Two studies presented at recent Triological Society meetings, both of which surveyed former otolaryngology residents about current otolaryngology surgical training and postgraduate practice and referrals, shed light on the direction in which the specialty’s training may need to move.
What Is Taught and What Is Practiced?
A study conducted by a University of Cincinnati team that included Christopher R. Savage, MD, Robert W. Keith, PhD, and Myles L. Pensak, MD, aimed to determine the most common otologic and neurotologic procedures performed after completion of otolaryngology residency. Savage et al.1 distributed an Internet survey to 128 alumni trained within the past 25 years and received 70 responses (54.7%). The findings revealed that a majority of former graduates performed external ear incision and drainage (abscess/hematoma), excision of soft tissue external canal lesion, ventilation tube placement, tympanoplasty/ossiculoplasty, and mastoidectomy. Twenty-two performed stapedectomies/stapedotomies. A smaller number performed more complex procedures, including excision of glomus tumors, lateral temporal bone resection, and implantation or revision of bone-anchored hearing aids.
In contrast, mostly fellowship-trained neurotologists performed more advanced procedures, including labyrinthectomy, endolymphatic sac procedure, cochlear implant, facial nerve decompression, acoustic neuroma surgery, and vestibular nerve section.
The investigators concluded that despite demographics supporting increased interest in fellowship training and subspecialty practice, most otolaryngologists continue to perform basic otologic procedures taught during residency. Complex cases, revision cases, and neurotologic procedures, however, are more likely to be performed by fellowship-trained otolaryngologists.
Dr. Pensak, the H. B. Broidy Professor and Chair of Otolaryngology-Head and Neck Surgery and Professor of Neurosurgery at the University of Cincinnati Health Sciences Center, said that residency programs generally include standard cases-such as tympanoplasty, tympanomastoidectomy, and ossiculoplasty-in core training; however, the nature and faculty of each program will dictate program variations.
For instance, at the University of Cincinnati, training has historically included endolymphatic shunt surgery, cochlear implant, and labyrinthectomy. Dr. Pensak said he was a bit surprised to discover from his study’s survey data that those procedures are now primarily being performed by fellowship-trained physicians.
That being said, we have always enthusiastically endorsed that our residency program trains people to go into the community, and we felt and continue to feel that it is vitally important that these residents are broadly trained to deal with common ear disease problems of a surgical nature.
Implications for Treatment and Referrals
Michael J. Ruckenstein, MD, MSc, also reported findings at the Triological meeting.2 Dr. Ruckenstein, Professor and Residency Director in the Department of Otorhinolaryngology-Head and Neck Surgery at the University of Pennsylvania in Philadelphia, surveyed otolaryngologists in community practice regarding their treatment of otosclerosis and the performance of stapedectomy.
Responses from 179 of the 500 general otolaryngologists surveyed, who are all treating adults and children in solo or group private practices in New Jersey and Pennsylvania, revealed that the majority (66%) diagnosed one to five new cases of otosclerosis per year. Of those surgeons, 10% graduated from residencies in the 1970s, 25% graduated in the 1980s, and 50% graduated in the 1990s. Of those who graduated in the 2000s, 90% had never performed stapedectomy as part of their practice. Similarly, a significant number of surgeons who formerly performed stapedectomies no longer do so.
Recent graduates also tended to more often prescribe the use of hearing aids to treat otosclerosis. When surgery was recommended, the surveyed practitioners reported that they referred to otologists and neurotologists.
Although this was just one study, Dr. Ruckenstein emphasized, he believes the findings speak to both specific and general issues.
Specifically, stapedectomy has historically been performed in the realm of general otolaryngologists, and each resident trains in a handful of these cases. Some residents perform a good number of stapedectomies, but that is rare; most residents do not meet this clinical criterion. Despite data showing that most referrals for stapedectomy are being made to neurotologists, there is no requirement specification in neurotology fellowship training for stapedectomy.
These neurotology fellows need to be adequately trained to do stapedectomies, points out Dr. Ruckenstein, who is a board-certified neurotologist. They are the ones de facto who are getting those referrals, he said. Whether that is what we want or not, that is what is happening.
Implications for Medical Education
Over the last five to 10 years, Dr. Pensak, President-Elect of the Triological Society, has noticed a trend in the community: residents who are joining otolaryngology practices and bringing a particular area of interest or expertise-for instance, endoscopic sinus surgery or otology. When they share those interests with a prospective employer during the interview process, they assume that role in the practice when they are hired.
They might do 30 percent or 40 percent general procedures and 50 percent to 60 percent otology, because they become known as the ‘ear guy’ or the ‘sinus person,’ Dr. Pensak said. Thus, focused areas of interest lead to the equivalence of a subspecialization.
As an illustration, over the 25 years that Dr. Pensak has been in Cincinnati, the number of stapedectomies that the residents at his institution are doing has increased every year even though the overall population of otosclerotic patients is decreasing.
When I arrived here, we had 20 or 25 otolaryngologists in the community who were doing stapedectomy surgery, and probably six or seven of them were doing revision stapedectomy surgery, he said. Now we have four or five otolaryngologists who do stapedectomy surgery and to my knowledge there are really just three of us who do revision stapedectomy surgery.
Marvin P. Fried, MD, Professor and University Chair of the Department of Otorhinolaryngology-Head and Neck Surgery at Montefiore Medical Center at Albert Einstein College of Medicine in New York, agreed that as trainees move on in their otolaryngology careers, those who are in academic or private practice become more differentiated, becoming known as nose specialists or larynx specialists, for instance.
The implications of that kind of future endeavor need to be brought in sooner rather than later, said Dr. Fried. Refine training to ultimate goals. That means that a program director has to be honest after an individual graduates; if a person expressed a particular interest in doing cosmetic surgery and was not trained in extensive otology, after that resident has completed training, the residency director has to sign off that the trainee’s otology training is less than that of others.
Dr. Pensak would like to see otolaryngology begin to scaffold or tier out to create a subspecialization during the residency program.
It has never made sense to me to have a senior or chief resident doing stapedectomies, as an example, spending six to eight months on my service to meet a board requirement and then spending the rest of their career doing facial plastic surgery, he said.
On the other hand, if otolaryngology were to reach a point of becoming a specialty of subspecialists, that would be destructive.
If we are otolaryngologists, we need to be able to perform the breadth and scope of our discipline, with the recognition that if you are not performing a sufficient number [of certain procedures], you have the wisdom to pass on that patient to someone who can best handle their problem, Dr. Pensak said.
The interviewees agreed that reviewing the epidemiology of the diseases along with the current training curriculum and the standards for stapedectomy performance, as an example, will need to be changed. Requiring a full two-year fellowship to perform stapedectomy may not be the appropriate solution, but there will need to be another way to ensure that practitioners have received adequate training.
One solution for the specific issue of stapedectomy requirements might be to train a resident particularly interested in that procedure to perform most of the stapedectomies; to be, in effect, the designated stapedectomy trainee. He or she would get the lion’s share of cases, proposed Dr. Ruckenstein.
A second option would be to create a surgical preceptorship in a localized center of excellence. An interested and qualified resident could spend one or two months at that center to accumulate adequate experience. This would obviate creating the exclusivity of neurotology fellows to perform stapedectomy.
In some large areas of the country, depending on the nature of training and core competencies, there may be very few people performing stapedectomies. But if it can be demonstrated that a resident has been given a sufficient volume of experience, then that should be acceptable. I would not like to see it fall into the realm of just fellowship-trained otologists, Dr. Pensak said.
The Broader Question
All those interviewed for this article believe that the current educational regime and qualifications for residency training will need to be modified.
But to what extent?
Dr. Ruckenstein suggested that otolaryngology as a specialty will need to consider whether an analysis of the nature of these studies should be extended to other surgical procedures in addition to stapedectomy: those procedures that are rarely done in training or can fall under a general otolaryngology umbrella or subspecialist purview. Should attention be given in fuller force to asking whether our residents are receiving adequate training to do any number of specific surgeries? Dr. Ruckenstein asked. To some extent we do that already. That’s why subspecialties exist. But once the qualifications for a subspecialty are established, they tend to be viewed as set in stone. Should we be more fluid in our analysis of what constitutes training in the subspecialties?
Changes and Mechanisms for Change
Another element that must be included in this exploration is the residency work-hours restraints.
By law, residents are not permitted to stay in the hospital over a certain amount of hours, said Dr. Fried, so even if a resident would like to perform a certain number of particular cases or a wider array of cases, that might not be possible.
There is also a movement on a federal level to constrict work hours even further.
If that comes to pass for all surgical specialties, Dr. Fried continued, the number of procedures that an individual will perform will be fewer. Yet training to proficiency is critical. If a resident can learn to do a procedure after five times, he shouldn’t be required to do it 15 times. The boards of our societies are going to need to modify what they feel are benchmark numbers that a resident is to perform. It will be more imperative than ever to train the individual as an individual.
In the near future, the American Academy of Otolaryngology-Head and Neck Surgery, the American Board of Otolaryngology, and the Accreditation Council for Graduate Medical Education (specifically the residency review will need to address how training is allocated and administered.
- Savage CR, Keith RW, Pensak ML. Evaluation of otologic and neurotologic procedures in residency trained otolaryngologists versus fellowship trained otologists/ neurotologists. Abstract presented at the Triological Society meeting, 2008.
- Ruckenstein MJ. Who is performing stapedectomy surgery? Implications for residency and fellowship training. Laryngoscope 2008; in press.
©2008 The Triological Society