Certification of Added Qualification in otology and neurotology.

Editor's note: The following series of letters is in reference to Dr. Pulec's editorial in the April issue (Ear Nose Throat J 2003;82:237).

Editor:

Otolaryngologists in America may soon be receiving a questionnaire seeking their opinion regarding a subspecialty certification/examination in neurotology by the American Board of Otolaryngology (ABOCto) scheduled for April 2004. I hope otolaryngologists will pay careful attention to this officially sanctioned mechanism and how it might affect their lives and livelihood.

My entire career has been and is still dedicated to the highest goals of optimal patient care, research, and education. I have trained several hundred otolaryngologists (residents and fellows), including neurotologists, and more than 25 professors and chairmen of otolaryngology in the United States and elsewhere. Of the many general otolaryngologists trained, at least half of their practice is spent diagnosing and treating diseases of the temporal bone or otology. Their level of otologic care for their patients is, in the main, excellent.

Curiously and paradoxically, the ABOto and the American Otological Society (AOS) definition of "neurotology" includes diagnosis and treatment of temporal bone disease (i.e., otology). For that matter, I am not aware of a single "neurotologist" in the United States whose career is solely dedicated to diagnosis and surgical treatment of intracranial diseases (acoustic tumors, vestibular neurectomy, etc.). In point of fact, they make their living by mostly practicing otology.

I am in favor of academic excellence and additional training, but I am not in favor of any official mechanism (such as the ABOto-sanctioned neurotologic examination) that could hurt staff privileges or otologic care rendered by general otolaryngologists.

I have written two recent letters-one to Horst R. Konrad, MD, president of the AOS, and one to David Schuller, MD, president of the ABOto-that amplify my thoughts in this regard. Please publish them with this letter if you wish [see below].

Michael M. Paparella, MD

Minnesota Ear, Head & Neck Clinic Clinical Professor and Chairman Emeritus Department of Otolaryngology University of Minnesota International Hearing Foundation Minneapolis

To: Horst R. Konrad, MD, President American Otological Society

From: Michael M. Paparella, MD

Here are some thoughts on the recent questionnaire regarding the neurotology subcertification examination scheduled for April2004. I completely disagree with the American Otological Society's (AQS) definition of a neuro-otologist. Your first definition is that he/she is a specialist of the temporal bone. In fact, it is almost paradoxical that the AOS has throughout its long history of excellence been dedicated to the temporal bone and even in some cases adjacent structures. Thus to relegate the temporal bone to a different or a new subspecialty does harm to the AOS and to the otologists who indeed pioneered the field of neuro-otology--such individuals as Bill House, Hal Schuknecht, and many others.

I am concerned that otology represents approximately half of what the average general otolaryngologist practices, and we certainly do not want to hurt his/her ability to perform otologic procedures such as placing ventilation tubes and performing tympanoplasties, etc., which are all part of a residency training program. I believe a neurootologist is an individual who subspecializes in diagnosis and treatment, specifically surgical treatment, of the intracranial space to include vestibular neurectomy, skull base tumors, vestibular schwannomas, etc.

Moreover, in the past, I and many other otologists, with the cooperation and participation of neurosurgeons, have done otologic cases that did indeed include surgery involving the dura and even the subdural area when disease in the temporal bone involved those areas. This has been done to the benefit of the patient and with complete cooperation on the part of the neurosurgeon. Recent surveys have indicated that the most common surgical procedure for intractable or progressive Meniere's disease is endolymphatic sac surgery. This is, of course, a transmastoid operation, and the sac is located in the dura. Would this mean, therefore, that the average otologist--including Michel Portmann, who pioneered this procedure in 1927--would not qualify because he/she happens to have performed otologic surgery involving the adjacent dura? Again, I think the otologist' s and the otolaryngologist's primary domain is the temporal bone traditionally, currently, and in the future, and certainly this is the purpose for the exist ence of the AOS, which has been a means and mechanism of promulgating excellent research studies and excellent contributions in this field.

Because of the above definition, I am not in favor of a subspecialty certification in neuro-otology as defined. If it were defined as a voluntary subspecialty certification without any implication--and, in fact, with explicit language--to relegate the subspecialty to intracranial, not intratemporal, bone pathology, then I would be in favor of it. We do not want to create a subcertification that many may use for economic and antitrust purposes, which in my opinion and in the opinion of many others could really be destructive to not only otologists, but to the general otolaryngologist as well.

I have on many occasions performed surgery of the temporal bone and adjacent structures. As mentioned, endolymphatic sac enhancement is one of those procedures, and we have done many of them. We have also done procedures with neurosurgeons in which cholesteatomas have been removed from the epidural and even subdural area at the recommendation of neurosurgeons and with their involvement. We have also been involved in treating brain fungi (mastoiditis cerebri) that involved the temporal bone and the adjacent brain. Furthermore, we have been involved in removing the temporal bone in cases of cancer of the temporal bone, which, of course, involves the dura and adjacent structures. All of these procedures and others have been within the realm of the "otologist."

For the above and other reasons, I am not planning to pay the exam fee nor annual payments for certification.

Again, the concern of the average otologist and the general otolaryngologist is that some of these subcertifications--which are meant to enhance specialty progress, which we are all in favor of--will end up becoming economic and political tools used to the disadvantage of the general otologist and the general otolaryngologist. In fact, we are in favor of additional training, we are in favor of the excellent contributions made by Bill House and the other skull base surgeons, and we cooperate and work with neurosurgeons in our fellowship training program. But we need to be careful that we don't subdivide our small specialty so much that we become small bits and pieces, which could lead to the demise of our specialty. Since we represent only 1 to 1.5% of all physicians in the United States, we already have the highest number of medical societies per capita, and we continue to create potentially self-destructive mechanisms such as subcertification. By the same logic, we could, for example, have a subcertification and specialized training for a "neurorhinologist." Many otolaryngologists perform hypophysectomy transnasally. How would this differ from what we are doing in neuro-otology?

To: David Schuller, MD, President American Board of Otolaryngology

From: Michael M. Paparella, MD

I wish to comment on the recent E-news communication I received from the American Board of Otolaryngology (ABOto). The ABOto appropriately expresses a number of concerns regarding the subspecialty certification examination scheduled for April 2004. Yet despite these reservations, the ABOto has still scheduled the examination. This indicates that the subspecialty examination is going to go forward apparently because there is "sufficient support from the subspecialty itself." Your communication further states, "The only active process at this time is neurotology." This is a mistake. The recent questionnaire sent out by the American Neurotology Society (ANS) shows a substantial majority vote against this subspecialty certification examination because of some of the concerns that the ABOto expressed in this recent communication, as well as some expressed in my response to the AOS [above].

I served for 18 years on the ABOto, and I always felt that one of its primary purposes was to protect the general otolaryngologist. I do believe that this process will be damaging, not only to those who practice otology but also to the general otolaryngologist. It would be very appropriate for the AiBOto or another agency to send a questionnaire to the general otolaryngologists throughout the country to learn what they think about this subspecialty certification examination process and what repercussions--economic, political, or otherwise--it might have on their staff privileges and their ability to practice otology. My strong suspicion is that the response on the part of the members will be quite similar to that of the ANS membership and show that a majority is not in favor of this process. For this and many reasons I could discuss, I believe it would be prudent for the ABOto to withhold scheduling of this examination and to find out what its membership truly thinks. I think this would be an important step f or the ABOto to not only be representative of its previous Board diplomates, but to provide positive leadership rather than a process that can inadvertently lead to division and difficulties for the general otolaryngologist.

As I mentioned in my response to the AOS questionnaire, the definition of "neurotology" is extremely ambiguous. For example, the AOS describes the neurotology specialty to be that of the temporal bone (i.e., otology). If this has not been the prerogative of and development by otologists and otolaryngologists for many decades and even centuries, I am not certain what is. I have had a discussion about this with Dr. William House, the pioneer of neurotology. His feelings are philosophically very similar to mine, and I believe that my views more than likely may represent those of the majority in this regard.

Any appropriate consideration you can give to this paradoxical dilemma would be responsive and responsible on the part of the ABOto and the board-certified members it represents and can help avoid any undesirable difficulties in the future.

Editor:

I read your editorial regarding Certification of Added Qualification in otology and neurotology. I share your concerns about the potential problems that the CAQ process will create for ourselves and for otolaryngology as a whole. Recently, the ABOto published a definition of a "Neurotologist." Based on that definition, I found it difficult to differentiate an otologist from a neurotologist.

I am taking the liberty of sending you a copy of a letter that I sent to Dr. Gerald Healy, executive vice president of the ABOto. It is apparent that the leadership of the American Neurotology Society had an agenda that was not in keeping with the opinions and wishes of its membership.

Thank you again for summarizing the process to date in your editorial. It was very well written and I hope it will send a message to the ABOto, to the leadership of the AOS and the ANS, and to fellow otolaryngologists.

Barry E. Hirsch, MD, FACS, Professor

Departments of Otolaryngology, Neurological Surgery, and Communication Science and Disorders

Director, Division of Otology

School of Medicine

University of Pittsburgh

To: Gerald B. Healy, Executive Vice-President American Board of Otolaryngology

From: Barry E. Hirsch, MD, FAGS

Until this point, I have withheld personal written communication regarding my concerns over the proposed Certificate of Added Qualification (CAQ) for neurotology. The issue prompting me to take further action is my receipt of a survey mailed by the American Otological Society (AOS) regarding the CAQ and proposed examination.

It was only last year that the many years of planning for recognizing subspecialization in otology and neurotology was brought to light. Last year, Dr. Bruce Gantz outlined publicly for the first time the history of why this CAQ was needed and the process that was involved. This announcement came as a significant surprise to the members of the AOS and the American Neurotology Society (ANS). The initial proposal detailed the establishment of the subspecialty of otology/neurotology for the CAQ. It became quickly evident that the inclusion of otology in the CAQ would serve to alienate all otolaryngologists because of the overlap in this field. You are well aware that similar concerns terminated the CAQ process for pediatric otolaryngology and plastic surgery.

The driving forces behind the otology/neurotology CAQ apparently accepted this concern and recently reformulated their proposal to apply only to neurotology. They described two pathways (standard and alternate) for qualifying for the exam. The standard pathway is to complete a neurotology specialty training program accredited by the Accreditation Council for Graduate Medical Education (ACGME). The alternate pathway is to satisfactorily practice neurotology for at least a 7-year period.

In the recent mailing by the AOS, a definition of a "neurotologist" has finally been put in print. It reads, "A neurotologist provides comprehensive medical and surgical care of patients with diseases and disorders that affect the temporal bone, lateral skull base, and related structures of the head and neck. The neurotologist should have command of the core knowledge and understanding of basic medical sciences relevant to the temporal bone, lateral skull base, and related structures; the communication sciences, including knowledge of audiology, endocrinology, and neurology as they relate to the temporal bone, lateral skull base, and related structures. A neurotologist has acquired expertise in the medical and surgical management of disease and disorders of the temporal bone, lateral skull base, and related structures beyond that inherent to the practice of otolaryngology--head and neck surgery by virtue of either satisfactory completion of an ACGME-accredited neurotology subspecialty training program (Standa rd Pathway) or satisfactory completion of neurotologic practice over at least a 7-year period (Alternate Pathway)."

It still remains very difficult for anyone to clearly differentiate otology from neurotology based on this definition. Given the inclusion of disease and disorders of the temporal bone, the AOS definition would certainly include problems related to the middle and inner ear. This would include disorders of hearing loss (e.g., sensorinenral hearing loss, otosclerosis, and chronic otitis media) and pathology (e.g., small glomus tumors). The surgical management of these disorders includes cochlear implants, stapes surgery, tympanomastoidectomy procedures, and removal of small glomus tumors. These are very common procedures performed by otologists and board-certified otolaryngologists. In fact, pediatric otolaryngologists are performing cochlear implants without formal otology/neurotology training. The evaluation and management of patients with dizziness entails knowledge of peripheral and central vestibular disorders along with other manifestations of neurologic disorders. General otolaryngologists are trained to evaluate and treat patients with these problems. Designating all of the above disorders as being within the realm of a neurotologist may be interpreted as restraint of trade by the general otolaryngologist or pediatric otolaryngologist.

I have great concern about being unable to clearly define what a neurotologist is. In my mind, it involves procedures affecting the lateral skull base, such as large glomus tumors. It entails facial nerve procedures medial to the geniculate ganglion. It encompasses procedures in the posterior fossa, such as acoustic neuromas, meningiomas, epidermoid tumors, vestibular nerve sections, and diseases of the petrous apex.

Now comes the problem of sitting for the neurotology subspecialty certification examination using the proposed guidelines. I would argue that the majority of all otologists/neurotologists truly have more of an otologic practice, given my definition of neurotology. According to the qualification criteria in the alternative pathway, the applicant must devote 60% of his/her practice to neurotology. Although I speak only for myself, I am quite sure that surgeons who are considered to be otologists/neurotologists do many more stapedectomies, chronic ear procedures, cochlear implants, tympanoplasties, and procedures for benign and malignant tumors of the ear canal and pinna than they do intracranial or medial temporal bone procedures. This applies not only to the physicians who would take the exam, but also to those people selected for the first wave of the exam who would serve as future examiners. Again, I would argue that it is a very select few individuals in the country who have truly a 60% neurotologic practic e.

The AOS definition of a neurotologist is too broad because it incorporates practices and procedures performed by otologists and otolaryngologists who are diplomates of the American Board of Otolaryngology (ABOto). If the intended definition were limited to the few neurotologic procedures as described, almost all of the practicing otologists/neurotologists would not qualify at the 60% practice cutoff. Despite the good intentions in recognizing neurotology as a subspecialty, the process has flaws related to the definitions, qualifications, and potential exclusionary consequences if the definition was accepted as proposed.

The ABOto has received the input of the members of the ANS via their recent survey, and you will shortly hear from the members of the AOS. The membership's objection to this process is not based solely on the inconvenience associated with taking the exam, or on paying the fee for the exam, or on paying $200 per year for active certification (for the first time publicized). The objection is based on the potential for the exclusion that it would create and the impact this will have on the entire field of otolaryngology.

The AOS survey asks, "Do you plan on taking the exam and paying the $4,500 fee and $200 per year for an active certificate?" This is a very poorly created question because it implies that the exam is sanctioned. If the exam is sanctioned, a failure to take it would cast one as an outsider and medicolegally liable should an untoward event occur. Phrasing the question in this manner creates a forced answer: "Yes." However, many ANS members indicated that they would not take the exam. Thus, the responses to this question cannot be misconstrued as acceptance of the CAQ process.

In summary, the effort to define and qualify the subspecialty of neurotology may have been born of good intentions, but neurotology remains indistinct from otology and otolaryngology. I view myself as a well-trained, competent, and successful neurotologist. Although I perform stapes procedures, chronic ear surgery, cochlear implants, labyrinthectomies, and glomus tumor surgery and manage patients with peripheral and central (neuro logic) forms of dizziness, I consider these to be within the realm of an otologist. Therefore, my practice is not 60% neurotology and I would not qualify for the exam. I am sure I stand with most other "neurotologists" who have similar practices. My personal bias is that this test will fragment and further divide a small specialty that needs unity. I remain an otolaryngologist," and I urge the ABOto to do the same.

Editor:

Despite the American Board of Otolaryngology' s having given the first examinations to fellow members of the board, and created the new additional "neuro-otology" certification, I am opposed to it.

The training process is already too long, and now to add an additional year of training, apparenfly in the research laboratory, to be certified as a neuro-otologist adds insult to injury.

What will these new board-certified "neuro-otologists" be able to do that anyone with a one-year neuro-otology fellowship will not be able to do? Will hospitals and university departments exclude those without this new certificate from doing acoustic neuroma, skull base surgery, etc.?

The move by the American Board of Otolaryngology, which most of the members of the Academy, American Otological Society, and American Neurotology Society oppose, has the potential to harm the already fragile specialty of otology.

John J. Shea, Jr., MD

Memphis, Tennessee