Published: October 21, 2013

Instrument Reprocessing in Otolaryngology

Patrick T. Hennessey, MD Lee D. Eisenberg, MD, MPH Ellen S. Deutsch, MD AAO-HNS Patient Safety and Quality Improvement Committee More than 1,000 patients were exposed to improperly reprocessed flexible fiber optic laryngoscopes in the Augusta, GA, Charlie Norwood VA Medical Center clinic in 2009. While no patients are known to have been harmed, the Department of Veterans Affairs Office of the Inspector General released a report detailing widespread improper reprocessing of these laryngoscopes, attributed to improperly trained and certified nursing staff.1 The same report documented widespread lack of adherence to reprocessing guidelines for colonoscopes at more than half of randomly inspected VA hospitals.1 This report resulted in national media attention after it was reported that six cases of HIV, 13 cases of hepatitis B, and 34 cases of hepatitis C resulted when more than 10,000 patients were exposed to contaminated scopes during colonoscopy.2 The report’s findings are sobering, and clearly illustrate the risks posed to patients by improperly reprocessed medical devices. Although most reported cases of contamination have occurred in the hospital setting, the majority of instruments used in otolaryngologists’ offices are reusable and require reprocessing in the office. Proper reprocessing of medical instrumentation is critical to prevent the spread of infectious diseases and to uphold our patients’ expectations that the devices used in their treatment are safe and clean. Indeed, a recent summit of the Association for the Advancement of Medical Instrumentation (AAMI) and the U.S. Food and Drug Administration (FDA) focused on the issue of medical instrument reprocessing.3 The proper reprocessing of flexible endoscopes has become the focus of increasing national attention. Cross-contamination from flexible endoscopes was listed as one of the Top 10 health hazards of 2012 by the Emergency Care Research Institute (ECRI).4 There is little information available regarding the sterility of instruments used in the otolaryngology outpatient setting; however, a paper by Powell and colleagues in 2003 showed that as many as 17 percent of the instruments used in otolaryngology offices, such as suctions and forceps, may be contaminated with bacteria at the time they are used on patients.5 Although this was a small study, the high rate of contamination of instruments, along with the ECRI cross-contamination concerns, demonstrate a need to revisit protocols used for reprocessing instruments. There is a paucity of published literature regarding office reprocessing of otolaryngology instruments. To determine the appropriate intensity of reprocessing, instruments may be divided into three broad categories: critical, semi-critical, and noncritical (see Table). These categories are based on the type of procedure for which instruments are used. Virtually all reusable devices used in the outpatient setting by otolaryngologists, including endoscopes and handheld instruments, come into contact with the mucous membranes or non-intact skin. Therefore, these instruments are classified as semi-critical devices, requiring at least high-level decontamination to destroy all microbes and most bacterial endospores. The proper reprocessing of semi-critical instruments occurs in three phases: cleaning and decontamination, disinfection or sterilization, and storage.6 Cleaning and decontamination entails the mechanical removal of all soil from the instrument and can be accomplished by manual or machine washing. For more complex instruments, such as endoscopes with working channels, special attention must be paid to ensuring that both the visible and internal components of the instrument are properly cleaned. The removal of all soil is important so no residual organic material can shield microbes during the second step, disinfection or sterilization, during which all microbes are destroyed.7 While the choice of the specific mechanism for disinfection or sterilization should be based on the type of instrument and the information provided in manufacturer’s written instructions for use (IFU), the majority of handheld instruments used in the office setting by otolaryngologists are sterilized by steam autoclaving, while flexible and rigid scopes are usually disinfected using liquid products containing 2 percent glutaraldehyde (Cidex®), 0.2 percent peracetic acid (Steris® 20), or 0.55 percent ortho-phthalaldehyde (Cidex® OPA). Finally, the instruments should be stored in such a way as to prevent recontamination prior to being used to treat the next patient. According to the Centers for Disease Control and Prevention (CDC), endoscopes should be hung vertically, and sterilized instruments should be stored in impermeable packaging to prevent recontamination prior to use.8 Additionally, the use of disposable single-use sheaths over endoscopes has been shown to provide a similar level of sterility as chemical reprocessing. Elackattu and colleagues found that using single-use sterile sheaths with flexible fiberoptic endoscopes had a similar efficacy as chemical disinfection in preventing microbe adherence to the scopes provided the manufacturers’ sheath handling protocols were followed.9 A recent review of the literature by Collins also found that sheaths can be as effective as conventional reprocessing of flexible fiber optic laryngoscopes.10 Regardless of the method used, office-based reprocessing protocols should adhere to CDC guidelines for disinfection and sterilization of instruments,8 including having a mechanism for transportation of dirty instruments to the processing room, sorting of instruments based on type and intensity of reprocessing required, cleaning, sterilization, and finally, storage. Additionally both the CDC guidelines and the AAMI/FDA Reprocessing Summit encourage a unidirectional work flow for reprocessing to prevent recontamination of instruments after they have been sterilized, and, if possible, to have available different designated areas for each phase of reprocessing. To ensure that reprocessing guidelines are properly followed, office staff should be provided with clear instructions, proper training, and adequate space to perform reprocessing tasks. The AAMI/FDA Reprocessing Summit suggestions for training included providing formal training on device reprocessing techniques and annual continuing education to ensure proper protocols are being followed.3 To meet our patients’ expectations of being treated with clean, safe instruments it is important to adhere to established guidelines to ensure that instruments are properly cleaned for each patient. Instituting in-office protocols for reprocessing and providing proper space, equipment, and training to staff is important to ensure the delivery of safe, high-quality care to our patients. References Healthcare Inspection – Use and Reprocessing of Flexible Fiberoptic Endoscopes at VA Medical Facilities. 2009, Department of Veterans Affairs Office of Inspector General: Washington, DC. O’Keefe, E., Report: VA Facilities Improperly Sterilized Colonoscopy Equipment. The Washington Post. 2009: Washington, DC. Priority Issues from the AAMI/FDA Device Reprocessing Summit. Association for the Advancement of Medical Instrumentation, 2011. ERCI, Top 10 Health Technology Hazards for 2012. Health Devices. 2011.40(11). Powell, S., Perry P., Meikle D., Microbial contamination of non-disposable instruments in otolaryngology out-patients. J Laryngol Otol. 2003;117(2):122-125. McDonnell, G., Burke P., Disinfection: Is it time to reconsider Spaulding? J Hosp Infect. 2011;78(3):163-170. Muscarella, L.F., Prevention of disease transmission during flexible laryngoscopy. Am J Infect Control. 2007;35(8):536-544. Rutala, W.A., Weber, D.J., Healthcare Infection Control Practices Advisory Committee (HICPAC). Guideline for Disinfection and Sterilization in Healthcare Facilities, CDC, Editor. 2008. Elackattu, A., et al., A comparison of two methods for preventing cross-contamination when using flexible fiberoptic endoscopes in an otolaryngology clinic: disposable sterile sheaths versus immersion in germicidal liquid. Laryngoscope. 2010;120(12):2410-2416. Collins, W.O. A review of reprocessing techniques of flexible nasopharyngoscopes. Otolaryngol Head Neck Surg. 2009;141(3):307-310. Table 1. Spaulding’s Classification for reprocessing of medical devices Classification Definition Level of Processing Required Critical Equipment/Devices Equipment/device that enters sterile tissues, including the vascular system Cleaning followed by sterilization Semicritical Equipment/Devices Equipment/device that comes in contact with non-intact skin or mucuous membranes, but does not penetrate them Cleaning followed by high-level disinfection Noncritical Equipment/Devices Equipment/device that touches only intact skin and not mucous membranes, or does not directly touch the patient Cleaning followed by low-level disinfection

Patrick T. Hennessey, MD
Lee D. Eisenberg, MD, MPH
Ellen S. Deutsch, MD
AAO-HNS Patient Safety and Quality Improvement Committee

More than 1,000 patients were exposed to improperly reprocessed flexible fiber optic laryngoscopes in the Augusta, GA, Charlie Norwood VA Medical Center clinic in 2009. While no patients are known to have been harmed, the Department of Veterans Affairs Office of the Inspector General released a report detailing widespread improper reprocessing of these laryngoscopes, attributed to improperly trained and certified nursing staff.1

The same report documented widespread lack of adherence to reprocessing guidelines for colonoscopes at more than half of randomly inspected VA hospitals.1 This report resulted in national media attention after it was reported that six cases of HIV, 13 cases of hepatitis B, and 34 cases of hepatitis C resulted when more than 10,000 patients were exposed to contaminated scopes during colonoscopy.2 The report’s findings are sobering, and clearly illustrate the risks posed to patients by improperly reprocessed medical devices.

Although most reported cases of contamination have occurred in the hospital setting, the majority of instruments used in otolaryngologists’ offices are reusable and require reprocessing in the office. Proper reprocessing of medical instrumentation is critical to prevent the spread of infectious diseases and to uphold our patients’ expectations that the devices used in their treatment are safe and clean. Indeed, a recent summit of the Association for the Advancement of Medical Instrumentation (AAMI) and the U.S. Food and Drug Administration (FDA) focused on the issue of medical instrument reprocessing.3 The proper reprocessing of flexible endoscopes has become the focus of increasing national attention. Cross-contamination from flexible endoscopes was listed as one of the Top 10 health hazards of 2012 by the Emergency Care Research Institute (ECRI).4

There is little information available regarding the sterility of instruments used in the otolaryngology outpatient setting; however, a paper by Powell and colleagues in 2003 showed that as many as 17 percent of the instruments used in otolaryngology offices, such as suctions and forceps, may be contaminated with bacteria at the time they are used on patients.5 Although this was a small study, the high rate of contamination of instruments, along with the ECRI cross-contamination concerns, demonstrate a need to revisit protocols used for reprocessing instruments.

There is a paucity of published literature regarding office reprocessing of otolaryngology instruments. To determine the appropriate intensity of reprocessing, instruments may be divided into three broad categories: critical, semi-critical, and noncritical (see Table). These categories are based on the type of procedure for which instruments are used. Virtually all reusable devices used in the outpatient setting by otolaryngologists, including endoscopes and handheld instruments, come into contact with the mucous membranes or non-intact skin. Therefore, these instruments are classified as semi-critical devices, requiring at least high-level decontamination to destroy all microbes and most bacterial endospores.

The proper reprocessing of semi-critical instruments occurs in three phases: cleaning and decontamination, disinfection or sterilization, and storage.6 Cleaning and decontamination entails the mechanical removal of all soil from the instrument and can be accomplished by manual or machine washing. For more complex instruments, such as endoscopes with working channels, special attention must be paid to ensuring that both the visible and internal components of the instrument are properly cleaned.

The removal of all soil is important so no residual organic material can shield microbes during the second step, disinfection or sterilization, during which all microbes are destroyed.7 While the choice of the specific mechanism for disinfection or sterilization should be based on the type of instrument and the information provided in manufacturer’s written instructions for use (IFU), the majority of handheld instruments used in the office setting by otolaryngologists are sterilized by steam autoclaving, while flexible and rigid scopes are usually disinfected using liquid products containing 2 percent glutaraldehyde (Cidex®), 0.2 percent peracetic acid (Steris® 20), or 0.55 percent ortho-phthalaldehyde (Cidex® OPA).

Finally, the instruments should be stored in such a way as to prevent recontamination prior to being used to treat the next patient. According to the Centers for Disease Control and Prevention (CDC), endoscopes should be hung vertically, and sterilized instruments should be stored in impermeable packaging to prevent recontamination prior to use.8

Additionally, the use of disposable single-use sheaths over endoscopes has been shown to provide a similar level of sterility as chemical reprocessing. Elackattu and colleagues found that using single-use sterile sheaths with flexible fiberoptic endoscopes had a similar efficacy as chemical disinfection in preventing microbe adherence to the scopes provided the manufacturers’ sheath handling protocols were followed.9 A recent review of the literature by Collins also found that sheaths can be as effective as conventional reprocessing of flexible fiber optic laryngoscopes.10

Regardless of the method used, office-based reprocessing protocols should adhere to CDC guidelines for disinfection and sterilization of instruments,8 including having a mechanism for transportation of dirty instruments to the processing room, sorting of instruments based on type and intensity of reprocessing required, cleaning, sterilization, and finally, storage. Additionally both the CDC guidelines and the AAMI/FDA Reprocessing Summit encourage a unidirectional work flow for reprocessing to prevent recontamination of instruments after they have been sterilized, and, if possible, to have available different designated areas for each phase of reprocessing.

To ensure that reprocessing guidelines are properly followed, office staff should be provided with clear instructions, proper training, and adequate space to perform reprocessing tasks. The AAMI/FDA Reprocessing Summit suggestions for training included providing formal training on device reprocessing techniques and annual continuing education to ensure proper protocols are being followed.3

To meet our patients’ expectations of being treated with clean, safe instruments it is important to adhere to established guidelines to ensure that instruments are properly cleaned for each patient. Instituting in-office protocols for reprocessing and providing proper space, equipment, and training to staff is important to ensure the delivery of safe, high-quality care to our patients.

References

  1. Healthcare Inspection – Use and Reprocessing of Flexible Fiberoptic Endoscopes at VA Medical Facilities. 2009, Department of Veterans Affairs Office of Inspector General: Washington, DC.
  2. O’Keefe, E., Report: VA Facilities Improperly Sterilized Colonoscopy Equipment. The Washington Post. 2009: Washington, DC.
  3. Priority Issues from the AAMI/FDA Device Reprocessing Summit. Association for the Advancement of Medical Instrumentation, 2011.
  4. ERCI, Top 10 Health Technology Hazards for 2012. Health Devices. 2011.40(11).
  5. Powell, S., Perry P., Meikle D., Microbial contamination of non-disposable instruments in otolaryngology out-patients. J Laryngol Otol. 2003;117(2):122-125.
  6. McDonnell, G., Burke P., Disinfection: Is it time to reconsider Spaulding? J Hosp Infect. 2011;78(3):163-170.
  7. Muscarella, L.F., Prevention of disease transmission during flexible laryngoscopy. Am J Infect Control. 2007;35(8):536-544.
  8. Rutala, W.A., Weber, D.J., Healthcare Infection Control Practices Advisory Committee (HICPAC). Guideline for Disinfection and Sterilization in Healthcare Facilities, CDC, Editor. 2008.
  9. Elackattu, A., et al., A comparison of two methods for preventing cross-contamination when using flexible fiberoptic endoscopes in an otolaryngology clinic: disposable sterile sheaths versus immersion in germicidal liquid. Laryngoscope. 2010;120(12):2410-2416.
  10. Collins, W.O. A review of reprocessing techniques of flexible nasopharyngoscopes. Otolaryngol Head Neck Surg. 2009;141(3):307-310.

Table 1. Spaulding’s Classification for reprocessing of medical devices

Classification Definition Level of Processing Required
Critical Equipment/Devices Equipment/device that enters sterile tissues, including the vascular system Cleaning followed by sterilization
Semicritical Equipment/Devices Equipment/device that comes in contact with non-intact skin or mucuous membranes, but does not penetrate them Cleaning followed by high-level disinfection
Noncritical Equipment/Devices Equipment/device that touches only intact skin and not mucous membranes, or does not directly touch the patient Cleaning followed by low-level disinfection

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Making a Difference in the Philippines
Ethan B. Handler, MD Kaiser Permanente-Oakland, CA Our Bay Area Surgical Mission (BASM) team, led by Raul M. Cruz, MD, left San Francisco for Manila, in the Philippines, at about 11:00 pm on February 9. Seventy large boxes overflowing with medical supplies rode in the belly of the plane. Total flight time was 20 hours, capped by a four-hour bus ride on rugged terrain, to finally arrive at our destination, Daet, in the Camarines Norte province. Daet is a frenetic town of more than 100,000 people. It bubbled with life, with street traffic littered with hundreds of motorcycles rigged to colorful sidecars. Our accommodations were comfortable, located a few blocks from a windblown beach famous for kite surfing, and a few kilometers from the hospital. We arrived Saturday afternoon, with Friday becoming a day that existed only in our minds. Sunday morning we were awake and working, furiously unpacking supplies, setting up the two connecting operating rooms to house a total of four OR tables. The local government was generous to grant us use of their Provincial Hospital for our mission. After unpacking we went downstairs to evaluate the packed clinic for surgical candidates. Filipinos traveled from a variety of provinces, alerted to the medical mission by radio and television broadcasts, and ragged billboards. The majority of our head and neck cases were subtotal and hemi-thyroidectomies. In addition, a few thyroglossal duct excisions were performed. No mass was under 5 cm. The bovie/bipolar machine worked sporadically and at one point the electrical arc melted the bovie tip. Right outside the OR doors was the designated “procedure room,” although in reality it was a musty hallway. Lighting for these cases came from infant warmers. This was epidermal inclusion cyst heaven. The largest was a 10 cm mass on the posterior scalp, successfully excised without bursting. Every patient was beyond thankful and gracious. Even when offered pain medication, they would seldom take it. The recovery area and patient rooms consisted of 85°F, 100-percent humidity rooms with patients and their families crammed onto cots. Yet nobody complained. Their stoicism and strong will was an example for all of us, and a point to remember. We operated full days, all week long. Our nights were packed with various hosted events sponsored by local organizations. Everyone was gracious. I feel blessed to have spent time with these people, inspired by their courage and resiliency, thanks to the AAO-HNSF travel grant. I’m always amazed and thankful as to how close you become with others when sharing an experience such as this one. Without a doubt, I would go back in a heartbeat.
kameswaran
35th AAOIH Annual Meeting to Take Place Sept. 10 in Washington, DC
The 35th Annual Meeting of the American Association of Otolaryngologists of Indian Heritage (AAOIH) will take place from 7:00 pm-11:00 pm Monday, September 10, at Rasoi Indian Kitchen, 1810 K Street Northwest, Washington, DC, (1-202-775-5660). The guest of honor, Prof. Mohan Kameswaran, FRCS, FAMS, FICS, president of the Madras Ear Research Foundation, will speak on “The State-of-the-Art in the Management of the Hearing Impaired on the Indian Subcontinent.” Residents of Indian heritage are encouraged to present original research at the meeting. Three prizes will be announced. Attendance is expected to be high so please RSVP. For charges and to learn more, email Pete S. Batra, MD, secretary at pete.batra@utsouthwestern.edu or Arun K. Gadre, MD, president at Arungadre@Yahoo.com, or visit www.theaaoi.org.
Thyroid Surgery in Migori, Kenya
Dunia Abdul-Aziz, MD Harvard Otolaryngology Program Boston, MA The singing of children greeted us. After an eight-hour journey through the magnificent Rift Valley, we drove up to the gates of a walled compound in Migori, Kenya—a welcome sign to Brittany’s Home of Grace inviting us in. In February, a team from the Massachusetts Eye and Ear Infirmary, Boston, composed of American Academy of Otolaryngology—Head and Neck Surgery members Gregory W. Randolph, MD; Paul Konowitz, MD; David J. Lesnik, MD; and myself, and surgical nurse Nancy Kotzuba, RN, joined nurses, anesthesiologists and local staff of KenyaRelief.org in a weeklong effort, with a goal of providing medical and surgical care to patients with head and neck disease, particularly goiters. The experience highlighted the power, the potential, and the challenges of international humanitarian initiatives. This was our first time in Kenya, a country of about 39.4 million people, where the average income is slightly more than $2 a day1. We planned a thyroid mission to tackle endemic goiters, which remain prevalent despite salt iodization and Kenya’s status as the largest regional supplier of iodized salt2. Pre-operative evaluation of each patient relied on history and physical examination, with screening for symptoms of thyroid dysfunction (specifically hyperthyroidism), anemia, and pregnancy. An excellent surgical nursing team ensured the two-bed operating rooms were properly prepared. We introduced our hospital’s time-out checklist, which we hope to formalize as a regular safety check in future surgeries performed at Kenyarelief.org. We worked side by side in a two-bed operating room, well stocked with equipment obtained through donations. All thyroid cases were performed with nerve monitoring and the aid of harmonic scissors. Given the limited access to medical care, performing total thyroidectomies, which would commit patients to lifelong daily medication, was not feasible. Thus, surgical planning focused on maintaining residual thyroid tissue to minimize the potential for hypothyroidism. Post-operatively, patients were monitored in the recovery room, often discharged the following day, trekking home on foot. Aside from visits to the clinic for suture removal, routine follow-up care including review of histopathology is currently unavailable. These limitations highlight important challenges and ethical considerations that still need to be overcome in the effort to provide safe care to our patients. At the completion of our three operative days, about 50 individuals were screened and 25 head and neck procedures performed, including 18 thyroidectomies for large goiters. Our experience, operatively and beyond, was inspiring. Our medical team, consisting of diverse medical personnel from across Kenya and the United States, shared a common mission and collaborated as though we had been operating together for years. Out of one week grew a fellowship with the local community, the orphans at Brittany’s Home, and our teammates that we hope will flourish with time. With a commitment to “never accept suffering,” we look forward to further collaboration to build on our efforts. With gratitude and appreciation to the AAO-HNSF Humanitarian Efforts Committee, Medtronic, Inc, and Ethicon, Inc for their generous support and donations. References UNICEF: The State of the World’s Children Report 2012. http://www.unicef.org/sowc2012 Adwok, John. Surgery in Africa—Monthly Review: Thyroid I: Endemic Surgery. 2006.  http://www.ptolemy.ca/members/archives/2006/Endemic_Goiter.htm
Maintenance of Certification: Living the Dream
Liana Puscas, MD, AAO-HNS Liason to the AMA I still remember the cover letter on my otolaryngology-head and neck surgery residency application explaining that starting in 2002, the American Board of Otolaryngology (ABOto) would issue time-limited certificates of 10 years’ duration. If only I could have been in the queue just one year earlier. How nice it would have been to be grandfathered in and not worry about maintenance of certification (MOC). It is now 10 years and one MOC exam later, and my attitude has changed. Not because I enjoy taking tests and paying fees, but because I understand now, better than I did then, the immense responsibility we have as physicians in taking care of patients. Despite the positive influence of educated patients on healthcare, physicians still direct patient care due to their knowledge and experience. Therefore, it is incumbent on physicians to stay current with the literature and change their practices accordingly. Intuitively, our profession understands that this is necessary. We pride ourselves on providing patients with good care. We study and work hard and expend much effort in the care of our patients. We get frustrated with noncompliant patients because we know they are sabotaging their own health. And we get really frustrated with third parties who interfere with our delivery of patient care. All of these symptoms signify an innate desire to do the best we can for our patients and live up to high standards. Medicine has a rich history of establishing standards to safeguard patients. The AMA was founded in 1847 in response to concerns about the number of uneducated quacks peddling at best useless, and at worst, dangerous medical “therapies.” At its inaugural meeting, delegates adopted the first code of medical ethics and established the first nationwide standards for preliminary medical education and the degree of MD.1 State medical boards and specialty boards were likewise established to create and hold physicians to agreed standards. Initial specialty board certification establishes minimum competency at the completion of training. MOC is the natural result of this entire process. Having taken the MOC exam, I will candidly say that some of the questions clearly reflected the bias of some institutions and their approach to head and neck cancer. And there were several granular questions that were irrelevant to my ability to provide good patient care. Is a MOC exam the best way to measure competency? No. Did it make me a better technical surgeon? No. Do I receive CME credit for the ABOto’s mandated MOC modules? No. But did I read and study in preparation for the exam? Yes. Did I review seminal articles in our literature? Yes. Does participation in MOC give my patients reassurance that I am keeping up with the newest advances in my field? Yes. Does MOC provide assurance to the public that we are continually striving to keep physicians accountable? Yes. MOC does not replace personal insight into individual ability or personal commitment to continued development. But it does provide an external impetus to physicians to keep up-to-date and to practice at high standards. And it gives our profession the moral high ground with patients and non-physician health providers as undeniable proof that we are continuing the tradition of keeping medicine’s standards high. For those who certified in otolaryngology prior to 2002, MOC is not part of their reality. However, according to Humayun J. Chaudhry, DO, president and CEO of the Federation of State Medical Boards (FSMB), all physicians will eventually be subject to Maintenance of Licensure (MOL). This MOL process will comprise three areas and will be phased in over the course of five to seven years: CME requirements, some type of self-assessment of knowledge/skills, and performance improvement. MOL will not require that a physician be board certified nor will it entail a high-stakes examination.2 However, the similarities between MOL and MOC are obvious. The challenge and the opportunity are to design MOC to be meaningful and practical. A process that is too “fluffy” is a disservice to patients, and a process that is too onerous is burdensome to physicians. Some solutions are obvious: give CME for MOC and MOL activities; have the American Board of Medical Specialties (ABMS) coordinate with the FSMB so that MOC activities satisfy MOL requirements (this is a stated intention of the FSMB); and create metrics that are easily tracked by physicians, but meaningful to patient outcomes. This will require effort, creativity and collaboration among the various organizations involved in CME, MOL and MOC within each medical specialty. It is imperative that physicians take the helm of these projects to avoid having these processes led by non-physician government entities—otherwise MOC/MOL will become a nightmare. References http://www.ama-assn.org/ama/pub/about-ama/our-history/the-founding-of-ama.page? HJ. Chaudhry; LA Talmage; PC. Alguire; FE. Cain; S Waters and JA. Rhyne. Maintenance of Licensure: Supporting a Physician’s Commitment to Lifelong Learning. Annals of Int Med 157 (4):1-4.
MOC Clinical Fundamentals at AAO-HNSF Annual Meeting & OTO EXPO
Participating in Maintenance of Certification? Join us on Tuesday, September 11, or online, beginning January 2013 for two instruction courses specifically designed to fulfill the ABOto’s Clinical Fundamentals requirement for Part III of Maintenance of Certification (MOC). Most of the Clinical Fundamentals topics are no longer included in the MOC exam, but candidates will be able to meet the ABOto requirements by completing these courses in person at the annual meeting or online and achieving an 80 percent passing score on a post test. Additional topics will be introduced each year. 3715-1 Clinical Fundamentals:  Treatment of Anaphylaxis  Tuesday, September 11, 3:00 pm-4:00 pm Track: Rhinology/Allergy Instructor: John H. Krouse, MD, PhD This course will review the clinical fundamentals on the treatment of anaphylaxis, including recognition, diagnosis, pathophysiology, and treatment of anaphylaxis in the clinical setting. It will examine risk factors that increase the likelihood of a patient experiencing an anaphylactic episode. In addition, it will provide clinical signs and symptoms that will help differentiate anaphylaxis from other patient responses with which it might be confused (e.g., vasovagal episodes). 3815-1 Clinical Fundamentals: Clinical Outcome Measures/Evidence Based Medicine  Tuesday, September 11, 4:15 pm-5:15 pm Track: Business of Medicine/ Practice Management Instructor: Michael G. Stewart, MD This course will review the clinical fundamentals of clinical outcomes measures and evidence-based medicine, research including instrument design, study design, and outcome instrument selection. It will review the results from several outcomes-based clinical research studies in otolaryngology and also the clinical outcomes instruments that are available. Clinical Fundamentals Instruction Course fees are $90 an hour for the hands-on courses. Register online at www.entnet.org/annual_meeting. Additional information is forthcoming regarding online participation in the courses beginning in January 2013.
Alpha-ABOto-logo
Good News on Maintenance of Certification
Mary Pat Cornett, Sr. Director, AAO-HNS Education and Meetings, with Martha Liebrum, special to the Bulletin The road to becoming an otolaryngologist was the same for decades. In 2002, a lifetime of new requirements was added to retain the hard-earned otolaryngology board certification. Maintenance of Certification (MOC) is a 21st century reality for recently certified physicians. Some champion MOC, however, for otolaryngologists who have more to do than time to do it, MOC has been perceived as a burden by some and misunderstood by many. The first decade of MOC has passed, and so have the first otolaryngologist-head and neck surgeon participants—95 percent of them. After 10 years, the news on MOC is good. “Physicians are finding MOC is a non-punitive program intended to promote lifelong learning and quality improvement,” said Robert H. Miller, MD, MBA, executive director of the American Board of Otolaryngology (ABOto), which oversees otolaryngology certification. Dr. Miller is the man whom others seek to discuss their questions and/or fears about MOC. “Even better news, some participants report that going through the assessments and preparing for the exam brings value to the physicians and their patients,” he said. That is the intent, and increasingly, the outcome of MOC. The ABOto has steadily worked at creating and revising MOC for otolaryngology since its inception in 2002 when all ABMS Boards, including the ABOto, began to issue time-limited certificates. Meanwhile, otolaryngologists and their societies endeavored to stay a step ahead of the changing standards. About 3,000 otolaryngologists are currently participating in MOC. “The American Board of Otolaryngology, the Academy, and the otolaryngology specialty societies communicate regularly as we all strive to support and encourage lifelong learning and quality improvement in otolaryngology,” said David R. Nielsen, MD, EVP/CEO of the Academy. “Support for members participating in MOC is a top priority for the Academy, particularly as these first time-limited certificates come due.” Dr. Miller reports that the final requirements for MOC Part IV are almost ready, and will be released later this year. ABOto is currently launching a campaign to update otolaryngologists on MOC requirements and procedures. Dr. Miller reviewed recent and upcoming developments in MOC for the Bulletin. In addition to earning required CME credit under MOC Part II “Lifelong Learning and Self-Assessment,” MOC participants are required to achieve an 80 percent passing score on one ABOto Self-Assessment Module (SAM) each year. ABOto currently has 22 modules and will offer eight new modules each year, including one for each of the otolaryngology specialty areas. ABOto SAMs are case-based and can be taken until a passing score is achieved. A panel discussion and reading list is included and outside study is encouraged. “The point is to find areas for improvement, review the material, and come back again to complete the module if necessary,” Dr. Miller said. “Cognitive expertise” is assessed in MOC Part III by means of an 80-question exam conducted at test centers around the United States every February. MOC participants have three chances to pass the exam during the last three years of each 10-year MOC cycle. “They are concerned mostly with the test,” Dr. Miller said. “I think they have flashbacks to the stresses of their primary certification.” The questions on the MOC exam come from the primary certification exams, although the MOC exam includes no basic science. Also, participants choose which test to take based on their practice focus area. “After eight or 10 years in practice, I know the vast majority of diplomates have more clinical knowledge in their practice focus area than a resident who just completed training,” Dr. Miller said. The exam pass rate is 95 percent. Initially, the exam included 12 questions on “Clinical Fundamentals,” the MOC term for basic knowledge required by all otolaryngologists regardless of practice area. This includes topics as diverse as ethics, universal precautions, and general anesthesia. That portion of the exam has been reduced to three questions. In place of the exam questions, the ABOto reached out to the AAO-HNS Foundation to develop Clinical Fundamental modules to address 10 of the required topics. The first two Instruction Courses to cover Clinical Fundamentals required topics will be introduced at the 2012 AAO–HNSF Annual Meeting & OTO EXPO, September 9-12, in Washington, DC. Courses will also be available online in early 2013. Requirements for MOC Part IV “Performance in Practice” are the last to be developed and will include patient and professional surveys and active engagement in performance improvement. “The surveys are meant to help doctors see what areas need improvement, particularly with regard to communication,” Dr. Miller said. Patients will be given instructions on how to complete the brief survey online or using a touchtone phone, and will be conducted every three to five years. The survey will provide physicians with feedback as to the patients’ experience under their care. An additional survey will gather feedback from other healthcare professionals who refer to, or work with, the physician in the healthcare system, providing perspective of how he or she functions within the system. Rounding out Part IV is engagement in a formal performance improvement activity following the traditional quality improvement process: Measure Analyze Develop Plan for Improvement Implement Re-measure Participants will enter data online in a Performance Improvement Module (PIM) and will receive feedback on strengths and areas for improvement. After implementing any identified changes, the participant will re-measure to confirm improvement. Last but not least, Structured Educational Modules (SEMOs) on the topics covered in the SAMs and PIMs will be created and made available to MOC participants as they go through those modules. “Performance in practice is the most critical aspect of MOC,” Dr. Miller said. “The opportunity to get specific feedback and act upon it is crucial to improved patient care.” The MOC cycle and pricing will change in November. The MOC fees were established piecemeal as the program rolled out during the past 10 years. With all four MOC components in place, the ABOto is able to reduce the costs and established a flat price of $310 a year that covers each part of the program. The payment cycle will shift from June to November. Take comfort in the knowledge that the members of the ABOto Board of Directors are personally engaged in MOC. The directors’ voluntary participation in support of MOC has helped fine-tune the process during the decade of development. Otolaryngologists holding a lifetime certificate are considered “grandfathered,” but would be wise to consider their own eventual participation in MOC. There are more inducements to participate voluntarily in MOC, Miller said. Some insurance providers offer financial advantages for doctors who are involved in MOC, and an increasing number of hospitals require that doctors participate in MOC. Malpractice rates for some specialists can be lower for doctors participating in MOC. The Federation of State Medical Boards (FSMB) continues its progress toward Maintenance of Licensure (MOL), which could require doctors to participate in continuing education, and develop competencies in patient care, communication skills, medical knowledge, and professionalism. MOC is a potential alternative to the MOL requirements. “At every phase of your career, the Foundation provides resources and support to improve patient care and to meet ever-increasing requirements for licensure and certification,” said Sonya Malekzadeh, MD, Foundation education coordinator. “Download the Foundation’s latest app—AcademyQ: Otolaryngology Knowledge Assessment Tool—to test your otolaryngology expertise anywhere anytime on your iPhone, iPad, or iPod Touch. Watch for a revised edition of the Maintenance Manual for Lifelong Learning.” Dr. Malekzadeh suggested, “The key is to continually self-assess, read the literature, and stay committed to the principles and practice of lifelong learning that led to your achievement as a board certified otolaryngologist in the first place.” As Dr. Miller concluded, “Certification is not just passing the exam. It starts when doctors begin their training, and it ends when they retire.”
ENT Carrier Advisory Committee Representatives: Who Are They and Why Should You Become One?
Joe Cody, MA AAO-HNS Health Policy Analyst Eighty-five percent of Medicare coverage determinations are local, making physician expertise and input vital to the correct development and implementation of these policies. But many members may wonder, how can otolaryngologist-head and neck surgeons actively help shape these local coverage determinations (LCDs)? Medicare Carrier Advisory Committees (CACs) are groups of physicians representing different medical and surgery specialties that advise and assist Carrier Medical Directors in the development of these important local coverage determinations for medical services. According to the Medicare Program Integrity Manual, 13.8.1.1, CACs serve the purpose of providing a formal mechanism for physicians to participate in the development of an LCD, discuss and improve policies developed by a carrier, and offer a forum for physicians and carriers to exchange information. Because of the important nature of CAC representatives, several years ago the Academy decided to create a formal program to identify members who participate in CACs in order to address any coverage issues in the different Medicare jurisdictions. This program has allowed Academy members and representatives to communicate quickly and resolve issues or concerns with LCDs that directly affect otolaryngologist-head and neck surgeons. For example, Denis C. Lafreniere, MD, of Farmington, CT, and chair-elect of the Board of Governors, had an issue with Medicare reimbursement for laryngeal botulinum toxin injections. He reached out to Ray Winicki, MD, his ENT CAC representative. After working with the local Medicare contractor, they agreed to revise language to resolve the issue, which involved having to use a new vial of botulinum toxin for each patient rather than allowing use of a multi-dose vial. The Academy frequently contacts CAC representatives to assist in issues with carrier LCDs because of their unique relationship with the Medical Directors and their local expertise. At the 2012 annual meeting, the Academy is hosting a CAC miniseminar designed to help members understand CACs, learn how to effectively use CAC representatives as a resource to help with local payment issues, and to discuss the effect of future Medicare regulations on reimbursements. Attendees of this miniseminar can speak with key Medicare carrier and CAC representatives and discuss issues that directly affected their practices. Members of the Physician Payment Policy Workgroup (3P) and Academy staff also plan to discuss the importance of active involvement from members in all states and Medicare jurisdictions. For those interested in serving as an ENT CAC representative, the Academy accepts nominations and facilitates the application of members for CAC positions with their specific carrier. Currently, the Academy is still seeking ENT CAC representatives for Colorado, Montana, Nevada, New Hampshire, and Utah. As with medical directors for private payers, it is important to nurture good relationships with carrier medical directors and decision makers, and to get involved in the committee structures and be well prepared to present a cogent argument supported by clinical data. CACs allow physicians to represent the Academy at a local level and directly influence local policy development. If you practice in any of the above states and are interested in becoming a CAC representative, email a letter of interest and your C.V. to healthpolicy@entnet.org and we will assist your nomination to serve as an ENT CAC representative for your Medicare carrier.
Another Survey?
Rahul K. Shah, MD George Washington University School of Medicine, Children’s National Medical Center, Washington, DC The Patient Safety and Quality Improvement (PSQI) Committee, which I co-chair with David W. Roberson, MD, has a broad charge—essentially to help ensure that Academy members are kept abreast of, and are leading, efforts toward improving the safety and quality of the care that is delivered to our patients. In the past decade, there have been tremendous efforts to understand the scope of the problem vis à vis adverse events, near misses, and medical/surgical error. These efforts have been led by myriad stakeholders, each with interests central to their strategy—non-otolaryngologist physicians, hospitals, insurance companies, medical liability insurers, and even the government. As a vulnerability of most research methodology, the outcomes can be somewhat predicted or manipulated based on the techniques employed to study an issue. PSQI efforts are not immune to this bias. To approach studying these issues, we can employ various research methodologies. Of course, the most robust research could be constructed to test a hypothesis regarding PSQI. Whatever confidence is gained by proper study design needs to be balanced with the resources necessary to do such a study. This would certainly be credible data, however, resources are not limitless and such a methodology may take significant time and resources and leave certain aspects of PSQI unstudied or unreported. A hallmark of most quality improvement projects is the Plan-Do-Study-Act (PDSA) cycle of iterative quality improvement. Perhaps we would be able to conduct a tremendous amount of PSQI work using the PDSA cycle and postulating strategies to reduce harm and errors. However, the ability to extrapolate these findings and the lack of rigor precludes using the PDSA as a sole source of PSQI work. The use of survey methodology has emerged as the workhorse for the PSQI committee. With the high number of responses and the excellent qualitative nature of the responses by Academy members, we have learned a tremendous amount about PSQI using surveys. The survey methodology allows us to cast a wide net and then lets the data guide us in future areas that need to be targeted. For example, we did not realize the scope of the problem with concentrated epinephrine in otolaryngology surgery or the role of inverted computed tomography scans in sinus surgery until they were highlighted qualitatively in free-text surveys. The survey tool is, in our opinion, an excellent mechanism to help us hone in on specific zones of risk in a discipline or with a procedure. Once we have broad data from the surveys, we then develop more robust research methodologies to take a deep, more quantitative dive into the data. Of course, it is imperative to acknowledge the Academy membership and your willingness to spend 10 minutes to answer myriad surveys. If you feel that surveys have become quite numerous as of late—you are correct. The landscape in the PSQI arena is constantly changing and being driven by many stakeholders. As such, the PSQI committee believes that the best way to understand the problem as it affects our members is via data and studies. It is imperative that we as otolaryngologists construct the surveys to ensure that the questions are appropriate for our patients and our practice types and furthermore to ensure integrity in reporting the results and understanding the context of the findings from the studies. If our specialty continues to produce PSQI-related work products and continues to lead the way, then perhaps other stakeholders will take our work and use it rather than relying on their own “research” into PSQI issues in our specialty. Ideally, it would be great to partner with other stakeholders to attempt to identify solutions for PSQI-related issues. Nevertheless, we should be leading the majority of the work in the PSQI as it directly pertains to our practices and we are the content experts. It is hard to know what the PSQI landscape will bring in the coming years, but I can be certain that the PSQI committee will think of techniques so that we can continuously provide a forum for members’ viewpoints and issues to be collated and properly disseminated. We can be certain that there will probably be another survey—soon! 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.
PQRIwizard_Logo
PQRIwizard Available for 2012 Physician Quality Reporting System (PQRS)
PQRIwizard has been relaunched for 2012 PQRS reporting. PQRIwizard, a Centers for Medicare & Medicaid Services (CMS) qualified registry, is an online tool to collect and submit quality measure data as part of the PQRS program. The 2012 version of the wizard has been updated to include a collection of individual quality measures specific to otolaryngology. In addition, the wizard now reflects the updated reporting requirements for the 2012 period. PQRIwizard can help you: Validate data automatically Minimize data entry time Eliminate claims and coding Report PQRS data prospectively or retrospectively Avoid future penalties (payment adjustments) Currently, the PQRS program offers a .5 percent incentive payment to physicians who successfully report quality measure data in 2012. However, beginning in 2015, the program will penalize eligible professionals who do not submit quality measure data as part of the PQRS program, also known as a payment adjustment. To avoid the 2015 penalty, physicians must submit quality measure data during the 2013 reporting period. Familiarize yourself and your practice with PQRS today and avoid future penalties. More information about the PQRS program and the PQRIwizard is available at http://www.entnet.org/Practice/PQRS.cfm. You can also email the Academy’s quality improvement staff at  qualityimprovement@entnet.org
Evidence-Based Guidelines Affecting Policy, Practice, and Stakeholders (E-GAPPS) Conference
2012 E-GAPPS Conference New York, NY Monday, December 10  to Tuesday, December 11 The E-GAPPS Conference is a two-day meeting cosponsored by the Guidelines International Network North America (G-I-N NA) and the Section on Evidence Based Health Care (SEBHC) of the New York Academy of Medicine. The E-GAPPS mission focuses on constructive dialogue and collaboration; best practices in guideline development, dissemination, and implementation; and perspectives, processes, values, and principles that influence healthcare policy. To register to attend, or learn more about the confirmed plenary speakers, conference themes, or breakout sessions, visit: http://www.nyam.org/events/2012/evidence-based-guidelines-conference.html
vote
Are You Registered to Vote?
November is just around the corner, which means it is time to make sure you are prepared to cast your vote on Election Day. If you are unsure of your voter registration status, visit www.canivote.org to review your current information and/or register to vote for the first time. It is particularly important to check your registration status this year, as several states are purging inactive and/or presumed deceased individuals from their voter rolls. Unfortunately, names are occasionally removed by accident, so please make sure your name is not one of them. We want your voice to be heard on November 6. Remember: Many states require proof of residency when voting. Please have a valid driver’s license or ID available that includes your most recent address on it. If you are unsure of your state’s identification requirements, visit http://www.ncsl.org/legislatures-elections/elections/voter-id.aspx. Exercise your right to be heard on Election Day by registering to vote or updating your status today.
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 page, you can learn more about the issues impacting 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.
New Look for ENT PAC
The ENT PAC Board of Advisors is proud to unveil a new look for our specialty’s political action committee, ENT PAC. If you take a moment to visit our redesigned webpage, www.entpac.org, you will notice some positive changes. First, a new patriotic logo and color scheme is now being used that more closely adheres to the current Academy/Foundation branding. Second, new features have been added, including: A message from the PAC chair; A “news ticker” for timely legislative updates; Improved navigation and more helpful resources; A full list of candidates/incumbents supported by ENT PAC; Recognition of current year Investors to the PAC; A “goal thermometer” to help track our progress to a fundraising target; and Coming soon, an interactive map to view your state’s standing in the ENT PAC State Challenge. ENT PAC also recently launched a new video that illustrates the importance of membership participation in the PAC and the necessity of this vital advocacy tool in today’s political environment. Please take a few minutes to watch the new video and better understand the Academy’s political efforts. You can find the video on the ENT PAC webpage at www.entpac.org. This election year, it is more important than ever for ENT PAC to garner support from otolaryngologist-head and neck surgeons of all ages and from all geographic locations. Help the ENT PAC Board of Advisors build a single, strong voice on Capitol Hill by supporting the PAC today. To make an investment in your future, visit www.entpac.org (member log-in required) or send your personal check payable to “ENT PAC” to 1650 Diagonal Road, Alexandria, VA 22314.* *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.
Advancement of Efforts to Expand Patient Access to Hearing Aids in New York
This year, the AAO-HNS, with the Patient Access to Hearing Aids (PAHA) Coalition, continued its advocacy efforts to amend an outdated hearing aid dispensing law in New York. The current New York state law prohibits physician offices, which conduct hearing loss evaluations for the estimated 1.85 million hearing-impaired New Yorkers, from selling hearing aids for profit—any profit. The PAHA coalition was formed in 2010 to educate New York legislators, patients, and otolaryngologist-head and neck surgeons about this archaic law and to advocate for change. The PAHA Coalition includes the AAO-HNS and the New York State Society of Otolaryngologists, along with the Medical Society of the State of New York (MSSNY), the American Medical Association, the American Osteopathic Association, the American Osteopathic Colleges of Ophthalmology and Otolaryngology-Head and Neck Surgery, the American Otological Society, and others. Legislators are generally supportive of the dilemma facing physicians, physician-employed audiologists, and their patients. However, the challenges in attaining passage of legislation (A. 1739A/S. 5164A) this year were many, including opposition by organized audiology and the misconceptions of the issue, which required ongoing meetings with key legislators about hearing care in physician offices. Opponents to the Coalition’s efforts maintain that physicians should not “benefit financially from the sale of products that they order or prescribe.” However, audiologists and hearing aid dispensers are able to provide this service without limitations. Unlike some other dispensers, physicians have little profit motive for one method of treatment over the other, and will focus on the right treatment for the problem—whether it is medical, surgical, or through the dispensing of hearing aids. These “profits” help cover the cost of overhead expenses, testing and equipment, follow-up appointments, and making instrument adjustments or addressing individual patient problems. In reality, the current system is advantageous for independent audiologists and hearing instrument specialists, as the law essentially creates a mandatory referral system from physicians to these independent providers. Outside sources have concurred with the AAO-HNS position calling for a collaborative approach to patient care. In July 2009, Consumer Reports published an article titled “Hear Well in a Noisy World: Hearing Aids, Hearing Protection, and More.” The article reinforced what the AAO-HNS has asserted all along—that the best provider for hearing aids is a medical office headed by an ENT physician, with an audiologist on staff to fit and dispense hearing aids. There are several reasons cited for this recommendation, including higher marks than other providers from patients for thoroughness in evaluating hearing loss, and the ability of the otolaryngologist to rule out medical conditions and remove cerumen prior to the hearing test. Essentially, when otolaryngologists and audiologists work together, this model ensures that all patients get the right care from the right professional. This year, the Coalition advocated for the introduction of amended legislation in both the Assembly and the Senate. The amended language focused on the collaborative relationship between audiologists and physicians, allowing those audiologists working in a physician’s office the opportunity to work within their full scope of practice and dispense hearing aids. By the session’s end, the Assembly bill had 39 cosponsors, and the Senate bill had five cosponsors. On average, bills can take several years to be adopted. Thanks to the remarkable efforts of many AAO-HNS New York members, tremendous progress was made in 2012. As part of the PAHA Coalition effort, Academy members wrote letters to legislators, obtained support from patients and colleagues, including audiologists, met with legislators prior to Lobby Day, and ultimately attended the New York Coalition of Specialty Care Physicians’ Lobby Day at the State Capitol in Albany. Overall this session, AAO-HNS members and other PAHA representatives participated in more than 50 meetings with legislators and sent more than 350 emails using the AAO-HNS and MSSNY advocacy alert systems. While ultimately we were unable to secure passage of the legislation this year, we will continue to push for fair laws that ensure patients have access to needed hearing health services. Thus, the PAHA Coalition plans to seek reintroduction of A. 1739A/S. 5164A in 2013. Although the efforts of the AAO-HNS and the PAHA Coalition are making a positive impact, this must remain a priority for all oto­laryngologist-head and neck surgeons, regardless of subspecialty. The AAO-HNS encourages all New York members to become involved and make a difference in the lives of their patients. For more information on the PAHA Coalition and our legislative efforts in New York, please visit the PAHA Coalition website at http://www.entnet.org/Practice/members/PAHA.cfm (AAO-HNS member log-in required). With questions, email the AAO-HNS Government Affairs team at legstate@entnet.org.
Dates to Remember
September 1 Monthly mini-PR and media outreach tools available for members at www.entnet.org/aboutus/PressRoom.cfm. September 9-12 AAO-HNSF 2012 Annual Meeting & OTO EXPO in Washington, DC. September 21-22 Coding Workshop, Wyndham Baltimore Peabody Court http://karenzupko.com/workshops/otolarngology/index.html. October 1 Bulletin feature: The Membership: The Value & Benefits, the Components, and AAO-HNS Committee Rosters. October 1 Monthly mini-PR and media outreach tools available for members at www.entnet.org/aboutus/PressRoom.cfm. October 26-27 Coding Workshop, Costa Mesa, CA, Westin South Coast Plaza http://karenzupko.com/workshops/otolarngology/index.html. November 1 Bulletin feature: The Payback in Giving, and the Annual Report, read it online too at:  www.entnet.org. November 1 Public and Media Relations Committee Mini-campaign, www.entnet.org/aboutus/PressRoom. November 16-17 AAO-HNSF Coding & Reimbursement Workshop, Chicago, IL, Wyndham Chicago, http://karenzupko.com/workshops/otolarngology/index.html.
The Doctors Company
As the nation’s largest insurer of physician and surgeon medical liability, The Doctors Company is on a mission to relentlessly defend, protect, and reward the practice of good medicine. The Doctors Company is the exclusively sponsored medical liability insurance carrier for the American Academy of Otolaryngology—Head and Neck Surgery (AAO-HNS). Qualified AAO-HNS members receive extensive benefits, including discounts and credits of up to 25 percent, the potential for dividends, free trial coverage for qualified members, and industry-leading patient safety tools. No other insurer defends doctors more fiercely, beginning with the promise never to settle a claim without a member’s consent, where permitted by law. The Doctors Company hosts annual legal summits, bringing together the nation’s most experienced medical malpractice defense attorneys to share information on trends, plaintiffs’ strategies, and best defense practices. The company’s regional Litigation Education Retreats offer training to physicians facing claims that prepares them to be active participants in their own defense. When physicians insured by The Doctors Company enter a courtroom, they are ready to fight and win. AAO-HNS members rely on The Doctors Company’s superior strength to provide unrivaled protection. With $4 billion in assets, more than $1 billion in member surplus, an A (Excellent) rating from A.M. Best Company, and an A (Strong) rating from Fitch Ratings, the company has the resources to protect its members. The Doctors Company has the national perspective and local expertise to look ahead at emerging trends and protect physicians with innovative coverage solutions. CyberGuard® shields doctors against cyber liability claims, today’s fastest-growing threat. MediGuard® provides doctors with legal representation to protect them during administrative actions. Both products are offered as part of the company’s core medical liability policy. The Doctors Company believes you deserve more than a little gratitude for a career spent practicing good medicine. That’s why the company created the Tribute® Plan, a groundbreaking benefit that rewards you for your loyalty to The Doctors Company and for your commitment to superior patient care. This year marks the five-year anniversary of the Tribute Plan—more than 22,700 members of The Doctors Company have already qualified for a Tribute award, and these members have an average balance of $11,500. We invite you to join your AAO-HNS colleagues and the 71,000 doctors nationwide who put their trust in The Doctors Company. To learn more about the special benefits for AAO-HNS members, visit www.thedoctors.com/AAOHNS.
eyemagination
Tools for Patient Education: EyeMagination, an AA Member
According to a recent University of Minnesota study, only 50 percent of the information provided by healthcare providers is retained by patients, with half of that information recalled incorrectly.1 Baltimore-based software company Eyemaginations aims to improve patient understanding and informational recall through a suite of tools to help practices simplify complex topics and reinforce clinical messaging before, during, and after the office visit. When used together, LUMA, ECHO, and Online create a great platform for otolaryngologists to present complex information to patients in an engaging, easy-to-understand manner. Eyemaginations LUMA provides a library of 3D-animated visuals including narratives, trivia slides, and vendor media that otolaryngologists and audiologists can use to create continuous educational loops on a PC or TV to educate patients on various conditions and treatments in the waiting room or exam room. Practices also can use the unique draw-over-technology feature, or Exam Advisor, to be as specific as needed when illustrating condition progressions and treatment options to increase patient understanding. A suite of LUMA ENT and audiology apps delivers the same level of content on the iPad, including a new ENT app featuring on-screen drawing with disease progressions, was just released this summer. With easy-to-understand videos and closed captions, LUMA apps can be used in the reception area to educate waiting patients before the exam or from anywhere in the office during the exam. Eyemaginations ECHO (available free for a limited time in a public BETA) can be used outside the office to reinforce important health information. Practices can send information, such as new patient forms, pre-operative instructions, and directions to the office prior to the visit to save staff time, or send content to patients post-visit to reinforce diagnosis and recommended treatment options that patients can then share with family and friends via email and social media. Eyemaginations Online integrates animations to a practice website, where patients can view them before and after the office visit to increase patient comprehension. For more information, call Eyemaginations at 1-877-321-5481, email entinfo@eyemaginations.com, or visit www.eyemaginations.com. You can also visit Eyemaginations at the AAO-HNSF 2012 Annual Meeting & OTO Expo at Booth 1315. Reference Margolis, Robert H. Informational Counseling in Health Professions: What do Patients Remember? Retrieved from http://audiologyincorporated.com/?s=what+do+patients+remember&submit.
dunham
Women in Otolaryngology: Why Residents Should Think About Gender Inequality
Elizabeth A. Dunham, MD, MPH, PGY-5, West Virginia University “Are you my nurse?” “You little girls are surgeons?” “Are you a crier?” These are actual questions that my female colleagues and I have been asked by superiors, peers, and patients. Most current female residents and medical students I know give these stories and comments a wry smile and shake of the head. They are dismissed by many current residents as the lingering death spasms of a different era and a culture of gender inequality and male dominance in surgery. More women are entering medical school than ever before. Women now comprise about 20 percent of otolaryngologists. About a third of last year’s applicants to my residency program were women, and indeed, one of our three interns is female. In a world where almost 50 percent of current medical students are women and the presence of women in surgical subspecialties continues to increase dramatically, many graduating medical students may feel as if their gender is no longer an issue in their future career. Not so long ago women were paid differently based exclusively on gender. My mentor throughout medical school, a pediatric anesthesiologist, trained in the late 1960s and early 1970s in Texas. At that time, her husband, also an anesthesiologist, earned significantly more than she did, since as a man he was the “head of the household.” This was true for all the men in her department who were paid more for the same work. When her husband died suddenly, she asked for a raise so that now as head of the household and single mother of two young children she would earn a salary commensurate to her male colleagues. They denied her request, so she quit her job and joined a private practice, resulting in a substantial pay raise. This story shocked me as a medical student, and made me appreciate how far women have come in terms of job equality. I also was inspired by my mentor’s courage in confronting the unfairness of the system and venturing out on her own with great success. Surely this kind of blatant gender discrimination does not exist anymore, right? Is gender inequality something women in residency programs should even worry about anymore? The answer is yes—nearly $17,000 says yes, women should keep an eye out for gender issues. A recent study of starting salaries of graduating residents, even adjusting for hours worked per week and specialty, demonstrated a $16,819 pay gap between male and female starting physicians, with the men making more.1 No clear explanation was present, though issues such as women taking a lower paying job for other non-salary benefits was suggested. It is unclear if this is a more subtle form of gender discrimination, a tendency to choose lifestyle choice over salary in women, or a lack of negotiating skill. Females have been shown to underrate their skills and knowledge in self-assessment studies of medical students.2 Other studies have shown women physicians spend more time on domestic chores and childcare than their male counterparts3, perhaps leading them to select a job with more flexibility, but a lower salary. These possibilities were not fully explored in the published study showing the nearly $17,000 income disparity. Gender inequality in residency is not an issue of salary. Resident salaries are published and standardized based on PGY (post-graduate year) level at their given institution. All graduating residents are likely ill prepared to negotiate contracts and to consider the business aspects of medicine; it seems that women are especially at risk to earn less money for the same work. In preparation for future job contract negotiation, residents, especially females, should consider attending negotiation seminars offered at annual meetings. With this new data in mind, I also intend to be more assertive in negotiating a future salary when the time comes. Female residents should consider asking how offers for an initial starting salary compare to colleagues’ salaries, male and female. A universal rule of salary negotiation includes researching regional salaries within your field and institution. Yet another consideration: Are these “non-salary” benefits, such as flexible scheduling or onsite childcare, truly worth a lower salary, or are physicians who request a better “work-life balance” being taken advantage of financially? Possibly, with the help of the WIO Section, these questions can be investigated. References Lo Sasso, AT, Richards MR, Chou C-F, Gerber, SE. The $16,819 Pay Gap for Newly Trained Physicians: The Unexplained Trend of Men Earning More Than Women. Health Affairs. 2011;30(2):193. Wynn R, Rosenfeld RM, Lucente FE. Satisfaction and Gender Issues in Otolaryngology Residency. Otolaryngol Head Neck Surg. 2005; 132(6):823-7. Grandis JR, Gooding WE, Zamboni BA, Wagener MM, Drenning SD, Miller L, Doyle KJ, Mackinnon SE, Wagner RL. The Gender Gap in a Surgical Subspecialty: Analysis of Career and Lifestyle Factors. Arch Otolaryngol Head Neck Surg. 2004; 130(6):695-702.
Brook
Honorary Lectures at Annual Meeting: Meet the Speakers
John Conley, MD, Lecture on Medical Ethics Sunday, September 9, 8:30 am, Ballroom A and B “A Physician’s Perspective as a Throat Cancer Patient” Itzhak Brook, MD, is an adjunct professor of pediatrics at Georgetown University in Washington, DC. He earned his medical degree and completed his residency at Hebrew University, Hadassah School of Medicine, in Jerusalem, Israel, and obtained his master’s degree in pediatrics from the University of Tel Aviv in Israel. Subsequently he completed a fellowship in adult and pediatric infectious diseases at the University of California, Los Angeles. He served in the Medical Corps of the U.S. Navy for 27 years. Dr. Brook is the past chair of the Anti-infective Drug Advisory Committee of the U.S. Food and Drug Administration. He has done extensive research on anaerobic and respiratory tract infections, anthrax, and infections following exposure to ionizing radiation. He is the author of six medical textbooks, 108 medical book chapters, and several hundred scientific publications. He is an editor, associate editor, and member of the editorial board of several medical journals and the Head and Neck Cancer Alliance. Dr. Brook was diagnosed with throat cancer in 2006. Two years later he had his larynx removed and currently speaks with a tracheoesophageal prosthesis. He is the author of the book My Voice, a Physician’s Personal Experience with Throat Cancer. Neel Distinguished Research Lecture Monday, September 10, 9:30 am, Room 202A “Towards Personalized Sleep Apnea Surgery” Allan I. Pack, MD, PhD, is professor of medicine and director of the Center for Sleep and Respiratory Neurobiology at University of Pennsylvania Medical Center’s Translational Research Laboratory. Dr. Pack is pursuing research on genetics/genomics of sleep and its disorders. His laboratory is conducting studies in drosophila and mice and translating these findings to humans. A focus of Dr. Pack’s work is to evaluate the genetic determinants of sleep homeostasis. Studies are ongoing to evaluate molecular mechanisms of sleepiness and sleep promotion using both hypothesis-driven and discovery science. The latter involves analysis of the changes in the transcription with sleep/wake and sleep deprivation in identified neuronal populations. Techniques being used include behavioral/sleep studies in drosophila and mice, RT-PCR, Western analysis of protein, expression profiling, laser microcapture dissection, and  immunohistochemistry. Dr. Pack is committed to research training and directs two training grants from the National Institutes of Health. Dr. Pack is well known for his outstanding leadership and vision in the sleep field, contributions to original research, and exceptional mentoring. AAO-HNSF/Michael M. Paparella, MD Endowed Lecture for Distinguished Contributions in Clinical Otology Tuesday, September 13, 8:00 am, Room 202A Joseph B. Nadol Jr., MD, is the Walter Augustus Lecompte Professor and chair of the department of otology and laryngology at the Harvard Medical School and chief of the department of otolaryngology at the Massachusetts Eye and Ear Infirmary. After completing his medical school training at Johns Hopkins School of Medicine, he did his residency training in otolaryngology at the Massachusetts Eye and Ear Infirmary/Harvard Medical School. Professional activities include the clinical practice of otology and neurotology, teaching residents and medical students, and otologic research for more than 35 years. His principal area of research is pathology of the ear as studied by light and electron microscopy. He was the recipient of the Claude Pepper Award for Excellence in Research from the National Institutes of Health in 1990, the Shambaugh Prize in otology by the Collegium Oto-Rhino-Laryngologicum Amicitiae Sacrum in 2008, and the Award of Merit from the American Otological Society in 2012. He has also served as the president of the American Otological Society. He was the Ben Senturia Lecturer in the department of otolaryngology at Washington University in 2011. He will lecture on the contemporary relevance of human otopathology to clinical otology. Eugene N. Myers, MD International Lecture on Head and Neck Surgery Wednesday, September 12, 9:30 am, Room 202A Johannes (Johan) J. Fagan, MBChB, FC(SA), is the Leon Goldman Professor and chair of the division of otolaryngology at the University of Cape Town, Cape Town, South Africa. After his residency training at the University of Cape Town, he completed two clinical fellowships at the University of Pittsburgh in head and neck/cranial base surgery and in otology/neurotology. He has published more than 100 peer-reviewed articles and book chapters. He is the president of the South African College of Otorhinolaryngology, Honorary Registrar of the Colleges of Medicine of South Africa, Assistant General Secretary of the Pan-African Federation of Otolaryngologic Societies (PAFOS), and represents Africa and the Middle East on the executive committee of the International Federation of Otolaryngologic Societies (IFOS). A major interest of his is to advance head and neck surgery in Africa and the developing world. He established the Karl Storz Fellowship in Advanced Head and Neck Surgery at the University of Cape Town, and is currently training the seventh African head and neck fellow. He maintains an educational website for ENT surgeons in the developing world, and has edited and co-written The Open Access Atlas of Otolaryngology, Head & Neck Operative Surgery. Of plans for the lecture, Dr. Fagan said, “I shall present an overview of the status of and the challenges relating to head and neck surgery in Africa and in the developing world. I shall discuss initiatives that address challenges relating to teaching and training and establishing head and neck surgery centers of excellence in Africa, and the need to promote open access educational resources.”
Edelstein
How to Be a Better Hospital Board Member
David R. Edelstein, MD, New York, NY Vice Chair, BOG Socioeconomic and Grassroots Committee My real education as a newly minted chair and hospital board member began in 1999 when the New York attorney general sat me down and explained to me why some hospital boards fail. I was there to save an institution, the Manhattan Eye, Ear, and Throat Hospital (MEETH), and he was there to teach me how to be an effective board member. I remember it clearly: “David,” he said, “these are your duties and these are your responsibilities.” It was bad enough that being chair came without instructions, but absolutely nothing in my medical training had prepared me to be a board member. MEETH was established in 1869 as a hospital devoted to the care of the indigent blind and deaf. As chair of ENT, I served as an ex-officio member of the board. Like many physician board members, the other doctors on the board and I seldom attended finance committee meetings, were excused routinely from “executive sessions,” and were called on last to give our opinions. This was a recipe for failure. When reimbursements changed in the late 1990s, the hospital began to experience losses. While reacting to this change was not easy, none of us anticipated the sudden decision by the nonphysician members of the board in “executive session” to close MEETH, abandon its residency programs, sell the real estate, and disperse the assets to an ill-defined plan for satellite clinics. In response, the hospital’s medical staff filed suit to stop the institution’s closure, a court case that would change how I think about and approach the role of being a board member. Duties of Board Members Board members have three duties: care, loyalty, and obedience. The duty of care requires a board member to be familiar with all of the hospital’s activities and finances, read all of the board materials, develop internal controls, and encourage diversity. The duty of loyalty encompasses the need to have an active conflict of interest process, a written code of ethics, and a process to insure that all transactions between the hospital and board members are “fair and legal.” The duty of obedience obligates board members to ensure that all of the hospital’s resources are dedicated to its mission. A few years ago, I was given a book written by Bob Garratt titled The Fish Rots from the Head: The Crisis in our Boardrooms: Developing the Crucial Skills of the Competent Director. This is a thoughtful book that should be required reading for all new board members. The book’s premise is that good board members are made and not born. Appointment to a nonprofit board does not make one omniscient about its business. Part of the reason for confusion on hospital boards is board members often have different backgrounds, perspectives, and training. Lawyers think about risks and liabilities. Business people think about productivity and efficiencies. Donors think about building projects, control of assets, and signage. Doctors think mainly about patients, quality of care, and equipment/resources. Each group believes it is uniquely educated to perform all of the above duties, but without multidisciplinary training and active board development as a whole, most do not succeed. The MEETH story ended with a ruling by the New York State Supreme Court that saved the hospital and led to an eventual merger with a stronger institution. The court’s opinion established a new “MEETH Business Judgment Rule” that implies that nonprofit boards have a higher duty of care than for-profit boards given that nonprofit boards must fulfill a public mission and guard public assets without having either shareholders or the elaborate regulatory and legal oversight frameworks that serve to protect for-profit companies. My experience on the MEETH Board helped me develop what I call the “Edelstein Board Rules for Doctors”: Know the corporate mission well. Read the bylaws and keep them handy. Read the monthly minutes. Follow the money—go to the finance committee meetings. Check the auditors. (Do you know what they really do?) Have perfect attendance. Be prepared to talk about the patient’s perspective and the role of healthcare professionals at every meeting. Explain how integrated healthcare should occur. Provide medical knowledge and presume that the board knows little about medicine. Beware if the only doctors on the board are there “ex-officio” and, consequently, removable at any time without cause. Doctors are trained to give bad news, and boards need to hear their perspectives. Remember the hospital only succeeds with three strong limbs like a three-legged stool—competent administrators, involved lay board members, and doctors who are willing to talk and be active board members.
David R. Nielsen, MD, AAO-HNS/F EVP/CEO
Who Is My Curator?
David R. Nielsen, MD, AAO-HNS/F EVP/CEO If you love the art world, enjoy visiting museums, or spend time at historical sites, you have had significant experience with both volunteer and professional curators. Traditionally, we think of curators as skilled experts who oversee a large volume of information, property, or history, and present those elements that are felt to be of the most worth to the public. The word, “curator,” comes from the Latin curatus, “to care,” or cura, “care.” This is also the root of the chiefly British term, curate, a member of the clergy employed to assist a vicar or parish priest, or any ecclesiastic who is entrusted with the care of the souls of the parish. As we watch the rapid advances of the digital age, the explosion of social media, and the exponential increase in available information, we increasingly hear the term “curator” used to describe people who select from an unmanageable and overwhelming mass of information and present content that is organized, useful, or more meaningful. In his book, Curation Nation, Steven Rosenbaum outlines the reactions taking place in all aspects of our culture as we deal with information overload. We live in an era, he states, of data abundance. “In the old world, a handful of media outlets and large corporations could set the agenda for political discourse, pop culture, and emerging trends.” But in a  few short years, all that has changed. “…thanks to the magic elixir of bandwidth and hardware, we’ve all got a television broadcast studio in our pocket, a printing press on our desktop, and a radio station in our [smartphone]…”1 With this explosion of information and content, opportunities for prioritizing, interpreting, organizing, selecting, combining, targeting, and sharing content are likewise exploding. In the strange supply and demand economics of social media, everyone is a provider, and anyone is a consumer. In this world, according to Rohit Bhargava on SocialMediaToday.com, “To satisfy the people’s hunger for great content on any topic imaginable, there will need to be a new category of individual working online. Someone whose job it is not to create more content, but to make sense of all the content that others are creating…The people who choose to take on this role will be known as ‘content curators.’”2 However, as Mark Schaefer posted recently on the same site, there are big problems with content curation, especially if it is being done commercially by business for customers. Following the announcement of a major financial institution’s initiative to roll out an automated content curation system he asks, “Why should I trust you with my news?…Whose problem are you solving?…One size does not fit all.” 3 Equally disturbing to him is the concern of an automated system of reviewing and choosing content. How can I be sure the content has been really customized for me? Is this something I want to turn over to a machine, or do I require the human touch? Because the Academy is an association of otolaryngologists, and is led, managed, funded, overseen, and strategically directed by otolaryngologists, we can answer Schaefer’s questions. Every otolaryngologist who is a member, participates in the annual meeting, serves on a committee, votes for officers, or engages in any other way in Academy or Foundation activity is a curator of content in some way. We can trust each other as colleagues, share perspectives, draw from common concerns, and find targeted information and solutions far more effectively than an outside proprietary interest group or media company. Yes, industry and media contacts, professionals, and interests are important to us. But as an association of volunteers, whose motivation is to provide the best patient care by collaborating on effective education, research, and health policy goals, we can be trusted. We can address our problems and our patients’ best interests, and we can prioritize, tailor, and target valued information to each other effectively. So I hope those who attend enjoy the week of “curated content” at our AAO-HNSF 2012 Annual Meeting & OTO EXPO in Washington, DC. I cannot thank you, our members, enough for the selfless manner in which you “curate” your world of knowledge and expertise and share with each other as we empower each other to provide the best otolaryngology care in the world. References Rosenbaum, S. Curation Nation. New York: McGraw Hill; 2011:72. (iBook version). Rosenbaum, S. Curation Nation. New York: McGraw Hill; 2011:73-74. (iBook version). Mark, S. Five Big Problems with Content Curation. Social Media Today. http://socialmediatoday.com/node/622296v. Accessed July 27, 2012.
Rodney P. Lusk, MD, AAO-HNS/F President
Searching for the Best Solution
Rodney P. Lusk, MD, AAO-HNS/F President I would like to spend my last Bulletin article emphasizing the Academy’s developing technology and how we serve our membership. We know our website needs to be more useful to those we serve: this includes both the public and Academy members. The needs of these two groups are different. The most active page on the site is “find an ENT.” In fact, it is so popular that we are currently creating an app for this page that will allow anyone to find an otolaryngologist within a defined location. Prior to this year the website did not have a good site map and the pages had not been adequately meta-tagged and maintained. This is one of the reasons why your searches were not efficient. During the past year, all pages—more than 5,000, have been reviewed and evaluated for “currency” and relevancy by the Academy staff and committees. This has been an onerous task, but it is now completed. After assessing each page, the content was meta-tagged, or assigned key words, to improve your searches. A new search engine from Google has been implemented for more rapid and efficient searches using these newly created meta-tags. We are now working on the new site map. Our goal is to provide the public and our membership with the most efficient tools for searching all otolaryngology or ENT literature. This is no easy task as searches are now performed from multiple devices, such as smartphones, tablets, laptops, and desktop computers. The operating systems of these devices are different and difficult to maximize for each utilization. We know that to maximize your efficiency we will have to deliver the information to you through any device connected to the Internet, whenever you need it. We are making steady progress and you should try the new search capacity, the following features, and give us your feedback as it continues to improve. Let’s start with the annual meeting. You may have noticed the article in this year’s printed April Bulletin that you can track all papers, panels, and instruction courses by subspecialty at www.entnet.org/annual_meeting, which markedly improves your ability to find the educational materials of interest. This is a result of having the courses and papers properly meta-tagged just as the webpages are now tagged. The website now has an improved itinerary planner capable of searches by specialty, event time, day, presenter, and keywords. AcademyU® has a wealth of information that is online and free to the membership. It’s easy to use—just log into the website as a member, select AcademyU, and log into the courses you want to take. Lectures are organized by subspecialty, searchable for content and we can even track your CME. A new e-bookshelf is being developed to allow downloading resources to your computer or mobile device. Primary Care Otolaryngology is popular with primary care residents, physicians, PAs, NPs, and students. The Pocket Guide to Tumor Staging of Head and Neck Cancer is now available in its new third edition, and the new Trauma Manual is available this month. Comprehensive Otolaryngologic Curriculum Learning through Interactive Approach (COCLIA) has been launched in a new online format with updated study questions for residents. Clinical Otolaryngology OnLine (COOL) is a learning experience for PCPs, NP, PAs, medical students, and other healthcare professionals who encounter otolaryngological symptoms. This information can be downloaded directly from our website. Patient Management Perspectives in Otolaryngology is now available completely online for both PC and Mac applications and is popular with our membership. We are making progress with the following applications for mobile devices. Our journal, Otolaryngology–Head and Neck Surgery, is now available as an app on the iPhone and iPad. The three most recent issues are available continuously, and efforts are being made to make archived articles available. The Academy has a large databank of questions that is being put into a mobile app called the AcademyQ, and can be used for maintenance of certification (MOC) preparation. These questions have associated correct answers and references for further information and study. Our goal is to provide you with a search tool for all your knowledge needs that will be broader than PubMed, but narrower and more focused than a typical Google Internet search. You will be able to define the journals and websites you want to search. The information should eventually be deliverable to any device connected to the web. The technology allowing this type of connectivity is just now becoming available. The delivery of this product will take time, but it is obvious that when we provide you with this functionality you will also want to come to our website for all your additional needs regarding our specialty.
Team members with the postoperative patients at Gitwe Hospital.
Thyroid Mission Trip to Gitwe, Rwanda
Anish Y. Parekh, MD PGY-5 Tufts Medical Center As I completed my fifth year of otolaryngology training at Tufts Medical Center, I had the opportunity to be part of a medical mission team of 15 healthcare workers and volunteers from across the United States to Rwanda, Africa, March 4-11, to perform partial and subtotal thyroidectomies. Jagdish K. Dhingra, MBBS, FRCS, an otolaryngologist from Boston, MA, led the mission team under the auspices of Medical Missions for Children (MMFC). We travelled to Gitwe, a small mountain village located 50 miles southwest of the capital city, Kigali. Due to iodine deficiency in salt and water, multinodular thyroid goiter is endemic in Rwanda. Local physicians lack the training and are ill equipped to deal with large goiters. This was Dr. Dhingra’s sixth annual mission to Gitwe, Rwanda, and during this time he has performed more than 100 partial and subtotal thyroidectomies. In the most recent trip, we performed 26 thyroidectomies. In addition to the thyroid mission, MMFC coordinates an annual cleft lip mission to Gitwe and 13 other annual missions to underdeveloped parts of the world. After landing in Rwanda, the journey to Gitwe is a grueling four-hour van ride from Kigali. The team brought all the administrative, anesthetic, surgical, and PACU supplies and medications necessary for surgery with them to Rwanda. The first day in Gitwe consisted of setting up the operating room and PACU and screening patients at Gitwe Hospital. Patients had been screened six months earlier by a surgeon and a nurse. In addition to word of mouth, radio announcements helped us reach remote villagers about our mission. Patients had traveled from many miles away, often walking several hours a day to reach the hospital. The primary complaints were pressure symptoms. During five days, 26 patients underwent partial or subtotal thyroidectomy. Excision specimens routinely measured more than 5 cm in largest diameter with the largest specimen measuring 12 cm and weighing about 500 grams. Postoperatively, patients stayed in the hospital until drains were removed. The trip was a unique learning experience and a great success overall. Planning for next year’s mission is already under way.
AAO-HNSF, AHNS Sponsor Thyroid Cancer Research
The incidence of thyroid cancer in the United States has more than doubled since the early 1970s. Between 1996 and 2005, the incidence rose annually by 5.8 percent among men and 7.1 percent among women, a more rapid increase than any other cancer site. This year the AAO-HNSF and the American Head and Neck Society (AHNS) are sponsoring two research projects aiming to increase our basic knowledge of thyroid cancer. The 2012 AHNS Alando J. Ballantyne Resident Research Pilot Grant was awarded to Neerav Goyal, MD, MPH, from the Pennsylvania State University College of Medicine in Hershey, PA, for his project entitled “Determining the Association between Radon Levels and Thyroid Cancer.” Exposure to radiation is one of the only known risk factors for developing thyroid cancer. However, in the vast majority of thyroid cancer patients, no such risk factor is ever identified. Radon is a radioactive colorless, odorless, and tasteless gas derived from the breakdown of uranium, which emits alpha particle radiation. Given the high rates of thyroid cancer in Pennsylvania relative to the rest of the United States, and the high levels of radon reported in many counties within Pennsylvania, Dr. Goyal and his team will look to determine if an association exists between radon levels and thyroid cancer, and also determine the strength of the association. The study will have three phases. First, the team will collect existing data on radon levels in Pennsylvania by geographic subunit. Secondly, the team will collect data on the incidence of thyroid cancer in these same subunits and determine if there is any correlation between the two variables using spatial analysis methods, such as the Moran I global measure and local indicator of spatial association tests. Thirdly, the team will compare areas by radon exposure and determine if there are significant differences in the characteristics of thyroid disease in the geographic subunits. Through this research, Dr. Goyal and his team hope to demonstrate a possible avenue of identifying a previously unidentified risk factor and preventing carcinomas of the thyroid. By shifting the paradigm from treatment to prevention, the research could provide a significant benefit to the general public. The proposed work is the first of its kind and innovative because it not only addresses the cause of an alarming trend of rising rates of thyroid cancer, but also may offer a solution and enable us to prevent further development of this disease. One of the 2012 AAO-HNSF resident research grants was awarded to Vlad C. Sandulache, MD, PhD, from Baylor College of Medicine in Houston, TX, for his project, “MRI-based Evaluation of Metabolic targeting in Anaplastic Thyroid Cancer.” Anaplastic thyroid cancer (ATC) accounts for about 50 percent of all thyroid cancer-related deaths. Current treatment paradigms rely on external beam radiation (XRT) as a primary treatment modality. As such, development of novel radiosensitizing regimens is crucial in the management of this deadly disease. XRT induces tumor cell death through the formation of reactive oxygen species (ROS), which cause DNA damage. Tumor cell resistance to XRT is driven in large part by the ability to generate sufficient reducing equivalents to neutralize ROS. Pharmacologic perturbation of metabolic pathways can decrease intracellular levels of reducing equivalents and potentiate ROS generation in response to XRT. Dr. Sandulache and his team have previously demonstrated that combining 2-deoxyglucose (a glycolytic inhibitor) with metformin (a mitochondrial respiration inhibitor) results in increased intracellular ROS levels and significant potentiation of XRT toxicity. To date, it has not been possible to evaluate the effects of this anti-metabolic regimen on tumor reducing potential in vivo. They propose to use real-time hyperpolarized (HP) magnetic resonance imaging (MRI) in the context of an orthotopic xenograft murine model of ATC to provide pharmacodynamic information meant to maximize radiosensitization. Using HP MRI they will optimize metabolic inhibition using the above mentioned agents and achieve maximal radiosensitization of ATC tumors. The study is expected to achieve two goals. First, it will begin to define a pharmacodynamic profile for metabolic inhibition, which can aid in the development of clinically relevant therapeutic regimens. Second, it will demonstrate that HP-MRI represents a suitable tool for evaluating the effects of metabolic targeting in this aggressive malignancy. Successful completion of this study will allow the team to draw meaningful conclusions regarding the validity of an anti-metabolic approach to radiosensitizing ATC tumors. Given the scarcity of available treatments for this deadly disease, any promising therapeutic regimen can significantly influence the current state of treatment. Although imaging is increasingly utilized in the discovery and staging of malignancy, it has rarely been employed to guide therapeutic intervention in real time. It is the team’s belief that an anti-metabolic strategy aimed at perturbing the tumor reducing potential can be facilitated by using HP-MRI in a manner that improves therapeutic effect. Using mathematical modeling, the group is currently developing new algorithms for the interpretation of HP-MRI data and adapting its utilization to multiple solid tumor models. The data obtained in this study are expected to contribute significantly to the development of these algorithms. In addition to providing novel pharmacodynamic information crucial to the development of new anti-metabolic agents, development of HP-MRI as a predictive tool will facilitate translation of treatment regimens used in this preclinical mode into clinical trials. Dr. Sandulache will conduct the above-described research under the mentorship of Stephen Y. Lai, MD, PhD, (Department of Head and Neck Surgery, University of Texas (UT) MD Anderson Cancer Center) and in collaboration with James A. Bankson, PhD, (Department of Imaging Physics, UT MD Anderson Cancer Center). Since 1997, more than $200,000 has been awarded to researchers through the Centralized Otolaryngology Research Efforts (CORE) grant program to improve our knowledge of thyroid cancer.
Maisie L. Shindo, MD, volunteer faculty at Ultrasound Course.
The Otolaryngologist and Thyroid Cancer
Lisa A. Orloff, MD Chair, AAO-HNS Endocrine Surgery Committee September is Thyroid Cancer Awareness Month, and the American Academy of Otolaryngology—Head and Neck Surgery encourages its members and affiliates to participate in this event again this year. The management and treatment of disorders and diseases of the thyroid (as well as parathyroid glands) are part of the fundamental training of otolaryngologist-head and neck surgeons, and some in the field even choose to make head and neck endocrine surgery their primary focus and area of expertise. However, all otolaryngologists should be aware of the many opportunities for collaboration aimed at enhancing early detection, evidence-based care, and research to achieve cures for all types of thyroid cancer. Thyroid cancer is one of the few cancers that continues to increase in incidence. The American Cancer Society estimates that more than 56,000 new cases of thyroid cancer will be detected in the United States this year and more than 200,000 people will be newly diagnosed worldwide. Surgery is the primary treatment modality for the vast majority of thyroid cancers, and otolaryngologist-head and neck surgeons around the world are responsible for the surgical care and surveillance of patients with thyroid cancer. Thyroid Cancer Awareness Month is a worldwide observance, sponsored and initiated by the Thyroid Cancer Survivors’ Association (ThyCa). The AAO-HNS is once again working with ThyCa to raise thyroid cancer awareness. In addition, throughout the year, the Academy is continually doing its part to promote awareness and expertise in the care of thyroid cancer and thyroid disorders. Did you know of these thyroid facts and opportunities? The core curriculum of the American Board of Otolaryngology lists this as a clinical skill “during training, the resident demonstrates the skill [to] perform real-time ultrasound of the thyroid and [to] identify nodular disease of the gland, and identifies and delineates pathologic lymphadenopathy.” The “ACS Thyroid and Parathyroid Ultrasound Skills-Oriented Course” will be offered for the third time before the AAO-HNSF 2012 Annual Meeting & OTO EXPO in Washington, DC, under the oversight of Robert A. Sofferman, MD, course director and chair of the National Ultrasound Faculty of the American College of Surgeons (ACS). The course will take place 8:00 am–4:30 pm Saturday, September 8. For details, visit http://www.entannualmeeting.org/12/index.php/education/saturday-workshop. The AAO-HNS Endocrine Surgery Committee and the ACS are evaluating means of obtaining accreditation for ultrasound training through the American Institute of Ultrasound in Medicine (AIUM) that may protect surgeons from refusal of reimbursement from insurance companies and possibly future governmental restrictions (see the July 2012 Bulletin) The AAO-HNS is currently developing a clinical practice guideline (CPG) focused on Improving Voice Outcomes after Thyroid Surgery. The guideline is entering the final stages of development by Academy members with expertise in this area, and is undergoing review by members of the Endocrine Surgery Committee. The American Association of Endocrine Surgeons, an organization established in 1981 and open to active membership for general surgeons who are certified by the American Board of Surgery (but open to “Allied Specialist” membership for otolaryngologists and others with an interest in endocrine surgery), oversees 19 clinical fellowships plus four research fellowships and three international fellowships in endocrine surgery, open to general surgeons only. The American Head and Neck Society (AHNS) currently oversees 29 Fellowships in Advanced Training in Head and Neck Oncologic Surgery, as well as three specific Fellowships in Advanced Training in Head and Neck Endocrine Surgery, open to otolaryngologists, general surgeons, and plastic surgeons. The AAO-HNS Endocrine Surgery Committee is working with other allied organizations, such as the American Thyroid Association, Endocrine Society, International Society of Endocrine Surgeons, Thyroid Cancer Survivors’ Association, and others in conducting and presenting research, participating at meetings, serving on committees, and working collegially with professionals from many disciplines interested in thyroid cancer. As noted in the July 2012 issue of the Bulletin, the ATA is an excellent collaborative venue for otolaryngologists, general surgeons, and medical endocrinologists. Visit www.thyroid.org. The AAO-HNS Endocrine Surgery Committee has reviewed and endorsed a variety of thyroid-related practice guidelines, most recently including the 2012 ATA practice recommendations “Essential Elements of Interdisciplinary Communication of Perioperative Information for Patients Undergoing Thyroid Cancer Surgery” http://thyroidguidelines.net/. Numerous miniseminars and instruction courses pertaining to thyroid surgery, parathyroid surgery, and ultrasound are being offered during the Annual Meeting. The AAO-HNS and ThyCa invite everyone interested in helping with thyroid cancer awareness efforts in their communities. For free materials from ThyCa and tips on how to raise awareness, and more details on thyroid cancer, e-mail outreach@thyca.org, call 1-877-588-7904, or visit www.thyca.org. For year-round AAO-HNS activities and information related to the management of thyroid disease, visit www.entnet.org.