It all begins here. You’re unsure whether you really want to have surgery. You’re worried about being too vain. You’re worried about what your spouse, friends, and coworkers will say. You watch those terrible television shows. You go on the Internet and read about the procedure. Your interest is piqued. Then you start looking for a surgeon.How a Doctor Becomes a Plastic SurgeonIt is important to choose the right plastic surgeon. Certainly, the surgeon’s medical school and residency training give you information about the doctor’s basic intelligence. Chances are good that if the doctor trained at Harvard, he’s not stupid. But that’s only the beginning.The training of a plastic surgeon is arduous. Only the best graduate from medical school and only the top surgical residents are accepted into plastic surgery residency programs. Most are at the top of their class and were likely inducted into Alpha Omega Alpha, the medical honor society.To become a plastic surgeon, a doctor must obtain an M.D. (Doctor of Medicine) or a D.O. (Doctor of Osteopathy) degree. Following this, there are several paths the doctor may follow. Many doctors now spend five to six years in an integrated plastic surgery residency, although some complete three years of general surgery and two years in plastic surgery. Alternatively, otolaryngologists (ear, nose, and throat specialists), orthopedic surgeons (bone doctors), neurosurgeons (brain surgeons), urologists, and oral surgeons with medical as well as dental degrees may enter the two-year plastic surgery residency.The marathon plastic surgery residency is a grueling learning process. The doctor learns how to take care of patients before, during, and after surgery during the internship, the first year. He learns how to suture and how to stop bleeding, and perfects his skills through animal surgery and computer simulations. In the operating room, interns, under the watchful eye of ‘‘attendings’’ (the fully trained surgeons), perform portions of procedures.With advancing years comes more responsibility. The education includes rotations in ophthalmology, orthopedics, otolaryngology, and even the medical specialty, dermatology.By the fourth year of residency, the doctor is immersed in plastic surgery. To gain experience in cosmetic surgery, the fifth- or sixth-year chief resident runs his own clinic, performing discounted-fee surgery. While the new doctor gains experience, this program allows lower income patients to afford cosmetic surgery.After completion of his residency, the new plastic surgeon may start his own practice, or he may join an established plastic surgeon or the faculty of a medical school or multispecialty group. Alternatively, he may continue his marathon education with another year or two of training, called a fellowship. It can be in cosmetic surgery, hand and microsurgery, burn surgery, craniofacial surgery, or head and neck cancer. Board Certification Is a Critical CredentialThe next hurdle is to pass the ‘‘boards.’’ The candidate takes a written examination during the first year in practice and an oral exam the next year. The written exam tests book knowledge, and the oral exam determines how the surgeon would handle clinical scenarios.Considering how long it takes to become a plastic surgeon—four years of college, four years of medical school, and at least five years of residency—it is hard to believe that many aspiring surgeons (13 to 23 percent) flunk the boards each year. But these are not ‘‘rubber stamp’’ exams. These doctors go back to their communities, in some degree of depression, to ponder their fate and plan for the exam next year. Each year the American Board of Plastic Surgery certifies about 200 new plastic surgeons. Since 1937, 7,003 plastic surgeons have become board certified.Board certification is the minimum criterion you should use in selecting a plastic surgeon. And don’t be confused between boards and societies. Societies are merely professional associations—glorified clubs—that vary in their selection criteria. Most just want the membership fees and will admit almost anyone.The American Medical Association, as well as state and county medical societies, only require a medical degree to qualify for membership. The American Society of Plastic Surgeons and the American Society for Aesthetic Plastic Surgery have stringent membership requirements, including a plastic surgery residency and certification by the American Board of Plastic Surgery.MORE: Watch Out for “Wannabe” Plastic SurgeonsHospital Privileges Are an Important ConsiderationTo operate in a hospital, a surgeon needs to be granted ‘‘privileges.’’ There are a wide variety of hospitals ranging from medical-school teaching hospitals to small community hospitals.Some surgeons gain privileges simply by joining a politically connected group of surgeons. If a surgeon brings millions of dollars of revenue into a hospital, it is unlikely that the hospital will prevent him from bringing an associate onto the hospital staff. There are hospitals with ‘‘open staffs’’ that will take any properly trained doctor and then there are ‘‘closed staff’’ hospitals that will only take on a new physician if he joins a practice of a physician already on the staff. These hospitals will keep a physician from gaining privileges if he is deemed to be a competitor. Not fair, but financially difficult for the new physician to challenge.A properly trained, board-certified plastic surgeon will usually be able to attain surgical privileges in at least one hospital in the area. If a surgeon has no hospital privileges and operates only in his office, I would be concerned. Certainly, there are surgeons who are extremely competent and are either politically boxed out of an area or choose to operate only in their office or a surgicenter. But the vast majority of legitimate plastic surgeons have hospital privileges. If yours doesn’t, ask why.But don’t just ask whether a doctor has hospital privileges. Make sure that the doctor has privileges at a hospital in exactly the procedure that you want performed. For instance, a dermatologist may have privileges to take care of medical problems of the skin in a hospital. But he may not have privileges to perform liposuction or a face-lift in a hospital. That is crucial information because the hospital provides an important level of scrutiny. If they won’t let the doctor perform the procedure in their hospital, why would you let him perform the procedure on you in his office?Professional Societies Have Some Weight in Your DecisionBeyond credentials and training, plastic surgeons who are upstanding members of their communities are eligible for membership in the American Society of Plastic Surgeons (ASPS), the American Society for Aesthetic Plastic Surgery (ASAPS), and the American College of Surgeons (ACS). If your plastic surgeon is a member of these organizations, there is a certain assurance of quality. These organizations only admit board-certified surgeons, and only surgeons who follow their rules of conduct and ethics. The American College of Surgeons awards the letters F.A.C.S. to surgeons: these letters, written after the letters M.D., mean ‘‘Fellow, American College of Surgeons’’ and again give some assurance that the surgeon meets certain criteria.Remember, these credentials are only starting points. Not every member of these groups is a perfect surgeon, ethically or technically. However, if your surgeon is not a member of these groups, you should be concerned.