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UPMC Updates in Otolaryngology: A Monthly Webinar Series

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The UPMC Department of Otolaryngology presents a free webinar series — UPMC Updates in Otolaryngology.

Upcoming webinars include:

December 6, 2016 – 8 p.m.: Tinnitus Retraining Therapy: How to Live with the Sounds
Presented by: Lori Zitelli, AuD, CCA-A
Moderated by: David Eibling, MD — Professor, Department of Otolaryngology

January 10, 2017 – 8 p.m.: Evaluation of Noisy Breathing in Infants and Children
Presented by: Jeffrey Simons, MD — Associate Professor, Department of Pediatric Otolaryngology
Moderated by: Jonas Johnson, MD, FACS — Professor and Chairman, Department of Otolaryngology

February 7, 2017 – 8 p.m.: Update in Implantable Hearing Devices
Presented by: Barry Hirsch, MD — Professor, Department of Otolaryngology
Moderated by: Jonas Johnson, MD, FACS — Professor and Chairman, Department of Otolaryngology

March 7, 2017 – 8 p.m.: Neurostimulation Therapy for Obstructive Sleep Apnea
Presented by: Ryan Soose, MD — Assistant Professor, Department of Otolaryngology
Moderated by: Bridget Hathaway, MD — Assistant Professor, Department of Otolaryngology

April 4, 2017 – 8 p.m.: Update on Sino-Nasal Malignancy
Presented by: Eric Wang, MD — Associate Professor, Department of Otolaryngology
Moderated by: David Eibling, MD — Professor, Department of Otolaryngology

May 9, 2017 – 8 p.m.: Advances and Novel Therapeutics in the Treatment of Chronic Rhinosinusitis
Presented by: Stella Lee, MD — Associate Professor, Department of Otolaryngology
Moderated by: TBD

June 6, 2017 –8 p.m.: Advances in Management of Oropharynx Cancer: HPV, Robotic Surgery, and Immunotherapy
Presented by: Robert Ferris, MD, PhD — Associate Professor, Department of Otolaryngology
Moderated by: Barry Schaitkin, MD, FACS — Professor, Department of Otolaryngology

For more information, to register for a webinar, or to view all past webinars, visit the Chorus Call website.

 

UPMC Department of Otolaryngology Launches Head and Neck Cancer Survivorship Program

The UPMC Department of Otolaryngology recognizes that cancer survivorship starts at diagnosis.  The multidisciplinary providers of UPMC’s Head and Neck Cancer Survivorship Clinic offer a comprehensive evaluation to patients before the start of their cancer treatment. This evaluation allows us to not only identify underlying issues patients may be experiencing regarding swallowing, dental care, and mobility, but also allows us to educate patients about strategies to optimize their health during treatment.  After treatment, we utilize a patient-centered approach that includes surveillance, assessment of treatment effects, identification of referral and resources to help our survivors live beyond their cancer.

For more information about patient referral, call 412-647-2100.

NIH-Funded Pitt Research Study to Evaluate New Voice Therapy Technique

A voice therapy program that was refined by experts at the UPMC Voice Center and successfully piloted on a small group of patients with voice disorders, will be reaching more patients due to a $300,000 National Institutes of Health (NIH) grant recently awarded to the University of Pittsburgh School of Medicine.

The new voice therapy approach, Conversation Training Therapy (CTT), concentrates on voice training in spontaneous, conversational speech for patients with voice impairment.

“With this approach, we focus on patients becoming aware and efficient in conversation, instead of in voice exercises. Results from our initial trial showed that patients met their voice therapy goals in just three sessions, substantially below the number of sessions typically required in traditional voice therapy programs, which can take up to 12 or even 24 sessions. Patients also reported that they noticed marked improvement in their voice impairment,” said lead researcher Amanda Gillespie, PhD,  assistant professor, Department of Otolaryngology, Pitt School of Medicine, and director of Clinical Research, UPMC Voice Center.

Treatment aimed at modifying behaviors that cause or contribute to voice disorders is the standard of care for many people experiencing voice issues. Although voice therapy is effective at treating voice disorders, substantial limitations exist with traditional treatment models. These limitations cause a protracted length of time in required treatment, as well as drop out and voice problem relapse rates approaching 70 percent, which contribute to the high costs associated with treating voice disorders.

CTT was developed by a team of expert voice-specialized speech-language pathologists at voice centers around the U.S. The goal of this study is to determine the effectiveness of CTT in the rehabilitation of patients with two common voice disorders—benign vocal fold lesions and muscle tension dysphonia. Once that is determined, the long term goal is to conduct multi-center trials comparing CTT to traditional voice therapy programs in people with voice disorders.

Pitt’s research study is the first to look at a voice therapy program based in theories of motor learning and neuroplasticity, developed with input from patients with voice disorders and expert, clinical, speech-language pathologists.

“Results of the current research have the potential to dramatically change how voice therapy is delivered, including the necessary time spent in treatment, resulting in a potential savings of health care funds and improved quality of life for people with voice disorders,” said Jackie L. Gartner-Schmidt, PhD,  co-investigator on the study, co-director of the UPMC Voice Center, and director of Speech-Language Pathology-Voice Division, Pitt School of Medicine.

Researchers will recruit 60 participants to undergo four weeks of treatment with a CTT-trained voice therapist. Each will be evaluated prior to starting CTT, before each treatment session, and at one-week and three-month intervals after the last CTT session. Outcome measures will include participant-perceived voice handicap, acoustic, aerodynamic and audio-perceptual voice analyses, and will be compared to matched past patients who previously underwent traditional voice therapy. Participants are compensated for their time.

The three-year grant (R03 DC015305) was awarded by the National Institute on Deafness and other Communication Disorders.

Other co-investigators at the University of Pittsburgh are Clark Rosen, MD, and Jonathan Yabes, PhD.

For more information, call 412-647-SING (7464) or email Tina Harrison, study coordinator, at harrisonta@upmc.edu.

Pitt Scientists Lead Consensus Guidelines for Thyroid Cancer Molecular Tests

PITTSBURGH, July 6, 2015 University of Pittsburgh Cancer Institute (UPCI) scientists recently led a panel of experts in revising national guidelines for thyroid cancer testing to reflect newly available tests that better incorporate personalized medicine into diagnosing the condition.

Their clinical explanation for when to use and how to interpret thyroid cancer tests is published in the July issue of the scientific journal Thyroid. The American Thyroid Association is revising its 2015 Guidelines for Thyroid Nodule and Thyroid Cancer Management to direct doctors to the scientific publication.

“Minimally invasive molecular testing for thyroid cancer has improved by leaps and bounds in the last several years,” said co-author Robert L. Ferris, M.D., Ph.D., professor and chief of the Division of Head and Neck Surgery in Pitt’s School of Medicine. “But different tests perform differently and, therefore, need to be interpreted carefully to make the best decisions regarding extent of surgery for patients with thyroid nodules. Our goal with this analysis is to give clinicians a clear understanding of what each type of test can tell them and when to use them to determine the best course of treatment.”

Cancer in the thyroid, which is located just below the “Adam’s apple” area of the neck, is the fifth most common cancer diagnosed in women. Thyroid cancer is one of the few cancers that continues to increase in incidence, although the five-year survival rate is 97 percent.

UPCI, partner with UPMC CancerCenter, has been a national leader in developing personalized genetic tests for thyroid cancer that have spared patients repeat or unnecessary surgeries. A low-cost test called ThyroSeq, developed by a team led by Yuri Nikiforov, M.D., Ph.D., director of Pitt’s Division of Molecular and Genomic Pathology, allows pathologists to simultaneously test for multiple genetic markers of thyroid cancer using just a few cells collected from the nodule.

This allows doctors to “rule-in” a specific cancer diagnosis with a high degree of certainty, without a biopsy to remove a large portion of the thyroid, which would then have to be followed with a second surgery if cancer is detected to remove the entire gland. As Dr. Nikiforov’s group added more genetic sequences to the ThyroSeq test to create a larger and more sensitive version of the test, it is now also performing as a “rule-out” test that can tell doctors with a high degree of certainty that a patient does not have cancer.

Other available tests use different technology to serve as accurate “rule-out” tools, but do not have the high sensitivity needed to also reliably “rule-in” cancer. And, in some cases, the accuracy of the “rule out” tests depends on the prevalence of cancer in the patients seen by each individual cancer institute. This is critical because clinicians must know this rate at their institution to correctly calculate the accuracy of “rule-out” test results for each patient.

In addition to Dr. Ferris and co-author Sally E. Carty, M.D., who is professor and chief of the Division of Endocrine Surgery in Pitt’s School of Medicine and co-director of the UPMC/UPCI Multidisciplinary Thyroid Center, the panel reviewing the tests was a multidisciplinary group from a dozen institutions in the U.S. and Canada.

“This was a very innovative and collegial initiative,” said Dr. Carty.  “Through an objective review of the existing tests and the scientific literature characterizing their performance, we are seeking to help clinicians make the best decisions for their patients.”

Dr. Ferris agrees, noting that “this is an exciting time in personalized medicine, and these tests give us the ability to not only better diagnose and treat thyroid cancer, but also significantly reduce surgeries for people who don’t have cancer.”

Additional authors on this publication are Zubair Baloch, M.D., Ph.D., University of Pennsylvania Medical Center; Victor Bernet, M.D., Mayo Clinic; Amy Chen, M.D., Emory University; Thomas J. Fahey III, M.D., New York Presbyterian Hospital; Ian Ganly, M.D., Ph.D., and Ashok Shaha, M.D., both of Memorial Sloan-Kettering Cancer Center; Steven P. Hodak, M.D., and Kepal N. Patel, M.D., both of New York University Medical Center; Electron Kebebew, M.D., National Cancer Institute; David L. Steward, M.D., University of Cincinnati Medical Center; Ralph P. Tufano, M.D., Johns Hopkins University; and Sam M. Wiseman, M.D., St. Paul’s Hospital & University of British Columbia.

Pitt Team Follows the Zinc to Uncover Brain Pathway that Fine-Tunes Neural Signaling

PITTSBURGH, May 4, 2015 – A study team led by researchers at the University of Pittsburgh School of Medicine who used specially developed technologies to “follow the zinc” have uncovered a previously unknown pathway the brain uses to fine-tune neural signaling—and that may play a role in Alzheimer’s and other diseases. Their findings appear online this week in the Proceedings of the National Academy of Sciences.Zinc signals in the brain

Scientists have long observed the presence of bubble-like vesicles that contain the neurotransmitter glutamate and zinc at the synapses, specialized contacts among neurons where neurotransmitters are released to propagate electrical signals through the brain. Glutamate is the major excitatory neurotransmitter in the brain, but the need for synaptic zinc, an essential element that acts as a co-factor for many enzyme and regulatory proteins, has not been understood, said Thanos Tzounopoulos, Ph.D., associate professor in the Auditory Research Group, Department of Otolaryngology, Pitt School of Medicine.

“Until now, we haven’t had the ability to quantify or follow zinc when it is released into the synaptic cleft,” he said. “In this study, we employed new tools to do that and found a pathway that could be important for conditions such as Huntington’s disease and Alzheimer’s.”

Co-investigator Stephen Lippard, Ph.D., and his team at the Massachusetts Institute of Technology (MIT) developed an agent that fluoresces when it binds zinc, making it possible for the first time to measure zinc levels accurately and track the element’s movements. They also created an agent that blocks zinc activity, thus allowing them to disrupt the metal’s actions to determine its function.

The researchers learned that, indeed, zinc was released from vesicles and diffused from the release site. Surprisingly, it could bind to so-called extrasynaptic glutamate NMDA-type receptors, just like the neurotransmitter glutamate. Whereas glutamate activates these receptors, zinc inhibits them.

“Glutamate acts like an accelerator of neuronal activity, while zinc behaves like a brake that fine tunes that signal,” Dr. Tzounopoulos said. “The receptors that zinc influences are thought to play a role in neurodegenerative diseases, so these findings could open new research avenues in the field.”

The team included Charles T. Anderson, Ph.D., of the University of Pittsburgh; as well as Robert J. Radford, Ph.D., Melissa L. Zastrow, Ph.D., Daniel Y. Zhang and Ulf-Peter Apfel, Ph.D., of MIT. The project was funded by National Institutes of Health grants DC011499, DC013734-01A, GM065519 and DC007905.

National Thyroid Cancer Experts Meet at UPMC to Advance Patient Care

PITTSBURGH, April 30, 2015 – Nearly 200 physicians and researchers from across the country will gather in the Herberman Conference Center at UPMC Shadyside Saturday to discuss adapting the new American Thyroid Association (ATA) guidelines into clinical practice and to find new ways of working together to improve patient care.

The Seventh Annual Multidisciplinary Thyroid Cancer Symposium, which is sponsored by UPMC, the University of Pittsburgh Cancer Institute (UPCI), partner with UPMC CancerCenter and the University of Pittsburgh School of Medicine, will bring together leading experts in the field to cover a wide variety of topics, including best practices in managing patients with advanced thyroid cancer, the value in predictive molecular testing,  and the latest surgical approaches in the field.

“Our understanding of thyroid cancer has advanced significantly in recent years, and new treatment guidelines were necessary to incorporate the latest research,” said Robert Ferris, M.D., Ph.D., chief of the Division of Head and Neck Surgery at Pitt and one of the conferences co-chairs. “The predictive molecular testing, which was researched and developed at UPMC, will be part of the recommendations for evaluation of a thyroid nodule and will arise in a new consensus statement recently developed by the ATA.  We are looking forward to the discussion this meeting will generate.”

Approximately 63,000 cases of thyroid cancer will be diagnosed in 2015. Thyroid cancer commonly is diagnosed at a younger age than most other adult cancers, and the chance of being diagnosed has risen in recent years as a result of the increased use of thyroid ultrasound.

The event includes a continuing medical education credit component for physicians.

Broccoli Sprout Extract Promising for Head and Neck Cancer Prevention

PHILADELPHIA, April 19, 2015 – Broccoli sprout extract protects against oral cancer in mice and proved tolerable in a small group of healthy human volunteers, the University of Pittsburgh Cancer Institute (UPCI), partner with UPMC CancerCenter, announced today at the American Association for Cancer Research (AACR) Annual Meeting in Philadelphia.

The promising results will be further explored in a human clinical trial, which will recruit participants at high risk for head and neck cancer recurrence later this year. This research is funded through Pitt’s Specialized Program of Research Excellence grant in head and neck cancer from the National Cancer Institute.

“People who are cured of head and neck cancer are still at very high risk for a second cancer in their mouth or throat, and, unfortunately, these second cancers are commonly fatal,” said lead author Julie Bauman, M.D., M.P.H., co-director of the UPMC Head and Neck Cancer Center of Excellence. “So we’re developing a safe, natural molecule found in cruciferous vegetables to protect the oral lining where these cancers form.”

Previous studies, including large-scale trials in China, have shown that cruciferous vegetables that have a high concentration of sulforaphane – such as broccoli, cabbage and garden cress – help mitigate the effects of environmental carcinogens.

Dr. Bauman collaborated with Daniel E. Johnson, Ph.D., professor of medicine at Pitt and a senior scientist in the UPCI Head and Neck Cancer Program, to test sulforaphane in the laboratory. For several months, Dr. Johnson and his team gave sulforaphane to mice predisposed to oral cancer and found that it significantly reduced the incidence and number of tumors.

“The clear benefit of sulforaphane in preventing oral cancer in mice raises hope that this well-tolerated compound also may act to prevent oral cancer in humans who face chronic exposure to environmental pollutants and carcinogens,” said Dr. Johnson.

Dr. Bauman treated 10 healthy volunteers with fruit juice mixed with sulforaphane-rich broccoli sprout extract. The volunteers had no ill-effects from the extract and protective changes were detectable in the lining of their mouths, meaning it was absorbed and directed to at-risk tissue.

These findings were enough to prompt a clinical trial that will recruit 40 volunteers who have been curatively treated for head and neck cancer. The participants will regularly take capsules containing broccoli seed powder to determine if they can tolerate the regimen and whether it has enough of an impact on their oral lining to prevent cancer. From there, larger clinical trials could be warranted.

“We call this ‘green chemoprevention,’ where simple seed preparations or plant extracts are used to prevent disease,” said Dr. Bauman, also an associate professor in Pitt’s School of Medicine. “Green chemoprevention requires less money and fewer resources than a traditional pharmaceutical study, and could be more easily disseminated in developing countries where head and neck cancer is a significant problem.”

Additional authors on this research are Yan Zhang, Ph.D., Malabika Sen, Ph.D., Daniel P. Normolle, Ph.D., Thomas W. Kensler, Ph.D., Sumita Trivedi, M.B.B.S., and Siddharth H. Sheth, D.O., M.P.H., all of Pitt; Jennifer R. Grandis, M.D., F.A.C.S., of Pitt at the time the research was conducted; and Patricia A. Egner, M.S., of Johns Hopkins University.

Coupling Head and Neck Cancer Screening and Lung Cancer Scans Could Improve Early Detection, Survival

PITTSBURGH, January 5, 2015 – Adding head and neck cancer screenings to recommended lung cancer screenings would likely improve early detection and survival, according to a multidisciplinary team led by scientists affiliated with the University of Pittsburgh Cancer Institute (UPCI), a partner with UPMC CancerCenter.

In an analysis published in the journal Cancer and funded by the National Institutes of Health (NIH), the team provides a rationale for a national clinical trial to assess the effectiveness of adding examination of the head and neck to lung cancer screening programs. People most at risk for lung cancer are also those most at risk for head and neck cancer.

“When caught early, the five-year survival rate for head and neck cancer is over 83 percent,” said senior author Brenda Diergaarde, Ph.D., assistant professor of epidemiology at Pitt’s Graduate School of Public Health and member of the UPCI. “However, the majority of cases are diagnosed later when survival rates generally shrink below 50 percent. There is a strong need to develop strategies that will result in identification of the cancer when it can still be successfully treated.”

Head and neck cancer is the world’s sixth-most common type of cancer. Worldwide every year, 600,000 people are diagnosed with it and about 350,000 die. Tobacco use and alcohol consumption are the major risk factors for developing the cancer.

The early symptoms are typically a lump or sore in the mouth or throat, trouble swallowing or a voice change, which are often brushed off as a cold or something that will heal. Treatment, particularly in later stages, can be disfiguring and can change the way a person talks or eats.

Dr. Diergaarde and her team analyzed the records of 3,587 people enrolled in the Pittsburgh Lung Screening Study (PLuSS), which consists of current and ex-smokers aged 50 and older, to see if they had a higher chance of developing head and neck cancer.

In the general U.S. population, fewer than 43 per 100,000 people would be expected to develop head and neck cancer annually among those 50 and older. Among the PLuSS participants, the rate was 71.4 cases annually per 100,000 people.

Recently, the U.S. Preventive Services Task Force, as well as the American Cancer Society and several other organizations, recommended annual screening for lung cancer with low-dose computed tomography in people 55 to 74 years old with a smoking history averaging at least a pack a day for a total of 30 years. The recommendation came after a national clinical trial showed that such screening reduces lung cancer mortality.

“Head and neck cancer is relatively rare, and screening the general population would be impractical,” said co-author David O. Wilson, M.D., M.P.H., associate director of UPMC’s Lung Cancer Center. “However, the patients at risk for lung cancer whom we would refer for the newly recommended annual screening are the same patients that our study shows also likely would benefit from regular head and neck cancer screenings. If such screening reduces mortality in these at-risk patients, that would be a convenient way to increase early detection and save lives.”

Dr. Diergaarde’s team is collaborating with otolaryngologists to design a national trial that would determine if regular head and neck cancer screenings for people referred for lung cancer screenings would indeed reduce mortality.

Additional researchers on this study are Ronak Dixit, Joel L. Weissfeld, M.D., M.P.H., Paula Balogh, D.N.P., F.N.P., Pamela Sufka and Jennifer R. Grandis, M.D., F.A.C.S., all of Pitt; and Jill M. Siegfried, Ph.D., of the University of Minnesota.

This research was funded by NIH grants P50 CA097190, P50 CA090440 and P30 CA047904.

University of Pittsburgh Medical Center Launches Initiative to Emphasize Concussions Are Treatable

PITTSBURGH, Oct. 22, 2014 – At a time when the national concussion conversation instills fear and uncertainty among parents and athletes at all levels, the UPMC Sports Medicine Concussion Program is working to change the current discussion where two powerful messages are lost: Concussions can be treated, and there are evidence-based therapies that result in full recoveries every day.

In striving to shift the national discussion to one based in fact and research, UPMC and the Concussion Program are unveiling the online destination ReThinkConcussions.com as part of an initiative to raise awareness about scientifically proven treatments currently available. The Concussion Program, the first in the world when it opened its doors in 2000, treats more sports-related concussions than any other program nationally with 17,000 patient visits per year. UPMC’s program consistently contributes to innovations in the field with nearly 20 published, peer-reviewed research studies annually.

“An important reality is this: Concussion is treatable if managed properly,” said Michael “Micky” Collins, Ph.D., clinical and executive director of the UPMC Sports Medicine Concussion Program. “With all the new research we’ve done and the nearly 200 papers we’ve helped to publish in the past decade or so, we now are able to provide proven treatments and evidence-based rehabilitation therapies. That should be the conversation now instead of the near-hysteria.”

“People should think of concussions as a treatable injury in the right hands, not some untreatable condition that causes you to retreat to a dark room. The individualized approach to this injury, the ability to use a multidisciplinary team to return patients to normal lives, has changed the course of the injury here – and our successes could be repeated across the world, too,” added Dr. Collins.

RethinkConcussions.com offers an interactive guide to understanding concussions and how UPMC approaches this complex but unseen injury. The website features information on concussion therapies and prevalent myths. It explains UPMC’s multidisciplinary approach to treating six different types of concussions – each carrying its own symptoms and outcomes. Additionally, the site provides insight into patients’ treatment experiences and emotional journeys through some of their stories.

As part of this important initiative, professional athletes and former UPMC patients such as NASCAR great Dale Earnhardt Jr. and Major League catcher David Ross tell their powerful tales in separate videos that will air on television regionally (Ross) and nationally (Earnhardt Jr.), in addition to being found at the new website. Each participated in the spots without compensation, wanting to help spread awareness and education about concussions and their successful rehabilitations.

“We went through activities with results that made sense,” Earnhardt says in his video. He visited the clinic and consulted with Dr. Collins regularly following multiple crashes in fall 2012, keeping him out of consecutive races for the first time in his career. “The best decision I made was to go to UPMC.”

Ross similarly turned to Dr. Collins following two injuries that removed him from behind the plate in 2013. He credits UPMC and its experts with developing an individualized program that allowed him to return to starting at catcher in time for a dramatic post-season run to a championship. As Ross says, “Without UPMC, I would not be a baseball player anymore. They saved my career.”

Other pro athletes who are or will be featured in the ReThinkConcussions.com initiative include former NFL quarterback Brady Quinn, Major League second baseman Brian Roberts and Tyler Hansbrough of the NBA, among others. Athletes of all ages and levels of play – from recreational to amateur to high school and beyond – also will participate in the effort, demonstrating how concussions strike every sport and walk of life.

Dr. Collins and the UPMC Concussion Program have been at the forefront of the national concussion community for years. He is a co-developer of the ImPACT neurocognitive test, a co-author of the Centers for Disease Control’s “Concussion Tool Kit for Physicians,” a consultant to a variety of professional and collegiate leagues, and a frequent presenter nationally and internationally helping to train thousands of health care professionals in concussion management and evaluation.

Dr. Collins leads a team of more than 30 clinicians and researchers, comprised of neuropsychologists, primary care sports medicine physicians, physiatrists, otoneurologists, physical therapists, neurosurgeons, neuroradiologists and orthopaedic surgeons, all devoted to concussion evaluation, treatment and rehabilitation.

“Concussion isn’t something you can detect on a CT scan or an MRI, or with a standard neurologic examination. To ‘see’ this injury you have to know what questions to ask, and our research has shown us this,” Dr. Collins said. “By asking the right questions and looking at the right systems in the right way with the right tools, we can put together a very coherent approach to understanding the injury and determining active treatment strategies. That’s the important message for people to know now.”

UPMC Residency Programs Rank Nationally

Physician network Doximity, along with U.S. News & World Report, announced the first comprehensive national evaluation of residency programs. In these results, 11 UPMC programs ranked in the top 10.

To determine the rankings, 3,691 residency training programs were evaluated by combining over 50,000 peer nominations from board-certified US physicians. U.S. News & World Report, nationally known for their education and health care rankings, consulted on the methodology.

Here is a listing of UPMC programs in the top 10:

  • Anesthesiology: No. 10
  • Obstetrics and gynecology: No. 3
  • Plastic surgery (integrated): No. 3
  • Otolaryngology: No. 4
  • Emergency medicine: No. 7
  • Physical medicine and rehabilitation: No. 7
  • Psychiatry: No. 7
  • Orthopaedic surgery: No. 8
  • Pediatrics: No. 8
  • Neurological surgery: No. 9
  • Surgery: No. 10

The results are used in a free tool from Doximity called Residency Navigator. The tool is designed for third- and fourth-year medical students.

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