PAEDIATRIC GENERAL SURGERY

DEFINITION:Pediatric General Surgery is the field of medicine that encompasses a broad range of diseases and malformations, both operative and non-operative, from the fetal period until the late teenage years. In addition to the body areas/systems covered by General Surgery, Pediatric General Surgery also deals with non-cardiac thoracic conditions and specific genito-urinary and gynecological problems in children. These are detailed in the Primary Objectives. Other topics that may be covered by Pediatric General Surgery, under some circumstances, are listed in the Secondary Objectives.

GENERAL OBJECTIVES:The objectives of training in Pediatric General Surgery are to develop a Pediatric General Surgeon who can assume complete responsibility for the preoperative, operative, and postoperative management of the problems relegated to his area of special expertise and who can interact appropriately with allied colleagues involved in the care of pediatric patients. Additionally, it is expected that the resident in Pediatric General Surgery will develop the sensitivity required to deal not only with pediatric patients, but their families; while maintaining the attitude and deportment commensurate with the primary care of pediatric patients. Interwoven within these objectives will be those of an ethical and academic nature that will reflect the conscience of modern Pediatric General Surgery and help shape its future. The summary objectives are to ensure that pediatric surgeons maintain the leadership and direction of the profession of Pediatric General Surgery.

Different geographic locations place different demands on pediatric surgeons. However, some educational objectives are considered mandatory and basic to the practice of Pediatric General Surgery and will be referred to as Primary Objectives. Certain other objectives are considered desirable and appropriate to include under the umbrella of Pediatric General Surgery, but are dependent on the trainee's personal objectives or those of the environment in which the resident intends to work.

For both sets of objectives, comprehensive and thorough understanding of the subjects listed will be expected. This will include, where appropriate, embryology, anatomy, physiology, pathology, natural history (both pre- and postnatal), diagnosis and management.

SPECIFIC OBJECTIVES:At the completion of training, the resident will have acquired the following competencies and will function effectively as:

Medical Expert/Clinical Decision-Maker

General Requirements

Specific Requirements

PRIMARY KNOWLEDGE OBJECTIVES

4.      Head and neck

Demonstrate knowledge of and the capacity to manage patients in relation to the knowledge of the differing patterns of disease, natural history, and responses to treatment of head and neck disease in children. This will include:

5.      Non-Cardiac Thoracic Surgery

Demonstrate knowledge of and the capacity to manage patients in relation to the knowledge of the differing patterns of disease, natural history, and responses to treatment of non-cardiac chest conditions in children. This will include:

6.      Abdomen

Demonstrate knowledge of and the capacity to manage patients in relation to the knowledge of the differing patterns of disease, natural history, and responses to treatment of abdominal disease in children. This will include:

7.      Genitourinary Tract Conditions

Demonstrate knowledge of and the capacity to manage patients in relation to the knowledge of the differing patterns of disease, natural history, and responses to treatment of genitourinary conditions in children. This will include:

8.      Gynecologic Conditions

Demonstrate knowledge of and the capacity to manage patients in relation to the knowledge of the differing patterns of disease, natural history, and responses to treatment of gynecologic conditions in children. This will include:

9.      Intersex Anomalies

Surgeons will care in collaboration with other health care professionals for children with intersex anomalies. They must therefore demonstrate knowledge of and the capacity to manage patients with these conditions based on a knowledge of the differing patterns of disease, natural history, and responses to treatment. This will include patients with adrenogenital syndrome (variants, enzyme deficiencies, diagnosis and treatment), mixed gonadal dysgenesis, true and pseudo-hermaphroditism; and testicular feminization syndrome.

10.  Endocrine Anomalies

Surgeons will care in collaboration with other health care professionals for children with endocrine anomalies. They must therefore demonstrate knowledge of and the capacity to manage patients with these conditions based on a knowledge of the differing patterns of disease, natural history, and responses to treatment. This will include:

11.  Oncology

Surgeons will care in collaboration with other health care professionals for children with cancer. They must therefore demonstrate knowledge of and the capacity to manage patients with these conditions based on a knowledge of the differing patterns of disease, natural history, and responses to treatment. This will include:

12.  Critical Care and Trauma

Surgeons will care in collaboration with other health care professionals for critically ill and injured children. They must therefore demonstrate knowledge of and the capacity to manage patients with these conditions based on a knowledge of the differing patterns of disease, natural history, and responses to treatment. This will include:

13.  Neonatology

Surgeons will care in collaboration with other health care professionals for premature and ill newborns. They must therefore demonstrate knowledge of and the capacity to manage patients with these conditions based on a knowledge of the differing patterns of disease, natural history, and responses to treatment. This will include:

14.  Skin and Subcutaneous Tissues

Demonstrate knowledge of and the capacity to manage patients in relation to the following knowledge of the differing patterns of disease, natural history, and responses to treatment of cutaneous and subcutaneous conditions in children. This will include skin and subcutaneous lesions (nevi, nevus sebaceous, pilomatrixoma, juvenile melanoma; hemangioma, lymphangioma, lipoma; dermoid and epidermoid cyst), ingrown toenails and paronychia; and pilonidal sinus and abscess.

15.  Transplantation

Surgeons will care in collaboration with other health care professionals for children with organ transplants. They must therefore demonstrate knowledge of and the capacity to manage patients with these conditions based on a knowledge of the indications for liver, kidney, small bowel transplants, and of immunosuppressive agents (effects and complications).

PRIMARY SKILLS OBJECTIVES

By the end of training, the resident should have acquired and demonstrate the following generic skills, as they apply to a pediatric surgical practice.

p.      Surgical Skills

The resident is expected to be able to perform independently the full spectrum of operative interventions related to the primary Pediatric Surgery conditions listed above. Several additional areas of skill expertise are listed below.

q.      Trauma

The Pediatric Surgery resident is expected to:

r.        Endoscopy

The resident should be familiar with the indications, techniques and complications of:

s.       Other Procedures

The resident should be familiar with the indications, techniques and complications of:

Communicator

General Requirements

Specific Requirements

Collaborator

General Requirements

Specific Requirements

Manager

General Requirements

Specific Requirements

Health Advocate

General Requirements

Specific Requirements

Scholar

General Requirements

Specific Requirements

Professional

General Requirements

Specific Requirements

Medical Expert/Clinical Decision-Maker

SECONDARY KNOWLEDGE OBJECTIVES

Emergency Care of Croup and Epiglottiditis

  1. Cardiac Surgery
  2. Vascular Conditions
  3. Urology
  4. Plastic Surgery
  5. Orthopedics
  6. Neurosurgery

SECONDARY SKILLS OBJECTIVES

Experience is recommended in the following areas:

  1. Other thoracic surgery

CONTENT AND ORGANIZATION OF THE RESIDENCY PROGRAM

There must be an organized program of rotations and other educational experiences, both mandatory and elective, designed to provide each resident with the opportunity to fulfill the educational requirements and achieve competence in the specialty.

The content and organization of each accredited program in pediatric general surgery must be consistent with the specialty training requirements.

The resident must be provided with progressively increasing responsibility for the management of surgical patients. Operative experience, ultimately including the major procedures in the specialty, must be provided under appropriate supervision. A statement regarding the responsibilities of senior residents in major procedures will be required.

RESOURCES:There must be sufficient resources including teaching faculty, the number and variety of patients, physical and technical resources, as well as the supporting facilities and services necessary to provide the opportunity for all residents in the program to achieve the educational objectives and receive full training as defined by the specialty training requirements in pediatric general surgery.

In those cases where a university has sufficient resources to provide most of the training in pediatric general surgery but lacks one or more essential elements, the program may still be accredited provided that formal arrangements have been made to send residents to another accredited residency program for periods of appropriate prescribed training.

Learning environments must include experiences that facilitate the acquisition of knowledge, skills, and attitudes relating to aspects of age, gender, culture, and ethnicity appropriate to pediatric general surgery.

  1. Teaching Faculty

There must be at least three teaching staff with acceptable qualifications to provide appropriate teaching and supervision of residents. The surgeons attached to each clinical teaching service must hold acceptable qualifications.

 

  1. Number and Variety of Patients

The number and variety of patients available to the program on a consistent basis must be sufficient to meet the educational needs of the residents.

  1. Clinical Services Specific to Pediatric General Surgery
    1. In-Patient

Pediatric surgical services participating in the pediatric general surgery program must be organized into one or more formal clinical services, each with an adequate number of patients available for teaching and administered by a chief-of-service to whom the senior resident is directly responsible.

    1. Ambulatory

In-patient and out-patient facilities should be integrated in so far as possible, in order to provide continuity of observation of patients both in and out of hospital. There must be an out-patient department or alternative facilities for the provision of experience in the pre-admission and pre-operative work-up of surgical patients and for follow-up care on an ambulatory basis.

    1. Consultation

The program must provide residents with the opportunity to obtain experience in the provision of a consultant service in pediatric general surgery to primary care physicians and other specialists.

    1. Emergency Department

The program must provide emergency experience in pediatric general surgery; consultations and trauma are sufficient not as a separate rotation but a daily experience.

    1. Intensive Care Unit

The program must provide residents with experience in evaluation and management in a pediatric and neonatal intensive care unit .

  1. Supporting Services — Clinical, Diagnostic, Technical

Liaison with Other Specialties and Subspecialties

There must be appropriate liaison with teaching services in pediatrics including subspecialties (hematology, medical oncology, gastroenterology, respirology, neonatology, endocrinology, cardiology, nephrology), anesthesia, pathology, radiology, and other pediatric surgical specialties such as urology, plastic surgery, cardiac surgery, orthopedic surgery, neurosurgery, gynecology, otolaryngology and ophthalmology.

ACADEMIC AND SCHOLARLY ASPECTS OF THE PROGRAM:

The academic and scholarly aspects of the program must be commensurate with the concept of a university postgraduate education. The quality of scholarship in the program will in part, be demonstrated by a spirit of enquiry during clinical discussions, rounds, and conferences. Scholarship implies an in-depth understanding of basic mechanisms of normal and abnormal states and the application of current knowledge to practice.

  1. Organized Scholarly Activities

Organized scholarly activities such as journal clubs, research conferences and seminars must be a regular part of the program.

  1. Basic and Clinical Sciences Relevant to Pediatric General Surgery

The academic program must include organized teaching in the basic and clinical sciences relevant pediatric general surgery. The program must have an adequate number of qualified teaching staff to supervise the residents and to provide teaching in the basic sciences related to surgery

  1. Biomedical Ethics

The academic program must ensure that residents gain an understanding of the basic principles and practice of biomedical ethics as it relates to pediatric general surgery.

  1. Communication Skills

The program must ensure that residents learn effective communication skills for interacting with patients and their families, colleagues, co-workers from other disciplines and students. Clearly defined educational objectives for teaching these skills and mechanisms of formal assessment should be in place.

  1. Patient Care Team

Residents must be given opportunities to develop effective skills in collaborating with all members of the patient care team.

  1. Teaching Skills

Residents must be given opportunities to develop effective teaching skills by teaching junior colleagues and students, as well as through conference presentations, clinical and scientific reports, and patient education.

  1. Management Skills

Residents must be given opportunities to develop skills in management as applied to pediatric general surgery such as efficient practice and records management and the ethical use of health care resources. Residents should also be prepared for their role as a health care advocate.

  1. Quality Assurance/Improvement

The program must provide residents with opportunities to gain an understanding of the principles and practice of quality assurance/improvement. Opportunities should be provided for residents to participate actively in such programs in their hospital departments.

  1. Research Opportunities for Residents

There must be a faculty member with the responsibility to facilitate the involvement of residents in research and other scholarly work. The academic program must provide the opportunity for residents to learn biostatistics and the critical appraisal of research methodology and medical literature. Such teaching must include issues related to age, gender, culture, and ethnicity in research protocols and data presentation and discussion. Residents should be encouraged to participate in clinical research during the course of the residency program.

  1. Faculty Research

A satisfactory level of research and scholarly activity must be maintained among the faculty identified with the program.

  1. Life-Long Learning

All programs must promote development of skills in self-assessment and self-directed life-long learning. To promote this end, the program should provide opportunities for residents to attend conferences outside their own university.

SPECIALTY REQUIREMENTS:

  1. Certification in General Surgery.
  2. Approved residency training in pediatric general surgery.

PROGRAMS (WITH TRAINING REQUIREMENTS):

Master of Surgery(M.S):

Thirty six months of approved residency training.

Doctor of Philosophy(Ph.D):

Sixty months(five years)of approved residency training.