Competitiveness of Oto fellowships

[DoctwoB]

Hello. I'm a medstudent trying to decide between Neurosurgery and ENT. I was wondering how competitive the various Otolaryngology fellowships were, Neurotology and head and neck in particular, and what the job prospects were like for the different fellowships. Any information would be greatly appreciated.

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[ZagDoc]

My general impression is that all are decently competitive but the order goes somewhat like FPRS > Neurotology ≈ Laryngology ≈ Peds > Sinus/Skullbase > H&N.

Of course there are specific highly competitive fellowships in each of the subspecialties, and you shouldn't construe that you can just waltz into a H&N fellowship. That being said, people tend to self select into these sort of things.

Some fellowships translate better into private practice more than others. Plastics, neurotology (typ in group practice), and laryngology (esp voice) can be particularly lucrative in PP in the right market. Peds you largely have to be in an academic or larger group practice (like Kaiser) setting, mainly if you're doing airway stuff for the NICU/PICU. It's difficult to survive as a PP H&N surgeon for financial reasons, so most tend to aggregate in academic centers where their salary can be subsidized by the more lucrative subspecialties. You can use any of the fellowships to augment your own generalist practice, but you wouldn't want to refuse too many of the general ENT referrals (esp early in your practice) if you want to keep a healthy referral base. Of course, a lot of these are dependent on where you want to practice. If you're the only ENT in the area who does ears, for example, you've created a nice niche for yourself.

 

[Leforte]

In general, Facial Plastics and Neurotology have more applicants than positions. Between 50-75% of applicants seem to find a position for these fellowships.

Ped's seems to have an equal number.

H&N has more positions than applicants.

Sinus and Laryngology have limited positions (and applicants) and I am not sure what their numbers are, but imagine that with the limited positions, it would be vary between the cycles.

Also, to the other response - I wouldn't say that H&N in an academic setting is subsidized by the other specialties. H&N attendings are often among the highest billers and collectors in many departments. It is just that they often require more resident involvement in the post-operative care, often run multiple rooms, etc. Most of our subspecialties can translate easily into PP or academics. It would be challenging to do free-flaps as a PP H&N surgeon, but can be done.

Once people are deciding on a pathway post-residency - whether that is generalist vs fellowship trained, PP vs academics, etc - I think that financial interests play a much more minor role that you would think as a medical student looking in the field. Most residents choose their final destination based on interests within ENT, desired lifestyle, closeness to family, ability to control your practice/office and a multiple of other reasons with finances being lower on the list.

Then again, maybe I am being idealistic.

 

[ZagDoc]

Also, to the other response - I wouldn't say that H&N in an academic setting is subsidized by the other specialties. H&N attendings are often among the highest billers and collectors in many departments. It is just that they often require more resident involvement in the post-operative care, often run multiple rooms, etc. Most of our subspecialties can translate easily into PP or academics. It would be challenging to do free-flaps as a PP H&N surgeon, but can be done.

Thanks for the clarification. Hadn't heard of PP H&N with my conversations with staff before.

 

[Pir8DeacDoc]

Lefort, you may have an unusually large percentage of insured H&N patients. Our H&N guys bill through the roof, but collect nearly nothing. Even those with insurance can be a loser on just the surgery. Our only "loser" for the division is one of the H&N guys, the sinus guy carries us along with the otologists.

I would find it hard to imagine someone doing big time head and neck surgery in private practice (i.e. doing a T1 tongue and a neck doesn't count). The global periods combined with the inevitable complications and time sink of rounding make it very time/labor intensive, and thus a money loser from purely a surgery standpoint (the ancillary services can make this up, but you don't see that if you aren't employed by the hospital). There are some private groups that do H&N but I imagine them few and far between. Plus, a cancer surgeon should have the support of a strong tumor board to provide the best care for these patients.

 

[Fah-Q]

Lefort, you may have an unusually large percentage of insured H&N patients. Our H&N guys bill through the roof, but collect nearly nothing.

That's because uninsured head and neck cancer patients are sent to academic centers. Insured head and neck cancer patients are treated in the community. Head and neck cancer surgery can be done in private practice. If your schedule is full you will make plenty of money.

 

[Leforte]

Our uninsured population is probably smaller than most academic centers, which is probably why our H&N surgeons collection rate is ~28%. The hospital is not a state or county owned facility and it takes an act of a higher power to get a case on for a patient without a payer source. Our H&N surgeons do well because they are always running two (and occasionally three) rooms. Big cases are 2 surgeons (resection and reconstruction), coding is thorough, rounding is sporadic and between cases, etc. I agree that a tumor board is standard of care and a T1 is H&N Light.

The few (n=2) H&N surgeons in PP that I know started in academics, developed into outstanding surgeons, decided that they had enough of the long nights of free flaps, bureaucracy of academics and went into PP, but still do big whacks (with plastics), carotid body tumors, skull base combos with neurosurgery (who then take care of the pt), etc. One has an "employed" relationship with the hospital and is reimbursed per RVU, the other in an ENT group. For some reason, however, the laryngeal SCCa post-radiation failures (and subsequent postoperative fistulas) do all seem to show up at the University, though

I do agree that sinus and otology is where the reimbursement is at. The cases are much faster, reimburse well, often go home, and have great outcomes. While I enjoy facial plastics, it is just not my thing and can take a long time to get a good referral base. If FP is what someone only wants to do, they should anticipate low reimbursement for a few years.

 

[Leforte]

That's because uninsured head and neck cancer patients are sent to academic centers. Insured head and neck cancer patients are treated in the community. Head and neck cancer surgery can be done in private practice. If your schedule is full you will make plenty of money.

Exactly.

 

[bobby6]

To answer the competitiveness question, I think the general rule is that if you want a fellowship, you will get one in whatever subspecialty you want. While it maybe hard to get a Toriumi Facial Plastics fellowship or a Neurotology fellowship at House Ear Institute, you should be able to get one somewhere.

I don't think ENT fellowships are anywhere near the competitiveness of general surgery fellowships like pediatric surgery. It appears for ENT, the competitive weeding out happens with residency selection. Keep in mind that you can technically still practice all parts of ENT and get privileges at hospitals without fellowship training. For example, doing a facial plastics fellowship does not give you any extra surgical privileges over a general ENT at a hospital unless you were doing free flaps in your fellowship.

 

[Pir8DeacDoc]

Just as means of an interesting follow up. I am doing research on a national level about rates of head and neck cancer surgery. For total laryngectomy in 2008 83% of them were done at teaching hospitals. Interestingly, the non-teaching hospitals had a significantly reduced length of stay and hospital charges compared to teaching hospitals. Haven't quite plugged in if they are more likely to have insurance if done at non-teaching hospital. Anyway reaffirms what you guys noted observationally.

 

[DoctwoB]

Just as means of an interesting follow up. I am doing research on a national level about rates of head and neck cancer surgery. For total laryngectomy in 2008 83% of them were done at teaching hospitals. Interestingly, the non-teaching hospitals had a significantly reduced length of stay and hospital charges compared to teaching hospitals. Haven't quite plugged in if they are more likely to have insurance if done at non-teaching hospital. Anyway reaffirms what you guys noted observationally.

Possibly b/c the community docs took the easy cases and sent the tough ones to academic mecca?

 

[Pir8DeacDoc]

absolutely, I can assure you there aren't any guys in private practice lined up to do a salvage laryngectomy. My guess is the insurance status is different based on whether private practice does the case or not too. Interesting trends, which is partly the focus of my project