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Comprehensive training of the head and neck surgical oncologist is complex. Head and neck fellows must become more experienced with technical surgical skills introduced in residency training while acquiring new surgical skills typically introduced at the fellowship level. In addition to their surgical training, the head and neck fellow must gain an intimate knowledge of non-surgical management of head and neck cancers, inclusive of rationale for, and design of, clinical trials necessary to advance the field. Exposure to research techniques and methodology is a component of many fellowships. Finally, the head and neck fellow must gain leadership skills necessary to lead the multidisciplinary medical teams that are critical to the contemporary management of the head and neck cancer patient. The Advanced Training Council (ATC) of the American Head and Neck Society (AHNS) currently oversees 50 head and neck fellowships in the United States and Canada. Given the complexity of the training of the head and neck surgical oncologist and given the existence of alternative training pathways which residency graduates may pursue to designate themselves as subspecialists in head and neck surgery, the ATC is requesting your participation in a short survey regarding issues of accreditation and certification of its head and neck fellowships.
Definition of terms:
Head and neck fellowship training in North America currently occurs in three primary forms. The majority of head and neck fellowships are accredited by the Advanced Training Council of the AHNS. The process of accreditation involves an application as a new program to the ATC, a site visit by 2 ATC members, presentation of the findings of the site visitors to the ATC as a whole, and finally review and approval of the recommendations of the ATC by the executive committee of the AHNS. Initial accreditation is for 2 years after which all programs undergo follow up site visits with updated program information reviewed by 1-2 site visitors and with final re-accreditation decisions approved by the same process as described above for initial accreditation. Re-accreditation approvals can be for a maximum of 5 years before another site visit for continuing accreditation is required.
The second form of head and neck fellowship training in North America is represented by non-AHNS approved fellowships based primarily or exclusively in Otolaryngology Head and Neck Surgery Departments. These fellowships may or may not have oversight by individual institutional graduate…..The third form of head and neck fellowship training is represented by Oral and Maxillofacial Surgery Head and Neck Fellowships. Oral surgery-based head and neck fellowships are accredited by the American Board of Oral and Maxillofacial Surgery (ABOMS).
Accreditation of head and neck fellowships, as described above, is either by the ATC of AHNS (AHNS approved fellowships), by the home institution or department (non-AHNS Otolaryngology head and neck fellowships), or by the American Board of Oral and Maxillofacial surgery (oral surgery fellowships). Certification of the graduating fellows is the process of determining they have satisfactorily completed their fellowship training and meet standards to qualify for and practice as specialty trained head and neck surgical oncologists. Application to an AHNS approved head and neck fellowship occurs through a formal match process, and match eligible fellow candidates must be board eligible in Otolaryngology, Surgery or Plastic Surgery. Eligible fellows successfully completing AHNS approved head and neck fellowships are certified by the AHNS and receive a certificate of completion from the AHNS if their fellowship director determines that they have satisfactorily completed their training. This process does not include a certifying examination. Fellows completing non-AHNS otolaryngology-based head and neck fellowships are certified by their sponsoring department and typically receive a certificate of completion from their individual department and/or institution. Fellows completing OMFS based head and neck fellowships are eligible to take a certificate of additional qualifications (CAQ) written examination in Head and Neck Surgery administered by the American Board of Oral and Maxillofacial Surgery. Notably, diplomates of the American Board of Otolaryngology Head and Neck Surgery and Otolaryngology Department chairs are also eligible to sit for the examination for CAQ in head and neck surgery of the ABOMS. Diplomates of ABOHNS are eligible to sit for this examination whether or not they have pursued head and neck fellowship training.
In summary, there are currently many practitioners who identify themselves as head and neck surgical oncologists with specialized expertise beyond that of the general otolaryngologist head and neck surgeon, and that are recognized as such by hospitals, health systems, patients and the public. These practitioners currently achieve this designation after completion of fellowship training that is characterized by differing standards of fellowship accreditation, and variable levels of rigor in fellow certification of training. It is in this context that the ATC and executive leadership of the AHNS are seeking your opinion via a short survey regarding options for certification of graduates of AHNS approved HN fellowships. This survey is being sent to program directors and co-directors of currently accredited AHNS HN fellowships, the senior leadership of the AHNS, and Otolaryngology Department chairs. The options for certification to be considered are as follows:
1. Continue current status of ATC certification of fellowship training contingent upon fellowship director approval and recommendation for certification without certifying examination.
2. AHNS development of a certifying examination, successful completion of which would be required for certification of AHNS approved head and neck fellowship training. Current process of accrediting AHNS head and neck fellowships via the ATC would remain the same.
3. Certification of fellowship training by the American Board of Otolaryngology Head and Neck Surgery, American Board of Surgery, or the American Board of Plastic Surgery (the three ABMS boards representing the three specialties eligible to match in AHNS approved head and neck fellowships). ABMS/ABOHNS certification would take the form of subcertification as the pathway that has been advised by ABOHNS in prior consultation between the leadership of AHNS, ATC and ABOHNS. Subcertification by an ABMS board requires completion of ACGME accredited residency training and successful passage of the primary certifying examination of the ABMS board, and completion of fellowship training in an ACGME accredited fellowship program in order for an examinee to be eligible to sit for the certifying examination administered by the appropriate ABMS board. If implemented, this pathway would have an initial period of time for existing practitioners who demonstrate substantial expertise such as previous fellowship training and representative case logs to sit for this examination. This alternative pathway for eligibility will sunset at a predetermined time from approval of subcertification, after which only the training pathway will be allowed for subcertification in head and neck surgery by the parent American Board of Medical Specialties (ABMS) of the diplomate (ABOHNS, ABS, ABPS).
Other Important points to understand regarding the subcertification process as outlined in option 3) are worth mentioning. Pursuit of subcertification will require application to the ABOHNS as the primary or sponsoring ABMS board given the fact that the substantial majority of AHNS fellowship graduates are diplomates of the ABOHNS. Once such an application is submitted to ABOHNS, it is anticipated that the ABS and ABPS will join in consideration of the application for their diplomates. Subcertification will require that the accreditation of currently approved HN fellowships must shift from the AHNS/ATC and be maintained by the ACGME. Recent changes in ACGME common program requirements do allow for fellows of ACGME approved subspecialty fellowships to spend a portion of their time practicing as attendings in their primary specialty while pursuing subspecialty training, allowing for fellows to be designated as instructors during their fellowship. Another important consideration is that pathways exist within each ABMS board by which Canadian graduates of ACGME approved subspecialty fellowship programs may sit for the subcertification examination of the ABMS board. Examples within otolaryngology of subspecialty certification that currently exist include neurotology, sleep medicine, and pediatric otolaryngology. The process for subcertification outlined above applies to these subspecialties as well.