In an address to the 2009 Combined Otolaryngological Spring Meetings in Las Vegas, neurosurgeon Harry Van Loveren, MD, chair of the department of neurosurgery at the University of South Florida, coined the term “fogeyphobia” to describe a tendency among older doctors to become reluctant to speak out against new surgical tools and techniques, out of fear of being viewed as old-fashioned.
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September 2010So does the phenomenon extend to otolaryngology?
“The problem is that all that is new is not necessarily good,” said Paul Levine, MD, Robert W. Cantrell Professor and chair of otolaryngology at the University of Virginia Health System. “There are questions about the proper handling of newer techniques, so that patients are made fully aware if they haven’t been totally proven. Also, very heavy advertising for newer techniques is focused toward the consumer, and that probably makes some of the senior surgeons uncomfortable.”
But are some physicians reluctant to speak out? “I’m certainly not!” Dr. Levine declared. Indeed, he raised questions of his own about current advances in head and neck cancer surgery in his Ogura Lecture at the Triological Society’s 2008 Annual Meeting: “Would Dr. Ogura approve of endoscopic resection of esthesioneuroblastomas?”
When Newer Isn’t Better
Patrick Antonelli, MD, who chairs the department of otolaryngology at the University of Florida College of Medicine, noted that in his experience, senior surgeons have stayed in touch with current technologies and “embrace what’s new and good.”
Among his faculty are the original founding member of the department, George Singleton, now 84, and Nicholas J. Cassisi, who followed Dr. Singleton as chair. “[Dr.] Singleton goes to the spring meetings of the academy and sits up front to learn about the newer technologies,” Dr. Antonelli said. “He doesn’t operate any more, but he has pretty sharp insight as to whether these things are truly a step ahead.”
Dr. Antonelli added: “There certainly are individuals who may not have been as aggressive about keeping their skills sharp, but that’s not been my experience here.”
Senior surgeons have stayed in touch with current technologies and “embrace what’s new and good.”—Patrick Antonelli, MD
Dr. Antonelli’s senior surgeons are more than willing to make their voices heard, he said. “Sometimes they’ll comment on something: ‘Hey, we tried that 20 or 30 years ago and it didn’t work. Even though it’s a fad now, it’s not going to be any better than it was back then,’” he recalled. “While it wouldn’t surprise me if they weren’t a little reluctant to speak about certain things, in areas where they feel comfortable, where they’ve seen fads come and go, they continue to be vocal and be respected.”
Another senior surgeon who recently served on Dr. Antonelli’s faculty is Tom Herman, MD, now practicing at MacDill Air Force Base in Tampa, Fla. After 30 years in the field, Dr. Herman had retired and then, some years later, decided to return to practice by helping to start a new otolaryngology department at the base. Dr. Antonelli appointed him to his staff in order to get back up to speed on current approaches.
“It’s true that it can be very difficult for senior people to dispense with preconceptions,” Dr. Herman said. “But that’s what you have to do. There are times when I see people abandoning techniques that, in my hands, I always thought were effective. For example, I have no idea why certain types of intranasal surgery are done under general anesthesia today, when you can do it much more quickly with the patient awake.”
But, Dr. Herman noted, he doesn’t operate anymore. “Whatever I say is anecdotal, and I don’t walk the walk, so I don’t raise those questions. You have to understand that it’s a new world, and there are better resources that we didn’t have 20 or 30 years ago,” he said.
“An older surgeon who has traction in the community, experience in the field and is a recognized thought leader will speak out irrespective of what the reaction might be.”—Gavin Setzen, MD
Setting the Tone
Several chairs of otolaryngology at major academic medical centers said that they take a conscious approach to ensuring that older surgeons feel comfortable speaking out within their departments.
Dr. Levine said it’s hard to stifle the opinions of a senior surgeon. “The tone has to be set by the chair,” he said. “It’s important that as the ‘leader of the pack,’ you create an opportunity for both sides of the coin to speak out.”
Kenneth Grundfast, MD, chair of otolaryngology at Boston University School of Medicine, agrees that the responsibility for combating any hint of “fogeyphobia” lies with the department chair. “It’s my responsibility to set a tone where that wouldn’t happen,” he said. “We have some very senior surgeons here, and I think that we’ve created an atmosphere where we appreciate their wisdom and experience,” he said. “We certainly know that there are some technical things that have come along that they’re not facile with, but we have created an atmosphere where they can share their wisdom without being characterized as antiquated. They’ve seen and handled situations that many of the younger people have only read about in textbooks.”
That’s an essential perspective for the new generation of otolaryngologists, said Ronald Kuppersmith, MD, who practices with Texas ENT and Allergy in College Station, Texas. “They’ve seen so many things over the years, if they are skeptical of a new technology, it should be taken seriously by younger physicians,” he said.
Dr. Kuppersmith said enthusiasm or skepticism about new surgical approaches or technical tools depends more on the individual than on age. “Some older physicians are into innovation and pushing the edge throughout their careers, while sometimes when people are starting out they want to stick with the things they know,” he said.
And how a surgeon’s perspective is received by colleagues will also depend on his or her general standing in the community. “An older surgeon who has traction in the community, experience in the field and is a recognized thought leader will speak out irrespective of what the reaction might be,” said Gavin Setzen, MD, president of the New York State Society of Otolaryngology-Head and Neck Surgery, who practices with Albany ENT and Allergy Services. “But if it’s someone who isn’t necessarily adept, they may well not raise concerns due to fear of being considered out of touch or dated—although I haven’t really encountered this as a significant issue in practice.”
Dr. Grundfast said an emphasis on mutual respect is important. “There’s always a tendency for differences of opinion to be addressed by innuendo, for senior surgeons to imply that the younger ones are inexperienced and lack the wisdom to choose the management method that’s most effective, and, conversely, young surgeons to imply that the senior ones have not kept up with advancements. But the chair cannot condone that kind of behavior,” he said.
Dr. Grundfast said his department’s solution is to hold regular case conferences and tumor boards where everyone is encouraged to express their opinions openly “and continually reconsider best practices in an open forum with their colleagues.”