Demographic status and training needs of aesthetic plastic surgeons in government and private hospitals: evidence from Guangdong, China [version 1; peer review: awaiting peer review]

Purpose: This study aims to survey the demographic status of aesthetic plastic surgeons in an economically developed region and to investigate their continuing training needs in contents, training methods, and barriers in private and government hospitals. Methods: A cross-sectional survey with a self-administered questionnaire was conducted from January to December, 2022 in Guangdong, China. In-depth interviews were conducted with key informants to gain insights on the current demographic status. Demographic data and training needs assessment were collected and compared with the chi-square test, Fisher’s test, Mann-Whitney U-test using R software. Results: The disparity


Introduction
Rapid economic development and "selfie culture" have driven the Chinese plastic surgery market to grow extremely fast in recent years. 1,2 It is expected that the total amount of spending on plastic procedures has increased up to approximately 122 billion US dollars by 2019, which ranks third in the world following United States and Brazil. 3 As a result, the past decade has witnessed drastic development of private aesthetic plastic hospitals, owing to high demand for all kinds of cosmetic plastic surgeries. 4 Meanwhile, surgical doctors area transferring their original practicing specialty into aesthetic plastic surgery after obtaining a training certificate from a tertiary government hospital recognized by the provincial health commission. The government hospitals serve as a training base for medical students who pursue a master degree or PhD degree in plastic surgery and also play pivot roles in continuing training for these doctors who've switched from other surgical specialties. 5 Private hospitals tend to develop even faster than government hospitals due to more flexibility in management and favorable government policies. The total number of aesthetic plastic procedures in private hospitals has exceeded that of government hospitals. 6 Our first hypothesis is that the difference of demographic status between aesthetic plastic surgeons in government hospitals and private hospitals would have different continuing medical training needs.
It has been documented that continuing medical training programs are significant to improve their serving quality for health professionals. 7,8 There have been various training programs available for the aesthetic plastic surgeons in recent years, which include conference sessions, further clinical education, operation demonstrations, and online training courses. But almost all those programs are organized and dictated by hospitals or organizations, the needs of learners have rarely been assessed. 9 As Goldstein training mode suggests that training candidates, training contents, organizational requirements be the three important factors while in designing a good health training program. 10 Our second hypothesis is the difference between private and government hospital in medical service would lead to different training needs.
Objectives: To date, there is a paucity of data investigating the current demographic status of aesthetic plastic surgeons both in government hospitals and private hospitals in China, and their respective needs in continuing training. To test the above two hypotheses, this study aims to survey the demographic status of aesthetic plastic surgeons from both governmental and private hospitals, and investigate their continuing medical training needs in contents, methods, and barriers within.

Ethics
Ethical approval for this study was obtained from the Ethics Committee of the Guilin Medical University Hospital (approval number: 21-216). Since this research is carried out in the field of continuing medicaleducation (CME) program or in a workshop, informed verbal consent was obtained from all participants.
Study design A mixed study combining a self-administered questionnaire survey with CME participants and in-depth interview with key informants was used.

Study site
The study site was conducted from January to December, 2022 in Guangdong, China. As a coastal province in South China, Guangdong's GDP in 2021 surpassed 1.5 trillion US dollars, which ranked first in China. 11 In this developed economic region, it is estimated that there are more than ten government hospitals with aesthetic plastic departments and two hundred private plastic hospitals with almost eight hundred aesthetic plastic surgeons in total.

Study population
Various CME key informants were identified in consultation with specialists at the department of plastic and aesthetic surgery in Nanfang hospital, Southern Medical University, which is the organizer for many CME programs. This list was expanded after the initial interviews, as the earlier interviewees suggested more informants. Recruitment stopped after the data were considered to be saturated by the researchers. The final informants were the directors of the plastic departments, the heads of medical associations, CME providers (affiliated hospitals of universities), CME users (plastic surgeons). The survey population of CME users included doctors, graduate students when they were attending a continuing medical education program or in a workshop. However, participants who had been employed for less than six months or would retire within a year were excluded.

Data collection method and instruments
Based on literature reviews and experts' consultation, we adapted a questionnaire which was reviewed by a statistician, two epidemiologists, four dermatologists, and two plastic and aesthetic surgeons to ensure its validity. The questionnaire included their demographic information on plastic surgeons, their frequency in attend CME, their preferred contents, type of CME, an barriers and facilitators in attending CME. A small pilot study was conducted to verify suitability of the questions before survey.
In-depth interviews were conducted with multiple key informants, including the directors of the plastic departments, the heads of medical associations, CME providers (affiliated hospitals of universities), CME users (plastic surgeons). The interview topics included comments on the current status of aesthetic plastic surgeons, current continuing training programs, potential problems, and solutions for the improvement. All interviews were taped and transcribed verbatim for thematic analysis.

Statistical methods
All data analyses were performed using R version 3.5.2 and EpiDisplay package. Categorical data were given as counts and percentages, to compare the difference in demographic information and training needs assessment, the chi-square test, Fisher's test, were used as appropriate for categorical variables. Mann-Whitney U-test was use to compare the knowledge gap for major aesthetic surgical procedures between surgeons in private and government hospitals. Statistical significance was set at 5%.

Results
Demographic information and needs assessment on aesthetic plastic surgeons Demographic data of aesthetic plastic surgeon 290 out of 356 attendees completed the questionnaire survey, the responding rate was 81.5%. 240 surgeons were practicing aesthetic plastic surgery after excluding those cosmetic dermatologists, and cosmetic doctors in traditional Chinese medicine.
Shown in Table 1, the distribution of gender, age groups, and years of practice, professional technical titles, and original working department among the 144 surgeons from government hospitals and 96 from private hospital was nearly the same. In general, over sixty percent of the surgeons were under 40 years of age, one third of the surgeons had less than three years of working experience with junior professional technical titles. Almost two thirds of surgeons' original working departments were not aesthetic plastic surgery. The distribution of educational degree between these hospitals was statistically different. There were more doctors with a graduate degree in government hospitals.  Table 2 summarized the current training status and study objectives for surgeons. Overall, there were some similarities between surgeons of government and private hospitals, half of the surgeons attended training less than three times with an affordable expense of 1000-5000RMB, surgeons in private hospitals were more likely to spend more than 10,000 RMB in training. The majority of them had strong willingness to attend training to improve their practical skills, gain clinical experience, and learn latest technologies.   Table 3 concluded the surgeons' favorable training methods and reported obstacles. Further study in a tertiary hospital, short training course focusing in specific topic by corresponding experts, and operation demonstration were regarded as the top three favorable choices. The number one obstacle was "nobody replaces me at work", however, training expenses was the second obstacle for doctors in governmental hospitals and the third one for doctors in private hospital, in converse, "I cannot learn the skills I want" was second obstacle and third one for doctors in private and government hospital respectively. Table 4 summarized their interest in major surgical procedures and self-assessed knowledge gap. For surgeons in private hospitals, 69.2% of them intended to learn rhinoplasty, and eye plastic surgery. Fat transplant was their third interesting procedures, which coincided with their self-assessed knowledge gap. For surgeons working in government hospitals, their top three interesting surgical procedures were eye plastic surgery, rhinoplasty, and minimally invasive plastic surgery, in terms of knowledge gap, they believed that they had more knowledge gap in external genitalia, perineal surgery, rather than eye plastic surgery.  Qualitative analysis on the current continuing training system for aesthetic plastic surgeons Continuing medical education programs are under the management and organization of medical associations at municipal or provincial levels. Doctors in government hospitals are required to abstain a minimum credit by attending different continuing education programs. However, the doctors in private hospitals are not compulsory required to get the credits.
In-depth interviews revealed that most continuing training conferences were co-organized by government and private hospitals. As non-profit medical organizations, the department of aesthetic plastic surgery in most government hospitals, were merged with burn surgery, therefore, they focused more on their social responsibility in repair and reconstructive surgery. Meanwhile, as a base to train medical students, government hospitals paid more attention on academic development and research on basic and clinical technologies. By contrast, private aesthetic plastic hospitals were forprofit originations and laid more emphasis on improving customers' experience. Since aesthetic plastic procedure were not covered by insurance schemes, customers were more likely to visit private hospitals for operations owing to more comfortable environment and individualized services. These organizational differences between government hospitals and private hospitals determined the different requirements of aesthetic plastic surgeons in their respective institutions, reflecting their needs difference in continuing medical training.

Discussion
This study suggested that after decades of rapid development of Chinese plastic surgery, the demographic data in private hospitals were quite similar to that of the government hospitals in such an economic developed province. In general, the plastic surgeons were young, with comparatively limited experience. In addition, almost two-thirds of them transferred from other specialties. The only difference was almost half of the doctors in government hospitals had a graduate degree, whereas, a quarter of them had a graduate degree in private hospitals. From the demographic data we concluded that it would be imperative to reinforce continuing training for aesthetic plastic surgery, meanwhile, considering the difference in demographic status.
In this study, the fact that half of the surgeons attended continuing training no more than three times in a year with limited affordable expense had great significance on planners in designing programs. Although most surgeons preferred to further their studies in a tertiary hospital, the chances were very limited. 12,13 This study suggested that a short course focused on specific topic with operation procedures demonstrations by experts would be a favorable training method, a similar finding to other research in surgical education. 14 Meanwhile, more attention should be laid on skills improvement in designing training curriculum, and with more consideration of reasonable price and flexible time for attendees.
This study also revealed a fact that rhinoplasty and new technologies such as fat transplant, minimally invasive plastic surgery were greatly concerning procedures for surgeons either in government hospitals or in private hospitals. To a certain extent, these training needs reflect the needs of the aesthetic market. Since the study site is located in southern China, and there is a big percentage of population with low nasal deformity, the focus on rhinoplasty has also increased accordingly. Minimally invasive cosmetic surgery has grown significantly in the world in recent years, and fat grafting technology is a hot spot in the current market in facial rejuvenation and breast augmentation. The results of selfassessed knowledge gap showed surgeons in government hospitals intend to acquire more continuing medical training in genitoperineal surgery, a newly popular surgical procedure in recent years while the surgeons in private hospitals believed more improvement should be made on plastic surgery for eyes, since blepharoplasty is the most popular procedure in China. The difference in training objectives was due to the different customer groups and social roles for government and private hospitals. Specifically, the government hospitals also took social responsibility for repairtive and reconstructive surgery, while, the private hospitals were more market-oriented, mainly focusing on aesthetic plastic surgery.
This study tested the hypothesis that the demographic difference for aesthetic plastic surgeons between government and private hospitals were getting narrower. However, the organizational difference had influence on their respective training needs, which coincided with the Goldstein training mode. 12,13 Conclusion The demographic disparity of aesthetic plastic surgeons between government hospitals and private hospitals was small. Continuing medical training is very important to improve the training and education of the large number of young aesthetic plastic surgeons in China. To design the training curriculum focused on practical skills, especially a short training course elicited by experts in rhinoplasty, eye surgery, and new technologies such as fat transplant, minimal invasive plastic surgery would be favorable. Meanwhile, the demographic status of aesthetic plastic surgeons and organizational needs should be taken into consideration. This project contains the following extended data:

Data availability
• questionaire and interview frame in Chinese.pdf Data are available under the terms of the Creative Commons Zero "No rights reserved" data waiver (CC0 1.0 Public domain dedication).