About Face

Procedural diversity, satisfying outcomes draw DOs to otolaryngology

Ear, nose and throat specialists split their time between the office and the OR and enjoy helping patients improve their quality of life.

One of the most procedurally diverse specialties, otolaryngology and facial plastic surgery encompasses everything from tonsillectomies to myringotomies (ear-tube insertions) to reconstructive rhinoplasty.

Along with general surgery, otolaryngology is a major pathway for DOs who want to subspecialize in reconstructive plastic surgery or cosmetic surgery.

Ear, nose and throat (ENT) specialists, as they are commonly called, split their time between the office and the operating room.

“There is a nice variety. It’s not all office. And it’s not just surgeries,” says Wayne K. Robbins, DO, the program director of the AOA-approved ENT residency at Genesys Regional Medical in Grand Blanc, Mich.

Otolaryngologists treat patients of all ages unless they focus on pediatrics. In children, otolaryngologists typically tackle persistent ear infections, hearing problems and congenital abnormalities, such as cleft lip. Adult patients are more likely to have sinus infections, age-related hearing loss, and cancers of the head or neck regions.

“The vast majority of the procedures we do are to improve the quality of life,” Dr. Robbins says. “With the exception of some serious cancers, most of the conditions we address are not life-threatening. This makes for a pleasant practice environment. Our book of emergencies is small.”

In other words, it is possible to have a life apart from medicine as an ENT doctor. And otolaryngologists don’t constantly have to break bad news.

But otolaryngologists also feel passionate about what they do.

“I love doing cochlear implants because I get to transform kids’ lives,” says pediatric otolaryngologist Michael S. Haupert, DO, the president-elect of the American Osteopathic Colleges of Ophthalmology and Otolaryngology—Head and Neck Surgery (AOCOO-HNS). “There’s nothing as rewarding as seeing a child respond to sound for the first time.”

Otolaryngologists experience mostly positive outcomes and grateful patients, observes Richard C. Scharf, DO, who directs the AOA-approved ENT program at St. Barnabas Medical Center in Livingston, N.J.

“Most of our patients have very good results,” he says. “So when you go home at the end of the day, you feel a sense of satisfaction in knowing that you have treated people successfully.

“And you can see the results of your interventions very quickly, which is so gratifying.”

The pay for otolaryngologists is also good, averaging more than $300,000 a year.

“In surveys, ENT salaries are consistently ranked as high as or higher than those of most other medical specialties,” Dr. Scharf says.

A cut above

Because it is both small and appealing, otolaryngology-facial plastic surgery is one of the osteopathic medical profession’s most competitive specialties.

For every opening, AOA-approved ENT programs receive 40 to 50 applications, Dr. Robbins notes. Altogether, no more than 25 osteopathic otolaryngology residency positions are available each year.

Students match into otolaryngology and facial plastic surgery, a five-year program, from their fourth year of medical school. Those with exceptional board scores are more likely to snag a spot.

Of all specialties participating in the 2011 AOA Match, graduates matching into otolaryngology as their first choice had the highest average scores on the Comprehensive Osteopathic Medical Licensing Examination of the United States (COMLEX-USA)—599 on Level 1 and 602 on Level 2—according to a report published by the American Association of Colleges of Osteopathic Medicine.

“We look for individuals who have excellent board scores and research experience,” Dr. Scharf says. “Typically, we consider those ranked in the top 20% of their class.”

While high scores are an important screening measure, rotating at targeted institutions is equally essential.

“It is rare that we would accept a student who didn’t rotate through our clinical services,” Dr. Scharf says. “And the same holds true for the vast majority of programs in otolaryngology and facial plastic surgery.”

ENT specialists, who develop long-term relationships with many of their patients, must be able to communicate well. Rotations are the best venue for assessing residency candidates’ interpersonal skills, says Dr. Scharf.

Ideally, students would serve two rotations at the targeted program: an elective rotation at the end of their third year or the beginning of their fourth year and an audition rotation during their fourth year.

Students rotating through Dr. Scharf’s program spend time in the office as well as the hospital. To assess each student, he taps the opinions of patients, attending physicians, residents, nurses and office staff.

“We find out how the individual is in terms of seeing patients,” Dr. Scharf says. “Also, did he or she hand in medical records and lab work in a timely fashion?

“And if a student is disrespectful to office staff, we’ll hear about it right away.”

Otolaryngologists, whose procedures range from microscopic handling of a tiny stapes to gross dissection of a pectoralis major flap, need outstanding manual dexterity, Dr. Scharf says. Generally, those who want to become surgeons are confident that they have the necessary fine motor skills and hand-eye coordination, he observes. This self-selection process weeds out most individuals who would never make the cut.

But picking the best potential ENT surgeons requires additional assessment.

Some residency programs use computer simulation models to evaluate manual dexterity. And some will have candidates tie various knots during the interview process.

Dr. Robbins requires candidates to do a manual task they’ve never been exposed to, something more difficult than tying shoes while looking in a mirror. “I want to see how well candidates can pick up a skill they’ve never seen before,” he explains.

Dr. Scharf, whose program is strong in cosmetic surgery, asks his residency candidates to sculpt noses and ears during their interview day. “In high school and college, I did sculpting as well as drawing, and that experience has definitely helped me as a surgeon,” he says. So he looks for artistic skills and sensibilities in his residents.

To evaluate candidates’ potential to perform mastoid surgery, Dr. Scharf asks them to use a drill on a hardboiled egg. “I see if they can remove the shell without roughing up the inside portion of the egg,” he explains.

Decide early, persist

Osteopathic medical students who become interested in ENT as premeds have an edge because they can focus on schools located near otolaryngology residency programs. Because otolaryngology is typically not covered in the regular curriculum and the AOCOO-HNS does not have an active student chapter, DO students must seek out preliminary training in the specialty on their own.

Students from the New Jersey and two New York osteopathic medical schools have shadowed Dr. Scharf in his practice. He also encourages them to participate in his residency program’s journal club. “The best time to get involved is before your third and fourth year,” he suggests.

“I think students who are successful getting into ENT spots tend to know early on—by their first or second year—that that’s their path,” Dr. Robbins agrees. “Many of these students do relevant research during their first two years, and their names end up on a couple of published articles.”

Candidates who do not match into otolaryngology in their fourth year of medical school should consider spending a year doing ENT research, says Dr. Scharf. “Many who have gone that route have later been accepted as residents,” he says.

DO graduates should not do a traditional rotating internship if they want to get into ENT because the Centers for Medicare and Medicaid Services does not like to fund an extra year of training.

Osteopathic graduates can sometimes transfer from a general surgery internship into a second-year ENT position, but this is rare because such openings in ENT are hardly ever available. Otolaryngology residents seldom fail to complete their programs.

Growing demand

Most DOs who complete otolaryngology and facial plastic surgery residencies do general ENT, though a growing number of otolaryngologists are pursuing subspecialty fellowships, Dr. Haupert says.

Cosmetic surgery can be a lucrative niche for DOs with an artistic bent.

“I became interested in cosmetic surgery as a child when I found a book on this topic at a garage sale,” says Peter M. Schmid, DO, a cosmetic surgeon in Longmont, Colo., who trained as an otolaryngologist.

After completing his ENT training at Doctors Hospital in Columbus, Ohio, he finished a fellowship through the American Academy of Cosmetic Surgery.

Of all the procedures he does, Dr. Schmid most enjoys doing face-lifts, rhinoplasty and reconstructive surgery for both trauma and cancer victims.

“I like the artistic component of cosmetic surgery,” says Dr. Schmid, a sculptor who is conducting a five-day workshop titled “Aesthetic Anatomy: Sculpture for Surgeons and Physicians” in August in Alameda, Calif. “I think that sculpting opens my eyes to perspective and three dimensions. Having an artistic approach elevates your outcomes and results as a plastic surgeon.”

With baby boomers aging, the demand for cosmetic surgey is rising. “People who are focused on attaining good health and educating their minds are also more open to self-improvement and self-image,” Dr. Schmid says.

Whether fellowship- or simply residency-trained, otolaryngologists overall have no trouble attracting patients. Most otolaryngologists today enter private practice, either in a small group or a large multispecialty group.

“There is a large demand for ENT and facial plastic surgery throughout the country,” Dr. Scharf points out. “Most residents coming out of our program have multiple offers.”

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