BYRON J. BAILEY,
MD
Thank you very much for the privilege of appearing before you as this
year's Guest of Honor. I have such respect for Dr Lauren Holinger, who
is truly a master of the intricacies of the pediatric airway, a most intimidating
and occasionally terrifying passageway. Its myriad potentially lethal pathologies,
combined with its unforgiving nature, causes strong men and women surgeons
to become humble as they gaze into its depths.
This is the highest honor of my career, and it certainly is the most appreciated,
as this is the specialty society for which I have the highest personal
regard and respect. But I must tell you candidly that this honor is more
a reflection of the honor that belongs to those who taught me, inspired
me, and motivated me to try to come up to their standards.
A review of the remarks of previous Guests of Honor reveals that most
of their addresses focused on personal reminiscence or philosophy. A small
number of presentations were scientific contributions or historical accounts,
and 2 focused on the subject of education and teaching, as I have chosen
to do.
Docendo Discimus, the motto of the American Laryngological Association,
can be translated as, "By teaching, let us learn." Several of
the giants of laryngology, when addressing this annual meeting, commented
on the significance of our motto and have reminded us that our title "Doctor" comes
directly from the Latin term doctus, which is translated as "teacher."
Let me propose another Latin phrase for your consideration. Non scholae
sed vitae discimus. This can be translated as, "Let us learn for life,
not for school." If we, as teachers, accept this concept as a guideline,
then we begin to see ourselves as teachers who are trying to promote the
process of clinical application of scientific knowledge on a lifetime basis.
Which brings us to a series of key questions. If we are teachers, what
are our educational goals, how can we measure the outcome of our educational
efforts, and how can we assess the relevance of our teaching?
First, what do we mean by educational outcomes in laryngology, and how
can we measure them? Each of us as an individual represents a unique educational
outcome. I am one, and you are one also. We represent the outcome of the
work effort of teachers who passed on to us the wisdom gained from their
experience. So, as a first step, I invite you to join me in honoring those
who have been our teachers. It is a part of my belief system that the debt
we owe those who taught us can be repaid only by teaching those who follow
us and by encouraging them to take our specialty to an ever higher and
more effective level.
I have been blessed to have as my most memorable teachers Dr Victor Goodhill
and Dr Joel Pressman. Both of these men were "gold standard" educators,
and both were academic triple threats of the highest order in their respective
fields. Both are inspirational.
By way of honoring Dr Pressman today, I want to recall for you these words
from his 1967 ALA Presidential Address:
As I see it, the preservation and advancement of these principles and
policies represent our role as heirs to the rich heritage we have
received from those who founded and nurtured this Association through
these many
years. Each generation of our membership has added its share to the
general storehouse of knowledge and to the advancement of laryngology.
We need
to see that this continues with ever increasing fervor. (1) (P16)
and elsewhere, progress depends upon the combined efforts of the academician,
the research worker, and the clinician working in cooperation with
one another.(1) (P16)
We should take the words of Dr Pressman to heart and heed his admonition
to keep our focus on encouraging the pursuit of important new scientific
information and on promoting its widest possible dissemination.
The year before Dr Pressman served as President of the ALA, I recall attending
the Spring Meetings at the American Hotel in Puerto Rico. Presiding at
that meeting was Lauren's father, President Paul Holinger, who urged the
members of the ALA to avoid the isolationist thinking and the separatist
and elitist behavior that was typical of several specialties and subspecialties
in medicine at that time.(2)
President Holinger's remarks were reinforced at that meeting in the address
of his Guest of Honor, who was Dr Francis Lederer. Dr Lederer (3) spoke
on the topic "The Best Milieu for Advancement of Otolaryngology," and
in his address he stated,
If the selection and education of our young men and women is maintained
at the highest level, we need have no concern. We have finally emerged
from our cocoon of educational complacency which placed technique as its
primary goal, identifying otolaryngology with only a few isolated procedures
as if each were a talisman.(3)(P18)
On the basis of this timeless advice from these giants in our specialty,
it seems to be a good idea to take a closer look at what we are doing in
terms of educating the bright young men and women who are the next generation
of laryngologists. During the past decade, the phrase "outcome studies" has
gained popularity as a clinical research technique. The rising costs of
medical care and the growth of for-profit managed care corporations (actually
functioning as managed cost corporations) have changed and limited the
decision-making role of physicians. Ideally, clinical outcome studies ask
the question, "How am I doing in managing my patients?" and the
answers could improve patient care by directing resources to the most effective
diagnostic and therapeutic interventions. At the same time, both the cost
and the importance of medical education have risen as well. This provides
strong motivation for some educational outcome studies that ask the parallel
question, How am I doing as a teacher? How valuable is the material that
we are providing to our residents? How relevant is the curriculum in our
residency to the practice of our specialty in local communities?
In an effort to explore these critical educational questions, I surveyed
the 64 residents who most recently completed our training program over
the past 22 years. We had 49 responses, for a 77% response rate, and I
appreciate this opportunity to share some of our survey findings with you.
In our survey instrument, we asked the following 12 questions.
1. What were your most valuable learning experiences during residency?
(The former residents were asked to rank 5 types of learning experiences
from the most valuable to the least valuable.)
2. What did you learn about laryngology during residency that has been
the most useful to you in your practice? (The former residents were asked
to grade 12 choices from extremely useful to not very useful.)
3. What areas of laryngology that you were taught during residency do
you diagnose and manage yourself and which do you refer to another specialist?
(For this item, 23 types of laryngeal pathology were listed, and a response
of Self or Refer was indicated for each item.)
4. List the most important/essential laryngology topics and areas that
were covered during your residency and remain the most useful in your practice.
(For this item, the response was to develop a list of topics and areas
on their own.)
5. List the least important/essential laryngology topics and areas that
were covered during your residency and remain the least important in your
practice. (Similar to No. 4.)
6. List the areas/topics in laryngology that were not covered in your
residency as fully as you now realize they should have been for your practice.
(Again, an open question to elicit a list in response.)
7. How do you continue to learn and keep up with the new advances in diagnosis
and management of laryngeal diseases and disorders? (Six items were graded
from 1 = extremely useful to 5 = not very useful.)
8. How could we do a better job of teaching about laryngeal diseases and
disorders during residency? (This was another open-response item.)
9. How could we do a better job of teaching and updating about laryngeal
diseases and disorders after residency? (Similar to No. 8.)
10. Rate the value of your residency training in each of the following
areas on a scale of 1 = poorest to 10 = best. (This item addressed 12 key
patient management areas within laryngology and asked for a scaled rating
from 1 to 10 to describe the value of their residency training in each
of these 12 categories.)
11. Looking back on my experience in laryngology when I was a resident
at UTMB, I feel that in the areas where my training was less than ideal,
the main causes were: (check all that apply and underline or circle the
most important ones). (The responses were to be chosen from a list of 5
items.)
12. When I entered practice, I was able to strengthen my areas of weakness
by: (check all that apply and underline or circle the most important ones).
(The responses were to be chosen from a list of 4 items.)
In the time allotted for my remarks, I will not be able to cover all of
the information we gathered from this survey, but I do want to share with
you a few of the most important observations and conclusions that can be
drawn at this point.
First, in response to the query regarding the most valuable learning experiences
during residency, the responses emphasized the perception that time spent
with the full-time faculty was the most valuable experience recalled by
our former residents. This was followed by time spent in personal study,
grand rounds and conferences, teaching by the clinical faculty, and attendance
at scientific meetings.
Second, we asked for feedback about what they had learned during residency
that had been the most useful in their clinical practice. By ranking these
responses numerically, we are also able to get an idea about the areas
that are least useful to them in practice. Leading the list of most useful
topic areas in laryngology were the evaluation and management of patients
with hoarseness and the treatment of benign lesions and laryngeal cancer.
These areas were followed, in decreasing order of responses, by reflux
laryngitis, vocal cord paralysis, airway obstruction, foreign bodies, papilloma,
and laser surgery. The least useful topics were congenital lesions, laryngeal
trauma, stage IV laryngeal cancer, spasmodic dysphonia, and laryngotracheal
stenosis. Most of the responders indicated that these items were chosen
as being less useful simply because they were not seeing patients with
these disorders.
That led us to seek a little more detail regarding what areas our former
residents actually treat themselves and which types of problems they refer
to others. The most commonly treated conditions were vocal cord polyps
and cysts, contact granuloma, foreign bodies, supraglottitis, moderate
laryngeal trauma, keratosis, unilateral vocal cord paralysis, Ti glottic
cancer, bilateral vocal cord paralysis, respiratory papilloma, and T2 glottic
cancer. The conditions that were somewhat intermediate in terms of whether
they were treated or referred were T1 supraglottic cancer, T3 glottic cancer,
congenital web, congenital cyst, T2 supraglottic cancer, and T3 supraglottic
cancer. Our former residents tended to refer patients with T4 glottic cancer,
T4 supraglottic cancer, severe trauma, subglottic hemangioma, and spasmodic
dysphonia.
We asked our former residents for feedback regarding the reasons that
they felt less well prepared to treat certain laryngeal conditions. They
responded that the most important limiting factor in their education in
laryngology was having an insufficient number of patients to manage themselves.
This was followed by inadequate faculty teaching, insufficient numbers
of conferences, and inadequate teaching by senior residents.
Finally, we asked the residents to tell us how they were able to strengthen
areas of weakness after they entered their practice. They reported that
their best postresidency learning was accomplished by attending national
and regional meetings. This was followed by information gained from scientific
journals, continuing medical education programs, practice colleagues, and
textbooks.
So, what I have tried to present today is a rather primitive and superficial
questionnaire survey designed to give us some feedback about the educational
outcomes of our efforts to educate residents in the evaluation and management
of laryngeal problems.
The feedback that we have received may not be transferable to other programs
and may be flawed in terms of the survey instrument that we developed.
At the very least, though, it does remind us of the importance of our efforts
to train the next generation of specialists more effectively in the area
of laryngology. The results emphasized the importance of our teaching efforts
as faculty and of the need to design a curriculum that will be relevant
to the eventual practice of our specialty.
I hope that some of you who hear these words or read the manuscript will
be challenged and stimulated to design better survey instruments and to
explore more adequately the educational outcomes that you are achieving
as you teach others about this remarkable field. Your efforts to become
more effective as teachers will be rewarded by the personal satisfaction
that you will gain as you realize that you are beginning to repay the debt
that you owe to your own teachers.
1. Pressman JJ. Presidential Address. Trans Am
Laryngol Assoc 1967;88:11-7.
2. Holinger PH. Remarks of the President. Trans
Am LaryngolAssoc 1966;87:11-4.
3. Lederer FL. The best milieu for advancement
of otolaryngology. Trans Am Laryngol Assoc 1966;87:15-9. |
INTRODUCTION