It’s an important question. “What if we had 100% of residents going into fellowship programs?” asked Dr. Tompkins. “That could lead to a mismatch between the training of a physician and the number of cases needed to maintain those skills. Both the patient and the doctor could suffer.”
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June 2023Cristina Cabrera-Muffly, MD, the otolaryngology–head and neck surgery residency program director at the University of Colorado in Boulder, said that she hasn’t seen a trend of residents pursuing fellowships more often over the past 10 to 15 years. “It’s been an even mix,” she said.
“I think certain procedures such as pediatric airway surgeries, free flaps, and skull base procedures require the additional training and surgical volume associated with being fellowship trained,” said Dr. Cabrera-Muffly. “At the same time, a well-rounded residency education is more than enough to provide excellent care for patients with more common otolaryngology diseases.”
She also said that generalists aren’t destined to become a rarity. “Generalists are especially needed for geographic areas with smaller populations that would not keep a fellowship-trained subspecialist busy enough, as well as to fill in practice gaps in group practices that may have a few but not all subspecialties represented,” said Dr. Cabrera-Muffly, who herself is a generalist.
Stories from the Field
Christian Francom, MD, who completed a pediatric otolaryngology fellowship at the University of Colorado, said he pursued a fellowship because he enjoyed the complexity. Part of the decision was “wanting to be the final person to go to for some of these complicated issues.” He also thought it would help his ability to pursue academic medicine, which he did—he’s currently an assistant professor of otolaryngology–head and neck surgery at the University of Colorado, where he focuses on cleft lip and palate care.
The first person who came to Dr. Fancom’s mind as an influence during his education was Stephen Park, MD, director of facial plastic and reconstructive surgery at the University of Virginia in Charlottesville, where Dr. Francom attended medical school. “He was like a superhero to the medical students,” said Dr. Francom. “He would come in and have these fantastic surgeries and outcomes. There wasn’t a thing that he couldn’t do.”
At Ohio State where he did his residency, Dr. Francom did work with generalists, but he also worked with many fellowship-trained physicians. He never felt pressured to pursue a fellowship, however; instead, it was a decision based on his interests and discussions with his wife. “When I see a resident come through, I just want them to be the best that they can be,” said Dr. Francom. “And if that’s in a general practice, then great.”
Brian Cervenka, MD, who studied head and neck oncologic surgery and microvascular reconstruction in fellowship at Vanderbilt University in Nashville and is now on the faculty at the University of Colorado, said he knew early on that he would pursue a fellowship—it was just a question of whether it would be in head and neck oncology or neuro-otology and lateral skull base surgery. During his residency at the University of California, Davis, most of his exposure was to fellowship-trained faculty, who outnumbered general otolaryngology faculty by about 90 to 10, he said.
“I was very much influenced by the academic fellowship-trained head and neck microvascular surgeons that I worked with in residency,” said Dr. Cervenka. “And seeing their skill set and what they were able to offer patients was something I really wanted to replicate.”
In the otolaryngology–head and neck surgery program at the University of Colorado, there are 34 faculty, of whom 29—or 85%—are fellowship trained. Dr. Cervenka said it isn’t surprising that academic medical centers produce many fellowship-trained physicians, as it’s the role models with whom you interact every day who shape the type of practice you want to develop. “If there’s a need to produce more general otolaryngologists, one consideration is increasing the exposure in residency to those types of practices, as there are many great residents who would likely pursue this path if they were exposed to great role models in training,” he said.
Both he and Dr. Francom described high satisfaction with their work, saying that even within their subspecialties, there’s a wide variety in the types of cases they see. Dr. Francom believes this holds true for other fellowship-trained physicians who have gone into generalist practice. In his conversations with them, they say they’re happier in their jobs as well.
William Blythe, MD, a general otolaryngologist at East Alabama Ear, Nose & Throat in Opelika, believes the otolaryngology field doesn’t need as much subspecialty as it’s currently producing. “I think we have way too many subspecialists,” he said, adding that there isn’t enough subspecialty pathology and surgery to support it. “I think what you’re seeing quite commonly is physicians with subspecialty training who are primarily doing general otolaryngology and then sprinkling in or enhancing their practice with their subspeciality area.”
Dr. Blythe said that a physician who is fellowship trained and who subspecializes could lose the skill set they developed while in residency or could lose their fellowship-acquired skills if they do mostly general otolaryngology. He also noted that otolaryngology is already “a very small surgical subspecialty” that recruits the “absolute best” people out of medical school. He acknowledged that fellowships are needed to learn how to handle less-common, highly complex cases. But fellowships aren’t needed for standard cases, and Dr. Blythe cautioned that he doesn’t believe a fellowship should be used as a marketing strategy, for instance, to suggest that a fellowship-trained otolaryngologist “can take out tonsils better than I can. They can certainly do advanced pediatric stuff—laryngotracheal reconstructions and taking care of neonates with airway obstruction—better than I can,” he said.
What the field needs, said Dr. Blythe, are more otolaryngologists who are very good at about 90% of the procedures that come through the door. “You really need very smart, good doctors at the open end of the funnel,” he said. “All of medicine would be better if we did that, if we had the smartest, brightest, most energetic doctors at the open end of the funnel.”
Dr. Tompkins said that residents should get a well-rounded exposure to otolaryngology, suggesting that exposure to private-practice general otolaryngology in residency may be too limited in many programs. “Whatever residents decide, I think they should do it with full transparency. I don’t think that to this point the decisions that have gone into choosing a fellowship have necessarily been made in the most transparent way possible,” he said.
Transparent numbers on the needs of the otolaryngology field, he hopes, will help residents make fully informed decisions on how to proceed in their careers and enable residency programs to shape the types of work to which their residents are exposed. Such transparent data, he said, is the only way to make changes in the subspecialization trend—if such changes are needed.
Thomas R. Collins is a freelance medical writer based in Florida.