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 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.     

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.     

Matching graduate education with societal need

OBJECTIVES/HYPOTHESIS: A number of prior Ogura lecturers have focused on the need to change residency education in otolaryngology-head and neck surgery; nothing has changed. The present discussion is based on the notion that graduate medical education should reflect societal need. STUDY DESIGN: Lecture. METHODS: Information on graduate medical education is presented. RESULTS: The information presented substantiates the maldistribution of otolaryngologists and the mismatch of the design and output of our programs from the perspective of public need. CONCLUSION: It is proposed that the American Board of Otolaryngology should take the lead in substantive change with the targets being 1) providing flexibility in program design, 2) a 1-year reduction in core training in otolaryngology, and 3) expanded interaction with family medicine.     

The otolaryngologist's attitude to facial plastic surgery

Of 453 Canadian otolaryngologist, 226 responded to a questionnaire, indicating significant interest in the state of facial plastic and reconstructive surgery. The majority of these otolaryngologists practised in larger cities and one-quarter received foreign training. Half of the respondents had academic affiliations and three-quarters considered themselves general otolaryngologists. Almost all the otolaryngologists believed that cosmetic and reconstructive surgery should form a major part of their specialty, this being unanimous among current residents. A large majority felt there should be more facial plastic surgical training, this both at the residency and fellowship levels, preferably through increased surgical exposure. With respect to sub-certification, only the resident group was in favor.     

Geographic differences in academic promotion practices,fellowship training,and scholarly impact

Purpose

Previous literature described how clinical fellowship training impacts scholarly production among academic otolaryngologists, finding that fellowship-trained practitioners had higher research productivity than their non-fellowship-trained peers, and head and neck (H&N) surgeons and otologists had the highest scholarly impact. In this analysis we investigate whether geographic differences in academic promotion and scholarly impact exist, and whether such differences are associated with emphasis on regional fellowship training patterns.

Methods

The Scopus database was used to determine scholarly impact (as measured by the h-index) of 1109 academic otolaryngologists from 97 departments. Online faculty listings were organized by fellowship training, academic rank, and location.

Results

Fellowship-trained practitioners had greater research productivity than non-fellowship-trained otolaryngologists (H = 9.5 ± 0.26 SEM vs. 6.5 ± 0.43, p < 0.001), a finding that persisted throughout except in the Mountain and East South Central Regions. H&N surgeons and otologists had the highest h-indices. Practitioners in the West had the highest h-index, with differences persisting upon examination of junior faculty. The West (62.1%) and Midwest (60.5%) had the highest proportions of senior faculty. Regional differences in scholarly impact and academic promotion were further noted upon organizing faculty by subspecialty fellowship training.

Conclusions

Geographic differences in academic promotion and scholarly impact exist, most markedly among junior faculty. Practitioners in the West had high impact and were more represented at senior ranks. Upon examination by fellowship training status, fellowship-trained otolaryngologists had higher impact in most, but not all, geographic regions. Regional variations in promotion were noted upon organizing faculty by subspecialty, although association with scholarly impact differs by region.     

Workforce Issues for the Academic Otolaryngologist

Background The current medico‐economic environment has led to profound changes in our health care system and questions of physician surplus. These issues have particularly affected the academic health care system, as research funding and departmental support have decreased, and many young otolaryngologists are questioning academic careers because of these uncertainties. The current study was undertaken to assess the workforce environment for the academic otolaryngologist, particularly the young physician. Methods Surveys were sent to the academic chairmen of all accredited otolaryngology residency programs in the United States, requesting information on faculty appointments—actual and projected—as well as subspecialty appointments and expectations of young faculty. Results The response rate was 60% (59/98). Faculty additions have been relatively stable from 1994 to 1998, with approximately 37 assistant professor and 5 associate professor positions filled yearly. Faculty additions were the result of departmental expansion in 83% of cases and spanned many subspecialties. The subspecialty positions most frequently added from 1994 to 1998 were generalists (57), head and neck oncologists (53), pediatric otolaryngologists (48), and otologists (39), with generalists filling 15 positions in 1998. Ninety‐three percent of programs anticipate faculty additions in the next 5 years; most will be at the assistant professor level (77%), with 30% of positions for generalists, 20% for head and neck oncologists, and 18% for pediatric otolaryngologists. Faculty expectations are primarily clinical, with research being least important. Conclusions Academic positions are available for the young otolaryngologist, particularly in the fields of general otolaryngology, head and neck oncology, and pediatric otolaryngology.     

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.     

Deficiencies of cross-training between pediatrics and otolaryngology

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. It is my hypothesis that there is a deficiency of cross-training between these two specialties. METHODS: All pediatric and otolaryngology program directors in Canada were contacted by mail. They were asked to complete a questionnaire regarding the need for further cross-training, what training their residents are presently receiving, and clinical entities that needed more attention. RESULTS: Data were tabulated and analyzed. 62.5% of pediatric program directors and 83.3% of otolaryngology program directors responded. All pediatric program directors indicated a need for teaching by otolaryngologists for their residents and 90% identified an area of deficiency in training. Similarly, 90% of otolaryngology program directors indicated a need for teaching by pediatricians for their residents and 89% of those identified an area of deficiency in training. CONCLUSIONS: These results suggest that there is a deficiency in cross-training between pediatrics and otolaryngology.     

Infant tracheotomy: results of a survey regarding technique

OBJECTIVE: To identify practice patterns regarding tracheotomy technique among pediatric otolaryngologists. DESIGN: Survey of physicians. SETTING: Academic medical center. PARTICIPANTS: Members of the American Society of Pediatric Otolaryngology (ASPO) residing in the United States. MAIN OUTCOME MEASURES: Physician responses to survey questions, including both multiple choice and free-text responses. We used chi(2) tests to determine if demographic factors (pediatric otolaryngology fellowship training, the number of tracheotomies performed yearly) correlated with differences in the technique used to perform infant tracheotomies. RESULTS: A total of 168 of 225 surveys mailed to ASPO members (75%) were completed and returned. Most respondents (87%) report that they make a simple vertical incision in the trachea. An even greater number (94%) use stay sutures routinely. On other technical points, such as management of the thyroid gland, the subcutaneous fat, and the method of securing the tracheostomy tube, there was much greater variability: 22% of respondents reported having had a serious tracheotomy-related complication in the immediate postoperative period, and 58% of these physicians changed their technique as a result. In several areas, chi(2) analysis revealed statistically significant differences in technique that were dependent on both fellowship training and the number of tracheotomies performed (P < or = .05). CONCLUSIONS: Among ASPO members practicing in the United States, there is near-unanimity on certain technical points, with considerable divergence on others. A substantial percentage of our colleagues have experienced a tracheotomy-related complication in the early postoperative period. In many cases, these incidents led to changes in surgical technique.     

Pediatric otolaryngologists' use of genetic testing

OBJECTIVE: To assess the use of genetic testing by pediatric otolaryngologists in evaluating a child with prelingual sensorineural hearing impairment (SNHI). DESIGN: Questionnaire on the use of genetic testing in the evaluation of prelingual SNHI was made available to pediatric otolaryngologists through the American Society of Pediatric Otolaryngology (ASPO) Web site (http://www.aspo.us). Each ASPO member was invited by e-mail to complete the questionnaire. PARTICIPANTS: Sixty-three ASPO members. RESULTS: Forty-two (69%) of 61 respondents indicated that they use genetic testing of the connexin 26 (Cx26) gene (GJB2) as an initial test in their workup of prelingual SNHI, and 30 (71%) of 42 reported that they provide genetic counseling for their patients and their families. However, 17 (45%) of 38 respondents answered questions regarding recurrence risks incorrectly or stated that they did not know the correct response. In addition, 7 (12%) of 60 respondents reported that they do not use DNA-based testing at any point in their workup. CONCLUSIONS: Many pediatric otolaryngologists use DNA-based testing in their evaluation of prelingual SNHI. However, many pediatric otolaryngologists do not have an adequate knowledge of the implications of genetic testing. Because it will take on an increasingly large role in clinical practice, pediatric otolaryngologists must be familiar with current genetic testing, counseling, and treatment recommendations. As these results demonstrate, such knowledge is still lacking in this physician population.     

Fellowship training in otolaryngology-head and neck surgery

Fellowship training in otolaryngology-head and neck surgery is a relatively new phenomenon that reflects the increasing complexity of clinical medicine. Despite an expansion of fellowship opportunities over the last three decades, there is still incomplete regulation and standardization of fellowship training. Approximately one third of residency graduates obtain some form of fellowship training. This article describes the fellowship opportunities that are currently available within the field of otolaryngology. Fellowship training serves as an avenue to gain further credentials and certification, although only the fields of neurotology, pediatric otolaryngology, and sleep medicine are accredited by the ACGME.     

Current practice patterns in tonsillectomy and perioperative care

OBJECTIVES: Tonsillectomy is one of the most commonly performed otolaryngologic procedures in the United States. Many options and controversies exist regarding techniques and peri-operative management. The purpose of the study was to examine current practice patterns among otolaryngologists regarding tonsillectomy. METHODS: A 13 question survey regarding tonsillectomy techniques and peri-operative management was mailed to 10% of randomly selected board certified otolaryngologists of the AAO-HNS in the spring of 2002. Four hundred and eighteen anonymously completed questionnaires were returned, for a response rate of 58.5%. Statistical analysis of survey data was performed by means of cross tabulation and Pearson Chi-Square Calculation. RESULTS: Monopolar electrocautery was the most common technique used among those surveyed (53.5%). There was a significant correlation between choice of monopolar electrocautery and the cited reason for choice of technique being decreased blood loss (P < 0.001). There was no relationship between pediatric fellowship training and choice of technique. 97.7% routinely admitted sleep apnea patients for post-operative observation. There was no significant correlation between practice setting (tertiary versus community) and type of post-operative monitoring for sleep apnea patients, with patients most commonly admitted to an intermediate care setting. CONCLUSION: In our survey, the most common surgical technique for tonsillectomy was monopolar electrocautery, chosen for the reason of decreased blood loss.     

Otolaryngology and deafness

Results of a survey of 113 departments of otolaryngology chairmen indicated that, in general, otolaryngologists are inexperienced in treating deaf children. Moreover, the education of residents is marginal in some topics related to deafness. We conclude that didactic work in these deficient areas should be included in the curriculum of otolaryngology residents so that the needs of patients with such problems will be better met. This study was stimulated by the results of a survey of schools for the deaf regarding the otologic care of deaf children. Questions arose as to what extent otolaryngology residents are instructed in topics related to deafness.     

Developing the next generation of otolaryngologist-researchers

The lifeblood of any specialty is innovation and discovery. It is important for the field of otolaryngology and its patients that we identify, recruit, train, and develop the next generation of researchers in otolaryngology. This article describes programs and resources currently available to otolaryngologists in training and early in their career for their development as clinician-scientists. We describe the background of the current generation of National Institutes of Health-funded otolaryngologists and discern where the next generation might come from. Special attention is given to the National Institute on Deafness and Other Communication Disorders, which focuses on supporting research and research training in hearing, balance, smell, taste, voice, speech, and language, and to programs aimed at the development of clinician-scientists.     

Otolaryngology manpower revisited.

In the December issue of the Archives, Nickerson et al published an article on the manpower resources of otolaryngology based on a report released in 1975. The conclusion reached by Nickerson and co-workers was that otolaryngology had a manpower pool too big for present and near future needs. This article was followed by a press release by the American Medical Association that endorsed the statements of the Archives article and in which Nickerson et al were quoted that no more otolaryngologists were needed from the training programs for some years. These statements were in sharp disagreement with the findings of the manpower studies carried out by another group in 1973-1975. Because the two surveys employed different statistical approaches, this article has been written to present the methods employed and to discuss the merits of the conclusions reached in each.     

Should otolaryngologists perform pH probe studies?

PURPOSE OF REVIEW: This commentary discusses recent developments in the methods available to pediatric otolaryngologists in the diagnosis of laryngopharyngeal reflux. RECENT DEVELOPMENTS: The development of detachable wireless monitoring allows the otolaryngologists to perform their own pH monitoring. It can be deployed while performing other procedures, such as laryngoscopy and bronchoscopy. The procedure to insert the probe and collect data is described. SUMMARY: It is hoped that the pH probe will play an important role in understanding the pathological role of pharyngeal reflux in terms of laryngeal, pharyngeal, sinus and ear pathology.     

A case study of an emerging community-based early hearing detection and intervention program: part II. Team building with otolaryngologists and pediatricians using a survey approach

PURPOSE: Physicians are vital team members of early hearing detection and intervention programs (EHDIPs), particularly in encouraging parents to comply with recommendations for follow-up services for their infants in universal newborn hearing screening programs (UNHSPs). This study describes a survey approach to help audiologists partner with otolaryngologists and pediatricians in EHDIPs. METHOD: We developed and mailed a 19-item questionnaire to all 12 otolaryngologists and 66 pediatricians potentially involved in a community-based EHDIP. The questionnaire assessed respondents' demographic data and knowledge of, experiences with, and attitudes toward the service-delivery continuum of UNHSPs. RESULTS: The overall response rate was 45%; all 12 otolaryngologists responded (100%; data from 7 were analyzed), and 23 pediatricians responded (34.8%; all were analyzed). Generally, they were positive toward and knowledgeable about UNHSPs and believed that (a) parent/infant bonding is unaffected by screening, (b) hearing reevaluations following medical services are important, (c) audiologists perform their role adequately, (d) it is important that hearing losses be identified and interventions begun before infants reach 6 months of age, (e) UNHSPs deserve funding, and (f) their role is important, but the physicians also wanted improvements in parent education and referral/follow-ups. CONCLUSION: The survey method was effective in identifying participating physicians' informational needs and attitudes toward UNHSPs, and in designing outreach programs for them.     

Preoperative thyroid scanning in presumed thyroglossal duct cysts.

The purpose of this study was to determine if preoperative thyroid scans are essential in the workup of presumed thyroglossal duct cysts. Questionnaires were sent to pediatric otolaryngologists and pediatric general surgeons with a 65% response rate. Fifty-seven percent of the physicians have encountered ectopic thyroid. In 58% of these, this was the only functioning thyroid tissue. Twenty eight percent of pediatric surgeons vs 65% of pediatric otolaryngologists routinely order scans. Two of the physicians encountering ectopic thyroid volunteered that they had successful litigation directed against them for removing the sole functioning thyroid and creating permanent hypothyroidism. There is a likelihood of encountering ectopic thyroid during the course of one's practice. A case of ectopic thyroid is presented, and management strategies are discussed.