Why is ENT Training Combined?

[capnamerica]

Quick question for anyone down to answer. I'm just curious as to why ENT specialists are trained specifically in the three anatomical regions of the ear, nose, and throat. Why not have separate specialists and training for each region? I'm just curious as to any history behind why this is the case, and why this model of training still exists. Thanks.

---

Members don't see this ad.

 

[DoctwoB]

Quick question for anyone down to answer. I'm just curious as to why ENT specialists are trained specifically in the three anatomical regions of the ear, nose, and throat. Why not have separate specialists and training for each region? I'm just curious as to any history behind why this is the case, and why this model of training still exists. Thanks.

ENT isn't any more "combined" then other surgical fields, it just happens to have three regions in its name. Urology could easily be KBB (Kidney, bladder, and balls), Ortho could be BTL (bones, tendons, and ligaments), gensurg could be BBA (belly, bowels, and ass), and so on. ENT just happens to be much easier for the general public to say then otolaryngology or otorhinolaryngology.

As for why not have separate residencies, at some point you need to have fields that are broad enough to be able to handle most complaints that walk through the door. If all ENTs only knew 1 subspecialty, then it would be a huge PITA for patients to find said super-sub-specialist, assuming the PCPs even knew who to refer to. The current model, where a pcp refers to the local general ENT, who refers to the major academic center subspecialist for very difficult cases works just fine. One could argue we're already too subspecialized as it is.

 

[OtoHNS]

Actually, we cover everything above the clavicles that isn't brain (neurosurg), spinal cord (ditto), vertebrae (neurosurg or ortho spine), eyeballs (ophtho), teeth (dentist/OMFS), or inside of a blood vessel (vascular surgeon).

 

[Leforte]

Our specialty used to be EENT before we separated into Opthalmology and ENT.

There is even talk of separating out otology (ears) from ENT - I guess we would then just be NT's (as a caveat, this would be far in the future). Indeed - Neurotology now has their own subspecialty boards - and they do require 2 years of fellowship training to be eligible to sit the exam and be certified. It may only be a matter of a decade or two until we diverge again.

 

[OtoHNS]

Our specialty used to be EENT before we separated into Opthalmology and ENT.

There is even talk of separating out otology (ears) from ENT - I guess we would then just be NT's (as a caveat, this would be far in the future). Indeed - Neurotology now has their own subspecialty boards - and they do require 2 years of fellowship training to be eligible to sit the exam and be certified. It may only be a matter of a decade or two until we diverge again.

I vote to break off a new specialty, "vertigepistaxicerumenology" that takes care of all the dizzy patients, nosebleeds, and earwax so that I don't have to anymore.

 

[neutropeniaboy]

I vote to break off a new specialty, "vertigepistaxicerumenology" that takes care of all the dizzy patients, nosebleeds, and earwax so that I don't have to anymore.

+1

Sent via Tapatalk.

 

[DrBodacious]

There is even talk of separating out otology (ears) from ENT - I guess we would then just be NT's (as a caveat, this would be far in the future). Indeed - Neurotology now has their own subspecialty boards - and they do require 2 years of fellowship training to be eligible to sit the exam and be certified. It may only be a matter of a decade or two until we diverge again.

Typical neurootology nonsense. Otology was not difficult for me to learn in my 5 year residency. I guess the only way this would make sense is if we actually go to a shortened residency with more fellowships. This has actually been discussed as a solution to the projected shortage of ENTs in the future, but I don't think there is much support for the idea right now.

In general, I am opposed to forced sub-specialization. For example, I don't even think stapedectomy is very difficult. I have had excellent outcomes in the few I have done in residency, and I can't imagine being better at the procedure after a fellowship. But, it isn't hard to find a neurootologist willing to testify that a fellowhip training is advisable. So, I probably won't be doing them in private practice. I guess it is not a big deal, because they are unlikely to come up to often, which is why it makes it so blatent that the neurootologists are full of bologna - they wouldn't get to do them nearly as often if genral ENTs are doing them. The whole basis of a neurootologist practice is that they get referrals from general ENTs. From my understanding, it can take a while for business to pick up as a new neurootologist starts a practice, becuase they are trying to do only ear cases, to avoid pissing off the general ENTs that refer them cases by doing general cases, also. I mean, I understand their plight, but lets not jump to the conclusion that general ENTs are not capable of doing most neurootology cases. And, I am not saying that every general ENT should feel compelled to do stapedectomy, I just think adding a fellowship may be totally unneccessary.

In regards to the idea of shortened residency to solve ENT shortage problems - I think there is also a potential conflict of interest there. Most of the people involved in ENT politics are fellowship trained. And, if you have a fellowship, it would probably be real nice to have leigons of partially trained ENT doctors coming out of residency each year to feed you cases. I am not saying the conflict of interest is huge here, as I believe most of the people involved in ENT politics are generally good intentioned, but I am not so sure the conflict of interest is well recognized.

 

[neutropeniaboy]

I feel some need to respond to this post, mostly because I think what is said in here is misleading and also not based upon the most sound judgment.

Typical neurootology nonsense. Otology was not difficult for me to learn in my 5 year residency. I guess the only way this would make sense is if we actually go to a shortened residency with more fellowships. This has actually been discussed as a solution to the projected shortage of ENTs in the future, but I don't think there is much support for the idea right now.

Shortening residency programs has been one proposal for dealing with a work place shortage that is likely (nay, is) to come. GME funding is not going to increase at any point in the near future, and with the passage for the ACA, very soon there will be many more people who will seek specialty (i.e., ENT) care. Simply put, at our present rates, we will have trouble meeting those demands unless something is done.

We have already shortened further intern hours. We have work duty hour restrictions. We are faced with much more administrative work, yet the length of residency is still the same. In fact, for many programs, otolaryngology used to be 6 years, not 5. Fewer hours worked during the same length of time with a compulsion to churn out a higher work force -- well, you do the math on that one.

In general, I am opposed to forced sub-specialization.

Many, such as myself, are opposed to this as well. That's why one of the proposed means for dealing with this issue is having a primary ENT route v. a specialized route. No one would be forced (at least not in concept) into one route or the other.

For example, I don't even think stapedectomy is very difficult. I have had excellent outcomes in the few I have done in residency, and I can't imagine being better at the procedure after a fellowship. But, it isn't hard to find a neurootologist willing to testify that a fellowhip training is advisable. So, I probably won't be doing them in private practice. I guess it is not a big deal, because they are unlikely to come up to often, which is why it makes it so blatent that the neurootologists are full of bologna - they wouldn't get to do them nearly as often if genral ENTs are doing them. The whole basis of a neurootologist practice is that they get referrals from general ENTs. From my understanding, it can take a while for business to pick up as a new neurootologist starts a practice, becuase they are trying to do only ear cases, to avoid pissing off the general ENTs that refer them cases by doing general cases, also. I mean, I understand their plight, but lets not jump to the conclusion that general ENTs are not capable of doing most neurootology cases. And, I am not saying that every general ENT should feel compelled to do stapedectomy, I just think adding a fellowship may be totally unneccessary.

Spoken like a true resident.

Any way, I felt the same way as you. I didn't feel I could do a stapdectomy any better compared to when I finished residency (that's a claim I hear of many chief residents). In reality, I did learn other techniques -- and some of them better. Suffice it to say, I am way better doing stapedectomies than I was when I finished residency.

But, that's not my point. Your claim that there are a bunch of neurotologists salivating to testify against your stapedectomy misadventure is just nonsense. I see no reason why you shouldn't do stapedectomies. I don't think you should do them if you don't do them often, however. I would say that of any general otolaryngologist for any type of procedure that can result in significant adverse outcomes. If you don't do them often or if you can't fix a problem you created, don't do the case.

For me, I went into neurotology for the tumors. I like tumors. I do chronic ears, stapes, bahas, etc. because I can and because I'm good when it comes to doing them. I don't "steal" cases from general otos. People do not come looking specifically for me. They come to the university and end up in my clinic. I do have community docs that send cases to me -- some of them very bland -- and I gladly accept them. It's my job, and I like doing them. I have never spoken negatively about a community oto who has really screwed things up. That's unnecessary, and it only fuels patients' anger more. I do my best to put out the flames and fix the problem.

So, if you want to do stapedecomies, go do them. Good for you. But if you're doing 1-2/y, you may want to rethink it, because then you will run into problems.

It still amazes me that even after 5 years of being out how much other stuff I have "forgotten" how to do -- or at least my hands don't do what my brain thinks they should be doing. Haven't done a laryngectomy in 5 years. Could I? I think. Should I? Probably not. There are better people out there to do them.

In regards to the idea of shortened residency to solve ENT shortage problems - I think there is also a potential conflict of interest there. Most of the people involved in ENT politics are fellowship trained. And, if you have a fellowship, it would probably be real nice to have leigons of partially trained ENT doctors coming out of residency each year to feed you cases. I am not saying the conflict of interest is huge here, as I believe most of the people involved in ENT politics are generally good intentioned, but I am not so sure the conflict of interest is well recognized.

Again, spoken from a position of misinformation.

I am not politically active. I sat for the boards. I am board certified. That's what I was required to do. David Kennedy seems to be spearheading this movement. He's actually an otologist who became a rhinologist. He isn't "fellowship trained." Pillsbury is "fellowship trained" in Europe (I think), but he has different opinions on residency training.

Surveys show that about 70% of residents show interest in otolaryngology fellowships. If that's the case (and about 50-75% of our residents do fellowship), then why not specialize sooner? General surgery and plastics do this sort of thing (or at least they did when I was in training).

I understand you're hot to trot as a new grad, but get a grip on things first. The specialist community isn't out to get you. I'm no more out to get your chronic ear than LeFort is out to get your submax excision. If you want to send it my way, thank you. If you don't, fine.

 

[DrBodacious]

I feel some need to respond to this post, mostly because I think what is said in here is misleading and also not based upon the most sound judgment.

Well, I wasn't sure which one of you was a neurotologist, but I guess I should have expected I would offend someone. I appreaciate your reply though, NPB, and I think your perspective is valid, and more seasoned than mine.

The gist of my response was that I am opposed to taking otology out of ENT residency, and I think I have sound experience and judgement to the effect of backing up that argument. Obviously, I am coming from a chief resident perspective, and I am not shy to say I want the opportunity to do everything I have been trained to do and feel comfortable doing once I get out in practice, and I think you get that. Again, my point is that assuming we have a 5 year ENT residency, it seems ridiculous for otology to be seperated out.

That being said, I think there are a lot of controversial things that IMO are interesting to discuss.

The reason I picked on neurootology is because a) otology was brought up as an example by LeFort, and b) the stapedectomy example is frustrating for me. There are so many articles with titles like "Who should be doing stapedectomy?," and it is carries the highest litigation risk of otologic procedures. It is suprising how willing a few subspecialists are to testify against ENT doctors. There is the whole thyroidectomy EMG controversy, for example. I am not speaking from personal experience, and hope I never will be. In summary, I agree with your arguments about needing some volume to maintain skills, but the procedure is summarized by 1) remove stapes suprastructure, 2) make stapedotomy, 3) place prosthesis in stapedotomy. As I came through training, hearing people talk about it and reading about it, it was made out to be some sort of mystery, and I found out the opposite. It requires a level of microsurgical skill to do the above-said manuevers, and to be able to regognize the uncommon pitfalls of the procedure such as dehiscent facial nerve, stapedial artery, PL gusher, etc. The problem is, that my case that gets hearing loss, even if it would have been the only one in 200 cases, will be construed as a "misadventure," where as if I referred the case to a neurotologist, the hearing loss will be acceptable. I guess we could blow smoke about this forever, in the end I don't disagree with your arguments, but your "misadventure" comment got me, because that is exactly what I am talking about.

Also, I know the current structure of how cases are referred works fine, and I don't neccessarily think fellowship trained people are "out to get me." The way things are structured does make a fellowship more neccessary to perform more specialized procedures if you are in a saturated environement.

As I have posted about in other threads recently, I just went through a job seeking process and what I found was that you have to be content with a lower complexity of cases or subspecializing in a saturated environment. So, I decided to go to a less saturated enviroment to get the scope of practice I want. Am I bitter about that? Slightly. But, I realize that is just part of coming to terms with how things are. I just think most of what you focus on through college -> med school -> residency is totally unrealated to how your scope and setting of your practice will be. I will probably end up wishing I had more fellowship-trained people nearby after I am in practe for 20 years, but hey...

Relating to the article by Kennedy I referrenced, I am not completely sold one way or the other on that, although my gut feeling is that it is pragmatic idea in theory, but bad in practice. I can say I like having the training I have had. If there was a 3 year basic ENT residency, I wouldn't be content with that, and I would not have wanted to go through a seperate match to follow a specific training path. But, it probably does solve some problems with ENT shortages, and who know's if you had an option to finish 3 year and be trained to do ENT clinic evaluations as well as basice ENT procedures, then maybe that would be a popular option? In that case, I believe a short-track ENT would be unqualified to do many of the procedures we get trained to do in a 5 year program. Of course it is up for debate, but I don't think it is too much of a stretch to include FESS, most otology, phononsurgery, head and neck, and plastics, for starters. I can say with certainty it would create an environment where general ENT doctors are doing less, and my stapedectomy concern would extend to many other procedures. It is a matter of opinion, but that seems like a very bland job to me, because even if you don't do those cases very frequently, they can be the most rewarding. I don't think it would be fair to make junior residents make decisions that have a huge impact on what their life will be in the future.

General surgery and plastics do this sort of thing (or at least they did when I was in training).

Obviously, neurootologists like plastic surgeons come from a standpoint of not using 90% of what they learned in ENT residency, but we are talking about a small number of spots a year and having to decide on doing a fellowship very early in residency? I think most fellowship trained people remain active in general ENT practice to a significant extent. Overall, I don' t think it is really that similar to the example of combined plastics programs. So it made me consider if there are conflicts of interest related to this idea. I am not saying the conflicts are from David Kennedy himself, but for this idea to be implemented, the conflicts of interest would be there in the political climate. I acknowledge the underlying drive is to find a solution to benefit the public from the ENT shortage standpoint. But, this specific plan sure doesn't seem to benefit residents in training, or future general ENT doctors. It also would create a maze of referrals for PCPs to navigate as DoctwoB mentioned, above. Furthermore, there would be localized shortages where you would have a town with no otologist, but 5 rhinologists and your general ENT wouldn't be capable of doing mastoids? This plan does seem to have a side effect of helping strengthen a fellowship/subspecialist model, that's all I am saying... which, I think in and of itself is uneccessary... I don't think I am providing any misinformation here...

 

[Leforte]

Look - at the end of the day - here is my humble opinion regarding sub-specialisation in our field.

I acknowledge that the vast majority of residents out of their training are capable of performing a majority of the procedures in our specialty. Most are quite keen - some are inadequately prepared, although this is a minority, but few have the competency to perform all operations. I feel that this is a reflection of our current work hours. In the past - residents who were deficient would stay longer to acquire their skills - we must now allow them to go home for dinner. If they are not allowed time to be at home - despite their deficiencies, then the program is at fault.

So how do we determine who is competent, and who is merely qualified. That is a question that academics are forced to choose when releasing hundreds of ENTs into the communities each year.

There are many trainees who just "get it" - they understand the limits of their operation - are willing to acknowledge their own limitations and are happy to refer. There are others who feel that they can do better than anyone else - and that any problem is not with their own technical ability - but with the patient. Unfortunately, many of the trainees who choose to be aggressive are the ones who we had problems with in training.

So how do we, as academics deal with this?

Do we allow residents to graduate carte blanche with the ability to do all operations within our field?

Do we instead restrict what they can and cannot do - and in doing so, open ourselves up to litigation from residents in "not adequately training" them - as has been litigated in the past...

Or do we simply restrict what all trainees are allowed to do upon graduation to the basics in our field. Any one else must be fellowship trained.

By doing so - we feed advanced cases to fellowship trained surgeons, ensure that marginally trained surgeons are not operating beyond the scope of their practice, etc.

That being said - if I were a well trained community ENT, I would be appalled by these changes - but at the end of the day, a community ENT is not legally responsible nor legally liable for the training of our current cohort of graduates, and their complications. Duty hour restrictions or otherwise.

However -- I am.

What do you all think?