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PRESIDENTIAL ADDRESS DELIVERED IN IAPSCON 2015, MUMBAI
Year : 2016  |  Volume : 21  |  Issue : 1  |  Page : 1-5
 

Indian Association of Pediatric Surgeons Golden Jubilee: The milestone and the signposts ahead


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Date of Web Publication17-Dec-2015

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DOI: 10.4103/0971-9261.171930

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How to cite this article:
Bajpai M. Indian Association of Pediatric Surgeons Golden Jubilee: The milestone and the signposts ahead. J Indian Assoc Pediatr Surg 2016;21:1-5

How to cite this URL:
Bajpai M. Indian Association of Pediatric Surgeons Golden Jubilee: The milestone and the signposts ahead. J Indian Assoc Pediatr Surg [serial online] 2016 [cited 2018 Feb 25];21:1-5. Available from: http://www.jiaps.com/text.asp?2016/21/1/1/171930



Dr. Minu Bajpai ,

Professor of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, India

President: Indian Association for Pediatric Surgeons

Editor:

Journal of Indian Association for Pediatric Surgeons

Editor-in-Chief: Journal of Progress in Pediatric Urology

Convener:

Indian and Asian Societies for Paediatric Urology

E-mail: bajpai2@hotmail.com; Website: http://www.paediatric-urologyonline.org/

Good evening friends,

During this year's meeting, we are commemorating 50 years of pediatric surgery in India. The celebration of a Golden Jubilee is a tribute to the founders of any organization. The difficulties faced by the society in general and our specialty in particular in India post independence cannot be fully realized in the present day. Developing a specialty out of general surgery could only be achieved by a generation of hard taskmasters. They not only successfully created a niche for this field but laid down a foundation, enabling us to see the light of today.

It is a great honor for me to represent our family of pediatric surgeons during this Golden Jubilee year. At the outset, on behalf of the Indian Association of Pediatric Surgeons (IAPS), I would like to compliment Dr. Ketan Parikh, Dr. Ravi Ramadwar, and all members of the organizing committee for arranging an exceptional meeting befitting the significance of this event. My immediate predecessors, Dr. Sudhakar Jadhav and Dr. Rasik Shah had successfully carried the torch forward. My fellow members in the Executive Council of IAPS, during this Golden Jubilee year 2015, were constantly aware of the milestone IAPS has scaled and suitably "upped the ante." As the buzz gained momentum, members of the IAPS from across the country have joined the party to make this event a resounding success.

The years gone by have seen a steady but slow growth of pediatric surgery in India. Twenty five years ago, there were 270 pediatric surgeons and the numbers have reached the 1,500 mark with 50 teaching departments. This is far lower than the country's requirement. The socioeconomic constraints of our country, directly or indirectly, may have denied the pace of growth our specialty deserves; however, the time is not for looking at scapegoats but for marching ahead with concrete steps. [1]

The year 2015 also proved to be a watershed year in many ways. In 1975, Prof. Upadhyaya [2] had suggested the referral of cases, which required specialized care to dedicated centers where the expertise kept growing vertically. This was followed by a series of articles, which addressed the education and training standards in the country. Not long ago in 2002, Prof. Chatterjee's editorial [3] again stirred up introspection about the specialty's future. Cognizant of this relentless hum, we have taken steps for steadying the ship by catalyzing a state of dynamic stability and creating signposts for the future.

Here are some specific problems, which need focus and the blueprints of solutions that we could put in place and galvanize:

The signposts ahead:

  1. Lack of uniformity in training across India.
    • Blueprint: Indian Academy of Pediatric Surgery (IAPS).


  2. Outreach services at the periphery:
    • Blueprint: Community Oriented Pediatric Surgery Chapter (COPS).


  3. Resource development and awakening social consciousness:


  1. Lack of uniformity in training across India
    • ACIAPS:


The foremost goals of ACIAPS are:

  1. To achieve uniformity of basic training across India.
  2. To achieve structured development of subspecialities.


With increasing awareness about surgical problems in children and the longevity of our specialty, a series of thought-provoking articles have appeared to address the issue of the nature of training in pediatric surgery. [3],[4],[5],[6],[7],[8],[9]

The Dutch model [10] of training also takes into account the needs as per regional requirements. Closest to this form of approach, would be the engagement of in-service candidates with preliminary training in general surgery, going back to their workplace and initiating the practice of pediatric surgery. Unfortunately, in a democratic setup trainees cannot be sent to requirement-specific areas. The latter approach, right or wrong, can probably be taken up in a communist country or by way of regulatory implementations. Further, even basic setups require electricity, laboratories for primary tests, imaging facility, and first and foremost anesthetists and nurses. Uniformity of training could be envisaged only with uniformity of suitable infrastructure. Therefore, a realistic approach would be to aim at optimally utilizing the available resources while aiming to pace synchronously with parallel developments.

Medical education in India is not the responsibility of the Ministry of Education but the Ministry of Health and Family Welfare. It is constantly recognized that medical education has adjusted inadequately both to changing conditions in the health care delivery system and to the locoregional needs and expectations of society. This is largely due to disconnected developments. IAPS is the National Scientific Association of Pediatric Surgeons. Ideally, its recommendations should be binding for all government and national agencies, such as Medical Council of India (MCI) and National Board, in matters of training and practice of pediatric surgery. We will seek to do just that.

During the Golden Jubilee Year 2015, a stage has been created in the form of the ACIAPS, which will have the mandate and will serve as the official organ to approach government agencies. The other aims of ACIAPS would be:

  • Searching for evidence and its collection.
  • Designing updates.
  • Measuring the impact.
  • Identification of controversial topics.
  • Development of the standards of procedures (SOPs) and related matters.


Objectives of ACIAPS:

  1. Inclusion of pediatric surgery in the undergraduate and pediatric postgraduate curriculum.
  2. Develop a mechanism for bringing uniformity of training standards across training centers in India [e.g., by way of developing periodic assessments during the courses - Master of Chirurgical (M.Ch.)/Diplomate of National Board (DNB) or Fellowships]. This would include curriculum development for MCI and the National board as well as recommending the list of examiners to choose from.
  3. It would also be appropriate for this forum of IAPS to develop guidelines and procedures for accreditation purposes. Crucial components of improvement in quality of training programs are institutional self-evaluation, external review, and consultation. The ACIAPS would also work out modalities to develop such consultation teams from among IAPS members with specified credentials.
  4. The need for organ-wise development of pediatric surgery training has been increasingly felt. Focus would be to develop the following (please see 'The Way Forward' below) subspecialties in India by starting one-year Fellowship programs for each. For development of curriculum and exploration of the modalities, one chairperson, each, shall oversee development of the subspecialties they are representing. [The "Chairperson (Academic Council)" and his/her subcommittee will have the role in policy-making and shall be different from the "Chairperson (Chapter) of IAPS"]. Apprehensions that pediatric surgeons would lose turf with specialty development are unreasonable as the volume of workload is already staggering with ever increasing discrepancy between demand and supply. There is no regulatory advisory in place, which can keep a check on who would treat children. The adult organ specialists cosset in the surgery of children but realize the need for further training in this area. Our approach should be to develop an inclusive development model (IDM) with an eye on national needs. Inclusive development means not being disinclined toward collaborative efforts with Pediatrics (Medicine) and Adult Specialty programs. For example, if a M.Ch. from an adult gastrointestinal (GI) Surgery program wishes to pursue a career in Pediatric GI Surgery, he/she needs 1 year of Pediatric Surgery + 1 year of Pediatric GI Surgery Fellowship. On the other hand, if a M.Ch. from Pediatric Surgery program wishes to pursue a career in Pediatric GI Surgery, he/she needs 1 year of Pediatric GI Surgery Fellowship. This approach is futuristic in several ways, as follows:


  1. It would establish a legitimate, regulatory requirement to recognize those who could practice pediatric subspecialties. This should be acknowledged by all concerned parties (my personal communications with coordinators of adult programs reveal that in contrast to the past, they have realized the necessity of adult-based trainees to have adequate exposure of pediatric surgery if they wish to pursue pediatric practice).
  2. It would educate additional trainees to in pediatric surgery programs from the adult-program aspirants even if for 1 year (we acknowledge that numbers from this stream are likely to be small).
  3. This would also help to enable pediatric surgery to justify its equitable place in the national health fabric.


E. It would project the requirements of pediatric surgery in the Ministries of Rural and Urban Development, Social Justice and Child Welfare, apart from Health and Family Welfare, especially in the context of COPS and the forthcoming smart cities.

F. Special cells within ACIAPS will oversee matters such as issues related to consumer protection, medical termination of pregnancy (MTP), human organ transplant acts, and insurance [11] -related matters.

G. In the present system (except in the autonomous institutions), the postgraduate programs of M.Ch. and Diplomate of the National Board are recognized by the MCI and National Board of Examinations (NBE), respectively, with little or no synchronization between them. Examiners travel across the length and breadth of the country to examine the candidates before the degree can be awarded. This effort by the academicians in the IAPS could be tapped to bring uniformity in training. At least by sharing the structured curriculum, which is recognized by IAPS through its forum, the ACIAPS can function as a bridge between MCI and NBE in the aforementioned context.

2. Outreach services at the periphery:

COPS: Community Oriented Pediatric Surgery Chapter.

A gross discrepancy exists between the requirement and availability of pediatric surgeons. With children below 18 years comprising 41% of India's population, there is an urgent need for every possible approach to fill this gap.

While the lack of infrastructural support is a crucial reason for the uneven distribution of health care facilities in favor of urban-centric development, the fewer number of pediatric surgeons remains the cause for worry. Nevertheless, the children requiring such care remain deprived. Who should provide this care? The level of care required varies widely. Not all patients require a tertiary level of care. In some countries, a minor procedure such as circumcision is performed by pediatricians or obstetricians. In India, there is a need to have training platforms for various levels of expertise. Still, the answer is not easy to come by. Aggressively conducted outreach programs have the potential to bridge these glaring gaps to some extent.

COPS - The subchapter of IAPS - Is aiming to do just that. In the last 1 year, this subsection has been revived. With active participation of the IAPS executive council, Dr. Ravinder Vora, our senior member from Sangli, Maharashtra, India and Dr. Sudhakar Jadhav, our past President, have taken steady steps toward this goal. Through COPS, IAPS has proposed an outreach program of pediatric surgery into health care policy, covering rural and tribal areas and collaboration with other specialists. A proposal has been submitted to the Rashtriya Bal Swasthya Karyakram in the Ministry of Health and Family Welfare, New Delhi, Delhi, India. COPS is seeking to materialize an alliance between existing the government machinery, insurance companies, and national scientific bodies. This includes obstetricians and gynecologists, the MCI, NBE, medical universities and insurance companies. Provisions have been made for holding camps, the visits of pediatric surgeons in the district hospitals, awareness campaigns, and even establishing a state-wise birth defects registry.

This is also an appeal to individual members of the IAPS to envision and gear-up for our expanded role. Medical officers and general practitioners are often handling surgical problems at the district level due to the resource crunch in trained manpower. [12] This would mean an undergraduate curriculum in surgery requires a greater exposure to pediatric surgery. Constant updates in knowledge are required for such a vast network of caregivers. Pediatric surgeons in nonteaching setups will need to take up this role in their respective regions. ACIAPS will design courses, which would stratify the levels of care vis a vis the level of trained persons available and the criteria for referral.

As our surgical neonates require initial stabilization and transportation, it is the need of the hour to have a meaningful liaison with pediatricians and their already robust national neonatal programs.

  1. Resource development and awakening social consciousness:
    • CHIPS: A foundation of child health initiatives by pediatric surgeons.


There is a need to bring awareness in the public as well as civic agencies about the need of children requiring specialized surgical care. These children not only require interventions to minimize and cure their disability with a desire to improve their quality of life but also efforts to make them independent. Rehabilitation and provision of guidance can make a huge difference on the future of these special children. Once empowered, they can lead a good and dignified life, and can then contribute to society in their own way. The mission of CHIPS is to make this happen.

Aims of CHIPS: To provide a platform of IAPS to bring about public awareness about the specialty.

Objectives of CHIPS for special children*:

  1. To bring awareness about their need through booklets/articles in newspapers or magazines.
  2. To support, protect and uphold their status, interest, prestige and dignity.
  3. To promote studies in the science of their needs.
  4. To promote scientific education in schools with respect to special children.
  5. To cooperate and/or affiliate with organizations with similar aims and objectives.
  6. To conduct medical camps headed by pediatric surgeons from within IAPS and paramedical staff for identifying and supporting special children.
  7. To set up research and development of technology in their welfare.
  8. Convincing the Government: May also be termed as "lobbying" for a cause.
  9. To undertake such work as may be decided upon by the trust from time to time.
  10. (*Definition of special children: Special children are those children who have some form of congenital or acquired disease needing care by pediatric surgeons).


The "Way Forward":

What should our advanced training programs be like?

Molenaar, et al. (Rotterdam Resolution of 1973) [13] envisaged a program of training wherein pediatric surgeons should be able to offer complete care to a child from head to toe.

That was then.

There is vertical growth in knowledge base and surgical skills pertaining to each region of the body, supplemented by advancements in miniaturization of instruments and optics ushering in the modern era with gadgets enabling state-of-the-art interventions in the field of microsurgery, laparoscopy, and robotics. In utero birth defect correction is now a reality. With the resonance of these technological advances, it could be "brain-picking" to conceive a cutting edge training program for a tertiary care center. A proposed perspective is as follows:

New organ-based fields:

  1. Urology.
  2. Gastrointestinal surgery.
  3. Hepatobiliary surgery.
  4. Neurosurgery.
  5. Thoracic surgery.
  6. Trauma.


Following subspecialities would be integral to each of the above broad areas*.

To be done by all specialists (6, as of now) within their fields:

  1. Neonatal surgery.
  2. Laparoscopy.
  3. Surgical oncology.
  4. Organ transplant.
  5. Basic pediatric surgery: Hernia, hydrocoele, cleft lip and palate, malignancies of the nonspecialized fields prescribed above;
  6. Fetal surgery.
  7. Regenerative medicine. (*as and when)


After the Mumbai IAPSCON, the party moves to Agra IAPSCON-2016 under a very dynamic and affirmative leader, Dr. Kishore Panjwani. As we enter into the second half of the century of our existence in India, we hope to marshal our resources for greater dividends. There is a need for IAPS headquarters with a permanent staff. While we are pinning our hopes on the model created through the Academic Council of IAPS, the individual efforts in the government sector and private sector by our members, such as Prof. N.C. Bhattacharyya (Guwahati) [14] and Dr. Sudhakar Jadhav (Sangli), [15] exemplify additional contributions to children's cause and one more "Way Forward" for our gigantic national compulsions.

 
   References Top

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Sripathi V. Presidential Address: 38 th Annual Conference of the Indian Association of Pediatric Surgeons, Bhopal, Madhya Pradesh - 2 nd November 2012. J Indian Assoc Pediatr Surg 2013;18:1-3.  Back to cited text no. 11
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Bickler SW, Kyambi J, Rode H. Pediatric surgery in Sub-Saharan Africa. Pediatr Surg Int 2001;17:442-7.  Back to cited text no. 12
    
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Jadhav S Dr. Presidential Address: 39(th) Annual Conference of the Indian Association of Pediatric Surgeons, Bhubaneswar, Odisha - November 8, 2013. J Indian Assoc Pediatr Surg 2014;19: 1-2.  Back to cited text no. 15
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  2005 - Journal of Indian Association of Pediatric Surgeons | Published by Wolters Kluwer - Medknow 

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