Tragic Optimism vs Learning on the Verge of More Change and Great Advances: Presidential Address, American Head and Neck Society

During the past year, I have given a great deal of thought to the choice of topic for this address. Having served as the chairman of the Finance Committee of the University of Oklahoma Physicians Medical Group, which oversees more than 200 contracts with about 320 physicians, and having educated residents and fellows for many years, I decided that it would be appropriate to share some thoughts about the remarkable changes we are experiencing in the business and education aspects of head and neck oncologic surgery. Some of them are relevant to everyone practicing head and neck surgery; others apply primarily to the United States. However, I believe our colleagues from abroad may find it interesting, if not informative, to find out how seriously the education of fellows is taken by the American Head and Neck Society.

Change has always gone hand in hand with the practice of medicine. In recent years, however, we have experienced, it seems, more rapid and more significant changes in the way that medicine and surgery are practiced in this country and abroad. As we stand today on the verge of yet more change and of great technologic advances, we cannot ignore the implications of change and the direction that changes in health care are taking. Alan F. Homer, president of the Pharmaceutical Research and Manufacturers of America, which represents the country's leading research-based pharmaceutical and biotechnology companies, characterizes this change in the following way:

"Health care has undergone a sea change—the hospital bed and the surgeon's knife are no longer its primary tools. They've been eclipsed by pharmaceutical therapies that open a whole new world of hope for better, healthier lives."¹

In addition, health care will change to include parameters never considered previously in determining the appropriateness of some aspects of medical care.

To the specialty of head and neck surgery, a specialty that has traditionally strived to remain clinically and academically vigorous, the prospect of these changes represents an opportunity. Unfortunately, it also represents a threat for several reasons. One is the defeatist attitude some of us are adopting: there is nothing we can do about these changes, so why bother. Even more concerning is the human phenomenon called "tragic optimism." In an essay written on the occasion of the new millennium, Stephen Jay Gould, PhD, professor of geology and curator of invertebrate paleontology at Harvard University, describes eloquently the most common human response to change as follows: "We do usually manage to muddle through, thanks to rationality with an adequate dose of human decency and hard work." This capacity marks the "optimism" in his designation. But we do not make our move toward a solution until a good measure of preventable tragedy has already occurred to spur us into action—the "tragic" component of it.²

Around the world and certainly in the United States, we are on the verge of more change in the reimbursement for hospitals and physicians. To the dismay of many physicians, we are rapidly moving from a practice of medicine in which the cost of providing care to a patient was not a question, and the primary focus of our activities was the physician-patient relationship, to a medical "industry" in which costs are rising faster than reimbursement.

Currently, there are 2 methods that can be used to determine the cost of a surgical procedure, including all the steps of care that are reimbursed by a "global" fee. One method determines the cost of care per relative value unit³; the other, an "activity-based cost" method, tracks and assigns a cost to every step of physician care. In preparation for this address, I prospectively determined the cost of 4 operations, performed in my practice, using both methods. The results are outlined in Table 1. A comparison of our costs with the current reimbursement by 4 third-party payers is shown in Table 2. In some cases, our costs are higher than the reimbursement (payer A). Considering that the majority of third-party payers reimburse procedures at a rate of 120% of Medicare fees (payer C), the gap between what it costs to perform these operations and what is reimbursed is narrow, and it is likely to narrow further in the future.

If we continue to believe that we will muddle through by working harder, it is very likely that either one or all of the following preventable tragedies will occur before we are spurred into action: (1) the bankruptcy of our practices; (2) the abandonment of head and neck oncologic surgery to embrace other types of surgery (endoscopic sinus surgery, cosmetic surgery, surgery for snoring) that are still lucrative; or, worse yet; (3) the forfeiting of our role as patient advocates. I would like to expand on the last possibility. Since the inception of managed care, the surgeon's role as patient advocate has changed dramatically. Currently, this role is focused on making sure that our patients have access to the best treatment. Do we not find ourselves, more often than ever before, pleading our patient's case to a nonmedical clerk or a medical director, and convincing them that the operation we have recommended is indeed indicated and is the best care for the patient? In the medical industry of the future, the surgeon's role as patient advocate may change even more drastically. I worry that, in the future, because of increasing financial constraints, we may need to make sure that we can afford to provide our patients the best possible treatment, particularly if that treatment is an operation. By its very nature, advocacy cannot be constrained,⁴ or else we get into the problem alluded to by Robert Byers, MD, in the Hayes Martin Lecture at this meeting: the "tension of opposites." What will happen if we find, the hard way, that we cannot afford to provide our patients such treatment? Would we continue, as an advocate should, to supply each patient all necessary care—even that of marginal benefit—regardless of cost?⁵ Or would we abandon our role as advocates and divert patients in the direction of whatever treatment is affordable? I wholeheartedly second the plea Dr Byers made for the preservation of professionalism, and I fervently hope that none of these scenarios comes to pass.

Faced with the possibility of such unpleasant consequences, tragic optimism is a dangerous attitude; instead, we should adopt a learning attitude. Eric Hoffer, the American blue-collar longshoreman-philosopher celebrated for his writings about life, power, and social order, wrote in his book In Our Time:

" . . . a learning society would have a decided advantage in a time of rapid change: while the learned usually find themselves equipped to live in a world that no longer exists, the learner adjusts readily to all sorts of conditions."⁶

A somewhat crass but realistic forecast for medicine in general, and surgery in particular, is that "the value of our services will eventually be defined as the quality of our surgical outcomes divided by their cost."⁷ If we are to follow Hoffer's admonition and behave as if we are learners, then learners anticipate and prepare for change. Thus, learning how to reach and maintain the critical balance of cost and outcomes will be one of the most important challenges to our specialty in the future. As we learn to do so, not only should we join the medical industry in its cost-reduction efforts but we must lead it in the direction of cost reductions that enhance quality-of-care outcomes. We will not be able to do this, however, unless we learn what our costs are. The methodology is at hand. We do have a responsibility in these matters whether we wish to accept that burden or not. Unquestionably, the methodology can be refined. Our Society can and must facilitate our behavior as learners by embracing these concerns now! This is the time to invest in adapting the available methodology, refine it to suit our needs, and make it available in a form that is usable by the solo practitioner or the academic group worldwide. By learning our costs, we will enhance our ability to maintain viable practices; advocate for our patients in front of health maintenance organizations, state legislatures, and the federal government; and, yes, continue to attract talented young physicians into the specialty. After all, if the viability of our clinical practices is jeopardized, everything else we do, including education and particularly research, will be in jeopardy! In this regard, it is disquieting to learn that more than 60% of the research activities of academic faculty in otolaryngology– head and neck surgery are supported by departmental funds, mostly derived from clinical practice.⁸

When we look at the results of the matching for head and neck surgery fellowship programs for the past 4 years (Figure 1), it is difficult not to be concerned by the declining number of applicants. Although reimbursement issues may already be playing some role in these trends, it would be prudent to consider other factors. Undoubtedly, the pool of applicants has become smaller. In the past, we used to draw from a pool of general surgery and otolaryngology residents; in recent years, the number of general surgery residents who consider head and neck surgery as a subspecialty has been minimal. It should be noted, though, that this trend began earlier than 4 years ago.

The number of fellowships in other subspecialties has not increased enough, during the past 7 years, to explain the decreased number of applicants to our training programs as a simple phenomenon of dilution (Table 3). It does not seem that our training programs are less attractive to residents than other subspecialties are. In preparation for this address, a survey was sent to the 296 residents graduating from otolaryngology training programs on June 30, 2000. Of the 141 who responded to the survey (response rate, 48%), 54 (38%) were taking additional (fellowship) training. The majority of the responders (66%) chose either head and neck surgery or facial plastic surgery as a subspecialty (Table 4). Also to be noticed is that 72% of them selected 1-year fellowships.

Another factor to consider, as a possible explanation for the decreasing number of applicants, is the level of knowledge and skill of the residents graduating from otolaryngology residency programs. If they were, or believed that they were, more qualified in head and neck oncology and surgery, they would be less interested in additional training. In fact, head and neck fellowships might have become unnecessary! This does not seem to be the case, judging from the number of graduating residents responding to our survey who admit to having minimal or no knowledge about basic contemporary concepts in head and neck oncology (Table 5), such as radiation biology (38%), hypofractionated radiation (58%), p53 (40%), and gene therapy in head and neck cancer (51%). Furthermore, residents graduating in 2000 were asked about their level of comfort in performing an operation, if they were given the opportunity to do it within 3 months of their graduation, by indicating whether they would perform a given operation alone, would perform it only with the assistance of a senior partner, would probably not perform it, or would definitely not perform it. The graduating residents do not seem to be overwhelmingly comfortable performing major head and neck oncologic procedures. Only 61% would perform alone a composite resection, 77% a total laryngectomy, and 38% a supraglottic laryngectomy (Table 6). Perhaps this is due to the relatively small number of such oncologic procedures residents perform during training. The average number of operations performed by graduating residents as surgeons, according to the American Board of Otolaryngology, is shown in Table 7.

It is difficult to ascertain whether duration of the fellowship is the most important factor, or even an important factor, in the decision of residents to pursue additional training. However, we cannot sidestep the observation that the number of applicants has decreased since 1995, when the duration of fellowships was increased to 2 years (Figure 1). It is also interesting to note that the majority of the residents going on to fellowships this year (72%) elected 1-year programs. Furthermore, we must keep in mind that, in addition to the reimbursement issues I discussed earlier, financial considerations, such as the debt acquired during medical school, probably weigh heavily on the decision of residents to pursue fellowship training. The average medical student debt ($63 000 on graduation in 1994 vs $97 400 in 1999)⁹ exerts obvious pressures to enter practice sooner rather than later, and may deter some residents from pursuing 2 years of additional training. It may also be a factor in the decision to opt for subspecialty choices that are perceived to be more lucrative.

After all of these factors are considered, we must not forget that the factor that influences students and residents the most, in their choice of specialty, is role models who demonstrate enthusiasm and a genuine love for what they do.¹⁰ It will be a challenge for us to not let what is happening in medicine dampen our enthusiasm for what we love to do: take care of patients with cancer of the head and neck and do surgery.

Also important in attracting young physicians to our specialty is what we do for them after we have attracted them. I believe this is crucial to the survival of the specialty, for as the Romans said, "Mighty oaks from acorns grow . . . mangle the nut and you'll get scrub; neither tall nor mighty." If our educational programs are sound and prepare the fellows well for the current and future demands of the specialty, they will continue to be attractive. Observing educational programs of different kinds, it is clear that the accomplishments of those programs that are successful can be largely credited to 3 factors: a continuous assessment of needs, a timely and objective evaluation of their outcomes, and a willingness to make a difference.

A continuous assessment of needs can be complex and is labor intensive, but it is necessary. A need is something required. Undoubtedly, what is required to educate our fellows has to be dictated, to a great extent, by the collective wisdom of the program directors and the leaders of the specialty. Byron Bailey, MD,¹¹ articulated this well in 1994, writing about the impact and long-range implications of fellowship proliferation:

"The first requirement—for a fellowship program accreditation—is that we develop high educational standards and clear statements with regard to linkage with formal educational units, educational objectives, and a length that is likely to train a unique individual. There is no place in the fellowship world for remedial fellowships in which individuals pursue additional training because of deficiencies in their residency."

Most of us agreed with Dr Bailey, and shortly thereafter, the length of fellowships was expanded to 2 years to include 1 year of research, and the accreditation process emphasized curriculum development.

A need is also something desired that is lacking. A survey of 344 fellowship-trained otolaryngologists was undertaken by the Educational Council for Otolaryngology Head and Neck Surgery in 1994.¹² The responses are outlined in Table 8. The main reasons responders cited for taking a fellowship were inadequate caseload (45%) and inadequate didactic teaching (29%) in a subspecialty area during residency.

Obviously, a discrepancy exists between what the specialty leaders believe is required and what the learners express as lacking. Clearly, neither opinion should be ignored. If we keep in mind that our primary responsibility as educators is to form physicians who can provide good care to their patients, we should respond to the need of those who seek acquisition of the knowledge and surgical expertise they believe they lack. This leads to the question: Should a 2-year "fellowship" program, with emphasis on research, as the fellowships are supposed to be structured now, be the only avenue for a resident to accomplish this?

Conducting a timely and objective evaluation of educational outcomes is an elaborate and costly undertaking. A common substitute used by most fellowship programs is a yearly subjective evaluation of the program by the graduating fellows. A survey was sent to all fellows graduating from fellowship programs accredited by the Council for Advanced Training in Head and Neck Oncologic Surgery in June 2000. Eleven (85%) of the 13 graduating fellows responded. Their responses to the same questions asked of the graduating residents are outlined in Table 9. The majority of fellows have at least a working or in-depth knowledge of current topics in head and neck oncology. It also seems that their level of comfort with all the surgical procedures listed in Table 6 is invariably high: 82% to 100% of the graduating fellows felt comfortable performing these procedures alone. Thus, it appears that the fellowships are doing well in terms of providing core knowledge and surgical experience.

One of the main reasons behind the expansion of the duration of fellowships to 2 years was to provide the fellows with a concentrated research experience of at least 1 year. Emphasis was placed on a basic science laboratory research experience; however, very few, if any, guidelines were issued by the Council about this aspect of fellowship training. According to our survey, at least 8 (62%) of the 13 fellows finishing their training in June 2000 had carried out a "formal basic science research" project. This is obviously gratifying and should be continued. It remains to be seen, however, whether this is adequate research training to provide fellows the expertise to become independent investigators. This does not seem likely in light of a recent appraisal of the efficacy of research training fellowships conducted by the National Institute on Deafness and Other Communication Disorders, which concluded that at least 2 years should be devoted specifically to research, to have any expectation of becoming an independent investigator.⁸ At this time, it is not clear how the research experience of the different fellowship programs is being mentored, how it is structured, and how its quality is evaluated. It is, thus, doubtful that such a poorly standardized research experience is equivalent to or better than that recommended by the National Institute on Deafness and Other Communication Disorders. Clearly, if we are to adhere to the strict standards called for by Bailey, we must establish guidelines for the fellows' research experience, monitor its quality, and track its outcome in terms of continued research involvement and funding. In time, it may become apparent that the duration of the research training during fellowships needs to be adjusted.

The next questions to be considered are: Do we have jobs for our graduating fellows? Are these jobs likely to further their research experience? I am pleased to report that 8 of the 11 graduating fellows responding to our survey were taking academic positions. However, it is a concern that the prioritization of time among academic otolaryngology–head and neck surgeons today is such that individuals holding junior academic positions in the United States, on average, devote only 13% of their time to research activities.⁸

One source of concern in the education of fellows and residents is the finding of our surveys that almost all of the graduating residents and at least 50% of the fellows graduating this year admit they have minimal or no knowledge of one or more of the concepts listed in Table 10. Because these are essential concepts or tools in clinical research, it is not unreasonable to conclude that our graduating clinicians are not prepared to plan and conduct patient-oriented research, such as clinical trials, treatment effectiveness, or patient outcomes research. Observations such as these are responsible, in part, for a bigger concern recently expressed by the Society of University Otolaryngologists–Head and Neck Surgeons. They warn that we have an undersupply of properly trained clinical investigators, and that this deficiency is getting worse.⁸

Clinical research is the "neck of the scientific bottle," through which all scientific developments must flow before they can be of real-world benefit to the public. The recent developments in genetics, bioengineering, and molecular biology are remarkable; also astounding are the resources that are being poured into the development of new drugs and other therapeutic modalities. As David Sidransky, MD, said in his keynote address, "Molecular Biology and Genetics," we are on the verge of great scientific and technologic advances. The following day, Dr Byers said that, for all of these developments, the bottom line for us and for our patients is the 5-year survival. Tragic optimism would have us think that we might muddle through and that these scientific developments will somehow be translated into better ways to treat our patients. On the other hand, a learning attitude would call for analyzing the concern and taking appropriate action. The analysis has been done and the results are contained in the report of an unprecedented Clinical Research Summit project that brought together more than 175 representatives from government and the private sector, was supported by 7 foundations, and took 18 months to complete.¹³ The summit participants recognized the following 9 core problems that confront clinical research and put forth an action agenda to address them:

• There is not an agreed-on definition of clinical research and its components.

• Clinical research is not adequately understood or valued by the public.

• There is a lack of data on clinical research funding and productivity.

• There is insufficient funding for the conduct of some types of clinical research.

• There are insufficient numbers of clinical investigators.

• There is insufficient emphasis on incorporating research findings into clinical practice.

• There is inadequate coordination of clinical research among research entities and disciplines.

• The ability of academic health centers to conduct clinical research is at risk.

• There is a lack of a comprehensive, dynamic clinical research agenda.

We should embrace this agenda and make provisions in the short- and long-range strategic planning of the American Head and Neck Society to include systematic efforts to advance it, particularly where it calls for preparing physicians to understand and participate in clinical research and contribute to the evidentiary base of our practice. We are more likely to be effective in this endeavor by coordinating efforts and integrating resources with other organizations. In this regard, I must commend Maureen Hanley, PhD, associate vice president and director of research of the American Academy of Otolaryngology, Head and Neck Surgery, Inc for her vision and initiative in putting forth a proposal for the creation of a National Center for the Promotion of Research in Otolaryngology. A key piece of this proposal is education and the development of the appropriate instruments to ensure that future physicians entering community or academic practices have an appreciation and understanding of the role of research in clinical care (Maureen Hanley, PhD, written communication, June 15, 2000).

The Joint Council for Accreditation of Advanced Training in Head and Neck Oncologic Surgery was created jointly by the American Society for Head and Neck Surgery and the Society of Head and Neck Surgeons in the early 1980s. Since its creation, it has shown clearly the willingness of the specialty to make a difference. The many people who have served in this council through the years have indeed striven to ensure that our trainees develop the knowledge, skills, and character necessary to become highly competent head and neck surgeons. I hope that the remarks I make today will support my belief that we should not disband the Council but rather strengthen it with clear, timely directives and adequate resources to continuously assess educational needs and outcomes.

How can the American Head and Neck Society address the needs we have identified and use the information presented here to enhance the education of future head and neck surgeons? Our accredited training programs are currently limited to 2-year fellowships, which may be deterring or preventing excellent candidates from obtaining the fellowship credentialing they need to pursue a career in head and neck oncologic surgery: for instance, an individual who has had adequate research experience during residency and may be seeking only increased clinical exposure, or a resident graduating with a strong head and neck clinical experience, who may be seeking only a research experience. It appears to me that the 2-year fellowships are working reasonably well and should not be eliminated. They should continue to be considered the standard for "advanced training" in head and neck surgery. However, we must expand the opportunities for training while maintaining high standards, and we must put equal emphasis on clinical and basic science research. To address all needs, particularly those expressed by the individuals seeking training, we should establish a 1-year "basic clinical fellowship" that is designed to provide additional surgical experience while ensuring that the fellow fulfills a comprehensive set of educational objectives determined by the Council. This type of fellowship could include the existing 1-year fellowships, currently not accredited by the Council, if the program director is willing to adhere to standardized documentation and curriculum requirements. We also should establish a 1-year basic research fellowship that is designed to provide essential training in clinical or basic science research. These basic fellowships would be clearly different, in certification and perhaps structure, from the 2-year advanced fellowship. In the long run, the graduates of any of these fellowships will be better prepared to provide care to patients and to advance the specialty.

In closing, I believe that if we take appropriate action, the future of the specialty can be bright. The other ingredients are there. We have no shortage of talented young head and neck surgeons, many of whom have presented their work here. Furthermore, the quality of coming leadership of this Society, exemplified by my successor, Ernest Weymuller, MD, is such that when dealing with the inevitable changes that lie ahead, we will not fall prey to tragic optimism, but we will remain committed to the never-ending process of learning how to do things better. After all, Eric Hoffer is right: "In times of change, learners inherit the earth."

Accepted for publication February 6, 2001.

Presented at the annual meeting of the American Head and Neck Society, Fifth International Conference on Head and Neck Cancer, San Francisco, Calif, August 1, 2000.

Corresponding author: Jesus E. Medina, MD, Department of Otorhinolaryngology, Oklahoma University Health Science Center, PO Box 26901, WP 1360, Oklahoma City, OK 73190-0001 (e-mail: jesus-medina@ouhsc.edu).