Dizziness, malpractice, and the otolaryngologist

A time-sensitive rubric for assessing mastoidectomy proficiency

OBJECTIVE

To develop a time-sensitive, standardized rubric for cadaveric temporal bone dissection for otolaryngology resident education.

METHODS

This is a five-year prospective cohort study that evaluated otolaryngology resident performance during sequential cadaveric temporal bone dissection courses at a single otolaryngology residency training program. A canal-wall-up mastoidectomy with a facial recess approach was performed adhering to a 30-minute time limit and graded according to a standardized rubric. Main outcome measures included: (1) correct structure identification and (2) injuries sustained to structures as compared by resident post-graduate year (PGY) level.

RESULTS

Thirteen residents were evaluated from October 2012 to March 2017. This included 57 individual graded exercises performed over ten dissection courses. The average score for PGY-2 residents was lowest (68.9), and PGY-5 residents achieved the highest average score (87.7). Junior residents correctly identified fewer structures (77.5%) when compared to senior residents (91.3%), p < 0.0001. Correct performance of a facial recess approach was achieved by 100% of senior residents, but only 59.3% of junior residents (p = 0.0003). The percentage of major injuries, which included the facial nerve, tegmen, labyrinth, and ossicular chain, decreased each PGY-level from a maximum of 17% by PGY-2 residents to a minimum of 5% by PGY-5 residents.

CONCLUSION

Senior residents correctly identify more structures and are able to complete a facial recess approach with higher fidelity when subjected to a time-sensitive graded mastoidectomy rubric.

Unsolicited Patient Complaints among Otolaryngologists

Objectives

To analyze unsolicited patient complaints (UPCs) among otolaryngologists, identify risk factors for UPCs, and determine the impact of physician feedback on subsequent UPCs.

Methods

This retrospective study reviewed UPCs associated with US otolaryngologists from 140 medical practices from 2014 to 2017. A subset of otolaryngologists with high UPCs received peer-comparative feedback and was monitored for changes.

Results

The study included 29,778 physicians, of whom 548 were otolaryngologists. UPCs described concerns with treatment (45%), communication (19%), accessibility (18%), concern for patients and families (10%), and billing (8%). Twenty-nine (5.3%) otolaryngologists were associated with 848 of 3659 (23.2%) total UPCs. Male sex and graduation from a US medical school were statistically significantly associated with an increased number of UPCs ( P = .0070 and P = .0036, respectively). Twenty-nine otolaryngologists with UPCs at or above the 95th percentile received peer-comparative feedback. The intervention led to an overall decrease in the number of UPCs following intervention ( P = .049). Twenty otolaryngologists (69%) categorized as “responders” reduced the number of complaints an average of 45% in the first 2 years following intervention.

Discussion

Physician demographic data can be used to identify otolaryngologists with a greater number of UPCs. Most commonly, UPCs expressed concern regarding treatment. Peer-delivered, comparative feedback can be effective in reducing UPCs in high-risk otolaryngologists.

Implications for Practice

Systematic monitoring and respectful sharing of peer-comparative patient complaint data offers an intervention associated with UPCs and concomitant malpractice risk reduction. Collegial feedback over time increases the response rate, but a small proportion of physicians will require directive interventions.