Wednesday, February 5, 2014

A med student loves open surgery, asks about the future of pediatric surgery

Dimitar [not his real name] writes [edited for length]: I am a medical student who has already applied to the field of general surgery and finished the interview process. I hope to become a pediatric surgeon because it is one of the last fields that allows for one to operate all over the human body and to be a true general surgeon.

However I have been struggling with something that I hope you can help me with. I love the technical aspect of surgery. I enjoy becoming better at tying knots, suturing, and various surgical skills, and above all I love traditional open procedures. I like to feel with my hands and not with those laparoscopic instruments, I like to see with my own eyes and not through a tiny little camera all through a tiny little port. My biggest fear is that everything will become robotic, and that an open procedure will be a rarity in the future. And pediatric surgery most of all is basically an advanced laparoscopic fellowship. I want to make clear that I do not hate laparoscopy, I just enjoy the open procedures much more. I understand that this is probably a very selfish thought as laparoscopy has better recovery times, less pain, shorter hospital stay etc., but I guess that is why we have websites like this where I can ask anonymously what I am to ashamed to asked in public with hopes of getting a non-judgmental response.

To sum it up, I feel like I was born to do surgery back in 1950 or something when everything was open. I would like to find a field that would allow me to operate all over the body and do it the traditional way. Other than trauma, and transplant, what are my options? Would general surgery ever get back to what is was before? If I don't learn to love this laparoscopic and robotic thing am I screwed?

Those are very good questions. Let's start with your worry that pediatric surgery "is basically an advanced laparoscopic fellowship." I'm not so sure about that. If you look at the statistics for residents who finished pediatric surgery fellowships in 2013, you will find that many open cases are being done. This link gives you all the information you need. By my estimation, more than half of all pediatric surgery cases done by fellows were open. That's the good news.

For some bad news, you need to get the full text of this American Journal of Surgery paper that appeared online in November 2013. Written by some senior pediatric surgeons, it gives some worrying information about the specialty of pediatric surgery. The number of complex cases being done by attending pediatric surgeons has remained static while the number of pediatric surgeons has increased. It looks like many pediatric surgeons, even in university hospitals, aren't doing enough complex surgery.

The other bit of bad news is that competition for pediatric surgery fellowship positions remains intense. Here are some data from the last five matches.

As you can see the number of applicants for each position ranges from 1.5 to 2, and the number of unmatched applicants is rather high.

Trauma surgery is not the answer. There are so few open trauma cases being done that in order for trauma surgeons to maintain their skills, the specialty has morphed into "trauma, critical care, and acute care surgery."

I may be wrong, but I don't see general surgery ever returning to the old days where open surgery ruled. Not only that, I think in the future more and more cases will be done with minimally invasive techniques, even if the robot turns out to be a bust.

So in answer to your final question, I think you will have a problem if you do not learn to love the laparoscopic approach.

I wish you the best of luck.