Interview with David R. Nielsen M.D., Chief Executive Officer and Executive Vice President (EVP) of the American Academy of Otolaryngology Head and Neck Surgery and its Foundation
BECK: Dr. Nielsen, thank you for your time today. If you don't mind, I'd like to start with a brief bio for the readers. Would you tell me where you went to medical school and where you did your residency and fellowship please?
NIELSEN: I went to medical school at the University of Utah School of Medicine and I graduated in 1979. I did a surgical internship at Providence Hospital in Southfield, Michigan. I returned to the University of Utah for my residency in Otolaryngology Head and Neck Surgery, and then I returned to Michigan to do a fellowship in otology at the Greater Detroit Otologic Group with Dr. T. Manford McGee. After that, I moved to Arizona where I started a solo private practice in otology. I practiced for about 13 years and then I went to the Mayo Clinic in Scottsdale as their medical otologist for five years, from about 1997-2002.
BECK: And after that you took over the helm at the AAO-HNS?
NIELSEN: Yes. That's when I took the position here.
BECK: I imagine this is a very different life as CEO and EVP than your previous career as a physician seeing patients on a daily basis, what was it that inspired you to make that transition?
NIELSEN: Well it was a serious change and you're right, it really is a change in careers. From very early in my career, I was interested and involved with the socioeconomic aspect of medicine. Before medical school, I got my undergraduate degree in business finance. At the time I was applying to medical school I had about a 1 in 10 chance of being accepted, and I figured I didn't want to be pumping gas with a chemistry degree or something like that, so I thought I'd do a double major; pre-med and business, and then if I got into medical school I'd be a better business man and if I didn't, I wouldn't be hanging out with nothing to do.
BECK: That sounds reasonable, always nice to have a "safety net."
NIELSEN: Agreed. So I had that background, and I had done a little MBA work before I got accepted to medical school, and I had a distinct interest in and an aptitude for socioeconomic issues. When I first moved to Arizona, Dr. Neil Ward called me and said, "I hear you're new in town and wondered if you might be interested in participating in the Young Physician's section of the Arizona Medical Association." I went to the meeting and they made me secretary of the Young Physician's section, and you know what happens next, if you do a good job, somebody gives you another assignment!
BECK: Yes, that is how it works. In my experience, you become secretary of most professional organizations by leaving the room for a few moments and then when you come back you've been nominated and awarded the position! OK, changing gears here, let's talk a little bit about the AAO-HNS leadership chronology?
NIELSEN: Sure. The first EVP of the Academy was Harry McCurdy. Dr. McCurdy came on board at the time the Council of Otolaryngology and the Academy of Otolaryngology were merged into the current AAO-HNS.
Jerry Goldstein was the EVP from 1984 to 1994 and then we had Michael Maves as the EVP. Of course, Mike was your chairman at Saint Louis University all those years ago, and he is now the Executive Vice President of the American Medical Association. Dr. Maves held the position from 1995 through 1999, and then Neil Ward was asked to step in as an interim EVP. Dr. Ward filled that position for six or eight months as interim EVP while a search was done and the search yielded Dr. Richard Holt. Dr. Holt was the EVP from 2000 to 2002, and in June of 2002 I replaced Dr. Holt.
BECK: Very good. What are you working on at this time as EVP and what would the AAO-HNS like to see occur in the near short-term?
NIELSEN: When I came on board, the Academy was doing a lot of expansion due to new technology, communication, advancements made online, educational materials, and it was really quite a challenge to the general organizational structure. From a financial perspective, the 1990's were good to everybody. Everybody saw the value of their reserves go up. As a result the Academy had expanded, and when 2000 rolled around and the stock market tanked and the value started to go down, the Academy found itself with a couple of years of deficit spending. So the number one goal when I got here was to get it back into the black, make contributions to reserves, and make sure we hadn't outstripped our roots by growing too fast, and that's what we've done. We've trimmed the budget, we've got ourselves back in the black, we're building our reserves, and we've gotten stronger financially, so we've got that under control.
The second issue was moving to a new level within the four areas the Academy focuses on; education, research, member services, and health policy and advocacy. Our research infrastructure has always been designed to provide support for our membership as they do research. We thought there was a lot more that could be and needed to be done to make us more "evidence based" in everything we do.
BECK: Of course, that's a good model and I think all health professions are leaning in that direction to validate that our treatments matter, are appropriate and are efficient.
NIELSEN: Yes, I agree. We've developed an aggressive program we call the Evidence Machine. We would like our practices and our policy statements and everything we produce to be evidence based. Doug, I believe you I can agree that to a large part, what we do in the practice of hearing healthcare involves tradition and judgment. People are trained, and are trained very well, but it's amazing the degree to which we do things that make intuitive sense and seem to work clinically, but really are not backed up by the level of evidence we would like as scientists and healthcare professionals.
BECK: I totally agree with you. And I think we've seen it time and time again where opinion and history determine treatment, rather than large-scale outcomes based analysis.
NIELSEN: Exactly, so we create study designs that help us obtain the goal. We do the study. We bring back the evidence. We teach it to our membership. We identify new clinical questions and we continue in an upward spiral of
building evidence for everything we do.
BECK: I am impressed, those are laudable goals, and that is no small undertaking! Can you walk me through an example?
NIELSEN: Sure. For example we can look at tonsillectomy and determine at which point to recommend a tonsillectomy based on factors such as; how many infections, over what period of time, and we go back and perform a literature search to learn what the literature supports as the appropriate definition for acute tonsillitis, the number of episodes, and at what point is a tonsillectomy indicated.
BECK: That's a great example, wasn't it Charles Bluestone who published that paper some ten years ago that kind of shocked the world?
NIELSEN: Yes. Dr. Bluestone and Dr. Rosenfeld and others have looked at the evidence base for what we do and they identified holes that had to be filled in.
BECK: Tonsillectomy really is a good example because in the 1960's, 70's, and 80's it was done much more readily than it is today.
NIELSEN: Absolutely. It almost got to the point where if you got a hangnail we took your tonsils out! There was also a period of time shortly after the 1950's when we believed tonsils protected you from polio and from all other kinds of stuff so for that period, nobody got their tonsils out. Of course, as a result of that, kids were getting rheumatic heart disease and rheumatic kidney disease because they weren't getting their strep throats under control. And so now the pendulum has swung back to the middle where we don't take tonsils out as often as we did in the first half of the last century, but we do take them out for specific indications like infection, obstruction, and swallowing and other presentations. Of course, this is a process that takes decades to complete. Then again, it used to take 2-3 years to do some studies and now we're cranking them out in six months, which is extremely fast, and that's great as long as the quality is maintained.
Let me give you another example. We've been doing septoplasties for decades. This has been the heart and soul of what otolaryngologists do. If people can't breathe, you re-align their septum and they breathe better. But in truth, the scientific evidence base was lacking. So we did a study. We had a validated instrument that surveyed the disability that caused people to not be able to breathe through their nose, we enrolled patients into the study, performed the study, reviewed the results and for the first time, we now have a validated study that proves septoplasty makes a difference in patient's health and their lifestyle. So we've actually proven scientifically with a higher level of evidence, what we used to know intuitively.
BECK: I imagine there must be some resistance to change, even though the change is warranted on scientific grounds. Do you have AAO-HNS members who continue to practice the way they were trained, despite evidence to the contrary?
NIELSEN: Yes, but it's becoming more rare. Clearly the majority of practitioners is open-minded and wants to provide the best care possible. But, well, let me give you an example of how hard it is to change the way you practice....As you know for years, we've used toxic ototopicals in patients with draining ears. We were trained that if a patient has a draining ear don't worry about putting neomycin in the ear, even though it's ototoxic, because the danger to the patient from the infection is greater than the danger to the patient from the ototoxic drug. Today, we have several choices of a non-toxic ototopicals that are effective, yet you'll see some doctors continuing to practice the old way, essentially because they have successfully practiced the same way for a long time! So, the evidence machine showed us there is no reason to use a toxic ototopical preparation when a non-toxic alternative exists and it will do as good or better job, but it takes time for people to change.
BECK: I'm very pleased that you're going in this direction. I'd like to see all the academies and all health sciences approach their practice protocols this way. It's an amazing step and you're to be congratulated for pushing it forward. Are other medical groups going in this same direction - and what are the long-term implications of this approach?
NIELSEN: I don't know of any other medical association that has adopted the strategy to review the evidence base for all their clinical indicators as well as their policy statements. To my knowledge, we are the first ones to do it on such a comprehensive scale. Regarding implications, the natural extension of this is evidence based health policy. And as you know Doug, health policy has a great deal to say about what patients get and what they don't get, and access to healthcare providers and who the provider is. So the implications are potentially enormous. Our attitude is whether it's a clinical question, a basic science question, a health policy question, a payment question, a socioeconomic question or whatever; the answer should be based on evidence. So again, we intend to extend this process to everything we do. It will include verification, research programs, member services, and our health policy and advocacy.
BECK: Very good. David, although we have thousands of readers who are ENT docs, we have tens of thousands of readers who are audiologists and hearing instrument specialists. I wonder if you can comment on the relationships between the national groups, and the relationships among the professionals?
NIELSEN: Well I think that's a good segue. Our concern is that we remain focused on insuring proper patient safeguards in everything we do and this requires us to work collaboratively with our colleagues in other medical and non-medically related areas. I find some irony in the fact that on a local level, when I look back at my private practice and my professional practice with Mayo Clinic my closest colleagues and best friends were members of the audiology department -- and yet on a national level when it comes to health policy there seem to be some conflicts. We remain concerned about the expansion of scope of practice for non-medical providers and yet we are supportive of any organization or any group of professionals who wish to advance their own education and their own skill. We feel that it's important to cooperate and collaborate with all hearing healthcare delivery partners in this process and we remained adamantly fixed on appropriate patient safeguards and making sure we recognize hearing loss as a medical condition that deserves medical evaluation.
BECK: Do you speak with the leadership of other national groups on a regular basis?
NIELSEN: Not as regular as it should be. I have spoken with their leaders on a couple of occasions and we discussed trying to find ways to create more open communication. We have made significant progress in some state-based legislation to appropriately define the roles of medical and non-medical providers. That's been accomplished in several states with our audiology and hearing dispenser colleagues to craft legislation. In Michigan, we're working on legislation that has the support of the greater hearing healthcare community and it's been a model for how we can work together. We're also working in New York and other states to accomplish the same thing. But it's not a universal or uniform effort across the states. But, if we're serious about evidence-based issues, we ought to engage in evidence based health policy and let evidence guide us in directions so everything we do is for the benefit of our patients.
BECK: One issue that has a few people concerned is that AAO-HNS recently started training techs for audiometric training. Can you comment on that please?
NIELSEN: Sure. The program you're referring to is the "CPOP," the Certificate Program for Otolaryngology Personnel, and the hearing-testing portion is the "Sound Training for Basic Hearing Testing." It's something that audiologists have been doing for years, training techs to assist in simple and basic office procedures. We recognize that audiologists and physicians see the need to provide basic services that are high quality at an affordable cost. And just as audiologists see the need to train techs to help them with basic screening, ENTs see the same need. So the program is a three-pronged program that includes a self-study phase, a hands-on training phase, and a six-month supervised phase. The student has to develop a basic understanding and knowledge of hearing and vestibular anatomy and physiology, and they must finish the curriculum and pass a written examination to move onto the second phase. The second phase is a 2 ½ day hands on practicum or training workshop. Trainees go to a site where they're trained by audiologists and physicians to do basic hearing testing. They learn to do a rudimentary otoscopic examination, tuning fork tests, and most important -- they must understand the limits of their training so they don't try to do what they're not trained to do! The third phase, after they pass the previous sections, is a six-month supervisory period under a sponsoring physician. During that time they keep a logbook of their procedures, how they performed them, and they have to perform a certain number of each of the procedures to qualify. The otolaryngologist has to certify that everything was done appropriately. After they completed that phase, they get their certificate as an Oto-tech. The CPOP program allows us to provide an opportunity to train workers in otolaryngology offices with skills specific to otolaryngology practice. So even though the highest demand we had initially was for an Oto-tech, the truth is we have the potential to train back office techs, front office techs, surgery techs, and other techs performing otolaryngology specific activities related to speech, voice, swallowing, rhinology, paranasal sinuses, otolaryngic allergy, facial plastic and reconstructive surgery, or whatever other area we may have demand for.
BECK: When did the CPOP program start?
NIELSEN: It's been up and running for less than a year and it requires at least a seven-month commitment by the trainee. We have about 30 people enrolled for next program, and the following program will be on the west coast, probably in LA in late summer 2004. And we haven't finalized the schedule beyond that point.
BECK: David, thank you for your time. I'm sure the AAO-HNS will continue to benefit from your leadership, and I am hopeful that the national groups will be able to work together, compromise and resolve issues for the benefit of those we serve in the near future.
NIELSEN: Thanks Doug. It's been a pleasure working with you.
