Upcoming ACGME Otolaryngology Changes Put Greater Emphasis on Surgical Training

In an effort to strengthen surgical training for otolaryngology residents, the Accreditation Council for Graduate Medical Education (ACGME) graduate medical education requirements will change as of July 1, 2016. Residents in their first postgraduate year (PGY-1) will now spend six months (up from one to three months in current curricula) in otolaryngology-specific rotations; the remaining six months will focus on patient-based skill development in topics such as airway management, interdisciplinary care coordination, and peri-operative care of surgical patients.

Residents will learn these patient-based skills through rotations chosen from nine non-otolaryngology specialties, including anesthesia, general surgery, neurological surgery, neuroradiology, ophthalmology, oral-maxillofacial surgery, pediatric surgery, plastic surgery, and radiation oncology.

Otolaryngology residents will now learn their basic surgical skills primarily from otolaryngology faculty, instead of general surgery faculty, and will be overseen closely by otolaryngology faculty the entire first year, according to a summary and impact statement of the requirement revisions from the ACGME Program Requirements for Graduate Medical Education in Otolaryngology. The other years of the otolaryngology residency program will not be affected by these changes.

“We believe the new standards will provide appropriate opportunity for first-year otolaryngology residents to develop non-operative skills, will enhance their training in surgical skills specific to otolaryngology, and will allow greater flexibility in later years of resident training,” said John R. Potts, III, MD, the senior vice president for surgical accreditation for the ACGME, in a released statement. Besides shifting greater responsibility for basic surgical training to the otolaryngology program, the changes will also give residents “earlier exposure to otolaryngology, thereby increasing flexibility later in resident training,” said Dr. Potts.

These are all welcome changes, because the general consensus has been that first-year otolaryngology residents weren’t learning the fundamental surgical skills, said Randal S. Weber, MD, professor and chair of the department of head and neck surgery at The University of Texas MD Anderson Cancer Center in Houston. “When they came to otolaryngology and the head and neck service, they often didn’t have the skills needed to progress more rapidly in skill acquisition,” he said. “This change will give residents a more focused education to prepare for otolaryngology. The expectation is that, for the first-year resident, the necessary basic surgical skills will be taught to them and [will] better prepare them for the ensuing years of training.”

Education Follows Profession’s Evolution

The modifications reflect changes both in medical education and in practice, noted Dr. Weber. “We talk about the way things used to be: Many years ago in my training, we used to do two years of general surgery and three or more years of otolaryngology,” he said. “There was a lot of time spent in the operating room, where the fundamental educational experience was in general surgery, and residents learned surgical skills such as how to tie blood vessels, surgical anatomy, tissue handling, and so on.”

But, over the years, actual hands-on surgical training has been reduced, he said. “When otolaryngology residents were on the general surgery service, they were mostly on the floor doing post-operative care and not participating in the operating room learning general surgery skills,” he said. “They weren’t really learning to operate as a fundamental skill.”

The opportunities to practice open head and neck surgery aren’t as common as they used to be, due to a shift toward more non-surgical treatments of head and neck cancers and the emergence of robotic and endoscopic procedures as opposed to traditional open surgical approaches, said Dr. Weber. “Furthermore, many of our procedures today are salvage surgery, for patients who have failed primary treatments. These are some of our most challenging cases and require a greater level of surgical expertise and judgment. The treatment paradigms have changed in the last five to 10 years, he said.

Jesus Medina, MD, a professor of otolaryngology at the University of Oklahoma Health Sciences Center in Oklahoma City, a former chair of the otolaryngology department, and a former Triological Society president, also cited the changes in surgical practice as the impetus for the curriculum changes.

“General surgery has evolved in a way that it no longer provides our junior residents sufficient exposure to traditional basic skills such as suturing and tying,” he said. “The continuing development of endoscopic techniques has practically eliminated the core open procedures like large abdominal incisions and limb vascular procedures, appendectomies, and hernia repairs. They’re now done using scopes and small incisions.”

Performing fewer of these open procedures leads to fewer teaching opportunities for post-operative care, said Dr. Medina. “For instance, when a junior resident assisted in an operation requiring a large incision, it was usually [the resident] who was most junior who was allowed to close that, which was a great opportunity to practice suturing techniques. Nowadays, they seldom do that anymore.”

And, finally, the nature of the surgical care of trauma patients has evolved away from surgical interventions and toward more conservative medical care, Dr. Medina added. “Years ago, in some cases we would do an exploratory open operation, but today, more patients are evaluated with more sophisticated imaging techniques and aren’t operated on as often.” As a result, there’s been a decrease in the opportunity to develop and use traditional surgical skills, he said, particularly as compared with five to 10 years ago.

Potential Challenges

While those interviewed believe the new curricula will be implemented smoothly, there may be some administrative adjustments, such as having fewer otolaryngology residents available for non-otolaryngology rotations. “The program directors in some programs will need to revise the rotations to which they have assigned (otolaryngology) PGY-1 residents in the past,” said Dr. Potts.

Sukgi Choi, MD, chair of ACGME’s Otolaryngology Residency Review Committee (RRC), as well as the chief of pediatric otolaryngology at Children’s Hospital of Pittsburgh and otolaryngology professor at the University of Pittsburgh School of Medicine, agreed. “When we pull residents out of other specialties, this impacts other services’ manpower,” she said. “If you have five residents who all take three months in ENT, the other services are losing 15 months of residents.”

But the benefits of the new curriculum will outweigh the administrative changes necessary, said Dr. Potts. “With the availability of more relevant and non-ENT rotations, the Review Committee believes that the curriculum changes will be viewed as an opportunity.”

Dr. Medina noted that higher level physicians would be affected, too. “The level of supervision needed for PGY-1 residents will be different than for residents in other years,” he said. “They must have direct immediate supervision available. If they are on call, unlike higher level residents, there must be a faculty person, a senior resident, or both available in house, while previously, neither of this level of physician had to be on call, in the hospital, at the same time senior levels are on call.”

The new curriculum calls for a shorter amount of time (four weeks to two months) available to fulfill all nine non-otolaryngology specialties within six months of rotation time. “The real challenge will be how to fit nine very desirable rotations into a six-month period—you can’t,” said Dr. Medina. “Someday, hopefully in the very near future, the powers that be might entertain the possibility of fourth-year medical students who are already matched, to use their last quarter of the fourth year to do a month-long sub-internship in areas such as anesthesia, intensive care, plastics, neurosurgery, and so on, so that they will have that under their belt, and then they can go do another six rotations during PGY-1.”

Ultimately, though, the changes are expected to help strengthen the education for residents, ensuring that training in otolaryngology is both relevant and rewarding. “What we hope to see is that residents in our specialty will be better prepared in their first year to get more benefit out of their subsequent years, with more of an acquisition of skills and knowledge and a focus on our field, rather than on things that won’t be as useful for them to do,” said Dr. Weber.

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Cheryl Alkon is a freelance medical writer based in Massachusetts.