Otolaryngology Residency Training

Otolaryngol Clin N Am 40 (2007) 1195–1201

Otolaryngology Residency Training: Resurgence of the Specialty Karen H. Calhoun, MD*, William E. Davis, MD, Jerry W. Templer, MD Department of Otolaryngology–Head and Neck Surgery, University of Missouri–Columbia College of Medicine, 1 Hospital Drive, Columbia, MO 65212, USA

In 1950, conventional wisdom said that otolaryngology was a dying specialty. Otolaryngology was primarily concerned with otitis, mastoiditis, sinusitis, neck abscesses, tonsillitis, and their complications, and new antibiotics were curing more and more infections [1–9]. At that time, head and neck cancer and thyroid surgery were commonly the purview of general surgeons,1 and cosmetic surgery was generally performed by plastic surgeons. Even tonsillectomy might be performed by general practitioners, general surgeons, and some pediatricians. Approved otolaryngology residency slots were often unfilled, and the quality of otolaryngology training programs was inconsistent. A good otolaryngology research program was the exception rather than the rule. Otolaryngology was also just emerging from The American Academy of Ophthalmology and Otolaryngology as the new American Academy of Otolaryngology.2 In perspective, medical students in 1950 seemed much less anxious about choosing a specialty than today’s students are. Residencies were plentiful and less competitive, and it was not uncommon to find medical school graduates returning after several years of general practice to what is considered today a ‘‘competitive’’ residency. Many medical graduates in the 1950s served ‘‘rotating internships’’ and then entered practice, and others made * Corresponding author. E-mail address: [email protected] (K.H. Calhoun). 1 Even into the 1960s, otolaryngology residencies were often limited in departments of surgery and could perform only partial or total laryngectomy, whereas other surgeons performed radical neck dissections and composite resections. 2 The American Academy of Ophthalmology and Otolaryngology was formed in 1896 as a foundation for continuing education. The two academies divided and otolaryngology became the American Academy of Otolaryngology. This academy was later renamed the American Academy of Otolaryngology/Head and Neck Surgery. 0030-6665/07/$ - see front matter Ó 2007 Elsevier Inc. All rights reserved. doi:10.1016/j.otc.2007.07.001

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their final specialty decision during internship or during military service. A ‘‘match’’ was generally achieved by a single visit to a couple of residency sites. From the late 1950s to the middle of the 1970s, draft-eligible medical graduates were routinely called to 2 years of military service; in the 1960s and 1970s numerous physicians served in Vietnam. In response, residency programs customarily required applicants to have either completed their military obligations or to have an official deferment through the Berry Plan before being accepted in otolaryngology.3 During this time period, residency directors labored to improve training; change was slow, however, and any change was normally driven by institutional factors rather than regulatory agencies. On the positive side, ‘‘paper work’’ in this environment was modest compared with today’s hours committed to documentation. An otolaryngologist of 1957 would be astounded by the breadth and depth of the vibrancy of the specialty in 2007. This 1957 otolaryngologist (almost certainly a white male) would be impressed to see that otolaryngology is now the primary provider of head and neck surgical oncology and skull base surgery. In addition, otolaryngologists are now routinely becoming ‘‘super specialists’’ in neurotology, laryngology, facial plastic and reconstructive surgery, pediatric otolaryngology, rhinology, and otolaryngic allergy. What happened to bring this ‘‘challenged’’ specialty to such heights over the past 50 years? Except for localized anecdotes from senior physicians, much of what has changed in the specialty is now remote, if not forgotten. There is the impression that the ‘‘chiefs of old’’ would neither be able to envision nor tolerate sitting passively while a room full of accomplished surgeons is chided by clerks over ICD-9 and CPT peccadilloes. Would these ‘‘chiefs’’ of the last century immediately equate codes and compliance regulations as symbols of quality care and good outcomes? Lamentably, reimbursement and ‘‘doctoring the chart’’ now often seem to take precedence over teaching, character, or performance. Physicians from 1957 would, however, be impressed with today’s computerized world and scientific technology that have led medicine to a ‘‘continuous quality improvement’’ in contemporary practice. They might be especially surprised to see women and minorities in leadership positions. Otolaryngology has changed in countless ways since 1957, a change driven, in part, by an unprecedented exponential growth of knowledge and technology in the physical, biological, and behavioral sciences. Clinical advances occurred because numerous otolaryngologists responded to these developments with dedication and innovation. Otolaryngology has particularly benefited from these scientific advances partly as a consequence of

3 The Berry Plan granted a military deferment for specialty training in exchange for 2 years of service after completion of specialty training. Thus, the armed services were able to guarantee highly trained medical personnel for their forces.

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otolaryngologists’ early expertise as microscopic surgeons and a keen interest in applying new knowledge in basic head and neck physiology and neurophysiology to clinical problems. The knowledge explosion reshaped otolaryngology training in the United States, and the following are thought to be the significant internal and external forces that shaped the modern otolaryngology residency:  The improvement in faculty quality and quantity  The American Academy of Otolaryngology/Head and Neck Surgery’s supporting presence  The development of academic departments of otolaryngology  Medicare and Medicaid  The Veterans Administration (VA) hospitals  Accreditation Council of Graduate Medical Education (ACGME)  The American Board of Otolaryngology (ABOto)  The Residency Match Program  Subspecialization These forces of change are discussed briefly below. Change factors within otolaryngology Otolaryngology has been blessed with talented and tenacious innovators who overcame intimidating obstacles to develop and expand this specialty in many directions. It was a partnership of many: otolaryngology chairs, academic faculty, and numerous dedicated private practitioners all contributed to the effort. Over the past 50 years, many residency programs were kept alive solely because dedicated private physicians would not let them die. In many cases, the surge in otolaryngology excellence was because of academic private physicians such as John Conley, John Shea, William and Howard House, Jack Anderson, Paul Holinger, George Shambaugh, James Willoughby, and others who often donated their efforts. Herbert Rinkel was an internist, as was his associate James Willoughby, but they both supported the development of allergy and immunology by otolaryngologists. Academic chairmen such as Walter Work, Dean Lierle, Harold Schuknecht, Bobby Alford, Ron Bailey, Joseph Ogura, Paul Ward, and John Kirchner are but a few of the many who wrote extensively and helped inspire and challenge academic otolaryngology to excellence. The American Academy of Otolaryngology has particularly supported resident education. The academy partnered with its members and the training programs to initiate a home study course, monographs, self-instructional packages, patient of the month, and an annual residency examination. In addition, the academy has maintained a research department that assists young academic investigators, and it acts as an agent and conduit for private and public funding. The academy’s Annual Meeting has continually brought national and international experts together so that

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residents could also experience a course by the expert and take notice of the latest in scientific presentations. From another perspective, the academy, through tact and compromise, has been a major factor for specialty unity despite the tension of widespread divergent interests from 50 years of subspecialization. Fifty years ago, significantly fewer medical schools had an otolaryngology residency program; if they did it was usually a division of otolaryngology. These divisions often lacked autonomy, and they were often disadvantaged politically. ‘‘Turf wars’’ were common. Many academic otolarynologists were forced to risk their jobs to obtain departmental status over the years. Today, most otolaryngology programs are autonomous departments, and departmental status has been a vital force for the academic maturity now seen in this relatively small specialty. (Otolaryngologists represent less than 1% of physicians in the United States.) With the complexity of newer procedures and pressure for excellent results, fellowship training for today’s academic otolaryngologists is almost an absolute requirement. The result is that residents receive the bulk of their procedural instructions and clinic instruction from fellowship-trained specialists or those who have additional experience. While one-on-one faculty-to-resident surgical training has increased under the new model, resident-to-resident teaching has decreased. (The mechanism of how the quality and quantity of faculty increased is discussed further in the section on external factors.) Besides the increases in number of faculty and increases in faculty specialization, another vital factor is the previously mentioned increased quality of otolaryngology residents. Otolaryngology is now viewed as a highly technical, fast-moving, forward- looking surgical field, resulting in a robust competition of residency applicants from the top of the bell curve. Achieving departmental status and hiring talented faculty were important steps in transforming otolaryngology. In 1957, new hires could be difficult because capital was often lacking. Many residencies in the 1960s had only one or two full-time faculty and could afford no moreda situation that often forced residents to function with minimal faculty supervision. Senior residents trained junior residents, and commonly the faculty was augmented by private physician volunteers. Today, a full-time on-site faculty predominates. Several external developments helped provide the necessary funding to build the modern academic department of otolaryngology. Changes external to otolaryngology New funding sources helped support academic departments and the residents they trained. Medicare and Medicaid brought the new funding needed for graduate medical education. The Social Security Act, passed in 1935, was funded with payroll taxes, and the first payments to those 65 years old began in 1940. The worker-to-retiree ratio at that time was high, and the

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system was soon flush with cash. Typically, however, politicians could not resist temptation, and a modest program became a large program. The most significant change to Social Security was in 1965, when Lyndon B. Johnson signed the Medicare bill and Title XIX of the Social Security Act. Medicare and Medicaid spurred rapid change and growth of otolaryngology residencies, and no other external factor has changed all of medicine more than Medicare and Medicaid. Although much of the specialty care for indigent patients was provided by residency programs at minimal cost to taxpayers, it was now paid by Medicare. Teaching hospitals and residency positions were also paid, and this new funding spilled over to departments: faculty positions, resident positions, and research could now be funded. Eventually this new funding became a federal commitment to provide more physicians and new medical schools. In the years following President Johnson’s signature, medical school graduates almost doubled from 8,000 to 15,000 per year. Gradually, funding became limited as the delivery system enlarged and surpassed its funding. Medicare’s financial windfall eventually became counterbalanced by progressive regulations to decrease spending and increase compliance. Regulations emerged that demanded changes in the residency model. Money now came with restrictions attached which translated into paperwork and much higher levels of supervision. Tension developed between time for resident education and time for documentation. Extreme oversight in time was tempered and a new model of graduate medical education has emerged. VA hospitals have been another important factor for change and financial stability in otolaryngology residency programs. After World War II, numerous new VA hospitals were built adjacent to teaching hospitals to take advantage of high-quality medical school faculty and resident availability. VA hospitals have been excellent sources for resident education, and faculty could move seamlessly between the university hospitals and VA hospitals to supervise clinics and surgical procedures as it was deemed prudent by the attending physician. The VA paid the resident salaries and usually a number of either part- or full-time faculty salaries. VA regulations have now defined faculty supervision of residents similar to Medicare’s regulations, and the VA residency education model has also changed to reflect the Medicare model. Taken together, the infusion of government money into the medical education enterprise was a strong force for growth in otolaryngology. Changes caused by organized medicine Over the years the American Medical Association and other organizations have significantly influenced graduate medical education. These organizations evaluated and monitored resident training, institutional support, and overall quality of residency graduates. Fifty years ago, significant qualitative differences existed between training programs. Some programs provided the entire spectrum of surgical experiences, while others seemed to

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have only certain areas of expertise. Some programs were, at best, of marginal quality. Today’s residencies are generally more standardized, and residency graduates generally finish with an acceptable level of training. Residencies and educational institutions now better understand their educational and social responsibility to produce competent, capable, and honest practitioners. The ACGME and the American Board of Otolaryngology (ABOto) are the two organizations at present that specify and measure a residency’s end product. The ACGME was established as an independent organization in 1981, and it is now the only official accrediting agency for residency training programs. The ACGME’s mission is to periodically assess, advance, and accredit the residency’s entire educational program. It sets mandatory standards for education and working conditions. On a continuing basis, residency review committees from the council conduct site visits to assess program competence. The council consistently strengthens weak programs by posing a potential threat to their accreditation, and Medicare support is contingent upon accreditation. The ABOto is a vital organization in the residency evaluation process. The ABOto, founded in 1924, is the second oldest board in the nation, and certification by the Board is a practical necessity. As the boards ere given at the Palmer House in Chicago for decades, he older practitioners all remember the motivating and fear-inspiring statement: ‘‘This may be asked at the Palmer House.’’ The ABOto has been instrumental in developing criteria for added qualification and subcertification. Today, it monitors resident progress in the in-training examination and examines the residents after graduation. The role of the ABOto is discussed further in this issue. Between 1957 and the early 1980s, an otolaryngology residency position was frequently attained by means of a single interview, and a simple handshake. This changed in 1980 with the otolaryngology ‘‘early match.’’ Otolaryngology residency positions today are given out in the general match with most other medical specialties. (The National Resident Matching Program [NRMP] was initiated in 1952.) The NRMP provides impartial matching of applicant preferences with residency preferences. This matching process is a dramatic improvement over the former method of resident selection. Summary Although perhaps ‘‘on the ropes’’ in the 1950s, otolaryngology has survived, grown, and prospered. Otolaryngology became the master of head and neck medicine and surgery. Over the past 50 years, otolaryngology residency training was systematically improved through the leadership of talented and selfless leaders in private practice and academia. Training was standardized and improved systematically through the efforts of the academy, the ABOto, and the ACGME. Medicaid, Medicare and the VA bolstered training through their financial support.

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References [1] Pratt LW, Goldstein JC, Bryan SA. A century of excellence: a 100th anniversary history of the American Academy of Otolaryngology/Head and Neck Surgery and its predecessor organizations. In: Hill ST, editor. Alexandria, VA: American Academy of Otolaryngology/Head and Neck Surgery Foundation Inc; 1996. [2] Osguthorpe JD. An otolaryngology residency: the evolution continues. Otolaryngol Head Neck Surg 2004;131(6):795–6. [3] King H. Allergy and immunology, an otolaryngic approach. In: Krouse JH, Chadwick SJ, Gordon BR, et al, editors. A history of otolaryngic allergy. Philadelphia: Lippincott Williams & Wilkins; 2002. p. 4–8. [4] Osguthorpe JD. Evolution of otolaryngic allergy and the American Academy of otolaryngic allergy. Otolaryngol Head Neck Surg 1996;114(4):515–24. [5] Social Security: a brief history. Available at: http://www.ssa.gov/history/pdf/2005. Accessed April 2007. [6] Medicare (United States) Wikipedia, the free encyclopedia. Available at: http://en.wikipedia. org/wiki/Medicare. Accessed April 2007. [7] AAO-HNS celebrates 110 years. (AA) American Academy of Otolaryngology Head and Neck Surgery. Available at: http://www.entlink.net/sitemap.cfm. Accessed April 2007. [8] American Board of Otolaryngology – History. Available at: http://www.aboto.org/history. aspx. Accessed April 2007. [9] National Resident Matching Program. Available at: http://www.nrmp.org/. Accessed April 2007.