General and Pediatric Surgeons Can Create Effective Models of Cross-Coverage

There is a pithy saying in pediatric surgery that, in many ways, defines the discipline—“children aren’t just little adults.”¹ Children have unique physiology, operative demands, psychological and social needs, and other distinctions from adult populations that can necessitate the specialized expertise of a pediatric surgeon.

In an ideal surgical landscape, a specialty-trained pediatric surgeon would be available to address the needs of any patient 18 years old and under with a smooth transition of care to an adult surgeon familiar with their pathology. But as surgeons and healthcare leaders well know, reality rarely falls along such neat dividing lines, and pediatric surgeons are among the projected 20,000-surgeon shortfall that the US could face in the mid-2030s.²

Pediatric surgery also contends with the familiar surgeon maldistribution of other disciplines, where surgeons are concentrated in urban and academic centers that leave smaller cities, towns, and rural areas lacking in representation.

However, even in areas affected by shortages, children’s health needs must be met—and general surgeons continue to serve a crucial role in pediatric surgical care.

Cross-Coverage Rooted in Familiarity

An ongoing conversation in modern surgery is appropriateness and necessity of general surgeons providing coverage for emergencies or patient complications in other abdominal-based specialties, such as select procedures in colorectal surgery or bariatric surgery (see March 2025 Bulletin article for more information).

A similar discussion is happening in pediatrics, where general surgeons are performing high-quality care for children as circumstances demand.

Rather than expanding beyond their usual anatomical scope, general surgeons who treat children are simply shifting the patient population they serve.

“The most common cases a general surgeon will usually encounter in terms of pediatric patients are appendectomies for nonperforated appendicitis, cholecystectomies, and pilonidal cysts,” said Michael Phillips, MD, MSCR, FACS, a pediatric surgeon and associate professor of surgery in the Division of Pediatric Surgery at the University of North Carolina School of Medicine in Chapel Hill. “These are three procedures that we hope our trainees graduating in general surgery would feel comfortable managing if they became community general surgeons.”

Data suggest that general surgeons who do not specialize in pediatric surgery perform the majority of these “bread and butter” procedures—though others include (to a much lesser extent) umbilical and inguinal hernia repair, and procedures for Meckel’s diverticulum.³

Dr. Phillips noted that this information came from a study he and his colleagues conducted on the reality of general surgeons operating on pediatric patients. The research was based on North Carolina patient cohorts specifically, but he suggested that because the state is ninth largest in population and has a representative mix of rural and urban populations, the data may be generalizable across the US.³

Looking at cholecystectomy, the operation adult general surgeons perform at the highest rate on pediatric patients at nearly 70%, illuminates one of the reasons why general surgeons can step in for some pediatric procedures—they have a high level of experience.

“General surgeons do many more gallbladder operations on adults than we do on children, since it is comparatively less common in our patient populations, and that high level of familiarity is likely why they do more of the gallbladder surgeries for pediatric patients than pediatric surgeons,” explained Dr. Phillips.

The higher prevalence of biliary disease in adults, relative to children, makes cholecystectomy one of the most common surgical procedures in this population, and enables surgeons to extend their expertise to older children and adolescents.⁴

Naturally, there are certain intraoperative accommodations that need to be made for children during an operation, particularly when they are on the younger side.

“For minimally invasive surgery, which is the primary approach for these common conditions, we tend to use smaller, shorter instruments and lower insufflating pressures, since we have less working space,” Dr. Phillips said. “Other times, the instruments are small enough that they may be placed directly through abdominal incisions without the use of a laparoscopic port, except one for the camera and insufflation.”

But these are minor differences that are frequently taught to general surgery trainees who rotate on pediatric surgery services or to general surgeons who frequently operate on children. In addition, the postoperative period may be less challenging for pediatric patients than for adults, as pediatric patients are likely to have shorter periods of convalescence and, as a population, have lower complications rates than adult patients due to relatively fewer comorbidities that can complicate perioperative management.

However, there are limits to what conditions general surgeons should expect to cover. According to Dr. Phillips, although inguinal hernias are approximately three times more common than cholecystitis in children, general surgeons perform a smaller percentage of those repairs than pediatric surgeons likely due to the notable differences in the anatomy and repair techniques of pediatric hernias compared with adult hernias.³

Additionally, hospital staff and anesthesia teams may not be equipped to support a general surgeon who feels comfortable performing surgery on a pediatric patient.

Meeting Multiple Needs

The data, while limited, suggest that general surgeons are performing select operations on pediatric patients, but it is equally important to understand why, when, and where this type of cross-cover is occurring.

To meet the needs of his community, Bryan K. Richmond, MD, MBA, FACS, a general surgeon in Charleston, West Virginia, helped create a program that elucidates these core questions⁵ and reinforces the findings that Dr. Phillips and colleagues reported in their study.

“I practice in a city of about 60,000 people in one of the most rural states in the country, and it’s difficult to recruit pediatric surgeons to the area. We found ourselves facing a pediatric surgical workforce shortage, down to one pediatric surgeon, sometimes two,” said Dr. Richmond, the Bert Bradford Professor and Chair of the Department of Surgery at the Charleston Area Medical Center Institute for Academic Medicine in West Virginia.

Noting that the call burden for pediatric surgery is extreme if a surgeon is on every other night, even in a low-acuity environment, Dr. Richmond and his team sought to create a more reasonable professional lifestyle to avoid attrition of their existing pediatric surgeons. To that end, Dr. Richmond’s team of general surgeons contracted with their hospital to provide a financial incentive to the adult acute care surgeons to cover all pediatric acute care for children ages 6 and up.

Age 6 is when many children begin to present with appendicitis, and his team forecasted that the most common cases they would see would be an appendectomy—“an easy lift for any adult surgeon,” Dr. Richmond said. Because patient safety is always paramount, a pediatric surgeon remains on call to address any findings or developments that were outside the covering surgeon’s comfort or expertise.

Dr. Richmond also stressed that this model is only applied to urgent cases from the emergency department.

“This was not a consult on the floor for a neuroblastoma in a 12-year-old,” Dr. Richmond said. “It was an appendix that night and a gallbladder the next day, or cases along those lines. In addition, if it was an established pediatric surgery patient who had been operated on for tracheoesophageal fistula, Hirschsprung disease, or something else requiring specialized care, then clearly that would go to the pediatric surgeons for continuity and for expertise.”

Importantly, while implementing and maintaining this coverage arrangement, Dr. Richmond and team were able to answer this question: was there a learning curve in preparing general and acute care surgeons to provide these types of operations on pediatric patients?⁶

“The short answer was there was not a learning curve. It appeared that the skill set that we came into the project with was adequate to maintain the same integrity of outcomes throughout, and we’ve really seen no substantial changes, seeing good-quality benchmarks and the same good outcomes,” Dr. Richmond said.

The agreement, which remains in place well into its second decade, has proven to be successful, providing high-quality, durable health results for the children in the community, an improved professional workload for the pediatric surgeons on call, and increased caseload for general and acute care surgeons providing the care.⁵

This unique model is one based on community needs and the proficiency of general and acute care surgeons, but it is also indicative of a health system that cultivates and maintains the comfort level of providers. In other regions or communities, where this kind of integrated model may not yet exist, decisions about how to provide coverage for pediatric patients will require a nuanced approach.

“A gallbladder surgery or appendectomy in a very young patient is likely to require the elements that a children’s hospital offers, rather than just the surgeon, and so that’s where I think the nuance has to come in,” Dr. Phillips said.

But because there are no defined, national age, weight, or developmental criteria for how to make these distinctions, he said, much of the decision-making comes down to provider comfort.

“You might have a general surgeon who says they are very comfortable doing an appendectomy on a 12-year-old, but their anesthesia team is not, their nurses are not. And that’s a limitation of an individual system that administrative datasets can’t capture,” Dr. Phillips said.

“I think what it allows us to say is that general surgeons should be able to do general surgery procedures on children if needed, but that is based on the system that’s around them and whether that system can support their surgical abilities,” he added.

But when both general and pediatric surgeons are aligned with their hospitals and health systems, a model that not only allows for but also promotes cross-coverage can be a valuable addition to areas that are limited in healthcare funding and population density.

“While our model was created out of necessity to preserve our pediatric surgical workforce, it also proved that when there are those resource limitations you can structure things to give your pediatric surgeons some much-needed relief and not sacrifice anything in terms of outcomes,” Dr. Richmond said.

Local, Timely, High-Value Care

Surgical care arrangements such as Dr. Richmond’s, or indeed the general surgeons in smaller communities who provide care for pediatric patients, provide a range of benefits.

When it comes to potentially specialized care in areas outside the standard catchment area of an academic medical center or a large, multidisciplinary hospital, one of the primary decisions that needs to be made is whether a transfer is necessary. But for pediatric patients, surgeon skill is not the only consideration when it comes to potentially needing to transfer a child to a specialist—there is also the stress of the transfer itself to consider.

“I think we just need to recognize that transferring to pediatric care is a difficult thing to add on top of what could be, for a lot of kids, one of the most traumatizing events of their childhood,” Dr. Phillips said. “Needing surgery is likely to be scary for them, and then we’re potentially taking them 100 miles away from their parents and their cousins and their siblings and their soccer team, and all the people who would normally visit you in the hospital at an already stressful time.”

Because children and families in nonacademic and rural settings often need to travel sometimes significant distances to receive surgical care,⁷ adding in a potential transfer can further extend time to treatment (in addition to increased risk of complications and higher costs associated with care transfers in general).⁸

A general surgeon closer to home should be capable of performing uncomplicated appendicitis on a 15-year-old with outcomes parity to pediatric surgeons, as Dr. Richmond’s efforts have shown, making a case that travel and transfers are not always necessary or even ideal.

“We need to be mindful of that shrinking elasticity in the workforce, and what cases can be safely done and provide good surgical care to children near their home and their support centers,” Dr. Phillips said.

Additionally, care by local general and acute care surgeons means that suffering children may be able to get their treatment in a shorter time compared with needing to wait for a pediatric surgeon.

“We observed that the time to the OR was actually quicker than our pediatric surgical counterparts, the reason for which is not a sign of quality, necessarily, but logistics,” Dr. Richmond said. “Because we were working over at the children’s hospital at night, but we had full operating schedules the next day, by necessity we got the pediatric cases done at night. If we needed to wait for pediatrics for that appendectomy, it may not have happened until the morning.”

The more expedient care of the patient, and sometimes next-day discharge, removes a possible extra day of hospitalization and saves time, money, and patient discomfort.

And in terms of overall resource allocation, data suggest that general surgeons are able to complete an adolescent appendectomy, for example, with similar costs and outcomes compared to pediatric surgeons.⁹ Some data even show that pediatric surgeons tend to have higher charges than general surgeons overall—though the nebulous nature of healthcare costs makes an assessment in that regard difficult to finalize.

“What we found in our examination is that pediatric surgeons tend to operate on younger children and tend to have higher charges,” Dr. Phillips said.

“But when we look at total charges and say, pediatric surgeons have a higher charge, that might be acceptable for a younger patient who required subspecialty nursing and hospital care. However, because children are generally healthier than adults, pediatric surgery is historically reimbursed at lower levels,” he said.

As value becomes an increasing focus in US healthcare, local and regional health systems will need to carefully analyze who can or should be performing common, low-risk pediatric surgeries when easy access to specialist is not a guarantee.

Preparing Surgeons to Share Surgical Burden

Research into the reality of how surgeons are sharing the burden of treating some surgical diseases in children, as well as the experiences from a historically successful and ongoing care model, suggests that general and pediatric surgeons already are working together to address potential care gaps or unsustainable practices. With that in mind, can general surgeons become better prepared to offer their services?

Depending on the circumstance, few modifications may be needed for general surgeon trainees to provide valuable care to pediatric patients, as seems to be evident with cholecystectomy or appendectomy.

“Appendectomy is one of the most straightforward laparoscopic cases that surgeons learn. These are the cases you teach the PGY-1s,” Dr. Richmond said. “So, when you are dealing with a kid 6 years and up, they are not little adults, but they are not babies either. There are no technical differences to the procedure, so I don’t think that there’s a modification required in the training paradigm.”

Rather, mentors can ensure that their junior operating surgeons become familiar with entering a smaller abdomen, for example, which is something practicing surgeons can provide as ongoing, “onsite” training.

Dr. Phillips suggested that including common procedures performed on pediatric patients (e.g., appendectomy, cholecystectomy, pilonidal cyst removal) in general surgery training for graduating residents is an important element that is sometimes overlooked, as it helps them recognize when to involve a general surgeon versus refer to a pediatric specialist.

“With that said, general surgery training is excellent, and I think that it’s been tailored to address this area specifically. This has been a challenge that’s been on the minds of general surgeons and pediatric surgeons for a long time,” he said.

With existing training paradigms continuing to set general surgeons up to succeed as the broad-based providers they are intended to be, it is incumbent on the providers and hospitals to take advantage of a unique skill set that can benefit children in need.

“What we’re seeing is that general surgeons’ skills are consistently marginalized, and sometimes this is a creature of their own creation,” Dr. Richmond said. “They find themselves retreating to the right upper quadrant to do gallbladder operations, when there may be no practice that is more valuable to a hospital than a general surgeon who’s well-rounded in terms of the services they can provide. As we see when we cover in pediatric surgery, I believe that using those skills when they are needed to keep our care models viable and to not overstress our specialists is a great service to patients and hospitals.”

Matthew Fox is the Digital Managing Editor in the ACS Division of Integrated Communications in Chicago, IL.

References

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