#APSA 50: Robert E. Gross Debate

Between 2015 and 2030, the pediatric surgery workforce will increase by 45% while index case numbers remain flat or decline

In 1987 there were 22 pediatric surgery training programs; now there are upwards of 60

In a recent 4-year period, pediatric urology increased 53% and pediatric ENT increased 73%

Pediatric surgery training requires 4 years medical school, 5 years general surgery, 2 years research, and 2 years fellowship for total of 9+ years

Applicants spend an average of $20,000 (more than half their after-tax income) to apply for pediatric surgery fellowship, and 50% fail to match

One in five pediatric surgery fellows fail their boards

Every pediatric surgery operation saves not just one life but lifetimes and generations, unlike adult surgery which saves one person who has already reproduced

Millennials and Gen Z require immediate gratification, and pediatric surgery cases like ECMO cannulation provide this (blue baby with 30% saturation becomes 100% and pink immediately)

One-third of pediatric surgery cases come from being on call

93% of all pediatric surgeons in the United States depend on hospital support through affiliation agreements, directorships, or call contracts

Hospital reimbursement is DRG-based (tied to Medicare), but pediatric surgeons operate in a Medicaid world where uninsured/Medicaid patients have increased from 30% to 70% in Miami over 25 years

Phoenix Children's Hospital Medicaid percentage increased from 45% to 54% in just 4 years

RRC approves programs algorithmically based on criteria with minimal interest in pediatric surgery workforce health (0-5% interest level)

American Board of Surgery only certifies whether individuals are safe surgeons, without regard to training program characteristics or workforce needs

There are 18 pediatric surgeons per 1 million children in the United States nationally, but in rural states like North Dakota, South Dakota, and Montana there is sometimes one pediatric surgeon per 5 million people

Patients now research surgeons online and ask how many of a specific operation the surgeon has performed, making subspecialization inevitable

Resident case volumes have not changed as fellowships have been added, though significant variation exists between high and low volume programs

Not every pediatric surgeon should do abdominal neuroblastoma with vascular encasement or long-gap esophageal atresia; subspecialization based on outcomes is appropriate

80% of general surgery residents now go into subspecialties, with programs begging people to become general surgeons

Many general surgery residents training in non-fellowship programs will become colorectal or bariatric surgeons and never perform pediatric cases, making that training time arguably wasted

The United States culture does not support centralization of care; parents will seek immediate repair rather than wait 18 months as accepted in Canada

Bad outcomes in children carry unique emotional toll compared to elderly patients because of truncated lifetime, similar to obstetrics

Academic success per capita in pediatric surgery is very high compared to other surgical specialties

Two years of research during training helps trainees identify whether they have passion for academic work and is necessary to answer unanswered questions like NEC prevention and biliary atresia prediction

When APSA was founded 50 years ago, similar challenges existed: local general surgeons opposed pediatric surgeons, surgeons took call every night, pediatric surgery boards had failed twice, Medicaid had just passed, and CHIP was 20 years in the future

The pediatric surgery board, ACGME, and program directors now meet regularly to work through workforce and training issues