Deficiencies of cross-training between pediatrics and otolaryngology: a survey of specialists in Canada

OBJECTIVE: Conditions relating to the ear, nose and throat are very frequent problems encountered by general pediatricians. Similarly, a major percentage of patients seen and operated on by the general otolaryngologist are of the pediatric age group. The pilot study demonstrated that pediatric program directors of both specialties in Canada have identified a deficiency of cross-training and desire the need for more cross-training. The aim of this study was to survey practicing physicians of both specialties for their input. METHODS: Surveys were sent to a large cross-section of pediatricians and otolaryngologists in Canada. They were asked to complete a questionnaire relating to their training experience, their desired training, important topics and general comments. Demographic data were collected including generalist versus sub-specialist, the year that residency was completed and country of training. Results were tabulated and analyzed. RESULTS: The response rate was high, being 70.6% and 76.2% for pediatricians and otolaryngologists, respectively. One hundred percent of pediatricians indicated that formal training by otolaryngologists was necessary, while 95% of otolaryngologists indicate a need for formal training by pediatricians during residency. Pediatricians desire more training using all three educational venues, namely lectures, clinics and rotations. While they are receiving lectures more often, they indicate that clinics are the most important mode of education. Otolaryngologists desire more formal training by pediatricians in the areas of lectures and clinics. They indicate the most important mode of education is lectures. There was no significant difference between generalists and sub-specialists or based on country of training for either group. There is some indication, in both specialties, of an increase of cross-training occurring within the past five years. CONCLUSIONS: This study has shown that there is a perceived deficiency of cross-training between the two specialties. Both pediatricians and otolaryngologists have indicated that they need more formal cross-training. This is a very important area to address, as this study relates directly to the optimum health of children in Canada and worldwide.     

National assessment of business-of-medicine training and its implications for the development of a business-of-medicine curriculum

OBJECTIVES/HYPOTHESIS: The objectives were, first, to determine the current state of business training in otolaryngology residency programs in the United States and, second, to lay the groundwork for development of a business-of-medicine (BOM) curriculum. STUDY DESIGN: Cross-sectional survey. METHODS: A survey concerning methodology and topics for management training of residents was mailed to the chairpersons or program directors of the 102 otolaryngology residency programs. A similar survey was sent to 576 otolaryngology graduates (classes of 2000, 2001, and 2002). An interactive BOM curriculum on CD-ROM was developed based on the results. RESULTS: The response rate among program directors was 74.5% (76 of 102), and among the otolaryngology graduates, 38.2% (220 of 575). Seventy-five percent of graduates rated their BOM training as poor or fair. Only 8% rated their BOM training as excellent. Twenty percent of the graduates responded to having a BOM course during residency. Recent graduates reported that a BOM course can best be taught through lectures and apprenticeship/mentoring, whereas program directors reported that a BOM course can best be taught through lectures and outside consultants. Graduates reported that coding compliance was the topic most neglected in residency, whereas program directors reported that coding compliance was the main topic covered in the business training. Both groups agreed that department attending physicians have the most impact on a resident's business training. Program directors reported that correct coding, planning one's entry into medical practice, risk management, and reimbursement issues are the most important topics for residents to learn, whereas recent graduates stated that the most important topics should be correct coding, office management, risk management, and reimbursement. CONCLUSION: The present study reflects a perceived necessity for improvement of BOM training in otolaryngology residency programs. Based on this finding, the outcome measures from the survey, and the authors' own experience from business courses given in the first author's department, a BOM curriculum was developed that is general enough to target all otolaryngology residents and intended to provide business skills which result in improved use of resources and, ultimately, higher quality of care.     

The residency experience in pediatric otolaryngology

OBJECTIVES: To assess the residency experience in pediatric otolaryngology, determine the impact of pediatric fellowship programs on residency training, and evaluate the need for fellowship training in pediatric otolaryngology. DESIGN: An anonymous, web-based survey of chief residents in otolaryngology. METHODS: Respondents described their experience in pediatric otolaryngology using a 5-point Likert scale and reported their comfort levels (yes/no) with various medical and surgical issues in pediatric otolaryngology. RESULTS: The survey was successfully completed by 70 respondents, representing a response rate of 26%. The majority of the respondents reported positive experiences with regard to the following aspects of pediatric otolaryngology training: didactics (81%), clinical research opportunities (78%), positive faculty role models (87%), career mentorship (74%), independent medical (84%) and surgical (81%) decision-making, and overall comprehensive residency experience (87%). Basic science research opportunities (50%) were reported as less available than clinical research opportunities (78%) (P = .002). Compared with other surveyed issues, a lower comfort level was reported for management of craniofacial anomalies (P < .001), excision of large lymphatic malformations (P < .001), cochlear implantation (P < .001), laryngotracheal reconstruction (P < .001), and surgical correction of velopharyngeal insufficiency (P < .001). No statistically significant difference was noted in responses based on the presence of a fellowship program at the institution. CONCLUSIONS: The residency experience in pediatric otolaryngology is perceived as comprehensive by graduating chief residents participating in this survey. The presence of a fellowship program does not appear to negatively impact the residency experience. Based on the reported comfort levels, the management of complex issues in pediatric otolaryngology may require additional training.     

Impact of duty hour limits on resident training in otolaryngology

HYPOTHESIS: Implementation of Accreditation Council for Graduate Medical Education (ACGME) duty hour standards has had limited effects on resident training in otolaryngology. STUDY DESIGN: Retrospective survey of residents and residency program directors (PDs). METHODS: Surveys were mailed to residents and PDs in otolaryngology asking about compliance with ACGME duty hour standards and perceptions of changes brought on by the new regulations. RESULTS:: Surveys were returned by 53.5% of PDs and 29.9% of residents. A majority of PDs described changes made to achieve compliance as "minor;" this consisted most commonly of altering call structure, although some programs hired new support staff or faculty. Mean estimated costs for changes were $14,211. Residents reported working a mean of 67.5 hours per week. Among PDs and residents, only 60% to 70% reported always being in compliance with the main components of the duty hour standards. Residents were largely divided in their opinions as to whether the duty hour limits had led to improvements in patient care, resident education, fatigue, or errors, although most felt that improvement in resident morale had occurred. PDs were more negative because almost half disagreed that improvement had occurred in any of these areas. CONCLUSIONS: Compliance with ACGME duty hour standards remains challenging in otolaryngology. Neither residents nor PDs agree that implementation of the duty hour standards has led to the intended improvements in patient care or resident education, although most agree that resident morale has improved. Further study of objective patient care and educational outcome measures is indicated to validate the need for this change in residency training.     

Program directors' opinions about surgical competency in otolaryngology residents

OBJECTIVES: The purpose of this study was to determine whether certain surgical procedures could be used as benchmark skills to monitor resident progress in developing surgical competency. STUDY DESIGN: Survey. METHODS: A two-stage survey was sent to otolaryngology residency program directors in the United States. Respondents were given a list of otolaryngology surgical procedures monitored by the American Board of Otolaryngology (ABO) and were asked to indicate whether they felt residents should be able to do each as a primary surgeon. The appropriate level of training for competency in each procedure and estimated number of procedures to competency was indicated by respondents. RESULTS: Respondents selected 16 common procedures they felt residents at different levels of training should be able to perform independently. There were discrepancies between estimated number of procedures needed for competence and the numbers reported by ABO graduates. CONCLUSIONS: Surgical skill is one aspect of clinical competency, and this indicates agreement among program directors with regard to a set of benchmark skills we can use for concentrated evaluation efforts.     

Impact of duty hour restrictions on otolaryngology training: divergent resident and faculty perspectives

OBJECTIVES: In 2003, the Accreditation Council for Graduate Medical Education (ACGME) passed a controversial mandate limiting resident work hours. We sought to examine the impact of these restrictions on otolaryngology programs and to explore faculty and resident perspectives. METHODS: Faculty and residents of all 102 ACGME-accredited otolaryngology residency programs were invited to participate in an anonymous online survey. RESULTS: The study population consisted of 460 respondents: 275 residents and 185 faculty (including 41 program directors) representing 57 otolaryngology programs. Sixty-five percent of programs implemented at least one change specifically to comply with duty-hour restrictions. Strategies included tracking work hours electronically (35.7%), utilization of "home call" (33.1%), and hiring additional healthcare professionals (23.1%). When asked if the restrictions have had a negative effect on patient care, 61% of respondents said no, but a surprising 33% said yes. Sixty-nine percent of faculty felt that the restrictions have actually had a negative effect on resident training compared with only 31% of residents (P<.001). Thirty-nine percent of participants felt resident workload was excessive before the restrictions. Opinions on whether duty-hour limits had fostered improvements in resident education, research, or examination scores varied, but most agreed that resident mental health had improved (67%). CONCLUSIONS: Otolaryngology programs have successfully restricted resident duty hours through significant infrastructural changes. Of concern, the majority of residents surveyed appeared to be in favor of the ACGME restrictions, whereas most program directors and faculty were opposed. Further studies are needed to establish whether limited work hours will enhance or hinder the residency training experience.     

Who is performing percutaneous tracheotomies? Practice patterns of surgeons in the USA

Tracheotomy is one of the most common surgical procedures performed in the ICU setting. Traditionally tracheotomy has been performed by otolaryngologists as well as general surgeons. While percutaneous tracheotomy (PT) has been available for some time, it has only recently gained widespread acceptance with the advent of convenient and safe kits. Over the past decade, there has been increased utilization of this technique. However, there is a relative reluctance of certain surgical specialties to perform and train residents in PT; a previous study identified that only 29% of otolaryngology head and neck surgery (OTO-HNS) departments in the USA perform PT. In this study we aim to investigate the trends of PT usage in general surgery training programs and compare them to those previously described in otolaryngology programs. The study design is multi-institution physician survey and the study method was a survey of 250 general surgery program directors. This survey was identical to a published survey of OTO-HNS and a head-to-head comparison of results was performed. The response rate was 53% (133 programs). 89% of general surgery programs performed open tracheotomy on a regular basis. 75% performed percutaneous tracheotomy on a regular basis. 79% use the Ciaglia Blue Rhino method. Simultaneous video bronchoscopy was used by 67%. 83% of general surgery residency programs train their residents in PT. 61% felt that PT was either safer than or equal to open tracheotomy. PT is performed in a majority of general surgery residency programs and taught to their trainees. This is in contrast to otolaryngology residency programs, which have been shown to prefer open tracheotomies in both practice and teaching. This trend may severely impact the skills of the next generation of otolaryngologists.     

Recognizing odontogenic sinusitis: A national survey of otolaryngology chief residents

PurposeOdontogenic sinusitis is underrepresented in sinusitis literature as well as in the otolaryngology teaching curriculum sponsored by the American Academy of Otolaryngology-Head and Neck Surgery. Otolaryngologists and residents in training may therefore have a decreased awareness of the condition. The objective of this study was to survey otolaryngology chief residents toward the ends of their training to determine how often they considered odontogenic sinusitis as a cause of unilateral sinus disease.Materials and methodsAn online REDCap survey was conducted from December 2018 to January 2019. Online surveys were emailed to 119 Otolaryngology residency program directors in the United States of America, which were then forwarded to their chief residents. Surveys included 3 demographic and 4 clinical questions. Clinical questions included 3 computed tomography-based questions requiring either differential diagnoses or most likely diagnosis, and 1 question on residents' perceived prevalence of odontogenic sinusitis as a cause of unilateral sinus opacification. Answer choices were tabulated and compared based on geographic region and post-residency career plans.ResultsOf 293 chief residents emailed, 94 completed the survey (32.1%). While answer choices on imaging-based questions varied, odontogenic sinusitis was generally underrecognized. Approximately 70% of residents felt odontogenic sinusitis represented 0%–40% of unilateral sinus opacification. There were no statistically significant differences in answers based on geographic distribution or post-residency career plans.ConclusionsOtolaryngology chief residents recognized odontogenic sinusitis with variable accuracy on imaging, and generally underestimated its prevalence as a cause of unilateral sinus opacification. Efforts should be made to teach otolaryngology residents about odontogenic sinusitis.     

Teaching emergency airway management using medical simulation: a pilot program

OBJECTIVE: Simulation is a tool that has been used successfully in many high performance fields to permit training in rare and hazardous events. Our goal was to develop and evaluate a program to teach airway crisis management to otolaryngology trainees using medical simulation. METHODS: A full-day curriculum in the management of airway emergencies was developed. The program consists of three airway emergency scenarios, developed in collaboration between attending otolaryngologists and faculty from the Center for Medical Simulation. Following each scenario, the participants are led in a structured, video-assisted debriefing by a trained debriefer. Didactic material on team leadership and crisis management is built into the debriefings. Pediatric otolaryngology fellows, residents, and medical students have participated in the four courses that have been held to date. Participants evaluated the program on a five-point Likert scale. RESULTS: A total of 17 trainees participated in four pilot training courses. The survey data are as follows: overall program, 5.0 (SD, 0.00); course goals, 4.79 (SD, 0.43); realism, 4.36 (SD, 0.63); value of lecture, 4.71 (SD, 0.47); and quality of debriefings, 4.92 (SD, 0.28). Sample comments include: "This is a valuable tool for students and residents since true emergencies in ORL are often life-threatening and infrequent," and "This is a great course-really all physicians should experience it." Overall evaluation was extremely positive and both residents and fellows described the course as filling an important void in their education. CONCLUSION: Medical simulation can be an extremely effective method for teaching airway crisis management and teamwork skills to otolaryngology trainees at all levels.     

Practice of pediatric otolaryngology: results of the future of pediatric education II project

OBJECTIVES: To define the practice of pediatric otolaryngology compared with general otolaryngology and to estimate pediatric otolaryngology workforce utilization and needs. METHODS: Survey of members of the American Academy of Pediatrics Section on Otolaryngology and Bronchoesophagology and the American Society of Pediatric Otolaryngology and of a random sample of the membership of the American Academy of Otolaryngology-Head and Neck Surgery. RESULTS: Pediatric otolaryngologists were more likely to practice in urban and/or academic settings than were general otolaryngologists. Children (age <18 years) comprised over 88% of the patients of pediatric otolaryngologists and 30% to 35% of the patients of general otolaryngologists. Pediatric otolaryngologists were more likely to see children with complicated diseases such as airway disorders or congenital anomalies than were general otolaryngologists. Pediatric otolaryngologists, unlike general otolaryngologists, reported an increasing volume of pediatric referrals, as well as increased complexity in the patients referred. The surveyed physicians estimated the present number of pediatric otolaryngologists in their communities as approximately 0.2 to 0.3 per 100 000 people. CONCLUSIONS: Most children receiving otolaryngologic care in the United States receive such care from general otolaryngologists. The patient profile and practice setting of the subspecialty of pediatric otolaryngology differ from those of general otolaryngology. The demand for pediatric otolaryngologists appears to be increasing, but many general otolaryngologists do not believe there is an increased need.     

The otolaryngology research paradox

OBJECTIVE: To determine the attitude toward and the state of research within the field of otolaryngology-head and neck surgery. DESIGN: A questionnaire was sent to the chairpersons of departments of otolaryngology where residency training is provided. PARTICIPANTS AND SETTING: Program directors of academic otolaryngology training programs. MAIN OUTCOME MEASURE: Responses to questionnaire. RESULTS: Questionnaires were sent to 95 programs from which 86 responses were received. Respondents believed strongly that research was important to the specialty. Only two thirds of the full-time clinical faculty, however, do research, and on average they devote only 17% of their time to this activity. About a third of those doing research have funding, and the National Institutes of Health support only 12% of clinician-investigators. Although program directors believe that clinicians should do research, three fourths stated that clinicians were too busy to accomplish this goal. Surprisingly, half of the respondents were unaware of residency programs that offered 2 years of research training, aimed to develop clinician-investigators, who can become competitive for attainment of research funding. CONCLUSIONS: Although leaders within our specialty believe that research is important, clinicians are not provided with enough time to conduct research. Furthermore, pathways that would enhance their competitiveness to obtain research funding are not recommended to our future clinicians.     

Otolaryngology resident experience with supraclavicular,submental and other regional flaps in the United States

Objective

Despite the resurgence in regional flap use, otolaryngology resident regional flap experience has been incompletely studied. We sought to characterize United States (US) otolaryngology resident exposure to, and perceptions of, supraclavicular flaps (SCFs), submental flaps (SMFs), and other regional flaps.

Professional diversity and personal commitments of pediatric otolaryngologists

OBJECTIVE: To characterize the time demands and practice patterns of pediatric otolaryngologists. DESIGN: Prospective survey of members from the American Society of Pediatric Otolaryngology. RESULTS: The survey response rate was 54% (n = 136) of practicing members of the American Society of Pediatric Otolaryngology. Respondents described being actively engaged in clinical otolaryngology (99%), hospital or practice administration (71%), private enterprise (17%), research (71%), and teaching (89%) on a weekly basis. Sixty percent considered their time demands to be "too busy"; however, few anticipated changing their activities in 5 years. Among the responding physicians, 90% believed that nonotolaryngology peers within their institutions viewed pediatric otolaryngology favorably whereas only 50% thought that other otolaryngologists held the same opinion. CONCLUSIONS: Pediatric otolaryngologists participate in many activities beyond clinical medicine. While most considered their time demands to be too busy, few anticipated a change in their activities. This may be reflective of a high level of job satisfaction, financial constraints, or the relative youth of the subspecialty.     

Who Is Performing Stapedectomy Surgery? Implications for Residency and Fellowship Training

Objectives: To demonstrate that 1) recent graduates of training programs in otorhinolaryngology–head and neck surgery are less likely to recommend/perform stapedectomy than more senior otolaryngologists; and 2) when surgery is recommended, referral is most commonly made to an otologist/neurotologist. Study Design: Survey of 500 regional otolaryngologists pertaining to their treatment of patients with hearing loss secondary to otosclerosis. Methods: Otolaryngologists in community practice were provided with written surveys pertaining to their treatment of otosclerosis. Results: Data were obtained from 179 general otolaryngologists treating adults and children in solo or group private practices in our geographic region. The majority (66%) diagnosed one to five new cases per year. Ten percent of surgeons graduating in the 1970s, 25% graduating in the 1980s, 50% graduating in the 1990s, and 90% of graduates in the 2000s never performed stapedectomy as part of their practices (P < .001). Similarly, a significant number of surgeons who formerly performed stapedectomies no longer do this surgery. A trend toward greater use of hearing aids for the treatment of otosclerosis was seen in more recent graduates (P < .08). When surgery was recommended, otologists/neurotologists received the majority of referrals (75%) from the practitioners surveyed. Conclusions: Stapedectomy is performed and recommended less often by more recent graduates of otolaryngology training programs. Training requirements for both general otolaryngologists and neurotologists may need modification given current practice patterns for stapes surgery.     

Adolescent otolaryngology

OBJECTIVE: To determine the pattern of disease amongst ambulatory adolescents referred to a pediatric otolaryngology outpatient department. METHODS: Retrospective chart review of adolescents newly referred to a tertiary pediatric otolaryngology outpatient department over a 12-month period. RESULTS: One hundred and fifteen patients were included (male 56, female 59) mean age 14.9 years. There were 36 (31%) patients who had previously required otolaryngology management for another condition, and 29 patients with complex medical conditions. Investigations, including audiology and medical imaging, were performed in 35 patients. The patients were managed surgically 34 (30%), medically 28 (24%), referred to other departments 10 (9%) had no intervention 21 (18%), while 22 (19%) failed to attend for follow up. CONCLUSION: Ambulatory adolescent patients present with a comparable spectrum of otolaryngological problems to other pediatric age groups. These patients appear to be well managed by pediatric otolaryngologists, and there does not seem to be a need to develop a free standing adolescent otolaryngology subspecialty within tertiary pediatric otolaryngology at this time.     

耳鼻咽喉科住院总医师1062例会诊病例分析

目的:分析耳鼻咽喉科住院总医师会诊患者的构成特点,从一个侧面反映住院总医师的工作情况。方法:统计第四军医大学西京医院耳鼻咽喉科1名住院总医师在2005年6月1日~2006年3月15日会诊的患者。结果:会诊患者共计1 062例,平均每周新会诊28例。其中急症会诊467例(43.97%),常规会诊595例(56.03%)。急症会诊的患者构成:鼻出血最多,共279例,占急症会诊总数的59.72%,病因主要为凝血机制障碍、高血压、肝肾功能衰竭、外伤等,少数为医源性诱发。喉阻塞及气管切开术113例,占急症会诊的24.19%,位于第2位。气管和支气管异物43例,病情均较危重。内科请常规会诊以炎症性疾病最多,慢性鼻炎及鼻窦炎169例,慢性咽炎及急慢性扁桃体炎162例,注意检查与诊断的全面性。外科因术前准备请耳鼻咽喉科常规会诊67例,目的是围手术期耳鼻咽喉科疾病风险评价和预防。结论:会诊工作具有特殊性和挑战性,住院总医师应该了解会诊患者特点,在会诊中学习和积累经验。     

Use of complementary and alternative medicine in pediatric otolaryngology patients attending a tertiary hospital in the UK

OBJECTIVE: Little data is available on complementary and alternative medicine (CAM) use in children attending otolaryngology services. We investigated the prevalence and pattern of CAM use among children attending the pediatric otolaryngology department in a tertiary pediatric teaching hospital in Scotland. DESIGN: A cross-sectional survey conducted by administering an anonymous questionnaire to the parents accompanying patients attending the pediatric otolaryngology department. Elective admissions and clinic attendees were included over a 3-month period in 2005/2006. SETTING: Academic tertiary care referral centre in North-East Scotland. PATIENTS: Five hundred and fifty-four consecutive patients aged less than 16 years were eligible. The response rate was 59% (n=327). MAIN OUTCOME MEASURES: Prevalence of CAM use in children. Secondary measures include types of CAM used, indications for use and communication with family physicians. RESULTS: Based on 327 responses, 93 patients (29%) had ever used CAM, 20% within the last year. Commonly used CAM preparations were cod-liver oil, echinacea, aloe vera, cranberry, primrose oil and herbal vitamin supplements. The popular non-herbal CAM included homeopathy, massage, aromatherapy, chiropractic, yoga and reiki. Nineteen percent used CAM for their admission illness. Sixty-one percent of parents thought that CAM was effective and 65% would recommend it to others. Fifty-one percent of parents stated that the family physician was unaware of CAM use by the child. CONCLUSIONS: Despite concerns regarding the efficacy, safety and cost effectiveness of complementary and alternative medicine, its use among the pediatric otolaryngology population is more common than many providers may realize. This has implications for all healthcare workers involved in their care.     

Safety of thyroidectomy in residency: A review of 186 consecutive cases

A retrospective review was performed to assess the surgical complications of thyroidectomy performed by otolaryngology residents under close supervision by faculty. One hundred eighty-six consecutive cases of thyroidectomy performed by the residents in the Department of Otolaryngology—Head and Neck Surgery at the University of Southern California were reviewed. Sixty-nine percent of thyroidectomies were performed for malignant or possible malignant diseases, and 31% were performed for benign conditions. Transient (less than 2 weeks in duration) hypocalcemia occurred in 26% of the patients; the vast majority of cases resolved within the first week. Five percent of the patients developed persistent hypocalcemia requiring prolonged replacement therapy. The incidence of unexpected postoperative permanent vocal cord paralysis was 0.9%. These complication rates are comparable to those in previously published large series on results of thyroidectomy. Thyroidectomy performed in an otolaryngology residency training program is a safe procedure when closely supervised by experienced faculty. Laryngoscope, 105:1173-1175, 1995