Capital District of New York. The tertiary care hospital in thearea currently has two pediatric surgeons, only one of whom isboard certified. I have heard from several area pediatricianswho have expressed concern about the difficulty they face ingetting their patients an appointment to see the pediatricsurgeons at the tertiary care center. As such I see a fair numberof pediatric surgery cases in my practice.

Having tried several times to obtain a fellowship in pediatricsurgery, I can tell you first hand how there are several well-qualified individuals who would be more than happy toprovide care in underserved areas if given the opportunity toobtain a fellowship. With so few fellowship positions annuallyoffered combined with those individuals who are fortunate toobtain a position often staying on at their place of training asstaff, I fear this problem will only continue to grow.

Is there any movement within APSA to creating afellowship or additional training in which basic pediatricsurgical procedures (hernias, circumcisions, pyloric stenosis,etc) are taught? It would be safe to say that there is a greaterneed for surgeons to perform these basic procedures than themore complex operations.

Thank you for your time.

Peter E. FiskEllis Surgical Associates

Ellis Hospital-McClellan CampusSchenectady, NY 12304-1020, USA

E-mail address: fiskp@ellishospital.org

doi:10.1016/j.jpedsurg.2010.01.032

Reference

[1] Nakayama DK, Burd RS, Newman KD. Pediatric surgery workforce:supply and demand. J Pediatr Surg 2009;44:1677-82.

Reply to letter to the editor by Fisk regarding pediatricsurgery workforce

To the Editor,

Our study documents that nearly one half of metropolitanstatistical areas ranked 51 or higher have general surgeonsproviding pediatric surgical services, mostly routine proce-dures such as appendectomies and hernia repair.

Current requirements for certification by the AmericanBoard of Surgery in general surgery require only 20 pediatriccases, of which 8 must be appendectomies, minimum thresh-olds that clearly do not reflect the demands of a surgeon whoregularly cares for straightforward conditions. Trainingprograms in pediatric and general surgery should take theworkforce shortage in pediatric surgery into account. Surgeons

in rural and community practices likely will have to regularlycare for infants and children and deserve substantive exposureto our field during their training.

Don K. NakayamaMercer University School of Medicine

Macon, GA 31201, USAE-mail address: Nakayama.don@mccg.org

doi:10.1016/j.jpedsurg.2010.01.034

Reply to letter to the editor by Fisk

To the Editor,

The problem of the pediatric surgical workforce is one ofboth supply and distribution as Drs Nakayama, Burd, andNewman have discussed [1]. There are additional issues notquickly remedied by APSA or pediatric surgical trainingprograms. Simply encouraging pediatric surgeons to work inunderserved areas may prevent a few transfers to tertiary carefacilities, but is this the best care for children? Patient safety andzero tolerance for preventable complications require anexpertise not available inmanyhospitals. TheAPSAWorkforceCommittee developed a position statement on the care of infantsthat was endorsed by the American Academy of Pediatrics [2].This statement focuses on the need for a team of specialistsexperienced in the care of children. This expertise can certainlybe needed to care for children requiring the basic pediatricsurgical proceduresmentioned byDr. Fisk.Although individualgeneral surgeons with experience, interest, and commitment topediatric surgical patients may be able to provide exemplarycare, trying to expand the number of general surgeons providingpediatric surgical care should not be a goal of APSA, as it is notin the best interests of children needing surgery.

The organization of trauma systems as advanced by theAmerican College of Surgeons provides a model for anapproach to providing excellent care based on the resources ofhospitals and the experience of surgeons that could be appliedto pediatric surgical patients. Perhaps rather than ensuring thatgeneral surgeons have done some pediatric cases during theirtraining, we should focus on the resources needed to care forchildren and how to best provide that care for children inunderserved areas. Perhaps it is time to write a resources guidefor children modeled after “Resources for Optimal Care of theInjured Patient” [3]. The pediatric surgical fellowshipcertification of special competence and experience may notbe sufficient to provide excellent care for children if otherresources are lacking. Conversely, a general surgeon withexperience in pediatric surgery working in a system withcommitted pediatric expertise may be able to provide surgicalcare for some routine pediatric surgery problems. Excellentsurgical care for children requires a system triaging patients

1070 Correspondence

based on their medical and surgical problems, resources of thefacility, and experience of the professional providing that care.The changing health care environment and problems withfunding ensure that children will continue to need strongadvocates for their care.

Julie LongAPSA Workforce Committee

Joe DiMaggio Children's HospitalHollywood, FL 33021,USA

E-mail address: julielong@earthlink.net

doi:10.1016/j.jpedsurg.2010.01.033

References

[1] Nakayama D, Burd R, Newman K. Pediatric surgery workforce: supplyand demand. J Pediatr Surg 2009;44:1677-82.

[2] Stolar C. Best practice for infant surgeryâ a position statement from theAmerican Pediatric Surgical Association. J Pediatr Surg 2008;43:1585-6.

[3] American College of Surgeons, Committee on Trauma, Resources forOptimal Care of the Trauma Patient, 2006.

Reply to letter to the editor by Fisk

To the Editor,

I read with interest the letter by Dr Peter Fisk responding tothe article by Nakayama et al [1] entitled “Pediatric SurgeryWorkforce: Supply and Demand”. Dr Fisk has articulated wellthe stressors felt by a general surgeon who is responsible for thecare of children. The issues he raises regarding options fortraining of general surgeons in pediatric surgery skills are valid.As the Chair of the Education Committee of the AmericanPediatric Surgical Association (APSA), I would like tocomment on behalf of our committee in regard to some issueshe raises.

First, the question of whether it is feasible to create a secondtier of fellowships in some aspects of pediatric surgery is notwithin the purview of APSA. Rather this is under the oversightof the Residency Review Committee of the AccreditationCouncil for Graduate Medical Education (ACGME) and theAmerican Board of Surgery. Although these types of programshave been tried in the past in some settings, they are difficult toadminister and generally have not resulted in long-termimprovement in manpower distribution.

Second, the question of whether it is appropriate forgeneral surgeons to perform surgical procedures on childrenhas been addressed by several national pediatric surgicalorganizations [2,3]. This enormously complex issue is notwithin the domain of the Education Committee of APSA butdoes raise several questions concerning ways to improve thehealth of children by expanding options for the continuingeducation of all practitioners who care for children.

Dr Fisk asks, “How can a non-pediatric surgeon learnmore about the surgical care of children?”As an organizationof pediatric surgeons, APSA has long supported thecontinuing medical education (CME) of pediatric surgeonsat all stages of their careers. The mission statement of theAPSA Education Committee states: “¦to enhance the surgicalcare of children and actively promote patient safety bymaintaining a wide array of educational programs thataddress the needs of practicing pediatric surgeons, surgeryresidents, medical students, surgical patients, and the public”.It must be emphasized that APSA's role is not only to servethe educational needs of its pediatric surgery members butalso to serve the children who deserve the best care.

For general surgeons, the optimal teaching of the basicprinciples of pediatric surgery begins during the generalsurgical residency. Pediatric surgery is considered anessential core component of all ACGME-accredited generalsurgery residency programs. During a pediatric surgeryrotation, residents should learn the fundamentals of surgicalcare of children, including preoperative assessment, intrao-perative skills, and postoperative care. For practitionersinvolved in the care of children, learning proper skills is alifelong process and requires ongoing training.

For all health care providers involved in the care ofchildren, APSA supports a range of CME activities. ManyCME activities take place at the APSA annual meeting,which is attended not only by pediatric surgeons but also bymedical students, general surgery residents, pediatricians,general surgeons, nurse practitioners, and other health careproviders. In addition to the annual meeting, APSA hasbegun a pediatric surgery self-assessment program, which isdesigned to review core pediatric surgery principles forsurgeons at later points in their careers. Satisfactoryperformance of this self-assessment tool will result in CMEcredits that are applicable to the American Board of SurgeryMaintenance of Certification Program, and the feasibility ofextending this program to nonpediatric surgeons is beingexamined by APSA.

In addition to the CME activities of APSA, there are anumber of other learning options for nonpediatric surgeonsinvolved in the care of children. Several other nationalassociations offer CME activities in pediatric surgery, includingthe American College of Surgeons and the Surgical Section ofthe American Academy of Pediatrics, among others.

Finally, the Journal of Pediatric Surgery itself is a richsource of content over a broad area of pediatric surgery, andit is quite notable that Dr Fisk is keeping current with JPS inregard to manpower issues.

Henry E. RiceDivision of Pediatric Surgery

Duke University Medical CenterDurham, NC 27710, USA

E-mail address: rice0017@mc.duke.edu

doi:10.1016/j.jpedsurg.2010.01.035

1071Correspondence