From Part-Time to Full-Time: The Rise of Otolaryngology in 20th-Century American Medicine

I graduated from the University of Virginia with a Bachelor of Arts in history, and my thesis, the title of this article, examined how our specialty overcame challenges during the 20th century to become what it is today, one of the most competitive and fastest-growing specialties in medicine. When ENTtoday’s physician editor, Robin Lindsay, MD, MBA, asked me to start a History of Otolaryngology column for the magazine, I thought to myself, “I finally get to use my history degree!”

This is the first article for this twice-a-year column; subsequent writings will interview people who helped shape the specialty as we know it today. First, though, I will summarize the history of our specialty and discuss why understanding where we came from is such an important step toward continuing to advance our specialty. We are building and adding to the work of our predecessors, not starting from scratch. We must study and understand the past, however, to add to it in a productive manner.

The History of Otolaryngology

The disciplines of otology, rhinology, and laryngology came to the East Coast of the U.S. in the first half of the 19th century. Early in this century, Philadelphia, New York, and Boston became centers of specialization in U.S. medicine and offered ports where American laryngologists, rhinologists, and otologists could travel to Europe, especially Germany and Vienna, to receive specialized training. These major seaports also offered access points for European physicians to come to the U.S. and help develop medical specialties. In 1820, the New York Eye Infirmary was established, and by 1873, the institution included otology and laryngology departments (Neil Weir, Otolaryngology: An Illustrated History).

Otolaryngologist and historian Neil Weir concluded in his landmark publication of our specialty’s history that the “comparative isolation of specialists in America” encouraged them to form specialty societies earlier than their European counterparts. Paul Starr determined that early specialization in U.S. medicine created interdependence among physicians and helped relieve competition among them, thus allowing them to consolidate their authority (Paul Starr, The Social Transformation of American Medicine: The Rise of a Sovereign Profession and the Making of a Vast Industry).

The first journals and societies that included otology in their names began to form in the U.S. during the 1860s. In 1888, the American Medical Association established the Otology, Rhinology, and Laryngology section, and in 1896, specialists formed the American Academy of Ophthalmology and Otolaryngology. In 1924, practitioners established the American Board of Otolaryngology, the second specialty licensing board in the U.S. This licensing board was created in large part to distinguish licensed otolaryngologists from medical practitioners who were ill-trained at performing operations such as tonsillectomies and adenoidectomies (Rosemary A. Stevens, Medical Specialization as American Health Policy: Interweaving Public and Private Roles, History and Health Policy in the United States).

Despite early success, by 1950, “conventional wisdom said that otolaryngology was a dying specialty” (Otolaryngol Clin North Am. doi: 10.1016/j.otc.2007.07.001). In 1951, one in three otolaryngology residency positions remained unfilled (Laryngoscope. doi: 10.1097/00005537- 199610000-00001). Antibiotics could now cure infections such as tonsillitis and sinusitis that previously had been the focus of many otolaryngology departments.

While specialization in U.S. medicine initially created interdependence among physicians, boundaries between the different specialties often included a gray area where patient assignment remained unclear. This gray area ultimately created competition between specialties, including general surgery and otolaryngology, which both wanted inclusion of head and neck cancer in their respective specialties. According to Calhoun, Davis, and Templer, “[In 1950,] head and neck cancer and thyroid surgery were commonly the purview of general surgeons, and cosmetic surgery was generally performed by plastic surgeons.” This control over head and neck cancer became even more important as federal research funding played an increasingly important role in academic medical centers in the post-World War II era. While much otolaryngology funding comes from the National Institute on Deafness and Other Communication Disorders today, this institute was not founded until 1988. The National Cancer Institute, though, was established in 1937 and funded head and neck cancer research from its early years.

Competition between general surgeons and otolaryngologists over the field of head and neck surgery increased during the 1950s. In 1954, the Society of Head and Neck Surgeons (SHNS) was founded and consisted primarily of general surgeons, and several years later, in 1958, a group comprised mostly of otolaryngologists formed a “parallel society,” the American Society for Head and Neck Surgery (ASHNS) (American Head & Neck Society. http://www.ahns.info/history-ahns).

Ultimately, over the next four decades, otolaryngology gained dominance over the head and neck subspecialty, and in 1998, the SHNS and ASHNS merged to form the American Head & Neck Society. Elliot Strong, a renowned head and neck surgeon with general surgery training, later wrote, “When I first started, of course, the controversy between the disciplines of surgery and otolaryngology was on the minds of most people …. As time has gone on, the demands for specialty and sub-specialty surgical training have increased, and I think in all honesty have tended to favor the otolaryngologist and his training as opposed to that of general surgery. The opportunities for a general surgeon in otolaryngology and head and neck surgery have diminished, and probably rightfully so.” (American Head & Neck Society. http://www.headandneckcancer.org/history/strong/).

As the second half of the 20th century progressed, academic medical centers transitioned from research grants to clinical practice income as their primary revenue source. As such, specialties such as otolaryngology, which brought in significant clinical revenue, became increasingly important. Otolaryngology solidified its importance by continuing to expand, ensuring a high clinical and surgical volume. What started as a specialty largely dedicated to tonsillectomy and adenoidectomy procedures today has seven subspecialty areas of practice.

Looking to the Future

Philosopher George Santayana said, “Those who cannot remember the past are condemned to repeat it.” I would take this a step further and argue that we must study the past, not just remember it, to continue to advance our field into the future. In the ever-changing medical landscape, remaining stable equates to falling behind as our specialty has in the mid-20th century. As otolaryngologists, we should embrace change—because change will always happen—and continually evaluate priorities within our discipline, as well as the medical profession, to ensure our decisions and goals are well-aligned. Lastly, continuing to innovate in the care we provide patients and the efficiency with which we provide this care will further solidify our importance within medicine.

Dr. Miller is an associate professor and director of the UNC Facial Nerve Center at the UNC School of Medicine in Chapel Hill, N.C.