Correspondence Address:
Venkat Sripathi
No.1, Damodaran Street, Chetpet, Chennai
India

Full Text

Respected Senior Colleagues, Ladies and Gentlemen, It has been a great honor to serve as the President of this August association. In the last one year I have travelled across the country and learnt a lot about the problems faced by the pediatric surgical community. Wherever I have gone, I have been received with great affection for which I am grateful. I thought I would address the most important and pressing issues, which affect us, and also suggest solutions:

What exactly is pediatric surgery?

I borrow from the Standard of Care document prepared by the British Association of Pediatric Surgeons "Pediatric Surgery embraces a wide range of organ systems and is the only specialty which is defined by age and as well as by disorder. Pediatric Surgery comprises Specialist Pediatric Surgery, General Pediatric Surgery and Pediatric Urology". [1]

Problems

1. Poor scope for Pediatric Surgery in India?

Our population in the 2011 census is 1.2 billion of which 41% are children (up to 18 years of age) (censusindia.gov.in). This gives us 492,000,000 children to work with. Assuming that 2% of them have congenital problems that require surgery, we come up with a figure of 9,840,000. The British Association of Pediatric Surgeons has recommended one specialist pediatric surgeon for every 300,000 population. According to this, we would require 4000 pediatric surgeons. We have 1200 pediatric surgeons as members of IAPS and perhaps another 500 not registered. So, there is enough work for everyone and scope for enormous expansion.

2. Paucity of Pediatric Surgical Trainees!!

However almost every postgraduate program in this country is reporting that seats are vacant. [2] In 2012 in Tamil Nadu of 15 seats available in the government hospitals only 3 have been filled. The main reason for this dismal scenario is - qualified pediatric surgeons don't earn enough unlike urologists, surgical oncologists or Gastro-Intestinal surgeons.

3. Why are Pediatric Surgeons inadequately paid?

Most pediatric surgical problems are seen in children whose parents are young and have modest incomes. Private insurance companies do not cover surgical problems in infancy and childhood because they do not see this as a viable option. 72% of the health care needs in this country are provided by the private sector. Of those who are treated in private hospitals, 89% meet the expenses from their savings, which leads to bankruptcy in major illnesses. [3] Indians take medical insurance policies late in life (usually after 50 years of age) and insurance companies are unhappy to pay out within five years of a policy being taken.

4. Lack of Job Opportunities in Government Hospitals

Most government hospitals do not have designated posts for pediatric surgeons. If pediatric surgeons are posted they are usually inducted into the general surgery workforce and prevented from practicing their art.

Private super-specialty hospitals do not have pediatric surgical departments. They rely instead on the various organ specialists to cater to children as well as adults. The outcome is of course less than desirable.

5. Awareness of Pediatric Surgery as a Specialty is non-existent MBBS students are not exposed to the topic of child surgery as an area of specialization. Instead they are taught that general surgery can cater to all age groups. In the same way students in pediatric medicine are inadequately exposed to pediatric surgical problems.

6. Flawed training programs

Currently, the entry criteria for Pediatric Surgery training is either after a 3-year course in General Surgery or a straight six-year course in Pediatric Surgery. We have two programs the MCh (overseen by the MCI) and the DNB (overseen by the National Board). DNB is easy to enter but hard to exit whereas MCh is hard to enter but easy to exit. However after qualification there seems to be a different take - DNB qualified candidates are not treated on par with MCh candidates!! Though we are desperately in need of students we have a peculiar situation - two streams of training of the same duration but a different benchmark after qualification!!

Solutions

Ensuring a good insurance plan:

Andhra Pradesh, Tamil Nadu and Karnataka have come out with innovative schemes to reimburse the cost of treatment (for the lower socio-economic group) for a defined set of pediatric surgical problems. On paper this scheme gives the patient the power to walk into any hospital and demand treatment at no cost. In reality the situation is not so rosy. Most private hospitals are not in favor of these schemes as the reimbursement covers only 50% of the cost of treatment. A lot of parents are also unhappy because they believe 'trainee surgeons' will operate on their wards. What then is the way forward?

Dr. Hariawala a US based Health Economist and Cardiac Surgeon has proposed a 'womb to tomb' health policy, which will ensure coverage for everyone. [4] Essentially this policy relies on everyone paying a small premium from birth till death. The premium will spike on obtaining gainful employment and will reduce on retirement. For those in the "Below Poverty Line" group the tab has to be picked up by the government. In this scheme the insurance will be provided by the private sector, which will make a profit (because of numbers covered). Private hospitals also will be happy to take care of children because the reimbursement will be realistic.

In addition I would propose that the government introduce a law, which ensures that every marriage is solemnized along with a health insurance policy. At the time of pregnancy the fetus will also be covered on payment of an additional premium. The extent of coverage can be tailored to the number of years that the policy has been in force. For example a couple who have (responsibly) decided to have a child five years after marriage will be completely covered whereas a child born after two years will attract less coverage. In this way the Family Planning Program will also get a boost.

2. Creating Pediatric Surgical posts in District Hospitals:

We should press the State Governments to provide posts for pediatric surgeons in every district hospital. The Indian Academy of Pediatrics is gearing up to start Level 3 Neonatal Care in District Hospitals. If we join them in this initiative we will achieve our objective as well. A pediatric surgeon who moves away from the Metro with a job in a district hospital will start a practice in a Tier 2 city and achieve monetary and professional satisfaction. This is already happening in Tamil Nadu. Of 167 pediatric surgeons 119 are in big cities like Chennai (66), Madurai (30) and Coimbatore (23). 48 are in smaller towns where they have a thriving practice and a relaxed lifestyle. Contrast this with the situation in very large states like Uttar Pradesh, Bihar or even West Bengal. Can we blame general surgeons for operating on children?

3. Bringing awareness of Pediatric Surgery as a specialty:

We petitioned the Vice Chancellor of the Tamil Nadu Dr. MGR Medical University and got an order from his office for twelve classes in Pediatric Surgery for final MBBS students and also a one week posting in Pediatric Surgery. This needs to be replicated across the country through the Medical Council of India. We also need to ensure that students in DCH, DNB and MD programs in Pediatrics are compulsorily posted for at least one month in a pediatric surgical department. We also need to expose the students of Obstetrics and Gynecology to antenatal diagnosis and their management. This will make sure that they do not unilaterally recommend termination for all in-utero problems.

Finally at least one question in the Final MBBS surgery exam paper and in DCH, DNB and MD (Pediatrics) papers should be on pediatric surgery.

4. Creating a uniform curriculum (the Ashley initiative) and ensuring quality-training programs:

In 2011 Dr. Ashley D' Cruz (during his presidential year) convened a massive exercise in Bangalore, which saw the birth of a curriculum, which is both comprehensive and current. I have written to both the National Board and the Medical Council of India to adopt this curriculum in both DNB and MCh programs. It is my dream that in the future the IAPS will have sufficient power to oversee the quality of training in centers across the country. Once uniformity of training is put in place, a Continuing Professional Development (CPD) program can be started. All members will need to update themselves on a regular basis to keep their licenses.

5. Ensuring that DNB and MCh are treated on par:

This matter needs to be addressed urgently. Job and promotion opportunities should be the same for both DNB and MCh. We cannot afford to have a superior and inferior qualification!!

6. Creating a core group and restructuring the Executive Committee:

There is an urgent need to constitute a 'core group' which is a given a specific task and a time period for completion. This group should be overseen by the President and be answerable to the General Body.

7. Lobbying for our interests in Delhi:

We need a professional lobbyist who can work for us full time and liaise with the National Board, Ministry of Health and Medical Council of India. This is the only way we can make any progress with these government bodies.

Friends, I would like to stop at this point. I hope all of you are enjoying this conference. Congratulations to Dr. Maudar, Dr. Keshav Budhwani and the entire Organizing Committee for organising a superb show. It is very commendable that all the pediatric surgeons of Madhya Pradesh have helped to make this conference a great success.To all the faculty members from overseas and from India, thank you for responding so readily to our invitation and for giving so freely of your valuable time and expertise. I take this opportunity to thank all the members of the Executive Committee and especially Dr. Kishore Panjwani the Honorary Secretary for his unstinted support. I lay down the office of President with a deep sense of satisfaction. I must thank my wife Dr. Jayanthi for being so understanding and completely supportive during the last year, when I was travelling, lecturing, and lobbying in earnest. I wish the incoming President Dr. Sudhakar Jadhav the very best. With his experience of running a very successful Pediatric Surgical hospital in Sangli, I am sure he can broaden our horizons in the years to come.

I see a very bright future for Pediatric Surgery in India. I am very confident that this will be the most sought after and monetarily satisfying specialty within the next five years. JAI HIND.

References