Journal of Pediatric Surgery 51 (2016) 143148

Contents lists available at ScienceDirect

Journal of Pediatric Surgery

journal homepage: www.elsevier.com/locate/jpedsurg

Subspecialization within pediatric surgical groups in North America,

Jacob C. Langer a,b,, Jennifer S. Gordon a,b, Li Ern Chen c
a
b
c

Division of General and Thoracic Surgery, Hospital for Sick Children, Toronto, ON, Canada
Department of Surgery, University of Toronto, Toronto, ON, Canada
Department of Surgery, Baylor University Medical Center, Dallas, TX, USA

a r t i c l e

i n f o

Article history:
Received 2 October 2015
Accepted 9 October 2015
Key words:
Optimization of care
Regionalization
Volume outcome relationship
Survey

a b s t r a c t
Purpose: The purpose of this study was to assess the current status of subspecialization in North American pediatric
surgical practices and to evaluate factors associated with subspecialization.
Methods: A survey was sent to each pediatric surgical practice in the United States and Canada. For each of 44
operation types, ranging in complexity and volume, the respondents chose one of the following responses: 1.
everyone does the operation; 2. group policy only some surgeons do the operation; 3. group policy anyone
can do it but mentorship required; 4. only some do it due to referral patterns; 5. no one in the group does it.
Association of various factors with degree of subspecialization was analyzed using nonparametric statistics with
p b 0.05 considered signicant.
Results: Response rate was 70%. There was signicant variability in subspecialization among groups. Factors found
to be signicantly associated with increased subspecialization included free-standing children's hospitals, pediatric
surgery training programs, higher number of surgeons, higher case volume, and greater volume of tertiary/quaternary cases.
Conclusions: There is wide variation in the degree of subspecialization among North American pediatric surgery
practices. These data will help to inform ongoing debate around strategies that may be useful in optimizing
pediatric surgical care and patient outcomes in the future.
2016 Elsevier Inc. All rights reserved.

In recent years, efforts have been focused on optimizing outcomes

for pediatric surgical patients through a number of suggested strategies.
These have included programs such as the National Surgical Quality
Improvement Program (NSQIP), which track and compare outcomes
among a large number of institutions [1,2], reimbursement schemes
that provide direct incentives for good outcomes [3], regionalization of
care for complex and rare conditions [4], and denition of levels of
care according to available resources [5]. One of the factors which has
been most often studied is the relationship between volume and
outcome, which has been shown to be present for a wide range of
conditions in adults, including pancreaticoduodenectomy [6], aortic
surgery [7], radical prostatectomy [8], complicated colorectal surgery
[9] and trauma [10]. In the pediatric age group, there is less evidence
to support such a relationship, but some data do exist for cardiac surgery
[11,12], Kasai portoenterostomy [13], pyloromyotomy [14], inguinal
hernia repair [15], congenital diaphragmatic hernia repair [16], and
Roles: JCL concept, analysis, manuscript; JSG survey management, graphics; LEC
data analysis, manuscript editing.
Level of evidence: 4.
Corresponding author at: Division of General and Thoracic Surgery, Hospital for Sick
Children, Rm 1524, 555 University Avenue, Toronto ON, M5G 1X8, Canada. Tel.: +1 416
813 7654x202413; fax: +1 416 813 7477.
E-mail address: jacob.langer@sickkids.ca (J.C. Langer).
http://dx.doi.org/10.1016/j.jpedsurg.2015.10.038
0022-3468/ 2016 Elsevier Inc. All rights reserved.

Wilms tumour resection [17]. However, other studies have failed to

demonstrate a volumeoutcome relationship for some of these operations [18]. The volumeoutcome relationship is complex, and may
include factors such as surgeon volume [19], surgeon training [20], institutional volume [21], and the resources available in each specic institution [22]. These variables are often interdependent, and it is difcult
to separate them when evaluating the literature, particularly in the
pediatric population [23].
One way of maximizing individual surgeon volume might be to
increase the amount of subspecialization within groups of surgeons, a
strategy which would theoretically concentrate experience and expertise with a smaller subgroup of surgeons and potentially improve
outcomes. This would be especially pertinent for those patients with
particularly complex or rare conditions, a situation which is particularly
relevant in pediatric surgical practice. Although the concept of
subspecialization within a single group or institution has been shown
to improve outcomes among pathologists [24], radiologists [25], and
various surgical specialties [20,26,27], there is very little information
with respect to subspecialization among pediatric surgeons. One study
from Liverpool suggested that establishment of a group of surgeons
with a subspecialty interest in esophageal atresia resulted in improved
outcomes for infants with this problem [28]. The goal of the present
study was to determine the current level of subspecialization within

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J.C. Langer et al. / Journal of Pediatric Surgery 51 (2016) 143148

groups of pediatric surgeons in North America as a way of initiating and

stimulating the conversation about this topic within the context of a
wider move toward optimization of care.
1. Methods
This study was approved by the Hospital for Sick Children Research
Ethics Board (approval #1000036508).
A survey was developed and distributed via Survey Monkey to one
member of each pediatric surgical practice group in the United States
and Canada. Only one member of each group was polled in order to
avoid bias from larger groups. The individual was usually the division
or department chief, but in some cases another surgeon was chosen
because they were well-known to the authors. The survey consisted of
a series of questions characterizing each practice, including: country,
type of hospital (community hospital, free-standing children's hospital,
or children's unit within a general hospital), academic appointments,
presence of a pediatric surgery training program, number of surgeons
in the group, and estimated numbers of cases for the group (inpatient
and outpatient). This was followed by a list of 44 procedures or conditions that ranged in complexity and incidence. For each procedure or
condition, the subject was asked to indicate one of the following options
for his/her practice group: 1. everyone in the group does the operation;
2. group policy only some surgeons do the operation; 3. group policy
anyone can do the operation but requires mentorship from an expert
within the group; 4. only some do the operation due to referral patterns;
or 5. no one in the group does this operation. Subspecialization ratio was
dened as # operation types rated as 24/# operation types rated 14.
Subspecialization policy ratio was dened as # operation types rated as
23/# operation types rated 14. Both ratios were calculated for each
respondent.
Statistical analysis was performed to investigate the association of
various factors with degree of subspecialization or presence of a
subspecialization policy, as reected in the subspecialization ratio and
the subspecialization policy ratio. KruskalWallis test, Wilcoxon ranksum test and Spearman correlation were performed with p b 0.05
considered signicant (SAS 9.3, Cary, NC).
Participants were invited at the end of the survey to add any
comments they might have on the advisability, need or practicality
of promoting sub-specialization within the eld of pediatric
surgery. These comments were collated and summarized, but
were not statistically analyzed.

2.1. Subspecialization for specic procedures or conditions

Fig. 1 shows the breakdown of the ve options for each of the 44
procedures or conditions. There was a wide range of distribution
among the options; the procedures for which there was the lowest
degree of subspecialization were neonatal bowel resection and repair
of gastroschisis or small omphalocele, and the procedures in which
there was the highest degree of subspecialization were renal and liver
transplantation, fetal surgery, and bariatric surgery.
2.2. Factors affecting level of subspecialization
Factors found to be signicantly associated with increased
subspecialization, as reected by a higher subspecialization ratio
included free-standing children's hospitals (medians, free-standing =
35%, children's hospital within a general hospital = 21%, community
hospital = 0%, p = 0.004) and presence of a pediatric surgery training
program (medians, yes = 37%, no = 24%, p = 0.0109). Additional
factors which were positively correlated with subspecialization included number of surgeons in the group (r = 0.41, p b 0.0001), total case
volume (r = 0.28, p = 0.0007), inpatient case volume (r = 0.27, p =
0.0018), outpatient case volume (r = 0.23, p = 0.0074), and volume
of tertiary/quaternary cases (r = 0.25, p = 0.0028). Country and
academic afliation were not associated with subspecialization ratio.
2.3. Factors affecting presence of a group policy around subspecialization
The only factor found to be signicantly associated with presence of a
group policy around sub-specialization, as reected by subspecialization
policy ratio was higher number of surgeons in the group (r = 0.27,
p = 0.0012). Country, hospital type, presence of a pediatric surgery training program, academic afliation, case volume, and volume of tertiary/
quaternary cases were not associated with subspecialization policy ratio.
2.4. Comments from participants
There were 78 comments from the survey participants. Many of the
comments were actually directed at the idea of regionalization of care
for complex pediatric surgical issues rather than at the idea of
subspecialization within groups of pediatric surgeons, indicating that
regionalization remains a very controversial idea. The comments specifically about subspecialization ranged from very supportive to very
critical of the idea. Representative comments appear in Table 1.

2. Results

3. Discussion

The survey was sent to 210 individuals, of whom 147 completed it

(70% response rate). Ninety percent of the groups were American, and
10% were Canadian. Groups worked in a community hospital in 8%, a
free-standing children's hospital in 42%, and a children's hospital within
a general hospital in 50%. Full-time academic appointments were held
by all of the surgeons in 68%, some of the surgeons in 11%, and none
of the surgeons in 21% of groups. Members of the group ran or participated in a pediatric surgical training program in 34%, and were not afliated with a pediatric surgical training program in 66% of groups.
Number of surgeons in the group ranged from 1 to 20, with a median
of 4. Estimated number of inpatient cases per year ranged from 75 to
2700, with a median of 700. Estimated number of outpatient cases per
year ranged from 110 to 3800, with a median of 800. Estimated percentage of secondary cases (such as hernia repair, orchidopexy, appendectomy, pyloromyotomy, etc) per year ranged from 10% to 95%, with a
median of 75%. Estimated percentage of tertiary cases (neonates,
tumours, other index cases) per year ranged from 5% to 85%, with a
median of 21%. Estimated percentage of quaternary cases (referred
from other pediatric surgeons) per year ranged from 0% to 20% with a
median of 1.6%.

Optimization of care for pediatric surgical patients has become an

important goal for the pediatric surgical community in North America.
A number of initiatives have been established over the past few years,
including the Pediatric National Surgical Quality Improvement Program
(NSQIP-P) which permits tracking and comparison of surgical outcomes
[1]. More recently, the Task Force for Children's Surgical Care developed
a framework for designating hospitals into one of three levels according
to their resources; a site verication program is being implemented
under the auspices of the American College of Surgeons [29]. Despite
these initiatives, there remains a great deal of suspicion among pediatric
surgeons about the need for and advisability of measures designed to
optimize patient care. There are many reasons for the controversy,
including the effect these measures will have on the viability of training
programs, fear that regionalization or subspecialization might decrease
the number of jobs available for the increasing number of pediatric
surgeons graduating from training programs every year, and concerns
about decreased reimbursement, skill levels and/or job satisfaction for
surgeons who experience a decrease in the volume of index and complex cases as a result of the new measures. In addition, subspecialization
makes it much more difcult to cover call responsibilities for patients

J.C. Langer et al. / Journal of Pediatric Surgery 51 (2016) 143148

145

Neonatal bowel resection

Gastroschisis and small omphalocele
Oophorectomy for tumor
Repair of esophageal atresia with TEF
Pull-through for standard segment..
Neonatal diaphragmatic hernia repair -..
Resection Wilms tumor
Resection stage 1-2 neuroblastoma
Giant omphalocele
Open pulmonary lobectomy
PSARP for rectourethral or..
Resection large sacrococcygeal teratoma
Repair of pure esophageal atresia
Pull-through for total colonic..
Choledochal cyst
Laparoscopic anti-reflux procedure
Large lymphatic/vascular malformations
Resection stage 3-4 neuroblastoma
Pancreatectomy for tumor
Kasai portoenterostomy
Heller myotomy
Re-do surgery for Hirschsprung's or..
0%

20%

40%

60%

80%

100%

No policy - everyone does this operation

Group policy - only some in group do this
Group policy - anyone can do this, but requires help from an "expert" within the
group
No policy, but cases limited to certain surgeons due to referral patterns
Not done by anyone in our group
Fig. 1. Range of responses regarding level of subspecialization for 44 pediatric surgical procedures and conditions.

with more complex problems, and also has implications for succession
planning for the group in the event that one of the subspecialized surgeons leaves the practice suddenly. All of these concerns were reected
in the comments we received from the participants in this survey.
This study documented signicant variability in the way pediatric
surgical groups in North America currently approach subspecialization.
It is not surprising that larger groups of surgeons with higher case
volumes are more likely to subspecialize, because they have the numbers to support the practice. However, it is less clear why they do it.
Possibilities include a belief that it leads to better outcomes or that
some or all members of the group have a particular interest in specic
areas of pediatric surgery. We also don't know how often everyone in
the group has a designated sub-specialty or if only some have that
designation. It was interesting that signicant sub-specialization
appears to be occurring for many procedures and conditions based on
referral patterns rather than through a formal policy within the group.
This suggests that referring pediatricians or pediatric specialists may

be driving the trend toward subspecialization; it is unknown whether

this is due to a belief that a volumeoutcome relationship exists for
specic types of cases, or whether it is simply the result of referrals
due to personal relationships or expressed interests of individual
surgeons. Future studies specically examining the referral process for
complex or rare pediatric surgical conditions would be valuable in
understanding this phenomenon.
More than half of the respondents contributed comments in addition to lling out the survey. Many of the comments specically
addressed the issue of regionalization of complex cases, which although
it wasn't the focus of this survey, does share many of the same issues
and concerns. Some of the respondents offered alternative solutions to
subspecialization that they have utilized to optimize care in their
groups. The most common solution was having two attending surgeons
scrub on complex cases (especially if one of the surgeons is experienced
or expert in that problem). This appears to be a particularly useful
paradigm for smaller groups where true subspecialization is more

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J.C. Langer et al. / Journal of Pediatric Surgery 51 (2016) 143148

Thymectomy
ECMO cannulation and management
Esophageal replacement
Restorative proctocolectomy for UC or..
Major liver resection (one lobe or more)
Thoracoscopic pulmonary lobectomy
Neonatal diaphragmatic hernia repair - MAS
Pancreatectomy for hypoglycemia
Ravitch repair of pectus excavatum
Cloacal exstrophy
Repair cloacal anomaly with short..
Nuss repair of pectus excavatum
Sentinel node biopsy
Thyroid/parathyrod
Repair cloacal anomaly with long common..
Separation of conjoined twins
Tracheal reconstruction
Surgery for portal hypertension
Liver transplantation
Bariatric surgery
Fetal surgery (open or fetoscopic)
Renal transplantation
0%

20%

40%

60%

80%

100%

No policy - everyone does this operation

Group policy - only some in group do this
Group policy - anyone can do this, but requires help from an "expert" within the
group
No policy, but cases limited to certain surgeons due to referral patterns
Not done by anyone in our group
Fig. 1 (continued).

difcult and problematic. This kind of approach represents one of many

alternative strategies for improving outcomes within a practice group or
institution, without the need for subspecialization. Other approaches
that have been described in the literature include mentorship during
the initial learning curves for individual surgeons [30], implementation
of clinical pathways [31], and the Evidence-based Practice for Improving
Quality (EPIQ) process, which involves identication of practice variation among centers, and subsequent targeted changes to these practices
with ongoing measurement of outcomes [32].
There are a number of limitations to this study. First, although we
tried to invite all of the pediatric surgical groups in North America to
participate, we may have missed some; this would have been more likely for smaller groups or individual practices. Second, we did not have
input from 30% of the groups that we surveyed. Both of these factors

may have introduced some selection bias into the study. However,
70% is an excellent response rate for a survey of this kind, and it is unlikely that additional respondents would have signicantly changed
the conclusion that the level of subspecialization is extremely variable
both among conditions and procedures, and among pediatric surgical
groups. Third, although there does appear to be a relationship between
the complexity of the 44 procedures and conditions and the degree of
subspecialization, we did not develop a complexity index for each of
them, so we are unable to statistically evaluate the effect of complexity
on the tendency toward subspecialization.
This study clearly documents extreme variability in both attitude
and practice with respect to subspecialization in North American pediatric surgery at the present time. However, it was not in the scope of
the study to evaluate the effect of subspecialization on outcomes for

J.C. Langer et al. / Journal of Pediatric Surgery 51 (2016) 143148

Table 1
Representative comments from respondents.
Good evidence that quaternary procedures (cloaca, Kasai) have better outcomes
in the hands of experienced center/surgeon....we owe it to our patients to subspecialize in these instances to achieve best outcomes. The challenge as a
profession is gaining evidence based outcomes that will help to inform us where
to draw the line.
Inevitable, but credentialing will be a nightmare.
Sub-specialization is a slippery slope.
While the premise for sub-specialization is understood, many practices are
limited to 2-3 pediatric surgeons. It is difcult to promote sub-specialization in
such a small group practice
It is in the patient's best interest that the surgeons with the most experience and
best results deal with the more complicated operations, but junior surgeons also
need to do big cases to develop critical experience. We continuously seek to
address appropriate supervision and graduated experience within our attending
group. We also support sub-specialization when it is within a faculty's academic
interest, while still attempting to maintain a wide range of capability for
individual surgeons.
The attraction of pediatric surgery as a profession is, at least partially, due to the
diversity of the pathologic diagnoses and the multitude of surgical procedures
utilized to attend to these diagnoses the vast majority of surgical
procedures should remain in the realm of the well-trained pediatric surgeon
as long as that person or an associate with experience has the expertise to
provide the service.
Where does it start, and where does it stop?
Sub-specialization will be important for certain cases like liver transplant, very
rare complex anomalies. We encourage 2 surgeons scrubbing for large and
complex cases to ensure good assistance, more exposure to cases and excellent
working relationships within the Section. Patient care is improved and surgeons
maintain their exposure and skills.
I don't think we can rely upon ourselves to make the appropriate decision to defer
a case to another colleague It is unfortunate that some egos stand in the way
of doing what is right for the patients we take care of.
It is impractical to entirely limit specic cases to a small number of surgeons
unless they are willing to be available. Even then, perhaps the best role of these
surgeons is to develop templated guidelines and management plans for cases
that can technically be done by all, and establish specic referral plans for cases
that cannot.
I am against sub-specialization. That being said, things like cloacas, conjoined
twins, fetal surgery, complex vascular or lymphatic malformations,
transplantation, complex airway reconstructions, difcult hepatic tumors,
complex chest wall deformities should be handled by surgeons that manage
them commonly. I would think common sense would prevail, but perhaps that's
asking too much.
The pitfall of sub specialization is that those not sub specialized lose all experience
with problems but are then asked to care for these patients when the sub
specialist is not available.
I believe that it will be the beginning of the downfall of our specialty.... I do not
plan to send cases away in my practice and will do all I can to prevent what
seems like an inevitable end result of sub specialization.
We have found that specialization has dramatically increased our volume of
surgery for complex surgery. The professional expertise level has risen as
well as the degree of professional satisfaction. Our more mature surgeons
have taken to this very readily and have intentionally stopped treating
patients for which they do not feel they have the expertise. The younger
surgeons still want to do everything but after about 5 years gravitate to their
own areas of focus and interest. All of our faculty do core general pediatric
surgery and take call.
We don't really have a designated expert for many of the cases listed, but some
people have more experience and so our practice is to schedule any complex
case with two attending surgeons, at least one of whom has a lot of
experience.
More than sub-specialization, I think it is crucial that we formalize the mentoring
process for young pediatric surgeons out of training, maximizing the experience
of the older generations.
Given the low numbers of each type of complex operation done by the vast
majority of pedi surgery groups, it is important to concentrate the experience
among 1 or 2 of the surgeons in order to develop the necessary expertise.
Total number of cases is small which makes specialization difcult. We are
identifying experts for esophageal, Wilms, neuroblastoma, surgical endoscopy,
and anorectal malformations who will act as knowledge and technical resource
to the other members of the group.
Sub-specialization within the eld may be appropriate within a few centers but
each location needs to be able to address its local needs. If pediatric surgeons are
given the message that they shouldn't do certain operations then access may
suffer or they may face liability risks for doing operations they are capable of
doing.
This is necessary but will be difcult to enforce in the US.

147

these conditions. As the ongoing debate about optimization of care unfolds, it is the responsibility of all pediatric surgeons to participate in the
conversation, and to lead and facilitate generation of high quality outcome data to further inform the discussion.
Appendix A. Discussions
Presented by Jacob Langer, Toronto, ON
MARSHALL SCHWARTZ (Philadelphia, PA): Jack, that is really an interesting study. I think all of us have thought about this but no
one has really looked at this in any kind of fashion as you
did and I think it's terric.
I want to make a comment about the regionalization issue.
There is a very good reason why this has no traction in the
United States and that is it is a political hot potato and it is
not just in pediatric surgery. I think at some point in time
this is a conversation that the medical profession is going to
have to have in this country because we have such duplication of care and it drives up the cost of health care in this
country enormously. It's not as much of an issue frankly in
pediatric surgery but if you think about the duplication of
care, that every hospital has a cardiac surgery program, an
oncology program, et cetera, that duplication of care cost a
lot of money. We have duplications of care in pediatric surgery in major cities and I think at some point that might be
part of our conversation.

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