SAN DIEGO-How can head and neck surgeons best meet the changing needs of patients and trainees in the 21st century? Where do they start, and will they be able to overcome tradition-induced inertia and natural objections to change?
These were among the issues addressed by Jesus E. Medina, MD, Chair of the Department of Otolaryngology at Oklahoma University Health Sciences Center (OUHSC), in the annual American Head and Neck Society’s Hayes Martin Lecture presented April 29 at the Combined Otolaryngology Spring Meetings. At the end of his presentation, Dr. Medina received a standing ovation for his comprehensive, thoughtful remarks and suggestions.
He began with a look at recent trends found in World Health Organization (WHO) databases covering 54 countries on five continents. He noted a decreasing trend in the incidence of cancer of the larynx in males and females and a similar statistically significant trend in the combined incidence of oral and oropharyngeal cancer. On the other hand, thyroid cancer is on the rise in males but decreasing in females. There has been a significant decrease in the incidence of melanoma in females, but an increase in males.
Based on these observations and on the recent downward trends in the global use of tobacco, he said, it is reasonable to anticipate that the future will bring fewer patients with squamous cell cancers of the upper aerodigestive tract and more patients with thyroid cancer and melanoma.
In addition to studying the WHO statistics, his colleagues in the Department of Statistics and Epidemiology at OUHSC analyzed data from the National Cancer Database, where they determined there is an increasing trend in the number of head and neck operations, which seem to be driven by a steep increase in the number of thyroidectomies.
Meanwhile, reports from the American Board of Otolaryngology and the American Head and Neck Society pointed to a slight upward trend in procedures performed by fellows and residents, although there is possibly the beginning of a downward trend (regarding residents) in the last two years, which merits keeping an eye on, Dr. Medina said.
Another important point to consider, Dr. Medina said, is the recommendations from multiple recent studies that quality cancer care ought to be provided in facilities by highly experienced surgeons with with large volumes of patients. With predictions that the head and neck surgeon workforce is decreasing, Dr. Medina said it is not unreasonable to anticipate that the surgical care of head cancer patients will increasingly be provided by fewer head and neck surgeons, mostly in centers recognized for their ability to provide excellent care.
Changing Patient Attitudes
Also important in shaping the future is to anticipate the changing attitudes and behaviors of patients, according to Dr. Medina. Noting patient access to health care information on the Internet, he said that patients armed with this wealth of information will undoubtedly have specific expectations for the latest and most effective care.
Perhaps the most important aspect of relating to patients in the future is to recognize that, in spite of the ever increasing and more sophisticated technological advances in medicine and in surgery, patients will always need, first and foremost, a trustworthy relationship with their physicians, Dr. Medina said. Technological advances, albeit enormously beneficial, bring with them the real danger of creating distance and uncertainty between our patients and us.
Meeting Trainees’ Needs, Expectations
With this background, Dr. Medina turned to the third aspect of creating the future-how to meet the needs and expectations of trainees. Never before have so many internal and external factors converged on the horizon that have the potential to influence the training of future head and neck surgeons, he said.
He shared 10 of these factors with audience members:
A declining applicant pool. Dr. Medina agreed with Dr. Jatin Shah that the profession should conduct a focused workforce study, advocate better reimbursement, increase exposure of medical students and surgical residents to the specialty, and develop international standards for training in head and neck surgery.
The restriction in resident work hours. Dr. Medina said restrictions are here to stay but need to be refined or the profession risks producing generations of surgeons with a unionized mentality and a sense of duty that ends with the punching of a clock.
Generational differences. Noting that today’s surgeons are more insistent on having a balanced lifestyle, he said, We should prepare to deal with a new set of career and social expectations, especially as it applies to women …. We must create the training and working conditions that members of the new generations require.
Medical economics. Through national organizations, head and neck surgeons should continue to advocate better reimbursement, he said.
The structure of training is no longer practical. With the expansion of knowledge, it will be impossible for an individual, training for a reasonable time, to master everything from otology, rhinology, allergy, and pediatric otolaryngology to laryngology, facial plastic surgery, and head and neck surgery, Dr. Medina said. He suggested a shorter training period that maximizes education and training in a specific area of practice.
Competency-based surgical education. Noting that the long-established experience-based model of surgical education is shifting to a proficiency-based model, Dr. Medina said training in the future is likely to be based on the achievement of benchmarks of knowledge and skill.
A declining emphasis on the importance of surgical skills. He called for the Accreditation Council for Graduate Medical Education to adopt a new competency for residents-a skill and judgment competency covering the skill to perform procedures and judgment to assess situations or circumstances and draw sound conclusions.
A decrease in the number of cases of cancer of the upper aerodigestive tract available for training. The problem, Dr. Medina said, is that invaluable cases are being diluted by teaching residents who in the end will never do these operations in their practice.
It will become increasingly more difficult to teach surgical skills by practicing on patients. This creates a growing need for training opportunities outside the operating room using simulators, artificial body parts, and animal models, he said.
Research experience in residency and fellowship. Calling most of this experience unstructured with a poorly defined and often misguided purpose, Dr. Medina said future training program requirements should be clear about the purpose of the research experience and should expose trainees to the discipline of research so that they gain a working understanding of research methodology.
How we effectively incorporate these 10 factors in shaping the future of training of head and neck surgeons is obviously complex and multifactorial, Dr. Medina noted. What is clear, however, is that head and neck surgery should not act in a vacuum. We must act in tandem with the underpinning disciplines: otolaryngology and general surgery. It is also clear that the time to do so is now or we will soon wake up in a world that no longer exists.
Recommendations for Training
Finally, Dr. Medina suggested that the training of future head and neck surgeons might involve a four-pronged process:
- Require fourth-year medical students interested in surgery to take basic rotations that currently take place in the first year of residency.
- Change residency to an initial two-year period of core training in either otolaryngology or general surgery, followed by the trainee’s choice to pursue two additional years of training in general otolaryngology or general surgery.
- Alternately, after the initial two years, a trainee interested in head and neck surgery could pursue additional training for three years and then attain certification.
- An optional phase of training would allow the pursuit of an academic career with additional training in clinical research (1 to 2 years) or basic science research (3+ years) with an option of obtaining an MS or PhD.
Noting that it would be naïve to think that these changes would occur overnight, Dr. Medina said that head and neck specialists and educational institutions must begin somewhere. He urged audience members to take action soon in redefining the scope of knowledge and skills of a modern-day head and neck surgeon, noting that this should lead to the development of a comprehensive curriculum for training that is periodically updated and includes topics in pertinent basic sciences as well as fundamental knowledge of radiation biology and therapy and of medical oncology.
Which Children Will Require Endoscopic Surgery Following Adenoidectomy?
Indications for surgery for chronic rhinosinusitis (CRS) in children lack consensus, and no scientific guidelines are available. Most experts agree that adenoidectomy should be considered for children with CRS who do not respond to medical management, as adenoidectomy improves major symptoms in about three-quarters of all patients. Jeremy Tiu, MD, and Hassan H. Ramadan, MD, MSc, performed a study to determine which children who are treated with adenoidectomy for CRS will ultimately require endoscopic sinus surgery (ESS) and to estimate the length of time between adenoidectomy and ESS.
The researchers employed a retrospective chart review of prospectively collected data in a tertiary pediatric otolaryngology service, looking at children who underwent adenoidectomy for CRS over a 10-year period after failing medical management.
Half the children failed the procedure and required ESS, according to this review. The mean time from adenoidectomy to ESS was 23.7 months; children with asthma had a mean failure time of 19 months, compared with a mean failure time of 28 months for children without asthma. Furthermore, children who failed within 24 months had a mean age of 6 years, compared with a mean age of 8 years for children who failed after 24 months.
The authors point out that the relationship between adenoid hypertrophy and sinusitis is unclear; however, if the adenoids were large and there was stasis of secretions, symptoms of sinusitis could be mimicked. These secretions could also cause inflammation of the sinuses with blockage of the ostia, causing sinusitis. The consensus is that an adenoidectomy should be the first surgical procedure performed on children with CRS, and that this will be effective in about half of all patients. A significant number of the remaining 50% of children will require ESS. Results of this study indicate that this will occur at an average of 24 months after adenoidectomy with children who have asthma and are less than 7 years of age; children who are older than 7 years or who do not have asthma will have a longer period before requiring ESS.
©2007 The Triological Society