Pediatric surgical training: an historic perspective, a formula for change

Trauma Leagues-A Novel Option to Attract Medical Students to a Surgical Career

BACKGROUND

In Brazil, most medical schools do not offer trauma surgery in their undergraduate curriculum. The Trauma Leagues arose in Brazil as an important promoter of trauma education and stimulated activities related to surgical skills and practices. In recent decades, studies have demonstrated that the number of surgical residency applicants has decreased worldwide. Strategies to motivate medical students to choose surgery are needed.

OBJECTIVE

To evaluate the impact of participation in the Unicamp Trauma League (UTL) during a 20-year period in the choice for a surgical career.

METHODS

The study included 276 students in a Brazilian university hospital who were part of the Trauma League. Research of records in universities and medical societies about the specialties chosen during residency were evaluated. A Likert questionnaire was sent to participants to evaluate the impact of participating in the Trauma League in the student's professional career.

RESULTS

The questionnaire was answered by 76% of the participants. Of those, 38.4% chose general surgery. About 55.1% did not know what medical career to choose when joined the league. Participation in the league had an influence on specialty choice in 79.1% of the students. Of those choosing surgery, 93.2% believed that participating in the league had positively influenced their career choice. Overall, 93.1% believed that participating in the league provided knowledge and information that the medical school curriculum was not able to provide.

CONCLUSION

Participation in Trauma League has been an effective strategy to encourage medical students to choose a career in general surgery in Campinas, Brazil.

Contemporary pediatric surgical training in the UK

INTRODUCTION

Pediatric surgical trainees worldwide face pressures from expansion of programs and training positions, subspecialization, regionalization, restrictions of working hours, and rigid training criteria. The era of apprenticeship training has long gone, and surgical education needs to be responsive and adapt to newer challenges. The aim of this study was to examine the teaching provision component of pediatric surgical training in the UK.

METHOD

A national teaching survey was sent to UK pediatric surgery trainees in 2010 and compared to results of a repeat survey in 2015. Analysis was carried out to compare type of teaching, trends in teaching delivery, quality, and attendance over time.

RESULTS

Regional variability was noted in teaching programs. Both provision of educational activities and ability to attend teaching improved between 2010 and 2015. Despite this, overall trainee satisfaction remained low, with 50% and 52% of respondents describing their teaching as "good" or "excellent" in 2010 and 2015, respectively (P=0.84). Seventy-five percent of centers provided simulation training, and 25% of respondents had regional teaching provided. Survey response rate was comparable between 2010 and 2015.

CONCLUSION

Variability in national educational provision was observed. We suggest regular national audit of educational activity and responsive adaption to external pressures on training if competent surgeons are to be the product of contemporary pediatric surgery training programs.

Global comparison of pediatric surgery workforce and training

INTRODUCTION

The number of pediatric surgeons and their distribution vary greatly throughout the world. The purpose of this study is to examine potential influential factors including the length of education and training, pediatric population, birth rate, and gross domestic product (GDP) per capita.

METHODS

An internet search was conducted to determine the duration of education from grade school to pediatric surgery fellowship, number of pediatric surgeons, birth rate, GDP, and population under 15 years of age in 15 countries. The number of pediatric surgeons per million children was correlated with these factors.

RESULTS

The number of pediatric surgeons per million children varied from 0.51 to 29.3. The total length of education from grade school to completion of pediatric surgery training ranged from 23 to 29 years. There was no correlation between pediatric surgeons per million children with the duration of training. The number of pediatric surgeon per million children was inversely correlated with the birth rate. There was a positive correlation between the GDP per capita and pediatric surgeons per million children.

CONCLUSION

There is a tremendous variability in pediatric surgeons around the world. There appears to be a significant shortage of pediatric surgeons in countries with a high birth rate and low GDP per capita.

Should general surgery residents be taught laparoscopic pyloromyotomies? An ethical perspective

OBJECTIVES

The authors examine the ethical implications of teaching general surgery residents laparoscopic pyloromyotomy.

DESIGN/PARTICIPANTS

Using the authors' previously presented ethical framework, and examining survey data of pediatric surgeons in the United States and Canada, a rigorous ethical argument is constructed to examine the question: should general surgery residents be taught laparoscopic pyloromyotomies?

RESULTS

A survey was constructed that contained 24 multiple-choice questions. The survey included questions pertaining to surgeon demographics, if pyloromyotomy was taught to general surgery and pediatric surgery residents, and management of complications encountered during pyloromyotomy. A total of 889 members of the American Pediatric Surgical Association and Canadian Association of Paediatric Surgeons were asked to participate. The response rate was 45% (401/889). The data were analyzed within the ethical model to address the question of whether general surgery residents should be taught laparoscopic pyloromyotomies.

CONCLUSIONS

From an ethical perspective, appealing to the ethical model of a physician as a fiduciary, the answer is no.

DEFINITIONS

We previously proposed an ethical model based on 2 fundamental ethical principles: the ethical concept of the physician as a fiduciary and the contractarian model of ethics. The fiduciary physician practices medicine competently with the patient’s best interests in mind. The role of a fiduciary professional imposes ethical standards on all physicians, at the core of which is the virtue of integrity, which requires the physician to practice medicine to standards of intellectual and moral excellence. The American College of Surgeons recognizes the need for current and future surgeons to understand professionalism, which is one of the 6 core competencies specified by the Accreditation Council for Graduate Medical Education. Contracts are models of negotiation and ethically permissible compromise. Negotiated assent or consent is the core concept of contractarian bioethics. Nonnegotiable goods are goals for residency training that should never be sacrificed or negotiated away. Fiduciary responsibility to the patient, regardless of level of training, should never be compromised, because doing so violates the professional virtue of integrity. The education of the resident is paramount to afford him or her the opportunity to provide competent care without supervision to future patients. Such professional competence is the intellectual and clinical foundation of fiduciary responsibility, making achievement of educational goals during residency training another nonnegotiable good.

The pediatric surgeon and the American Academy of Pediatrics (AAP): an important partnership for surgeons and children

The American Academy of Pediatrics provided a home for pediatric surgery when organized surgery did not recognize the specialty. They have continued to support surgical specialties in their pursuit of quality in education, training and practice. The AAP has appropriate infrastructure to support advocacy at both the federal and state levels. The fact that it does not have a PAC, and that it always puts the child first, has given it great credibility. Much of the AAP infrastructure is already used by surgeons to advocate for their patients, but still more opportunities for collaboration are available.

Trends in operative experience of pediatric surgical residents in the United States and Canada

PURPOSE

Expansion of the number of training programs in pediatric surgery occurred from 2003 through 2010. We sought to determine the effect of program expansion on case volume and distribution of operative experience.

METHODS

Public domain data on pediatric surgery resident summary statistics available from the Accreditation Council for Graduate Medical Education (ACGME) from July 2003 through June 2010 were analyzed. Total case volume as primary surgeon or teaching assistant, mean case volume per resident, standard deviation, mode, minimum, and maximum number of cases per resident were evaluated. Mean total cases per resident, minimally invasive laparoscopic and thoracoscopic cases, and requisite cases as defined by the ACGME categories of: tumor, important pediatric surgical, and neonatal cases were analyzed by a Cuzick Wilcoxon-type nonparametric trend statistic using a significance level of 0.05. Skew was assessed by Pearson coefficient with levels of -0.5 to 0.5 defining a parametric distribution.

RESULTS

The number of pediatric surgical training residents increased by 42% during the years reported, from 24 to 34. No statistically significant difference was found in the mean number of total cases or requisite cases per resident. The mean volume of minimally invasive procedures increased significantly. Case volume per resident was non-parametrically distributed with increasing positive skew over time.

CONCLUSIONS

The increase in number of pediatric surgical resident training positions has not adversely affected overall operative experience or exposure to highly specialized requisite cases, on average. The increasing positive skew of total and index cases, however, suggests that variability between programs in case exposure is increasing over time.

State of the practice for pediatric surgery--career satisfaction and concerns. A report from the American Pediatric Surgical Association Task Force on Family Issues

BACKGROUND

There has been increasing interest and concern raised in the surgical literature regarding changes in the culture of surgical training and practice, and the impact these changes may have on surgeon stress and the appeal of a career in surgery. We surveyed pediatric surgeons and their partners to collect information on career satisfaction and work-family balance.

METHODS

The American Pediatric Surgical Association Task Force on Family Issues developed separate survey instruments for both pediatric surgeons and their partners that requested demographic data and information regarding the impact of surgical training and practice on the surgeon's opportunity to be involved with his/her family.

RESULTS

We found that 96% of pediatric surgeons were satisfied with their career choice. Of concern was the lack of balance, with little time available for family, noted by both pediatric surgeons and their partners.

CONCLUSION

The issues of work-family balance and its impact on surgeon stress and burnout should be addressed in both pediatric surgery training and practice. The American Pediatric Surgical Association is positioned to play a leading role in this effort.

Pediatric surgery: a career resource

Pediatric surgeons provide care to neonates and children with a unique range of congenital, oncologic, infectious, and traumatic disorders. This unique surgical subspecialty continues to recruit outstanding trainees, despite the additional training required. This career resource guides the interested medical student and physician through the pathway to a practice in pediatric surgery. It includes a discussion of training requirements, research opportunities, board certification, and continuing education.

Creativity and the surgeon

This Robert E. Gross lecture is an analysis of the concept of creativity and how it relates to the practice of surgery. The questions-why surgery and creativity are closely associated; what influences creativity; why we should be concerned about it; and, finally, what rewards it brings-are discussed. In a personal note, the author describes his approach to creativity, with simplification as a central theme. He presents 6 examples of his work and the lessons learned from this activity. He stresses the importance of fostering creativity in all institutions in which physicians are trained and the need to focus on medical students, residents, and fellows. The critical importance of identifying, nurturing, and protecting innovators, as well as the role of the mentor, is emphasized. Because creativity has a place in many settings and discovery encompasses a wide spectrum, the author provides multiple suggestions aimed at encouraging the participation of those providing surgical care in the fulfilling experience of creative activity and innovation.

Ensinar cirurgia: como e para quem?

O autor discute a crise atual de formação de médicos e de cirurgiões fazendo uma revisão de dados de literatura atual, referentes ao quantitativo de médicos e discussão de referências éticas e filosóficas da profissão. Há uma diminuição crescente na formação de médicos e cirurgiões, com uma crescente participação de mulheres. Os médicos jovens buscam qualidade de vida e autonomia profissional como principais requisitos profissionais. As síndromes de burn-out são comuns entre os médicos em atividade, e a perda de autonomia profissional tem papel preponderante na determinação da doença. A crise que atinge a profissão médica e as especialidades cirúrgicas tem bases éticas, sociais e financeiras. É necessário e fundamental discutir novos paradigmas de educação e atuação profissional na sociedade moderna.

Temporal geomapping of pediatric surgeons in the United States

BACKGROUND

Several studies have addressed the issue of manpower needs in pediatric surgery. The number of training programs has multiplied dramatically over the past decade. The distribution of surgeons is more significant than the absolute change in numbers--are major metropolitan areas seeing a more dramatic increase than less populated areas? To evaluate the geographic and demographic changes associated with this increase, we used choropleth and geomapping techniques to evaluate the change in number and distribution of American Pediatric Surgical Association (APSA) members (and by proxy, pediatric surgeons) in the United States over the past decade.

MATERIALS AND METHODS

Data regarding membership were obtained from APSA. In 1996, management companies changed, and accurate data for initial year of membership were only available after 1996. Online sources (www.services.alphaworks.ibm.com/manyeyes/home and www.mapresso.com) were used for data analysis.

RESULTS

There was a 175% increase in the number of APSA members over the past decade. The geographic distribution parallels the state population to some extent but is uneven. The number of APSA members by state over time is displayed in color density maps. Predictions of prior manpower studies were generally accurate.

CONCLUSION

The number of pediatric surgeons in the United States has rapidly increased in the past decade, with no sign of diminution in this trend. Increases in the number of surgeons correlates with state population, indicating a tendency for surgeons to reside in more densely populated areas, as expected. Areas with a disproportionately high or low number of surgeons can be identified via choropleth mapping.

The impact of managing moderately injured pediatric trauma patients without immediate surgeon presence

PURPOSE

The purpose of this study was to determine the outcome of "minor resuscitation" trauma patients managed without the immediate presence of a surgeon.

METHODS

In 2003, our hospital replaced surgeons with pediatric emergency medicine physicians for level 2 (minor resuscitation) trauma alerts, whereas the level 1 (major resuscitation) alerts remained surgeon directed. We compared patients treated in the 3 years before (period 1) and after (period 2) this change. Patient records were analyzed for discharges, alert upgrades, Injury Severity Score (ISS), time to destination, and mortality.

RESULTS

There were 918 admissions and 93 discharges in period 1 compared with 815 admissions and 652 discharges in period 2. In period 1, 3% were upgraded to level 1 status compared with 9% in period 2 (P < .0001). The mean ISS of admitted patients and the percentage of critical (ISS >15) patients were greater in period 2 (P < .001). The time to inpatient floor was longer in period 2, but the elapsed times to operating room and to pediatric intensive care unit were not significantly different.

CONCLUSION

Pediatric emergency medicine physicians discharged more patients than the surgeons, but also upgraded more to level 1 status. Level 2 trauma patients can be safely managed without immediate surgeon presence.

Analysis of the Current Applicant Pool to Vascular Surgery: Who Are They and Where Do They Come From?

There is a manpower crisis in vascular surgery. There may be too few vascular surgeons to meet the demands imposed by the aging of the "Baby-Boom" generation. More than 20% of vascular surgery positions were not filled through the match in 2004 and 2005. The number of vascular surgery training positions has doubled in the past 15 years, based on manpower studies projecting a need for additional vascular surgeons. During the same time period, the number of vascular surgery applicants has remained static. In addition, the proportion of international medical graduates has increased significantly. Furthermore, medical students appear to be selecting "lifestyle-friendly" specialties, such as emergency medicine, radiology, ophthalmology, anesthesiology, and dermatology, with increasing frequency. Approximately 60% of undergraduates in the United States and almost 50% of graduating medical students are currently women. Yet only about 25% of general surgery residents and less than 20% of current vascular surgery trainees are women. Strategies to expand the applicant pool for vascular surgery are needed and discussed in this article.