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Kathryn D. Anderson, MD Surgeon in Chief Childrens Hospital Los Angeles Professor of Surgery Vice Chairman of Surgery University of Southern California Pediatric surgery is a multifaceted discipline. Theoretically it is general surgery but confined to the child. For most children's hospitals and children's training centers the child is defined between zero and 21 years. In some institutions the zero is a minus quantity as there are a number of centers, which are adding the fetus as a patient. Pediatric surgery has maintained a very broad definition. Many of the areas which have been lost to the general surgeons and taken over by subspecialties have been retained by the pediatric surgeon who therefore operates not only in the abdomen but also in the chest, in the head and neck and many pediatric surgeons continue to do reconstructive urologic procedures. This makes it a very attractive specialty because of the breadth of surgery performed; it is also very attractive because of the complexity of many of the cases. It requires a special love of children and their families and it requires special knowledge of the physiology of children from the very tiny premature infant to the emerging adult. Residency RequirementsAt the moment completed training to board eligibility in general surgery is required for entry into a pediatric surgical training program. There has been some recent talk of curtailing the number of years in general surgery training and a number of specialties have gone in this direction, for example plastic surgery and cardiovascular surgery. Pediatric surgeons feel that a thorough background of training in general surgery is required to be able to serve the pediatric patient well and so the requirement for completed training in general surgery through the chief residency is presently mandated. The training programs in North America, which includes Canada, work with the National Residency Matching Program (NRMP).1 Interviews take place in the winter through the following spring each year. The matching list both from the candidates and from the programs are usually submitted to the NRMP in late spring and the results are known within one month or so. The match is one and one-quarter years ahead of the start date therefore most resident applicants will be in their fourth postgraduate clinical year when they interview for pediatric surgical training. Although this has never been a formal requirement many candidates will take one to two years for research. This is not necessarily in a pediatric setting nor is the research necessarily directly related to pediatric surgery; however, some advantage exists to be in the laboratory of a pediatric surgeon. As stated there is no mandate for this unless individual programs require it but one or two years of research usually produce a very mature resident applicant. This time is also quite useful for learning the research method since the two years of pediatric surgical residency in most programs are entirely clinical years. These two clinical years are the minimum required to obtain enough experience in the surgical treatment of children and therefore no time for dedicated bench research time is allotted. There is also some advantage to be in a general surgery residency where there is a pediatric surgery residency. Residency Pediatric surgical residency is two years in duration. Although the Residency Review Committee (RRC), with the advice of the training directors of pediatric surgery has published the "minimum" number of cases which are required, most of the programs far exceed these numbers. Therefore the clinical training in all of the training programs can be considered adequate. Depending on what cases are done on the general surgical services in the training programs, the resident may rotate to other services. For example otolaryngology for airway experience, urology for reconstructive urologic surgery, and sometimes rotations through the neonatal and pediatric intensive care units are also offered to the resident. Most of these rotations outside of general surgery occur during the first year. The second year is almost always exclusively running the pediatric surgical service.Since the residents become board qualified in general surgery as a rule they are mature, experienced operators and therefore most of the programs will allow a great deal of independence for the residents during their two years. During the two years of residency formal and informal evaluations of the residents occur periodically. The residents should also have the opportunity to evaluate their teachers and also the program itself. The American Board of Surgery in-training exam is subscribed to by all of the training programs and the residents take this examination in February of each their two years. Board Certification Residents in pediatric surgery will be eligible to take the board examination in Surgery by American Board of Surgery. Therefore, the pediatric surgery resident should become certified by the American Board of Surgery during this time. At the end of two years they are eligible to take the board examination for the Pediatric Surgery Board. This is given every two years and as in the general surgical examination consists of two parts, a written certifying examination and an oral qualifying examination. This will be taken either immediately following the residency or the following year depending on when the Board examinations are given.Grant Funding, Research Fellowships Since the two clinical years of training in pediatric surgery are so packed there is little or no opportunity to do ongoing bench research and certainly not enough protected time can be given to obtain grant funding. Several courses in advanced laparoscopy are given through the country and the pediatric surgical resident may have the opportunity to participate in one or more of these courses at the training director's discretion. Research fellowships either before or after the clinical training may be available but there is no formal requirement for this by the Residency Review Committee.The American Pediatric Surgical Association (ASPA) foundation also gives scholar awards to young pediatric surgeons doing basic or translational research.2 This is a relatively small stipend, but most of the recipients of these awards have gone on to obtain significant National Institutes of Health (NIH) funding. For those pediatric surgeons interested in clinical research, the APSA Outcomes and Clinical Trials Center was established in July 2000, and is located within at the American College of Surgeons, Headquarters, in Chicago IL. The goal of this center is to conduct and promote research efforts in pediatric surgery, and to define evidence-based guidelines through outcomes assessment. They provide a nationally centralized data and communication hub for a network of participating study centers. Membership in SocietiesPediatric surgical residents are encouraged to become candidates and associate members of the American College of Surgeons (ACS). Most pediatric surgeons ultimately become Fellows of the ACS. The APSA also has a candidate membership available to pediatric surgical residents and this is also encouraged.2 Money is usually available within each of the training programs for residents to attend one to two meetings a year to present clinical papers. Another organization to participate in is the Surgical Section of the American Association of Pediatrics (AAP).3 Journals Journal of Pediatric Surgery (main journal for pediatric surgeons)Pediatric Surgery International Journal of American College of Surgeons Professional Development Professional development after training should be ongoing. Young academic pediatric surgeons should attend: the ACS Pediatric Surgery Forum Session; ACS Panels and postgraduate courses; the AAP Annual Meeting (Surgical Section); and the APSA Annual Meeting. Young pediatric surgeons should also become involved in committee work in their societies and become actively involved in ACS activities. References 1. National Resident Matching
Program (NRMP)
2. American Pediatric Surgical
Association (APSA) 3. The American Academy of
Pediatrics
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