SPECIAL TOPIC

Continuing Medical Education in Emergency

Plastic Surgery for Referring Physicians: A
Prospective Assessment of Educational Needs
Alexander Anzarut, M.D.,
M.Sc.
Prabhjyot Singh, B.Sc.
Geoff Cook, M.D.
Trustin Domes, M.D.
Jarret Olson, M.D.
Edmonton, Alberta, Canada

Background: Continuing medical education for referring physicians is an essential part of raising the profile of plastic surgery and improving patient care.
The authors conducted a prospective cohort study to assess the educational
needs of emergency and primary care physicians who refer patients to the on-call
plastic surgeon.
Methods: The following information was collected for telephone referrals from
emergency and primary care physicians over a 1-year period: date, location of
referral center, population of referral center, distance between referral center
and tertiary care hospital, patient age, presenting problem, anatomical location
of the problem, and treatment plan proposed by the plastic surgeon. In addition,
the 50 physicians who most frequently referred patients were surveyed to identify
which topics they perceived to be of the highest educational utility and which
were frequently encountered.
Results: There were a total of 1077 referrals to on-call plastic surgeons,
mostly for trauma (83 percent) and injuries involved primarily the upper
extremity (65 percent) or head and neck regions (26 percent). Five percent
or more of all referrals involved mandible, phalangeal, metacarpal, or zygomatico-orbital complex fractures, minor burns, flexor tendon injuries,
single digits requiring revision of an amputation, and extensor tendon
injuries. Referring physicians reported that the topics of most educational
utility were management of hand infections, minor burns, nasal fractures,
boxers fractures, complex facial lacerations, frostbite, metacarpal fractures,
and scaphoid fractures.
Conclusions: To have the greatest potential affect on changing physicians
behavior and improving patient care, continuing medical education should
focus on traumatic injuries to the upper extremity and head and neck
regions. A prioritized list of topics should include management of minor
burns, hand fractures, hand infections, nasal infections, and complex facial
lacerations. (Plast. Reconstr. Surg. 119: 1933, 2007.)

o improve patient care and raise the profile of plastic surgery, plastic surgeons
must be involved in continuing medical
education for referring physicians. Our institution is developing a series of initiatives in
plastic surgery education directed toward
emergency plastic surgery problems. The tarFrom the Division of Plastic and Reconstructive Surgery,
Department of Public Health Sciences, EPICORE Center,
and Faculty of Medicine and Dentistry, University of Alberta.
Received for publication May 21, 2005; accepted August 11,
2005.
Copyright 2007 by the American Society of Plastic Surgeons
DOI: 10.1097/01.prs.0000259209.56609.83

get audience is emergency and primary care

physicians from the community.
Continuing medical education is defined as
activities designed to help doctors enhance the
knowledge, skills, attitudes, and judgment necessary to improve the health care of their patients and communities.1 Unfortunately, continuing medical education often consists of . . .
faculty members who could be persuaded to do
so giving lectures on subjects of their own choosing to audiences they do not know, who had
assembled only because they wanted to put in
enough hours of classroom attendance so that
they could meet a relicensure requirement.2
However, over the past decade, an entire field of

www.PRSJournal.com

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Plastic and Reconstructive Surgery May 2007

research dedicated to physician education has
developed. We now have scientifically tested
strategies to change physician behavior and improve patient outcomes through education.3
To date, there has been a paucity of educational research in plastic surgery. Past research has
focused on the training of plastic surgery residents
and awareness of breast reconstruction.4,5 There
are no plastic surgery publications focusing on
continuing medical education for emergency and
primary care physicians.
The assessment of educational needs has been
identified as the crucial first step to effective
continuing medical education.3 This is true
when addressing primary care or specialty
physicians.6 Regardless of whether education involves didactic lectures, practice workshops, or

outreach visits, recognition of educational needs

will increase the likelihood of improving clinical
practice.7 Furthermore, identifying which physicians have the highest educational need will help
to allocate limited resources.
Assessment of educational needs can be determined by reviewing which services are being used
(utilization assessment).1 Alternatively, one can
survey physicians to identify their perceived educational needs.1 A previous article in this Journal described the types of operating room procedures
performed by plastic surgeons at a Level I trauma
center.8 However, little is known about the types of
services provided to emergency and primary care
physicians by on-call plastic surgeons.
This study aimed to identify and prioritize the
emergency plastic surgery educational needs of

Fig. 1. Cause of problems referred to the on-call plastic surgeon.

Fig. 2. Anatomical location of problems referred to the on-call plastic surgeon.

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Volume 119, Number 6 Emergency Plastic Surgery

emergency and primary care physicians. We conducted a prospective cohort study to assess the
resource utilization of referring physicians. In
addition, we surveyed referring physicians to
assess their perceived educational needs and
compared these results to the types of problems referred.
Our specific objectives were to (1) describe
the frequency of plastic surgery referrals from
physicians outside the tertiary care hospital, (2)
identify the referring centers and travel distances involved, (3) identify any temporal trends
in the pattern of referrals, (4) describe the characteristics of patients being referred, (5) categorize and describe the reasons for referrals, (6)
describe the anatomical location of the presenting problems, and (7) describe and categorize
the type of treatment provided. Finally, we
wanted to characterize how referring physicians
perceived their educational needs.

PATIENTS AND METHODS

Utilization Assessment
This study took place at a large tertiary care
hospital where the on-call plastic surgery resident
received telephone referrals. All telephone referrals from community primary care and emergency
room physicians were included in the study. Referrals from physicians within the tertiary hospital
were excluded. Data collection was over a 1-year
period, from August of 2003 through September
of 2004. Information collected included the date,
location of the referral center, patient age, presenting problem, anatomical location of the problem, and the treatment plan proposed by the plastic surgeon. The treatment plans were divided into
three categories: (1) transport immediately to the
tertiary care hospital, (2) referral to the next
available plastic surgery clinic, or (3) telephone
advice only. The population of each referral
center was obtained from Statistics Canada.9
The distance between the referring center and
the city of the tertiary care hospital was obtained
using Mapquest.10 Finally, the 50 physicians who
most frequently consulted the on-call plastic surgeon were identified.
Perceived Assessment of Educational Needs
On the basis of the types of referrals and the
opinions of two plastic surgeons involved with continuing medical education, a list 40 of potential
educational topics was compiled. The 50 community physicians who most frequently referred patients were sent this list by fax. Using 0 to 10

Table 1. Categorization and Detailed Description of

the Types of Referrals to the On-Call Plastic Surgeon
Description of the Problem
Upper extremity (n 700)
Phalangeal fracture(s)*
Metacarpal fracture(s)*
Flexor tendon injury*
Single-digit amputation or
revision amputation*
Extensor tendon injury*
Crush injury
Boxers fracture
Hand infection
Digital dislocation
Hand fracture (not defined)
Digital nerve injury
Fracture at base of first
metacarpal
Major nerve injury proximal
to wrist
Mallet finger
Human bite
Nail in hand
Multiple digit revision
amputations
Scaphoid injury
Hamate injury
Thumb revision amputation
Mangled digit or hand
Possible digital or hand
replantation
Gamekeepers thumb
Mangled digit or hand
Human bite
Facial trauma (n 280)
Mandible fracture*
ZMO*
Nasal fracture
Complex facial laceration
Facial fracture not
determined
Frontal sinus fracture
NOE
Other (n 97)
Minor burn*
Other
Laceration (not a complex
facial laceration)
Acute infection (not hand)
Frostbite
Chronic infection
Dog or cat bite
Removal of foreign body
Difficult open wound (acute)
Foot injury
Major burn
Minor abrasion
Chronic lymphedema

Frequency
(%)

% of Total
Referrals

108 (15)
89 (13)
71 (10)

8
7
6

70 (10)
63 (9)
46 (7)
33 (5)
32 (5)
29 (4)
29 (4)
29 (4)

5
5
4
3
3
2
2
2

21 (3)

13 (2)
8 (1)
8 (1)
7 (1)

1
1
1
1

7 (1)
6 (1)
6 (1)
5 (1)
5 (1)

1
1
1
1
1

5 (1)
4 (1)
4 (1)
2 (1)

1
1
1
1

125 (45)
80 (29)
31 (11)
31 (11)
10 (3)
2 (1)
1 (1)

10
6
2
2
1
1
1

23 (24)
19 (19)

6
5

16 (16)
11 (11)
7 (7)
7 (7)
4 (5)
3 (3)
2 (2)
2 (2)
1 (1)
1 (1)
1 (1)

4
3
2
2
1
1
1
1
1
1
1

ZMO, zygomatico-orbital complex fracture; NOE, naso-orbital ethmoidal.

*Problems accounting for more than 5 percent of all referrals.

numerical rating scales, they were asked to rate the

perceived educational utility of each topic, where
0 represented a topic with no educational utility
and 10 was a topic of extreme educational impor-

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Plastic and Reconstructive Surgery May 2007

60

Number of referrals

50

40

30

20

10

0
0.00

10000.00

20000.00

30000.00

40000.00

50000.00

60000.00

Population of the referring center

Fig. 3. Scatterplot of the number of calls versus the population of the referring centers.

tance. In addition, they were asked to rate the

frequency with which they encountered each
topic. Zero represented a topic that was never
encountered and 10 represented a topic that was
encountered extremely often. An impact factor,
ranging from 0 to 100, for each topic was calculated by multiplying the educational utility and
frequency.
Statistical Analysis
Data analysis was compiled using SPSS version
12.0 (SPSS, Inc., Chicago, Ill.). Categorical data
were described using frequencies and percentages. Continuous variables were described using
mean and SD or median and interquartile range,
as appropriate. Analysis of variance was used to
compare the number of calls between the days of
the week and the months of the year. Pearson
product-moment correlation coefficients were
used to explore the relationship between both the
number of referrals and the population of the
referral center and the distance to the referral
centers. Three referring centers had their own
plastic surgery services and were excluded from
the analysis when looking at population of and
travel distance from the referring centers. The
study was approved by the university institutional
ethics review board.

RESULTS
Over a 1-year period, we recorded 284 (78
percent) call days. There were 1077 individual

1936

calls from primary care and emergency physicians. The mean SD number of calls per day
was 3.8 2.0 (range, 0 to 10). There were no
significant differences in the number of calls by
day of the week (p 0.565) or month of the year
(p 0.121).
The mean SD patient age was 32 18
years, and 80 percent of patients were male patients. The cause and anatomical location of the
problems referred are displayed in Figures 1 and
2. Most (83 percent) were referred for trauma
management of an injury located in the upper
extremity (65 percent) or the head and neck (26
percent) regions. A detailed description of the
types of problems referred and their relative
frequencies is displayed in Table 1. Problems
accounting for greater than or equal to 5 percent of
referrals included mandible fractures, phalangeal
fractures, metacarpal fractures, zygomatico-orbital
complex fractures, minor burns, flexor tendon injuries, single digits requiring revision of an amputation, and extensor tendon injuries.
Referrals were from 84 separate centers, with
16 centers accounting for 60 percent of referrals.
The median population of the referring center
was 5376 (interquartile range, 2337 to 8810). A
scatterplot of the number of referrals versus the
population of the referring center is shown in
Figure 3. A large number of small centers, each
referring less than 30 patients, accounted for the
majority of referrals. As the size of the centers

Volume 119, Number 6 Emergency Plastic Surgery

60

Number of referrals

50

40

30

20

10

0
0.00

500.00

1000.00

1500.00

2000.00

Distance from the referring centers to the city of the tertiary

care hospital (km)

Fig. 4. Scatterplot of the number of calls versus the distance from the referral centers.

increased, there was no definitive effect on the

number of referrals. The correlation between the
number of referrals and the populations of
the referring centers was not statistically significant (r 0.217; p 0.098). The median distance
from the referring centers to the city of the tertiary
care hospital was 197 km (interquartile range, 96 to
422). Similarly, a scatterplot of the number of referrals versus the distance between the referring centers and the tertiary care center is shown in Figure
4. A large number of centers within 500 km of
the tertiary care center, each referring less than
30 patients, accounted for the majority of referrals. As the distance from the tertiary care center
increased, there was no definitive effect on the
number of referrals. The correlation between
the number of referrals and the distance between the referring centers and the tertiary care
center was not statistically significant (r
0.171; p 0.135) (Fig. 4). A breakdown of the
treatment plans provided by the plastic surgery
service is displayed in Figure 5. More than half
the referrals (54 percent) resulted in immediate
patient transfer to the tertiary care hospital.
Table 2 lists the self-perceived educational
needs of emergency and primary care physicians.
Of the 50 surveys sent out, 41 were returned completed (82 percent response rate). Referring physicians reported information on the management
of hand infections, minor burns, nasal fractures,
boxers fractures, complex facial lacerations, frostbite, metacarpal fractures, and scaphoid fractures as

the eight topics of greatest perceived educational

utility. They ranked simple lacerations, minor abrasions, boxers fractures, metacarpal fractures, phalangeal fractures, minor burns, and acute infections
as the eight problems they felt were encountered
most frequently. The eight conditions with the highest impact factor were boxers fractures, simple lacerations, minor burns, hand infections, metacarpal
fractures, phalangeal fractures, nasal fractures, and
acute infections.

DISCUSSION
Our study defines the educational needs of
primary care and emergency physicians as they

Fig. 5. The treatment plan provided by the plastic surgery service.

Tertiary Care, immediate transfer to the tertiary care center. Plastic
Surgery Clinic, referral to the next available plastic surgery clinic.

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Plastic and Reconstructive Surgery May 2007

Table 2. Assessment of the Perceived Educational Needs of Referring Physicians [mean (SD)]
Description of the Problem
Hand
Boxers fracture
Hand infection
Metacarpal fracture(s)
Phalangeal fracture(s)
Scaphoid injury
Crush injury
Mallet finger
Single-digit amputation or revision amputation
Digital dislocation
Human bite
Management of a foreign body in the hand
Extensor tendon injury
Digital nerve injury
Fracture at base of first metacarpal
Flexor tendon injury
Mangled digit or hand
Thumb revision amputation
Gamekeepers thumb
Major nerve injury proximal to wrist
Hamate injury
High-pressure injection injury
Multiple digit revision amputations
Possible digital or hand replantation
Facial trauma
Nasal fracture
Complex facial laceration
Mandible fracture
ZMO
Frontal sinus fracture
NOE
Other
Laceration (not a complex facial laceration)
Minor burn
Acute infections
Minor abrasion
Chronic infection
Dog or cat bite
Foot injury
Frostbite
Major burn
Chronic lymphedema

Impact
(0 100)

Utility
(0 10)

Frequency
(0 10)

69 (30)*
63 (25)*
62 (22)*
61 (22)*
53 (27)
45 (32)
44 (28)
43 (28)
42 (23)
39 (30)
43 (25)
37 (24)
31 (24)
27 (23)
27 (23)
23 (24)
23 (21)
22 (17)
20 (18)
19 (15)
18 (18)
18 (17)
14 (16)

8.6 (1.8)*
8.8 (1.4)*
8.3 (1.8)*
8.2 (2.0)
8.3 (1.9)*
7.5 (2.4)
7.4 (2.8)
7.8 (2.5)
7.9 (2.5)
7.1 (2.9)
7.8 (2.1)
8.0 (2.6)
6.1 (3.1)
6.4 (2.6)
6.3 (3.2)
5.9 (3.0)
6.1 (2.8)
6.4 (3.0)
6.5 (2.8)
5.9 (2.6)
5.7 (3.1)
5.2 (2.8)
5.3 (3.0)

7.7 (2.6)*
7.1 (2.4)*
7.4 (2.0)*
7.4 (1.8)I
6.2 (2.5)
5.4 (3.1)
5.5 (2.4)
5.2 (2.7)
5.3 (2.4)
5.1 (2.9)
5.3 (2.5)
4.4 (2.2)
4.3 (2.4)
3.9 (2.3)
4.0 (2.2)
3.2 (2.5)
3.4 (2.2)
3.4 (2.1)
2.8 (2.0)
2.8 (2.0)
2.7 (1.9)
2.7 (1.9)
2.3 (1.8)

56 (25)*
55 (28)
34 (26)
25 (20)
20 (18)
18 (21)

8.6 (1.8)*
8.5 (1.9)*
7.4 (2.4)
6.8 (2.4)
6.5 (3.0)
5.6 (3.0)

6.4 (2.2)
6.2 (2.7)
4.6 (2.8)
3.5 (2.1)
2.8 (1.9)
2.7 (2.2)

64 (35)*
64 (24)*
55 (25)*
51 (31)
50 (27)
49 (26)
49 (28)
46 (24)
35 (24)
26 (22)

7.4 (3.2)
8.7 (1.3)*
7.1 (2.9)
6.2 (3.0)
8.1 (2.2)
7.9 (2.1)
7.1 (2.9)
8.3 (1.9)*
7.9 (2.1)
6.0 (2.5)

8.6 (2.5)*
7.1 (2.1)*
6.9 (2.9)*
7.9 (2.7)*
5.9 (2.4)
6.1 (2.3)
6.2 (2.9)
5.5 (2.3)
4.3 (2.5)
4.1 (2.2)

ZMO, zygomatico-orbital complex fracture; NOE, naso-orbital ethmoidal.

*The eight highest ranked problems for impact, utility, and frequency.
Impact factor utility frequency the condition is encountered.

relate to emergency plastic surgery. The vast majority of referrals were for traumatic injuries to the
upper extremity or head and neck regions. These
findings support a recent consensus statement by the
American College of Surgeons emphasizing the important role of plastic surgeons in the trauma
center.11 This is the first study to characterize the
services on-call plastic surgeons provide to referring physicians in the community.
Reviewing the results of both the utilization
and perceived needs assessments, we are able to
identify a prioritized list of educational topics for
continuing medical education in emergency plastic surgery. The management of minor burns,
metacarpal fractures, and phalangeal fractures

1938

were uniformly identified as high-priority educational needs. The management of mandible fractures, zygomatico-orbital complex fractures, flexor
tendons, extensor tendons, and digits requiring
revision amputation accounted for a large proportion of referrals but were not highly ranked by
physicians as areas of perceived educational need.
Referring physicians perceived information on
hand infections, nasal fractures, frostbite, scaphoid fractures, and complex facial lacerations to be
of highest educational utility; however, these problems did not account for a large proportion of
referrals. These differences between utilization
and self-perceived educational needs highlight
the importance of using more than one method to

Volume 119, Number 6 Emergency Plastic Surgery

determine and prioritize educational needs and
showed that identification of educational needs is
essential to establishing continuing medical education programs that can successfully change physician behavior and improve patient care. In addition, identifying which topics have the highest
educational needs allows educators to direct limited resource to the areas that would have the
largest potential impact.
We were unable to demonstrate a strong relationship between the number of referrals and
the referring centers population or the distance
between the referral center and the tertiary care
center. This may be because the population and
travel distance of the centers had a skewed distribution. Most centers had similar travel distances and
populations, making it difficult to show a relationship between these variables and the number of
referrals. Another reason could be that there is no
relationship between these variables and the number of referrals. It is possible that a factor we did not
identify, such as economic prosperity or industrialization of the center, would better predict the number of referrals. This finding illustrates the importance of studying referral patterns to identify where
the educational needs are, rather than basing them
on the travel distance or population alone.
More than half of all referrals resulted in patients being transferred to the tertiary care hospital for immediate evaluation. The median patient transport distance was 197 km. This high rate
of patient transfer and the large distances involved
heighten the demand for already stretched health
care resources. Efforts to decrease rates of transfer
through physician education might reduce health
care costs. We have identified the communities
that most routinely transfer patients and the most
common reasons for transfer. This information
will allow us to prioritize areas in which continuing
medical education will have the greatest impact on
health care costs.
The major limitation of this study was that a
small number of referrals were made directly to the
staff plastic surgeons and were not included. It is
possible that the patient and geographic characteristics of these referrals differed systematically. However, the educational needs identified by the 1077
referrals recorded in this study would not be
changed by the inclusion of a small number of direct
referrals to the staff plastic surgeons.

CONCLUSIONS
Our findings suggest that successful continuing medical education programs for community

physicians should focus on traumatic injuries to

the upper extremities and head and neck regions.
A prioritized list of continuing medical education
topics should include the management of minor
burns, hand fractures, hand infections, nasal infections, and complex facial lacerations. Future
studies are needed to develop the ideal methods
for plastic surgery continuing medical education
and to assess the impact of educational programs
on patient care and health care costs.
Alexander Anzaur, M.D., M.Sc.
Division of Plastic and Reconstructive Surgery
10820-63 Avenue, N.W.
Edmonton, Alberta T6H 1P8, Canada
aazarut@ualberta.ca

ACKNOWLEDGMENTS

The authors acknowledge the University of Alberta

Endowment Fund for providing salary support for P.
Singh. They also thank Dr. Michael Jacka, for his editorial comments.
DISCLOSURE

None of the authors has a financial interest in any of

the products, devices, or drugs mentioned in this article.
REFERENCES
1. Hoyal, F. M. Skills and topics in continuing medical education for rural doctors. J. Cont. Educ. Health Prof. 20: 13, 2000.
2. Houle, C. O. Continuing Learning in the Professions. San Francisco: Jossey-Bass, 1980.
3. Mazmanian, P. E., and Davis, D. A. Continuing medical education and the physician as a learner: Guide to the evidence.
J.A.M.A. 288: 1057, 2002.
4. Wanzel, K. R., Brown, M. H., Anastakis, D. J., and Regehr, G.
Reconstructive breast surgery: Referring physician knowledge and learning needs. Plast. Reconstr. Surg. 110: 1441,
2002.
5. Wanzel, K. R., and Fish, J. S. Residency training in plastic
surgery: A survey of educational goals. Plast. Reconstr. Surg.
112: 723, 2003.
6. Davis, D. A., Thomson, M. A., Oxman, A. D., and Haynes, R. B.
Changing physician performance: A systematic review of the
effect of continuing medical education strategies. J.A.M.A. 274:
700, 1995.
7. Davis, D. A., Thomson, M. A., Oxman, A. D., and Haynes, R. B.
Evidence for the effectiveness of CME: A review of 50 randomized controlled trials. J.A.M.A. 268: 1111, 1992.
8. Peterson, S. L., and Moore, E. E. The integral role of the
plastic surgeon at a level I trauma center. Plast. Reconstr. Surg.
112: 1371, 2003.
9. Statistics_Canada. Canadian Census Data. Available at:
http://www.statcan.ca. Accessed October 27, 2004.
10. Mapquest. Mapquest distances. Available at: http://www.
mapquest.com/. Accessed October 27, 2004.
11. American College of Surgeons Committee on Trauma. Resources for Optimal Care of the Injured Patient: 1999. Chicago:
American College of Surgeons, 1999.

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