The Laryngoscope VC 2014 The American Laryngological, Rhinological and Otological Society, Inc. The Value of a Collaborative Course for Advanced Head and Neck Surgery in East Africa Kyle J. Chambers, MD; Joyce Aswani, MMed; Asmeeta Patel, MBBS, MS(ENT); Christopher Fundakowski, MD; Kyle Mannion, MD; Derrick T. Lin, MD; James Netterville, MD Objectives/Hypothesis: To determine the value of a collaborative course for advanced head and neck surgery in East Africa. Study Design: Survey of participants. Methods: A 3-day course in head and neck surgery was designed for otolaryngologists and trainees from Kenya and surrounding countries through a collaborative effort between Kenyatta National Hospital, the University of Nairobi, and the Head and Neck Divisions from the Vanderbilt Bill Wilkerson Center and the Massachusetts Eye and Ear Infirmary. Topics included neck dissection, parotidectomy, total laryngectomy, parapharyngeal space tumors excision, and pectoralis myocutaneous flaps. A pre- and postcourse self-evaluation survey was administered to measure course impact. Results: Eighteen otolaryngologists and trainees participated in the course, with 17 completing course surveys. The majority of participants (72%) were from Kenya. Prior to the start of the course, 41%, 71%, 23%, 12%, and 0% of participants indicated they could complete a neck dissection, parotidectomy, parapharyngeal space mass excision, total laryngectomy, and pectoralis myocutaneous flap, respectively. Following the course, 50%, 94%, 69%, 25%, and 38% of participants indicated they could complete a neck dissection, parotidectomy, total laryngectomy, parapharyngeal space tumors excision, respectively, with a statistically significant increase identified for pectoralis myocutaneous flaps (P <.001) and total laryngectomy (P 5.009). There was also a trend toward an increase in the number of participants indicating an ability to complete parotidectomy following the course (P 5.085). Conclusions: This survey demonstrates the potential value of a collaborative course in advanced head and neck surgery as one useful model for increasing the number of well-trained head and neck surgeons in East Africa. Key Words: Head and neck surgery, surgical training, global otolaryngology, global health. Level of Evidence: NA Laryngoscope, 125:883 887, 2015 INTRODUCTION The World Health Organization estimates an annual incidence of head and neck cancer in sub- Saharan Africa of approximately 33,000, 1 creating a significant disease burden for the region. The most common sites of cancer diagnosis include the oral cavity, nasopharynx, and larynx, with squamous cell carcinoma as the most common pathology. 2,3 Age-standardized mortality from head and neck cancer in sub-saharan Africa From the Department of Otolaryngology Head & Neck Surgery (K.J.C., D.T.L.), Massachusetts Eye & Ear Infirmary, Boston, Massachusetts, U.S.A.; Department of Otolaryngology, Harvard Medical School (K.J.C., D.T.L.), Boston, Massachusetts, U.S.A.; Department of Surgery, Kenyatta National Hospital (A.P.), Nairobi, Kenya; Department of Surgery, University of Nairobi School of Medicine (J.A.), Nairobi, Kenya; Kenya Ear Nose & Throat Society (J.A., A.P.), Nairobi, Kenya; Division of Head & Neck Surgery, Vanderbilt Bill Wilkerson Center (C.F., K.M., J.N.), Vanderbilt Department of Otolaryngology and Bill Wilkerson Center (C.F., K.M., J.N.), Vanderbilt University Medical Center, Nashville, Tennessee, U.S.A. Editor s Note: This Manuscript was accepted for publication October 14, 2014. The authors have no funding, financial relationships, or conflicts of interest to disclose. Send correspondence to Kyle J. Chambers, MD, Department of Otolaryngology, 243 Charles Street, Boston, MA 02114. E-mail: kyle_chambers@meei.harvard.edu DOI: 10.1002/lary.25028 varies by region from 3.4 per 100,000 in middle Africa to 7.6 per 100,000 in southern Africa, with an overall average mortality roughly double that of North America. 1 Currently, there exists an insufficient number of well-trained head and neck surgeons in sub-saharan Africa to adequately treat the total number and full extent of advanced head and neck cancers in the region. 4 Only one fellowship program exists in South Africa providing training for the entire region. Several potential strategies for addressing the surgical need in sub-saharan Africa include increasing the number of existing training programs in the region, short-term medical mission trips, and the offering of international advanced training fellowships in high income countries. Another option is to strengthen surgical skills through collaborative courses in advanced topics. Potential benefits of a collaborative course include: region-directed topics, exposure to new techniques, hands-on experience in advanced topics, moderation by experienced surgeons, and the ability to bring trainees from multiple countries to one regional location. Potential drawbacks include the concentrated nature of a course and the difficulty of measuring improvement in surgical skill over a short duration. We sought to evaluate the benefit of a collaborative course in advanced head and neck surgery in East 883
TABLE I. Demographics No. (%) Level of training Practicing physician 11 (65) Trainee 6 (35) Country of origin Kenya 13 (76) Uganda 2 (12) Zambia 1 (6) Rwanda 1 (6) Africa. Through collaboration between the Kenya Ear Nose and Throat Society, Kenyatta National Hospital, University of Nairobi School of Medicine, Vanderbilt University, and Harvard University, a 3-day course in advanced head and neck surgery was held for otolaryngologists from East Africa. The primary objective of this article was to review the results of a precourse and postcourse skill assessment survey administered during the course as a marker of overall value of the course for participants. MATERIALS AND METHODS Through a collaborative effort between the Kenya Ear Nose and Throat Society, Kenyatta National Hospital, University of Nairobi School of Medicine, Vanderbilt University, and Harvard University, a 3-day course in advanced head and neck surgery was designed for otolaryngologists and trainees from Kenya and surrounding countries. Course topics were chosen by otolaryngologists from Kenya and included neck dissection, parotidectomy, total laryngectomy, partial laryngectomy, parapharyngeal space tumors, and myocutaneous rotational flaps. Three otolaryngologists with fellowship training in head and neck surgery (two from Vanderbilt University and one from Harvard University) acted as the primary course moderators. The first day consisted of lectures on each of the designated topics. The second day consisted of cadaver dissections, with prosection demonstrations by course moderators, followed by hands-on dissection by course participants. The third day of the course consisted of live surgery demonstrations by the course moderators. Evaluation of the course consisted of a precourse and postcourse survey given to participants of the course that was deemed exempt from institutional review board approval as an educational survey. The precourse survey identified demographic information. Both precourse and postcourse surveys consisted of skill self-assessment, in which participants indicated their skill level for each designated course topic from five possible choices, including: 1) Can not complete, 2) Can assist someone in completing, 3) Can complete with some assistance, 4) Can complete, and 5) Expert (defined as comfortable teaching others how to complete the procedure). Selfassessment responses were then grouped into one of three categories for analysis based on similarity of answer choice, including: 1) Can not complete, 2) Can assist someone in completing/can complete with assistance 3) Can complete/expert. The postcourse survey also consisted of a 5-point Likert scale, in which participants indicated the degree of agreement or disagreement for the following statement: This course improved my understanding of (designated topic). Analysis of selfassessment responses were grouped. v 2 testing was then used to determine if changes occurred in participant response from the precourse survey to the postcourse survey. Statistical significance was set at P <.05. RESULTS A total of 18 otolaryngologists and trainees participated in the course, with 17 (94%) completing precourse surveys (Table I). Of those completing the surveys, 11 (65%) had completed otolaryngology training and six (35%) were still in training. The majority of participants (72% percent) were from Kenya. The remainder of participants were from Uganda, Zambia, or Rwanda. Sixteen (89%) course participants completed postcourse surveys. Four (23%) of the participants indicated they could complete a total laryngectomy prior to the start of the course, with 11 (69%) indicating they could complete a total laryngectomy following the course (P <.01) (Fig. 1), of which two (13%) indicated having new ability to teach the procedure to others. None (0%) of the participants indicated they could complete a pectoralis myocutaneous flap prior to the start of the course, with six (38%) indicating they could complete a pectoralis myocutaneous flap following the course (P <.01) (Fig. 2), of which one (6%) indicated having new ability to teach the procedure to others. Fig. 1. Neck dissection. 884
Fig. 2. Parotidectomy. Improvement was also seen in the number of participants indicating they could complete a neck dissection, parotidectomy, or parapharyngeal space mass resection between pre- and postcourse surveys, however, to a lesser extent. Seven (41%) of the participants indicated they could complete a neck dissection prior to the start of the course, with eight (50%) participants indicating they could complete a neck dissection following the course (P 5.61) (Fig. 3). Twelve (71%) of the participants indicated they could complete a parotidectomy prior to the start of the course, with 15 (94%) indicating they could complete a parotidectomy following the course (P 5.09) (Fig. 4). With regard to parapharyngeal space mass resection, two (12%) of the participants indicated they could complete a parapharyngeal space mass resection prior to the start of the course, with four (25%) indicating they could complete a parapharyngeal space mass resection following the course (P 5.32 (Fig. 5). No participants indicated any new ability to teach neck dissection, parotidectomy, or parapharyngeal space mass resection to others following the course. Regarding improvement in overall understanding of designated topics, the majority of participants indicted improved understanding in all topics presented. For laryngectomy, parotidectomy, parapharyngeal space tumor resection, and myocutaneous flap surgery, the number participants indicating they agreed or strongly agree that the course improved their overall understanding was 15 (94%), 15 (94%), 16 (100%), 15 (94%), and 14 (88%), respectively. One (6%) participant reported no improvement in understanding parapharyngeal space tumor resection and myocutaneous flap surgery. The remainder of participants indicated they were neutral. When asked which aspect of the course participants found most useful, nine (56%) indicated all aspects were equally useful. Of the remainder of participants, four (25%) indicated cadaver dissections, two (13%) indicated live surgery demonstrations, and one (6%) indicated lectures as the most useful aspect of the course. Sixteen (100%) of the participants indicated that they would attend a similar course in the future. A list of topics participants indicated they wished to see in future courses is provided in Table II. DISCUSSION The ideal method for increasing the availability of skilled head and neck surgeons in sub-saharan Africa is currently not known, but will likely involve a variety of simultaneous approaches. The use of intensive shortterm collaborative courses has reportedly demonstrated long-term benefit with at least one surgical procedure to Fig. 3. Parapharyngeal space surgery. 885
Fig. 4. Total laryngectomy. date. 5 This study offers support for collaborative courses in advanced topics of head and neck surgery as one valuable model. The vast majority of participants of this course indicated improved understanding in all topics covered in the course, with a significant shift in perceived skill level for several of the operations, including total laryngectomy and myocutaneous pectoralis major flaps. Several participants even indicated a new ability to teach these procedures (expert) following the course. Additionally, a greater number of participants indicated ability to complete neck dissection, parotidectomy, and parapharyngeal space mass resection between pre- and postcourse surveys. Although the vast majority of participants gave an overall positive response to the course, we did have one participant indicate an inability to complete a neck dissection and one participant indicate an inability to complete a parapharyngeal space tumor resection following the course. This finding may highlight the difficulty of instructing advanced surgical topics in a short 3-day course. It is also possible that this finding reflects a response-shift bias, in which a change occurred in the participant s understanding of what it meant to complete the specific surgery as a result of participation in the course. 6 Several limitations of our method of course evaluation also exist. Primarily, we were evaluating participant perception of change in surgical skill using a survey not validated against objective measures in surgical competency. Our survey has also not been directly linked to patient outcomes. Despite these shortcomings, the information gained from the survey offers insight into the value of a course in advanced head and neck surgery from the participant s perspective, one key component of improving surgical capacity. Additionally, the use of intensive short-term collaborative courses has demonstrated long-term benefit with other surgical procedures, such as in hernia repair, 5 providing rationale for continued exploration of the long-term value of such collaborative courses in the field of otolaryngology. More work is undoubtedly necessary to validate the survey as well as the training method. Additional options for increasing the availability of skilled otolaryngologists and surgeons in sub-saharan Africa have been promoted, some of which include increasing sustainable long-term surgical mission trips, 7 increasing residency/fellowship training programs, 8,9 offering more international fellowship positions to qualified African otolaryngologists, and building surgical specialty hospitals in regional locations for treatment and Fig. 5. Pectoralis flap. 886
Topic TABLE II. Potential Topics for Future Courses Free flaps/reconstructive 4 Thyroid/parathyroid 6 Maxillectomy 1 Endoscopic sinus/skull base 2 Partial laryngeal/microlaryngeal 2 Oral cavity/tongue 1 training purposes. 10,11 Simulation technology may also play a role in availability of training opportunities and the improvement of surgical skill, as has been demonstrated in other surgical subspecialties. 11,12 Currently, one postgraduate head and neck fellowship exists for sub-saharan Africa, 4,8 which is a small number compared to the >35 fellowship programs in the United States, a country with roughly less than twice the head and neck cancer incidence. 13 The authors of this article applaud the work Dr. Fagan has done in promoting head and neck surgery on the continent and support the creation of additional centers of training that may act as ideal locations for collaborative courses in the future. CONCLUSION This survey demonstrates the potential value of a collaborative course in advanced head and neck surgery No. as one useful model for increasing the number of welltrained head and neck surgeons in East Africa. BIBLIOGRAPHY 1. Ferlay J, Soerjomataram I, Ervik M, Dikshit R, Eser S, Mathers C, Rebelo M, Perkin DM, Forman D, Bray F. GLOBOCAN 2012 v1.0, Cancer Incidence and Mortality Worldwide: IARC CancerBase No. 11 [Internet]. Lyon, France: International Agency for Research on Cancer; 2013. Available from: http://www.iarc.fr/. Accessed on November 11, 2014. 2. Onyango JF, Awange DO, Njiru A, Macharia IM. Pattern of occurrence of head and neck cancer presenting at Kenyatta National Hospital, Nairobi. East Afr Med J 2006;83:288 291. 3. Gathere S, Mutuma G, Korir A, Musibi A. Head and neck cancers four year trend at the Nairobi Cancer Registry. Afr J Health Sci 2011;19:33 39. 4. Fagan JJ, Jacobs M. Survey of ENT services in Africa: need for a comprehensive intervention. Glob Health Action 2009;2:10.3402. 5. Wang YT, Mehes MM, Naseem HR, et al. Assessing the impact of shortterm surgical education on practice: a retrospective study of the introduction of mesh for inguinal hernia repair in sub-saharan Africa. Hernia 2014;18:549 556. 6. Howard GS. Response-shift bias: a problem in evaluating interventions with pre/post self-reports. Eval Rev 1980;4:93 106. 7. Rogers DJ, Collins C, Carroll R, et al. Operation Airway: the first sustainable, multidisciplinary, pediatric airway surgical mission. Ann Otol Rhinol Laryngol 2014;123:726 733. 8. Aswani J, Baidoo K, Otiti J. Establishing a head and neck unit in a developing country. J Laryngol Otol 2012;126:552 555. 9. Fagan JJ. Developing world ENT: a global responsibility. J Laryngol Otol 2012;126:544 547. 10. Shrime MG, Sleemi A, Ravilla TD. Charitable platforms in global surgery: a systematic review of their effectiveness, cost-effectiveness, sustainability, and role training [published online ahead of print March 29, 2014]. World J Surg. doi: 10.1007/s00268-014-2516-0. 11. Palter VN, Grantcharov TP. Virtual reality in surgical skills training. Surg Clin N Am 2010;90:605 617. 12. Nimmons GL, Chang KE, Funk GF, Shonka DC, Pagedar NA. Validation of a task-specific scoring system for a microvascular surgery simulation model. Laryngoscope 2012;122:2164 2168. 13. American Cancer Society. Cancer Facts & Figures 2012. Atlanta: American Cancer Society; 2012:4. 887