New Research and Education at COSM 2019

AUSTIN, Texas—In May, Triological Society members and other attendees came together for the society’s 122nd Annual Meeting to share research and foster new ideas within the field of otolaryngology. The 2019 Triological Society Annual Meeting, held in conjunction with the Combined Otolaryngology Spring Meetings (COSM), welcomed 470 attendees plus residents and medical students, who joined discussions, heard panelists debate, and viewed an extensive array of scientific posters.

Nearly 900 residents and medical students attended COSM, many of whom were offered the opportunity to present clinical and research papers and posters during the society meetings. “I attended the conference to learn about the newest developments in otology and to support the excellent work of some of the medical students and residents with whom I work,” said Aaron Moberly, MD, an assistant professor in the division of otology, neurotology, and cranial base surgery in the department of otolaryngology–head and neck surgery at  The Ohio State University Wexner Medical Center in Columbus.

During the Triological Society’s scientific sessions, 65 podium presentations and seven panels were given. More than 160 posters were presented as a part of a combined poster session. The Triological Society again funded travel grants to fellows, residents, and medical students selected to present oral and poster presentations during the Society’s scientific sessions.

Presidential Address: A Patient’s Perspective on HNC

Sigsbee Duck, RPh, MD, said that he has had an incredible year as the president of the Triological Society. His presidential speech was made “to simply remind all otolaryngologists how important empathy and caring are for our cancer patients. I am just laying out the stark and personal reality of being a head and neck cancer patient first hand and the feelings associated with the treatment process.” He went on to thank all of his head and neck surgery colleagues who selflessly care for patients like him on a daily basis.

Dr. Duck definitely understands the importance of empathy and caring for cancer patients, as he himself is a head and neck cancer survivor. “On the morning of March 9, 2015, I was getting ready for work, shaving actually, when I felt a mass in my right upper neck. Denial set in and I convinced myself that it was an infection.” He put himself on antibiotics and after a few doses he realized it was not going down and seemed to be larger. Becoming quite concerned, he called the Huntsman Cancer in Salt Lake City and drove three hours from Wyoming the same Thursday for a biopsy. The physician told him the ultrasound characteristics appeared benign and to come back in one month if the mass was still present for a FNA. He responded, “I’m here now, so please proceed.” He did and the next Monday the endocrinologist called to inform him “you have metastatic epidermoid carcinoma.” Reality quickly set in.

“This couldn’t be happening to me,” Dr. Duck thought. He was asked to be back at the Huntsman on Wednesday for a PET scan, but as he had NCAA basketball tournament tickets in Kentucky the following weekend, he opted to wait a week and meet his family to let the reality of a totally surrealistic situation settle in. The next week the PET scan was completed. With his surgeon, Dr. Jason Hunt’s hand on his shoulder, he was informed he had a “large tonsillar carcinoma with neck metastasis.”

Dr. Duck underwent a radical tonsillectomy and a modified RND the next day. “I was still in denial,” he said. “Five hours later reality took hold when I awakened to find an NG tube, a Foley, a JP drain, an IV between the toes on my right foot, an inability to swallow and complete anesthesia from my mid cheek to my clavicle. When I finally woke up, reality once again hit and I sat up with a very kind nurse and cried for about three hours. Then came swallowing therapy and ultimately tubes were removed one at a time as my wife and I waited for the pathology reports to assure clear margins and positive testing for HPV and P-16.” He was blessed to have these findings. The day he left the hospital, a Basset Hound therapy dog came by to visit and he realized that “it’s the small things that really mean the most to patients.”

Sigsbee W. Duck, MDAs physicians, we must take extra time with our cancer patients. We must show genuine empathy. —Sigsbee W. Duck, MD

“Emotions run amuck while going through cancer treatment and they are very difficult to control,” Dr. Duck found out. “When I finally returned to work in Wyoming prior to radiation therapy, I was not successful—or nice. I was curt and downright rude. I had not realized the emotional toll cancer takes on patients.”

Radiation therapy was next. “Despite having sent hundreds of patients for these treatments, it was at this point that I realized that I really didn’t know anything about it. Now, more than ever, I genuinely admire my cancer patients, particularly the ones without the financial means or family support like I was blessed to have who must complete this therapy.” Dr. Duck recalled an older man who sat next to him before his first radiation treatment. “He had been told his radiation was palliative and to get his affairs in order. He asked why I was there and I told him and he said good luck. The next day, he was not there and I never saw him again. It is sad and disconcerting to see all these patients every day, and suddenly they are not there anymore.”

On his last day of radiation, the waiting room was full and he was informed that the machine was down. “I figured my options were to get mad, sulk, or cry. Well, I’m a crier,” he said. The other patients with whom he had bonded huddled around him for support, the machine was ultimately repaired and with radiation therapy completed, he finally left the Huntsman.

Dr. Duck’s long and emotionally difficult experience with surgery and radiation were not only grueling, but also educational. “The post-traumatic effects of surgery and radiation therapy, especially as radiation is over-utilized to treat this disease, particularly when used in conjunction with chemotherapy, are very real,” Dr. Duck stated. “And radiation is definitely the gift that keeps on giving—for the rest of your life. Your taste is permanently altered, you have pain and cramping with exercise, and you can never taste or swallow effectively.”

“And there is a stigma associated with HPV H&N cancer. Even my colleagues make jokes about sexual transmission. I had been married for 33 years, and I found no humor in their jokes,” he said. “Frankly, who knows what  bacteria any of us are harboring as otolaryngologists? My entire family has been tested and cleared and we have received the HPV vaccine including the P-16 and P-18 strains.

“No matter how many H&N cancer patients  you have cared for, always remember the absolute feelings of fear and helplessness that your patients experience. As physicians, we must take extra time with our cancer patients. We must show genuine empathy. Sit down by the bed as if you are not busy. These days, I share my experience with my patients and it reassures them in a positive way.” Dr. Duck added. “Most importantly, an opportunity to convey information to a patient’s family and exude a feeling of optimism and trust as to the care we are taking of their loved ones, is one of the greatest opportunities we have as physicians—to demonstrate compassion and caring through simple communication and basic kindness.”

Dr. Duck’s hard-earned message is this: “As cancer patients we are always looking over our shoulders; fear, anxiety, and reality are always lurking. More than ever [these patients] need a physician who is sensitive to that reality and who can show genuine empathy and caring.” 


Elizabeth Hofheinz is a freelance medical writer based in Louisiana.

Upcoming Triological Society Meetings

Combined Sections Meeting
January 23-25, 2020
Coronado, Calif.

123rd Annual Meeting at COSM
April 24-25, 2020
Atlanta, Ga.

Visit triological.org for more information.

ENT Today

Tips to Help You Regain Your Sense of Self

When I was 10, my family and I lived in rural Pennsylvania. I had three siblings and we made our own fun. We climbed trees, made friends with spiders, and played with the neighbor’s horse until the fence broke and it almost stepped on my baby brother. We mostly played outside to stay out of trouble, but inside could be equally entertaining. There were inside rules—no running, quiet voices, no bouncy ball—which were sometimes circumvented, but almost universally obeyed.

One day, left to my own devices, 10-year-old me disobeyed one of the more sacrosanct decrees of my household: Thou shalt not climb on the cabinets. My need for fun eclipsed my innate desire to follow the rules and up, up, up I went. A moment basking in the glow of my success was followed by panic. My mom was on the porch and would enter the house momentarily. I jumped. White hot pain exploded in my left foot. It had landed, big toe first, in an open box of Legos. I stifled a scream and fell to the floor. “What on earth is going on?” my mom asked. “I think I stubbed my toe,” I lied.

My parents were confused as to how a stubbed toe could cause so much pain, as were the emergency department physicians who evaluated me when my agony had not subsided several hours later. However, I was now committed to my lie and kept retelling the same story. We were reassured that nothing was wrong. My stubbed big toe would heal up just fine on its own. And heal it did, only an inch shorter and fused at the proximal and distal interphalangeal joints. I am reminded of my trivial childhood decision to lie every time I put on a pair of shoes, one of which will forever either be too big or too small. It makes me wonder if the truth and a plaster cast may have been the better option. I also wonder how, without the benefit of time, wisdom, and retrospection, we can know this in advance.

For me, this is also true when it comes to the decisions we make daily. Some decisions are like a mask we put on. Ten-year-old me wanted her “good girl,” rule-following mask to stay intact more than she wanted to have her toe properly addressed. That same year, we fifth graders were eligible to join the school band. During an informational session, they told us that the flute was one of the more difficult instruments to learn. I heard nothing else; that was all I needed to know. Another layer of my mask at the time was proving that I could excel at all the difficult things. Flute it was, regardless of whether or not another instrument would have brought me more joy. The elements of our masks may be genetic, learned, taught, or arise from trauma or other experiences. They are almost always well intentioned.

However, I believe that the mask analogy isn’t entirely accurate. These things do not make up our masks; they make up our casts. They are put on to protect us or to help us move with more ease through our circumstances. There are plenty of resources available to show us how to add layers to our casts. Facebook and Instagram have taught a generation to post smiling pictures showcasing “Living Your Best Life.” The importance of this careful curation of visual snippets of your life is to project the image of who you want the world to think you are. Peeling away the layers and exposing what’s underneath is not nearly as publicized or glamorous.

Jennifer A. Villwock, MDI was really struggling then too. I didn’t have anyone to talk to because everyone seemed to have all their stuff together except me. If only we had known, we could have probably really helped each other. —Jennifer A. Villwock, MD

I recently gave a local TEDx talk. Some of what I said you might have read before in my last wellness column (ENTtoday. 2018;13:1). Some of it was new. The gist of the talk was about the importance of the stories we tell ourselves about our experiences, illustrated by examples from my life as a surgeon. Some people told me my talk moved them to tears. Several that knew me during the difficult stages in my life that I talked about said, “I was really struggling then too. I didn’t have anyone to talk to because everyone seemed to have all their stuff together except me. If only we had known, we could have probably really helped each other.” I didn’t say anything that most of us haven’t experienced. I just peeled back a tiny bit of one of my casts.

So what happens if you don’t take a cast off or if you don’t know how? It gets itchy. Probably a little smelly too. The strength underneath can atrophy, the skin turning pale. As time progresses, it can take not only an increasing amount of effort, but also courage, to try and take off the cast. Because of this, we may elect to accept the itch. I wonder if more of us were willing to peel back our casts with an attitude of, “Hey, look at this. Isn’t this strange, but also normal considering what we’ve been through? Won’t it be cool to watch this limb rehabilitate and be strong again?”—would we all be healthier as a community?

Because the location and substance of our casts can be so different, generic one-size-fits-all wellness advice can fall short. For example, online wellness modules are typically not universally well received. At best, one size fits some. Additionally, this type of well-intentioned advice can be counterproductive. If you absolutely cannot sit still, hearing that you need to do sitting meditation daily may just create stress and angst and another plaster layer on your cast as you try to comply. Similarly, I dislike running; my marathon-running partner is my exercise-kryptonite. The “couples who sweat together, stay together” mantra does not apply to us; trying to follow it would harm our relationship.

Do you know where your casts end and your own skin begins? As you head to bed and reflect on your day, maybe catching a glimpse of yourself in the mirror, do you ever get that nagging sensation that you’re not who you wanted to be? Great news! This is your own subtle call to action and tomorrow is another opportunity to be the better person you had hoped you would be today. The only question now is what to do with that sensation. Perhaps consider answering the following questions for yourself and experiment with implementing the answers in your own life:

  • What foods do you actually enjoy eating that also healthfully fuel your body? Eat those things. If you don’t know, ask for help. Your health insurance may include free health coaching or nutrition perks. Maybe organize a healthy potluck or meal exchange.
  • What activities do you enjoy that move your body and keep you active? Do more of that. If you don’t know, consider signing up for a random class or take advantage of a Groupon offer.
  • Feeling too introverted or embarrassed for an exercise class? Sign up for a two-week free trial of one of the many exercise apps available.
  • Do you have a hobby or interest? Nurture it. Can’t remember what you find fun? Ask a friend or colleague for a recommendation or to come with you to a random community event. (I recommend children’s musical theater. There are few things cuter than a multitude of 5-year olds singing Disney songs!)
  • Do you like to create? Decide to make something and, if you don’t already know how, watch a YouTube video and learn (if you’re interested in crochet, check out Wooly Wonders crochet channel ϑ). If you realize you hate the process halfway through, give yourself permission to quit!
  • What new horizons would you like to explore through music or literature? Ask a friend if they’ve come across any up and coming artists or find an open mic night. Maybe join, or start, a book club.

And to you medical students and residents reading, or anyone else who’s overwhelmed with their exceptionally busy life, actively thinking to yourself, “I do not have the time, or the money, for any of your suggestions,” I see you. I hear you. I understand. Perhaps a follow-up question to the ones above may be, “What is the smallest next step I can take towards those goals?” Could you carry almonds or other nuts in your white coat pocket to have a healthy snack option? Can you commit to taking the stairs up one more flight of stairs than you normally would while rounding on patients? Can you sneak away for five minutes in between consults to go stand in a patch of sunlight and take 10 deep breaths? Could you focus on having one genuine, human interaction with another person per day?

As you consider these options, be kind to yourself as you experiment. Not everything is going to feel “right.” It may take some time to remember who you are under all the layers and after all the years of focusing on your training and the welfare of others. Try to avoid “should-ing all over yourself” and doing things out of guilt because they’re what you think you’re supposed to do, lest they drain you while adding another layer of plaster.

“Love takes off casts* that we fear we cannot live without and know we cannot live within.”—James Baldwin

*original quote: “Love takes off masks…” 


Dr. Villwock is an assistant professor of  otolaryngology–head and neck surgery in the division of rhinology and skull base surgery at the University of Kansas Medical Center in Kansas City. She is also a member of the ENTtoday editorial advisory board.

Call to Action

How you can explore your sense of self:

  • Sign up for a class or take advantage of a Groupon offer.
  • Organize a healthy potluck or meal exchange.
  • Sign up for a trial with one of the many exercise apps available.
  • Ask a friend or colleague to accompany you to a random community event.
  • Decide to make something and, if you don’t already know how, watch a video online.
  • Join—or start—a book club.
  • If you know you don’t like something, allow yourself to say no, and try to let go of feeling guilty.

ENT Today

Is Core Needle Biopsy Effective for Assessment of Head and Neck Lesions?

TRIO Best PracticeTRIO Best Practice articles are brief, structured reviews designed to provide the busy clinician with a handy outline and reference for day-to-day clinical decision making. The ENTtoday summaries below include the Background and Best Practice sections of the original article. To view the complete Laryngoscope articles free of charge, visit Laryngoscope.

Background

Ultrasonography in combination with fine needle aspiration (FNA) has served as the primary line of investigation for head and neck lesions. In the 10% to 15% of cases for which FNAs yield nondiagnostic material, the next option is often excisional biopsy under general anesthesia. In patients who are poor surgical candidates, core needle biopsy (CNB) with a larger gauge needle under ultrasound guidance has emerged as a simple, minimally invasive, and accurate method for the diagnosis of head and neck lesions, especially when conservative treatment is likely. CNB has been shown to yield a higher sensitivity and specificity compared to FNA in head and neck lesions, including malignant lymphoma. Surveys show physicians are reluctant to incorporate this diagnostic method into practice due to concerns regarding bleeding, infection, nerve injury, and tumor cell seeding. This article reviews the evidence for the safety of CNB in the diagnosis of head and neck lesions, with an emphasis on the risk of tumor cell seeding and bleeding.

Best Practice

Based on current studies, ultrasound guided CNB is a minimally invasive and accurate diagnostic option for the assessment of head and neck lesions, including lymphoma. In comparison to FNA, CNB has achieved a higher accuracy in providing specific diagnoses, detecting malignancy, and identifying true neoplasms. CNB should be the procedure of choice in patients with multiple nondiagnostic FNAs prior to excisional biopsy. These studies have shown that CNB has enhanced accuracy and equivalent safety compared to FNA and lower rates of complications as compared to excisional biopsy (Laryngoscope. 2018;129:2669–2670)

ENT Today

Mild Obstructive Sleep Apnea in Children: What Is the Best Management Option?

TRIO Best PracticeTRIO Best Practice articles are brief, structured reviews designed to provide the busy clinician with a handy outline and reference for day-to-day clinical decision making. The ENTtoday summaries below include the Background and Best Practice sections of the original article. To view the complete Laryngoscope articles free of charge, visit Laryngoscope. May 2019

Background

Pediatric obstructive sleep apnea (OSA) is characterized by upper airway obstruction, poor sleep, and daytime sequelae such as hyperactivity. Although controversy exists regarding the ideal evaluation for children with sleep-disordered breathing, the severity of OSA is currently determined by full-night polysomnogram (PSG). Mild OSA is defined by an apnea-hypopnea index (AHI) > 1 and <5. The majority (approximately 85%) of healthy school-aged children evaluated by otolaryngologists for tonsil hypertrophy and obstructive symptoms have either primary snoring or nonsevere OSA.

The treatment of mild OSA in children is controversial. There is a lack of data on the natural history of mild sleep apnea. Furthermore, a poor correlation exists between quality of life (QOL) scores and OSA severity; mild OSA in children may have a significant impact on their general health and well-being. High-quality studies comparing observation, medical management, and surgery for mild pediatric OSA are just beginning to emerge. Many of these studies use varied measures to assess outcomes. Thus, it may be difficult for providers treating children with mild OSA to counsel parents on the optimal treatment for their child.

Best Practice

Multiple therapeutic options may be effective for treating mild pediatric OSA including observation, management with anti-inflammatory medications, and surgery (Table 1). Validated instruments that assess symptom burden and the impact of OSA on QOL may be useful in determining which treatment option is most appropriate for the child. Shared decision making between caregiver, child (when appropriate), and physician may be useful in developing a management strategy for mild OSA. Data on the sequelae of mild OSA in children, including the impact of obstruction on cardiovascular parameters and neurocognition, are lacking. Future research is needed to compare long-term outcomes for the different treatment options for mild OSA in children (Laryngoscope. 2018;128:2671–2672).

ENT Today

Do Preoperative Corticosteroids Benefit Patients with Chronic Rhinosinusitis with Nasal Polyposis?

TRIO Best PracticeTRIO Best Practice articles are brief, structured reviews designed to provide the busy clinician with a handy outline and reference for day-to-day clinical decision making. The ENTtoday summaries below include the Background and Best Practice sections of the original article. To view the complete Laryngoscope articles free of charge, visit Laryngoscope.

Background

Optimizing the surgical field in patients with chronic rhinosinusitis with nasal polyposis (CRSwNP) increases the chances for a safe and efficient surgery. Preoperative medical management, anesthetic choice, patient positioning, and topical vasoconstrictors are methods currently used to mitigate cumbersome bleeding during surgery. Decreased bleeding improves the quality of the optical cavity, thereby enhancing visualization of nearby critical structures.
Pretreatment with corticosteroids is a common practice with the theory that decreased preoperative mucosal inflammation and edema results in less blood loss and better surgical visualization. Several randomized trials have addressed the efficacy of CRSwNP pretreatment with corticosteroids with respect to bleeding loss and surgical field quality.

Best Practice

Preoperative treatment of patients with CRSwNP undergoing endoscopic sinus surgery with corticosteroids is indicated and beneficial. Pretreatment with corticosteroids shortens operative time, likely decreases bleeding, and improves the quality of the surgical field allowing for safe and efficient surgery. There are known risks of administration of systemic corticosteroids, and clinicians must take these into account when evaluating an individual patient. Additionally, future studies are needed to determine the optimal dose and duration of treatment (Laryngoscope. 2019;129:773–774).

Table 1. Summary of Management of Pediatric Obstructive Sleep Apnea

(click for larger image) Table 1. Summary of Management of Pediatric
Obstructive Sleep Apnea

ENT Today

Clinical Judgment: Balancing Evidence-Based Medicine and Patient Self-Determination

Clinical Scenario: You are seeing a patient, Henry Jones, in your faculty clinic with a second-year otolaryngology resident. Mr. Jones is a 78-year-old gentleman who was referred by a neurology colleague for the evaluation of an incidental finding seen on an MR scan obtained during the course of a late-onset Alzheimer’s disease workup. The neurologist sent both the scan images and the neuro-radiologist’s report, which stated that, in addition to some early changes suggestive of neurodegeneration, there is a 3-mm presumed acoustic tumor in the right internal auditory canal.

The resident evaluated and examined the patient prior to presenting him to you, and you confirm the history, signs, symptoms, and examination findings with your own evaluation. Mr. Jones and his wife explain that he has had some hearing loss that has been present since his discharge from the military, where he completed 21 years as an aircraft mechanic. When pressed, he indicates that perhaps his hearing is worse in the right ear, but not substantially so. The tuning fork tests at 512 Hertz were normal. The neurological examination, including neuro-vestibular, facial, and oculomotor tests, was unremarkable. The patient states that he has had some occasional imbalance, but no falls and no vertigo. His neurology consultation was primarily for memory loss. You feel that he appears to be competent in his judgment. Before the patient is escorted to the audiometry suite, he emphatically states that he is not interested in any surgery or radiation at this time, which is what the neurologist had mentioned to him.

You and the resident return to discuss the findings with the patient, and review the MR scan, the audiogram, the history, and physical findings. An onsite audiogram demonstrates bilateral noise-induced hearing loss with a downward slope from 1000 Hertz, slightly worse in the right ear. When queried about what should be the recommended course of action for the patient, the resident excitedly tells you that, with a small tumor, either surgery or radiation therapy would be indicated. He further shows you printouts of several systematic reviews that support early intervention to lessen the effects of the mass on auditory and vestibular function. You remind him that the patient stated he did not want surgery or radiation treatments, but the resident makes his case for intervention—“We’re here to cure disease, aren’t we? And, we know much better than the patient what treatment is called for.” It is clearly time for a teaching moment.

How would you handle this moment?


Discussion

The current state of patient care has been significantly influenced by the expansion of, and reliance on, evidence—acquired through outcome studies, systematic reviews, higher-level research, and other scientific work. There is no doubt of the importance of evidence-based medicine studies in clinical decision-making, but where now is the place for patient self-determination and the art of medical care? Past generations of physicians relied heavily on the history, physical examination, fundamental diagnostic tests, and subsequent discussions with patients about the physician’s diagnosis and recommended treatment. While technological advances have greatly enhanced physicians’ diagnostic capabilities, some feel that it may have been at the sacrifice of an extensive physical examination and patient-physician discussions. The profession now has become increasingly reliant upon algorithmic medicine, which outlines, to a significant degree of complexity, protocols and best practices, which are designed to reduce variance in patient care across the population and are based on available evidence acquired through scientific studies. The specialty of otolaryngology-head and neck surgery, along with every specialty through the efforts of groups of experts, reviews the available data for many diseases and disorders and develops practice guidelines which inform the otolaryngologist-head and neck surgeon in her/his clinical decision-making. How the individual otolaryngologist utilizes the recommendations, evidence, and data in the care of an individual patient is called “clinical judgment.”

What then, are the elements of clinical judgment that come to play in our care of patients? There are many synonyms for clinical judgment, and many authors have proposed various elements. This author believes that there are four major elements in clinical judgment that eventually lead to the therapeutic plan for a patient. These are:

  • Knowledge;
  • Critical thinking and interpretation;
  • Patient self-determination; and
  • Shared decision-making.

Impacting each element of clinical judgment is the acquisition of experience.

The first fundamental step is the acquisition of knowledge—the knowledge of anatomy, pathophysiology, metabolic pathways, evidence, pharmaco-therapeutics, surgical techniques and outcomes, and so much more—acquired over the long course of education, training, and practice. This author often tells medical students and residents that the acquisition of knowledge is an ethical responsibility to patients and fundamental to their care. It is driven by an ultimate obligation to patients to know as much as humanly possible about the diseases and disorders across our entire specialty. The patient expects us to know the information, or to seek the information as we develop a recommendation for their care. Knowledge in medicine is always changing; therefore, we must continue to learn new knowledge throughout our professional career—it is not trite to repeat the mantra “life-long learning.”

Every act we perform in the course of evaluating a patient is knowledge acquisition—the history and physical examination is appreciated in the context of our knowledge of normal versus abnormal findings; our appreciation of various facial expressions and body language that can be interpreted in the light of the patient’s response to her/his health concerns; an understanding of side effects and adverse reactions of pharmaco-therapeutics—and we both consciously and unconsciously add these observations to our database of clinical medicine.

There is no doubt of the importance of evidence-based medicine studies in clinical decision-making, but where now is the place for patient self-determination and the art of medical care?

The second important element of clinical judgment is the dyad of critical thinking and interpretation. This dyad is informed by our knowledge, both fundamental and that which is pertinent to the individual patient through consideration of the evidence in the literature and how closely the evidence applies. The history and physical examination give rise to a differential diagnosis set, and from there we work with pertinent evidence to determine how to proceed with diagnostic testing. One can approach the critical thinking either pragmatically or open-mindedly, casting a narrow diagnostic net or a wide one. We are primarily biological scientists, so we can use the scientific method to follow the trail of evidence to the point of reasonable confidence in our interpretation in the context of population-based studies.

The third element of clinical judgment is decision-making. This is the culmination of acquisition of knowledge about the patient (history, physical examination, diagnostic studies, interpretation of the evidence, and critical thinking leading to a presumptive diagnosis) and the consideration of what recommendation(s) should be made to the patient for her/his consideration. The impact of clinical experience is quite important here, for the experienced otolaryngologist has an internal database of similar compilations of symptoms, signs, findings, and diagnoses that inform her/him what should be recommended to a given patient.

At times, the evidence-based recommendations will fit nicely with our working diagnosis, and the course of recommended action to the patient will be clear-cut. With other patients, some uncertainty in the diagnosis and management may be present—so how to deal with, or manage, uncertainty becomes our challenge. Some uncertainty is part and parcel of even the most refined scientific study, and when dealing with human illness, uncertainty may often play a role—uncertainty in how you should proceed in formulating a therapeutic recommendation, and uncertainty in how the patient will consider and respond to your recommendations. Herein lies the fourth element of clinical judgment—patient self-determination.

© BlurryMe / shutterstock.com

© BlurryMe / shutterstock.com

The primary ethical principle in patient care is often said to be “autonomy,” which is the right of patients to make their own decisions about their health care, in the context of unbiased explanation of the options and their basis by the clinician. In earlier times, where information technology was not prevalent, the physician held sway over the recommendations, for she/he had the information. Now, many patients are so much more prepared to make their own decisions, based on their own information, as well as what their otolaryngologist has explained to them. That doesn’t mean that the otolaryngologist has to compromise her/his professional integrity for a patient’s decision, but rather to accept a patient’s wishes after all information has been given and all professional recommendations have been discussed.

In most clinical encounters, physicians utilize some form of “shared decision-making” with patients that usually results in an acceptable therapeutic plan to both patient and physician. In shared decision-making, the physician explores the patient’s personal and health values, which can have a tremendous influence on what therapeutic plan will be acceptable to the patient. Other important factors may be religious and cultural preferences/influences, or constraints due to social, economic, or financial burdens. The otolaryngologist has an obligation to mitigate any “solvable” constraint, but also an obligation to understand and support the patient’s wishes, as long as they are professionally ethical. Gaining experience in dealing with patients, particularly in complex diseases and difficult therapies, can be helpful in developing a shared plan for the patient’s care.

In this clinical scenario, Mr. Jones is an older gentleman with the likely diagnosis of a progressive neurodegenerative disorder. Indeed, he does have a small tumor in the internal auditory canal, but his symptoms at this time are minimal from this tumor. You should discuss patient autonomy and clinical judgment with the resident, and point out that you could achieve a shared decision with the patient and his wife by accepting his decision to not have an intervention, and by offering to follow him closely for new signs or symptoms that may call for revisiting a potential intervention if indicated in the future. At this time, the patient appears to be competent to make his own healthcare decisions, and to cognitively understand the risks and benefits of observing a small acoustic tumor over time. Take the time to answer the patient’s and his wife’s questions to their satisfaction in the resident’s presence. Through appropriate and experienced clinical judgment, you will have followed an acceptable course of professionalism and ethics, supported the patient’s wishes, and shared an appropriate decision with the patient. You also may have impacted the resident’s understanding of clinical judgment.


Dr. Holt is professor emeritus in the department of otolaryngology–head and neck surgery at the University of Texas Health Science Center in San Antonio.

Hospitalists as Test Subjects

  1. Knowledge: The knowledge of anatomy, pathophysiology, metabolic pathways, evidence, pharmaco-therapeutics, surgical techniques and outcomes, and so much more acquired over the course of education, training, and practice.
  2. Critical Thinking and Interpretation: Physician knowledge, both fundamental and that which is pertinent to the individual patient through consideration of the evidence in the literature and how closely the evidence applies.
  3. Decision-Making: The culmination of acquisition of knowledge about the patient and the consideration of what recommendation(s) should be made to the patient for her/his consideration.
  4. Patient Self-Determination: Acceptance of a patient’s wishes after all information has been given and all professional recommendations have been discussed.

ENT Today

Letter from the Editor: Otolaryngology Must Address Diversity, Gender Bias

Cultural conditioning shapes who we think we are at any given point in our lives. Few are those who ever challenge or outgrow the beliefs that have been instilled by family and society during those early years.—Mooji

I have always advised students to avoid the doctors’ lounge, especially those filled with pessimistic physicians who talk about how medicine is not what it used to be or reminisce about how the good old days were so much better. Unfortunately, this attitude is non-productive, is highly contagious, and reinforces old biases and behaviors. I worry about becoming one of those physicians. If I resist change in medicine, is it really different this time or am I just getting old?

While I was fortunate to be involved in our specialty’s leadership at a young age, it was obvious at the time that our leaders did not reflect the reality of my medical school experience in Ann Arbor or residency training in Houston.

In March 2007, at the AAO–HNS annual advocacy conference in Washington, D.C., during Richard Miyamoto’s presidency, I attended a meeting of multiple otolaryngology organization presidents. Everyone was discussing issues within the specialty, most of which were focused on clinical topics, specialty politics, or reimbursement problems. Duane Taylor and Lisa Perry-Gilkes, representing the National Medical Association’s otolaryngology section and the Harry Barnes Society, raised concerns about diversity, health literacy, and cultural competency in our specialty. In the room, these topics seemed out of place and were not further discussed. Yet, their comments clearly resonated with the Academy leadership and quickly led to the development of the Academy’s first diversity policy and the creation of the inaugural Diversity Committee. Around the same time, Sonya Malekzadeh and others led the creation of the Section for Women in Otolaryngology. Both groups were immediately given representation in the Academy’s Board of Directors.

When we attempt to avoid change and cling to the ‘way things were,’ we stop moving forward and growing, and we become part of the problem.

These impactful efforts, reflecting the leadership of many people over the years, opened a new era in an important ongoing conversation within our specialty. Unfortunately, the people who would benefit the most from receiving this information are the most likely to ignore relevant communications or close their minds to the benefits of different perspectives, equity, or new ways of doing things. People who are committed to change and moving forward bear the responsibility to learn, teach, and reach out to help others. Together, we need to develop better ways to frame the benefits to bring along those who are not ready. This is how change works, and there is still a lot of work to do.

Life and medicine are continuously changing at a seemingly accelerating pace. When we attempt to avoid change and cling to the ‘way things were,’ we stop moving forward and growing, and we become part of the problem. We need to open our minds, try to understand
perspectives that are unfamiliar or uncomfortable, and embrace change. Change will never end. We will never get “there.” We are fortunate to have many exceptionally talented and inspiring colleagues who can help us along this journey. They encourage us to improve and help us provide more effective care to our patients.

This issue of ENTtoday highlights ongoing critical issues related to diversity/inclusion, gender bias, and health literacy within otolaryngology–head and neck surgery. The articles include interviews with many leaders in our field who are actively addressing these issues. Erin O’Brien’s viewpoint on the gender gap in otolaryngology provides a timely update. She makes the point, which can be generalized to many problems facing the specialty, that leaders need to participate in order to address these issues, and affected groups cannot be expected to achieve parity without the support and effort of those with the power to make changes. Duane Taylor, now the current president-elect of the AAO–HNS, discusses the importance of the well-informed patient and the Academy’s new tools to help physicians and patients.

As a specialty, let’s not get stuck in the doctor’s lounge; as leaders in medicine, we should stay open minded, be active and honest participants in these conversations, embrace change, and drive our specialty forward to its ultimate potential.

Ronald B. Kuppersmith, MD, MBA
Deputy Editor, ENTtoday

ENT Today

How Far Women Have Come in Otolaryngology Compensation Parity and What Needs to Happen Next

On these pages in 2010, Linda Brodsky, MD, discussed the gender gap in compensation and leadership positions in otolaryngology (ENTtoday. February 1, 2010. Available here). How far have we come since she highlighted issues of gender inequity nearly a decade ago?

In the two decades since I was a medical student rotating in otolaryngology, women have made progress in leadership roles in our academic societies and training programs. However, progress toward equity in our specialty has not come quickly enough.

A pay gap still exists in salaries for women in otolaryngology. In 2004, Jennifer Grandis, MD, a professor of otolaryngology–head and neck surgery at the University of California San Francisco, reported a 15% to 20% gender pay gap even after controlling for confounding variables (Arch Otolaryngol Head Neck Surg. 2004;130:695–702). More recent data suggests this pay disparity persists. The 2018 Medscape survey of full-time otolaryngologists found that women were paid $75,000 (19%) less than men. A 2016 study of 10,000 university physicians also found a pay gap for female physicians despite controlling for experience, faculty rank, specialty, research productivity, and clinical volume, with surgical specialties demonstrating the largest absolute adjusted sex differences in salary (JAMA Intern Med. 2016;176:1294–1304) (See “Sex Differences in Physician Salary and Rank in U.S. Public Medical Schools,” below).

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ENT Today

Gender Differences and Work–Life Integration among Head and Neck Surgeons

As a whole, head and neck surgeons are highly satisfied with their career choice. Fewer women, however, are lacking in senior academic positions, and more remain unmarried with fewer children when compared with their male counterparts. This is the main finding of a study that assessed the association of gender difference with the perceived quality of life among head and neck surgeons (JAMA Otolaryngol Head Neck Surg [published online ahead of print March 21, 2019]. doi: 10.1001/jamaoto.2019.0104).

Investigators sent a web-based survey to members of the American Head and Neck Society to assess daily lifestyle and quality of life. The survey consisted of 37 questions on demographics, academic status, mentorship experience, daily lifestyle, family life, personal health, and job satisfaction. Of the 261 respondents, 71 (27.2%) were women and 190 (72.8%) men. By age, 38 (71%) women were between 30 and 50 years of age compared to 93 (49%) men and one woman was older than 60 years compared to 24 (18%) of men aged 60 to 70 years and six (3.2%) older than 70 years.

Following are the key findings of the study:

  • Most worked in an academic institution: 66 (92.5%) women and 152 (80%) men.
  • Associate professors: 20/64 (31%) women and 37/152 (24%) men.
  • Professors: 18/64 (28%) women and 72/152 (47%) men.
  • Department chairs: 4 (6.2%) women and 23 (17.6%) men.
  • Single (not in a long-term relationship or divorced): 18 (25%) women and 6 (3.25%) men.
  • Children: mean of 1.18 (median of 1) for women and mean of 2.29 (median of 2) for men.
  • Mean age of having a first child: 35.1 years for women, 31.9 years for men.
  • Felt family life was limited compared to other otolaryngological subspecialties: 45 (67.2%) of women and 117 (61.9%) of men.

Despite these disparities, both women and men reported a good work-life balance (55.2% and 53.4%, respectively).“In spite of head and neck surgery being a highly demanding subspecialty within otolaryngology, women and men report equivalently high levels of satisfaction with their career choice,” said senior author Amy Chen, MD, MPH, Willard and Lillian Hackerman Professor and Vice Chair for Faculty Development, department of otolaryngology, head and neck surgery at Emory University School of Medicine in Atlanta. “However, we as a specialty need to improve women’s representation in senior leadership.”

“The lower rates of married women and fewer children among women head and neck surgeons deserve further examination in order to ensure that these women have joy in their home life,” she added.

ENT Today

How Otolaryngology Programs Are Working to Create a More Diverse Workforce

Increased diversity among medical professionals helps counteract the fears of racism, inequality, and other issues that may prevent patients of color from seeking out health care. A more diverse workforce also helps healthcare professionals learn from one another as the field expands to include people with differing backgrounds and perspectives.

For David Brown, MD, associate vice president and associate dean for health equity and inclusion and associate professor of otolaryngology-head and neck surgery at the University of Michigan Medical School in Ann Arbor, diversity’s benefits are rooted deeply in his career. He recalled a story one of his African-American residents told him when the resident first had to perform a tracheotomy on a child as an early-career otolaryngologist. The resident went to introduce himself to the patient’s family before beginning the procedure. Seeing that the resident was a person of color like themselves “created a sense of relief and trust,” he said.
“Seeing me, they said they didn’t feel like their child would be experimented on,” the resident told him.

Many marginalized communities have distrust of the healthcare system.“Having people who share their identities helps to foster stronger trust and communication and can lead to fewer healthcare disparities,” Dr. Brown added. Physicians of various ethnicities can help patients feel more comfortable, believing that the provider more fully understands their own cultural perspectives. Without that understanding, a patient’s lack of trust can be perceived as refusal to adhere to a physician’s orders.

As a result, “I no longer call a patient a non-compliant patient; if they don’t show up, you need to ask why,” said Dr. Brown. “Sometimes, they have transportation issues or there’s been a death in the family. If you are more open and more inclusive, you can find out more of the root cause, rather than just assuming they didn’t show up because they are ‘bad’ people.”

Efforts by medical schools and specialty associations and organizations to increase diversity helps build understanding among different groups of people, as well as improve the field of otolaryngology overall. Candidates with different backgrounds, perspectives, and experiences begin to fill the pipeline into medical schools, residencies, fellowships, and beyond.

“I would say [the subject of diversity] has become more front and center in the last few years, because the Accreditation Council for Graduate Medical Education has made it a priority to ask about the diversity composition of resident trainees,” said Cristina Cabrera-Muffly, MD, associate professor and residency program director in the department of otolaryngology at the University of Colorado School of Medicine in Aurora. “Unfortunately, otolaryngology has one of the lowest rates of underrepresented minorities (URM) among medical and surgical residencies.”

Diversity in the Workplace

Top Row: Carrie Francis, MD; David Brown, MD; Zainab Farzal, MD. Bottom Row: Cristina Cabrera-Muffly, MD; Duane Taylor, MD; Oneida Arosarena, MD

Top Row: Carrie Francis, MD; David Brown, MD; Zainab Farzal, MD. Bottom Row: Cristina Cabrera-Muffly, MD; Duane Taylor, MD; Oneida Arosarena, MD

The benefits of diversity in all workplaces, not just medicine, have been publicized. In 2013, the Harvard Business Review reported that diversity, both inherent (including the characteristics one is born with such as gender, ethnicity, and sexual orientation), and acquired (traits such as knowledge learned while living outside the country where one was raised), “unlocks innovation and drives market growth—a finding that should intensify efforts to ensure that executive ranks both embody and embrace the power of differences,” wrote Sylvia Ann Hewlett, the lead author of the study (Harvard Bus Rev. Published December 2013.).

A 2018 study of diversity in venture capital firms, also published in the Harvard Business Review, found that “diversity significantly improves financial performance… and even though the desire to associate with similar people—a tendency academics call homophily—can bring social benefits to those who exhibit it, including a sense of shared culture and belonging, it can also lead investors and firms to leave a lot of money on the table,” wrote lead author Paul Gompers (Harvard Bus Rev. Published July 2018. Available at: hbr.org/2018/07/the-other-diversity-dividend). And, finally, a 2004 study published in the Proceedings of the National Academy of the Sciences found that “groups of diverse problem solvers can outperform groups of high-ability problem solvers” (PNAS. 2004;101:16385–16389).

“From a social justice standpoint, increasing diversity in the physician workforce has been shown to reduce health disparities,” said Oneida Arosarena, MD, associate dean for diversity and inclusion at the Lewis Katz School of Medicine and a professor of otolaryngology at Temple University in Philadelphia.

What is medicine, and otolaryngology in particular, doing to address diversity in the field?

Diversity in Education

Different academic institutions are taking similar approaches to identifying the best candidates for their medical schools, even when those applicants might not be obvious by traditional measures. At Temple University, which in 2015 established its office of health equity, diversity and inclusion, a diversity council works among all members of the health system community to help address concerns among racial, ethnic, and gender minorities, and also implemented implicit bias training for the medical school’s admissions team. As a result, applicants are considered for admission under holistic review, which analyzes everything about a candidate, rather than merely looking for high marks on standardized tests.

“Traditional medical school and residency committees would just screen people with a cutoff based on a score on the MCATs or USMLE Step 1 test,” said Dr. Arosarena. “But by doing that, you really eliminate people who are great candidates but are not great test takers. Instead, we look at grades as a measure of academic performance, leadership qualities such as whether the candidate was involved as a leader in sports or other organizations, and also humanitarian qualities, such as how involved they were in the community.”

The process also considers how far a candidate has come to achieve what they have achieved. “If both your parents are doctors, it’s not so great a stretch to think you might be a doctor,” said Dr. Arosarena. “If you come from a single-parent and/or a low-income home, you had a lot to overcome to get to the point where you are applying to medical school.”

Holistic review takes longer than simply scanning through test scores for acceptance, and it requires more people to sit on the application committee. But more voices in the process produces a more diverse group of accepted applicants. In 2016, when Temple began using holistic review, there were six accepted URM applicants, out of a total of 210. Today, classes average between 20 and 30 URM.

The University of Michigan Medical School in Ann Arbor is currently three years into a five-year diversity, equity, and inclusion plan to improve diversity at every level so that the climate is more inclusive of all people, said Dr. Brown. Various initiatives, such as training in unconscious bias and other educational efforts, grants for diversity projects by different members of the Michigan community, and mentoring opportunities, all help to increase awareness about the importance of a diverse academic community. All medical departments are asked to attend the Student National Medical Association’s (SNMA) annual conference, where medical students can learn more about different clinical opportunities with the medical school. The students have the opportunity to work through medical simulations alongside Michigan medical faculty and residents.

At Michigan, about 20% of medical students each year are URM, said Dr. Brown, and that number has gone up about 1% each year for the past four years. The percentage of URM residents has doubled in the past three years, from 3% to 6.5% identifying as Black, Latino, Pacific Islander and/or Native American, he added.

Diversity in Otolaryngology

Otolaryngology, like other specialties, is eager to attract the brightest people to the field. To that end, there are several initiatives from organizations such as the Society of University Otolaryngologists (SUO) and the American Academy of Otolaryngology–Head and Neck Surgery (AAOHNS).

Mentoring, coaching, and early exposure to the field of otolaryngology help bring more ethnically and culturally diverse talent and voices into the otolaryngology field, said Carrie L. Francis, MD, SUO’s diversity chair and associate professor and assistant dean of student affairs in the department of otolaryngology, head and neck surgery at the University of Kansas Medical Center in Kansas City. “Having an otolaryngology presence in medical school is helpful and harkens back to early exposure.” The society does this by developing relationships with various medical student associations and historically Black colleges such as Morehouse and Meharry Medical College as well as the SNMA and the Latino Medical Student Association.

Dr. Cabrera-Muffly cites mentoring as a way to increase diversity in the field of otolaryngology. “It’s important at all levels of the pipeline,” she said. “We need to mentor students to join our field, provide support to residents during their training, and ensure continued mentorship for URM faculty so that they will stay in academics to be examples for the next generation.”

Mentors needn’t be minorities themselves, either, she added. “As a Latina in otolaryngology, my mentors have not all been female or Latino, but they have made a huge impact in my life regardless.” Irrespective of their background or ethnicity, a senior-level person who has made her/his way through the otolaryngology field has a lot to offer earlier-career otolaryngologists. “Most senior faculty are not URM, but chances are that they will be in the position to mentor URM students and residents as the numbers increase.”

Without those increases, “we are doing a disservice to our patients and we are leaving talent on the table,” said Dr. Cabrera-Muffly. “If we discriminate against any group, we leave out the potential world-changing contributions of that group.”


Cheryl Alkon is a freelance medical writer based in Massachusetts.

Key Points

  • Efforts to increase diversity help build understanding and improve the field of otolaryngology overall.
  • Academic institutions are implementing implicit bias training for medical school admissions teams.
  • Mentoring, coaching, and early exposure to the field help attract more ethnically and culturally diverse talent and voices.

Ways to Increase Diversity in Otolaryngology

  1. Implement implicit bias training for medical school admissions teams: Doing so helps widen the scope when considering candidates for medical school admission. Holistic review, a process that analyzes everything about a candidate and not merely high marks on standardized tests, can help identify diverse candidates who can show a clear interest in medicine or ripe potential that may not be obvious if test scores and grades don’t meet a specific measure.
  2. Make mentoring a priority: Formal relationships between senior and junior-level otolaryngologists is a crucial way to help bring more diverse people to the field, though if collaborations happen on their own, that is fine, too. “Some of the best relationships happen organically, but we can assign them until people find their own mentors, because it’s important for all leaders to provide mentorship,” said Cristina Cabrera-Muffly, M., associate professor and residency program director, department of otolaryngology at the University of Colorado School of Medicine. “As a Latina in otolaryngology, several of my mentors have not been female or Latino, but they made a huge impact in my life regardless.”
  3. Find opportunities to showcase early exposure to otolaryngology as a specialty: SUO has developed relationships with historically black colleges and minority student organizations so that there is an SUO presence at annual national conference and regional events, said Dr. Francis. Having SUO available as a resource for earlier career medical students allows them to learn about the field of otolaryngology and to have enough information about it to properly consider it as a specialty.—CA

The Drawbacks of Lower Rates of Diversity

Without concentrated efforts to increase diversity in the otolaryngology field, let alone in medicine itself, the profession won’t reflect the patient population it serves and won’t benefit from new ideas that come from different perspectives, experts say.

That ultimately limits opportunities for both patient care and research and widens health disparities across different populations.

“If we don’t do it, we will do the same old things and hear the same old voices,” said David Brown, MD, associate vice president and associate dean for health equity and inclusion and associate professor of otolaryngology-head and neck surgery at the University of Michigan Medical School in Ann Arbor.

Michigan’s intent is to take the best care of patients and attract the best in the field for career opportunities. “If we are seen as monolithic, and people feel they are different, they won’t have a sense of belonging and won’t want to be a part of the team,” he said. “Instead, we want to make it so that anyone can be a part of our team.”

Efforts to identify promising candidates for medical school, residencies, fellowships, and medical careers should be intentional. “The medical profession loses out on the richness of what makes us different” if diversity isn’t encouraged, said Carrie L. Francis, MD, SUO’s Diversity Committee chair and associate professor and assistant dean of student affairs in the department of otolaryngology, head and neck surgery at the University of Kansas Medical Center in Kansas City. That includes diversity of culture, the richness of thought, “and everything else related to innovation,” she said.

ENT Today