Recruitment, Evaluation, Regionalization Among Novel Challenges to the Specialty

PHOENIX-The speciality of head and neck surgery has come a long way. But, along with huge advances in the types of treatments available and the technologies used, the profession is facing challenges-such as the recruitment of good candidates into the field and issues related to the regionalization and globalization of care. These were the themes discussed in the Hayes Martin Lecture at the annual meeting of the American Head and Neck Society (AHNS) at the Combined Otolaryngology Spring Meeting (COSM) here.

Our specialty has evolved from an era where the therapist was a warrior with a single arrow in his quiver to one armed with many options, said Charles W. Cummings, MD, Professor of Otolaryngology-Head and Neck Surgery and Oncology at Johns Hopkins University in Baltimore. The past 60 years have seen huge advances in terms of treatment and technologies, and in many ways, all these advances make the profession more complex than the one early practitioners faced.

Today’s head and neck surgeons must be multifaceted; must be facile in molecular biology and radiobiology; must be skilled with the traditional head and neck surgical procedures as well as the less complex, robotically influenced techniques that are evolving today, he said.

The complexity of the specialty may be linked to some of the challenges in recruiting new talent. Dr. Cummings noted that although each of the last three match classes resulted in all available positions being filled, there was no surplus of candidates.

This lack of a surplus is worrying. One reason this is happening is the greater value new doctors place on lifestyle-they want a better balance between their professional lives and their personal time.

But a second reason could be that head and neck surgery has evolved into a field perceived as being a less appealing one to enter.

In some ways, head and neck surgery has evolved to represent the court of last resort, Dr. Cummings said. More often than not, the surgical patient results from a previous single or combined therapeutic failure, where surgery becomes the only option remaining. It becomes an exercise consisting of complicated procedures in a hostile environment.

This perception could be related to what happens in training. Often, residents are not exposed to the lesser surgical procedures, such as the surgical treatment of early-stage disease, the staging of procedures prior to definitive treatment, and the like. Importantly, many residents miss out on the enduring relationships that develop with patients over time.

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.

Much effort is being directed to create an effective assessment formula incorporating multiple evaluative elements. No single dependable formula exists to measure the graduate’s competencies in varied and disparate environments, he said.

Right now, technical skills are the most weakly assessed. A recent study of 72 US otolaryngology HNS program directors found that 69 used subjective evaluations, and objective structured assessments of technical skills was used in only 11 of the 72 programs.

In otolaryngology-HNS surgical training, the standards for the evaluation of surgical competency fall below a level that we should expect, he said. To improve this, Dr. Cummings suggested that the specialty draw on experiences from the aviation industry to improve standards in training and competency, as other medical researchers have suggested.

Paradigms from aviation that could be applied to surgical training include testing applicants for innate dexterity and personality traits; defining a designated learning objective for each clinical encounter; developing a checklist of objectives for residentt/fellowship rotations; dissecting benchmark operations into essential steps that are drilled with deliberate practice in skill trainers and the operating room; having a checklist of essential skills (for both operative and other tasks) for tracking residency training and competency; and having residents use the designated learning objectives in a way so that learning is more active than passive.

Global Participation

Looking at HNS from a more global perspective is useful for the profession too.

Globally, the volume of head and neck tumor cases is huge, and the number of experienced surgeons is relatively infinitesimal-a scenario that cries out for linkages to our surgical training programs and fellowships, Dr. Cummings said.

Having some of these cases treated by our trainees would elevate the quality of care for the afflicted and contribute in a most positive way for the trainee to gain the experience and judgment expected of the mature head and neck surgeon, he said. Worldwide, he noted, there is a shortage of 4.3 million health care workers, with Africa alone being short by a million even though it bears 25% of the global burden of disease.

Physicians have a responsibility to get involved in global foundations that help people in other parts of the world, he said. Not only will it help people in need, but it gives doctors a wide experience in terms of working with a variety of cases, as well as working under different circumstances.

Exposure to advanced disease would be substantive, surgical skills would be enhanced by repetition, and the core element of medicine, the improvement of the human condition would be served, he said.

©2009 The Triological Society