Training

Training in microvascular anastomosis is commonly included at the very beginning of the training of hand surgeons, mostly during orthopedic surgery residency in China, because orthopedic surgeons commonly perform soft tissue reconstructions and any on-call resident is likely to need to connect vessels during his or her third or fourth year of residency. Rat tails are usually used for practice, because the vessels are long and can be repaired at each segment under an operating microscope. Clinically digital replantation is usually performed by rather young surgeons, from fourth-year residents to junior attendings. However, there is no requirement that an attending be present for replantation; if the attending surgeon considers a senior resident sufficiently proficient, the attending may not scrub. If trauma is extensive or more than one digit are severed, replantation is usually performed by a team of two or three attending surgeons with assistants. Replantation is also done very frequently in non–teaching hospitals: one attending surgeon usually works with two assistants (hand or non–hand surgeons). Thus, training of microsurgical anastomosis is routine during very early hand surgery training. Consequently, one may also find some young surgeons who are very proficient at vascular anastomosis, yet still just beginning to learn classic hand surgery. In the United States, orthopedic or plastic surgery residents are often more exposed to classical hand surgery, but practice and training in microvascular anastomosis are usually delayed compared with those in the Chinese system; such training is also less mandatory in the United States than it is in China. When I compare residents at year four or five, I feel that those in the United States have much greater knowledge of disease classification and the mechanics of deformities in the hand, but some have had few opportunities to use microscopes and are virtually unable to dissect under a microscope. In contrast, after 4 or 5 years, it is common for a Chinese surgeon in a hand surgery center to perform a skillful replantation and to be very comfortable with microscopic dissection. These differences reflect variations in the requirements set by the department or training program in either country.

Proficiency of microsurgical skills at expert levels likely is very similar in the two countries and in top microsurgical institutes training of residents and fellows under master surgeons likely is equally excellent in either country, but trainings in microsurgical skills differ greatly in general in the two countries. I believe that both countries would benefit from being aware of these differences in emphasis. In observing a young surgeon who skillfully performs a free flap transfer or a complex multiple digital replantation in China, one should not assume he or she is equally skillful in tendon transfer or secondary reconstruction of an extensor tendon defect. When a senior resident or junior hand surgeon in the United States impresses you with a wonderful presentation and systematic explanation of a topic of classic hand surgery, you should not assume he or she would impress you similarly with dissection under a microscope.

Training background and culture are different; young residents and surgeons are more outspoken in the United States, while asian culture dictates residents and young surgeons speak less and be more silent in clinical or training settings. Some skilled surgeons in China often refrain from extensive speaking. Such cultural influences are seen not only in China but also in Japan and Korea. Understanding the differences enhances communication and exchanges across continents.