Chicago— How much do your treatments and procedures vary from the established standard of care? Does it matter?
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July 2006The Triological Society panel on “The Elusive Standard of Care,” addressed these questions here at the 2006 Combined Otolaryngology Spring Meetings (COSM). The panel, moderated by Mark S. Persky, MD, Chair of Otolaryngology–Head and Neck Surgery at Beth Israel Medical Center in New York City, provided an opportunity to review how four established otolaryngologists would approach the same patient.
No one on the panel uses facial nerve monitoring regularly during procedures, but the audience was in favor of it.
Panelists included Daniel Descher, MD, Director of the Norman Knight Hyperbaric Medicine Center at the Massachusetts Eye and Ear Infirmary in Boston; Paul Donald, MD, Professor and Vice Chairman of Otolaryngology–Head and Neck Surgery and Director of the Center for Skull Base Surgery at the University of California-Davis; Gady Har-El, MD, Professor of Otolaryngology and Neurosurgery at State University of New York-Downstate in Brooklyn; and Richard Smith, MD, Associate Professor of Clinical Otorhinolaryngology–Head and Neck Surgery at Albert Einstein College of Medicine in the Bronx, NY.
Dr. Persky began by providing a definition of standard of care, stating that it commonly accepted as “How similarly qualified practitioners manage a patient’s care under the same or similar circumstances.” However, he asked, “Could there be different standards of care?” Different physicians may be influenced by their personal experience or training, the medical community in which they practice, and the resources available to them.
Dr. Persky set out to vividly demonstrate possible differences in standards of care by asking the panel for their opinions on a specific case study. The case involved a 32-year-old woman with a two-year history of a slowly enlarging, two-centimeter, painless parotid mass. The woman’s cranial nerve (CN) VII was intact with no enlarged nodes.
Standards for Evaluation and Pre-Operative Tests
“How would you evaluate the patient?” Dr. Persky asked the panel. Dr. Donald spoke first, saying “I’d take her history and do a complete head and neck physical exam. Next, I’d ask for imaging. A CT scan or MRI is expensive, and they can add additional information—or not. Cytology is of some value, but it’s limited. I’d include cytology, and judge whether to do a CT scan on an individual case.”
Different physicians may be influenced by their personal experience or training, the medical community in which they practice, and the resources available to them.
Dr. Har-El said, “I was taught to just take [the mass] out—that that’s treating the patient. But I’ve seen more and more cases where there may be some exception. So now I ask for CT scan and needle biopsy.” Dr. Smith agreed: “Fine needle aspiration is used for everyone in our practice, pretty much. It’s our first diagnostic; it helps me decide whether the patient needs imaging or not.”
Next, Dr. Persky revealed the second phase of the case study: A fine needle aspiration (FNA) biopsy showed cellular pleomorphic adenoma, with possible low-grade mucoepidermoid carcinoma. What now?
Dr. Descher began: “I don’t know that every patient who has a mass removed needs the same treatment. I mean, do you trust the report if it comes from an outside pathologist? We have our own pathologist look at the results. We still have to consider that it may be malignant.” Dr. Persky’s response to this was, “It all depends on your experience. Do you believe imaging is necessary?” Dr. Donald agreed that pathology can be deceptive. “You’re often influenced by your last experience,” he mused. After a recent experience with questionable pathology, he said, “I’m more inclined to order CT scans now.”
Asked about concerns with FNA biopsies spreading disease, every member of the panel said they were not concerned.
Dr. Persky went on: The patient undergoes a CT scan, which shows the mass. It may be a benign tumor. The next issue in the standard of care: discussing the operation with the patient.
Standards for Discussion of Operation
The panel was asked how each would handle pre-operative topics including risks, complications, and sequella. Dr. Descher said, “I talk about what may be required, and the side effects of that. I quote national data on complications that occur. It’s critical to discuss handling the possibility of malignancy. As I was taught, everything you tell the patient before an operation is information; everything you tell them afterwards is an excuse.” He added, “I also tell them about my personal experience with similar cases, but I also warn them that that doesn’t mean they won’t have complications.”
Dr. Har-El said he covers sequella in detail in pre-operative discussions. “I tell them it’s not unusual to wake up with a numb ear lobe,” he said. “I cover side effects—and I do use the term ‘side effects’ rather than complications or sequella.”
Dr. Smith said that his practice has simplified these discussions in the last few years. “We focus on scarring and malignancy risk,” he said, because these seem to be the two biggest concerns of patients. “Also, I tend to quote my own statistics [on patient complications] rather than the national data. I believe it’s more meaningful to them.”
Dr. Donald added that, “It all depends on how well the patient likes you and respects you. I underplay the malignancy part, and don’t talk about national statistics. I do tell them about scarring. They’re quite concerned about that.”
Standards for Surgery
Dr. Persky asked the panel to talk about their surgical practices on patients similar to the woman in his case study. Dr. Donald reported that he obtains frozen sections on all patients he operates on. “My colleagues do not do this,” he said. “We only have about two or three [technicians] we can really count on to diagnose the samples correctly.”
Dr. Persky asked the panel if they use facial nerve monitoring during procedures. No one on the panel uses it regularly, but the audience was in favor of it.
Continuing with his case study, Dr. Persky told the panel that when the patient was incised, the mass turned out to be low-grade carcinoma. “The facial nerve is involved intimately with the tumor,” he said. “What do you do?”
“I like to get a biopsy and have the diagnosis before sacrificing the nerve,” said Dr. Descher. Dr. Smith said he would “definitely do a frozen section before sacrificing it. I’ve had a couple that were not malignant. Unless it’s definitive, I would stop.”
Fine Needle Aspirations
Dr. Persky went on to lead the panel in a discussion of fine needle aspirations, asking them to review a different case study: A 52-year-old man presents with a six-month history of a slowly enlarging, painless right parotid mass. FNA shows lymphoid tissue. “Most of us would take out that mass anyway,” said Dr. Persky.
Regarding FNAs, he continued, the American Head and Neck Society (AHNS) practice guidelines dictate that “If the parotid mass is mobile, discrete, and confined to the superficial lobe, no pre-operative FNA is necessary unless the patient’s medical condition is such that a general anesthetic would be very risky and a priority needs to be established.” This was obviously contrary to what the panel believed in as standard of care.
Furthermore, American Academy of Otolaryngology-Head and Neck Surgery clinical indicators for parotidectomy call FNAs, ultrasounds, CT scans, and MRIs “optional tests.” Dr. Persky pointed out, however, that this “represents guidelines only, this does not represent standard of care.”
Facial Nerve Monitoring
The AHNS guidelines do not mention facial nerve monitoring, Dr. Persky pointed out. “The literature shows that there is no difference in postoperative CN VII integrity” with facial nerve monitoring,” he added.
“If you’re going to use [facial nerve monitoring] in your practice,” said Dr. Descher, “you have to be able to explain why.” Dr. Persky countered, “and good clinical experience trumps that.”
Although the panel did not provide definitive guidelines for the cases discussed, it was valuable to see how similarly and differently each would approach the same patient, from evaluation through surgery.
©2006 The Triological Society