Program Requirements Submitted by the RRC for Ophthalmology

September 8, 2010

The Program Requirements submitted by the RRC Ophthalmology for the subspecialty Ophthalmic Plastic & Reconstructive Surgery were reviewed by the Executive Committee of the American Rhinologic Society during the current period of public comment. This review raised significant concerns regarding the unrestricted scope of endoscopic sinus surgery implied by wording within this document. Through communication with the Plastic Surgery RRC and the Otolarynogology RRC, we were informed that these same concerns had been addressed by a previously convened ad hoc committee and that the changes instituted by that same committee had been
removed from the current program requirements available for review. Recognizing the importance of this document upon resident training and patient safety, the Executive Committee of the American Rhinologic Society is unanimously opposed to its current form. Specifically, the three changes found in lines 487, and 488 under Patient Care Competency of the resubmitted program requirements are here challenged.
As background to this discussion, ACGME had convened an ad hoc committee mads up of representatives from the Ophthalmology, Plastics Surgery, and Otolaryngology RRCs, which met in Chicago as a component of the development of these program requirements to discuss the impact of the specific wording within the document. It was agreed that the resident in Ophthalmic Plastic Surgery should be trained in the use of endoscopes to help facilitate those procedures directly related to the lacrimal system. Specifically, endoscopic retrieval of nasolacrimal stents and manipulation
confined to the inferior turbinate to enable access to the Hasner’s valve constituted the scope of this training. The ad hoc committee agreed at that time to the following language:
  • “Nasal procedures, endoscopy, partial inferior turbinectomy, and procedures related to the management of lacrimal and periorbital processes.”
However, review of lines 487 and 488 of the most current Program Requirements submitted by the RRC Ophthalmology for the subspecialty Ophthalmic Plastic & Reconstructive Surgery available for public comment reveals the following language had been replaced after agreed deletion by the ad hoc committee:
  • “Nasal and sinus procedures, endoscopy, partial inferior turbinectomy, and sinus procedures related to the management of lacrimal and periorbital processes.”
Lines 487 and 488 pertain to the addition of sinus procedures beyond the nasal endoscopy needed for lacrimal system surgery. As Otolaryngologists, we spend at least 4 years dedicated to head and neck anatomy and acquisition of endoscopic skills. Specifically, the paranasal sinuses are complex anatomically and the use of nasal endoscopes, external monitors, and computer assisted image guidance render acquisition of the surgical skills necessary to independently perform endoscopic sinus surgery a progressive learning experience that starts during the early phases of Otolaryngology training and progresses continually through the PGY-5 year. Complications ranging from significant bleeding to blindness, CSF fistula, stroke and death have been reported as result of this procedure and remain an area of significant concern. Given the potential for significant complications, studies examining the impact of training have been performed and demonstrate a significant decrease in both minor and catastrophic complications observed in residents trained within an Otolaryngology training program as compared to those who acquiring such skills outside of that environment (Keerl R, Stankiewicz J, Weber R, Hosemann W, DrafW.
Surgical Experience and Complication during Endoscopic Sinus Surgery. Laryngoscope 1999;109(4):546-550.).
As currently worded, lines 487 and 488 expand the scope of endoscopically directed surgery from those procedures associated with lacrimal pathology to the broader realm of general endoscopic sinus surgery. To perform endoscopic sinus surgery beyond that involved directly with the lacrimal system (e.g retrieval of stents, and partial resection of the inferior turbinate) in the absence of adequate progressive surgical training would be irresponsible and would place patients at unnecessary risk.
For the above reasons, we oppose the changes made to the proposed Program Requirement for Ophthalmic Plastic & Reconstructive Surgery. We recommend that they return to the wording negotiated and agreed upon by the ad hoc committee before moving forward.
Stilianos Kountakis, MD
President, ARS

Revised 9/2010
©American Rhinologic Society

PDF ARS Letter Regarding RRC Ophthalmology
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