Pediatric Surgery Overview
Pediatric Surgery Overview

The ACGME Accredited Pediatric Surgery Training Program began in 1975 when one Pediatric Surgery Resident (PSR) was accepted for a 2-year period of training. In 1988, the Residency Review Committee approved expansion of this program to one resident per year. The Sponsoring Institution for the program is the Unviersity of Missouri-Kansas City School of Medicine. The 9 Pediatric Surgeons who serve as the teaching staff for the Pediatric Surgery Training Program include: George W. Holcomb, III, MD, MBAJ Patrick Murphy, MDCharles L. Snyder, MDWalter S. Andrews, MDJohn J. Gatti, MDRichard J. Hendrickson, MD, and Shawn D. St. Peter, MD

The Pediatric Surgey Training Program participates in the National Resident Matching Program (NRMP). Residents who wish to apply for a two-year position as a PSR are required to submit a Common Application Form, Personal Statement, and three letters of recommendation through Elecronic Resident Application Services (ERAS).

During the two years of training, the PSR will encounter a broad exposure to general, thoracic, urologic, and minimally invasive surgery. In addition, the residents may spend up to three months of their 24-month residency on clinical services other than pediatric surgery. During the first year, one month will be spent in the Neonatal Intensive Care Unit. Goals and objectives of this rotation include a thorough understanding of the nutritional requirements, ventilatory management, management of the infant on ECMO as well as basic neonatal care. During the second year, there is also a one month period when the PSR may pursue an elective rotation, most of which have been either anesthesia, gastroenterology, surgical pathology, radiology, or cardiac surgery. As the resident progresses through this two-year period, he/she will be expected to make the transition from a novice in the area of pediatric surgery to being capable of practicing pediatric surgery independently and confidently in either an academic or private setting. Because of an extensive operative case-load, the PSRs reach the completion of their two years in the training program with an operative experience which allows them to transition into a staff position with a great deal of confidence in their own judgement and technical capabilities.

The resident will be allowed graduatial responsibility for formulating the differential diagnosis for a patient's symptoms, for developing a plan of treatment and for implementing the treatment plan. One resident will always be a Senior Resident to the other residents and will serve as an educational resource to the more Junior Residents. The Senior Residents primary responsibility for the education of the pediatric surgical residents lies with the attending staff. All Residents are "on call" with and supervised by one of the staff surgeons.

Educational Goals

The overall Educational Goal of the Pediatric Surgery trainees is to allow that person to gain knowledge and experience in physiology, the disease processes and the preoperative, intra- operative, postoperative care of infants and children. This goal is achieved through didactic and other educational conferences, and through clinical training. Through these educational avenues, the resident acquires an understanding of general and thoracic pediatric surgical conditions, an in-depth exposure to the management of burned children, an understanding of the physiology and operative procedures for liver and kidney transplantation, and a significant exposure to the indications for and operative management of minimally invasive surgical procedures. In addition, non-operative care of injured children is an important part of the training program as is management of the critically ill neonate or pediatric patient in an ICU setting. Finally, there is a significant exposure to pediatric urological conditions.

Achievement of the proposed goals will be accomplished by:

  1. Resident participation in and supervision of the pediatric surgical service under faculty direction.
  2. Resident participation in and supervision of pediatric surgical critical care patients under faculty direction.
  3. Resident participation in outpatient evaluation and management of common conditions referred to pediatric surgeons as well as preoperative and post-operative evaluation of patients seen in consultation.
  4. Operative experience emphasizing all areas of pediatric general and thoracic surgery, including surgical endoscopy and minimally invasive procedures.

The second fundamental resource for achieving the goals of the residency program is provided through conferences that are designed for resident education. The didactic teaching program consists of a series of lectures by the pediatric surgical staff or other surgical and medical staff specialists. Barring emergencies, resident attendance is mandatory. Participation at regularly scheduled conferences is required and consists of:

  1. weekly hospital Grand Rounds, including a monthly surgical topic. The Chief PSR is responsible for preparing one Grand Rounds toward the end of his/her training period.
  2. a monthly Surgery Conference whose subject selection and presentation are the responsibility of the Chief PSR or his/her designee. This session is attended by pediatric residents, medical students, the surgical faculty and several of the pediatric staff.
  3. bi-weekly Surgical Mortality and Morbidity Conferences which are attended by the pediatric surgical staff, the pediatric surgical residents and the rotating residents. Minutes are prepared by the Program Director or his designee.
  4. a monthly combined Pathology/ Radiology/Surgical Conference which is attended by a radiologist and a pathologist with the case selection and presentation under the direction of the Chief PSR.
  5. a monthly Urology Conference which is attended by members of the Nephrology Section and the General Surgery and Urology Sections, the purpose of which is to discuss interesting cases.
  6. an every other month Trauma Conference attended by the residents and surgical staff.
  7. a monthly multi-disciplinary Cancer Care Conferences dealing with current cases which serve as a forum for discussion of diagnoses and management.
  8. a monthly Journal Club at which articles from current pediatric surgical journals and articles of historical interest are discussed. This conference is under the direction of the first year PSR.
  9. a monthly Surgical Research Conference.

In addition, constant attention to reading not only from text material in pediatric surgery, but also seeking out the best references for individual pediatric surgical problems, as well as for operative and non-operative case management, is the individual responsibility of the resident and cannot be overlooked as one of the cornerstones for successful accomplishment of the goal of the program. One of the three commonly referenced pediatric surgical textbooks was initiated and continues to be edited by members of the teaching staff at Children's Mercy. A copy of this textbook is given to each PSR if he/she does not already have it.

Objectives

The objectives of training in pediatric surgery are to develop a pediatric surgeon who can assume complete responsibility for the preoperative, operative and postoperative management of the surgical problems related to infants and children, and who can interact appropriately with allied colleagues involved in the care of pediatric patients. Additionally, it is expected that the resident in pediatric surgery will develop the sensitivity required to deal with more than pediatric patients in the context of family centered care. Interwoven within these objectives will be those of an ethical and academic nature that will reflect the conscience of modern Pediatric Surgery and help shape its future. The summary objectives are to ensure that these future pediatric surgeons obtain and, through lifelong learning, maintain the involvement and leadership necessary for the modern management of pediatric surgical conditions.

For all objectives, a comprehensive and thorough understanding of the subjects listed will be expected. This will include, where appropriate, embryology, anatomy, physiology, pathology, natural history (both pre and postnatal), diagnosis and management.

Residents must demonstrate the knowledge, skills and attitudes relating to gender, culture and ethnicity. They must similarly demonstrate an ability to incorporate all of these important societal perspectives in research methodology, data presentation and analysis.

At the completion of training, the resident will have acquired the following competencies and will function effectively as a clinical decision maker based on the best clinical evidence, founded in a complete fund of knowledge.

  • Demonstrate diagnostic and therapeutic skills for ethical and effective patient care.
  • Access and apply relevant information in clinical practice.
  • Demonstrate effective multidisciplinary implementation of consultation services with respect to patient care, education, ethics and medicolegal opinions.

A. Primary-Knowledge Objectives

1. Head and neck
Demonstrate knowledge of, and the capacity to manage patients in relation to the different patterns of disease, natural history and responses to treatment of head and neck disease in children. This will include:

  • congenital lesions: thyroglossal duct cyst, branchial cleft cysts; sinuses and other remnants; cystic hygromas / lymphangiomas, hemangiomas
  • salivary glands : tumors, hemangiomas, inflammation/calculi, ranula
  • neck masses: inflammatory (acute and chronic adenitis); tumors (lymphoma, rhabdomyosarcoma, neuroblastoma, teratoma, nasopharyngeal carcinoma); congenital torticollis
  • cranial trauma: diagnosis and emergency management including indications for increased intracranial pressure (ICP) monitoring, Glasgow Coma Scale (GCS)
  • cervical trauma: injuries to the esophagus, trachea, blood vessels; airway management; tracheostomy; recognition and emergency management of cervical spine fractures

2. Non Cardiac Thoracic Surgery
Demonstrate knowledge of, and the capacity to manage patients in relation to the different patterns of disease, natural history, and responses to treatment of non-cardiac chest conditions in children. This will include:

  • esophageal atresia and tracheoesophageal fistula (TEF): embryology, classification, diagnosis, treatment, complications with their treatment
  • esophageal achalasia, webs, stenosis (congenital and acquired), duplications
  • acquired esophageal conditions: gastroesophageal (GE) reflux, Barrett's esophagus, hiatal hernia; strictures, perforations (cervical, distal), foreign bodies, lye ingestion
  • congenital lung lesions: cystic adenomatoid malformation (CCAM), pulmonary sequestration, lobar emphysema, blebs and spontaneous pneumothorax; hypoplasia and pulmonary hypertension
  • acquired lung lesions: emphysema, abscess/pneumatocele, empyema, chylothorax, pulmonary metastases, infiltrates in immunosuppressed patients, lung complications in cystic fibrosis (CF).
  • congenital airway lesions: stenosis, broncho- and tracheomalacia
  • acquired airway lesions: bronchial adenoma (carcinoids, etc.); recognition of foreign body aspiration
  • mediastinal lesions: cysts, tumors according to location (anterior, middle, posterior)
  • chest wall conditions: pectus excavatum and carinatum; tumors; reconstruction
  • diaphragmatic conditions: congenital diaphragmatic hernia (Bochdalek, Morgagni); diaphragmatic eventration and phrenic nerve palsy; trauma

3. Abdomen
Demonstrate knowledge of, and the capacity to manage patients in relation to the different patterns of disease, natural history, and responses to treatment of abdominal disease in children. This will include:

  • gastrointestinal physiologic issues: secretion, absorption, motility, blood supply; continence, defecation; short bowel syndrome, intestinal adaptation; physiologic testing (manometry, pH study)
  • gastric conditions: pyloric stenosis (including physiologic disturbances), antral web; spontaneous perforation, antral dysmotility; stress ulcer, gastritis and other forms of acid/peptic disease
  • duodenal conditions: atresia, stenosis, webs (including windsock variant); diverticula, duplications; peptic ulcer
  • small intestinal conditions: malrotation, jejunoileal atresia / stenosis, meconium ileus and equivalent; Meckel's diverticulum and related vitelline duct anomalies; necrotizing enterocolitis (NEC); intussusception; duplications, mesenteric cysts; neoplasms; Crohn's disease; congenital bands, mesenteric defects, bowel obstruction
  • colonic conditions: appendicitis; inflammatory bowel disease, typhlitis; meconium plug syndrome, intestinal pseudo-obstruction; Hirschsprung's disease, neuronal intestinal dysplasia; colonic atresia, polyps (juvenile, familial, adenomatous)
  • anorectal conditions: imperforate anus (and variants); fissures, abscesses, fistulae, condylomata, rectal prolapse; constipation, fecal incontinence
  • hepatic conditions: congenital and acquired liver cysts, trauma, tumors (see oncology section); portal hypertension; liver abscess
  • biliary conditions: biliary atresia, biliary hypoplasia; bile duct perforation, choledochal cyst; gallstones, acute/chronic cholecystitis; physiologic jaundice, cholestatic syndromes; liver transplantation (indications, complications, results)
  • splenic conditions: hereditary spherocytosis, thalassemia, sickle cell disease; red blood count (RBC) enzyme deficiencies (pyruvate-kinase, hexose-kinase); other hemolytic anemias, idiopathic thrombocytopenic purpura (ITP); Gaucher's disease, splenic cyst, lymphangioma, abscess
  • pancreatic conditions: cystic fibrosis; pancreas divisum, annular pancreas; pancreatitis (trauma, lipid, steroid, drug induced, gallstone induced, ductal anomaly); congenital cysts, pseudocysts, tumors, hyperinsulinism
  • abdominal wall conditions: gastroschisis, omphalocele and variants; hernias (umbilical, inguinal, epigastric, femoral, etc.); vitelline duct remnants; umbilical granuloma
  • abdominal trauma: intestinal trauma, lap belt injury; hepatic trauma (operative and non operative management, hemophilia); splenic trauma (non operative management, indications for surgery, splenorrhaphy, partial splenectomy, vaccines, prophylactic antibiotics, splenectomy risks)

4. Genitourinary Tract Conditions
Demonstrate knowledge of, and the capacity to manage patients in relation to the different patterns of disease, natural history, and responses to treatment of genitourinary conditions in children. This will include:

  • penis: phimosis, paraphimosis, balanitis, circumcision (indications and contra-indications, including complications and their treatment)
  • inguinoscrotal area: cryptorchidism, varicocele, hydrocele, acute scrotum (torsion, etc.)
  • bladder: exstrophy (bladder, cloacal); urachal anomalies
  • tumors: (see oncology section)
  • trauma: kidney, ureter, bladder with adequate knowledge of pelvic fractures and urethral injuries

5. Gynecologic Conditions
Demonstrate knowledge of, and the capacity to manage patients in relation to the different patterns of disease, natural history, and responses to treatment of gynecologic conditions in children. This will include:

  • congenital conditions: vaginal atresia, hemato/hydro(metro)colpos, bifid vagina, duplex uterus, urogenital sinus
  • inflammatory conditions: pelvic inflammatory disease, vulvovaginitis, vulvar abscess, fusion labia minora
  • traumatic/mechanical conditions: vaginal laceration, child abuse; torsion (normal ovary, cyst, tumor)
  • neoplastic conditions: ovarian cysts (follicular, teratomatous, carcinomatous, serous, mucinous); ovarian solid tumors (yolk sac, teratoma, carcinoma, theca/lutein, arrhenoblastoma, dysgerminoma); vaginal and uterine tumors (yolk sac, rhabdomyosarcoma); vulvar lesions (cysts, nevi, hemangioma)

6. Intersex Anomalies
Pediatric surgeons will, in collaboration with other health professionals, care for children with intersex anomalies. They must therefore demonstrate knowledge of, and the capacity to manage patients with these conditions based different patterns of disease, natural history, responses to treatment and ethical implications of gender assignment. This will include patients with adrenogenital syndrome (variants, enzyme deficiencies, diagnosis and treatment), mixed gonadal dysgenesis, true- and pseudo- hermaphroditism, testicular feminization syndrome and its variants, and gonadal tumors that may develop in these patients.

7. Endocrine Anomalies
Pediatric surgeons will, in collaboration with other health professionals, care for children with endocrine anomalies. They must therefore demonstrate knowledge of, and the capacity to manage patients with these conditions based on different patterns of disease, natural history, and responses to treatment. This will include:

  • thyroid problems: hyperthyroidism (diagnosis, medical therapy, management of thyroid storm, preparation for surgery, surgical techniques); thyroiditis; tumors (role of FNAC [fine-needle aspiratory cytology], other diagnostic techniques; therapy by type, multiple endocrine neoplasia syndromes); management of thyroid mass following neck irradiation; postoperative management (hypocalcemia, respiratory distress, recurrent nerve palsy, follow-up for malignancy)
  • parathyroid conditions: hypoparathyroidism; hyperparathyroidism (primary, secondary, tertiary)
  • breast conditions: neonatal hypertrophy, mastitis; gynecomastia; nipple discharge; fibroadenoma, fibrocystic disease; cystosarcoma phyllodes; premature thelarche
  • gastrointestinal problems: gut hormones; all endocrine disorders affecting the gastrointestinal tract
  • pancreatic conditions: hyperinsulinism (newborn - adenoma vs. neonatal pancreatic dysplasia, diagnosis, medical and surgical treatment; older child - adenoma, hyperplasia); Tumors (islet cell tumors, VlPoma, gastrinoma including Zollinger Ellison (Z-E) syndrome); (see gastrointestinal and trauma sections)
  • adrenal conditions: adrenocortical tumors (aldosteronoma Conn's syndrome ; Cushing's syndrome hyperplasia vs. carcinoma ; virilizing tumors) ; pheochromocytoma (diagnosis, sites including extra-adrenal, bilateral, localization techniques, surgery perioperative blood pressure control, technique, search for multiple/extra adrenal tumors); (see section on tumors); testicular conditions: cryptorchidism; tumors - (see oncology section)

8. Oncology
Pediatric surgeons will, in collaboration with other health professionals, care for children with cancer. They must therefore demonstrate knowledge of, and the capacity to manage patients with these conditions based on the different patterns of disease, natural history, and responses to treatment. This will include:

  • general principles: oncogenes, DNA-flow cytometry (diploid, aneuploid); paraneoplastic and tumor-associated syndromes (e.g., opsomyoclonus); hyperthermia, immunotherapy, radiation biology, immunosuppression and opportunistic infections, cancer nutrition, chemotherapy and drug action; surgical complications of chemotherapy and bone marrow transplantation
  • renal tumors: Wilms' tumor, mesoblastic nephroma, nephroblastomatosis, adenocarcinoma and rhabdoid tumor
  • adrenal tumors: neuroblastoma, ganglioneuroblastoma, carcinoma
  • liver tumors: benign (hemangioma, hemangiomatosis, hemangioendothelioma, hamartoma, adenoma, focal nodular hyperplasia [FNH]); malignant (hepatoblastoma, hepatocellular carcinoma)
  • soft tissue sarcomas: rhabdomyosarcoma (all sites; principles of therapy according to site/histology), fibrosarcoma, leiomyosarcoma, liposarcoma, neurofibromas
  • teratomas: sacrococcygeal and gonadal tumors with embryology, pathology, familial teratomas,
    associated syndromes; other teratoma sites
  • lymphoma: Hodgkin's Disease; Non-Hodgkin's Disease, including pathology (surface markers),
    sites, patterns of presentation including post-transplantation lymphoproliferative disease (PTLD) and
    AlDS (acquired immunodeficiency syndrome)
  • bone tumors: osteogenic sarcoma and Ewing's sarcoma (including peripheral neuroectodermal
    tumors [PNET]) as they relate to pediatric surgical intervention (rib resection, lung metastases, etc.)
  • gonadal tumors
    • testicular: benign and malignant, including teratoma, other germ cell and non-germ cell tumors,
      paratesticular rhabdomyosarcoma, metastatic i.e. leukemia
    • ovarian: see gynecology section 

9. Critical Care and Trauma
Pediatric surgeons will, in collaboration with other health professionals, care for critically ill and injured children. They must therefore demonstrate knowledge of, and the capacity to manage patients with these conditions based on the different patterns of disease, natural history, and responses to treatment. This will include:

  • fluids and electrolytes: maintenance requirements, management of dehydration, third-space loss; renal output, acid-base equilibrium; correction of perioperative electrolyte disturbances
  • shock: hypovolemic (hemodynamic monitoring, resuscitation, crystalloid vs. colloid), cardiogenic (inotropic agents, etc.), septic (hyperdynamic state, fluid resuscitation, Swan-Ganz monitoring, antibiotics)
  • pulmonary physiology: normal lung function and volumes, ventilation/perfusion abnormalities; ventilators (pressure vs. volume cycled, positive end-expiratory pressure [PEEP], continuous positive airway pressure [CPAP], intermittent mandatory ventilation [IMV], high frequency and jet ventilation); adult respiratory distress syndrome [ARDS]
  • nutrition: normal caloric requirements by age group, carbohydrate, fat and protein contributions and concentrations, vitamins, trace elements, minerals; nutritional assessment techniques; enteral vs. parenteral nutrition; enteral formulas, defined diets; parenteral nutrition (peripheral vs. central solutions, techniques, complications), influence of disease on nutritional requirements (trauma, burns)
  • coagulation: normal coagulation cascade; management of specific coagulation disorders (hemophilia, von Willebrand's disease, diffuse intravascular and consumptive coagulopathy, fibrinolysis, sick platelet syndrome, idiopathic thrombocytopenia purpura, thrombosis; effects of heparin, anti-platelet agents, thrombolytics
  • anesthesia: inhalation agents, muscle relaxants, recognition and management of malignant hyperthermia; differential diagnosis and treatment of cardiac arrest during surgery; management of postoperative pain in infants and children
  • extra corporeal membrane oxygenation (ECMO): indications in neonates and older children, techniques of cannulation, monitoring, and complications
  • trauma: demographics, epidemiology; recognizable patterns of injury (i.e., seat belt syndrome, patterns of child abuse); initial priorities; principles of operative and non-operative management of head, neck, chest, abdomen, pelvis, genitourinary and extremity trauma
  • burns: pathophysiology of severe burn injury; fluid resuscitation (initial and maintenance); nutritional management

10. Neonatology
Pediatric surgeons will, in collaboration with other health professionals, care for premature and ill newborns. They must therefore demonstrate knowledge of and the capacity to manage patients with these conditions based on the different patterns of disease, natural history, and responses to treatment. This will include:

  • physiology of the premature infant: comparison with small for gestational age infants, complications, fluid requirements, thermal neutrality, response to cold, metabolic rate, renal function, hepatic immaturity, formulas and caloric requirements, etc.
  • hyperbilirubinemia: physiology, phototherapy, exchange transfusion, cholestasis hypoglycemia, hypocalcemia
  • intracranial bleeding: staging, techniques of diagnosis, site of blood, management, outcome
  • newborn respiratory distress syndrome: etiology, diagnosis, treatment, complications
  • neonatal sepsis: immune status (comparison of premature and full-term infant), diagnostic workup,bacteriology, treatment, pharmacokinetics

11. Skin and Subcutaneous Tissues
It is important for pediatric surgeons to demonstrate knowledge of and the capacity to manage patients in relation to the different patterns of disease, natural history, and responses to treatment of cutaneous and subcutaneous conditions in children. This will include skin and subcutaneous lesions (nevi, nevus sebaceous, pilomatrixoma, juvenile melanoma; hemangioma, lymphangioma, lipoma; dermoid and epidermoid cyst), ingrown toenails and paronychia; and pilonidal sinus and abscess.

12. Transplantation
Pediatric surgeons will, in collaboration with other health professionals, be involved in the care of children with organ transplants or awaiting transplantation. They must therefore demonstrate knowledge of the indications for pediatric liver, kidney, small bowel transplants, and of immunosuppressive agents (effects and complications).

 13. Fetal Medicine
Pediatric surgeons are an integral part of the prenatal evaluation of parents and infants with a known surgical disease. Pediatric surgeons participate in a number of ways in this prenatal management.

  • Prenatally diagnosed surgical conditions: pediatric surgeons are often involved in counseling of future parents of fetuses with gastroschisis, omphalocele, congenital diaphragmatic hernia, cystic adenomatoid malformation of the lung (CCAM), pulmonary sequestrations, congenital tumors (teratomas), ovarian and abdominal masses and cysts, esophageal atresia, and others. Counseling includes a description of the condition and its scope, treatment options, complications and long-term outcome.
  • Conditions that may require immediate intervention at birth, in particular those lesions and conditions that may compromise the airway and breathing of the fetus: the surgeon plays a central role in the planning and performance of ex-utero, intrapartum (EXIT) procedures, in conjunction with members of the maternal-fetal medicine, neonatology and anesthesia departments; planning includes prenatal, preoperative imaging and discussions regarding timing of the intervention.
  • Many more indications for fetal surgery have been proposed over the last two decades; although most have not stood the test of time and are no longer considered appropriate, the pediatric surgeon needs to know these conditions and understand the rationale for fetal intervention, the reasons for failure of this approach and the current treatment options and outcomes. Conditions include congenital diaphragmatic hernia, myelomeningocele, congenital hydrocephalus, hypoplastic left (and right) heart syndrome and aortic (pulmonary) stenosis, urinary tract obstruction and abdominal wall defects.

B. Primary Skills Objectives

By the end of training, the resident should have acquired and demonstrated the following generic skills, as they apply to a pediatric surgical practice.

Surgical Skills
The resident is expected to be able to perform independently the full spectrum of operative interventions related to the primary pediatric surgery conditions listed above. Several additional areas of skill expertise are listed below.

Trauma
The Pediatric Surgery resident is expected to: function as a trauma team leader, function as the operating surgeon for pediatric multiple trauma patients, and as supervising surgeon in an operating room in which several specialty groups may be working simultaneously, if required, have primary responsibility for the non-operative care of the trauma patient including burns and be able to obtain airway and vascular access in the trauma patient, and perform appropriate diagnostic procedures

Endoscopy
The resident should be familiar with the indications, techniques and complications of laryngoscopy/bronchoscopy, esophagoscopy, thoracoscopy, laparoscopy, cystoscopy and proctosigmoidoscopy. The resident must also know the basics of cystoscopy and vaginoscopy as applied to the treatment of ambiguous genitalia and imperforate anus.

Other Procedures
The resident should be familiar with the indications, techniques and complications of central line insertion or other vascular cannulation (temporary and long-term, implantable ports, ECMO) and tracheostomy, gastrotomies and other enterostomies, pleural and peritoneal based shunts, intestinal
and airway dilatation techniques

C. Competency-Based Objectives

The PSR is expected to demonstrate an appreciation of the unique psychological needs of pediatric patients and their families and must be able to deal effectively and compassionately with family members. They should develop an understanding of the ethical principles as related to the complex issue of congenital abnormalities and as applied to children undergoing medical treatment, participating in research, etc. They should demonstrate an appreciation of the economic factors that influence decision making and the impact of such factors on families. They are expected to be aware of legal issues regarding consent, confidentiality and refusal of treatment.

The PSR should communicate effectively with the hospital's physicians, nurses, other health professionals and health-related agencies. He/she should be able to act in a consultative role with other physicians and health professionals. The PSR should demonstrate high standards of ethical behavior and respect the dignity of patients and colleagues, including their age, culture, disabilities, ethnicity, gender and sexual orientation. They should demonstrate integrity, honesty, compassion and empathy in caring for the patients. He/she is expected to maintain comprehensive, timely and legible medical records.

Patient Care

General Requirements: Provide care that is compassionate, appropriate, and effective for the treatment of surgical problems of infants and children. Obtain and synthesize relevant history from patients, their families and the community. Establish a therapeutic relationship with patients and their family and discuss appropriate information with the health care team. Listen effectively. Demonstrate effective communication skills. Maintain adequate records.

Specific Requirements: Demonstrate an appreciation of the unique psychological needs of pediatric patients. Demonstrate an appreciation of the unique relationship between pediatric patients and their families and be able to deal effectively and compassionately with family members by establishing therapeutic relationships.

Interpersonal and Communication Skills

General Requirements: Consult effectively with other physicians and health care professionals. Contribute effectively to other interdisciplinary team activities.

Specific Requirements: Effectively use the team approach in the management of critically and chronically ill patients, such as newborns with congenital anomalies and children with cancer, inflammatory bowel disease, or transplantation.

Practice-Based Learning and Improvement

General Requirements: Utilize resources effectively to balance patient care, learning needs, and outside activities. Allocate finite health care resources wisely. Work effectively and efficiently in a health care organization. Utilize health care technology to optimize patient care, life-long learning and other activities.

Specific Requirements: Demonstrate an appreciation of the economic factors that influence decision-making and the impact of such factors on families. Understand the principles and practice of quality assurance and improvement, and actively participate in hospital-based quality assurance and improvement programs.

Systems-Based Practice

General Requirements: Identify the important determinants of health affecting patients and the larger context and system of health care with the ability to effectively call on system resources to provide care that is of optimal value. Contribute effectively to improved health of patients and communities and importantly, injury prevention. Recognize and respond to those issues where advocacy is appropriate.

Specific Requirements: As an example, be knowledgeable about appropriate use of car safety restraints according to the child's size (ie. rear-facing infant seats, forward-facing car seats, booster seats, lap-shoulder belts). Contribute to health-maintenance advocacy for children, including such areas as travel safety, helmet use, children operating machinery or motorized vehicles and accessibility to firearms.

Medical Knowledge

General Requirements: Develop, implement and monitor a personal continuing education strategy. Critically appraise sources of medical information to formulate evidence based practices. Facilitate learning of patients, house staff/students and other health care professionals through formal and informal teaching opportunities. Understand and appreciate the patterns of study and review that will constantly update the knowledge, technical skills and innovations that will maintain competence in the future.

Specific Requirements: Contribute to development of new knowledge to foster the academic growth of the specialty of Pediatric Surgery by participating in scholarly work.

Professionalism

General Requirements: Deliver the highest quality care with integrity, honesty and compassion. Exhibit appropriate personal and interpersonal professional behaviors. Practice medicine ethically consistent with one's obligations as a physician.

Specific Requirements: Demonstrate sensitivity to age, gender, culture and ethnicity in dealing with patients and their families. Understand the ethical principles as related to the complex issue of congenital abnormalities and as applied to children submitted to medical treatment, research, etc. Recognize the importance of maintenance of competence and evaluation of outcomes. Understand the legal issues related to consent, confidentiality, and refusal of treatment.

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