LAUSR

This issue is unique. It provides paediatricians with a concise and practical overview of many of the surgical conditions that they may encounter in their daily clinical practice but which tend to be at the edge of their knowledge or expertise. This special issue answers many of those questions paediatricians have always wanted answered but were too afraid to ask. The importance of paediatricians having a working knowledge of surgical conditions in children relates in part to the increasing specialisation that is occurring in all areas of medicine. For most of us, increasing specialisation means a greater depth of expertise in an increasingly limited scope of practice. Specialisation also leads to changes in the configuration of clinical services. Paradoxically, an under-recognised consequence of this specialisation is that clinicians actually need to strengthen knowledge at the edges of their scope of practice rather than allow it to decline. When my second cousin Donald Beasley returned to Whangarei (in the far north of New Zealand) in 1954, having gained 3 years of extensive training under the auspices of Sir James Spence in Newcastle-upon-Tyne and Robin Illingworth in Sheffield, he struck a problem: the local physicians saw no need to have a paediatrician in their hospital. They claimed they were quite capable themselves of treating what were after all only little adults. So they blocked his appointment. The result: this highly trained paediatrician found himself unable to secure a hospital position. Whilst under-employed, he became increasingly involved in the Intellectually Handicapped Children’s Society and ultimately became president of the World IHCS. It was to be six long years before he finally managed to gain a hospital position as a paediatrician in Whangarei, the first paediatrician in Northland. In due course, he was appointed chairman of the hospital board and used that position to facilitate some much needed change. His outstanding contribution to children’s health in Northland, New Zealand, over the next 22 years that he was there on his own is now very well recognised. There are many messages that could be derived from his experience, but the one that should be highlighted is that doctors are not always good at recognising the limits of their expertise (quite apart from any inclination to engage in turf protection). And to work beyond these limits tends not to be in the best interests of the children they treat. The corollary of this may be that those who do have good insight into the boundaries of their expertise probably make the best clinicians: they are the ones who are most likely to put their patients’ best interests foremost, and they are almost certainly the safest. Fast forward a generation. Until 1996, there were no paediatric surgeons in the whole of the South Island of New Zealand. Nature abhors a vacuum, so surgery in children was performed, as well as it could be in the circumstances, on an ad hoc basis. Various adult surgeons with limited knowledge and experience were required to handle many of the everyday conditions, and sometimes the more complex. Fortunately, in a couple of centres, general surgeons with an interest in and commitment to paediatric surgery attempted to channel the more challenging cases to themselves. The most complex cases were transferred to Auckland where there were paediatric surgeons. But within a few years of a specialist service being established in Christchurch, all that changed. Now, for more than 20 years, a regional paediatric surgical service has provided for the entire South Island, with a focus on quality care as close to the patients’ homes as possible so as to ensure equity of access and minimal disruption (time and financial) to families. This has led to significant improvements in outcomes for children. One key element of the success of this service model has been the close rapport between the paediatric surgeons and the local paediatricians (and surgeons). The local paediatricians remain the ones who frequently have to see children with actual or potentially surgical conditions first. But they must be adequately supported, and paediatric surgeons have to accept responsibility for providing that support. There are now agreed clinical pathways, including triage and management guidelines, for those conditions less familiar to the paediatrician. Specialist advice is never more than a phone call away. For their part, paediatricians have an obligation to be reasonably familiar with those surgical conditions that they are likely to encounter. The message here is that none of us can be expected to be a master of all areas of child health, but the reality is that all of us may still have to deal with problems at the edge of our scope of practice. We may not feel comfortable in this space, but the more informed we are, the better it is for our patients. And this is the main reason that this Special Issue has evolved: it has been designed mainly for the paediatrician and trainee who, from time to time, encounter children with surgical conditions. Hopefully, this issue will give them greater confidence in the diagnosis, triage and management of these (mostly common) surgical conditions of childhood. This can only be to the benefit of the children they then see. And for the record, Donald is still very much alive, and even though he is now in his late nineties, he remains astute and follows what is happening in paediatrics in Australasia with interest.