As published in the American Journal of Surgery (February 2010, Volume 199, Number 2) Re-published at OnSurg by permission of our collaborative partners at the Association of Women Surgeons.
Author: Danielle Walsh MD
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.
Nearly 75 years ago, pediatric surgery began an evolution into its own specialty due to increasing awareness that “children are not just little adults.” From congenital defects to variable physiology, neonates and children have distinctive constellations of problems and complex surgical needs rarely seen in adults. The surgical treatment of the child requires a love of children, patience with their families, understanding of their unique physiology, and delicate surgical technique. Pediatric surgery is sometimes described as the “last bastion of the true general surgeon” as the pediatric surgeon typically performs the gastrointestinal, thoracic, vascular, transplant, and trauma care of the patient; there is much less the division into the organ specific sub-specialization seen in management of adult surgical patients.
There are an estimated 800 practicing pediatric surgeons in the US, though they compose less than 2% of all surgeons.(1) Women, minorities, and international graduates are an important component of the pediatric surgical workforce. According to the AMA, 19.1% of full-time active pediatric surgery faculty are women, while 30.7% of pediatric surgery residents are women. Just under 5% are international medical graduates.(2) A wide-range of practice settings are available to the surgeon including provision of care in a full-service adult hospital with a pediatric unit, a freestanding children’s hospital, or even an urban community hospital. Because of the volume of births and children needed to sustain an exclusively pediatric practice, these subspecialists are unlikely to be found in a rural setting. While many pursue academic careers with research and significant educational commitments, others explore small group or private practice with strictly clinical responsibilities. Though the vast majority are in full time practice, a small number practice part time or serve as locum tenens.
Medical students with an interest in pursuing pediatric surgery should strongly consider an elective in the subspecialty during the fourth year of medical school. Students at medical schools not offering rotations in the specialty will find that most pediatric surgeons at other institutions are happy to have them rotate if the appropriate administrative arrangements are made. While not mandatory, the elective may allow the trainee to determine of the field is a “good fit” for their personality, and it may impact his/her choice for a general surgery training program. Attending a general surgery program with a pediatric surgery fellowship is not mandatory, though some residencies provide more or less exposure to the subspecialty and residency choice may impact the availability of mentors for career development. A series of excellent interviews from 15 different pediatric surgeons is available on the Website of the American Medical Student Association and provides some insight on the training, challenges, and rewards of a pediatric surgery career.(3)
Completion of a full residency in general surgery remains a requirement for entering a residency in pediatric surgery. Interviews for pediatric surgery residency generally occur from January through April in the year prior to the anticipated start of training. As such, most applicants have made their decision to pursue sub-specialty training no later than the start of the 4th year of general surgery training. There are now 44 ACGME approved training programs distributed between the US and Canada, though some of the programs only accept one fellow every two years.(4) The traditional format of online application through the Association of American Medical College’s Electronic Residency Application Service followed by a period of interviews and a subsequent match day is used. Occasionally, programs may elect not to enter the match and select a promising candidate directly.
Unlike many other surgical subspecialties, the number of applicants for pediatric surgery residency continues to exceed the number of available training positions. Competitive applicants will have letters of recommendation describing excellent clinical judgment, strong technical skills, a high degree of professionalism, good work ethics, and effective personal skills. Most, though not all, will have spent a period of time in research endeavors and demonstrated success in writing, presenting, and publishing.
Candidates who do not match in pediatric surgery, but are committed to a career in pediatric surgery, may elect to spend an additional period of time in either research further clinical training. For these trainees as well as interested general surgery residents, a number of programs have developed for concentrated clinical training in specific areas of pediatric surgery. Current offerings include ECMO, Endosurgery, Critical Care, Fetal Surgery, and Vascular Malformations. While some have been evaluated and approved by the ACGME, none of these positions count towards the two year requirement for pediatric surgery residency training. Acceptance of these positions provides clear exposure to working pediatric surgeons and an opportunity to see firsthand the challenges and rewards of pediatric surgery. A full listing of the available positions is posted on the APSA Website by the Association of Pediatric Surgery Training Program Directors.(5)
Residency in pediatric surgery consists of two years with focus on “congenital, neoplastic, infectious, and other acquired conditions” of the abdomen and thorax. Exposure to the operative and non-operative management of pediatric multi-system trauma remains an integral component of training. Residents are expected to develop minimally invasive and endoscopic skills for evaluation and treatment of both the respiratory and gastrointestinal tracts. Components of training will also focus on care of the critically-ill infants and children with understanding of ventilator management, nutrition, cardiopulmonary resuscitation, and extracorporeal membrane oxygenation (ECMO).
To better achieve these requirements, a standardized core curriculum has been developed, including a series of basic science lectures for pediatric surgical trainees. To supplement the experience at the individual training program, several resident training sessions with focus on advanced laparoscopic techniques, colorectal procedures, and other uniquely pediatric disorders are held nationally. Individual programs may also include training in pediatric transplantation, obesity surgery, urology, and even limited cardiovascular procedures. In January of each of the two years of residency, an in-training examination is administered through the American Board of Surgery (ABS) to monitor the progress of the trainee’s knowledge acquisition.(6)
Like general surgery residency, pediatric surgical training complies with the ACGME 80 hour work week and the requisite days free of training responsibilities. Because pediatric surgery residents are already fully trained as general surgeons, most programs allow a greater degree of independence in management of patients and decision making. Most fellows will find the training of general surgery residents and medical students to be an important component of their responsibilities. At the completion of the program, residents are expected to have performed at least 800 major pediatric surgical cases and overseen the non-operative trauma management of 90 children, though most well exceed these minimums. A plethora of job opportunities in a wide variety of practice settings remain available to those who complete their training and a sampling can be seen on the APSA Website.(5)
In addition to completion of training and board certification in general surgery, pediatric surgeons may also earn a Certificate of Special Qualification in Pediatric Surgery. Since 1973, the ABS has granted the additional certification to those who complete a two year, ACGME approved pediatric surgery residency and successfully pass both the qualifying (written) and certifying (oral) examinations in the specialty.(7,8) Just under 1,000 pediatric surgeons have achieved board certification in the specialty as of January 2008.(6)
Following certification or recertification, pediatric surgeons are now enrolled in the new ABS Maintenance of Certification programs. Surgeons must document programs of continuing medical education above and beyond state licensing requirements. All must take a self assessment examination every 3 years in addition to participating in an outcomes database or program to assess quality of care. Finally, a secure written examination in pediatric surgery must be passed every 10 years. Pediatric surgeons are not required to maintain General Surgery certification, though it is highly encouraged.
Research Fellowships and Grant Funding
Pediatric surgeons have long promoted themselves as true surgical scientists with a higher emphasis on basic science and translational research than found in other surgical subspecialties. As such, a number of research positions studying a broad range of diseases are available to trainees with an interest in pediatric surgery. Many of these positions include funding for those who also accept clinical call responsibilities while others have opportunities, though not requirements, for moonlighting. A large number of these available positions are listed on the APSA Website. Some general surgery residencies will fund the salaries of their resident during the research years. Additional funding opportunities are available through surgical organizations, to include the American College of Surgeons, the American Academy of Pediatrics, and the Association of Women Surgeons.
Though the two year clinical residency in pediatric surgery rarely provides opportunity for basic science investigation, it is common for clinical papers and case presentations to come to fruition. A number of the more research oriented training programs will also offer financial support for a year or more prior to or subsequent to the actual clinical residency for the developing pediatric surgeon to establish a foothold in basic science research at the beginning of his or her career. For the very talented budding surgical scientist, some residency programs have even supported the pursuit of a PhD degree at the completion of clinical training.
APSA has also developed an Outcomes & Clinical Trial Center within the American College of Surgeons to assist in the organization of outcomes research, promotion of active projects, and collection of data. A number of prospective, randomized, multi-centered trials in progress through the center can be reviewed on the APSA Website.(6)
Even after completion of all training and entry into the workforce, pediatric surgeons remain dedicated to the pursuit of optimal care of the child. Organizations such as APSA, the Surgical Section of the AAP, and the American College of Surgeons support continuing medical education through annual conferences, forums, and journal. In addition, some pediatric surgeons develop a particular area of practice within the field, to include trauma, transplantation, ECMO, and minimally invasive techniques and additional memberships in related organizations supplement ongoing education.
Author: Danielle Walsh MD
Clinical Associate Professor
Division of Pediatric Surgery
Brody School of Medicine
East Carolina University
Greenville, NC 27834
Link to descriptions in other gen surg subspeciaties: