Published: October 24, 2013

Personalized Healthcare: Identifying the Gaps

Minka Schofield, MD Member, Diversity Committee, AAO-HNS Assistant Professor  Department of Otolaryngology—Head and Neck Surgery  The Ohio State University Medical Center Healthcare costs continue to rise, representing one of the key concerns of America. In 2005, about 16 percent ($2 trillion) of the gross domestic product (GDP) constituted healthcare expenses. This is expected to increase to about 20 percent ($4 trillion) by 2015. Despite the steady increase in healthcare spending, the quality of care based on outcomes of chronic health conditions and the life expectancy of the U.S. population remains lower compared to other developed countries. Furthermore, standard drug treatments are less than 60 percent effective in treating common chronic diseases. This trend has led to the concept of personalized healthcare to help lower the costs of healthcare delivery while improving patient health outcomes and quality of life. Leroy Hood, MD, PhD, a physician-scientist with a key role in the Human Genome Project, initiated the concept of P4 medicine: predictive, personalized, preventive, and participatory. This concept focuses on health and wellness of patients by predicting the risk of disease through the incorporation of genetics, behavioral and environmental factors, and preventing disease development via a more proactive model of healthcare delivery. Through personalized medicine, the goal is to treat patients with targeted and presumably more effective therapy and to move from a physician-directed practice of medicine to a participatory model that actively involves patients in their health management. Like any new concept, there are challenges or gaps that must be overcome to allow for change and “hard-wiring” of new ideals and practices into the healthcare community. Some of these gaps include accessibility of care, costs of development, negative physician and patient perspectives, regulation barriers set by governing bodies, private industry profit-driven focuses, and reimbursement limitations. Approximately 28 percent of U.S citizens have difficulty accessing medical care. Eliminating this problem has been one of the premises for President Barack Obama’s healthcare plan. This will remain a challenge even in the era of personalized medicine unless measures are taken to provide affordable healthcare services to U.S. citizens. Cost has always represented a barrier in healthcare delivery and advancement. Drug development has proven to be a costly process, often requiring billions of dollars and several years before new medications are available for use. This same resource utilization has been demonstrated in other areas of study including genomics, bioinformatics, systems biology, and nanotechnology. Research funding is also required to validate these new technologies through clinical trials. Other costs include those to promote patient and physician education and the coordination of patient data through health information technology systems such as the electronic medical record. The dedication of research dollars from both government and private industry are essential to help fund and validate targeted medical therapies and provide resources and reasonable incentives to physicians for personalized healthcare promotion. In order to develop these new technologies, research on human subjects is required. This brings to surface the ethical principles that must be maintained through this research, particularly when studying the genetic code to predict disease. Naturally, the fear of exploitation, loss of privacy, and discrimination are real barriers for patients when accepting genetic testing. Regulatory guidelines are needed to protect the patient from misuse of genetic data. In addition, the “contract” between science and society needs to be reframed to promote trust among patients. Meslin and Cho propose a “recipe for reciprocity” calling for scientists to provide society with: • a clear articulation of goals and visions of what constitutes benefit; • a commitment to achieving these goals over the pursuit of individual interests; • greater transparency; and • involvement of the public in the scientific process. • In return, society would provide: • trust in the process and goals of science; • a greater willingness to volunteer and participate in research trials; • sustained reliable funding; and • support for greater academic freedom, free from manipulation by political goals and ideology.4 Adopting the concept of personalized medicine also requires a modification of physician perspectives. For many practicing physicians, this represents a new concept and would require a shift in practice style. The education of physicians on the importance of P4 medicine and providing reimbursement incentives are key to effecting this change. Physician organizations, such as AAO-HNS and the AMA, must be actively involved in the institution of personalized healthcare by establishing new standards of care through evidence-based medicine and lobbying for improved reimbursement for physician time and effort required to establish the diagnosis. There are at least 75 university-based centers or institutes in the U.S. that focus on personalized medicine, genomics, and/or systems biology. The Ohio State University Medical Center has partnered with the non-profit Institute of Systems Biology, co-founded by Dr. Hood, to form the first organization of its kind, the P4 Medicine Institute. Finally, a change is needed in the current model of practicing medicine in the U.S., which is largely controlled by the Centers for Medicare and Medicaid Services (CMS). Physicians are in essence rewarded for procedures performed, hence the CPT code, and under-compensated for time and effort needed to obtain the correct diagnosis. CMS’s focus on the CPT code limits the use of new technology and procedures by failing to correlate CPT codes for services provided. This results in failure to reimburse for testing or procedures performed or inadequate reimbursement. As new technologies arise, it is essential that new codes are devised to encourage the process of personalized medicine. Furthermore, health promotion programs driven by insurance companies along with other patient incentives are essential to encourage patient participation in their healthcare. The era of personalized healthcare represents the beginning of efforts to reduce healthcare costs and improve health outcomes by preventing disease development and providing targeted medical therapies. Recognition of the patient, physician, and economic challenges and revision of the current model for practicing medicine are essential to the widespread institution of personalized medicine. References: 1. National Coalition of Healthcare website: http://nchc.org. 2. Aspinall MG, Hamermesh RG. Realizing the promise of personalized medicine. Harv Bus Rev 2007; 85: 108-117. 3. Hood L, SH Friend. Predictive, personalized, preventive, participatory (P4) cancer medicine Nat Rev Clin Oncol 2011; 8: 184-187. 4. Meslin EM, Cho MK. Research ethics in the era of personalized medicine: updating science’s contract with society. Public Health Genomics 2010; 13: 378-384. 5. Hwang J, Christensen C. Disruptive innovation in healthcare delivery: a framework for business-model innovation. Health Affairs 2007; 27: 1329-1335.

Minka Schofield, MD
Member, Diversity Committee, AAO-HNS
Assistant Professor 
Department of Otolaryngology—Head and Neck Surgery 
The Ohio State University Medical Center

SchofieldHealthcare costs continue to rise, representing one of the key concerns of America. In 2005, about 16 percent ($2 trillion) of the gross domestic product (GDP) constituted healthcare expenses. This is expected to increase to about 20 percent ($4 trillion) by 2015.

Despite the steady increase in healthcare spending, the quality of care based on outcomes of chronic health conditions and the life expectancy of the U.S. population remains lower compared to other developed countries. Furthermore, standard drug treatments are less than 60 percent effective in treating common chronic diseases. This trend has led to the concept of personalized healthcare to help lower the costs of healthcare delivery while improving patient health outcomes and quality of life.

Leroy Hood, MD, PhD, a physician-scientist with a key role in the Human Genome Project, initiated the concept of P4 medicine: predictive, personalized, preventive, and participatory. This concept focuses on health and wellness of patients by predicting the risk of disease through the incorporation of genetics, behavioral and environmental factors, and preventing disease development via a more proactive model of healthcare delivery. Through personalized medicine, the goal is to treat patients with targeted and presumably more effective therapy and to move from a physician-directed practice of medicine to a participatory model that actively involves patients in their health management.

Like any new concept, there are challenges or gaps that must be overcome to allow for change and “hard-wiring” of new ideals and practices into the healthcare community. Some of these gaps include accessibility of care, costs of development, negative physician and patient perspectives, regulation barriers set by governing bodies, private industry profit-driven focuses, and reimbursement limitations.

Approximately 28 percent of U.S citizens have difficulty accessing medical care. Eliminating this problem has been one of the premises for President Barack Obama’s healthcare plan. This will remain a challenge even in the era of personalized medicine unless measures are taken to provide affordable healthcare services to U.S. citizens.

Cost has always represented a barrier in healthcare delivery and advancement. Drug development has proven to be a costly process, often requiring billions of dollars and several years before new medications are available for use. This same resource utilization has been demonstrated in other areas of study including genomics, bioinformatics, systems biology, and nanotechnology. Research funding is also required to validate these new technologies through clinical trials. Other costs include those to promote patient and physician education and the coordination of patient data through health information technology systems such as the electronic medical record. The dedication of research dollars from both government and private industry are essential to help fund and validate targeted medical therapies and provide resources and reasonable incentives to physicians for personalized healthcare promotion.

In order to develop these new technologies, research on human subjects is required. This brings to surface the ethical principles that must be maintained through this research, particularly when studying the genetic code to predict disease. Naturally, the fear of exploitation, loss of privacy, and discrimination are real barriers for patients when accepting genetic testing. Regulatory guidelines are needed to protect the patient from misuse of genetic data. In addition, the “contract” between science and society needs to be reframed to promote trust among patients. Meslin and Cho propose a “recipe for reciprocity” calling for scientists to provide society with:

• a clear articulation of goals and visions of what constitutes benefit;
• a commitment to achieving these goals over the pursuit of individual interests;
• greater transparency; and
• involvement of the public in the scientific process.
• In return, society would provide:
• trust in the process and goals of science;
• a greater willingness to volunteer and participate in research trials;
• sustained reliable funding; and
• support for greater academic freedom, free from manipulation by political goals and ideology.4

Adopting the concept of personalized medicine also requires a modification of physician perspectives. For many practicing physicians, this represents a new concept and would require a shift in practice style. The education of physicians on the importance of P4 medicine and providing reimbursement incentives are key to effecting this change. Physician organizations, such as AAO-HNS and the AMA, must be actively involved in the institution of personalized healthcare by establishing new standards of care through evidence-based medicine and lobbying for improved reimbursement for physician time and effort required to establish the diagnosis.

There are at least 75 university-based centers or institutes in the U.S. that focus on personalized medicine, genomics, and/or systems biology. The Ohio State University Medical Center has partnered with the non-profit Institute of Systems Biology, co-founded by Dr. Hood, to form the first organization of its kind, the P4 Medicine Institute.

Finally, a change is needed in the current model of practicing medicine in the U.S., which is largely controlled by the Centers for Medicare and Medicaid Services (CMS). Physicians are in essence rewarded for procedures performed, hence the CPT code, and under-compensated for time and effort needed to obtain the correct diagnosis. CMS’s focus on the CPT code limits the use of new technology and procedures by failing to correlate CPT codes for services provided. This results in failure to reimburse for testing or procedures performed or inadequate reimbursement. As new technologies arise, it is essential that new codes are devised to encourage the process of personalized medicine. Furthermore, health promotion programs driven by insurance companies along with other patient incentives are essential to encourage patient participation in their healthcare.

The era of personalized healthcare represents the beginning of efforts to reduce healthcare costs and improve health outcomes by preventing disease development and providing targeted medical therapies. Recognition of the patient, physician, and economic challenges and revision of the current model for practicing medicine are essential to the widespread institution of personalized medicine.

References:

1. National Coalition of Healthcare website: http://nchc.org.
2. Aspinall MG, Hamermesh RG. Realizing the promise of personalized medicine. Harv Bus Rev 2007; 85: 108-117.
3. Hood L, SH Friend. Predictive, personalized, preventive, participatory (P4) cancer medicine Nat Rev Clin Oncol 2011; 8: 184-187.
4. Meslin EM, Cho MK. Research ethics in the era of personalized medicine: updating science’s contract with society. Public Health Genomics 2010; 13: 378-384.
5. Hwang J, Christensen C. Disruptive innovation in healthcare delivery: a framework for business-model innovation. Health Affairs 2007; 27: 1329-1335.

More from September 2011 - Vol. 30 No. 09
academyadvantage
Academy Advantage Partner Spotlight
To Lower Your 401(k) Fees, Raise Your 401(k) Understanding Are your 401(k) fees too high? If so, is there anything you can you do to lower them? The first thing to do when faced with these questions is to consider the acceptable fee ranges for most plans of your size. Plans under $1 million should have fees from 1.42 percent to 2.3 percent; plans over $1 million and up to $10 million: .87 percent to 1.62 percent. Now that you have a frame of reference for evaluating the sum total of your fees, it’s time to find out exactly what fees are included in your plan. (Hint: You can request a fee disclosure form from Academy Benefit Partners to assist you.) Does your 401(k) plan charge for any of the following services: record keeper fee; third-party administrator fee; custodian fee; advisor fee; fund cost fee; 3(38) manager fee (if applicable)? Once armed with the facts about your fees, you can consider what changes you may make to your plan. Follow up with questions to your plan provider. You also can reduce costs by changing your advisor or changing plans. But should you actually change plans? Is it worth the pain of change? First, consider the costs of changing plans. Some vendors will levy a fee to move to another provider, but don’t let that stop you from continuing your quest for reduced costs. Compare the cost of moving a plan to the excess cost of keeping it status quo. If your provider is overpriced, it may still be more economical to move the plan despite the penalty fee. Once your new, improved lower-fee 401(k) plan is established, don’t take it for granted. Employee education is the key to ensuring that your plan is used efficiently. Good plan advisors hold meetings for employees at least every six months to answer workers’ questions. Schedule regular reviews with your plan and vendors and you will help to secure your employees’ financial futures as well as protect yourself from fiduciary liability. This article was provided by The Payroll Company, an AAO-HNS Academy Advantage Partner. Contact Erika Young at 1-608-826-1111, via email at: erikay@payrollcompany.biz or  www.academybenefitpartners.org  to learn more.
Patient Notification for Self-Payer Payment Policies for Certain In-Office Procedures
The AAO-HNS has drafted a template letter that members may use to notify patients of additional payments for certain diagnostic procedures performed during office visits for which they may be financially responsible. This letter is generic and acts only as guidance for you to construct your notification; you should edit the list of procedures to reflect the specific procedures you performed on your patient on the stated date of service. Use your company letterhead/logo as well as fill in the blanks. To view the letter, go to http://www.entnet.org/Practice/Appeal-Template-letters.cfm. Contact the Health policy department at Healthpolicy@entnet.org if you have any questions on this letter. Company Logo [centered] [the rest align left] Patient Name:  ___________________________________ Please be aware that certain procedures performed in our office are not included in the standard office visit.  These procedures will be billed separately and in addition to office visit charges.  We have become aware that some insurance carriers are classifying these procedures as “Surgery” and applying the charges to a higher deductible amount.  The result may be insurance payment for an office visit but not a procedure.  In such cases, payment for the procedure will be due from the patient.  Be assured that we are following accepted billing and coding guidelines and that all procedures are performed in the best interest of patient care. Examples of in-office procedures include: – Flexible laryngoscopy:  This procedure involves passing a long thin flexible fiberoptic scope through the nasal cavity and into the throat.  The fiber-optic scope enables the physician to visualize areas of the throat not readily seen using the laryngeal mirrors. – Nasal endoscopy:  This procedure uses the flexible or rigid scope attached to a light source to view areas of the nasal cavities that cannot be viewed by the physician using the standard nasal speculum and head mirror. – Nasal endoscopy with debridement or biopsy: This is the same procedure as above with removal of crusting or tissue. Please speak with our nurse or clinical assistant if you have any questions. ___________________________            _________________ Patient Signature                                   Date
docpatient
What Are OPPE and FPPE?
Ongoing Professional Practice Evaluation (OPPE) and  Focused Professional Practice Evaluation (FPPE) Rahul K. Shah, MD  George Washington University School of Medicine, Children’s National Medical Center, Washington, DC The legitimacy of a concept or term can be ascertained by how successful your Internet search is when you begin to research the topic. A couple of years ago, it was difficult to find information on  Ongoing Professional Practice Evaluation (OPPE) and Focused Professional Practice Evaluation (FPPE). Today, a search of such reveals pages of websites that define OPPE, teach us about the term, help medical staff strategize in using OPPE, and even offer consultants for OPPE. What is OPPE? The Ongoing Professional Practice Evaluation is a standard from the Joint Commission (JC) that requires medical staff to collect and distribute to physicians specific data regarding the core competencies and quality improvement. Fortunately, the core competencies are now second nature to residents as their program evaluations use this structure and they have become accustomed to these from the American Board of Medical Specialties (ABMS) and the Accreditation Council for Graduate Medical Education (ACGME). The six core competencies are: patient care, medical/clinical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and system-based practice. This Ongoing Professional Practice Evaluation will be a continuous process in which physician-specific metrics will have to be disseminated, and if needed, quality improvement initiatives can be targeted to deficient areas. One of the strengths and potential pitfalls of the OPPE is that the metrics are defined by the institution or service chiefs. This is a tremendous amount of latitude and can be an issue if the metrics are the same for a head and neck surgeon and an otologist. The metrics are derived from a multitude of sources: patient satisfaction surveys, morbidity and mortality conferences, infection rates, compliance to guidelines, participation in CME activities, 360-degree evaluations, etc. Many had issues with the first iteration of OPPE because of the light scrutiny by regulatory agencies on compliance with this standard and institutions struggling to grasp the concept and usefulness. Now, there are many institutional, computer-based, and consultancy resources to use in creating OPPE metrics and scorecards that undoubtedly have raised the bar of scrutiny, and the standard is higher. In this column, we have written a few times that physicians and institutions should concentrate efforts on defining metrics that are reasonable for their practice patterns and, most importantly, define metrics that matter. If a metric shows no distribution among physicians and is not particularly amenable to perhaps quality improvement strategies for outliers, then it is not a robust OPPE metric. For example, post-tonsillectomy bleed rates certainly will vary from physician to physician, but the range is tight and the intervention on how to deal with outliers with a bleed rate of 3.5 percent compared to a practice average of 2.75 percent escapes me. Discussion of OPPE often involves FPPE, which we will discuss in greater detail in future columns. FPPE also comes from the Joint Commission and is an acronym for the Focused Professional Practice Evaluation. This evaluation tool helps monitor physician performance and outcomes if there is concern about one’s practice patterns. Otolaryngologists are going to have to work diligently to define OPPE metrics that demonstrate the value and quality of the care we give, yet provide opportunity for improvements.  This is much easier in other venues in the hospital, such as ICUs, where the central line infection rates or compliance with clinical pathways can be measured. The OPPE is another level of transparency for physician performance and outcomes that is now a regulatory requirement. Many institutions are currently working through the process. We expect  many Academy members will need to begin this process. By sharing our efforts and knowledge, we hope we will be able to confidently define metrics that matter. References 1. http://med.stanford.edu/shs/update/archives/FEB2007/president.htm, accessed, July 11, 2011. 2. http://www.compass-clinical.com/hospital-accreditation/2011/06/oppe-measuring-for-healthcare-quality-not-just-compliance/, accessed July 11, 2011.   We encourage members to write us with any topic of interest. 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 for their names to be used. Email the Academy at qualityimprovement@entnet.org to engage us in a patient safety and quality discussion that is pertinent to your practice.
When “Doctor” Doesn’t Mean Physician
Megan Marcinko, MPS AAO-HNS Senior Manager, Congressional & Political Affairs  Although we are more than a year beyond passage of the Affordable Care Act (ACA), efforts remain under way to advance various health-related pieces of legislation that focus on areas of the health system not adequately addressed in the health reform law. Specifically, advocates for “transparency” in patient communications, including the AAO-HNS, argue that clear and accurate information empowers patients with an improved understanding of the healthcare delivery system. Currently, there is little transparency associated with the most fundamental and important component of healthcare delivery—the many health professionals who interface with patients every day. The continuing evolution of the healthcare delivery system has included the emergence of a variety of new non-physician medical provider degrees and/or accreditations. Although non-physician healthcare providers are an important component of the U.S. healthcare delivery system, it is critical that patients understand the level of training associated with various providers. Today, being a “doctor” does not necessarily mean that an individual has completed the training associated with the Medical Doctor (MD) or Doctor of Osteopathy (DO) degrees. Little has been done to ensure patients are able to identify and/or recognize the differences between providers. Recent studies confirm American patients prefer a physician-led approach to healthcare and are often confused about the level of training and education of their healthcare providers, including physicians, technicians, nurses, physician assistants, and other allied providers. Patients lack information about the wide variety of professionals who work in healthcare settings, and they are confused by the increasing ambiguity of healthcare provider-related advertisements and marketing. To address this serious health policy void, the AAO-HNS and others in the healthcare community continue to advocate for state and federal legislation that would require all healthcare providers to fully disclose their credentials and/or level of training in all patient communications. Across the nation, there have been numerous state legislative proposals introduced in the past several years, with additional states adopting and implementing transparency legislation each year. Prior to this year’s state legislative sessions, truth-in-advertising legislation has been enacted in Arizona, California, Florida, Illinois, Oklahoma, and Pennsylvania. In 2011, there were truth-in-advertising bills introduced in Colorado, Connecticut, Idaho, Indiana, Massachusetts, Minnesota, Missouri, Montana, Nevada, Tennessee, Texas, Utah, and Wyoming. Most recently, Connecticut joined Oregon, Tennessee, and Utah in successfully passing healthcare truth and transparency legislation this year. On June 6, 2011, Governor Dannel P. Malloy (D-CT) signed into law Public CT House Bill 5045 (CT Public Act 11-32), which requires healthcare providers to wear a photographic identification badge during work hours that display the facility name, the provider name, the type of license held, and the individual’s title/position with the facility. In addition to the positive truth-in-advertising measures that many states have taken, there are also some proposals being considered that are cause for concern. The Massachusetts legislature is currently considering a bill, MA House Bill 1490, that would add the term “oral physician” for dentists’ scope of practice and for compliance with the state’s current truth-in-advertising language. Support for federal healthcare truth-in-advertising legislation also continues to grow. In January 2011, U.S. Representatives John Sullivan (R-OK) and David Scott (D-GA) introduced H.R. 451, the Healthcare Truth and Transparency Act of 2011. As written, H.R. 451 is designed to empower patients by improving transparency in healthcare provider-related advertisements and marketing. The legislation provides modest, yet meaningful, increases in resources to marketplace regulators so they can effectively enforce federal consumer protection laws pertaining to the healthcare setting. Although similar legislation has been introduced in past years, H.R. 451 has garnered more co-sponsors in 2011 than in any other Congress. As of August 24, the bill has broad bipartisan support and a total of 45 cosponsors. The AAO-HNS is a strong supporter of H.R. 451 and will continue to work with Represenatives Sullivan and Scott to advance this important legislation. Information is power, and the AAO-HNS strongly believes that increased efforts to educate patients about the qualifications and training of their healthcare providers will benefit the delivery of quality care as a whole. The AAO-HNS encourages its members to contact their state and federal elected officials to urge support of efforts to better inform our patients. To learn more about the Academy’s state and federal advocacy efforts, visit AAO-HNS Legislative and Political Affairs at www.entnet.org/advocacy or contact the Government Affairs team at legstate@entnet.org or legfederal@entnet.org.
AAO-HNS Advocacy Center Makes Legislative Outreach Quick and Easy
The AAO-HNS online Advocacy Center makes it quick and easy for Academy members to contact their elected officials on key state and federal legislative issues affecting the specialty. The Advocacy Center, via the Surgery State Legislative Action Center (SSLAC), is co-sponsored by several surgical societies and can be viewed at www.capwiz.com/sslac/home or through the AAO-HNS Legislative and Political Affairs website at www.entnet.org/advocacy. Effective grassroots advocacy requires the participation of Academy members. Given the demanding schedules of AAO-HNS members, the Advocacy Center is designed to allow members to participate in the legislative process on their own time. The AAO-HNS Government Affairs staff provides “Action Alerts” and pre-written, customized emails/letters for U.S. AAO-HNS members to send to their legislators. These Action Alerts make legislative advocacy quite easy by providing background information on key legislation, followed by instructions for contacting your legislators by phone or email/letter. It only takes a few minutes to send an email or print a letter by entering your name and address into the pre-written form. Members also have the option to personalize the communication by adding an anecdote to the pre-written email and/or letter. Currently, there are several important federal legislative issues featured on the Advocacy Center site. At the top of the AAO-HNS federal legislative priority list is our continuing effort to oppose a bill (H.R. 2140) which, as written, would inappropriately provide audiologists with unlimited direct access to Medicare patients without a physician referral. As of August 15, more than 700 communications have been sent to Congress through this Action Alert. Members can act now to oppose H.R. 2140 and protect patient safety by visiting https://ssl.capwiz.com/sslac/issues/alert/?alertid=49564501. The Academy also continues to advocate for passage of comprehensive medical liability reform. The “HEALTH” Act of 2011 (H.R. 5), introduced by Rep. Phil Gingery, MD, (R-GA), seeks to fairly compensate those harmed by the negligent actions of their healthcare providers, while still preserving patient access to quality healthcare and reducing frivolous lawsuits. The AAO-HNS strongly supports H.R. 5, which includes a reasonable cap on non-economic damages, and believes the legislation will return stability and equity to our medical liability system for patients and providers alike. AAO-HNS members can contact their U.S. Representatives to urge support of H.R. 5 by visiting https://ssl.capwiz.com/sslac/issues/alert/?alertid=45607501. Finally, the Academy remains an active supporter of legislation designed to better educate patients about the level of training associated with various healthcare providers. Studies show there remains substantial patient confusion regarding the various healthcare providers available today. The Healthcare Truth and Transparency Act of 2011 (H.R. 451) would require all healthcare providers to fully disclose their credentials and level of training in all patient communications. The AAO-HNS strongly supports H.R. 451 and encourages AAO-HNS members to contact their Members of Congress by visitingwww.capwiz.com/sslac/issues. Coming soon to the online Advocacy Center will be an Action Alert urging Congressional action to avert a nearly 30-percent cut in Medicare physician payments scheduled for January 1, 2012, as a result of the continued use of the flawed Sustainable Growth Rate (SGR) formula. The AAO-HNS and other physician organizations have urged Congress repeatedly to permanently repeal the SGR formula and develop a new payment system that will provide stability for patients and providers in the Medicare system. Remember: Lobbying alone does not win a legislative battle ­­— it is the grassroots effort that makes success possible. The AAO-HNS needs your continuous support and participation to help effect positive change in Congress and the statehouses and to successfully advocate for issues impacting otolaryngology–head and neck surgery. Advocacy Center Sections and Features Elected Officials – provides contact information, with email options, for executive branch officials and Members of Congress. State Elected Officials – offers information on governors and state legislators, including contact information, bios, and committee assignments. Local Officials – lists information on local officials and governments, including cities, counties, and townships. Issues & Legislation – highlights the latest legislative alerts, current legislation, how Members of Congress voted on key Congressional votes, and tips on effectively communicating with your elected officials. Election & Candidates – provides election information and voting procedures, including what campaigns and ballot initiatives will be on each state’s ballot. Media Guide – finds and provides contact information for national and local media outlets.
AAO-HNS Government Affairs Launches ENT Advocacy Network Recruitment Contest
During the 2011 AAO-HNSF Annual Meeting & OTO EXPO in San Francisco, the Government Affairs team will kick off a contest to recruit U.S. AAO-HNS members for the ENT Advocacy Network. Academy members are challenged to sign up their colleagues for the network to help strengthen otolaryngology—head and neck surgery’s voice and influence in the legislative and political arenas. Contest forms will be available at the ENT PAC Booth, located in the South Lobby of the Moscone Convention Center, or online at www.entnet.org/advocacy. Participation in the ENT Advocacy Network Recruitment Contest will be recognized in several ways. The top recruiter will receive a $200 American Express gift card. The top two recruiters will be awarded one (1) AAO-HNS Honor Point, and will be featured in the BOG eNews and The ENT Advocate. All contest participants will be featured on the Academy’s Legislative & Political Affairs website. Completed forms should be delivered to Government Affairs staff at the ENT PAC Booth, or faxed to 1-202-544-8454, by October 1, 2011.
The AMA Annual Meeting Report
Liana Puscas, MD  AAO-HNS Delegation Chair  to the AMA Duke University Durham, NC  In June, the American Medical Association (AMA) held its 2011 Annual Meeting in Chicago, IL. Your Academy was represented by Liana Puscas, MD, Delegation Chair, and Delegates Michael S. Goldrich, MD, Chair of the AMA Otolaryngology Section Council; Shannon P. Pryor, MD; Robert Puchalski, MD; and Alternate Delegates Alpen A. Patel, MD, and David R. Nielsen, MD, AAO-HNS EVP/CEO. The AMA House of Delegates (HOD) discussed implementation issues surrounding the Patient Protection and Affordable Care Act (ACA), the healthcare reform law enacted in 2010. The HOD reaffirmed policy advocating that state governments be given the freedom to develop and test different models for covering the uninsured, which now number approximately 50 million. Specifically, the AMA HOD adopted policy directing the AMA to pursue: • repeal of the Independent Payment Advisory Board (IPAB); • repeal of the non-physician provider “non-discrimination” provision; • enactment of comprehensive medical liability reform; • enactment of long-term Medicare physician payment reform, including permitting patients to privately contract with physicians not participating in the Medicare program; • enactment of antitrust reform to permit independently practicing physicians to collectively negotiate with health insurance companies; • expansion of the use of health savings accounts as a means to provide health insurance coverage; and • study of the repeal of the Medicare Cost/Quality Index. The AMA HOD also voted to urge third-party payers to include facility fee payments for procedures using more than local anesthesia in accredited office-based surgical facilities. Currently, there are a number of insurers that do not pay a physician the facility fee if a conscious sedation procedure is performed in an office-based, accredited facility, even if they would normally pay that facility fee to a hospital or an ambulatory surgical center. The HOD also discussed the simplification and reimbursement of the “prior authorization” process. The HOD asked the AMA to foster, via regulatory or legislative means, the creation of a mechanism beyond the Resource-Based Relative Value Scale (RBRVS) to allow physicians to receive payment for the professional time and office expense involved in preauthorization. In a different but related resolution, the HOD also passed policy asking the AMA to work toward a requirement that physicians be paid appropriately and promptly for any and all services performed for their patients as required by insurance companies, Medicaid, or Medicare. The AMA was instructed to encourage appropriate payment for physician and staff work and time with prior authorizations and other restrictive formulary processes, as well as simplification of forms and streamlining of procedures to reduce physician and staff workload and time expended. The next meeting of the AMA HOD is scheduled for November 2011 in New Orleans, LA.
Endowment_3Medals
Hal Foster, MD, Endowment Campaign Update – Founding Donors
“I could not be more proud of the significant strides that are being made every day, and the passion and effort put forth to improve the specialty and to promote the best patient care. Your generosity in support of our mission is truly appreciated.” – J. Regan Thomas, MD, AAO-HNS/F President, 2010/11 In October 2009, the AAO-HNS/F Boards of Directors initiated the Hal Foster, MD, Endowment Campaign with a goal of raising $30 million to provide a sustained source of funding for the future. During the 2010 Annual Meeting & OTO EXPO, a 10-year campaign with a $15 million goal (one-half of the total campaign goal) by the conclusion was formally announced. Just one year later, thanks to the generosity of Academy members, the goal is attainable with nearly $6 million already raised in outright cash and planned gifts. But there is still much more to be done. The AAO-HNS/F is grateful to the Founding Donors of the Hal Foster, MD, Endowment Society for their visionary contributions. Sincere appreciation is extended to the newest Founding Donors, Andrew Blitzer, MD, DDS; Stacey L. Ishman, MD, and Jim McCarthy; Rodney P. Lusk, MD, and Constance C. Lusk, RN; Phillip Massengill, MD; Duane J. Taylor, MD, and Nikhil J. Bhatt, MD, and Anjali Bhatt, MD. These members join current Founding Donors in ensuring that the AAO-HNS/F’s vital mission continues to thrive well into the future as the organizations continue to address the challenges facing tomorrow’s specialists. The prestigious status of Hal Foster, MD, Founding Donor will be held by donors whose planned or cash gifts of $50,000 or greater are confirmed by December 31, 2011. As the Foundation moves toward the final phase of welcoming new Founding Donors of the Hal Foster, MD, Endowment Society, this Bulletin article is an invitation for others to become engaged in this historic event. Generous endowment donors will be recognized on a special campaign commemorative display being erected at the AAO-HNSF headquarters in Alexandria, VA. The commemorative display will give Founding Donors the opportunity to share their thoughts about their decision to support the endowment. It will also give members and headquarters visitors a chance to feel the important role the Founding Donors played in shaping tomorrow’s specialty and patient care. Other recognition of Founding Donors includes acknowledgement in donor communications, at events, special annual meeting donor recognition, and by the awarding of special medallions. In addition, Founding Donors of the Hal Foster, MD, Endowment Society will be honored through recognition as Life Members of the Millennium Society. Donors giving through a planned gift will  be recognized also as members of the Legacy Circle. The AAO-HNSF Development staff is pleased to work with members between now and December 31, 2011, to ensure that any individual who would like to become a Founding Donor has the opportunity to do so. To learn more, please contact 1-703-535-3717, email development@entnet.org, or visit www.entnet.org/endowment. If you have already made provisions for the Foundation in your estate and would like to be recognized as a Hal Foster, MD, Endowment Society Founding Donor, please call so the AAO-HNSF may begin to recognize you immediately for your generosity. With Grateful Appreciation to the AAO-HNSF Hal Foster, MD, Endowment Society Founding Donors  Centurions  Ronald B. Kuppersmith, MD, MBA, and Nicole Kuppersmith Stewards  Nikhil J. Bhatt, MD and Anjali Bhatt Neil Bhattacharyya, MD, and Anjini Bhattacharyya, MD Andrew Blitzer, MD, DDS  I. David Bough, Jr., MD  Sujana S. Chandrasekhar, MD, and Krishnan Ramanathan Noel L. Cohen, MD, and Baukje Cohen Lee D. Eisenberg, MD, MPH, and Nancy Eisenberg Barry Jacobs, MD, and MaryLynn Jacobs Jonas T. Johnson, MD, and Janis Johnson David W. Kennedy, MD Thomas B. Logan, MD, and Jo Logan Rodney P. Lusk, MD and Constance C. Lusk, RN Phillip L. Massengill, MD James L. Netterville, MD  David R. Nielsen, MD, and Becky Nielsen Richard M. Rosenfeld, MD, MPH  Harlene Ginsberg and Jerry Schreibstein, MD  Gavin Setzen, MD, and Karen Setzen James A. Stankiewicz, MD  J. Pablo Stolovitzky, MD, and Silvia P. Stolovitzky Sustainers  Kenneth W. Altman, MD, PhD, and Courtney Altman Seilesh Babu, MD, and Abbey Crooks-Babu, MD Raghuvir B. Gelot, MD, and Carolyn Gelot Stacey L. Ishman, MD, and Jim McCarthy Helen F. Krause, MD Michael Seidman, MD, and Lynn Seidman Nancy L. Snyderman, MD Duane J. Taylor, MD Peak Woo, MD As of July 13, 2011
Yaremchuk
Achieving Work-Life Balance
Kathleen Yaremchuk, MD, MSA Women in Otolaryngology Section Henry Ford Hospital, Detroit, MI Scholarly and lay press have discussed work-life balance for many years as a process of seeking equilibrium between the two competing pressures of work and life. Although most of us think we can clearly define work, life may be more of a challenge. The idea that we can balance the two may be even more difficult to actualize if we adopt the definition in Webster’s Dictionary:  “balance” is to “arrange so that one set of elements exactly equals another.” If a physician’s work were limited to an eight-hour shift, much of the literature would be pertinent regarding work-life balance. However, in a surgeon’s world, despite planning for the operating room day that ends at a set time, unplanned and unforeseen events occur that prevent the surgeon’s attendance at that evening’s planned life event, regardless of best intentions. That goes without mentioning a physician’s responsibilities of being on call, clinic patients who turn out to be more complex than originally promised, and possibly a surgical complication that has to be dealt with immediately. “Life” typically refers to demands of the family. But the responsibilities of life have expanded to include involvement in our communities – where we live, work, or worship ­— and the idea of time spent on oneself to replenish core values. The concept of volunteerism has grown far beyond cupcakes for a Halloween party. The idea of separation between the roles of work and personal life was once based on the belief that each side did not influence the other. There was a true physical and temporal separation of the two roles and their innately different functions. With the presence of digital imaging, Wi-Fi access, and smartphone technology, the physician can manage a patient by viewing a CT scan on a cell phone and order the appropriate medical therapy. With the 24/7 society we now enjoy, the clinic visit notes that weren’t dictated during the day can be done at home by giving up a few hours of sleep.  The boundaries between work and home have overlapped to the degree that they are often one and the same. Since the work and life parts of the problem remain difficult to manage, there has been a belief that increased efficiency would lead to success in the “balance” part of the equation. Unimportant or non-urgent tasks were thus attempted to be removed from the schedule. However, friends, neighbors, and colleagues seldom felt they should be in the unimportant category. Time spent sitting in the garden or talking with neighbors usually became a non-urgent task category. In effect, all available waking hours can now be categorized as a work-life activity. The concept of spontaneity has become a task that needs to be scheduled and put on the balance scales to determine if it is a necessary work or life activity. Perhaps work-life balance is similar to that elusive unicorn: Everyone seems to know what it looks like, but no one has actually seen one. For the type A individual, which defines most physicians, there has been an attempt to add activities to each side of the work-life equation without recognizing that there are finite resources with which to accomplish our goals, and despite great advances in technology, there are still only 24 hours in a day. The idea of finding perfect balance between work and life may not exist if every hour of every day is scheduled. Success in work-life balance may depend on scheduling 80 percent of our time and leaving 20 percent free for the unexpected, for spontaneity, and what we cannot plan. Work-life balance requires the flexibility that will allow us to juggle the demands of work and life without dropping the ball on either. It is a worthwhile option to hire someone to do the mundane tasks of running errands, cleaning the house, and doing the laundry to free up time for quality activities. A renewed approach may be to recognize not whether an activity is considered part of work or life, but whether it provides value or satisfaction in the truest sense. Are we glad for having spent the time on the activity, and will it be something that we remember — or will it register as another check on a “to do” list that is soon forgotten? The activities and people that bring joy to our lives are what we will remember and give us dividends far into the future. Focus not on the work-life balance, but on finding moments of joy throughout each day. As John Lennon said, “Life is what happens to you while you’re busy making other plans.”
Cultural Sensitivity and Respecting Muslim Patients’ Needs
By Tamar Abel-Halim Ghanem, MD, PhD Diversity Committee Henry Ford Medical Group Bloomfield Hills, MIAs an immigrant to the United States, what has impressed me most is the sense of democracy and respect for diversity, which is lacking in other places in the world. As a member of the Diversity Committee and as a practicing Muslim, I am priviledged to share my perspective on cultural sensitivity to caring for Muslim patients in medical practice. Cultural sensitivity in caring for the Muslim patient requires a basic understanding of Islam. Islam, which in Arabic, is derived from the word salam, or peace. It is the second largest world religion with 1.57 billion Muslims worldwide. There are approximately seven million Muslims in the United States. Islam is based on five pillars: • believing in Allah, Arabic for God, and Mohamed as his prophet (the last prophet in the lineage of prophets starting from Abraham); • performing five daily prayers; • fasting the holy month of Ramadan; • contributing to charity; • performing the haj or the pilgrimage to Mecca at least once. • Muslims follow both the teachings of the Prophet Mohamed and their holy book, the Quran. These teachings are parallel to the Ten Commandments and in congruence with Judeo-Christian teachings. Encountering and caring for Mulim patients requires knowledge of and respect for cultural observances. For example, Muslim women wear the hijab (head covering) which is worn by females volitionally in most instances and primarily for modesty.  Just like other religions, Muslims vary in their interpretation and practice of their religious beliefs. Some Muslim women will request to be seen by only female practitioners, whereas the majority may be comfortable being treated by male practitioners. I recommend that the office staff or nurse first ask the patient if she is comfortable being seen by a male physician. If so, another way to make the patient more comfortable with a male physician is to include a female chaperone in the room, especially during a physical exam. Some female patients will not shake hands with a male practitioner, and therefore, it is important to ask before offering a handshake, “Do you feel comfortable shaking hands?” This advice also holds true for a female physician with a male Muslim patient. For the head and neck exam, ask if the female patient feels comfortable removing the hijab to facilitate the exam. If not, ask what can be done to make the patient feel comfortable during this part of the exam. The most important aspect is, do not make assumptions about the patient’s beliefs. By inquiring about what makes the patient feel comfortable, sensitivity to the patient’s needs is expressed. Another unique aspect about Muslim patients that the practicing otolaryngologist may encounter is sialadenitis or sialoliths during the month of Ramadan. The Muslim calendar is lunar-based with 12 months. The month of Ramadan is the ninth month of the Muslim calendar, and that month commemorates when the holy Quran was revealed to the Prophet Mohamed. Muslims are supposed to refrain from eating and drinking from dawn to sunset during Ramadan. If someone is sick or has a medical reason for not being able to tolerate fasting, they are permitted to feed instead of fasting. For a Muslim patient with sialadenitis or sialoliths, it would be useful to ask about recent fasting history. Alcohol is strictly forbidden in Islam. Nevertheless, a physician must inquire about alcohol use and other social history especially for a patient with a suspected head or neck malignancy. Even though alcohol is forbidden, it is wrong to assume that all Muslims do not drink. It is also important to be sensitive in asking the question, as patients may not readily admit it with family members around. Smoking is also not encouraged in Islam, yet smoking cigarettes or the hooka is common in Muslim countries. Many mistakenly believe that hooka smoking is safe because the smoke is passed through a water bath, but this form of smoking is just as dangerous, possibly even worse than cigarette smoking. Betel nut (Areca catechu) chewing is common in certain cultures such as Yemen or the Indian subcontinent. Therefore, it’s important to ask about chewing tobacco when discussing substance use history. In an ethnically diverse society such as the United States, many Muslim patients can come from a variety of backgrounds, such as from the Indian subcontinent to those born in the United States. It’s critical to not only understand some of the unique aspects of Islam, but also to avoid assumptions of stereotypes. Like anyone anywhere, Muslims can have varied backgrounds and variable adherence to certain beliefs.
Paul M. Imber, DO Chair-Elect, Board of Governors
The Sun Will Come Out Tomorrow?
The future of healthcare delivery in the United States is capricious, swinging on the thread of public opinion, legislative whim, and financial variances. If politics make for strange bedfellows, healthcare reform is creating the most conspicuous alliances. The resident physicians of today, who will soon enough be the practicing physicians of this brave new world, will have to be adroit in traveling the path of their medical careers. It has been 18 months since the passage of the Patient Protection and Affordable Care Act (ACA1), and the devil in the details are starting to surface. The Independent Payment Advisory Board (IPAB) will probably sit dead in the water as public and medical provider pressure pokes holes in its framework. However, in every hospital boardroom and cafeteria, discussions of Accountable Care Organizations (ACO) abound. The ACO is currently a poorly-defined confederation of hospitals, physicians, and myriad possible providers and diagnostic services, working together to administer payments, measure performance, and distribute the shared savings or losses.2 In western Pennsylvania, the University of Pittsburgh Medical Center (UPMC) began this process over 10 years ago bringing together 20 hospitals with more than 4,200 beds, 5,000 physicians (2,700 of whom are employees) and provided the full range of inpatient, outpatient, and preventative care. It then went the next step and created its own medical insurance company. UPMC Insurance Services now covers 1.4 million membership lives. UPMC had an $8 billion budget in 2010.3 UPMC has tremendous weight in its region, and uses this strength in current contentious negotiations with Highmark Blue Cross Blue Shield.4,5 In June 2011, Highmark BCBS announced plans to purchase West Penn Allegheny Health Systems (WPAHS), a consortium of five hospitals, two nursing schools, and the future home (2013) of the western campus of Temple University Medical School.4,5,6 WPAHS is in direct competition with UPMC. Highmark BCBS serves more than 4.8 million members in western Pennsylvania and West Virginia, and is in the process of acquiring Blue Cross Blue Shield of Delaware (the largest insurer of health benefits in that state). Highmark also serves Medicare beneficiaries in the region, and is one of the largest Blue plans in the country. The hospital/medical school/physician consortium owns the insurance company, and the insurance company owns the hospital/medical school/physician consortium. The battle lines are drawn, and the next few years will probably bring a multitude of lawsuits and sabers rattling. In the end, they will both co-exist in the same region with a few lawyers much wealthier for the experience. However, what about the patients? The common integral factor throughout is the physician—we are the link between the patient and the hospital and ACOs and all the rest of the corporate stakeholders. What do future physicians think of the ACA, of this reform? A recent study reviewed the responses of 1,576 residents, representing a diverse cross-section of primary care and specialty physicians and geographic regions.7 The participants gave their opinions on various aspects of the ACA. In summary, they agreed that Electronic Health Records (EHR) and tort reform would help contain healthcare costs. EHR is currently under attack as technical standards for EHR are being challenged, playing the private sector (software development companies) against government controls in developing technology standards for effective use.8 Unfortunately, the ACA has minimal language related to tort reform, and even then it is fully elective for the plaintiff.1  The residents did not believe that bundling services, hospital-acquired condition penalties, or quality-based reimbursement would improve quality of care.7 This is supported by another study that shows that inefficient care is much more costly than ineffective care in accounting for excessive hospital costs of elective surgical care.8 Currently, the search for pathways to cost containment is driving healthcare reform, not quality patient care. Healthcare is big business, and every player wants its piece of the pie. This is leading to a complex web of various alliances whose only focus is fiscal profiteering. The attempts to create “meaningful use” data collection are, in practicality, collecting data that is neither meaningful nor useful. The future of healthcare delivery is ubiquitous. It is unlikely only one system will prevail; multiple systems will surface, and several will survive. It will be the responsibility of the physician to speak for the patient, ensuring patient care and safety are not sacrificed in the name of cost-containment. The practicing physician of the future will indeed need to be adroit in traversing the complex landscape of a continuously evolving tapestry of healthcare reform. Resources: 1. H.R. 3590 “Patient Protection and Affordable Care Act.”Washington, DC: U.S. House of Representatives. April, 2010. 2. Betbuzi, P. The Physician’s Place in the ACO Health Leaders Media. 3. www.upmc.com/aboutupmc/fast-facts. 4. www.myfoxnepa.com/story/14989788/highmark-an-west-penn-alleghany-health-system-announce-plans-to-pursue-affiliation. 5. www.WTAE.com/print/28381185/detail.html. 6. www.post-gazette.com/pg/11180/1156838-28-0.stm. 7. Frake, P. Resident Physicians’ Perspective on Health Care Reform Otolaryngology-HNS.2011.145.1,p.30-34. 8. Lohr, S. Seeing promise and perils in digital records. New York Times. July 17, 2011. 9. Fry, D. The Impact of Ineffective and Inefficient Care in the Excess Costs of Elective Surgical Procedure. Journal of the American College of Surgeons. 2011, 212: 779-786.
David R. Nielsen, MD, AAO-HNS/F EVP/CEO
Delivering the Best Healthcare
In 1962, U.S. biochemist Albert Szent-Györgyi said: “Discovery consists in seeing what everybody has seen, and thinking what no one has thought.” The entire medical profession, along with other major groups with high stakes in reforming and improving healthcare in the United States (patient and public interest groups; employers; health plans, hospitals, and systems; insurers; federal and state governments; allied health providers; and others) have discussed, debated, argued, proposed, tested, refined, implemented, and re-tested so many different approaches and solutions to the fiscal and quality challenges we face that it seems impossible that there could remain any perspectives that are unexplored. Yet, there is still much expertise, opinion, and experience from which providers and patients could draw that is not yet in the forefront of our minds.  And we, the healthcare providers and patients are, after all, the primary participants in the actual delivery of care. For many years, the Institute of Medicine’s Roundtable on Value & Science-Driven Health Care has been meeting, setting goals, and discussing the achievement of those goals The Roundtable’s “Charter and Vision Statement” describes a goal that “by the year 2020, 90 percent of clinical decisions will be supported by accurate, timely, and up-to-date clinical information and will reflect the best available evidence.” It is important to reassure clinicians that the drive toward better use of the “best available evidence” is not a prescription for “cookbook” medicine. Among the core concepts and principles defining the work of the Roundtable is the goal that decisions by all who shape the healthcare of Americans “will be grounded on a reliable evidence base, will account appropriately for individual variation in patient needs, and will support the generation of new insights on clinical effectiveness.” The National Academy of Sciences (often referred to as The National Academies) is a “private, non-profit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare.” Its authority stems from a charter granted by Congress in 1863 that mandates it advise the federal government on scientific and technical matters. It is composed of three arms, the Institute of Medicine, the National Academy of Engineering, and the National Research Council. In keeping with its charter and mission, two of these institutes, the Institute of Medicine and the National Academy of Engineering, have combined to give us an additional perspective on engineering a more effective healthcare system from experts in systems analysis, design, and implementation. In the summer of 2011, a report on this paper titled, “Engineering a Learning Healthcare System: A Look at the Future” was published and distributed widely to a broad range of interested parties. The addition of the technical and systems engineering perspective broadens our options and understanding of the challenges before us, reinforces many principles, and suggests additional concepts that may be critical as healthcare delivery adapts over the coming years. The application of scientific engineering principles to healthcare delivery systems is addressed in a section of the report, “Engaging Complex Systems through Engineering Concepts.” The questions of affordability of innovative technology and its role, designing integration into an adaptive system, and applying science and best practices to the operational management of healthcare are addressed. Other sections focus on learning and teaching opportunities for healthcare, learning by example from engineering, and the challenges to be overcome in initiating systems changes. The incredible complexities of any solution for healthcare delivery are addressed, and case studies in transformation through systems engineering are described. Common themes and key principles in the report include (among others) the following: • The system’s processes must be centered on the right target – the patient. • System excellence is created by the reliable delivery of established best practice. • Complexity compels reasoned allowance for tailored adjustments. • Emphasize interdependence. • Teamwork and cross-checks trump command and control. • Performance, transparency, and feedback serve as the engine for improvement. • Expect errors in the performance of individuals, but perfection in the performance of systems. • Align rewards on the key elements of continuous improvement. There are more! Please read them. These discussions published in this report are worthy of the perusal and study of every physician. Adding this additional perspective to the wisdom, experience, and basic desire of every practicing physician to provide the best care for his or her patients will strengthen and accelerate our efforts to provide better care for every person who entrusts us with their health. I urge you to make the best of all the resources at your disposal to improve the care you give and the systems in which you work.
J. Regan Thomas, MD AAO-HNS/F President
Looking Back, Looking Forward
As I reviewed the program for the 2011 AAO-HNSF Annual Meeting & OTO EXPO, I observed that the attendees and the activities that take place are the perfect representation of the Academy’s constituency, successes, and ongoing efforts across the board. That’s the way it should be. This meeting should not take you out of your element; it enhances it and give you the tools and relationships you need to take the best of what we have to offer and bring it into your everyday work. Our Global Outreach Last year when I gave my address as incoming President, I talked about how critical it is to continue to grow our global community – not only as a way to reach out to other countries, but also as a way to make inroads enabling other countries to reach out to us. One significant development in that area is that we’ve gone from having a single international coordinator to creating a Steering Committee of 11 Regional Advisors. These advisors serve as touch points between the U.S. and more than eight geographical regions across the globe. Our global constituency is evident in the numbers: Out of more than 11,000 members, 1,000 hail from outside the United States. We currently boast 48 international corresponding societies. These societies are our channel to communicate with our counterparts all over the world. It also enables them to communicate with each other. Thus, each of you has worldwide access to techniques, education, and relationships. The international influence has been reflected in our programming this year. Twenty-three percent of our international members are from Latin America, and 8,000 attendees from Latin America have attended the meeting in the last 12 years. This year, we have developed our inaugural Spanish language orientation for first-time attendees, with printed materials in Spanish. That’s just the beginning. Joint Meetings and National Congresses are being held in countries around the world, including Turkey, the Caribbean, Mexico, Colombia, Honduras, and Egypt. In response to this global activity, we are again holding the African Caucus that was so successful last year, and we are introducing our first Middle Eastern caucus, bringing delegates from Israel and Arabian countries together. Last year, we introduced the Global Health Symposium. That programming was so successful that we are expanding on it. This is a truly international organization in every sense of the word. The Academy itself is developing as an invaluable mechanism for the cultivation of personal and professional friendships that will facilitate a powerful and respectful exchange of information all year through. WIO The power of AAO-HNS/F sections has been brilliantly demonstrated by Women in Otolaryngology (WIO). Last year, I stressed how crucial it is for the Academy and for members to recognize and support Women in Otolaryngology. The WIO has grown from a committee to a section, earning it a general assembly with unlimited membership and a dedicated governance structure. This change also earns WIO a seat on the Board, and a powerful voice within this organization. We are already seeing the ripple effect of WIO throughout the organization. If you refer to the June 2011 issue of the Bulletin, you will see that out of 20 candidates for Leadership, nine of them were women. Like WIO, the influence of our societies and committees reaches into every area of this organization, including Humanitarianism. In fact, at the San Francisco meeting, we presented a panel dedicated to looking at the American female otolaryngologist as an instrument of international humanitarian outreach, and also at the international woman as a target of humanitarian outreach. It is the enhanced and strategic architecture of the Academy that is making it possible for  initiatives such as the Regional Advisors, WIO, and Humanitarianism to increase to the level they have in our organization and at this meeting. Our Voice in Government Too, our government affairs team has been busier than ever. More of our members are taking an active role in the legislative and political process, but there is much more that can be done. Your time and energy have never been in as great demand as they are now, as the remainder of 2011 promises to be an extremely busy time on Capitol Hill. The outcomes of the decisions being made are going to have a significant effect on your lives as medical professionals. The first step is educate yourself on the key issues of your state as well as federal legislative priorities, and understand how they affect you and your patients. I’d like to direct you to the advocacy website (www.entnet.org/advocacy) where you can view summaries of our priorities and become familiar with our advocacy programs. Our Future The next step is to make a commitment to act. We are making it easier for you to add your voice and expertise to the powerful presence we are cultivating. You don’t have to go to Washington to make a difference. When you join the ENT Advocacy Network, you will receive: a subscription to The ENT Advocate, a bi-monthly legislative e-newsletter; email alerts on federal and state legislative issues affecting the specialty; and advocacy “Calls to Action” with easy instructions on contacting your legislators. Finally, as I leave this office, I ask you to help us educate our policy makers so they can make informed and responsible decisions. Become part of the ENT Advocacy Network. Membership is free, but your presence is priceless.
Fine Needle Aspiration: Information for Patients
Note: this information, from the Academy website, is appropriate to share with your patientsFine needle aspiration (FNA) is a technique that allows a biopsy of various bumps and lumps. It allows an otolaryngologist to retrieve enough tissue for microscopic analysis and thus make an accurate diagnosis of a number of problems, such as inflammation or even cancer. FNA is used for diagnosis in: • Neck lymph nodes • Neck cysts • Parotid gland • Thyroid gland • Inside the mouth • Any lump that can be felt Why is FNA important? A mass or lump sometimes indicates a serious problem, such as a growth or cancer*. While this is not always the case, the presence of a mass may require FNA for diagnosis. The patient’s age, sex, and habits, such as smoking and drinking, are also important factors that help diagnosis of a mass. Symptoms of ear pain, increased difficulty swallowing, weight loss, or a history of familial thyroid disorder or of previous skin cancer (squamous cell carcinoma) may be important as well. *When found early, most cancers in the head and neck can be cured with relatively little difficulty. Cure rates for these cancers are greatly improved if people seek medical advice as soon as possible. What are some areas that can be biopsied in this fashion? FNA is generally used for diagnosis in areas such as the neck lymph nodes or for cysts in the neck. The parotid gland (the mumps gland), thyroid gland, and other areas inside the mouth or throat can be aspirated as well. Virtually any lump or bump that can be felt (palpated) can be biopsied using the FNA technique. How is FNA done? The doctor will insert a small needle into the mass. Negative pressure is created in the syringe, and as a result of this pressure difference between the syringe and the mass, cellular material can be drawn into the syringe. The needle is moved in a to-and-fro fashion, obtaining enough material to make a diagnosis. This procedure is generally accurate and frequently prevents the patient from having an open, surgical biopsy, which is more painful and costly. The procedure generally does not require anesthesia. It is about as painful as drawing blood from the arm for laboratory testing (venipuncture). In fact, the needle used for FNA is smaller than that used for venipuncture. Although not painless, any discomfort associated with FNA is usually minimal. What are the complications of the FNA procedure? No medical procedure is without risks. Due to the small size of the needle, the chance of spreading a cancer or finding cancer in the needle path is very small. Other complications are rare; the most common is bleeding. If bleeding occurs at all, it is generally seen as a small bruise. Patients who take aspirin, Advil®, or blood thinners, such as Coumadin®, are more at risk to bleed. However, the risk is minimal. Infection is rarely seen.
ThyCa executive director Gary Bloom says the organization is using social media to spread its message to patients and doctors alike.
Thyroid Cancer, Social Media, and Medicine — A Good Marriage
Social media is a tool that offers connections, collaboration, and an expansion of learning capabilities to the doctors, health professionals, and patients who choose to make use of it. For every specialty and survivor group out there, the chances are good that at least one blog or chat board exists to discuss the latest findings, debate current best practices and explore the fringe of what is possible. And for those particular diseases and medical topics that haven’t yet found their way to the web, it is a good bet that day is fast approaching. According to data from the Pew Research Center, the Washington, DC-based nonpartisan “fact tank” that provides information on issues, attitudes, and trends shaping America, 66 percent of Internet users look online for information about a specific disease or medical problem each year. Also, 55 percent of Internet users go online to find information on medical treatments and procedures. This is up from 47 percent in 2002. Although people continue to flock to the web for medical reasons in greater numbers every year, Pew also states that the Internet still only plays a supplemental role: “E-patients are likely to dip into social media activities related to health, but posting comments, reviews, or other health content are not yet mainstream online activities.” Regardless of its not-quite-prime-time status, social networking still allows people — specifically physicians and the patients they treat — an opportunity to engage their chosen community and connect with their colleagues. According to Spencer C. Payne, MD, assistant professor in the division of Rhinology & Sinus Surgery in the department of Otolaryngology—Head & Neck Surgery at the University of Virginia Health System, two of the more popular social media outlets — Facebook and Twitter — are a real boon to his department and allow him to cast a wider net when passing on information he finds noteworthy. “We can do a lot with our Facebook site,” Dr. Payne said. “Everything autolinks to our Twitter account, so all of our posts also appear on our Twitter feed. We post what our various members are doing, where they are giving lectures, and who is doing what types of surgery, as well as linking interesting articles that come across our computer screens. “I can link an article I find interesting to the Facebook site and target that information to patients that need to see it,” he said. “Social media is not only a way to communicate and publicize what your department or practice is doing, but considering how Google and other media outlets spider off of each other, it gives you more of a presence.” Patient perspective Social media also allows patients the ability to talk to one another, as well as the ability to dispel false information. Gary Bloom, executive director of the Thyroid Cancer Survivors’ Association, Inc. (ThyCa) (http://www.thyca.org/sept-ember.htm), said his organization has reaped huge benefits through the use of the social media. The Academy is currently teaming up with ThyCa to raise thyroid cancer awareness. “We originally developed out of a web-based bunch that met through a Yahoo! chat board and got to communicating by email and phone,” he said. “And as we have grown, just like the web, we have evolved.” ThyCa is a national nonprofit 501(c)(3) organization of thyroid cancer survivors, family members, and health care professionals dedicated to education, communication, support services, awareness for early detection, and thyroid cancer research fundraising and research grants. Bloom, a 16-year thyroid cancer survivor, explained that while ThyCa makes use of Facebook, Twitter, and Inspire to distribute its message to members, i­t also uses the tools to spread its message beyond the existing “fan base” to patients and doctors alike. “Every month, we do an e-newsletter, sending it out to our entire mailing list, as well as through the social media channels,” he said. “This ‘splintering’ effect creates more work for us because of all the distribution points, but that is not a complaint, it is simply the way of the world on the web. The analogy is that the Internet allows you onto the information superhighway, then you work down to the major artery roads and now I think we are down into the neighborhoods, which is where we need to be.” One of the “neighborhoods” Bloom said his organization has set up shop in is with physicians. He said that the discussions on the ThyCa site, like any other online forum, can go off the rails into pseudo-science from time to time. When this happens, moderators flag the issue and send it to him. From there, he gets in touch with a physician to get an evidence-based, best-practice answer. “We are diligent about identifying any problem issues and getting the answers,” he said. “If something is posted that a moderator thinks is too fringe or just plain wrong, they pass it on to me and I go out and get help. It is a delicate balance, but it is necessary. “We get physicians to answer these questions without burdening them with having to answer 100 questions a day,” he said. “By using me as a filter, the physicians we rely on are shielded from any of the unpleasantness that one might associate with an online medical forum.” Bloom said he is interested in involving physicians more in the everyday workings of the ThyCa site, possibly starting a monthly blog or Q&A, but he is going to investigate the options with the utmost amount of caution. “The last thing I would ever want to do is chew up a doctor’s time when he or she could be out saving lives or resting up,” he said. “When you’re off, you want to be off. I mean, I’ve always thought being a doctor must be an amazing job because you’re helping to save peoples lives, but do you love your job every day? “The point is there is every reason to believe that a doctor can hate his or her job every once in a while just like the rest of us,” he said. “Maybe Dr. Smith is getting audited today and she just doesn’t have the time to be on call 24/7 for people on our site to ask 1,000 questions. That just isn’t realistic.” Dr. Payne, who is also a member of the AAO-HNS Medical Informatics Committee, agreed with the sentiment, saying that while blogs often become another version of e-medicine, social media allows for a clearer message. “Social media lets you interact more personally with patients,” he said. “I think the downside of blogs is that, many times, patients are in desperate need of help, and come to those sites looking for a miracle cure. “Physicians need to be cautious, because as useful a tool as blogs can be, you can get trapped in bad situation, giving advice to a patient you’ve never even laid eyes on. You have to establish a distance between yourself and patients you’ve never met or seen.” Dr. Payne said that in today’s instant gratification society, email and social media can allow doctors to respond in an organized fashion on a timetable that works for them and allows better-quality follow-up. “The response we’ve seen here, and particularly the response I’ve seen from my patients, has been great,” he said. “Not only are you providing information and getting good communication, but when you put good information out there for your particular set of patients to read, you are building a relationship prior to them coming into the clinic.” Possibilities Bloom said he likes the idea of setting up an offshoot Facebook or Inspire ThyCa page just for physicians who want to discuss thyroid cancer issues. “It would be great to have a forum where a physician like Dr. Lisa Orloff wouldn’t be out there, exposed on our Facebook page, but would instead be able to come in and make submissions that other physicians could discuss without getting tapped by patients,” he said. “From there, if she wanted to publish a Marcus Welby-type blog about something on our forum, we could make sure no one could connect back to her personal site. “It would be great to get a physician’s take on novel treatments like robotic thyroidectomy through the arm and see what other physicians think about it before we published for the wider audience. It is a good idea, but we will just have to see what possibilities the future holds.” Bloom said he hopes he can strengthen the bond between physicians in the Academy and ThyCa, because it can only help patients out there looking for good answers to tough questions. He said he aspires to the getting a “Good Housekeeping seal” for the site, serving as a counterpoint to refute the bad information floating around out there. Using social media, he hopes to attract more hands-on physician participation on his site. “The nice thing with social media is that it allows physicians to contribute in line with their weird schedules,” he said. “If you’re up in the middle of the night doing dictation, and it strikes you that a particular treatment is good or bad, and you want to log on and say something about it, that’s an option. “That stimulates new discussion points, creates clarity and gets rid of confusion, which is the whole point of our site in the first place. With buy-in from the doctors, we might really have something there.” ThyCa Links Fine needle aspiration biopsy http://www.entnet.org/HealthInformation/fineNeedleAspiration.cfm ThyCa-Inspire Online Support Community: http://www.inspire.com/groups/thyca-thyroid-cancer-survivors-association/ Facebook Community:  http://www.facebook.com/pages/THYCA/231492537404?ref=mf Twitter Community:  http://twitter.com/#!/ThyCaInc e-mail Support Groups:  http://www.thyca.org/email.htm
AAO-HNSF, AHNS Sponsor Thyroid Cancer Research
Paul M. Weinberger, MD Medical College of GeorgiaThe incidence of thyroid cancer is increasing at an alarming rate, with an estimated 48,000 new thyroid cancer diagnoses expected in 2011. Although most thyroid cancers are found during evaluation of a thyroid nodule, only 5 percent of thyroid nodules are malignant. Currently, most thyroid nodules are evaluated by histological analysis of fine needle aspirates (FNA). Depending on collection technique, up to 20 percent of FNAs can be inconclusive; most such patients will undergo surgical resection of part of the thyroid. Three-fourths of these cases then prove benign on final histological examination, but the patient had to undergo a surgical procedure to make that determination. Biomarkers that could discriminate between benign and malignant are therefore desperately needed to help in the management of patients with nodular thyroid disease. In 2011, the AAO-HNSF and the American Head and Neck Society (AHNS) co-sponsored a Young Investigator Grant for $40,000.  The grant was awarded through the Centralized Otolaryngology Research Efforts (CORE) grant program and awarded to Paul M. Weinberger, MD, at Georgia Health Sciences University in Augusta, GA, for his project titled “Minimally Invasive Multiplexed Assays for the Detection of Thyroid Cancer.” Much research has already been done in this area. So far, an adequate biomarker-based test has not been identified. It has been proposed that a panel of biomarkers may instead represent the best approach. Dr. Weinberger’s preliminary data show real promise for a combination of two biomarkers Galectin-3 and HBME-1. He will apply two proteomics techniques multiple reaction monitoring (MRM) and Luminex, for the detection of these biomarkers in complex biological fluids. Preliminary studies have shown that MRM has exquisite sensitivity, detecting as little as 100 attomoles of Galectin-3 in a patient sample (similar in scale to detecting a single grain of salt dissolved in a swimming pool). Using this novel approach, Dr. Weinberger and his team hypothesize that detection of these biomarkers by MRM or Luminex will allow minimally invasive detection of Papillary Thyroid Carcinoma from thyroid FNA needle washings and serum. By the end of the study, they hope to have an assay ready for testing in the clinical setting, able to distinguish the 95 percent non-cancerous thyroid nodules from the 5 percent that actually harbor thyroid cancer. This will hopefully translate in the long run into fewer surgeries performed for diagnosis, and improved patient outcomes.
thyroidcheck
Thyroid Cancer Awareness Month
Lisa A. Orloff, MD Chair, Endocrine Surgery Committee Professor, Head & Neck Surgery  Robert K. Werbe Distinguished Professor in Head and Neck Cancer  Chief, Division of Head & Neck & Endocrine Surgery  University of California, San Francisco  September is Thyroid Cancer Awareness Month, and the AAO-HNS would like to encourage all of its members and affiliates to participate in this event. Because otolaryngologist—head and neck surgeons are concerned for, and pre-eminently qualified in the management and treatment of disorders and diseases of the thyroid, this collaboration is intended to enhance early detection, care based on expert standards and guidelines, and research to achieve cures for all types of thyroid cancer. Thyroid cancer is one of the few cancers continuing to increase in incidence, with a record high of more than 48,000 people newly diagnosed in the United States last year and more than 200,000 people newly diagnosed worldwide. It is also a cancer that affects people of all ages, from young children to seniors. When detected early, most thyroid cancers are treatable. However, some thyroid cancers are aggressive and difficult to treat. These are some of the many reasons why the AAO-HNS is teaming up with ThyCa: Thyroid Cancer Survivors’ Association, Inc., to raise thyroid cancer awareness. Thyroid Cancer Awareness Month is a worldwide observance, sponsored and initiated by ThyCa: Thyroid Cancer Survivors’ Association, Inc. (http://www.thyca.org/september.htm). It began in 2000 as Thyroid Awareness Week, and in 2003 expanded to the entire month of September. People and organizations in at least 55 countries now take part. Thyroid Cancer Awareness Month is listed in official health events calendars and directories, including the American Hospital Association’s Calendar of Health Observances & Recognition Days. ThyCa is a national nonprofit 501(c)(3) organization of thyroid cancer survivors, family members, and healthcare professionals dedicated to education, communication, support services, awareness for early detection, and thyroid cancer research fundraising and research grants. In addition to sponsoring Thyroid Cancer Awareness Month each September, ThyCa also sponsors free seminars, workshops, the annual International Thyroid Cancer Survivors’ Conference, plus other year-round awareness campaigns, and provides free educational materials upon request.As partners, participating otolaryngologists are asked to help promote Thyroid Cancer Awareness Month, and to acknowledge ThyCa (www.thyca.org). Individual organizations will be recognized in ThyCa’s newsletters and on ThyCa’s website. Information about participants’ organizations will also be included at the next annual International Thyroid Cancer Survivors’ Conference, both on the resource tables and in the program booklet given to all attendees. Large or small, local events are also a great opportunity to raise awareness of thyroid cancer and acknowledge the contributions of everyone involved. Partnering otolaryngologists and organizations are encouraged to let ThyCa know the details of any hosted event in order to receive recognition, benefit from promotion, and offer guidance to others who may wish to develop a similar event. In addition to Thyroid Cancer Awareness Month, the AAO-HNS continues to do its part to raise awareness and expertise in the care of thyroid cancer and thyroid disorders through resources that include: • Online fact sheets such as: • Thyroid disorders and surgery http://www.entnet.org/HealthInformation/Thyroid-Disorders.cfm • Pediatric thyroid cancer http://www.entnet.org/HealthInformation/Pediatric-Thyroid-Cancer.cfm • Fine needle aspiration biopsy http://www.entnet.org/HealthInformation/fineNeedleAspiration.cfm • Numerous miniseminars and instruction courses during the 2011 Annual Meeting & OTO EXPO September 11-14, 2011, in San Francisco. www.entnet.org/annual_meeting • Ongoing activities of the Endocrine Surgery Committee of the AAO-HNS, including: • Public education campaigns about radiation exposure and health risks • Professional campaigns emphasizing the importance of baseline laryngoscopy in the evaluation of patients with thyroid disorders, as well as postoperative laryngoscopy in patients who undergo thyroid surgerydo • Thyroid cancer research collaborations, database development, and outcomes studies • Participation in humanitarian missions involving thyroid surgery in underserved parts of the world • Organization and management, under the guidance of course director Robert Sofferman, MD, of the ACS Ultrasound Course: Thyroid and Parathyroid Ultrasound Skills-Oriented Course (Saturday, 8:00 am–4:00 pm, September 10, 2011, San Francisco.) • Review and endorsement of thyroid-related practice guidelines, most recently including the 2011 American Thyroid Association practice recommendations “Radiation Safety in the Treatment of Patients with Thyroid Diseases by Radioiodine (131I)” http://www.thyca.org/ataradiation.pdf The AAO-HNS and ThyCa invite everyone interested to help with thyroid cancer awareness efforts in their communities. For free materials from ThyCa and tips on how to raise awareness, as well as more information about thyroid cancer, e-mail outreach@thyca.org, call toll free 1-877-588-7904, fax to 1-630-604-6078, write to PO Box 1545, New York, NY 10159-1545, or visit www.thyca.org.