Nasir Bhatti

Surgical competency is traditionally considered as an ability to perform surgery successfully. However, patient outcomes do not depend only on the surgical skills of a surgeon which calls for the revision of the concept of surgical competency. Surgical competency is a combination of skills which allow the surgeon to successfully apply his knowledge and skills to understand and make necessary changes according to the needs and circumstances of an individual patient to solve the clinical problem. Accordingly, the assessment of competency depends on various factors; however, patient outcomes are the ultimate result of the surgeons’performance. Patient outcomes can be measured in terms of mortality, morbidity, resolution of patient’s symptoms, length of stay, complication rates, functional status, quality of life, satisfaction with treatment results, readmission rates and healthcare costs. As every surgical specialty is different with wide range of procedures, the skills that determine ...

To test the validity, reliability, and feasibility of an evaluation tool designed to measure the development of trainees' surgical skills in the operating room for thyroid surgery. Prospective validation study. A modified Delphi technique was employed to develop a new Objective Structured Assessment of Technical Skills-based instrument for thyroid surgery. During a 1-year period, 16 otolaryngology-head and neck surgery residents (ranging from postgraduate year 2 to 6) and one endocrine surgery fellow were evaluated by one faculty member obtaining a total of 94 evaluations. Performance was rated using a task-based checklist (TBC) and a global rating scale (GRS). The TBC measured trainees' thyroidectomy technical skills, and the GRS assessed their overall surgical performance. Based on four clinical levels (junior, intermediate, senior, and surgical fellow) our tool demonstrated construct validity for both components of the assessment instrument, specifically for the TBC showi...

Otolaryngology residency programs have been mandated by the ACGME to demonstrate teaching and assessment of core competencies. Operative competency is an essential part of patient care in otolaryngology. Currently there are no reliable, valid and feasible mechanisms and instruments to objectively evaluate operative competency. A recent survey of program directors in otolaryngology reveals lack of objective instruments for this assessment. We presented a miniseminar on general and targeted needs assessment and reviewed current practice in other surgical specialties at 2007 academy meeting. We wish to present an update on progress made since then through six 6-minute talks each followed by four minutes of interactive discussion. 1) Concept of developing instruments for objective assessment of operative competency in the context of a curriculum. The underpinning of this curriculum will be a benchmark of surgical competency required for graduating residents. 2) Results of a pilot project involving objective assessment of tonsillectomy and tracheostomy by internal and external evaluators will be discussed. 3) Analysis of trends noted from the survey of program directors will be presented. 4) Report on a survey of recent otolaryngology graduates for identifying their perspective on current and ideal assessment mechanisms will be discussed. Simulators are slowly gaining a role in teaching and assessment of operative competency in otolaryngology and other specialties. 5) Discussion of currently available simulators and their perceived role in residency training in otolaryngology in the near future. 6) Setting up and maintaining effective remedial mechanisms for surgically challenged residents without disrupting existing rotation schedules.

A hospital-wide difficult airway response team was developed in 2008 at The Johns Hopkins Hospital with three central pillars: operations, safety monitoring, and education. The objective of this study was to assess the outcomes of the educational pillar of the difficult airway response team program, known as the multidisciplinary difficult airway course (MDAC). The comprehensive, full-day MDAC involves trainees and staff from all provider groups who participate in airway management. The MDAC occurs within the Johns Hopkins Medicine Simulation Center approximately four times per year and uses a combination of didactic lectures, hands-on sessions, and high-fidelity simulation training. Participation in MDAC is the main intervention being investigated in this study. Data were collected prospectively using course evaluation survey with quantitative and qualitative components, and prepost course knowledge assessment multiple choice questions (MCQ). Outcomes include course evaluation scor...

Objective Our aim was (1) to develop an objective structured clinical examination (OSCE) for obstructive sleep apnea (OSA) and (2) to test the reliability and evaluate the feasibility of this OSCE while assessing residents' clinical skills in multiple core competencies via the standardized patient methodology. Study Design Development of assessment tool. Setting Johns Hopkins Medicine Simulation Center. Subjects and Methods Residents of the Department of Otolaryngology-Head and Neck Surgery at The Johns Hopkins University School of Medicine were invited to participate. A 2-station OSCE was developed. The first station used a standardized patient, and the encounter was videotaped for later evaluation by medical faculty not familiar with the participants being tested. The second was a computer-based station developed per a modified Delphi technique, based on feedback from otolaryngology and sleep medicine faculty involved in the care of patients with OSA. Checklists were developed...

Students pursuing a medical career in the US are subject to standardized testing at regular intervals. These standardized tests not only quantify the milestones students have already achieved, but also define the path for future achievements. The purpose of these examinations is to help students become self-directed, lifelong learners - an essential attribute of a medical professional. However, whether preparing for these examinations actually makes students such disciplined learners needs to be examined. Especially during residency training with its limited time and unpredictable exposure, trainees must learn in the most efficient way for their learning styles, and thus develop attributes that will be helpful to them in their medical career. In this review, we propose that a personalized, learner-centered approach tailored to residents' educational needs and preferences can not only fulfill learning interests and objectives but also serve as a time-efficient and cost-effective ...

Difficult airway cases can quickly become emergencies, increasing the risk of life-threatening complications or death. Emergency airway management outside the operating room is particularly challenging. We developed a quality improvement program-the Difficult Airway Response Team (DART)-to improve emergency airway management outside the operating room. DART was implemented by a team of anesthesiologists, otolaryngologists, trauma surgeons, emergency medicine physicians, and risk managers in 2005 at The Johns Hopkins Hospital in Baltimore, Maryland. The DART program had 3 core components: operations, safety, and education. The operations component focused on developing a multidisciplinary difficult airway response team, standardizing the emergency response process, and deploying difficult airway equipment carts throughout the hospital. The safety component focused on real-time monitoring of DART activations and learning from past DART events to continuously improve system-level perfo...

To describe the types of talking tracheostomy tubes available, present four case studies of critically ill patients who used a specialized tracheostomy tube to improve speech, discuss their advantages and disadvantages, propose patient selection criteria, and provide practical recommendations for medical care providers. Retrospective chart review of patients who underwent tracheostomy in 2010. Of the 220 patients who received a tracheostomy in 2010, 164 (74.55%) received a percutaneous tracheostomy and 56 (25.45%) received an open tracheostomy. Among the percutaneous tracheostomy patients, speech-language pathologists were consulted on 113 patients, 74 of whom were on a ventilator. Four of these 74 patients received a talking tracheostomy tube, and all four were able to speak successfully while on the mechanical ventilator even though they were unable to tolerate cuff deflation. Talking tracheostomy tubes allow patients who are unable to tolerate-cuff deflation to achieve phonation....

Tracheostomies are performed to improve health-related quality of life (QOL) in patients requiring prolonged mechanical ventilation. As the lengths of stay in intensive care units (ICU) increase and higher rates of tracheostomies are becoming more prevalent, issues regarding patient perceptions of their own prognoses and outcomes after tracheostomy can considerably impact QOL and in turn their care and recovery. Whether tracheostomy improves QOL, however, has not been studied adequately. Current studies investigating QOL have been limited to pre- and post-ICU admission, have relied on surrogate measures such as clinical outcomes and proxy reports, and have used inadequate instruments, failing to capture all domains of QOL. Studies using a robust instrument to investigate QOL in the ICU before and after tracheostomy are lacking. To explore the feasibility of assessing patient-reported QOL of mechanically ventilated ICU patients with a tracheostomy. A prospective longitudinal pilot st...

Introduction The Accreditation Council for Graduate Medical Education (ACGME) introduced the Outcome Project in July 2001 to improve the quality of resident education through competency-based learning. The purpose of this systematic review is to determine and explore the perceptions of program directors regarding challenges to implementing the ACGME Outcome Project. Methods We used the PubMed and Web of Science databases and bibliographies for English-language articles published between January 1, 2001, and February 17, 2012. Studies were included if they described program directors' opinions on (1) barriers encountered when attempting to implement ACGME competency-based education, and (2) assessment methods that each residency program was using to implement competency-based education. Articles meeting the inclusion criteria were screened by 2 researchers. The grading criterion was created by the authors and used to assess the quality of each study. Results The survey-based data...

To this date the effect of the time taken to complete an evaluation on the psychometric properties of the instrument has not been reported. The goal of our study was to assess the effect of time taken to complete an evaluation on its validity. Cross-sectional validation study. The global and checklist parts of tonsillectomy, mastoidectomy, rigid bronchoscopy, and endoscopic sinus surgery were used in the operating room by the otolaryngology faculty to evaluate the surgical skills of the residents. We categorized evaluations into two groups depending on the time taken to complete an evaluation (group A ≤ 6 days, group B >6 days). Construct validity was calculated for both groups by comparing the mean global and checklist scores of the residents across advancing postgraduate year levels. A total of 468 evaluations, consisting of global and checklist parts, were completed for 29 residents by 32 evaluators. Mean number of days taken to complete an evaluation was 7.7 days. For all the evaluations completed within a 6-day time period, the construct validity was significant for both global and checklist parts of the four instruments. In cases of the evaluations completed after 6 days, the construct validity was significant for the tonsillectomy instrument only. Our results indicate that the time taken to complete an evaluation has a significant effect on the construct validity of the objective instrument. In the future, efforts should be focused on faculty development to ensure timely completion of the evaluation for a more valid assessment process.

To develop a valid and reliable tool for an objective structured clinical examination (OSCE) on hoarseness. To pilot-test the feasibility by assessing residents' clinical skills in various core competencies while assessing hoarseness on a standardized patient (SP). Educational tool development. The OSCE checklists were developed using modified Delphi technique after obtaining feedback from faculty involved in providing care to hoarseness patients. SP-based and rest stations were created to assess clinical skills. Twelve Otolaryngology-Head and Neck Surgery residents participated in the study. Video recordings of residents' performance and their written documentation were rated by faculty members. The OSCE that we developed is a valid method of assessing residents' clinical skills for evaluating hoarseness. Senior residents performed better in all of the tasks such as obtaining history and performing a physical exam on an SP, ability to perform flexible laryngoscopy on a mannequin, and interpretation of radiologic findings. Internal consistency assessed by Cronbach's alpha as measure of inter-item reliability was 0.92 for laryngoscopic station and 0.95 for radiology station. This OSCE can be effectively used for the objective assessment of clinical competency in hoarseness. Our pilot study evaluated multiple competencies on a single occasion, including medical knowledge, patient care, professionalism, and communication and interpersonal skills. Clinical competence in history taking, physical examination, flexible fiber-optic laryngoscopy, and ability to interpret radiologic findings improved with increasing year of training. This OSCE provides targeted assessment of practice-based learning and feedback for improvement of clinical performance.

Previous studies have identified a predominant learning style in trainees from different specialties, more recently in otolaryngology residents. The purpose of our study was to determine a predominant learning style within otolaryngology fellowships and to identify any differences between otolaryngology fellows and residents. We conducted a survey of otolaryngology fellows at 25 otolaryngology fellowship programs accredited by the Accreditation Council for Graduate Medical Education. We emailed Kolb's Learning Style Index version 3.1 to 16 pediatric otolaryngology (PO) and 24 otology/neurotology (ON) fellows. This index is a widely used 12-item questionnaire. The participants answered each item in the questionnaire as it applied to their preferred learning style: accommodating, converging, diverging, or assimilating. Results were then analyzed and compared between each subspecialty and the previously reported preferred styles of otolaryngology residents. Ten PO and 20 ON fellows completed the survey, with an overall response rate of 75%. PO and ON fellows (60% of each group) preferred a learning style that was…

Background: The steady rise in the number of critically ill patients in the USA has led to an increase in the need for tracheostomies in patients requiring chronic ventilatory support. There is a matched need for experienced operators to safely and efficiently perform these procedures. Objectives: We evaluated the effects on procedural outcomes and efficiency of percutaneous dilatational tracheostomy (PDT) placement in the medical intensive care unit (MICU) by the surgical team (ST) or interventional pulmonologists (IP). The IP team joined the PDT team in September 2007 and became primarily responsible for all PDT in the MICU. Methods: A retrospective analysis of prospectively collected data of patients who received PDT in the MICU by ST and IP from September 2007 to August 2010 was made. Outcomes including safety, efficacy, and procedural efficiency were compared. Results: One hundred seven patients underwent bedside PDT in the MICU during this period. Forty-three procedures (40.2%...

Objective To examine whether the implementation of a multidisciplinary percutaneous tracheostomy team decreases complications, improves efficiency in patient care, and reduces length of stay and cost in patients undergoing percutaneous tracheostomy. Study Design Case series with planned data collection. Setting Urban, academic, tertiary care medical center. Subjects and Methods Patients who underwent a percutaneous tracheostomy in 2004 and 2008, before and after the formation of a multidisciplinary percutaneous tracheostomy team, were included in the study. Data for the study were retrieved from a tracheostomy database. Measured outcomes include complications, efficiency, length of stay, and cost. Results Complications such as airway bleeding and physiological disturbances decreased significantly in 2008 as compared with 2004. The percentage of patients who received a tracheostomy within 2 days increased from 42.3% to 92% (2004 vs 2008), showing improvement in efficiency of care. Th...

Objective: To perform risk analysis of tracheal injuries caused by endotracheal intubation (ETI) and to estimate the financial impact of these sequelae.Study Design: Cost analysis using a national database.Settings: The Agency for Healthcare Research and Quality (AHRQ) 2006 National Inpatient Sample.Subjects and Methods: We identified clinical manifestations and treatments of complications associated with endotracheal tubes and codified them into International Classification of Disease-ninth revision diagnosis and procedure codes, intentionally excluding alternative etiologies of tracheal injury. Using the AHRQ 2006 National Inpatient Sample, we then compared patients with tracheal injury coded during the medical or surgical stay for length of stay (LOS) and mean hospital cost with diagnosis-related group (DRG)-matched controls; we also examined readmissions treating tracheal injury.Results: Tracheal injury presents as tracheal stenosis, tracheomalacia, tracheoesophageal fistula, la...

We present what to the best of our knowledge is only the fourth case of a primary nasopharyngeal paraganglioma to be reported in the literature, and we describe a novel surgical approach to its removal. The patient was a 53-year-old woman who presented with a nasopharyngeal mass. A subtotal resection and biopsy of the mass identified it as a paraganglioma. The remainder of the tumor was completely excised via a combined transnasal endoscopic and transoral approach that allowed us to spare the palate. The total operating time was less than 90 minutes. Blood loss was estimated at 300 ml, and there were no intraoperative or postoperative complications. At follow-up 12 months later, endoscopic examination and imaging found no residual or recurrent tumor.

Despite careful selection processes, residency programs face the challenge of training residents who fall below minimal performance standards. Poor performance of a resident can endanger both patient safety and the reputation of the residency program. It is important, therefore, for a program to identify such residents and implement strategies for their successful remediation. The purpose of our study was to gather information on evaluation and remediation strategies employed by different otolaryngology programs. Cross-sectional survey. We conducted a national survey, sending a questionnaire to the program directors of 106 otolaryngology residency programs. We collected information on demographics of the program, identification of problematic residents, and remediation strategies. The response rate was 74.5%, with a 2% cumulative incidence of problematic residents in otolaryngology programs during the past 10 years. The most frequently reported deficiencies of problematic residents ...

Evidence shows a positive association between quality of surgical training received and patient outcomes. Traditionally, improved patient outcomes are linked with increased operative volume. However, generalizing this finding to surgeons in training is unclear. In addition, reduced exposure due to work-hour restrictions calls for alternative methods to determine the quality of training. The purpose of this study was to identify the indicators of high-quality training by surveying the trainees and trainers. A questionnaire was developed based on input from faculty and previous studies. The survey was divided into three sections asking about the indicators of quality training, methods to measure them, and interventions for improvement. The questionnaire was administered to program directors (PDs) and senior residents of otolaryngology training programs nationwide. The strongest indicators of quality training that were agreed upon by both residents and PDs were having faculty developme...

To evaluate the clinical, radiological presentation and surgical management of fibrovascular polyps of the hypopharynx. Retrospective medical analysis of a case report. We report the case of a 66-year-old man, who presented with an incarcerated left inguinal hernia, vomiting and regurgitation of a large mass into the oral cavity resulting in syncope. MRI and cine-esophagram demonstrated a large mass in the cervical esophagus. At the time of herniorrhaphy, endoscopy revealed an 11.8-cm hypopharyngeal mass that completely obstructed the oropharynx. The airway was secured by tracheostomy and the lesion was subsequently removed via open pharyngotomy. Postoperatively, a second polyp was found ball-valving into the airway, and an endoscopic resection was performed prior to decannulation. Histopathology of both lesions confirmed the diagnosis of a fibrovascular polyp. Fibrovascular polyps are rare benign intraluminal esophageal lesions resulting in mild symptoms of dysphagia that may also cause significant morbidity such as syncope and asphyxia. This is the first report of synchronous fibrovascular polyps of the hypopharynx.

The Difficult Airway Response Team (DART) was implemented in July 2008 to address emergent difficult airway situations. The main objective of this study was to highlight the unique role and skill set that otolaryngologists bring and their impact on patient outcomes. Retrospective review of prospectively collected data from the hospital's airway registry. We collected data on demographics, airway characteristics, airway management techniques used by each specialty, and clinical outcomes (such as cricothyrotomies) for patients for whom a code was activated between July 2006 and June 2010. We compared data between pre- and post-DART cohorts and between DART and non-DART patients using a matched case-control approach. Of the 2,826 codes, 90 patients required DART management between July 2008 and June 2010. Body mass index, cervical spine injury/fixation, history of difficult airway, head and neck mass, and oropharyngeal and/or supraglottic angioedema were identified as significant predictors for DART activation. Forty-nine (60%) patients' airways were secured by anesthesiologists, 30 (36%) by otolaryngologists, and three (4%) by trauma surgeons. Otolaryngologists were able to use specialized techniques such as Holinger and Dedo laryngoscopes to significantly decrease the number of cricothyrotomies from seven (0.73%) pre-DART implementation to four (0.21%) post-DART implementation. Otolaryngologists were able to decrease the need for cricothyrotomies using specialized techniques for patients with difficult airways. Otolaryngologists bring a special skill set to the DART that is beyond the scope of anesthesiologists and trauma surgeons and that can improve patient outcomes by preventing unnecessary emergency surgical airways. 2b Laryngoscope, 125:640-644, 2015.

To assess whether practice on a virtual-reality (VR) temporal bone simulator improves acquisition of technical skills in mastoid surgery. Prospective blinded study. Using a previously validated objective structured assessment of technical skills (OSATS) tool, performance was assessed in 12 residents for two tasks of cortical mastoidectomy: 1) identifying and defining the tegmen and 2) defining the sigmoid sinus and sinodural angle. These surgical tasks were chosen as key steps in mastoid dissection because they were of intermediate complexity. Videos of virtual dissections were captured at baseline and again after practicing each task four to six times. OSATS scores for the tegmen task increased from 2.125 ± 1.25 to 3.1 ± 0.85 (P = .026), whereas for the sigmoid task scores increased from 2 ± 0.45 to 2.75 ± 1.125 (P = .0098). The time to complete the tasks decreased from 8.37 ± 4.78 minutes to 5.39 ± 3.06 minutes (P = .018) for the tegmen task and from 8.99 ± 6.7 minutes to 8.68 ± 5.98 minutes (P = .594) for the sigmoid task. There was a decline in number of injuries from 0.5 ± 1.5 to 0 ± 0.5 (P = .594) for the tegmen task and from 2.5 ± 4 to 0.5 ± 1 (P = .029) for the sigmoid task. Technical skills in mastoidectomy surgery can be acquired during even brief practice on the VR temporal bone simulator. It is anticipated that longer periods of practice presented within the fundamentals of comprehensive curriculum will facilitate procedural learning. Further studies are required to elucidate evidence of transference of these skills to the operating room and to procedures of greater complexity.

... Health-Related Quality of Life in Mechanically Ventilated Patients: Pilot Study Vinciya Pandian PhDc, CRNP; Gayle Page DNSc. RN, FAAN; Nasir Bhatti MD, MHS, FACS ... between those continuing to be endotracheally intubated versus those receiving tracheostomy? ...

Morbidity and mortality (M&M) conferences provide a forum for discussing adverse events and systems-based practice (SBP) issues; however, few models for implementing multidisciplinary, systems-focused M&M conferences exist. To implement a new systems-focused M&M conference and evaluate success in focusing on adverse events and systems issues in a nonpunitive, multidisciplinary manner. We implemented a new M&M conference into our large university-based internal medicine residency program. Using content analysis, we qualitatively analyzed audio recordings of M&M conferences from the first year of implementation (2010-2011) to determine the frequency of adverse events (injury resulting from medical care), SBP discussion, and allocation of blame. Multidisciplinary attendance was evaluated by attendance logs. Surveys assessed change in interns' perceptions of M&M conferences before and after the conference series (measured by median Likert-scale response) and trainee/faculty attitudes regarding the goal of M&M conferences. There were 226 attendees (66 faculty, 160 residents/fellows) at 9 M&M conferences. Average attendance per conference was 71, with representation from 16 disciplines. All M&M conferences (100%) included adverse events, SBP discussion, and lacked explicit individual blame. Interns' perceptions improved, including their belief that the M&M conference's purpose is systems improvement (4.35 versus 4.71, P  =  .02) and complications are discussed without blame (3.81 versus 4.34, P  =  .01). After experiencing M&M conferences, trainees/faculty reported favorable ratings, including beliefs that the M&M conference is important for education (97%) and the purpose is systems improvement (95%). The implementation of a new systems-focused M&M conference resulted in a conference series focusing on adverse events and associated system issues in a nonpunitive, multidisciplinary context.

1) Assess current status of operative competency assessment and feedback among US Otolaryngology residency programs. 2) Evaluate correlations between assessment or feedback tools and remediation. Survey of Program Directors. The survey was sent to 100 Program Directors inquiring about program size, mode of feedback, assessment tools, surgical portfolios, remediation, and number of residents requiring remediation in past 5 years. Associations between assessment questions and remediation (yes or no) were statistically assessed with the [chi]2 goodness-of-fit test. For more complicated analyses, multiple logistic regression models were created to assess predictors of the binary outcome of radiation. Among 72 respondents, subjective evaluations are used by 95.8% (69 of 72). Formative feedback after cases is used by 38.9% (28 of 72). Summative feedback at end of the rotation is done by 57.0% (41 of 72). Objective Structured Assessments of Technical Skills is used by 15.3% (11 of 72) of programs, most are large on the basis of number of residents or faculty or both. Operative portfolios are kept by 48.6% (35 of 72) of programs. The percentage of programs with mechanisms for remediation is 41.7% (30 of 72). Similarly, of the programs who responded to the remediation question, the percentage with at least one resident requiring remediation is 37.5%. Programs who report at least one resident remediation are statistically more likely to have a remediation mechanism in place (75% vs. 27.5%; P <.001). There is also a statistically significant association with formative feedback and having resident remediation (58.3% vs. 30%; P = .025). Standardized surgical curricula and assessment tools are needed. Programs with more intensive evaluation or remediation mechanisms are statistically more likely to report residents requiring remediation. This may reflect their ability to better identify the struggling resident. Alternatively, having a resident requiring remediation may be the catalyst that initiates the need for more intensive evaluation tools and remediation mechanisms. The Accreditation Council for Graduate Medical…

The purpose of this study is to compare faculty and trainees' perceptions of their mentorship experience in otolaryngology training programs in order to identify areas where improvements could yield more productive mentorship. Cross-sectional survey design. Residents and faculty from three otolaryngology-head and neck surgery programs were surveyed regarding their perceptions of their mentoring relationship. Trainees were asked about the characteristics of their mentorship experience. Separately, faculty were asked to describe their mentorship relationship, available resources to provide effective mentorship, and to identify areas in which formal training would improve their mentoring skills. Forty-eight trainees (72%) and sixty-one faculty members (73%) completed the survey. Ninety percent of residents meet with their mentors at least twice a year. Faculty and residents (> 80%) agreed that career planning was the most commonly addressed topic in mentorship sessions. However, faculty and residents differed in their perceptions of providing mentorship in other areas including clinical judgment (P = 0.003). The majority of faculty (56%) felt that formal mentorship training would improve their mentorship skills. While 95% of mentees agreed that their mentor is accessible, only 46% of faculty believed they have enough time to dedicate to mentoring (P < 0.001). Mentees are generally satisfied with the mentoring they receive, while most mentors are not satisfied with the time they have to provide mentorship. Further insights into differences in faculty and trainee perceptions may improve the mentorship experience.