Published: June 23, 2015

The expansion of fellowship training and the modern-day residentExpanded from the print edition

In 1994, Byron Bailey, MD, and Robert H. Miller, MD, MBS, examined the explosion in the amount of otolaryngology subspecialty programs and number of fellowship trainees.1,2 By 1994, 25 percent of the 260 otolaryngology residents were entering fellowship.2

By John M. Carter, MD, SRF Information Officer, New Orleans, LA

In 1994, Byron Bailey, MD, and Robert H. Miller, MD, MBS, examined the explosion in the amount of otolaryngology subspecialty programs and number of fellowship trainees.1,2 By 1994, 25 percent of the 260 otolaryngology residents were entering fellowship.2 Fast forward 20 years and subspecialty pursuits among otolaryngology trainees have only expanded further. Greater than 50 percent of the approximately 300 graduating otolaryngologists are deciding to pursue subspecialty fellowship, and in the most recent unpublished data from the 2014 AAO-HNS SRF survey, 61 percent of all residents stated that they planned to pursue fellowship. Currently the most popular fellowships are pediatric otolaryngology, facial plastic surgery, and head and neck oncology.3 This compares similarly to 1994. The only major shifts are the increase in the number applying to pediatric otolaryngology and a relative decrease in the proportion of applicants applying to neurotology. Both are perhaps greatly affected by the number of available positions. There were 27 neurotology programs in 1994 compared to only nine to 12 programs [requirement having tightened for subcertification] participating now (varies by year). On the converse, pediatric otolaryngology now has 31 programs participating compared to only 16 in 1994.1,3

The reason for the spike in interest in subspecialty training is likely multifactorial and not all together clear. In 1994, Dr. Bailey postulated that the likely motives behind why residents decide to pursue subspecialty training are to 1) gain additional experience to provide superior care; 2) reach a sense of mastery in a subspecialty field; 3) limit their practice to an area they find more satisfying; 4) obtain a marketing advantage over colleagues who practice more broadly; and 5) obtain job security.1

In 2015, these motives likely still largely hold true, but are there new factors that are driving this overall increase in fellowship interest? In the 2014 AAO-HNS SRF survey (approximately 460 respondents), residents were asked “What is the most important factor in determining which fellowship you decide to pursue?” The most common responses were types of surgical cases (50 percent), nature of clinical and medical problems (33 percent), and lifestyle (6 percent). However, this survey gave residents limited choices and may not have captured the true responder attitudes. In this same survey, 46 percent of respondents identified location as the most important factor in determining their practice choice. Practice location is clearly important to the majority and there is a distinct possibility that market forces in certain geographical locations may play a role in the decision-making. Residents may find that fellowship helps them to gain a niche or occupational advantage in certain competitive or saturated areas.

A recent 2014 cross-sectional survey performed in Canada demonstrated that 78 percent of graduating otolaryngologists reported pursuing fellowship training. Ninety percent identified the pursuit of fellowship training as moderately influenced by limited job opportunities. The ability to find and secure full-time employment, losing technical skills if underemployed/unemployed, and being required to consider working in a less-desired city/province were most concerning to those surveyed.4 While the job market in Canada is not the same as in the United States, it is certainly interesting to consider that some of these same forces may be driving resident decision-making in the U.S.

Otolaryngology continues to advance at an amazing pace. Subspecialization has aided our field in providing the highest level of care to our patients and has encouraged academic pursuits in specific areas, helping our field to evolve and expand the limits of what we can accomplish as practitioners. Major questions residents face entering our increasingly subspecialized field are: 1) What will the value of our general otolaryngology certification be? 2) Are we poised to be successful in a broad-based practice after our general otolaryngology training? Additionally, one wonders that if the amount of trainees entering fellowship continues to expand, is there a need to augment our current five-year training system in an effort to facilitate early transition to advanced subspecialty training? This is an exciting time and one that is sure to be filled with positive change.

References

  1. Bailey BJ. Fellowship proliferation. Impact and long-range implications. Arch Otolaryngol Head Neck Surg. 1994 Oct;120(10):1065-1070.
  2. Miller RH. Otolaryngology residency and fellowship training. The resident’s perspective. Arch Otolaryngol Head Neck Surg. 1994 Oct;120(10):1057-1061.
  3. SF Match Residency and Fellowship Services website. Accessed on November 1, 2014. https://www.sfmatch.org/Specialty.aspx.
  4. Brandt M, Scott G, Doyle P, Ballagh R. Otolaryngology-head and neck surgeon unemployment in Canada: a cross-sectional survey of graduating otolaryngology-head and neck surgery residents. J Otolaryngol Head Neck Surg. 2014 43:37.

 

More from July 2015 - Vol. 34 No. 06
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TMJ Next Generation
research
Supporting the future
The Centralized Otolaryngology Research Efforts (CORE) grants program plays a critical role in advancing the field of otolaryngology by providing support to research projects, research training, and career development.
measures
Working together on performance measures
Measurement aligns with registry, payment models Quality metrics and performance measures have assumed center stage as payment progresses forward to alignment with quality of care and efficiency in care. To address Member needs for clinical quality measures, the AAO-HNSF launched the Performance Measures Task Force (PMTF) comprised of Richard M. Rosenfeld, MD, MPH, Chair, and Lisa E. Ishii, MD, MHS, James C. Denneny, MD, Richard V. Smith, MD, Jane T. Dillon, MD, MBA, Julie L. Goldman, MD, and David R. Nielsen, MD, in 2014. The Task Force held its first meeting in February 2015. Specific outcomes included a commitment to develop two prioritized sets of measures based on clinical practice guidelines (CPG), a continued collaboration with the AMA-convened Physician Consortium for Performance Improvement® (AMA-PCPI®) for measures testing, and exploration of tools that will facilitate faster development of measures from CPGs. Over the past year, the Foundation has produced a measures development strategy aligned with its registry initiative and new payment models to meet critical Member needs in the realm of quality reporting and support of Medicare and commercial reimbursement with an overarching goal of reinforcing the value of care provided by Members. The AAO-HNSF is moving forward for Members on three fronts in the realm of clinical quality measures. First, the Foundation took over ownership and stewardship of the AMA-PCPI® measures most applicable to our Members, which include acute otitis externa (AOE), adult sinusitis, and otitis media with effusion (OME) in December 2014. Each of the measures had time-limited endorsement from the government contractor for measure endorsement, the National Quality Forum (NQF). One of the key roles of measure owners and stewards is ensuring the continued validity and endorsement, as well as dissemination and use of the clinical quality measures in its portfolio. To this end, the acute otitis externa (AOE) and otitis media with effusion (OME) measure groups are under consideration in NQF for continued endorsement under their Head, Eyes, Ears, Nose, and Throat (HEENT) measures initiative. This particular NQF project seeks to identify and endorse clinical quality measures for accountability and quality improvement that address these structures. The NQF Committee overseeing this project has two Academy Member appointees, Kathleen Yaremchuk, MD, MSA, and Michael G. Stewart, MD, MPH. Dr. Rosenfeld will provide his expertise in responding to any questions from the panel during the AOE and OME measures review. Much work has been done behind the scenes to prepare the measures applications, identify all uses of the measures since their initial endorsement, gather all research on gaps in care these address, and all testing and reporting data for submission to NQF for review. During May and June conference calls were held with the NQF HEENT Committee overseeing this initiative. The process concluded with a formal presentation of the measures by the AAO-HNSF to NQF in June. As the AOE and OME measures were prepared for NQF endorsement, the Foundation launched its own review of the adult sinusitis measures. This review of the measure specifications highlighted several issues that may have impacted Members’ quality reporting in 2014. Staff worked closely with the Centers for Medicare & Medicaid Services (CMS) executive leadership and with the Physician Quality Reporting System (PQRS) vendors to assure correct reporting for Academy Members in 2014 and 2015. Complete revisions to these measures will be in place for 2016 reporting as well. These measures are now under Academy ownership and stewardship, which will allow for continued utilization in the PQRS program and for broad dissemination to assure use. The Foundation’s work on the second front in clinical quality measures centers on its work to assure that an adequate pipeline of measures is available for Maintenance of Certification (MOC) by otolaryngologists and other physicians for quality improvement and quality reporting purposes. This is where the registry will play a critical role. With a registry, the Foundation will be able to utilize EHR data as well as claims data to craft quality metrics quickly for inclusion in quality reporting programs such as PQRS, Meaningful Use, and the Value-Based Modifier. Concurrently, it is also critically important that the AAO-HNSF disseminate its current measures as broadly as possible to improve patient care and outcomes. To this end, the Foundation has secured inclusion in PQRS of the adult sinusitis and acute otitis externa measures and measure groups. Academy staff has also researched every measure available in PQRS that might have applicability to Member practices and has organized all of these measures and related information on the AAO-HNS/F website at www.entnet.org/content/quality-measures. The third domain of measure activity focuses on staying abreast of changes to federal rules and regulations in the realm of quality reporting. At this point, it is worthwhile to share just what is happening with your Foundation measures for quality reporting in 2015. This is where measures have a profound impact for Members. As we noted earlier, AOE and sinusitis measures are contained within PQRS. This year, both Meaningful Use and the Value Based Modifier will be linked to PQRS. Concurrently, this is the year when fines will be levied for failure to report in PQRS with downstream ramifications into other quality reporting programs—all of which could have an impact on reimbursement in 2017. The most important point is to start early. To avoid penalties and fines, report to PQRS in 2015. Do you report to PQRS as an individual or as a group? You may report through the PQRSwizard® made available through the Academy, an EHR, or a registry. You may report either as an individual or as a group. This is an important decision to make early. Reporting as an individual If you decide to report individually, you may report using measure groups. If you choose this option, you must report on one measures group on a 20-patient sample, a majority of which (at least 11 out of 20) must be Medicare Part B patients. If you choose to create your own list of measures from the table below, you will have to select nine measures covering three quality domains and report for at least 50 percent of your Medicare Part B patients. Reporting as a group If you choose to report as a group, you must first register with CMS. Then, you will identify nine measures from the individual measures list below that cross at least three quality domains. You will report for at least 50 percent of your group’s Medicare Part B patient population. For more information on group reporting, visit www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Registry-Reporting.html. The good news is the Academy has made the process of measure selection easier by having identified all the measures that could be used by Academy Members and sorted them by quality domain for ease of use. The measures highlighted in red were developed and stewarded by the Academy. To secure information on all of the individual measures contained in the table at right, visit www.entnet.org/content/individual-quality-measures. It is clear with the passage of H.R. 2 Medicare Access and CHIP Reauthorization Act of 2015, the need for quality measures will continue well into the future. The Academy recognizes the complexity and difficulty of the CMS quality reporting and hence, the decision to invest resources into quality measurement development specific to our specialty. 2015 National Quality Strategy Domains (Individual/Claims Measures)   Patient Safety Person and Caregiver- Centered Experiences and Outcomes [Patient and Family Engagement]   Communication and Care Coordination   Effective Clinical Care [Clinical Processes/Effectiveness]   Community/ Population Health [Population/Public Health]   Efficiency and Cost Reduction [Efficient Use of Healthcare Resources] Perioperative Care: Selection of Prophylactic Antibiotic – First OR Second Generation Cephalosporin PQRS #21 Patient Centered Surgical Risk Assessment and Communication PQRS #358 Medication Reconciliation PQRS #46 Controlling High Blood Pressure PQRS #236 Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention PQRS #226 Acute Otitis Externa (AOE): Systemic Antimicrobial Therapy – Avoidance of Inappropriate Use PQRS #93 Perioperative Care: Discontinuation of Prophylactic Parenteral Antibiotics (Non- Cardiac Procedures) PQRS #22 Optimal Asthma Control PQRS #398 Care Plan PQRS# 47 Acute Otitis Externa (AOE): Topical Therapy PQRS #91 Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented PQRS #317 Adult Sinusitis: Antibiotic Prescribed for Acute Sinusitis (Appropriate Use) PQRS #331 Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in All Patients) PQRS #23 Functional Outcome Assessment PQRS #182 Diabetes: Hemoglobin A1c Poor Control PQRS #1 Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan PQRS #128 Adult Sinusitis: Appropriate Choice of Antibiotic: Amoxicillin Prescribed for Patients w/ Acute Bacterial Sinusitis PQRS #332 Perioperative Temperature Management PQRS #193 Falls: Plan of Care PQRS #155 Asthma: Pharmacologic Therapy for Persistent Asthma Ambulatory Care Setting PQRS #53 Preventive Care and Screening: Influenza Immunization PQRS #110 Adult Sinusitis: CT for Acute Sinusitis (Overuse) PQRS #333 Falls: Risk Assessment PQRS #154 Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with Neck, Cranium, Mandible, Thoracic, Spine, Ribs, or Other General Orthopedic Impairments PQRS #223 Immunizations for Adolescents PQRS #394 Adult Sinusitis: More than One CT Scan Within 90 Days for Chronic Sinusitis (Overuse) PQRS #334 Documentation of Current Medications in the Medical Record PQRS #130 Biopsy Follow-Up PQRS #265 Tobacco Use and Help with Quitting Among Adolescents PQRS #402 Appropriate Treatment for Children w/Upper Respiratory Infection PQRS #65 Radiology Exposure Time Reported for Procedures Using Fluoroscopy PQRS #145 Pain Assessment and Follow-Up PQRS #131 Appropriate Testing for Children with Pharyngitis PQRS #66 Pneumonia Vaccination Status for Older Adults PQRS #111 Reporting as individuals For physicians reporting as individuals, you may use these clinical quality measures groups or the other measures groups listed on our web site at www.entnet.org/content/quality-measures-groups. Sinusitis Measures Group Measure #130 Documentation of Current Medications in the Medical Record Measure #131 Pain Assessment and Follow-Up Measure #226 Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention Measure #331 Adult Sinusitis: Antibiotic Prescribed for Acute Sinusitis (Appropriate Use) Measure #332 Adult Sinusitis: Appropriate Choice of Antibiotic: Amoxicillin Prescribed for Patients with Acute Bacterial Sinusitis (Appropriate Use) Measure #333 Adult Sinusitis: Computerized Tomography (CT) for Acute Sinusitis (Overuse) Acute Otitis Externa Measures Group Measure #91 Acute Otitis Externa (AOE): Topical Therapy Measure #93 Acute Otitis Externa (AOE): Systemic Antimicrobial Therapy – Avoidance of Inappropriate Use Measure #130 Documentation of Current Medications in the Medical Record Measure #131 Pain Assessment and Follow-Up Measure #154 Falls: Risk Assessment Measure #155 Falls: Plan of Care Measure #226 Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention Measure #317 Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented
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Registry 101
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H. BRYAN NEEL III MD, PHD DISTINGUISHED RESEARCH LECTURE“Leading the Biomedical Revolution in Precision Health: How Stanford Medicine Is Developing the Next Generation of Health Care”
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The Academy needs you! Fill out a RUC survey
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WIO: role models, trail blazers
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Eugene L. Son, MD, PGY-4 at University of Texas Medical Branch, Galveston, TX
2015 AAO-HNS/F Leadership Forum—a resident’s perspectiveExpanded from the print edition
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kenya
One humanitarian mission: two perspectives Expanded from the print edition
Since 2009, several otolaryngology-head and neck surgery trips have been organized to Eldoret, Kenya.  The trips are part of an overarching program, the Indiana University-Kenya AMPATH Partnership (ampathkenya.org). Months of planning in both the United States and Kenya culminate in an intense two-week “ENT Camp,” which provides medical and surgical care, training, and relationship building between the U.S. and Kenyan otolaryngologists.
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2015 AAO-HNS Election results
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State Trackers, take a bow
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As Meaningful Use changes, we’re advocating for you
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denneny
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Gripers and whiners
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