Residency versus Fellowship in Otolaryngology: What is Practiced and Referred after Graduation?

When I arrived here, we had 20 or 25 otolaryngologists in the community who were doing stapedectomy surgery, and probably six or seven of them were doing revision stapedectomy surgery, he said. Now we have four or five otolaryngologists who do stapedectomy surgery and to my knowledge there are really just three of us who do revision stapedectomy surgery.

Marvin P. Fried, MD, Professor and University Chair of the Department of Otorhinolaryngology-Head and Neck Surgery at Montefiore Medical Center at Albert Einstein College of Medicine in New York, agreed that as trainees move on in their otolaryngology careers, those who are in academic or private practice become more differentiated, becoming known as nose specialists or larynx specialists, for instance.

The implications of that kind of future endeavor need to be brought in sooner rather than later, said Dr. Fried. Refine training to ultimate goals. That means that a program director has to be honest after an individual graduates; if a person expressed a particular interest in doing cosmetic surgery and was not trained in extensive otology, after that resident has completed training, the residency director has to sign off that the trainee’s otology training is less than that of others.

Dr. Pensak would like to see otolaryngology begin to scaffold or tier out to create a subspecialization during the residency program.

It has never made sense to me to have a senior or chief resident doing stapedectomies, as an example, spending six to eight months on my service to meet a board requirement and then spending the rest of their career doing facial plastic surgery, he said.

On the other hand, if otolaryngology were to reach a point of becoming a specialty of subspecialists, that would be destructive.

If we are otolaryngologists, we need to be able to perform the breadth and scope of our discipline, with the recognition that if you are not performing a sufficient number [of certain procedures], you have the wisdom to pass on that patient to someone who can best handle their problem, Dr. Pensak said.

The interviewees agreed that reviewing the epidemiology of the diseases along with the current training curriculum and the standards for stapedectomy performance, as an example, will need to be changed. Requiring a full two-year fellowship to perform stapedectomy may not be the appropriate solution, but there will need to be another way to ensure that practitioners have received adequate training.

Possible Solutions

One solution for the specific issue of stapedectomy requirements might be to train a resident particularly interested in that procedure to perform most of the stapedectomies; to be, in effect, the designated stapedectomy trainee. He or she would get the lion’s share of cases, proposed Dr. Ruckenstein.