Published: October 9, 2013

Pediatric OSAS: Guidelines, Evidence, and Nuance

Ron B. Mitchell, MD Scott E. Brietzke, MD, MPH Peter D. O’Connor, MD, OD Steve Maturo, MD Pediatric Obstructive Sleep Apnea Syndrome (OSAS) is frequently a result of adenotonsillar hypertrophy and is one of the most common referrals to otolaryngologists. Nearly 500,000 tonsillectomies are performed annually for OSAS in the United States. During the past three years, the AAO-HNSF, American Academy of Pediatrics (AAP), and the American Academy of Sleep Medicine (AASM) have published clinical practice guidelines regarding the diagnosis and management of OSAS. Although the three guidelines are targeted at somewhat different audiences who evaluate slightly different patient populations, these documents have conflicting information about indications for polysomnography and perioperative management of children with OSAS. This has led to some confusion among practicing physicians in how to appropriately manage children with clinical symptoms of sleep-disordered breathing in such areas as pre-operative evaluation, post-operative management, and long-term follow up. One key source of variability among the three published guidelines is in the use of polysomnography (PSG) for the diagnosis of pediatric OSAS. The use of clinical parameters in the form of the history and physical exam is limited in specific ways in the reliable diagnosis of OSAS and in the determination of OSAS severity. The three guidelines have different recommendations regarding the utilization of PSG ranging from obtaining PSG in all children prior to adenotonsillectomy to limiting its use to high-risk patients (e.g., obesity, Trisomy 21) and in situations when there is significant doubt about the diagnosis. Unfortunately, universal use of PSG for the diagnosis of pediatric OSAS is not feasible due to high costs and limited access in many areas. The situation is further complicated by an incomplete understanding of the morbidity of primary snoring and mild OSAS. Careful examination of the three guidelines and the basis behind them is a useful endeavor to fully understand this complicated issue and to improve clinical diagnosis and the judicious use of pediatric PSG. With increasing pressure to maintain health costs and the inability to obtain laboratory PSG in a reasonable time, one recurring question is the availability and accuracy of home sleep studies. Improved technology, accessability, and cost containment have driven the change toward out-of-center testing for adult patients where a growing body of data showing that outcomes following home studies are comparable to in-lab testing. However, there is a considerable knowledge gap in the use of home sleep monitoring technology for the evaluation of pediatric sleep disorder as recognized in the recent AAO-HNS guideline. Research of portable testing in pediatric patients typically includes a measure of oxygen saturation, and cardiac activity, along with respiratory effort and oronasal flow. Paramount to any evaluation of pediatric patients is that the testing should be interpreted in the context of the history and physical. If the patient is suspected of having SDB despite negative in-home testing, consideration for overnight laboratory testing should be considered. If there is a positive test, strong consideration for treatment should be made. Any portable testing should be done along with a comprehensive evaluation. Additional research on portable testing in pediatric patients is needed in such areas as relevant health and functional outcomes, along with reliability, acceptance, and the impact on time to treatment (for patients recommended to have PSG testing). Once the determination has been made to proceed with adenotonsillectomy for OSAS, there is wide variation as to the peri-operative management of children. The majority of surgeries are carried out as an outpatient procedure, but there continues to be wide variation regarding which children require admission. Recently studies have demonstrated that certain populations have increased perioperative risk. The rise in overweight/obese children in the United States has resulted in more children presenting with OSAS. Often OSAS in obese children is more severe, leads to more per-operative morbidity, and is more likely to result in persistent OSAS after surgery. Sunday, September 29 10:30 am-11:50 am Miniseminar: Pediatric OSAS: Guidelines, Evidence, and Nuance Moderator: Steve Maturo, MD Presenters: Scott Brietzke, MD, MPH, Stacey L. Ishman, MD, Ron B. Mitchell, MD Guideline evaluation and peri-operative management of Pediatric OSAS will be a few of the topics discussed by an experienced panel during a miniseminar at the upcoming AAO-HNS Annual Meeting in Vancouver, BC, Canada. Scott Brietzke, MD, a pediatric otolaryngologist and sleep surgeon will analyze the guidelines and discuss their differences. Ron Mitchell, MD, professor and chair of UT Southwestern in Dallas, will be discussing peri-operative management strategies and focusing on children with obesity. Stacey Ishman, MD, also a pediatric otolaryngologist and sleep surgeon will discuss subtleties of sleep studies, to include home sleep studies, and persistent OSAS after tonsillectomy.

Ron B. Mitchell, MD
Scott E. Brietzke, MD, MPH
Peter D. O’Connor, MD, OD
Steve Maturo, MD

Pediatric Obstructive Sleep Apnea Syndrome (OSAS) is frequently a result of adenotonsillar hypertrophy and is one of the most common referrals to otolaryngologists. Nearly 500,000 tonsillectomies are performed annually for OSAS in the United States. During the past three years, the AAO-HNSF, American Academy of Pediatrics (AAP), and the American Academy of Sleep Medicine (AASM) have published clinical practice guidelines regarding the diagnosis and management of OSAS. Although the three guidelines are targeted at somewhat different audiences who evaluate slightly different patient populations, these documents have conflicting information about indications for polysomnography and perioperative management of children with OSAS. This has led to some confusion among practicing physicians in how to appropriately manage children with clinical symptoms of sleep-disordered breathing in such areas as pre-operative evaluation, post-operative management, and long-term follow up.

One key source of variability among the three published guidelines is in the use of polysomnography (PSG) for the diagnosis of pediatric OSAS. The use of clinical parameters in the form of the history and physical exam is limited in specific ways in the reliable diagnosis of OSAS and in the determination of OSAS severity. The three guidelines have different recommendations regarding the utilization of PSG ranging from obtaining PSG in all children prior to adenotonsillectomy to limiting its use to high-risk patients (e.g., obesity, Trisomy 21) and in situations when there is significant doubt about the diagnosis. Unfortunately, universal use of PSG for the diagnosis of pediatric OSAS is not feasible due to high costs and limited access in many areas. The situation is further complicated by an incomplete understanding of the morbidity of primary snoring and mild OSAS. Careful examination of the three guidelines and the basis behind them is a useful endeavor to fully understand this complicated issue and to improve clinical diagnosis and the judicious use of pediatric PSG.

With increasing pressure to maintain health costs and the inability to obtain laboratory PSG in a reasonable time, one recurring question is the availability and accuracy of home sleep studies. Improved technology, accessability, and cost containment have driven the change toward out-of-center testing for adult patients where a growing body of data showing that outcomes following home studies are comparable to in-lab testing. However, there is a considerable knowledge gap in the use of home sleep monitoring technology for the evaluation of pediatric sleep disorder as recognized in the recent AAO-HNS guideline. Research of portable testing in pediatric patients typically includes a measure of oxygen saturation, and cardiac activity, along with respiratory effort and oronasal flow. Paramount to any evaluation of pediatric patients is that the testing should be interpreted in the context of the history and physical. If the patient is suspected of having SDB despite negative in-home testing, consideration for overnight laboratory testing should be considered. If there is a positive test, strong consideration for treatment should be made. Any portable testing should be done along with a comprehensive evaluation. Additional research on portable testing in pediatric patients is needed in such areas as relevant health and functional outcomes, along with reliability, acceptance, and the impact on time to treatment (for patients recommended to have PSG testing).

Once the determination has been made to proceed with adenotonsillectomy for OSAS, there is wide variation as to the peri-operative management of children. The majority of surgeries are carried out as an outpatient procedure, but there continues to be wide variation regarding which children require admission. Recently studies have demonstrated that certain populations have increased perioperative risk. The rise in overweight/obese children in the United States has resulted in more children presenting with OSAS. Often OSAS in obese children is more severe, leads to more per-operative morbidity, and is more likely to result in persistent OSAS after surgery.

AM 13_VancouverLogoSunday, September 29 10:30 am-11:50 am
Miniseminar: Pediatric OSAS: Guidelines, Evidence, and Nuance
Moderator: Steve Maturo, MD
Presenters: Scott Brietzke, MD, MPH, Stacey L. Ishman, MD, Ron B. Mitchell, MD

Guideline evaluation and peri-operative management of Pediatric OSAS will be a few of the topics discussed by an experienced panel during a miniseminar at the upcoming AAO-HNS Annual Meeting in Vancouver, BC, Canada. Scott Brietzke, MD, a pediatric otolaryngologist and sleep surgeon will analyze the guidelines and discuss their differences. Ron Mitchell, MD, professor and chair of UT Southwestern in Dallas, will be discussing peri-operative management strategies and focusing on children with obesity. Stacey Ishman, MD, also a pediatric otolaryngologist and sleep surgeon will discuss subtleties of sleep studies, to include home sleep studies, and persistent OSAS after tonsillectomy.

More from September 2013 - Vol. 32 No. 09
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Dates to Remember
April 15: International Travel Grant application deadline. Email international@entnet.org. April 16: World Voice Day www.entnet.org/bulletin andwww.entnet.org/HealthInformation/worldVoiceDay.cfm April 14-20: Oral Head and Neck Cancer Awareness Week May 1: International Visiting Scholars application deadline. Email international@entnet.org. May 15: Otolaryngology Historical Society submissions deadline. Email museum@entnet.org. June: Early June International Travel Grant notifications sent. June: Early June Otolaryngology Historical Society paper acceptance notifications sent. June: Mid June International Visiting Scholars grant notifications sent.
07_Cabrera-Muffly
Time to Retool the Mommy Track from the WIO Section
Cristina Cabrera-Muffly, MD Assistant Professor, University of Colorado Aurora, CO for Women in Otolaryngology (WIO) Section Last month, while driving my 3-year-old to daycare, he emphatically stated, “Mommy, you can’t be a doctor and a mommy.” This was a complete non sequitur to the prior discussion of trucks on the highway that morning. Completely taken aback, it took all my willpower not to pull over and address his comment. Instead, I calmly stated that I was both a mommy and a doctor and vowed to repeat this message multiple times in the coming weeks. His statement did get me thinking, however. Is this just “kids say the darndest things,” or does he have a point? As an academic otolaryngologist, can I be as successful and advance in my career as quickly and as effectively as my male colleagues, or does motherhood put me on the dreaded “mommy track” to nowhere? There has been a lot of discussion about motherhood and career advancement recently. The two loudest voices in popular culture are Facebook COO Sheryl Sandberg through her book Lean In: Women, Work, and the Will to Lead (which reached No. 1 on The New York Times bestseller list) and Anne-Marie Slaughter, whose article in The Atlantic, “Why Women Still Can’t Have It All,” was the most read story on The Atlantic’s website ever. While both argue that societal constructs such as lack of female role models to sponsor changes, the stigma of maternity leave, and impractical school schedules keep women from advancing in their fields, they differ in their opinions about how to solve the problem. Sandberg puts the onus on women themselves, advising them to be more ambitious and aggressive. Slaughter opines that ambition is not enough, and real progress will not occur until the subtle (and sometimes not-so-subtle) stereotypes about working mothers begin to change. In light of this debate, I turned to other female academic otolaryngologists for their opinions. One woman stated, “There is no such thing as ‘mommy track,’ and I think we have to be careful what women in otolaryngology or any field use as a term to describe what we want.” Another recommended renaming the mommy track to the “integrated career and family track.” No one liked the term “mommy track” and I wholeheartedly agree. If we are to propagate the species, pregnancy and childbirth are a biologic fact for women, not a “track” to be chosen in lieu of a career. By labeling working mothers in this way, we become an easy target for our colleagues to diminish our contributions. After all, women do not leave medicine only for motherhood. No one would think to label an “illness or disability track.” How do we become both the types of doctors and mothers we want to be? The greatest frustration voiced by many women was the lack of work schedule flexibility. While in medicine we cannot work from home, adjustments in school schedules and operating room schedules would make it significantly easier to care for both our patients and our children. Summer vacations and late school start times are difficult for any working parent, not just female physicians. The ability to be flexible also depends on the home support system. Most women I spoke with who had partners at home attributed much of their success to such assistance. Another theme was that opinions about female career advancement seem to be a “generational difference, not a gender difference.” One woman stated that both she and her male colleague have young children, and they both work hard during the week but do not volunteer for “extras” such as having dinner with a new faculty candidate or spending Saturday at a low-yield meeting. Most women felt that faculty members early in their careers, whether male or female, prioritize family life more than a generation ago. Another woman commented, “The old guard that worked and neglected their families might not only have it wrong, but their disconnect from society might keep them from being as good a doctor as one with a balanced life. There is value in life outside of medicine, and we are richer for it.” “Solutions for systems and institutions must meet and improve lives for all, not just one group, and not just for women” stated one. I could not have put it better myself. It is critical to have a supportive chair and mentor who can facilitate these solutions. Subtle departmental cues, like believing that it is okay to go home early to play a round of golf but not to take your child to the doctor, negatively impact every member of the department. Why should chairs and mentors strive to help women find solutions for balancing work and home? The answer is to improve both immediate and future productivity. Women who feel supported will work harder and be more committed to their careers and their departments. In “Gender disparities in scholarly productivity within academic otolaryngology departments” Eloy, et al.1 show that women produce less research output early in their careers, but meet or exceed this output later in their careers. If women leave before they become a professor, they will never achieve that later career contribution. Secondly, there is a significant potential impact of having a female mentor available to you as a female resident or medical student. The only way to increase the number of female professors and chairs is to encourage them to step into the pipeline when they are residents. Is it any surprise that in my role as associate program director to a male program director, female residents turned to me first when divulging they were pregnant? In my case, the male program director was just as supportive as I was, but as a woman who had just had a child, they felt more comfortable approaching me about how to announce their pregnancy to the department. When they confided in me, I always told them the road would be difficult, but it was still possible to achieve their goals in their career. The keys are to work as hard as possible, find good help at home, and don’t let anyone have low expectations of you. In short, they, too, can be both a doctor and a mommy. Hopefully, some day, my son will understand this, too. Reference Eloy JA, et al. Gender disparities in scholarly productivity within academic otolaryngology departments. Otolaryngol Head Neck Surg. 2013 Feb;148(2):215-222. Dates to Remember Go to http://www.entnet.org/conferencesandevents to see a full listing; to list events, email memberservices@entnet.org. September 29-October 2 AAO-HNSF 2013 Annual Meeting & OTO EXPOSMCoding and Reimbursement Workshops September 13-14 – Minneapolis, MN October 25-26 – Las Vegas, NV November 8-9 – Chicago, IL November 4 Instruction Course and Miniseminar – Call for Papers is open.
02_VancouverClub
John Joseph Conley, MD: Innovator in Head and Neck Reconstructive Surgery
Masoud Saman, MD, with Claude Douge, MD Having completed my surgical internship at Saint Vincent’s Hospital (affectionately known as “Vinny’s”) Manhattan, NY, the year its doors were permanently shut, I feel compelled to ponder the life of a man whose portrait hung by the elevators and whose anecdotes I heard each time my attendings remembered that I was an OTO-HNS resident. The portrait’s subject was the prominent surgeon, musician, and gentleman from Pennsylvania, who spoke with a noble accent and whose charisma enlightened any room: John Joseph Conley, MD. After receiving his medical degree in 1937, Dr. Conley started residency at Kings County Hospital in cardiology. Soon after, he was diagnosed with paroxysmal atrial tachycardia and was advised to switch to a less demanding specialty: otolaryngology. His years during World War II in the U.S. Army Medical Corps in the South Pacific, working alongside plastic and maxillofacial surgery colleagues on reconstructing traumatic head and neck defects, gave him the experience that proved to be instrumental in his rise as a leader and innovator in head and neck and facial surgery upon his return to New York. Dr. Conley was known to be eloquent and captivating. Once as the defendant in a case, he told the court that he would summon himself to the stand as the expert witness. He dressed handsomely and walked with authority. At Vinny’s, he worked with Ricardo Bizi, MD, the son of an Argentine otolaryngologist, and Robert C. Eberle, MD, of Geneva. Among his many unsalaried fellows were Peter Cinelli, MD, and Stanley M. Blaugrund, MD, with whom Dr. Conley chose to have surgery himself. Dr. Conley’s contributions to head and neck surgery and facial plastic surgery ranged from novel techniques and approaches in cancer extirpation, to various flaps in facial reconstruction, and more. He paved the way for the new generation of otolaryngologists interested in these subspecialties. It is upon the shoulders of giants like Dr. Conley that we stand and proudly represent our field. The John Conley, MD Lecture on Medical Ethics was founded in his name, and is delivered during the Opening Ceremony at every AAO-HNSF Annual Meeting & OTO EXPOSM. Celebrate the Specialty’s History with Us Marc D. Eisen, MD, PhD, cordially invites Academy members and their guests to the next meeting and reception of the Otolaryngology Historical Society (OHS), in Vancouver’s historic and elegant Vancouver Club, taking place in conjunction with the 2013 Annual Meeting & OTO EXPOSM. Date: Monday, September 30, 2013 Time: 6:30 pm–8:30 pm Place: Vancouver Club Room: Bar Room III An informal reception will follow a short program of presented papers on a variety of historical topics about the specialty. Program Marc D. Eisen, MD, PhD, president, Otolaryngology Historical Society Welcome and Introductions P. Ryan Camilon, BA, University of South Carolina Medical School “Vestibular Experiments Conducted in Space” Amit A. Patel, MD, University Medicine and Dentistry of New Jersey “Thyroglossal Duct Cysts, Elephantitis, and More: the Different Sides of William E. Sistrunk” C. Eduardo Corrales, MD, Stanford University “Otologic Anatomical Advancements in 18th Century England—or Lack of: the Case of William Cheselden” Lanny G. Close, MD, Columbia University “Medical Education in America: the Impact of the Flexner Report over the Past 100 Years” OHS members receive advance notice and a complimentary ticket for the evening reception. To renew your OHS membership dues of $50, please email memberservices@entnet.org. For OHS members who wish to bring a guest, there is a fee of $85 per guest ticket. If you are not an OHS member, but wish to attend this event, there is an $85 fee. Please email ohs@entnet.org for RSVP information.
Denis C. Lafreniere, MD Chair, BOG
The BOG Is Ready to Help You Navigate the Waters of Healthcare Reform
The AAO-HNSF 2013 Annual Meeting & OTO EXPOSM will convene at the end of this month in the beautiful city of Vancouver, BC, Canada. The setting, off the gorgeous Strait of Georgia and Vancouver Bay, will be truly inspiring. The trip to one of our northern neighbors’ most impressive cities will no doubt enlighten the international audience of otolaryngologists, residents, scientists, and administrators. We encourage all AAO-HNS members to register and take full advantage of the research presentations, miniseminars, clinical courses, and the always-informative OTO EXPO while in Vancouver. The international flavor of this year’s meeting gives us the opportunity to look at our healthcare delivery system from a global perspective as we work to fully understand, and to mold, the details of healthcare reform. The changes currently underway ensure our healthcare system will demand that we adapt appropriately to these changes, and work to ensure our ability to provide the best care possible to our patients and their families. Your BOG and the AAO-HNS are poised to help guide you through the myriad changes that have already occurred as a result of the Affordable Care Act (ACA) and will work to inform you of the further changes that await us in the coming years. The BOG meetings, in conjunction with related miniseminars being held during the Annual Meeting, will give members multiple opportunities to be informed about our changing healthcare system and to evaluate the impact of these changes on providers’ practices. The BOG kicks off its events beginning on Saturday morning, September 28, with its Rules and Regulations Committee, Legislative Representatives Committee, and Socioeconomic and Grassroots Committee meeting sessions. These committees will discuss topics including pay-for-call, maintenance of hospital privileges, and acquisition of practices by hospital systems, as well as current legislative issues. We will have reports from the regional BOG representatives giving us an update of the current issues affecting their component local societies. The regionalization of the BOG state and local societies is a modification of the BOG structure that was initiated more than a year ago. The BOG regions match the HHS regions that we are all familiar with. This regionalization will help solidify the conduit for the free flow of information from the local societies to the Academy and back. This regional approach will be vital as local issues related to healthcare reform, and/or local state legislative challenges occur. Changes are occurring swiftly and our ability to gather information and respond will be vital as we work to properly influence these changes. Also on Saturday, there will be a BOG luncheon seminar where C. Brett Johnson, MD, the associate director of the Center for Medical and Regulatory Policy for the California Medical Association, will talk to us about Health Exchanges and the implications for our practices. The Physician Payment Policy (3P) workgroup, in conjunction with the BOG, will present a miniseminar at 10:30 am on Sunday, September 29, called “Alternative Payment Models and Academy Advocacy for Physician Payment: What You Should Know.” Michael Setzen, MD, will moderate this discussion, which should be timely and relevant. There will be an additional miniseminar at 8:00 am on Monday, September 30, to prepare members for the transition to ICD-10 in 2014. The BOG Executive Committee-sponsored miniseminar will take place at 8:00 am on Tuesday, October 1. This year’s seminar will address the impact of Accountable Care Organizations (ACO)s for the otolaryngologist practice. BOG Secretary Wendy B. Stern, MD, will moderate the seminar and our guest speakers will include Raymund King, MD, JD, who will talk to us on the legal implications of an ACO, and C. Brett Johnson, MD, who will be addressing physician concerns when considering joining an ACO. We hope to see many of you there and the panel will be ready to take your questions. The obstacles we face every day in both the academic and private practice setting can be daunting as costs rise and reimbursement drops, making our goal of excellent patient care, delivered in an efficient manner, a challenge. Informing our members and responding to their needs is why the BOG exists. Our plan is to consistently provide our members with the most current information regarding the ever-changing healthcare landscape. We encourage all of you to make the trip north and enjoy the hospitality of our Canadian neighbors. Your BOG will help to provide you with the tools you need to navigate the healthcare rapids that may lie ahead in our home waters. See you soon in Vancouver!
David R. Nielsen, MDAAO-HNS/F EVP/CEO
A Preparation Medley
This is the month of our Annual Meeting & OTO EXPOSM. By now, most of you have made preparations to attend. The excitement this year is extremely high as once again (for only the second time in Academy history) we cross our northern border and join our colleagues in Canada to conduct our Annual Meeting in Vancouver. Our previous foray into Canada was to Toronto in 2006. If there are any of you who have not yet completed your plans, we hope you will take the time to join us for this outstanding gathering of the world’s most collegial doctors, the best exhibit hall in the specialty, the expansive educational offerings, and the community and connection that many of us find to be the best reason to attend. While the meeting educational content and programming is superb, what is unique about our Annual Meeting & OTO EXPO is the unparalleled opportunity for combining great programming with discussions, interaction, committee work, social renewal, coordinating specialty society action, and invigorating our practices. Since a large number of our members practice in settings of five or fewer otolaryngologists, the social interactions and the clinical discussions and sharing are a great relief. Having spent 13 years as a solo practitioner, I remember with fondness the satisfaction of having my friends and colleagues at my elbow for the week of the Annual Meeting. Upholding Our Public Image Public perception of the medical profession remains a challenge. Several times during the last year, articles have appeared in major newspapers with an exposé or “investigative reporting” tone, casting a negative light on the AMA Relative Value Update Committee (RUC) that advises CMS on setting appropriate relative value units (RVU’s) for medical services. The RUC does not set physician prices, but only addresses relative values of services across the Medicare Physician Fee Schedule (MPFS). It is not a “secret committee” as reported, but invites all relevant stakeholders, including Centers for Medicare & Medicaid Services (CMS) representatives and members of the Medicare Payment Advisory Commission (MedPAC), to attend and only embargoes its work to prevent exploitation prior to publication of final MPFS each fall. The Academy has been involved in the RUC process since its inception more than 20 years ago, and we support continued use of the AMA RUC as the primary method for validating physician work RVUs. We believe physician input allowed by the RUC valuation process serves as an essential piece of evaluation for the work and intensity of physician services. The continued and almost willful misinformation that is generated paints physicians as self-serving and incorrectly tarnishes those who contribute many hours of service to help navigate the morass of codes and descriptors we must use to report our work. One of the most recent examples in The Washington Post on July 21 took particular issue with what it presented as physicians padding the time it takes to perform a procedure. While the article focused on gastroenterology, orthopedics, hand surgery, and ophthalmology, the implication is that the practice of reporting more time than actually needed for a procedure is widespread and intentionally done to increase reimbursement. The AMA staff and RUC leadership have responded with appropriate corrections to the misinformation and made these available. We should familiarize ourselves with the correct information and at least have a minimal understanding of how we participate to fairly represent the relative value of our work. See www.bit.ly/RUCprocess. Spearheading Our Leadership Selection By the time you read this, those elected to Academy office this summer will already have been announced and will be assuming their roles very shortly. Periodically, I try to remind each of us of the great depth of effective leadership, mentors, and role models within our membership. We have a Nominating Committee, which takes seriously its charge to put forward names of highly motivated and devoted individuals who will serve the Academy and Foundation well. Most of our Nominating Committee members do their work quietly and without much notice from the majority of the Academy members. But their task is arguably one of the most important of all our elected officials, as they are primarily responsible for the quality of the next generation of board members and officers. I take this opportunity to thank them for their work on behalf of the entire membership and personally as well. The process by which they consider and choose candidates has improved each year. More preparation goes into studying what is needed for each position. More familiarizing takes place on the strategic plan and direction of the Academy and Foundation. Knowing that every name they consider is a leader and an exceptional physician, they keep their discussions confidential and discreet, and ensure the names of all being considered are given the respect and honor they deserve. Next month we will begin a new leadership year. Please join us in Vancouver as we celebrate an exceptional year of accomplishment and kick off a new year of continued growth and improved service to all otolaryngologists.
James L. Netterville, MD AAO-HNS/F President
The Community of, and for, Otolaryngology
So I came in a believer, and I go out a believer—I believe in our “Community of Otolaryngology.” I think this is a wonderful outcome for my presidential year at the AAO-HNS/F. I have become more aware during this past year of the threats and distractions that are a constant for those who take on the job of keeping our community together. As I was thinking about this, my last column, the U.S. Senate has just barely avoided use of the nuclear option over presidential executive branch approvals. While I am relieved by this news, I am not untouched by the drama. I can see more clearly than ever that for a community to be sustained, its members must put the health of the community before the concerns of its components. I am convinced we must persist in our scientific and humanistic engagement. What Defines Our Community? I have tried to put my arms around our own community to isolate the basis of its power. Our community experiences all the challenges of similar groups: It struggles with diversity, growth cycles, challenges to its purpose, claims for its attention, changing demographics, and technology to name a few. It has many aspects of a scholarly community. It regularly collaborates toward continued improvement in outcomes and learning through supportive leadership and structural conditions. It collectively challenges, reflects, and advances understanding; it acts with consensus on essential activities. It has similar challenges to that of a business community—it is not a static entity. It has cycles that are specific to its groups and its governance. It needs to respond to its members’ needs, innovate, sustain, grow, and maintain a mutually trusting relationship that is both personal and professional. It needs economy of scale, and it is challenged to be more personal and available. Late last decade, we recognized the emergence of Communities of Practice. These were defined as groups of people who share a concern or a passion for something they do and learn how to do it better as they interact regularly. They enable practitioners to take collective responsibility for managing the knowledge they need, recognizing that given the proper structure they are in the best position to do this. There is no doubt that the broader otolaryngology community functions in the same way. What Do We Have in Common? Well, I think we are all of these types of community and more. Aside from our particular expertise and unique medical skills, we share a vision and a mission for this community. We consistently demonstrate commitment to patient care, improving world health, and supporting the whole medical community. We challenge each other to be our best, to move forward, to improve and grow as a group, and as individuals. While community identity is hard to pin down, there is a sense that a desire to be part of a community is strengthening. I have seen evidence of our commitment and passion with every issue of the Bulletin published during my presidential year. I invite you to review the reading list below from this year’s Bulletin. Taken together, these articles articulate a community that is vital, challenging, questioning, and committed to our future. 2012 October page 20—Academy and Foundation Cluster and Committee Rosters October page 41—Summary: Proposed CY 2013 Medicare Physician Fee Schedule November Center insert—2012 Annual Report November page 20—The Hal Foster, MD Endowment—From Dream to Reality December page 20—Education: Meeting the Needs of All Our Learners December page 25—You Asked and The Academy Answered: Introducing AcademyQ January pages 34 & 35 Academy Highlights Success: Changes in 2013 Coding and Reimbursement for ENT Services in 2013 2013 January page 37—Clinical Consensus Statement: Tracheostomy Care February page 30—Position Statement Updates (A second round will be completed this month). February page 41—Communication Is Key (Continuing series on Patient Safety by Rahul K. Shah, MD) March page 14—Choosing Wisely: Our List of Five Things Physicians and Patients Should Question March page 20 and insert—World Voice Day 2013: Connect with Your Voice (included poster) April pages 26 & 27—Overviews of 2013 Federal Legislative Priorities and State Legislative Priorities April page 22—The BOG Spring Meeting & OTO Advocacy Summit May page 36—You’re Invited: 2013 Annual Meeting & OTO EXPOSM
International Resident Exchange
In the fall of 2012, Gregory W. Randolph, MD, international coordinator and chair, International Steering Committee, commissioned a task force to investigate the possibility of an international resident exchange program as a collaborative effort between the committee and Latin American International Corresponding Societies. Members of this task force are Hilary A. Brodie, MD, PhD, Juan Manuel Garcia, MD, Dr. Randolph, J. Pablo Stolovitzky, MD, and Mark E. Zafereo, MD, PhD. Goals of the exchange include providing U.S. residents and international residents an opportunity to experience unique aspects of otolaryngology-head and neck surgery training and patient care at an international academic institution, and to foster relationships between U.S. and international training programs. The task force extended invitations to six American and five international residency programs to take part in a resident exchange program. The six American institutions include programs from five states, and the international institutions include programs from Mexico and Central and South America. Residents from these programs will be invited to visit an international OTO-HNS training program. Any U.S. or international programs that wish to participate in this international resident exchange program can email Dr. Zafereo (mzafereo@mdanderson.org) for details.
Changing Lives in Rwanda, the Land of a Thousand Hills
Yi-Hsuan E. Wu, MD Tufts Medical Center Boston, MA Inspiring. Refreshed. Energizing. Humbled. Those are some of the words my fellow team members and I use when describing our mission experience. With the help of a grant from the AAO-HNSF Humanitarian Efforts Committee, I had the privilege of joining Medical Missions for Children (MMFC) on its annual trip to Gitwe, Rwanda, in March to treat patients with endemic goiter due to iodine deficiency. Jagdish K. Dhingra, MD, has led the team, made up of 15 healthcare professionals and volunteers from the United States and Rwanda, for the past seven years. We arrived with 44 pieces of luggage in tow, including instruments, electrosurgical generators, and medications. The first day was spent turning two nearly empty rooms of the hospital into a functional operating room and recovery unit. With the help of Vianney Ruhumuliza, our in-country partner, prescreened patients were already at the hospital awaiting our evaluation and hopefully, surgical intervention. One woman had walked for three days for her chance to meet us. Unfortunately, not everyone with an operable goiter was able to be treated during our short time in Gitwe. These patients were given follow-up instructions and asked to return next year. Throughout the week, we took note to be thankful for the amenities taken for granted back home. Power went out unpredictably and frequently during surgeries, often leaving the surgeons without the ability to use electrocautery and the anesthesiologists with the task of keeping patients ventilated with an Ambu bag. Without a sterile processing unit (only a small autoclave), the surgical technologists diligently cleaned and packed the instruments between operations and rationed the use of clean towels, drapes, and sponges. Despite these hurdles, the team completed 25 subtotal thyroidectomies in six days. Everyone will remember Liliane, a friendly and attractive young woman with a contagious smile and an enormous goiter that involved her entire neck and extended to her left ear. Her surgery was the longest and most challenging. It was particularly rainy that day, and we lost power a few times during her seven-hour procedure to remove the two-pound mass from her neck. She had lost a fair amount of blood and also required nasogastric tube feeds for a few days. The team celebrated each step in her recovery, from drain and staple removals to finally being able to tolerate a regular diet. Despite being away from her children for nearly two weeks while recuperating in the hospital, Liliane smiled every day. Our last day in Gitwe was filled with hugs and “murakoze” (“thank you” in Kinyarwanda). In return, we are thankful for the opportunity to change lives and to “return to the essence of the profession,” as well expressed by David Gregg, MD, one of the attending surgeons on the team. I remain touched by every patient’s gratitude and positive attitudes and look forward to my next medical mission trip.
Congratulations to 2013 International Visiting Scholars
Please welcome the following scholars at our Annual Meeting & OTO EXPOSM in Vancouver. They will be recognized and receive their certificates and scholarship grants during the International Assembly from 2:00 pm-4:00 pm Tuesday, October 1. Ahmed Hassan Allam, MD, MRCS, MSc, Mansoura University School of Medicine, Egypt (University of British Columbia) John W. Ayugi, MBChB, MMED ENT, University of Nairobi, Kenya (University of Kentucky) Tripti Kaur Brar, MS ENT, DNB, MBBS, Maulana Azad Medical College, India (University of Miami) Angela Maria Campos, MD, Fundacion Universitaria de Ciências de la Salud, Colombia (University of Iowa) Guyan A. Channer, MD, Kingston Public Hospital, Jamaica (Johns Hopkins University) Wakisa Katepala Mulwafu, MBBS, FCORL (SA), University of Malawi College of Medicine, Malawi (Vanderbilt University) Christian Gomez Quiroz, Universidad San Martin de Porres, Peru (House Research Institute) Doreen Nakku, MBChB, Mbarara University of Science and Technology, Uganda (University of British Columbia) Sunita Chhapola Shukla, MS, DNB, FCPS, DORL, Mumbai Port Trust Hospital, India (Columbia Cochlear Implant Center) Kapil Sikka, MBBS, MS, DNB, All India Institute of Medical Sciences, New Delhi, India (Stanford University) Myrton Smith, MBBS, DM (ORL), University Hospital of the West Indies, Jamaica Basim Metwally Wahba, MD, DOHNS, MRCS, Cairo University Faculty of Medicine, Egypt (Yale University) Dr. Campos is the Antonio de la Cruz Scholar. Dr. Nakku is the Nancy L. Snyderman Scholar. Dr. Mulwafu is the Gelot Scholar.
Manohar Bance, MB, MSc
2013 Annual Dinner Meeting of the Otolaryngologists of Indian Heritage
The 36th Annual Meeting of the American Association of Otolaryngologists of Indian Heritage (AAOIH) will take place 6:45 pm-11:00 pm Monday, September 30, at Maurya Indian Cuisine, 1643 West Broadway, Vancouver, BC,  Canada. The featured speaker will be Manohar Bance, MB, MSc, FRCSC, of Dalhousie University, Halifax, NS, Canada.For charges and details about the upcoming meeting, please contact Pete Batra, MD, secretary (pete.batra@utsouthwestern.edu), or Satish Govindaraj, MD, president-elect (satish.govindaraj@mountsinai.org). Attendance at the Annual Dinner meeting is anticipated to be large and an RSVP is strongly encouraged. Otolaryngology residents of Indian heritage are encouraged to present their scientific work at the meeting. Three prizes will be announced. Residents who would like to present are urged to email Kevin D. Pereira, MD, at kevindpereira@gmail.com. Those desiring to join the organization are encouraged to contact Ameet Singh, MD, membership secretary. Email dr.ameetsingh.ent@gmail.com or visit www.aaoih.com. In addition, Arun K. Gadre, MD, AAOIH president, will convene a meeting of the Executive Board 4:30 pm-6:00 pm on Sunday, September 29, in the Vancouver Convention Centre, ICS room (Room 111). Board members are requested to RSVP Dr. Gadre at akgadr01@exchange.louisville.edu.
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Education Evaluations: Why Your Answers Matter
As we approach the 2013 Annual Meeting & OTO EXPOSM in Vancouver, it is important to look at the value of education activity evaluations and the role they play in the overall education program of the Foundation. At the end of each Annual Meeting miniseminar and instruction course, attendees line up at the onsite computer stations to answer a series of questions pertaining to the session they just attended. This is also true for everyone who participates in our more than 150 online courses and lectures, as well as Patient Management Perspectives in Otolaryngology and Home Study Course subscribers. The responses to these questions represent an integral part of what the education leadership considers as they plan education activities that will benefit both our members and their patients. First and foremost, the evaluation process is a requirement for awarding AMA PRA Category 1 Credit™ for the education activity. One of the AMA PRA core requirements for certifying activities specifically states “the activity must evaluate the effectiveness in achieving its educational purpose and/or objectives.” This effectiveness is measured in three ways: knowledge, competence, and performance. A change in knowledge answers the question, “Did I learn new information about the topic at hand?” A change in competence answers, “Did I learn how to apply the new information I learned?” A change in performance answers, “Did I master the new skills I acquired through practice?” With the current emphasis on improving patient outcomes, it is critical that physicians are educated on specific skills that will lead to improved practice and quality of care. All education activity objectives are written as outcome objectives that assess whether the participant has learned a new concept, learned a new skill, or perfected a new technique. The Foundation’s focus is always on measuring not just knowledge, but, more importantly, competence and performance. Other questions found on a typical education activity evaluation include an assessment of the content and format of the activity, the resource materials accompanying the activity, the quality and expertise of the faculty, and if there was any appearance of commercial bias associated with the activity. Annually, staff compiles this evaluation data from all the education activities conducted in a given year in order to get a sense of the overall perceptions of activity participants regarding the quality of our offerings and faculties and whether they are influencing patient care outcomes. The summaries from all this data are used by the eight education committees, who serve as content experts and activity planners, to determine future education resources that will be of value to our members. Recently the Foundation acquired a new education data management system to assist in the reporting and assessment process within education. This database helps us to summarize the evaluation responses from participants in all of our education activities. We are currently inputting evaluation data for all activities conducted during the last three years. This information will be valuable to determine which of our products are succeeding at improving the knowledge, competence, and performance of our members. This new tool will help us better access and utilize this data during future education planning. Needs Assessment Evaluations are just a part of the process of determining the education needs of our members. As mentioned throughout the year, the Foundation has been involved in a membership-wide education needs assessment initiative. One of the components of this initiative has been to perform a gap analysis within the discipline of otolaryngology-head and neck surgery. A gap analysis is a formal study of what the profession is doing currently and where it needs to be in the future. In relation to the practice of otolaryngology-head and neck surgery, this analysis will provide evidence where physician knowledge, competence, and practice may be lacking or best practices are not being utilized. The results of this analysis will help the Foundation determine where best to allocate its time and resources to address these gaps through education and knowledge products. Another component of this initiative was the education needs assessment survey sent to members in August. This survey was another important tool to help paint the overall picture of where the Foundation currently stands in providing valuable education to our members and where it should be going in improving these efforts. While individual education activity evaluations provide insight into one specific education activity, the member-wide survey targets the needs of the entire membership. Results of this initiative will be shared and discussed in a future Bulletin. Combined, all of this evaluation data is critical to help the Foundation create a quality and effective education portfolio that will provide the best service to our members. So the next time you hear “be sure to complete your evaluation,” do so knowing your input is vital to the success of the education program at the Academy.
Learn about Clinical Practice Guidelines at Annual Meeting
Each year, the AAO-HNSF looks to the annual meeting as the premier venue to present its most recently published Clinical Practice Guidelines to the otolaryngology community. This year, those guidelines will include tympanostomy tubes and Bell’s palsy. In 2012, annual meeting attendees listed guidelines as the No. 1 topic they wanted to learn more about in 2013. In response, there also will be a miniseminar that presents the American Academy of Pediatrics’ Clinical Practice Guideline on the Diagnosis and Management of Obstructive Sleep Apnea Syndrome and an instruction course that revisits the AAO-HNSF Clinical Practice Guideline: Polysomnography for Sleep Disordered Breathing. At this year’s meeting we will have two opportunities to learn about the methodology behind clinical practice guidelines. First, an instruction course will teach attendees how to interpret and prepare a systematic review that clinical practice guideline developers use to inform guidelines. A second course will focus on the methodology behind the AAO-HNSF clinical practice guidelines. Sunday, September 29 10:30 am-11:50 am NEW Miniseminar: AAO-HNSF Clinical Practice Guideline: Bell’s Palsy Moderator: Reginald F. Baugh, MD Presenters: Gregory J. Basura, MD, PhD; Lisa Ishii, MD, MHS; Seth R. Schwartz, MD, MPH 10:30 am-11:50 am Miniseminar: Pediatric OSAS: Guidelines, Evidence, and Nuance Moderator: Steve Maturo, MD Presenters: Scott Brietzke, MD, MPH; Stacey L. Ishman, MD; Ron B. Mitchell, MD 3:00 pm-4:00 pm Instruction Course: How to Interpret and Prepare a High Quality Systematic Review Instructors: Martin J. Burton, MD, and Richard M. Rosenfeld, MD, MPH Monday, September 30 8:00 am-9:20 am NEW Miniseminar: AAO-HNS Clinical Practice Guideline on Tympanostomy Tubes Moderator: Richard M. Rosenfeld, MD, MPH Presenters: Melissa Pynnonen, MD, MS; David E Tunkel, MD; Seth R. Schwartz, MD, MPH Tuesday, October 1 3:00 pm-4:00 pm Instruction Course: Review of Pediatric Polysomnography Guidelines Instructor: Norman R. Friedman, MD Wednesday, October 2 1:45 pm-2:45 pm Instruction Course: Understanding Clinical Practice Guidelines Instructor: Richard M. Rosenfeld, MD, MPH
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Patient Safety and Quality Improvement: What is the Next Goal?
Rahul K. Shah, MD George Washington University School of Medicine Children’s National Medical Center, Washington, DC A start of a new academic year is ahead of us and I am preparing to orient new residents and fellows to our hospital’s safety culture. As I reflect on the lecture, I recall my orientation to internship, which lasted just long enough to sign my paperwork (without reading it) and get an ID badge. Orientations for current residents and fellows now take three to four days! Why? What are they learning that is so crucial that we attendings are left alone to care for our patients this first week of July? At our hospital, one of the first things trainees learn about is our safety culture. Interestingly, the boring parts of orientation were pushed back onto days three and four. Yes—days three and four. These poor residents and fellows have a week of orientation (excluding July 4th) prior to being set free in the hospitals. The first words many of the trainees hear are about the safety culture and the safety transformation. The last decade has brought about significant advancements and strides in improving patient safety and quality improvement. If you are dubious, simply look at our academy. Much of what we talk about, what we are concerned about being measured upon, and what our payment ultimately will depend upon are the quality of care we provide and how we demonstrate that the care is on par with the standard. Indeed, the orientation for the incoming residents and fellows made me ponder what are the next goals for the patient safety and quality improvement initiatives especially vis a vis our Academy membership. There is myriad data showing that quality improvement is needed in American healthcare and that such improvements have demonstrable improvement in the overall quality patients receive. My thoughts (and only mine, not the Academy’s or others) are that there will be three areas that much attention will be devoted toward as we embark upon a new year of interns, residents, and fellows. The use of big data to drive quality improvement will begin to take form. Indeed, the Global Tracheostomy Collaborative (see: http://globaltracheostomycollaborative.org/, which I am honored to be a part of) is one such example of using institutional datasets to improve the care of a specific condition on a macro-level (in a collaborative). There will be an emphasis on the role of the smaller group practices and the private physicians and how they can drive quality improvements (and measure such interventions). The majority of initiatives and studies in the last decade have disproportionally focused on inpatients. There are more studies and quality improvement measures emerging about surgical quality improvement in the latter half of the last decade. The next frontier will be affecting where the majority of patients receive their care—out of the hospital. Finally, my thoughts on the last macro level trend would be focused attention on “getting to zero.” I do not know whom to attribute this classic quotation to, but it has been garnering significant attention in the patient safety and quality improvement world. The basic concept is even one child harmed is one too many, etc. The concept of “getting to zero” is to completely eliminate medical error as a source of patient harm. Of course, this is a lofty goal and perhaps not even attainable, but it is nevertheless worth striving for. In the past decade, major institutions have noted a marked decrease in serious safety events by more than 80 percent. Just as in most business and operations, the next 20 percent will take most of the effort and time. It will be interesting to see the path that the patient safety and quality improvement initiatives take in the coming years, but I believe the next goals will focus on collaborative initiatives to drive improved outcomes, an increased focus on outpatients (where most patients receive care), and finally there will be significant efforts geared toward “getting to zero.” We encourage members to write us with any topic of interest and we will try to research and discuss the issue. Members’ names are published only after they have been contacted directly by Academy staff and have given consent to the use of their names. Please email the Academy at qualityimprovement@entnet.org to engage us in a patient safety and quality discussion that is pertinent to your practice.
3P Update: Academy Advocacy Efforts with United Healthcare and Aetna Coverage Policies
James C. Denneny III, MD, Michael Setzen, MD, MPh, MA Jenna Kappel, AAO-HNS Health Policy Director Harrison Peery, AAO-HNS Health Policy Analyst During the last year, several Academy members have experienced reimbursement issues with larger insurers for procedures associated with rhinoplasty, septoplasty, and repair of vestibular stenosis. In response, the Physician Payment Policy (3P) workgroup, supported by Health Policy staff and Academy committees, have been working with Aetna and United Healthcare (UHC) to revise their medical policies. The Academy has written several letters during the past four years to UHC requesting changes to its clinical policy and has gradually received positive revisions from UHC. Many changes have been made to the policy on rhinoplasty, septoplasty, and repair of vestibular stenosis in response to our recommendations. In recent efforts, the Academy wrote another letter requesting that UHC make several modifications to the policy based on outstanding issues. Below is a table indicating how UHC has responded to the most recent Academy requests. The Academy, similarly, has initiated advocacy efforts with Aetna to change its rhinoplasty and septoplasty policy due to specific reimbursement issues members have reported to Health Policy. In April, 3P and Health Policy staff worked with the Rhinology and Paranasal Sinus Committee and the Facial Plastic and Reconstructive Surgery Committee to assimilate comments into a letter sent to Aetna. Notably, Russell W. H. Kridel, MD, and Steve Duffy of the American Academy of Facial Plastic and Reconstructive Surgery Association assisted with advocacy and along with 3P, participated on a recent conference call with Aetna executives. The Academy anticipates positive changes to Aetna’s policy and potential future collaborations with Aetna policy executives. These policy changes show how important it is for Academy members to advocate at the local level and keep Health Policy staff informed about reimbursement issues. It is important to nurture good relationships with medical directors and decision makers, get involved in the committee structures and be well prepared to present a cogent argument supported by clinical data. For more information on the Academy’s guidance in addressing local and state private payer denials, see http://bit.ly/payerdenials. “Persistence beats resistance” in most cases, according to Dr. Setzen. Regarding policy changes requested, but not accepted by UHC, the Academy continues to advocate for necessary revisions and sent a follow up letter to UHC in early August revisiting those concerns. If you receive an inappropriately denied rhinoplasty or septoplasty claim from an insurer, email healthpolicy@entnet.org so that we may track the issue. – See more at: http://aaobulletin.365.staging2.ascendmedia.com/Highlight.aspx?p=479&id=6354#sthash.AbUhGdqc.dpuf
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Imaging Committee Update
Gavin Setzen, MD, chair  Jenna Kappel, MPH, MA, director, Health Policy and Staff Liaison, Imaging Committee On behalf of the Imaging Committee, we want to share some of the recent efforts with members, including involvement in the new head and neck ultrasound accreditation program, updates on the joint survey with the American Rhinologic Society on CT imaging, participation in the Academy’s Clinical Practice Guideline on Bell’s palsy, comments on the Milliman Care Guidelines regarding their requirement for a CT scan for stapedectomy, and review of AcademyU® courses to develop a CME resource for members to help them meet accreditation requirements. New Opportunity for Academy Members: AIUM Head and Neck Ultrasound Accreditation   The Academy’s Imaging Committee continues to educate members on CT imaging policy and regulation. During the past year the committee has also assumed a more proactive role in ultrasound imaging in the head and neck region as this modality has become an integral part of contemporary management of patients with a variety of head and neck conditions. The Imaging Committee and the Head and Neck Surgery Education Committee facilitated a course in thyroid and parathyroid ultrasound at its Annual Congress Meetings, and Head and Neck Ultrasound Exported Courses, provided by the American College of Surgeons, were available via a variety of selected venues to include the American Academy of Otolaryngology—Head and Neck Surgery. Individuals who attended these courses and took the online post-test completed the first step in developing the opportunity to provide point-of-care ultrasound in their practice. However, until now there was no way of accrediting a subsequent experience and documented expertise in ultrasound of the head and neck. The American Institute of Ultrasound in Medicine (AIUM) and our Academy have merged their interests in head and neck ultrasound to provide a comprehensive accreditation process, which should be available for application by the time of the Annual Meeting in Vancouver. This will require successful completion of an ACS-sponsored course, a waiting period of a minimum of six months to accrue adequate experience, submission, and examination by an appointed Review Board of a requisite number of cases to include documentation of guided FNA, and maintenance of AMA PRA Category 1 CreditsSM. This is a preliminary notice that will be followed by formal details and means of applying in a subsequent issue of the Bulletin. The ultrasound workshop, led by Robert Sofferman, MD, with Russell Smith, MD, Lisa Orloff, MD, and Merry Sebelik, MD, worked diligently with AIUM and ALS to develop this opportunity, and we thank them. AAO-HNS/ARS CT Imaging Survey The Academy’s Imaging Committee joined with the American Rhinologic Society (ARS) to develop a questionnaire to jointly survey Academy and ARS members, including residents and fellows in training, regarding practice patterns and other aspects of CT imaging in patients with paranasal sinus disease. The response rate to the survey was tremendous with more than 300 surveys completed. The Imaging Committee and the ARS are currently analyzing the data to assess potential areas to improve care provision, safety, and quality, as well as address potential issues relating to knowledge gaps and educational opportunities. These data, together with the Clinical Consensus Statement on Appropriate Use of Computed Tomography for Paranasal Sinus Disease, will be helpful to members and payers and policy makers alike. A subsequent issue of the Bulletin will include a summary of the results of the survey. Bell’s Palsy Clinical Practice Guideline The Imaging Committee was asked to participate in the external peer review process for the newly developed clinical practice guideline (CPG) on Bell’s Palsy, chaired by Reginald Baugh, MD. Members who participated in the external peer review process for the guideline included Joseph Scharpf, MD, and David Friedmann, MD. This multidisciplinary guideline addresses the management of acute idiopathic unilateral facial nerve paresis or paralysis, and is intended for any clinician involved in the care of a patient presenting with Bell’s palsy. The primary purpose of this guideline is to improve the quality of and reduce variation in the care Bell’s palsy patients receive. Review of Milliman Care Guidelines on Requirement of Use of CT Scan for Stapedectomy   The Academy sent a letter on May 14 to leaders at Milliman Care Guidelines (MCG) regarding their guideline requiring a CT scan prior to a stapedectomy procedure. Many health plans utilize MCGs as the basis for coverage determinations. After thoroughly researching the issue, we received approval from Gavin Setzen, MD, and the Academy’s Physician Payment Policy (3P) workgroup to request that MCG provide a copy of the guideline and work with the Academy to align it with current clinical care, which does not require a CT scan. Early in August, the MCG Medical director  responded  that he had received our letter and found the information most helpful, noting it is under consideration along with the rest of  the medical evidence base that might help inform  improvements to the MCG guidelines as part of their current cycle of research and guideline updating. Any additional updates received on the outcome of this effort will be provided to members via the News, HP Update, and a future Bulletin issue. Review of 100-plus Online Courses  The Imaging Committee is also in the process of reviewing more than 100 online courses to determine whether they are imaging-related or not. This is an important activity because the new CME library will provide members who perform CT Imaging with CME resources to meet accreditation, particularly if they cannot wait to attend the annual meeting. Accreditation for CT imaging is a requirement by the Centers for Medicare & Medicaid Services (CMS) for practices to receive payment for Medicare patients. The link to the online courses that are imaging-related will be available by the end of 2013.
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Proposed CY 2014 Medicare Physician Fee Schedule (MPFS): What Does It Mean for You?
On July 8, the Centers for Medicare & Medicaid Services (CMS) posted the proposed Medicare physician fee schedule (MPFS) for calendar year (CY) 2014. In addition to payment policy and payment rate updates, the MPFS addresses a number of quality initiatives. The Academy will submit comments to CMS on the proposed rule by the September 6 deadline. The Academy also developed a member summary, which can be accessed here: http://bit.ly/CMSregs. Key provisions Members should be aware of from the proposed rule include: Medicare Sustainable Growth Rate (SGR) Formula The overall estimated impact of the policy changes within the proposed rule for CY 2014 MPFS on otolaryngology is -2 percent. [Note: This amount does not include the possible 24 percent reduction to the conversion factor (CF) that could result if Congress does not take action to prevent the annual cuts from the SGR]. As in years prior, it is expected that Congress will take action to avoid the impending cut before the January 1, 2014 deadline. The Academy continues to campaign for a permanent repeal and replacement of the SGR formula, and has submitted comments on the recent SGR repeal and payment reform legislation. Practice Expense One of the biggest changes in the proposed rule is CMS’ suggestion to change to the methodology for setting practice expense RVUs for services under the PFS. Specifically, they propose that for PFS services provided in the physician offices whose payment rates exceed payment for the same procedure when performed in a facility (hospital outpatient department (HOPD) or Ambulatory Surgical Center (ASC)), CMS would use current year OPPS or ASC rates as a point of comparison in establishing PE RVUs for services in the office under the PFS. For services on the ASC list, they would make the same comparison except they would use the ASC rate as the point of comparison instead of the OPPS rate. In these cases, CMS proposes to limit the office PE RVUs for individual codes so that the total office PFS payment amount would not exceed the total combined amount Medicare pays for the same code in the facility (hospital or ASC) setting. Of note, this policy will severely affect several key Otolaryngology services and the Academy plans to submit comments to CMS on this issue. See the Academy’s summary for a full analysis of impact on ENT service here http://bit.ly/entPEchart. Requirements for Billing “Incident To” Services CMS proposes to revise its regulations to require that individuals performing “incident to” services meet any applicable requirements to provide the services, including licensure imposed by the state in which the services are being furnished. CMS says this will not only provide health and safety benefits to the Medicare patient population, but also assure that federal dollars are not expended for services that do not meet the standards of the states in which they are being furnished. This change will also allow CMS to recover federal government funds paid where services and supplies are not furnished in accordance with state law. This will affect Otolaryngology offices providing incident to services, thus we encourage all practices to ensure their non-physician providers are in compliance with state licensure requirements, to allow for appropriate Medicare reimbursement for the services they provide. Physician Quality Reporting System (PQRS)  CMS proposes many overarching changes to the PQRS system, highlights of those affecting otolaryngology are below: As a direct result of Academy advocacy during the past several years, CMS proposes inclusion of four of the Academy Sinusitis Measures for reporting in 2014. CMS proposes eliminating two measures applicable to otolaryngology and eliminating the claims based reporting option for two additional measures applicable to otolaryngology. CMS proposes increasing the number of measures Eligible Professionals (EPs) must report on to qualify for an incentive payment in CY 2014, from three to nine measures. CMS proposes to remove the option of reporting via administrative claims for CY 2014 reporting. CMS proposes to reduce the percentage of patients EPs must report on using a registry from the previous 80 percent down to 50 percent for CY 2014. As indicated below, physicians are eligible to receive a .5 percent incentive payment, or could be subject to a two percent penalty, assessed in 2016, based upon PQRS reporting in 2014. It is important to note these penalties and incentives are separate from other programs such as the EHR Meaningful Use, Electronic Prescribing, and Value Based Payment Modifier programs. Physician Compare Website Recently, CMS released a redesigned Physician Compare website that includes a physician’s address, education and ABMS board certification information, hospital affiliations, and EPs’ language skills.  CMS is required to post the names of EPs who satisfactorily report under PQRS and those who are successful e-prescribers under the Medicare eRx Incentive Program. CMS intends to place a check mark moving forward for any individual who has earned a Maintenance of Certification additional Incentives starting with data reported for CY 2013. CMS also plans to post 2014 PQRS GPRO performance data and data from the CG-CAHPS surveys for group practices of 100 or more EPs reporting data under the GPRO in 2013, and for ACOs participating in the MSSP in 2014. For future years CMS proposes to post adding performance rates on measures and patient experience survey measures such as Clinicians and Group Consumer Assessment of Health Providers and Systems (CG-CAHPS) for groups participating in the and Accountable Care Organization (ACO) programs. These proposed changes will likely affect otolaryngology-head and neck surgeons as more information regarding the public’s opinion of the quality of care they received will be posted. The information available on the website is populated automatically from CMS’ PECOS system, so it is critical that members verify their information is accurate. Visit the Physician Compare website at http://www.medicare.gov/physiciancompare. For additional information on what CMS intends to post in future years, access the full Academy summary at http://bit.ly/CMSregs. Electronic Health Record (EHR) Incentive Program CMS proposes that EPs may use the new qualified clinical data registry (QCDR) mechanism to report clinical quality measures that meet both EHR Meaningful Use and PQRS reporting specifications. The measures included in a QCDR are not required to be approved by the National Quality Forum (NQF). Aligning with proposed changes to PQRS reporting, EPs would report nine Clinical Quality Measures (CQMs) included in the Stage 2 final rule covering at least three domains. The Academy is reviewing the requirements to determine if this may be a feasible avenue for otolaryngologists use in the future and will be commenting on the proposal. Value Based Payment Modifier  & Physician Feedback Program  CMS proposes expanding the Value Based Payment Modifier (VBPM) to groups of 10+ EPs in CY 2014. The VBPM is based on PQRS participation. Groups would report via GPRO-web interface, qualified registries, EHRs, or individually if 70 percent of all EPs in the group report successfully. 2014 reporting will be used to determine whether a payment penalty will apply in CY 2016. CMS plans on expanding the VBPM to all EPs by 2017.  An outline of how the program will coincide with PQRS, and how payment adjustments or incentives will be allocated, is below. Members should also know that as of September 16, groups of 25+ will receive physician feedback reports based on their 2012 PQRS performance. For a more detailed explanation, view the Academy’s Value Based Payment Modifier webpage at http://bit.ly/entVBPM. For a more detailed summary on the proposed requirements for the programs highlighted above, visit the Academy’s CMS Regulations page at http://bit.ly/CMSregs or email questions to Academy health policy staff at HealthPolicy@entnet.org.
Annual Meeting Preview
Get to Know AAO-HNS Advocacy Programs in Vancouver! With the AAO-HNSF 2013 Annual Meeting & OTO EXPOSM fast approaching, now is the time to learn more about the advocacy-related programming available at this year’s meeting. As in past years, the ENT PAC and Grassroots Advocacy Booth will serve as the Government Affairs “hub” in Vancouver. AAO-HNS members are encouraged to visit the booth to learn more about easy ways to support the Academy’s various legislative, political, and grassroots advocacy programs. Be sure to visit to: Obtain information on becoming a 2013 ENT PAC Investor; See who is “investing” in ENT PAC, and at what level, by viewing the renowned ENT PAC “Wall of Investors” for 2013; Hear about ENT PAC’s exciting new resident outreach campaign; Join the ENT Advocacy Network to receive timely updates on political and legislative issues impacting the specialty and a free subscription to a biweekly e-Newsletter, The ENT Advocate; Learn more about the Academy’s new localized grassroots program, “I-GO”; and Receive the latest updates on legislation affecting your practice and your patients. ENT PAC, the political action committee of the AAO-HNS, financially supports federal Congressional candidates and incumbents who advance the issues important to otolaryngology–head and neck surgery. ENT PAC is a non-partisan, issue-driven entity that serves as your collective voice on Capitol Hill to increase the visibility of the specialty with key policymakers. To learn more about ENT PAC, visit our PAC website at www.entpac.org (log-in with your AAO-HNS ID and password).
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Follow Government Affairs on Twitter  Do you want to be one of the first to know the status of healthcare bills moving through Congress? Follow the Government Affairs Twitter account @AAOHNSGovtAffrs. By following us, you can learn more about the issues impacting the specialty, including repeal of the flawed Sustainable Growth Rate (SGR) formula, medical liability reform, scope-of-practice battles, Graduate Medical Education (GME) funding, truth-in-advertising initiatives, and efforts to repeal the Independent Payment Advisory Board (IPAB). Not a fan of Twitter? You can also check the Government Affairs webpage for updates at http://www.entnet.org/Advocacy.
On the Frontlines: State Legislative Tracking
AAO-HNS members are a key resource for tracking state legislation and helping to communicate to policymakers its influence on the specialty and patients. Join the growing team of AAO-HNS state trackers by signing up at govtaffairs@entnet.org to receive daily or weekly legislative tracking updates. If you identify legislation needing Academy action (e.g. letter, action alert, testimony), simply fill out the new online State Action Form at www.entnet.org/Advocacy!
Exclusive Events for ENT PAC Members during Annual Meeting
ENT PAC, the political action committee of the AAO-HNS, financially supports incumbent Members of Congress and viable candidates—regardless of their party affiliation—who champion the specialty’s legislative priorities. Please mark your calendars to join the ENT PAC Board of Advisors and staff for the following 2013 events: The annual ENT PAC Investors “thank-you” reception. This popular event will take place on Monday, September 30, at the Rogue Kitchens. U.S. AAO-HNS members who make donations to ENT PAC prior to or during the meeting are invited to the event! A special “thank-you” luncheon for members of the ENT PAC Chairman’s Club ($1,000+ donors). The luncheon, hosted by members of the ENT PAC Board of Advisors, is a unique opportunity to learn about the Academy’s political strategy and decision-making process. This year’s luncheon will feature an exciting guest speaker from the Canadian Parliament and will take place on Tuesday, October 1. For more information on becoming an ENT PAC Investor, please visit www.entpac.org (log-in using your AAO-HNS user ID & password) or email ENT PAC staff at entpac@entnet.org. *Contributions to ENT PAC are not deductible as charitable contributions for federal income tax purposes.  Contributions are voluntary, and all members of the American Academy of Otolaryngology—Head and Neck Surgery have the right to refuse to contribute without reprisal. Federal law prohibits ENT PAC from accepting contributions from foreign nationals. By law, if your contributions are made using a personal check or credit card, ENT PAC may use your contribution only to support candidates in federal elections. All corporate contributions to ENT PAC will be used for educational and administrative fees of ENT PAC, and other activities permissible under federal law. Federal law requires ENT PAC to use its best efforts to collect and report the name, mailing address, occupation, and the name of the employer of individuals whose contributions exceed $200 in a calendar year.
OTO EXPOSM Open Invitation
The doors of the Vancouver Convention Centre will open soon for the AAO-HNSF 2013 Annual Meeting & OTO EXPOSM. Following up on the feature article in the August Bulletin, we want you to view the OTO EXPOSM as an open invitation to experience first-hand nearly 300 exhibiting companies presenting hundreds of products and services. One new area in particular is the new AAO-HNSF Product Showcase. This venue is designed to enhance Annual Meeting attendees’ product awareness. Don’t miss presentations of innovative and cutting edge ENT products from leading companies like ArthroCare, Olympus, NeilMed Medical PENTAX Pharmaceuticals, and Siemens Hearing Instruments. Our sponsors are eager to share their industry products to help you in your quest to provide the best patient care. Seating is limited to the first 200 people so be sure to include the Product Showcase, Booth 1146, in your plans when completing your Annual Meeting schedule. Look for the schedule of presenting companies in the Final Program and on our Annual Meeting website. We want to be certain that you have the most updated list of exhibitors. Following this piece is a list of the companies we have added since the last issue. At any time we invite you to view the current list and floorplan on our new OTO EXPOSM webpage tailored just for you: www.entannualmeeting.org/13. The excitement continues to build and we are looking forward to welcoming all of our valued attendees to this great event. Vancouver is set to be a gracious host and our team is ready to provide you with what you will need for a terrific experience. Don’t forget, September 29-October 2! New Exhibitors (as of August 1, 2013) Booth 1st Line Medical 2339 Beijing Fanxing Guangdian Medical Treatment Equip 1241 BIOLASE + Valam 1750 Biomet Microfixation 744 Dr. Kim Co 518 ELMED Incorporated 524 European Laryngological Society—ELS 2014 2310 ENTrigue Surgical—new location 2013 GlaxoSmithKline 2240 Healthcare Research Analytics 742 Hospital Information Services (Canada) 436 Immco Diagnostics 526 ImThera Medical Inc 1944 KLS Martin—new location 1118 Laser Engineering 1550 Lippincott Williams & Wilkins 509 Lumenis—Additional For Show Floor Meeting Room 1734-M Magnolia Regional Health Center 2411 Newport Surgical Instruments Inc. 2322 Olive Medical Corporation 542 OtoSim 2236 Passy-Muir Inc 952 Phacon GmbH 1443 QED Medical 2404 RG Medical 1050 Sidra Medical and Research Center 505 Stryker—Additional For Show Floor Meeting Room 2050-M The Oral Cancer Foundation 1946 Theravent Inc. 503 Toshiba Ultrasound 2326 Veracte Inc. 1140 Visionsense 1749 Vivosonic Inc 520 Waiting Room Solutions EMR 2409
Roland D. Eavey, MD, SM In recognition of his selfless dedication to create opportunity and advance the careers of those under his wing
2013 Presidential Citation Recipients
Each year at our Annual Meeting, AAO-HNS/F presidents honor those who have made significant contributions to otolaryngology and have been especially influential in his/her career. This year, President James L. Netterville, MD, has selected six talented individuals to receive the 2013 Presidential Citations and be recognized during the meeting’s opening ceremony in Vancouver, BC, Canada. Dr. Eavey is the director of the Vanderbilt Bill Wilkerson Center for Otolaryngology and Communication Sciences in Nashville, and the Guy M. Maness Professor and chair of the Department of Otolaryngology. He obtained a master’s degree in healthcare management from the Harvard School of Public Health. He trained as a pediatric otolaryngologist and evolved into a pediatric otologist with contributions such as becoming (probably) the first otolaryngology microtia surgeon, inventing the butterfly inlay graft myringoplasty, and serving as the clinical trial site PI of the first widely used pneumococcal vaccine. His collaborative research foci on the pediatric ear, which has received NIH funding, include tissue engineering of an auricle for microtia, the molecular genetics of hearing loss, and hearing loss epidemiology. Dr. Eavey has contributed more than 200 publications, including the New England Journal of Medicine, JAMA, and Nature Genetics. His educational initiatives include creating a novel didactic Vanderbilt resident training program that promotes interactive learning and removes traditional lectures; additionally, he has created a unique four-year resident leadership training program. His service and outreach activity includes serving as the American ear representative of the World Health Organization, making about 30 trips to Latin America to teach primary care providers about otitis media for which Dr. Eavey was honored with the 1997 AAO-HNS Jerome C. Goldstein Public Service Award. Dr. Glasscock earned his medical degree from the University of Tennessee in 1958. He completed residencies at Methodist Hospital-Dallas, Kennedy Veterans Administration Hospital-Memphis, John Gaston Hospital-University of Tennessee, and The Memphis Eye, Ear, Nose and Throat Hospital. His fellowships were in otology and neurotology at the Otologic Medical Group (House Ear Clinic) and the University of Southern California, Los Angeles, CA. Nashville, TN, was the site of his otology/neurotology practice, where he was associated with Vanderbilt University. At Vanderbilt, Dr. Glasscock served as a clinical professor of surgery (otology and neurotology) from 1981-1997, associate clinical professor of neurosurgery from 1985-1997, and adjunct professor division of hearing & speech from 1986-1997. He has recently returned to The Otology Group at Vanderbilt to work with residents and otologic fellows in the mining of data from the practice and preparation of scientific articles for publication in peer-reviewed journals. Michael D. Maves, MD, is a leader. Recently, he has served as senior vice president of Development and Global Health Impact Programs for U.S. Pharmacopeia (USP). Before that, he was executive vice president of Project HOPE, with programs in more than 35 countries. Dr. Maves served from 2001-2011 as executive vice president and chief executive officer of the American Medical Association. During his tenure, he provided a stable platform of consistent executive presence through personal leadership and stability that allowed the AMA to concentrate on moving critical national health policy forward. Dr. Maves served as professor and chairman, Department of Otolaryngology–Head and Neck Surgery at Saint Louis University College of Medicine from 1988-1994. He also held faculty appointments at the University of Iowa Hospitals and Clinics, Indiana University School of Medicine, and Georgetown University School of Medicine. He currently is adjunct professor of otolaryngology at the Saint Louis University School of Medicine. From 1994-1999 he was the executive vice president of the AAO-HNS. Under his leadership, AAO-HNS increased visibility in Washington, DC, with its first political action committee. Raised in Toledo, OH, Dr. Maves received his undergraduate degree from the University of Toledo and his medical degree and residency in otolaryngology from Ohio State University. He received an MBA from the University of Iowa College of Business Administration. Dr. Maves has a passion for the people and culture of India. Dr. Maves, his wife Elizabeth, and his youngest son Christopher, support the Chinmaya Vijaya Orphanage and NRI Academy of Sciences in Vijayawada, Andhra Pradesh, India. Dr. Netterville has served as president and founding director of Third World Medical Missions and co-director of African Medical Mission outreach since 1999. These two organizations oversee, organize, and fund otolaryngology–head and neck surgical medical mission trips to Aba, Nigeria, and Malindi, Kenya. As director, he oversees the anesthetic services for each trip, which provides surgical care in underserved rural regions. During each mission, he and his team manage difficult anesthetic care for more than 100 advanced head and neck tumors and congenital malformations, with limited equipment and resources. Hundreds of otolaryngology head and neck surgery attendings, fellows, residents, and medical students have benefited from his wisdom, generosity, and his example of unselfish service. In recognition of his service outside of our U.S. borders, Dr. Netterville was awarded the George Burrus M.D. Humanitarian Service Award by his peers at St. Thomas Medical Center of Ascension Health. He has also served on the board of Wayne Reed Inner City ministries of Nashville, TN. After graduating with highest honors from Lipscomb University, he attended medical school at the University of Tennessee Medical Center. He completed his residency in anesthesiology at Vanderbilt University Medical Center, followed by advanced training in cardiovascular anesthesiology. He was invited to join Cardiovascular Anesthesiologists P.C., based at St. Thomas Health Care in Nashville, where he has served as both president and senior partner. From 1989–2000, he served as adjunct assistant professor of anesthesiology at Vanderbilt Medical Center. After many years as lecturer and clinical faculty, he was elected to the Board of Trustees of Middle Tennessee School of Anesthesia. Dr. Ossoff is the Maness Professor of Laryngology and executive medical director of the Vanderbilt Voice Center. After completing his residency training at Northwestern in Chicago in 1980 and fellowship training in 1981, he became the first Maness Professor and chairman of the department of otolaryngology at Vanderbilt University Medical Center (VUMC) in 1986. In 1991, he established the Voice Center as the first modern advanced training program in laryngology and voice care where more than 44 fellows have been trained. Dr. Ossoff was also a founding director of the Vanderbilt Bill Wilkerson Center for Otolaryngology and Communication Sciences. After 22 years as department chairman, was appointed assistant vice chancellor of compliance in 2008. In 2013, he was appointed as special assistant to vice-chancellor for health affairs at VUMC. Dr. Ossoff is a AAO-HNS former director. He served on numerous committees, including a five-year term as the development coordinator. He is a member of numerous otolaryngology societies and has served as past president of several. In April 2012, he completed his term as president of the Triological Society. He is certified in healthcare compliance by the Compliance Certification Board. Dr. Ossoff has lecturered at numerous local, regional, and national otolaryngological and compliance meetings. Dr. Ossoff serves on the editorial and advisory boards for several otolaryngology professional and compliance journals. Dr. Sofferman is emeritus professor of surgery at the University of Vermont School of Medicine/Fletcher Allen Health Care, and in 2006, he retired as chairman of division of otolaryngology. He graduated magna cum laude from the University of Maryland School of Medicine and trained in general surgery at the University of Colorado, which was interrupted by a military stint. He completed his residency at the Massachusetts Eye and Ear Infirmary/Harvard Medical School and joined the University of Vermont Faculty in 1975. He became chairman of the division of otolaryngology in 1978, a position he had for 28 years. He received the Harris B. Mosher Award from the Triological Society for his work on “Recovery of the Optic Nerve,” and has published more than 70 manuscripts and book chapters on topics including head and neck oncology, and thyroid and parathyroid surgery. His 2012 textbook, Thyroid and Parathyroid Ultrasound, is the culmination of immersion in the clinical application of ultrasound. He established Vermont’s first cochlear implant program in 1986, which remains the state’s only clinically active site. In conjunction with the neurosurgical skull base team he performed all of the division’s neurotologic surgery from 1975 to 2006. He has been chairman of the Endocrine Surgery Committee of the American Academy of Otolaryngology—Head and Neck Surgery and chair of the post-graduate course in head and neck ultrasound of the American College of Surgeons and its National Ultrasound Faculty for the past five years. His focus now is on the application of ultrasound to the diagnosis and management of a variety of head and neck conditions, ultrasound education, and his position on the Admissions Committee of the University of Vermont School of Medicine.
2013-guest-lecturers
Guest Lecturers Carry on Tradition of Excellence
The leaders in medical science of the past built a platform for the leaders of today. And those leaders are now building a platform for the leaders to come. Sometimes their paths have crossed generations, sometimes not. One such leader, Nancy L. Snyderman, MD, a TV medical news star and a head and neck surgeon, will present the John Conley, MD Lecture. Dr. Conley was famous as one of the most innovative and successful of otolaryngological surgeons. Derald E. Brackmann, MD, another of the special speakers at the AAO-HNSF 2013 Annual Meeting & OTO EXPOSM, will present a lecture in the name of his own mentor, who taught him, “Always adapt to changes as they develop.” Change in all medical particulars is the norm now, from economics to reporting systems to the practice of medicine. Some of the leading otolaryngology-head and neck surgery experts will speak before the attendees at this year’s meeting. They will provide the platform to educate their peers and the young physicians who will follow. John Conley, MD Lecture on Medical Ethics 9:10 am-9:30 am Sunday, September 29 “Conversations with Yourself: The Natural  Metamorphosis of a Surgeon” Nancy L. Snyderman, MD, has won research grants and journalism awards, a rare combination in either medicine or journalism, and a tribute to her drive and the conquering of fear, which she says keeps many people from achieving everything they want. She told a biographer: “When I’m sitting at a patient’s bedside explaining surgery, my challenge is still to take very complicated stuff, and in a non-condescending manner, talk to a patient. Well, on television it’s the same thing. I have to take complicated stuff and explain to 10 or 12 million people. The skill set is exactly the same.” A third-generation physician, she says her three mentors were her parents and her chief of surgery during her residency at the University of Pittsburgh, Eugene N. Myers, MD, FRCS Edin. (Hon). “He taught me how to be a really good surgeon… and it’s a lot for him that I vowed that no matter what my other careers were, I would never give up medicine.” And she hasn’t; she is still a practicing head and neck cancer surgeon. She is also Chief Medical Editor for NBC News and AARP The Magazine’s newest columnist. Eugene N. Myers, MD International Lecture on Head and Neck Cancer 9:30 am-10:20 am Monday, September 30 Piero Nicolai, MD, will deliver the Myers lecture, contributing his extensive experience on the subject of when, what kind of surgery, what is new, and more. Nicolai is professor and chairman of the department of otorhinolaryngology at the University of Brescia, in northern Italy. He completed his residency in otolaryngology and subsequently in medical oncology. His clinical and research activities are focused on head and neck oncology and endoscopic sinus and skull base surgery. He has traveled extensively to advance the knowledge of his specialty. In April, he participated in an endoscopic sinus and skull base surgery program presented in Phoenix as a Mayo Clinic Continuous Professional Development program, and he has been awarded the American Academy of Otolaryngology—Head and Neck Surgery Honor Award in recognition of his volunteer contributions to the Academy and its Foundation. Eugene N. Myers, MD, FRCS Edin (Hon), is Distinguished Professor and Emeritus chair, department of otolaryngology of the University of Pittsburgh Medical College. A man active in the practice and the science of medicine, he is a celebrated author of many books in the field. His own research specialty is head and neck oncologic surgery. Howard P. House, MD Memorial Lecture for Advances in Otology 8:00 am-9:20 am Tuesday, October 1 Derald E. Brackmann, MD, of the House Clinic, trained with the medical genius who was Howard P. House, MD. Dr. House, who died at age 95 in 2003, is a legend in the hearing impairment world, having developed groundbreaking surgeries to restore hearing. His one-man laboratory in Los Angeles eventually became the clinic that draws otolaryngologists from around the world to advance treatments for hearing problems. Dr. Brackmann joined the House Institute in the early 1970s. He is now a foremost neurotologist, and will speak on skull base tumors. Dr. Brackmann has helped develop the auditory brainstem implant and is a leader in removal of acoustic neuromas. “Many changes have occurred in the management of skull base tumors during my career,” Dr. Brackmann said, and his work with Dr. House trained him to be prepared for changes. Author of four textbooks and co-editor of an annual series on advances in otolaryngology and head and neck surgery, Dr. Brackmann is clinical professor of otolaryngology and head and neck surgery and neurosurgery at Los Angeles County USC Medical Center. Neel Distinguished Research Lecture 9:30 am-10:20 am Tuesday, October 1 Martin A. Birchall, MD, FRCS, and Professor of Laryngology at the University College of London Ear Institute, Royal National Throat, Nose, and Ear Hospital, will present the Neel lecture. The Neel family and friends established the award in 1993 to disseminate information on new developments in biomedical science. Dr. Birchall will bring his expertise to bear on a subject guaranteed to spur discussion and draw listeners: the exciting prospects and problems with stem cells and airway transplantation. His view: “The drive to regenerate man, or indeed create new human life in whole or in part, is as old as history itself. The legend of Prometheus has been recapitulated throughout the centuries, including by Mary Shelley and Asimov. The contemporary surgeon can take parts from dead human donors and bring them ‘back to life’ in transplantation. “Early first-in-man successes with stem-cell based tracheal replacements in adults and children suggest great promise for such technology… [but] before the Promethean dream can be realized, if indeed it is, many hurdles, scientific, practical, financial and ethical, have to be negotiated. A potential route to clinic will be presented for these exciting new therapies.” Cotton-Fitton Endowed Lecture In Pediatric Otolaryngology 9:30 am-10:20 am Wednesday, October 2 A lecture established to educate otolaryngologists in the care of children will have acclaimed physician Joseph E. Kerschner, MD, as its speaker. Dr. Kerschner is dean of the medical school and executive vice-president of the Medical College of Wisconsin. His subject will be otitis media (OM). He explained, “As we have entered the age of molecular and personalized medicine, our relatively basic understanding of mechanisms of pathophysiology has made quantum leaps with the promise for innovative and novel solutions for OM in the near future.” Dr. Kerschner has a long history of work in pediatric medicine, including as president-elect of the American Society of Pediatric Otolaryngology. He has written 17 books, is a mentor to students, residents, and junior faculty, and maintains an active clinical practice. He also represents his fellow physicians, for example, as a co-writer of a white paper published in the Milwaukee Journal-Sentinel on the dangers of sequestration to Wisconsin’s medical.