More from August 2014 - Vol. 33 No. 08
Virginia Society of Otolaryngology-Head and Neck Surgery Receives BOG Model Society Award
The Virginia Society of Otolaryngology-Head and Neck Surgery (VSO-HNS) is the recipient of the 2014 Board of Governors (BOG) Model Society Award. Spencer C. Payne, MD, governor, Patrick J. Gibbons, MD, legislative affairs representative, and Eric M. Gessler, MD, socioeconomic and grassroots representative, represent the society on the BOG.
Among their many community-based outreach activities, last September VSO-HNS provided a free screening for head and neck cancer at the Richmond International Raceway prior to a NASCAR event. The event allowed VSO-HNS members to raise awareness of head and neck cancer and its risks, as well as the role of otolaryngologists in the diagnosis and treatment of head and neck cancer. Society members from around the state, including representatives from all four academic departments in the state, participated in the event. A total of 95 individuals were screened, and all individuals were provided with information regarding head and neck cancer risks and the role of the otolaryngologist. If indicated, the individuals were given recommendations for further follow-up or evaluation. Review of the screenings revealed 14 individuals required follow-up: ears (1), skin (1), oral cavity (5), neck (2), throat (2), vocal cords (1), sinus (1), and head (1).
This past February, VSO-HNS representatives were well received by their state legislators. Cristina Baldassari, MD, and Kelley M. Dodson, MD, met with Delegate Patrick Hope to talk about expanding Medicaid and opening up the HPV vaccine to boys in Virginia. They expressed VSO’s interest in mandating the vaccine for boys. Delegate Hope advised he would like to convene a workgroup with all stakeholders and the Virginia Department of Health. Though VSO, the Medical Society of Virginia, and Virginia Chapter, American Academy of Pediatrics, testified in support, the bill was killed in subcommittee. In April, Dr. Dodson attended the HPV workgroup on how to communicate more effectively to the public the necessity of the HPV vaccine.
BOG Practitioner Excellence Award
The 2014 BOG Practitioner Excellence Award will be presented to Joseph A. Brennan, MD, Colonel, Medical Corps, U.S. Air Force, Fort Sam Houston, TX. Colonel Brennan has distinguished himself in the combat casualty care of wounded warriors in both Operation Iraqi Freedom and Operation Enduring Freedom (Afghanistan) as the de facto leader of military otolaryngologists, preparing them properly for the care of combat wounds to the face, head, and neck. Col. Brennan is arguably the most experienced combat head and neck surgeon in the U.S. military today. In his own right, he has cared for many wounded American and Allied military personnel in Iraq and Afghanistan, saving dozens of lives of true American heroes in these wars.
He has brought back the surgical and clinical experience to teach other otolaryngologists to care for combat casualties, and is the lead editor of a military medicine textbook, Otolaryngology-Head and Neck Surgery Combat Casualty Care in Operation Iraqi Freedom and Enduring Freedom, which will be the guidebook for future combat care of head and neck wounds. His experience and teaching has already influenced civilian otolaryngologists in improving their care of traumatic wounds through his award-winning Triological Society paper on “Head and Neck Trauma in Iraq and Afghanistan: Different War, Different Surgery, Lessons Learned.”
Col. Brennan is also the co-founder and current chair of the AAO-HNS Trauma Committee, which is rejuvenating the importance of trauma care in the practice of otolaryngology-head and neck surgery. Due to his leadership and experience, Col. Brennan was chosen as the chairman of surgery of the San Antonio Military Medical Center, the largest surgical department in the Department of Defense. He was also awarded the Ronald Speirs Award for Combat Medicine at Task Force Med, Bagram Theater Hospital, Afghanistan, October 2009. Col. Brennan is an otolaryngologist among otolaryngologists, and what he has done for combat casualties in Iraq and Afghanistan, as well as his practice of head and neck surgery in the military, deserves the appropriate recognition of Practitioner Excellence Award.
Please join the BOG in honoring VSO-HNS and Dr. Brennan during the BOG General Assembly meeting, Monday afternoon, September 22, in Orlando, FL. Stanley W. McClurg, MD
University of North Carolina
Humanitarian Travel Grant Awardee
Five patients in the examining room at the same time, extreme emphasis on footwear, but not so much on sterile instruments. These were some of the culture gaps I observed on a recent medical humanitarian trip to Ho Chi Minh City, Vietnam. On the plus side: We all got a tea break right before surgery.
As a rhinology, endoscopic skull base, and allergy fellow at the University of North Carolina, I travelled to Vietnam February 28 through March 8 with a group under Brent Senior, MD, as part of REI Vietnam. We worked at multiple hospitals there, including the ENT hospital and Gia Dinh Hospital. I was able to give presentations to the physicians there on sinus surgery and some of my research on fluid dynamics of the nasal airway. It was a great opportunity for me to teach and also to see a different perspective on ENT and rhinology practices in another country.
I personally performed four sinus surgeries and one endoscopic pituitary surgery with my neurosurgery colleagues. These included mostly endoscopic sinus surgery procedures for mucoceles, chronic sinusitis, nasal polyposis, septal deviation, and pituitary adenomas. I did take some of my own sinus instruments along, but overall, they had most of the appropriate instruments that were needed for sinus surgery. The monitors, facilities, and beds, however, were not optimal. The sterility practices were fairly odd, placing extreme emphasis on footwear, and not so much on actual sterile techniques for instruments.
I do feel that the overall care that is being given at these hospitals is adequate, and at times superior to practices in the United States. There is a large emphasis placed on seeing as many patients as possible. This does provide care for the extremely large volume of patients, but it did appear that patients were not given adequate attention and focus at times. Patient confidentiality was also not high on their priority list. At some times, there were as many as five patients in the same room being examined. This just seemed like the normal way of doing things, and no one seemed to feel violated at all. Interestingly, they also put a high priority on making sure that everyone had a tea break prior to surgery, and once during the afternoon.
My biggest misconception before the trip was the overall exceptional knowledge of endoscopic sinus surgery that the ENT doctors in Vietnam already had. They had a significant knowledge base, but were willing to learn new techniques. Many doctors were able to see me do sinus surgery, and learned many different and new techniques. I had many questions that were asked of me during the course, and feel that I made a true impact on their practice.
I do feel that future focus on neurosurgical interventions would be beneficial for the people of Vietnam. We were able to take two neurosurgeons with us there, and the facilities and overall operative techniques of the neurosurgeons in Vietnam were suboptimal. Many of the ENT physicians there had never had any experience with endoscopic pituitary surgery, and this is an important area to address in future endeavors. I would definitely recommend this humanitarian trip to other ENT physicians. It is well established by Dr. Senior, and definitely provides an academic and immersive experience in a third world country. I would like to personally thank the AAO-HNSF Humanitarian Efforts Committee for the grant that was provided for my travels. Daniel Q. Sun, MD
The red earth of Africa gripped me. It seemed to be everywhere—coating banana leaves larger than umbrellas and dusting roadside stands selling grilled goat. This was the dry season and we were in Cameroon. The fine red dust followed us from the south, where we landed, to the northwest—a place called Mbingo, situated in the Cameroon mountains that we would call home for the next two weeks. By working at the Mbingo Baptist Hospital (MBH), our mission was to provide otolaryngologic and, specifically, head and neck surgical training to general surgery residents there. My experience, however, was remarkable in so many ways.
Shortage of health professionals is a pervasive problem in developing countries such as Cameroon, which has fewer than 30,000 doctors, nurses, and midwives per 10 million people according to a recent article in the New England Journal of Medicine. Subspecialty care is almost non-existent and general surgeons are called upon daily to do everything under the sun. Surgeons at MBH move from drilling burr holes for evacuation of a subdural hematoma in one patient to a C-section in another. Our team, led Wayne Koch, MD, has established a longitudinal partnership with the general surgery residency program at MBH and Everistus Acha, MD, a Cameroonian otolaryngologist, to provide head and neck surgical training to general surgery residents training at MBH. During the course of two weeks, we worked with Steve Kyota, MD, who is a general surgery resident in his third year of training, to perform nearly 40 operations, including five mandibulectomies, five maxillectomies, and 11 thyroidectomies.
While it was gratifying to put our technical expertise to work, the greater impact lies in our ability to transfer our expertise into the hands of people like Dr. Kyota, who will hopefully go on to serve the communities around him. Indeed, during the course of our short time there, his progress in gaining a more in-depth appreciation for the anatomy, soft tissue skills, and principles of head and neck surgery was evident. In addition, we delivered educational lectures on airway management and physiological principles of hearing and balance. Dr. Acha’s expertise also allows us to be confident that we are leaving our post-operative patients in good hands, with an expert who will be able to monitor their progress and treat complications that arise.
In addition to our clinical and educational projects, we also successfully carried out a pilot study on the prevalence of otitis media with effusion (OME) in the local pediatric population. After screening more than 80 children between the ages of 3 and 11 using otoscopy and tympanometry, we found the prevalence of chronic otitis media with effusion to be only about 3 percent, despite limited access to primary and tertiary care that renders most cases of otitis media and its complications unrecognized and untreated. Our findings stand in contrast to previous epidemiology studies in other developing regions of the world (but never in West Africa) that have identified rates of OME to be as high as 15 percent. As we expand our collaboration in Cameroon, we intend to build on studies such as this to investigate the differential burdens of disease and identify epidemiological and biological factors that will expand our understanding of the otolaryngologic disease processes we encounter each day.
By working with local partners, focusing on building capacity through education and training, and developing avenues of research, we are excited about our efforts toward building a sustainable collaboration to advance subspecialty care in Cameroon. For young physicians in training such as myself, it also makes for a profound experience in personal and professional development, as I look outward at the inspirational community of people that have gathered in a beautiful village in the northwestern mountains of Cameroon to meet the challenges of building a healthcare system, and inward at what my patients have taught me about the indomitable human spirit and dignity that are at the core of my profession.
Trip information:
Name of training program: Department of Otolaryngology–Head and Neck Surgery, Johns Hopkins University School of Medicine
Mission to: Mbingo, Cameroon
Date of travel: February 6-21, 2014
Sponsoring organization: Department of Otolaryngology–Head and Neck Surgery, Johns Hopkins University School of Medicine, AAO–HNSF Humanitarian Travel Grant, Cameroon Baptist Convention
Supervising Otolaryngologist: Wayne M. Koch, MD
Local contact and hospital: Dr. Everistus Acha, Mbingo Baptist Hospital In order to ensure that our education activities address physicians’real-world practice needs, the Foundation must identify the education needs (knowledge, competence, or performance) that coincide with the professional practice gaps of our learners. A Gap Analysis process is underway that will determine key topics for future Foundation education activities. The Gap Analysis answers the overall question “Why is this topic important to our members?”
The AAO-HNS Foundation’s Continuing Professional Development (CPD) mission states: We will enhance the quality of patient care and remain the premier source of otolaryngology education and knowledge. We will deliver resources and education activities that address gaps in care and improve the knowledge, competence, and practice of otolaryngologist-head and neck surgeons, residents, medical students, non-otolaryngologist physicians, allied healthcare professionals, and the public.
As an ACCME-accredited continuing medical education (CME) provider, the Foundation is required to comply with several accreditation criteria. According to these criteria, the Foundation’s CME activities must be designed to change physicians’competence or performance, and/or patient outcomes. The simplest way to describe a professional practice gap is the difference between “what is current practice”and “what should be optimal practice.”
The Foundation requires an organized and thoughtful assessment of the target audiences’practice gaps and education needs. Foundation staff coordinates with the Education Steering Committee and the Annual Meeting & OTO EXPOSM Advisory Committees to review, clarify, and determine the critical practice gaps to address in the annual education work plan.
The Foundation utilizes a planning process that links identified professional practice gaps and education needs with expected outcomes (knowledge, competence, performance, or patient outcomes) in its provision of CPD activities. This analysis data is incorporated into the planning of all education activities. This process utilizes the ACCME model for CPD for physicians, which shows a cyclical process that includes:
Begin with question in practice—data, information, analysis, synthesis, judgment
Gain new knowledge—wisdom, strategy
Develop new strategy to ultimately apply to practice
Physician competence in practice
Physician performance
The eight Education committees, under the leadership of Sonya Malekzadeh, MD, and the Education Steering Committee are currently completing a formal Gap Analysis. This is critical to ensure we are offering the best education resources that focus on improved professional practices and patient outcomes. Gavin Setzen, MD, Chair
Jenna Kappel, MPH, MA
Director, Health Policy and Staff Liaison, Imaging Committee
The following is an update on the continued efforts of the Imaging Committee on the behalf of members.
AAO-HNS Imaging Committee Members Take on Leadership Roles at Imaging-Related Societies
The Intersocietal Accreditation Commission (IAC) CT Division (IAC-CT)
As a follow-up to the Academy’s submission of several nominees for the open seat on the Intersocietal Accreditation Commission (IAC) CT Division (IAC-CT), Rakesh Chandra, MD, from Northwestern University Feinberg School of Medicine, and Imaging Committee member, has been elected to the IAC CT board of directors. The CT board was impressed by Dr. Chandra’s level of expertise and knowledge and looks forward to working together to help further the mission and importance of IAC accreditation.
The American College of Radiology Appropriateness Criteria® (AC) Expert Panels on Neurologic Imaging
The ACR Committee on Diagnostic/Interventional Appropriateness Criteria invited AAO–HNS to select a new representative on the American College of Radiology Appropriateness Criteria® (AC) Expert Panels on Neurologic Imaging. To note, AC are evidence-based guidance used by providers in making the most appropriate imaging or treatment decision for a specified medical condition. The ACR feels the expertise of AAO–HNS members contributes to producing stronger, more relevant recommendations. The AAO–HNS greatly appreciates the opportunity to participate in the process of reviewing and updating relevant AC to otolaryngologists.
In June, David Conley, MD, replaced Brian Nussenbaum, MD, as an AAO-HNS representative to the ACR AC Expert Panel on Neurologic Imaging. We greatly appreciate all the time and effort that Dr. Nussenbaum has given during the past several years in this role. Dr. Conley will work with the panel to develop and update topics for select neurological conditions.
National and State Efforts Related to the In-Office Ancillary Services Exception (IOSE)
Physician Community Urges Congress to Preserve Stark Law Exemption
On a national level, on March 18, the AAO-HNS joined the Coalition on Patient-Centered Imaging (CPCI) in sending a letter to Congress urging preservation of the in-office ancillary services exception (IOASE) to the Stark law and rejection of the Administration’s budget proposal to restrict the IOASE. Leaders of the Senate Finance, House Ways & Means, and Energy & Commerce Committees received the letter. To view the letter, visit the Imaging Services webpage at http://www.entnet.org/content/imaging-services.
State Advocacy Efforts in California Lead to Defeat of Bill to Remove Stark Law Exemption
At a state level, in April the AAO-HNS was approached by the CPCI regarding a sign-on letter opposing California Senate Bill 1215, which would have removed the exemption for in-office advanced imaging. The Academy’s Government Affairs team moved quickly to receive support from the California Otolaryngology Society and San Diego Academy of Otolaryngology, as well as the AAO-HNS to sign on to the opposition letter. The California Medical Association also took action to oppose the bill. Thanks go to Board of Governors and California Otolaryngology Society leaders Marci Bothwell, MD,Christopher Bergeron, MD, and Steven Kmucha, MD, JD, for their local advocacy efforts. As a result of these actions, SB 1215 was defeated in the California Senate Business, Professions and Economic Development Committee and it is dead for the year.
AAO-HNS Submits Comment Letters to Private Payers Regarding Restrictive Policies
The Academy’s Health Policy team worked with the Imaging Committee and coordinated with the IAC to submit comments to Coventry/National Imaging Associates (NIA),Humana, and Blue Cross Blue Shield of Idaho opposing their policies that restrict the use of mini-CT scans and/or limit the ability for otolaryngologists to interpret and provide imaging services. The letters incorporate language from AAO-HNSF’s position statement on point-of-care imaging to support providers who utilize point-of-care imaging when medically necessary and appropriate, in order to improve efficiency in diagnosing and managing a patient’s condition.
In addition, in response to Humana’s request for additional evidence in specific criteria where computer assisted navigation is needed, comments were submitted to Humana’s Medical Director with updated references added to the AAO-HNS/F position statement on Intra-Operative Use of Computer Aided Surgery. While their medical policy on Computer Assisted Surgical Navigation (CASN) currently does not provide payment for the service, Humana stated that they are willing to review any new information provided on this topic. While we are hopeful that these policies will be changed to allow for coverage, the Academy is appreciative of the open channels of communication with these payers. 
