|Year : 2016 | Volume
| Issue : 2 | Page : 47-48
Pediatric surgery in India - The way forward
Ashley LJ D'Cruz
Director and Senior Consultant, Pediatric Surgery/Urology Head, Solid Organ Transplant Program, Narayana Hrudayalaya Woman and Child Institute, Bengaluru, Karnataka, India
|Date of Web Publication||18-Feb-2016|
Ashley LJ D'Cruz
Director and Senior Consultant, Pediatric Surgery/Urology Head, Solid Organ Transplant Program, Narayana Hrudayalaya Woman and Child Institute, Bengaluru, Karnataka
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
D'Cruz AL. Pediatric surgery in India - The way forward. J Indian Assoc Pediatr Surg 2016;21:47-8
The "status quo" in pediatric surgery in our country is unacceptable and if we fail to act now, we would have failed future generations of children and pediatric surgeons.
An association endeavors, through its members, to establish high ideals, develop some rules of engagement, and eventually leave to society a service that is uplifting and equitable. In the context of the Indian Association of Pediatric Surgeons (IAPS), it must develop the highest standards of surgical care for our children, and make it affordable and available across the country. If the association becomes engaged in political chicanery, is divided by strong opinionated groups, and wastes time and resources in conducting routine assemblies and meetings without purpose then no ideals will be developed, no standards will be set, and no benefits will come to the ones they serve.
There are fundamentally three objectives the association should address to become relevant:
- Educational reform in pediatric surgery.
- Standard treatment guidelines.
- Infrastructure development.
| Educational reform in pediatric surgery|| |
There are two streams of training in pediatric surgery recognized by the Medical Council of India (MCI), the Magister Chirurgiae (M. Ch) course and the Diplomate of the National Board (DNB). Both are supposedly equivalent, but in practice, perceived differently. For some intangible reason, the former is considered superior, perhaps because it is older in existence, usually awarded by training in National Institutes or colleges of Medicine. To quickly remedy this misplaced perception, the final award degree should be just one as in the American system - just Doctor of Medicine (MD). Further training could be a fellowship in a particular area of interest awarded as such by an accreditation board of the association.
The more important question to address is how to unify these two streams of training by developing a common comprehensive curriculum. The emphasis should be on learning and not teaching. Professor Spencer Beasley  in an address to the association many years ago outlined the "current principles of surgical education and training" considered by the Royal Australasian College of Surgeons (RACS):
- Competency-based (rather than time-based).
- Entire training in hospitals, common accreditation process.
- Monitor acquisition of competencies against defined standards.
These were concepts driven by the members of the RACS and not some governmental agency. In addition, a strong research component should be incorporated and mandated. The exit system should be uniform, objective, and applicable to both streams of training. A committee of the association called the "Standards and Accreditation Board of the IAPS" will administer this activity. The Ministry in charge, would be on board but have a limited role to play. A prototype curriculum for the DNB course was developed at a consensus meeting in Bengaluru, Karnataka, India, and may serve as a starting point. Utopian is what comes to mind, but achievable, if differences are put aside and common good becomes the driving principle.
| Standard treatment guidelines|| |
The UK has the National Institute for Health and Care Excellence (NICE), the USA has the American Pediatric Surgery Association (APSA), the American Academy of Pediatrics (AAP), and the American Urology Association (AUA) - all associations with some federal prompting acting as bodies that develop guidelines to establish standards of care. The benefits to patients are evidence-based practice, less complications, and early rehabilitation. The benefits to society will be to lessen the burden of long-term medical care and decrease the costs of providing a service. Insurance providers, whether private or state sponsored, will have definable benchmarks to reward doctors for their professional services and reimburse costs of treatment to the institutions. If we do not move to adopt standard treatment guidelines, the day will come when insurers will decide reimbursements and doctors and hospitals will be the poorer for it.
| Developing the infrastructure|| |
The most recent data available (below) indicate that pediatric surgery is not a popular choice of subject for postgraduate (PG) training, regional imbalances exist, and preference is for government institutions.
Data from 2014 (source Dr. Raghunath BV):
Total number of MCI recognized seats: 133 in 49 medical colleges and PG institutes.
Total number of seats filled up: 75 (56.3%)
North India: Allotted-32, Filled-26 (81.2%)
South India: Allotted-58, Filled-24 (41.3%)
Eastern India: Allotted-15, Filled-11 (73.3%)
Western India: Allotted-28, Filled-14 (50%)
| Government seats: Sanctioned-113, Filled-70 (61.9%)|| |
Private seats: Sanctioned - 20, Filled - 5 (25%)
DNB - 6
Coupled with preference to work in metros and large cities and given the small number of trained pediatric surgeons available, an unbalanced state exists. The society will soon tire and lose interest. Two outcomes will eventually emerge. Either pediatric surgery will cease to exist as a specialty, a frightening proposition, or the care of children will pass to generalists and super specialized groups. To correct this anomaly, IAPS needs to act decisively. There are many initiatives suggested by various groups, but the way forward is to push through reforms suggested above and find the monetary resources to make the specialty attractive to young surgeons.
The average salary in the private sector for a trained pediatric surgeon with 5 years of experience is 2-3 lakhs per month. Pediatric surgeons all over the world command premium salaries. Central and State governments should match these payouts either as cash or as privilege.
| Infrastructure|| |
Uniform standards of training and clinical practice (guidelines-based) will automatically improve the infrastructure for pediatric surgical services wherever it is established. The often heard unacceptable refrain "we do not have facilities" will end and pediatric surgeons will have professional satisfaction in their work. The resources for this to happen will come from the government, the private sector, and the industry. Recent success stories of public-private partnerships or strong government support to develop infrastructure for pediatric surgery are many and others can learn from them. A good example is the Vanivilas Hospital for children in Bengaluru, Karnataka, India. It can be transformational and inspiring.
Finally, the need of the hour is cooperation between established centers and those less fortunate - to share expertise, cross-pollinate, exchange students, and wrest back from others what was lost to competing specialties. History tells us that a child with a surgical problem cries out for an empathetic and committed pediatric surgeon.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Beasley SW. The educational theory behind training the paediatric surgeon in the 21 st
century. Lecture at the annual meeting of IAPS 2011.
| Authors|| |