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Abstract

Objectives:The study aimed to address the shortage of pediatric surgery specialists globally by investigating the discrepancies in training programs and population metrics across different countries and regions. Methods: An international survey of pediatric surgeons gathered data on training duration, examination procedures, certification, and population metrics like mortality rate and surgeon-to-population ratio. Results: The study included 44 countries. The average length of pediatric surgery training was 5.7 years, with no significant difference between different regions. The pediatric mortality rate and surgeons count per 100 000 people were inversely correlated, while training duration was associated with GDP and life expectancy, but not pediatric mortality rate or surgeons’ count. Conclusion: Many countries’ pediatric surgery training programs do not align with their actual need for pediatric surgeons. Nations with limited economic resources may opt to shorten residency programs or offer pediatric surgery as a direct specialty after medical school to mitigate the shortage effectively.

Keywords

pediatric surgery workforce pediatric surgery training residency program pediatric surgery shortage

Introduction

The training programs for pediatric surgery vary widely across the world, with differences in the duration of education and lack of an integrated residency program among countries. While some countries provide pediatric surgery as a specialty, others require previous surgical training to become a pediatric surgeon.¹ Reports on the availability of pediatric surgeons worldwide are limited, but many studies and surveys suggest a shortage of pediatric surgeons compared to other surgical specialties, particularly in low- and middle-income regions and countries.^2,3 Unfortunately, there are limited data on the number of pediatric surgeons needed per population. but this number varies across countries based on their level of income.⁴ For instance, in high-income countries it is reported that the number of pediatric surgeons per population is 1 per 100 000, while in low-income societies this number falls to 1 per 500 000. It should be noted that this number is about 20% of what it should be. Consequently, with the shortage of worldwide data it is difficult to estimate a minimum cut-off for the number of pediatric surgeons.⁵ Nevertheless, the factors contributing to this shortage are not well studied. Metrics such as surgical cost, gross domestic product, long surgical training, birth rate, and access to physicians have been proposed as potential predictors of the lack of pediatric surgeons.⁶ Unfortunately, these factors vary between countries and may not be reliable metrics showing the condition of pediatric surgery training. However, in a worldwide scale using these factors is inevitable. As a result, the global shortage of pediatric surgery specialists persists.⁷ Furthermore, the quality of healthcare provided by different pediatric surgical training systems is not adequately compared. It is still unknown whether general surgery training is a prerequisite for being competent pediatric surgeons or not. Therefore, in this study, we aim to investigate whether the pediatric surgery workforce and education duration in countries is tailored to their needs. We will gather information about pediatric surgery training systems from various countries and their respective population dynamics.

Methods

A survey was conducted among pediatric surgeons from different countries who were attended in “7th World Congress of Pediatric Surgery in Prague” from all around the world, to find out the crucial differences in becoming a pediatric surgeon in various countries and regions. The congress was held in 12 to 15 October, 2022. The questionnaire was designed and developed on one paper, and included yes/no and number questions (See Appendix). The main purpose of this questionnaire was to collect data on pediatric surgery training in different populations. These data include years needed to become a pediatric surgeon, the length of general surgery course (if necessary), mandatory entrance and final exams, and the type of certifications. As previous surveys in this specific field was not done before, a new questionnaire was developed. Then, the survey was pilot-tested in an electronic online sheet with 16 pediatric surgeons from different regions of Iran.

Also, the population indices of each country were collected from web-based sources (World Health Organization’s Global Health Workforce Statistics) to investigate any correlation between these factors and the pediatric surgery workforce. These indices include population, pediatric population (children under the age of 15), pediatric to total population ratio (PTR), birth rate, pediatric mortality rate, growth rate, life expectancy, specialists in surgical workforce, and gross domestic product (GDP) per capita.^8,9 These indices were measured in 2021 and 2018 for population dynamics and GDP, respectively.

Completed questionnaires were reassessed by a pediatric surgeon, and entered into an electronic dataset. Afterwards, the information was rechecked for validity with online sources. Moreover, the study was conducted in 6 months.

Exclusion Criteria

Although the study included a pilot-tested questionnaire, the incomplete forms or those with missing answers were not included in the study.

Statistical Analysis

Simple analytic functions were used to evaluate the questionnaire results. Moreover, Chi-Square, one-way ANOVA, and Pearson correlation analysis were implemented to indicate any differences or similarities among categorical and interval parameters. Bivariate analysis was done with Pearson correlation. Also, Multiple linear regression was used in order to perform multivariate analysis of continuous variables. It should be noted that the level of significance was considered 5%.

Ethical Approval and Informed Consent

A written informed consent was taken from all the participants in the survey. Furthermore, as the survey research does not impose risks on participants, ethical approval may not be necessary.¹⁰ As the study is a survey, it falls under the category of minimal risk research and does not require formal ethics approval in our institutional review board guidelines (Research Institute for Children’s Health Review Board).

Results

Training Years

Among 91 participants, 68 entries from 44 countries were included in the study. Thirteen countries (29.5%) had more than one participant, while the other countries had only one candidate. Twenty-four countries provide pediatric surgery training as a specialty with straight residency program after medical school (PS-S), while in other 20 countries being a general surgeon is a prerequisite for beginning pediatric surgery (PS-SS). The detailed information about the training years is represented in Table 1.

Table 1.

An Overview of Surgical Training in Different Countries.

Countries where PS^a is a sub-specialty^b	Pediatric surgery training (years)	General surgery training	Board of general surgery certificate	Entrance exam	Final exam	Countries where PS is a specialty	Pediatric surgery training (years)	Entrance exam	Final exam
Belgium	1	6	−	−	−	Luxamburg	6	+	+
Canada	2	5	+	−	+	Australia	6	+	+
Croatia	1	6	−	−	+	Austria	7	+	+
Czech	4	2	+	−	+	Bolivia	4	+	+
Egypt	3	2	+	−	+	Cameroon	6	+	+
Greece	4	3	−	−	+	Costa Rica	5	+	−
India	2	3	+	+	+	Ecuador	6	−	+
Iran	3	4	+	+	+	Germany	6	−	+
Israel	2	7	+	−	+	Hungary	6	−	+
Japan	5	3	+	−	−	Indonesia	5	+	+
Korea	2.5	2	+	+	+	Ireland	5	−	+
Ksa	3	5	+	−	+	Italy	5	+	+
Latvia	3	2	−	+	+	Lithuania	5	−	+
Pakistan	3	2	−	+	+	Macedonia	6	−	+
Palestine	4	1	+	+	+	Panama	6	+	+
Singapore	4	3	+	−	+	Poland	6	−	+
Sudan	3	2	+	+	+	Portugal	6	+	+
Thailand	3	1	+	+	+	Russia	2.5	+	+
Tunissia	1	5	+	+	+	Slovakia	6	−	+
USA	2	5	+	−	+	South Africa	5	−	+
						Spain	5	+	+
						Turkey	5	+	+
						UK	6	−	+
						Uzbekistan	2	+	+

PS stands for pediatric surgery.

Some participants from similar countries have stated nonconforming data. In these cases the mean number is indicated.

Overall, the average length of pediatric surgery course was 5.7 ± 1.3. Besides, these numbers were 5.3 ± 1.1 and 5.7 ± 1.1 for PS-S and PS-SS countries, respectively (P = .02). Additionally, the mean training years sorted by continent is depicted in Figure 1. Although the training years varies from 5.7 in Europe to 7.2 in middle east, no significant difference was observed in training years between different regions regardless of the type of residency program (P = .399).

Figure 1.

World map representing the average training years for each country. Darker areas show higher training years. The figure is used under the Creative Commons Attribution-ShareAlike 4.0 International License (CC BY-SA 4.0), allowing for reuse and adaptation with proper attribution.

Population Dynamics

Table 2 represents population dynamics for each country. Regression analysis predicted a linear correlation between pediatric mortality rate with pediatric/total ratio, birth rate, growth rate, life expectancy, GDP, and surgeons count per 100 000 people (Figure 2a). In addition, bivariate analysis showed GDP, life expectancy, and surgeons count are negatively connected to pediatric mortality rate, while mortality rate increases with growth rate, birth rate, and pediatric/total ratio (Figure 2b-g). These findings suggest that countries with higher pediatric population, growth rate, birth rate along with lower GDP and life expectancy confront more pediatric health issues and mortality. Also, in terms of surgical specialists’ training years, the surgeons count in countries is negatively associated with birth rate, mortality rate, and growth rate, while GDP and life expectancy correlates positively with the number of surgical specialists (P-values < .001). Consequently, these results imply that countries with overgrowing population have lower GDP, life expectancy, and surgical specialists. Accordingly, two metrics, pediatric mortality rate and surgeons count can be good indicators of pediatric surgical care. Additionally, the number of surgeons per 100 000 is inversely related to pediatric mortality (r = −.533, n = 42, P < .001).

Table 2.

Population metrics separated by the type of pediatric surgery workforce.

Countries where PS^a is a sub-specialty^b	Pediatric surgery training (years)	Pediatric/total ratio	Growth rate	Birth rate	GDP per capita (US $)	Life expectancy	Specialists (per 100 000)	Countries where PS is a specialty	Pediatric surgery training (years)	Pediatric/total ratio	Growth rate	Birth rate	GDP per capita (US $)	Life expectancy	Specialists (per 100 000)
Belgium	7	0.17	0.50	10.05	$39 756	81.9	89.76	Luxamburg	6	0.16	1.44	10.36	$57 428	82.6	80.75
Canada	7	0.16	0.71	9.82	$44 869	82.7	43.87	Australia	6	0.18	0.97	11.54	$49 831	84.5	45.11
Croatia	7	0.14	−0.93	8.54	$22 012	77.6	81.24	Austria	7	0.14	0.17	9.50	$42 988	81.6	109.88
Czech	6	0.16	−0.25	9.89	$30 749	77.7	124.52	Bolivia	4	0.31	1.15	21.84	$6696	63.6	33.87
Egypt	5	0.33	1.59	22.56	$11 957	70.2	50.08	Cameroon	6	0.42	2.60	34.94	$2888	60.3	1.15
Greece	7	0.14	−0.68	7.57	$23 451	80.1	163.54	Costa Rica	5	0.21	0.51	11.87	$14 686	77.0	25.46
India	5	0.26	0.68	16.42	$6806	67.2	6.82	Ecuador	6	0.26	1.21	16.82	$10 639	73.7	59.39
Iran	7	0.24	0.76	13.70	$17 011	73.9	5.02	Germany	6	0.14	0.04	9.17	$46 178	80.6	108.00
Israel	9	0.28	1.59	19.61	$32 955	82.3	75.59	Hungary	6	0.15	−0.44	9.47	$25 623	74.5	55.69
Japan	8	0.12	−0.54	6.57	$38 674	84.8	37.36	Indonesia	5	0.25	0.63	16.43	$11 852	67.6
Korea	4.5	0.12	0.00	5.58	$37 928	83.7	49.63	Ireland	5	0.20	0.78	11.76	$64 684	82.0	71.97
Ksa	8	0.26	1.04	17.47	$50 305	76.9	2.67	Italy	5	0.13	−0.41	6.93	$34 364	82.9	142.40
Latvia	5	0.16	−1.38	9.07	$24 313	73.6	67.62	Lithuania	5	0.15	−1.29	9.62	$27 371	73.7	130.92
Pakistan	5	0.37	1.83	27.52	$5510	66.1	5.53	Macedonia	6	0.16	−0.46	9.56	$13 074	73.8	61.22
Palestine	5	0.39	2.20	28.24	$5208	73.5		Panama	6	0.26	1.29	17.69	$22 637	76.2	26.22
Singapore	7	0.12	0.50	7.12	$68 402	82.8	31.45	Poland	6	0.15	−0.37	9.49	$27 455	76.5	67.86
Sudan	5	0.45	1.51	29.11	$3380	55.0	2.67	Portugal	6	0.13	−0.15	7.83	$27 036	81.0	86.09
Thailand	4	0.16	0.11	9.00	$16 649	78.7	13.09	Russia	2.5	0.18	−0.51	9.64	$24 669	69.4	63.12
Tunisia	6	0.25	0.75	16.09	$11 354	73.8	47.63	Slovakia	6	0.16	−0.30	9.98	$27 076	74.9	53.90
USA	7	0.18	0.30	11.06	$55 335	77.2	54.71	South Africa	5	0.29	0.86	19.82	$12 166	62.3	11.42
								Spain	5	0.14	0.38	7.55	$31 497	83.0	79.90
								Turkey	5	0.23	0.75	14.68	$19 270	76.0	47.63
								UK	6	0.18	0.34	10.08	$38 058	80.7	133.30
								Uzbekistan	2	0.30	1.59	23.55	$11 220	70.9	50.43

PS stands for pediatric surgery.

Subspecialty training programs are offered after finishing specialty in general surgery.

Figure 2.

Correlation of pediatric mortality with socioeconomic variables shown in graphs. (a) Regression multivariate analysis showed a liner correlation between pediatric mortality rate and pediatric/total ratio, birth rate, growth rate, life expectancy, GDP, and surgeons count per 100 000 people. This graph indicates that the pediatric mortality can be predicted by mentioned factors. (b) GDP and pediatric mortality rate graph. (c) Life expectancy and pediatric mortality rate graph. (d) Surgeons count and pediatric mortality rate graph. (e) Growth and pediatric mortality rate graph. (f) Birth and pediatric mortality rate graph. (g) Pediatric/total population ratio and pediatric mortality rate graph.

Correlation Between Population Metrics and Training Duration

Overall, pediatric surgery training duration did not follow any linear rules with pediatric mortality or surgeons count (P = .154, P = .487 respectively). Although it seems that the pediatric mortality rate could be a good indicator of the healthcare system, pediatric surgery duration is associated with life expectancy and GDP (r = .429, n = 44, P = .004, r = .424, n = 44, P = .004). Interestingly, the type of training program (PS-S or PS-SS) did not significantly influenced by population metrics or GDP (Table 3).

Table 3.

The Influence of Various Parameters on Pediatric Surgery Workforce Type (PS-S or PS-SS).

Statistical significance	Mortality rate	Population	Children population	Pediatric/total ratio	Birth rate	Growth rate	Life expectancy	GDP	Surgeons
P-value	.514	.195	.188	.485	.67	.815	.781	.959	.184

Abbreviation: GDP, gross domestic product.

Discussion

The present study could be able to show a linear correlation between the pediatric mortality rate with other population dynamic metrics. This finding suggests that improving the healthcare system and increasing the number of pediatric surgeons can significantly reduce pediatric mortality rates. Also, the correlation between pediatric/total ratio and pediatric mortality rate indicates that the ratio of pediatric patients in a healthcare system is a significant determinant of pediatric mortality rates. This finding suggests that healthcare systems that prioritize pediatric patients and allocate appropriate resources for their care can significantly reduce pediatric mortality rates. Similarly, the correlation between growth rate, life expectancy, and GDP with pediatric mortality rate suggests that socioeconomic factors play a crucial role in determining pediatric mortality rates. Countries with higher economic growth, better life expectancy, and higher GDP tend to have better healthcare systems, which in turn reduce pediatric mortality rates. Conversely, this study could not find a correlation between healthcare metrics and pediatric surgical training duration. It can be concluded that pediatric surgery training regardless of its type (PS-S or PS-SS) is affected by internal decisions of each country policymakers, while we expect the pediatric surgery training duration should be dependent on each county’s needs and demands to lower the mortality rate and improve the health care system for children.

As previously mentioned, several predicting factors have been introduced so far to find the potential causes of pediatric surgeons shortage in the world. A review of 15 different countries workforce revealed that countries with lower GDP per capita and higher birth rate are more prone to have shortage in pediatric surgeons.⁶ Furthermore, a comprehensive review on low- and middle-income countries (LMIC), thoroughly evaluated the population dynamics of these countries and stated that several socioeconomic factors led to the shortage of pediatric surgeons in these regions. Lack of funding, training opportunities, and financial motivation for new entrants were described as contributing factors.² Although, it seems that there is no more data on global comparison of pediatric surgery workforce in the literature, several national and regional investigations exist. Many of these articles introduced financial issues as the main cause of pediatric surgery shortage.^3,11-14 Additionally, a randomized cross-sectional survey in 4 low-income countries, the most unmet surgical needs were procedures in head, face and neck.¹⁵ Although in LMICs the primary cause of pediatric surgery shortage appeared to be financial issues, in high-income countries root causes vary. In these countries, the inadequacy of infrastructure, insurance coverage, and distribution of manpower across the country led to inequality in providing surgical care for pediatric population.^16-19 The present study, also introduced lower GDP and life expectancy lead to the shortage of surgical specialists. Therefore, it is recommended for LMICs to increase their GDP for overcoming these issues. However, increasing GDP is not a simple solution. Governments should pay special attention to pediatric surgery training as an indicator of public healthcare system. Using short-term education models like surgical trips, partnerships, academic collaborations, and workshops may charge lower fees for countries.²⁰ We hope that small-budget training models could lower pediatric mortality rate in these countries. As in the present study, training surgical duration is positively associated with GDP and life expectancy, we suggest all LMICs lower their duration of surgical training to confront their shortages. However, the competency of pediatric surgeons with lower learning curvature is not understood well.²¹ Nevertheles, Reduced exposure to diverse cases, limited hands-on experience, risk of inadequate preparation and negative impact on patient safety could be drawbacks of shortening training programs. On the contrary, unplanned growth of pediatric surgeons may mismatch the number of graduated trainees with available job positions leading to a lack of motivation for medical doctors to continue their career as pediatric surgeons.^21,22 It should be noted that increasing GDP and changing national training programs are long-term solution for the countries which suffer the lack of pediatric surgeons. But there may exist some short-term suggestions such as continuously available workshops, congresses. Furthermore, short-term fellowships focusing on the management of fatal and urgent pediatric surgical conditions could be considered as a fine option in LMICs. Additionally, online courses from professionals of high-income countries may help increase the knowledge of surgeons who are working in the field of pediatric surgery in LMICs without specific academic degree for pediatric surgery.

Like any other studies, this work may have several limitations that should be addressed. Relatively small sample size without power analysis, and gathering information from a specific congress attendees may introduce some biases, and the results should be extended with caution. Furthermore, the survey data were self-reported, which may have introduced some degree of response bias. Moreover, we came across a notable number of incomplete or missing data in forms which can indicate the language barrier, as the majority of participants were from non-English-speaking countries. Another limitation that we met was there is no official statistics for the exact number, required number and the current situation of pediatric surgeons in even some high-income countries. Moreover, non-survey data were extracted from online sources that are repeatedly updating and it may affect the reproducibility of the study. Future studies with larger sample sizes and more diverse populations are needed to mitigate these limitations and further explore the factors affecting pediatric surgical care globally.

Conclusion

In conclusion, this study investigated the differences in pediatric surgery training programs and population metrics among different countries and regions. The results indicate that the type of pediatric surgery training around the world is not related to their public healthcare needs, while many countries with poor economic status suffer the lack of pediatric surgeons and high pediatric mortality rate. Although there is not a single metric to show the situation of pediatric workforce in each country, we recommend governments should adjust their residency programs in low- and middle-income countries based on their current specialists status and demands. Despite the limitations of the study, the findings provide insights into the global landscape of pediatric surgical care, which can inform efforts to improve access to and quality of pediatric surgical services worldwide.

Supplemental Material

sj-pdf-1-gph-10.1177_2333794X241263169 – Supplemental material for Pediatric Surgery Workforce Around the World: A Need to Revise Residency Programs?

Supplemental material, sj-pdf-1-gph-10.1177_2333794X241263169 for Pediatric Surgery Workforce Around the World: A Need to Revise Residency Programs? by Ahmad Khaleghnejad Tabari, Leily Mohajerzadeh, Manoochehr Ebrahimian, Mohsen Rouzrokh, Fariba Jahangiri, Saghar Rouzrokh, Reyhaneh Eghbali Zarch and Arian Ahmadi Amoli in Global Pediatric Health

Footnotes

Acknowledgements

None.

Author Contributions

AKT: Contributed to conception and design; Contributed to analysis; critically revised the manuscript; Gave final approval; Agrees to be accountable for all aspects of work ensuring integrity and accuracy; Designed and managed the study. LM: Contributed to acquisition of data; critically revised the manuscript; Gave final approval; Agrees to be accountable for all aspects of work ensuring integrity and accuracy; Validated the questionnaire. ME: Contributed to analysis and interpretation; drafted the manuscript; Gave final approval; Agrees to be accountable for all aspects of work ensuring integrity and accuracy; Analysis and writing the manuscript. MR: Contributed to conception and design; critically revised the manuscript; Gave final approval; Agrees to be accountable for all aspects of work ensuring integrity and accuracy; Gathering internet data. FJ: Contributed to interpretation; critically revised the manuscript; Gave final approval; Agrees to be accountable for all aspects of work ensuring integrity and accuracy. SR: Contributed to interpretation; drafted the manuscript; Gave final approval; Agrees to be accountable for all aspects of work ensuring integrity and accuracy. REZ: Contributed to interpretation; drafted the manuscript; Gave final approval; Agrees to be accountable for all aspects of work ensuring integrity and accuracy. AA: Contributed to analysis; drafted the manuscript; Gave final approval; Agrees to be accountable for all aspects of work ensuring integrity and accuracy. All authors read and approved the final manuscript.

Authors’ Note

Arian Ahmadi Amoli is also affiliated to School of Medicine, Tehran University of Medical Sciences, Tehran, Iran.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Ethical Approval

As the study is a survey, it falls under the category of minimal risk research and does not require formal ethics approval in our institutional review board guidelines (Research Institute for Children’s Health Review Board).

Consent

Written informed consent was obtained from the participants. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Registration of Research Studies

Not applicable.

Provenance and Peer Review

Not commissioned, externally peer-reviewed.

ORCID iD

Manoochehr Ebrahimian

Supplemental Material

Supplemental material for this article is available online.

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Supplementary Material

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