New data has given doctors and patients more to think about. The MSLT-II (Multicenter Selective Lymphadenectomy Trial II) assessed whether completion lymph node dissection gave a benefit compared to post-operative diligent ultrasound monitoring of the draining nodal basins in patients with a positive sentinel lymph node (N Engl J Med. 2017;376:2211-2222). Data from approximately 2,000 patients found no difference in three-year melanoma-specific survival between patients who were dissected and those who were only observed. But researchers also found that the rate of disease-free survival was higher in the dissection group, and that the cumulative incidence of non-sentinel nodal metastases was higher in the observation group.
Explore This IssueMarch 2018
“Somewhere between 10% and 20% of patients will have a positive non-sentinel node,” Dr. Bradford said. “We know that most of those patients ultimately will relapse in the nodal basin…. The question is, do you take that node out early or do you watch and wait and take it out later?”
Howard Francis, MD, MBA, chief of head and neck surgery and communication sciences at Duke University in Durham, N.C., said that otolaryngology programs might want to reassess how they evaluate residency applicants, considering the decline in application numbers and evidence that the admission process might overemphasize cognitive ability at the expense of other important traits.
Dr. Francis said the process tends to be skewed toward good test-takers and those with higher socioeconomic backgrounds, leading to a perception of elitism, a less diverse medical specialty, and an even further decline in applications to otolaryngology residency programs due to medical students’ fear that they have little chance of acceptance. “As a specialty, we must be proactive in preserving our relevance in a health system that would increasingly value our contributions to the health of an increasingly diverse population,” he said. “The selection process should reflect the kind of resident we’re trying to attract.”
Traditional factors in choosing residents don’t always translate into quality residents, he said. Dr. Francis shared published data showing that once med school graduates hit USMLE scores of 200 to 220, there’s a high likelihood they’ll pass the boards. (Otolaryngol Head Neck Surg. 2017;156:985-990).
Upgrades to the selection process, such as structured behavior-based interviewing and interpersonal simulations, combined with less emphasis on test scores in initial application screening, could help reverse declines in number of applications and attract more students with important characteristics such as integrity and the ability to work in a team, Dr. Francis said. “What we should look at is broadening our selection criteria beyond purely academics,” he said. “I think that our U.S. medical graduates are generally very well-prepared and that we should make it clear to medical students and vice deans of education that our field is interested in selecting candidates based on a more holistic evaluation of cognitive and affective domains.”