Certification in Pediatric Surgery, American Board of Surgery
Although the Surgical Section of the AAP was the first organization of pediatric surgeons, the alignment was with pediatricians, and a membership requirement included certification by the American Board of Surgery (ABS). The first formal effort at pediatric surgical board certification was initiated in 1955, when C. Everett Koop petitioned the ABS for certification of special proficiency in pediatric surgery. The request was formally denied in 1957, apparently because pediatric surgery crossed many existing specialties, and such certification would foster more specialty boards. A second effort was initiated in 1960 by E. H. Christopherson, Executive Director of the AAP, a request denied in 1961 by the ABS when a definition for pediatric surgery was incompletely formulated, and the ABS instead suggested that pediatric surgeons seek Surgical Section AAP membership as their home for recognition. A third effort began in 1965 and culminated in a direct petition to the ABS by Mark Ravitch, seeking an affiliate board for pediatric surgery. The ABS agreed to study the problem. A fourth effort was launched in 1967, seeking reapplication for an affiliate board status. In the final analysis, the ABS Committee chaired by John Kirklin of Alabama recommended against such an affiliate board status. Next, in 1971, Harvey Beardmore of Montreal, with support from the AAP, the Canadian Association of Pediatric Surgery, and the American Board of Pediatrics, was invited to present to the ABS. An ABS Committee of Drs Reemstma, Nardi, and Drapanis was appointed to liaison with a pediatric surgical committee of Beardmore, Gross, Holder, Kiesewetter, Cloud, Clatworthy, and Koop. Negotiations continued, and despite a moratorium on new requests for subspecialty certificates by the American Board of Medical Specialties, the ABS under new chairman David Sabiston unanimously approved certification in pediatric surgery in 1972. “Special Certification in Pediatric Surgery” under the aegis of the ABS was officially and finally approved at the American Board of Medical Specialties meeting in April 1973. The first examination for “special competence in pediatric surgery” occurred in April 1975, in Darado Beach, Puerto Rico, an exam written by Harvey Beardmore, Judson Randolph, and Marc Rowe and administered to all qualifying pediatric surgeons, no “grandfathering” being done.
The relationship between pediatric surgery and the ABS continued to mature, and in 2000 a so-called pediatric surgery “sub-board” of the ABS was developed that consisted of 6 pediatric surgical members, 1 of whom as sub-board leader also served on the parent ABS. Over time as the ABS assumed in-training examination responsibility for resident trainees that complemented their written qualifying and oral certifying exam responsibilities, they turned to the sub-board for their leadership in exam question writing, curricular reform, and an assessment of competency and maintenance of certification.
In the final analysis, this quest for specialty certification took a remarkably long 18 years, and it required the efforts and commitment of many. Pediatric surgeons Ladd, Koop, Gross, Pickett, Swenson, Bill, Potts, Clatworthy, Ravitch, Bishop, Snyder, Izant, Beardmore, Smith, Cloud, Holder, and Kiesewetter, multiple general and thoracic surgeon members of the ABS, and, in the end, support from urologists as well as pediatricians were critical to accomplishing this milestone.
Surgical Section of the American Academy of Pediatrics
The AAP itself was founded in 1930, and in 1934, Dr Herbert Coe of Seattle led a Round Table Discussion on the Acute Abdomen of Childhood, the first discussion of a surgical topic at the AAP. Coe subsequently in 1946 wrote to request of AAP President Joseph Wall, MD, that a section on surgical conditions in infants be included in the Academy program. Thereafter, Coe expanded his request to include consideration of a surgical fellowship affiliate member category to be established at the AAP for physicians not certified in pediatrics but who specialized in surgery and treated children exclusively. Coe was subsequently appointed to chair an academy committee to explore an enlarged scope of membership to physicians in allied branches of medicine who confined their work to the pediatric age group. In December 1947, the AAP Board established a new class of membership known as “Affiliate Fellows” who were surgeons, pathologists, psychiatrists, allergists, and others devoting most or all of their time to the care of children. This was more formally expanded to form new AAP Sections of Allergy, Mental Growth and Development, and Surgery in June 1948.
The first meeting of the Surgical Section occurred on November 21, 1948, at the 17th Annual Meeting of the AAP in Atlantic City (Fig. 1-5). Coe was directed to choose a steering committee of 5, which he chaired: O. S. Wyatt, Robert E. Gross, Jesus Lozoya, William E. Ladd, and Henry Swan. Of the 20 charter members, those present at the first meeting were Ladd, Coe, Wyatt, Bowman, Ingraham, Koop, Lanman, Lozoya, Potts, and Swan. The other 10 approved charter members were Bill, Cachof, Chisholm, Gross, Moore, Mustard, MacCollum, Serinanan, Swenson, and Wilkinson. Requirements for membership for these 20 charter members included their practice of not less than 90% children's surgery. The first meeting was devoted to a discussion of interesting cases, a review of training needs, as well as a strategy for the development of a Board of Pediatric Surgery.
First charter meeting of the Surgical Section, American Academy of Pediatrics, Atlantic City, November 21, 1948. Standing (left to right): Henry Swan Jr, J. Robert Bowman, Willis Potts, Jesus Lozoya-Solis, C. Everett Koop, and Professor Fontana. Seated (left to right): William E. Ladd, Herbert E. Coe, Franc Ingraham, Oswald S. Wyatt, Thomas H. Lanman, and Clifford Sweet.
The Surgical Section evolved its governance to an elected Executive Committee whose members would eventually each succeed to the office of committee chairperson. The Section also developed a series of awards. The William E. Ladd Medal awarded by the AAP is the highest recognition an American pediatric surgeon can receive. The first medal was awarded in 1954 to Thomas Lanman, Ladd's prot ég é, and during the first 50 years of the Section, 23 such medals were awarded, 4 recognizing nonpediatric surgeons whose contributions in EA, urology, nutrition, and transplantation each had a remarkable impact on the surgical care of children. The Section also has hosted overseas guests as a part of its annual meeting, and in 1997 that award was renamed the Stephen Gans Overseas Lecturer in honor of the late Dr Gans. The annual meeting also came to evolve an annual resident papers competition, and following the death in 1987 of Jens Rosenkrantz, the Section's 1977 Chairperson, the Rosenkrantz Fund was established at the AAP to support this resident competition. Finally, in 1997, following the death of Dr Arnold Salzberg of Richmond, Virginia, the Arnold Salzberg Mentorship Award was established by the Section to recognize that pediatric surgeon most known for contributing in a role as mentor to future pediatric surgeons.
For its 50th anniversary year, 1998, the Surgical Section was recognized for its leadership in American surgery and pediatrics. After beginning as a quite exclusive organization, it has evolved into a more inclusive role, counting among its 500-plus members either certified pediatric surgeons or those devoting a minimum of 50% of their activity to the surgical care of the pediatric age group.
In the last decade the AAP has further codified its relationship to the surgical specialties with the formation of the Surgical Advisory Panel (SAP), a group with representation from the multiple children's surgical specialties whose broad agenda has included advocacy for patient safety and quality, enhancement of trauma care systems, relevant review of Academy policies and procedures, and surgeon-specific coding and compensation issues.
American Pediatric Surgical Association
The concept of an independent surgical organization for pediatric surgeons was felt to resolve one of the perceived barriers to becoming a recognized specialty; the others included the lack of certification, lack of training standards, and previous professional affiliation with another specialty, namely, pediatrics. Young members of the field particularly desired to have a professional identification with fellow pediatric surgeons rather than with pediatricians.
In October 1968, at the American College of Surgery meeting in Atlantic City, a group of pediatric surgeons—C. Everett Koop, Keith Ashcraft, John Campbell, Dale Johnson, and Lucian Leape—discussed the advisability of securing an identity by standing alone as a group of surgeons. Koop advised that because of strong ties to the AAP, it would be up to the younger surgeons to carry this initiative. Two months later Leape and Tom Boles resolved to act by sending a letter in April 1969 to 18 young pediatric surgeons proposing an independent pediatric surgical organization. Twenty-four founding members formed the organizing group: Fred Arcari, Tom Boles, Jack Campbell, Al Delorimier, Frank DeLuca, Bob Filler, Rick Fonkalsrud, Ed Free, Alex Haller, Bob Izant, Dale Johnson, Peter Kottmeier, Lucean Leape, Jules Lister, Lester Martin, John Raffensperger, Jud Randolph, Jim Rosenkrantz, Marc Rowe, Bill Sieber, Ide Smith, Bob Soper, Jim Talbert, and Ed Tank. Over the next 12 months a series of meetings occurred addressing the various needs: to raise standards of the specialty, to credential/approve residency training programs, to define requirements for residency training, to require for membership a 100% restriction to the practice of pediatric surgery, and to develop the mechanics of electing officers. The group sought and received endorsement from most of the leaders of pediatric surgery, and in January 1970, an invitation for charter membership in the American Pediatric Surgical Association (APSA) was mailed to 200 of the then 300 current members of the Surgical Section of the AAP. The criteria for membership included US or Canadian citizenship, practice confined to the surgery of infants and children, certification by the ABS or fellowship in the Royal Canadian College of Surgeons, and at least 2 years' experience in practice after completion of the residency. The first official meeting of the new organization was held on April 17, 1970, at Pheasant Run, Illinois. Harvey Beardmore called the meeting to order, E. Thomas Boles Jr was nominated as temporary chairman, and Lucian Leape as temporary secretary. Robert Gross was elected President, and C. Everett Koop president-elect. At the suggestion of Robert Soper, Program Committee Chair, the Journal of Pediatric Surgery was to become the official journal of the new society, as was a requirement that papers presented at the annual meeting be submitted for publication in that journal. Furthermore, the subscription to the Journal would be included in the annual APSA membership fee. Robert Izant had drafted both bylaws and articles of incorporation. Half of the paid 191 charter members attended the meeting and approved the founding resolution:
Be it resolved that a new society, The American Pediatric Surgical Association, now be formed to encourage specialization in the field of pediatric surgery, to promote and maintain the quality of education in pediatric surgery, to raise the standards of the specialty by fostering and encouraging research in pediatric surgery, to establish standards of excellence in the surgical care of infants and children, and to provide a forum for the dissemination of information with regard to pediatric surgery.
APSA has thrived well in its first 42 years. It hosts a highly successful annual spring meeting, and its committees monitor multiple clinical parameters and subspecialty programs, pediatric surgical manpower, continuing education requirements as well as an online method of continuing medical education (CME) accreditation, ethical issues in pediatric surgery, as well as practice management parameters. In 1998, the APSA Foundation was formed, with a mission to raise philanthropic dollars, largely from APSA membership, to support 2 or more annual competitive seed grants for those young pediatric surgeons beginning a research career.
American College of Surgeons
In 1967 the American College of Surgeons (ACS) began listing “pediatric” as a legitimate category of surgery. In 1969 the ACS established an Advisory Council for Pediatric Surgery, and C. Everett Koop was appointed as the first Advisory Council Chairman. This Council was recognized for the specialty of pediatric surgery, a group of surgeons who at the time lacked independent specialty recognition or board certification. After a long history of being included in the annual postgraduate course offerings of the ACS as well as on the forum for presentation of “What's New,” pediatric surgery achieved the status of having its own Surgical Forum in 1988, the 44th issue of that publication. Finally, the ACS not only included pediatric surgery in its activities of surgical education, standards, and ethics but, since 1985, has also represented pediatric surgery in both political and socioeconomic advocacy areas.
Perhaps most important is the partnership role that the ACS has played with APSA by their development of 2 areas that are mutually beneficial to the field of surgery as a whole and the role that the ACS plays in it as well as to the specific benefit of the pediatric surgeon. In 2008, the Pediatric Surgical Case Log Registry was developed at the ACS to serve as a repository of electronic data of clinical case procedures along with a limited notation of operative outcome assessed and entered by the individual surgeon. This voluntary registry has become a valuable tool for those surgeons contemplating recertification.
A second venture is the formation, under the aegis of the ACS but in partnership with APSA, of the National Surgical Quality Improvement Program, Pediatric (NSQIP-P). It began as a model based on the original NSQIP developed in the Veteran's Administration Hospitals. Thereafter, it was successfully modeled for both private and academic health system models of adult care, but it had not previously been applied to the pediatric surgical specialties. After several years in development, a multispecialty program (excluded were ophthalmology and cardiovascular surgery) was developed designed to employ at participating hospitals a trained nurse specialist to review more than 120 variables in real time on a predetermined inpatient case type and frequency, assessing morbidity and mortality up to 30 days postoperatively. This then would permit the calculation by regression analysis of best practice “low outliers” and worst practice “high outliers.” Data-driven process improvement would follow, and the hope for a favorable outcome similar to that occurring in adult hospital participants was the ultimate outcome target. In 2009, a proof of principle was realized when an alpha phase of 4 hospitals (Yale New Haven Children's Hospital, A.I. DuPont Children's Hospital, Children's Hospital of Wisconsin, and the Children's Hospital, Denver) reported a review of more than 3000 patients. A year later the beta phase report from more than 40 participating hospitals and 37,000 patients reinforced the proof of principle and, after calculating observed/expected ratios (O/E), opened the way for high outliers to influence low outliers in process improvement. This first ever risk-adjusted multispecialty assessment of children's surgical quality and safety holds great promise for the future.
Association of Pediatric Surgical Training Program Directors
After the development of the Boston School of Pediatric Surgery, trainees dispersed from the Ladd and Gross training milieu to establish training programs at a variety of American children's hospitals and university hospitals. Around 1950 such pediatric surgical training programs were “self-declared” and were approved by the Conference Committee on Graduate Training in Surgery, sponsored jointly by the American Medical Association (AMA) and ABS. Over the next 30 years the name of this review group and its constituency changed several times: Conference Committee on Graduate Education in Surgery (1950), Liaison Committee on Graduate Medical Education (1974), and the Accreditation Council on Graduate Medical Education (ACGME) in 1981, the latter sponsoring the Residency Review Committees (RRCs). These training programs varied in length (1-4 years) as well as their emphasis on neonatal surgery, urology, and cardiac surgery. Dr Herbert Coe, as Chairman of the Surgical Section, AAP, had as early as 1952 appointed a review committee to oversee the then-approved programs. In 1966, the Surgical Section of the AAP published a booklet listing 18 US and 2 Canadian fellowships plus 17 US and 4 Canadian residency positions in pediatric surgery. A Surgical Section Committee on Postgraduate Education and Residency Training was appointed to develop standards. H. William Clatworthy Jr was committee chair, and members included Drs Chisholm, Ferguson, Haller, Kiesewetter, and Randolph. They published the Special Requirements for Residency Training in General Pediatric Surgery in September 1967. This document was also studied by the American Board of Medical Specialties, and a revised “Essentials” was formatted. The revised form was subsequently sent to the AMA Council on Medical Education and its Liaison Committee for Specialty Boards. By spring 1970, the “Clatworthy Committee” had completed 25 program site surveys, and they recommended approval of 12 US programs, provisional approval of 4 Canadian training programs, and nonapproval for 8 programs; 1 program was “tabled.”
As the Clatworthy Committee continued its activity during the time that APSA was founded, between 1970 and 1972, the function was assumed by the APSA Education Committee. Recognition of “index cases” and their importance to training came to the forefront, and the Surgical Section's Post-graduate Education Committee wrote a new document entitled Special Requirements for Residency Training in General Pediatric Surgery. Thereafter, the APSA Education Committee under Jud Randolph, Committee Chair, continued to evaluate training programs and recommend them for approval to the ABS until 1977. However, before the first examination to award the “Certificate of Special Competence in Pediatric Surgery” in 1975, the approval of programs by the RRC and ABS was indeterminate, and in August 1976, an invitation to reapply for approval was tendered by the ACGME to the training directors. The RRC assumed control of the approval process of training programs by 1977, it developed the “Essentials” on listing the series of requirements to be met to gain approval, and the list of approved programs was reported in the Directory of Graduate Medical Education published by the AMA. The RRC approved the following numbers of US programs: 1977, 5; 1978, 10; 1979, 1; 1980, 1; 1982 to 1991, 5; 1992 to 1994, 5; by 2008 there were 33 American and 7 approved Canadian training programs; and by 2011 this number, respectively, had increased to 39 and 9, a total of 48 programs.
In the mid-1970s, the selection process of residents for training in pediatric surgery moved from the apprentice model of random interviews and selection to a formalized matching process organized within pediatric surgery by ad hoc members of the APSA Education Committee. Also, by the early 1980s, the training program directors themselves formed the Association of Pediatric Surgical Training Program Directors to develop a structured training curriculum for pediatric surgical trainees as well as to oversee the selection process. This organization, under the guidance of J. L. Grosfeld and D. R. Cooney, was formally incorporated in 1989. In the meantime, the APSA Education Committee formally adopted a new focus of defining training requirements in pediatric surgery for residents in general surgery as well as defining CME requirements. By 1990 the training program directors turned over the matching function to the National Resident Matching Program. Since that time there have been refinement of the program requirements that include case numbers and case quality, careful scrutiny of the surgeon's role in primary management of the critically ill newborn and pediatric patient while in his or her intensive care unit setting, development of a standardized in-service exam for resident trainees, and a contemporaneous scrutiny of North American manpower needs for this specialty field.
Pediatric Surgical Publication
After publication of The Surgery of Childhood, Including Orthopaedic Surgery by Deforest Willard in 1910, a more major modern compilation awaited the assimilation of the Boston Children's Hospital experience. This was tabulated by publication of Abdominal Surgery of Infancy and Childhood in 1941 by William E. Ladd and Robert E. Gross. Eleven years thereafter, Gross's classic The Surgery of Infancy and Childhood was published. The early 1960s brought publication of the 2-volume Pediatric Surgery, a multiauthored text project spearheaded by Dr Welch and including Benson, Mustard, Ravitch, and Snyder as coeditors. An additional series of American pediatric surgeons have followed as editors or authors of texts dealing with a variety of pediatric surgical topics.
Publication of articles in journals devoted to pediatric surgery began when Drs Owen Wangensteen and Alton Ochsner, editors of Surgery, invited Mark Ravitch to serve as section editor of a section on pediatric surgery in 1958.
As chairman of the Surgical Section's Publication Committee in 1964, Stephen L. Gans, MD (Fig. 1-6), observed that few papers presented at the annual meeting were in fact being published. He perceived that as a specialty needing to secure appropriate recognition, it would be necessary to have a journal unique to the specialty. Gans enlisted and received positive feedback to that effect from 20 prominent pediatric surgeons from the United States and Canada, a group that eventually constituted an “Advisory and Editorial Board.” To add an international audience, Gans met that same year with the Council of the British Association of Pediatric Surgeons. In February 1966, the Journal of Pediatric Surgery was founded after Dr Henry Stratton, president of Grune & Stratton in 1965, agreed to publish this journal. In that same year both the British Association of Pediatric Surgeons and the Surgical Section of the AAP approved it as their official organ. Stratton and Gans also asked C. Everett Koop, MD (Fig. 1-7), to serve as the first Editor-in-Chief of the Journal. In the inaugural issue, I. S. Ravdin, MD, John Rhea Barton Professor of Surgery at the University of Pennsylvania School of Medicine, wrote an introductory editorial, and in the subsequent issue the editor outlined the goals of the Journal: “to publish clinical experience, pertinent laboratory and clinical investigation, case reports, and an abstract section of the world's literature.”
Stephen L. Gans (1920-1994).
C. Everett Koop (1916–2013).
In 1967, the first supplement to the Journal was published, a Conference on the Biology of Neuroblastoma. In 1971, the newly formed APSA also had chosen the Journal of Pediatric Surgery as its official publication. A second supplement entitled Advances in Endoscopy of Infants and Children was published in 1971. In 1977, Stephen Gans assumed the role as Editor-in-Chief, prompting a letter from Dr Gross in which he stated: “I think the Journal has done more to advance children's surgery, not only here but around the world, above anything else in the last couple of decades.” In 1979 the Journal announced its association with the Canadian Association of Pediatric Surgeons. A third supplement was published in 1981 dedicated to C. Everett Koop, MD, on his retirement from the Children's Hospital of Philadelphia. In 1984 Peter Rickman retired as Editor for Europe, and he was replaced by John Scott (United Kingdom) and Michel Carcassonne (Continental Europe). In 1985 the Journal grew from a bimonthly to a monthly publication. In 1988, the Pacific Association of Pediatric Surgeons announced its affiliation with the Journal. Also that same year Dan Young became Editor for the British Isles, and in 1990 Jan Molenaar was appointed Editor for Europe. In 1994 Takeshi Miyano was appointed Editor for Asia. Following the death of Dr Gans, Dr J. L. Grosfeld became the third Editor-in-Chief of the Journal in 1995.
In 1992 the second American journal devoted to pediatric surgery appeared with publication of Seminars in Pediatric Surgery, J. L. Grosfeld serving as Editor-in-Chief. Four issues were published annually. In 1997, the third journal, Pediatric Endosurgery and Innovative Techniques, was published with Thom E. Lobe, MD, as Editor-in-Chief. Pediatric Surgery International with coeditors Puri and Coran from Europe and the United States is still another publication with increasing success and impact factor for pediatric surgical publication.