The field of rhinology is an exciting area with new surgical techniques constantly introduced. The way surgical skills are taught is changing with use of surgical simulators. Training programs are evolving to a competency-based model, and rhinology-specific tools need to be developed to assess the endoscopic sinus surgery skills of trainees. There is a need for accreditation of rhinology fellowships to ensure fellows receive advanced training. This article reviews these issues, including new and alternative methods for rhinologic surgical training.
The specialty of otolaryngology–head and neck surgery has expanded into multiple subspecialties due to advances in technology, surgical techniques, medical care, and research. Rhinology is a relatively new field compared with more established subspecialties, such as oncologic head and neck surgery and otology. Rhinology surgery, however, is arguably one of the more complex subspecialties in otolaryngology. Surgeons operate within a small bony anatomic space with vital structures, such as the brain and orbit, in close relation. Skills are required to maneuver the endoscope, manipulate instruments, and dissect within this space. The field of rhinology is rapidly growing due to advancements in instrumentation, technology, and research. Examples of the changes in rhinologic surgery in the past 2 decades include endoscopic sinus surgery (ESS) in the management of inflammatory sinus disease, endoscopic transphenoidal pituitary surgery, and, more recently, endoscopic skull base surgery. This has implications for residency or specialist surgical training programs and post-training fellowships.
Residency training
Residency or specialist surgical training is the preparation of recently graduated medical students with knowledge, skills, ability, and judgment to practice as otolaryngologists. The period of training ranges between 4 and 6 years depending on individual programs and whether or not a period of research is undertaken as part of training. For the purposes of this article, the terms resident and trainee are used interchangeably.
The history of surgical training and different models have been previously reviewed. In brief, the most common and well-established method of training is the apprenticeship model, where a trainee observes and then practices surgical procedures under direct supervision of a consultant. It is the origin of the saying, “see one, do one, teach one,” that has been passed on through the years.
The Halsted model of training is an apprenticeship style of training where surgical trainees are supervised and taught by skilled and experienced surgeons with trainees receiving increasing responsibility with each advancing year of training. The level of supervision and mentoring varies depending on a trainee’s level of experience. The Osler model of training, adopted for clinical clerkships in medical school, is similar to the Halsted model, but with greater emphasis on the role of mentoring. Both models are based on an apprenticeship style of training. Trainees learn preoperative preparation, performing incisions, tissue handling and dissection techniques, postoperative care, and managing complications, thus learning the art as well as the science of surgery. Today’s training programs, based on the Halsted and Osler models, use a combination of various methods of teaching and assessment ( Table 1 ).
| Skills Assessed in Training | Methods of Teaching Surgical Skills | Assessment Tools Used |
|---|---|---|
| Cognitive | Didactic lectures, self-directed study, grand rounds, participation in continuing medical education, research and publications in peer-reviewed literature | Multiple choice questions, other written or computerized tests, case-based presentations, and patient management problems |
| Clinical | Bedside teaching, operating room cases | Objective structured clinical examination |
| Technical | Operating room cases, surgical simulators | OSATS, surgical simulators, surgical logbooks, morbidity and mortality audits |
Today’s training programs face new challenges, however, due to resident work hour restrictions. This issue arose due to a concern about possible fatigue, sleep deprivation, and potential for medical errors. It was thought that limiting work hours would address these concerns. The Accreditation Council for Graduate Medical Education (ACGME) in 2003 mandated an 80-hour resident workweek in the United States ( Table 2 ). In France, the resident workweek restriction is now 52.5 hours per week whereas Canada has adopted workweek hour restriction similar to the ACGME mandate. In Australia, the Royal Australasian College of Surgeons released a position statement on safe working conditions for surgeons and trainees. Unlike the ACGME, however, these are guidelines and recommendations rather than mandatory requirements.
| 1. | Maximum of 80 duty hours per week, including in-house call, averaged over 4 weeks |
| 2. | 1 Day of 7 free from all clinical and educational responsibilities averaged over 4 weeks |
| 3. | Cannot be scheduled for in-house call more than once every 3 nights, averaged over 4 weeks |
| 4. | Duty periods cannot last for more than 24 hours, although residents may remain on duty for 6 additional hours to transfer patients, maintain continuity of care, or participate in educational activities |
| 5. | At least 10 hours for rest and personal activities between daily duty periods and after hours call |
| 6. | In-house moonlighting counts toward the weekly limit |
Anonymous surveys were performed in 2005 and 2006 to assess the perceptions of otolaryngology residents and residency program directors to the ACGME changes in residency training. Residents reported an average of 67.5 hours per week worked (range 40 to 120 hours) but less than half of the responders felt that the work hour restrictions had led to improved patient care or resident education. Similarly, less than half reported no change in fatigue or errors. Most residents, however, reported an improvement in morale, a reduction in noneducational duties, and increased time for self-study. The majority of program directors reported making minor changes to comply with ACGME requirements but most disagreed that the duty hour restrictions led to improvements in residency training. Program directors’ negative perceptions included decreased operative cases and continuity of care.
In general surgery research, the rate of bile duct injury was found reduced after the implementation of the ACGME requirements. A recent retrospective study of one institution compared several parameters related to otolaryngology residency training before and after institution of the ACGME duty hour mandate. It found no significant differences in the otolaryngology training examination results, number of operative cases, 30-day hospital readmission rates, length of stay, or hospital mortality rates. The conclusions from this study were that the ACGME requirements did not improve certain patient care measurements or adversely affect the number of operative cases in otolaryngology training.
Today’s trainees may or may not have sufficient exposure to the number of cases to feel competent in ESS at the end of their training period. Due to workweek restrictions, trainees may see certain operations only a few times whereas previously they may have observed ESS procedures more frequently. Furthermore, if trainees have not acquired sufficient skills for basic ESS, they may not be able to progress to more advanced sinus surgery cases during their training. Therefore, they may not feel confident in managing certain major or revision cases after finishing their training. Lengthening the period of training is an alternative that is used in some European countries where supervision of junior consultants is required for an additional period of time by more experienced colleagues before they are allowed to practice autonomously. This is unlikely to be embraced in North America or Australia where the current trend is to shorten training time.
Furthermore, the need to improve patient safety and reduce the threat of litigation has resulted in trainee surgeons having less opportunity to learn by operating on patients. There is also greater complexity of cases in teaching hospitals resulting in more cases performed by consultant staff rather than allowing a resident to be the primary surgeon. Research into surgical education has identified use of surgical simulators as a method of improving surgical training. Simulators allow trainees to practice and master skills to perform an operation before they lay hands on a patient.
The Fitts-Posner 3-stage theory of acquiring motor skills—cognition, integration, and automation—was discussed in a review article on surgical education. The theory emphasizes practice of basic skills until they become automatic, resulting in the tasks gradually being completed smoothly without interruptions ( Table 3 ). Mastery of these basic skills allows trainees to focus on more complex issues in an operating room. A recent editorial discussed an alternate view where circumventing the cognitive stage of skill learning by directly observing without instructions promotes development of enhanced procedural skills. This view of implicit motor learning is thought to be more stable over time and under conditions of psychological stress because learners are more likely to automatically perform a movement and less likely to think about previous instructions.
| Stages | Fitts-Postner Model | Implicit Motor Learning Model | Description of surgical performance at each Stage |
|---|---|---|---|
| Cognitive | Trying to understand the task, explicit hypothesis testing, building declarative knowledge, requires explanation | Bypasses this stage to prevent declarative knowledge build up | Erratic, slow, procedure performed in distinct steps, hesitates |
| Integration | Understands the task, repeated practice, receives feedback from expert | Learn by expert demonstration, frees up “mental space” for decision making, skills thought more robust under stress | Movement more fluid, less thinking about the steps |
| Automatic | Automated movements, requires little cognitive input, can concentrate on other aspects of the procedure | Automated movements, requires little cognitive input, can concentrate on other aspects of the procedure | Continuous movements performed with ease and precision |
A large volume of cases used to be the hallmark of surgical training and a method of measuring technical skills of trainees was to use the logbook system. The number of cases performed, however, does not necessarily correlate with surgical competence. The number of hours spent in deliberate practice, not just the number of hours spent in surgery, is critical to achieving a level of expertise. Therefore, it could be argued that learning to do a case well is better than doing many cases poorly.
Trainees acquire skills with manipulating an endoscope and instruments, maintaining a good surgical field, recognizing anatomic structures, and having the setup ergonomically positioned. Many basic skills must be acquired by trainees before they perform ESS. The 3-D nature of structures is also not easily appreciated when trainees begin ESS using a camera and monitor-type system. Trainees have to build a 3-D picture in their head of a patient’s sinus anatomy from 2-D CT scan images. A major development with ESS is use of a monitor as a teaching tool, allowing trainees to observe surgery and, vice versa, consultants to observe and teach trainees, compared with performing sinus surgery with the use of a headlight or looking directly through an endoscope. An alternative teaching method is to use an endoscope with a beam splitter and observation arm. The traditional method for trainees acquiring these skills is performing as many procedures as possible on patients while they are supervised. This follows the time-honored tradition of the apprenticeship model for surgical training. Otolaryngology chief residents were surveyed recently regarding their rhinology experience in terms of teaching, research opportunities, and surgical experience using a 5-point Likert scale. Although the response rate was poor, at 17.6%, the overall experience in rhinology was reported as positive (median 4 points) with no negative effects reported in programs with rhinology fellowships.
Research in surgical education has led to a change from the traditional methods of teaching. The teaching of basic skills should take place outside the operating room, for example in surgical skill centers, and trainees would only be allowed to operate on patients once they had met predetermined criteria. The focus on surgical training is changing to competency based rather than time or caseload based. Previous methods of training might not be applicable for teaching rhinology surgical skills in today’s training programs. This has resulted in a need for newer methods of assessing surgical skills. Further research is required to develop and validate safer and more effective methods of teaching rhinologic surgical skills. In the future, program directors may need to restructure the rhinology component of their training program to implement newer methods of training.
Rhinology fellowships
Otolaryngology fellowships refer to a period of focused, intensive, education experience in a recognized subspecialty area. There has been a rapid growth in the number and type of otolaryngology fellowships in North America. In 1994 there were only 8 rhinology fellowships listed in the fellowship directory of the American Academy of Otolaryngology–Head and Neck Surgery. Currently, there are 23 rhinology fellowship positions listed on the San Francisco matching program (SF Match) Web site ( http://www.sfmatch.org ) at the end of June 2009. The American Rhinologic Society sponsors the rhinology fellowship match through the SF Match program and provides a directory of fellowship programs available in the United States but does not certify or monitor any of these programs. There are also many rhinology fellowships available in countries other than United States. Rhinology fellowships are generally 1 year in duration and usually located at academic institutions.
There are various reasons why people might choose to do a fellowship after their training. A survey of postgraduate fellows, with a reasonable response rate (46.2%), found that inadequate operative caseload during residency training was the most common reason. An article by Byron Bailey in 1994 stated, “there is not place in the fellowship world for remedial fellowships in which individuals pursue additional training because of deficiencies.” A survey found that most residents felt pursuing a fellowship was necessary due to inadequate residency training. This implies that for some residents a fellowship is used to compensate for a perceived weakness in their training program. Other reasons for pursuing a fellowship include perception of inadequate didactic teaching in a subspecialty during residency, need to secure an academic position, desire to enhance private practice, and an extra year for additional certification or board examination. More than 70% of respondents thought, “there should be a centralized system of standards and accreditation of fellowships rather than the present system,” and a majority preferred a certificate of added qualifications.
One of the concerns is the variability of the quality of these fellowships. Some fellowships have a significant quantity of hands-on surgical experience, research, didactic lectures, and one-on-one teaching whereas others might be deficient in 1 or more of these areas. Bailey in his article argued that fellowship training should go beyond simply providing surgical case numbers and provide education, training, and intellectual challenge. He controversially argued against preceptorship-style fellowship training, stating, “preceptorship training was eliminated from residency training 50 years ago but we tolerate preceptorships in fellowship training today. That is illogical and I believe that it is no longer acceptable.” He proposed that accreditation and regulation of fellowships are required to ensure they are of high quality. This was echoed in previous surveys of fellows and residents.
More recently, a survey of rhinology fellows found that most were satisfied with the overall experience of their fellowship training. Most respondents were more comfortable with advanced endoscopic procedures for the frontal sinus, anterior skull base, and orbit, and most were in academic practice, highlighting the value of fellowship training for future rhinologists. In contrast, lower comfort levels were associated with craniofacial procedures, frontal sinus obliteration, and dacryocystorhinostomy. Again, the survey highlighted issues with lack of a formalized process for fellowship accreditation, assessment of core competencies after training, and determining the minimum criteria for a fellowship program.
Therefore, more than 15 years later, the same issues of accreditation are present with today’s rhinology fellowships. The question remains, Who needs to do a rhinology fellowship and is such a fellowship necessary? Many expert rhinologists today did not do a rhinology fellowship and trained themselves to become experts in their field. There are also competent otolaryngologists today who did not do a rhinology fellowship but are skilled in ESS due to the standards of their training program. It is essential that ESS remains part of training for general otolaryngologists whereas advanced procedures, which remain to be defined, should be part of fellowship training. Future research needs to define minimum requirements and curriculum for rhinology fellowship training and an accreditation body in order to provide training that advances the skills of fellowship trainees, not simply providing a substitute for inadequate residency training.
Rhinology fellowships
Otolaryngology fellowships refer to a period of focused, intensive, education experience in a recognized subspecialty area. There has been a rapid growth in the number and type of otolaryngology fellowships in North America. In 1994 there were only 8 rhinology fellowships listed in the fellowship directory of the American Academy of Otolaryngology–Head and Neck Surgery. Currently, there are 23 rhinology fellowship positions listed on the San Francisco matching program (SF Match) Web site ( http://www.sfmatch.org ) at the end of June 2009. The American Rhinologic Society sponsors the rhinology fellowship match through the SF Match program and provides a directory of fellowship programs available in the United States but does not certify or monitor any of these programs. There are also many rhinology fellowships available in countries other than United States. Rhinology fellowships are generally 1 year in duration and usually located at academic institutions.
There are various reasons why people might choose to do a fellowship after their training. A survey of postgraduate fellows, with a reasonable response rate (46.2%), found that inadequate operative caseload during residency training was the most common reason. An article by Byron Bailey in 1994 stated, “there is not place in the fellowship world for remedial fellowships in which individuals pursue additional training because of deficiencies.” A survey found that most residents felt pursuing a fellowship was necessary due to inadequate residency training. This implies that for some residents a fellowship is used to compensate for a perceived weakness in their training program. Other reasons for pursuing a fellowship include perception of inadequate didactic teaching in a subspecialty during residency, need to secure an academic position, desire to enhance private practice, and an extra year for additional certification or board examination. More than 70% of respondents thought, “there should be a centralized system of standards and accreditation of fellowships rather than the present system,” and a majority preferred a certificate of added qualifications.
One of the concerns is the variability of the quality of these fellowships. Some fellowships have a significant quantity of hands-on surgical experience, research, didactic lectures, and one-on-one teaching whereas others might be deficient in 1 or more of these areas. Bailey in his article argued that fellowship training should go beyond simply providing surgical case numbers and provide education, training, and intellectual challenge. He controversially argued against preceptorship-style fellowship training, stating, “preceptorship training was eliminated from residency training 50 years ago but we tolerate preceptorships in fellowship training today. That is illogical and I believe that it is no longer acceptable.” He proposed that accreditation and regulation of fellowships are required to ensure they are of high quality. This was echoed in previous surveys of fellows and residents.
More recently, a survey of rhinology fellows found that most were satisfied with the overall experience of their fellowship training. Most respondents were more comfortable with advanced endoscopic procedures for the frontal sinus, anterior skull base, and orbit, and most were in academic practice, highlighting the value of fellowship training for future rhinologists. In contrast, lower comfort levels were associated with craniofacial procedures, frontal sinus obliteration, and dacryocystorhinostomy. Again, the survey highlighted issues with lack of a formalized process for fellowship accreditation, assessment of core competencies after training, and determining the minimum criteria for a fellowship program.
Therefore, more than 15 years later, the same issues of accreditation are present with today’s rhinology fellowships. The question remains, Who needs to do a rhinology fellowship and is such a fellowship necessary? Many expert rhinologists today did not do a rhinology fellowship and trained themselves to become experts in their field. There are also competent otolaryngologists today who did not do a rhinology fellowship but are skilled in ESS due to the standards of their training program. It is essential that ESS remains part of training for general otolaryngologists whereas advanced procedures, which remain to be defined, should be part of fellowship training. Future research needs to define minimum requirements and curriculum for rhinology fellowship training and an accreditation body in order to provide training that advances the skills of fellowship trainees, not simply providing a substitute for inadequate residency training.
Rhinology surgical simulators
Simulators are widely used in the aviation and military fields whereas their use in surgical training is more recent. Surgical simulators offer significant advantages over traditional didactic teaching and learning by operating on patients. They cause no harm to patients, can be used as teaching tools, shorten learning curves, allow learners to make mistakes, and enable standardized training and repeat assessment of technical skills. These simulators have to be validated before they can be widely and effectively implemented into the surgical training program. Validity can be defined in many ways ( Table 4 ) and there are different methods of assessing validity. Time to complete a task is often used as a measure of success but speed is not necessarily indicative of better outcomes. The definitions of novice and expert are variable as well. Some studies define novices as those with no surgical experience at all (eg, medical students) whereas others define novices as trainees who have not performed much of the study procedure. Other studies define experts by an arbitrary number of cases performed per year and some studies do not even define what constitutes being an expert. There is no conclusive proof regarding the minimum cases a surgeon needs to perform to be classified as an expert. This is an important issue in validation studies as experts generally form the benchmark level of competency.
