Enhance Your Practice Podcast
Enhance Your Practice Podcast
EP80 International Residents Forum: Inside Residency
Welcome to the International Residence Forum podcast series presented by the ASPS International Residence Forum. I'm Dr Jing Kin Teh Chair of the ASPS IRF, and I'm currently a plastic surgery resident working at Oxford University Hospitals in the United Kingdom. I'm very excited to be the first to kick off this podcast series. Excited to be the first to kick off this podcast series. The aim of the IRF podcast is to provide a platform for international plastic surgery residents to share their experiences, insights and aspirations, while exploring topics that might impact training and career development around the world. I'm truly honored to be joined by two incredible panelists today. First, dr Gregory Greco, who is the past president of the American Society of Plastic Surgeons and currently serves as a trustee to ASPS. He's also the chairman of the Division of Plastic Surgery at Rutgers Health Monmouth Medical Center in Long Branch, new Jersey. Our second panelist is Dr Stephen Williams, the ASPS immediate past president and founder of Tri-Valley Plastic Surgery in California. Dr Greco, dr Williams, thank you both for joining us today. Thank you for having us.
Speaker 2:Yeah.
Speaker 1:Lovely so. In today's episode, what we're trying to do is to explore the unique journeys, challenges and successes of different clinical training systems across the continents. We'll specifically examine how core residency training requirements differ between countries, the varying emphasis placed on aesthetic versus reconstructive training worldwide, how patient care volumes and case diversity impact clinical competency during residency, and practical tips for international residents seeking international fellowship. So let's start with the fundamentals. Dr Greco, could you walk us through the structure of plastic surgery training in the United States, particularly how it differs from what many of our international listeners might be familiar with?
Speaker 3:Yes, I'm happy to do that.
Speaker 3:So plastic surgery training in the United States we have actually two pathways.
Speaker 3:We have a traditional pathway where the applicant typically has completed five years of training in either ENT, orthopedic surgery, general surgery, neurosurgery or urology and then applies to what we call the traditional pathway, which would be an additional two to three years of plastic surgery training, versus our integrated plastic surgery training programs, which the majority of our programs have transitioned to, which is six years of plastic surgery training, and the first several years, usually years one through three, are comprehensive surgical training which include anesthesia, burn surgery, cardiothoracic surgery, critical care, dermatology, emergency medicine, general surgery, neurosurgery, oral surgery, orthopedic surgery, ent and a host of other things like trauma surgery, vascular surgery and thoracic surgery, whereas the plastic surgery specific curriculum starts years four through six, although there may be some plastic surgery training in the earlier years, but typically years four through six are going to include the general plastic surgical principles, including injectables and surgery of the core hand upper extremity.
Speaker 3:So the RRC, which is the Residency Review Committee for Plastic Surgery. We have a bunch of suggested training that our residents should be getting in burn management, oral and maxillofacial surgery, dermatology, orthopedic surgery and anesthesia. However, it's very specific that each resident has to train at least 48 weeks per year in head and neck and congenital surgery. Head and neck oncologic surgery, breast reconstruction, hand trunk, lower extremity aesthetic microsurgical surgery, as well as aesthetic or injectables for those following years.
Speaker 2:If I can just add on to that. First of all, you asked the right person the right thing. Dr Greco has intimate knowledge with the residency program, know a program chair for general surgery, and you know. One of the important things that I want to point out is the fact that there are two pathways points to the fact that all of these training programs have undergone evolution.
Speaker 2:Originally, plastic surgery was primarily a fellowship. That was something that people pursued after a different surgical core training, something that people pursued after a different surgical core training. But that has largely changed and most programs now are combined or coordinated, meaning that you get into a plastic surgery residency, at least here in the United States, and then the last portion of that training, whether it's four years or three years or sometimes two, is all plastic surgery and under that section or department at that appropriate program. But the important thing to recognize here is that residency programs are continuing to evolve and the way that we're training residents continues to evolve as the demands for our patients and as new science comes out. And the most important thing here is there has to be some flexibility, there has to be an evolution of the overall of the process.
Speaker 1:Yes.
Speaker 3:I think that's really important, the fact that, like every program, you know it is an evolution because so much changes in plastic surgery. So the listeners are aware you know we do have a series of oversight committees in the States that make a very kind of it's very regimented as to the training and the oversight committees. For the residency is the ACGME, which is the organization that oversees the residents. Then we have something called ACAPS, which is the American Consortium of Aesthetic Plastic Surgeons, and now it's Educators in Plastic Surgery and this is for the program directors. So this is where the program directors go for curriculum, this is where you as a resident and international member you can join, and this is all free to all of you. And then our next organization is the ABPS, which is the American Board of Plastic Surgery, and this kind of is the oversight organization for the public. This serves the public, making sure that the members who are board certified plastic surgeons are following the oversight rules.
Speaker 2:And then ultimately we have the membership organizations like the American Society of Plastic Surgeons which is the member organization for oversight, and all of these organizations have input and provide resources to the best way to train medical students, the best ways to train plastic surgery residents and fellows and provide additional continuing support throughout their careers and pathways.
Speaker 1:That's interesting. So in the UK for me personally, from my experiences our training is slightly different. We have a different structure progression to various surgical specialties before focusing on plastic surgery. So after medical school, which typically lasts for five to six years, we go into our internship, which is two years, followed by what we call core surgical training, where we go through various surgical specialties to get a feel of how different specialty works before we apply for a plastic surgery residency. And in many European countries the training is also often longer but more specialized early on, for example, in Germany, for example, residents might spend two to three years in general surgery before entering plastic surgery, and some of them will prefer to do what we call doctor of philosophy or PhD during the training, which can extend the training up to eight to 10 years. So, dr Greco and Dr Williams, what are your thoughts on these different approaches? Are they advantageous to each system?
Speaker 3:You know, I think as old as Dr Greco. I think that if you look at the statistics across Europe because we have pretty good stats across Europe as far as training compared to the United States, the United States, when you look at general surgical training, is specifically two years. Norway is two years. Sweden is one year. Germany is approximately one year although you are in Europe training so they could have changed these numbers. The Netherlands is two years.
Speaker 3:The UK is a minimum of two years and when you look at him, it's between that one year to two year training in general surgery. I think ultimately, the general surgical training I think is very important to the plastic surgery resident because that specific training not only teaches you how to operate. You know, as plastic surgeons, we truly are head to toe surgeons. So I think that ultimately, although it will be varied, I think the end product we're turning out, a product that certainly is a competent plastic surgeon and we have specific requirements before we let someone go. So ultimately I think it probably works. Unfortunately, the UK has the longest training, on an average of eight years when you look at from the general surgical training to the finishing plastic surgeries approximately eight years. So you know, but once again, I think that the goal is to turn out a competent plastic surgeon, and I think some of this is Steve Williams.
Speaker 2:I think some of these, and I think some of this is Steve Williams I think some of these differences that you're seeing reflect the individual needs of specific regions or countries, provided in a prescripted way through, you know, overall managed central health care, or whether it's federated and distributed through private insurers with some government oversight or government input. All those things really deeply affect how many plastic surgeons you need, how many physicians you need and how they're allocated. You know, around the country, the respective countries, that's an interesting point.
Speaker 1:This actually bring us to a topic that many of our international listeners are also curious about the balance between aesthetic and reconstructive training during the residency. From my perspective, in the, we see a very strong emphasis on reconstructive work during our training, with aesthetic surgery often being something surgeons pursue through additional fellowship training or continuing education. Dr Greco, how does this compare to the training in the United States?
Speaker 3:So, it's very hard for me to specifically address the aesthetic experience in other countries, but in the United States one of the things that we have seen is the expansion of the resident aesthetic clinics.
Speaker 3:So the majority of programs, in order to enhance the aesthetic experience, have specific resident clinics, whether it's aesthetic surgery or some reconstructive surgery.
Speaker 3:The focus of plastic surgery training is the reconstructive component of plastic surgery. However, with the growing demand for aesthetic surgery, especially when you look at the procedural statistics year after year, there is a growing demand and our residents have to leave as competent aesthetic surgeons. We're well aware of that, especially because the space is occupied by so many unqualified people trying to perform this. So, with the growth of, as I mentioned, these resident aesthetic clinics, our residents now, whether it's in their second to last year, so in their fifth and sixth year, have specific clinics which they get to perform and basically have their own practice with oversight for aesthetic surgery. So we are seeing these numbers increase beyond our basic minimums. You know, in the past we always had an experience and now it's a requirement. Experience and now it's a requirement. So, with that said, every program is going to be slightly different, but I think the focus on making sure that the residents are aesthetically trained prior to leaving the program has been somewhat more under scrutiny.
Speaker 2:Yeah, I would agree with Greg really strongly here. I think that there's a recognition that aesthetic plastic surgery is a large component of people's future plans as they're going into plastic surgery, and there's the mandate to try to make sure that residents get those types of experience. I will say that I think that there's at least in the United States. There's an increasing reliance, or at least residents are increasingly seeking out fellowship opportunities, and part of that may be reflected in the United States' efforts to reduce resident hours.
Speaker 2:When Dr Greco and I trained, we very commonly had 110, 120-hour work weeks. It was kind of the norm, and there are good and bad things about that, and there are good and bad things about that. One of the great things about that is when I came out of residency, I was very, very prepared to operate on my own because I had done thousands, literally thousands of cases. You know I think I had done 200 breast reductions and 50 of those were completely by myself, without an attending anywhere near me. And so you know, as those experiences somewhat diminished because of hour restrictions, to try to have a more balanced residency where resident safety, work-life balance, those are all things that I think are increasingly important in the resident experience as those things have come out. I think sometimes residents have felt a little bit less prepared compared to some of the older surgeons, that those hour restrictions weren't present, and so fellowships are a way for residents to further hone specific areas of experience and expertise.
Speaker 3:Steve, can I just add to that? I think that that's a very good point. And when you look at duty hour restriction, although old, there's a study which came out in PRS Global Open in 2016, which looked at duty hour restriction on training programs throughout different countries. The good thing was that the average training, if it was reduced to 48 hours per week, they did not see worse patient outcomes. So I think that's important to understand. However, more operative experience correlated with improved patient outcomes.
Speaker 3:When you look overall at duty hours, the United States by far is 80 hours, which is the longest training week. Of all the countries looked at, the majority of them were around 50 hours or so. Looked at, the majority of them were around 50 hours or so. Spain was the next largest with about 68 hours or so, and all of them most of the European countries all fell about 50 hours or so, with the shortest work week noted in or work hour week in Italy around that 48 hours or so. So it's just interesting to look at. You know, I think that, without a doubt, the experience is always helpful and maybe a lot of people didn't go on to fellowship training because they couldn't bear the thought of being in residency another moment because of all the hours we worked before these roles were in place. However, it's nice to know that there is a number that equates to competency and no worse patient outcomes.
Speaker 2:Well, and I'll expand on that even more, greg, and this is a topic I think we could kind of debate. You know, part of the challenge is, at least in the United States, there's a very heavy, you know, medical legal burden that physicians face as they're coming out in training and I think that really pushes people to have, you know, even beyond the standard of care, really this core competency to be able to provide just outstanding care, just because they're worried about everything being picked apart a little bit, not the saying that they're not worried about patient safety, but you know, the concept of having medical legal consequences for what could be very common complications I think really drives people to work really hard. If you also look at the data about reduced residency hours, you'll also find it hasn't increased patient safety and so it doesn't seem like it's really shifted the needle that much. Either way, the studies I've reviewed do say that residents feel better about their time, their overall time in the institution in terms of overall burnout. So that's probably improved and that's probably something that's very valid.
Speaker 2:But there's still this core issue of when you get out and when it's just you and when you're on your own. You know your patients really don't care that you're tired. The hospital administrators don't care that you're tired, they want you know an incredibly competent surgeon. And so in some ways, there's a probably a valid debate that some of these guardrails that we're putting up in residency because they don't at least in the United States, because they don't exist out in actual practice, residents rightfully so have a little bit of culture shock as they leave residency and then they're out in the real world.
Speaker 1:Absolutely. That's a very crucial observation. I, as a resident myself in the UK. Our duty hour restriction is actually heavily imposed, so we work about 48 hours work week with on-call on top of that. With that limited time and restriction, how do you think the residents can maximize their learning, regardless of the training environment?
Speaker 2:Yeah, I mean, if you ask me, unfortunately I'm kind of an old world surgeon and you know, I believe that a lot of things that were present, at least in the United States, in terms of, you know, discrimination, workplace violence, you, those things, those things have zero place. But residency is a very special time. You have this structured protected area where you can learn. You learn what it feels like to be tired, you learn what it feels like to be under stress and see how that affects your decision making and your physical acumen, and you do it in a way that protects patients and that allows you to continue to grow and learn. And so what I tell residents that want advice on this is from a very old world perspective. I say you should really lean into it, and I'm not saying violate your institution's hours restrictions, but you really want to be available and understand that it's a very special time to learn and you'll never have it again and you should take as much advantage of it as you can.
Speaker 3:Steve, thanks. I think that's very important and I think it can't really be truly understood until you are in practice.
Speaker 2:Yeah, I agree with you.
Speaker 3:And again, that's what we call the retrospective scope.
Speaker 3:We look at our residency fondly and I think if you went to our own self Mostly fondly, no-transcript they're bright intellectual people, highly motivated, and you have to take the time you have to study on your own because at the end of the day lectures are wonderful. But you know we kind of have that balance. If there are too many lectures, then we're taking away from your clinical experience. If there's too much clinical experience, we're taking away from your educational time. So there is a self-directed portion of residency where I think that the resident has to own the experience and truly make it. Take those years and make them as educational for yourself as possible, because once you're done it's very hard to kind of capture that time back.
Speaker 2:Yeah, I think that's a very interesting retrospective view, greg. You know, when I was in residency, I'm not sure I had the choice to not do it. There was a lot of just expectation and this is what you're supposed to do. You know, one of my favorite stories about residency was the former chair of the department. I wound up getting married as a resident and the former chair of the department told me with all seriousness that if he were still chair he wouldn't let me get married. And you know he meant that in a constructive way.
Speaker 2:But when you think about that as a perspective of that kind of old style training versus a new style training, things have really changed and I think that you've hit on the critical point. Residents have to take responsibility to augment the basic residency experience, understanding that they may not actually have the full core competencies that are going to be required of their future practices. It really falls back down on their shoulders and maybe I had it easy back in the old days because I didn't have a choice. They were going to make sure I knew it. That's a very interesting point.
Speaker 1:Okay, let's move on and talk about subspecialty exposure. Plastic and reconstructive surgery is such a vast area of surgery that sometimes it's just impossible for a single center to offer all the exposure that the residents need to achieve the competency as a day one attendings or consultants. How do you think the different training system can approach this subshared specialty training or rotations to make sure that the residents are competent at least on the first day when they are board certified?
Speaker 2:Yeah, I'll jump in on that. Since Greg's taken the lead on a couple of these, I'll make the first crazy comments that Greg can disagree with. I think that there are certain areas of plastic surgery, at least in the United States, where particular fellowships are important, and those fellowships usually have what's called a CAQ or Certificate of Additional Qualifications around them, and those include things like craniofacial and hand surgery. Those are areas of plastic surgery that I think it's recognized that there are additional clinical experiences that may be required. There may be additional specialty attention to those procedures and they are generally because those requirements are higher. There's a specific pathway for those types of things.
Speaker 2:Now, again, as I spoke about earlier, increasingly residents are doing aesthetic fellowships and again, when I was initially training in the United States, aesthetic fellowships and again when I was initially training in the United States, aesthetic fellowships were largely to start planting your feet in a particular geographic area that you wanted to work in. But I think increasingly they are serving as ways for residents to bolster experiences that they don't have. They're not getting as much in residency and so there is an increasing network of opportunities available for residents after training for additional experience. There's additional resources available online in terms of, you know, online webinars from accredited universities and experiences to provide additional resources for residents as they're completing their training.
Speaker 3:Thanks, steve. Yeah, I think those are all really valid points. I think ultimately, as I mentioned earlier, there are oversight committees. So when you look at the ACGME, which is the council that accredits the programs, there are minimums and there's committees that determine what the minimum number of cases are. That maybe will infer competency we should say versus, you know, a complied competency and I think that when you look at this, the program has to have a very honest look at itself and see where they have to, where they're not, maybe meeting the patient, the resident's needs.
Speaker 3:And that's where you look at other institutions to help and you look at other specialties plastic surgeons in your area that can help your residents attain these qualifications. So I think ultimately there are specific things like head and neck surgery, I'm sorry like craniofacial surgery. Like Steve said that you know it's really important that you probably do fellowship training. But when you look at microsurgery now and super microsurgery so many of the programs, when we were training microsurgery it wasn't certainly in its infancy but it certainly wasn't as prolific as it is now.
Speaker 1:And.
Speaker 3:I think, resident, like when I was in training, going back to my general surgical training, I wouldn't even think about doing a laparoscopic fellowship because we did so much laparoscopic surgery and I think you graduated general surgery as a very competent laparoscopic surgeon, whereas now I think most of our residents are leaving their programs very trained in microsurgery and probably very efficient and qualified to perform microsurgery, regardless of whether or not they did a fellowship. So again, I think there's super microsurgery and there's other levels of microsurgery that you know maybe require fellowship training, but it is really up to the program to look at the competency of their resident and the needs are going to be, you know, greater met by the program and certain there are going to be some voids and they have to make up those voids to comply.
Speaker 2:The other thing I would add to that and, greg, I think you're spot on with those comments, you know. The other thing that I would add to that is, again, things continue to evolve and change and that's the one thing that's consistent is that there will always be change. Residency programs now are especially looking at what that last year residency looks like and if some of those core competencies are met. There are several programs in the United States that are experimenting with kind of an in-residency fellowship where they're allowing motivated, competent residents their last year to kind of travel and get different experiences. We have hired someone at our practice who showed up having done, you know, almost 100 rhinoplasties and my jaw kind of fell on the floor when I realized his core competency. I mean, he was essentially showing me rhinoplasty techniques and I've been doing this for 20 years and so you know there is that flexibility. But again it's beginning to fall more and more on the residents to identify and take advantage of some of those opportunities.
Speaker 1:That's all very interesting points. Talking about fellowship is something that our international residents on this forum are particularly interested in. We are thinking about for the listeners, especially for international residents that are interested in international fellowship and exchanges. What advice would you give to these residents seeking fellowship in the US?
Speaker 2:Yeah, it's. You know I am approached consistently by residents around the world who want opportunities in the United States and you know the wonderful thing is plastic surgery is a very small community and I think we all want to help. So a lot of it is relationship-based and trying to find those connections to identify opportunities as they come up. I will say to the contrary to that there is also increasing pressure from all sides to find these opportunities. Medical students, particularly in the United States, now see doing research as a requirement to get into residency programs and some of them are taking even a year off and are very heavily pressure many academic programs to find space to fit into labs or to do clinical research and so all of that potentially takes away some space and some opportunity, potentially for international candidates. But it really comes down largely to relationships and going to the meetings you know being involved in ASPS, making sure that there are those connections so when those opportunities arise you can take advantage of them.
Speaker 3:Yeah, steve, I think yeah, when you look at making yourself competitive for fellowship and fellowship training. If you look statistically at the numbers in the United States, about 3.5% of our trainees are actually international medical graduates. So again, I can't break that down, unfortunately, specifically into fellowship program per se versus actual residency. We know those are the residency numbers and if you look at the residency numbers we have a little under 1,000 residency spots, which keeps changing in the integrated programs and we have about 250 of the traditional spots still.
Speaker 3:So I think, as Steve mentioned, being competitive from a research standpoint, because when you're looking now, it's interesting, when you look at the average plastic surgery applicant, they have on average six to eight publications. You know it's incredible how many research experiences and that's what they call it is experiences. So it can be a poster presentation, it can be more of these other research kind of touch points. So I think to be competitive you certainly have to have the academic background. The other thing that is a bit of a problem lately is visa status. Problem lately is visa status and you know, I think we're all aware of the international situation and that's certainly between funding and some of the visa issues in the United States.
Speaker 3:It's been a very complex road to navigate, for our program directors, our fellowship directors, and we don't have any great answers right now because every day it's a moving target. So it's been very frustrating for many of our current research fellows, our current clinical fellows, so I don't know what else to say about that. This is the wrong podcast.
Speaker 2:Well, I agree with Craig in terms of sentiment, 100% on that last point, but I'll try to strike a more hopeful note. I do think that you know, sometimes these tumultuous things are driven by politics are generally temporary. Plastic surgery is a small, small specialty. We have amazing colleagues everywhere in the world. There's an amazing, there's amazing talent. Everywhere in the world, the demand for talented plastic surgeons is only rising, and so, you know, my advice to residents that are somewhat frustrated or intimidated by the political scenario is just keep trying. Most of the time, these political things are temporary and balance out over time.
Speaker 1:So, building on that point, dr Greco, dr Williams, what resources would you recommend for international residents, from the practical point of view, seeking international fellowship? Is there any platform that you would recommend for them to use or who to approach?
Speaker 3:to use or who to approach. I think, without sounding proprietary or like someone, I think the American Society of Plastic Surgeons becoming an international member is by far one of the most important things you can do Almost all of our societies have free, if not nominal fee, international memberships available to you to help you with resources.
Speaker 3:If you look at ACAPS, if you look at ASPS, all of these and even the Aesthetic Society, all of these have really great resources available for everybody. To kind of walk you through the steps, I think that we have so many international partners now and so many meetings that you know you have the opportunity to come and be at and meet so many of the people that you may want to work with. I think, although it's difficult getting on a plane, coming to our meetings and to kind of be available and to start meeting some people, this is the perfect opportunity. I think the residence forum, I think the international residence forum, these are all opportunities. I think Steve can agree. We've met so many students and medical students and residents and fellows over the course of the last who knows how many years that have kind of kept in touch and you know we've helped them and just kind of do whatever we can to help them with their journey as accomplishing whatever they want to accomplish.
Speaker 2:So we can at least make the introductions and go from there.
Speaker 2:Yeah, I agree. I think that. And again, not to again, you're talking to two former presidents of ASPS, so we may be biased, but I think that if you look at ASPS's track record and how hard they've worked to develop MOUs and expand internationally, provide education and training resources, to provide real resources at the meeting, you know all that effort and energy is because we want to be a network and we want to support international residents. For, however, their journey is whether it means getting some training in the United States, whether it means getting some training in the United States, whether it means continuing to train in their native countries you know ASPS is there to support it and I think that it's an incredible investment in your future and it's a wonderful way to network and make the connections that can open up the doors that you need to be open to move forward in the future.
Speaker 1:Looking towards the future, how do you see international training collaboration evolving, either through ASPS or through other international bodies?
Speaker 3:Well, I think ultimately we now understand that we are a small community of plastic surgeons and I'm talking about globally and I think that as we continue to grow these relationships on the international basis, we understand that we're all facing the same challenges. As plastic surgeons, we face the encroachment on our profession by so many other specialties and I think what it's done it's kind of galvanized us whether you're a medical student or a plastic surgery resident or a fellow or attending surgeon, in whatever country you're in, we all are facing the same challenges.
Speaker 3:So I think that this has made us really I think, especially over the last probably 10 years understand the need for global collaboration, and I think that everybody who is up and coming it's such a great time for you because you know, the world has become a very small place because we have things like this now, if you're listening to this podcast or if you're watching a Zoom or all this other training that's available through all these electronic platforms other training that's available through all these electronic platforms you have the opportunity to meet so many people without ever leaving your room. So this is something again we understand that we are stronger and, as a big giant voice of plastic surgery, by kind of collaborating with our international plastic surgeons, fellows, residencies, and we now have exchanges through residency exchanges. We have microsurgical exchanges, whether it's through our SHARE program or through our GAPS program. We recognize this and we're acting on it and we're trying to really enhance the experience for everybody globally.
Speaker 2:Couldn't agree more.
Speaker 1:And just for the final advice, what advice would you give to international residents listening to this podcast in terms of how you think the plastic surgery training is heading in the next 10 years?
Speaker 2:Yeah, I think plastic surgery continues to be absolutely the most amazing specialty in all of medicine and so you know it's the same advice I give to international residents, I give to our domestic residents, is you're going to have setbacks, are going to be challenges. This is an incredibly competitive specialty but it's all going to be worth it and there are multiple pathways to success. And lean into them, lean into your networks, you know, form those important connections to move forward and find strength in that.
Speaker 3:Yeah, I don't have much more to add.
Speaker 3:I think that over the next 10 years we certainly, once again, are going to continue to collaborate and we as a community recognize the importance of the collaboration, the worldwide collaboration, and although it may not necessarily be as relevant to some of the listeners on this podcast, but the scope of practice, encroachment by other specialties. And I think when Steve can probably echo this, is that when we sit around and if you're at, I'll say if anybody's in New Orleans, come to our global meeting and you'll see and you'll listen to leaders from all over the world talk about the fact that you know what have they done to battle the internists who are trying to perform cosmetic surgery on the unlicensed providers. You know we're all committed to patient safety and we're all committed to the delivery of personalized, safe plastic surgical care. So I think that we're going to see this kind of worldwide movement grow. And how do we do that? We do that by getting you know really well-trained plastic surgeons throughout the world to kind of spread the message that we are different than other providers.
Speaker 1:Thank you so much for both your discussion. So, as we conclude today's discussion, I would like to thank both Dr Greco and Dr Williams for sharing your extensive experience and insights with our international residents community, and thank you for taking your time.
Speaker 3:Thanks, for having us yeah.
Speaker 1:And to our listeners. Thank you for tuning in to this episode of the International Residents Forum podcast. We hope today's discussion has provided valuable insights into the diverse world of plastic surgery training. If you're an international resident with questions about training opportunities or considering international fellowship, please don't hesitate to reach out to the ASPS International Residence Forum. We are here to support your educational journey. Stay tuned for our next episode, which I think will be highly relevant to all the residents. We'll be talking about board exams in plastic surgery and have a discussion on clinical preparation strategies. Until next time, keep learning, keep questioning and keep striving for excellence in everything you do. Thank you.
Speaker 2:Thank you.