Abstract
To survey Otolaryngology residents to evaluate their operative airway exposure during their training and to assess if the exposure was adequate to decide whether to pursue fellowship in pediatric. A modified and validated survey was distributed among otolaryngology trainees in the Western region of Kingdom of Saudi Arabia. It assesses operative airway exposure during training, adequacy of experience to decide on whether to pursue fellowship in pediatric otolaryngology, and plan to perform the following six procedures (diagnostic rigid bronchoscopy, diagnostic flexible bronchoscopy, endoscopic airway foreign body removal, rigid esophagoscopy with or without foreign body removal, suspension microlaryngoscopy procedures, open tracheostomy) in practice. Only 24/60 (60%) of respondents perceived that they had adequate training as to whether or not to make them decide to pursue fellowship in pediatric. In regard to over all assessment of the level of exposure: the vast majority of trainees regarded the training as adequate 30/60 (50%), 3/60 (5%) thought it was excellent, 6/60 (10%) thought it was good, and 21/60 (35%)assessed the training adequacy as poor. 24/33 (72.7%) perceived that the presence of a pediatric fellow with them enhanced their training. In regards to performing surgeries after training, 78% were planning to perform rigid bronchoscopy, flexible bronchoscopy (58%), endoscopic airway FB removal (92%), esophagoscopy (54%), suspension microlaryngoscopy (82%), and open tracheostomy (100%). The presence of a pediatric fellow in service was thought of by most residents as being beneficial, however, the exposure to airway surgeries were not adequate as to inform trainees if they want to pursue fellowship in pediatric, when they were not exposed to a fellow.
Keywords: Residency, Airway Surgeries, Fellowship, Exposure
Introduction
Surgeries involving the airway, such as open tracheostomy, are considered to be among the most commonly performed procedures in the field of otolaryngology. Dealing with the airway requires focus and vigilance, as the consequences can be detrimental.
To train young surgeons, there needs to be a shift in learning outside the operating room (OR). One way to achieve such a shift is through simulated surgery for the pediatric airway, which can be used to train otolaryngology residents in how to deal with airway emergencies and to perform endoscopic as well as open airway procedures [1–4].
With the increase in the concept of subspecialization and the emergence of post-residency fellowship training, there are concerns that this could limit the operative experience of residents [5–9].
For trainees to be able to perform procedures that involve both the upper and lower airways during practice, adequate exposure while training is essential. The amount as well as the timing of surgical exposure can determine career choices for trainees [7, 8]. To our knowledge, operative airway experience during training has not been evaluated before.
This cross-sectional study was conducted to survey residents to determine their level of exposure to airway surgeries during practice. The survey also assessed whether the surgical exposure was enough to help trainees decide whether they wanted to apply for a pediatric fellowship.
Methods
This project received ethical approval from the Faculty of Medicine ethics board.
The questionnaire used in this study was originally taken from Montague P et al. [11] publication; it was modified for airway surgeries and pediatric fellowships, and the procedures were changed to match our objectives. Validation of the survey was performed in multiple steps. The first was through running it by experts in the field for face validity and content, followed by a pilot study on 10 volunteers. This was performed by administering the survey to them twice two weeks apart and checking their responses for interrater reliability.
After validation was achieved, the final survey product was administered to trainees who are in the Otolaryngology–Head and Neck Surgery residency program in the Western region in Saudi Arabia (a total of 75 residents). The survey was conducted between February 2019 and June 2019. The survey was distributed electronically and consisted of 26 questions. The goals were to evaluate surgical airway exposure during training, adequacy of experience in deciding whether to pursue fellowship in pediatric otolaryngology, and plans to perform six procedures (i.e., diagnostic rigid bronchoscopy, diagnostic flexible bronchoscopy, endoscopic airway foreign body removal, rigid esophagoscopy with or without foreign body removal, suspension microlaryngoscopy procedures, and open tracheostomy) in practice.
Demographic data of the respondents were gathered, and then the data were grouped according to the responses to the following topics: (1) Presence of a pediatric otolaryngology fellow. (2) Having adequate exposure to the operative airway to decide on the pursuit of a fellowship. Comparisons of outcome measures were performed using t tests for continuous data and Fischer’s exact tests for categorical data. SAS software was used for data analysis.
Results
The questionnaire had an overall intra-rater reliability of 86%. All questions received more than 82% intra-rater reliability.
The overall number of eligible residents who should respond to the survey is 75. Sixty participants responded, constituting an 80% response rate. There were 33 (55%) residents who trained in a center where there was a pediatric fellow. Overall, 24 (40%) thought that the exposure was enough to let them decide about getting into a pediatric fellowship, while 36 (60%) did not. All of those 24, were trained alongside a pediatric otolaryngology fellow.
The vast majority of trainees (39/60) regarded the training was at least acceptable. This was subdivided into adequate 30/60 (50%), 3/60 (5%) thought it was excellent, 6/60 (10%) thought it was good, where as 21/60 (35%) assessed the training adequacy as poor. The exact subdivision of the trainees responses to when they were exposed to the various airway surgeries is highlighted in Table 1.
Table 1.
Table 1 shows the PGY level of the respondents at which they first observed, performed and performed with minimal supervision the six airway surgeries (rigid bronchoscopy, flexible bronchoscopy, endoscopic airway foreign body removal, rigid esophagoscopy with or without foreign body removal, suspension microlaryngoscopy procedures, and open tracheostomy)
| When in Residency was the Respondent Exposed to Each Surgery? | |||||||
|---|---|---|---|---|---|---|---|
| Exposure to airway cases helpful | presence of fellow | ||||||
| Yes (24) | No (36) | p value | Yes (33) | No (27) | p value | ||
| PGY | PGY | PGY | PGY | PGY | |||
| Rigid Bronch | |||||||
| Observed | 2.2 | 2 | 1.9 | > 0.05 | 2.1 | 1.8 | > 0.05 |
| Performed | 2.6 | 2.2 | 1.6 | > 0.05 | 1.9 | 1.5 | > 0.05 |
| autonomously | 3.4 | 2.2 | 1.5 | 0.04 | 1.8 | 1.5 | > 0.05 |
| Flexible Bronch | |||||||
| Observed | 2.3 | 1.5 | 1.3 | > 0.05 | 1.5 | 1.2 | > 0.05 |
| Performed | 2.8 | 1.4 | 1.1 | > 0.05 | 1.3 | 1 | > 0.05 |
| autonomously | 3.1 | 1.8 | 1.2 | 0.02 | 1.6 | 1 | 0.03 |
| Airway FB Removal | |||||||
| Observed | 2.3 | 2 | 2 | > 0.05 | 2.1 | 1.8 | > 0.05 |
| Performed | 2.6 | 2.3 | 1.3 | 0.01 | 1.6 | 1.3 | > 0.05 |
| autonomously | 3 | 2 | 1 | 0.04 | 1.4 | 1.1 | > 0.05 |
| Esophagoscopy | |||||||
| Observed | 2.2 | 2.1 | 2 | > 0.05 | 2.2 | 2.2 | > 0.05 |
| Performed | 2.7 | 2.5 | 1.7 | > 0.05 | 2 | 1.9 | > 0.05 |
| autonomously | 3.2 | 1.9 | 1.6 | > 0.05 | 1.5 | 1.8 | > 0.05 |
| Microlaryngoscopy | |||||||
| Observed | 2.2 | 2 | 2 | > 0.05 | 2 | 2 | > 0.05 |
| Performed | 2.8 | 2.4 | 2.1 | > 0.05 | 2.2 | 2.1 | > 0.05 |
| autonomously | 3.4 | 2.1 | 1.5 | > 0.05 | 1.6 | 3.1 | 0.02 |
| Tracheostomy | |||||||
| Observed | 2 | 2 | 2 | > 0.05 | 2 | 2.1 | > 0.05 |
| Performed | 2.2 | 2.1 | 2.1 | > 0.05 | 2 | 2.1 | > 0.05 |
| autonomously | 3.1 | 2.6 | 2.1 | > 0.05 | 2 | 2.4 | > 0.05 |
Significant p value figures are highlighted in bold italic
The table also compares the presence of a fellow or not as well as if the airway exposures were helpful in determining their opinion of pursuing a pediatric otolaryngology fellowship
**PGY = Postgraduate Year (residency level 1–5)
Only 33/60 trainees trained in a center where there is a pediatric fellow. Twenty-four participants (72.7%%) thought that their presence was helpful, 3 (10%) indicated that it was not beneficial, and 3 (10%) were neutral. Respondents who thought they had adequate airway surgery exposure to decide on pursuing a pediatric fellowship did not differ significantly from their counterparts in regard to the time at which they first observed and performed the procedures in question.
In some of the procedures, it was noted that the presence of a fellow was associated with late performance compared with trainees who did not train with a fellow. The two procedures were performing flexible bronchoscopy with autonomy and performing suspension microlaryngoscopy with autonomy. All 24 who responded they had adequate airway exposure had trained in a centre which had a pediatric otolaryngology fellow, while all respondents who did not have a fellow with them in service thought that the exposure was not enough. It is also important to mention that 24/33 (72.7%) thought that the presence of a fellow was helpful in their training process and help them decide whether or not to pursue pediatric otolaryngology fellowship.
When asked whether or not they would perform these procedures in practice after training, 78% were planning to perform rigid bronchoscopy, flexible bronchoscopy (58%), endoscopic airway FB removal (92%), esophagoscopy (54%), suspension microlaryngoscopy (82%), and open tracheostomy (100%) (Table 2).
Table 2.
This table demonstrate the percentage of trainees who are planning to perform airway surgeries in their practice and which airway surgeries are they planning to perform
| Plan to Perform these Surgeries After Training | |||||||
|---|---|---|---|---|---|---|---|
| Exposure to airway cases helpful | Presence of a Fellow | ||||||
| All Respondents | Yes (24) | No (36) | p value | Yes (33) | No (27) | p value | |
| No. (%) | No. (%) | No. (%) | No. (%) | No. (%) | |||
| Rigid Bronch | 47 (78.3) | 12 (85.7) | 35 (76) | > 0.05 | 24 (72.7) | 23 (85) | > 0.05 |
| Flexible Bronch | 35 (58.3) | 10 (71) | 25 (54) | > 0.05 | 18 (54.5) | 17 (63) | > 0.05 |
| Airway FB Removal | 55 (91.6) | 14 (100) | 42 (91) | > 0.05 | 30 (90.9) | 25 (92) | > 0.05 |
| Esophagoscopy | 54 (90) | 13 (93) | 41 (89) | > 0.05 | 29 (88.9) | 26 (96) | > 0.05 |
| Microlaryngoscopy | 49 (81.6) | 12 (86) | 37 (80) | > 0.05 | 23 (70) | 26 (96) | > 0.05 |
| Tracheostomy | 60 (100) | 14 (100) | 43 (93) | > 0.05 | 33 (100) | 27 (100) | > 0.05 |
It also compares the presence of the fellow or not and those who felt their exposure was helpful in pursuing fellowship
Discussion
This study’s results indicate that most trainees found their operative airway training to be adequate or good; however those who were not exposed to a pediatric fellow found it difficult to decide whether to pursue a fellowship in pediatric or not. Overall, all six procedures in the survey were first observed at an average of PGY-2, performed around PGY-2 or PGY-3 and performed with minimal supervision around PGY-3 or PGY-4. Although there are no studies in the literature that evaluate operative airway experience during residency, there is one article in which program directors were asked about which PGY year trainees became competent in certain surgeries. Most program directors thought that residents would become competent in esophagoscopy and tracheostomy during PGY-2 [10]. Another article with a similar idea evaluated otology/neurotology (ON) training, and it was found that exposure to ON cases was adequate to let trainees decide if they wanted to pursue fellowships in ON [11]. In our study, there was no significant difference between surgeries when they were first observed or performed when compared between respondents who thought they had adequate exposure or not.
The presence of a fellow in service could contribute to the learning process of residents. Although only 33/60 (67%) had trained with a pediatric otolaryngology fellow, they thought that their presence was beneficial and that they did not detract from their learning experience. It was observed that trainees with fellows performed some of airway surgeries approximately half to one year later than those who did not have fellows with them. This could be related to the advanced nature of the cases in fellowship training centres.
In the literature, there are mixed results on the effect of the presence of a fellow in resident training. In one of the articles that evaluated whether the presence of a pediatric fellow affected the learning process of residents, the results showed that there was no impact due to the rarity of the presence of cases that were categorized at the fellowship level [8]. In another study, it was shown that the presence of head and neck fellows did not affect the operative experience of senior residents but actually enhanced their learning process [12].
In the analysis of Table 2, the data concerning practice patterns show that most respondents plan to perform all airway surgeries except for fixable bronchoscopy, where approximately half of trainees do not intend to perform it. Generally, the respondents’ likelihood of performing these procedures in practice was not affected by the presence of a fellow, nor was it affected by whether the exposure was sufficient to let them decide about pursuing pediatric fellowship.
Designing residency training is not an easy task. To train residents well, there must be maximum benefit for residents and patients [13]. Regardless of the balance, the main problem that residents face is that they have only 5 years of training. Moreover, this time period might not be sufficient to let trainees decide which subspecialty they wish to pursue. In this survey, in particular, the vast majority of trainees indicated that the exposure was not adequate to decide if they wanted to subspecialize in pediatric fellowships.
The data presented in this paper offer the foundation for pediatric otolaryngologists and program directors to enable them to maximize the surgical experience of trainees and open for them the path for career choices. In the literature, there is little mention about how the presence of pediatric fellows can affect residents’ education, and this paper can serve as a springboard to further examine this relationship.
Conclusions
The presence of a pediatric fellow in service was thought of by most residents as being beneficial; however, exposure to airway surgeries for those not trained with a pediatric otolaryngology fellow was not adequate to inform trainees if they wanted to pursue fellowships in pediatric otolaryngology.
Author Contributions
Faisal Zawawi: Senior Author, Data collection, Data analysis, Manuscript writing, Study design, revision editing, final manuscript review and production. Yousef Marzouk: Data collection, Data analysis, Manuscript writing and final manuscript review and production. Hala M.A. Kanawi: Data collection, Data analysis, Manuscript writing and final manuscript review and production.
Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Declarations
Conflict of interest
None of the authors have a conflict of interest.
Ethical Approval
This study has been approved by the institutional ethics approval board the Faculty of Medicine, King Abdulaziz University, Jeddah–Saudi Arabia.
Footnotes
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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