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Table of Contents   
LETTERS TO THE EDITOR
Year : 2023  |  Volume : 28  |  Issue : 2  |  Page : 179-180
 

Personal viewpoint: “Turf wars in paediatric surgery and paediatric urology in India”


Division of Paediatric Surgery, The Children's Hospital, Mumbai, Maharashtra, India

Date of Submission31-Dec-2022
Date of Decision16-Jan-2023
Date of Acceptance04-Feb-2023
Date of Web Publication03-Mar-2023

Correspondence Address:
Jahoorahmad Zainuddin Patankar
202 Cliff Tower Apartment, III Cross Road, Lokhandwala Complex, Andheri West, Mumbai - 400 053, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiaps.jiaps_185_22

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How to cite this article:
Patankar JZ. Personal viewpoint: “Turf wars in paediatric surgery and paediatric urology in India”. J Indian Assoc Pediatr Surg 2023;28:179-80

How to cite this URL:
Patankar JZ. Personal viewpoint: “Turf wars in paediatric surgery and paediatric urology in India”. J Indian Assoc Pediatr Surg [serial online] 2023 [cited 2023 Mar 29];28:179-80. Available from: https://www.jiaps.com/text.asp?2023/28/2/179/371170




Sir,

Every few years Journal of Indian Association of Pediatric Surgeons (JIAPS) publishes papers highlighting “Current Status of Paediatric Surgery in India/Way Forward” by eminent members highlighting ongoing “Turf Wars” in pediatric surgery and pediatric urology in India. The last article published in JIAPS by Bhaumik writes about the status of pediatric surgery in India from its inception to the travails of today and the way forward.[1]

In a guest editorial in the Indian Journal of Urology, Prof. Joshi[2] writes that “Turf Wars” continue because pediatric surgeons usually treat children below the age of 12 years in all government and teaching medical colleges in India. This has had an adverse effect on the growth of pediatric urology as a subspecialty. Prof. Joshi further writes that the development of endourology, urodynamics, and renal transplantation work requires specialized training and skills which cannot be learned during a pediatric general surgical training.

We have frequently had this “Turf Wars” discussion over years (since 2012) in our IAPS Yahoo Mail groups and IndPedSurgeons Mail groups. It is globally accepted that pediatric practice has to be exclusive. Any mixing with adult practice produces unfavorable results in children.[3],[4] When asked to define the field of pediatric surgery, Robert Gross was said to have replied, “It is a field that is impossible to define exactly; it is easier to tell what it is not”.

Pediatricians have stuck to “AGE” as a criterion for their specialty with great success. We do not see adult physicians (general and even subspecialists) encroaching upon their specialty. Not even DM gastroenterologists/nephrologists/neurologists or for that matter not even cardiologists step upon their territory! Similarly, we as pediatric and neonatal surgeons should stick to AGE as a criterion for defining our specialty (accepted normal from newborn up to 18-year-old children). The reason I say this is as follows:

No adult urologist will ever think of operating upon an infant or neonate. They are comfortable only after the age of 3–4 years at the earliest. No neurosurgeon will operate on a neonate with leaking meningomyelocele/spina bifida on day 1 or day 2 of life, or even at 1 month. Would they be able to manage the bowel and bladder symptoms that arise later in life? Are there any general surgeons that would operate on a neonate with imperforate anus (anorectal malformation on day 2 or day 3 of life)? Hirschsprung's is beyond the understanding of any general surgeon. Visceral-sparing surgery for neuroblastoma may be attempted only by pediatric surgeons. Chemotherapy for Wilms' tumor can be given by pediatric surgeons. Furthermore, no general surgeon is doing any thoracotomies and expects a cardiac surgeon to do it, not true for a pediatric surgeon – they are comfortable with thoracotomy/esophageal/tracheal/mediastinal/lung and pleural surgeries. Similarly, thoracoscopy/laparoscopy/endoscopy/cystourethroscopy is in the domain of pediatric surgeons. In fact other than cardiac thoracic and intracranial space-occupying lesion brain, we operate head to toe (pediatric surgeons remain the true general surgeons indeed).

Neonatal surgery is our flagship subspecialty. Most congenital anomalies are picked up early; some are antenatally diagnosed, and others are picked up very much after birth; all these should be aptly addressed in the first 2 years of life itself. Why should an antenatal diagnosed pelviureteric junction or vesicoureteric reflux grow to 4 years before they receive pediatric surgical counsel?

Finally, it is not in the surgical technique but in our spirit and declaration of the world federation. And also, in our empathy with the parents of those babies, therein lies our specialty.

Prof. Veereshwar Bhatnagar, an eminent senior pediatric surgeon in a personal communication, said that departments (not individuals) of pediatric surgery should not let go of traditionally practiced procedures in preference for currently more popular/lucrative procedures. Somebody in the department has to take up these procedures. Otherwise, not only will modern training of residents be deficient but also the nibbles will become big bites! He further states, that is why we need to develop subspecialties which will remain under the umbrella of pediatric surgery.

In the field, outside the referral hospitals and apex institutes, where the majority of the patients are, the patient is going to pediatric surgeons as well as urologists and everyone works according to his capability and competence. Independently, pediatric urology as a specialty shall require a collective will and radical changes in curriculum, training, and practice in apex institutes and medical colleges of the country, which, according to our estimates, is a distant dream.

So far that place has not been achieved by any of the super specialties and we see underqualified and cross-specialty people encroaching upon each other's domains, much to the loss of quality treatment of their patients. Our patients also cannot afford the expensive treatment that becomes inevitable, as we train ourselves further and further for achieving excellence.

With the existing training in our country, while it seems like an uphill task for a trained adult urologist to acquire skills in pediatric urology, it seems to be a bit easier for a pediatric surgeon to acquire the skills required to upgrade himself or herself as a pediatric urologist. Till that minimum level of skill is attained, pediatric surgeons are at the forefront in the “Turf Wars.” As per a recent article, pediatric urology in India has come of age thanks to the contribution of pediatric surgeons.[5]

“Until the lions have their own historians, the history of the hunt will always glorify the hunter,” wrote Chinua Achebe, the Nigerian novelist, in some other context.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Bhaumik K. Pediatric surgery in India: From inception to the travails of today and the way forward. J Indian Assoc Pediatr Surg 2020;25:1-5.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Joshi S. Pediatric urology: An emerging subspeciality. Indian J Urol 2007;23:383.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Arul GS, Spicer RD. Where should paediatric surgery be performed? Arch Dis Child 1998;79:65-70.  Back to cited text no. 3
    
4.
Thomas DF, Kapila L. Children′s Surgery: A First Class Service. Report of the Paediatric Forum of the Royal College of Surgeons of England; 2000.  Back to cited text no. 4
    
5.
Babu R, Chandrasekharam VV. Pediatric urology in India has come of age. J Indian Assoc Pediatr Surg 2022;27:513-4.  Back to cited text no. 5
  [Full text]  




 

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