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February 2012MIAMI BEACH — Four pairs of experts squared off here on Jan. 26 at the Triological Society Combined Sections Meeting in a session of mini-debates over limits on training of residents, treatment of Zenker’s diverticulum, implantable hearing aids and the best approach to oropharyngeal cancer.
In the process, presenters offered important analyses of key subjects, often while finding some middle ground.
Work-Hour Limits
Bradley Marple, MD, professor and vice chair of otolaryngology-head and neck surgery at the University of Texas Southwestern Medical Center in Dallas, argued in favor of the changing paradigms in resident duty hours. He acknowledged that the limits seem to have had no effect on medical errors made. But the data regarding their effects on other areas, including surgical experience and exam scores, have been mixed.
“It’s hard to be completely pro in the argument about the duty hours, but one thing that we do have to acknowledge is that the duty hours are here,” he said. “They’re not driven by us, they’re driven by public perception. And they’re here to stay.”
He said that “one size doesn’t fit all,” that the standards should be matched with residents’ experience levels and that the ultimate goal should be to get residents ready to practice medicine outside the confines of the learning environment.
Paul Levine, MD, chair of otolaryngology-head and neck surgery at the University of Virginia Health System in Charlottesville, pointed out that handoffs play a bigger role in medical errors than fatigue. While “everybody has to accept” that there’s a point of fatigue when people don’t perform well, Dr. Levine said that the duty hour limits lead to fragmentation of care, missed educational opportunities and a shift of resident work to different personnel, among other problems.
He said working according to strict hour limits is not a mirror of reality in the medical world. It’s important, he said, to “instill in our residents that occasional self-sacrifice is, and has always been, a fundamental principle of being a physician.”
Open vs. Endoscopic Surgery
Albert Merati, MD, professor and chief of the laryngology service at the University of Washington in Seattle, argued for open procedures in cases of Zenker’s diverticulum, saying it puts patients in the best position for complete symptom relief after just one procedure.
In a 2002 study of 197 patients, open surgery was compared to endoscopic procedures, with the percentage of totally asymptomatic patients significantly higher after open procedures than after those treated endoscopically, no matter the size of the pouch (Ann Thorac Surg. 74:1677-1683). Eighty-five percent of patients with pouches smaller than 3 cm were asymptomatic when treated with open surgery, compared to 25 percent undergoing endoscopic treatment. For patients with pouches of 3 cm or greater, the numbers were 86 percent compared to 50 percent. Other studies have found similarly favorable results for open procedures.