Core program curriculum

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.