Getting Training on Track
Are otolaryngology training programs serving the overall needs of the community?
There is growing concern among leaders in otolaryngology about early-career training and how it is driving the decisions of students and residents in terms of their career choices. These choices ultimately define the workforce that delivers otolaryngology care in communities and is responsible for meeting the healthcare needs of the population.
Albert L. Merati, MD, AAO-HNS/F Past President and professor and chief of laryngology at University of Washington School of Medicine’s Department of Otolaryngology-HNS in Seattle, Washington, said this concern is a result of challenges within the existing system.
“The current system creates a tremendous amount of pressure on students to portray someone dedicated to a career in academic medicine,” said Dr. Merati. “This image is created to impress academic teaching programs that will rank and accept the candidates for training. The mask is worn by many, and feigning or overstating interest in research and teaching is just the currency used to enhance admission into the field. This dance occurs despite what real interest a student may have and is not always empowered to share.”
Additional challenges that may unintentionally be driven by academic programs include the choice of rotations and exposure to faculty along the way. Currently, fewer and fewer trainee interactions with faculty occur in general otolaryngology and/or comprehensive care.
“In most programs, they’re spending the vast majority of their time with subspecialists,” Dr. Merati said. “There is no question of the quality of each interaction or its value, but the end result is muted or limited exposure to what the bulk of otolaryngology care is in the United States—general otolaryngology practiced outside of subspecialty-dominated tertiary/quaternary medical centers.”
These challenges and their potential solutions will be up for discussion as Dr. Merati leads Monday’s AAO-HNS/F EVP/CEO Spotlight Series and a new addition to the Annual Meeting program: “Crucial Conversations: Examining the Relationship Between Otolaryngology Training and Our Field: How Are We Doing?”
A skewed exposure is limited to just the subspecialty components of otolaryngology during training in many programs, according to Dr. Merati. Each year, more and more trainees pursue fellowship training after residency. This in turn has created downstream repercussions affecting the workforce and has limited access to the specialty predominantly to urban cities and suburbs.
There are relatively fewer general otolaryngologists at a time when broad access to otolaryngology care is varied and often lacking, particularly in less densely populated regions.
More students are doing research years and gap years to build an attractive CV hoping to impress academic programs and to ultimately secure competitive OTO training spots. Dr. Merati said this tends to favor socially and economically advantaged students. “While the value of research training is pure and valid, there is a deep and pervasive disingenuousness to the pressure that exists for students to have been extensively involved in research prior to entering training,” he said.
Although academic otolaryngology is a gateway for those entering a career in the field, Dr. Merati said the forces compelling the choice of who enters and who does not may not be adequately responding to what is really needed within the community.
“Each actor in this arena is responding rationally—pursuing the best candidate, buffing the CV, leveraging specialty training for a better position or contract in a city where someone wants to practice,” he said. “But partially because there is no single organizing or oversight body, the result fosters a research arms race where students pretend to want to have one career while concealing their actual personal wishes, and academic programs design entry criteria and training experiences that are high quality but may not be what is ideal for our communities across the U.S.
“There is no end in sight. Whatever the journey, whatever the aspiration, otolaryngologists everywhere will be well served to think nationally about the workforce we are creating. I need our private practice and academic colleagues, our societies, and organizations to come together, to convene and reflect on the collective road we are on. As my friend Dr. Sujana Chandrasekhar said so eloquently: ‘We must work to normalize all career pathways in our field’.”