Spotlight Interview: Why Did You Choose ENT?

Neck Dissection
 

An Otolaryngology (ENT) Resident’s Perspective: From an interview with an ENT resident at from the Midwest.

Part of an interview series entitled, "Specialty Spotlights", which asks medical students' most burning questions to physicians of every specialty.  See what doctors from every specialty had to say about why they chose their specialty and how to match in their residency.

 

  • What attracted you to ENT?

I was attracted to surgery initially.  After shadowing in ENT I realize that I really enjoyed the anatomy, I enjoyed the personalities that I encountered in the specialty and I thought that the idea of treating deafness with cochlear implants and the idea of helping kids with cleft lip really exciting.

 

  • Describe a otolaryngologist’s typical work day?

Work is usually in the office or in the operating room.  Some ENTs split their day between both, but most have "clinic days" and "OR days".  A resident will round in the morning (early like surgery) and either go to the assigned OR or go to the assigned clinic.  Rarely do residents have days to just do floor work after internship.  After the day's work is done residents will finish any consults from the day, round on the patients in the evening and sign out to the covering resident.  

Attendings will typically come in to start their OR or clinic in the morning, check on their patients during the day, and head home when the work is done.

 

  • What type of lifestyle can a otolaryngologist expect?  

ENT lifestyle is good.  Most ENTs have predictable hours and flexibility to arrange their schedule to avoid working late into the night.  In private practice, ENTs finish by 5 o'clock and their family can count on them to be home.  In academic practice, there can be more evening meetings or emergent consults; and family flexibility is important.  Many ENTs are in academic medicine or practice in private groups and divide call across the group. 

 

  • What is the potential salary of a otolaryngologist?

$200-300k for someone starting academic job, 400-600k+ for private (Midwest estimates)

 

  • What is the job market like for otolaryngology?

There seems to be a shortage of ENTs currently and private groups are recruiting heavily across the country.  Academic jobs are available, but may require flexibility on location to get exactly what you are looking for.  Fellowships are generally available, although trends seem to ebb and flow & are unpredictable.  (i.e. recently facial plastics fellowships were very popular: twice as many applicants as positions, but not the case this year (2015))

  • What can you tell us about otolaryngology subspecialties?

Options for otolaryngologists include General ENT, Head and Neck Oncology, Facial Plastics and Reconstructive surgery, Advanced Pediatric Otolaryngology, Laryngology, Rhinology/Allergy, Otology/Neurotology, Skull Base, Surgery, Sleep Medicine.  All differences in salary are mainly determined by private vs. academic setting.

+General ENT- no extra training, most are in private practice with great salary and wide open job market

+Head and Neck oncology- 1-2 year fellowship required, almost all are associated with academic department, most likely type of ENT to have long hours- because surgeries are complex and urgent due to cancer treatment.  Airway and bleeding emergencies happen in the patient population, so call can include overnight emergencies requiring surgery.

+Facial plastics and reconstructive surgery: 1-year fellowship, there is variability within this subspecialty from purely cosmetic facial plastic practice to free flap reconstruction after major cancer surgery.  The lifestyle of the cosmetic surgeon in private practice can be as glamorous as it sounds.  The free flap surgeon lifestyle resembles the head and neck-oncologist.

+Advanced pediatric otolaryngology- 1-2 year fellowship, generally associated with tertiary referral hospital and/or academic center.  Lifestyle is a bit busier because they are more likely to have ICU patients than General ENT counterparts.  Kids are frequently getting things stuck in their trachea at night so call often involves surgery.  

+Laryngology- 1 year fellowship: voice surgery, again typically associated with academic center/tertiary hospital.  Some of these ENTs treat professional vocalists and their practice may resemble the cosmetic (posh) clinic.  Most laryngologists have consistent hours but airway emergencies can be quite stressful.  

+Rhinology/Allergy- 1 year fellowship. Generally specialize in sinus surgery and there is a trend to managing allergy.  May be in private or academic setting.  Lifestyle is good because emergencies are rare- consults can generally wait until office hours.  Somehow billing has been very favorable for rhinology and they are in demand because their practice is lucrative.  

+Otology/Neurotology- 2 year fellowship. Focus on treating ear disease and ear surgery including operations on the internal auditory canal (between the brainstem and the inner ear.)  They are associated with tertiary referral centers/academic centers and have a good lifestyle- consults can generally wait for business hours.  

 

  • What are the potential downsides of otolaryngology that students should be aware of?

The residency is a surgical residency and that comes with the long hours, pimping, and no service cap.  ENT does not have strong history of research and there are many aspects of treatment which are based on expert opinion as the best evidence.  If you want evidence like cardiology has- it just isn't there yet.  You will encounter snot, ear wax, tracheostomy secretions, pus from neck infections.  If this is unacceptable- stay away.  

 

  • What else would you tell medical students who are considering otolaryngology?

Many ENT's enjoy all of the gizmos.  Our academic meetings feature many companies coming up with gadgets, scopes and tools for work in the ear/nose/throat.  Robotic surgeries are becoming common in ENT practice.  Minimally invasive surgery is progressing rapidly.  Some of the first applications of 3D printing in medicine have occurred in ENT.  If  you love innovation, look into this specialty.  We have been curing deafness with cochlear implants for decades.  There are many more examples.

There is a big variety within the field and you can perform simple procedures like ear tubes or tonsillectomies- all the way to reconstructing a baby's trachea or removing the voicebox for cancer treatment.  We frequently work alongside other specialities; neurosurgery has overlaps, endocrine surgery with the thyroid and parathyroid glands, oral surgery, ophthalmology, plastic surgery, pediatric surgery, cardiothoracic surgery etc.   

Another strength of the specialty, in my opinion, is that there is no direct medical counterpart (for example neurosurgery and neurology).  Which means that we treat head and neck diseases and we decide when to treat medically and when to treat surgically.  

 

Editor's Note: For more help choosing a specialty in medicine, I highly recommend one or both of these two great books. I found both very useful.

 

Spotlight Interview: How to Match in ENT

Ear Exam

 

An Otolaryngology Resident’s Perspective:  From an interview with an ENT resident from the Midwest

 

Part of an interview series entitled, "Specialty Spotlights", which asks medical students' most burning questions to physicians of every specialty.  See what doctors from every specialty had to say about why they chose their specialty and how to match in their residency.

 

  • How competitive is the Otolaryngology match?

The match is very competitive, recently it has been otolaryngology matched applicants with the highest average Step 1 score.   

 

  •  What must a student do to match well in Otolaryngology ?

Generally applicants need to have good test scores, and strong research and extracurricular features in their CV to be ensured an interview.  However, the programs are small- and personality conflicts are hard to avoid, so the interview becomes crucial to actually matching.  Programs have many qualified applicants and interviews are important for finding people who will be a good fit.  Also, the field is small, a well-connected chairman seems to know all the ENT's in the country, so your letters of recommendation (specifically who wrote them) is vitally important to where you match.  

 

  • What are residencies looking for in a Otolaryngology applicant?
Residencies are looking for someone who they get along with, someone they can trust to tell them the truth when staffing a consult in the middle of the night (not just what they want to hear).  Big academic centers are looking for hard-working and successful researchers with a record of being able to get a project to publication as a student.  Of course, any concerns that the resident will have professionalism or personal coping issues during training will flag them to fall way down the rank list.  (Programs are generally 2-3 people per year/ 5 year program, losing one resident means losing 10% of the residency).

 

  • What should students look for in a Otolaryngology residency?

Students should pay attention to what graduates  have been doing.  If everyone is going into fellowship and becoming chairman somewhere- you can be sure that there is some unstated expectation that matched applicants will continue that trend.  On the flip-side, if everybody goes into general practice and you want an academic job, there may not be mentors or support for you to get there.  Think honestly about what you ultimately desire- then come up with a politically correct way to convey those career goals to discuss in interviews.  

Another thing to look for is representation of all the subspecialties.  It can be hard for academic programs to retain facial plastic surgeons. If you hope to treat cleft lips, make sure there is someone to learn it from.  

Observe the general happiness of the residents.  If you match, you will join that small cohort of people and spend more time with them than your spouse.  Watch for anything that might be intolerable.

 

  • Do you have any advice on the application, letters of recommendation, personal statements, or how to rank programs?

It is a competitive match so seek a mentor who is well-connected in the field.  They will help you with curating experiences to put on your CV and where to get letters of recommendation.  This may mean looking outside your institution.  Successful research is sought and will be discussed at all interviews.   Letters of recommendation are almost all positive, so it becomes important WHO wrote the letter.  If you have your heart set on a specific program, make sure your letter writers know the chair/program director.  Be proactive without being annoying in the process.  One of my co-residents was not offered an interview here, but she called and politely discussed her situation with the coordinator and program director.  She got an interview and ended up matching.  The corollary is that if you are rude to the secratary managing interviews, they can mention it to the committee and get you off the rank list.  Be professional!  Rank lists are deeply personal and involve many factors- but basically rank where you WANT to go. 

 

  • What do you wish you knew before application/interview season?  

I wish I knew how small the field is.  Fortunately my letter writers were well known- to my benefit.  In a competitive specialty like this one, small things matter- if you are professional and hard-working it will show. 

 

Editor's Note: Applying for residency or preparing for your interviews? I highly recommend First Aid for the MatchThe Successful Match: 200 Rules to Succeed in the Residency Match, and The Residency Interview: How To Make the Best Possible Impression .


 

Top Ten Books for Intern year

This list is part of a series of articles about the best books for medical students. Click on the Med School Books Main Page to see other lists including the best books for each year in medical school, the best books for each clinical rotation, and the best books for USMLE Steps 1, 2, and 3.

Many residents will say that there is no time for reading during your internship, but I disagree. You will work very hard, but there are still three types of books that you will need to have access to: 1) great reference material while you are working, 2) more in-depth reference material when you are home so you can read about your difficult patients, 3) "other" books that are either not related to work at all or only loosely related to work.  Below is my list of the Top Ten Books for newly minted interns. Good Luck!

  • Updated May 2015

1. House of God:

I debated for a long time where to put this book on the list, or if it should even be on the list at all. As I shuffled the books in my list, this one kept coming to the top. The truth is, every intern and resident, no matter your specialty, should read this book. Whenever I ask older docs what books new residents should read, this is the first book they mention. It is a classic, quintessential diary of one man's internship in Boston. I don't want to build it up too much, but trust me, you NEED to read this book.

2. Pocket Medicine:

In the category of "pocket reference materials to use at work" nothing is better than Pocket Medicine. The product is unmatched in my opinion. The book addresses common diseases we will all encounter and takes the reader on a step-by-step course from diagnosis to long-term management. There is no better use of your white coat pocket.

3. On Call Principles and Protocols:

While I feel strongly that Pocket Medicine is the best product on the market, On Call Principles does come in second. Some argue that the format is more inviting and the design more elegant, which is true. If this is important to you, On Call Principles is your book. If the content is more important, you will probably like Pocket Medicine better.

4. First Aid for the USMLE Step 3:

It is never too early to start studying for Step 3. Many of you will put off this exam until late in your residencies, something I do not understand. If you take the exam during your internship the material from medical school will be more fresh in your mind, and you will not have the exam hanging over your head throughout residency. If you did well on the previous Steps, a quick breeze through First Aid will get you up to speed. Don't spend too much time studying for this one.
.

5. The Washington Manual Internship Survival Guide :

This unique book is a change of pace from most pocket reference manuals. It focuses a bit more on procedures and general resident life, but is also a great medical reference.

6. Tarascon Pharmacopedia:

As I have said in other posts, a great pharm book is a huge asset in residency. We all have phones and apps, but if you have an easy-to-use pharmacology reference like Tarascon, you will find that it is much faster and more efficient because you will know exactly where things are. This is a GREAT book.

7. The Sanford Guide to Antibiotic Therapy:

I found myself borrowing other students' and residents' Sanford Guide so long that I final got my own. You will never remember all of the bugs and drugs material, and there will always be patients with obscure infectious diseases. This is a great book to keep in your white coat or in your call bag, you will use it weekly no matter your specialty.

8. The Little ICU Book:

You don't need an ICU manual, but your life will be much more simple with one. Whether you spent time in the ICU as a student or not, your experience as a resident is different. There are so many things that you need to be able to juggle, it is often overwhelming. A great reference book in your workroom will become your best friend. I prefer the Little ICU book, but many residents also like the  Marino's ICU Book which is also very good.

9. Harrisons:

In the category of "reference material for home use" I put Harrison's first. Most students and residents are familiar with this famous text. It is thorough, up-to-date, and and not too dense. You will always have difficult patients on your service. You will be thinking about them as you go to bed and as you wake up, you need a great and complete reference at your home to read about them.

10. A Crock Pot Recipe Book:

No, I am not joking! You aren't going to have time to cook, but you have to find a way to eat healthy. Even if your hospital provides food money, you can not eat every meal at the hospital, you will go insane. Buy a $50 Crock-Pot, learn a few easy recipes, throw the food in at 6:00 am and have a great meal when you get home.

 
 
 

A Map of All Medical Schools in the United States

Wondering where to apply for medical school or how many medical schools are located in your state? Check out my new map of all medical schools in the United States. As of May 2015 there are 179 total medical schools in the United States. This includes 143 allopathic (MD) and 36 osteopathic (DO) medical schools. I obtained the list and associated locations of each school from Wikipedia's current list of medical schools in the United States. Interestingly, New York is the state with the most medical schools (15), even more than both California (12) and Texas (11). Idaho is the largest state without a medical school (>1,500,000 people living in the state). Click on the icons below to see the name of each medical school.

 

John Oliver: Marketing to Doctors

A few months ago on Last Week Tonight with John Oliver, he spoke about the amount of money pharmaceutical companies spend marketing to physicians. Check out the video clip, the numbers are staggering. I am certainly not an anti-pharma type of person, but this should make you think twice about the free lunches and events provided by drug companies. 

 

Picmonic: A Cursory Review

When I heard about Picmonic, I actually let out a little yelp of excitement and anger. Excitement because I wish I had such a tool while I was in the first and second year of medical school; anger because I thought about building just such a company about a hundred times but never went through with it. Picmonic was developed too late for my first years of medical school, but I keep hearing great things about it from our medical students. Because of all the buzz, I recently downloaded their trial software to test it out and I am impressed. The idea behind Picmonic is to develop absurd images in order to help memorize difficult to understand concepts. Each Picmonic image contains a number of important pearls that should be memorized. Picmonic walks the learner through the image to highlight each pictoral 'mnemonic'. The staff at Picmonic were kind enough to send us their image for clindamycin [shown below]. In this way, any time a student is placed in a situation (in the hospital or on an exam) where he/she must remember these important concepts, the absurd image will pop right into their head, increasing memory recall.

Clindamycin-Picmonic

Increased memory retention using absurd images is actually a well-known phenomenon in teaching organizations. In fact, the best memorizers in the world often use abstract and absurd imagery to memorize lists of random words and numbers. The developers at Picmonic openly state that their software increases memory retention by "300%" and may increase scores on exams by "50%". These numbers seem a bit outrageous, but they recently published their results in a peer reviewed journal (pub med link) and they seem to have some evidence to support their claims. Thousands of medical students are using their software and I have never heard anyone unhappy with the purchase. Some use it far more than others, but everyone who purchases the resource appears to be quite happy. Of course, the utility of this type of device is likely more useful to those students who are more visual, but its effect on memory retention is likely to be universal.

If you haven't tried it out, go to their website, www.picmonic.com, and download their free trial. This is a great resource.

Top Ten Books for Ophthalmology Residents

This list is part of a series of articles about the best books for medical students. Click on the Med School Books Main Page to see other lists including the best books for each year in medical school, the best books for each clinical rotation, and the best books for USMLE Steps 1, 2, and 3.

No one outside of ophthalmology can truly appreciate the breadth and depth of this specialty. Most doctors assume that it must be quite simple to learn everything you need to know about one small organ. Though I had been told this many times prior to ophthalmology residency, I was still shocked but the amount of pathology that occurs in the eye. With a few years of residency under my belt, I will try to answer the most important question: what are the ten best books for ophthalmology residents.

Let me preface this list by saying two things.

  1. To do well on exams (OKAPs, ABO Board Exam) I can not rely on books, but rather I rely on questions. I have previously written a review of Ophthoquestions, which I think is a fantastic online resource and has helped me prepare very well for OKAPS. So while the following books are important, I would not recommend studying for OKAPS without a question bank, either online or in print.
  2. Your attending physicians will tell you that you can not ignore the current literature. For a while I convinced myself that I did not have time or desire to read current journals. However, the longer I am in ophthalmology, the more I realize how effective it is to read through the top ophthalmology peer-reviewed journals. As a resident you will get the "Blue" Ophthalmology Journal at your home. It takes no more than 10-15 minutes to read the abstracts. You will learn a ton and stay up-to-date on what is important in ophthalmology
  • Updated May 2015

1. The Wills Eye Manual:

A great reference manual is a must for all ophthalmology residents. The Wills Eye Manual, or as I call it, The Bible, always has everything I need to complete a workup or start a treatment regimen. Some residents also enjoy The Massachusetts Eye and Ear Infirmary Illustrated Manual of Ophthalmology. Both are good, just make sure one of them is in your bag when you take your first call.

2. The Basic and Clinical Science Course (BCSC):

I know what most of you are thinking…What? The BCSC is second? Sacrilege! It is true, the BCSC is a great resource, but I must put the Wills Manual first because of its universal utility. You can carry 15 BCSC books to the hospital with you every day. Most of you will get these from your residency program; if not, you should seriously consider spending the money for them.

3. Friedman's Review of Ophthalmology:

Friedman's is like the "First Aid Series" for ophthalmology. The book is full of high yield facts and pearls. It is surprisingly thorough and is a great resource to study prior to a subspecialty rotation or OKAPs. I have found, however, that reviewing the lists of facts presented in Friedman's is not very useful until you have a grasp of the concepts…something that will come from time in clinic and the BCSC series.

4. Nerad: Techniques in Ophthalmic Plastic Surgery

I will list a number of subspecialty texts in this Top Ten list, but not have I turned to more often than the Nerad text. This is the perfect book to prepare for oculoplastic surgery patients in the clinic and the OR. The night before every oculoplastic OR day I would read through the techniques of the upcoming surgeries and I was always very well prepared to learn in the OR and to answer most pimp questions that came up. I HIGHLY recommend this book. 

5. Last Minute Optics:

I previously wrote about Dr. Hunters free optics lectures. This is the text that parallels his free lectures. If you prefer written text over video lectures, this is the best optics book available. You can read it in a few hours and you will learn a surprising amount of clinical optics. It is perfect for last minute OKAPs studying or if you actually want to learn clinical optics but don't have much free time.

6. Chern: Review Questions in Ophthalmology

There are many great resources for ophthalmology residents looking for good questions. I have already written about the online questionbank, Ophthoquestions, which I highly recommend. There are also 50 questions at the end of each BCSC book, which are very good. As far as printed question books, the Chern book takes the cake. It has hundres of great questions and great explanations.

7. Chang: Phaco Chop and Advanced Phaco Techniques:

Every ophthalmology resident wants to become a safer, faster, more efficient surgeon. Dr. Chang is world renowned in his phaco technique and his ability to teach his phaco tecnique. I found this book to be incredibly useful as I approached my third year surgical rotations. It discusses general techniques and also advice for getting out of difficult situations. You really need to read about everything that can happen in the eye, because you will not see everything as a resident. 

8. Cornea: Krachmer, Mannis, Holland:

The last three suggestions I will make are large, dense, subspecialty textbooks. The BCSC series is simply not robust enough to help with difficult cases. A good cornea text or atlas is a must for all clinics as a reference. I have been very impressed with the organization and clarity of the Mannis text, though there are a few others. For a less dense option with beautiful photos, Krachmer has also put out his Cornea Atlas, which is full of great cornea photos.

9. Ryan's Retina:

A retina reference text is another must-have for residents and clinics. Most of you will have access to these reference books in your libraries or clinics. If not, consider purchasing one early in training so you can familiarize yourself with it and bring it with you to your private clinics after training. The Ryan text is very well known, but another great option is Gass' Atlas of Macular Diseases.

10. Walsh and Hoyt's Clinical Neuro-ophthalmology:

A final must-have reference is a great neuro-ophthalmology text. Remember, these are the issues that can kill ophthalmology patients. You will not always have fellows and neuro-ophthalmologists in the room next door and you will need a great reference book. The Walsh and Hoyt text is the favorite of most ophthalmologists. 

 
 
 

ophthoquestions.com: A Review

 

I realized early in medical school that, for me, the best way to learn is by doing questions. USMLE World and Kaplan's QBank got me through Step 1, Step 2, and Step 3. When ophthalmology residency started, I was relieved to hear about www.ophthoquestions.com. A much smaller pool of buyers (US and maybe UK ophthalmology residents) means the company can not have nearly the same profit margin as USMLE World and Kaplan. Nevertheless, I was quite surprised to see that the product was still very good. I have been VERY please with my experience, here are my thoughts…

 

ADVANTAGES

  • The online format is unique in the field of ophthalmology. There are many great review books and question books to prepare for the OKAPs and the American Board of Ophthalmology (ABO) Exam, but nothing as portable and technologically savvy as ophthoquestions.
  • The questions are well written and parallel very well the questions on the OKAPs. I am told they also parallel well the questions on the written ABO Exam. Having not taken the ABO Board, I can not verify this.
  • For the most part, the explanations are detailed enough to learn the finer points of the pathophysiology without being overbearing. If anything, ophthoquestions errors on the side of being to succinct. They can do better at having more robust explanations. In this regard, USMLE World and Kaplan's Q-Bank are superior products. 
  • The questions are obviously written by subspecialists with knowledge in the specific fields, making the answer explanations very reliable.
  • If you do all the questions in the database you will be VERY well prepared for OKAPs
  • The price may seem steep (~$150 per year) compared to question books, but with 3,500+ questions nothing has the same amount of content

DISADVANTAGES

  • In my opinion, the current (May 2015) content on the site does not properly reflect to proportions of subspecialty content on exams. For example, and huge proportion of the ophthoquestions content is devoted to refractive surgery, while very little is devoted to uveitis. This does not reflect the content on exams, and certainly does not reflect the content that ophthalmologists should know.  Of course, you can simply not do all the refractive surgery questions, and this would solve the problem. 
  • The writers occasionally become defensive and personal when defending their questions and answers. I respect their opinions but I really don't think that a question bank is the place for defensive answers. 
  • If you do NOT complete all the questions in the database, the price (~$150 per year) is certainly very high. If you are only going to do a few hundred questions, you might as well purchase a question book like Chern: Review Questions in Ophthalmology

CONCLUSION

I am very pleased with my ophthoquestions.com experience and recommend it to all new residents. It is the best product on the market for OKAP and ABO board preparation. It has some faults, but to be honest, not that many. I am not someone who will read the whole BCSC series, because I will never remember chapters and books. But the content in ophthoquestions is presented in a memorable and organized way that has CERTAINLY helped me do well on the OKAPs exams.

 

Some other ophthalmology review tools:

The Anti-vaccination Movement, According to The Daily Show

I try not to touch on too many hot-button issues on this website; vaccines are the exception. In my few years as a medical student and resident I have already personally witnessed too many terrible things that could have been easily prevented with vaccines. No matter your political affiliation, this bit by John Stewart is incredibly funny. Thank you, Daily Show, for finding a way to make me laugh out loud about something that I find so not funny most of the time.

 

 

 

Hunter Optics Lectures and Last Minute Optics

David Hunter md phd

If you are a current or future ophthalmology resident, you should become familiar with the lectures produced by Dr. David Hunter MD PhD. He is the Chief of Ophthalmology at Boston Children's Hospital and has produced four, one-hour lectures that are incredibly high yield. I heard about these lectures before I took the OKAPs in-service exam during my first year of ophthalmology residency and I haven't looked back. Optics was, by far, my best score on the OKAPs my first year and I credit Dr. Hunter's lectures for the success. 

You can find all of his lectures on video, for free, on the Boston Children's Hospital website (link).  He has specifically said that he would love for everyone to have these lectures for free. Therefore, I will link to each of his lectures below. I have found that the above link occasionally does not work (usually in early March of every year, because we are all downloading from it). If you have issues, let me know and I can send you the files from my computer.

I really like the video lectures, however he has also published a book with the same content. Most of the residents in my program actually prefer the book because they feel like they can get through it faster and things are more clear when they read the book.  Whether you use his lectures or his book, the content is the same and it is fantastic. Take a few hours before the OKAPs to really learn this stuff, it will pay off in the long run.

 

   LINKS TO LECTURE VIDEOS

 

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