The expansion of fellowship training and the modern-day residentExpanded from the print edition
In 1994, Byron Bailey, MD, and Robert H. Miller, MD, MBS, examined the explosion in the amount of otolaryngology subspecialty programs and number of fellowship trainees.1,2 By 1994, 25 percent of the 260 otolaryngology residents were entering fellowship.2
By John M. Carter, MD, SRF Information Officer, New Orleans, LA
In 1994, Byron Bailey, MD, and Robert H. Miller, MD, MBS, examined the explosion in the amount of otolaryngology subspecialty programs and number of fellowship trainees.1,2 By 1994, 25 percent of the 260 otolaryngology residents were entering fellowship.2 Fast forward 20 years and subspecialty pursuits among otolaryngology trainees have only expanded further. Greater than 50 percent of the approximately 300 graduating otolaryngologists are deciding to pursue subspecialty fellowship, and in the most recent unpublished data from the 2014 AAO-HNS SRF survey, 61 percent of all residents stated that they planned to pursue fellowship. Currently the most popular fellowships are pediatric otolaryngology, facial plastic surgery, and head and neck oncology.3 This compares similarly to 1994. The only major shifts are the increase in the number applying to pediatric otolaryngology and a relative decrease in the proportion of applicants applying to neurotology. Both are perhaps greatly affected by the number of available positions. There were 27 neurotology programs in 1994 compared to only nine to 12 programs [requirement having tightened for subcertification] participating now (varies by year). On the converse, pediatric otolaryngology now has 31 programs participating compared to only 16 in 1994.1,3
The reason for the spike in interest in subspecialty training is likely multifactorial and not all together clear. In 1994, Dr. Bailey postulated that the likely motives behind why residents decide to pursue subspecialty training are to 1) gain additional experience to provide superior care; 2) reach a sense of mastery in a subspecialty field; 3) limit their practice to an area they find more satisfying; 4) obtain a marketing advantage over colleagues who practice more broadly; and 5) obtain job security.1
In 2015, these motives likely still largely hold true, but are there new factors that are driving this overall increase in fellowship interest? In the 2014 AAO-HNS SRF survey (approximately 460 respondents), residents were asked “What is the most important factor in determining which fellowship you decide to pursue?” The most common responses were types of surgical cases (50 percent), nature of clinical and medical problems (33 percent), and lifestyle (6 percent). However, this survey gave residents limited choices and may not have captured the true responder attitudes. In this same survey, 46 percent of respondents identified location as the most important factor in determining their practice choice. Practice location is clearly important to the majority and there is a distinct possibility that market forces in certain geographical locations may play a role in the decision-making. Residents may find that fellowship helps them to gain a niche or occupational advantage in certain competitive or saturated areas.
A recent 2014 cross-sectional survey performed in Canada demonstrated that 78 percent of graduating otolaryngologists reported pursuing fellowship training. Ninety percent identified the pursuit of fellowship training as moderately influenced by limited job opportunities. The ability to find and secure full-time employment, losing technical skills if underemployed/unemployed, and being required to consider working in a less-desired city/province were most concerning to those surveyed.4 While the job market in Canada is not the same as in the United States, it is certainly interesting to consider that some of these same forces may be driving resident decision-making in the U.S.
Otolaryngology continues to advance at an amazing pace. Subspecialization has aided our field in providing the highest level of care to our patients and has encouraged academic pursuits in specific areas, helping our field to evolve and expand the limits of what we can accomplish as practitioners. Major questions residents face entering our increasingly subspecialized field are: 1) What will the value of our general otolaryngology certification be? 2) Are we poised to be successful in a broad-based practice after our general otolaryngology training? Additionally, one wonders that if the amount of trainees entering fellowship continues to expand, is there a need to augment our current five-year training system in an effort to facilitate early transition to advanced subspecialty training? This is an exciting time and one that is sure to be filled with positive change.
- Bailey BJ. Fellowship proliferation. Impact and long-range implications. Arch Otolaryngol Head Neck Surg. 1994 Oct;120(10):1065-1070.
- Miller RH. Otolaryngology residency and fellowship training. The resident’s perspective. Arch Otolaryngol Head Neck Surg. 1994 Oct;120(10):1057-1061.
- SF Match Residency and Fellowship Services website. Accessed on November 1, 2014. https://www.sfmatch.org/Specialty.aspx.
- Brandt M, Scott G, Doyle P, Ballagh R. Otolaryngology-head and neck surgeon unemployment in Canada: a cross-sectional survey of graduating otolaryngology-head and neck surgery residents. J Otolaryngol Head Neck Surg. 2014 43:37.