The role of pediatric surgery in general surgical education

The role of pediatric surgery in general surgical education

The Role of Pediatric Surgery in General Surgical Education By William P. Tunell M OST PEDIATRIC SURGEONS believe their speciality to be in the main...

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The Role of Pediatric Surgery in General Surgical Education By William P. Tunell

M

OST PEDIATRIC SURGEONS believe their speciality to be in the mainstream of general surgical education and practice and, in fact, many pediatric surgeons are involved in the training of general and thoracic surgery residents. Proper training of general and thoracic surgery residents without diluting the pool of newborn surgery, necessary for a viable speciality, is the educational goal of most pediatric surgeons. Since, 1954, a pediatric surgeon has been a member of the full-time faculty in the Department of Surgery at the Louisiana State University (LSU) School of Medicine in New Orleans. A review of the practices of the surgical residents completing training after this date can be expected to define the type and amount of pediatric surgery they perform and to elicit subjective comments on the role of pediatric surgery in general surgical education. METHOD

The residents who completed the general and thoracic surgical residencies at LSU in New Orleans from 1955 through 1971 were surveyed by written questionnaire. Three groups of questions were included. The first group inquired demographically concerning the practices of these surgeons. The second requested estimation of the proportion of pediatric surgery in their entire surgical practice and a tabulation of the personal pediatric operative cases in the year preceding the survey. The third asked if pediatric surgery was a worthwhile component of general surgical education and suggested additional comments if desired. RESULTS

One hundred-three residents completed training in general and thoracic surgery from 1955 through 1971; nine could not be located; two are pediatric surgeons and were not surveyed. Of the 92 questionnaires sent, 78 were completed and returned (85%). Four surgeons who returned the questionnaire are not practicing, so the results are based on 74 active surgeons. Most, but not all, answered every question thus accounting for variations in total replies in the tabulated categories. (A)

Practice Demographics

Sixty-four of the 74 practice general surgery, eight thoracic and two plastic surgery. The mode of practice is indicated in Table 1. Thirty-nine are in LouiFrom The Section of Pediatric Surgery, Department of Surgery, Louisiana State University School of Medicine. New Orleans. La. Presented before the Ftfth Annual Meeting of the American Pediatric Surgical Association, New Orleans, La.. April 4-6. 1974. Address for reprint requests: William P. Tunell. M.D.. 1542 Tulane Ave., New Orleans, La. 70112. o 1974 by Grune & Stratton, Inc. Journal d Pddiatric Surgery, Vol. 9, No. 5 (October), 1974

743

744

WILLIAM

P. TUNE11

Table 1. Mode of Practice Private Solo

27

Group

42

Surgical

20

Mixed

14

Institutional

4

Teaching

1 74

siana; overall distribution is indicated in Fig. 1. Nearly half are located in communities with a population under 50,000 (Fig. 2). There were at least two returns for each yearly group of “graduating” residents. (B)

Pediatric Surgery in Practice

(1) Pediatric surgery as a percentage of total practice. Three respondents did not do any pediatric surgery. Fifty-seven stated pediatric surgery was a small part of their practice, while 11 described as moderate the contribution of pediatric surgery to their total practice. Percentage estimates ranged from less than 1% to 15x, while one surgeon, doing institutional oncologic surgery, noted that children comprise 25% of his practice. (2) Type and amount of pediatric surgery. The surgical case load for the year preceding the survey is shown in Table 2. Twenty-nine of the 74 surgeons

Fig. 1. Geographical distribution of former residents.

1-5,Gtm

t i;i A t: S E 5 0 Fig. 2. Pmctice of commtinity sire’:

former

residents by

5#oct10,ooo 10,cto@25#00 2s,octcMo,ooo 5o,ow-loG,ooo loG,ooS5oo,ooo ~5Go,ooo

PEDIATRIC

SURGERY

IN GENERAL

SURGICAL

745

EDUCATION

Table 2. One-Year Opemtive

Experience Number of Surgeons

(l-2 Cores)

Common Conditions Pyloric

stenosis

lnguinal

hernia

Appendicitis Trauma

Uncommon Conditions

(l-2

lntussusception tfirschsprungs

disease

tumor

Urologic

(major)

3

58

18

40

(l-2

Congenital

Esophageal Intestinal

atresia atresia

lmperforate

25 Mony (Over 2 Cores)

Cases) 10

2

2

0

6

0

1

0

21

cases

Cardiac

anus

Omphalocele Total

54

with

neuroblastoma

Total

5

6

Many

cases

Wilms’

29

2

Fractures Totol

(Over 2 Cases)

NonCardiac

Cases

7 (Over 2 Cares)

Cases) 2

4

4

0

6

0

3

0

5

0

22

0

stated that they perform definitive surgery on newborns. In tabulating the operative cases done by these 29 surgeons it was found that eight of the 22 general surgeons in that group had operated upon at least one newborn in the preceding year (Table 3). An overall analysis of newborn cases revealed that ten genera1 surgeons did a total of 15 newborn cases (Table 4). Eight of these ten surgeons were in the group of 23, who replied that no pediatric surgery consultation was available to them; 45 having replied they had access to pediatric surgery consultation and referral. (C) Value of Pediatric Surgery in General Surgical Education Sixty-one of 72 (85%) responding stated that pediatric surgery was “a worthwhile component of general surgical education.” Five made the additional comment that it was indispensable. Thirteen stated that pediatric surgery was not worthwhile, with seven of the 13 noting limited clinical experience as their prime consideration. One general surgeon had special training in children’s oncologic

Table 3.

Surgeons Who Choose To Do (Major)

Newborn

Surgery

No. Surgeons Total

29

so choosing 7

Thoracic

22

General Cases

previous

year

Yes

8

No

14

WILLIAM

746

Table 4. (Surgeons

performing

Newborn

P. TUNE11

Surgical Cases

at least one operation in survey year) No. of Surgeons 16

Total (incl. thoracic)

10*

General surgeons Total cases lntestinol otresia

15 6

Esophageal atresia

1

lmpetforate anus

3

Ompholocele

5

*Ten of the 15 operations were performed by general surgeons.

surgery, and of the general surgeons, only he declared special competence pediatric surgery.

in

DISCUSSION

The dilemma for pediatric surgeons is to meaningfully supplement and influence the education of general and thoracic surgical residents, anticipating that general and specialty surgeons will continue to provide most of the surgical care to children, while at the same time maintaining an elitist view of neonatal and uncommon children’s surgery as the province of the pediatric surgeon.’ This, indeed, is especially true if, as has been suggested, one pediatric surgeon, per one million population, can provide satisfactory neonatal care.2 However, the viewpoint of the general or thoracic surgeon, trained with the assistance of pediatric surgery, toward the value of pediatric surgery in education, and toward his own competence in pediatric surgery is uncertain. This survey indicates that general and thoracic surgeons recognize and appreciate pediatric surgery as an important part of surgical education and furthermore indicates that the average general surgeon does little neonatal or uncommon children’s surgery. Ten genera1 surgeons did operate on a newborn during the survey year. Two noted that their cases were unusual emergencies. The remaining eight were in practice in predominantly smaller communities. It would seem fortuitous that each of the eight fell into the group of 23 respondents who recognized no pediatric surgery referral route; in fact, the volume of uncommon and newborn pediatric surgery, done by general surgeons, may be significantly influenced by the needs of geography. The intent of this survey was to help determine the needs of the individual surgical resident as defined by his likely future practice. The author concludes from this survey that pediatric surgeons should teach general and thoracic surgical residents; without feeling compelled to assign major neonatal surgical procedures to them and without fearing the production of large numbers of pseudopediatric surgeons. The average surgical graduate will do a little neonatal and uncommon children’s surgery. SUMMARY

Seventy-four practicing surgeons were surveyed regarding pediatric surgery in their surgical education and practice. Most care for the common surgical diseases of childhood; ten (13.5%) had

PEDIATRIC SURGERY IN GENERAL SURGICAL EDUCATION

747

done major noncardiac neonatal procedure in the preceding year. Sixty-one (8273 considered pediatric surgery to be a valuable component of general surgical education. ACKNOWLEDGMENT The author thanks Rowena Spencer and James A. O’Neill, Jr., the Pediatric Surgeons at Louisiana State University during the years covered by this survey. REFERENCES 1. Editorial. J Pediatr Surg 1:119, 1966 2. Rickham PP: An analysis of pediatric

surgery in North America and Northwestern Europe. J Pediatr Surg 7:475, 1972

Discussion Dr. E. Fonku/srud(Los Angeles): We owe a lot of gratitude to Bill for taking on this study which is indeed a great amount of statistical work, but which gives us a great deal of information on a localized community. With the discussions that we had yesterday about the pediatric surgery programs being so few in number, I think there are 62 or so, if I recall; it is quite obvious that if we train only 13 residents a year in pediatric surgery then about 80% to 85% of our neonatal centers are going to be staffed by a general surgeon. The exposure of a general surgery or thoracic surgery resident to pediatric surgery rotations of 3 to 6 mo during the course of his third or fourth year of training has been a particularly valuable experience for him. Not necessarily in just doing a few cases, but primarily learning the fine techniques. Learning to handle tissues in a little different manner than he might do if he were rotating on a gynecology service. Furthermore, others have indicated that their whole background in intravenous hyperalimentation, fluid and electrolyte balance, and other areas such as this, has primarily been taught in the field of pediatric surgery rather than in their general surgery rotations. Dr. A. Hailer (Bakimore): This is very useful and helpful information, but I disagree that this is necessarily typical of all the training programs in the United States. Each of us has our own local guidelines and our own individual kinds of relationships in general surgery. Our chief surgical residents, up until we had a children’s surgical training program at Hopkins, were trained to do major pediatric surgery and they continue to do major pediatric surgery as general surgeons throughout the United States. The point that I would like to make is that we must be very careful in our training programs that we do not expose young residents to doing things that they will not be called upon to do later. The most dangerous kind of thing that we see in our training programs is overtraining people for what their job descriptions will be. It is not a good idea to take a fifth year resident in general surgery through the first T.E. fistula he has ever seen and then give him the impression that he is technically able to do it. My own conviction is that general surgeons should come through the program as interns and first year assistant residents where they can learn how to take care of children. They can learn how to do a good hernia operation in an infant and to do a good pyloric operation. Dr. J. Dickenson (New York): I think we make an unwarranted assumption that the quality of those hernia operations done are good. I see a distressing number of hashed-up testes and excised navels which were done by general surgeons.