Published: October 18, 2013

Laryngectomy and Laryngeal Cancer: A Fascinating and Inspiring Chapter in the Expansion of Otolaryngology

Valerie A. Fritsch, MD Medical University of South Carolina, Charleston Once a universally fatal diagnosis, “epithelioid” carcinoma of the larynx has evolved during the past 150 years into one of the most curable cancers. A historical overview of the diagnosis and surgical management of laryngeal carcinoma shows how this disease became the cornerstone of otolaryngology cancer care. Highlights include important contributions, such as Billroth’s first total laryngectomy in 1873, and Gluck and Cohen’s modified version (1884), which involved completely separating the trachea and pharynx to reduce the risk of post-operative aspiration. Still, at the turn of the 19th century, operative and peri-operative mortality rates were reportedly as high as 50 percent and the procedure was nearly abandoned. Fortunately, rapid biomedical and technologic advances during that time eventually lifted many of the initial limitations. The evolution of laryngoscopy, tracheostomy, neck dissection, and reconstructive surgery, as well as the availability of antibiotics, endotracheal anesthesia, intravenous access, and blood replacement led to a resurgence of radical surgical extirpation in the 1940s. The role of otolaryngologists in improving diagnostic techniques and surgical approaches and reconstruction was key. Since the latter half of the last century, efforts have focused on refining more advanced techniques to improve voice and swallowing outcomes, while maintaining or improving oncologic outcomes. In addition, an increased understanding of the molecular basis of cancer has catalyzed a significant interest in individualized, targeted therapies. Although the prognosis of laryngeal carcinoma remains far from “favorable” by today’s standards, the astoundingly rapid advances of knowledge and technology by our innovative predecessors illustrates the unbounded potential for future discoveries and improvements in our understanding and management of this complex disease. Otolaryngology Historical Society Call for Papers If you are interested in presenting at the next OHS meeting, which will take place Sept. 30 in Vancouver, BC, Canada, email museum@entnet.org.To join the society or renew your membership, please check the box on your Academy dues invoice or email Catherine R. Lincoln, CAE, MA (Oxon) at clincoln@entnet.org or call 1-703-535-3738.

02_Dr-Fritsch_green_fig1Valerie A. Fritsch, MD
Medical University of South Carolina, Charleston

Once a universally fatal diagnosis, “epithelioid” carcinoma of the larynx has evolved during the past 150 years into one of the most curable cancers. A historical overview of the diagnosis and surgical management of laryngeal carcinoma shows how this disease became the cornerstone of otolaryngology cancer care.

Highlights include important contributions, such as Billroth’s first total laryngectomy in 1873, and Gluck and Cohen’s modified version (1884), which involved completely separating the trachea and pharynx to reduce the risk of post-operative aspiration. Still, at the turn of the 19th century, operative and

02_Dr-Fritsch_ukmss-2842-f0002

peri-operative mortality rates were reportedly as high as 50 percent and the procedure was nearly abandoned. Fortunately, rapid biomedical and technologic advances during that time eventually lifted many of the initial limitations. The evolution of laryngoscopy, tracheostomy, neck dissection, and

reconstructive surgery, as well as the availability of antibiotics, endotracheal anesthesia, intravenous access, and blood replacement led to a resurgence of radical surgical extirpation in the 1940s.

The role of otolaryngologists in improving diagnostic techniques and surgical approaches and reconstruction was key. Since the latter half of the last century, efforts have focused on refining more advanced techniques to improve voice and swallowing outcomes, while maintaining or improving oncologic outcomes.

In addition, an increased understanding of the molecular basis of cancer has catalyzed a significant
interest in individualized, targeted therapies. Although the prognosis of laryngeal carcinoma remains far from “favorable” by today’s standards, the astoundingly rapid advances of knowledge and technology by our innovative predecessors illustrates the unbounded potential for future discoveries and improvements in our understanding and management of this complex disease.

02_Dr-Fritsch_Billroth

Otolaryngology Historical Society Call for Papers

If you are interested in presenting at the next OHS meeting, which will take place Sept. 30 in Vancouver, BC, Canada, email museum@entnet.org.To join the society or renew your membership, please check the box on your Academy dues invoice or email Catherine R. Lincoln, CAE, MA (Oxon) at clincoln@entnet.org or call 1-703-535-3738.
More from March 2013 - Vol. 32 No. 03
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2013 Humanitarian Travel Grants: Congratulations to the 15 Residents, Fellows-in-Training Awarded
Thanks to the generous support of Academy members who donated to our humanitarian efforts projects, 15 residents and fellows-in-training received grants of $1,000 each toward medical missions from January through July 2013. For more than a decade, our AAO-HNS Foundation’s Humanitarian Efforts Committee has selected senior residents and fellows-in-training for travel grants to accompany mission teams. While the grants of $1,000 each cannot cover the travel costs, they are an inspiration to the grantees, who return profoundly changed by their experiences. Feedback from returning residents has demonstrated how invaluable these encounters are for both their personal and professional development. Overwhelmingly, the awardees commit themselves to continuing to volunteer for missions throughout their lives. The awardees will be recognized during the AAO-HNSF 2013 Annual Meeting and OTO EXPOSM, Vancouver Convention Centre in Vancouver, BC, during the Humanitarian Forum. Please join us in congratulating these dedicated residents and fellows-in-training. Sarah N. Bowe, MD, Ohio State University Medical Center, Project EAR, Inc., Dominican Republic, Los Alcarrizos, April 13-21, 2013. Do-Yeon Cho, MD, Stanford University, Myungsung Christian Foundation, Ethiopia, Addis Ababa, May 20-31, 2013. David J. Crockett, MD, University of Utah, division of otolaryngology, Operation Restore Hope, Philippines, Cebu, February 15-24, 2013. Ethan B. Handler, MD, Kaiser Permanente Oakland, Faces of Tomorrow, Ecuador, Quito, June 8-17, 2013. Andrew C. Heaford, MD, University of Iowa Hospitals and Clinics; department of otolaryngology: head and neck surgery, Miles of Smiles in Guatemala; Iowa MOST mission, Guatemala, Huehuetenango, February 14-24, 2013. Evan R. McBeath, MD, University Hospitals Case Medical Center, Case Western Reserve University, Concern for Children, El Salvador, San Salvador, January 9-19, 2013. Bryan R. McRae, MD, Indiana University School of Medicine, department of otolaryngology-head & neck surgery, IU-Kenya Program, Kenya, Eldoret, January 19-February 3, 2013. Sachin S. Pawar, MD, Oregon Health & Science University, FACES Foundation, Peru, Lambayeque, January 25-February 3, 2013. Angela S. Peng, MD, University of Minnesota, department of otolaryngology-head & neck surgery, Mayflower Medical Outreach, Nicaragua, Managua, February 16-24, 2013. Maria de Lourdes Quintanilla-Dieck, MD, Oregon Health & Science University, FACES Foundation, Peru, Lambayeque, January 25-February 3, 2013. Joseph W. Rohrer, MD, San Antonio Uniformed Services Health Education Consortium, Face the Future Mission Rwanda, Rwanda, Kigali, February 1-10, 2013. Dhave Setabutr, MD, Penn State Hershey Medical Center, Faces of Tomorrow, Ecuador, Quito, June 7-16, 2013. Laura L. Shively, MD, Dartmouth-Hitchcock Medical Center, Mayflower Medical Outreach, Nicaragua, Jinotega, Managua, February 17-25, 2013. Yi-Hsuan E. Wu, MD, Tufts Medical Center, Medical Missions for Children, Rwanda, Gitwe, March 7-17, 2013. Estelle S. Yoo, MD, Alfred I. DuPont Hospital for Children, department of surgery/division of otolaryngology, World Hearing Foundation, Honduras, Tegucigalpa, March 23-39, 2013. Visit the Humanitarian Efforts Member Engagement Portal to help facilitate matching critical needs with medical specialty expertise: www.entnet.org/humanitarianportal. To learn more about Humanitarian Resident Travel Grants visit http://www.entnet.org/HumanitarianTravel. May 31, 2013, is the deadline for grant applications for mission trips during July 1 through December 31, 2013. Join KJ Lee, MD, for the 2013 China TourKJ Lee, MD, invites you to experience China, June 5-16, after the IFOS World Congress, Seoul, South Korea, and ending at the World Chinese ENT Academy Congress, Hong Kong. Exchange ideas with Chinese otolaryngology leaders and enjoy Chinese cultural heritage, with such famous sights as: The Great Wall, Beijing’s Summer Palace, Tiananmen Square, and Forbidden City Peking Opera and Peking duck banquet Xi’an’s terra cotta warriors and the World Heritage Site, Fujian Tulou Hong Kong To reserve, call 1-203-772-0060, 1-800-243-1806 or email donna.dalnekoff@atpi.com. Questions? Contact Dr. Lee, Academy past president, by calling 1-203-777-4005 or emailing kjleemd@aol.com.
Dr. Azzi, preoperatively with a cleft-lip patient.
Healing the Children: Ecuador
Jean-Paul Azzi, MD New York Eye and Ear Infirmary On Saturday, November 3, 2012, 29 other volunteers and I from Healing the Children Northeast flew from New York City to Guayaquil, Ecuador, on our way to Babahoyo. This would be a new site for us, and with this, we expected to face new challenges. As we discussed our concerns in the airport and on the flight to Ecuador, it was clear that despite this, our goal remained the same: to help these children and their families. Upon arrival we were greeted by our hosts Drs. Roxana Roman and Rafael Hernandez, as well as the local police force who escorted us to Babahoyo and our hotel. The team included administrators, technicians, nurses, pediatricians, anesthesiologists, and surgeons. Manoj T. Abraham, MD, a facial plastic surgeon, led the surgical team, which included myself, Augustine L. Moscatello, MD, and Craig H. Zalvan, MD—all members of the American Academy of Otolaryngology—Head and Neck Surgery. John G. Bortz, MD, an oculoplastic surgeon, also joined us. Drs. Moscatello and Azzi entertain a preoperative cleft lip patient. Drs. Moscatello and Azzi entertain a preoperative cleft lip patient.On Sunday, we evaluated 207 patients of which 91 were scheduled to have surgery during the next five days. Ages ranged from a few weeks old to adulthood, with most requiring either revision or repair of cleft lips and palates. Many of these children and their families traveled several hours across very difficult terrain. Some traveled by foot or on donkeys for days to reach our clinic, Fundacion Ceolinda Troya, where a tent with fans and cold water was erected the evening before. Healing the Children, with its goal of organizing humanitarian medical missions to perform surgeries on needy children around the globe, has made a lasting impact on the vulnerable and impoverished throughout the world. I feel fortunate to have contributed again this year. I’m humbled by the impact I made even as just one part of a larger effort. It really puts things in perspective. I know I speak for the entire team when I say we will continue to do everything we can to heal the children worldwide.
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AcademyU® Online Education Offers Hundreds of Learning Opportunities
AcademyU®, the Foundation’s otolaryngology education source, offers five types of learning formats that include knowledge resources, subscriptions, live events, eBooks, and online education. Each one contains elements that make up the breadth of the education opportunities available through the Foundation. In this second article in the series, we explore the variety of activities that make up the online education component of AcademyU®; these include online courses and lectures and COOL cases. AcademyU® Online Education (www.entnet.org/onlinecourse) is organized by the eight subspecialties within otolaryngology-head and neck surgery to make it easy for any otolaryngology specialist to find the courses that best fit his or her education needs. In addition, the online platform makes it easy for learners to take advantage of these education opportunities on their own schedules and at their own pace. Online Courses and Lectures Online Courses are learning activities developed by the Foundation education committees. These peer-reviewed courses provide in-depth study of otolaryngology head and neck surgery topics determined by an expert-driven analysis of learner education needs. These high-quality courses offer 45 to 60 minutes of detailed instruction on a particular topic. Each contains rich media elements such as detailed images and short video clips. The online courses are: Preventing Operating Room Fires Optimal Safety in Otolaryngic Allergy Practice Chin Augmentation: Sliding Osteotomy and Alloplastic Implants Nasal Trauma Graves’ Disease Alternative Medicine: Perioperative Management Issues of Herbal Supplements and Vitamins Basic Head and Neck Pathology Laser Safety Evaluation of an Adult Patient with a Benign Neck Mass Evaluation of an Adult Patient with a Malignant Neck Mass Loco-regional Recurrence in Head and Neck Squamous Cell Carcinoma Introducing the AAO-HNS Expert Witness Guidelines English-to-Spanish Ear Examination Phrases Gender Equity in the Workplace Hearing Assessment Understanding Stereotactic Radiation for Skull Base Tumors The Ten Minute Exam of the Dizzy Patient Office Otoscopy I: Normal Examination, Spectrum of Otitis Media, and Characteristic Appearances of Abnormal Pathologies Office Otoscopy II: Case Studies Office Otoscopy III: Clinical Case Studies Featuring Long-term Serial Examination and Anatomic Cross Section Risks of Steroids for Sudden Sensorineural Hearing Loss Cleft Lip and Palate Overview Introduction to Velopharyngeal Dysfunction Management of Sinonasal Cerebrospinal Fluid Leaks Online Lectures are based on the Annual Meeting & OTO EXPOSM instruction courses of the same name. They are selected from the top abstracts submitted to the Annual Meeting; faculty are invited to record a condensed version of their presentation for publication to the AcademyU® website. Each lecture provides highlights of key sessions in short 20- to 40-minute segments using the speakers’ slides and audio recordings. There are online lectures available, including more than 100 from the 2012 Annual Meeting & OTO EXPO. The 2013 Online Lectures are: Worldwide Otolaryngology Humanitarian Missions Developing a Quality Control Program for Surgeons Rhinoplasty: Arming Novices for Success Facial Aesthetic Enhancements: Chemodenervation and Tissue Augmentation Current Management of Oropharyngeal Cancer The Management of Glottic Cancer in 2012 Endoscopic and Robotic Thyroid Surgery Minimally Invasive Salivary Endoscopy Chronic Cough: Hacking Up a Treatment Algorithm Endoscopic Microsurgical Techniques for Laryngeal Disease Laryngopharyngeal Reflux (second edition) Tympanoplasty/Ossicular Reconstruction—Some Novel Ideas? Balance Problems in the Elderly Tinnitus: New Frontiers in Radiology and Brain Imaging Meniere’s or Migraine: Similarities, Differences, Treatments Surgical Management of Eustachian Tube Disorders Pediatric Obstructive Sleep Apnea What to do after T and A? Chronic Rhinosinusitis in Children (second edition) Stertor, Stridor, and Babies that Squeak: A Practical Approach Up-to-Date Management of Recalcitrant Sinonasal Polyposis Five New Landmarks to Make You a Better Sinus Surgeon Target audiences for both the online courses and online lectures are practicing otolaryngology-head and neck physicians, surgeons, and residents. Most online courses and lectures offer continuing medical education credit. Clinical Otolaryngology OnLine (COOL) Clinical Otolaryngology OnLine, (COOLSM) cases are free, peer-reviewed, interactive case studies that lead the learner from patient presentation through diagnosis, treatment, and referral. COOL is an excellent instructive program for non-otolaryngologist physicians and other health professionals who regularly encounter otolaryngology-related problems. The 34 COOL Cases are: Ear Adult with Otitis Media due to MRSA Bloody Otorrhea Ear Canal Obstruction Dizziness in the Elderly Otalgia Otoscopy Cholesteatoma Part I Otoscopy Cholesteatoma Part II Sensorineural Hearing Loss Tinnitus Mouth, Neck, and Throat An Approach to the Pediatric Patient with a Neck Mass Chronic Cough Dysphagia HPV and Head and Neck Cancer Indications for Tonsillectomy Management of the Thyroid Nodule Non-Melanoma Cutaneous Malignancies Oral Cavity Lesions Pediatric Aerodigestive Tract Foreign Bodies Pediatric Neck Abscess Due to MRSA Pediatric Stridor Pharyngitis Reflux Salivary Disease Upper Airway Obstruction—Obstructing Laryngeal Cancer Nose and Sinus Allergy Emergency Chronic Rhinosinusitis Facial Soft Tissue Trauma General Exam of the Nose Management of Acute Rhinosinusitis Nasal Trauma Orbital Complications of Rhinosinusitis in Children Target audiences for COOL include physician assistants and nurse practitioners, non-otolaryngologist health professionals, and medical students. COOL has been reviewed and approved for AAPA Category 1 Credit by the Physician Assistant Review Panel.
Errors in Otolaryngology: Revisited
Rahul K. Shah, MD George Washington University School of Medicine Children’s National Medical Center, Washington, DC I was a resident almost a decade ago, working with David W. Roberson, MD, at Children’s Hospital Boston when we both asked the question, “Where are we with errors in otolaryngology?” At that time, the study of patient safety and quality improvement was in a resurgence, which was in its relative infancy. To properly conduct studies, we were trained in the research methodology: ensuring a proper sample size and looking for statistical significance when comparing two groups. In an attempt to design a proper study of errors in otolaryngology, this methodology proved to be a stumbling block. There had been seminal work on a classification of errors in family medicine. That manuscript and methodology resonated with us as it elegantly provided a framework to assess, measure, quantify, and perhaps ameliorate errors in that specialty. Like good researchers, we emulated their methodology and it worked. In 2004, we published a classification of errors in otolaryngology along with the implications of those errors. When looking at zones of risk in our specialty, we would often revisit the data from that set to understand vulnerabilities in our realms of practice. We would then design a deeper dive study or approach to tackle a specific zone of risk. We have done that a few dozen times and hope we have made the practice of otolaryngology safer and more standardized. In the past months, we have been struggling with the concept that our Academy Members’ understanding, appreciation, and sophistication vis-à-vis patient safety and quality improvement have grown tremendously as a result of specific Academy initiatives, mandates from the government and payers, and personal interest from our dedicated Academy Members. To this end, we felt it compulsory to check the pulse of our members with regard to understanding errors in otolarygnology almost a decade after our initial survey study. We needed to ensure that we would be comparing apples to apples so we could make meaningful comparisons between the data from 2004 and the current data. Hence, we used a similar question set in an updated survey tool with some additional questions focusing on the nature of our practices and perceived zones of risk, attribution for the errors, culpability, and improvement processes implemented. After much consideration, we decided we should embrace technology (and keep costs low) and use an online survey tool to conduct the survey. The survey closed at the end of November after being open for fewer than 20 days. We have not sat down to properly classify and sort through the responses; we’ve only spent a few moments to ensure the integrity of the responses and confidential data capture of the online survey tool. We will, of course, properly classify the responses, write up the results in a peer-reviewed manuscript, and publish it for Academy members to continue to reference. However, we were shocked by the number of responses we received. In fewer than 20 days, more than 677 Academy Members took time from their busy practices in the winter season to respond to a survey that was essentially self-reporting of errors in our specialty. The response rate is staggering and clearly shows the passion of Academy Members and sheer interest we each have in improving the quality of care we deliver. Members clearly understand that, collectively, we have the power to improve our own practices. The high response rate resonates with us because it implies that we are aware of the concept that we may proceed through our entire career and never experience an error such as mis-administration of concentrated epinephrine because it is so rare, however, if we collectively look at our practices, it is a problem that needs to be considered. The sheer volume of responses also validates the PSQI Committee’s commitment to a secure, online patient safety event reporting portal, which will be available soon on the Academy website. As this issue of Bulletin goes to press, we will be properly classifying and understanding the huge volume of responses we received from Academy members. We should all take a moment to pause and appreciate how collectively our specialty continues to move the needle toward improving the care and safety of patients with otolaryngology diseases because we are so passionate as a specialty and as Academy Members about ensuring that we deliver quality care. 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.
Physician Compare: What Is CMS Posting about Me?
You’ve probably heard about CMS’ Physician Compare Website. You may even know that the development of this public website is a statutory mandate from the Affordable Care Act. Unfortunately, what many physicians and members are not aware of is the information that’s available about them, and their practices, on this website. The first thing members should know is that this program is updated and modified on an annual basis through federal rulemaking. This means that CMS will announce proposed revisions or additions to the Physician Compare Website in the notice of proposed rulemaking (NPRM) of the Medicare Physician Fee Schedule (MPFS) each calendar year. They then accept feedback on their proposals from the public during a 60-day comment period and finalize their policies in the final MPFS for that year, typically published on or around November 1 each year. The Website can be accessed at: http://www.medicare.gov/find-a-doctor/(X(1)S(0grwmc55y5poo245uxj5ifv5))/provider-search.aspx?AspxAutoDetectCookieSupport=1. Background The Physician Compare Website was launched in December 2010 and originally included data on those eligible professionals (EPs) who successfully reported on the Physician Quality Reporting System (PQRS) measures in CY 2009. Today, the Website includes the following information on providers: The provider’s primary, and any applicable secondary, specialty(ies); The provider’s practice locations; The providers group practice or hospital affiliations, where applicable; The provider’s education information, language skills, and gender; The names EPs who have successfully reported on quality programs, specifically e-prescribing and PQRS for CY 2011. What to Expect in 2013 By January 2013, CMS is required to outline a plan for posting information on provider’s quality performance, as well as patient experience data, on the Physician Compare Website. CMS is presently undertaking a full Website redesign project aimed at improving the usage and function of the site. In addition, CMS has finalized the following information for release in CY 2013: 2012 data on PQRS Group Practice Reporting Option (GPRO) measures for practices that meet the minimum sample size of 20 patients; Whether providers accept Medicare patients; Board certification information; and Improved information on language skills and hospital affiliations. As part of the Website redesign project, CMS allowed the Academy to view and comment on the proposed redesign. In the letter, the Academy addressed several issues included in the proposed redesign. Visit the Academy’s “What’s New” page at: http://www.entnet.org/Practice/CMS-News.cfm to access the full letter. Areas addressed by the Academy included: Data accuracy is paramount in the physician compare site and CMS proposes including claims based verification for physician information rather than just relying on PECOS; Concern regarding the small sample size used for posting information such as participation in PQRS GPRO; The posting of GPRO performance rates and the need for a review period to ensure the data posted is accurate; and The inclusion of CG-CAHPS survey data, as well as the S-CAHPS data, into the Physician Compare website. What to Expect in 2014 and Beyond For 2014, CMS anticipates posting information on provider performance rates on measures reported by physician groups or Accountable Care Organizations (ACOs) via the GRPO web interface system. These groups will have 30 days to review their information for accuracy before it becomes publicly available. CMS also hopes to post patient experience survey data gathers using the CG-CAHPS survey method for groups of 100 or more providers. Finally, CMS will post information on providers who obtain PQRS maintenance of certification incentives during CY 2014. Other information CMS is considering for inclusion on the website in the future are performance on quality measures developed by specialty societies, continued efforts to align the PQRS and value based payment modifier (VBP) program measures, the release of provider performance in these programs, as well as individual EP performance measure data. Data Accuracy Currently, the website pulls physician information from the PECOS enrollment system. CMS plans to verify the accuracy of PECOS information via a claims based verification, which the Academy supports. Until these changes are implemented, the Academy encourages members to check their PECOS enrollment information, as well as what information is currently available about them on the Physician Compare website, and to contact CMS if they find the information is incorrect. The Academy’s health policy team will continue tracking the development of this important public website and will alert members to any key changes to the program in the future. Should you have any questions or concerns about the website, or your publicly available information, please contact us at healthpolicy@entnet.org.
What Are RUC Surveys and Why Should They Matter to Me?
As an Academy member, you’ve probably seen frequent requests distributed in “The News” asking for volunteers for upcoming AMA Relative Value Scale Update Committee (RUC) surveys of physician services. Many of you may have asked yourself, “what the RUC is and why are these surveys important?” During the last several years, the Academy has provided members with background on the RUC in an effort to educate and engage members in the annual RUC process. This year, we’d like to address the common questions that arise during the RUC survey process in hopes of outlining why member participation in these surveys is so critical. What is the RUC and Who Participates? The AMA RUC was developed in response to the transition to a physician payment system based on a Resource-Based Relative Value Scale (RBRVS). The RUC is a multispecialty committee that provides clinical expertise and input on the resources required to provide physician services. The RUC submits recommendations annually to the Centers for Medicare and Medicaid Services (CMS), which uses them to develop relative values for physician services provided to Medicare beneficiaries. The RUC, in conjunction with the Current Procedural Terminology (CPT®) Editorial Panel, has created a process where specialty societies can develop relative value recommendations for new and revised codes, and the RUC carefully reviews survey data presented by specialty societies to develop recommendations for consideration by CMS. CMS then issues final payment policies and values in the final Medicare Physician Fee Schedule rule, which is typically released around the first of November each year. The RUC is intended to represent the entire medical profession and includes the following medical specialties: anesthesiology, cardiology, dermatology, emergency medicine, family medicine, general surgery, geriatrics, internal medicine, neurology, neurosurgery, obstetrics/gynecology, ophthalmology, orthopedic surgery, otolaryngology, pathology, pediatrics, plastic surgery, primary care (rotating seat), pulmonary medicine (rotating seat), psychiatry, radiology, rheumatology (rotating seat), thoracic surgery, urology, and vascular surgery (rotating seat). Four seats rotate on a two-year basis, with two reserved for an internal medicine subspecialty: one for a primary care representative, and one for any other specialty. The RUC chair, the co-chair of the RUC Health Care Professionals Advisory Committee Review Board, and representatives of the AMA, American Osteopathic Association, the chair of the Practice Expense Review Committee and CPT Editorial Panel hold the remaining six seats. The AMA Board of Trustees selects the RUC chair and the AMA representative to the RUC. The individual RUC members are nominated by the specialty societies and are approved by the AMA. Who Represents the Academy at the RUC? The Academy actively participates in the RUC process and surveys codes for nearly every RUC meeting. Meetings take place every winter, spring, and fall. The Academy’s current RUC representatives are RUC panel member Charles F. Koopmann Jr., MD, MSHA, and panel member alternate, Jane T. Dillon, MD, as well as our RUC advisors Wayne M. Koch, MD, and advisor alternate John T. Lanza, MD. It is important to recognize that the RUC panel member representatives for each specialty are not advocates for their specialties, rather, they participate in an individual capacity and represent their own views and independent judgment while serving on the panel. In contrast, AAO-HNS’ RUC advisors are responsible for working with the Physician Payment Policy Workgroup (3P) and Academy staff to develop relative value recommendations and practice expense direct inputs for otolaryngology services that are presented to the RUC on behalf of the Academy. Why are RUC Surveys Conducted? Surveys are used by the AMA RUC to allow medical specialty societies to have an active role in ensuring that relative values assigned to medical procedures and services are accurately and fairly presented to CMS. These surveys are critical because the values derived by member survey responses are used by our RUC advisors to make valuation recommendations to the AMA RUC. The goal of the surveys is to obtain time and complexity estimates required when performing a specific medical procedure. This information is then used to estimate a recommended physician work value. How Does the Survey Generate a Recommended Value? The surveys will ask physician members to compare the time, complexity, and work required to perform the procedure being surveyed as compared to another existing medical procedure. A list of possible comparator, or reference, procedures is provided to survey respondents as part of the survey. What are the Key Components of the RUC Survey? First, it is critical that members carefully review the code descriptor and vignette. This is critical because code descriptors may have been modified and survey respondents will be asked if the descriptor and vignette match their typical (i.e., more than 50 percent of the time) patient. If the descriptor and vignette do not match the respondent’s typical patient, the respondent will be asked to write a brief rationale for how their typical patient differs from the survey descriptor or vignette. Next, surveyees will be asked to review and provide their basic contact information. They will then be asked to identify a reference procedure from the list of potential reference codes. Respondents should select the code from the list that is most similar in physician time and work to the new/revised CPT code descriptor and typical patient. The reference service does not have to be clinically similar to the procedure being surveyed, but must be similar in work required to perform the procedure. It is also important that respondents consider the global period of the service being reviewed. For CPT codes with 000, 010, or 090 day globals, physician services or visits provided within 24 hours prior are included and should be considered by respondents in their recommended value for the service. Likewise, for 010 and 090 globals, the post care following the procedure should be included in the estimate of physician work for a given procedure. Another key component to the RUC survey is estimating physician time. Respondents should base their recommendations of the time it takes them to perform the procedure under review on their own personal experience. It is important to note that time estimates provided should be based on the typical patient and not the most straightforward or most complex case the physician respondent has encountered. There are three components to time estimates. First, the pre-service time, which begins the day prior to the procedure and lasts until the time of the operative procedure. Pre-service time is divided into three activities: evaluation; positioning; and scrub, dress, and wait time. Second, the intra-service time, which includes all “skin to skin” work that is a necessary part of the procedure. And last, the post-service time, which includes the physician services provided on the day of the procedure after the procedure has been performed.One common source of confusion is the component of moderate sedation. Moderate sedation is a service provided by the operating physician or under the direct supervision of the physician performing the procedure. If anesthesia is provided separately by an anesthesiologist who is not performing the primary procedure, this work should not be included in the valuation of the procedure for the purposes of the RUC survey. Finally, survey respondents will be asked to evaluate physician work and assign a recommended relative value unit for the work required to perform the procedure. Physician work includes the time it takes the physician to perform the procedure. Physician work should also include the mental effort and judgment necessary, as well as the technical skill required to perform the procedure. Note, time and work valuation should not include any work or service provided by clinical staff that are employed by the physician’s practice and cannot bill separately. It is important to keep in mind that the survey methodology aims to set the work RVU for the procedure under review “relative” to the comparable reference procedure selected at the outset of the survey, and respondents may want to print out the reference service list to refresh them on the value of the comparator code selected. What About the Practice Expense Portion of My Payment? As part of its role in the RUC process, the Academy RUC team is asked to provide the AMA RUC and CMS with information regarding the direct practice expense inputs for all procedures that undergo RUC review. This includes recommendations on clinical staff time needed during the procedure, as well as equipment and supplies required for the procedure. These recommendations are reviewed by the Practice Expense Advisory Committee (PEAC) of the RUC and approved or modified prior to being submitted to CMS for acceptance in the final CY MPFS. What About the Malpractice Portion of My Payment? The AMA RUC sends recommendations to CMS on practice liability crosswalks for each procedure reviewed by the AMA RUC. This occurs in May of each year and, similar to the practice expense and physician work recommendations submitted by the AMA RUC, are approved or modified by CMS in the MPFS for that calendar year. All values finalized in the final rule then take effect the following January. Still Have Questions? For more background on the RUC survey process, members can access the following PowerPoint presentation on the Academy website: http://www.entnet.org/Practice/upload/2012-ruc-survey-presentation.pdf. Members can also email any questions to Jenna Minton at Jminton@entnet.org. We hope this information will assist members in better understanding the composition of the RUC surveys as well as the importance of your participation in future surveys and the valuation of otolaryngology-head and neck surgery procedures.
New Trend: Increased FTC Involvement in State Professional Boards
In recent months, the Federal Trade Commission (FTC) has become more involved in the states’ rulemaking process by increasing its antitrust examination of state professional board actions, particularly board decisions and regulations, state legislation relating to scope of practice. These antitrust examinations by the FTC reportedly are to promote and protect competition by prohibiting agreements that unreasonably restrict trade. However, concerns about this increased involvement exist, and the American Medical Association (AMA) with the Scope of Practice Partnership (SOPP), which the AAO-HNS is a member of, are closely monitoring and addressing the FTC’s inappropriate involvement as it arises. The new trend by the FTC threatens patient safety and the structure of determining what is appropriate within a professional’s scope of practice. Scope of practice guidelines are typically determined by the legislature and state professional boards. These methods help to ensure that unqualified practitioners are not rendering services they are not trained to perform. There is concern that the FTC’s involvement will discourage state boards and state legislatures from engaging in defining appropriate scope of practice guidelines for fear of potential antitrust lawsuits. The FTC recently has taken action in the form of letters and enforcement actions directed at state boards and state legislators. The FTC has issued several letters urging state boards to reject, or more thoroughly analyze, regulations that could potentially affect competition. One of the first examples of the FTC becoming more involved with state boards was a letter in 2010 that was sent to the Alabama State Board of Medical Examiners (ASBME). The FTC encouraged the board to reject a regulation that would prohibit non-physician professionals from providing advanced interventional pain management services, noting it would adversely affect competition. This letter was sent to the ASBME without any studies or evidence indicating this to be true. Although the FTC did not directly threaten to bring an antitrust action, the letter itself provided enough of a threat. The effect of the letter on the ASBME resulted in the board immediately ceasing activity on the proposed regulation. Since the letter to the ASBME in 2010, the FTC has reached out to legislators and state boards in Florida, Kentucky, Louisiana, Missouri, Tennessee, and Texas, where it commented on bills to regulate providers of interventional pain management procedures and proposed regulations to expand the scope of practice of nurses. Some of the FTC’s activity in the states has morphed into enforcement actions. In North Carolina, the State Board of Dental Examiners was attempting to approve a regulation that would prohibit non-dentists from providing teeth-whitening services, which the board had determined constituted the practice of dentistry. The FTC issued an order directing the board to stop regulating teeth-whitening, alleging that the board was harming competition by blocking non-dentists from providing the services. The case is currently awaiting consideration in the U.S. Court of Appeals. The AMA and the SOPP have made progress toward working with the FTC to address the over-involvement of the FTC with state boards and state legislatures. The FTC letters that are now distributed no longer attempt to make clinical judgments. Instead, disclaimers have been added outlining that FTC staff members are not subject-matter experts on clinical or patient safety issues and are not offering advice on such issues. Furthermore, the FTC has now acknowledged that “certain professional licensure requirements are necessary to protect patients.” The FTC has also agreed to work with the states by reaching out to state medical associations before drafting letters. The AAO-HNS, the AMA, and others in the physician community are concerned that these actions by the FTC will prevent state legislatures, regulators, and medical boards from performing their duties and enacting legislation, proposing regulation, or other actions to protect patient safety for fear of reprisal and antitrust liability. The AAO-HNS will continue to work with the AMA and the SOPP as this issue progresses and advocate where necessary. For more information, email AAO-HNS State Legislative Affairs at legstate@entnet.org. In addition, to receive timely updates on state, federal, or grassroots initiatives, AAO-HNS members are encouraged to join the ENT Advocacy Network—a free member benefit. To join, email govtaffairs@entnet.org.
Recognizing Your Commitment—Thank You to Our 2012 ENT PAC Investors!
Special thanks to our 2012 ENT PAC Investors for their commitment to advancing the specialty! 2012 Chairman’s Club Investment of $1,000+ Annually Leonard P. Berenholz, MD William R. Blythe, MD Marcella R. Bothwell, MD Jeffrey S. Brown, MD Henry Frederick Butehorn, MD C. Y. Joseph Chang, MD Richard B. Collie, DO Susan R. Cordes, MD Stephen P. Cragle, MD Jeffrey J. Cunningham, MD Lawrence J. Danna, MD Scott A. Dempewolf, MD Lee D. Eisenberg, MD, MPH Cameron D. Godfrey, MD Denis K. Hoasjoe, MD Kenneth M. Hodge, MD Paul M. Imber, DO Stacey L. Ishman, MD Michael A. Kaplan, MD Alice L. Kuntz, MD Steven B. Levine, MD Thomas B. Logan, MD Rodney P. Lusk, MD Theodore P. Mason, MD William H. Merwin, MD Samantha Marie Mucha, MD David R. Nielsen, MD Simon C. Parisier, MD George P. Parras, MD David Poetker, MD, MA Anna M. Pou, MD Eric S. Powitzky, MD Robert Puchalski, MD Richard M. Rosenfeld, MD, MPH Michael D. Seidman, MD Gavin Setzen, MD Adam M. Shapiro, MD Mariel Stroschein, MD John H. Taylor, MD Ken Yanagisawa, MD Kathleen Yaremchuk, MD Jay S. Youngerman, MD Jan S. Youssef, MD Oliver S. Youssef, MD 2012 Resident Chairman’s Club Investment of $500 Annually Nathan A. Deckard, MD 2012 Capitol Club Investment of $535-$999 Annually Vijay K. Anand, MD Dole P. Baker, MD Drupad Bhatt, MD Michael K. Bowman, MD Richard J. Brauer, MD Jeffrey M. Bumpous, MD Luke I. Burke, MD Giulio I. Cavalli, MD Robert H. Chait, MD Sujana S. Chandrasekhar, MD Ryan C. Cmejrek, MD John U. Coniglio, MD Michael W. Criddle, MD Agnes Czibulka, MD Lisa B. David, MD Eduardo M. Diaz, MD Elizabeth Dinces, MD Randy J. Folker, MD Michael Gerard Glenn, MD Steven M. Gold, MD Michael S. Goldrich, MD Joseph E. Hart, MD, MS Erik Hartman—staff Joseph T. Hoang, MD Michael R. Holtel, MD Steven D. Horwitz, MD John R. Houck, MD Barry R. Jacobs, MD Bruce C. Johnson, MD Felicia L. Johnson, MD Madan N. Kandula, MD Ronald H. Kirkland, MD Timothy D. Knudsen, MD Greg Krempl, MD Russell W. H. Kridel, MD John H. Krouse, MD, PhD John T. Lanza, MD Dennis Lee, MD, MPH Anthony C. Manilla, DO Phillip L. Massengill, MD W. Scott McCary, MD J. Cary Moorhead, MD James L. Netterville, MD Rick Odland, MD, PhD Spencer C. Payne, MD Liana Puscas, MD Rance W. Raney, MD B. Todd Schaeffer, MD Scott R. Schoem, MD Jerry M. Schreibstein, MD Lawrence M. Simon, MD Gary M. Snyder, MD Joseph R. Spiegel, MD James A. Stankiewicz, MD J. Pablo Stolovitzky, MD Oscar A. Tamez, MD Duane J. Taylor, MD J. Regan Thomas, MD Joy L. Trimmer, JD—staff Paulus D. Tsai, MD William Turner, MD Dale A. Tylor, MD Keith M. Ulnick, DO Wesley D. Vander Ark, MD Richard W. Waguespack, MD Michael D. Weiss, MD Samuel B. Welch, MD, PhD Raymond Winicki, MD Douglas L. Worden, MD Todd A. Zachs, MD 2012 Resident Capitol Club Investment of $250 Annually Scott R. Chaiet, MD Dollar-a-Day Club Investment of $365-$534 Annually Peter Abramson, MD Ravi Prakash Agarwal, MD Sudhir P. Agarwal, MD Michael Agostino, MD J. Noble Anderson, MD Thomas M. Andrews, MD Sanford M. Archer, MD Seilesh Babu, MD Charles J. Ballay, MD, PA Carlos G. Benavides, MD Wayne E. Berryhill, MD Nikhil J. Bhatt, MD David S. Boisoneau, MD William R. Bond, MD Peter C. Bondy, MD K. Paul Boyev, MD James T. Brawner, MD Laura Devereux Brown, MD Daniel E. CaJacob, MD Jasper V. Castillo, MD Kevin C. Cavanaugh, MD Stephen J. Chadwick, MD Ajay E. Chitkara, MD Jason P. Cohen, MD Kieran Connolly, MD Joehassin Cordero, MD Anthony J. Cornetta, MD Michael J. Cunningham, MD Shane P. Davis, MD Robert L. Dean, MD James C. Denneny, MD John E. Dickins, MD Sherman Don, MD John S. Donovan, MD Norman S. Druck, MD Bradford J. Dye, MD David R. Edelstein, MD B. Kelly Ence, MD Moshe Ephrat, MD Theodore W. Fetter, MD Frederick Fiber, MD G. Glen Fincher, MD Steven M. Fletcher, MD Paul L. Friedlander, MD Stephen M. Froman, MD Michael J. Fucci, MD Stephen P. Gadomski, MD Neil A. Giddings, MD Michael E. Glasscock, MD Frederick A. Godley, MD Debora W. Goebel, MD Mariano E. Gonzalez-Diez, MD John J. Grosso, MD Anil K. Gupta, MD Patrick Hall, MD Paul E. Hammerschlag, MD Ronald D. Hanson, MD Brenda Hargett, CPA—staff James M. Hartman, MD Michael S. Haupert, DO Heidi Heras, MD Frank K. Hixon, MD Neil Hockstein, MD John W. House, MD Mark A. Howell, MD John J. Huang, MD David Huchton, MD Kenneth V. Hughes, MD Michael K. Hurst, MD, DDS Thomas M. Irwin, MD Chandra M. Ivey, MD Ofer Jacobowitz, MD, PhD David M. Jakubowicz, MD Habibullah Jamal, MD Basem M. Jassin MD Kenneth A. Kaplan, MD Ayesha N. Khalid, MD Sheldon N. Klausner, MD Steven T. Kmucha, MD, JD Robert Knox, MD Stephen A. Kramer, MD Judyann Krenning, MD Geeta Krishnan, MD Jeffery J. Kuhn, MD Denis C. Lafreniere, MD Christopher G. Larsen, MD Arthur M. Lauretano, MD Pierre Lavertu, MD Dwight A. Lee, MD Joel F. Lehrer, MD Jonathan A. Lesserson, MD Marc J. Levine, MD Sandra Y. Lin, MD Jay Luft, MD Amber U. Luong, MD, PhD Sonya Malekzadeh, MD Lance Anthony Manning, MD Megan K. Marcinko, MPS—staff Ralph Marrero, MD Marc D. Maslov, MD Mary Melissa McBrien, MD Timothy M. McCulloch, MD Scott A. McNamara, MD Gregory K. Meekin, MD Abby C. Meyer, MD John W. Miller, MD Charles Mixson ,MD William H. Moretz, MD Alice H. Morgan, MD, PhD Srinivas B. Mukkamala, MD V. Rama Nathan, MD Paul R. Neis, MD David C. Norcross, MD J. David Osguthorpe, MD Ira D. Papel, MD Gregory S. Parsons, MD Michael L. Patete, MD Philip W. Perlman, MD Lisa Perry-Gilkes, MD Guy J. Petruzzelli, MD, MBA, PhD Alan T. Pokorny, MD Juan C. Portela, MD William S. Postal, MD John C. Pruitt, MD Eileen M. Raynor, MD Andrew J. Reid, MD John R. Resser, MD John S. Rhee, MD, MPH Adrian Roberts, MD Grayson K. Rodgers, MD Greg S. Rowin, DO Paul A. Sabini, MD Barbara A. Schultz, MD Janice L. Seabaugh, MD Samuel H. Selesnick, MD Janet Seper, MD Rasesh P. Shah, MD Michael Shohet, MD Jamie D. Sisk, MD William H. Slattery, MD Louis L. Sobol, MD Neil M. Sperling, MD Aaron T. Spingarn, MD F. Thomas Sporck, MD Robert J. Stachler, MD Jamie Stern, MD Wendy B. Stern, MD Michael G. Stewart, MD, MPH Robert N. Strominger, MD Jerome O. Sugar, MD Thomas G. Takoudes, MD Justin M. Tenney, MD Larry R. Thomas, MD Thomas B. Thomason, MD Dennis F. Thompson, MD Arthur J. Torsiglieri, MD Monty V. Trimble, MD Theodore O. Truitt, MD Debara L. Tucci, MD Ira D. Uretzky, MD Steven Marc Vetter, MD Eugenia M. Vining, MD Gary S. Voorman, MD Hayes H. Wanamaker, MD Robert L. Weiss, MD Phillip R. Wells, MD Daniel L. Wohl, MD Danny Wong, MD Glen Y. Yoshida, MD John J. Zappia, MD Lauren S. Zaretsky, MD General Member Investment of $1-$364 Annually Moufid H. Abdo, MD David A. Abraham, MD Allan L. Abramson, MD Stewart Adam, MD Jeffery R. Adams, MD Ashley D. Agan, MD Karen K. Ahlstrom, MD Gurpreet S. Ahuja, MD Mohammad M. Akbar, MD Keith J. Alexander, MD Mark V. Alexander, MD Kyle P. Allen, MD, MPH Allan L. Allphin, MD Melissa M. Amorn, MD Kurt M. Anderson, MD Scott R. Anderson, MD Lauren C. Anderson de Moreno, MD Laurence Ariyasu, MD Jeffrey H. Aroesty, MD Scott A. Asher, MD Jonathan E. Aviv, MD Roya Azadarmaki, MD Ronaldo A. Ballecer, MD Christopher F. Baranano, MD John M. Barlow, MD James P. Bartels, MD Stuart Barton, MD Jonathan Z. Baskin, MD Richard M. Bass, MD Robert J. Baumgartner, MD Charles W. Beatty, MD Robert J. Bechard, MD Mark G. Bell, MD Karen M. Bellapianta, MD Thomas J. Benda, MD Leslie R. Berghash, MD Michael H. Bertino, MD Mary Blome, MD Isaac A. Bohannon, MD John M. Bosworth, MD Alexis C. Bouteneff, MD Phyllis B. Bouvier, MD Charles M. Bower, MD Derald E. Brackmann, MD Jean Brereton, MBA—staff Robert S. Bridge, MD Bert M. Brown, MD Seth Brown, MD, MBA Scott L. Busch, DO James E. Bush, MD Arkadiush T. Byskosh, MD Richard K. Caldwell, MD Edward J. Callan, MD C. Ron Cannon, MD Roy D. Carlson, MD Thomas L. Carroll, MD Eric S. Carter, MD Wade R. Cartwright, MD Ajaz Chadhry, MD Fayez F. Chahfe, MD Hosakere K. Chandrasekhar, MD Louis Chanin, DO David R. Charnock, MD Hamad Chaudhary, MD Jay Chavda, MD Daniel C. Chelius, MD Theodore Chen, MD Bradford S. Chervin, MD Stanley Hung-hsuan Chia, MD Dev R. Chitkara, MD Sukgi S. Choi, MD Clifford T. Chu, MD Mark P. Clemons, MD Barbara J. Cobuzzi, MBA Andrew M. Compton, MD Bryant T. Conger, MD Mary Pat Cornett—staff Alejandro J. Correa, MD Douglas D. Dedo, MD Frank R. Dellacono, MD Devang P. Desai, MD Joseph R. Di Bartolomeo, MD Edward E. Dickerson, MD Michael J. Disher, MD Hamilton S. Dixon, MD Justin W. Douglas, MD Jayme R. Dowdall, MD Thomas F. Dowling, MD Colin S. Doyle, MD Carl Drucker, MD Clifford B. Dubbin, MD Melinda A. Duncan, DO Roy J. Dunlap, MD Bernard J. Durante, MD Ann L. Edmunds, MD James E. Ewing, MD Paul T. Fass, MD Richard E. Ferraro, MD Dennis C. Fitzgerald, MD Cecil J. Folmar, MD William I. Forbes, MD, PhD James W. Forsen, MD Paul C. Frake, MD Howard W. Francis, MD Ellen M. Friedman, MD Carter C. Friess, MD Robert Furman, MD Judith E. Gallagher, MD Daniel Ganc, MD Glendon M. Gardner, MD Frank G. Garritano, MD Clarence W. Gehris, MD Mark E. Gerber, MD Randal B. Gibb, MD Kevin L. Gietzen, DO Eric A. Goebel, MD Scott H. Goldberg, MD Lindsay I. Golden, MD Elliot Goldofsky, MD Herman Goldstein, MD Stephen A. Goldstein, MD Rebecca D. Golgert, MD Justin S. Golub, MD Ron D. Gottlieb, MD Neerav Goyal, MD Robert P. Green, MD Samuel P. Gubbels, MD Mark Gutowski, MD Yoav Hahn, MD Cheryl Hall Marc David Hamburger, MD Steven D. Handler, MD Charles J. Harkins, MD Anthony E .Harris, MD John R. Harris, MD Anna Kristina E. Hart, MD Geoffrey T. Harter, MD Graves Hearnsberger, MD Diana H. Henderson, MD Webb S. Hersperger, MD Steven R. Herwig, DO, MBA Jo Anne Higa Ebba, MD David H. Hiltzik, MD Barry Hirsch, MD Paul T. Hoff, MD James J. Holt, MD Robin S. Horrell, MD, PhD Rebecca J. Howell, MD P. David Hunter, MD Charles G. Hurbis, MD Jon E. Isaacson, MD Geza J. Jako, MD Zi Yang M. Jiang, MD Gary K. Johnson, MD Gary W. Jones, PhD John W. Jones, MD Stephanie L. Jones—staff James R. Jordan, MD Christopher H. Jung, MD Prajoy P. Kadkade, MD Jenna Kappel—staff Lawrence Katin, MD Nader Kayal, MD Kanwar S. Kelley, MD Samuel C. Kerns, MD Richard L. Kersch, MD Sid Khosla, MD Susan M. King, MD Louis E. Kleager, MD Barton E. Knox, MD Sharen J. Knudsen-Jeffries, MD Charles F. Koopmann, MD Alan D. Kornblut, MD Michael J. Kortbus, MD *Ronald B. Kuppersmith, MD, MBA Daniel B. Kuriloff, MD J. Walter Kutz, MD Alexander Langerman, MD Donald C. Lanza, MD, MS Miguel A. Lasalle, MD Derek S. Lee, MD K. J. Lee, MD Sherrod Lee, MD Francis E. LeJeune, MD Thomas H. Lesnik, MD Alexa S. Lessow, MD Katherine Lewis—staff Carl M. Lieberman, MD Jeffrey C. Liu, MD Jeffrey J. Liudahl, MD Lloyd M. Loft, MD Christopher P. Lombardo, MD Paul E. Lomeo, DO Douglas T. Lowery, MD Steven L. Lyon, MD Dino Madonna, MD James R. Magnussen, MD Kshitij V. Majmundar, MD James A. Manning, MD Frances E. Marchant, MD Albert W. Marchiando, MD Frank I. Marlowe, MD Bradley F. Marple, MD Wm Stephen Martin, MD Dean L. Martinelli, MD Felipe J. Martinez, MD Nicholas Mastros, MD Bruce H. Matt, MD Mark E. McClinton, MD Clement J. McDonald, MD Edith A. McFadden, MD, MA John R. McFarlane, MD Richard McHugh, MD William J. McMillan, MD Bryan R. McRae, MD Howard B. Melnick, MD Frank M. Melvin, MD Michael R. Menachof, MD Albert L. Merati, MD Ralph Metson, MD Bruce P. Meyers, MD Donna J. Millay, MD David W. Miller, MD Robert S. Miller, MD Todd C. Miller, MD James W. Mims, MD Foy B. Mitchell, MD Edwin M. Monsell, MD, PhD Willard B. Moran, MD Shannon Morey, JD—staff Philip R. Morgan, MD William C. Morgan, MD Garrison V. Morin, MD, MBA Michael R. Morris, MD David D. Morrissey, MD Todd A. Morrow, MD James J. Murdocco, MD James G. Murray, MD Ednan Mushtaq, MD Michael J. Nathan, MD Jeffrey C. Nau, MD David E. Nissan, MD Phillip E. Noel, MD Joseph P. Olekszyk, DO Samuel M. Overholt, MD R. Glen Owen, MD Michael Owens, MD Constantine William Palaskas, MD John F. Pallanch, MD Meredith K. L. Pang, MD Basil J. Paparone, MD William M. Parell, MD Stephen E. Parey, MD Kourosh Parham, MD, PhD Sanjay R. Parikh, MD Stephen P. Parsons, MD Andrew K. Patel, MD Nilesh Patel, MD Jennifer Ann Pesola-Engebretson, DO Linnea Peterson, MD Joseph L. Petrusek, MD James D. Phillips, MD Scott E. Phillips, MD Nathan Pierce, MD Sarah P. Powell, MD Robert B. Prehn, MD Shannon P. Pryor, MD Frederic A. Pugliano, MD Eric B. Purdom, DO Max D. Pusz, MD David J. Quenelle, MD Scott Ramming, MD Gregory W. Randolph, MD Nikhila Raol, MD Mark E. Reader, DO Michael J. Reilly, MD Bruce Reisman, MD David W. Roberson, MD Jason M. Roberts, MD, MHA Brianne B. Roby, MD Daniel Rocke, MD Eric Roffman, MD Jeffrey D. Roffman, MD Neal L. Rogers, MD Anthony R. Rogerson, MD Sarah L. Rohde, MD Allan M. Rosenbaum, MD Eben L. Rosenthal, MD Lee D. Rowe, MD Marisa A. Ryan, MD Ron Sallerson—staff John D. Schaefer, MD George Schein, MD Andrew P. Schell, MD Michael Scherl, MD Jonathan L. Schmidt, MD Richard L. Schultz, MD Kristine Schulz, MPH John C. Scott, MD Curtis M. Seitz, MD Armen Serebrakian, MD Michael Setzen, MD Erwin B. Seywerd, MD Clough Shelton, MD Katherine J. Shen, MD Peter M. Shepard, MD Jeanne Shepherd, MD William M. Sheppard, MD Steven G. Shimotakahara, MD Edward J. Shin, MD Michael J. Shinners, MD Jack A. Shohet, MD Abraham Shulman, MD Joseph D. Siefker, MD John G. Simmons, MD Jesse E. Smith, MD Danny Soares, MD Keith C. Soderberg, MD Ray Soletic, MD Daniel A. Spilman, MD Michael S. Srodes, MD Douglas M. Stevens, MD Harry B. Stone, MD George B. Stoneman, MD John A. Straka, MD Wilbur Suesberry, MD Mark J. Syms, MD Monica Tadros, MD John M. Tarro, MD Michael T. Teixido, MD Mark H. Terris, MD Charles B. Tesar, MD Richard A. Tibbals, MD Wilfredo A. Tiu, MD Mark Toma, MD Lenhanh P. Tran, MD Roger M. Traxel, MD John Martin Ulrich, DO Atul M. Vaidya, MD Emilio R. Valdes, MD Victoria E. Varga-Huettner, MD Michael C. Vidas, MD Daniel Viner, MD Valerie J. Vitale, MD Trang T. Vo-Nguyen, MD Marshall D. Walker, DO W. Juan Watkins, MD Samuel C. Weber, MD Roger E. Wehrs, MD Mark T. Weigel, MD Debra G. Weinberger, MD Charles Z. Weingarten, MD Jeffrey S. Weingarten, MD Richard Alan Weinstock, DO Adam S. Weisstuch, MD Josh Werber, MD Charles B. West, MD Ralph F. Wetmore, MD James A. White, MD Chad Whited, MD Thomas Whiteman, MD Eric P. Wilkinson, MD Glenn B. Williams, MD Neil P. Williams, MD Kevin F. Wilson, MD Meghan N. Wilson, MD Norman M. Woldorf, MD Peak Woo, MD Troy D. Woodard, MD Murray A. Woolf, MD Eiji Yanagisawa, MD Mark J. Yanta, MD Mike Yao, MD C. Alan Yates, MD Anthony J. Yonkers, MD William Gregory Young, MD Mani H. Zadeh, MD Mark E. Zafereo, MD Timothy P. Zajonc, MD Jeffrey M. Zauderer, MD Alice Zhuo, MD Kevin L. Ziffra, MD Lee A. Zimmer, MD, PhD Michael Zoller, MD Kenneth Philip Zuckerman, MD 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 and helps to increase the visibility of the specialty with key policymakers. To learn more about ENT PAC, visit our new PAC website at www.entpac.org (log-in with your AAO-HNS ID and password).For more information about ENT PAC and its applicable programs, visit www.entpac.org (log-in with your AAO-HNS user ID and password).*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.
Stay Informed: Bookmark the AAO-HNS Legislative and Political Affairs Webpage
Do you want to be one of the first to know the status of healthcare bills moving through Congress or your state? Bookmark the Legislative and Political Affairs webpage today! By visiting the webpage, you can learn more about the issues affecting the specialty, including 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). Visit www.entnet.org/advocacy.
Why You, Dr. OTO-HNS, Should Go to Washington in May
Kristina E. Hart, MD Women in Otolaryngology Section Historian For years, like many of you, I’ve been reading about the past JSAC meetings, the BOG Spring Meeting, and more recently, the combined BOG Spring Meeting & OTO Advocacy Summit. One only has to open the monthly Bulletin or read ones email to see that our Academy staff and an equally dedicated contingent of our membership are diligently working on our behalf to ensure that our specialty remains at the forefront of continuing education, innovation, policymaking, and reimbursement, and that our collective healthcare concerns as otolaryngologists-head and neck surgeons are being heard. So, why attend this meeting? The informative, yet necessarily abbreviated, “sound bites” in our news media and our Academy’s publications have long inspired me to gain a better understanding of the politics that affect how we practice medicine. The idea of being an advocate for our specialty did seem daunting, but curiosity and a desire to participate overcame intimidation and distance. I am so glad that I finally attended the 2012 BOG Spring Meeting & OTO Advocacy Summit, and I intend to make the trip again. As with many things, being there was far more interesting than reading about it. It was highly energizing to be surrounded by fervent and knowledgeable AAO-HNS members including residents, who form the nucleus of the Academy’s grassroots efforts. They, together with a broad network of ENT PAC supporters, put their money where their mouths are and work to change what we all find unacceptable for our practices and our patients. Our elected lawmakers could learn something about working together by watching our Academy members rally around common objectives regardless of personal political affiliation. My initial concerns about preparedness for meetings with Congressional staffers quickly evaporated thanks to the well-organized advocacy preparation provided by our talented Government Affairs (GA) team. By reviewing and discussing our issue-specific talking points, we were quickly prepared to present a unified voice on Capitol Hill. Truly, who better than we—the constituents in the trenches—to advocate for our specialty? You’ve heard terms like “individual mandate” and “severability,” but do you really know what these mean? What does insurance have to do with the Commerce Clause of our Constitution? What does the 10th amendment have to do with healthcare reform? The answers to these questions were among many illuminating and relevant facts that were expounded upon during this meeting. We also learned about the Capitol Hill version of “TIA” among many other acronyms and definitions. “Truth in Advertising” or the “Healthcare Truth and Transparency Act,” is legislation designed to help distinguish medical doctors from those who have doctorates in other health-related fields. One of the primary talking points was the repeal of the Sustainable Growth Rate (SGR) formula. What does the SGR have to do with our practices and us? Though illogical, more than a decade ago, the SGR was tied to the Gross Domestic Product and incorporated in a formula to calculate physician payment for Medicare services. This formula fails to accurately estimate the actual present day cost of practicing medicine. It must be repealed and replaced with a more appropriate barometer of the “real time” cost of providing healthcare.Why should we care what issues lurk behind the acronyms of today’s healthcare realities? Because, as students, we’ve invested many years continually training in our profession to do what is best for our patients. We have an instinct for self-preservation; no one else is likely to be as interested in, or as informed about, developing policies favorable to our patients and our profession as we are. We work hard to be effective communicators and to support effective communication among our patients through prevention and treatment of hearing and phonatory disorders. We’re also educators. A staffer’s questions regarding her niece’s tympanostomy tubes during discussion of the Congressional Hearing Health Caucus afforded me both a teaching moment and a perfect segue to inviting this senator’s team to seek me as a subject-matter expert on other specialty-specific topics. Our nation’s leaders can only represent us effectively if we communicate with them on a regular basis. We are citizens. In addition to having a responsibility to vote, we cannot complain about unfavorable outcomes if we are not part of the team that ensures implementation of sound policies. Freedom is not free. People from many nations are losing their lives for an opportunity to speak freely and choose their leadership. We are fortunate to already have a system in place that makes advocacy without fear of retribution possible. Our efficient GA team works hard to identify issues that may or will impact the work we do every day. While we each have the freedom to independently meet with our legislators, attendance at the Spring BOG Meeting & OTO Advocacy Summit creates myriad opportunities to a.) collaborate with colleagues; b.) hear from passionate, knowledgeable “insiders;” c.) participate in lively conversations with the Board of Governors on issues that directly affect our specialty; and stand united with our colleagues on Capitol Hill. I’ve barely scratched the surface of understanding all the intricacies of these policies and proposals, but I left Washington DC, more motivated than ever to continue my political education and advocate for our specialty. The meeting reaffirmed my conviction that as imperfect as our nation’s political system is, our forefathers had an ingenious idea. We ought to take advantage of it. Please attend this year’s meeting, Sunday, May 5 through Tuesday, May 7.
AcademyU® Connects You to Online Learning Options for Voice Disorders
The Foundation’s comprehensive otolaryngology education source, contains hundreds of learning options presented in a variety of formats to complement different learning styles. Developed by leading expert volunteers, the materials are designed to deliver relevant education that is meaningful to your practice. In recognition of World Voice Day, a list of online lectures addressing issues related to voice disorders is included below: Phonomicrosurgery for Benign Pathology Steven M. Zeitels, MD Phonosurgery: What to Do and What to Avoid, Laser and Cold Instruments Jean Abitbol, MD Professional Singers: The Science and Art of Clinical Care Robert Thayer Sataloff, MD A Diagnostic Model for Voice Disorders Robert W. Bastian, MD Vocal Fold Injection: Fact, Fiction, and Material Selection Clark A. Rosen, MD New Lasers: Office and OR, Fiber Cutting and Pulsed Angiolysis Steven M. Zeitels, MD Vocal Nodules, Polyps, and Cysts: Diagnosis and Current Treatment Clark A. Rosen, MD Presbyphonia Michael M. E. Johns III, MD Edie Renee Hapner, PhD Online Lectures are based on annual meeting instruction courses of the same name. Each lecture provides the highlights of these key sessions.
Dates to Remember
April 15: International Travel Grant application deadline. Email international@entnet.org. April 16: World Voice Day www.entnet.org/bulletin and www.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.
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The Voice Committee Speaks about Voice
“I occasionally encounter difficulties with other people accepting my weak voice; sometimes it seems to border on overt discrimination. An example was the attitude I faced when I responded to an invitation to participate in a medical survey, (after repeated skepticism on the part of the survey organization) I completed this interview successfully. On being asked back again to respond to another one (survey), I did the same (completed it), but faced the same initial discrimination as the first time. This experience was an acute reminder that I may always face a harsh reality of potential discrimination based on the quality of my voice.” — Itzhak Brook, MD, MSc Author, My Voice: A Physician’s Personal Experience with Throat Cancer, and the John Conley Medical Ethics Guest Lecturer of the AAO-HNSF 2012 Annual Meeting & OTO EXPOSM Opening Ceremony. No one is more passionate about the power and frailty of the human voice than those who have lost this functionality, such as the amazing AAO-HNSF John Conley, MD, Guest Lecturer, Dr. Itzhak Brook. Each year, aside from working to ensure that quality and appropriate patient care is available to all who need it, the 22 people who make up the Academy Voice Committee champion awareness of the importance of caring for the voice through the World Voice Day campaign on April 16. The theme of this year’s campaign, “Connect with Your Voice,” is explained on previous pages. A full-size poster is bound into the print edition of Bulletin as a member bonus to help you promote this year’s campaign. Mount it in areas where patients can learn that otolaryngologists care for voice conditions and care about patients’ voice health. The poster also offers access to more health information about the voice at www.entnet.org. To assist the individual Academy members in outreach activities prior to the campaign in her/his community, several committee members discuss key points about the otolaryngologist’s role in voice health by responding to some important questions. The seven committee members were asked to respond to several, but not all the questions. Their responses follow. What is the Role of the Otolaryngologist in Treating Voice Conditions? Dr. Altman: The role of the otolaryngologist is the medical diagnosis, medical care, and to perform surgical interventions, if needed. Dr. Akst: Based on history, physical examination, and laryngeal exam, the first role of the otolaryngologist is in accurately diagnosing the nature of the voice problem. Accurate diagnosis then leads to appropriate treatment planning, which might involve some combination of medication, surgery, and voice therapy. The otolaryngologist coordinates this treatment plan, making treatment decisions with the patient that take into account the nature and severity of the voice problem. Dr. Cohen: The otolaryngologist is the physician with skills in examining the larynx, which is essential for accurately diagnosing voice conditions. The otolaryngologist has an essential role in treating voice conditions as treatment depends on diagnosing the cause. Dr. Heman-Ackah: The otolaryngologist is a physician who diagnoses, directs, and coordinates treatment of voice problems. He or she works closely with the patient, voice therapists, and voice teachers to help an individual who is having problems with his or her voice to improve the voice. Dr. Hogikyan: The otolaryngologist is the person who diagnoses and prescribes treatment for patients with voice disorders in order to set them on the path to vocal wellness. Treatment options commonly include medication, voice therapy, or surgery, and multiple approaches are sometimes employed for an individual patient. Dr. Young: Hoarseness that lasts longer than two weeks is not normal, and a laryngeal examination should be performed to rule out more serious causes of persistent hoarseness. This type of examination, a laryngoscopy, is typically performed by otolaryngologists. More specialized care of voice conditions may be performed by fellowship-trained laryngologists (voice specialists). Dr. Smith: The otolaryngologist diagnoses the condition for the voice problem. By discussing the cause of the problem, what is occurring functionally, and treatment options, the patient becomes a student of his or her own voice. The voice “team,” including the patient, physician, and voice therapist, then works to improve the voice problem. What New Resources are Available or on the Horizon for Physicians in the Treatment of Voice Problems? Dr. Altman: We already see greater access to stroboscopy and other high-resolution diagnostic tools, and the advent of clinical practice guidelines defining standards of care (which enhances how we employ a standardized approach to medical and surgical management). Dr. Heman-Ackah: The biggest resource available for physicians in the treatment of voice problems is laryngeal videostroboscopy. Videostroboscopy provides a magnified view of the vocal folds and allows the otolaryngologist to observe the motion of the vocal folds while they are vibrating. This is an invaluable tool in helping to delineate the cause of an individual’s voice problems and is the key to directing treatment. Dr. Hogikyan: We will more and more be able to translate knowledge acquired through research into active treatments for voice patients. This includes research related to tissue scarring, laryngeal paralysis, and new types of lasers. We also are training an increasing number of laryngologists, and this will make subspecialty voice care more broadly available to patients. Dr. Akst: One relatively new technology, which helps otolaryngologists care for patients with voice problems, is digital imaging. This technology provides for high quality laryngeal exams. Laryngologists may use videostroboscopy to supplement laryngoscopy, allowing insight into vocal fold function and structure. A variety of new technologies and techniques have allowed for many beneficial procedures to be performed in the office rather than the operating room, including office-based laser therapy, vocal fold injection, transnasal esophagoscopy, and pH probe testing. Taken together, these resources are allowing for ever-greater quality of care to be provided to patients with voice complaints. Dr. Young: The field of voice-related disorders is ever expanding. We are able to perform more surgical procedures in the office setting, thus avoiding general anesthesia and intubation. This is a significant benefit to patients, in terms of both time- and cost-savings. We are able to treat and improve more complex voice problems, and there are more laryngologists (voice-specialists) available to treat people with complex voice issues. Dr. Smith: Real-time imaging of vocal fold physiology is an area of constant improvement. With better visualization, and therefore improved characterization of what is occurring, the otolaryngologist becomes a better diagnostician. What Would You Like the Healthcare Consumer With a Voice Problem to Know? Dr. Altman: I would like to tell those with concerns not to delay proper evaluation, and to be aware of risk factors such as tobacco smoking, reflux, and HPV. Dr. Cohen: Voice problems are common and may be caused by a variety of conditions from benign to neurologic to malignant. They can have a significant impact on patients’ ability to communicate, work, function socially, and are treatable. Patients should seek evaluation if symptoms persist more than three weeks. Dr. Heman-Ackah: As industry and technology require a greater use of the voice on a daily basis for working and communicating, more individuals are experiencing difficulties with their voices. Devices as commonplace as a Bluetooth headset present a unique demand on the vocal folds that most people never had to accommodate before, and many individuals are experiencing vocal problems in numbers that did not previously exist. Voice problems today are the 21st century version of carpel tunnel syndrome from the 1980s and 1990s. Many voice problems are the direct result of repetitive use of the vocal folds and occur from repetitive vocal fold injury. Dr. Hogikyan: I feel that there are two key items here: 1. Hoarseness or voice change can be a sign of a serious problem and should be evaluated by an otolaryngologist if it is persistent (longer than about two weeks can be considered persistent), and 2. Most voice problems can be helped so don’t just accept hoarseness without pursuing treatment by a specialist. Dr. Akst: Voice quality is an important part of how we present ourselves to others and how we are perceived by others. Voice problems are a very common source of work-related difficulties, especially as more jobs depend on verbal communication. Voice disorders need not be “accepted as normal”—very often, there are things that can be done to diagnose and treat voice problems.Diagnosis and treatment for voice disorders should involve an otolaryngologist with experience in working with voice patients. Dr. Young: Many voice disorders can be improved with proper treatment. Evaluation by an otolaryngologist (or laryngologist) is invaluable. Hoarseness does not need to be simply “tolerated.” The most important message is that persistent hoarseness is not normal, and laryngeal examination should be performed to rule out more serious underlying causes, such as cancer. Dr. Smith: There are dedicated otolaryngologists/laryngologists and voice therapists who want to help. We realize that voice is often a reflection of self, especially for the professional voice user (singer, preacher, teacher, etc). But, the quality of life related to voice is just as important for non-professional voice users, as it allows us to communicate with friends and family, conduct our jobs, and sing. How Does the Observation of World Voice Day Benefit the Public? Dr. Altman: It raises awareness for the working public, but also helps expand the limits of care we provide for voice professionals. Dr. Cohen: By promoting awareness of how vital the voice is to our everyday life, awareness of resources if problems do arise, and discussing prevention in order to keep the voice healthy. The voice is often taken for granted until its function becomes compromised. Dr. Heman-Ackah: Observation of World Voice Day helps to bring awareness of the fact that hoarseness and vocal fatigue are medical problems that can be treated medically and successfully. It helps the general public understand that there is something that can be done to help when one is experiencing difficulties with the voice, and it brings awareness to the fact that voice problems are occupational health issues that contribute to significant disability and absences from work. Dr. Young: So many people use their voices extensively in their day-to-day life (work, home, etc.) and yet most people don’t think about their voice or how to care for their voice properly. World Voice Day is a wonderful opportunity to bring awareness to this supremely important, but often overlooked, ability. Many people with voice problems or difficulties think that hoarseness should just be tolerated or that it will go away on its own. World Voice Day is a great time to remind people that persistent hoarseness is not normal and should be investigated further! Dr. Smith: By placing a spotlight on the importance of voice in all realms of society, we hope that people with hoarseness will seek help. Whether hoarseness is caused by cancer or a noncancerous process, voice does matter. Dr. Akst: By increasing awareness that vocal difficulty is a medical condition that can be evaluated and treated, we help the public understand that they can be helped. Dr. Hogikyan: It reminds us of the importance, power, and beauty of the human voice. Educational outreach efforts related to World Voice Day help educate the public about how to maintain good vocal health and when to seek an otolaryngology evaluation. Can You Give an Example of How Use of Your Voice has Helped You to Connect With Others? Dr. Altman: The voice is a window to the soul, and conveys emotion on top of the words that are communicated. Dr. Cohen: I feel most connected when speaking with my patients, reading to my children. Dr. Heman-Ackah: I use my voice on a daily basis to teach both patients and students. My voice is the essence of my ability to impart information to others. Dr. Hogikyan: I think about this every day when I interact with patients. Particularly when people come to see me about a serious health problem, the voice I use in the clinic is vital to letting the patient know I care and that I will take care of them; the voice establishes our doctor-patient connection. Dr. Young: As a physician, I spend all day talking to my patients. I am able to connect with them, communicate with them, and educate them. Every day, I describe to my patients the findings of their laryngeal exam, what it means, and what we will do next to address their voice problem. I absolutely could not do my job if I didn’t have my voice. And I know that there are many other jobs for which this is also true. Some of these are obvious (teachers, call center workers, lawyers, radio and television personnel) and some are less evident (cashiers, secretaries, nurses, flight attendants). For most people, if they stop to ask themselves if they could still do their job if they didn’t have a voice, the answer would be “no.” Dr. Smith: As a laryngologist, I speak with patients all day. They know I care about their voice, much like they do. Through the connection of talking and singing with patients, their knowledge about voice improves. This allows them to “own” their voice. Together with the voice “team,” their voices are heard. Lee M. Akst, MD Director, Voice Center Assistant Professor of Otolaryngology-Head and Neck Surgery Johns Hopkins Medicine Kenneth W. Altman, MD, PhD Director, Eugen Grabscheid, MD, Voice Center Associate Professor of Otolaryngology Mount Sinai School of Medicine Seth M. Cohen, MD, MPH Associate Professor of Surgery, Division of Otolaryngology-Head and Neck Surgery Duke University Medical Center Yolanda D. Heman-Ackah, MD Associate Professor of Otolaryngology Drexel University College of Medicine Philadelphia Voice Center Norman D. Hogikyan, MD Professor and Director of Vocal Health Center Department of Otolaryngology-Head and Neck Surgery University of Michigan Libby J. Smith, DO Assistant Professor UPMC Voice Center University of Pittsburgh VyVy N. Young, MD Assistant Professor UPMC Voice Center University of Pittsburgh
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World Voice Day 2013: Connect with Your Voice
Norman D. Hogikyan, MD When you really need to connect with people, there is no substitute for the human voice. Connecting is about bringing people or things together and establishing relationships. Pause for a moment and think about how you personally connect with people. Sure, you can send emails, texts, tweets, and photos in order to transfer information or data, but are you really making a connection? How often do these methods lead to misunderstandings or misinformation? Have you ever had the experience of needing to speak with someone in order to clarify what was sent in an email or to soothe angry emotions or hurt feelings from a charged message? For most of us, the answer to this question is a definite yes. The voice conveys a rainbow of emotion and provides a window into an individual’s personality and intentions. It is both the choice of words and how the voice sounds that convey their true meaning. This is true of the conversational speaking voice, and is elevated to a wondrous level when considering the singing voice. The profound connection and the range of possible emotions that can be elicited by singing are truly without equal. The singing voice is our natural instrument of artistic expression. For 2013 World Voice Day, you can connect with your own voice; establish a rapport with it. This can mean listening to yourself on a whole new level. How do you sound to yourself and to others? Confident or insecure? Kind or inconsiderate? Strong or meek? This can also mean gaining a better understanding of how voice is produced, how to care for it, and how to keep it in optimal shape. The sound-producing structures in your larynx are the vocal folds, or vocal cords. These remarkable little structures vibrate many times a second to generate sounds that are then shaped by other parts of the throat, mouth, and nose. Together they create the instrument that produces speech or song. As you celebrate World Voice Day 2013, take some time to connect with your own voice and the voices of others and work to be at your vocal best. You can help maintain good vocal health by following a few simple vocal health tips. Tips for Vocal Health Never smoke. Keep yourself well hydrated. Water is the best. Don’t scream or shout. Use a microphone if you need to project your voice. Speak in an easy, unstrained voice. Rest your voice if you have laryngitis. Get evaluated by an otolaryngologist if you have hoarseness that lasts longer than two weeks.
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Continue the Choosing Wisely® Conversation: Find AAO-HNSF Updates and Resources 24/7
Continue the conversation with resources from www.entnet.org/choosingwisely.cfm. Additional resources can be found via the ABIM Choosing Wisely® campaign website at www.choosingwisely.org. To help continue to spread the word about Choosing Wisely®, visit www.entnet.org/choosingwisely.cfm. Here you can find the announcement and formal list of “Five Things Physicians and Patients Should Question.” In addition to the list, you will find direct access to the sources from which the list was developed. You can also watch a brief video with AAO-HNSF EVP/CEO David R. Nielsen, MD, that explains the scope and purpose of the campaign and the AAO-HNSF commitment to the effort. Follow the conversation about the campaign though the Academy’s social media sites on Twitter, Facebook, and LinkedIn right from the page. Using the Twitter hashtag #ChoosingWisely will allow you to be part of what the medical community and consumers are saying about the campaign.
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Choosing Wisely®: Our List of Five Things Physicians and Patients Should Question
A Campaign to Improve the Nation’s Healthcare Quality and Safety On February 21, the American Academy of Otolaryngology—Head and Neck Surgery Foundation (AAO-HNSF) released its list of five things physicians and patients should question as part of the American Board of Internal Medicine (ABIM) Foundation’s Choosing Wisely® campaign. To date, 25 specialty societies have developed and released lists as part of the initiative. This month we highlight our five items and provide a set of questions and answers to stimulate discussion of the campaign in your practice and with your patients. Further information about the campaign is available at http://www.entnet.org/choosingwisely and http://www.choosingwisely.org/. In releasing the list, the AAO-HNSF would like to thank everyone who provided leadership and input during the list’s development. In particular, we would like to highlight the role of the Patient Safety and Quality Improvement Committee that spearheaded the AAO-HNSF list development process. What Is the Choosing Wisely Campaign? The campaign is an initiative of the ABIM Foundation to help physicians and patients engage in conversations about the overuse of tests and procedures and support physician efforts to help patients make smart and effective care choices. Recognizing the importance of physicians and patients working together, leading specialty societies, along with Consumer Reports, have joined the campaign to help improve the quality and safety of healthcare in America. What Issues Stimulated the Campaign? As the nation continues to tackle the rising costs of healthcare, it is important for physicians to take a leading role in ensuring patients receive the safest and highest quality of care. According to the ABIM Foundation, “The Congressional Budget Office estimates up to 30 percent of care delivered in the United States goes toward unnecessary tests, procedures, hospital stays, and other services that may not improve people’s health—and in fact may actually cause harm.” The campaign promotes physicians and patients working together and having conversations about wise treatment decisions. How Was the List Developed? The AAO-HNSF’s list was developed during a six-month period beginning in May 2012. The Academy’s Patient Safety and Quality Improvement Committee spearheaded the list development process. Input was sought from Academy and Foundation Committees, the Specialty Society Advisory Council (SSAC), and the Guidelines Task Force (GTF), previously known as the Guidelines Development Task Force. The AAO-HNSF’s final list was based on support of the above groups, evidence supporting each of the items (such as clinical practice guidelines), and the current frequency/use of the test or treatment. A more detailed description of the list development process can be found in a commentary in April’s edition of Otolaryngology–Head and Neck Surgery. What Resources Are Available? The ABIM Foundation has made each participating society’s list available publicly. In addition, Consumer Reports has begun translating the lists into patient education materials. The AAO-HNSF plans to have patient materials available in the coming months. All AAO-HNSF resources related to the campaign can be found at http://www.entnet.org/choosingwisely. Will the AAO-HNSF Develop Further lists? Yes, the AAO-HNSF will continue to participate in the campaign and we hope to develop several more iterations of the list. A third phase of specialty societies have agreed to join the campaign and their lists will be released later this year. Which Specialty Societies Have Participated? Twenty five specialty societies have participated in the campaign and released lists of five items. The first phase included nine societies that released lists in April 2012, they included: American Academy of Allergy, Asthma, & Immunology American Academy of Family Physicians* American College of Cardiology American College of Physicians American College of Radiology American Gastroenterological Association American Society of Clinical Oncology American Society of Nephrology American Society of Nuclear Cardiology * Released its second list on February 21, 2013. The second phase included 16 new societies, with the following societies releasing their lists alongside the AAO-HNSF: American Academy of Hospice and Palliative Medicine American Academy of Neurology American Academy of Ophthalmology American Academy of Pediatrics American College of Obstetricians and Gynecologists American College of Rheumatology American Geriatrics Society American Society for Clinical Pathology American Society of Echocardiography American Urological Association Society for Vascular Medicine Society of Cardiovascular Computed Tomography Society of Hospital Medicine Society of Nuclear Medicine and Molecular Imaging Society of Thoracic Surgeons Sources Stachler RJ, Chandrasekhar SS, Archer SM, Rosenfeld RM, Schwartz SR, Barrs DM, Brown SR, Fife TD, Ford P, Ganiats TG, Hollingsworth DB, Lewandowski CA, Montano JJ, Saunders JE, Tucci DL, Valente M, Warren BE, Yaremchuk KL, Robertson PJ. Clinical practice guideline: Sudden hearingloss. Otolaryngol Head Neck Surg [Internet]. 2012 Mar [cited 2012 Oct 18];146(3 Suppl):S1-35. Goldblatt EL, Dohar J, Nozza RJ, Nielsen RW, Goldberg T, Sidman JD, Seidlin M. Topical ofloxacin versus systemic amoxicillin/clavulanate in purulent otorrhea in children with tympanostomy tubes. Int J Pediatr Otorhinolaryngol. 1998 Nov 15;46(1-2):91-101.Rosenfeld RM, Schwartz SR, Pynnonen MA, Tunkel DE, Hussey HM, Fichera JS, Grimes AM, Hackell JM, Harrison MF, Haskell H, Haynes DS, Kim TW, Lafreniere DC, LeBlanc K, Mackey WL, Netterville JL, Pipan ME, Raol NP, Schellhase KG. Clinical Practice Guideline: Tympanostomy tubes in children. Otolaryngol Head Neck Surg. 2013; Submitted for publication. Rosenfeld RM, Brown L, Cannon CR, Dolor RJ, Ganiats TG, Hannley M, Kokemueller P, Marcy SM, Roland PS, Shiffman RN, Stinnett SS, Witsell DL. Clinical practice guideline: Acute otitis externa. Otolaryngol Head Neck Surg [Internet]. 2006 Apr [cited 2012 Oct 18];134(4 Suppl):S4-23. Rosenfeld RM, Andes D, Bhattacharyya N, Cheung D, Eisenberg S, Ganiats TG, Gelzer A, Hamilos D, Haydon RC 3rd, Hudgins PA, Jones S, Krouse HJ, Lee LH, Mahoney MC, Marple BF, Mitchell CJ, Nathan R, Shiffman RN, Smith TL, Witsell DL. Clinical practice guideline: Adult sinusitis. Otolaryngol Head Neck Surg [Internet]. 2007 Sep [cited 2012 Oct 18]:137(3 Suppl):S1-31. Schwartz SR, Cohen SM, Dailey SH, Rosenfeld RM, Deutsch ES, Gillespie MB, Granieri E, Hapner ER, Kimball CE, Krouse HJ, McMurray JS, Medina S, O’Brien K, Ouellette DR, Messinger-Rapport BJ, Stachler RJ, Strode S, Thompson DM, Stemple JC, Willging JP, Cowley T, McCoy S, Bernad PG, Patel MM. Clinical practice guideline: Hoarseness (dysphonia). Otolaryngol Head Neck Surg [Internet]. 2009 Sep [cited 2012 Oct 18];141(3 Suppl 2):S1-S31.
Denis C. Lafreniere, MD Chair, BOG
Using Our Voices to Connect on Grassroot Initiatives
To promote World Voice Day, April 16, many of our BOG state and local societies have successfully petitioned their state legislators to formally recognize the day. The voice is vitally important to our patients and ourselves as practitioners, allowing us all the ability to communicate, educate, and entertain. The evolution of our ability to diagnose and treat voice disorders has certainly accelerated during the last several decades. Technological innovations have continually improved our ability to visualize the larynx and measure physiologic functions involved in voice production. Endoscope images with stroboscopic capabilities can now be seen in high definition, making the diagnosis of even the most subtle mucosal abnormality easier than before. Our ability to perform in-office diagnostic and therapeutic procedures has also improved with these technologic advances, and we routinely perform biopsies, laryngeal EMGs, medialization laryngoplasty injections, and laser treatment of laryngeal lesions under local anesthesia. Perhaps the most congenial development has been that the comprehensive care of the voice-disordered patient has led to a significant partnership between the otolaryngologist, the speech pathologist, and vocal pedagogues. Many voice centers can provide expert evaluation of the functional issues involved in many voice disorders and develop a team approach to the resolution of each patient’s voice disorder. This successful collaboration between the otolaryngologist and the allied healthcare provider has required a complete understanding of the roles of each member of the voice care team, which has resulted in the best patient care experience. The ability to work together toward the goal of optimum vocal care ensures that voices will continue to be heard. This metaphor is one that now needs to be applied to the House of Medicine. Affordable Care Act As this column is being written, we have just postponed the “fiscal cliff,” but still have no definitive answer to the many fiscal questions that desperately need answers such as the upcoming debt ceiling, underfunded entitlement programs, etc. The Affordable Care Act (ACA) is now in full swing with many states still trying to find their way in this new healthcare world. The meaningful use incentives are now in effect and many, if not most, of our practices have implemented electronic medical records as we work to meet the criteria for incentive payments. During the next several years, we will see these incentives turn into penalties for those not on board. The near future will also mean the introduction of quality metrics that will also result in penalties if these parameters are not measured and met. There are many aspects of the ACA that we as your BOG of the AAO-HNS are working to amend to allow us to maintain our ability to take outstanding care of our patients. The legislative arm of the AAO-HNS has been working with our colleagues from the House of Medicine to repeal the Independent Payment Advisory Board (IPAB) from the ACA as it allows payment decisions for medical expenditures to be influenced by non-elected officials. Many fellows of the AAO-HNS signed a “Declaration of Independence” from the flawed Sustainable Growth Rate Formula this past September in Washington, DC. In this document we collectively raised our voices on this particular issue, and we plan to continue this fight during this current legislative session. This is a battle that requires as many voices as we can muster. We, the BOG, are asking for your help! Spring Meeting and Advocacy Summit The 2013 BOG Spring Meeting & OTO Advocacy Summit of the AAO-HNS will be taking place May 5-7 in Alexandria, VA. This meeting will immediately follow the Academy’s Boards of Directors meeting on May 4. Visits with our individual Members of Congress’ offices will take place nearby on Capitol Hill on May 7. I strongly encourage all Academy members, especially our new members and resident members in-training, to invest your time in these meetings. The BOG Spring Meeting will include useful practice information with talks on quality measures, and the changes scheduled to occur with ICD-10. The OTO Advocacy Summit will educate you on current issues being considered on Capitol Hill as we hear from several legislators. We will also discuss talking points for our meetings with our representatives. The stakes for our patients and us as practitioners has never been so high. We need our “voices,” both as individuals and as a collective, to be heard loud and clear.
David R. Nielsen, MDAAO-HNS/F EVP/CEO
How Comparatively Effective Are We?
David R. Nielsen, MD AAO-HNS/F EVP/CEO As everyone knows by now, embedded in the Patient Protection and Affordable Care Act of 2010 (ACA) is language designed to address the unsustainable cost of healthcare in the United States by reducing waste, eliminating unnecessary care, and dealing with the unwanted and unexplained variations in care. One specific method the ACA employs is support for comparative effectiveness research (CER)—defined by the Agency for Health Research and Quality (AHRQ) as research methods “designed to inform healthcare decisions by providing evidence on the effectiveness, benefits, and harms of different treatment options. The evidence is generated from research studies that compare drugs, medical devices, tests, surgeries, or ways to deliver healthcare.” See http://effectivehealthcare.ahrq.gov/index.cfm/what-is-comparative-effectiveness-research1/ . The Patient-Centered Outcomes Research Institute (PCORI) was founded within the ACA language specifically for the purpose of providing direction and oversight for an entire spectrum of envisioned comparative effectiveness research that could dramatically and positively influence the decision making of professionals, bring consensus around the most efficient ways of providing high quality care for those conditions and interventions for which there is enough data to support a conclusion, and achieve the three aims of the National Quality Strategy: better individual health outcomes, better population health, and reduced cost of healthcare. While using this approach to improve quality and resource use is a laudable goal and one that every physician and surgeon can support, the challenge of prioritizing clinical topics, designing relevant and meaningful studies, and acting on what is learned can be complex and daunting. The concept of CER is not new. The medical profession has many years of experience in this approach, but, to date, limited benefit to show from what we have learned. While there are many examples of how such research has improved quality and reduced cost, the promise of CER as envisioned by those who crafted the ACA language remains largely unfulfilled. What are the reasons for this? A recent article in Health Affairs (October 30, 2012) is instructive. After careful study of the literature on many types of CER, the authors conclude that five root causes appear to be responsible for the failure of CER to be translated into positive changes in clinical practice. Misalignment of incentives, ambiguity of results, cognitive biases in interpreting the new information, failure to take into consideration the needs of end users of the data, and limited use of clinical decision support tools all impair the goal of changing clinical behavior. The cognitive biases alone reveal that physicians are not exempt from the powerful effect of traditional behavior and thought processes. As clinicians, the paper discovers, we demonstrate confirmation bias (the effect of believing and acting on that data that supports our pre-conceived notions of what is true); pro-intervention bias (that is, we tend to want to act, rather than to observe or wait, even when the evidence clearly shows that intervention has little or no benefit or may be harmful); and a pro-technology bias (more recent technological advances are superior to existing modalities). The article concludes that PCORI has learned that multi-stakeholder involvement in CER from design to implementation is essential to minimize the negative effects of these five barriers and three biases to changing clinical practice for the better. The AAO-HNS/F agrees that collaboration is essential, and has made multi-disciplinary engagement in our Guidelines Task Force a hallmark of our published evidence-based guideline development process. Now in its third edition, if you have not read it, please take the time to review the supplement to the January issue of Otolaryngology–Head and Neck Surgery. Since learning to eliminate bias, carefully searching for and critically examining data, and being willing to change our clinical practice to achieve better results are all essential to improving quality, we each need to become familiar with relevant health services research and CER and master the ability to implement what we learn. Source: Timbie JW, Fox DS, Van Busum K, Schneider EC. Health Aff (Millwood). Five reasons that many comparative effectiveness studies fail to change patient care and clinical practice. 2012 Oct;31(10):2168-75. The particular approach championed by ARHQ and the ACA includes seven distinct steps for optimal implementation: Identify new and emerging clinical interventions. Review and synthesize current medical research. Identify gaps between existing medical research and the needs of clinical practice. Promote and generate new scientific evidence and analytic tools. Train and develop clinical researchers. Translate and disseminate research findings to diverse stakeholders. Reach out to stakeholders via a citizens’ forum.
James L. Netterville, MD AAO-HNS/F President
World Voice Day: Our Efforts Connect Us to the Future
James L. Netterville, MD AAO-HNS/F President April 16 is coming. Aside from the fact that it is the day after our taxes are due, otolaryngologists should better know the day as World Voice Day. In a Google search of “World Voice Day,” the Academy’s 2012 campaign material comes up first and second, and our images for the campaign come up third. Following these entries are more than 20 pages of World Voice Day listings from organizations such as the University of Utah, Cleveland Clinic, WBAL News, Johns Hopkins, and the University of Cincinnati with the Cincinnati Opera, as well as international listings from the UK, Brazil, and other international observances. This day is no small deal. Our Voice Committee, chaired by Clark A. Rosen, MD, with the help of Michael M.E. Johns III, MD, and Norman D. Hogikyan, MD, developed a task force to lead this international observation, and it met during our AAO-HNSF Annual Meeting 2012 & OTO EXPOSM last September to plan the 2013 and 2014 campaigns. The task force heard about the highly successful observances in France and Belgium, (from Marc J. Remacle, MD, PhD) and the country where the observance originated (from Mario Andrea, MD, PhD). While it was noted that it is difficult to engage a renowned celebrity for our domestic campaigns due partially to privacy issues, attendees noted that a campaign featuring the importance of voice to all professions would be the approach to take and to build on. The committee then chose “Connect with Your Voice” as its theme this year. In following that lead, I came upon a blog by Katie Peters, a professional speaker. Katie agreed to support World Voice Day 2013 in her blog as she did last year, and she offered this thought on our 2013 theme: “As humans, we are passionately driven to communicate. We want to be heard. We want to be understood. But to be heard above all the noise of our culture, you must have a voice that others will listen to. There has never been a better time to develop and care for that voice. Resources for study and practice are abundant. Expertise is at an all-time high and instead of taking on less importance as our technology advances, the human voice is more important than ever, adding warmth and humanity to a digital world.” To help members support this observance and promote the special role otolaryngologists play in the treatment of voice disorders, this Bulletin offers you some starting tools. You’ll find a message about the importance of a healthy voice from committee member Norm D. Hogikyan, MD, that may be offered to your patients and referral base prior to the observation. Also included in this issue is a fold-out poster to display in your offices that offers an Academy link for additional information about the campaign. Other materials for outreach have been developed by the Voice Committee and the Media and Public Relations Committee (Wendy B. Stern, MD, and Ramon A. Franco Jr., MD) and include a template letter to send to local media when you login as a Member. In conclusion, I offer an example of the power of the voice to move human endeavor. The following “interplanetary voicemail” by NASA administrator Charles Bolden was returned to Earth via the Mars rover, Curiosity. The message, which had been sent to Mars and back, was played on Aug. 27, 2012, becoming the first voice transmission from Mars.”Hello. This is Charlie Bolden, NASA administrator, speaking to you via the broadcast capabilities of the Curiosity rover, which is now on the surface of Mars. Since the beginning of time, humankind’s curiosity has led us to constantly seek new life…new possibilities just beyond the horizon.” (Hear the actual message athttp://www.nasa.gov/mission_pages/msl/news/bolden20120827.html.) While the message itself is simple, I was struck by the significance of the broadcast as explained by the NASA Curiosity program executive, Dave Lavery, “With this voice, another small step is taken in extending human presence beyond Earth…we hope these words will be an inspiration to someone alive today who will become the first to stand upon the surface of Mars. And like the great Neil Armstrong, they will speak aloud of that next giant leap in human exploration.” Surely, this is a “connection” to the future powered by the human voice.