Fellowship in Otolaryngology

Early in residency, I viewed fellows as mini-attendings: younger, with vast knowledge but earlier in their careers, and not completely differentiated yet. I still remember all the first cases I did with new fellows, from the unexpected awake tracheostomy to an after-hours mandible fracture repair to an urgent invasive fungal sinusitis biopsy. The fellows were still developing their technical expertise, and as an added bonus, they were extremely approachable teachers. 

Fellows are closer to the learning process than anyone else in the room, close enough to remember what it felt like to struggle through a first neck dissection or a first airway. Seeing not only their surgical excellence but also their thought processes in real time made the learning points even more approachable. As the years in residency progressed, my interactions with fellows became a lens through which I viewed surgical training as a whole and the growing accountability and ownership of becoming a surgeon.

Over the past 20 years, fellowship training in otolaryngology has become increasingly common. In the early 2000s, a minority of graduating residents completed additional subspecialty training, whereas more recent analyses suggest that approximately 60% now pursue fellowship. A multi-institutional analysis of American Board of Otolaryngology case logs by Miller and colleagues demonstrated that fellowship applications increased from 45.6% to 61.5% between 2011 and 2019 (Otolaryngol Head Neck Surg. doi:10.1177/0194599821994477). These trends parallel expansion in fellowship infrastructure itself. American Head and Neck Society-accredited fellowship programs have increased from just a handful of programs in the 1970s to more than 30 nationally, reflecting both rising demand and increasing subspecialization within the field (JAMA Otolaryngol Head Neck Surg. doi:10.1001/jamaoto.2023.2021). Advances in microvascular reconstruction, skull base surgery, airway innovation, endoscopic technology, and aesthetic techniques have expanded what is possible, while increasing the training required to perform the most complex aspects of otolaryngology.

As fellowship has become more common, its presence is increasingly felt in day-to-day residency training. At my residency program, we have fellows in abundance, with every subspecialty represented. Not every program integrates fellows the same way, and concerns about operative autonomy are valid.

Stephen Park, MD, otolaryngology department chair at the University of Virginia in Charlottesville, said it well: “Often residents have little concern that a fellow will detract from their educational experience. Having had fellows in our program for a number of years, I can say with confidence that the fellows uniformly enhance the education of residents.”

Jenny Chen, MD, EdM, neurotology faculty member at Johns Hopkins in Baltimore, said that fellows are often better positioned to teach, as senior surgeons can develop an “expert blind spot,” as it can become easy to forget what it is like to be a novice, making it harder to break down complex processes into clear, teachable steps. Day to day, this dynamic is reflected in how fellows approach patient care in the hospital: the laryngology fellow knows every patient with dysphonia, the rhinology fellow tracks the invasive fungal rule-out scopes vigilantly, and the otology fellow reviews each temporal bone fracture. As Travis Tollefson, MD, MPH, professor and director of facial plastic and reconstructive surgery at UC Davis in Sacramento, Calif., said, fellows learn to “simplify, package, and deliver complex surgical decision making into small morsels of wisdom,” reinforcing the idea that surgical education is a continuum across all levels of training.

Being around fellows made the idea of fellowship itself more tangible for me, not as an abstract next step, but as an exciting and natural path forward in my own career. In the marathon of surgical training, we look to the next step ahead to find role models, but also to envision how we would approach that next frontier in training. That next frontier for many otolaryngology residents is fellowship. The interview process for me has reflected this shift: not just evaluating programs, but finding the people you will train alongside, mentors who will shape your thinking, and a community you will rely on during some of the most formative years of your career.

As Amber Luong, MD, PhD, professor and vice chair for academic affairs at McGovern Medical School in Houston, Texas, said, a fellowship provides an opportunity to “identify mentors and obtain additional training” while beginning to define one’s role as a surgeon. To me, it also signals an entry into the field at a deeper level, as a commitment not just to practice, but to contribute to and advance the specialty.

The term “fellow” is admittedly a bit unusual, rooted as much in the idea of a colleague or partner as in that of advanced training and shared purpose, reflecting a group aligned toward a common goal. In medicine, a fellow is a physician who has completed residency and pursues additional subspecialty training, an apprenticeship that bridges the transition from resident to independent surgeon. Dr. Chen said, “For many residents, applying to a fellowship is an important part of their professional identity formation. Choosing a subspecialty and ranking fellowship programs pushes them to name their values and future career goals.” Dr. Tollefson likens fellows to high-performing athletes or musicians who “build strengths and talent, structuring their lives around discipline and lifelong commitment to learn and grow.” He advises fellowship applicants to “find a program that matches this commitment.”

When I am a fellow, I hope to embody the best of those who have come before me. They are leaders yet remain close enough to their training to remember what it feels like to need guidance. They are often the first to translate attending-level expectations into something actionable. They are the ones who say, “Here’s how I think about this,” instead of, “Do it this way.” They are not yet finished products but are on their path to becoming and inspiring the next generation of otolaryngologists.    

Dr. Berges is a PGY-4 resident in the department of otolaryngology–head and neck surgery at Johns Hopkins University in Baltimore and a resident member of the ENTtoday editorial board.