Introduction

Pediatric surgery represents a uniquely demanding subspecialty that requires additional training beyond general surgery residency. In recent years, the majority of general surgery residents (over 90%) have pursued fellowship training, a trend that continues to rise.1,2 Among these fellowships, pediatric surgery remains one of the most selective, with a five-year average match rate between 50% and 57%, and an average of 1.74 applicants competing for each available position.1–3

While general surgery training is designed to offer comprehensive exposure to a wide range of subspecialties, including pediatric surgery, the depth and structure of this experience vary substantially among programs. Some residency programs are affiliated with a freestanding, designated pediatric-only hospital as part of their training site, which provides high-volume and high-quality exposure, whereas others have a pediatric rotation embedded in an adult hospital, which may offer limited and less immersive pediatric surgical exposure.

There is growing concern in the literature regarding the sufficiency of pediatric surgery exposure during general surgery residency. Previous studies have noted a reduction in the volume and variety of pediatric operative cases encountered by residents.4–7 Given the increasing competitiveness of pediatric surgery fellowships and the reported decline in clinical pediatric experience during general surgery residency, it is critical to explore factors that may influence residents’ decisions to pursue this career path. This study describes the residency program characteristics of current pediatric surgery fellows and recent graduates, with particular attention to institutional type and affiliation with designated pediatric-only hospitals.

Materials and Methods

Study Design

This was a cross-sectional, descriptive study using publicly available data to characterize the general surgery residency training backgrounds of current pediatric surgery fellows and recent program graduates in the United States. The study did not involve private identifiable data or direct interaction with human subjects; an IRB exemption determination was requested and was pending at the time of submission.

Data Collection

Information on current pediatric surgery fellows and graduates from the preceding five years was systematically obtained from two national databases: the American Pediatric Surgery Association (APSA) website and the American Medical Association Residency and Fellowship Database (AMA-FREIDA), supplemented by publicly available web-based professional profile searches.8,9 Data were collected for all 51 ACGME-accredited pediatric surgery fellowship programs in the United States. For each identified trainee, the corresponding general surgery residency training program was recorded, and the following program-level variables were abstracted: institutional program type, presence or absence of a freestanding dedicated pediatric-only hospital affiliated with the residency training site, and whether the institution concurrently hosted an ACGME-accredited pediatric surgery fellowship program.

Inclusion and Exclusion Criteria

All individuals currently enrolled in an ACGME-accredited pediatric surgery fellowship program in the United States, as well as graduates from these programs within the preceding five years, were eligible for inclusion. Trainees for whom general surgery residency program data could not be identified through publicly available sources were excluded from program-level subgroup analyses but were retained in overall cohort counts.

Classification of Residency Programs

General surgery residency programs were classified according to the institutional designations provided in the AMA-FREIDA database. University-based (UB) programs were defined as those affiliated with a university medical school. Non-university-based (NUB) programs included community-based university-affiliated (CBUA) programs and community-based only (CB) programs. Military-affiliated programs constituted a separate category. The presence or absence of a freestanding designated pediatric-only hospital as a component of the affiliated residency training site was determined through review of institutional websites and publicly available hospital designation databases. Programs for which classification or hospital affiliation could not be confirmed from available sources were categorized as unknown.

Statistical Analysis

Descriptive statistics were used to summarize all program and fellow characteristics, reported as frequencies and proportions. Chi-square goodness-of-fit tests were performed to evaluate whether the distribution of fellows across program types (UB vs. NUB vs. military) and across pediatric hospital affiliation categories (with vs. without a dedicated pediatric-only hospital) differed significantly from what would be expected if fellows were distributed proportionally to the representation of each program type among fellowship-producing programs. The mean number of fellows produced per program was calculated for each subgroup as an additional measure of program productivity. A two-sided p-value of less than 0.05 was considered statistically significant. All statistical analyses were performed using R statistical software (version 4.x.x; R Foundation for Statistical Computing, Vienna, Austria).

Results

Program Characteristics (Table 1)

A total of 59 pediatric surgery fellowship programs were identified across North America, with 51 programs based in the United States, collectively offering 46 fellowship positions annually. A cohort of 332 current pediatric surgery fellows and recent graduates from the past five years was analyzed.

Among the 362 ACGME-accredited general surgery residency programs in the United States, 125 (34.5%) programs accounted for all 328 pediatric surgery fellows and recent graduates with available training data, while the remaining 237 programs (65.5%) produced no identifiable fellows during this period. When stratified by institutional affiliation, 84 (67.2%) were classified as university-based, 32 (25.6%) were non-university-based programs, and 7 (5.6%) programs were affiliated with the military. Among the 32 non-university programs, 31 were community-based university-affiliated programs (CBUA) and 1 was a community-based only program. Program classification could not be determined for 2 programs.

Affiliation with a freestanding dedicated pediatric-only hospital was identified in 72 (57.6%) of the 125 contributing programs, whereas 49 (39.2%) programs lacked such an affiliation. Hospital affiliation data were not available for 4 (3.2%) programs. Additionally, 46 (36.8%) of these 125 general surgery programs were located at institutions that also offered an ACGME-accredited pediatric surgery fellowship.

Table 1.Characteristics of General Surgery Residency Programs Producing Pediatric Surgery Fellows and Recent Graduates
Program Characteristics Number (n) Percent (%)
Total general surgery programs in the U.S. 362 —
Programs producing current fellows and recent graduates 125 34.5%
By Program Type
University-based (UB) 84 67.2%
Non-university-based (NUB) 32 25.6%
Military-based 7 5.6%
Unknown 2 —
By Pediatric Hospital Affiliation
Programs with dedicated pediatric-only hospital 72 57.6%
Programs without dedicated pediatric-only hospital 49 39.2%
Unknown 4 3.2%
By Pediatric Surgery Fellowship Co-location
Programs with co-located pediatric surgery fellowship 46 36.8%

UB = university-based; NUB = non-university-based (includes 31 community-based university-affiliated and 1 community-based only programs). Percentages calculated among the 125 fellowship-producing programs.

Fellow Characteristics (Table 2)

Of the 332 fellows and recent graduates included in the cohort, general surgery training program data were available for 328 (98.8%) individuals. Most pediatric surgery fellows — 255 (77.7%) completed their general surgery training at university-based residency programs, 66 (20.1%) trained at non-university-based institutions, and 7 (2.1%) completed residency training within military-affiliated programs.

The distribution of fellows across program types differed significantly from the proportional representation of each program type among fellowship-producing programs (χ² = 15.96, df = 2, p < 0.001). University-based programs yielded a mean of 3.04 fellows per program over five years, compared to 2.06 per program at NUB institutions and 1.00 per program at military programs, indicating that UB programs were disproportionately productive in generating pediatric surgery trainees relative to their share of fellowship-producing programs.

Among the 328 fellows with available data, 191 (58.2%) trained at programs affiliated with a freestanding dedicated pediatric-only hospital, and 133 (40.5%) trained at programs without such affiliation. The distribution of fellows by pediatric hospital affiliation did not differ significantly from proportional expectations (χ² = 0.041, df = 1, p = 0.84). Programs with a dedicated pediatric-only hospital produced a mean of 2.65 fellows per program, compared with 2.71 per program at programs without such affiliation, suggesting that among programs already contributing to the fellowship pipeline, the presence of a pediatric-only hospital was not independently associated with greater fellow output. The chi-square statistical analyses for both comparisons are summarized in Table 3.

Table 2.Distribution of Pediatric Surgery Fellows and Recent Graduates by Residency Program Characteristics
Fellow Characteristics Programs (n) Fellows, N (%) Fellows per Program χ² p-value
Total fellows — 332 (—) — — —
Fellows with program data available — 328 (98.8%) 2.62 — —
By Program Type 15.96 < 0.001
University-based (UB) 84 255 (77.7%) 3.04 — —
Non-university-based (NUB) 32 66 (20.1%) 2.06 — —
Military-based 7 7 (2.1%) 1.00 — —
By Pediatric Hospital Affiliation 0.041 0.84
With dedicated pediatric-only hospital 72 191 (58.2%) 2.65 — —
Without dedicated pediatric-only hospital 49 133 (40.5%) 2.71 — —
Unknown — 4 (1.2%) — — —

Chi-square (χ²) goodness-of-fit test. p-values test whether fellow distribution differs from proportional program representation. χ² and p-value shown in the group subheading rows; individual category rows show observed counts and percentages. Fellows per program calculated among programs with available data. UB = university-based; NUB = non-university-based.

Table 3.Summary of Chi-Square Statistical Analyses
Comparison Observed, N (%) Expected (%) χ² df p-value
By Program Type 15.96 2 < 0.001
University-based (UB) 255 (77.7%) 68.3% — — —
Non-university-based (NUB) 66 (20.1%) 26.0% — — —
Military-based 7 (2.1%) 5.7% — — —
By Pediatric Hospital Affiliation 0.041 1 0.84
With dedicated pediatric-only hospital 191 (58.2%) 59.5% — — —
Without dedicated pediatric-only hospital 133 (40.5%) 40.5% — — —

Chi-square (χ²) goodness-of-fit test. χ², df, and p-value shown in each group subheading row. Expected distributions based on proportional representation of each program subtype among the 125 fellowship-producing general surgery programs. N = observed number of fellows; significance threshold p < 0.05. UB = university-based; NUB = non-university-based.

Discussion

This study provides a national descriptive assessment of the residency training backgrounds of current pediatric surgery fellows and recent graduates. We found that a limited number of general surgery residency programs accounted for all identified trainees entering pediatric surgery, and these programs were predominantly university-based and frequently affiliated with a designated pediatric-only hospital or an on-site pediatric surgery fellowship. These findings demonstrate a concentrated pediatric surgery training pipeline, although the study design does not allow conclusions regarding causation.

The predominance of trainees from programs with pediatric-specific infrastructure suggests that exposure to pediatric surgical environments during residency may be associated with greater representation in the pediatric surgery pipeline. However, this relationship should be interpreted cautiously. Prior literature has described the influence of clinical exposure, fellowship competitiveness, operative experience, and career preferences on specialty selection and training pathways.1,10–13 Individual factors such as mentorship, research involvement, resident preference, academic performance, and prior interest in pediatric surgery were not available in this study and likely influence fellowship pursuit and match outcomes.

Notably, while UB programs contributed disproportionately more fellows per program than NUB or military programs (χ² = 15.96, p < 0.001), among fellowship-producing programs, the presence of a dedicated pediatric-only hospital was not associated with a significantly greater fellow yield per program (χ² = 0.041, p = 0.84). This suggests that institutional types rather than pediatric hospital infrastructure alone — may be the primary structural determinant of fellowship pipeline contribution, and that efforts to expand the pipeline may benefit most from targeting program-level academic and mentorship resources across all institutional categories.

These findings may also relate to broader patterns in pediatric surgery workforce distribution. Previous studies have shown that pediatric surgeons are commonly concentrated in metropolitan, academic, or tertiary care settings, with ongoing concerns regarding access to pediatric surgical care in rural and underserved environments.14–16 The predominance of fellows from university-based programs with pediatric-specific infrastructure may reflect a training pathway that reinforces existing academic and geographic patterns within the specialty. However, further studies using resident-level data are needed to determine whether training environment independently influences fellowship pursuit or long-term practice location.

Recent data indicate a decline in both the volume and complexity of pediatric operative experience among general surgery residents.17 Although ACGME minimum requirements are being met, pediatric operative exposure remains heavily concentrated in common procedures such as appendectomy and hernia repair, with limited exposure to more complex pediatric operations such as pyloromyotomy, fundoplication, and congenital anomaly repair.18 These trends raise concerns regarding the ability of general surgeons to maintain broad pediatric surgical competency, particularly in regions without ready access to pediatric surgical specialists.

Several strategies may help address this exposure gap and broaden access to pediatric surgical training. Expanded pediatric surgery rotations, structured exposure at high-volume pediatric centers, and simulation-based educational models may help improve pediatric operative familiarity among general surgery residents, particularly in programs without freestanding children’s hospitals.19–21 Such approaches may be especially relevant for non-university and community-based programs, where pediatric surgery exposure may be more limited. However, the long-term impact of these interventions on fellowship interest, match outcomes, and workforce distribution remains uncertain and requires further study.

This study has several limitations. It relied solely on publicly available data, which may be incomplete or outdated, and residency training site classifications are therefore potentially subject to error. Important individual factors such as mentorship quality, research involvement, academic performance, prior interest in pediatric surgery, and participation in additional training experiences could not be evaluated, yet these elements likely influence fellowship pursuit and match outcomes. In addition, the presence of a pediatric-only hospital does not necessarily reflect the quality, duration, or intensity of pediatric surgical training. Long-standing institutional relationships may further influence fellowship selection and contribute to the concentration of trainees from certain programs. Finally, the cross-sectional design limits the ability to assess temporal changes in residency structures or evolving training models, and causation cannot be inferred.

Despite these limitations, this study provides a comprehensive national overview of the pediatric surgery training pipeline by analyzing all U.S. pediatric surgery fellowship programs and the residency backgrounds of current fellows and recent graduates. The large national sample, inclusion of all identified pediatric surgery fellowship programs, and consistent classification framework strengthen the reliability of the observed trends. The findings highlight important and previously under-described patterns in training environments and fellowship pathways, offering useful insight for surgical educators, fellowship programs, and workforce planners seeking to improve access to pediatric surgical training.

Conclusion

This national descriptive study demonstrates that the current pediatric surgery fellowship workforce is predominantly drawn from a concentrated subset of general surgery residency programs, specifically those that are university-based and affiliated with a freestanding designated pediatric-only hospital. Approximately one-third of all ACGME-accredited general surgery programs in the United States accounted for the entirety of identified pediatric surgery fellows and recent graduates, and more than three-quarters of trainees completed their residency training at university-based institutions. Statistical analysis confirmed that university-based programs yielded significantly more fellows per program than non-university-based or military programs (χ² = 15.96, p < 0.001), while the presence of a dedicated pediatric-only hospital alone was not significantly associated with greater fellow output among already-contributing programs (χ² = 0.041, p = 0.84), suggesting that institutional type and its associated academic infrastructure may be the more meaningful driver of fellowship pipeline contribution. These patterns are consistent with the broader literature documenting declining pediatric operative experience in general surgery residency, particularly in programs without dedicated pediatric surgical infrastructure. While individual factors such as mentorship, research involvement, academic performance, and personal career interests undoubtedly influence fellowship pursuit and cannot be fully captured in a descriptive study of this design, the structural characteristics of residency programs appear to be closely associated with fellowship representation. Expanding structured, high-quality pediatric surgery exposure beyond traditional academic and university-based centers — through extended pediatric rotations, formalized partnerships with children’s hospitals, or simulation-based curricula — may help broaden the pipeline and diversify the future pediatric surgery workforce to better serve patients across varying geographic and practice settings.