Plastic surgeons as hand surgery specialists : determinant factors of public ’ s perceptions

Introdução: O objetivo deste estudo foi avaliar os possíveis determinantes para o público escolher os cirurgiões plásticos como especialistas em cirurgia de mão. Métodos: Membros do público (n = 701) escolheram um ou dois especialistas que eles acreditassem serem experts para 11 cenários relacionados à cirurgia de mão. Análises bivariadas e multivariadas foram aplicadas para avaliar os possíveis determinantes (dados sociodemográficos, fontes de informações e contato prévio com a cirurgia plástica) para o público escolher os cirurgiões plásticos como especialistas em cirurgia de mão. Resultados: Houve uma compreensão limitada (p < 0,05 para todas as comparações) sobre o papel dos cirurgiões plásticos em infecção da mão, tumor da mão, fratura da mão, lesão tendinosa da mão, síndrome do túnel do carpo, artrite reumatoide e contratura de Dupuytren. Apenas a idade foi um (p < 0,05 para todas as comparações) determinante significativo de cirurgião plástico como um padrão de resposta. Conclusão: A idade foi um fator determinante da escolha pública de cirurgiões plásticos como especialistas em arena de cirurgia da mão. ■ RESUMO

Participants who were younger than 18 years or did not choose at least one response for each question were excluded from the study.The study was carried out in accordance with the ethical standards of the 1964 Declaration of Helsinki and its subsequent amendments.

Statistical Analysis
For the descriptive analysis, we used means for metric variables, and percentages were given for categorical variables.Response profiles were defined as: "plastic surgeon alone" (respondents listing only plastic surgeon as expert), "plastic surgeon combined with other specialists" (respondents listing plastic surgeon and others as experts), or "no plastic surgeon" (no respondents listing plastic surgeon as expert) 3 .
All scenarios were also divided into two percentage response patterns: plastic surgeons most frequently chosen and plastic surgeons infrequently chosen (plastic surgeons selected by > 70% and < 30% of respondents, respectively).The frequency distribution was calculated for each specialist, and "plastic surgeons" response was identified as the primary variable of interest.We used as statistical comparisons the ANOVA, Tukey's multiple comparisons, equality of two proportions, paired student's t, X 2 , and confidence interval for the mean tests.The overall average of responses per plastic surgeons was used in the comparisons made among specialists.

INTRODUCTION
Plastic surgery is recognized as a broad-based medical specialty with emphasis on areas such as breast, craniofacial, burn, aesthetic, hand surgery, among others 1 .Therefore, it is paramount that all of the plastic surgery community gives attention to the alarming data about the lack of knowledge, misconceptions, and underestimation of medical and nonmedical subjects regarding the field of plastic surgery practice presented in a number of studies worldwide [2][3][4][5][6][7][8][9][10] .
Examining public's perception of plastic surgeons' practice is the basics to support health policy decisions, to designate research funding, and to design tailored patient information to update the public regarding the diversity and nature of plastic surgeons' expertise [5][6][7][8] .However, the public's perceptions of plastic surgeons, particularly in the hand surgery arena, have received little attention in previous surveys [5][6][7][8] .Furthermore, the possible determinant factors of public's perceptions have been poor evaluated in previous studies [5][6][7][8] .

OBJECTIVE
This cross-sectional study assessed the possible determinants that lead public to choose plastic surgeons as an experts in the hand surgery-related scenarios.We hypothesized that health care professionals and subjects who had previous exposure to plastic surgeons during clinical/surgical consultations would have a better understanding of the role of plastic surgeons as hand surgery specialists compared with their peers who did not have contact with this specialists.

METHODS
An anonymous survey with closed-ended questions was randomly applied to general public members at public places in southeastern Brazil from September to October 2014.All questions were multiple-choice, included 11 hand surgery-related scenarios, and were adapted from previous surveys [2][3][4][5][7][8][9][10] .
Respondents were asked to select one or two specialists (general surgeons, dermatologists, orthopedic surgeons, ophthalmologists, vascular surgeons, plastic surgeons, otolaryngologists, head and neck surgeons, or neurosurgeons) who they perceived to be an expert for each question.All questions and specialists were randomly organized.
All respondents were not informed about the plastic surgery source and the purpose of the survey, and none of them could access a question already answered.Further questions allowed participants to indicate socio-demographic data (gender, age, marital (73.9%).The mass media (81.6%) was the main (all p < 0.05)source of reported information.There were no significant (all p > 0.05) differences in comparisons of gender, marital status and religion."Plastic surgeon alone" was chosen by more than 70% of respondents and less than 30% of responded none (0%) in the 11 (100%) hand surgery-related scenarios (Table 1)."Plastic surgeon combined with other specialists" was significantly (all p < 0.05) more identified as an expert than other response patterns in two (18.18%)hand surgery-related scenarios (hand burn management and hand transplantation surgery), whereas "no plastic surgeon" was significantly (all p < 0.05) more recognized as an expert in nine (81.81%) hand surgery-related scenarios (Table 1).

DISCUSSION
Different specialists (e.g., general surgeons, orthopedic surgeons, and plastic surgeons) played a pivotal role in the creation, development, and establishment of hand surgery as a specialty worldwide 1,11 .However, several surveys [2][3][4][5][6][7][8][9][10] have revealed a lack of knowledge and comprehension of plastic surgeon's practice in the hand surgery field.These previous surveys 2-10 evaluated the perceptions of outpatients, medical students, primary care physicians, among others.
However, only few prior surveys 5,7-10 included the public's perception of plastic surgeons in the hand surgery arena, and there is limited similar data from a Brazilian plastic surgery perspective [12][13][14][15] .In fact, we [12][13][14][15] previously demonstrated that Brazilian medical residents' and public's perceptions of plastic surgery practice are limited in Brazil.We are not aware of any data on the relationship of independent variables with public' perceptions of the plastic surgeons as hand surgery specialists.Therefore, we sought to statistically correlate independent variables with the public's choice of plastic surgeons in hand surgery area.
We showed that plastic surgeons were significantly less identified as experts than other specialists in different hand surgery-related scenarios, including hand interventions fundamental to plastic surgery as a broad-based medical specialty such as hand tumor surgery, hand fracture management, hand tendon surgery, carpal tunnel release surgery, rheumatoid arthritis deformity surgery, and dupuytren contracture surgery.
These findings demonstrated that the knowledge and perceptions of plastic surgeons as hand surgery specialists are not well-known and widespread among Brazilian public members, similar to the trends   previously described in plastic surgery surveys from the Brazil, United Kingdom, Australia, United States, Ireland, and India 5,7-10,12,13,15 .We also sought to correlate independent variables with the plastic surgeons response, as its statistics were not fully investigated in previous studies [2][3][4][5][6][7][8][9][10]13 . Intrestingly, our bivariate and multivariate analyses demonstrated that the age variable was a significant predictor of selecting plastic surgeon as expert.In the literature, few surveys 3,7 evaluated the statistical impact of sex and showed that women had a higher perception of the scope of plastic surgeons' practice.
Different from our study, Dunkin et al. 7 reported no significant association between age of members of the public and the responses they gave.In addition sex and age were not significant determinants of plastic surgeons as the main response our 14 previous bivariate and multivariate analyses of public perception of plastic surgeons as craniofacial surgery specialists.However, as these previous authors 3,7 could not offer a rational explanation for the difference between sex, we do not own plausible explanations for the absence of differences between women and men or significant differences in the age.
In addition, we believe that an increased education level would determine a greater choice of plastic surgeons, because the breadth of accumulated general knowledge (including plastic surgery-related information) would be potentially greater.However, contrary to our hypothesis, health care professionals were not determinants of selecting plastic surgeon as expert.Interestingly, different professionals (medical students, primary care physicians in training, general practitioners) with potentially greater knowledge (including medical knowledge) did not recognize the full scope of plastic surgeons practice in previous studies 2,3,7,12 .
Denadai R et al.
www.rbcp.org.br"reality television" viewing negatively influences the public perception of the broad scope of plastic surgery 15 .
In Brazil, the mass media in particular has been very positive about aesthetic surgery, viewing the growth of the industry and aesthetic surgery tourism as an indicator of economic health or national pride 17 .In addition, the mass media recently disseminated that Brazil edges out the United States in terms of the number of aesthetic surgical procedures performed, according to the most recent International Society of Aesthetic Plastic Surgery (ISAPS) Global Statistics 18 .
In this context, the Brazilian Aesthetic surgical culture has been overshadowing the work of plastic surgeons outside of the aesthetic area.This is probably because aesthetic plastic surgery in Brazil has become a mass phenomenon with important implications for society and individuals, and it has been highlighted as a high value assigned to the body by Brazilians, because body has been identified as a status symbol, and it has demonstrated physical appearance as an essential element to the construction of the national identity 17 .
Interestingly, we demonstrated that respondents' identified plastic surgeons as experts in hand transplantation surgery, although no hand transplantation has ever been performed in Brazil according to the most recent world data (International Registry on Hand and Composite Tissue Transplantation) 19 , and complex reconstructions is not as widespread in Brazilian plastic surgery practice as in another country that also showed this trend 4 .
One explanation for this particular finding could be that worldwide mass media plays a role in the dissemination of information related to hand transplantations performed by multidisciplinary teams (including plastic surgeons) 19 .
This hypothesis is supported by a previous plastic surgery survey 9 revealing that Australian's mass media disseminated information about the care of burn patients, and public members identified more plastic surgeons in burn-related scenarios.We also observed this identification in our survey related with hand burn management.However, further research should investigate the real explanations for this specific finding, because mass media primarily provides information on the aesthetic side of plastic surgery practice 15,16 , and mass media was not a determinant of plastic surgeons response in our analysis, although this has been the main source of reported information in our and other surveys 6,8 .
Finally, the Brazilian hand surgery setting can also explain our findings.As described in other countries [20][21][22] , there are many gaps in Brazilian hand surgery education.Few Brazilian plastic surgery residency programs offer Moreover, the increase in the postgraduate year of training of the primary care physicians did not determine an increase in the respondent choosing plastic surgeons 3 ; on the other hand, there were mixed results regarding the association between the year of medical student training and plastic surgeons chosen 2,7 .
Previous authors 9,10 also hypothesized that respondents with prior plastic surgeon interactions would have a better understanding of the field of plastic surgery than their peers without prior plastic surgery contact.Plastic surgeons may be an import basis for transference of accurate information to the general public, as previously demonstrated in a medical student survey (prior clinical exposure to plastic surgery increased the selecting plastic surgery) 2 .
We included subjects with previous plastic surgery interaction to assess if exposure to plastic surgery through clinical/surgical encounters may have resulted in a greater understanding of the plastic surgery field.However, we showed that prior plastic surgery exposure was not independent variable determinants of plastic surgeons response in bivariate and multivariate analyses.Caution should be taken when interpreting our data, as we have not quantified the rate of real contact between the included subjects and plastic surgeons, and further surveys should expand these findings.
Hand surgery as a particular field of practice also sits at the intersection of overlapping specialties including plastic surgeons, orthopedic surgeons, general surgeons, neurosurgeons, and vascular surgeons 1,2,11 .As the lines that divide these specialties are tenuous and sometimes non-existent, the public may be confused about the work of each specialty within the health care system.In addition, the high proportion of respondents that considered specialists other than plastic surgeons may also be a reflection of increasing marketing and education by all other overlapping specialties 3 .
Second, several investigations [3][4][5][6][7][8][9][10]12,13,15 have revealed that plastic surgeons are primarily recognized as aesthetic surgeons. Such pereptions are most likely derived from the exposure given to cosmetic/aesthetic surgery by pervasive social media and popular "reality television" shows broadcasted worldwide.It was previously highlighted in a report 16 that demonstrated both the growing and predominant aesthetic side of specialty (plastic surgery) in the mass media.It was also demonstrated that aesthetic surgery hand surgery training and/or hand surgery fellowships 23 , and the number of graduating plastic surgery residents who completed plastic surgery training and pursued hand surgery fellowships is extremely low, compared with data from the United States 24 .
In addition, the status of the unstable national economy 25 , and the distribution of hand surgery centers within the national territory 26 , may also influence the plastic surgeon's practice in the field of hand surgery, and consequently, the public perceptions.
All this lack of knowledge about plastic surgeons as hand surgery specialists showed in our and previous surveys [2][3][4][5][6][7][8][9][10]12,13,15 requires educational measures to be established immediately. As previusly highlighted in a survey from the United States 2 , if Brazilian plastic surgeons want to continue to be recognized as hand surgeons, the Brazilian plastic surgery community (Brazilian Society of Plastic Surgery [SBCP], all plastic surgery residency programs accredited by SBCP, and Brazilian plastic surgeons) should actively participate in the public's education about the plastic surgeon's role in the hand surgery arena.
Multiple educational pathways can be adopted, for example: sending activity reports by email and to local newsletters; publishing an overview of plastic surgery articles/summaries in popular magazines and journals; using web-based technologies such as social media platforms and high-quality websites with reliable content; and educating and sensitizing the mass media regarding the role of plastic surgeons within the hand surgery field 3,8,15,16 .
Additionally, as differences in clinical exposure during training (residency and fellowship type) are reflected in hand surgery clinical practice and persist over time 27 , the next generation of plastic surgeons should be encouraged to embrace the entire scope of the specialty, including "part-time hand surgery" practice 1 .
As previously described in others fields 14 , we believe that a Brazilian task force committed to the endeavor of improving, strengthening, and encouraging hand surgery training within the plastic surgeon community is necessary, following previously established models [28][29][30] .
Caveats of the current study should be addressed.As in similar previous reports 2,5,8,[12][13][14][15] , our data are susceptible to regional bias, because only public members from a single geographical area were included.As there is currently no consensus on what constitutes the scope of hand surgery practice within plastic surgery 22 , we included 11 hand surgery-related scenarios based on previous investigations [2][3][4][5][7][8][9][10] ; however, we did not assess the full field of hand surgery practice.
In addition, sending this survey to other subjects (medical students and primary care physicians) may provide a better overall understanding of the perceptions of plastic surgeons as hand surgeons in Brazil.Although we have included possible explanations for our findings, we do not present causal investigation.
Finally, as our coefficient of determination for the multiple linear regression model was relatively low, additional independent variables could explain the plastic surgeons response.Despite these limitations, we believe that our data can yield several benefits and modifications for the future of hand surgery practice.Further surveys should be performed to address our limitations.

CONCLUSIONS
Age was a determinant factor of public choice of plastic surgeons as experts in hand surgery-related scenarios.

COLLABORATIONS RD
Analysis and/or interpretation of data; conception and design of the study; final approval of the manuscript; writing the manuscript or critical review of its contents; completion of surgeries and/or experiments; statistical analyses.

Table 1 .
Public's perception of the plastic surgeons as hand surgery specialists (n = 701).
N: Number of respondents; M: Mean; SD: Standard Deviation; PS: Plastic surgeon; PS alone: Respondents listing only plastic surgeon as expert; PS + others: Respondents listing plastic surgeon and others as experts; No PS: No respondents listing plastic surgeon as expert; NS: No significant.* PS alone < PS + others < No PS (p < 0.001 for all comparisons); ** PS + others > No PS > PS alone (p < 0.001 for all comparisons, except PS alone versus No PS with NS p-value); *** PS alone < PS + others < No PS (p < 0.001 for all comparisons, except PS + others versus No PS with NS p-value); **** PS alone < PS + others = No PS (p < 0.001 for all comparisons, except PS + others versus No PS with NS p-value); ***** PS + others > No PS > PS alone (p < 0.001 for all comparisons).

Table 2 .
Bivariate analysis for plastic surgeon response.

Table 3 .
Multiple linear regression analysis of possible predictors for plastic surgeon response.
Analysis and/or interpretation of data; final approval of the manuscript; completion of surgeries and/or experiments.CER Final approval of the manuscript; writing the manuscript or critical review of its contents.