Year : 2020 | Volume
: 25 | Issue : 1 | Page : 1--5
Pediatric surgery in India: From inception to the travails of today and the way forward
Professor of Pediatric Surgery, Institute of Child Health, Kolkata, West Bengal, India
Prof. Kuntal Bhaumik
Department of Pediatric Surgery, Park Clinic. 4, Gorky Terrace, Kolkata, West Bengal
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Bhaumik K. Pediatric surgery in India: From inception to the travails of today and the way forward.J Indian Assoc Pediatr Surg 2020;25:1-5
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Bhaumik K. Pediatric surgery in India: From inception to the travails of today and the way forward. J Indian Assoc Pediatr Surg [serial online] 2020 [cited 2019 Dec 9 ];25:1-5
Available from: http://www.jiaps.com/text.asp?2020/25/1/1/271731
The time has come to look back so as to what motivated us to become pediatric surgeons. Children are not little adults. The pathophysiology of their complicated congenital problems requires very special surgical management. It is our responsibility to attract the undergraduates to our specialty where there is a wide range of treatment options and extensive and complete training is given to treat these defects. Dr. Judson Randolph truly said that Pediatric Surgeons are “general surgeons and something more, and something more.” As per the Kyoto Declaration of WOFAPS in 2002, all the newborns, infants, and children deserve to be treated only by experienced and qualified medical personnel.
It may be of interest to note that the first children's ward in India was established way back in 1911 in the Medical College, Calcutta, under the charge of Professor of General Surgery. However, the first organized pediatric surgical unit was established in the same institute, named Sisur Nivas under Dr. Umesh Chandra Chakraborty in 1946. In spite of absence of any infrastructure in the specialty, he nurtured and cared for the infants and small children with the skill of a master surgeon and the enthusiasm of a pathfinder. A testimony to his hard work is his paper on the cleft palate in the Annual Conference of the Association of Surgeons of India (ASI) as early as 1954. He served this institute single handedly for 10 years and then joined the Institute of Child Health, which was inaugurated by the India's first Prime Minister in 1957. He developed the first Department of Pediatric Surgery in a Children's Hospital in the country and was appointed as Professor and Head.
Dr. Arthur De Sa and Dr. Rustom Irani started Pediatric Surgery in erstwhile Bombay in addition to their general surgery work. Dr. Raman Nair started doing Surgery in children in Trivandrum in 1954, Dr. Anjaneyulu at Niloufer Hospital, Hyderabad, in 1958, and Col. R. D. Ayyar in Delhi in 1958. They are the stalwarts who decided to devote their careers to Pediatric Surgery.
Attempts to make organized Department of Pediatric Surgery were started by foreign trained pediatric surgeons from all over India in the sixties. To name a few, Dr. R. K. Gandhi, Dr. V. C. Talwalker, and Dr. Subhash Dalal in Mumbai; Dr. P. Upadhyay in Delhi; Dr. M. S. Ramakrishnan in Chennai; Dr. I. C. Pathak in Chandigarh; Dr. T. Dorairajan in Madurai; Dr. Subir K. Chatterjee, Dr. B. C. Talukdar, Dr. A. K. Nandy, and Dr. P. K. Sarkar in Calcutta; Dr. George Taliat and Dr. K. K. Verma in Calicut; Dr. Meera Bai in Hyderabad, Dr. Singhal in Varanasi; and Dr. K. C. Sogani in Jaipur are the founders who devoted their career to Pediatric Surgery only. Initial resistance was high as the general surgeons were losing their domain. Subsequently, the resistance waned with the realization that the physiology of small children is different and they require special tissue handling. The main challenges at that time were anesthesia in the newborn, correct size of endotracheal tube, venous access and maintenance of intravenous fluid, fluid and electrolyte replacement, proper use of antibiotics, and postoperative care. It is the strong foundation laid by our forefathers that enabled us to improve the success rate of complex surgeries from 20% to >90%.
With the increasing workload of pediatric surgery cases, there was a need for training centers and the first postdoctoral course was started by Madras University under Dr. M. S. Ramakrishnan at the Government Medical College, Madras. Dr. T. K. Subramaniam was the first to secure M. Ch. in Pediatric Surgery. Gradually, postdoctoral courses were started in different institutions. At present, there are more than 60 pediatric surgery training centers in India, which offer M. Ch. and DNB courses.
As the ASI celebrated its 25th year, the section of Pediatric Surgery was born by the proposal put forward by Dr. R. K. Gandhi and Dr. T. Dorairajan. Other signatories of this resolution were Tripta Dutta, P. Upadhyay, T. E. Udwadia, L. B. M. Joseph, M. B. Shah, S. J. Dalal, A. S. Fenn, S. Sontakay, V. Talwalkar, and M. S. Ramakrishnan. The proposal was accepted on December 29, 1964. Dr. R. N. Cooper, the then President of ASI, accepted the proposal and his famous quote was “The baby is born.”
The first general body meeting was held on March 12, 1966, at New Delhi with 15 members. The constitution of the section was drafted and adopted in 1967. Dr. A. E. De Sa was elected as first President, Col. R. D. Ayyar as Vice President, and Dr. R. K. Gandhi as Honorary Secretary. The sectional meetings of Indian Association of Pediatric Surgeons (IAPS) were held along with Annual Conference of ASI. The first separate meeting of the section was held in Bombay in 1967 as a midterm conference and the second was held at Calcutta in 1969. In 1972, at the Annual General Body Meeting, the Pediatric Surgery section of ASI became “The Association of Pediatric Surgeons of India.” It is currently known as “IAPS”. Since 1983, midterm conferences were being held every year. Gradually, attendance of pediatric surgeons in the midterm conferences increased and attendance at annual conferences dwindled. After prolonged deliberations in various conferences, a landmark decision was taken in the Lucknow conference in 1995. A resolution was passed to amend the constitution where the name of the midterm conference was changed to the Annual Conference of the IAPS. Qualified pediatric surgeons could now become members of the IAPS without being a member of the ASI.
Our members have taken a very active part to establish the specialty in Asia and the rest of the world. Forerunner was Dr. R. K. Gandhi, who was founder secretary of Asian Association of Pediatric Surgeons (AAPS) and later became its President. Dr. R. K. Gandhi also became President of World Federation. Later on, Dr. P. Upadhyay became President of AAPS and Dr. D. K. Gupta became the President of AAPS and WOFAPS. India has the honor of holding Asian Congresses and World Congresses; the last one was held in New Delhi in 2010.
Notable achievements in the academic life of the members of the association are – Dr. S. S. Deshmukh and Dr. Sanjay Oak held the post of University Vice Chancellor in Bombay and Dr. S. Chooramoni Gopal and Dr. D. K. Gupta in Lucknow. Dr. R. K. Gandhi received “Padma Shri,” the fourth highest civilian award in 1985, Dr. S. Chooramoni Gopal in 2013, and Dr. S. N. Kureel in 2016, for their outstanding contribution to Pediatric Surgery. Besides the other awards, Dr. R. K. Gandhi also received Sir Denis Browne Gold Medal of British Association of Pediatric Surgeons in 1993.
We are very proud that our association has started two prestigious orations in the name of two past Presidents – Mridula Rohatgi oration from 1994 and M. S. Ramakrishnan oration from 1997 to commemorate their services. During the conference, several awards are also presented to its members from postdoctoral to senior surgeon levels. Dr. U. C. Chakraborty award is awarded to junior surgeons for outstanding research papers since 1982.
Among the state chapters, the West Bengal chapter is the oldest in India and was started in 1971 under the leadership of Dr. Subir K. Chatterjee. Twelve state chapters are active at present, and they hold their annual conferences regularly under the banner of IAPS generally in the presence of our President and Secretary.
In the Annual General Meeting of IAPS held in erstwhile Madras in December 1993, it was unanimously decided that the association should have a journal of its own and Dr. D. Basak and Dr. A. K. Basu were given the responsibility to take necessary steps. On return to Kolkata, they formed an editorial board with Dr. Subir K. Chatterjee as Editor-in-Chief. The national journal was named JIAPS. The inaugural issue came out in October 1995, and it has now completed 25 years. The journal publishes review articles, original articles, case reports, images in practice, and letters to editors. The journal is published quarterly and articles can be submitted online at http://www.journalonweb.com/jiaps. In the last 25 years, the journal has improved so far as the scientific content is concerned and is receiving articles from all over the world. The editorial board has decided to publish six issues per year from 2020 and an additional e-issue containing the abstracts of the papers presented during the annual conference. IAPS also publishes its newsletter electronically every month.
As is inevitable, our association has grown so much that it now has four subchapters – Pediatric Endoscopic Surgeons of India (PESI), Surgical Oncology, Research and Pediatric Urology. Among these chapters, PESI is the most active which was formed in 2005 in Coimbatore as many pediatric surgeons showed interest in minimal invasive surgery in children. At present, all the subchapters organize annual conferences and workshops.
IAPS has several avenues of communications – Yahoo group was formed by Dr. V. R. Ravikumar on August 15, 2004. Members can interact through this group and it is very active. He also launched IAPS website in 2004 – www.iapsonline.org. The new website is very much updated due to the efforts of our webmasters – Dr. Sanjay Rao and Dr. Ravi P. Kanojia. This is now the official source of all communications.
More than 50 years has passed since our association was formed, but till now, we have not been able to consolidate our position in the society. This is also reflected in the fact that young graduates are not interested to join our discipline. This raises the question, who will serve the future generation of the large pediatric population in India. At present, out of 1.37 billion populations, 370 million are children under 14 years of age. Current infant mortality rate is 33 per 1000 live births. 8.02 lakh infants died in 2018. Less than 5-year mortality rate is 39 in 1000 for male and 40 in 1000 for females. This indicates that there is a lot of scope for improvement in child health care. As far as pediatric surgery is concerned, about 2%–3% babies are born with congenital malformations, which constitute the fifth largest cause of mortality in our country. Every year, around 5 lakh infants are born with congenital defects and about 1.3 lakh die without treatment. There are some government institutes and a few private sector hospitals, which have well-equipped neonatal and pediatric intensive care unit (NICU and PICU), but the number is not sufficient, particularly in the district levels. Further, the incidence of congenital malformations is more common in low socioeconomic groups and the availability of pediatric surgical facilities is very poor in rural areas. Although IAPS has approached the Central Government to expand the facility to all Government hospitals and rural areas, there is lack of initiative from the Government due to fund restrictions. The association should approach the Ministry of Health and Family Welfare to develop well-equipped Pediatric Surgical Department with NICU and PICU in all medical colleges in the country and to allocate more funds to the health sector.
There are various national health programs – In 2013, National Child Health Screening and Early Intervention Services covered 30 health conditions of the children aged 0–18 years through various approaches. India Newborn Action Plan (INAP) formulated in September 2014 has integrated the approaches for the prevention and care of the newborn with birth defects into primary health care. INAP is India's committed response to the Global Every Newborn Action Plan by the WHO with a vision to eliminate preventable newborn deaths and still births. I appeal to the younger pediatric surgeons to take advantage of these plans for better treatment of the less endowed patients. It is not possible for the peripheral health centers to deal with complex congenital defects. We need to develop tertiary care hospitals where there is a team of pediatric surgeons, pediatricians, pediatric anesthetists, radiologists, pathologists, well-trained nurses, paramedical staff, and well-equipped NICU and PICU. The referral services should be developed so that the neonatal surgical patients can be transferred safely from peripheral to tertiary care centers. There should be a mechanism of assured referral system where admission to higher center will not be refused. The association can also approach nongovernment organizations and rich industrialists to develop more mother and child healthcare centers to establish quality health care for all the children.
It is true that we have made some progress from the earlier years when we had inadequate infrastructure, lack of awareness of pediatric surgical problems and training was sparsely available, but we are facing the following problems.
We are presently competing with other specialists such as urosurgeons, neurosurgeons, oncosurgeons, transplant surgeons, and adult laparoscopic surgeons. Although some people prefer the organ-based specialists, they can only treat the local anatomical defects, but long-term follow-up is needed in cases of multiple congenital problems such as VACTERL anomaly and only the pediatric surgeons can take care of all the defects. Pediatric urological problems comprise more than 50% of surgical work, and pediatric surgeons are better exposed to these problems. Moreover, adult surgeons are not exposed to the principles of pediatric care. Our association has already taken few steps by creating chapters, such as PESI, PUC, Oncology, and Research sections. Postdoctoral trainees should attend the conferences of these subchapters and also the training courses. Very few centers presently teach laparoscopic surgery. The hand-on training courses were first organized by Dr. Selvarajan at Coimbatore. Since then, many such training courses have been organized by various centers throughout the country. One-year fellowship program in pediatric laparoscopy is being carried out in Indira Gandhi Institute of Child Health, Bangalore, and in KEM Hospital, Mumbai. One-year fellowship program in Pediatric Urology is being carried out in Apollo Hospital, Chennai, and in Amrita Institute of Medical Sciences, Kochi.
Although we have acquired expertise in these specialties, we should also develop expertise in microvascular and plastic surgery, neurosurgery, robotic surgery, transplant surgery, and fetal surgery. Robotic surgery has been started for the last few years in Apollo Chennai, Apollo New Delhi, and PGIMER, Chandigarh, and pediatric liver transplant in Narayana Hrudayalaya, Bangalore. These require a lot of expertise and practice. Fetal surgery has started in Amrita Institute of Medical Sciences and Research Centre, Kochi – the first in Asia and fourth in the world after USA, France, and Spain. There is a great prospect in this field. Unless we take necessary steps to master in these specialties, the adult surgeons will invade our specialty.
Pediatric surgical training is incomplete and not up to the mark in many of the training centers. There should be uniformity in the training program, and the association should develop a committee to raise the standard of training. We have to talk with NBE administrators to create a comprehensive curriculum. There should be regular seminars, journal clubs, and case presentation by the students and the department should organize CME programs. There should be a specified period earmarked for teachers during their working hours. Besides submitting thesis papers, the students must attend and present papers in conferences and publish papers in indexed journals. There should be an exchange program between the institutes so that they are exposed to different environments. They should assist in more cases and when they perform operations independently that should be under supervision. There should be a common uniform exit program across the country.
Another burning problem is poor job opportunities for newly trained pediatric surgeons. There is a gross violation of the Kyoto Declaration for Care of Children, which leads to discrepancy between the job opportunities of pediatric surgeons. Many pediatric surgeons are posted in General Surgery Department as there are few designated posts in many Government hospitals. Most of the private superspecialty hospitals do not have designated departments as these are not profitable and mostly ornamental in their eyes. Our association should have a talk with the Central and all the State Governments to create posts not only in all medical colleges but also in district hospitals.
There is a loss of interest in taking the specialty because of less lucrative value. I strongly suggest that the remuneration of pediatric surgeons in India should be commensurate with our colleagues of the developed world as the risk taken and skill required by pediatric surgeons are far higher than many other specialties. Another major hindrance is existence of bond during admission in M. Ch. courses which should be abolished. To increase the awareness of pediatric surgery, classes should be taken by the pediatric surgeons at MBBS level. During internship training, they should be posted in our department at least for 2 weeks so that they are exposed to and get interested in pediatric surgical problems. A lot of centers do not have pediatric surgery units, and the postgraduate trainees (PGTs) in general surgery of these institutes should get a rotation in other centers. Furthermore, the PGTs of Pediatric Medicine should be posted in our departments for 2 months so that they are exposed to surgical cases and they acquire the knowledge of these malformations and their management and realize when to refer these children to their surgical colleagues. The PGTs of Obstetrics and Gynecology should also be trained that most of the anomalies are correctable. During the conferences, there should be skill development program for OT technicians and nurses.
No health insurance policies cover congenital defects in India unlike USA where they have changed this by law. In a reply to a PIL filed by Dr. Sanjay Kulshrestha, the court stated that insurance contracts are commercial contracts and no insurance can be directed by the court to include any particular ailment against their wishes. However, as per rules and regulations of IRDA, the Central Government has power to issue directions on policy matters. Among the existing policies, there are serious drawbacks such as there is a minimum waiting or exclusion period from 1 to 3 years and there is unnecessary categorization among anomalies. This discrimination by the insurance sector is also one reason for abortion in cases of birth defects which are correctable. The legal fight is still on and we need a universal health policy. In the Ayushman Bharat Scheme, many pediatric surgical procedures are not included and underrated, and many are listed under other superspecialty branches. Hence, certain changes need to be suggested to Niti Ayog members. We have to create charitable organizations for needy children like Smile Train, which is doing a great job by providing free treatment to cleft lip and palate patients. We could approach Lions Club, Rotary Club, different NGOs, and industrial houses to create a fund to treat all those poor children. Simple measures by the Central and State Governments and by the insurance companies can help to reduce the infant mortality rate in India.
We run a very high risk of consumer protection. We should take utmost care for proper counseling of the parents to avoid litigation. Informed consent needs to be taken mentioning all the postoperative complications. Medical records must be maintained in prescribed format. Daily communication with the parents or legal guardian is essential to avoid mistrust between surgeon and parents. We should not be fearful or apprehensive of dealing with complicated cases where the chance of survival is low. We should be liable only when there is lack of professional integrity, and our conduct falls below that of the standard of a reasonably competent surgeon in our branch. We should not criticize our colleagues in front of patient and their relatives. We can adopt the system of group practice to decrease stress and improve the quality of care and results of surgery. All of us should have a medical indemnity of a reasonable amount at the start of our professional career.
IAPS started with 15 members which has grown to more than 1750 members, but the number is not sufficient and we are mostly concentrated in the big cities. Although there is advancement of our branch over last few decades, it has still not received recognition as compared to other superspecialties. Many steps have been taken by our predecessors, but a lot remains to be done, which has to be fulfilled by the younger pediatric surgeons. Two important achievements worth mentioning in the last year are – IAPS has opted for electronic voting from last year and IAPS textbook of pediatric surgery is published which is a useful reference to all pediatric surgeons. We should concentrate more on research work and we have to reach to the rural areas to serve the community.