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

Responses from 179 of the 500 general otolaryngologists surveyed, who are all treating adults and children in solo or group private practices in New Jersey and Pennsylvania, revealed that the majority (66%) diagnosed one to five new cases of otosclerosis per year. Of those surgeons, 10% graduated from residencies in the 1970s, 25% graduated in the 1980s, and 50% graduated in the 1990s. Of those who graduated in the 2000s, 90% had never performed stapedectomy as part of their practice. Similarly, a significant number of surgeons who formerly performed stapedectomies no longer do so.

Recent graduates also tended to more often prescribe the use of hearing aids to treat otosclerosis. When surgery was recommended, the surveyed practitioners reported that they referred to otologists and neurotologists.

Although this was just one study, Dr. Ruckenstein emphasized, he believes the findings speak to both specific and general issues.

Specifically, stapedectomy has historically been performed in the realm of general otolaryngologists, and each resident trains in a handful of these cases. Some residents perform a good number of stapedectomies, but that is rare; most residents do not meet this clinical criterion. Despite data showing that most referrals for stapedectomy are being made to neurotologists, there is no requirement specification in neurotology fellowship training for stapedectomy.

These neurotology fellows need to be adequately trained to do stapedectomies, points out Dr. Ruckenstein, who is a board-certified neurotologist. They are the ones de facto who are getting those referrals, he said. Whether that is what we want or not, that is what is happening.

Implications for Medical Education

Over the last five to 10 years, Dr. Pensak, President-Elect of the Triological Society, has noticed a trend in the community: residents who are joining otolaryngology practices and bringing a particular area of interest or expertise-for instance, endoscopic sinus surgery or otology. When they share those interests with a prospective employer during the interview process, they assume that role in the practice when they are hired.

They might do 30 percent or 40 percent general procedures and 50 percent to 60 percent otology, because they become known as the ‘ear guy’ or the ‘sinus person,’ Dr. Pensak said. Thus, focused areas of interest lead to the equivalence of a subspecialization.

As an illustration, over the 25 years that Dr. Pensak has been in Cincinnati, the number of stapedectomies that the residents at his institution are doing has increased every year even though the overall population of otosclerotic patients is decreasing.