#APSA 50: Robert E. Gross Debate

Welcome to the latest episode of Stay Current in Pediatric Surgery. Today's podcast was created and edited by Todd Ponsky, Alex Cassar, Ray Hankey, and me, Alexander Gibbons. In collaboration with the Behind the Knife team of Wu Do and Megan Akash, we continue our focus on the 50th ABSA meeting with a presentation of the Robert E. Gross debate, which sought to address whether practicing pediatric surgeons would encourage their children to enter the field. Which side emerged victorious? Find out in this episode. So thank you everybody for um sticking around. I'm looking forward to this next hour. We're going to have a debate in the style of the Monk debates which are put on in Toronto every year and some of you may have seen some of them. Um, the Monk debate, there's a pro and a con side, and we have two people arguing each side. On the and the resolution today is, be it resolved that I would not encourage my daughter or son to become a pediatric surgeon, and we don't mean that literally your daughter or son. We mean, would you encourage your best trainee? Would you encourage somebody in the younger generation to follow in your footsteps as a pediatric surgeon? So taking the pro side that they would not encourage their child to be a pediatric surgeon is Dan Ostley and Andrea Hayes Jordan. No, and we switched it a couple of weeks ago, so I got confused. We understand we look alike. You're dressed the same. I don't know. All right, so, we've got Dan Osley and Kathy Burnwhite taking the pro side, and Doug Barnhart and Andrea Hayes Jordan taking the con side. The format of the debate is one member of each side. will speak for 5 minutes and then a member of the other side will speak for 5 minutes, and then there'll be another 5 minute discussion from each side. Um, and then there's a rebuttal. One person from each side will spend 3 minutes uh with a in a rebuttal. And then there will be a few minutes for me to try and uh explore some of the topics that have come up, ask some general questions of the panelists, and then each person will have 2 minutes at the end for a final statement. We're going to start with, uh, everybody's got their clickers. We're going to start by polling the audience, whether you would take the pro side or the cons side. Can we have that up, please? Be it resolved that I would not encourage my daughter or son to become a pediatric surgeon. So please push agree or disagree. And then we're going to repeat this at the end of the debate to see whether anybody's mind has been changed. Can we have the uh result, please? OK, so, pretty much, we're there, buddy. We already won. I'm really glad I swapped with you, Dan. OK, we're starting with, with, uh, Kathy Bernwhite. You have you have 5 minutes. I'm near the year, I'm near the end of a pretty spectacular career in pediatric surgery, but the storm clouds of trouble which were, uh, starting over our profession about 15 years ago are now completely engulfing pediatric surgery to the point where it would be very hard to encourage a youngster coming up in medicine to go into pediatric surgery. I'm gonna start the debate with 3 things the burgeoning number of pediatric surgeons. The inroads other pediatric subspecialties are making into our line of work, and the training, the stress, the length, the uncertainty of matching. In 1987, there were 22 programs. Now there are upwards of 60. Such that between 2015 and 2030, a mere 15 years, the pediatric surgery workforce will increase by 45%. And at the same time, the number of index cases is staying the same and in some entities actually dropping. So my daughter wanting to go to general surgery and pediatric surgery and finishing, if she's lucky, more on that later, in 2029, will have double the number of pediatric surgeons vying for the same paltry number of TEFs. And it's worse than that. The other pediatric subspecialties are increasing at rates more rampant than ours. In a recent 4-year period, the number of pediatric urologists has increased 53%. We've already given up the reconstructive urology, and now they want our orchidopexies, our circumcisions, our hernias, and heaven forbid, our Wilms tumors. In that same 4 years, pediatric ENT increased a whopping 73%, elbowing in on our bronx and traches, our brachial clefts, and heaven forbid, our thyroid cancers. Pediatric plastics, pediatric interventional radiology, ortho, they all want to pick off our work. Now, we went into pediatric surgery because it was the last bastion of, of general surgery. I could do a thyroglossal, a thoracoscopic thymectomy, a PAP, and a couple of appies to round out my day. But with the increased numbers, the dilution of our experience by other subspecialists, and clear-cut scientific evidence. That volume increases quality we are now becoming subspecialized. You have the hepatoblastoma doc. You got the colorectal surgeon. You got the esophageal specialist and while this may actually improve care in each of those entities. Will it mean that the pediatric surgeon will become the appendix hernia center line doc? And is that really worth 9 years of bone breaking residency? You got 4 years of medical school, you got 5 years of general surgery. You have to step out of general surgery for 2 years to do research because you can't match in pediatric surgery without a CV the size of Montana. And then you have 2 years of fellowship. And those applicants will now spend an average of $20,000 that is more than half their after-tax income for a year to apply, and 50% of them will fail. And then they either have to go a different track. Or they have to redouble and do some super specialized pediatric surgery fellowship in critical care or colorectal surgeon surgery, something they will never use in their career unless they spend another $20,000 or $40,000 to go around the match the 2nd and 3rd time. And if they do end up matching, Believe it or not, 1 in 5 of them will fail their pediatric surgery boards. So we pediatric surgery training program directors the other day were looking at each other saying, oh no, we need to extend the training period another year or 2. At the same time when other surgical specialties cardiothoracic, plastics, vascular are all helping to curtail their training periods. Now I know my estimable colleagues are gonna tell you a lot of warm and fuzzies about taking care of children. And, and they'll be absolutely right. It is a gift to be able to take care of children, but let's face reality, there are too many of us. Other experts are eating our lunches, and the training period, it's so long, it's so stressful, you give up your youth, you give up money. And the emotional and physical stress is, is, is tough, and I cannot encourage it. And we haven't even talked about malpractice, the workload, the lifestyle, and the decreasing economic pressures. Thank you. You know. This is great. I just love this. I love it. This is gonna be awesome. So, um, I've been practicing pediatric surgery for about 17 years. I was privileged to match during a time when there was 15 programs in the United States and about 6 in Canada, and I was excited and I'm still completely excited and privileged to be a pediatric surgeon. And even when you're exhausted, you know, I had a fellow tell me once we had been operating all night on this NEC baby, then we had to cannulate an echo kit, and it was, you know, the next morning, Saturday morning for rounds, and I was exhausted and I, she saw that I was exhausted. We had a round in about 40 kids. I said, OK, Laura, let's go, let's let's get this done. And she said, Doctor Hayes Jordan, this is the best job in the world. What is wrong with you? And I said, OK, best job in the world, got it. OK, so, and it is, it's the best job in the world. And when I, uh, had the opportunity to bring my daughter into the operating room, she was 12 years old, and we, I brought her on a Saturday, and this was sort of before all the HIPAA stuff and everything, and so she, um. Got to watch me operate on Saturday. It was a Saturday, so typically we had 3 appendectomies, 3 laparoscopic appendectomies in a row. Then I rounded, and then at the end of the day I said, Wasn't that fabulous? Like, don't you wanna be a pediatric surgeon because it's just so awesome. And uh she said that was boring. I could have done that. That was totally boring. I know I've taken out appendix, and why do we even have appendixes anyway and why do you spend so much time taking them out? It's totally boring. Just looks like a fancy video game. I'm not interested. So I was like, OK, so I was just disappointed that she didn't see the depth of, you know, what we did in our profession. But then she asked me about a week later, she said, Mom, how many operations do you do that actually save lives? How many times do you go to the operating room? And if you weren't there, the child would die. And I thought about it for a minute and I said to myself. And I smiled and I said, every single time. All those G tubes, all those central lines, whether you're Darwinian about the G tubes or not, it's the bane of our existence that saves lives. The broviacs, the Ay, the I&Ds of the buttocks abscesses, we are constantly in every single thing we do saving lives. And as our title says in APSA, we're not just saving lives, we're saving lifetimes, and lifetimes means generations. These adult surgeons, they spent all this effort doing all these operations, and they saved one of me. They saved one of us. I've already had my children. I've had my life. You saved one of me. You've saved one of me. You save a child, you save generations. That child goes on to have children, they have children, they have children's children. You saved millions of lives in that one GTube and that one Ay and that one abscess that you've I&D. It is the most incredible profession in the world. And now as we talk about whether you would advise your son or daughter again it's not necessarily your son or daughter, but we're looking into 20 years from now, so 20 years from now how is pediatric surgery gonna look? And the people we're talking about training are these millennials and these Gen Z's, right? So these are the guys that need immediate gratification. They have grown up in immediate gratification completely unlike we did or unlike our fathers and grandfathers did. I remember actually going to the library. Driving to the library, learning the Dewey Decimal System, finding a book, reading it and finding out the answer. Now all they do is go, Siri, how far is it from here to New York City? And it's just they have so much immediate gratification they have access to. This is the generation that we really want to do pediatric surgery because in pediatric surgery there is some incredible cases that provide that immediate gratification, that ability to leave the operating room and just feel absolutely fantastic about what you've just done. One of those cases, as much as I don't like it because it happens in the middle of the night, is ECMO. And VA ECMO is one of those cases um that that does that for you. You take a baby who's blue, the SATs are 30%, you put in the cannulas, 100% sat, baby pinks up and it's just, it's fabulous. It's immediate gratification. And these millennials are really gonna love that immediate gratification that comes with taking care of children in pediatric surgery. You can't get that anywhere else. I don't care what you say, you can't get that anywhere else. You save someone's life. You see it happen. You take out a big wombs tumor. You, you, you fix a pyloric stenosis. That is immediate gratification as just what this generation is gonna be good at, and that's just what they're gonna enjoy. Thank you. All right. First of all, do I look like Garth Brooks up here because I feel like him. So my partner Doctor Burn White has addressed some of the concerns about case demand and training and, and the, and the hurdles that we face and, and Doctor Hayes Jordan put the warm and fuzzy out there and how media gratification is gonna be something that changes the world and I'm sure Doctor Barnhardt's got something quite just as ineffective. Let's talk about a few things that are hit home to each one of us every day, lifestyle. As pediatric surgeons, we take call and it's not superficial call, it's real life call. We, we live our lives in the hospital. In fact, 1/3 of our cases come from being on call. So we don't have the insulation of being not engaged in call. We, we have to be there. In fact, if you work in a hospital system that has a trauma center, you're only on call, you're on call in the hospital, right? Because more and more pediatric surgeons are now the surgical attending in the hospital. But if you're not in the hospital, you're still required to take call. And that call's real because there's the PD catheter that has to be put in because the nephrologist says it needs to go in even though he's not actually seeing the patient. And then there's the 650 g preemie who somehow miraculously got strong enough to pull out their line in the middle of the night that has to go back in, or the trauma activation or the ECMO. So call is real and we work really, really hard for that call and I'm not entirely sure with work hour restrictions and call hour restrictions, day restrictions that we're actually training my child anyway to be prepared to do that. We don't even have our fellows taking in-house call at times now. Well, one of the good things about that is we've generally gotten rewarded financially for that. Right? Because that was one of the things that we got as being pediatric surgeons. I would anticipate that anybody in this room or anybody that's not in this room that wants to be a pediatric surgeon is gonna have an expectation that there's gonna be a financial reward that comes along with being in pediatric surgery. Although I don't know that I can stand up here on this stage and look you all in the eye and say that the financial state of pediatric surgery is that secure, of what that will look like in 2029, I think Kathy said. Did you guys know that 93% of all pediatric nurses in the United States are dependent on some sort of hospital support, whether that be through affiliation agreements, directorships, or call contracts for ECMO, trauma, NICU call? And that hospital, by the way, is dependent on other sources of income which we don't control. So hospital reimbursement is DRG based, not professional fees, not what you and I get paid to do an operation, but hospitals are based on DRGs and DRGs are based on Medicare. Medicare is not really attached to Medicaid, but we live in a Medicaid world. And if you look across the United States over the last 25 years, there's a trend that I would say is fairly concerning in children's hospital. And that's the unencumbered, almost. Attainable to reverse trend of increased uninsured Medicaid patients in our country. If you live in Miami, Doctor Burnwhite's hometown, that number has gone from 30 to 70% over the last 25 years. CHLE is close to that. Most metropolitan, even rural areas sit between 50 and 60%. Phoenix, where I'm at, when I got there 4 years ago, was around 45%. It's now 54%. It's 18% in the last 4 years. Where does policy get made for that? The government level, right? Medicare, who sits in congressional seats? People that are worried about adult and elderly health care much more, not that they're not worried about newborn health care, but newborn health care is not, I would say a priority for them. So if somebody's gonna go into pediatric surgery and they expect that the financial rewards are gonna be what we get today, I don't know that we can actually tell them that. I don't know what it will look like. But hospitals are gonna have to look at ways to reduce costs to cover the losses they're gonna get for cutbacks. And that's gonna have to come back to pediatric surgery. If we think that we're not gonna have to be part of that cost cutting, that's irrational for us to think that way. To be, to believe that we're special enough and we do warm and fuzzy things enough that we're gonna be able to avoid that. So we talked about a few things today, but I did want to just end with one thing is that I remember something as a sophomore in college in my economics class. I think you guys have heard of it. It's called supply and demand. I'd say that we have a supply and demand conundrum in pediatric surgery and that we believe there's demand for pediatric surgeons, so we're supplying them, right? But maybe we've got something a little bit worrisome that I would call a demand and supply crisis because we have a demand in this country to provide highly trained, incredibly competent pediatric surgeons, and that I'm not sure we can actually supply it, given our current environment in pediatric surgery over the next two decades. Thank you. Good afternoon. Uh, I just wanted to start by reading the resolution again. Uh, be it resolved that I would not encourage my daughter or son to become a pediatric surgeon. Because I think when I read that this debate's easier to win than I thought, because it seems like Cathy and Dan came to argue a different question. They came to argue, do we have problems in our specialty. Where the real question that we've got up there on the screen is, do we have problems that are so great, so intimidating, so intractable, that it fundamentally undermines the great things about our specialty. And I don't think that's the case. The resolution that's on that screen is fundamentally about what do we want for our children and other young people we care about. When I think about my kids and what I want for them and their job. I want them to have a vocation that's meaningful, that when they reach the end of their career, they feel like they made a real contribution. Secondly, I want them to have. An honest chance of success. Can they get trained? Can they get the job? And then I want them to be able to provide for themselves. They don't need to be the kid that's the richest that graduated from their class though. So if you share aspirations for your kids similar to what I have, I think the debate's over. Reflecting on my career, case closed. But I've got 5 minutes and I'm not gonna concede the time back to them. So, um, I think as we think about these problems, I would like us to put down some basic principles of how we're gonna approach the problems. The first is The patients come 1st, our trainees come 2nd, and our desires come 3rd. Secondly, let's agree that transparency is a good thing. And then we'll, we'll do research, we'll get data, we'll share it, and then we'll agree to make decisions based on it. And thirdly, let's agree that we can be flexible. We're a small specialty. And we can fix ourselves. So with, with those guide rules in mind, let's talk a little bit about some of the training problems to start out with. There's no doubt our training is long. It's 9 years for most people, and other people, it's much longer. And that may be too long for some people. There's no doubt about it. We have a lot of a lot of learning that we try to get into our trainees, both technically and cognitively, and maybe we can do better. What are some solutions? Well, first, we could actually be more efficient with our didactic teaching. In this era, there's no reason that there can't be a national curriculum where every fellow in the country participates in one or two lectures a week that's done nationally, taught by national experts. There's no reason our fellows can't get a weekly diet that's like the colorectal symposium that we started this meeting with. Secondly, Could we use competency-based training like they're experimenting with at Michigan? Would it make them, their clinical judgment mature more quickly? Maybe it will, maybe it won't, but we should experiment with it. In terms of training duration, the one thing I agree with him about is we need to move the career development years to the end of the career training. Research years, super specialty fellowships should come after your general pediatric surgeon. The reason for that is so that we don't have these people that have invested a significant amount of time to try to get a fellowship that they'll never achieve. That is a change we need to make. That's a change I'd want for my son or my daughter. Next, we've, we've had the same duration of training since we began as a subspecialty. And we ought to look at whether we ought to come up with a different model for that. A lot has changed in that time and we need to think about whether this is really still the right model, and we have options. There are options that exist right now in the RRC in the American Board of Surgery that we can use. One option is early specialization. In early specialization, you identify a junior resident that's interested in pediatric surgery, and from that point on, you begin to modify their training so that it meets both their general surgery requirements and their pediatric surgery requirements. It allows you to eliminate the parts that are less useful and emphasize the parts that are most useful. They're actually specialties that have begun to do integrated surgery training, where you take medical students and put them right into the beginnings of the training of a subspecialty, so that all of the training can be focused on that. That would be a big, big change for us. But we should consider these things, and these are things that the pediatric surgery board is thinking about. There needs to be a real discussion around how much operative experience fellows need to have to be qualified. And that's begun. This year's class of fellows is the first group that will have to submit a case requirement, a case log that has requirements by area and by complexity to allow them to sit for the pediatric surgery boards. My initial time is up. So the take home message is, the answer is that we've already answered the question, case closed. Have your sons and daughters go into pediatric surgery. But I'll look forward to the next hour to talk about how we solve these problems. Thanks. Thank you for rebuttal. OK, now we'll uh have a rebuttal from one of you. We're doing the questions first, OK. So, He tried, didn't he? He gave it a good run. Yeah, good job there, Dougie. So before I go into things, maybe I should just pose one thought or a question. Maybe the reason that Cathy and I have, uh, that's not true. We didn't actually choose this side of the, we were actually assigned this side yeah. But maybe it's a little hard to encourage our son or daughter to become a pediatric surgeon because you just heard everything on both pros and cons, but for me personally, I'm not sure I believe that the specialty I love and enjoy today is gonna be the same specialty that my son or daughter sees me be today is what they will be in 20 years. Because I don't know that it'll ever be able to stay that way, and evolving is always a good thing, but it's also a random event. So let's just talk a little bit about these things that Doug and And Andrea thought would be so fixable. So, uh, I've been at this about 20 years. I can tell you that in 20 years we've heard concerns about, uh, fellowship, uh, numbers growing. We've heard at the program directors meeting how we need to change it. We've heard from the RRC and the American Board of Surgery, how they recognize that there may be a crisis coming. But yet in that 20 years, there's really nothing that's ever been done. There's more pediatric surgery training programs today. I'm at fault. I'm a program director. I just started 2 years ago. I'm proud to have trained the fellows I trained. Having said that, I'm also the person up here stating that that maybe isn't the best thing. So, the dilemma that's facing us in the next two decades, I don't believe can be fixed in a meaningful fashion that's gonna allow this specialty to be what it is today. If you look at the accrediting bodies, we just talked about them for a real quick minute and a half here. So we have the RRC that sits over here, and I know Doug has commented that we are now instituting case, case metrics into the American Board of Surgery. We could talk about that in a second. The RRC sits here. What does the RRC do? The RRC approves programs. They don't have anything to do with accrediting fellows. In fact, I would say their level of interest in terms of the health of pediatric surgery would be somewhere between 0 and 5%. They are an algorithmic machine that says these are the criteria. If you meet those criteria, you can have a program. Simple as that. Then over here you have the American Board of Surgery. American Board of Surgery, their entire goal in life is to certify individuals. Is this person a safe surgeon? Doesn't make a difference where they trained, doesn't make a difference what their training was, doesn't make a difference how their training was set up. All they do is say they're a safe surgeon or not. How is it possible that these two bodies that have so much to do with us as a profession can't talk to each other and figure out the crisis that we're facing today and what we're going to face over the next 30 years, as my partner Kathy said, with the growth of 45%, how is it possible that these two people are, these two organizations are being allowed to drive our specialty forward, and we as pediatric surgeons and more specifically pediatric surgery program directors are not stepping in more aggressively, and I am one of those people, so I take fault in it. But I don't see how that's fixable in the way that everybody in this room sees their profession and everybody in this room answers this question which Doug so prophetically reminded you of 3 times that we fix it so that they become a pediatric surgeon in the form that we all enjoy today, which I love by the way, so. Back to you guys. OK. Andrea. So I'm gonna talk about my 3 minute rebuttal. I'm gonna talk about the points of lifestyle and that there's too many of us, um, and the last bastion of general surgery. So. Lifestyle, yes, we, we have a lot of call and some of us have more call than others, but when you look at things like burnout, which is a hot topic these days, there's a study from the American Physicians and it was published in 2019. And they surveyed 19,000 physicians and between 44% and 58% of physicians, depending on specialty had experienced burnout and surprisingly about 15% of them had either thought about or knew somebody else that committed that wanted to commit suicide. Now if you then look at the subset of surgeons, when they looked at the number of surgeons, they looked at 39,000 surgeons in another article that was published in the Journal of the American College of Surgeons, of 39,000 surgeons, surgeons subspecialty with the highest burnout rate. And I don't know if you guessed this, the highest burnout rate is trauma surgeons. I would've guessed that because of what trauma surgeons do. I could see they have the highest burnout rate. The lowest burnout rate, pediatric surgeons. No matter what our lifestyle is, we have managed to either get the positive energy from the warm fuzzies. To balance our life so that even if our call schedule and our lifestyle doesn't appear to be as nice as the general surgeons that are on call every 1 and 22 nights or the trauma surgeons that get 24 hours on and 24 hours off, they're having a higher burnout rate. So whatever our lifestyle is, what we do on a day to day basis gives us the best job satisfaction, as evidenced by the fact that we have the lowest burnout rate of all physicians of all surgeons. Too many of us, nah, not too many of us. If you look at the statistics for the United States, there, they say there's 18 pediatric surgeons per 1 million children, not 1 million people, but 1 million children. That's all of the United States. But if you look in states like North Dakota, South Dakota, Montana, any rural area that you pick, sometimes you've got one pediatric surgeon for 5 million people. So we don't have, there's not too many of us. There's just not enough of us in the areas where we need to be, and that's where we need to define our profession. But I would still 100% encourage my son or daughter, someone be practicing in 20 years, because we are gonna need people in those rural areas to practice pediatric surgery at a high level. We don't want people there that are just doing Apis and pylorics. We want people there that can provide a high level of pediatric surgery in those areas. So it's not too many of us. We're very, very far from that. If you look at specific rural areas. And um per the comments today as well as yesterday about us being the last bastion of general surgery, forget about it, OK, we, we're not gonna be able to do heart surgery. What did Doctor Raffensberger say? Heart surgery, bone surgery, appies, and a gunshot wound in the same day. It's just not gonna happen. We have surgical subspecialists now. We have cardiac surgeons who do what they do. We have pediatric urologists who do what they do, and we just aren't gonna be able to go backwards. Plus our patients come to us and what do they ask you, how many tracheoesophageal fistula repairs have you done? How many would fill in the blank. They go online and look up somebody who they think is the expert in whatever it is. We cannot go back to the days of doing everything for everybody. It's not gonna be that way in 20 years. It's still gonna be an awesome thing to practice, but there's no way we're gonna be able to go back to operating on the whole body well and then and then need the number of pediatric surgeons that we do. So it's still the best profession. The lifestyle doesn't, it lends itself to us not being burned out, so we still have the greatest profession in the world. So we now have a few minutes to have a little bit more free form discussion. Um, and the first question I, I wanna ask is, it relates to the increasing number of women. In pediatric surgery, and I think we're probably up to at least 50% now of of our trainees. And so that's changed the um the way our profession looks and um at the risk of being politically incorrect, I would say that men and women are not the same. They should be equal, but they are not the same both in in the way they approach things and in the demands of motherhood, for example, and and those sorts of things. So. Can I ask, uh, what are your thoughts about the effect on the future of our profession and on its desirability for our children? What's the effect of having more women as part of our specialty? I've always taken the view that to have a mother that has a socially responsible important job and have your child see that mother do that job. Is worth is worth so much. I, I used to go to the playground in my gym shorts and t-shirt, and I'd see all these mothers in their, their capris and their hair done, and I used to feel kind of bad, like, oh my gosh, you know, but then I, I, I see that my children look at this example of a woman that is working. And the socially responsible job that she has, and they also know that they get, they have, they're, they're in a socially, a socioeconomic group that allows them to do a lot of travel and things in school and, and I think that we women are great examples. Yes, there are downsides to being a working mother. No one's ever going to argue against that. But I think that what we bring to the table and show our children is really way, way, way outbalances those downsides. Yeah, so you're actually arguing that that you would whose team are you on? Can I, can I, can I jump on the bandwagon of why it's gonna be a better specialty and why our, why our son or daughter should go into so much with pediatric surgery as it has to do with the number of women in the workforce, in the surgical workforce. Yeah, I think, I think as a woman, whether you have children or not, what is the, what is the saying, the courage of a lion, the hands of a woman, I'm missing one. That the same I know somebody in the audience knows the other third part of it to be a pediatric surgeon, you have to have the courage of a lion in the hands of a woman. So I think women in general in the operating room who may or may not have more delicate hands, but just having that perspective of a woman, even if you don't have any children and being in pediatric surgery is a really important perspective to have. Um, I think we, we bring a lot of sensitivity. I think even though there's, there's no really such thing as this whole work-life balance thing for men or women. I think that's, that's sort of a misnomer. But, um, as Cathy was saying, you can if you can inspire your, uh, your girls, you know, my daughter, even though she's, she's, she's not gonna be a pediatric surgeon, she's clearly an athlete, but she, um, she really respects the fact that I, I have a job in which I take care of children and I help save children's lives, and I think giving younger girls that perspective that, that they can, they can, they can do things as impactful as that if I could bring us back to try to get that other 21%. Um, I, I think, uh, and, and I appreciate you giving us a lob to go to our side, right? If the one thing we gained from the presidential symposium yesterday and the workshop today is. The diversity makes us better. So if that's happening, another argument for my kid to go into pediatric surgery, you're going to be in a more diverse workforce and it's gonna be a better special to be in than it is right now. I got nothing. But, but let's just talk about a little bit about the. About the workload, alright. It's inhumane to have medical students up all night anymore, right? I mean, you can't have a medical student do 24 hours and stay overnight in the hospital and then work the next day. But we are gonna be doing that much of our career and that's a real downside. I mean our families and our children are important and there are other specialties that don't suck your youth away from you. Uh, the one thing about the two years of research is it lets you have a baby, uh, you know. But you, you don't have to do that 9 years and now we're thinking 10 years of training and you get to be 40 years and you look around and you say holy crap, where did it go? I can't have a baby. I'm 40 years old. Anyway, so I think there are other specialties that have been much more sensitive to this length of training. Many people have commented that The problems we face in our specialty are insurmountable, and one of the problems we have is that our organizations that represent us like ABSA have been ineffective so far in changing the the specialty to make it more um more of a specialty we would want our child to go into. Does anybody want to comment on on how there may we can change ABPSA and the other organizations we belong to to be more effective on our behalf? So I'll start that one since I was the one that put the tirade up here, um. So I think the, the biggest concern I see in our organizations, whether it be apps, AAP, not, that's not so much AAP, but, but we'll include AAP program directors is that. It, it's, it's a sense of a we're afraid to make a hard decision because we're gonna either bruise somebody's ego or we're gonna be perceived as trade restraint instead of looking at what is the right thing for the profession, and we're not the first profession to have gone through this. We, whether it be training paradigms or cases or types of operations that let get slipped, let slip away because the organization didn't focus on that. You look at cardiac surgery when when stents came into place and angioplasties came into place, you know, they didn't see that coming, whereas the vascular surgeons saw it and they jumped on it and they saved their profession by becoming the endovascular surgeons and cardiac surgery now I could personally probably get a cardiac surgery program in July if I wanted it by just calling around the country. And so I do think that if we don't start to make hard decisions now as organizations, APSA, the Program Directors Association, then we are going to be at risk for having our specialty not be what it has the potential to continue to be over the next two decades and be relegated to something that we didn't control but just responded to after the fact. Yeah, Doug, I, I want fewer training programs, so I want, I think your training program should be the one. That drops out. I think that's great. Let's let's let's let's talk training programs. Uh, no, I, I, when we talk about workforce, and there was, there was a period of time where Kevin Lally was like an Old Testament prophet going around talking about doing. And I think they asked him why he stopped, and he basically was afraid nobody would talk to him at the cocktail parties anymore, so he, so he gave up. So maybe it's maybe it's time for somebody else to take it up, right? And I, and when we went through that, my conclusion was, be prepared to live on a hot planet with too many pediatric surgeons. And um and I was pretty hopeless about how that was gonna get fixed until I watched what was happening in the political environment, and this is the invitation. To everybody that's not a program director. What you saw is people started asking other people hard questions about why they make individual decisions. There you're right, there's no regulatory body that can change the number of residencies. There is in the number of residents, there is a small contingent of people that can though. They're the program directors, right? So that's why I laid those principles out in the beginning. Let's go patients first, residents second, us third. There's a lot of reasons why people have 2 fellows. There's a lot of reasons people have 3 fellows. There aren't many of them that are patient or resident driven. And there's a lot of them that are us driven. There's a lot of you that take trauma call without a fellow. There's a lot of you that take care of patients without a fellow. You take a call, you do all these things. You, you, you do academic work without a fellow. What I would encourage, I think the solution is to give everybody in this audience freedom to look on the website of the program directors and the ones you know, ask them why do you have two pediatric surgery fellows? Given what we talk about, and we all talk about it. Why do you have 2? Yeah, it's a great question. Why do I have to? Yeah, why, why does anyone have to? I have no senior residents. I have interns in 2 years. Are there people in the audience that have no senior residents? Uh, I mean, again, I think, I think it's, we all, it's, it's our internal thing. It's a, it's the question of, and I don't mean to pick on you, it's a question, do we do what's good for the common good or for us individually? And I, I think that each of us that have a fellowship need to need to reflect on that. I think more of the problem than the number of programs, although that just the extended training program is just onerous, um. Because I drop out a fellow or you drop out a fellow, it's not gonna make that TEF go from Salt Lake City to Washington. That TEF is gonna be lost. The bigger problem is that we as pediatric surgeons have fewer cases to stay good at and when you people are out in your communities, if you do one TEF every 2 or 3 years, that is not enough to stay expert. That's the bigger problem than training. Yeah, so I, I agree. So let's talk about the issue. I think there are two issues, training and maintenance of competency. That's why it's so specialized. That's why the people are doing surgery because you can't just be good at just doing one. That's why you're doing surgery or gut surgery. But, but just in point of fact, in terms of resonant case volumes. That has not changed as the addition of fellowships, and this, this is data that's available through the RRC that we've looked at. There's significant variation between programs with high volume and low volume programs. The distribution of those types of programs has not changed as we've added on programs. So that's, that's an old problem that there may be some that are low. I agree with you. The question of how do we maintain competency as we get more and more and as Andrea said, it part of that solution probably is this subspecialization. There's probably, it does make sense that every pediatric surgeon. We'll do a Wilms tumor, but not every pediatric surgeon probably should do an abdominal neuroblastoma with vascular encasement. You do a standard oesophageal atresia. You don't do a long gap esophageal atresia. I, I think, and I think that's, that's being honest about what our outcomes are and what would be best for our patients. The other thing about the training is, you know, it used to be when in, in places where there was not a pediatric surgery fellowship program, which used to be the majority of general surgery training programs, you did not have a pediatric surgery fellowship, and you were training general surgeons to do some pediatric surgery. Now all of our residents are going into most 80% of the residents are going into subspecialist, they're begging people to be general surgeons. They're being colorectal surgeons, trauma surgeons, bariatric surgeons. So I find myself spending a lot of time in the groups in my group and other groups where you don't have a fellowship doing these cases with residents who are going into colorectal and bariatric surgery, never gonna do a TEF, never gonna do a diaphragmatic, never gonna do a pyloric, never gonna do a hernia. So, so why should we sort of the other perspective is why should we sort of quote unquote waste that training on a general surgery resident who's not gonna become a general surgeon. And is and and perhaps that training should be spent on someone who's gonna be a pediatric surgeon. That's the other are you gonna send all your index cases to a training program. Yeah, our country is not ready for any kind of centralized anything. I mean this, this, this country, uh, has a lot of issues, but it, um, you know, having trained in, in Canada where I saw that it was really no harm in letting an inguinal hernia, for example, be repaired when they're 2 years old, even though you diagnose it as a newborn and going through a clinic where you'd say, Miss So and so, see you in 18 months, we'll fix your kid's hernia, and everyone said, thank you very much, doctor, see you in 18 months. In the United States, I say that they're just gonna go to Doug or someone who else, who whoever's gonna fix it tomorrow is where they're gonna go. But we're limited by our culture and the liability issue is one that really is, we have not talked about that, but. When you have a bad outcome in a child and when you have a bad outcome in an 85 year old or a sixty-five-year-old, I mean it's sad and it takes it out of you. But when you have a child that has a really bad outcome and you Get sued or you, even if you don't get sued, you see a video of that five year old at the playground last week. It, it is something that is emotionally draining that. In my personal life, I have never gotten over those cases. And that is something that really, it's, I think, um, unique to pediatric surgery. Not, not the, not the kind of shame and the fear that that the previous speaker talked about, but the idea that you truncated a life or wasted a lifetime. It's a, that's, that's a real downer and, and it's a tough thing. The OB's I think also deal with that kind of stress in their um line of work and that's, that's something that really argues against what we do. Let me just ask one other question, which we haven't touched upon, but which I think some people would feel is a is a big draw towards pediatric surgery, and that is the huge number of unanswered questions, the huge number of research opportunities in pediatric surgery, which I would argue is probably much higher than in many other specialties. Uh, can you guys comment on that. The academics, and this is probably not good because I maybe go across as I'm actually helping the two defendants over there. I'm not gonna rebut you, Dan. Um, but the, if you look at pediatric surgery as a specialty. The academic success of a, of a true of a true academic surgeon is related in, in per capita, let's say, as compared to other surgical specialties is very, very high, right? But having said that, I don't think we need 45% more pediatric surgeons to continue that academic success. In fact, you might argue that it would be the opposite. But the inquisitiveness, the, the research milou, you know, Petri disc that is pediatric surgery that leads to academic and research stimulation success is, is, is something that's truly unique to this specialty. I agree. That's all the more reason for stopping that two years of research and putting it at the end. No, it's just the opposite, just the opposite. So we need that two years of research to get people excited about research, to find, to sort of swap chairs with separate. I wanna, I wanna argue with her. To separate, uh, to separate so people can identify for themselves whether they have that passion or not. Some people do, some people don't. We don't need 100% of pediatric surgeons doing, doing research, but we do need the people who have a passion for doing it, and we have so many unanswered questions. We still don't know how to anticipate any see or prevent any C. We still don't know how to get prevent a baby from developing an esophageal resia. We still don't know how to predict biliary tree. and keep keep that child out of the operating room. There's so many questions and if we take away those two years of research, then we're, we're never, we're never gonna get any of these questions answered. We have to, we have to train ourselves in a way that we can help identify those folks who have the passion and the drive to answer those questions. Good. So, uh, we now head into the last part of the debate where each of the debaters will have 2 minutes for a final statement, and I think we'll start with you guys this time. first? It's only fair. It's only fair. I think it's only fair to say that they probably honestly would have picked our position if they if they. Um. Because I'm gonna make a warm argument at the end. I, I'll argue that it's not fuzzy, um, but it is. History informs the future, and I think this meeting has really emphasized our history. And it, and for for those of us who are just starting to get, gray hair, it's a significant. Interval for us because we were born when ABSA started. And so it makes you reflect on the question of whether or not Given what's going on in the history, our parents should have discouraged us from going into pediatric surgery. Because there's a lot of bad stuff going on at that point, as we learned this history. The local. The, the The He's let's not I think I just got cut off here. We'll get rid of that one and I'll stand here to remind you that all the bad things were going on in pediatric surgery when I was a child, and why my parents and Doctor Haller should have discouraged me from going into pediatric surgery. The local general surgeons opposed you being a pediatric surgeon. You were the only pediatric surgeon in the city, so you took call every night. You'd failed twice to get a pediatric surgery board. Uh, Medicaid had just been passed. Funding's uncertain because of the war in Vietnam, and the idea of Children's Health Insurance Program is 20 years in the future. So it probably would have been quite rational for them to discourage us from being pediatric surgeons, and I'm quite glad that, quite glad that they didn't. Um And for sure, we, we've got challenges in our special, and I, the one thing I agree with Dan about is we need, we need to make some hard decisions and we need to make them as a specialty and the group needs to do that. And there, and there, there will be, there will be hard decisions, there may be tough days and um. In my desk at home, I've got, got my folder that's in case of a bad day folder, and Mark wouldn't know this because he's in my office. Um, and I, I suspect that every pediatric surgeon in the audience knows what you keep in that folder. And it's not your Fidelity account balances, right? What what's in that folder is photos of kids and letters from parents. It's pictures of girls in prom dresses that had wilm's tumors. It's trauma patients that are pitching high school baseball games. It's babies that had CDHs are now graduating from high school. And, and the most precious letters in there are the letters from parents where the kids never got out of the NICU. And I'm sure that we've, we've got challenges that we've got to fix. But we do have the structures in place. One thing we didn't talk about is the pediatric surgery board, the ACGME, and the program directors are now in a phase where we meet on a regular basis to try to, try to work through these issues. So we've got the structures in place to deal with these things. It's our turn to lean in and fix these problems. We can do it. We need to do it, because when my kids are 50, I want them to have a folder like that. Thank you. Well, there was warm and fuzzy, and then there was Doug. How do you follow up a folder? I mean that's just. So, um, for every great debate there's a question, right? And most great debates have great questions to them. So I'm gonna steal a page from Doug and have everybody look at this comment. It says, be it resolved that I would not encourage. My child or daughter daughter or son to become a pediatric surgeon. So when I look at this debate, that means if my son is telling me I'm going to go into international economics, I'm not going to go out there and tell him you should become a pediatric surgeon. But if my son comes to me and says, or my daughter comes to me and says, I want to be a pediatric surgeon, that does not mean that I have any intention to not support them down that pathway. But you can be darn sure that they're going to know every single thing that I shared with you today to make sure that the decision they make is going to be the right decision. Because if they don't have that toolkit in front of them, then it's on me as a father, it's on all the program directors out there, it's on all the mentors out there that you failed that person in preparing them for what they thought they were getting into, and it's not what you're gonna see today. So when you get your little clicker, it's gonna come up here in a minute and it's gonna ask you that same question. Every debate has a great question. You have to dissect the great debaters win the debates by answering the question the way the audience expects it to be answered. Read that question. It says encourage my son or daughter to become a pediatric surgeon. It does not say I would not support my son or daughter to become a pediatric surgeon. So, thank you. Very lo. Andrea. I'll win by any measure, by the way. 20 years from now, 30 years from now, who knows what we're gonna have in pediatric surgery? We may have holograms, we may not even have to go to clinic. We may be able to do clinic from our homes. We may be rid of Epic, thank God. We may be, uh, we may have the all the things that we hate about pediatric surgery are probably gonna be gone. But the thing that we love being in the operating room repairing something so the child can eat, drink, poop swallow normally is never gonna go away it's always gonna be extraordinarily satisfying and there's never gonna be anything to replace it. I think it's only gonna get better. I think it's only gonna get better. I think the fact that we're gonna have more pediatric surgeons is gonna allow us the luxury to focus on what we enjoy. And having that luxury will allow us to answer questions that come to our mind. The more operations you do for some things, the the, the easier the questions come, and these will allow us to move our field forward. If we just have pediatric surgeons doing one TEF a year and one biliary atresia a year, that's not gonna help us move forward. We need to be focused. We need more pediatric surgeons, and we need to continue to be excited about the best profession in the world. OK, so let's sum this up. There are too many of us for all of us to do those great cases that got us into the profession with enough frequency to be really good at them. 2. Our specialty is largely emergency and urgent care driven. That means we're gonna be up all night. We're gonna have little control over our schedules. We, the workload is great, the lifestyle is not. With the increasing Medicaid and self-pay population in my, in my practice, that means no pay population because of the high supply low demand, because of the increasing specialists honing in on our scope of practice, and because of the belt tightening of all the healthcare organizations. I'm going to have a hard time recommending 9 years of training when reimbursements, not reimbursements, when. Economic stability is not what it has been in the past, and they tell us that there are a whole bunch of jobs out there, but those jobs are in more rural areas where we're gonna do appendix, gallbladders, hernias, central lines, lumps and bumps, I&Ds, and that does not require 9 years of every other night or every 3rd night call and the foregoing of your youth. And then when a child goes bad, there is that incredible emotional toll that's gonna stay with you. It's gonna stay with you whether or not there's malpractice or not. So can I encourage my child to embrace this nine-year training program when the scope of practice is being diminished. I don't think so. Can I encourage my child to embrace this 9 years of training when there's fewer healthcare dollars for children because children don't vote, when there's really no solution to the uninsured and the underinsured. When there's no arbitration board that can decrease the number of pediatric surgeons and decrease the number of specialists, I can't. And so pediatric surgery as I have known and loved it for the past 40 years is probably gone for good. Rest in peace. This is Alexander Gibbons from Akron Children's Hospital, the contributing editor for this episode of Steyer in Pediatric Surgery. You just listened to a very lively debate about whether we should be encouraging our children to enter the field of pediatric surgery. The audience at Absa seemed to be at least somewhat convinced by the arguments of Doctor Burnwhite and Doctor Osley. Although 80% of the audience was against the resolution at the start of the debate. Afterwards, only 60% remained opposed. What are your thoughts? Would you encourage your daughter or son to enter the field? If not, what are things that we can do to help change it? Let us know in the community section of our app. And until next time, remember, knowledge should be free.