Journal of Pediatric Surgery 50 (2015) 223–231

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Journal of Pediatric Surgery

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

Journal of Pediatric Surgery Sponsored

Daniel G. Young Lecture

Understanding the responsibilities and obligations of the modern

paediatric surgeon
Spencer W. Beasley ⁎
Christchurch School of Medicine and Health Sciences, University of Otago, Clinical Director of Paediatric Surgery, Christchurch Hospital, Christchurch, New Zealand

a r t i c l e i n f o a b s t r a c t

Article history: The modern paediatric surgeon needs to be competent in multiple domains that extend well beyond their clinical
Received 21 October 2014 and technical expertise. This article, based on the Journal of Pediatric Surgery Lecture at the BAPS Congress
Accepted 2 November 2014 (2014), explores some of these less well understood responsibilities and obligations, including professionalism,
leadership, effective clinical teaching, and research. The consequence of falling short in these areas includes
Key words:
risks to our profession as a whole as well as compromising our ability to provide our patients with the best clinical
Paediatric surgeon
Professionalism
care. Paediatric surgeons have a responsibility to influence the configuration of services to improve the quality of
Leadership care and equity of access to specialist services for all children in their region. Evidence presented shows how a
Surgical teaching well-organised and funded regional paediatric surgical service allows children to receive quality treatment
Research closer to home and is reflected in better clinical outcomes, less unnecessary surgery, and fewer complications.
Configuration of services A paradigm for support to emerging countries as they increase the capacity and infrastructure of their paediatric
Overseas aid surgical services is proposed. The way we judge ourselves and others should relate to our performance across the
full scope of roles that a responsible and committed paediatric surgeon is expected to display.
© 2015 Elsevier Inc. All rights reserved.

In some circles, surgeons have been regarded as being merely doc-
tors with the added skill of being able to perform surgical procedures.
Cynically, and perhaps with a tinge of envy, the less than charitable phy-
sician has been inclined to dismiss surgeons as being little more than
highly skilled technicians: they are generally perceived to be affable,
confident and simple folk — but not always capable of deep or painstak-
ing consideration of clinical complexity. Not surprisingly, this character-
isation has been vehemently rejected by surgeons; instead, they have
viewed their own ability to make decisions quickly when the need
arises as being a strength and usually in the patients’ bests interests,
particularly in the operating theatre. Some surgeons might be tempted
to counter the physicians’ view by further suggesting that this ability
has often enabled them to influence disease processes within the
lifetime of the patient in a way that the non-proceduralist cannot!
Of course, this sort of argument has little merit as it completely fails
to acknowledge the many other areas of expertise that contribute to
surgical competence.
Indeed, it is probable that virtually all of us already see our role as
paediatric surgeons as extending well beyond the clinical and technical
domains. Our professional Colleges certainly do. Publication of the seven
Royal College of Physicians and Surgeons of Canada (RCPSC) CanMEDS
competencies in 1996 [1] led the way in our understanding and
acceptance of the broad range of skills required of clinicians across
all specialty areas. In 2003 these were expanded and refined by the
⁎ Tel.: +64 3 364 0432; fax: +64 3 364 1584.
E-mail address: spencer.beasley@cdhb.health.nz.
Royal Australasian College of Surgeons (RACS) to define nine surgical
competencies that were more specifically applicable to surgeons [2].
These nine competencies were designed to underpin all aspects of
surgical training and to provide a framework to assess the performance
of practising surgeons. It is interesting to note that only the first three of
these nine competencies pertain directly to clinical and operative
expertise (Table 1): the remainder are described as non-technical skills,
and the teaching of these has now become routine across all nine
surgical specialties in Australia and New Zealand. Indeed, teaching of
the same non-technical competencies has become commonplace in
many other surgical training programmes as well.
In an attempt to make them easier to understand and be applied to
everyday surgical practice the RACS identified markers of good (and
bad) behaviour for each competency domain [2]. Initially they were
used by specialty training boards to assess trainee progress, but now,
there is increasing enthusiasm for them to be used to review the perfor-
mance of consultant surgeons as well. Slowly, they are being built into
the very framework of institutions’ processes around accountability
for the performance of their senior medical staff. For example, my
own institution the Canterbury District Health Board incorporates the
Management and Leadership behavioural markers as outlined by the
RACS in its process for reviewing the performance of its clinical direc-
tors. Moreover, acceptance of the importance of the non-technical skills
has been the catalyst for a number of courses that specifically focus on
these domains of surgical behaviour. One of the first, and perhaps best
known, is the NOTSS course [3] which has been provided under the
auspices of the Edinburgh College.

http://dx.doi.org/10.1016/j.jpedsurg.2014.11.003
0022-3468/© 2015 Elsevier Inc. All rights reserved.
224 S.W. Beasley / Journal of Pediatric Surgery 50 (2015) 223–231

The relevance of three of the non-technical competencies (3) A duty, collectively and individually, to put the best interests of
(Professionalism; Management and Leadership; and Scholarship and clients ahead of their own (“duty of public service”).
Teaching) to paediatric surgery will be discussed in more detail in this
article. While it is acknowledged that there are many other important He warns that these ongoing rights are dependent on a continued high
roles in which paediatric surgeons may be involved, including patient standard of performance. The exclusive right to work in a defined area is reg-
advocacy and public education, just two are highlighted in this paper: ulated by a number of external jurisdictions, which may include a national
medical registration board (or equivalent), and at a more local level the
1) Configuration of clinical services
employing hospital’s process around credentialing. Most jurisdictions now
This relates to how paediatric surgeons should be proactive in ensuring
demand demonstration of maintenance of standards of performance, and
the configuration of the paediatric surgical service they provide to their
compliance with a continuing professional development (CPD) programme.
drainage population best serves the needs of those children with surgi-
The right to professional autonomy is given on the basis of trust [4]. It is con-
cal conditions. Each surgeon has a responsibility to work with manage-
ferred on professional bodies because of a public expectation of gaining public
ment and other jurisdictions at a governance level to make sure their
benefit, but the processes and benefits need to be transparent and de-
service is configured in a way that facilitates accessible and high qual-
monstrable. The challenge to us as paediatric surgeons is that retention
ity care for all children in the region.
of these rights is dependent on the public perception of our ability to
2) Pro bono work overseas to support paediatric surgery in emerging nations
continue to perform that duty. One difficulty we face is that while we
This questions what are the responsibilities of paediatric surgeons who
may have a vague idea of what that might involve, there are few objective
contribute in this area if they are to ensure that any assistance they
parameters that we can use to measure our degree of professionalism.
provide is effective and appropriate? The suggestion is that this must
To address this problem, and in an attempt to bring an understand-
be considered from the recipient country’s perspective, within a
ing of professionalism in a way that can be applied to everyday clinical
framework of the longer term goal of establishing a self-sufficient
practice, the RACS has provided its Fellows with a publication [5] that
and sustainable service in that country.
includes three illustrative examples of professional behaviour
(Table 2). For each of these it provides multiple examples of both
In short, the purpose of this article is to explore some of the less well
good and bad behaviours which can be used as a yardstick against
understood responsibilities and obligations paediatric surgeons have to
which performance can be measured. It is a good start.
their specialty and to their colleagues (including trainees and overseas
So where do we sometimes fall short? Certainly, there is risk to us
colleagues).
and to our profession if we were to see our work primarily as a business
rather than a vocation [4]. This may be most obvious in the private sec-
1. Professionalism
tor, and recently in Australia the whole issue of excessive surgical fees
and co-payments has received much public attention. Recent focus on
While all paediatric surgeons believe that they are professional in the
safe hours of work has exposed the importance of making sure the pro-
conduct of their work, their understanding of what constitutes profes-
cess of handovers is robust and that all relevant clinical information is
sional behaviour may vary quite widely. Even the term “professionalism”
passed on (a professional responsibility) to ensure that continuity of
can be interpreted in a variety of ways. A general and encompassing def-
care is not compromised. The risk here is that we might not always
inition of professionalism for paediatric surgeons might be along the
place our patients’ best interests first, ahead of our own. It may also
lines: “demonstration of a commitment to the children we treat, their
colour the underlying nature of our relationship with our patients.
families, the community and the profession through the ethical practice
A second danger is failure to have processes around self-regulation
of paediatric surgery”.
and discipline within our own specialty. We expect – often demand –
This definition makes an assumption that paediatric surgeons are
a high level of autonomy and wish to practice in a milieu devoid of
highly trained and skilled (which they are), that this expertise is confined
excessive external interference. But we may be denied this if we are
largely to those within the specialty (which increasingly is the case) and
perceived from the outside – by politicians and the community at
that these surgeons confine their work to their specific area of expertise
large – as being self-serving and as a profession failing to deal effectively
(which they should be expected to do). It implies an acceptance of profes-
with poor performance amongst our colleagues.
sional ethical behaviour and adherence to an agreed code of conduct.
Professions are conferred both rights and responsibilities. The gener-
2. Leadership
ic definition of a profession provided by the Hon. Geoffrey Davies QC [4]
is directly applicable to paediatric surgery:
When people talk about leadership they usually focus on the great
(1) The exclusive right to work in defined area, usually highly skilled. leaders of history, perhaps not always fully appreciating that leadership
(2) The right to professional autonomy. is something that pervades all parts of our complex social structure and

Table 1
The nine RACS surgical competencies.

SURGICAL COMPETENCE DESCRIPTOR

Medical expertise Integrating and applying surgical knowledge, clinical skills and professional attitudes in the provision of patient care.
Judgement and clinical Making informed and timely decisions regarding assessment, diagnosis, surgical management, follow-up,
decision-making health maintenance and promotion.
Technical expertise Safely and effectively performing appropriate surgical procedures.
Professionalism Demonstrating commitment to patients, community and the profession through the ethical practice of surgery.
Health advocacy Identifying and responding to the health needs and expectations of individual patients, families, carers and communities.
Communication Communicating effectively with patients, families, carers, colleagues and others involved in health services to facilitate the
provision of high quality health care.
Collaboration and teamwork Ability to work co-operatively with peers, trainees and other health professionals to develop a shared picture of the clinical
situation and facilitate appropriate task delegation, to ensure the safe delivery of safe, effective and efficient surgery.
Management and leadership Leading, providing direction, promoting high standards, matching resources to demand for services and showing consideration
for all members of staff.
Scholarship and teaching Demonstrate a life-long commitment to reflective learning, and the creation, dissemination, application and translation
of the medical knowledge
 S.W. Beasley / Journal of Pediatric Surgery 50 (2015) 223–231
occurs at many levels. Even within our own surgical specialty, we may
acknowledge the more prominent leaders amongst us, yet all of us
have to demonstrate reasonably good leadership skills in our day to
day work. Only by doing this can we function at the highest level, get
the best out of those who work around us, and act in the best interests
of our patients. Despite the intricate part that leadership plays in the
daily conduct of our work, it is not always fully understood, and there
persist a number of myths around what good leadership actually
means and involves.
One of the most useful and encompassing definitions of a leader
comes from David Pendleton & Adrian Furnham [6]. They have defined
a leader as someone who can create the conditions for people to thrive,
individually and collectively, and achieve significant goals. Implicit in
this – and this is where many of the myths surrounding great leaders
are debunked – it is (virtually) impossible for any single individual to
be the “complete leader”. But while a complete leader may be difficult
to find, it would seem that teams provide the best means of finding
complementary leaders who together can provide complete leadership
[6]. It may be a surprise to some that personality seems to be more influ-
ential than intelligence in effective leadership — although undoubtedly
intelligence does help! While a leader’s personality may not change
with time, his or her leadership style may. Fortunately leadership style
can be modified by experience and skill acquisition. There is substantial
evidence that leadership has a strong influence on a group’s performance.
It is useful to consider leadership within three main domains:
strategic, operational and interpersonal, and these are closely inter-
linked [6] (Table 3). In its simplest terms, “strategic” refers to the ability
to define the goal and work out how best to achieve it; “operational” de-
notes the organisation required to get to that outcome, and the “nuts
and bolts” of its implementation; and “interpersonal” relates to the abil-
ity to bring together everyone’s efforts in a constructive way so that the
goal is achieved efficiently and with the support of stakeholders. The
three domains are closely interlinked and interdependent. For example,
setting strategic direction relies on the operational domain for planning
and organisation, and on the interpersonal domain for creating
alignment i.e. everyone pulling in the same direction. Delivering results
(operational domain) requires building and sustaining relationships
(interpersonal domain) for the team to work together effectively.
Consequently, it would be reasonable to expect that all paediatric
surgeons should be reasonably proficient in their leadership skills. For
the paediatric surgeon doing clinical work, this means someone who
can continue to anticipate, think, and make correct decisions when
stressed. There is an expectation that they will retain a calm demeanour
and lead by example when under pressure. Surgeons should be able to
assume overt leadership when the situation requires it (at the right
time and in the right way), be able to resolve conflicts within the
team, and provide solutions to challenging situations [2]. Leadership
encompasses their ability to negotiate effectively, be an advocate for
their patients, take responsibility for key issues/problems that arise
within their clinical practice, and to be proactive in dealing with them.
A good leader does not function in isolation, but instead freely consults
with colleagues and listens to other members of the team. The leader is
sensitive to the needs and concerns of work colleagues. Consistent with
this, the NOTSS course summarises leadership behaviour as: leading the
team and providing direction, demonstrating high standards of clinical
practice and care, and being considerate about the needs of individual
Table 2
The RACS descriptors for “Professionalism”.
1. Reflection on one’s own surgical practice and having insight into the implications
[of one’s behaviour] for patients, colleagues, trainees and the community;
2. Maintenance of [high] standards of ethics, probity and confidentiality,
and respecting the rights of patients, families and carers;
3. The maintenance of personal health and well-being and considering
the health and safety needs of colleagues, staff and team members.
225
team members [3]. In summary, in the context of paediatric surgery,
leadership involves setting and maintaining standards, supporting
others and coping with pressure.
The challenge for each of us is to incorporate leadership attributes
into our daily work. Competent leadership by consultant staff goes a
long way to ensuring a functional and content department, and as a
consequence is likely to improve patient outcomes.
3. Teaching
By and large we are a group of extremely fortunate people in that our
community has bestowed upon us the opportunity and privilege of
practicing paediatric surgery. Undoubtedly, we have been endowed
with the intellect and have put in the years of hard study needed to
gain the expertise that has culminated in us being authorised to practice
without supervision. But we must not forget that we have only achieved
our current position because of the commitment and selfless efforts of
our various mentors and teachers on the way, to whom we must remain
enormously indebted. So in turn, we have an obligation to give some-
thing back to our specialty [4], and to teach those who follow us, such
that they can continue our work at the highest level for the benefit of
the next generation. We owe this to our specialty and to the community.
Many of us may have observed (and wondered why) not all clinical-
ly competent surgeons make equally good teachers. Of course, many are
outstanding, but the ability to teach is not uniform. There could be var-
ious explanations for this, including the continuous pressure on time
under which the busiest surgeons function, reluctance to allow the
trainee to be the primary surgeon, or rarely, lack of inclination. But it
is likely that the main reason some highly competent surgeons may
not be as good at teaching as they are with their clinical work is much
more fundamental, and to explain why, it is first necessary to under-
stand how clinical decision-making occurs.
There is a difference in the way clinical decision-making occurs be-
tween the novice and expert. Surgeons use a continuum of processes
to acquire, assimilate and evaluate clinical information as they decide
on a management plan for their patient [7]. At one end they rely on an-
alytical thinking (sometimes called hypothetico-deductive reasoning),
a relatively slow and deliberate approach in which their knowledge is
applied objectively and consciously to the clinical situation. At the
other end of the spectrum, there is an intuitive (often subconscious) ap-
proach which relies on pattern recognition from previous experience. In
comparison with analytical thinking, intuitive thinking is fast and eco-
nomical of effort. It also leaves more room available for other cognitive
activities such as situation awareness, something that can be an advan-
tage in the operating theatre. Good clinical surgeons can move seam-
lessly between the ends of the spectrum according to need, whereas
the novice has to rely mostly on analytical thinking — and this is more
demanding, slower and less efficient. It can come at a cost of reduction
in situational awareness.
The problem some expert surgeons have when teaching is that the
steps they take in their clinical decision-making occur so quickly and
effortlessly it is often hard to disentangle them or to slow the process
down sufficiently for the logic of the individual steps to be shared
Table 3
Leadership in paediatric surgery.
DOMAIN DESPRIPTION
Inter-personal Building and sustaining relationships with colleagues
and other health carers: sensitive and supportive of
surgical team, empathetic, recognise where support
and encouragement are required
Strategic Setting strategic direction: identify issues and ability to
negotiate for service, share vision; understand
dynamics of hospital and how to achieve goals
Operational Delivering results: be a good role model, demeanour,
integrity, performance under stress; can implement plans
226 S.W. Beasley / Journal of Pediatric Surgery 50 (2015) 223–231
with the trainee. The trainee may be impressed with the speed and
ultimate accuracy they observe of their teacher’s clinical decision-
making, but may not be able to see exactly how the expert has
reached the particular conclusion, and therefore has learnt little from
the encounter.
There is even more to clinical decision-making than this: at a higher
cognitive level the evaluation of clinical information and developing a
plan of management is influenced by the ability to incorporate a wide
variety of external factors. These may include the more subtle nuances
and circumstances of the case, the availability of resources, being able
to place the correct weighting on each piece of information, and
knowing where critical elements of information are missing or need
further evaluation. This process may cause the management plan to be
modified to accommodate the specific circumstances and needs of the
patient. Some clinicians have called this “individualising treatment”,
an unhelpful term that tends to be used when clinicians themselves
cannot adequately explain how or why they came to a certain decision.
In other words, they could not understand the complexity of their
own thinking, or identify precisely what factors caused them to modify
the management they would institute normally. It might be better
to call it “professional judgement”, and reflect on the higher order
thinking involved!
In addition, expert surgeons are able to accommodate uncertainty,
incomplete information and contradictory information better than the
novice. They detect deviation from the expected, and variation from
normal, at a much earlier stage than the less experienced surgeon,
and can modify what they do in response to their observations more
quickly — this is of particular importance during operative surgery.
Expert surgeons can recognise and accept the limitations posed by
inadequate or confusing clinical information (or unexpected operative
findings) more readily than the novice. And they know how best to rec-
tify the deficiencies in the form of a logical management plan and take a
decisive course of action [8]. Their previous experience allows them to
better see what information is essential and why, and where additional
information must be sought (and why) in any particular clinical situa-
tion. In practice, this translates into fewer (unnecessary) investigations
and knowing with greater confidence when there is sufficient evidence
to act in a certain way.
It is mastery of these processes – rather than pure technical opera-
tive ability – that distinguishes the marginally competent from the high-
ly expert and safe surgeon. Yet despite this, technical dexterity sadly
tends to be the main focus of much surgical teaching. Even within the
operating theatre, most mistakes that compromise the patient occur
because of deficiencies in higher cognitive function rather than through
lack of knowledge or technical expertise. An audit of adverse events
in Australian hospitals has shown that about 45% of human errors
occurred because of errors of cognitive function, compared with a lack
of knowledge contributing to only 1% [9].
This then poses the question: how can we improve the quality of
clinical teaching and professional judgement, especially by the experts
in our midst? This has been the subject of considerable interest to the
RACS for several years, culminating in the RACS offering a course in clin-
ical decision-making for its Fellows who are involved in teaching [10].
The rationale is that if surgeons understand better exactly how they
assess patients and come to a management plan, they might be better
at communicating it to their trainees. The degree to which this course
is successful in addressing this issue is yet to be established.
4. Research
Research is one method by which paediatric surgeons can improve
the quality of their surgical practice. We all desire to foster a critical
and enquiring mind in our trainees, such that they will pose and want
to answer unresolved clinical questions as they encounter them,
even after they have completed training. But exactly where and how
research training best fits into the actual paediatric surgical training
programmes, and into subsequent practice, remains contentious.
In some programmes, previous research experience or a higher
degree are key criteria for selection onto training. The potential advan-
tages of this are that skills in critical analysis, scientific writing, research
methods, and presentation at international meetings are acquired early,
at least by the commencement of training [11]. Networking, broader ex-
posure at scientific meetings (which may open subsequent employ-
ment opportunities) and time for reflection may be additional benefits
to the doctor. Finally, it would be reasonable to assume that well con-
ducted research may also confer benefits to future patients. But overall,
there has been no consistency around the use of research criteria for se-
lection onto surgical training programmes. Research requirements are
somewhat arbitrary, vary significantly between specialties and regions,
and have not been shown to be a good discriminator of applicant poten-
tial. When used as a parameter for selection, research experience usual-
ly appears as marks on the curriculum vitae (CV). Those with substantial
academic output tend to score more highly (which undoubtedly acts as
an incentive for aspirant surgeons to gain research experience and aca-
demic output prior to applying) but unfortunately, of the three main se-
lection tools normally employed (CV, referees reports and interview)
the CV is the poorest predictor of subsequent success in examinations
and completion of training [12]. Part of the reason for this may be that
the CV does not measure career trajectory well, and sometimes less ca-
pable surgeons who have been around for many years slowly accumu-
lating papers and presentations are advantaged at the expense of the
more recently graduated but highly capable younger applicant with
great potential.
In a few training programmes a dedicated period of research is man-
datory and integrated into training. This is justified by a conviction that
there is merit in giving every surgical trainee an opportunity to become
an academic surgeon. However, it is hard to undertake useful basic sci-
ence research for a short period (such as one year) irrespective of
whether it is before, during or after training. Unlike in decades past,
the skills required to undertake high quality basic science research are
highly specialised and complex: often it involves expertise in molecular
biology or other non-surgical fields that is difficult to gain quickly. The
logistics, funding and complexities of collaboration with other research
groups are such that it really only works when the surgeon’s project fits
into an already well-established research programme. Also, there is an
emerging realisation that fulltime research is not always in the best
interests of the potential or actual trainee. It may prolong training, con-
tribute to loss of technical skills during a critical period of training, and
be perceived adversely in some circles (“those who cannot operate
teach, and those who cannot teach do research”) [11]. Training boards
complain that it complicates the logistics around the organisation of
allocation of trainees to training posts. From the trainees’ perspective,
especially by those with a strong clinical bent, it may be seen as an un-
wanted encumbrance. Nonetheless, while mandatory dedicated re-
search periods may not be a requirement of all training programmes,
most training programmes require some form of research or academic
output (often described as a minimum research requirement) [13–15].
There is no dispute that it is essential “to bring an academic compo-
nent to [the surgeon’s] practice” [16]. Courses taken during surgical
training already attempt to assist in this, such as the Critical Literature
Evaluation and Research Course of the RACS [17]. However, the perti-
nent question is: what are the minimum competencies we expect of
all surgeons to enable them to perform their clinical work to the highest
level, as distinct from those needed by surgeons who wish to pursue an
academic career? The UK Foundation programme Academic Compendi-
um 2013 [18] clearly outlines research competencies, but does not
made any distinction between those that are generic to all surgeons,
and those that are more applicable to the specialist academic surgeon.
What is desperately needed is clarity around what could reasonably
be considered generic or core research competencies that all (paediat-
ric) surgical trainees should acquire, and what are the additional
 S.W. Beasley / Journal of Pediatric Surgery 50 (2015) 223–231
competencies required by career academic surgeons. Once those have
been established, a more logical approach to the place of research as a
criterion for selection or as part of the training curriculum can be
achieved. The expectation is that these competencies, once learnt,
would be of value throughout active clinical practice.
5. Configuration of services to provide high quality care and equity
of access
In first world countries, most paediatric surgical units depend on a
population of about 1 million or greater to be viable. This translates
into 3 or 4 consultant staff, the minimum number considered acceptable
if acute call rosters and leave requirements are accommodated whilst
maintaining a reasonable work-life balance. Fewer than that number
leads to issues around peer review, maintenance of standards, vulnera-
bility during absences for leave or illness, “burn out”, ability to maintain
linked services (e.g. paediatric anaesthesia, pathology, oncology), and
restricted scope of practice (a consequence of numbers, expertise or
facilities). Larger centres have sufficient numbers to allow varying
degrees of subspecialisation within the specialty, but because they
tend to be based in larger cities, they run the risk of perpetuating
inequities in access, especially if they provide no outreach services or
have no operational links with their regional hospitals.
A problem of equity of access also arises when the population is
relatively dispersed, sparse or isolated by difficult topography. The
South Island of New Zealand provides such an example: like many
other parts of the world, it is handicapped by all three (Fig. 1). This cre-
ates a challenge for the paediatric surgeon: how to provide the highest
quality of clinical care across the entire drainage area, yet to provide that
care as close to the home of the child as possible and with the minimum
disruption and cost to the family. Working from the comfort of a
large tertiary centre may be convenient for the surgeon, but it does
not necessarily translate into the best clinical outcomes for every child
across the region.
What our unit has demonstrated is that a well organised and funded
paediatric surgical outreach service not only improves access to special-
ist services and allows children to receive quality treatment closer to
home, but also is reflected in better clinical outcomes, less unnecessary
surgery and fewer complications. This configuration of service also
provides better support to local rural surgeons who frequently have to
deal with acute paediatric surgical problems. Obviously, all complex
cases still require transfer to the tertiary centre, but this should occur
in a reliable and timely fashion, and according to predetermined and
agreed guidelines. Provision of a comprehensive regional service
in the South island has resulted in demonstrable improvements in the
outcomes for a variety of conditions, some of which are described
below as illustrative examples:
Herniotomy
It is perhaps surprising that reliable data on long-term outcomes
after herniotomy are scarce, given that herniotomy is one of the most
commonly performed surgical procedures in children. Interpretation
of the literature has been made difficult, in part because most reports
of day surgery performed in children in district hospitals have provided
more an audit of throughput rather than an audit of outcome, fail to
document the key outcome measures, and may suffer publication bias.
For example, Calder et al. [19] described complications such as wound
infection, but their patients were not reviewed post operatively and
they did not record relevant measures of long-term outcome.
Despite this, there is considerable evidence that surgeons trained in
paediatric surgery obtain better outcomes and fewer complications
than those untrained in this type of surgery. The information that is
available suggests that rates of recurrence and testicular atrophy after
herniotomy in the UK are higher in district general hospitals than in
specialist units, and that, specialist paediatric surgeons achieve lower
227
recurrence and atrophy rates than non-specialist surgeons or trainees
[20–22]. By way of a local example, an audit of 32 consecutive
herniotomies performed in children under one year of age by a general
surgeon with a paediatric interest showed re-operations were required
in seven (22%). Indications for reoperation included recurrent hernia,
testicular atrophy and acquired cryptorchidism. This compares with
the outcomes reported in a prospective study of five outcome measures
in the same country where the surgery was performed by a specialist
service [23] (Table 4). There were 3128 herniotomies performed, with
a recurrence rate of 0.58%, although in two of these there was a direct
inguinal hernia. Children under one year of age were more likely to de-
velop wound infection (P =0.01) and recurrence (OR =3.2, P =0.03).
The rates of acquired cryptorchidism were 0.4%, injury to the vas
deferens 0.13%, and testicular atrophy 0.79% of boys (inclusive of all
who presented with a strangulated hernia) [23]. Infants b 5 kg have
the highest complication rates [24,25]. These complication rates could
be used to benchmark performance [23], and the data must provide
a strong incentive for paediatric surgeons to ensure their service is
responsible for all herniotomies in their region.
Basically, there is now sufficient evidence available to propose
with confidence that best practice dictates that all herniotomies (and
orchidopexies, vide infra) should be performed by surgeons trained in
paediatric surgery. In some countries, this already happens; but in
others it does not. There is plenty of room left for improvement, includ-
ing in the UK and USA [26,27]. Moreover, it would now be reasonable
to expect that any future report on outcome after herniotomy must
be prospective and include, as a minimum, the following key measures
of outcome:
(1) recurrent hernia;
(2) acquired cryptorchidism; and
(3) testicular atrophy.
Strictly speaking, the denominator of any such study should include
all children within the drainage area; not just those treated by the single
paediatric hospital, but also those who should have been but were not!
One of the more important components of the South Island outreach
programme has been to teach adult general surgeons how to reduce
strangulated hernias in infants and children. By reducing the number
undergoing emergency surgery, there is then a corresponding reduction
in the likelihood of testicular damage from that surgery. The incidence
of testicular atrophy following incarceration has been reported to be be-
tween 10% and 15% [28,29], mostly in infants who required emergency
surgery where the hernia was not reduced manually. Much of the atro-
phy rate probably results from injury to the testicular vessels during
surgery, consistent with the observation of Puri et al. [29] of no signifi-
cant difference in testicular volumes in children with strangulated in-
guinal hernia and aged matched controls in one tertiary paediatric
centre. Consequently, a higher rate of manual reduction of strangulated
hernia by rural surgeons, and transfer of the infant to the tertiary centre
when attempts at reduction have been unsuccessful, has minimised the
rate of testicular atrophy [23]. Configuration of regional services in this
way might also be expected to minimise mortality and “near-miss”
anaesthetic events, given the young age of most of these neonates
and infants, and the non-availability of specialist paediatric anaesthetic
services in many provincial hospitals.
Orchidopexy
The incidence of bilateral cryptorchidism is normally considered to
be about 10%–15% [30]. Before the establishment of the South Island
outreach service the rate of bilateral orchidopexy varied markedly
between hospitals, but reached 75% in one provincial hospital. This
suggests that many of the orchidopexies were probably unnecessary,
perhaps being performed for retractile testes rather than true
undescended testes. It highlights the importance of having children
228 S.W. Beasley / Journal of Pediatric Surgery 50 (2015) 223–231

Fig. 1. The major population centres and topography of the South Island of New Zealand. The regional paediatric surgical service provides regular clinics and operating to all six centres
outside Christchurch with public hospitals. More recently, clinics have been commenced in Queenstown as well, to provide access to specialist advice closer to home for children in the
Southern Lakes District. The paediatric surgeons travel to each hospital on commercial air flights, apart from Timaru which is 2 h away by car. Major cases are transferred to Christchurch
for treatment. Paediatric oncology drains the southern half of the North Island as well. The total population of the South Island is 1.05 million, of whom half live within an hour’s drive from
Christchurch. Much of the island is mountainous and the weather in winter can sometimes make air retrieval difficult.

suspected of having undescended testes being examined by surgeons education and training, the age of referral in our drainage area has
trained in assessing the paediatric scrotum. changed little in the last decade [33].
A second indicator of the quality of care for boys with cryptorchi-
dism is the age of referral for a specialist opinion and the age at which Intussusception
orchidopexy is performed (Table 5). The optimum age for orchidopexy
is generally accepted to be about 12 months if not earlier [31,32], yet in Before the establishment of a paediatric surgical service in 1996,
many regions the majority of boys with undescended testes are identi- the majority of children with intussusception in the South Island
fied at a much later age [33]. The implication of this is that if the best underwent surgery [34]. The ready availability of specialist advice
long-term outcomes are to be achieved for fertility, more attention (usually by telephone) for all cases outside the tertiary centre, expanded
needs to be directed at improving the early detection and referral of indications for attempting enema reduction, increasing use of the gas
boys with primary undescended testes. Moreover, it is necessary that enema, and the use of a delayed enema after incomplete initial reduc-
once referred, the health system should be capable of ensuring surgery tion are all factors that have markedly reduced the number of children
is undertaken in a timely fashion (Table 5). Ultimately, it is the paediat- requiring surgery (Table 6).
ric surgeon, as the advocate for these patients, who has to take on the Perhaps the most important factor has been the development of
responsibility of ensuring this happens. Sadly, despite attempts at agreed guidelines for the management of intussusception in the South
Island. They accommodate variations in the facilities and expertise of
each hospital. In general, an initial enema (gas or barium, according to
Table 4
Outcome measures for herniotomy in children.
expertise) is performed in the rural centre if the child is in a good clinical
condition. Where it, or a delayed repeat enema, has been unsuccessful
Complication Comment the child is referred to the tertiary centre. If the child is in poor clinical
(1) wound infection All occurred in infants: mostly in the premature condition it is deemed safer to transfer to the tertiary centre during re-
(2) recurrence of hernia More common in boys and in neonates, suscitation, and prior to contemplation of surgery. Taking into account
rare beyond infancy
the anaesthetic and peri-operative care likely to be required, there are
(3) acquired Must ensure testis is in scrotum at completion
cryptorchidism of procedure few indications for emergency surgery for intussusception in a provin-
(4) testicular atrophy Complication of strangulation or technical error. cial hospital. McAteer et al. [35] found that although patients cared for
Much more likely with emergency surgery in paediatric hospitals had more severe disease at presentation, the like-
(5) injury to vas deferens More likely in infants with large sacs (technical error), lihood of bowel resection in a child under 4 years of age with intussus-
Important to identify at time of surgery
ception was only about 20% that of one in a non-paediatric hospital.
 S.W. Beasley / Journal of Pediatric Surgery 50 (2015) 223–231 229

Table 5 Outreach services: logistics and communication

Factors that contribute to determining the age at orchidopexy.

FACTOR COMMENT It is acknowledged that many paediatric surgeons have undertaken

1. Delay in diagnosis 1. Initial assessment at birth
"outreach" on an ad hoc basis to one or more (usually smaller) adjacent
2, “Well child” routine checks centres, and the service provided is almost always valued highly by the
(e.g. at time of immunisation) during local community. It has been seen as a means of providing access to
first year of life quality specialist services, without the inconvenience to patients having
3. Empty scrotum noticed by parents
to travel vast distances to be seen, and the consequent disruption this
4. Influenced by ability of health providers
to correctly assess the infant’s scrotum causes to family, job and income. Fortunately, paediatric surgery lends
2. Delay in referral to 5. General Practitioners awareness of itself well to this type of service: first, most paediatric surgical proce-
paediatric surgeon recommended age for orchidopexy dures can be performed on a day surgical basis safely by a specialist
6. If uncertain about interpretation of signs, team (including a paediatric anaesthetist for younger children) with lit-
referral to paediatric surgeon appropriate
tle likelihood of complications; and secondly, there is a huge social ad-
3. Delay between referral 7. Delay before being seen in outpatient clinic
and surgery 8. Delay due to waiting list for surgery vantage if the surgery can be performed “close to home” to minimise
the inconvenience and cost to families. So the challenge is for all paedi-
atric surgeons to review whether they are fully meeting the needs of
Pyloric stenosis children in their drainage population in terms of equitable and conve-
nient access.
The factors that determine the best outcomes for pyloric stenosis are It would be wrong to imagine that these services can be set up over-
well documented [36] and mostly relate to non-surgical aspects such as night: they require patience, perseverance and a measure of diplomacy.
timely diagnosis, correction of fluid, glucose and electrolyte disturbance, Inevitably resource and funding arrangements have to be negotiated in
and availability of paediatric anaesthetic expertise. Some of these have an environment of competing priorities. Yet the importance of working
proved hard to quantify, and have been under emphasised or ignored closely with local general surgeons and paediatricians cannot be over
in many published audits of pyloric stenosis. emphasised. It is likely that these people will still have to triage and
Virtually all reports have focussed on duodenal perforation as the manage emergency cases. Luckily for the general surgeon most are
only outcome measure. In the UK some general district hospitals within their comfort zone — appendicectomy, exploration of the acutely
without paediatric surgeons have achieved similar rates for this compli- painful scrotum and abscess drainage being the most common acute
cation as those from specialist paediatric surgical units, but given the conditions. It is essential to have good lines of communication in both
other determinants of outcome, this complication alone may give directions and to ensure adequate provision is made for any ongoing
a false impression of the quality or safety of a service. Nevertheless, it management that is required between outreach visits. The presence
remains the one most widely used to measure surgical performance. on the ground has to be regular and reasonably frequent, generally
The duodenal perforation rate at the time of pyloromyotomy for py- more than 4 times a year. The development of a good working relation-
loric stenosis in the South Island of New Zealand varied between 20% ship and rapport with local personnel makes the process of undertaking
and 30% [37,38] prior to the establishment of a specialist service. Now, local clinics and operating, and referral to the tertiary centre, easier for
almost all infants with pyloric stenosis in the provincial hospitals of both parties. The outreach service should be seen as supporting the
the South Island are transferred to Christchurch for surgery, often justi- local institutions, and help overcome some of their problems of isola-
fied on the basis of their anaesthetic and peri-operative requirements. tion. It can be administered locally. Our service discovered that a num-
The same trend is occurring in the parts of the USA [27]. In ber of rural and provincial surgeons said they had been unaware of
New Zealand, this has led to an overall reduction in the duodenal perfo- what was currently considered appropriate treatment for a variety of
ration rate to less than 2%. It should be remembered that pyloric stenosis surgical conditions in children (eg. recent developments in the manage-
does not represent a surgical emergency, so there is always plenty of ment of intussusception) until the regional service was established.
time to transfer these infants while fluid and electrolyte disturbances They felt that the regular up-skilling courses that our service provided
are being corrected. in the early years (that focussed on the early management of common
paediatric surgical emergencies) not only gave these surgeons insight
into best practise, but also provided them with non-threatening lines
Hirschsprung disease of communication which helped with discussion of difficult cases. No
longer is transfer of a patient seen as an admission of failure locally,
Increased awareness of the possibility of Hirschsprung disease, but rather a reflection of the success of the outreach service.
prompt referral of suspected or proven cases, and upskilling of key pa-
thologists have led to a decrease in the age at diagnosis from a median 6. Acute paediatric surgery
age of 63 days before an outreach service to 4.5 days after the outreach
service was established. In conjunction with this, the availability of a In many areas, adult general surgeons in peripheral hospitals should
specialist service has produced an ongoing reduction in the age at be encouraged to continue to deal with acute paediatric surgical condi-
which children received their definitive procedure, from 296 days tions such as non-specific abdominal pain, older children with appendi-
before 1996, to 105 days from 1997 to 2003, and down to 14 days citis, minor head or other injuries, the acutely painful scrotum,
from 2008 to 2014. abscesses and minor burns, provided it is within a child-friendly envi-
ronment with appropriate facilities and resources. These types of condi-
tions comprise about 90% of all acute general surgical emergencies in
children. But it must be remembered that the success of this arrange-
Table 6
ment relies on there being clear guidelines for their triage and manage-
Influence of a regional specialist service on the success rate of enema reduction of
intussusception. ment, and for identifying correctly which children need transfer. The
emerging threat to this is that some provincial general surgeons see
Establishment of regional paediatric Barium (%) Air (%)
the credentialing process as a means of extracting themselves from
surgical outreach service
these obligations. The impetus for this mainly comes from younger gen-
Before outreach 26 75 eral surgeons who are appointed to rural centres but have had limited or
After outreach 75 86
no training in paediatric surgery and who feel reluctant to take on
230 S.W. Beasley / Journal of Pediatric Surgery 50 (2015) 223–231
responsibility for acute paediatric surgical care. As a profession, we must
ensure that we provide these surgeons with the support and skills they
require in those regions where their ongoing involvement is in the best
interests of the patients.
7. Support to emerging countries
Paediatric surgeons historically have been generous in their support
of colleagues working in less well-resourced areas, and often have
participated in teams of visiting health professionals to emerging
nations to operate on children with congenital and other abnormalities.
Their time is given pro bono and there is little doubt that this form of
voluntary assistance to less privileged countries has benefited many
individual patients.
It is only gradually becoming understood that this might not be the
best form of assistance in the longer term, mainly because the overall
capability and capacity of the local service has not been enhanced
[39]. On occasions, these visits can even compromise the reputation
and standing of the local surgeons in the eyes of their community —
“look what the clever overseas surgeons can do: they are so much better
than our own”. On other occasions, there can be a non-alignment
between the health priorities of the recipient nation and the type of
assistance that the visiting surgeons offer to provide. There may be
issues around continuity of care, and dealing with post-operative com-
plications once the visiting team has left.
Another form of First World “assistance” includes sending relatively
untrained medical students for an elective period to an under-resourced
country. This provides a wonderful experience for the student but may
be of limited value for the recipient nation: there may be limited over-
sight, and it leaves little long-term gain in expertise locally.
It is my belief that all paediatric surgeons involved in overseas assis-
tance programmes should respond to and work according to the local
needs – as determined locally – and to ensure that what they are
doing is part of an integrated and long-term programme designed to
promote local capability and infrastructure. The ultimate aim is to create
a self-sufficient and sustainable local service. There are several ways in
which this can be done. Perhaps the most important is to identify
early on young surgeons (even medical students) who have the poten-
tial to be future leaders of surgery in their country, and then to support
and nurture them through surgical training until they are at a standard
where they can return to their homeland. This will often include a peri-
od overseas. It necessitates a long term commitment on the part of the
supporting surgeon, institution or aid programme. As far as possible,
their training should be fashioned to align with local needs which may
involve some adjustments to the usual training programme: this may
be challenge for some institutions.
Unfortunately, one of the impediments preventing these surgeons
from eventually returning to their native land is the lack of an appropri-
ate and resourced job to go to. Even though they may become well
trained, there may be no political willingness (seen as the burden of an-
other salary) or capacity for them to return home to a position that is
supported and viable. This obligates those who are providing the gover-
nance over the support programme to engage at a high political or min-
istry of health level to make sure these young doctors have a job to
return to once they have completed their overseas training. Also, their
new position must provide the linked services necessary for them to
succeed. The implications of this for paediatric surgery are that overseas
training also may need to be organised in paediatric nursing, paediatric
anaesthesia, pathology and paediatric imaging: otherwise the newly
formed paediatric surgical service is unlikely to be sustainable.
Another key element is the recognition that expansion of internal capa-
bility incorporates much more than just the specific skills of medical
staff, and should include establishing good governance, alignment
with ministry of health priorities and policies, and encouraging effective
clinical leadership.
At the end of the day, help from more privileged countries, no matter
how well intentioned, is only of lasting value if it improves the infra-
structure and sustained capability of the local service.
8. Conclusion
A well rounded and competent paediatric surgeon requires skills in
many domains beyond knowledge and operative skills. This paper has
outlined some of these, and the issues and challenges that each poses.
It is hoped that the paradigm by which we judge ourselves and others
accommodates the full scope of our responsibilities and obligations.
Failure to do so could compromise the quality of the service we provide
to children with surgical conditions.
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