Abstract
Purpose
(1) Ascertain the most important concepts and topics for otolaryngology resident education in sleep medicine and surgery, as determined by faculty who teach sleep medicine to otolaryngology residents. (2) Create learning objectives within the area of otolaryngologic sleep medicine in order to design a sleep medicine curriculum for otolaryngology residents.
Materials and methods
Two web-based surveys were sent to 163 academic otolaryngologists who teach sleep medicine. The first survey determined the topics, and their relative importance, considered most vital to learn during otolaryngology training. Using the Delphi method, the second clarified questions regarding topics determined by the first survey. Sleep medicine learning objectives for residents were ascertained from responses.
Results
The response rate of first and second surveys were 24.5% and 19%, respectively. Topics ranked most important for resident education included upper airway anatomy, polysomnogram interpretation, and understanding the range of medical and surgical therapies used to treat sleep disorders. Respondents listed surgical therapy as the most critical topic that most residents do not understand well. The second survey clarified the specific anatomic features, surgical techniques, and polysomnography data points deemed most critical for resident learning.
Conclusions
Academic otolaryngology sleep experts hold opinions regarding relative value of different topics for teaching sleep medicine, which is useful in creating a curriculum for otolaryngology residents. Otolaryngology learning objectives related to sleep medicine identified during this study are being used to create an online curriculum to supplement resident education.
1
Introduction
Otolaryngologists care for patients with sleep disorders and are responsible for their surgical management. Residency programs are tasked with training members in sleep medicine and sleep surgery. Most training programs do not have a board-certified otolaryngology-trained faculty member who is also boarded in sleep. In a survey-based study conducted in 2010, nearly half of program directors regarded the sleep medicine training provided to residents as only “fair” . Also, although resident training in oropharyngeal surgical management of obstructive sleep apneas has increased to the point of near universal proficiency, training in newer surgical techniques lags far behind, though proficiency is increasing . Supplemental learning on the part of residents may therefore be useful in the field of sleep medicine.
The last 10 years have seen the creation of a one-year, ACGME-accredited sleep medicine fellowship, which shares support among various medical specialty boards and residency review committees. As the only surgeons eligible to take the sleep medicine board examination (other specialties eligible are internal medicine, pediatrics, neurology, and psychiatry), otolaryngologists are uniquely prepared to lead in the field . However, although many otolaryngologists sat for the sleep medicine boards when first offered due to eligibility criteria that included experience treating patients with sleep disorders, this opportunity has since expired; after 2011, the only way to become certified is to complete an ACGME-accredited sleep medicine fellowship and then pass the board examination. Because of this, the number of otolaryngologists obtaining sleep medicine certification has plummeted in recent years .
The purpose of this study was to identify key learning objectives in the area of sleep medicine in order to create a curriculum which could be communicated in a concise manner conducive to resident learning. Sleep board certified otolaryngologists and faculty who teach sleep medicine to residents were deemed most appropriate to survey regarding the importance of various topics within sleep medicine for resident education.
Online modules have been shown to be a helpful adjunct to traditional methods in the education of otolaryngology residents . The information from this study was gathered with the intent to create free online modules for use by residents to enhance their knowledge on the topic of sleep medicine.
2
Methods
Approval for this study was obtained from the Colorado Multiple Institution Review Board.
Through the American Academy of Otolaryngology website and each academic otolaryngology program’s website, 163 otolaryngologists were identified who either hold board certification in sleep medicine, teach sleep medicine to otolaryngology residents, or both. These otolaryngologists were determined to be experts in otolaryngologic sleep and are referred to as sleep experts in the remainder of the manuscript.
Two surveys were created by the authors and sent to the identified otolaryngologic sleep experts. The first attempted to elicit topics within sleep medicine and sleep surgery that residents should be comfortable with upon graduation, as well as the relative importance of these topics to one another. The second survey clarified learning objectives of particular importance within the generalized topics previously specified as important to sleep specialists in the first survey. The surveys were each sent three times, two weeks apart. Delphi analysis—a forecasting method which relies on a group of independently operating experts —was performed on the data gathered by the first survey to design the second.
2
Methods
Approval for this study was obtained from the Colorado Multiple Institution Review Board.
Through the American Academy of Otolaryngology website and each academic otolaryngology program’s website, 163 otolaryngologists were identified who either hold board certification in sleep medicine, teach sleep medicine to otolaryngology residents, or both. These otolaryngologists were determined to be experts in otolaryngologic sleep and are referred to as sleep experts in the remainder of the manuscript.
Two surveys were created by the authors and sent to the identified otolaryngologic sleep experts. The first attempted to elicit topics within sleep medicine and sleep surgery that residents should be comfortable with upon graduation, as well as the relative importance of these topics to one another. The second survey clarified learning objectives of particular importance within the generalized topics previously specified as important to sleep specialists in the first survey. The surveys were each sent three times, two weeks apart. Delphi analysis—a forecasting method which relies on a group of independently operating experts —was performed on the data gathered by the first survey to design the second.
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Results
The first survey was sent to 163 otolaryngologists identified as sleep experts who had a teaching role at allopathic otolaryngology residency programs in the United States. 40 responses were returned (24.5%). Regarding the preliminary workup of patients with sleep disorders, sleep experts noted anatomy of the upper airway to be the most important topic, followed by history and physical exam. Sleep disorder definitions and terms, and the evaluation of disorders other than apnea and snoring were ranked as less important. In diagnosis and management, experts ranked polysomnogram report interpretation as most important, followed by surgical therapies, then medical therapies and finally radiologic evaluation. Table 1 shows the anatomical sites listed as most important for residents to know.
| Rank | Topic | % Responses mention |
|---|---|---|
| 1 | Tongue and base of tongue | 70 |
| 2 | Palate, velum, velopharynx | 65 |
| 3 | Nose, nasal valve | 40 |
| 4 | Tonsils including pillars | 25 |
| 5 | Hypopharynx | 18 |
| 6 | Lateral pharyngeal walls | 15 |
| 7 | Epiglottis | 13 |
The sleep experts were asked to comment on whether to keep or delete each of the proposed sleep disorder terms, patient history questions, and physical exam components to be included in the modules. Responses are listed in Table 2 . A few write-in terms mentioned by 5% of respondents included periodic limb movement (PLM), restless legs syndrome (RLS), rapid eye movement (REM), and the stages of sleep.
| Rank | Term | % Keep | % Delete |
|---|---|---|---|
| 1 | AHI | 100 | 0 |
| 1 | Hypopnea | 100 | 0 |
| 1 | Obstructive Apnea | 100 | 0 |
| 1 | PSG | 100 | 0 |
| 1 | BMI | 100 | 0 |
| 1 | Central Apnea | 100 | 0 |
| 7 | BiPAP | 98 | 2 |
| 7 | Mixed Apnea | 98 | 2 |
| 7 | RERA | 98 | 2 |
| 7 | RDI | 98 | 2 |
| 11 | CPAP | 95 | 5 |
| 12 | EOG | 80 | 20 |
| 13 | EEG | 79 | 21 |
| 14 | EMG | 74 | 26 |
| 15 | EKG | 72 | 28 |
When taking the history of patients with sleep disorders, sleep experts felt it most important to discuss snoring, witnessed apneas, daytime fatigue, morning headaches, and prior upper airway surgeries, all receiving 100% endorsement to keep in the module. Physical examination topics deemed 100% important by sleep experts were height/weight/BMI, septal deviation, turbinate size, base of tongue size, tonsil size, and mandible position. Table 3 lists the symptoms and physical exam findings deemed important to keep or delete from the curriculum by sleep experts.
| Rank | Term | % Keep | % Delete |
|---|---|---|---|
| 1 | Snoring | 100 | 0 |
| 1 | Witnessed apneas | 100 | 0 |
| 1 | Daytime fatigue | 100 | 0 |
| 1 | Morning headache | 100 | 0 |
| 1 | Prior upper airway surgeries | 100 | 0 |
| 6 | Duration of symptoms | 98 | 2 |
| 6 | Severity of symptoms | 98 | 2 |
| 6 | Weight (current and change over time) | 98 | 2 |
| 6 | Nasal airway status | 98 | 2 |
| 6 | Prior diagnostic tests and/or treatments | 98 | 2 |
| 6 | Epworth sleepiness scale | 98 | 2 |
| 6 | Hypertension history | 98 | 2 |
| 13 | Concentration issues | 97 | 3 |
| 14 | Wake up gasping for air | 95 | 5 |
| 14 | Sleep position | 95 | 5 |
| 16 | Number of hours of sleep in a 24-hour period | 93 | 7 |
| 17 | Restless Sleep | 90 | 10 |
| 17 | Exacerbating factors | 90 | 10 |
| 19 | Ameliorating factors | 88 | 12 |
| 19 | Trouble staying asleep | 88 | 12 |
| 21 | Trouble falling asleep | 85 | 15 |
| Physical Exam Components During Sleep Disorder Patient Physical Exam | |||
| 1 | Height, weight, BMI | 100 | 0 |
| 1 | Septal deviation | 100 | 0 |
| 1 | Turbinate size | 100 | 0 |
| 1 | Tonsil size | 100 | 0 |
| 1 | Base of tongue size | 100 | 0 |
| 1 | Mandible position (prognathic, retrognathic) | 100 | 0 |
| 7 | Polyps or other masses | 97 | 3 |
| 8 | Vital signs | 95 | 5 |
| 8 | Neck circumference | 95 | 5 |
| 8 | Laryngoscopy—anterior/posterior and lateral wall collapse at rest | 95 | 5 |
| 11 | Friedman score | 93 | 7 |
| 12 | Length/size of uvula | 90 | 10 |
| 13 | Neck masses or lesions, thyromegaly | 85 | 15 |
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