Rules of engagement: one association's attempts to engage younger members and confront career-stage differences pay off.

AS EXECUTIVE DIRECTOR OF THE AMERICAN SOCIETY OF PLASTIC SURGEONS (ASPS), Arlington Heights, Illinois, for the first time in my career, I work for a profession that most people recognize. That recognition is thanks, in large part, to the media, including reality television such as Extreme Makeover, talk shows, health documentaries, and the countless consumer magazine articles devoted to plastic surgery procedures and makeovers. Largely as a result of this media attention, however, when I speak with people in social situations, they often express a view of the field of plastic surgery that differs dramatically from reality. Many think that the average plastic surgeon is a white, photogenic male in his 40s to 50s who has a successful practice performing cosmetic surgery.

[ILLUSTRATION OMITTED]

While that assessment was once fairly accurate--and while that demographic is certainly still represented within the specialty--plastic surgery is becoming increasingly diverse. In terms of procedures, along with cosmetic surgery, plastic surgery represents an entire range of reconstructive procedures and subspecialties dedicated to correcting deformities caused by birth, injury, or disease. As for those practicing in the profession, women and minorities represent growing numbers of plastic surgeons. While minority membership within ASPS and within the profession itself is still relatively low, female plastic surgeons compose roughly 15 percent of ASPS membership--up from only 10 percent two years ago.

Most significantly, I have observed the impact of age diversity within the profession. Currently, ASPS can count among its members three discrete generations: late career, mid-career, and early career.

Certainly age diversity has existed within the ASPS membership for decades, as it has for most individual member organizations. However, until the past 10 years these generational divides had not challenged the association to provide tailored benefits and accelerated avenues for leadership participation for younger members. Now, however, generational diversity presents ASPS with both opportunities and challenges.

Our recent strategies to manage the relationships among our multigenerational membership are already having a profound impact on the health of our organization and should positively affect the future of the plastic surgery specialty in years to come. Some of the actions that we are taking may be useful to your association and the profession or industry it represents.

Organizational origins

Plastic surgery derives its name from the ancient Greek plastikos, meaning "fit for molding." While some surgical techniques have been in existence for centuries, plastic surgery as a professional specialty emerged from the trenches of World War I to help restore function and appearance to those severely injured. Established in 1931, ASPS is the major organization representing board-certified plastic surgeons in North America. Our 5,000 members represent 94 percent of eligible practitioners. Today, most members are in private, solo practice and perform a mix of both cosmetic and reconstructive surgery. And as mentioned, they fall into three career-stage categories:

Late career (age 55-plus). This group represents 30 percent of ASPS members and corresponds to the pre-boomer generation. It consists of two cohorts: those still in practice and retirees.

Mid-career (ages 45-55). The baby boomers represent 34 percent of association members. With rare exceptions, they are in active practice.

Early career (ages 25-45). Roughly corresponding to generation X, this group represents 36 percent of ASPS members. It consists of three cohorts: those in training (residents), those who recently completed training and progressed to candidacy (candidates), and those in early practice (young plastic surgeons).

ASPS provides programs and services to support continuing education, the marketing and management of members' practices, public education, and advocacy. Its affiliated foundation provides programs in education, research, and international service.

Traditionally, ASPS operated similar to a guild, with membership in the society an expectation of professional life. Leadership opportunities were reserved for those in mid- and late-career stages, partially due to the energy and time required for early-career practitioners to build their practices. For most of the association's existence, this model worked well in supporting organizational growth and stability. However, by the late 1990s, several indicators related to generational differences pointed to weaknesses in this model.

One factor in particular has facilitated the need for ASPS to not only sit up and take notice of the expressed desires of early-career members, but also to implement substantive educational and governance changes to meet their needs. During the past 10 years, generation X members hit a critical mass within ASPS membership. Unlike the pre-boomers and baby boomers, whose cultural upbringing emphasized the importance of belonging to an organization for the long term, gen X-ers are far less content to sit on the sidelines and wait their turn to play. They want and expect to feel part of an organization from the start. Yet from a historical standpoint, many elements of the association's membership required stages of involvement and affiliation for which these members have little or no tolerance. As such, the changing mix of generational representation and expectations within ASPS's membership was starting to challenge our modus operandi in a big way.

Changing organizational dynamics

Organizations rarely fail as a result of a sudden catastrophe. Rather, they suffer because they have ignored the changing expectations of their members and customers, shifting market dynamics, or emerging competition. Until recently, ASPS did not pay attention to the changing expectations of its increasingly diverse membership, and we paid a price for it in terms of competitiveness, financial strength, and organizational vibrancy.

I joined ASPS in August 2002 as the organization was emerging from a period of financial difficulty. During the preceding two years, the society's leaders had accomplished an organizational turnaround, including stronger financial management, a new strategic plan, and streamlined governance. However, concerns were still being voiced among staff and elected leaders that the organization was rusting out. Signs of trouble were becoming evident in many areas.

Flat growth. The organization was stagnating in key categories: membership, annual meeting attendance, and symposia registration. The number of new candidates and residents--the future lifeblood of the association--was trending downward. Surveys showed growing unhappiness with the annual meeting due to its sameness each year and lack of opportunity for younger members to participate in planning or presenting. The number of new members was also declining, as was the percentage of all board-certified plastic surgeons who were members of ASPS (from 97 percent to 94 percent across a five-year period). Not surprising, the drop-off was largely the result of declines in the numbers of early-career members.

Increased competition. While ASPS was stagnant, subspecialty organizations were adept at understanding the importance of bonding with the younger plastic surgeon. And these groups were developing aggressive recruitment programs, including subsidization of dues, journal subscriptions, and meeting registrations for residents and candidate members. This had dual implications of fragmenting the field and weakening the programmatic and financial health of ASPS.

Leadership burnout. Too few volunteer leaders held too many positions. Senior volunteers, including past presidents and those in the presidential pipeline, would often serve as chair of three to five committees. While these individuals were clearly overworked, younger members lacked opportunities and voice. A typical statement from a focus group of candidate members speaks volumes: "There's an ivory tower concept for the board. There's an elite 5 percent of the association who keep shuffling through those positions."

Generational inequity. Early-career members expressed increasing concerns about equity. For instance, candidates paid the same dues as active members, but they could not display the society logo or cite their ASPS affiliation in their advertising because they were not yet board certified.

Likewise, new professional requirements threatened to affect young practitioners but not those in mid- to late-career stages. For instance, while previous generations of plastic surgeons essentially graduated with a certificate allowing them to practice for life, a new standard instituted in the mid-1990s by the American Board of Medical Specialties (ABMS) now requires professional recertification every 10 years with a cognitive exam. The first round of those affected--early-career members--are preparing to take the exam in 2005. To exacerbate a sense of inequity among early-career members, a more stringent set of ABMS "maintenance of certification" requirements is set to kick in during the next several years that will involve ongoing practice assessment and evidence of learning.

To further fuel the irritation of many early-career members, the number of ASPS life members--who pay no dues and no fee to attend ASPS's annual meeting--was growing rapidly. In subsidizing nearly 800 members, this benefit, like that for Social Security and Medicare, placed a financial burden on early-career members.

And finally, the society's governance structure--while serving the needs and expectations of the most established members--often left younger members underserved. ASPS's board and committees were dominated by mid- to late-career practitioners who were making decisions about programs that benefited their groups, but which often did not address the needs of--or might even adversely affect--younger members. Examples include:

* Educational offerings focused on in-person seminars. Registration fees were high, and many events were scheduled in resort locations that were inconvenient and too expensive for younger members. At the same time, few resources were dedicated toward creating the types of low-cost and easily accessible programs desired by younger members, such as Web-based, CD-ROM, and DVD education and programming that could be accessed at any time.

* Advocacy efforts focused on priority issues for older members. Surveys showed that younger members were most concerned about insurance reimbursement, costs of maintaining their practices, and competition from nonplastic surgeons from other specialties such as dermatologists, ophthalmologists, and oral surgeons. However, ASPS advocacy resources were primarily focused on issues affecting mid- to late-career members, such as regulation of office-based surgery and Food and Drug Administration regulation of medical devices.

Assessing needs

To address membership discontent, you must first pinpoint the root of that discontent. For the most part, ASPS volunteer leadership had become attuned to the generational issue prior to my arrival. But to really understand in detail what younger generation priorities were and how to address them, good market research was in order. We accomplished this through a variety of techniques, including person-on-the-street interviews, quantitative surveys, and focus groups.

Because surveys and focus groups elicit response and participation primarily from those most vocal or most motivated, beginning in 2002 we initiated random spot interviews of members at the annual meeting. These interviews revealed significant criticism regarding the lack of diversity in annual meeting presentations. Understandably, younger members wanted to see a broader range of subspecialties and greater representation by their peers. They also expressed the desire for more real-world material as opposed to well-established practitioners showcasing the ideal results from their best surgical cases.

In addition to a comprehensive member survey that we conduct annually, we survey members quarterly via our Web site to ask about specific program and product offerings, including potential new products and services. For all surveys, we ask basic demographic questions that allow us to track product preferences and views by generational category. Among the most significant findings to emerge from these member surveys: the specific educational needs of early-career members. Traditionally, most ASPS programming has been clinical in nature, focusing on new surgical procedures and improvements. However, early-career members expressed an urgent need for practice-management programming that encompasses how to market their practices, hire staff, implement office information systems, and comply with regulatory requirements. They also wanted education related to risk-management issues and contractual arrangements.

Each year since 2001, we have conducted a series of focus groups during our annual meeting. Based on focus groups composed of early-career members at our October 2002 annual meeting, we discovered specific views about membership and benefits held by residents, candidates, and young plastic surgeons. For instance, we learned that residents viewed ASPS as providing little or no real value to them. Rather, they believed one joined automatically. Among the benefits they most desired were the society's professional journal, its job listings, and assistance with finding a job.

Candidates viewed membership in ASPS as a necessity for recognition and professional credibility. Topping their list of desirable member benefits were advocacy, education, and resources for practice development.

Because young plastic surgeons considered ASPS the spokesperson for the specialty, they joined as an expectation and to be part of the community. Desired benefits for them included advocacy, education geared toward new techniques, marketing resources, meetings, and networking opportunities as well as use of the ASPS logo to market their practices.

All our market research efforts indicated the need for ASPS to make some key changes in its benefits for younger members, including

* paying more attention to member value in setting dues and pricing for early-career members;

* providing more practice resources and education geared to the needs of younger member segments;

* aligning health policy and advocacy more to the needs of younger members; and

* providing more effective avenues for leadership development and participation.

Bringing youth to leadership

But how do association leaders make such sweeping changes to an organization set in its ways? As with most large-scale transitions, the best approach is one step at a time. During the past two years, ASPS has initiated an aggressive campaign to more effectively engage early-career members and address their needs. These strategies encompass several critical aspects.

First, we knew that it was important to both develop and engage young leaders in the society, and we took steps to encourage potential young leaders to get involved.

1. Young leaders conference. In 2002, we launched an annual fall program called Leadership Tomorrow, which brings 25-30 prospective leaders together for two days of intensive training in leadership, advocacy, ethics, and media contact. Members self-nominate or nominate others by submitting a letter of application indicating the individual's vision for the specialty and demonstrated leadership in advocacy and education. ASPS recognizes each class of Leadership Tomorrow Fellows in our publications and at our annual meeting.

2. Leadership appointments. This group is fast-tracked into key committee chair and task force appointments, as well as external appointments to serve on committees of other organizations, such as the American Medical Association and the American College of Surgeons. In 2002, we also established a "young plastic surgeon" seat on our board, with an age requirement of 40 or younger. While we are considering making this an elected position, currently the seat is filled by the chair of our Young Plastic Surgeons Forum or by appointment of the society's president based on informed inquiry about who is highly respected within this peer group.

3. New committee. We recently established a Leadership Development Committee, the charge of which is to evaluate and improve the Leadership Tomorrow curriculum and develop a means for tracking and placing emerging leaders throughout the plastic surgery specialty. This committee, which is co-chaired by an established leader and a young plastic surgeon, will work closely with the nominating committee.

4. Strategic planning involvement. Earlier this year, we began inviting four to six Leadership Tomorrow Fellows to our annual strategic planning session. Formerly, only members of the board attended this session.

Delivering the right value

In addition to understanding the need to involve more younger members earlier, we believed it was important to aggressively promote early-career member benefits and features. We established a Membership Strategies Task Force, which includes representation from all membership segments, to make recommendations to the board about benefits and dues. As a result, changes we have made include

* lowering candidate dues;

* allowing candidates to make reference to their membership status in advertising;

* repackaging resident benefits to include free registration to the annual meeting;

* establishing a special interest group for residents to help develop programming for "Resident's Day" at the annual meeting;

* developing more practice marketing resources as well as specific training programs in practice management; and

* ramping up advocacy efforts to address issues of concern to young plastic surgeons.

Advocacy changes include a greater emphasis on training, increased participation in activities--including committees, task forces, and fly-ins--and the establishment of a new Washington, D.C., office. The society now allows the creation of self-governing, special-interest groups to meet emerging needs more swiftly. Forums have been established for both women plastic surgeons and young plastic surgeons.

We've also placed special attention on upgrading our educational resources.

Software programs. In response to the American Board of Medical Specialties' recertification and maintenance of certification requirements, we designed a CD-ROM program that allows for professional self-assessment. Since we debuted the product three years ago, sales have increased each year, reaching 2,000 copies sold this year alone.

New database. Also in an effort to providing useful assessment tools for members, we've developed a national procedures database that allows for normative comparisons of practice mix and outcomes. This tool has proven popular among early-career members in particular, who are able to track their practice patterns and compare their results to those of their peers.

Revamped annual meeting. The annual meeting now provides greater opportunities for young plastic surgeons to plan and present, placing greater emphasis on emerging techniques as well as practice-related issues.

In-office delivery. E-learning as well as point-of-practice-based resources top our priority list in terms of future educational development, and we will soon launch an Internet series on practice management.

Equitable terms of membership. Finally, we are addressing the issue of generational equity. For the first time, the board is considering establishing a dues assessment for active life members and encouraging all ASPS members to participate in the recertification process--something currently required only of early-career members.

Measuring results

While it is still early in the evaluation of our new ideas and goals, evidence of progress can be seen. Interest and demand for the Leadership Tomorrow program has been strong. Early-career members feel empowered and are actively seeking and getting key positions on committees and task forces. While membership trends have not yet turned around, annual meeting attendance among early-career members is seeing a rebound, with more than 10 percent growth across the past two years. Advocacy activities have likewise been reenergized, with a 50 percent growth in participation from younger members in legislative fly-ins and in state-level activities.

At the same time that we are strengthening relationships with our early-career members, we are also reaching out to the subspecialty organizations within the field. Rather than competing directly with these organizations, ASPS is working to co-opt competition and build complementary and collaborative relationships with the range of subspecialty groups so that members are not compelled to choose between ASPS and a subspecialty association, but rather understand the complementary value provided by these organizations.

No doubt, the association must continue to monitor critical aspects of the profession and of our association culture and mind-set as we prepare to welcome a new generation of plastic surgeons--during the next 10 years individuals in the millennial generation will enter residency status. As such, the strategy we have undertaken at ASPS to address the society's ongoing generational issues is focused on embracing the values, attributes, and aspirations of all membership stages through systematic business processes that include extensive market research, inclusive governance, and strategic planning.

Want more information on this topic? Check out the "Outtakes and Exclusives" and "Link to Learn" areas at www.amonline.org.

BY PAUL POMERANTZ, CAE 

Paul Pomerantz, CAE, is executive director, American Society of Plastic Surgeons, Arlington Heights, Illinois. E-mail: [e-mail].