumas or wounds. It was a fine-tuned machine in which the elective patients typically underwent Duplex scanning prior to the case, minimizing decision-making in the OR. Blondeel directed a 3-month fellowship to study perforator flaps in honor of Stephen Kroll, MD. The timing had not worked for me, but the recipient, an English woman, contributed to the distinct multinational presence at this program.
The residents were primarily Belgian, but the other visitors and fellows that were staying there for 4 weeks to 2 years hailed from Canada, Germany, Italy, and Iran. The work was plentiful and interesting, and extra hands were always put to work. The staff was eager to teach, and their hospitality was immense.
In Ghent, someone asked me how it felt to sit among a group of three individuals speaking three different languages, none of which was English—not an unusual event. I said it was an opportunity for self-reflection, with the conversation more like background noise. One constant, however, in all the locations I visited was the OR. The rhythm and alarms of the ventilators, the music, and the background chatter were all exceedingly familiar. Even the jokes among the surgeons and the anesthesiologists were the same, regardless of the country or the language.
Back to the States
The last stop on my tour was Charlotte, NC. My exposure to Hunstad had been limited prior to graduation. When I attended an abdominoplasty seminar and heard him speak at previous meetings, I was impressed with his technique, his enthusiasm, and his results. One of my previous mentors encouraged me to work with him. After I contacted him, we discussed what would be a new arrangement for him: He proudly said I would be his “prototype.” “We’ll see how it goes,” he said, “and maybe I’ll do it again!” He was all smiles.
My arrival in Charlotte was welcomed by my sister and her dog, who, coincidentally, had moved there from Michigan earlier that year. As an assistant, I worked with Hunstad in the office and the OR. He ran a tight ship, to which I brought a certain amount of entropy. His staff was wonderful to me, and they seemed to breathe a sigh of relief when I arrived.
As a solo practitioner, Hunstad works in his own certified surgical facility, operating at least 3 days per week. With two ORs and a full-time anesthesiologist, he prides himself on efficiency and can be ready to begin a case in the next room with only minutes of turnover time. His personality is warm, his mind is quick, and his attitude is optimistic.
My experience with him had more impact on my current practice than any of the other experiences I had. I recognized that the era of body contouring was just beginning, and that Hunstad’s specialization in this field—specifically, abdominoplasty and liposuction—could not have been a better choice for me. He reinforced procedures that I learned in residency, but his technique, end point, and expectations were vastly different. His concepts emphasized safety while pushing the envelope of improvement. Whether we performed circumferential abdominoplasty, liposuction, leg lifts, or facelifts, we worked long hours and shared information.
We also worked closely to write book chapters and journal articles, using even the spare minutes between cases. For 2 months, he pushed me physically and intellectually to the point that, in the evenings, I’d have only enough energy to walk the dog and fall into bed.
Home at Last
Fellowship is the condition of sharing similar interests, ideals, or experiences. Each and every location I visited was extraordinary—culturally, intellectually, academically, and personally. Since my arrival home, my friends, family, and new partners tire of me reporting to them, “I’ve never been happier in my life.” Who knows whether the source of my happiness is the unburdening that comes with the completion of medical school and surgical residency; the return home after 6 months of traveling; the exciting start of a new career; or the knowledge that after all this hard work, it was the right choice for me?
Finally, I have found the “place” where I am similar to my contemporaries, where I am at home no matter where I am. The field of plastic surgery contains a group of inspired, creative, out-of-the-box thinkers with a passion for their jobs and a compassion for their patients. This was a rich experience that brought me knowledge as well as camaraderie and the confidence to go home to my new practice and experience life as a plastic surgeon. So the next time I see a patient with swollen lower lids walking into my office only 5 days after surgery, I will know how to say—with conviction—“You look gooooooood!”
Marguerite E. Aitken, MD, is the newest member of Plastic Surgery Associates, a six-man, one-woman practice in Grand Rapids, Mich. She can be reached at (616) 451-4500 or firstname.lastname@example.org.
1. Bronson JG. Natural selection. Plastic Surgery Products. 2003;13(12): 10–12.