Recruitment, Evaluation, Regionalization Among Novel Challenges to the Specialty

Much patient contact is only acquired during the fellowship training process.… We, as mentors, must assume the responsibility of exposing our residents in training to the full spectrum of care provided to our patients, he said.

Dr. Cummings also questioned whether the profession needs to take a closer look at the idea of formally changing referral patterns, and that treatment for more complex cases should be more regionalized. This is something that should be investigated further in head and neck surgery. Studies in other surgical areas show that complex cases have better overall outcomes and improved survival when treated in high-volume specialty centers.

I am not advocating a wholesale exodus of head and neck cancer patients to regionalized cancer centers; rather, that those requiring multidisciplinary technologically intensive treatment should be so directed, he said. Lower-intensity procedures such as total laryngectomy, partial glossectomy, thyroidectomy, neck dissections, and most laryngeal procedures would still be treated locally, assuming there is an experienced head and neck surgeon available.

Dr. Cummings acknowledged that this sort of referral pattern is likely already practiced in many locations, but it could be more formalized, and would have a better tie-in with training programs. Today, graduates from residency programs have a level of competency in the core of head and neck surgery, whereas those with fellowships have acquired an added level of competency to include the high intensity, more demanding head and neck procedures, he said.

Selective referrals to specialty centers have been shown to improve overall outcomes for various complex cancer surgeries, including pneumonectomy, esophagectomy, liver resection, and other high-risk surgical procedures. One study from the New England Journal of Medicine found that mortality rates from open heart surgery, vascular surgery, and coronary bypass were lower in centers that treated larger numbers of cases when compared with the rates in lower-volume centers. The study also noted that the outcomes for cholecystectomy, a lower-risk procedure, were the same in high- and low-volume centers.

Certainly, a study sponsored by AHNS may provide a pathway to more successful head and neck cancer management, he said.

Evaluation of HNS Trainees Is Limited

Another issue in the profession is that there is a lack of tools to objectively evaluate the global competency of our finishing residents or fellows, yet we are called upon by society to certify competency, Dr. Cummings said. By this, he meant the assessment of a new surgeon’s ability to apply acquired skills in the real world, as well as adapt to new situations.