Mind the Gap: A Nationwide Analysis of Case Distribution, Resident Exposure and Institutional Variation in German...

Background: Pediatric surgical care in Germany is delivered within a highly decentralized system, and training structures vary considerably between institutions. Adequate operative exposure is essential for competency-based training. The specialty requires a high number of operative procedures during training, yet concerns have been raised that residents may not achieve the required case numbers within the standard training period. The German Model Training Regulations (Musterweiterbildungsordnung, MWBO) define 22 procedural categories with specific case number targets for pediatric surgery. However, the extent to which current training structures allow for the fulfillment of these requirements remains unclear. This study examines the distribution of procedures and residents across different hospital types and estimates whether the available procedural volume may be sufficient under simplified allocation assumptions. Methods: We conducted a nationwide analysis of pediatric surgical training capacity in Germany using procedural data from hospital quality reports published by the Federal Joint Committee (Gemeinsamer Bundesausschuss, G-BA) between 2012 and 2023. A total of 3440 OPS codes were assigned to 22 training categories, and case volumes were analyzed across different hospital types. The estimated training capacity was calculated assuming even distribution of cases among residents, and that all eligible procedures are performed with full resident access. Results: Data from an average of 82.3 pediatric surgical departments per year were analyzed, including 29.7% university hospitals, 58.7% non-university departments, and 11.7% other institutions. Most departments reported fewer than five residents. Between 2012 and 2023, the mean number of residents increased slightly across all hospital types, while inpatient numbers declined. Consequently, inpatient exposure decreased from 469.8 to 354.0 cases per resident per year. Patient exposure differed significantly by institutional category (p < 0.001), with higher exposure in non-university departments compared with university hospitals. Across all hospital types, the mean number of fulfilled procedural training categories declined over time. No institution met the target numbers for all categories without cooperation with other units. Thoracic surgery procedures were least frequently covered, whereas appendectomies and inguinal hernia repairs were most consistently fulfilled. Distinct patterns of subspecialization emerged, with trauma procedures less frequently reported at university hospitals and thoracic procedures less frequently reported at non-university departments. Although the overall national procedural volume appears sufficient for most training requirements, low-volume and highly specialized procedures were concentrated at selected centers, limiting their accessibility for trainees. Conclusions: Even though there are sufficient pediatric surgical procedures in Germany, they are unevenly distributed between hospitals. Under a simplified allocation model, many pediatric surgical departments in Germany currently lack sufficient procedural volume to meet training requirements in the defined training timeframe for all trainees. Structural reforms-including mandatory national documentation, minor MWBO adjustments and the creation of training networks-are necessary to ensure comprehensive and equitable pediatric surgical education. Without these changes, extended training durations and reduced trainee satisfaction may contribute to workforce shortages and limit the future quality of pediatric surgical care in Germany.