Fellowship Structure

Background of the FHNO

The Foundation for Head and Neck Oncology (FHNO) is a multispecialty national society for propagation of best management practices in head and neck cancers in India. Membership is drawn from the entire gamut of medical specialties involved with head and neck cancers including but not limited to Otolaryngology- Head and Neck Surgery, Surgical Oncology, Oral and Maxillofacial Surgery, Radiation Oncology, Medical Oncology, Reconstructive Surgery, Basic Scientists, Speech/Swallowing therapy and other allied specialties.

Head and neck cancers as a group are among the most prevalent cancers in India and the Indian subcontinent. The FHNO was conceived in 2001 with the teaming together of a national group of clinical and research scientists, who felt the necessity of an active body to oversee the standards of care, education and research for this significant health problem of the country. The three main thrusts of activity for the Foundation have been towards establishing uniform and internationally accepted standards of care in head and neck cancers in the country; promote research programs in basic sciences as well as clinical areas and initiate educational activities like structured oncology training programs and fellowships in head and neck oncology.

Objective of the initiative

To provide structured and didactic training in all aspects relevant to research, prevention, diagnosis, treatment and rehabilitation of head and neck cancers, with specific emphasis on hands-on surgical training in head and neck oncology and contemporary reconstruction.

The fellowship will have two paths for training with different curricula, according to the primary qualification of the candidates. The fellows with Maxillofacial background will be trained for “FHNO Oral Oncology Fellowship” and will be awarded certificate for “Oral Oncology”. The fellows with other background (MS / DNB / Diploma ENT, MS/DNB Gen. Surgery, MCh/DNB Surgical or Head Neck oncology) will be trained for “FHNO Head & Neck Fellowship” and will be awarded certificate for “Head & Neck Oncology”.

A dedicated website https://fhnofellowship.org/index.html will have all updated instructions regarding fellowship.

Requirements and eligibility for candidate

1. Essential : The applicant should possess either of the following postgraduate degrees:
   • MS or DNB in either of the following disciplines: Otolaryngology-Head and Neck Surgery or General Surgery
   • MDS in Oral and Maxillofacial Surgery
   • MDS must have minimum 6 months of observership at a reputed head & neck centre approved by the task force. Any institute where HN MCh/Surgical Oncology MCh / FHNO HN Fellowship are available can be recognised as approved observation centres.
   • M.Ch. or DNB in either of the following disciplines: Surgical Oncology, Head & Neck Oncology or Plastic Surgery
2. Desirable (not mandatory) : An inclination toward head and neck oncology corroborated by relevant supporting documentation for the below-mentioned:
   • A significant proportion of head and neck surgeries assisted/performed under supervision during residency training
   • A postgraduate thesis topic pertinent to head and neck oncology
   • Active participation in and presentations at oncology meetings
   • Observership at institution/s specializing in head and neck oncology (for MS / MCh)
   • Prior publications relevant to head and neck cancers
   • Letter/s of recommendation by head and neck faculty who were prior mentors.

Duration of the program

The program will start from 15th November of the year.

Two years (twenty-four months) incorporating supervised and independent operating responsibilities pertinent to head and neck extirpation, reconstruction and surgical rehabilitation; outpatient clinics; inpatient care; teaching activities including Tumor Boards and academic Grand Rounds; research projects, and presentations at regional/national/international meetings.

At the completion of the fellowship program, the fellow, if so inclined, should have the option to request i) additional subspecialty training pertinent to his/her specialty at another participating centre; or ii) a period of additional research responsibility at the same or other participating centres. There will also be an option of a similar expression of interest at the time of the periodic 6-monthly reviews. The grant of such a request will be subject to institutional discretion and availability at participating centres.

For detailed timeline, please refer to Task Force Document / website.

Selection of participating institution

(Even though the presence of all of the below mentioned allied specialists at the training centre is ideal, trainees should be scheduled for rotations at outside affiliated centres if the above is not practicable)

• An application form for institutions will be available on the FHNO Institutional Fellowship website.
• The eligibility criteria for institute is mentioned on FHNO Institutional Fellowship website.
• It will be the responsibility of the participating institution to provide information specific to the program, including a list of teaching faculty, surgical workload, clinical and research responsibilities anticipated from the fellow, careers of former graduates if applicable, and core subspecialty competence of the department.
• The institute will be inspected by member of FHNO Institutional Fellowship approval committee, designated by Task Force. The task force will review recommendations of the inspector and take appropriate decision.
• The institution will also appoint a Fellowship Program Director, an Assistant Program Director and a Program Co-ordinator.
• FHNO Institutional Fellowship can be over and above any ongoing fellowships at the centre.
• At present one fellow per institute will be approved (for initial two years of period)
• Accredited institutes will be able to apply for one more fellow (total 2) for year 2020 intake, provided they have enough workload and infrastructure, which will be decided after evaluation of its merit by the task force.
• Application fees for centre for approval for fellowship will be Rs 10,000 which will be non-refundable, payable to FHNO.
• If the centre is approved, it will have to pay FHNO a one-time payment of Rs 50,000 as charges for fellowship proceedings, which is valid for four years.

Selection process of a candidate into a program

• The FHNO Institutional Fellowship website (https://fhnofellowship.org/) will display a list of the participating institutions and their contact information for convenient reference. The website will also display the common application period, central exam/ interview date and tentative notification date of eventual selection. The notification date will be around three months prior to the tentative start date of the fellowship program (usually first week of June).
• Prospective applicants will download and complete an application form, available on the FHNO Institutional Fellowship website (https://fhnofellowship.org/index.html). They should include their current resume (mandatory) and a maximum of two letters of recommendation (desirable but not mandatory) as part of their application materials. The same documents should be scanned and mailed to fhnofellowship@gmail.com with the subject matter ‘Application for FHNO Institutional Fellowship (commencement year)’. Candidates with incomplete applications will not be allowed to participate in the central exam.
• The candidate will need to submit a non-refundable fee of Rs 10,000 as application fees to FHNO along with the form.
• The central exam will be conducted over one or two days (depending on number of applicants) at a venue designated by the Task Force. Venue will be preferably at annual FHNO meeting. It should be conveniently accessible by multiple modes of transport. The exam will be conducted as a written test followed by a personal interview/ review of application materials, which will both bear equal point value. Members of the task force will be present for the central exam.
• Center selection choice list: Each candidate will need to give a choice list of his/her selected centres in chronology (in written as well as mail) between 12 noon to 3 pm on the day of interviews.
• Each accredited institute will form institutional rank order list of candidates, usually based on their review of application of the candidate and/or other information. These lists will be submitted to the Fellowship Committee prior to interviews, and will be kept confidential. Institutes need to submit the list by the morning of the day of the interview (between 9 am and 11 am) (written as well as mail). FHNO will look for the possibility of arranging a meeting place between institute representatives and candidates during FHNO annual conference prior to interview.
• Written Exam
• The written test will be multiple choice question (MCQ) based in a single correct option format.
• The written test will be multiple choice question (MCQ) based in a single correct option format. The questions will be limited to basic aspects of prevention, diagnosis, treatment, rehabilitation, surveillance and research pertaining to head and neck oncology
• The approximate distribution of the 60 questions will be:
  1. Basic sciences incl. head and neck anatomy and physiology- 10
  2. Questions on published clinical, basic and outcomes research- 10
  3. Surgical decision-making including incision, approach, resection, neck dissection and reconstruction- 15
  4. Multidisciplinary decision making e.g. adjuvant therapy- 10
  5. QoL/Rehabilitative strategies incl facial, swallowing, speech and other functional rehabilitation- 5
  6. Strategies of prevention and early detection- 5
  7. Future directions- 5
• 50 questions out of the 60 (and no more) must be answered. The candidates will get 90 minutes to answer the 50 chosen questions. If a candidate answers over 50 questions, the first 50 marked answers will be considered.
• To accommodate the multidisciplinary applicant base, no more than 5 questions will pertain to a single site within the head and neck.
• Given the multidisciplinary applicant base, the questions will be limited to basic aspects of prevention, diagnosis, treatment, rehabilitation, surveillance and research pertaining to head and neck cancers.
• Advanced aspects will be in the scope of fellowship training, including decision making on controversial or evidence-insufficient topics- these subjects will not constitute part of the exam. There will be no intended ambiguity or duality in the answers, which will embody the application of standard practice guidelines obtained from high-quality evidence and standard textbooks. A suggested bibliography will be available on the FHNO Institutional Fellowship website.
• Interview
• Following the written exam, all candidates with complete applications who also answered at least 50 theory questions will be interviewed by a panel, in order of merit based on marks scored in written exam.
• The interview process will include general assessment, appraisal of short-term and long-term goals and a review of application materials including resume, training background, past experience, letters of reference and personal statement.
• SELECTION PROCESS
• The Fellowship Committee will subsequently collate the institutional and candidate rank order lists, to ensure optimal candidate selection, during this matching process. Matching during subsequent fellowship cycles will be computer-based and automated.
• The final list of selected candidates will be displayed on the FHNO Institutional Fellowship website.

FHNO Institutional Fellowship task force can change above mentioned schedule and process. Candidate and Institutes needs to refer for updates on the FHNO Institutional Fellowship website and keep updated.

Core program curriculum:

1. Surgical training
   During his/her training, the fellow is expected to have seen, evaluated and participated in the treatment of at least 200 patients with head and neck cancer. 
   • The fellow is expected to have participated in at least 200 major and minor head and neck surgical procedures over the 2-year fellowship period.
   • A minimum of two full operative days per workweek (equivalent to 16 hours of operating room time) are recommended.
   • The fulfilment of the recommended number of site-wise surgical procedures will be considered an essential requirement for fellowship completion- this will be maintained as a surgical case log in the standard format. List and format will be available on FHNO Institutional Fellowship website.
   • It is recommended that of the total number of major surgeries listed on the operative case log, a minimum of 60 should bear the fellow’s designation as chief surgeon.
   • It is recommended that the scope of the procedures should be expanded to include surgically amenable benign thyroid/parathyroid disease, benign salivary gland and skull base neoplasms etc.
   • Though not part of curriculum, other subspecialty training requiring head/neck expertise pertinent to Otolaryngology- Head and Neck Surgery (CO2 laser surgery or endoscopic skull base surgery for benign indications, sleep apnea surgery) or Plastic/Maxillofacial Surgery (trauma, cleft/craniofacial surgery) can be allowed to be incorporated in training based on mutual consent. This is subject to the core focus of training being head and neck oncology.
   • At the end of 18 months (third review), the fellows are expected to be competent in all common ablative head and neck surgery. At the end of 24 months (fellowship completion), the fellow is expected to be performing common reconstructive surgery with acceptable competence.
   • The fellow will be required to maintain a surgical case log with a comprehensive list of all cases participated in. Submission of a completed operative case log will be an essential requirement for issuance of the fellowship completion certificate.
   • The log book will be countersigned by the Program Director each month, and case log review will form an essential component of the periodic fellowship review (to be performed every 6 months till the completion of the fellowship).
2. Clinics:
   • The number of hours spent in the outpatient clinic and patient numbers seen will be documented and standardized. These may be variable across multiple training institutions.
   • A minimum of two full clinic days (at least one of them directly supervised by the Program Director or the Assistant Program Director) is recommended.
   • Clinic case presentations should be at least one per full clinic day per fellow. There should also be the provision of incorporating case presentations into the weekly Multidisciplinary Tumor Board Conference.
   • There should be a recommendation and provision for periodic interaction with the social worker/s and the psychological counsellor/s.
   • Formal training in patient and grief counselling should be incorporated wherever possible.
3. Academic program and Tumor Board:
   • As part of the academic program, the trainee will help organize and attend a weekly Multidisciplinary Tumor Board Conference, to be attended by all disciplines present in the institution and pertinent to the practice of head and neck oncology, including but not limited to Head and Neck Surgery, Reconstructive Surgery, Radiation Oncology, Medical Oncology, Pathology, Radiology, Nuclear Medicine, Dietetics, Speech/ Swallowing Therapy, Psychological Counselling, Nursing Supervisors, social workers etc. All cases presented in the meeting should preferably be presented by the trainees. The tumour board format and consensus recommendations will prepare the trainees to make well-informed decisions and prepare them for future team leading positions.
   • Wherever feasible, a Head and Neck Reconstructive Board should be encouraged with participation by Head and Neck Surgery, Plastic/ Reconstructive Surgery, Psychological Counselling, Dietetics, Physical therapy etc. The frequency of this meeting will be at the discretion of the participating institution.
   • There should be a provision for didactic training in a Grand Rounds format. The series of lectures should be delivered weekly with a cyclical frequency of 12 months. The recommended format of Grand Rounds will include a minimum of one trainee lecture and one lecture by program faculty, and should encourage extensive interaction. All topics pertinent to the management of head and neck oncology should be incorporated in the lecture schedule. The lecture draft and list of topics will be at the discretion of the participating institution. A suggested minimum list of presentation topics can be found on FHNO Institutional Fellowship website.
   • Morbidity/mortality meetings, journal club and guest faculty presentations in a standard format are recommended to occur on a monthly basis for each activity.
   • The creation of an online training forum under the aegis of the FHNO will be encouraged, where the trainees can share their perspectives via discussion threads. The registered users will have login privileges for accessing uploaded relevant course materials and recent literature.
4. Training in allied specialities

   (Even though the presence of all of the below mentioned allied specialists at the training centre is ideal, trainees should be scheduled for rotations at outside affiliated centres if the above is not practicable)

   
   Dental oncology/maxillofacial prosthetics/implantology:

   This recommendation should be for 1-2 days each month, or a 15-day continuous rotation.

   This will allow the trainees to interact with the dental oncologist regarding preradiation prophylaxis, post radiation conservative dental management and prevention/management of osteoradionecrosis.

   Maxillofacial prosthesis training is important, as dental and prosthetic rehabilitation is integral for patients to return to their premorbid state.

   Basic implantology training for timing and technique of implants, and surgical modifications to increase rates of dental rehabilitation, are essential.

   
   Speech and swallowing rehabilitation:

   This recommendation should be for 1-2 days each month, or a 15-day continuous rotation.

   Trainees will be instructed by the SLP/equivalent in alaryngeal speech/dysphagia rehabilitation following management of laryngeal/hypopharyngeal cancer, speech articulation/dysphagia management post glossectomy, and dysphagia rehabilitation post organ preservation treatment in pharyngeal cancer.

   The fellow is expected to become proficient in TEP troubleshooting, compensatory manoeuvres/rehabilitation, interpretation of tests (VFS, FEES) and other aspects of voice and dysphagia management.

   
   Diagnostic anatomical and functional imaging/nuclear medicine:

   A week-long interactive rotation between the trainee and a radiologist experienced in head and neck imaging is recommended. This allows for discussion of a wide variety of cases by the trainee to allow understanding of radiological staging and subsequent surgical planning wherever indicated. The trainee should be able to understand the decision making as regards choice of investigation modality, and also understand the indications of therapeutic nuclear medicine.

   
   Pathology:

   A week-long interactive rotation with an experienced pathologist is recommended. Training will include essential aspects as cytopathology, processing of diagnostic biopsy, surgical specimen orientation, margin assessment, and a basic overview of routine as well as intraoperative pathology.

   
   Radiation oncology:

   The recommendation is for 2 weeks of rotation each year. At the completion of this rotation, the trainee should be able to understand the interplay between the two specialties in guiding decision-making, understand the indications of radiation therapy in head and neck cancers, and understand the sequelae and toxicities of radiation therapy and their management/ mitigation.

   
   Medical Oncology:

   The recommendation will be for 1-2 weeks of training. At the completion of this rotation, the trainee should be able to understand the rationale of decision making as regards cytotoxic and biological agents including immunotherapy, and regimen choice based on treatment setting and performance status. He/she should also be able to understand and recognize toxicities of common chemotherapeutic agents and their basic management.

   
   Pain management and palliative care:

   This is recommended as a monthly interaction with the pain/palliative care specialist to understand cancer-associated pain and the pharmacological/ interventional modalities utilized to manage the same. This interaction will be aimed at gaining further perspective on end-of-life issues.

   
   Grief/psychosocial counselling:

   It will be integrated with the outpatient clinic experience as abovementioned.

   
   Preventive Oncology:

   This constitutes an essential recommendation, and will incorporate strategies of tobacco cessation, community and physician initiatives, current role of HPV and the appropriate counselling, management of leucoplakia and other premalignant lesions, trismus rehabilitation, among others. Fellow is expected to have conducted at least one screening camp & one public education activity.

5. Research experience
   • Clinical research will be an essential component. The aim will be developing concise and focused thinking in a structured training environment.
   • The research will be expected to be original and clinically relevant- the trainee should be enrolled as the investigator in at least four clinical studies/papers during the course of his/her fellowship. This is an essential requirement to become eligible for exit exam. (Each candidate to publish/submit two papers a year – one in an Indian journal and one in an international journal)
   • The institution will provide infrastructural support, provision for maintenance of electronic or file data, IRB support, biostatistics support (in-house or outsourced as applicable) and permission to trainee to present or publish on behalf of the institution.
   • The decision on provision of protected research time will rest on a mutual decision made together by the trainee, program faculty and the institution.
   • An induction training format for aspiring researchers will be made available on the FHNO Institutional Fellowship website. This can include instructional videos or power point presentations on paper writing and critique, basic statistical analyses etc.
   • Basic research will necessitate protected time, and will depend as abovementioned on the institutional decision made mutually by all parties concerned.
   • At the completion of the fellowship term, a research term may be recommended based on the trainee’s aptitude. The additional experience gained thus may be appended to the previous experience obtained.
6. Rotations at outside centres:
   • External rotation (outside institute) is recommended if the institute doesn’t have necessary allied departments suggested for internal rotation. (especially for Rotations are preferred for dysphagia, dental rehab and reconstruction, pain palliative and psychology)
   • It needs to be done under an External Mentor.
   • The external mentor will have the following responsibilities: ensuring a beneficial supplemental training period by providing perspectives of management practised by another institution, signing off on the operative log book at the end of the rotation, and ensuring that the trainee gets adequate operating room experience during the rotation.
   • Trainees need to log their observation and participation during these external postings. The trainee also has to submit a written report on their experience.
   • Upon the fulfilment of the above pre-requisites, a certificate signifying the satisfactory completion of the external rotation will be issued. This will be an essential document at the time of completion of fellowship. Rotation record format is available on FHNO Institutional Fellowship website.
7. Meetings/Conferences:
   • The trainee is encouraged to present original work at regional, national and international meetings, which will inspire confidence, bolster awareness and enhance study patterns.
   • The institution may, at its discretion, choose to reimburse the registration cost of meetings attended.
   • An annually replenished fellow allowance from the institution’s end is desirable and should be separate from the stipend, which should support conference costs & other academic activities.
   • Candidate must attend two meetings every year. (one FHNO annual meet, one regional meet)
   • Candidate must present one papers every year in head neck or allied meetings
   • Attendance at course and meeting format is available on the FHNO Institutional Fellowship website.
8. Suggested syllabus/bibliography
   • A selected collection of textbooks including basic science texts, operative and lab manuals and compendia will be recommended for reading during the trainee period. It will be available on website under “educational material”
   • Additionally, a list containing recommended and pertinent journals will be generated for reading.
   • By no means should these lists be considered all-encompassing. The trainee will be encouraged to read other standard texts and journals as per his/her discretion under the supervision of the program faculty.

Assessment and review

• The trainee’s assessment should be an ongoing process with six monthly reviews recommended incorporating the following: operative log, growth in fund of knowledge, operative performance, publications, presentations, interpersonal conduct with colleagues and patients. Corrective measures or modifications as deemed necessary should be suggested and noted in the ensuing review. The faculty assessor (PD/APD) should make recommendations for additional training and suggest areas of improvement.
• All presentations made by the trainee over the six-monthly period should be rated by program faculty and the assessment should be included in the periodic review.
• PD will be required to submit six monthly appraisal report for FHNO Institutional Fellowship committee.
• A set of online training modules will be available on the FHNO Institutional Fellowship website, and the trainee will be expected to complete all training modules within the time specified.
• The institution should be subject to confidential feedback as well by the trainee/s utilizing a standard format.
• FHNO will have yearly review of candidate log books. Candidates will need to fill a concise summary form for that which will be available on fellowship website. The review will be done during FHNO annual meeting.

Exit Exam Exit Exam

• The exit exam will be conducted at FHNO Annual conference venue.
• The candidate needs to register as FHNO life member before appearing for the exam as prerequisite of the fellowship.
• The exit exam will be taken in theory / OSCE / viva format.
• The questions will be set by a panel of examiners (exam committee) appointed by task force.
• Exam results will be posted on FHNO Fellowship website.
• If candidate is not able to clear exit exam (score less than 50%), he has an option to appear in next exit exam for 2 years with exam fees of Rs. 10,000 for each attempt.

Code of conduct:

• Responsibility of fellows’ clinical work will be on Program Director of that institute and not on FHNO.
• In case of misconduct / breech of rules by fellow, local committee and the task force can jointly decide required actions (including warning, termination, black listing etc).
• In case of misconduct / breech of rules by the centre, task force committee is entitled to withdraw the fellowship program from the centre and will transfer the existing fellow to an appropriate centre for his remaining term.

Renumeration to the candidate

The candidate will receive minimum stipend of Rs. 50,000 per month by the centre. Institute has liberty to increase this amount.