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The pediatric general surgery undergraduate medical curriculum: What should medical students learn?
The Pediatric General Surgery Undergraduate Medical Curriculum: What Should Medical Students Learn ? By Ray Postuma Winnipeg 9 Pediatric general surgery should be included in the undergraduate medical curriculum for reasons of improving the total surgical care of infants and children, to enable teachers to serve as role models to students considering a career in pediatric surgery and to ensure survival of pediatric surgery in the medical school curriculum. A survey of recent medical literature and surgical textbooks revealed little or no discussion concerning the aims, objectives, content, and design of the pediatric surgical curriculum. A survey of 15 Canadian medical schools showed that students are assigned very little didactic time for pediatric surgery (average total seven hours) and only 25% of graduates proceed to a clerkship in pediatric surgery, usually as an elective. The Association hereby proposes an undergraduate medical education curriculum in pediatric surgery for Canadian medical schools in order to stimulate discussion and achieve uniform input of pediatric surgery in the undergraduate medical program. 9 1987 by Grune & S t r a t t o n , Inc.
survey was followed up by telephone contact where necessary (institution survey). A suggested pediatric undergraduate surgical curriculum was then formulated by the CAPS Education Committee and approved in principle at the CAPS annual meeting in September 1985. Following minor revisions, the revised curriculum (appendix) was circulated in February 1986 for feedback to the 80 members of CAPS (curriculum survey). In addition, members were asked to complete a questionnaire concerning their personal involvement in pediatric undergraduate surgical teaching (teachers' survey).
RESULTS
From the Education Committee, Canadian Association of Pediatric Surgeons. Presented at the 18th Annual Meeting of the Canadian Association of Paediatric Surgeons, Halifax, Nova Scotia, August 28-30, 1986. Address reprint requests to Ray Postuma, AID, Chairman, Education Committee, Canadian Association of Pediatric Surgeons, 840 Sherbrook St, Winnipeg, Manitoba, R3A ISI Canada. 9 1987 by Grune & Stratton, Inc. 0022-3468/87/2208-0013503.00/0
The literature search produced eight articles in the English language. All were concerned with aspects of postgraduate education in pediatric surgery and none dealt with the undergraduate curriculum. Twelve pediatric surgery textbooks were reviewed: none offered advice or discussion concerning the pediatric surgery undergraduate program. Two textbooks were specifically aimed at the medical students, t'2 Rickham recommends that the medical student should be aware of the fundamental and pathophysiologic differences in children when managing their surgical problems? This is a point made by most authors. The results of the institutional survey are summarized in Table 1. Pediatric surgery is formally taught at all 15 medical schools. Information was not available from one school (100 graduating students). The amount of assigned teaching in pediatric surgery averaged seven hours (range 1 to 25 hours). Five schools had written objectives and two schools were developing them. Twelve schools offered clerkships in pediatric surgery; in one school the clerkship is compulsory for all students. The proposed curriculum survey yielded responses from 15 members (19%). The responses were generally very positive and encouraging. Six members offered several additions to the proposed curriculum and these are included in the revised curriculum (appendix). However, five members questioned whether the proposed curriculum was too exhaustive for medical students particularly since the amount of time available in the undergraduate curriculum was limited. In particular, there is concern that the number of conditions listed under "content, part 5" was too comprehensive and esoteric for students. Two members suggested the conditions listed could be categorized as "essential," "recommended," and "ideal." This has not been done. One member suggested that the curriculum should
746
Journal of Pediatric Surgery, Vol 22, No 8 (August), 1987: pp 746-749
INDEX WORDS: Pediatric surgery, undergraduate curriculum.
rHAT SHOULD undergraduate medical stu-
W dents learn about pediatric surgical conditions and their management? How and when should it be taught? These questions probably concern most members of the Canadian Association of Pediatric Surgeons (CAPS) since, as the following study will show, most members are involved in the teaching of pediatric surgery. MATERIALS A N D METHODS
A Medline literature search was conducted of all pediatric surgery education publications for 1969 to 1986. Also, the pediatric surgery textbooks found in the Medical Library of the University of Manitoba were reviewed for advice and discussion concerning the aims, objectives, content, and design of a pediatric surgery undergraduate medical education curriculum (literature review). In November 1984, a survey was conducted of the CAPS education representative in each of 15 cf the 16 Canadian medical schools. They were asked to submit details, including objectives, and opinions concerning the program at their respective medical schools. This
Table 1. Survey of the Pediatric Surgery Undergraduate Medical Curriculum at Canadian Medical Schools, 1985 to 1 9 8 6 (Institutional Survey) 1. University
MEM
2. No. of pediatric surgery hospitals 3. No. of 1985 graduates 4. Duration of Medical Program (yr)
DAL
LAV
MON
McG
Ol-r
Q U E E TOR
McM
WES
MAN SASK ALT
CAL
B.C.
1
1
1 200
1 154
1 88
1 78
1 269
2 106
3 103
2 92
2 57
2 113
1
60
1 158
1
57
69
121
4
4
4
5
4
4
4
4
3
4
4
5
4
3
4
1
3
2
8
4
3
2
6
2
2
5
31
2
1
4
3
1 Yes
7 Yes
3 No
3 Yes
2 No
5 No
2 No
2 No
2 Yes
31 No
2 No2
2 3
0 0
O 0
0 0
0 0
P
0 0
0 2
0 1
0 0
0 2
10 10 --
3 0
4 0
0 12 .
4 2
1 1
1
6
1L Yes
7.5 LT Yes
3 E 2 20
4 E 2 25
A,W
A,W
5. No. of CAPS members (active) 6. No. of CAPS teachers scheduled
1
7. Objectives (yes/no) 8. Med 1 (hr) 9. Med 2 (hr)
No 0 0
No= 0 2
3 0
6 0
10. Med 3 (hr) 11. Med 4 (hr) 12. M e d 5
--
13. Total didactic hours 14. Type (Lect./Tut.)
8 T
Yes
Yes
4 E 2 10
4 E 4 40
A,W
A,W
15. Clerkship in pediatric surgery 16. 17. 18. 19.
Curriculum year(s) Status (Elect/Comp) Duration (wk) % class taking
20. Type (Arab/Ward)
--
3 L
p
.
.
25
3
4
12
T Yes 3,4 E 4 2 A,W
L Yes 5 E 1 75 A
LT Yes 4 E 4 15 A,W
LT Yes 4 C 2 100 A,W
.
1
. 6
LT Yes 4 E 4 33 A,W
1 2 .
0 11.5 ~ .
4 0
5 1
1 1 p
4
11.53
64
7
2
4
LT Yes 4 EC 4 15 AW
L No 5 -----
LT No 3,4 -----
LT Yes 4 E 4 20 A,W
LT Yes 4 E 4 10 A,W
LT No 3 -----
1 No 0 0
4 Yes 1.5 0
--
IOne teacher not CAPS member. 2Objectives being developed. 3th class - 5.5 hrs only. 4~ class = 2 hrs only.
Table 2. Survey of Pediatric S u r g e r y Medical U n d e r g r a d u a t e Teaching by C A P S M e m b e r s During 1 9 8 5 to 1 9 8 6 (Teacher Survey} Canadian
U.S.A.
Other
Total
No. surveyed
60
16
4
80
No. completed survey (%) Possible reasons for not responding Retired
45" (75)
14 (88)
2 (50)
61 (76)
Quit pediatric surgery Unknown Members with university affiliation
7 2 6
2
2
(%) No. of universities Members" academic rank (%)
43 (96) 15
Lecturer Assistant Professor Associate Professor Professor Emeritus Unknown Members with scheduled pediatric
4 8 16 13 ( 9 ) * * 1 1
surgery teaching as preceptor contact only (%) Type of teaching
35 (78) 7
12 (86) --
1
Lectures Tutorials Hours of didactic pediatric surgery teaching
29 23
12 7
1 1
Average Range Hours of didactic nonpedlatric teaching Average Range *Includes 1 Retired Ped. Surgeon. * * ( ) - No. of Universities.
13 (93) 12
2 (100) 2
58 (95) 29
1
5 (8) 14 (24) 22 (38) 15 (26) 1 (2) 1 (2)
6 6 2
--
48 (79) 7 42 31
30 (n = 30) 1-120
42 (n = 11) 2-200
160 (n = 1) --
36 (n = 42) 1-200
39 (n = 7) 8-96
---
48 (n = 1) --
41 (n = 8) 8-96
748
RAY POSTUMA
focus on a few common or important conditions in addition to the most important clinical problems listed under "content, part 4." The results of the teachers' survey of members from Canada, the United States, and elsewhere are found in Table 2. Most respondents had university affiliation (96%) and most (90%) had assigned pediatric teaching or contact with undergraduate students. Over 60% held the academic rank of Associate or Full Professor. The average assigned teaching hours was 36 hours per academic year involving lectures and tutorials. The survey was not able to determine the amount of preceptorial and informal teaching performed by members. DISCUSSION There are several important reasons why pediatric surgery should be taught in the undergraduate medical program: it could improve the quality of primary care of infants and children with surgical conditions since over 50% of Canadian graduates enter primary care and will not receive further instruction in pediatric surgery. Also, contact with pediatric surgery teachers could serve as role models for medical students and attract trainees into a career in pediatric surgery and thus alleviate the anticipated manpower shortage in Canada. 3 Third, with the increasing interest in undergraduate medical education and with the increased focus on curricular objectives and course design, pediatric surgical input is mandatory lest it disappear from the undergraduate curriculum of most medical schools. The recent medical literature and pediatric surgery textbooks, including several specifically aimed at medical students, lack discussion concerning the aims, objectives, content, and design of an appropriate undergraduate medical curriculum in pediatric surgery. The Education Committee of the APSA, as reported at its recent May 1986 meeting, is preparing a pediatric surgery undergraduate medical curriculum. Similar plans are in progress in the recently formed Association for Surgical Education. The Canadian Committee for Surgical Undergraduate Education recently prepared a proposed surgical undergraduate curriculum that includes a small section in pediatric general surgery. The written objectives available from five Canadian medical schools were excellent but varied considerably in scope, depth, and curricular content. Furthermore, the results of our institutional survey revealed that there is also a considerable lack of uniformity in the pediatric surgery curriculum of the 15 medical schools. The total amount of assigned time for pediatric surgery teaching is small, average seven hours, which
Table 3. CAPS Education Committee Members 1984 to 1985
1985 to 1986
G. Cameron (EO) J. Ducharme R. Kennedy
S. Mercer (EO) J. Dueharme R. Kennedy
R, Postuma* J. Fallis L. Levasseur
R. Postuma* A. Juckes
Abbreviation: EO, ex officio. *Chairman.
represents <0.2% of the total teaching time during the first 3 years in most schools. With one exception, a pediatric surgery clerkship was elective or not available in all schools. Only 25% of Canadian graduates received a pediatric surgical clerkship. The undergraduate curriculum hereby proposed by the CAPS may be too comprehensive for most medical schools, particularly in view of the limited time available. Nevertheless, we feel it can serve as a useful starting point for discussion and development of a uniform undergraduate curriculum across Canada. In fact, two Canadian schools are presently using it to develop their own curricular objectives. Hopefully, it will also stimulate schools to establish or review their own objectives. Members of the CAPS do have the potential for making curricular changes since 96% of those surveyed have university affiliation and 64% hold senior academic rank (Table 3).
APPENDIX PEDIATRIC GENERAL SURGERY UNDERGRADUATE CURRICULUM
Introduction This document outlines the knowledge, skills, and attitudes that medical undergraduate students should possess about Pediatric General Surgical conditions at the time of graduation from a
Canadian MD Program. The aim, objectives,and content of the PediatricGeneralSurgery Medical UndergraduateCurriculumis as follows.
Aim The aim of the PediatricGeneral Surgery UndergraduateCurriculum is to enable the student to learn and understand the pathophysiologyand diagnosisof commonand rare but importantsurgical conditionsin infantsand childrenand the principlesof their management.
Objectives In addition to the general objectives of the medical undergraduate program, the student is expected to achieve the following objectives
as they relate to Pediatric General Surgicalconditions. 1. Demonstratean understandingofthe embryology,physiology, and pathologyof commonand important PediatricGeneralSurgical conditions.
UNDERGRADUATE MEDICAL CURRICULUM
2. Demonstrate the ability to derive a differential diagnosis of common and important Pediatric General Surgical conditions. 3. In consultation with the pediatric specialist be able to initiate preoperative management when required in cases of emergency. 4. Learn the principles of decision-making regarding the timing of surgical therapy treatment. 5. Demonstrate competence in communicating with the child, parents, and consulting physician. 6. Demonstrate a responsible and humanitarian attitude in dealing with children and their parents.
Content The student will demonstrate an understanding of the following. 1. Embryology of malformations of the respiratory, gastrointestinal, genitourinary system, neck, and skin. 2. Physiology of fluid and electrolytes, nutrition and metabolism, temperature regulation, infection, growth and development, and psychologic aspects of infants and children. 3. The pathophysiology and principles of management of infants and children with acute respiratory distress, intestinal obstruction, malnutrition, multiple trauma, sepsis particularly peritonitis. 4. Pathology, physiology, and principles of management for the following clinical problems: Acute abdominal pain Vomiting Gastrointestinal bleeding Gastrointestinal obstruction in the newborn Foreign body aspiration and ingestion Acute respiratory distress Acute swellings of the groin and scrotum Abdominal masses Solid tumors Obstructive jaundice in the infant Swellings about the head and neck 5. Pathophysiology, diagnosis and principles of management of the following conditions.
Head and Neck Bronchiogenie anomalies Thyroglossal duct lesions Dermoids Tortieollis Cervical lymphadenitis Cervical lymphadenopathy Respiratory Epiglottitis Pierre Robin syndrome Choanal atresia Tracheo-esophageal fistula Traeheobronchial malacia Diaphragmatic hernia Lobar emphysema Pulmonary sequestration Congenital cystic lung disease Vascular rings Pneumothorax Bronchieetasis Empyema Chest Wall Pectus exeavatum Pectus carinatum
749
Gastrointestinal Appendicitis Adhesive obstruction Esophageal atresia and fistula Gastroesophageal reflux Intestinal atresia Intestinal malrotation/volvulus Meconium ileus Meconium pl.ug syndrome Intestinal duplication Omphalomesenteric duct lesions Imperforate anus Hirschsprung's disease Necrotizing enterocolitis Hypertrophic pylorie stenosis Intussusception Meckel's diverticulum Inflammatory bowel disease Intestinal polyps Anorectal conditions Hepatobiliary Cholelithiasis Hepatoblastoma Biliary atresia Portal hypertension Choledochal cyst Abdominal Wall and Genitalia Gastroschisis Omphalocele Umbilical hernia Inguinal hernia Hydrocele Undescended testicle Testicular torsion Acute scrotal lesions lntersex problems Female ovarian, hematocolpos Abdominal Trauma Liver injuries Spleen injuries Pancreatic injuries Battered child syndrome Tumors Neuroblastoma Nephroblastoma Teratoma Rhabdomyosarcoma Skin, Subcutaneous Layers, and Lymph Nodes Hemangiomas Nevus Dermoids Lymphadenopathy Lymphadenitis
REFERENCES
1. Rickham PP: Synopsis of Pediatric Surgery. Stuttgart, George Thieme, 1975 2. Jones PG: Clinical Paediatric Surgery Diagnosis and Management. Oxford, Blackwell, 1976 3. Mercer S: CAPS and Royal College of Physicians and Surgeons study of pediatric surgery manpower, 1986 (unpublished)
survey was followed up by telephone contact where necessary (institution survey). A suggested pediatric undergraduate surgical curriculum was then formulated by the CAPS Education Committee and approved in principle at the CAPS annual meeting in September 1985. Following minor revisions, the revised curriculum (appendix) was circulated in February 1986 for feedback to the 80 members of CAPS (curriculum survey). In addition, members were asked to complete a questionnaire concerning their personal involvement in pediatric undergraduate surgical teaching (teachers' survey).
RESULTS
From the Education Committee, Canadian Association of Pediatric Surgeons. Presented at the 18th Annual Meeting of the Canadian Association of Paediatric Surgeons, Halifax, Nova Scotia, August 28-30, 1986. Address reprint requests to Ray Postuma, AID, Chairman, Education Committee, Canadian Association of Pediatric Surgeons, 840 Sherbrook St, Winnipeg, Manitoba, R3A ISI Canada. 9 1987 by Grune & Stratton, Inc. 0022-3468/87/2208-0013503.00/0
The literature search produced eight articles in the English language. All were concerned with aspects of postgraduate education in pediatric surgery and none dealt with the undergraduate curriculum. Twelve pediatric surgery textbooks were reviewed: none offered advice or discussion concerning the pediatric surgery undergraduate program. Two textbooks were specifically aimed at the medical students, t'2 Rickham recommends that the medical student should be aware of the fundamental and pathophysiologic differences in children when managing their surgical problems? This is a point made by most authors. The results of the institutional survey are summarized in Table 1. Pediatric surgery is formally taught at all 15 medical schools. Information was not available from one school (100 graduating students). The amount of assigned teaching in pediatric surgery averaged seven hours (range 1 to 25 hours). Five schools had written objectives and two schools were developing them. Twelve schools offered clerkships in pediatric surgery; in one school the clerkship is compulsory for all students. The proposed curriculum survey yielded responses from 15 members (19%). The responses were generally very positive and encouraging. Six members offered several additions to the proposed curriculum and these are included in the revised curriculum (appendix). However, five members questioned whether the proposed curriculum was too exhaustive for medical students particularly since the amount of time available in the undergraduate curriculum was limited. In particular, there is concern that the number of conditions listed under "content, part 5" was too comprehensive and esoteric for students. Two members suggested the conditions listed could be categorized as "essential," "recommended," and "ideal." This has not been done. One member suggested that the curriculum should
746
Journal of Pediatric Surgery, Vol 22, No 8 (August), 1987: pp 746-749
INDEX WORDS: Pediatric surgery, undergraduate curriculum.
rHAT SHOULD undergraduate medical stu-
W dents learn about pediatric surgical conditions and their management? How and when should it be taught? These questions probably concern most members of the Canadian Association of Pediatric Surgeons (CAPS) since, as the following study will show, most members are involved in the teaching of pediatric surgery. MATERIALS A N D METHODS
A Medline literature search was conducted of all pediatric surgery education publications for 1969 to 1986. Also, the pediatric surgery textbooks found in the Medical Library of the University of Manitoba were reviewed for advice and discussion concerning the aims, objectives, content, and design of a pediatric surgery undergraduate medical education curriculum (literature review). In November 1984, a survey was conducted of the CAPS education representative in each of 15 cf the 16 Canadian medical schools. They were asked to submit details, including objectives, and opinions concerning the program at their respective medical schools. This
Table 1. Survey of the Pediatric Surgery Undergraduate Medical Curriculum at Canadian Medical Schools, 1985 to 1 9 8 6 (Institutional Survey) 1. University
MEM
2. No. of pediatric surgery hospitals 3. No. of 1985 graduates 4. Duration of Medical Program (yr)
DAL
LAV
MON
McG
Ol-r
Q U E E TOR
McM
WES
MAN SASK ALT
CAL
B.C.
1
1
1 200
1 154
1 88
1 78
1 269
2 106
3 103
2 92
2 57
2 113
1
60
1 158
1
57
69
121
4
4
4
5
4
4
4
4
3
4
4
5
4
3
4
1
3
2
8
4
3
2
6
2
2
5
31
2
1
4
3
1 Yes
7 Yes
3 No
3 Yes
2 No
5 No
2 No
2 No
2 Yes
31 No
2 No2
2 3
0 0
O 0
0 0
0 0
P
0 0
0 2
0 1
0 0
0 2
10 10 --
3 0
4 0
0 12 .
4 2
1 1
1
6
1L Yes
7.5 LT Yes
3 E 2 20
4 E 2 25
A,W
A,W
5. No. of CAPS members (active) 6. No. of CAPS teachers scheduled
1
7. Objectives (yes/no) 8. Med 1 (hr) 9. Med 2 (hr)
No 0 0
No= 0 2
3 0
6 0
10. Med 3 (hr) 11. Med 4 (hr) 12. M e d 5
--
13. Total didactic hours 14. Type (Lect./Tut.)
8 T
Yes
Yes
4 E 2 10
4 E 4 40
A,W
A,W
15. Clerkship in pediatric surgery 16. 17. 18. 19.
Curriculum year(s) Status (Elect/Comp) Duration (wk) % class taking
20. Type (Arab/Ward)
--
3 L
p
.
.
25
3
4
12
T Yes 3,4 E 4 2 A,W
L Yes 5 E 1 75 A
LT Yes 4 E 4 15 A,W
LT Yes 4 C 2 100 A,W
.
1
. 6
LT Yes 4 E 4 33 A,W
1 2 .
0 11.5 ~ .
4 0
5 1
1 1 p
4
11.53
64
7
2
4
LT Yes 4 EC 4 15 AW
L No 5 -----
LT No 3,4 -----
LT Yes 4 E 4 20 A,W
LT Yes 4 E 4 10 A,W
LT No 3 -----
1 No 0 0
4 Yes 1.5 0
--
IOne teacher not CAPS member. 2Objectives being developed. 3th class - 5.5 hrs only. 4~ class = 2 hrs only.
Table 2. Survey of Pediatric S u r g e r y Medical U n d e r g r a d u a t e Teaching by C A P S M e m b e r s During 1 9 8 5 to 1 9 8 6 (Teacher Survey} Canadian
U.S.A.
Other
Total
No. surveyed
60
16
4
80
No. completed survey (%) Possible reasons for not responding Retired
45" (75)
14 (88)
2 (50)
61 (76)
Quit pediatric surgery Unknown Members with university affiliation
7 2 6
2
2
(%) No. of universities Members" academic rank (%)
43 (96) 15
Lecturer Assistant Professor Associate Professor Professor Emeritus Unknown Members with scheduled pediatric
4 8 16 13 ( 9 ) * * 1 1
surgery teaching as preceptor contact only (%) Type of teaching
35 (78) 7
12 (86) --
1
Lectures Tutorials Hours of didactic pediatric surgery teaching
29 23
12 7
1 1
Average Range Hours of didactic nonpedlatric teaching Average Range *Includes 1 Retired Ped. Surgeon. * * ( ) - No. of Universities.
13 (93) 12
2 (100) 2
58 (95) 29
1
5 (8) 14 (24) 22 (38) 15 (26) 1 (2) 1 (2)
6 6 2
--
48 (79) 7 42 31
30 (n = 30) 1-120
42 (n = 11) 2-200
160 (n = 1) --
36 (n = 42) 1-200
39 (n = 7) 8-96
---
48 (n = 1) --
41 (n = 8) 8-96
748
RAY POSTUMA
focus on a few common or important conditions in addition to the most important clinical problems listed under "content, part 4." The results of the teachers' survey of members from Canada, the United States, and elsewhere are found in Table 2. Most respondents had university affiliation (96%) and most (90%) had assigned pediatric teaching or contact with undergraduate students. Over 60% held the academic rank of Associate or Full Professor. The average assigned teaching hours was 36 hours per academic year involving lectures and tutorials. The survey was not able to determine the amount of preceptorial and informal teaching performed by members. DISCUSSION There are several important reasons why pediatric surgery should be taught in the undergraduate medical program: it could improve the quality of primary care of infants and children with surgical conditions since over 50% of Canadian graduates enter primary care and will not receive further instruction in pediatric surgery. Also, contact with pediatric surgery teachers could serve as role models for medical students and attract trainees into a career in pediatric surgery and thus alleviate the anticipated manpower shortage in Canada. 3 Third, with the increasing interest in undergraduate medical education and with the increased focus on curricular objectives and course design, pediatric surgical input is mandatory lest it disappear from the undergraduate curriculum of most medical schools. The recent medical literature and pediatric surgery textbooks, including several specifically aimed at medical students, lack discussion concerning the aims, objectives, content, and design of an appropriate undergraduate medical curriculum in pediatric surgery. The Education Committee of the APSA, as reported at its recent May 1986 meeting, is preparing a pediatric surgery undergraduate medical curriculum. Similar plans are in progress in the recently formed Association for Surgical Education. The Canadian Committee for Surgical Undergraduate Education recently prepared a proposed surgical undergraduate curriculum that includes a small section in pediatric general surgery. The written objectives available from five Canadian medical schools were excellent but varied considerably in scope, depth, and curricular content. Furthermore, the results of our institutional survey revealed that there is also a considerable lack of uniformity in the pediatric surgery curriculum of the 15 medical schools. The total amount of assigned time for pediatric surgery teaching is small, average seven hours, which
Table 3. CAPS Education Committee Members 1984 to 1985
1985 to 1986
G. Cameron (EO) J. Ducharme R. Kennedy
S. Mercer (EO) J. Dueharme R. Kennedy
R, Postuma* J. Fallis L. Levasseur
R. Postuma* A. Juckes
Abbreviation: EO, ex officio. *Chairman.
represents <0.2% of the total teaching time during the first 3 years in most schools. With one exception, a pediatric surgery clerkship was elective or not available in all schools. Only 25% of Canadian graduates received a pediatric surgical clerkship. The undergraduate curriculum hereby proposed by the CAPS may be too comprehensive for most medical schools, particularly in view of the limited time available. Nevertheless, we feel it can serve as a useful starting point for discussion and development of a uniform undergraduate curriculum across Canada. In fact, two Canadian schools are presently using it to develop their own curricular objectives. Hopefully, it will also stimulate schools to establish or review their own objectives. Members of the CAPS do have the potential for making curricular changes since 96% of those surveyed have university affiliation and 64% hold senior academic rank (Table 3).
APPENDIX PEDIATRIC GENERAL SURGERY UNDERGRADUATE CURRICULUM
Introduction This document outlines the knowledge, skills, and attitudes that medical undergraduate students should possess about Pediatric General Surgical conditions at the time of graduation from a
Canadian MD Program. The aim, objectives,and content of the PediatricGeneralSurgery Medical UndergraduateCurriculumis as follows.
Aim The aim of the PediatricGeneral Surgery UndergraduateCurriculum is to enable the student to learn and understand the pathophysiologyand diagnosisof commonand rare but importantsurgical conditionsin infantsand childrenand the principlesof their management.
Objectives In addition to the general objectives of the medical undergraduate program, the student is expected to achieve the following objectives
as they relate to Pediatric General Surgicalconditions. 1. Demonstratean understandingofthe embryology,physiology, and pathologyof commonand important PediatricGeneralSurgical conditions.
UNDERGRADUATE MEDICAL CURRICULUM
2. Demonstrate the ability to derive a differential diagnosis of common and important Pediatric General Surgical conditions. 3. In consultation with the pediatric specialist be able to initiate preoperative management when required in cases of emergency. 4. Learn the principles of decision-making regarding the timing of surgical therapy treatment. 5. Demonstrate competence in communicating with the child, parents, and consulting physician. 6. Demonstrate a responsible and humanitarian attitude in dealing with children and their parents.
Content The student will demonstrate an understanding of the following. 1. Embryology of malformations of the respiratory, gastrointestinal, genitourinary system, neck, and skin. 2. Physiology of fluid and electrolytes, nutrition and metabolism, temperature regulation, infection, growth and development, and psychologic aspects of infants and children. 3. The pathophysiology and principles of management of infants and children with acute respiratory distress, intestinal obstruction, malnutrition, multiple trauma, sepsis particularly peritonitis. 4. Pathology, physiology, and principles of management for the following clinical problems: Acute abdominal pain Vomiting Gastrointestinal bleeding Gastrointestinal obstruction in the newborn Foreign body aspiration and ingestion Acute respiratory distress Acute swellings of the groin and scrotum Abdominal masses Solid tumors Obstructive jaundice in the infant Swellings about the head and neck 5. Pathophysiology, diagnosis and principles of management of the following conditions.
Head and Neck Bronchiogenie anomalies Thyroglossal duct lesions Dermoids Tortieollis Cervical lymphadenitis Cervical lymphadenopathy Respiratory Epiglottitis Pierre Robin syndrome Choanal atresia Tracheo-esophageal fistula Traeheobronchial malacia Diaphragmatic hernia Lobar emphysema Pulmonary sequestration Congenital cystic lung disease Vascular rings Pneumothorax Bronchieetasis Empyema Chest Wall Pectus exeavatum Pectus carinatum
749
Gastrointestinal Appendicitis Adhesive obstruction Esophageal atresia and fistula Gastroesophageal reflux Intestinal atresia Intestinal malrotation/volvulus Meconium ileus Meconium pl.ug syndrome Intestinal duplication Omphalomesenteric duct lesions Imperforate anus Hirschsprung's disease Necrotizing enterocolitis Hypertrophic pylorie stenosis Intussusception Meckel's diverticulum Inflammatory bowel disease Intestinal polyps Anorectal conditions Hepatobiliary Cholelithiasis Hepatoblastoma Biliary atresia Portal hypertension Choledochal cyst Abdominal Wall and Genitalia Gastroschisis Omphalocele Umbilical hernia Inguinal hernia Hydrocele Undescended testicle Testicular torsion Acute scrotal lesions lntersex problems Female ovarian, hematocolpos Abdominal Trauma Liver injuries Spleen injuries Pancreatic injuries Battered child syndrome Tumors Neuroblastoma Nephroblastoma Teratoma Rhabdomyosarcoma Skin, Subcutaneous Layers, and Lymph Nodes Hemangiomas Nevus Dermoids Lymphadenopathy Lymphadenitis
REFERENCES
1. Rickham PP: Synopsis of Pediatric Surgery. Stuttgart, George Thieme, 1975 2. Jones PG: Clinical Paediatric Surgery Diagnosis and Management. Oxford, Blackwell, 1976 3. Mercer S: CAPS and Royal College of Physicians and Surgeons study of pediatric surgery manpower, 1986 (unpublished)