Besides the love of children and the secret desire to never grow up, one of the draws of pediatric surgery was to forever be a “true general surgeon”. However, during residency, it became clear that “true general surgeons” were becoming extinct. For example, one of the general surgeons at my residency institution did a majority of the foregut procedures and had privileges to operate both in the chest and abdomen. Starting residency, I thought this was normal. It was not until later that I realized that 1) this was a rarity, and 2) my attending was a specialist (in every sense of the word); by the time I finished, his entire practice focused solely on foregut surgery.
Hence the draw of pediatric surgery. Not only was the anatomy and congenital disease processes fascinating, but it was also the wide breadth of operations in the surgeon’s repertoire and wide variety in the patient population that intrigued me. A pediatric surgeon could do a thyroidectomy, umbilical hernia repair, esophageal atresia repair, appendectomy, rigid bronchoscopy, and PSARP all in the same week. THIS is what I thought I wanted from my surgical career. Then I did clinical research at a large children’s hospital.
I was fortunate enough to have the opportunity to do both research and a pediatric surgical critical care fellowship at the same institution. This institution was completely different than what I had imagined. Every attending had a niche or sub-specialty. As a result, I saw sicker patients than I could ever imagine, the complexity of which was in some degree unparalleled to my previous training, and the volume was extraordinary, with patients being referred from all over the world. My time in the ICU was invaluable to learn not only the “basics” of pediatrics and pediatric surgery management, but how to manage ECMO, use the oscillator or JET ventilator and what complications to look out for during the post-operative recovery.
While appendicitis and hernia repair were also a part of the surgeons’ practice, it was the more complex patients that started to change my understanding of pediatric surgery. Children with complex congenital diseases, long-gap esophageal atresia, for example, are patients that some pediatric surgeons see only once a year; however, this institution was seeing new patients every week. This meant that the ancillary staff and other specialties were also on the cutting edge, forming multidisciplinary teams focused solely on each area of care for a specific disease. They were able to push the boundaries and had the resources to handle any complicated patient or complication that came through the door.
But is this realistic for everyone? Can every center be this highly specialized? If all you see are zebras, how do you recognize a horse when you hear its hoofs beat? Being able to recognize common problems, efficiently formulate treatment plans and understand all the potential presentations and complications is perhaps just as important, if not more so. By not pigeon-holing oneself into a particular subspecialty, a general pediatric surgeon can also be a resource and a leader for the entire surrounding medical community. By maintaining a wide scope of practice, the pediatric surgeon becomes a safety net for both the pediatric and adult communities, willing to accept any patient that others feel uncomfortable treating and being able to provide quality care for both the patient and family.
So which is the correct route? Be a general pediatric surgeon or be highly sub-specialized? Or does the answer change based on the individual and their goals? From the perspective of a patient, both are very much needed. Perhaps regionalization is the answer – a marriage between both extremes. With regionalization, the general pediatric surgeon can still provide care for the variety of common surgical diseases that arise in the pediatric population and remain the necessary link to the surrounding community. However, in order to advance the field, some specialization is probably required. Surgeons who have a special interest in a rare or complex congenital malformation, can collaborate with ancillary staff and other subspecialists to expand the knowledge and treatment options of these patients.
These are some things that I think about when I look ahead towards the future. As one of my former attendings used to say “the eyes only see what the brain knows.” Does one learn best from seeing common disease processes over and over, simulating ‘real world’ experiences? Or is being exposed to the rare, but still possible, malformations or complications what is needed to feel competent and prepared for anything as an attending? From a training perspective, I do not know what the best answer is for me yet. Ideally though, pediatric surgery should be able to blend the all-encompassing and the specialization that will ultimately provide care for everyone while pushing the field into the future.