The year 2020 began quietly, except for the news of a novel virus
outbreak, felt to be a local problem in Wuhan, China. In the United
States, economy was booming and the world had great expectations of a
wonderful 2020., What followed has stunned the world with a ‘never seen
before’, calamity, the Covid-19 Pandemic, , with over one and a quarter
million individuals infected, and over 70000 lives lost so far.. The
havoc created by this global tragedy has impacted upon many lives in
many ways. We need to quickly think and to plan, as to how our
professional and personal lives will be conducted in the days, weeks,
months and years ahead.
At the moment there is total chaos, in every part of the world,
particularly in New York city. The day to day life is disrupted, regular
patient care of diseases and cancers is in disarray, with the focus of
medical care shifted to the management of patients with Covid-19.
Surgery is limited to emergencies, and cancer cases that can be, are
postponed without a negative impact on their outcome. The Great majority
of hospital beds are occupied by Covid-19 patients, and sudden make
shift hospitals are created to accommodate the surge. Temporary morgues
in refrigerated trucks are to be seen at every local hospital in New
York city to “house’ the over 4700 patients who have died in the last
two weeks. What comes next, and when this will end is unknown; our
future, and the future of the world is frightening in its uncertainty.
With a fragile future, how do we conduct our day to day activities, and
plan to retain our robust education and training programs, to educate
and train the next generation of Head and Neck Surgeons? The major
onslaught of the first wave of cases and mortality from those exposed to
the disease may slow down in the weeks to come, as observed in China,
but life is unlikely to return to normal in the foreseeable future.
“Business as usual” will not work, since we do not know the impact of
the aftermath of this Pandemic, the risk of a rebound second cycle of
splurge in the number of cases worldwide in the fall and winter, and the
potential risk of annual outbreaks from Covid-19., We have great
expectations from our scientists, that we will find a therapeutic
solution for the treatment of Covid-19, and great hopes that a vaccine
would be developed in the future to prevent infection. , We have to
develop strategies, to modify, devise and reshape our current methods of
education and training to sustain a robust training program and continue
to support our current work force geared to educate and train succeeding
generations of students and trainees. (1) The drastic changes that have
affected our work and life during the past two months, has taught us,
that remote communications, education, teaching, learning and training
is possible, and has to be incorporated in our current systems.
Communications: Human communication for ever has been practiced
on a one to one basis with the production of sounds/ verbal speech and
the ability to hear and interpret spoken words. Science and technology
permitted the transmission of spoken words to be heard at a distance
with the introduction of the megaphone. Advancing technology, gave us
the Radio to hear people from remote distances, and television gave us
the capability to see and hear people ‘live’ from remote distances. The
internet and development of social media made human communications, a
‘norm’ in the current generation. We can now communicate with not one
but multiple individuals thru multiple platforms and applications. The
development of these technologies in remote communication can easily be
applied to remote learning.
Academic Activities: The usual academic activities occupying
good part of our working week involves, Lectures, Grand Rounds Tumor
Boards, Case conferences, Journal clubs and other similar activities.
All of these activities had required, physical presence and an assembly
of individuals, but, we have come to realize that nearly all of these
activities can be conducted remotely thru the internet. Live video
lectures, and Grand Rounds can be easily and effectively delivered thru
webex or zoom conferencing where hundreds of people are able to see /
hear the speaker live with the ability to interact with two way
conversations. Case conferences and tumor boards can be conducted quite
effectively on these platforms with screen sharing. The need to be
‘physically present’ is not essential for conducting most academic
activities. Even after the passing of the current pandemic, such
activities may continue to be conducted on such platforms. This would be
convenient and effective, and can offer such activities to an even
larger audience. We can imagine a future where every Institution and
Academic Center will have an open “on line book”,where every learning
activity is available to world..
Remote Learning: With easy access to internet in every part of
the world, remote learning has become a way of life in many domains of
education and learning. This is vividly demonstrated by a plethora of on
line courses available from many Universities around the world. In the
specialty of Otolaryngology / General Surgery / and Head and Neck
Surgery, even operative surgery is possible to be learnt, by watching
expertly demonstrated surgical procedures performed by leading surgeons
and surgical educators, on the web sites of the American College of
Surgeons (ACS), American Academy of Otolaryngology Head and Neck
Surgery,(AAOHNS), the International Federation of Head and Neck
Oncologic Societies (IFHNOS) and other similar organizations., Remote
learning in all domains of surgical education is feasible and available.
Validation and Certification: Testing and examinations have
traditionally required the candidates to report to a designated
location, where the examination in paper form is handed to the
candidates to be completed in the designated time frame, while a proctor
is supervising the candidates. That is no longer necessary. Multiple
choice written examinations can be taken securely on line, with defined
time limits.. Many Universities and Colleges offer these examinations
coordinated and conducted by commercial examination companies such asExam Soft. Offering such examinations on line is less labor
intensive, more cost effective, more practical and may attract a larger
number of students from remote locations to participate.
Traditionally oral examinations are conducted “in person”, where the
candidate and the examiner /s, meet in private and conduct face to face
conversation with questions and answers. The purpose of this exercise is
to assess the candidates immediate assessment,judgment and knowledge
However, with modern technology and two way private video platforms ,
such an encounter can be effectively conducted remotely. .
Global On Line Fellowship(GOLF): The IFHNOS has taken a lead on
developing the first remote learning , on line fellowship program in
head and neck surgery and oncology, which has been in existence for the
past six years. (2) The Global On Line Fellowship (GOLF) program was
introduced in 2014. It is a two year curriculum, with seven written
multiple choice on line examinations, a one month of observership and an
oral examination.
(www.ifhnos.net/global ). Nearly
400 candidates have registered from 48 countries during the past six
years, and 244 have graduated. The goal of this program is to
improve the knowledge base and judgment of surgeons in their own home
environment, without displacing them, within their resources, in their
institution or place of practice, and on their own patients. This
program has been very successful and is received enthusiastically in all
parts of the world. In the past the oral examinations were conducted on
site in various locations in Australasia, Central Asia, Europe and Latin
America. Beginning this year, IFHNOS plans to conduct the oral
examinations on line, either using Webex , Zoom, or a similar
technological platform.
Telemedicine: Medical consultations, conversations and office
visits in the private office or in clinics is the mainstay of practice
inhead and neck surgery, where follow up visits form a large percentage
of our office or clinic volume. With the risk of loco regional failure
of up to 40% and the risk of developing multiple primaries approaching
35%, post treatment follow up or surveillance have been emphasized thru
decades. This takes a significant amount of investment of time , effort
and personnel on the part of the clinician, and an expense, in travel
and investment of time away from work and home on the part of the
patient. In the past when surgery was the only treatment of mucosal
cancers of the head and neck the follow up schedule recommended was very
laborious. The common practice was once a month the first year, every
other month the second year, every three months the third year, every
four months the fourth year, and every six months thereafter. After
discovery of a second primary or a recurrence patients were put back on
the same schedule. In head and neck surgery the stringent follow up
schedule was designed on the basis that nearly 80% of the patients who
were to recur, would have recurred in the first 24 months, with a median
time to recurrence of 9 months. However, with the combination of surgery
and radiotherapy, the loco regional recurrence rates declined
significantly, and the median time to recurrence was also prolonged.
Thus the need to see the patients every month in the first year, or
every two months in the second year, became less compelling. Many have
argued against such intensive physician /patient personal interactions,
and suggested less stringent follow up schedules. Multiple trials of
close follow up vs less stringent follow up for similar staged patients
have been proposed, but rarely accepted or came to fruition. (3). The
absolute benefit of detecting an asymptomatic recurrence or a new
primary during routine follow up examination is questioned, compared to
the patient who reports for examination when the earliest symptoms
develop suggesting a recurrence. Although, there are no randomized
trials to compare this, the probability of a major difference in outcome
is unlikely. In addition, only a very small number of patients are found
to have recurrence or a new primary which is totally asymptomatic during
a routine follow up examination. Some institutions and practices have
transitioned the follow up care of low risk patients to “survivorship
clinics” run by Physician Assistants / Advanced practice providers
(APP) or nurse practitioners. This second level of care for low risk
patients will reduce the follow up volume for the clinician, but will
still not do away with the inconvenience of travel, and investment of
time and cost of the service, on the part of the patient.
It is in this arena, that telemedicine will play an important role. Many
patients who are at low risk of recurrence can be followed by
telemedicine on a video call. If during that call, the care giver finds
the need for a close physical examination, the patient may be asked to
see his / her primary care physician, closer to home, and a clinical
picture, intra oral photograph or a picture of larynx / pharynx done
with a fiberoptic laryngoscope can be sent to the head and neck surgeon.
Imaging studies can be read and reviewed on line and avoid the need for
“physical presence” of patient and surgeon. This practice will require
a culture change amongst head and neck surgeons, and their trainees. We
will have to train our Residents / Fellows in developing a work ethic of
practicing telemedicine.
Physician compensation for remote consulatation: . The current
methodology of payment is “procedure” based. (CPT). To adequately
compensate the specialist for his time, talent, expertise and opinion, a
new methodology or codes will need to be developed from current
procedural terminology (CPT) to current expertise terminology (CET). An
entirely new payment schedule will be required dependent on the extent
of consulattion; mail review, telephone, video consultation, tumor board
, involving multiple physicians will all require redefinition. For many
institutions, including our own this already exists for the
International patient, and has been high lighted by the current Covid
outbreak..
Fellowship Training: The events experienced in the past few
weeks has put a significant strain on the practice of medicine in
general, and head and neck surgery in particular. They have forced us to
think and develop strategies for transition of our current practices in
patient care, education and training to innovative solutions, and
prioritize the levels of patient care. Only within the past several days
numerous guide lines have appeared in all media and means of
communications to strategize the optimal use of operating room space and
staff. Conduct of safe surgery avoiding exposure to aerosolized viral
transmission, and prioritizing patients at high risk of an adverse
outcome if surgery is not performed have been put into practice. Routine
and elective cancer surgery is being postponed. If the pandemic
continues for several months, the current fellows in training will not
have the volume of the required surgical cases to gain the experience
necessary for completing the fellowship. One solution to address this
problem is to extend their fellowship by 3-6 months. However, this may
prove to be impractical due to a variety of reasons. These include,
commitments made to incoming fellows who will start their training on
July 1st , additional salary support, housing, and the
fellows themselves may have made personal or professional commitments
for their respective post fellowship careers. We will need to develop
ongoing tele education, much as is being done with the IFHNOS GOLF
program , with similarly defined goals and expectations to be met before
certiifcation Another potential solution is to implement regular
operative techniques group discussions with faculty members with video
demonstration of surgical techniques highlighting the finer details of
operative procedures and the “dos” and “donts” in the operative
procedure.
Experiencing the huge impact of the Covid Pandemic on the society and
economy of the globe, and the severe strain it has put on the health
care systems has been a humbling experience. It has brought the
realization, that all medical and surgical training programs, have a
component of disaster management.
Surgical manpower: We need a complete reassesment of man power
needs, how many surgeons were lost during this Pan endemic? How many
more Senior surgeons have elected to take early retirement/ were some
lost to Covid? What are the manpower needs for increasing remote
evaluation? What new technology is needed ?Current platforms like Zoom ,
cannot handle the chaos . what are the Privacy issues of remote
consultation ?We have many challenges to face, but with challenge comes
opportunity.
The challenge created by the Covid-19 Pandemic has brought reality to
life and humility in our minds, and has given us the appreciation of the
“luxuries and comforts” in which we practiced, taught and trained head
and neck surgery. I have shared my thoughts for dealing with these
difficult times , and any such future calamity that may come, to keep
our education and training programs sustainable by embracing technology
and alternative means to teach and train our younger generation.
Acknowledgment: The author appreciates the input from Dr.
Murray Brennan, Director of the International Center of Memorial Sloan
Kettering Cancer Center, in the preparation of this manuscript.
Full author list: Jatin P. Shah, MD, PhD(Hon), DSc(Hon), FACS, FRCS(Hon), FDSRCS(Hon), FRCSDS(Hon), FRCSI(Hon), FRACS(Hon) Prof. of Surgery, E W Strong Chair in Head and Neck Oncology Memorial Sloan Kettering Cancer Center, New York, NY. 10065. e mail:
shahj@mskcc.org References:
- Shah JP. Training of a Head and Neck Surgeon. In Head and Neck Surgery
by DeSouza C. pp 1514-1526. Jaypee publishers, , India 2009.
- Shah J,, O’Neil P., and Brennan M. Global On line fellowship. JACS.
2020. (In press)
- Shah J and Harrison L. Personal communication. (1996)