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Session 166
Do you need to love children to be a pediatric surgeon? Dr. Kimberly Lumpkins joins me to share her thoughts, and as she talks about her lifestyle, training pathway, and more.
If you’re interested in learning more about this specialty, visit the American Pediatric Surgical Association and if you’re interested in pediatric urology, check out the Societies for Pediatric Urology.
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[01:58] Interest in Pediatric Surgery
Kimberly had gone into general surgery, and thought she wanted to be a trauma surgeon. And then when she did trauma surgery, she quickly found out it wasn’t for her. She couldn’t find anything else that seemed to fit her properly.
So she was going to do private practice general surgery because it was the only way she could have different kinds of cases. And it wasn’t until her sixth year of residency that she came back to pediatric surgery. She realized that if she wanted to do as many different kinds of cases as possible, this is the field to do it.
Kimberly had two problems with trauma surgery. Every trauma center has its own way of managing things. She found the hours to be very brutal especially that great trauma usually happens at night. So being awake most of the night, just didn’t make her feel physically well. Then there’s a signal to noise ratio issue for trauma. It means that you spent a whole lot of time doing things that weren’t surgery. And she wanted to do a lot of surgeries. So those two things together just didn’t suit her personality.
[03:52] Traits that Lead to Becoming a Good Pediatric Surgeon
You have to have a lot of curiosity and a lot of problem-solving. Every baby with congenital birth defects is a different puzzle. And they didn’t all read the same textbook. So you cannot apply the same thing to each child. You really have to think about each problem. And then there’s the whole range of developmental ages and parental styles. That means you have to have soft skills on a lot of different levels.
[04:41] Training in Pediatric Surgery vs. Pediatric Urology
If you look at the two-volume Bible of Pediatric Surgery, a third of it is on pediatric urology. Interestingly, different places in the world train differently. In the United States, pediatric urology is a fellowship of Adult Urology. So you do your adult urology residency and then train in pediatric urology. And if you want to be a pediatric surgeon, you do your adult general surgery, and then you train in pediatric surgery. But that’s actually not true pretty much almost everywhere else in the world.
In many parts of the world, the two are the same training pathway until the very end. And many people don’t diverge. Kimberly’s boss is from New Zealand who had practices in both and was trained in both. And she came to be his partner. She also went to England and did an additional pediatric urology fellowship to learn more about urology and practicing it. So it is a very unusual pathway.
“Seeing how other countries practice medicine is an incredibly eye-opening experience, even a country that seems so similar to us as the UK.”
Therefore, if someone was in a general surgery path residency in the States, they cannot go on and become a pediatric urologist unless they did something and go somewhere else. Because pediatric urology is still considered to some extent a subset of general pediatric surgery. Additionally, you will find pediatric surgeons in some areas who do a fair bit of pediatric urology.
[07:22] The Biggest Myths or Misconceptions Around Pediatric Surgery or Pediatric Urology
Kimberly used to think that you would have to love children to get into pediatrics. But not everybody in pediatric surgery wants to have a billion children and loves toddlers. Some people really enjoy operating and making patients feel better. And that’s okay, too.
“Not everybody in pediatric surgery wants to have a billion children and loves toddlers.”
[08:10] Typical Day
Every day is a little bit different. Pediatric surgery combines both outpatient practice and emergencies. In a typical week, Kimberly will maybe have a day to two days scheduled in the operating room and a day to two days scheduled in the clinic. Then she would have some additional time there to work on academic projects or education.
But every few weeks, she is on call, which throws a whole lot of chaos into the mix, depending on the type of emergency that comes her way.
[09:02] Types of Cases
She does 100% assessment. People come into pediatric surgery to do tracheoesophageal fistula, imperforate anuses, and all sorts of big wacky surgeries. But 95% of the time, she’s dealing with inguinal hernias, umbilical hernias, circumcision revisions, or undescended testicles. In an emergency setting, she handles lots of appendicitis and some emergencies for newborns like bowel perforations.
Some exotic cases they sometimes handle include congenital birth defects. The ones that really get people’s attention are abdominal wall defects. These are babies born with their intestines on the outside. Another case is the tracheoesophageal fistula where babies can’t eat because the esophagus is not connected from top to bottom. Instead, it connects into the trachea. And that needs to be fixed quite urgently.
“There are really a lot of different problems such as holes in the diaphragm and many different things that can require a surgeon very soon after birth.”
[10:30] Ratio of Diagnosed Cases vs. Undiagnosed Cases
When a patient comes to her and says they have an inguinal hernia, the pediatrician usually made that diagnosis. So Kimberly evaluates it and works through the process of fixing it. But many newborns that come from the emergency patients usually have a lot of detective work that goes in.
In terms of the ratio of surgery cases, about 20-30% is actually spent in the operating room. That being said, you will be seeing lots of outpatients to fill up the scheduled time that you have.
“People probably underestimate the number of patients you need to see to fill that operating time.”
In outpatient urology, the operating case ratio is actually not so high. So she would probably see eight to 10 for a case sometimes. Whereas, her pediatric general surgery colleagues see a bit fewer to book a case because most people are coming in with lumps or bumps or hernias that are most likely going to translate directly into an operation.
[12:29] Taking Calls and Life Outside of the Hospital
The call depends on a fair bit on the kind of practice that you join. Pediatric surgery is definitely fairly intense for calls if you’re covering hospitals. And you do have to come in for a fair amount of things like intestinal perforations. Babies don’t wait till the morning.
She has five partners so she actually does it by week. She’s on call for a week and then off for four weeks. She would usually come in maybe a quarter to a third of the time in the middle of the night. So it can get pretty tiring depending on how it’s all strung together.
“For any surgeon and for anyone in an intense specialty, you have to learn to some extent to carve that time out for yourself.”
A lot of very driven people have been working very hard to get where they’re at. And you have to realize that sometimes you need to step back and the next paper or the next committee meeting can take a backseat so you can have your own work-life balance. It can be a difficult lesson for people to learn. But it is doable.
[14:19] The Training Path
Pediatric surgery is a subspecialty of general surgery. You have to complete a general surgery residency first, which comes in two flavors. They come in a flavor of seven years, which has two years of research in the middle of it or five years that doesn’t. And for pediatric surgery, because it’s a very competitive match process, 99% of the people that are applying in it will have gone through the seven-year program. So seven years of general surgery residency then you complete your board.
Kimberly is a fully boarded adult general surgeon. And then you do two years of pediatric surgery fellowship on top of that. So it is a long training pathway to get to the end.
“Pediatric surgery fellowship is the most competitive of the general surgery matches.”
There are about 45 spots a year in the country with usually around 70 to 90 applicants. A lot more people would apply, but they are warned off because the bar to success is pretty high. You have to be very academically prolific to be competitive, and you need to have good in-service scores. So some people are deterred from even applying.
Kimberly advises that you shouldn’t stress out too much about the pediatric surgery match, because you got a bunch of steps in between.
The best thing you can do overall is the same whether you’re applying for residency, or you’re applying for a pediatric surgery match. Read avidly, read about everything, whatever system of notes you take for yourself, however, that looks for you. Keep those notes and keep reviewing them.
You will have to be a great test performer to do well. So the better practice you get now and the more you work at it for your in-services, the better you’re going to be.
[16:52] Message to Osteopathic Students
The best thing to do in general is to get to the highest quality general surgery residency that you can. It comes down a lot to performance and numbers. So do the best that you possibly can on your exams to try to get that spot.
“Where you come from in residency is probably going to be more important than the degree that you have.”
[17:22] Subspecialty Opportunities
There are so many subspecialties of pediatric surgery that people subspecialize in oncology surgery for children or fetal surgery. Or they do colorectal surgery because there are a lot of colorectal anomalies.
Sometimes they do a formal fellowship to follow or sometimes they just set up a practice and create a focus in that area. The other side of that is people who are more generalists who went into pediatric surgery for generalism. So you can do both. There are very large centers that will tend to have subspecialists. Smaller places will tend not to.
“You can’t support a pediatric subspecialist ecosystem in a small community. There just aren’t enough people.”
[18:48] What She Wished She Knew that She Knows Now
Kimberly says she wished she had appreciated just how long she would be training. She was 20 when she went to medical school. And then she went to 10 years of residency and fellowship. That’s a really long time in which people are moving about and their lives are moving forward. You’re sort of like a perpetual trainee.
And that’s something that she didn’t really fully appreciate till after she was done. But looking back, she wouldn’t do a thing differently. She loves her job and she can’t imagine doing anything different than what she does.
“There is a very real opportunity cost to the amount of time that you spend in training.”
[20:07] The Challenges of a Female in a Male-Dominated World
When Kimberly was applying for residency, she went into an interview with the chief of cardiothoracic surgery on the program who asked her what she was doing there. That being said, she’s surrounded by incredible women surgeons, with families at all stages.
It’s not going to be easy but there are many women who make it work – and you can too.
“There’s absolutely no reason you can’t have a family and be a surgeon.”
[21:18] Most and Least Liked Things
Kimberly says she loves the variety and the challenge of each patient and the joy that you get from helping someone for their whole life. We’re not just talking about a temporary improvement in someone’s quality of life. Sometimes when you do these cases, you really are changing their future.
On the flip side, what she likes the least is getting really bad and exhausting calls. It’s all part of the deal. But it does get and it gets harder physically. Now that she’s 49, it takes a lot more time for her to recover from a full overnight call than she did when she was 24. And in coping during those times, Kimberly feels blessed to have a very supportive partner who cooks food for her and shoves her, and tells her to get some sleep.
[23:52] Major Changes in the Future
The whole field is moving towards hyper-specialization. Kimberly doesn’t think it’s practical to expect people to do 10 and 11 years of training. So the training has to change in some other way.
“I don’t think a true pediatric general surgeon is ever going to disappear.”
There are only so many babies with some of these complex congenital anomalies and you can’t support everybody being a subspecialist.”
[25:19] Communicating with Parents
“The parents are 100% – your patients. And sometimes, they’re more your patient than anybody else.”
You have to approach it with an open mind. We’re all mired in the biases of how we grew up. And so when you see parents that seem to behave in a direct, very different way, from the way you would expect parents to behave, it can be easy to judge. You have to really appreciate that these people’s lived experiences can be very different from yours. So you have to be able to open up to that reality.
At the end of the day, be more open and flexible with things to allow people’s lives to be appreciated and understood. Especially with chronically ill children, it’s very difficult for these families. And we often come in like on the doctor, you’re going to do X, Y, and Z. And that’s just not where they’re at, and not where you should be at either.
[27:52] Final Words of Wisdom
If she had to do it all over again, Kimberly would still have chosen the same specialty. She never really had an adult experience to compare it to since she went into medicine when she was 20 years old. So she can’t picture what else she would be. Sure, there would be some days she would just want to walk out, but overall, it’s a great field to be in.
Finally, she wishes to tell students who might be interested in this field to keep your eyes open. Be able to keep that same open mind to make sure that you wind up in the place that’s home for you.
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