Welcome to the latest episode of State Current and Pediatric Surgery, a multimedia production designed to spread the latest knowledge freely. This chapter is created and edited by Todd Ponsky, Alex Cassar, Alex Gibbons, and myself, Ray Hankey, in partnership with the Behind the Knife podcast crew, Wu Doe and Meganna Cashship. Our coverage of AFSA's 50th anniversary meeting wouldn't be complete without a little history lesson and guidance for the future. Today we join Doctor Jim O'Neill from Vanderbilt and Doctor Joe Shapiro from Brigham and Women's as we journey through the past and peek into the future. Over this week we've had the chance to reconnect with or learn about so many individuals essential to the field of pediatric surgery. Dr. O'Neill, would you mind giving us some highlights? Well, thank you. The job that I was given had to do with a short talk that discussed the journey that the pioneers in pediatric surgery had to follow, and It was an interesting history because it, I believe, serves as a model for how the future should be carved out. We have to have some idea of what the times were like, what the times are like now, things like that. And so that's the value of history. The story of what's passed is prolonged. So at the beginning of pediatric surgery, there really were only 3 people who struggled over a period of years to devote their energies exclusively to children's surgery, and they were William Ladd, who worked for close to 28 years before he was able to specialize. Dr. Ladd was the first professor of pediatric surgery at Harvard and the Boston Children's Hospital, but he was taken on the staff, and it was a good 5 years before he was made professor and head of the service. He had political struggles, but he was excellent. He was very able in research, and so he began to talk about. What needed to be better in children's surgery. Fortunately he was not alone. There was Dr. Herbert Koh in Seattle, and Dr. Koh was a general surgeon out there in the Pacific Northwest who became very discouraged by the poor care of children who had surgical disease. The other asset that he had other than a strong sense of ethics. And belief in advocacy for the child was that he was an astute politician. So anyhow, Dr. Kh went off and got some extra training, but really it was just kind of an apprenticeship or observership, and he went back to Seattle and initiated a practice that was associated with the University of Washington. So he established this powerhouse which today is even more of a powerhouse. And the 3rd person, there are only 3, was Oswald Wyatt in Minneapolis, and he too established a very, very strong practice. He was another story of a general surgeon who got expertise in pediatric, general, and thoracic surgery. Pediatric surgery was much broader in scope in those days because there were no specialists otherwise. So those 3 men began an example of what was needed for childcare, and fortunately they were situated in different parts of the country, and each of them brought in more people and expanded. Dr. Ladd was in an influential institution that was able to train people and they We were able to send them out. Now the person I highlighted in my speech was H. William Clatworthy. Now the reason that I chose Dr. Clatworthy was that he had insight into how could pediatric surgery develop itself in a credible fashion so that the specialty would be validated alongside general surgery, and what he did was to first find out why pediatric surgery could not obtain boards. And I don't have time to go into all of the details, but he was able to find out what the objections were on the part of the American Board of Surgery to pediatric surgery, having what what you would call a sine qua non of acceptance, that is board certification, but there were Many, many steps along the way before structural steps that had to be taken before you could even apply for boards, but since there had been an abortive attempt by Dr. C. Everett Koop, who was my predecessor in Philadelphia, they had an idea. Dr. Clatworthy in particular had an idea. About going to the chair of the American Board of Surgery, finding out from him what the deficiencies were, and then creating an intentional, I emphasize intentional strategy to achieve board certification, and there were 4 major factors involved. The first was that there was the impression that pediatric surgery had no unique body of knowledge above general surgery. Over time, with the production of textbooks, journals, the establishment of the journal. Pediatric surgery and the establishment of this organization beyond the surgical section of the American Academy of Pediatrics because the second objection or deficiency was that we had no organization with surgical roots. We're only with the pediatricians that didn't count in their view, so that led to the formation of APSA. Dr. Clapworthy was one of those people. The third deficiency was that there was no evidence that the educational programs in pediatric surgery had a, uh, curriculum that was approved, other approved standards, metrics for certification. Any of those things. And interestingly, Dr. Clatworthy decided to tackle that one himself and so he developed a curriculum. He developed metrics for certification. He got these things approved in the preamble of his document at the very beginning. He said these requirements, these were the essentials for training in pediatric surgery, these requirements are designed to meet the requirements of the, wasn't the ACGME at that time, the accrediting organization, the American College of Surgeons, and the American Surgical Association. Now remember this was all general surgery in that day and the other had to do with a structure of governance and so forth that could relate to the major accrediting organizations, so this strategy was organized and carried out in an intentional fashion by Doctor Clatworthy and so I chose him because without his savvy. In terms of knowing how to go about the process, it couldn't happen. It did happen after things came into place. APSA was a linchpin. The Journal of Pediatric Surgery was a linchpin. All of these were designed to meet those four deficiencies, um, and of course by 1970, um, 1971, we had actually done all those things. We had our infrastructure, so in 191971, the fifth application for boards. Was finally approved by 1973. Well, since that time over the 50 years, there have been developments clinically with a strong technological sidelight. They have certainly developed further educationally. But ala Doctor Clatworthy, they were all designed to adhere to the general guidelines used by by all surgical specialties. So that there were was a single standard of, uh, accreditation and, um, education. Obviously the curricula vary by specialty, um, and, uh, then, um, I think. Maybe even more important, the tremendous expansion in scientific activity, the development of new knowledge that could be applied. And so this 50 year transition. In the life of any specialty is really relatively short, although it was long. In terms of the people who were involved. As that time of the 50 years went along, The body of knowledge expanded so much. That we began to see actually pediatric general surgery actually promote. Their specialties and their organizations such as urology, otolaryngology, neurosurgery, etc. etc. and of course I think that's the pathway to the future. I would also perhaps like to see, I mentioned three things patient care, education, and research. We are very good at collaborating in research. We are pretty good at collaborating in terms of care, particularly in institutions. We are lousy about collaborating in education. We do not share the advantages each of our specialties has, with one exception. Today, if one works globally. In the educational mission hospitals you immediately see total collaboration, people scrubbing together, people sharing knowledge, and I think that's the next step or the next challenge for the future to be less insular and more cooperative, more collaborative in terms of sharing. The wonders of science and so forth. And so the value of a historical review is to point the pathway for the future. There was an incredible air of change at this year with the reveal of a new strategic goal, equity and social justice, built. On the foundation of inclusion, representation, and participation for all, as Doctor O'Neill shared his hopes for change and future educational collaboration amongst pediatric specialists, Doctor Shapiro shares another exciting opportunity for the future of pediatric surgery. The area that I'm particularly interested in is the well-being of us as surgeons, as people, as professionals, and. Um, there's certainly great minds working on this across the country and, and, and outside of our country. What, what strikes me as such a perfect opportunity in an organization like ABSA is you have respected leaders. Who have tremendous connections with other leaders in other specialties and and other places across the country, cross generational where we could work together to move forward interventions that actually will positively impact the well-being of us as surgeons and I think it's that kind of collaboration with the energy and resources of this organization. That's really gonna, I think, catapult us beyond where we are now because I think we're still at the figuring this out stage. These problems are really challenging. We are in the best profession in the world, I believe, and it's also incredibly challenging, and I think the challenges have changed from when I trained um to what it's like to practice now at, at my age, our age, and then also for, for you all coming through the system. And we need to be responsive to those changes and then what we can do both personally but also as groups of leaders and involved surgeons in in in our other roles. So to be more specific, um, one of the things that I've been interested in is trying to operationalize a program in peer support where we are proactive in reaching out to colleagues after they've been involved in potentially emotionally stressful events. The most difficult one in some ways is when we're involved in adverse events where we may have had some kind of hand in an outcome that was unexpected and absolutely not desired by us or our patients and families. It's a very vulnerable moment as it should be for any clinician because we feel terrible and what we know from the data is not doing anything about that, just leaving us to our own devices and get over it, get back on the horse next case doesn't work. It can work for certain people in certain circumstances, but if you look at the literature, it is absolutely a driver of burnout, depression, and suicide, and it's on us to do something about that, to try to intervene and prevent those bad ultimate outcomes for us as surgeons for two reasons. One is, of course. Our own emotional, physical well-being will impact the care we give to patients and families, no question about that. So it's actually a safety and quality issue and also we are really dedicated, caring human beings and we deserve care to to to care for ourselves and also to be cared for as a community to care for each other and I think as surgeons in some ways we're taught that it shouldn't hurt. That these things are not supposed to affect us when in fact I think it would be a very walled off and probably ineffectual clinician who was in that much denial about his or her humanity. And I think we know that now. It's certainly not. Most of us were trained. We were trained to ignore that part of ourselves, but I think most of us also learned very early on that if we don't bring our humanity to our work and our patients and their families, then we're not really good surgeons at all. One of one of the joys of working on these programs with surgeons is that we're very we're really good at operationalizing. And I think we we've gotten to the point for example in well-being where we've all said we've got a lot of studies, there's a lot of data showing what the status quo has brought us, um, and there's something about surgeons where we're willing to say let's do something about it and so it's been, it's really a wonderful collaboration because people really want to do something and we do have programs we have them we just need to figure out a way to to spread them and to improve them. So I, I'm very excited again for the future possibilities of collaboration, mining the expertise and also the different perspectives of, of, of people who are in ABSA to be able to bring forward some of these programs to just begin addressing some of these vulnerabilities and challenges that we have because of our the incredible honor we have of of being in these positions where we have people's lives in our hands. As Doctor Shapira mentioned, surgeons are great at operationalizing. Will you accept their challenge to 1, increase educational collaboration, and 2, encourage wellness amongst those around you? Continue this conversation on the Stay Current app. Join us next week as we bring you a few highlights captured by the Behind the Knife podcast team. This is Ray Hankey from Cincinnati Children's Hospital. Remember, knowledge should be free.
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