Advancing Otolaryngology Education

Otolaryngol Clin N Am 40 (2007) 1191–1194

Advancing Otolaryngology Education in the New Millennium Matthew W. Ryan, MDa,*, Francis B. Quinn, Jr, MD, FACS, MS(ICS)b a

Department of Otolaryngology, The University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-9035, USA b Department of Otolaryngology, The University of Texas Medical Branch, 7.104 JSA 301 University Boulevard, Galveston, TX 77555-0521, USA

By the end of my medical school years, the Korean war and the ‘‘doctor draft’’ were in full swing, so I elected to sign up with the US Air Force (USAF) for a rotating internship and two payback years as flight surgeon. During this period I decided on a career in ENT [ear, nose, and throat] and applied to Iowa, Michigan, and Temple. I was accepted at all three, since ENT was considered a ‘‘dead specialty’’ at that time. The University of Michigan paid $142/month, $5 more than either of the others, so I went there. And so began my career in otolaryngology. On discharge from the USAF I carried my little family to Ann Arbor, Michigan, and began residency training on July 1, 1955, in the Department of Otology and Maxillofacial Surgery, as it was called then. There were three full-time faculty and two residents per year. The first-year resident was allowed to do T&A’s using a head mirror and ether insufflation anesthesia. He was allowed to perform tracheotomies with the supervision of a fourth-year resident. Days were spent in the clinic under the supervision and tutelage of a second-year resident. Saturday morning professors’ rounds were the highlight of the week, where the fourth-years presented patients to faculty for approval of their contemplated surgery. Second-year residents were allowed to do submucous resections of the nasal septum, as well as adult tonsillectomies. Both procedures were done under local (cocaine) anesthesia and heavy (barbiturate, morphine, and atropine) premedication. Anesthesia for submucous resection consisted of cocaine mud (a paste of cocaine flakes moistened with 1:1000 epinephrine solution) painted on the septum, and novocaine infiltration of the nasal spine. Gauze packs were inserted at the end of the procedure, and the septum was not sutured. * Corresponding author. E-mail address: [email protected] (M.W. Ryan). 0030-6665/07/$ - see front matter Ó 2007 Elsevier Inc. All rights reserved. doi:10.1016/j.otc.2007.08.001

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For tonsillectomy, the sedated patient was seated opposite the (seated) surgeon, both on steel stools. The patient was draped with a sheet, on top of which he was required to hold a basin in his lap. The surgeon used a head mirror, and had the services of a half-time circulating nurse, but no assistant, scrub technician, or nurse. Anesthesia was administered in the form of 5 mL (total) of 0.5% cocaine solution injected into each tonsil capsule. Dissection was with scissors and tenaculum. Bleeding was controlled by pressure from large ball-shaped tonsil sponges. Bleeding was minimal, thanks to the vasoconstricting action of the cocaine solution. Salivation was eliminated by the 0.6 mg of atropine premedication, and any troublesome bleeding was controlled by 2-0 chromic lasso ties or by the patient spitting into the basin. It was not until the fourth year that residents were permitted to perform surgery without faculty supervision. This consisted mostly of mastoidectomydtympanoplasty and stapedectomy came laterdand endoscopy, with the occasional laryngectomy. I don’t remember seeing a neck dissection, parotidectomy, rhinoplasty, or facial fracture repair during my time there. If the resident needed help, a faculty member would step in, finish the operation, and say, ‘‘Next time do it like that.’’ There was no surgical ‘‘teaching’’ as there is today. At the end of my second year my wife’s father became ill and we wanted to be near him. His home was in Los Angeles. I asked permission to transfer to a residency program in the Los Angeles area and was fired on the spot. I will always remember my chairman’s words: ‘‘Dr. Quinn, you’ve always been a restless chap. I think you’d better leave tonight.’’ So I did. And became the very first resident in the new UCLA Department of Surgery, Division of Head and Neck Surgery. I was required to spend a year as a PGY2 in general surgery, rotating through the specialties, followed by two years as senior resident in head and neck surgery. The difference between the two programs was like night and day. I did stapedectomies, tympanoplasties, rhinoplasties, open reduction of midface and mandible fractures, endoscopies for foreign bodies, and for diagnosis of laryngeal disorders. I did Caldwell Luc’s, external fronto-sphenoid-ethmoidectomies, parotidectomies, laryngectomies, radical neck dissections, and ‘‘commando’’ operations (composite resections of the oral cavity and neck). It was my first experience operating on ears through a surgical microscope. The call system was unique in that no one was ever considered off call. Surreptitious call coverage was the rule; however, no call schedule was ever published. Most of what I learned was across the table from a brilliant but unstable DDS/MD who was willing to teachdwhen I could find him. I remember scrubbing with my chairman, Joel Pressman, only once during my 3 years at UCLA. My most memorable events were two cardiac arrests during surgery, in which I performed open chest cardiac massage (closed chest had not been invented yet). One was in a bronchoscopy using an experimental form of insufflation anesthesia, and the other was an esophagoscopy, which bled out through the esophagoscope from a tumor of the mediastinum.

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Both patients died. All surgical patients were admitted the afternoon before surgery and were kept the night after surgery. The nurses wore caps. During my years of residence I had published three articles: Cogan’s Syndrome, Prostate Metastasis to the Larynx, and a series of cases of ‘‘Fatal Epistaxis.’’ An academic career looked nice but wasn’t offered to me, so it was time to bite the bullet, gird my loins, and start my own private practice. And I did. Francis B. Quinn, MD

Just as the practice of otolaryngology has changed over the years, so too the educational enterprise that supports the growth and development of the field continues to evolve. This issue of the Otolaryngologic Clinics of North America addresses many aspects of the changing educational missions and activities within otolaryngology–head and neck surgery. As highlighted in Dr. Quinn’s vignette, many of the positive changes in otolaryngology training are obvious and have been developing for decades. There is now a match program (since 2005 as part of the National Residency Matching Program) that optimizes the selection process for both applicants and residency programs. The requirements for residency training in otolaryngology have been elevated and standardized. The scope of otolaryngology practice has dramatically expanded beyond ‘‘ear, nose, and throat,’’ and there is much more uniformity in the residency experience. The training of residents throughout the United States now includes direct involvement with teaching faculty, an explicit curriculum, and a variety of nonclinical educational experiences. These developments are not new but are examples of important improvements over the last 50 years. The advances of the past are currently being melded to fit with new paradigms of educational theory; these changes, described in this issue, will be new to many readers. The evolution of otolaryngology education has been driven by multiple internal and external factors. Some of these could be considered ‘‘physician friendly,’’ such as the many medical and specialty organizations. However, other important influences come from organizations whose relationship with physicians may be considered neutral at best. Commercial and governmental payors as well as regulatory agencies are exerting ever more control over the practice of medicine and the education of physicians. These influences need to be understood, and a proactive, cooperative approach by the members of otolaryngology is required to help shape the changes taking place to ultimately benefit this specialty, its patients, and its practitioners. Over the last several decades, otolaryngology has expanded its scope of practice, and it is now a thriving specialty. It takes no persuasive powers to convince readers of the dramatic transformation that has occurred in this time span in the practice of otolaryngology. But to sustain this growth and manage change, the educational efforts within otolaryngology must continue to adapt to changes in technology, health care regulation, and economic realities. The success of this specialty depends on the capability to train a highly qualified cadre of doctors. As such, all who practice

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otolaryngology are stakeholders in the outcomes of otolaryngology education. Rapid growth in the clinical sciences, newer techniques, and initiatives to improve the quality of the health care system mandate that modern otolaryngologist–head and neck surgeons actively engage in continuing education, professional development, and lifelong learning. Educational theory and the work of professional educators are becoming increasingly important in otolaryngology education. The educational methods of the pastdparticularly the apprentice model and the didactic lecturedare becoming obsolete. Adult learning theory is changing the way doctors are educated. Within undergraduate medical education, there is a push to synchronize medical school education and subsequent graduate medical education. Similarly, the strict dividing lines between graduate medical education, board certification, and continuing medical education are beginning to blur. The educational enterprise in otolaryngology now spans a continuum from graduate medical education (residency) to the continued professional development of practitioners in the field. Even board certification from the American Board of Otolaryngology, previously considered to be a career milestone, is now becoming a ‘‘process’’ rather than an endpoint. This seamless educational continuum is a focus of this issue. Technologic advances are also expanding the available educational options. Access to the Internet facilitates rapid retrieval of reference material that can have a real-time impact on patient care. One challenge for the present is to prepare the physician workforce to be able to access, retrieve, and incorporate into practice the copious volumes of medical information available on the Internet. Of course, the ability to (1) judge the credibility and applicability of this information and (2) integrate this information into practice is just as important as learning how to access it. These challenges are discussed in this issue within the context of teaching evidence-based medicine. The Internet is also opening new horizons in continuing medical education. Internet-based continuing education is still in its infancy, but will undoubtedly expand and perhaps supplant many of the more traditional forms of continuing education. Finally, evolving computer technologies have led to increased interest in computer-based simulation as a means to teach clinical decision-making and surgical skills. Simulator-based education is commonly employed in other high-risk fields, and it will undoubtedly play a future role in the education of otolaryngologists. Various articles within this issue describe the current evolution of these technology-driven educational innovations. As described in many of the articles in this issue, the resident in otolaryngology is graduating to enter into a career of lifelong learning. The goal of this issue of the Otolaryngologic Clinics of North America is to explain developments in otolaryngology education at all stages of professional development to better equip the members of this specialty to be teachers, students, and lifelong learners all.