TORS Training

[Graywolf]

Hey all!

Current 4th year med student interviewing over the next couple months. I've got a special interest in Head and Neck, and I would like to go to a program that has good TORS training. My goal with this might be to bring TORS to a multi provider private practice in my hometown, which currently doesn't do it due to physicians not having robotic surgery available in their time in residency.

I know TORS is standard at most academic centers, but the actual resident training can be a mixed bag -- as in you might just be there to change to instrumentation but get minimal actual training performing surgeries while the attending and fellow do it.

Is it better to get TORS training at a smaller program (2-3 residents) without H&N fellow around? Or is better to go to a huge program with a large H&N volume and a fellow or two? Or is best to just aim on getting that training in your fellowship? (I'm still undecided on fellowship).

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[VisionaryTics]

Realistically the places that have the volume to teach you TORS in residency (some data suggests the learning curve is about 20 cases) will have H&N fellowships.

Most people get training through some combination of residency, H&N fellowship, and courses.

I think if you want to do TORS for oncologic cases, you should be a H&N specialist, which realistically requires fellowship these days. This is not something generalists dabble in. Of course I'm biased since I'm starting H&N fellowship in July.

 

[Pir8DeacDoc]

I think the above is great advice. I would add that I went to a one a year program without a fellow and got to do some TORS due to staff interest. That was six years ago. So I'd imagine the current residents get more than I did. So look around

 

[lildave2586]

If you really want to do TORS then you'll need to do a fellowship. My reasons are you are unlikely to get enough case volume in a private practice setting to do the "easy" TORS cases (T2 tonsils, T1 BOT, T1 laryngeal masses). The more advanced TORS cases typically require some type of reconstruction, usually with a free flap. Unless you can build a tertiary referral in private practice I think you are unlikely to have the volume. You would be better off having a fellowship training that is TORS heavy so you can do PPS tumors, large pharyngeal masses, nasopharynx, etc. You just can't learn all that in residency.

With that being said, I think you would be better off at a smaller program with high head and neck volume. Some of the programs that take 3-4 residents a year can have very high H&N volume. You will have to show interest and spend time outside of the OR practicing with the robot. Many programs will have a simulation lab for surgical education that will have a robot you can get trained on. My program did, and I trained at a small place (3 residents a year). None of us every really took much interest in TORS, we would head for the hills when we saw a TORS case (I referred to them as the "trainwreck TORS" cases).

 

[Krukenberg]

Rad onc resident here, but I’ve chatted with ENT attendings at my institution about TORS in the community setting out of curiosity. They said they thought uptake would be low because time on the robot is booked out with prostatectomies, and it’s more profitable for the hospital to book prostatectomies than HN cases. Here they get reserved time because they have such a high volume. There might be reasons other than the ENTs in your hometown being old.

 

[HighPriest]

You'd have to find a niche geographic area without fellowship training. I see a fairly busy general ENT clinic with multiple partners, and I bet I see maybe 1 patient per year who is a TORs candidate. We're the only game in town, so I don't think they're getting past us. I know one of the many head and neck oncologists in the nearby metro area, and he's not getting patients from the area here that didn't come through us. So I think part of the reason may be a cost/benefit issue, but you really need a wide referral net to have cases that are going to be well off with TORs. Caveat that there are places and people out there who will do TORs on anyone for any reason whether it actually offers much of a benefit or not.

That being said, those areas do exist. I have a former partner who moved to an area with a large catch basin, but no nearby head and neck oncologists, and he does some TORs. Not a ton, but some. And when he was in the Army he did more, actually, in the form of BOT reduction surgery for OSA. So your application of the skill definitely matters.

 

[Graywolf]

You'd have to find a niche geographic area without fellowship training. I see a fairly busy general ENT clinic with multiple partners, and I bet I see maybe 1 patient per year who is a TORs candidate. We're the only game in town, so I don't think they're getting past us. I know one of the many head and neck oncologists in the nearby metro area, and he's not getting patients from the area here that didn't come through us. So I think part of the reason may be a cost/benefit issue, but you really need a wide referral net to have cases that are going to be well off with TORs. Caveat that there are places and people out there who will do TORs on anyone for any reason whether it actually offers much of a benefit or not.

That being said, those areas do exist. I have a former partner who moved to an area with a large catch basin, but no nearby head and neck oncologists, and he does some TORs. Not a ton, but some. And when he was in the Army he did more, actually, in the form of BOT reduction surgery for OSA. So your application of the skill definitely matters.

Sounds like the indications/criteria for a patient to be a TORS candidate is the real limit. Maybe in the future we'll see indications for TORS expand. I'm starting to realize that TORS (and free flaps for that matter) is only a small portion of true H&N in the community/private practice, and certainly not something you would do for generating revenue.

 

[HighPriest]

Take this with a grain of salt because I'm not doing TORS:

A large number of the head and neck guys I know feel like TORS is a solution looking for a problem. Most of their oropharyngeal tumors are still getting chemorads, and the huge non-responsive ones are getting split mandibles. Their criticism is that a lot of the guys advocating TORs are not always getting margins for large tumors, and that small tumors can often just be addressed in a traditional fashion through the mouth. The exception is BOT for which TORs gives great visualization, but the guys who were trained with TLM feel like they haven't had any issues with BOT in the first place (beyond the expected access issues). Most of the oropharyngeal patients I see end up getting chemorads - even the ones I send to the "local" TORs epicenter - whether they have TORs or not.

A lot of guys who do lots of TORs often feel like it's a great solution for everything. But you gotta take that with a grain of salt too, because a lot of them are publishing almost exclusively on TORs research, and so if you're the guy selling pork pies you're going to talk about how great pork pies are.

That's just my observation as an ENT guy who doesn't do TORs. I don't have a horse in the game because if I think I can get it with a radical tonsil, I just do that. If I don't, then I'm sending them to someone who's TORs trained and they're making the call.

Most of the guys in my area doing TORs -regularly- are at academic centers, even though there are a number of TORs-trained guys doing surgery either privately or as employed physicians. So that, to me, indicates either:

1 - The academic guys feel much more comfortable with TORS (very possible)
2 - The pay isn't as good for TORS (very likely)
3 - There's more incentive to do TORS when you're publishing on it (very likely)

I'm not criticizing it, but I ask about it all of the time to a variety of HN oncologists because it's not entirely clear to me who is a TORs candidate and who isn't. I seem to get different answers every time I ask. I know what the lit says, but just because a T1 tumor is a candidate for TORs doesn't mean everyone will take it out with TORs - even if they can. I understand the theoretical (and practical benefits), and I also understand the financial and practical limitations.