Short Report
Training general surgery residents in paediatric surgery
Muhammad A Khan1, Shabbir Hussain2, Faisal Siddiqui3
Departments of General Surgery1 and Pediatric Surgery2, Liaquat National Hospital, Department of General Surgery3, Ziauddin University, Karachi.
Abstract
Children have special needs as surgical patients and are best
treated by specialist Paediatric Surgeons, who are confined
to large centers especially in developing countries. General
Surgeons are thus required to fill in the lacunae. In order to
assess whether general surgical trainees receive adequate
training for treating children in Pakistan, a cross-sectional
survey was conducted at recognized teaching hospitals in
Karachi among residents and fellows. Responses were
received from 90.4% of surveyed candidates. Only 25% of
the respondents were aware of the CPSP guidelines for
training with paediatric patients. Nearly half planned to
include paediatric patients in their practice. Most respondents believed that training by their programmes was adequate in this regard. In contrast most did not feel confident
in operating on paediatric patients. In conclusion current
training paradigm does not give General Surgery residents'
sufficient confidence in dealing with surgical problems in
children.
Introduction
Surgical care of children requires focus on their peculiar
needs as patients. It involves understanding of differences in
presentation and management. Paediatric surgeons are specially trained and thus attuned for this. Their services however, are confined to larger centres as dictated by cost considerations and other logistics. This is especially true in a
large number of Asian countries including Pakistan where
the mean number of paediatric surgeons ranges from 0.1 to
0.5 per million population1 as compared to 2 per million
recommended by the American Paediatric Surgeons
Association Manpower Task Force.2
distributed among general surgery residents and fellows in
several institutions of Karachi. The form comprised of two
sections.
The first section dealt with the queries regarding residents' institution and residency programme. Queries relating to perception about adequacy of training were scored on
Likert Scale (agree=1, partially agree=2, do not agree=3) in
this section. Other queries defined number of beds in the
institution, presence of an independent paediatric surgery
department, and estimate of paediatric caseload among others.
The second section was related to residents' confidence and self-assessment of ability in dealing with children
as surgical patients. Confidence and competence in aspects
of patient care were scored on Likert scale (agree=1, partially agree=2, do not agree=3 and adequate=1, fair=2, none=3)
in this section. For the sake of comparison we adopted the
list of common paediatric surgical procedures as reviewed
by the Education Committee of Canadian Association of
Paediatric Surgeons and reported by Poenaru et al earlier.4
Among other questions residents completion of paediatric surgery rotation was inquired as a categorical binary
variable (yes/no) along with year of residency when rotation
was performed and duration of rotation. Pearson's chiTable 1. Residents' Perception of Training (n=36).
Agree
Partially Agree Do Not Agree
Exposure to Paediatric
Patients is Adequate
30.6 %
(n=11)
58.3%
(n=21)
11.1%
(n=4)
Training in General
Surgical Management
is Adequate
58.3%
(n=21)
33.3%
(n=12)
8.3%
(n=3)
Arguably there is a set of surgical problems of children that can be accommodated in the realm of expertise of
a General surgeon.3 General surgeons in training are thus
required to learn the principles and skills of dealing with
problems in children. Training general surgery residents is
also a defined goal for paediatric surgeons.4
Training in Specific
Operative
Management is
Adequate
41.6%
(n=15)
44.4%
(n=16)
13.8%
(n=5)
This study was conducted to delineate organization
of current training of General Surgeons in dealing with paediatric problems in Pakistan and adequacy of this training
based on trainees' self assessment.
Confident in General
Surgical Management
30.6%
(n=11)
52.8%
(n=19)
16.6%
(n=6)
Confident in Specific
Operative
Management
22.2%
(n=8)
36.1%
(n=13)
36.1%
(n=13)
1.
2.
3.
Employing a survey we focused on:
The organization of training programmes.
Residents' perception about their training.
Level of confidence the training imparted.
Methods and Results
A survey form containing twenty-one questions was
Vol. 57, No. 5, May 2007
Table 2. Residents' Confidence in Managing Paediatric Patients (n=36).
Agree
Partially Agree Do Not Agree
square test was used to define significant difference in selfassessment of confidence and competence in relation to
year of training when paediatric surgery rotation was performed. Statistical analyses were performed using SPSS
version 11.0.
257
There were a total of 38 respondents to the 42 forms distributed (response 90.4 %). Two incomplete forms were
excluded. The 36 respondents included 5 fellows and 31
residents who had either completed or were training in
general surgical residency programmes. Less than a third
(27.8 %, n=10) were females and rest were males (72.2%,
n=26).
Three of the five institutions, where survey was conducted had an independent paediatric surgery department
and represented 72.2% (n=26) of the respondents. Twenty
four of these 26 respondents had completed paediatric surgery rotation. Out of these, 20.8% (n=5) had done so in first
year of training, 37.5% (n=9) in second year, 29.2% (n=7)
in third year and 12.5% (n=3) in fourth year. The duration
of rotation ranged between 2 and 12 months with median of
3 months.
Ten remaining respondents belonged to institutions
where there was no independent paediatric surgery department. Asked to mention approximate percentage of paediatric patients in their practice yielded a mean of 24.8+12.6.
Twenty seven (75%) of the respondents believed that
their programme defined specific learning objectives as
regards to management of paediatric patients. Nine (25%)
were aware of the College of Physicians and Surgeons
Pakistan's guideline as regards to training with paediatric
patients. Seventeen (47.2%) planned to practice with paediatric patients after completing training.
Residents' perception of training has been detailed in
Table 1. Most respondents either agreed or partially agreed
that exposure, training in general surgical and operative
management of paediatric patients was adequate in their
programme.
Residents' confidence in managing paediatric
patients is detailed in Table 2. More respondents were confident about general surgical management than operative
management.
cedures including orchidopexy (17.39%), pyloromyotomy
(17.39%), inguinal herniotomy (21.73%), umbilical hernia
repair (26.08%) and rectal polypectomy (34.78%) where they
clearly lacked confidence.
There are certain limitations of this study. Most
importantly number of participants in the survey is small.
This was dictated by logistical considerations as in order to
ensure adequate response rate the survey was conducted on
sites and correspondence was not relied upon. Additionally
there is a reliance on subjective perception of participants as
regards to adequacy of training, self-confidence and personal competence. Unfortunately short of resource intensive
audit, there are few validated tools for more objective
assessment. Nonetheless surgeon's critical self assessment
does represent at least an important surrogate marker in
gauging confidence and ability.
Conclusion
It is concluded that there are variations in training of
general surgery residents as regards to management of paediatric patients between programsme. The guidelines set by
CPSP as a regulatory body in this regard are not widely
known and the current training paradigm does not give residents sufficient confidence in dealing with surgical problems of paediatric patients.
References
1.
Saing H. Training and Delivery of Pediatric Surgery Services in Asia. J
Pediatr Surg 2000;35:1606-11.
2.
O'Neil JA Jr, Vander Zwaqq R. Update on The Analysis of The Need for
Pediatric Surgeons in the United States. J Pediatr Surg 1980;15:918-24.
3.
Brain AJ, Roberts DS. Who Should Treat Pyloric Stenosis: The General or
Specialist Pediatric Surgeon? J Pediatr Surg 1996;31:1535-37.
4.
Poenaru D, Fitgerald P. Training General Surgery Residents in Pediatric
Surgery: A Canadian Survey. J Pediatr Surg 2001;36:706-10.
5.
Ziegler MM. Pediatric Surgical Training: An Historic Perspective, a Formula
for Change. J Pediatr Surg 2004;39:1159-72.
In order to see association of confidence achieved with
the year of residency when paediatric surgery rotation was
performed and duration of rotation Pearson Chi-Square test
was applied. No statistically significant association was seen.
The survey included a list of procedures and respondents were asked to rank the level of confidence they felt in
performing each of these. Most trainees were confident in performing procedures that are cross-over from general surgery
including incision and drainage (73.91 %), circumcision
(65.23%), appendectomy (60.86 %) and rigid sigmoidoscopy
(47.82%) as opposed to common core paediatric surgery pro-
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J Pak Med Assoc