One of the enjoyable aspects of our specialty is the variety of patients and problems we see every day. Another stimulating part of our practice is the many areas where we consult and collaborate with a variety of other specialists that also treat head and neck problems. While consultation is an everyday part of contemporary medicine, otolaryngologists-head and neck surgeons might be unique in the number of specialties and territories that we overlap with-or bump into.
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May 2006Looking at it another way, we could wryly note the number of possible turf battles we might need to navigate on any given day. This could be seen as a problem or a challenge, but I think we should see it as an opportunity. In fact, the history and growth of our specialty can be attributed to strong leaders and talented practitioners who seized such opportunities while working alongside other specialists and demonstrating otolaryngology’s good outcomes. Indeed some areas that are part of our everyday practice in 2006 were mainly performed by other specialties in the past.
I believe the way to maintain and extend our specialty’s strength in the future is to work with other specialties, demonstrating our training and expertise. It might be tempting to just move into other areas and begin working in isolation, however that approach could be counterproductive. Keep in mind that one important factor in the growth of our specialty was integration into the mainstream of surgical practice, which was partly inculcated by extending the surgical portion of residency training.
Now that our specialty has taken control over the PGY-1 year of otolaryngology-head and neck surgery residents’ training, we should not take lightly the implications of separating our residents from other surgical specialties in that year.
Benefits of Multispecialty Collaboration
Surgical specialties can help each other: we have learned from other specialties, and they have learned from us. A friendly encounter with technology used in orthopedic surgery-the shaver, also known as the microdebrider-led to welcome advances in tools for endoscopic sinus surgery, with subsequent refinements applicable to other areas including tonsil and adenoid surgery and laryngology. We all know the impact that otologic surgical techniques have had on neurosurgical practice through things like the powered drill, operating microscope, and transmastoid approaches for access to the middle and posterior fossa. In addition to the incorporation of new techniques, collaboration with other surgeons also enhances patient care. For example, consider the obvious benefits of working with plastic and reconstructive surgeons for free tissue transfer and other advanced reconstructive techniques.
Dr. Stewart, an ENToday Editorial Board member, is Chair of Otorhinolaryngology at Weill Medical College of Cornell University and Otorhinolaryngologist-in-Chief at New York-Presbyterian Hospital/Weill Cornell Medical Center in New York, NY.Let’s explore two examples of the power of collaboration: sleep apnea and skull base surgery. Sleep apnea is an increasingly important health issue today, and it’s clear that no one has yet developed the best treatment for this complicated problem. Chances are, if you have sleep apnea and you see a pulmonary- or neurology-trained sleep specialist, you will be prescribed CPAP; an otolaryngologist will recommend a combination of nasal and palatal surgery; a dentist will recommend a dental appliance; and an oral surgeon will advocate mandibular surgery. While there is clearly a role for each treatment option, when applied in isolation using a one size fits all strategy, results are typically disappointing.
Sleep apnea treatment is an area which seems especially conducive to multispecialty collaboration, which would benefit many patients. Collaboration in this area was recently enhanced by the creation of the new conjoint American Board of Sleep Medicine (the American Board of Otolaryngology is a co-sponsor), and otolaryngologists are eligible for board certification (see ENToday, inaugural issue, page 18 for more information).
Surgical Collaboration and Beyond
Skull base surgery is another area where head and neck surgeons, rhinologists, neurotologists, neurosurgeons, and others are working together to advance the frontiers of surgical resection as well as to decrease the morbidity of surgical approaches. From neurotologic approaches to the lateral skull base, to craniofacial approaches, and now to endoscopic-guided trans-nasal and -sinus approaches, otolaryngologist-head and neck surgeons have a proud history of surgical teamwork.
There are many more examples of opportunities for collaboration, consultation, and mutual benefit, and not all involve surgery. We work with ophthalmologists in orbital decompression, orbital trauma and reconstruction, and dacryocystorhinostomy. In the management of laryngopharyngeal reflux, dysphagia, and other esophageal disorders, we work with gastroenterologists and speech language pathologists. Increasingly, otolaryngologists are leaders in the multidisciplinary design of clinical trials and creation of treatment guidelines for sinusitis, working with allergists, primary care physicians, and pulmonary physicians. Collaborative care also benefits patients with combined sinonasal and lower respiratory disease. In addition, we share the airway with anesthesiologists and pulmonary specialists, and our expertise and innovation in endoscopic techniques and lasers is called on frequently by both groups.
Clearly, our patients are the major beneficiaries of these advances. Further advances and collaborations will only enhance the care we provide, which will benefit our patients and our specialty.
Decisions for Our Future: Training Our Residents
Although several factors have contributed to the steady growth in the scope and influence of our specialty, we should be mindful of the benefits of otolaryngology-head and neck surgery residents spending one or two years of training in general surgery, integrated alongside other surgical residents. Having our resident trainees working alongside the general surgeons, neurosurgeons, and other surgical specialists clearly enhanced our stature and helped pave the way toward our status as definitive head and neck surgeons.
‘While consultation is an everyday part of contemporary medicine, otolaryngologists-head and neck surgeons might be unique in the number of specialties and territories that we overlap with-or bump into.’
However, the landscape of residency training is changing. This year, otolaryngology-head and neck surgery training programs have the option of taking control of the PGY-1 year of surgical training, with some designated time for surgery and electives. This is not unique; other surgical subspecialties have also moved control of the PGY-1 year to their own residency programs. While this change was initiated for good reasons, I am concerned that the importance of a full year of surgical training, as well as the surgical integration that occurs during that year, could be lost in the future. In addition, there could be other potential unintended consequences. For example, too much emphasis on non-surgical electives could result in residents starting the PGY-2 year with poor surgical skills.
Happily, the quality of applicants to our field continues to improve, which results in increasing competition between programs to attract the best candidates. The PGY-1 year could also become a recruiting tool, with programs vying to create the most attractive year, rather than focusing on maximizing education and preparation. As a specialty, we should resist these temptations and keep the residents’ training first in mind.
Our specialty is based on a very solid foundation, and with all of the potential opportunities for enhancements and collaborations, our future should be even brighter.
©2006 The Triological Society