Fellowship Training In

Otolaryngol Clin N Am 40 (2007) 1311–1322

Fellowship Training in Otolaryngology–Head and Neck Surgery Matthew W. Ryan, MDa,*, Felicia Johnson, MDb a

Department of Otolaryngology, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-9035, USA b Department of Otolaryngology, The University of Arkansas for Medical Sciences, 4301 W. Markham Street, Slot 543, Little Rock, AR 72205, USA

The purpose of fellowship training after completion of an otolaryngology residency is to provide a focused, intensive, educational experience in a recognized subspecialty area [1]. There are various reasons why a graduating resident may wish to pursue further training. People choose a fellowship to master a content area, usually in a field that interests them and in which they would like to focus their practice. In other instances, fellowship training may facilitate hospital credentialing to perform certain procedures that are considered to be outside of the scope of practice of general otolaryngology, such as cleft lip/palate repair, skull base surgery, or free-tissue transfers. For some, fellowship training functions as a mechanism to achieve a market advantage over colleagues with a general practice. Specialization within a narrow field also may confer a perceived improvement in job security or safety from malpractice litigation [1]. Currently, the American Academy of Otolaryngology–Head and Neck Surgery (AAO-HNS) Web site has links to information for fellowships in facial plastic and reconstructive surgery, head and neck oncologic surgery, laryngology and voice disorders, otology/neurotology/skull base surgery, pediatric otolaryngology, rhinology and sinus surgery, and sleep medicine. Fellowship training is commonplace within otolaryngology, and the purpose of this article is to summarize the current fellowship training opportunities available in otolaryngology and discuss current trends and attitudes toward subspecialization within otolaryngology–head and neck surgery. Fellowship training in otolaryngology–head and neck surgery is a relatively new phenomenon. During the1960s there were fewer than 10 fellowship

* Corresponding author. E-mail address: [email protected] (M.W. Ryan). 0030-6665/07/$ - see front matter Ó 2007 Elsevier Inc. All rights reserved. doi:10.1016/j.otc.2007.07.009

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programs in otolaryngology; however, this number grew to approximately 25 in the 1970s, and by 1991 there were 105 fellowships listed in the American Academy of Otolaryngology fellowship directory. This explosion in fellowships was so dramatic that by 1993 151 fellowships were listed in the same directory [1]. The reasons behind this explosion included deficiencies in the standard otolaryngology residency, expansion of the clinical scope of practice of otolaryngology, and socioeconomic forces that favored fellowship directors and the trained fellow. The dramatic changes taking place within fellowship training were concerning to many who felt that the strength of our specialty depended on maintaining the integrity of the general practice of otolaryngology and the unity of the specialty. In the early 1990s, Dr. Byron Bailey raised the issue of proliferation of fellowships in a series of editorials and papers [1–3]. He recommended that steps be taken to ensure that subspecialization within otolaryngology would be helpful for the specialty. In particular, he recommended that studies be undertaken to determine the number and type of fellowships needed to meet public need. He stressed that manpower studies and workforce optimization (oriented toward the public welfare) should be the guiding factors in determining the number and variety of subspecialty fellowships offered. He also called on the specialty to establish educational standards for fellowship training, take steps to accredit fellowships, and study the effect of fellowships on residency education. Finally, he advised that we develop a method to certify/credential fellows and define the content of general otolaryngology–head and neck surgery [2]. Fellowship training in otolaryngology has gone through many changes over the last 15 years, and to varying degrees these admonitions have been heeded. Who does a fellowship and why? Fellowship training is important in the academic setting. Academic programs at tertiary care institutions are burdened with caring for complex, difficult cases, and a subspecialty-trained faculty is most capable of caring for these patients. Academic departments with residency training programs also are charged with training residents in the depth and breadth of the field of otolaryngology–head and neck surgery. A complement of faculty trained in the various subspecialty areas is crucial to expose otolaryngology residents to the myriad highly specialized diagnostic and treatment strategies within the broader field of otolaryngology. It is no surprise that a survey by Nadol [4] of young academics in 1997 found that 71% had done a clinical fellowship after residency. It should be remembered, however, that many of the prominent fellowship mentors around the country, and those who have pioneered many of the techniques of subspecialty otolaryngology, were not themselves fellowship trained. So fellowship training is not a requirement for an academic career and, in fact, general otolaryngologists within academic faculty can serve as effective role models for most residents who eventually enter careers in general otolaryngology.

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The motivations for pursuing fellowship training are many and various. In a 1994 survey study of fellowship-trained otolaryngologists, various motivations were uncovered [5]. The primary reason for taking a fellowship was a perceived inadequate operative case load in the subspecialty area during residency. This was followed by a perceived need for an extra year of training to secure an academic position and a need for an extra year of training to enhance private practice. Interestingly, 87% of respondents, all of whom completed fellowships, felt that the number of fellowship slots should not be increased. This study was published in 1994, and 80% of survey respondents finished their fellowship since 1980, demonstrating the relative novelty (at the time) of fellowship training. Miller [6] studied the attitudes of residents about fellowship training. In his 1994 survey study, 32% thought that taking a fellowship would be necessary for success in their careers, whereas 44% thought it unnecessary. He suggested that residents may seek fellowship training because of a perceived inadequacy of their residency. Other reasons included the desire to develop a subspecialty practice, enhance academic progression, avoid malpractice suits, gain more hospital privileges, improve competitiveness for patients, and increase income [6]. Various benefits accrue for otolaryngologists who pursue fellowship training. Spending even a single year concentrating on one aspect of otolaryngology with the exposure to increased numbers of higher complexity surgical cases can be a valuable investment. Surgical expertise comes with the performance of large numbers of specialized procedures; for some procedures this experience is not available in residency. A broad, diverse education in otolaryngology often does not allow a resident to perform the numbers of cases in some subspecialty areas that are required to achieve a high level of expertise. There is also the invaluable experience of learning under the guidance of fellowship mentors. A common reason that most residents decide against fellowship training is their desire to practice general otolaryngology and the fact that they feel adequately trained by their residency program. This reason differs from a prevalent problem in the past, when most residents who went into fellowships did so because of inadequate training and teaching. Undoubtedly, modern residency programs are doing a better job of training residents; consequently, the motivation for additional training has shifted. We agree with Dr. Bailey [1] that ‘‘there is no place in the fellowship world for remedial fellowships’’ and that the purpose of fellowship training always should be to achieve a higher level of mastery in a given subspecialty, for the benefit of patients and the public as a whole. Fellowships should not make up for inadequacies within residency training but should enrich a physician’s career, whether it be in academic or private practice. What fellowships are available? Currently, fellowships are available in the following subspecialties: facial plastics, head and neck oncology, pediatric otolaryngology, otology/neurotology/skull base surgery, rhinology/sinus surgery, and laryngology/voice.

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Otolaryngologists are also eligible to participate in the newly accredited sleep medicine fellowships. The subspecialties of rhinology, facial plastics, neurotology, and pediatric otolaryngology all participate in a formal match through the San Francisco Match (SFMatch) program, whereas the programs in head and neck oncologic surgery participate in a separate match that is sponsored by the American Head and Neck Society (AHNS). Laryngology fellowships and some other nonaccredited fellowships do not participate in a formal match. The following section details the current fellowship training options. Sleep medicine Currently, more than 50 sleep medicine fellowships are available as listed on the American Academy of Sleep Medicine Web site [7]. Of these fellowships, 43 are Accreditation Council for Graduate Medical Education (ACGME) accredited (Box 1). Sleep medicine fellowships prepare otolaryngologists to provide comprehensive medical care to patients who have disordered sleep. Additional education is provided in the basic sciences related to normal sleep and sleep disorders, organ system physiology in sleep, advanced diagnostic and management skills (eg, the interpretation of polysomnography,) pharmacology and medical management, and the whole range of sleep disorders (ie, insomnia, parasomnias, sleep-related movement disorders, and hypersomnia). Most of these fellowships are mentored by non-otolaryngologists and are 1 year in duration. A fellowship in sleep medicine can be a useful training experience for individuals who wish to focus their practice on the medical and surgical management of sleep disorders or plan to operate a sleep laboratory. A sleep medicine certification program was developed recently by the American Board of Otolaryngology (ABOto) in conjunction with the American Board of Internal Medicine, American Board of Pediatrics, and American Board of Psychiatry and Neurology. For ABOto purposes, a sleep medicine specialist is a board-certified otolaryngologist who has been prepared by an ACGME-accredited sleep medicine fellowship or who meets the alternative pathway requirements and has passed the ABOto sleep medicine certification examination. This special certification for sleep medicine first became available in 2007. The alternative pathway is valid through 2011 for people without 12 months of dedicated sleep training and is based on practice experience with sleep medicine and interpretation of polysomnograms or prior certification by the non–American Board of Medical Specialties/American Board of Sleep Medicine. More detailed information can be found at www.aboto.org. Neurotology The neurotology fellowship program is the most developed subspecialty fellowship in otolaryngology. Fellowship training in otology/neurotology

Box 1. ACGME-accredited sleep medicine fellowships University of Florida University of Iowa Rush University Beth Israel (Boston) Hennepin County Medical Center, Minnesota Washington University (St. Louis) Dartmouth-Hitchcock Medical Center Albert Einstein University New York University Ohio State University Temple University Vanderbilt University University of Vermont Medical College of Wisconsin Northwestern University University of North Carolina Duke University University of Louisville Johns Hopkins University Mayo Clinic University of Mississippi Seton Hall University University of Buffalo Case Western Reserve University Drexel University University of Pennsylvania UT Southwestern University University of Washington University of Michigan Long Island Jewish Hospital University of Cincinnati Brigham and Women’s Hospital Wayne State University University of Missouri University of Nebraska University of New Mexico Winthrop University Cleveland Clinic Thomas Jefferson University University of Pittsburgh University of Utah University of Wisconsin Henry Ford Hospital

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spread across the United States as otolaryngologists trained by Howard House started their own fellowships and promulgated the neurotologic techniques they had learned at the House Clinic [8]. By 1990, there were 31 known neurotology programs [8]. Neurotology certainly has been the leader among the otolaryngology subspecialties to demand accreditation through a governing body such as the ACGME. Through a long and difficult process, leaders at the American Otologic Society, American Neurotologic Society, and American Board of Otolaryngology forged a vision for otology/neurotology as a distinct specialty in medicine. Over a period spanning more than a decade, these leaders navigated through uncharted waters to achieve a series of accomplishments. In 1992, otology/neurotology became the first American Board of Medical Specialties–approved subspecialty of otolaryngology. A 2-year fellowship plan with detailed curriculum and requirements was then submitted to the ACGME and finally approved in 1995. The first training program was approved by the ACGME in 1997. The ABOto approved a certificate of added qualification in 2002, and the first subspecialty examination in neurotology was administered by the ABOto in 2004 [8]. To obtain this certificate of added qualification, an individual must complete one of the accredited fellowship training programs or meet the criteria spelled out in the alternative pathway. The alternate pathway to neurotology certification will be available until 2012. It requires 7 years of clinical practice in neurotology, submission of 2 years’ operative experience, and documentation of at least ten intracranial exposures in the last 2 years. Currently, there are 15 ACGME-accredited programs in neurotology, all of which require 2 years of training. The Joint Residency Committee of the American Otologic Society and American Neurotologic Society sponsors the matching process and restricts programs listed through the SFMatch program to approved programs. Because of the requirements of the ACGME, the fellowship is designated as ‘‘neurotology residency’’ [9]. The neurotology residency provides advanced education beyond that provided in otolaryngology residency in the basic sciences related to the temporal bone and lateral skull base, communication sciences, neurophysiology, advanced audiologic and vestibular testing, and diagnostic evaluation and management, including advanced surgical management of diseases of the auditory and vestibular system, temporal bone, cerebellopontine angle, lateral skull base, and related structures. Of the 2-year experience, a maximum of 6 months is dedicated to protected time for research. The neurotology residencies are subject to the same strict curricular requirements that are standard in otolaryngology residency, including work hour restrictions, a dedicated didactic program, and instruction and evaluation based on the six competencies. The AAO-HNS directory lists 15 otology/neurotology and 7 neurotology/skull base fellowships (Box 2), some of which are not ACGMEaccredited fellowships. These other nonaccredited fellowships are usually

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Box 2. ACGME-accredited neurotology fellowships Stanford University University of California San Diego University of Southern California Jackson Memorial Hospital (Miami, FL) University of Iowa Northwestern University Massachusetts Eye and Ear (Harvard) Johns Hopkins University Michigan Ear Institute/Wayne State University University of Michigan New York University Ohio State University Vanderbilt University Baylor College of Medicine University of Virginia

1 year in duration, and their quality and content are unregulated. Current and future participants in these nonapproved fellowships are not eligible to obtain the certificate of added qualification in neurotology unless they also complete an ACGME-accredited neurotology residency. Rhinology Fellowships in rhinology provide additional training in the diagnosis and medical and surgical management of sinonasal disease. These fellowships have proliferated with the introduction of endoscopic sinus surgery and development of endoscopic techniques to address pathology of the anterior skull base. Fellowships are usually 1 year in duration, and a formal matching program was initiated in 2006. Currently, no specialty organization or accrediting body provides oversight or quality control for these fellowships. Although the American Rhinologic Society sponsors the rhinology fellowship match through the SFMatch program and provides a directory of programs, it does not monitor or certify any rhinology training program. In the June 2007 match for rhinology, there were 18 participating programs with 18 positions offered. Further information about the rhinology match can be found at www.american-rhinologic.org/fellowship.phtml. Pediatric otolaryngology Pediatric otolaryngology is a subspecialty defined by the age of the patients and the training of the physicians. Pediatric otolaryngologists are expected to have education and experience that exceeds that afforded in

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otolaryngology residency. Pediatric otolaryngologists manage neonates and children with complex otolaryngologic problems who often have significant comorbidities. ACGME-accredited fellowships must be based at tertiary care children’s hospitals. The ACGME-approved ‘‘pediatric otolaryngology residency’’ must provide educational experiences in the diagnosis and treatment of complex congenital and acquired conditions that involve the ear, nose, throat, head and neck, and aerodigestive tract. Additional education is also provided in management of disorders of voice, speech, language, and hearing. Currently, five ‘‘pediatric otolaryngology residencies’’ are ACGME accredited, each fellowship being 2 years in duration (Box 3). ACGME-accredited pediatric otolaryngology residencies are subject to the same stringent educational requirements mandated of otolaryngology residency programs, including a formal curriculum, monitoring of case numbers, nonclinical educational experiences, work hour restrictions, and instruction and evaluation in the six competencies. Most pediatric otolaryngology fellowships are not accredited by the ACGME, however. Overall, 21 programs are listed in the American Society of Pediatric Otolaryngology directory, and there are approximately 26 positions available per year. Fifteen programs participated in the most recent match in May 2007. The nonapproved fellowship programs last from 1 to 2 years [10]. The total number of pediatric otolaryngology fellowship programs and positions has remained stable over the last decade. In a survey of fellowship programs, Zalzal [11] reported that there were 23 programs in 1994 and 21 programs in 1995. Twenty-four fellows graduated in 1994, and 27 fellows graduated in 1995. These numbers are roughly equivalent to current training numbers. The fellowship match for pediatric otolaryngology was established in 1999 and is sponsored by the Fellowship Committee of the American Society of Pediatric Otolaryngology. The American Society of Pediatric Otolaryngology does not certify or monitor any of the pediatric otolaryngology fellowships, however, so that only ACGME-approved programs are subject to external monitoring and verification of educational standards. Because there is no centralized application service for the pediatric otolaryngology match, applicants should contact programs directly to learn their individual requirements. Additional information can be found at www.aspo.us.

Box 3. ACGME-accredited pediatric otolaryngology fellowships Baylor College of Medicine University of Iowa University of Cincinnati Children’s Hospital of Philadelphia University of Pittsburgh

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Facial plastic and reconstructive surgery Fellowship training in facial plastic and reconstructive surgery affords eligible otolaryngologists or plastic surgeons the opportunity of a 1-year focused experience in the evaluation and medical and surgical management of aesthetic or reconstructive problems of the face, head, and neck. These fellowships are sponsored by the Education and Research Foundation of American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS). These fellowships are also regulated by the Fellowship Review Committee of the AAFPRS to ensure educational integrity of the fellowships sponsored under this program. Fellowships are 1 year in duration, and a matching program is coordinated through the SFMatch program. Approximately 38 spots are available per year [12]. The salary range for this type of fellowship is highly variable and ranges from a meager stipend to a more typical resident’s salary. Individuals who complete an AAFPRSapproved fellowship are eligible to apply through the fellowship track for board certification by the American Board of Facial Plastic and Reconstructive Surgery. Laryngology Laryngology fellowships provide experience in the advanced evaluation and medical and surgical treatment of problems related to voice, swallowing, and the laryngopharyngeal complex. Currently, eight laryngology fellowships are listed in the AAO-HNS directory. None of these fellowships is accredited, evaluated, or approved by an external body. Most fellowships last for periods of 1 or 2 years, with a variable research component. There is no matching program for laryngology fellowships. Head and neck oncology Head and neck oncology/oncologic surgery fellowships provide advanced training in the diagnosis and management of neoplastic disease of the head and neck. AHNS-approved fellowships are available to candidates who are board eligible in surgery, plastic surgery, or otolaryngology. Fellowships typically last 1 to 2 years, with a minimum of 12 months of clinical training required. The first regulated fellowship programs were approved by the Joint Council for Approval of Advanced Training in Head and Neck Oncologic Surgery in 1978 [13]. Currently, these fellowships are regulated, reviewed, and approved by the Advanced Training Council of the AHNS. These fellowships are designated ‘‘AHNS Fellowships in Advanced Training in Head and Neck Oncologic Surgery,’’ and a diploma is awarded to individuals who successfully complete the fellowship. The AHNS fellowships should be distinguished from fellowships not associated with the AHNS, for which no accreditation, external monitoring, or quality control applies. Some of the

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non-AHNS fellowships are dedicated to specific aspects of head and neck surgery, such as skull base surgery or microvascular reconstruction. The number of ‘‘approved’’ fellowships has remained stable over the last decade. Close and Miller [13] reported that 21 fellowship positions were available at 18 institutions in 1995. Those numbers are roughly comparable to the current 28 positions at 18 programs listed on the AHNS Web site [14]. A complete listing of AHNS programs is available at www.headandneckcancer. org, and another listing of head and neck surgery fellowships is available at www.entlink.net/residents/education/fellowship.

Foreign medical graduates in fellowship training Foreign medical graduates may apply to many of the available fellowship programs described previously. The requirements of the different subspecialties or individual programs vary, and interested individuals should contact programs well in advance of anticipated training to ensure that all requirements are met. Applicants to ACGME-approved fellowships first should obtain Educational Commission for Foreign Medical Graduates (ECFMG) certification; however, ECFMG sponsorship is also available for many other types of fellowship. The following subspecialty areas are considered nonstandard subspecialty disciplines recognized by the ABOto for purposes of J1 visa sponsorship by the ECFMG: craniomaxillofacial, facial plastic and reconstructive surgery, head and neck surgery, head and neck oncologic surgery, laryngology, microvascular surgery, and rhinology.

Current state of fellowship training The total number of fellowship programs within otolaryngology has decreased over the past decade. Currently, 108 fellowship programs are listed in the AAO-HNS fellowship database. The overall number of programs has decreased significantly from the 151 programs listed in the database in 1994 [1]. For reference, within all of otolaryngology for the year 2005–2006 there were 103 ACGME-approved otolaryngology residencies with 1406 total positions available (at all five levels of training) [15]. Current fellowship programs, namely in neurotology and pediatrics, have gone through the process of strict accreditation through the ACGME. These programs are directly associated with ACGME-approved residencies and have well-defined educational curricula and objectives that meet the ACGME’s stringent criteria, which elevates the standards of subspecialty training among the various programs. According to a survey in 2005 by the AAOHNS section for residents and fellows, 38% of respondents were pursuing fellowship training. This number has been fairly stable over the last 7 years with similar percentages noted in other surveys. Apparently, the interest in fellowship training has not waned.

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According to recent statistics from the SFMatch program, the number of residents applying for fellowships each year has remained fairly stable with no identifiable trends (Table 1). The popularity of certain subspecialties has not changed much since the early 1990s, with facial plastic surgery having the most applicants. One area that has grown in popularity is pediatric otolaryngology. There is a notable trend (Table 1), with more applicants participating in the pediatric otolaryngology match in recent years. This trend differs significantly from the early 1990s, when head and neck surgery attracted a larger proportion of resident applicants. In the last 10 years, however, there has been a notable decline in the number of applicants for head and neck surgery fellowships (Fig. 1). Why this change in subspecialty popularity? One possibility is that the length of the training program determines its popularity. One-year fellowships may be more attractive than 2-year fellowships. Another factor determining subspecialty popularity may relate to changing reimbursements in otolaryngology. Graduates may be seeking subspecialty training in areas with anticipated growth in demand for subspecialty expertise, or they may have an expectation of greater financial rewards in certain fields. The decline in overall fellowship program numbers within otolaryngology is probably a positive development. There are potentially negative consequences if we splinter the attractive diversity of our specialty with excessive subspecialization. The breadth of otolaryngology practice is, after all, one of the most attractive aspects cited by medical students interviewing for otolaryngology residency. The decline in overall fellowship program numbers also is a reflection of the increasing regulation and standardization of fellowship training. This regulation of fellowship programs is beneficial because it elevates educational standards and ensures a level of consistency in training among the various programs. It is hoped that this trend will continue, with other subspecialty organizations taking a leadership role in raising the educational standards of subspecialty fellowship. Fellowship training beyond otolaryngology residency can be a valuable career decision for individuals interested in focusing their practice in a narrower area of otolaryngology–head and neck surgery. Although there is still uncertainty about the appropriate number of subspecialists within otolaryngology, organized otolaryngology has responded to the alarm sounded by Dr. Bailey more than a decade ago. In conjunction with the increased options for fellowship training, there has been an improvement in the

Table 1 Resident applicants participating in a fellowship match

Pediatrics Facial plastics Neurotology

2002

2003

2004

2005

2006

17 53 7

11 53 19

17 40 14

23 46 22

29 46 14

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Fig. 1. Numbers of applicants for head and neck surgery fellowship match. (From Medina JE. Tragic optimism vs learning on the verge of more change and great advances: presidential address, American Head and Neck Society. Arch Otolaryngol Head Neck Surg 2001;127:751; with permission.)

regulation and standardization of fellowship training. Subspecialties that are most successful in raising standards for education are also the most likely to thrive in the future.

References [1] Bailey BJ. Fellowship proliferation: impact and long-range implications. Arch Otolaryngol Head Neck Surg 1994;120:1065–70. [2] Bailey BJ. Fellowship proliferation. Part I: impact and long-range trends. Arch Otolaryngol Head Neck Surg 1991;117:147–8. [3] Bailey BJ. Fellowship proliferation. Part II: impact and long-range trends. Arch Otolaryngol Head Neck Surg 1991;117:265–6. [4] Nadol JB. Training the physician-scholar in otolaryngology-head and neck surgery. Otolaryngol Head Neck Surg 1999;121:214–9. [5] Crumley RL. Survey of postgraduate fellows in otolaryngology-head and neck surgery. Arch Otolaryngol Head Neck Surg 1994;120:1074–9. [6] Miller RH. Otolaryngology residency and fellowship training: the resident’s perspective. Arch Otolaryngol Head Neck Surg 1994;120:1057–61. [7] Available at: http://www.aasmnet.org/FellowshipTraining.aspx. Accessed July 2, 2007. [8] Gantz BJ. Fellowship training in neurotology. Otol Neurotol 2002;23(5):623–6. [9] Available at: www.sfmatch.org/residency/neurotology/index. Accessed July 2, 2007. [10] Available at: www.aspo.us/information.php?info-1d¼14. Accessed July 2, 2007. [11] Zalzal GH. Projected societal needs in pediatric otolaryngology. Laryngoscope 1996;106(9): 1176–9. [12] Available at: www.aafprs.org. Accessed July 2, 2007. [13] Close LG, Miller RH. Head and neck surgery workforce in the year 2014. Laryngoscope 1995;105:1081–5. [14] Available at: www.headandneckcancer.org/residentfellow/fellowships.php. Accessed July 2, 2007. [15] Available at: www.acgme.org. Accessed July 2, 2007.