A History of United States Graduate Medical Education in Otolaryngology

Richard K. Gurgel, MD, for the Otolaryngology Historical Society Graduate medical education in otolaryngology has evolved dramatically in the United States during the past century. The establishment of training requirements and objective assessments paralleled the maturation of otolaryngology as a distinct specialty. Describing the many events that have shaped our modern training programs is beyond the scope of this brief summary. This report will therefore focus on some critical early developments that established graduate medical training in otolaryngology. In the mid- and late-1800s, physicians seeking specialization often spent time at dedicated eye and ear infirmaries, most of which were established in large cities, such as Boston, Chicago, New Orleans, New York, and Philadelphia. More commonly, however, an aspiring specialist would travel to Europe to take courses in otology and laryngology at a university-based program, mainly in Germany and Austria.1 In the late 1800s, William Halsted pioneered the standardization of surgical training at Johns Hopkins University. By 1910, Abraham Flexner was charged by the Carnegie Foundation to assess the state of U.S. medical education. His report fundamentally changed undergraduate and graduate medical education by calling for a standardized, university-based medical education and concomitant attrition of proprietary medical schools. Amid this progressive background and influenced by European models, the American Laryngological, Rhinological, and Otological Society formed a committee in 1912 to guide the best methods of teaching otolaryngology in post-graduate schools. The committee acknowledged that “on this continent, there is no recognized portal to the specialty,” with the concern that otolaryngology would be, “dragged into the mire as a result of ignorance … by the rank and file who style themselves specialists in diseases of the ear, nose, and throat.”2 The committee recommended six months of university-based basic science instruction, followed by at least 18 months of work as “resident assistants.” This training would then culminate with an examination for a formal degree. However, implementation of these recommendations took many years, with the delay due in part to World War I. Some military data give insight into the state of otolaryngology at that time. The army rejected 70 percent of all alleged otolaryngologists, more than any other specialty, due to lack of sufficient expertise and training.3 This staggering statistic caused L. W. Dean from the University of Iowa to comment, “If the army, in order to protect its men, found it necessary to reject 70 percent of so-called otolaryngologists, what possible way exists at this time for the laity to protect themselves?”4 After many years of deliberation, a standardized curriculum was agreed upon and, in 1924, the American Board of Otolaryngology (ABOto) was organized. The ABOto certified graduates from approved training programs and functioned as the residency review committee for program accreditation until 1953. This brief summary illustrates a cycle by which subspecialization occurs. New branches of medicine emerge from increased understanding of diseases and their management, technology, and innovation. As this process occurs, training in a specialty progresses from unstructured apprenticeships to developing standardized curricula on the subject matter. This begets a need to formally assess those trainees through the formation of specialty boards and competency exams. Otolaryngology went through this process in the early 1900s and, as a specialty, we continue striving to improve the training experience of future otolaryngologists. References Mygind H, Watson-Williams P, Birkett HS. Discussion on the education of the specialist in laryngology and otology. BMJ. 1912;2(2695):413-421. Wishart D, Smith SM, Richardson C. Report of the committee appointed by American Laryngological, Rhinological and Otological Society to consider the best methods to be followed in the teaching of otolaryngology in undergraduate and postgraduate schools. Laryngoscope. 1913;23(10):1010-1017. Munson EL. The needs of medical education as revealed by the war. JAMA. 1919;72(15):1050. Dean L. The graduate teaching of otolaryngology. JAMA. 1919;73(3):159.