Every so often in the operating room, what is handed to me is not what I asked for. I ask for a 4-0 suture and a slightly heavier 3-0 arrives.
"I said 4-0, didn't I?"
These days the reply is often this:
"You asked for 3-0, sir."
I had pointed out a mistake, and by the time the answer comes back, the one under suspicion is me. There is something almost funny about the moment I find myself searching my own memory.
It used to be different. People would first wonder whether they had misheard, or would let it pass even when they knew the other person had misspoken. Correcting a senior colleague or a professor to their face was not easily done.
And of course I may have misspoken. I could have been thinking 4-0 and said 3-0. Absorbed in the operation, I cannot swear I remember exactly what I said without thinking.
My colleagues and I laugh about these moments — "the younger generation really is different." No generation can be summed up in one sentence, but there is a change I feel in the room. They know what they want. When a demand does not make sense to them, they ask why. And they do not accept that because their seniors put up with something, they must put up with it too.
What once felt unfamiliar in the operating room, I now recognise in the junior doctors choosing their careers.
Not long ago I heard about this year's symposium of the Federation of Korean Surgeons for Children and Adolescents. Last year, as the reimbursement policy director of the Korean Society of Pediatric Urology, I had compiled and sent in the data for our field. The worries I had turned over while looking at those figures came back, and I was sorry to be abroad on fellowship this year and unable to attend.
When the various specialties that operate on children gather in one room, they share a single concern. Who is going to carry this work on?
I find it hard to explain this as a decline in the sense of vocation among young doctors. Look one by one at the conditions they face at the moment of choosing, and their hesitation becomes understandable.
Paediatric surgery demands precision with small structures, long hours, and meticulous care before and after the operation. Whether that effort and responsibility are adequately reflected in the fee schedule — the answer felt on the ground is sceptical. Fields that can secure income through high-cost imaging, drugs or robotic surgery are structured differently from the paediatric surgical specialties. We are also largely excluded from the revenue that flows through uninsured services tied to private indemnity insurance. Examining a child, operating with one's own hands, and seeing the recovery through — that alone does not build a foundation on which the work can be sustained.
Junior doctors have other options. The days when finishing medical school, completing a long residency, becoming a specialist and staying on at a university hospital was the default path are gone. They can practise as generalists, or move into aesthetics or other fields. To weigh the years of training and effort against the income and the life that follow is only natural. If the future we offer cannot justify those years, it is hard to blame anyone for considering another road.
And along that road, the path into paediatric surgery narrows more than once. One must choose specialist training, then a surgical specialty, and then, within it, children. In my own field of urology, finding a junior colleague who will choose paediatrics as a subspecialty has become difficult again. Training urologists and raising the doctors who will carry paediatric urology forward are two different tasks.
The burden of paediatric care itself is heavy. To the strain of being responsible for the outcome of an operation on a small child is added the worry that a poor result may lead to a dispute or a lawsuit. A long decline in births, and with it in the number of children, feeds anxiety about the future of the field. One wonders whether there will still be a place to practise the expertise that took so many years to acquire.
Yet fewer children does not mean lighter work for the doctors who remain. As the hospitals and people able to provide this care dwindle, patients concentrate where the care still exists. There are fewer colleagues to share the on-call, to think through a difficult case together, to cover when someone steps away. The work of those who stay grows heavier — and the juniors watching them hesitate once more.
Hospital decisions can accelerate the cycle. When a doctor leaves, the post is sometimes left unfilled on the grounds of low profitability, and even the existing headcount is not always maintained. On the ground, people are desperately needed; the institution's judgement moves the other way. Nor can a surgeon trained in paediatric surgery simply open a private practice and continue the same work. It needs an operating theatre, paediatric anaesthesia, and the staff and facilities to support inpatient care.
Few come in, the places to stay are uncertain, and the work of those who remain grows heavier. It is this cycle that worries me.
There is a clear fulfilment in operating on children. Sometimes the children I operated on come back to the clinic grown, healthy and bright. Watching that is a joy much like watching one's own child or nephew grow up. I too have worked leaning on that joy, and I want to tell the juniors about it.
But that story is no longer enough on its own. Behind the explanation that this work is worthwhile there has to be an answer about what kind of life the person doing it can live. It takes fair compensation, colleagues to work alongside, and a system in which a bad outcome does not have to be borne alone. It takes time to have dinner with one's family, to look after one's own body and mind, and to be able to predict what tomorrow will look like. A doctor who protects patients' lives must also be able to keep the dignity and stability of their own.
Just as, when something goes wrong, I have come to search my own memory before thinking of someone else's fault, I suspect that when our juniors decline to follow the path we walked, it is our side we should look at first. Before we lament their attitude, we should ask whether the life we are trying to hand down is one worth choosing.
If one day they ask, "Why did you leave things like this?", searching my memory will not be enough of an answer. Rather than telling them how much we sacrificed, I hope we can tell them what we changed so that they would not have to repeat it. There is far too much still to be fixed by our own hands to sit and lament that the line is ending, with the seat we should be handing on left empty.