Recent nationwide trends in pediatric neurosurgery have created challenges to resident training in this subspecialty. Some of the major changes surrounding pediatric neurosurgery especially over the past decade have been: (1) the centralization of pediatric subspecialty care to large children’s hospitals; (2) the standardization of fellowship training for board certification in pediatric neurosurgery; and (3) the overall trend of families increasingly demanding that surgical care be given by the senior-most members of the neurosurgical team.
The first trend is part of a nationwide regionalization of specialized pediatric care to larger children’s hospitals. Medical centers with lower volumes of pediatric patients are increasingly becoming deficient of pediatric neurosurgeons. This trend is largely attributable to economic factors, according to R. Michael Scott, MD, neurosurgeon-in-chief at Children’s Hospital Boston and professor at Harvard Medical School.
“Pediatrics is an expensive milieu,” he said. “You can’t do state-of-the-art pediatric neurosurgery without pediatric intensivists, cardiologists, endocrinologists, neuroradiologists, etc., and hospitals can’t afford to fully staff a children’s hospital if they don’t have the volume.”
Further, the American Board of Pediatric Neurological Surgery requires applicants for certification or recertification to submit case logs demonstrating that their practices center on pediatric neurosurgery. Therefore, hospitals cannot attract pediatric neurosurgeons if there are not enough cases.
As a result, many residents train in programs that do not have a pediatric neurosurgeon at their hospital. Over the past decade, the Residency Review Committee has been citing neurosurgery training programs for not having enough pediatric volume, putting those programs at risk of probation or losing accreditation.
“There is some uncertainty as to whether regional demographics allow adequate numbers of pediatric neurosurgical cases for all 90-plus programs,” explained Howard Eisenberg, MD, professor and chair of the Department of Neurosurgery at the University of Maryland.
Some programs have responded by sending their residents to rotate at larger children’s hospitals. For example, at Children’s Hospital Boston, in addition to residents from the Brigham and Women’s/Children’s Hospital program, neurosurgery residents rotate yearly from three outside programs. Residents from these institutions must spend considerable time away from their home institutions, leading these institutions to experience increased expenditures for housing and traveling expenses and increased pressure on resident time allocations.
The standardization of fellowships in pediatric neurosurgery has also significantly impacted resident training in this subspecialty. The ABPNS was founded in 1996, and shortly thereafter firm guidelines for pediatric neurosurgical fellowships were defined. There are currently 21 accredited fellowship programs in North America. At these hospitals, fellowship training may potentially interfere with resident training because the fellow usually operates on the more complex cases and therefore valuable educational opportunities for residents on service may be lost. Ironically, less resident exposure to pediatric neurosurgery because of fellows may reduce resident interest in pursuing a pediatric fellowship.
Recent data from the pediatric match indicates that some pediatric fellowships have difficulty filling their slots. This further reduces the pool of qualified pediatric neurosurgeons and increases the trend toward regionalization of care. Currently there are 44 open pediatric neurosurgery positions across the country, according to Rick Abbott, MD, professor of neurosurgery at Children’s Hospital at Montefiore and chair of the AANS/CNS Section on Pediatric Neurological Surgery.
Another factor that affects direct resident involvement in pediatric neurosurgical cases is the increasing demand by families that care is given directly by the attending surgeons. While this trend is a challenge for all neurosurgical training, this demand arguably may be more emphatic from the parents of pediatric patients. In addition, there is a notion that pediatric neurosurgeons may have a continued stake in the outcome of an individual operation because they may follow their patients for several decades after the procedure. Because of this combination of factors, attending neurosurgeons may feel compelled to take a more active role in operations, which limits the major decision-making by residents throughout the surgical procedure.
Residents now face new challenges in obtaining pediatric experience: regionalization of pediatric care, standardization of fellowship training, and the increasing demand for delivery of care exclusively by attending surgeons. Underlying these factors is the gradual conversion to subspecialty care on a nationwide basis, both in academic and private practices.
“It’s a natural outcome of what’s happening in America in every profession from the law to medicine,” said Dr. Scott. “Patients as consumers are demanding subspecialty care.”
Pediatric neurosurgeons as a group think their subspecialty is improving patient care, but as in other neurosurgical subspecialty areas, data that support this idea are still being gathered.
Edward S. Ahn, MD, is completing a pediatric fellowship at Children’s Hospital Boston. Lawrence S. Chin, MD, is chair of the Department of Neurosurgery at Boston University School of Medicine and chair of the AANS Young Neurosurgeons Committee.