Resident Training Strategies and a Rhinology Research Update

Podcast Transcript

Paul Bryson: Welcome to Head and Neck Innovations, a Cleveland Clinic podcast for medical professionals exploring the latest innovations, discoveries, and surgical advances in otolaryngology-head and neck surgery.

Thanks for joining us for another episode of Head and Neck Innovations. I'm your host, Paul Bryson, Director of the Cleveland Clinic Voice Center. You can follow me on X, formerly Twitter, @PaulCBryson, and you can get the latest updates from Cleveland Clinic Otolaryngology-Head and Neck Surgery by following @CleClinicHNI on X. That's @CleClinicHNI. You can also find us on LinkedIn at Cleveland Clinic Otolaryngology - Head and Neck Surgery, and Instagram at Cleveland Clinic Otolaryngology.

Today I'm delighted to be joined by my colleague, Dr. Mamie Higgins, in our Division of Rhinology and Skull Base Surgery. Welcome to the podcast, Mamie.

Mamie Higgins: Thanks for having me. Really excited to be here.

Paul Bryson: Well, we've had the opportunity to work together now for a few years, and this is your first time on the podcast. So, would you just share with our listeners a little bit about you, where you're from, where you trained, and how you came to Cleveland?

Mamie Higgins: So, I grew up mostly in Northern California. I went to school at UC Berkeley, but I went to medical school out at the University of Buffalo. I then did my residency training in otolaryngology head and neck surgery at Albany Medical Center up in Albany, New York before then heading to Seattle at the University of Washington for my neurology skull base fellowship. And right after fellowship I joined here. So, I've been here since.

Paul Bryson: So quite a bit of transcontinental work here between California and Seattle and upstate New York and here. Was there much of an adjustment for you as you came back to the sort of Midwest northeast climate?

Mamie Higgins: Absolutely. So, it's nice to, I haven't lived in California for a long time as our training is very extensive, so I haven't lived in California since the early 2000s, but most of my family's from the northeast, from the Boston area, so I'm kind of used to the cold in that sense. But Cleveland's such a great area. We have such a great institute and great colleagues and the collegial environment and just the learning and research opportunities here are what really brought me here, so I'm excited.

Paul Bryson: Yeah, no, it's been great to have you as part of the group. Can you share a little bit more about your clinical interests, surgically, clinically, how your practice has grown and things that you've taken any particular interest in over the years?

Mamie Higgins: Sure. As a rhinology specialist, sometimes I will see patients who need primary surgery, meaning they've never had surgery before. Many times, these patients might go to a comprehensive ENT or head and neck surgeon, which is also appropriate. But some patients who have more extensive sinus disease might have anatomical variants that make their surgical intervention a little bit more difficult and a bit more high risk. But definitely those revision surgeries where sinus surgery was done before but maybe didn't quite get the effects and the benefits that they were looking for are pretty much the majority of my practice at this point. Chronic sinus disease, although tumors and cancers are exciting to obviously make such an impact on patients' lives with this kind of dire prognosis or diagnosis, chronic sinus disease with or without polyps, really has this humongous impact on quality of life that nobody really understands unless you're a sinus patient.

And they'll be the first to tell you, I can't go to work. I miss all this work. I'm always needing to go to urgent care and needing antibiotics, and I'm just run down, and I don't feel well. And it's not a condition where you get a lot of sympathy because it's not a heart attack or a stroke, even though sinus disease has been shown to have a much more significant impact on your quality of life than either of those two conditions on a day-to-day basis. So, the ability to intervene and decrease the severity and the frequency of those chronic symptoms is really such a delight in terms of just making the day-to-day so much better for patients in general.

Paul Bryson: Yeah, no, it's great to hear it. You don't know how you can feel with something that can be chronic like that until you see the right person and get the right treatment and surgery, I'm sure it's a big improvement for these folks that are lucky enough to come and see you.

Mamie Higgins: Right. It's great to give a second opinion.

Paul Bryson: Yeah. Yeah. Well, I understand you also have; besides your clinical practice, you also have a number of interests in research and education, and you recently attended the Society of University Otolaryngologists meeting. I don't know, I forget where it was this year.

Mamie Higgins: This year I was in Washington, DC so it's a group of people who met up.

Paul Bryson: Yeah. Can you tell us a little bit more about the meeting and some of the things you learned or were maybe excited to hear about that may come back to your own practice and educational endeavors?

Mamie Higgins: So what's really interesting about this group, and it's also with the program directors and the chairs of all the ENT residencies across the nation, and this was actually my first SUO meeting, but what it really focuses on is our resident training and changes to both in terms of how we train our residents as well as making sure they are competent to graduate, to pursue fellowships and further advanced training, or to become a comprehensive ENT and start seeing patients. And so, a couple of the key points from this meeting were how we're switching from our traditional model of training based off meeting these core understandings of different topics, but rather switching to a competency-based model. And one of the main speakers was Dr. Resnick, who is not an ENT, but he is a surgeon up in Canada, and they've done a lot of training and studies to show that with competency-based model, they can get their residents trained faster, more efficiently, their surgical skills get to a level, a more advanced level at a quicker pace, which is more relevant for a lot of the surgeons that you're graduating and going into the world.

Only a subset of ENTs are going to go into academic medicine and maybe research, but the majority go right into the general population to treat people. And so, if that's the case, then we need to change the way we train our resident physicians to make it applicable. What we want is value-based care, and we keep hearing that over and over in terms of how are we going to reshape medicine, make it more cost effective, since it is such a huge financial burden nationally for our deficit and going to this value-based model means we also need to be more competency-based. And it was a really interesting concept. And as you know, whenever there's new concepts for something that's been done the same old way over and over, including something as storied as surgery, there was a lot of backlash. And so, Dr. Resnick's stories in terms of how much fight he got back from the general surgeons of this is never going to work, but their studies showed it really does.

And the residents tend to be happier as well because they're getting into the operating room faster, they're becoming more self-sufficient, quicker, and they're still being observed and supervised in an appropriate way where their patients are getting even better care as well. So, we're a little behind, I think, in terms of the US of switching to a competency-based model, but actually ENT head and neck surgery was one of the first residency programs or residency surgical specialties that switched over to the competency base. But I think in terms of the objective measures that we're going to look at, we now need to work out the kinks in terms of making it come to fruition.

Paul Bryson: Well, yeah, that's very exciting. And change is always often hard and there are some headwinds to it.

Mamie Higgins: Absolutely.

Paul Bryson: But no, it sounds like we're kind of already getting there a little bit as a specialty, some good lessons learned were shared and strategies for trying to implement this.

Mamie Higgins: Absolutely, yes. The strategies, maybe some of the failures, how to get people on board, just a lot of really good discussion, which was hopefully going to instigate some changes here, which is great. And then we discussed, there's different changes to the residency training, so anyone who might be listening, that's a future applicant, our boards have changed where we still have our written boards, but our oral boards are going to be based off of your practice if you go straight into practice. And so, the reasonings behind that, and so we can better educate our residents in terms of those board testing changes.

Paul Bryson: Yeah. Well, thanks for sharing those changes that are coming up across the specialty. I think both are exciting. I think the change in the oral board format has potential to really be pretty nice and pragmatic for people as they're in that first year of practice and looking at their cases and being able to bring cases. I think it'll be good.

Mamie Higgins: As you can imagine, there was a lot of discussion with that as well, because again, our oral boards have been such a certain way for so long, but again, there have been multiple specialties who have kind of paved the way before us, and so hopefully it will be meaningful.

Paul Bryson: Yeah, I think so. And you're right, it's not like we're completely in the wilderness on this. I think we can look to some of our other colleagues and surgical specialties.

Mamie Higgins: Absolutely. Yeah.

Paul Bryson: Well, I wanted to also ask you to share what are some of your research interests? I know you're part of a pretty dynamic group, but yeah, what are you interested in personally with your practice and what research opportunities are there?

Mamie Higgins: Most of my research interests are based in clinical application of much of the scientific knowledge that we have, or there are some things as we just do and sometimes, we don't have a good reasoning behind it. And really everything that we strive for is kind of this evidence-based medicine model. And so, what's really interesting is the more I've practiced, my clinical questions have kind of narrowed down into certain areas that I never thought I would be interested in. So, some areas have to do with in terms of patient symptoms and flares and how best we can create, whether it's AI or a survey model in terms of better understanding and identifying people who truly have a bacterial flare where an oral medication is warranted and kind of sifting out the background noise and hopefully getting better. Again, value-based care for our chronic sinus patients because it is a chronic problem.

And I think the biggest complaint we get from many of our patients is when I flare, which will undoubtedly happen, how can I get care in an efficient fashion without feeling - patients are always so kind - and they always feel like they're bothering someone. And so, we want to work out a way where we can save the patient some time and get the appropriate care that they need, but also needed antibiotic treatment. So, we're working on some diagnostic tools in order to help for that. Additionally, as I kind of discussed earlier with SUO, a lot of my interests rely on research and how we can better educate not just the public, but also the residents. So, residency training for those who don't know for head and neck surgery is five years. It includes an internship year where half of the year is dedicated to ENT head and neck, and the rest is in other specialties.

But then there's another four years of dedicated training. And although it seems like a really long time and some days it can feel very long, it goes by very quickly and you want to make the most bang for your buck. And everybody also learns in a unique way. And although our residents perform surgeries and learn to become better in the operating room, there are other ways, especially with AI technology and 3D printing and using some of these silicone models and some of the technology that we have to advance our training for our residents, especially for those cases that we don't have many numbers of some pathology that's thankfully not high in frequency, but are needed skills that we just don't have enough repetitions to teach our residents. So, we have some exciting educational research projects. And then additionally, we have some pharmaceutical clinical studies that are ongoing, especially for those chronic sinus patients that might be listening who have had multiple revision surgeries, and despite good surgery and appropriate topical medical management, their disease is just so severe that they're not getting the improvement that they really desire. Or perhaps you're too sick to get another surgical intervention. There are some new drugs, medications that are in the pipeline for better medical management of the different types of inflammation associated with chronic sinus disease. So, here at the Cleveland Clinic, we kind of have our foot in the door with some of these new medications. So, a really interesting opportunity for those patients who just feel like they've kind of hit a dead end at this point. So, we have two different studies ongoing that people should reach out for.

Paul Bryson: Yeah, that's very exciting. I feel like in so many areas that touch otolaryngology, we're sort of on the precipice of some of the biologic drugs that are out there, and ways to influence disease or diseases that were difficult to manage and difficult to handle flares, and where maybe surgery alone, it's not enough. We need to maybe be a little more precision medicine oriented.

Mamie Higgins: Correct. It's been that uniquely tailored medicine for so long. Our chronic sinus patients are just kind of grouped into those without polyps or with polyps, but really there's so much more nuance to that. There's different types of inflammation that we usually categorize to those, but we know there's a lot of crossover, and especially in terms of the biologics, these medications that are uniquely designed to attack these inflammatory cytokines, they just weren't around when you and I trained and have really changed the landscape in terms of how we treat chronic sinus disease that is refractory to surgical interventions. So, I mean, I am sure you as well, we are both surgeons, but it's really amazing how much medicine is involved within the field of ENT.

Paul Bryson: Yep. I think in a number of areas, we're getting a better sense for what these inflammatory phenotypes are or what some of these molecular phenotypes are in some of the recurrent things that we do, and I think it's very exciting. We have an opportunity to really get back to that quality-of-life improvement for patients.

Mamie Higgins: Absolutely.

Paul Bryson: Well, I really appreciate you joining the podcast, and it's great to be a colleague of yours here. And yeah, thanks for coming on.

Mamie Higgins: Thanks for inviting me.

Paul Bryson: For more information on Cleveland Clinic’s Section of Rhinology, Sinus, and Skull Base Surgery, please visit ClevelandClinic.org/Rhinology. That's ClevelandClinic.org/Rhinology. And to speak with a specialist or submit a referral, please call 216.444.8500. That's 216.444.8500. Dr. Higgins, thanks for joining Head and Neck Innovations.

Thanks for listening to Head and Neck Innovations. You can find additional podcast episodes on our website clevelandclinic.org/podcasts. Or you can subscribe to the podcast on iTunes, Google Play, Spotify, BuzzSprout, or wherever you listen to podcasts. Don't forget, you can access real-time updates from Cleveland Clinic experts in otolaryngology - head and neck surgery on our Consult QD website at consultqd.clevelandclinic.org/headandneck. Thank you for listening and join us again next time.