Published: October 25, 2013

EMR: Revolutionizing PSQI

Rahul K. Shah, MD George Washington University School of Medicine Children’s National Medical Center Washington, DC I recently spent two days at the world headquarters of one of the largest electronic medical record (EMR) vendors. I left impressed by the role that EMR is playing regarding patient safety and quality improvement (PSQI) and the potential for such in the near future. EMR has taken on somewhat of a negative reputation in surgical circles, as many of us fear the loss of efficiency with its implementation. However, in the last couple of years, there have been huge iterative improvements in EMRs, to the extent that the design and platforms for them have become much more user-friendly. During my visit, I discovered the potential for PSQI with EMRs is exciting and the capacity to provide clinical decision support is amazing. It was unbelievable to see the algorithms actually present. The vendor I visited has created and is live with a sepsis pathway whereby, if a patient has specific parameters vis-á-vis lab findings, physical examination variables, etc., the clinician is prompted to consider a sepsis pathway. Throughout the patient’s hospital course, suggestions and prompts guiding and promoting the most current treatments, interventions, and medications are provided. We all are aware of the exponential increase in medical knowledge over the past few decades. Fortunately, EMRs have simultaneously developed to help us in this cognitive overload by having embedded clinical decision support in electronic health record (EHR) systems. This powerful combination may be able to synthesize vast amounts of information and focus on the minutiae so that the clinician can focus on the patient as a whole. I am convinced the future of PSQI must involve EMRs. As I witnessed, EMRs have embedded clinical decision support algorithms that undoubtedly are going to improve patient care. The most basic example of such is catching a potential drug-drug interaction and alerting the clinician prior to the patient receiving the medication. Or, if a patient’s lab values are not safe to metabolize a specific medication, the EMR would be able to prevent the ordering of the medication of concern. More sophisticated decision support algorithms will be developed. With data aggregation, the potential for EMR to affect health outcomes on a macro-scale is limitless; imagine that an intervention can be measured with a sample size in the tens of thousands. In such a scenario, randomized trials can be performed quickly and patients will be provided with the superior intervention in much more rapid fashion than the status quo. With these advances, another technology–data registries–will soon be mandatory. It will be imperative for physicians to maintain or participate in some type of data registry, not only for patient care mandates, but also to meet requirements for maintenance of certification. Currently, there are few, if any,  systems, to my knowledge, that have EMRs and data registries linked. In many instances, this requires an interface to be built between the two systems, an expensive and not always successful solution. Privacy requirements also need to be maintained. However, the potential seamless transition of data from EMRs to data registries would certainly provide a means to improve care. The surgical community has expressed concern that EMR will halt the efficiency of their practices. However, given patient demand and financial incentives for deployment, the reality is that EMR will become part of our practices in the near short-term. We must consider fundamental changes to our practice paradigms or be forced to implement EMR in our existing paradigm, which most certainly will be a much more difficult undertaking. Whatever the manner in which we embrace EMRs, the reality is that even with the existing platforms, the quality of patient care will certainly be augmented and our patients will be safer. The caveat is that the clinician must be an astute user of EMR, or one’s efficiency will plummet and the safety of his or her patients will be in jeopardy. We encourage members to write to 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.

psqiRahul K. Shah, MD
George Washington University School of Medicine
Children’s National Medical Center
Washington, DC

I recently spent two days at the world headquarters of one of the largest electronic medical record (EMR) vendors. I left impressed by the role that EMR is playing regarding patient safety and quality improvement (PSQI) and the potential for such in the near future.

EMR has taken on somewhat of a negative reputation in surgical circles, as many of us fear the loss of efficiency with its implementation. However, in the last couple of years, there have been huge iterative improvements in EMRs, to the extent that the design and platforms for them have become much more user-friendly.

During my visit, I discovered the potential for PSQI with EMRs is exciting and the capacity to provide clinical decision support is amazing. It was unbelievable to see the algorithms actually present. The vendor I visited has created and is live with a sepsis pathway whereby, if a patient has specific parameters vis-á-vis lab findings, physical examination variables, etc., the clinician is prompted to consider a sepsis pathway. Throughout the patient’s hospital course, suggestions and prompts guiding and promoting the most current treatments, interventions, and medications are provided.

We all are aware of the exponential increase in medical knowledge over the past few decades. Fortunately, EMRs have simultaneously developed to help us in this cognitive overload by having embedded clinical decision support in electronic health record (EHR) systems. This powerful combination may be able to synthesize vast amounts of information and focus on the minutiae so that the clinician can focus on the patient as a whole.

I am convinced the future of PSQI must involve EMRs. As I witnessed, EMRs have embedded clinical decision support algorithms that undoubtedly are going to improve patient care. The most basic example of such is catching a potential drug-drug interaction and alerting the clinician prior to the patient receiving the medication. Or, if a patient’s lab values are not safe to metabolize a specific medication, the EMR would be able to prevent the ordering of the medication of concern.

More sophisticated decision support algorithms will be developed. With data aggregation, the potential for EMR to affect health outcomes on a macro-scale is limitless; imagine that an intervention can be measured with a sample size in the tens of thousands. In such a scenario, randomized trials can be performed quickly and patients will be provided with the superior intervention in much more rapid fashion than the status quo.

With these advances, another technology–data registries–will soon be mandatory. It will be imperative for physicians to maintain or participate in some type of data registry, not only for patient care mandates, but also to meet requirements for maintenance of certification. Currently, there are few, if any,  systems, to my knowledge, that have EMRs and data registries linked. In many instances, this requires an interface to be built between the two systems, an expensive and not always successful solution. Privacy requirements also need to be maintained. However, the potential seamless transition of data from EMRs to data registries would certainly provide a means to improve care.

The surgical community has expressed concern that EMR will halt the efficiency of their practices. However, given patient demand and financial incentives for deployment, the reality is that EMR will become part of our practices in the near short-term. We must consider fundamental changes to our practice paradigms or be forced to implement EMR in our existing paradigm, which most certainly will be a much more difficult undertaking. Whatever the manner in which we embrace EMRs, the reality is that even with the existing platforms, the quality of patient care will certainly be augmented and our patients will be safer. The caveat is that the clinician must be an astute user of EMR, or one’s efficiency will plummet and the safety of his or her patients will be in jeopardy.

We encourage members to write to 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.

More from January 2011 - Vol. 30 No. 01
Private Payer Advocacy: United Healthcare Guideline Rhinoplasty, Septoplasty, Turbinate Resection
Michael Setzen, MD, Richard W. Waguespack, MD, and Udo Kaja  In August 2010, the Academy’s Health Policy (HP) department learned from members and the American Rhinologic Society (ARS) that United Healthcare (UHC) had released a problematic guideline draft for Rhinoplasty, Septoplasty, Turbinate Resection (http://tinyurl.com/2g6v26v) that did not align with current medical practice and evidence. The guideline’s purpose was to provide UHC subscribers and providers with conditions of coverage for reconstructive septoplasty and turbinate resection. Currently, the insurer does not cover these procedures for cosmetic indications. Our response to the policy was a joint effort of coordination and collaboration among a number of stakeholders. The Academy’s Health Policy (HP) staff disseminated the policy draft to the Rhinology and Paranasal Sinus (RPS), Plastic & Reconstructive Surgery (PRS) committees and the Physician Payment Policy (3P) workgroup for comment. The committees systematically reviewed this policy and 3P provided strategic oversight and recommendations for our final response to UHC. Our major concerns in the initial guideline draft included: A requirement for a formal, signed computed tomography (CT) scan, which UHC would use to determine whether the rhinoplasty, septoplasty or turbinate resection was performed for reconstructive or cosmetic purposes. Trial of medical treatment including decongestants for septal deviation. Before the Academy drafted a response to UHC, staff from the California Medical Association (CMA) and Lionel M. Nelson, MD, (an Academy member in California) contacted the medical director of UHC in California to address the CT scan requirement. As a result, the insurer removed this condition if the physician or patient declined the CT scan. As soon as the updated policy was released, the HP staff disseminated it to the RPS, PRS, and 3P to determine if there were still requirements that did not align with current medical practice or were unsupported by published guidelines. Based on their review and comments, staff drafted a response to UHC requesting removal of the two-year requirement for office notes. Staff also asked for clarification defining criteria for moderate to severe septal deviations; broadening the definition of reconstructive surgery to reflect evidence-based medicine; and allowing the physician to determine whether a patient needs a diagnostic trial of decongestive therapy, rather than requiring this for all septoplasty and rhinoplasty cases. You may view a copy of the letter we sent to UHC (http://tinyurl.com/2df3aga). We made the effort collaborative because we realize the strength and effectiveness of alliances. We also obtained feedback and input from the ARS, the American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS), the American Society of Plastic Surgeons (ASPS), and the American Society of Aesthetic Plastic Surgery (ASAPS). These societies collaborated in creating and signing the final letter, which was sent to UHC on September 22, 2010. In the future, we will use this strategy when national coverage issues arise, whether of an intra- or inter-specialty nature. In August, 3P members Bradley F. Marple, MD, Richard W. Waguespack, MD, and HP staff joined a conference call with Aetna’s medical directors and physician liaisons and successfully overturned Aetna’s previous coverage position. That position allowed bundling CPT code 30930 (Fracture nasal inferior turbinate(s), therapeutic) when it was performed on the same date of service as CPT code 30520 (Septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement with graft). Before the implementation date of the policy (December 1, 2010), we followed up with UHC to find out whether they had made any changes based on our recommendations. Due to our advocacy, UHC removed the two-year requirement for office notes in lieu of CT scans, limited the photograph requirements for nasal deformity to only one, and modified the requirement for the CT report for nasal deformities. While we appreciate these changes, we are disappointed that UHC has not completed review of the other recommendations we made in our letter. We plan to have a conference call with Richard A. Justman, MD, the National Medical Director of UHC this month to follow up on the other outstanding issues and will update members as soon as we hear more from UHC. This case highlights how Academy members can make a difference and be their own advocates. It also shows the importance of alerting your state societies of any coverage issues you come across. As you work to resolve your local coverage issues, please refer to the resources available on the website, including a step-by-step list: Determine whether the insurer denied the claim because of billing errors. (Contact the Academy’s coding hotline at 1-800-584-7773. This is a FREE service for members. You may also visit the Academy’s website [http://www.entnet.org/conferencesandevents/codingworkshops.cfm] to obtain information on Karen Zupko coding workshops and webinars held by the Coding Institute under our Business of Medicine program). Determine whether you submitted the appropriate supporting medical documentation. After you have determined there was no billing or documentation error, please appeal the denial, using the Academy’s resources (http://www.entnet.org/Practice/Private-Payer-Resources.cfm). Report the issue to your state medical or otolaryngology society if you determine the issue is state-wide. If you determine that the coverage issue is nation-wide, contact Udo Kaja, program manager for private payer advocacy at 1-703-535-3727. The Academy is able to respond to payers as they draft coverage guidelines contrary to Academy guidelines and Position Statements. To learn more about the Academy’s latest private payer advocacy efforts, see the weekly The News, our website (http://www.entnet.org/Practice/News-and-Updates-from-Private-Payers.cfm), or contact Healthpolicy@entnet.org.
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2011 OIG Work Plan: Things You Should Know
In an effort to promote efficiency and eliminate waste, fraud, and abuse, the Office of Inspector General (OIG) takes a look at Medicare and Medicaid programs every year. In doing so, it provides an annual work plan stipulating areas of these programs that require monitoring and investigation by components of the OIG (Office of Audit Services, Office of Evaluation and Inspections, Office of Investigations, and Office of Counsel to the Inspector General). During the fiscal year, these offices typically audit and review Medicare Part A and B claims to determine whether providers billed appropriately for services they furnished. They also ensure that Medicare contractors and/or Medicaid programs correctly paid for these services. The OIG releases the details of its findings in reports that show the methodology for determining payment or billing errors and recommendations to the CMS to recoup erroneous payments. Also, the Medicare Recovery Audit Contractors monitor the improper payment trends identified by the OIG to use as they select new issues to audit in Medicare Parts A and B claims. AAO-HNS staff reviewed the 2011 work plan and identified key areas of focus for otolaryngologist—head and neck surgeons. The OIG will review: Medicare excessive payments to find out if they are appropriate and how effective the claims processing system edits are in identifying incorrect high payments. Medicare payments for Part B imaging services to find out whether these payments appropriately represent the practice expense components and whether the current equipment utilization rates accurately reflect current industry practices. (For 2011, the utilization assumption rate for expensive [priced over $1 million] advanced imaging equipment is 75 percent.) Medicare Part B paid claims and medical records for interpretations and reports of diagnostic radiology services (X-rays, CTs, and MRIs) performed in emergency hospital settings to determine whether the payments were appropriate. Medicare payments for observation services provided during outpatient visits in hospitals and whether hospitals’ use of observation services affects the care that Medicare beneficiaries receive and their ability to pay for out-of-pocket expenses. Medicare Part B claims to determine whether physicians appropriately reported the correct place of service codes (Medicare pays a higher amount when a service is performed in a non-facility setting [ambulatory surgical center or physician’s office] compared to when it is performed in a facility setting [in-patient hospital]). The appropriateness of the process for setting ambulatory surgical center (ASC) reimbursement rates under the revised ASC payment system. Evaluation and Management (E&M) Services to determine whether coding patterns vary by provider characteristics. How E&M services are incorrectly paid and the consistency of medical reviews for paid E&M claims. The E&M claims of providers who have identical documentation across all of their performed services to determine any electronic health record documentation practices associated with potential improper payments. Industry practices related to the number of E&M services provided by physicians and paid as part of the global surgery fee to verify whether these practices have changed since the global surgery fee concept was created. Whether Medicare appropriately paid for sleep studies, examine the factors contributing to the surge in billing, and evaluate provider compliance with the Federal requirements for sleep studies. The appropriateness of Medicare reimbursement for sleep test procedures performed in sleep disorder clinics. Medicare payments for high-cost diagnostic tests to determine whether they were medically necessary. The extent to which providers comply with assignment rules (for participating and non-participating providers) and determine whether providers are inappropriately balance-billing Medicare beneficiaries in excess of the Medicare allowed amounts. Medicare Part B claims that providers bill as “not reasonable and necessary” services (identified by modifiers GA or GZ) to determine the types of providers and services associated with these claims  and evaluate the policies that Medicare contractors have for handling these types of claims. Appropriateness of providers’ use of modifier GY (services that are not covered by Medicare). Medicare Part A and B claims submitted by top error-prone providers based on expected dollar error amounts and will recoup these improper payments. Incentive payments made to eligible professionals under the Medicare and Medicaid EHR incentive program to ensure they were accurately made. Because the work plan mainly focuses on providers’ compliance to CMS’s guidelines, we cannot stress enough the importance of documentation; when submitting claims E&M services (and other procedures) make sure that your documentation supports the level of E&M service you report on your claims. Contact Healthpolicy@entnet.org for your inquiries. Contact the Academy’s coding hotline at 1-800-584-7773 for guidance before submitting your claims. Confirm whether there are edits associated with the code pairs that you are reporting, and use the appropriate modifiers if needed: (Correct Coding Initiative Edits, https://www.cms.gov/NationalCorrectCodInitEd/NCCIEP/list.asp#TopOfPage) Ensure that you are aware of maximum units you can report for a service on the same patient on the same date of service (Medically Unlikely Edits–MUEs– https://www.cms.gov/NationalCorrectCodInitEd/08_MUE.asp#TopOfPage). Remember global periods for procedures when submitting claims. Take advantage of the Academy’s CPT for ENT articles (http://www.entnet.org/Practice/cptENT.cfm) and other resources (http://www.entnet.org/practice/Guidelines.cfm) as you prepare claims for submission. View the complete 2011 OIG work plan at http://oig.hhs.gov/publications/workplan/2011/. Reference Office of Inspector General 2011 Work Plan. Accessed at  http://oig.hhs.gov/publications/workplan/2011/ on November 9, 2010
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Update: Medicare and Medicaid Electronic Health Records (EHR) Incentive Program
On July 28, 2010, the Centers for Medicare and Medicaid Services (CMS) released the final rule for the Medicare and Medicaid Electronic Health Records (EHR) Incentive Program. This is the implementation phase of the American Recovery and Re-investment Act (enacted on February 17, 2009) under the Health Information for Economic and Clinical Health Act (HITECH) provision. This provision established incentive payments (IPs) for eligible professionals (EP) and eligible hospitals that meaningfully use EHRs. The CMS final rule provides guidelines on how to adopt and use EHR technology in a meaningful way to improve the quality, safety, and efficiency of patient care. It also defines how providers can qualify for the Medicare and Medicaid EHR Incentive Programs (http://www.cms.gov/ehrincentiveprograms/). Although the Academy supports adopting EHR to improve health outcomes and quality of care, it addressed these reservations in a letter to CMS: Opposed the “all or nothing” approach for EPs to obtain incentives and supported a more gradual process for EPs to adopt EHRs. Recommended reduction of  the threshold submissions for electronic prescriptions Suggested modification of the criterion for recording chart changes by requiring EPs to report only relevant vital signs based on their specialty Requested CMS require EPs to supply clinical summaries for patients only upon request Motioned that CMS postpone implementing the five clinical decision support rules from the meaningful use criteria Asked CMS to exclude otolaryngologist—head and neck surgeons from reporting specialty clinical measures because there weren’t any specialty groups applicable to us. In the final rule, due to our advocacy, CMS reduced the total number of objectives that EPs must satisfy to show meaningful use (MU). Also, they decreased the threshold levels for clinical quality measures, established two sets of objectives — core and menu — and will allow EPs to be excluded from reporting measures that they attest don’t apply to them. CMS reduced the clinical decision support rules from five to one, reduced the clinical quality measures from 90 to 44, and removed the requirement of reporting specialty group measures. Clinical quality measures for Medicare and Medicaid EPs To fulfill the MU criteria for the 2011 payment year (PY), EPs must submit (to CMS) required clinical quality data with an attestation that they used certified EHRs to collect the data elements, calculate the results, and vouch for the accuracy and completeness of their data. EPs are required to submit the numerators, denominators, and exclusions for the required measures for all applicable patients (not just Medicare and Medicaid patients). For the 2011 and 2012 EHR reporting periods, CMS requires each EP to submit information on six measures from the 44 clinical quality measures: three core and three quality measures. To be exempt from reporting these measures, EPs must attest that all of the other clinical measures calculated by the certified EHR have a value of zero for the denominator. According to Edward B. Ermini,  MD, Chair of the Medical Informatics committee, there aren’t any clinical decision support rules that apply to otolaryngologist—head and neck surgeons; they can probably only perform three measures on the menu set list. The Medicare EHR incentive program  The EHR reporting period may be “any continuous 90-day period within the first payment year and the entire payment year for all subsequent payment years.” The Medicare EHR Incentive program will be consecutive; CMS will treat every year following the first PY as a PY whether the EP received an incentive payment or not. The first PY for the program is calendar year (CY) 2011. EPs who change practices during the reporting period may still be eligible for IPs if they demonstrate MU. Incentive payments  EPs who are meaningful EHR users during the relevant EHR reporting period are entitled to an IP amount, subject to an annual limit, equal to 75 percent of the CMS’ secretary’s estimate of the Medicare allowed charges for covered professional services furnished by the EP during the relevant PY. EPs are eligible for IPs for up to five years (2011-2016). The last year to begin participation is 2014. EPs cannot reassign their benefits to more than one employer or entity and are responsible for reimbursing relevant parties or associates with IPs. Payment adjustments (penalties)  There will be a 1- to 5-percent payment adjustment for EPs who are not meaningful Certified Electronic Health Records (CEHR) users after 2015. EPs who can prove “significant hardship” may be exempt from this payment adjustment. EPs will need to renew their status annually with a limit of five years. How can EPs register? Registration for the Medicare program begins in January 2011 at:  http://www.entnet.org/MedicareRegistration. CMS requires each EP establish an enrollment record in PECOS. If you do not have one, visit: http://www.entnet.org/PecosEnrollment The Medicaid EHR incentive program The definition for MU will be the minimum standard for the Medicaid program. States may obtain approval from CMS to add more objectives to the MU definition. In CY 2011 and 2012, CMS will only consider states’ requests to modify the stage 1 objectives for public health or data registries. In the first year, EPs may obtain incentives through upgrading, adopting, or implementing a CEHR. For subsequent PYs, they must demonstrate MU of their EHRs. To be considered EPs for the Medicaid program, at least 30 percent of EPs’ patient volume must receive Medicaid over any continuous 90-day period within the most recent CY prior to reporting. EPs need not participate on a consecutive basis in the Medicaid EHR incentive program to obtain IPs. Incentive payments  IPs for Medicaid EPs will equal 85 percent of “net average allowable costs” associated with adopting EHRs, with a $63,750 maximum over a six-year period. IPs would be disbursed by states within the CY. EPs practicing in multiple states must select one state Medicaid EHR incentive program to participate. There are no penalties for EPs who do not participate in this program. Follow up with your state Medicaid provider to find out how to register for the incentive program. For resources on the EHR incentive program, visit: http://www.entnet.org/Practice/ONC.cfm Reference Medicare and Medicaid Programs; Electronic Health Record Incentive Program; Final Rule. Accessed at http://edocket.access.gpo.gov/2010/pdf/2010-17207.pdf on August 10, 2010. Full article will be available online at www.entnet.org/Practice/regulatorySocioAdvocacy.cfm.
Interview with Bryan Ambro, MD, MS, President, Maryland Society of Otolaryngology
Bulletin: Tell readers what led you to become president of the Maryland Society of Otolaryngology-Head and Neck Surgery. Dr. Ambro: After completing residency in Philadelphia and a Facial Plastic and Reconstructive Surgery fellowship in Seattle, I joined the University of Maryland Medical Center Department of Otolaryngology in 2006. The Maryland Society of Otolaryngology (MSO) leadership typically alternates between an otolaryngologist in private practice one year and in an academic practice the next. The nomination/election process is not terribly complex, and in fact it has been increasingly common for the president to be elected in absentia. My guess is that members believe there is less of a chance for the elected individual to respectfully decline. At least that’s how I came to hold the position. Several years ago, our president was elected while he took a restroom break. Bulletin: Until 2006, the focus of the MSO-HNS was centered on educational activities. However, that year the priorities shifted to the legislative arena. What happened? Dr. Ambro: That was the year that the audiology scope-of-practice issue arose. The amount of work required to properly research and defend our position was simply too cumbersome for our president to handle on his own. It became apparent that we needed to increase our advocacy efforts and we hired a lobbyist whose experience with the legislative process was greatly needed. Since that time, she has continued to be instrumental in voicing our specialty’s concerns in Annapolis. Bulletin: In what ways has the AAO-HNS helped on the scope-of-practice bill and other issues? Dr. Ambro: Throughout the two-year scope-of-practice battle, the Academy provided significant support in the form of testimony (written and oral), as well as financial backing to help the efforts of our lobbyist. They were involved every step of the way and were critical to our success in preventing the expansion of audiology’s practice scope. The Academy has always been a great resource for information regarding the status of legislative issues that have been previously encountered or are ongoing in other states. In turn, our Society has involved the Academy on all of our issues so that our experiences in Maryland can be shared with other state societies. Bulletin: How has the role of your lobbyist/executive director changed over the past few years? Dr. Ambro: Our lobbyist and her team have played an important role in maintaining a presence for the MSO in the state legislature. Although the number and complexity of issues that directly impact our state’s otolaryngologists can vary from one year to the next, she continually keeps us current with all aspects of Maryland healthcare legislation. She and her team are truly our eyes and ears in Annapolis. Bulletin: Tell us about any recent successes and pending issues, and how they impact Maryland’s otolaryngologists. Dr. Ambro: Recent legislative successes include the overturning of CareFirst BlueCross/BlueShield’s decision to extend a balance billing prohibition on hearing aid devices that is contained in the Federal Employee Health Plan to all of its Maryland products. MSO’s advocacy was effective in CareFirst rescinding its policy for all products except for the Federal Plan. Our efforts are now focused on changing the Federal Employee Benefit Plan’s policy, which affects many of Maryland’s otolaryngologists and their patients. Another huge success was the recent passage of the “Assignment of Benefits” bill. Through the efforts of several key legislators, MedChi (the Maryland state medical society), and MSO leadership, the passage of “Assignment of Benefits” provides Maryland physicians (especially hospital-based physicians) with a critical tool for negotiation with insurers as we continue to move forward into the changing climate under new healthcare legislation. This bill will also have a significant impact on the retention and recruitment of physicians in the state of Maryland. Bulletin: What challenges do you face in your society’s operation? Dr. Ambro: Our biggest challenge is to get more of our state’s otolaryngologists to participate in our society. At the beginning of my term, I typed a letter outlining our recent legislative successes as well as our future advocacy goals, and asked for dues that would go directly toward protecting Maryland otolaryngologists and their patients’ interests. I sent this to nearly 400 otolaryngologists and received dues from less than 60. Currently, almost 100 percent of our dues goes toward supporting our advocacy efforts, and with the Society’s limited coffers, we don’t have very much financial flexibility to cope with unforeseen issues. As the current president, my goal is to continue to raise awareness among not only our members, but all our of state’s otolaryngologists. Bulletin: What advice do you have for other state societies that are considering taking a more active role in legislative and regulatory activities? Dr. Ambro: If the funding and interest for a lobbyist/executive director is present, I would strongly encourage other state societies to become more actively involved in the legislative process. Our Society’s successes could not have been achieved without lobbyist support. Helping your members to understand the role government plays in shaping their practices will hopefully embolden them to become and stay engaged in advocacy efforts that positively impact our specialty and the care of our patients. The AAO-HNS applauds the volunteerism and commitment of our state otolaryngology society leaders, including Dr. Ambro.
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2010 Mid-Term Elections Bring Focus to 2011 Issues
Online legislative advocacy resources  • Legislative and Political Affairs: www.entnet.org/advocacy • 2010 Federal and State Elections:http://www.entnet.org/Practice/members/politics2010.cfm • Healthcare Reform Information: www.entnet.org/hcr • State Advocacy:http://www.entnet.org/Practice/members/stateAdvocacy.cfm • ENT Advocacy Network:http://www.entnet.org/Practice/members/entAdvocacyNetwork.cfm • The ENT Advocate:http://www.entnet.org/Practice/can/ENTAdvocate.cfm • ENT PAC: www.entent.org/entpac* *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. ENT PAC is a program of the AAO-HNS that is exempt from federal income tax under section 501 (c) (6) of the Internal Revenue Code. The contentious 2010 mid-term elections culminated in the Republican Party taking back the majority in the U.S. House of Representatives. The Republicans now have 242 seats in the House of Representatives, leaving the Democratic Party with 193 House members. Although Republicans also gained seats in the U.S. Senate, they did not gain control. Specifically, the Republicans now hold 47 Senate seats compared to the Democrat’s 53 seats. In total, 29 physicians ran in the 2010 mid-term elections.The number of physician members of Congress increased from 15 to 19 – 16 in the House and three in the Senate. ENT PAC, the political action committee of the AAO-HNS, had a success rate of 90 percent in its funding of victorious Congressional candidates. ENT PAC supports federal candidates and incumbent Members of Congress who champion issues specific to the specialty and the surgical community. ENT PAC remains one of the key advocacy tools the AAO-HNS has for gaining access to public policy deliberations.* The changes in the two chambers of Congress make for an unpredictable legislative session. Analysts predict President Obama will use his veto power, especially if Congress tries to make changes to the Patient Protection and Affordable Care Act (ACA). Although there is uncertainty in legislative outcomes, the Republican Party has outlined its legislative priorities, which include repealing the Independent Payment Advisory Board (IPAB) and ACA. It is unlikely the Republicans will be successful in repealing ACA altogether, considering Democrats still control of the Senate. Instead, Republicans may try to retool the law through implementation modifications and by blocking funding. The Academy is closely monitoring all issues related to healthcare reform and its implementation. AAO-HNS 2011 legislative priorities  Once the 112th Congress convenes in January, the AAO-HNS will continue working with legislators to develop a permanent solution for the flawed Sustainable Growth Rate formula, advance truth-in-advertising legislation, and oppose audiology direct access legislation. During the 2010 lame duck session, Congress failed to pass a permanent fix to the flawed SGR formula. Instead, Congress passed another “patch” to extend current payment rates through December 2010 and then again through December 2011. The “Healthcare Truth and Transparency Act of 2010,” better known as truth-in-advertising legislation, H.R. 5295, was introduced in May 2010 by Representatives John Sullivan (R-OK) and David Scott (D-GA). The bill, which must be re-introduced in the new Congress, sought to provide modest increases in resources to regulators to ensure patients are well-informed regarding the training and expertise of all healthcare providers. The AAO-HNS and other supportive organizations will seek re-introduction of the bill and push for its enactment in 2011. With many states passing similar truth-in-advertising laws, the medical community hopes this will increase likelihood of passage at the federal level. Barring direct access for audiologists to Medicare patients without a physician referral is again a key legislative priority for the AAO-HNS.  In the 111th Congress, audiologists were able to get the “Medicare Hearing Health Care Enhancement Act of 2009” introduced by Representative Mike Ross (D-AR). However, the number of cosponsors supporting the bill dropped compared to previous legislative efforts. In this Congress, AAO-HNS expects organized audiology to renew its efforts to pass direct access legislation. The AAO-HNS will continue to oppose direct access of audiologists to Medicare patients. Keep informed To receive updates on public policy debates and the AAO-HNS legislative priorities during the 112th Congress, join the ENT Advocacy Network. The Network is a free member benefit that provides network members information on federal and state legislation and politics. Stay connected through the ENT Advocacy Network as healthcare reform implementation takes shape and Congress continues to work on Medicare physician payment. Network members receive The ENT Advocate, a bi-weekly legislative e-Newsletter, along with additional informational communications. Join today by contacting the Government Affairs team at govtaffairs@entnet.org.
tonsils
Talking Points for AAO-HNS Tonsillectomy Guideline
As the new Tonsillectomy Guideline is released this month as a supplement to the AAO-HNSF journal, Otolaryngology—Head and Neck Surgery, many of our members may be contacted by the media and by patients with questions about what it suggests. Here are “talking points” you can use to answer those questions. “Over half a million tonsillectomies are done every year in the United States,” says Richard M. Rosenfeld, MD, MPH, guideline author and consultant. “The tonsillectomy guideline will empower doctors and parents to make the best decisions, resulting in safer surgery and improved quality of life for children who suffer from large or infected tonsils.” What is tonsillectomy and why is it important? Tonsillectomy is the third most common surgery (after circumcision and ear tubes) performed on children in the United States, with more than 530,000 annual procedures (one in seven ambulatory surgeries under age 15 years). Tonsillectomy removes two walnut-sized masses from the back of the throat, most often due to frequent throat infections or obstructed breathing when asleep (sleep-disordered breathing, or SDB). When performed in properly selected children, tonsillectomy can reduce throat infections, doctor visits, and antibiotic use, and can improve a child’s quality of life, daytime functioning, and ability to sleep soundly. Despite the frequency of tonsillectomy, until now there have been no evidence-based national guidelines to assist doctors in providing the highest quality care and help children recover safely and rapidly. Why is the Tonsillectomy Guideline newsworthy? It is the first – and only – national, evidence-based guideline on tonsillectomy in the United States. President Obama highlighted tonsillectomy in a September 2009 address on healthcare reform. The guideline was created by a multidisciplinary panel, including consumers and healthcare professionals representing nursing, pediatrics, family medicine, otolaryngology—head and neck surgery, anesthesiology, sleep medicine, and infectious disease. In an era of comparative effectiveness research, well-crafted guidelines help improve quality, promote optimal outcomes, minimize harm, and reduce inappropriate variations in care. What is the purpose of the Tonsillectomy Guideline? To help clinicians identify children who are the best candidates for tonsillectomy (and those who are not) To optimize the before and after care of children undergoing tonsillectomy To improve counseling and education of families who are considering tonsillectomy for their children. What are the newsworthy points made in the Guideline? Most children with frequent throat infections get better on their own; watchful waiting is best for most children with fewer than seven episodes in the past year, five a year in the past two years, or three a year in the past three years. Severe throat infections are those with fever of 101 or higher, swollen or tender neck glands, coating (exudate) on the tonsils, or a positive test for strep throat. Tonsillectomy can improve quality of life and reduce the frequency of severe throat infection when there are at least seven well-documented episodes in the past year, five a year in the past two years, or three a year in the past three years. Children with less frequent or severe throat infections may still benefit From tonsillectomy if there are modifying factors, including antibiotic allergy/intolerance, a history of peritonsillar abscess (collection of pus behind the tonsil), or PFAPA syndrome (periodic fever, aphthous stomatitis, pharyngitis, and adenitis). Large tonsils can obstruct breathing at night, causing sleep-disordered breathing (SDB), with snoring, mouth breathing, pauses in breathing, and sometimes sleep apnea (pauses of more than 10 seconds). Doctors should ask parents of children with SDB and large tonsils about problems that might improve after tonsillectomy, including growth delay, poor school performance, bedwetting, and behavioral problems. Although most children with SDB improve after tonsillectomy, some children, especially those who are obese or have syndromes affecting the head and neck (e.g., Down), may require further management. Doctors should give a single, intravenous dose of dexamethasone (a steroid medicine) during tonsillectomy to reduce pain, nausea, and vomiting after surgery. Doctors should not routinely prescribe antibiotics to improve recovery following tonsillectomy surgery, because medical studies show no consistent benefits over placebo and there are associated risks and side effects. Doctors should educate parents about the importance of managing and reassessing pain after tonsillectomy.  Strategies include drinking plenty of fluids, using acetaminophen or ibuprofen for pain control, giving pain medicine early and regularly, and encouraging their child to tell them if his or her throat hurts.
Millennium Society: Giving Back
“As I reflect upon my career in otolaryngology, the symmetry between Academy activity and my career track is very evident. I am delighted to have this opportunity to help ensure the continued support of otolaryngology everywhere through the AAO-HNS.” —Jonas Johnson, MD, and Janis Johnson  (Millennium Society Life Members and Hal Foster, MD, Endowment Society Founding Donors)“The Academy inspires and equips me to be a better surgeon, student, teacher, advocate and scientist. I believe that investing in the Academy is one of the best ways I can ensure that my patients and my family will have excellent access to quality healthcare in the future. Our role models and mentors created this Academy, and I believe it is our duty to continue and build upon their work in society just as much as we continue and build upon their work in the OR, at the bench, and at the bedside.” —Daniel C. Chelius Jr., MD  (Millennium Society Young Physician Member and Bobby R. Alford, MD, Endowment Founding Donor) “The AAO-HNS/F is an invaluable resource for education, grants, and research.  Exposure to the Academy early in my residency training utilizing one of the Resident Travel Grants solidified my desire to be an active member. I am proud to be able to financially support ongoing efforts to engage other young physicians through the many worthwhile AAO-HNS/F programs.” —Angela M. Powell, MD  (Millennium Society Life Member) Greetings and Happy New Year! As the 2011 calendar starts, there are many ways to get involved with the AAO-HNS/F. One way to directly support the mission of your specialty is by joining the Millennium Society, www.entnet.org/donate. The Millennium Society is our annual philanthropic program that provides a vital means of financial support for the AAO-HNS/F mission. Millennium Society gifts are essential to expanding the significant accomplishments of the AAO-HNS/F in improving patient care. The 2011 Millennium Society program year runs January 1 through December 31. Donors of the Millennium Society can choose to support their personal area of passion, whether it is education, research/quality, resident programs, humanitarian, international, or to support the general mission of the Foundation. In return, the members of the Millennium Society receive benefits such as: Tax deductions for their philanthropic gift. Early access to annual meeting registration and housing reservations. Year-round recognition and special acknowledgements in the Bulletin, AAO-HNS website, and other publications. Recognition on the Donor Wall of Honor during the annual meeting, with access to a special concierge lounge at the annual meeting with complimentary breakfast and lunch. VIP seating at the annual meeting Opening Ceremony. The Millennium Society experienced growth last year as more than 370 members pledged over $1 million, with many increasing the impact of their gifts by extending their pledges to donate in multiple years. These multi-year pledges enable a more reliable source of funding for our mission. The number of Life Members, the highest giving category in the Millennium Society, more than doubled in 2010.  These gifts, along with the support of corporations and foundations, helped to facilitate the following: Four new Endowed Funds: Bobby R. Alford Endowed Research Grant; Women in Otolaryngology Endowment; the Harry Barnes Society Endowed Leadership Grant; and the Nancy L. Snyderman Endowed International Visiting Scholarship Grant. Three new Named Funds: Dinesh and Pravina Mehta International Visiting Scholarship; Vijay and Nanda Anand International Indian Visiting Scholarship; and the Association of Otolaryngologists of Indian Heritage International Visiting Scholarship. Helping to develop the evidence base for otolaryngology by awarding 47 CORE research grants, four International Visiting Scholar grants; five International Travel Grants; three research studies and three published manuscripts; three manuscripts under development; and three new clinical guidelines. Awarding of 169 Resident Leadership grants to help defray costs associated with attendance at educational meetings. Funding 17 humanitarian resident travel grants, humanitarian service and aid, and international exchange and outreach. Practice management and business of medicine tools designed to aid you and your staff in the complex management of today’s otolaryngology practice. And more than 2,900 users of AcademyU. As these awards and grants grow, we need your support to continue to develop the essential programs and leaders for tomorrow while maintaining a quality of excellence within your specialty. We are excited about the growth of your Foundation, and with your continued help, we can continue to strive for excellence. If you have any ideas or questions on how we can best serve the AAO-HNSF through philanthropic support, please contact the development department via email at development@entnet.orgor by phone at 703-535-3718. Or, visit www.entnet.org/donate.
Bulletin advertising
For advertising in the Bulletin, new contact information is: Suzee Dittberner, at Ascend Integrated Media, 1-913-344-1420, or sdittberner@ascendmedia.com. The mailing address is 7015 College Blvd., Suite 600, Overland Park, KS 66211.
New Publisher and Reader Survey for Journal
This month brings a new publisher for the AAO-HNSF journal, Otolaryngology—Head and Neck Surgery. The journal will now be produced by SAGE, a leading international publisher of journals, books, and electronic media for academic, educational, and professional markets. Since 1965, SAGE has served scholars and researchers in a wide range of subjects, including more than 150 journals in science and medicine. Their partnership with HighWire Press will give Academy members increased online accessibility and visibility. The journal will be connected to more than 500 SAGE journals and more than 600 other titles on HighWire, including NEJM, JAMA, Science, BMJ, and many others. In December, all Academy members should have received in The News a readership survey, asking your opinions about our peer-reviewed journal, to help us serve you better. Please take a few minutes to send us your thoughts: http://www.entnet.org/ReaderSurvey For advertising in Otolaryngology—Head and Neck Surgery, please contact the following numbers: Display/product advertising For companies beginning with A-L: Amanda Pulse, SAGE, 1-805-410-7345, amanda.pulse@sagepub.com For companies beginning with M-Z: Brett Goldfine, SAGE, 1-484-231-1308, brett.goldfine@sagepub.com Classified/recruitment advertising Jovi Candelaria, SAGE, 1-805-410-7132, jovi.candelaria@sagepub.com
Developing the Leader in You
Apply Now for an AAO-HNS/F Committee Get involved with your Academy by applying to become a committee member. Visit www.entnet.org/committees to complete an application before February 1. Be part of Foundation education activities, the BOG grassroots work, or any committee that fits your area of expertise.”This is your opportunity to make your voice heard. It’s your Academy. Get involved.”  —J. Regan Thomas, MD, AAO-HNS/F President Mimi S. Kokoska, MD, MHCM Chief of Otolaryngology—Head & Neck Surgery Richard L. Roudebush, VA Medical Center and Professor, Indiana University School of Medicine This article was presented at an Academy Leadership Development Training Seminar September 25, 2010, during the Annual Meeting in Boston. The overall goals of the AAO-HNS Leadership Development Training Seminar were to discover, uncover and encourage leadership qualities in its participants. Specifically, the program sought to educate attendees about AAO-HNS organizational structure and leadership opportunities. It accentuated this background with a “how I did it” moment from a member of the Board of Governors. Ultimately, the seminar sought to increase awareness of attendees’ leadership strengths and potential. This awareness was heightened using the 4 E’s of Leadership: enable, envision, engage, and energize. The specific objectives of the “Developing the Leader in You” portion of the program were: To better understand and appreciate tendencies in oneself and others. To encourage participants to become aware of and maximize their position and influence as individuals and as team members within an organization. To assist participants in understanding and applying knowledge, skills, ability, and power to positively impact organizational structure and change where appropriate. Self-awareness Participants assessed their self-awareness and tendencies by taking a Myers-Briggs type of personality profle. They viewed their own results in the context of the general population and aligned themselves with famous individuals who shared their personality tendencies. Most of the participants had never completed that type of test and found the experience insightful and entertaining. The group discussed whether one personality tendency was necessarily better than another and identified the value of diversity in decision-making and problem-solving.  Digging deeper, they defined whose lenses or perspectives provide the most valuable information to an organization. Influence Taking those findings, the group considered their present sphere of influence and asked themselves if they have the tools to be influential and powerful. The ensuing conversation focused on influence and power and which techniques could contribute to an individual’s ability to influence in a positive manner. Various tools and techniques provided stimulation for audience members to determine what tools they already possess and use, where their gaps may lie, and what opportunities may exist. Relationships Discussing relationships resulted in some contemplation. Examples of relationship data mining in other industries were used to challenge the group to consider how technology can facilitate and reinforce relationships. Corporate and individual rights with respect to privacy and use of technology were discussed. Leadership development programs and organizations It is important for individuals to have a firm understanding of the organizational mission, vision, values, culture, and ethics in their workplaces. Ideally, this understanding would be gleaned prior to accepting a position within an organization, but frequently these characteristics are not fully evident until much later. In addition, it is wise for a developing leader to understand which competencies and skills are necessary for further maturation and then ensure he or she has a means of acquiring them. The following list includes some critical subject matter for future leaders to have a firm understanding of, in addition to the traditional leadership curriculum: Organizational behavior, Systems redesign (Lean, Six Sigma), Balance scorecards (QI, service excellence, financial performance), and 360 assessments. Continuous leadership development We discussed the motivation and rationale for pursuing leadership development. Too often the media has shown infamous cases where misdirected motivation and greed resulted in financial devastation to individuals and groups. The importance of integrity, follow-through, and the golden rule were stressed, as well as the steps to achieving self-development in leadership. Many participants in the Leadership Development Training Session said they received significant value from the experience. The program was designed to show them how they could take the 4 E’s and not only exercise them in their own learning, but also apply them in their professional and personal lives to produce a more fulfilling experience and a better end result.
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Dear National Public Radio
The following is a letter written by Academy member Sujana Chandrasekhar, MD, in August 2010 to National Public Radio (NPR) about a program on hearing loss, quoting an audiologist. Dear NPR, I  am an avid listener and contributor to NPR. I value it for the new knowledge it brings me, and for the accurate way NPR delivers stories on myriad topics. However, I was perturbed by your piece on hearing loss in U.S. teenagers on Aug. 20, 2010’s All Things Considered show, hosted by Michele Norris and Robert Siegel, and reported by Patti Neighmond. The paper referred to in the piece appeared in JAMA this week. There are four authors, all MDs, two of whom are otolaryngologists (ear-nose-throat physicians and surgeons). None of the authors is an audiologist. The conclusion of the paper is that, yes, there is a disturbing increase in the prevalence of hearing loss in U.S. teens, based on two large national surveys, one conducted from 1988-94, and the other from 2005-6, but the reasons for the increase are not clear and must be investigated more thoroughly. The paper also points out that medical causes for the hearing loss, such as conductive hearing loss, wax, otitis media, etc., were not tested for and cannot be excluded. It is a well-written paper that raises a very serious issue to the national spotlight. There are myriad causes for hearing loss, including cerumen (wax), foreign body entrapment in the ear canal, otitis media and externa (ear infections), congenital hearing loss, inner ear malformations, labyrinthitis, ossicular abnormalities, cholesteatoma, idiopathic sudden hearing loss, and noise-induced hearing loss (NIHL), to name a few. The best qualified professionals for thorough evaluation of hearing, hearing loss, and its causes are otolaryngologists—ear-nose-throat specialists—physicians who are subspecialty-trained in this field. NPR did not interview an ENT physician for this piece; instead, you only interviewed an audiologist. You called her Dr. Alison Grimes and stated that she “sees patients and does audiological tests” at UCLA Medical Center. Alison Grimes is not a medical doctor, a fact which was never pointed out in the NPR piece. She has a doctorate in Audiology, the science of testing hearing and balance. She is not able, by law, to make diagnoses or offer treatments. She cannot determine the cause of hearing loss and cannot intervene to correct it, unless a medical doctor clears the patient for fitting for amplification, such as hearing aids. Audiologists are valuable members of the hearing healthcare team, but they are not physicians and it is very important that patients and the public are made aware of this important distinction. For me, as a practicing otolaryngologist with subspecialty in otology/neurotology (disorders of the ear/hearing/balance/lateral skull base), the take-home message from this paper was that physicians—primary care as well as ENTs, nurses, school health personnel, and audiologists—are all members of a teen’s hearing healthcare team. They have to be much more proactive in examining ears and treating obvious problems, checking for metabolic, endocrine, or infectious diseases that can cause hearing loss, counseling parents, teens, and children regarding hearing health and avoidance of noise exposure, proper diet and exercise to maintain ear health, and being alert to the higher probability of hearing loss in a heretofore unheralded at-risk population. There are a number of patient-centered information leaflets available on ear function and disorders at the American Academy of Otolaryngology-Head and Neck Surgery website, which you might wish to peruse at http://www.entnet.org/HealthInformation/ears.cfm. You can also learn more about my specialty at http://www.entnet.org/healthinformation/AboutOtolaryngology.cfm. Thank you for your attention. I look forward to continuing to enjoy NPR and its reporting, and hope that you will stay alert to very important patient protection issues such as the one I raised here regarding “truth in advertising” of audiologists as audiologists and not as physicians. Sincerely, Sujana Chandrasekhar, MD Director, New York Otology Chair-Elect, AAO-HNSF Board of Governors
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Don’t Forget These Dates!
January 1 Become a 2011 Millennium Society Member (page 19) 3 Guideline on Tonsillectomy published (more on page 20) 19 Submissions open for scientific program at the 2011 Annual Meeting & OTO EXPO in San Francisco   February KidsENT Month Campaign—www.entnet.org/kidsENT 1 Deadline for committee applications 1 Deadline for nominations for Distinguished Award for Humanitarian Efforts 14 Submissions close for Scientific Program at the 2011 Annual Meeting & OTO EXPO in San Francisco
In Memoriam
Dr. Haydon was a critical leader in the Academy and the specialty. A past committee chair, he was also president of the AAOA, and instrumental in developing specialty society unity. Our sympathies go out to his family. Richard C. Haydon III, MD November 21, 2010 Lexington, KY University of Virginia, 1978
Joseph E. Hart, MD, MS, Chair, BOG Rules & Regulations Committee
Head and Neck Cancer Awareness—and the Local ENT
Eleven years ago, Terry A. Day, MD, asked me to consider participating in the Yul Brynner Head and Neck Cancer Foundation screening program. I agreed to get involved, and have remained an active participant ever since. I was the only respondent from my state that year. Since then, the University of Iowa and many more of my colleagues in Iowa have also become involved. The Brynner family supported this nationwide effort, and today there are more than 100 participating otolaryngologists in North America. Originally in 2001, the screening program was known as the Oral, Head and Neck Cancer Awareness Week; now it is called the Head and Neck Cancer Alliance. This year, it will be celebrated May 8-14, 2011. After being diagnosed with lung cancer, the Oscar-winning actor actively advocated for cancer awareness. The focus of his efforts was a need for lifestyle changes as an effective route to preventing cancer, as he pointed out that he had been frequently photographed with a lit cigarette. Brynner succumbed to lung cancer in October 1985. There is still a great need to promote cancer awareness and the steps to reduce one’s risk, as head and neck cancer strikes 40,000 new patients each year. I am no stranger to this statistic, as this type of cancer has struck my family. My uncle, a pediatrician in Oregon, chewed tobacco whenever he could. He succumbed to squamous cell carcinoma of the tongue and left a wife and seven children. The tragedy of his loss motivated my brother and me to pursue otolaryngology as a career path. My brother completed a fellowship in head and neck oncology, and I have immensely enjoyed otolaryngology as a vocation. With all of the opportunities I have been given, I felt the need to give back to my local community, and I do this through administering head and neck cancer screenings. I take a day off from clinic and see people who have concerns about their ears, nose, or throat. Some of these concerns relate to the possibility of cancer. Many of the people who see me fear that their seemingly innocuous complaint may represent something much worse. I am able to take a history and perform a physical that helps them. It can either reassure them of no pathology, or can involve a referral to their primary care physician and then back to an otolaryngologist for a formal consultation if something more serious is found. I let my local cancer society know how many people I screen each year, highlighting the importance of preventive action. I also give back to my community by organizing 5K/10K runs to benefit head and neck cancer victims. The process  of organizing head and neck cancer prevention screenings is relatively simple. I obtain an online form from the program and fill it out as it relates to each patient. I see between 30 to 50 people during each year’s screening program, and the number of patients with significant pathology varies from year to year. These free head and neck cancer screening clinics are a way to give back to your community. It is an uplifting experience, the patients are very grateful, and it helps to demonstrate that the physician’s primary motivation is to serve the patient. (An added bonus includes not having to be concerned with insurance forms.) We all have the desire to help the suffering among us, to alleviate some of the challenges that can ensue after diagnosis and subsequent treatment related to head and neck cancers. I believe we otolaryngologists are some of the most empathetic and involved members of our communities. We see people without some of the basic framework of the face or neck and are accepting of them. We deal with some of the most difficult problems with the airway and swallowing that can occur with these patients. We all would like to make a difference in the disease process. The best way may be by making the diagnosis earlier. Organizing or participating in screenings is an easy and effective way to do your part in advocating for cancer awareness. (For information on the OHANCAW program, please visit http://www.ohancaw.com.)
David R. Nielsen, MD, AAO-HNS/F EVP/CEO
What’s on Your Radar Screen?
The fresh start of a new year always provides us opportunity for personal new beginnings. But sometimes, before we start to launch our automatic “New Year Resolutions” internal software, it might be worth it to take a step back and ask ourselves, “What is really important to me?” A useful technique often used by facilitators of strategic planning is to ask participants to plot significant concerns on a virtual “radar screen.” These visual representations of issues that confront us can be sobering, inspirational, informative, and suggestive of how to prioritize our businesses and our personal lives. Each of us can (and usually does) have multiple radar screens of important issues. We might have one screen related to business affairs, one for family issues, one for personal concerns, and so on. A professional radar screen of a busy medical practitioner might include concerns about healthcare reform, hospital privileges, new business models for medical practice, payment reform and its effects on profitability, CME, how to improve quality care and reduce risk for medical error, volunteer Academy service, staffing of the office, sub-specialization, access to care, and many more issues. (See Figure 1.) Looking at our personal lives, we might have a radar screen that includes personal health problems, care of a chronically ill parent or other family member, attending our teens’ school or sports functions, managing day care, putting time into our marriages and valued relationships, or community roles (PTA, homeowners association, public service), or saving for retirement.  (See Figure 2.) Radar screens can represent any issue or set of issues that has a significant impact on our lives or a demand on our time and attention. We could create a time-based screen, showing a longitudinal view of the development of specific areas of interest. For example, most of us spend significant amounts of time and energy dealing with the Internet and social media. Plotting the amount of time spent on this demand for our attention over the years, we can begin to evaluate whether it is an irritation and intrusion on our lives or a valuable tool for desired communication. We also can make informed judgments about how it may change or affect us in the future. Significant public use of the Internet began in 1994. Today, its virtual offspring include not only email communications, but real-time audio and video communications, gaming, virtual reality, learning systems, shared business applications, cloud computing, and more. You can envision as many radar screens as needed to evaluate the various segments of your life. However, at some point, realistically, we have to superimpose all of these radar screens upon one another to get a true picture of the complexity of our lives. (See Figure 3.) This is where we see graphically all of the hats we wear and all of the commitments.  We also may see why at times we have a sense of being out of control. Our radar screens can get pretty crowded. But this is also where we can start to get some clarity; we begin to see the need for simplification and prioritization. Just as with an air traffic controller, when the radar gets too crowded with too many aircraft in too close proximity, near misses can quickly turn into disasters. Are we living our lives with a high number of near misses? Is some of the air traffic on our radar screen distracting us from managing more carefully what we value most? Can we clear the radar screen of some excessive and distracting blips and focus more closely on the highest value priorities? As we embark on another challenging year, your Academy staff commits to continued focus on providing you with high value membership, meaningful and high quality medical education, excellence in research support and quality tools, and optimal communication. We look forward to working with you to make 2011 the best year yet.
J. Regan Thomas, MD, AAO-HNS/F President
A Key Component of Success: Specialty Unity
One of the strongest attractions drawing bright medical students into the specialty of otolaryngology—head and neck surgery is the intriguing variety of subspecialty areas. You can focus on allergy, or facial plastics, or any number of other areas related to the ear, nose, throat, head, and neck. This spectrum of subspecialties persists as a key strength of the overall specialty itself. As the largest organization in the specialty, representative of all otolaryngologists, the AAO-HNS covers a wide range of disciplines. Academy activities are organized with specific attention toward being inclusive of all of our otolaryngology subspecialties (formerly called our “sister societies”). It is a major goal of my presidency to both ensure recognition of the important contribution to the overall specialty that each of the subspecialities provides, and to strengthen the cohesive, cooperative, and collective advantages that a unified participation through the Academy makes possible. At the beginning of my tenure as President of the Academy, I named a number of endeavors in my goals for the organization. These included enhanced support of diversity within the specialty and active support of the role of women in otolaryngology; recognition of the importance of our role at the international level through strengthening our ties with our international otolaryngology colleagues; and encouraging individual member commitment to advocacy support. Equal in importance is the goal of enhancing and strengthening subspecialty unity within otolaryngology—head and neck surgery through the Academy. Continued active unification of our specialty, our subspecialty organizations, and our membership make all of those endeavors a stronger reality. Many of our subspecialty organizations schedule their meetings to coincide with our Annual Meeting & OTO EXPO in the fall. At the 2010 Boston meeting, nine societies sponsored a total of 14 miniseminars, and some offered workshops in concert with the Academy. Many also participate in the grants program of the Centralized Otolaryngology Research Effort (CORE). Ten did so last year, and, since 1985, CORE has not only awarded more than $7 million in 400 grants for research training and projects, but by consolidating the effort, has actually increased the amount of money that can go to young researchers. A diversity of specialty interests, but unity of action After a specialty summit meeting three years ago, the AAO-HNS convened the various otolaryngology groups to form the Specialty Society Advisory Council (SSAC), to enhance intraspecialty cooperation and collaboration. Realizing that many of the topics that affect one society affect us all, the SSAC serves as a conduit for information to and from the member groups, and as an advisory body on such issues to our AAO-HNS/F Boards of Directors. The SSAC includes the following 11 groups: American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS) American Academy of Otolaryngic Allergy (AAOA) American Academy of Otolaryngology—Head and Neck Surgery (AAO-HNS) American Broncho-Esophagological Association (ABEA) American Head and Neck Society (AHNS) American Laryngological Society (ALA) American Laryngological, Rhinological and Otological Society (Triological Society) American Neurotology Society (ANS) American Otological Society (AOS) American Rhinologic Society (ARS) American Society of Pediatric Otolaryngology (ASPO) And our outreach extends in other ways. In this issue of the Bulletin, for example, you’ll find the annual report from the American Board of Facial Plastic and Reconstructive Surgery (ABFPRS, page 40). In June 2010, the magazine included an issue of OTO’s Scope, the publication of the Association of Otolaryngology Administrators (AOA), and in May, an update from the American Society for Pediatric Otolaryngology (ASPO). The American Board of Otolaryngology (ABOto) wrote in February 2010 about their cooperative efforts with the Academy called “Red Carpet Meetings.” We welcome contributions from all members of the SSAC. Our collective voice has significantly more impact in meeting the challenges our specialty confronts. We see those advantages in dealing with legislative and regulatory issues, interspecialty interaction, as well as public relations and education. So this year, be sure to add your voice to the collective one—the whole of our specialty needs your input.
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“Head and Neck Surgery Is Supposed to Be Fun”
A Resident’s Perspective on the Head and Neck Surgery Rotation Mark Domanski, MD Chief Resident, Otolaryngology George Washington University At the close of an interesting case, my attending physician remarked, “Head and neck surgery is supposed to be fun.” The case had been enjoyable. However, my attending’s statement seemed at odds with the attitudes of some otolaryngology residents. In discussions among themselves, many residents will remark about the pleasure of coming off their head and neck service, or the dread of soon resuming it. This is unfortunate, particularly from an educational standpoint. Over the past three years of otolaryngology residency, I have been blessed to work with a diversity of great surgeons. During a facelift, my facial plastics attending remarked how the technique was similar to raising flaps for a parotidectomy. When my rhinology attending asked me about treatment of orbital hematomas, he wanted to hear me describe a lateral canthotomy. While watching a pediatric otolaryngologist drain a neck abscess, I observed how comfortable she was with neck anatomy. Despite these otolaryngologists’ divergent subspecialties, each of them had learned fundamental operative technique, decision-making, and complication management from head and neck surgery. A danger exists if a resident moves on to other subspecialties without fully mastering the principles of head and neck surgery: wound healing, patient selection, postoperative care, and most importantly, critical decision-making. These skills learned in head and neck training, are well-suited to the mastoid, airway, and sinus. For these reasons, academic programs must ensure that their residents look forward to the head and neck surgery rotation. Today’s otolaryngology residents may fail to attain many of the education benefits of head and neck surgery because of a negative attitude. They make excuses such as, “I will not be doing commandos when I graduate,” or “This is a case that I am going to refer to the university hospital.” Certainly, most residents’ future practices will not be primarily head and neck oncology. But I think this misses the point. It’s easier to learn soft tissue handling in a neck dissection than in a rhinoplasty. The approaches to orbital fractures are the same as used for blepharoplasty. No place is better to learn laryngeal anatomy than during a laryngectomy. As a resident, I have observed that many of my counterparts have a poor perception of head and neck surgery. Simply put, their head and neck rotation is “not fun.” Head and neck rotations can include long hours, imperfect outcomes, and difficult patients. However, neuro-otology cases are not quick, nasal polyps can recur, and even facial plastic patients can be unsatisfied. There must be something else to explain resident attitudes. I am lucky to be at a program where residents enjoy head and neck surgery. Our head and neck attendings encourage residents to take ownership of patient care. Head and neck can provide residents a level of autonomy that is difficult in subspecialties like facial plastics or pediatric otolaryngology. Our patients benefit from (intensivist controlled) closed ICUs, which manage vent settings, pressors, and electrolytes. Closed ICUs free otolaryngology residents to focus on the operating room, floor patients, and consults. Our institution uses implantable Dopplers for free-flap monitoring. This eliminates the need for Q2 hour flap checks by the junior resident. As a result, junior residents start off with a better attitude toward head and neck surgery. Because our program is small, there is no task too junior for the senior resident. If anything remains to be done, the junior and senior work as a team to get it done. Head and neck surgery provides educational opportunities that are difficult to find elsewhere in otolaryngology residency. For this reason, programs should be aware of their residents’ attitudes toward head and neck surgery. By keeping head and neck surgery fun, the way it’s supposed to be, residents and patients both benefit.
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The Next Generation of Head and Neck Surgeons: Opportunities and Challenges
Mark E. Zafereo, MD Chair, Section for Residents and Fellows MD Anderson, Houston The early 21st century represents an exciting time to train in the art and science of head and neck surgery. While the incidence of tobacco-associated head and neck cancers continues to decrease, increasing incidence of other head and neck malignancies, including thyroid carcinoma, non-melanoma and melanoma cutaneous malignancies, and HPV-associated oropharyngeal squamous cell carcinoma, present new challenges in patient care and research. Treatment strategies for mucosal head and neck malignancies over the last half century have largely shifted from surgery to radiation and chemotherapy, but despite advances in treatment, mortality from mucosal head and neck cancer remains unchanged. Surgical innovation in head and neck surgery during the 1980s and 1990s came largely from advances in microvascular reconstructive techniques.1 But overall surgical innovation has declined over the last several decades.2  This may be changing as endoscopic head and neck surgery, including minimally invasive and robotic surgery, has emerged as an important new aspect within the specialty during the past five years.3 These novel technologies and innovative techniques must be examined in the context of rising healthcare costs and perhaps the future prospect of limited healthcare dollars to care for each individual patient. In the midst of this excitement about surgical innovation in head and neck surgical oncology is a recent increase in applicants to head and neck surgery fellowships, following a decline in the late 1990s. Head and neck surgery fellowships in the United States are generally one to three years and offer a variety of combinations of ablative surgery, reconstructive surgery, and research.  Within the future of the specialty, there remains a role for the ablative surgeon, the reconstructive surgeon, and the scientist. The term “scientist” includes those who: develop basic sciences; translate basic sciences into clinical applications; study epidemiology of disease; study outcomes and develop quality improvement measures; study the cost effectiveness of medicine within a societal context; and develop and implement clinical trials. Head and neck surgeons have developed successful careers with many combinations of these clinical and research interests.  An important aspect of discovery in clinical and translational research is enrollment in clinical trials. Less than 5 percent of cancer patients nationally participate in clinical trials. As care of the head and neck cancer patient continues to shift to regional and tertiary care centers where patients can be availed of the expertise of multidisciplinary teams and clinical trials, both individual patients and society will benefit in terms of cost effectiveness, greater discovery, and more specialized care. The role of the head and neck surgeon within the house of medicine continues to evolve. The head and neck surgeon of the future will be enhanced by the wisdom and accomplishments of an older generation, coupled with the enthusiasm and ideas of a younger generation. Important aspects of fellowship in head and neck surgery include not only learning surgical techniques, but perhaps more importantly, learning surgical decision-making and multidisciplinary care. There are roles for many different types of head and neck surgeons, but they should remain leaders in the field of surgical oncology, understanding and coordinating multidisciplinary care for their patients. Through a combination of discovery in the basic sciences, translational research, surgical innovation, and leadership in multidisciplinary care, it is hoped that the next generation of head and neck surgeons can continue to “stand tall on the shoulders of giants.” References Gilbert, RW. Innovation in the surgical management of head and neck tumors. Hematol Oncol Clin North Am. 2008 Dec;22(6):1181-91. Rosow DE, Likhterov I, Stewart MG, April MM. Reduction in surgical innovation, 1988 to 2006. Otolaryngology Head Neck Surg. 2009;140:657-60. Holsinger FC, Sweeney AD, Jantharapattana AS, Weber RS, Chung WY, Lewis DM, Grant DG. The emergence of endoscopic head and neck surgery. Curr Oncol Rep. 2010;12:216-22.
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Head and Neck Surgery Overview
It’s the second half of our name—Otolaryngology–Head and Neck Surgery— even though most of us tend to talk about “otolaryngologists” or “ENTs.” But that other half is a large part of what our members do. The “Head and Neck Surgery” umbrella covers not only head and neck cancer/oncology, but endocrine surgery, skull base surgery, and facial plastic and reconstructive surgery. The word surgeon is operative. Here are notes from three of the Head and Neck committee meetings in September 2010. During their meeting in September 2010 in Boston, the Skull Base Surgery Committee (Douglas D. Backous, MD, Chair) discussed the need for more training on skull base anatomy for all OTO residents. The enhanced training is designed to avoid surgical complications during procedures that are carried out near the skull base. The Head and Neck Surgery and Oncology Committee (Daniel G. Deschler, MD, Chair) works to provide responsive, excellent educational opportunities within the Academy. The committee includes specialists from across the country who devote time and effort to the committee, and seek member input for further endeavors. On the Saturday before the AAO-HNSF Annual Meeting & OTO EXPO, the committee co-sponsored the Sisson Head and Neck Surgery Course for residents and fellows, in conjunction with the American Head and Neck Society. Scheduled again for the 2011 meeting, the course provides an outstanding platform for education of residents and fellows, as well as educating them about the specialty of Head and Neck Surgery. The committee also will propose two miniseminars for 2011, addressing case management in HPV positive oropharyngeal cancer and management of the neck in the current era. The committee is also revising the Academy’s monograph on neck dissection and head and neck cancer staging to coincide with most recent edition of American Joint Committee on Cancer’s staging manual. Endocrine surgery makes up a large portion of head and neck surgery. The day before the opening of the Boston meeting, which offered 23 instruction courses and four miniseminars on thyroid and parathyroid surgery, the Endocrine Surgery Committee  (Lisa A. Orloff, MD, Chair) sponsored its first Ultrasound Workshop for Thyroid and Parathyroid. It was licensed by the American College of Surgeons (ACS). Past committee chair Robert A. Sofferman, MD, who heads the ACS Head and Neck Ultrasound Faculty, was course director, with several residents among the 65 registrants. Hands-on instruction in the afternoon used a variety of ultrasound machines with 13 volunteer patients recruited by past committee chair Gregory W. Randolph, MD. (Dr. Sofferman reported that ACS certification is a useful credential to show insurance companies.) Immediate Past President Ronald B. Kuppersmith, MD, MBA, and Dr. Randolph have submitted a proposal for the Guideline Development Task Force about “Perioperative and Surgical Management of the Recurrent Laryngeal Nerve (RLN) during Thyroid Surgery.” This guideline will reflect the critical progress that has occurred in patient care. Marc D. Coltrera, MD, and Dr. Randolph are working on a tumor database by pooling outcome data from two centers, with opportunities for future growth. There are other head and neck activities taking place, such as outreach to other endocrine societies, including the American Thyroid Association (ATA), American Association of Endocrine Surgeons (AAES), American Head and Neck Society (AHNS), and the American Institute for Ultrasound in Medicine (AIUM). The Endocrine Surgery committee has been named a Model Committee by the AAO-HNS/F.