#APSA 50: Robert E. Gross Debate

Topic overview

The 50th APSA meeting featured a debate moderated by Dr. Jacob Langer from The Hospital for Sick Children. The topic debated was:
"Be it resolved that I would NOT encourage my daughter or son to become a pediatric surgeon."

Representing the side supporting this statement were Dr. Cathy Burnweit from Nicklaus Children's Hospital and Dr. Daniel Ostlie from Phoenix Children's Hospital. Representing the side against this statement were Dr. Andrea Hayes-Jordan from North Carolina Children's Hospital and Dr. Douglas Barnhart from Primary Children's Hospital.

Intro and outro tracks are adapted from "I dunno" by grapes, featuring J Lang, Morusque.
Artist URL: ccmixter.org/files/grapes/16626

• Dr. Langer’s Preface
• "Be it resolved that I would NOT encourage my daughter or son to become a pediatric surgeon.”
• Pro-Side: Dr. Cathy Burnweit and Dr. Daniel Ostlie
• Con-Side: Dr. Barnhart and Dr. Hayes-Jordan
• Audience Poll Before Debate: 21% agree with the resolution, 79% disagree.
• Dr. Burnweit’s Opening Argument (Pro)
• Burgeoning number of pediatric surgeons
• There are upwards of 60 fellowship programs
• Between 2015 and 2030, the pediatric surgery workforce will increase by 45%, while the number of index cases is staying the same (or even dropping)
• Inroads of other pediatric surgical specialties
• Pediatric urologists increased 53% and pediatric ENT increased 75% in four years, and are vying for the same cases
• The stress of training
• Nine years of post-medical school training
• Applicants spend an average of $20,000, and half of them do not match
• One in five fellowship graduates fail their boards, prompting some to recommend increasing the length of training further
• Dr. Hayes-Jordan’s Opening Argument (Con)
• This is the best job in the world!
• We are constantly saving not just lives, but lifetimes; entire generations are saved by saving a child’s life
• Millenials and Generation Z enjoy instant gratification, which pediatric surgery has plenty of examples of
• Dr. Ostlie's Continued Argument (Pro)
• Lifestyle
• We live our lives in the hospital (one-third of cases come from call) and our call is real
• Work hour restrictions may limit the ability to handle this work load
• Financial Reward
• 93% of pediatric surgeons are dependent on hospital support, and hospital incomes are based on Medicare
• There are increasing numbers of uninsured Medicare/Medicaid patients, which decreased hospital incomes
• The need for reduced costs will affect pediatric surgeons’ incomes
• Demand and Supply Crisis
• There is a demand for highly-trained pediatric surgeons, but these may not be able to be supplied in the current environment
• Dr. Barnhart’s Continued Argument (Con)
• The problems pediatric surgery faces are not so great that they undermine the great things about pediatric surgery
• Our children’s vocations should be meaningful, have an honest chance of success, and should allow them to provide for themselves
• Patients come first, trainees come second, and personal desires come third
• Transparency is a good thing
• We can be flexible; as a small specialty, we can fix ourselves
• Although training is long, there are areas for improvement
• A national curriculum for all fellows is achievable
• Competency-based training may allow for quicker maturation of clinical judgment
• Training development years should be moved to the end of fellowship training
• The model for training should be re-evaluated; early specialization or integrated residency are possibilities
• Dr. Ostlie’s Rebuttal (Pro)
• It is hard to ENCOURAGE our children to enter a field that is changing
• Although the increasing number of fellowships has been discussed for 20 years, there have not been any changes, and in fact they have continued to grow
• There is no relationship between the Review and Recognition Committee, which approves programs, and the American Board of Surgery, which accredits individuals to practice; this lack of communication is creating a crisis in the number of trainees
• Dr. Hayes-Jordan’s Rebuttal (Con)
• Lifestyle
• Pediatric surgeons have the lowest burnout rate out of all specialties
• The day-to-day of pediatric surgeons is rewarding enough to more than make up for their call
• Number of Trainees
• There are not too many pediatric surgeons; there are 18 pediatric surgeons per million children in the US as a whole, but in other rural areas, there is sometimes only 1 surgeon covering 5 million children
• Last Bastion of General Surgery
• This is no longer a possibility in an increasingly specialized world, but that does not make the job any less awesome
• Discussion Question 1: What are your thoughts about the effect of having more women in the specialty?
• Dr. Burnweit: Having a mother with a socially important job is so important for our children to see.
• Dr. Hayes-Jordan: The courage of a lion and the hands of a woman.  Having women’s perspective is important in the workforce.  Work-life balance is a misnomer regardless of gender.
• Dr. Barnhart: Diversity makes us better, so a more diverse workforce makes it even more desirable.
• Discussion Question 2: How can we change APSA and other organizations to make them more effective in changing the specialty to make it more appealing to enter?
• Dr. Ostlie: We are afraid to make a hard decision due to fear of bruising egos.  If we do not make these hard decisions now, then we will be at risk for the specialty declining.
• Dr. Barnhart: No regulatory body can change the number of residencies or residents, but there is a small number of people who can: program directors.  Fewer trainees may be better for patients and the trainees themselves.
• Dr. Burnweit: Pediatric surgeons have fewer cases to remain an expert.
• Dr. Hayes-Jordan: Sub-specialty is necessary to help maintain competency.  General surgeons are no longer training to cover pediatric cases.  Should these cases instead be given priority to training programs?
• Discussion Question 3: What are your thoughts on the huge number of unanswered questions and research opportunities in pediatric surgery?
• Dr. Ostlie: Pediatric surgery as a specialty has a very high level of academic success per capita compared to other specialties.
• Dr. Burnweit: The two years of research should be at the end of training.
• Dr. Hayes-Jordan: The two years of research are necessary in the middle to help identify those who have a passion for research, and this is necessary in the field due to the high number of unanswered questions.
• Dr. Barnhart’s Closing Arguments (Con)
• 50 years ago, the specialty faced plenty of problems, too
• Local general surgeons opposed pediatric surgeons
• You were the only pediatric surgeon in the entire city
• You failed twice to get boarded
• Funding was uncertain
• Despite these problems, our parents did not discourage entry into the field
• Hard decisions and tough days are inevitable, but the benefits of the specialty outweigh these problems (the "Bad Day” folder)
• There are structures in place to address the problems; it is up to surgeons to lean in and fix them
• Dr. Ostlie’s Closing Arguments (Pro)
• Not encouraging our children to enter the field is not the same as discouraging them from entering it or not supporting them
• Dr. Hayes-Jordan’s Closing Arguments (Con)
• Although many aspects of the field may change, the aspect of it that we love (being in the operating room fixing children) is never going to change
• Having more surgeons will allow all of them to focus on areas that they enjoy, which will help advance the field
• Dr. Burnweit’s Closing Arguments (Pro)
• There are too many of us for all of us to be able to do the index cases frequently enough
• We are up all night and have little control over our schedules; the workload is great, but the lifestyle is not
• Increases in Medicaid and self-pay patients, high supply of surgeons, other specializations, and belt-tightening of health organizations, it is hard to recommend nine years of training when economic stability is not what it has been in the past
• There is an incredible emotional toll when there is a poor outcome in a child

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