Accomplishment and opportunity in geriatric otolaryngology.

Abstract

Geriatric otolaryngology is an emerging medical subspecialty developed in response to a pressing societal need. In this article, the author explains the rationale for this new subspecialty, reviews the landmark events that led to the creation of an organizational structure, celebrates the accomplishments that have been achieved thus far, and discusses the challenges that remain and the opportunities for future growth.

Introduction

Geriatric otolaryngologyis a relatively new subspecialty. Many of the events in its history are recorded in the literature. (1-7) That history began with the early recognition of the need for such a subspecialty by a few visionary otolaryngologists more than 25 years ago. Since then, the subspecialty has grown and begun to take on the trappings of a recognized field. Those early visionaries have become the senior leaders of the subspecialty and have mentored others who have taken on the responsibilities of developing a vibrant organization and devoted time to a variety of activities essential to the further development of geriatric otolaryngology.

When a subspecialty evolves as rapidly as geriatric otolaryngologyhas and is intently focused on the future, it is instructive to pause and reflect on accomplishments achieved to date in order to see future opportunities. This article reflects the perspective of one of the leaders in the geriatric otolaryngology movement. The author presents a brief review of the significance of geriatric otolaryngology for our aging society, a summary of recent accomplishments, and a look at challenges and opportunities for growth.

Significance of geriatric otolaryngology

The need for geriatric otolaryngology as a response to the aging of our population was first voiced by our colleagues in the early 1980s. (7,8) Our society expects specialists to provide healthcare that can be continually tailored to patients' needs as they continue to age. In other words, Americans expect that a specialist who is treating an 80-year-old patient should know something about 80-year-olds. This is obviously relevant to otolaryngology. (9) The domain of our specialty includes diseases and conditions that are very common to late life and processes that are influenced by senescence. (2,6,10) Americans expect that geriatric knowledge be incorporated into otolaryngology.

While these expectations might seem to be rooted in a universal "medical" common sense, our observations tell us that evidence relevant to the care of older adults is used inconsistently and incompletely in the practice of otolaryngology today. (3,5,11) Indeed, while the aging of our society is widely acknowledged, it is often inadequately addressed. Medical education and research do not fully reflect the aging demographic or its far-ranging implications. (3,8,12) In otolaryngology, geriatric content is rare in medical school and postgraduate curricula. (3) As a consequence, practice lags behind societal expectations and the evidence that is available is not fully used. Even in head and neck diseases and conditions that are most common in the elderly, otolaryngologic practice lacks sufficient integration of geriatric content. Again, lags in evidence-based clinical practice and in the research that generates specific science for geriatric otolaryngology hinder our opportunities to optimize care and outcomes. (13)

Accomplishments

Three landmark events marked the evolution of geriatric otolaryngology. Each of these generated tangible results on which the subspecialtyis founded, and each increased the level of organizational sophistication:

* the first Geriatric Otolaryngology Cherry Blossom Conference in the late 1980s;

* the Geriatrics for Specialists Initiative, launched in the 1990s; and

* the formation of the American Society of Geriatric Otolaryngology in the early years of the 21st century.

The Cherry Blossom Conference. The foundation of our subspecialty was laid at the first Geriatric Otolaryngology Cherry Blossom Conference in Washington, D.C., March 24-26, 1988. The meeting was attended by a group of visionaries headed by Jerome Goldstein, MD. This conference led to the publication of the off-cited monograph Clinical Geriatric Otolaryngology. (1)

The Geriatrics for Specialists Initiative. To coordinate efforts with various specialty organizations, the American Geriatrics Society launched the Geriatrics for Specialists Initiative (GSI) in 1994. (14) The American Academy of Otolaryngology--Head and Neck Surgery (AAO-HNS) was among the original participants in this collaborative effort. Funded by the John A. Hartford Foundation and The Atlantic Philanthropies, the GSI is a comprehensive interdisciplinary program that meshes geriatric medicine with 10 specialties; in addition to otolaryngology, the GSI member specialties are anesthesiology, emergency medicine, general surgery, gynecology, ophthalmology, orthopedic surgery, physical medicine and rehabilitation, thoracic surgery, and urology. Heinrich Staecker, MD, PhD; Steven Parnes, MD; and Ara Chalian, MD, led otolaryngology's initial participation in the GSI Research Agenda-Setting Process (RASP). Dr. Staecker's review, (2) published as a book chapter in 2004, addressed gaps in the current literature and asked three key questions:

* How can research be used to improve hearing-related quality of life for elderly persons?

* Can disorders of the peripheral vestibular system be accurately recognized and their causes determined, and does targeted treatment benefit elderly patients with balance disorders or dizziness?

* Does standard management of head and neck cancer compromise quality of life in the elderly patient to a greater degree than in the younger patient?

Michael Johns, MD; Sarah Wise, MD; and Parnes updated the RASP in 2007. (6) They combined previous research with new knowledge accumulated since the original RASP and identified four areas in which research is needed:

* Diseases in the otolaryngic arena commonly present diagnostic challenges for primary care physicians. These challenges are often magnified by the hearing and communicative difficulties of older persons. Research is needed to develop simple high-yield diagnostic tools that the primary care practitioner can use to detect otolaryngic diseases.

* Multiple medical comorbidities among older persons often increase the medical and surgical risk for older otolaryngology patients. Research is needed to determine whether the use of minimally invasive diagnostic and therapeutic techniques in the geriatric patient decreases the medical and surgical morbidity in this age group.

* Laboratory investigation and application of stem cell and other biological therapy for restoration of special sense and communication organs may provide elderly persons with olfactory, gustatory, and hearing rehabilitation without the use of external devices. Research is needed to determine whether stem cell therapy is a viable alternative for rehabilitation of the special senses in the elderly patient.

* Hearing aids have been used for many years for rehabilitation of failing auditory nerves or presbycusis. As patients age, nerves of swallowing and communicative organs also begin to have decreased function. Research is needed to determine whether advances in engineering solutions can assist in rehabilitation of failing swallowing or communicative organ function in the elderly person.

In the first of these four items, Johns et al addressed the need for partnership with primary care physicians, and in the second, they recognized and elevated the status of investigating the influence and impact of comorbid diseases. In the third and fourth items, they recognized the importance ofbiologictechnologies andbioengineering as tools to advance the science of geriatric otolaryngology. The authors advocated a continued transcendence of traditional boundaries between specialties.

The creation of the GSI broadened the responsibilities oftheAAO-HNS'Geriatric OtolarYngologyCommittee. The committee had existed before the development of the GSI, but the new partnership expanded the scope of its work and increased its productivity. The committee's work yielded tangible benefits for geriatric otolaryngology and enhanced its visibility throughout medicine. One such product was Geriatric Care Otolaryngology Online, an eight-chapter reference for members of the AAO-HNS. (10) The committee also produced this reference on compact disk. In addition, committee leaders and a wide cross-section of members have conducted miniseminars and courses on geriatric otolaryngology at AAO-HNS annual meetings, and they have mentored colleagues in the presentation of papers and courses relevant to this field. (3,5,15) The committee's work has become integral to the effective contemporary function of the AAO-HNS.

The American Society of Geriatric Otolaryngology. The American Society of Geriatric Otolaryngology (ASGO) was formed in 2006 to serve as a focal repository for work that advances geriatric otolaryngology exclusively and as a resource for the dissemination of the fruits of that work. It also provides an organizational home and identity for those otolaryngologists who are interested in this still-emerging subspecialty. Its mission and activities are detailed on the ASGO Web site (http:// home.comcast.net/~asgo).

Coincident with the founding of the ASGO was the publication of Geriatric Otolaryngology. (4) This volume was edited by two of the most visible leaders of the ASGO, Karen Calhoun,MD, and David Eibling, MD. Many other ASGO members and other colleagues contributed to this 783-page volume, which is a testament to the group synergy that characterizes the ASGO.

Opportunities for future growth

The accomplishments that geriatric otolaryngology has enjoyed thus far herald promise that more successes will follow if opportunities for growth are seized. For example, the expansion of geriatric competence in otolaryngology would be enhanced by the development o four own cadre of dedicated clinical specialists and dedicated investigators. However, we must carefully prioritize needs and allocate human and financial resources to promote achievement of future successes.

The grooming of future leaders specifically deserves our attention. The American Geriatrics Society has two mechanisms already in place to help identify, educate, and cultivate future scientific and clinical leaders: the Dennis W. Jahnigen Career Development Awards Program (16) and the Geriatrics Education for Specialty Residents (GSR) Program. (17) As physician-scientists in academic institutions, Jahnigen Award recipients benefit from a sizeable investment of time and funding. The GSR program provides moderately sized grants of $20,000 to medical residency training programs to develop educational geriatric content. The support of young scholars and trainees requires the watchful supervision of leaders in geriatric otolaryngology, the commitment of department chairs and others in programs fortunate enough to house them, and global support from within the larger structures of otolaryngology and medicine.

Even as we prepare for the future, we have much to do now. The author has developed a six-point working agenda to keep us mindful of the tasks at hand (see" A six-point working agenda for geriatric otolaryngology").

Conclusion

Those who presume to lead geriatric otolaryngology must be willing to take risks to overcome the obstacles we face as a subspecialty. We need to collaborate with colleagues in geriatric medicine, internal medicine, and family medicine to meet the expectations of our aging population. Encouraging transdisciplinary perspectives and initiatives will allow us to breach current boundaries and act on our vision to meet the needs of our aging society. There are many rewards to be reaped by taking the lead and fully realizing the field of geriatric otolaryngology.

A six-point working agenda for geriatric otolaryngology

1. Disseminate relevant geriatric evidence and clinical knowledge to generalist and subspecialist otolaryngologists.

2. Disseminate practical knowledge of otolaryngology to geriatricians and primary care providers to better address common geriatric complaints and improve collaboration in primary and specialty care.

3. Develop evidence and programs that improve the safety and quality of surgical care for geriatric otolaryngology patients.

4. Advance both independent and collaborative research in geriatric otolaryngology within a transdisciplinary framework.

5. Develop new clinical initiatives and adapt and test existing innovative models of care, and train clinicians to implement them.

6. Establish geriatric otolaryngology think tanks to provide an environment in which creative thought and innovation can flourish.

References

(1.) Kashima HK, Goldstein JC, Lucente FE. Clinical Geriatric Otolaryngology. 2nd ed. St. Louis: Mosby; 1991.

(2.) Staecker H. Geriatric otolaryngology. In: Solomon DH, LoCicero J III, Rosenthal RA, eds. New Frontiers in Geriatrics Research. An Agenda for Surgical and Related Medical Specialties. New York: American Geriatrics Society; 2004.

(3.) Potter JF, Burton JR, Drach GW, et al. Geriatrics for residents in the surgical and medical specialties: Implementation of curricula and training experiences. J Am Geriatr Soc 2005;53(3):511-15.

(4.) Calhoun KH, Eibling DE, eds. Geriatric Otolaryngology. New York: Taylor & Francis; 2006.

(5.) Chalian AA, Eibling DE. Miniseminar: Reimbursement, EBP, and outcomes in geriatric otolaryngology [abstract]. Otolaryngol Head Neck Surg 2007;137(2 Suppl):112.

(6.) Johns MM, Wise S, Parnes SM. Geriatric otolaryngology. In: LoCicero J III, Rosenthal RA, Katlic MR, Pompei P, eds. A Supplement to New Frontiers in Geriatrics Research. An Agenda for Surgical and Related Medical Specialties. New York: American Geriatrics Society; 2007.

(7.) Goldstein JC. The American Society of Geriatric Otolaryngology. Ear Nose Throat J 2007;86(12):718-19.

(8.) Institute of Medicine (IOM). Retooling for an Aging America. Washington, D.C.: The National Academies Press; 2008.

(9.) Francis AD, Bentsianov BL. Residential geriatric otolaryngology related complaints [abstract]. Otolaryngol Head Neck Surg 2005; 133(2 Suppl):201.

(10.) Geriatric Care Otolaryngology Online. American Academy of Otolaryngology-Head and Neck Surgery Web site. http://www. entnet.org/mktplace/GeriatricOtolaryngology.cfm. Accessed Aug. 14, 2009.

(11.) Christmas C, Makary MA, Burton JR. Medical considerations in older surgical patients. J Am Coll Surg 2006;203(5):746-51.

(12.) Doerr T, Brickman TM, Hengerer AS. Incorporating geriatrics into the otolaryngology residency educational curriculum [abstract]. Otolaryngol Head and Neck Surg 2005;133(2 Suppl):198-9.

(13.) Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Bethesda, Md.: National Academies Press; 2001.

(14.) Geriatrics for Specialists. The American Geriatrics Society Web site. http://www.americangeriatrics.org/specialists/. Accessed Aug. 17, 2009.

(15.) Sataloff RT, Johns MM, Benninger MS, et al. Miniseminar: Management of the aging voice: Consensus and controversy [abstract]. Otolaryngol Head Neck Surg 2007;137(2 Suppl):103.

(16.) Geriatrics for Specialists. The Dennis W. Jahnigen Career Development Awards Program. The American Geriatrics Society Web site. http://www.americangeriatrics.org/hartford/jahnigen.shtml. Accessed Aug. 18, 2009.

(17.) Geriatrics Education for Specialty Residents (GSR). The American Geriatrics Society Web site. http://www.americangeriatrics.org/ specialists/gsr/default.asp. Accessed Aug. 18, 2009.

Ara A. Chalian, MD, FACS 

From the Department of Otorhinolorayngology--Head and Neck Surgery, University of Pennsylvania School of Medicine, Philadelphia.

Correspondence: Ara A. Chalian, MD, Department of Otorhinolaryngology--Head And Neck Surgery, University of Pennsylvania, 3400 Spruce St., 5 Silverstein, Philadelphia, PA 19104-4283. E-mail: ara. [e-mail]

Previous presentation: The information in this article was originally Presented at the 2nd annual meeting of the American Society of Geriatric Otolaryngology; April 30, 2008; Orlando, Fla.