Prioritizing Diversity in Otolaryngology-Head and Neck Surgery: Starting a Conversation.

Academic centers embody the ideals of otolaryngology and are the specialty's port of entry. Building a diverse otolaryngology workforce-one that mirrors society-is critical. Otolaryngology continues to have an underrepresentation of racial and ethnic minorities. The specialty must therefore redouble efforts, becoming more purposeful in mentoring, recruiting, and retaining underrepresented minorities. Many programs have never had residents who are Black, Indigenous, or people of color. Improving narrow, leaky, or absent pipelines is a moral imperative, both to mitigate health care disparities and to help build a more just health care system. Diversity supports the tripartite mission of patient care, education, and research. This commentary explores diversity in otolaryngology with attention to the salient role of academic medical centers. Leadership matters deeply in such efforts, from culture to finances. Improving outreach, taking a holistic approach to resident selection, and improving mentorship and sponsorship complement advances in racial disparities to foster diversity.

Assessment of a virtual reality temporal bone surgical simulator: a national face and content validity study.

BACKGROUND: Trainees in Otolaryngology-Head and Neck Surgery must gain proficiency in a variety of challenging temporal bone surgical techniques. Traditional teaching has relied on the use of cadavers; however, this method is resource-intensive and does not allow for repeated practice. Virtual reality surgical training is a growing field that is increasingly being adopted in Otolaryngology. CardinalSim is a virtual reality temporal bone surgical simulator that offers a high-quality, inexpensive adjunct to traditional teaching methods. The objective of this study was to establish the face and content validity of CardinalSim through a national study. METHODS: Otolaryngologists and resident trainees from across Canada were recruited to evaluate CardinalSim. Ethics approval and informed consent was obtained. A face and content validity questionnaire with questions categorized into 13 domains was distributed to participants following simulator use. Descriptive statistics were used to describe questionnaire results, and either Chi-square or Fishers exact tests were used to compare responses between junior residents, senior residents, and practising surgeons. RESULTS: Sixty-two participants from thirteen different Otolaryngology-Head and Neck Surgery programs were included in the study (32 practicing surgeons; 30 resident trainees). Face validity was achieved for 5 out of 7 domains, while content validity was achieved for 5 out of 6 domains. Significant differences between groups (p-value of < 0.05) were found for one face validity domain (realistic ergonomics, p = 0.002) and two content validity domains (teaching drilling technique, p = 0.011 and overall teaching utility, p = 0.006). The assessment scores, global rating scores, and overall attitudes towards CardinalSim, were universally positive. Open-ended questions identified limitations of the simulator. CONCLUSION: CardinalSim met acceptable criteria for face and content validity. This temporal bone virtual reality surgical simulation platform may enhance surgical training and be suitable for patient-specific surgical rehearsal for practicing Otolaryngologists.

"Barbed snore surgery" simulator: a low-cost surgical model.

BACKGROUND: "Barbed snore surgery" (BSS) represents one of the last innovation for obstructive sleep apnea syndrome (OSAS) surgical management. Although this technique represents an effective and minimally invasive surgery, it is not still widespread in many ENT centers. The aim of our study was to develop an inexpensive surgical simulator useful to expedite the surgical learning curve for BSS in untrained ENT surgeons. MODEL ASSEMBLY: The simulator is a simple model composed of a manually shaped silicone palate (3 × 4 × 1 cm) fixed on a resin skeleton (21 × 16 × 12 cm) using a transparent silicon rubber. The mandible is fixed bilaterally with the aid of two screws allowing for modular inter-incisive distance. SIMULATION: Barbed anterior pharyngoplasty (BAPh) was readily performed on the simulator to show the feasibility of this BSS model. All surgical steps were carried out determining a lift and a shortening of the palate as in real surgery. CONCLUSIONS: This is the first surgical model that provides a realistic, easily repeatable training in the performance of BSS. Our BSS surgical model is very inexpensive with a cost of approximately 19.25$ dollars and it is manufactured to facilitate a worldwide diffusion of this promising palatal surgery for OSAS.

Skills transfer to sinus surgery via a low-cost simulation-based curriculum.

BACKGROUND: Surgical skill development outside the operating room aims to improve technique and subsequent patient safety. The purpose of this study was to evaluate the correlation between technical and cognitive skills with cadaveric endoscopic sinus surgery (ESS) performance and change in ESS performance before and after implementation of a dedicated ESS simulation-based and knowledge-based curriculum. METHODS: A before-after study design was implemented among 10 medical students and 10 junior otolaryngology residents. Participants completed a knowledge-based, multiple-choice ESS pretest and watched an ESS prosection video. Participants performed 9 tasks on a previously validated low-cost, low-technology, nonbiologic sinus surgery task trainer followed by cadaveric maxillary antrostomy and anterior ethmoidectomy. Participants then completed a simulation-based and knowledge-based ESS curriculum followed by a repeat cadaveric maxillary antrostomy and anterior ethmoidectomy. Performance was graded with a 5-point global rating scale (GRS) and a 5-point ESS-specific checklist. RESULTS: We observed a stronger correlation between the multiple-choice, knowledge-based, ESS pretest scores and cadaveric ESS GRS score (r = 0.73) than between task trainer performance and cadaveric ESS GRS score (r = 0.43). We also noted a significant increase in precurriculum vs postcurriculum mean ± standard deviation (SD) cadaveric ESS checklist scores for both medical students (1.18 ± 0.25 vs 2.58 ± 0.57; p = 0.0002) and residents (2.09 ± 0.78 vs 2.88 ± 0.54; p = 0.023). The greatest improvements for residents were in performance of uncinectomy, enlargement of maxillary os, and identification of the bulla. CONCLUSION: These findings provide evidence supporting the use of ESS training curricula outside the operating room.

Systematic Review of the Use of 3-Dimensional Printing in Surgical Teaching and Assessment.

OBJECTIVE: The use of 3-dimensional (3D) printing in medicine has rapidly expanded in recent years as the technology has developed. The potential uses of 3D printing are manifold. This article provides a systematic review of the uses of 3D printing within surgical training and assessment. METHODS: A structured literature search of the major literature databases was performed in adherence to PRISMA guidelines. Articles that met predefined inclusion and exclusion criteria were appraised with respect to the key objectives of the review and sources of bias were analysed. RESULTS: Overall, 49 studies were identified for inclusion in the qualitative analysis. Heterogeneity in study design and outcome measures used prohibited meaningful meta-analysis. 3D printing has been used in surgical training across a broad range of specialities but most commonly in neurosurgery and otorhinolaryngology. Both objective and subjective outcome measures have been studied, demonstrating the usage of 3D printed models in training and education. 3D printing has also been used in anatomical education and preoperative planning, demonstrating improved outcomes when compared to traditional educational methods and improved patient outcomes, respectively. CONCLUSIONS: 3D printing technology has a broad range of potential applications within surgical education and training. Although the field is still in its relative infancy, several studies have already demonstrated its usage both instead of and in addition to traditional educational methods.

Clouds of different colors: A prospective look at head and neck surgical resident call experience.

Graduate medical education programs typically set up call under the assumption that residents will have similar experiences. The terms black cloud and white cloud have frequently been used to describe residents with more difficult (black) or less difficult (white) call experiences. This study followed residents in the department of head and neck surgery during call to determine whether certain residents have a significantly different call experience than the norm. It is a prospective observational study conducted over 16 months in a tertiary care center with a resident training program in otolaryngology. Resident call data on total pages, consults, and operative interventions were examined, as well as subjective survey data about sleep and perceived difficulty of resident call. Analysis showed no significant difference in call activity (pages, consults, operative interventions) among residents. However, data from the resident call surveys revealed perceived disparities in call difficulty that were significant. Two residents were clearly labeled as black clouds compared to the rest. These residents did not have the highest average number of pages, consults, or operative interventions. This study suggests that factors affecting call perception are outside the objective, absolute workload. These results may be used to improve resident education on sleep training and nighttime patient management in the field of otolaryngology and may influence otolaryngology residency programs.

Assessment of Surgical Skills and Competency.

Evaluation of surgical skills and competency are important aspects of the medical education process. Measurable and reproducible methods of assessment with objective feedback are essential components of surgical training. Objective Structured Assessment of Technical Skills (OSATS) is widely used across the medical specialties and otolaryngology-specific tools have been developed and validated for sinus and mastoid surgery. Although assessment of surgical skills can be time-consuming and requires human and financial resources, new evaluation methods and emerging technology may alleviate these barriers while also improving data collection practices.

[Simulation in surgical training]. / Op.-Simulation in der Chirurgie.

BACKGROUND: Patient safety during operations hinges on the surgeon's skills and abilities. However, surgical training has come under a variety of restrictions. To acquire dexterity with decreasingly "simple" cases, within the legislative time constraints and increasing expectations for surgical results is the future challenge. OBJECTIVES: Are there alternatives to traditional master-apprentice learning? MATERIALS AND METHODS: A literature review and analysis of the development, implementation, and evaluation of surgical simulation are presented. RESULTS: Simulation, using a variety of methods, most important physical and virtual (computer-generated) models, provides a safe environment to practice basic and advanced skills without endangering patients. These environments have specific strengths and weaknesses. CONCLUSIONS: Simulations can only serve to decrease the slope of learning curves, but cannot be a substitute for the real situation. Thus, they have to be an integral part of a comprehensive training curriculum. Our surgical societies have to take up that challenge to ensure the training of future generations.

Phonomicrosurgery simulation: A low-cost teaching model using easily accessible materials.

OBJECTIVES/HYPOTHESIS: To introduce the use of a new phonomicrosurgical trainer using easily accessible materials, and to establish the effectiveness of the model. STUDY DESIGN: The model uses a grape imbedded in gelatin, a microscope, and microlaryngeal instruments. The study was designed to test baseline differences in training levels, as well as improvement in performance after training with the simulation model. METHODS: Thirty subjects enrolled in the Stanford University School of Medicine otolaryngology training program performed microlaryngeal surgery tasks on a grape. Tasks were designed to model both excision of a vocal fold lesion and vocal fold injection. Anonymized video recordings comparing presimulation and postsimulation training were collected and graded by an expert laryngologist. Both objective comparison of skills and subjective participant surveys were analyzed. RESULTS: Objectively, trainees in all groups made statistically significant improvements across all tested variables, including microscope positioning, creation of a linear incision, elevation of epithelial flaps, excision of a crescent of tissue, vocal fold injection, preservation of remaining tissue, and time to complete all tasks. Subjectively, 100% of participants felt that they had increased comfort with microlaryngeal instruments and decreased intimidation of microlaryngeal surgery after completing the simulation training. This appreciation of skills was most notable and statistically significant in the intern trainees. CONCLUSION: Microlaryngeal surgical simulation is a tool that can be used to train residents to prepare them for phonomicrosurgical procedures at all levels of training. Our low-cost model with accessible materials can be easily duplicated and used to introduce trainees to microlaryngeal surgery or improve skills of more senior trainees. LEVEL OF EVIDENCE: NA Laryngoscope, 126:2528-2533, 2016.

Teaching the pharyngeal flap and sphincter pharyngoplasty: The sticky note method.

OBJECTIVE: To demonstrate a cost-effective, quick, and easily reproducible three-dimensional sticky note model to enhance the understanding and conceptualization of the geometry and steps of the pharyngeal flap and sphincter pharyngoplasty. METHODS: The method involves making specified incisions and rearrangements of readily available components, including disposable clear plastic cups, yellow and pink sticky notes, and white paper. Once assembly is complete, further incisions and remodeling are performed to simulate a pharyngeal flap or sphincter pharyngoplasty. RESULTS: The cost of the materials to make one model was $0.94. Average construction time was less than 10 min. CONCLUSION: This three-dimensional model is an efficient, interactive, and simple visual aid to teach surgical trainees the geometry and steps of the pharyngeal flap and sphincter pharyngoplasty.

Construct validity of cadaveric temporal bones for training and assessment in mastoidectomy.

OBJECTIVE: To determine the construct validity of cadaveric temporal bones in mastoidectomy training. STUDY DESIGN: A prospective observational study. METHODS: Trainees from the North London otolaryngology training program performed step-wise modified radical mastoidectomy on cadaveric temporal bones under faculty supervision. Performance was assessed using a validated mastoidectomy assessment tool. A longitudinal assessment of nine trainees was also carried out over two sessions separated by 12 months. The main outcomes measures were task-specific (TS) and global skills (GS). RESULTS: Twenty-six intermediate and eight novice trainees participated and were assessed by a minimum of two assessors each. Intermediate trainees performed significantly better than novices in TS and GS (P < 0.001). Performance correlated well with training level using Spearman rank correlation coefficient (r(s)) (TS r(s) 0.265 and GS r(s) 0.503). The number of otological procedures performed, and in particular mastoidectomies, correlated well with performance (TS r(s) 0.327 and GS r(s) 0.528). Longitudinal assessment showed significant improvement with iteration (TS P = 0.008 and GS P = 0.008). Attending otological courses also improved performance significantly (TS r(s) 0.345 and GS r(s) 0.469). CONCLUSIONS: The cadaveric temporal bone demonstrated construct validity and can be used to detect progress in performance of otolaryngology trainees. This is a keystone in moving toward a competency-based training system. LEVEL OF EVIDENCE: N/A.

[Outpatient Surgery in German ENT in Teaching Hospitals--Economic Nonsense?]. / Ambulante Operationen in HNO-Ausbildungskliniken - ökonomischer (Un)sinn?

INTRODUCTION: There is an ever-increasing demand to increase efficiency and decrease costs in health care. This leads to an growing number of outpatient surgeries which are less cost effective. Especially in the setting of university teaching hospitals, this may lead to both an undersupply of qualified physicians, as well as to a worsening of clinical training of residents. In order to quantify a possible undersupply and estimate the expense of teaching residents, the time for medical procedures needs to be quantified and compared between board-certified physicians and residents. This was the aim of the current study. MATERIAL AND METHODS: All outpatient adenotomies of children with or without paracentesis or tympanic drainage insertion performed in 2012 in 2 ENT teaching hospitals were analyzed. The length of the surgical procedure as well as the level of training of the surgeon was analyzed. Operating times of residents in training were analyzed stratified by training level and then compared to operation times of board-certified ENT surgeons. RESULTS: 255 procedures were analyzed. Significant differences of the mean operation time could be identified depending on the level of training of residents compared to board-certified ENT surgeons for all investigated training levels. E. g. 1(st) year residents' surgeries required 2.4 times more time than those of board-certified ENT surgeons. CONCLUSION: Based on an analysis of outpatient ENT-surgical procedures it becomes apparent that due to the extended operating times of residents in training outpatient surgery is by far less cost-effective than by board-certified physicians. To cope with the demand of teaching residents for their clinical training, more resources are necessary in the setting of teaching hospitals.

Impact of resident surgeons on procedure length based on common pediatric otolaryngology cases.

OBJECTIVES/HYPOTHESIS: Surgical education remains an important mission of academic medical centers. Financial pressures may favor improved operating room (OR) efficiency at the expense of teaching in the OR. We aim to evaluate factors, such as resident participation, associated with duration of total OR, as well as procedural time of common pediatric otolaryngologic cases. STUDY DESIGN: Retrospective cohort study. METHODS: We reviewed resident and attending surgeon total OR and procedural times for isolated tonsillectomy, adenoidectomy, tonsillectomy with adenoidectomy (T&A), and bilateral myringotomy with tube insertion between 2009 and 2013. We included cases supervised or performed by one of four teaching surgeons in children with American Society of Anesthesiology classification < 3. Regression analyses were used to identify predictors of procedural time. RESULTS: We identified 3,922 procedures. Residents had significantly longer procedure times for all procedures compared to an attending surgeon (4.9-12.8 minutes, P < 0.001). Differences were proportional to case complexity. In T&A patients, older patient age and attending surgeon identity were also significant predictors of increased mean procedural time (P < 0.05). CONCLUSIONS: Resident participation contributes to increased procedure time for common otolaryngology procedures. We found that differences in operative time between resident surgeons and attending surgeons are proportional to the complexity of the case, with additional factors, such as attending surgeon identity and older patient age, also influencing procedure times. Despite the increased procedural time, our investigation shows that resident education does not result in excessive operative times beyond what may be reasonably expected at a teaching institution.

A validation study on the use of intra-operative video recording as an objective assessment tool for core ENT surgery.

OBJECTIVES: To investigate the reliability and validity of remote scoring a video assessment of a core ENT surgical procedure (myringotomy and grommet insertion) and its suitability as an objective tool for assessing the technical skills of ENT surgeons. DESIGN: Single-blinded (raters) video assessment. SETTING: Tertiary Care University Hospital. PARTICIPANTS: Consultant and trainee [Specialty Registrar (StR) and Core Trainee (CT)] ENT surgeons performing a total of 30 consecutive index procedures. MAIN OUTCOME MEASURES: To determine the construct validity and the reliability of video assessment scoring of myringotomy and grommet insertion by two raters at ENT Consultant level with a subspecialty interest in Otology. To measure the performance (by rating) of participants compared to operative time. RESULTS: A strong correlation between scores by the two blinded raters was demonstrated (ρ = 0.748; P < 0.001). Median scores (/45) for each group were as follows: CT 25.5 (IQR 21.13-31.25), StR 33 (IQR 24.88-35) and Consultant 40 (IQR 35.38-42.63). Kruskal-Wallis test analysis showed statistically significant mean rank scores between the three different levels of experience (H = 12.77, P = 0.002). Multiple group comparisons indicated a significant difference between CT and Consultant groups (P < 0.001) and StR and Consultant groups (P = 0.007). Analysis of the time taken between the experience groups demonstrated a difference (H = 8.689, P = 0.013) although individual intergroup comparisons indicated this was only significant between CT and Consultant groups (P = 0.004). There was a significant negative correlation (ρ = -0.842; P < 0.001) between time taken for procedure and score achieved. CONCLUSIONS: Video assessment of myringotomy and ventilation tube insertion may represent a valid, feasible tool for use in summative and formative assessments of trainee ENT surgeons. Remote scoring of assessment procedures minimises bias and enables blinding of raters. ENT is well positioned to benefit from video assessment due to the high number of surgical procedures within the specialty that are performed utilising digital technology.

[Safe patient care: safety culture and risk management in otorhinolaryngology]. / Patientenversorgung--aber sicher: Sicherheitskultur und Risikomanagement in der Hals-,Nasen-, Ohrenheilkunde.

Safety culture is positioned at the heart of an organisation's vulnerability to error because of its role in framing organizational awareness to risk and in providing and sustaining effective strategies of risk management. Safety related attitudes of leadership and management play a crucial role in the development of a mature safety culture ("top-down process"). A type marker for organizational culture and thus a predictor for an organizations maturity in respect to safety is information flow and in particular an organization's general way of coping with information that suggests anomaly. As all values and beliefs, relationships, learning, and other aspects of organizational safety culture are about sharing and processing information, safety culture has been termed "informed culture". An informed culture is free of blame and open for information provided by incidents. "Incident reporting systems" are the backbone of a reporting culture, where good information flow is likely to support and encourage other kinds of cooperative behavior, such as problem solving, innovation, and inter-departmental bridging. Another facet of an informed culture is the free flow of information during perioperative patient care. The World Health Organisation's "safe surgery checklist" is the most prevalent example of a standardized information exchange aimed at preventing patient harm due to information deficit. In routine tasks mandatory standard operating procedures have gained widespread acceptance in guaranteeing the highest possible process quality.Technical and non-technical skills of healthcare professionals are the decisive human resource for an efficient and safe delivery of patient care and the avoidance of errors. The systematic enhancement of staff qualification by providing training opportunities can be a major investment in patient safety. In recent years several otorhinolaryngology departments have started to incorporate simulation based team trainings into their curriculum.