Fellowship training in otolaryngology–head and neck surgery is a relatively new phenomenon that reflects the increasing complexity of clinical medicine. Despite an expansion of fellowship opportunities over the last three decades, there is still incomplete regulation and standardization of fellowship training. Approximately one third of residency graduates obtain some form of fellowship training. This article describes the fellowship opportunities that are currently available within the field of otolaryngology. Fellowship training serves as an avenue to gain further credentials and certification, although only the fields of neurotology, pediatric otolaryngology, and sleep medicine are accredited by the ACGME.
The purpose of fellowship training after completion of an otolaryngology residency is to provide a focused, intensive, educational experience in a recognized subspecialty area . There are various reasons why a graduating resident may wish to pursue further training. People choose a fellowship to master a content area, usually in a field that interests them and in which they would like to focus their practice. In other instances, fellowship training may facilitate hospital credentialing to perform certain procedures that are considered to be outside of the scope of practice of general otolaryngology, such as cleft lip/palate repair, skull base surgery, or free-tissue transfers. For some, fellowship training functions as a mechanism to achieve a market advantage over colleagues with a general practice. Specialization within a narrow field also may confer a perceived improvement in job security or safety from malpractice litigation .
Currently, the American Academy of Otolaryngology–Head and Neck Surgery (AAO-HNS) Web site has links to information for fellowships in facial plastic and reconstructive surgery, head and neck oncologic surgery, laryngology and voice disorders, otology/neurotology/skull base surgery, pediatric otolaryngology, rhinology and sinus surgery, and sleep medicine. Fellowship training is commonplace within otolaryngology, and the purpose of this article is to summarize the current fellowship training opportunities available in otolaryngology and discuss current trends and attitudes toward subspecialization within otolaryngology–head and neck surgery.
Fellowship training in otolaryngology–head and neck surgery is a relatively new phenomenon. During the1960s there were fewer than 10 fellowship programs in otolaryngology; however, this number grew to approximately 25 in the 1970s, and by 1991 there were 105 fellowships listed in the American Academy of Otolaryngology fellowship directory. This explosion in fellowships was so dramatic that by 1993 151 fellowships were listed in the same directory . The reasons behind this explosion included deficiencies in the standard otolaryngology residency, expansion of the clinical scope of practice of otolaryngology, and socioeconomic forces that favored fellowship directors and the trained fellow. The dramatic changes taking place within fellowship training were concerning to many who felt that the strength of our specialty depended on maintaining the integrity of the general practice of otolaryngology and the unity of the specialty.
In the early 1990s, Dr. Byron Bailey raised the issue of proliferation of fellowships in a series of editorials and papers . He recommended that steps be taken to ensure that subspecialization within otolaryngology would be helpful for the specialty. In particular, he recommended that studies be undertaken to determine the number and type of fellowships needed to meet public need. He stressed that manpower studies and workforce optimization (oriented toward the public welfare) should be the guiding factors in determining the number and variety of subspecialty fellowships offered. He also called on the specialty to establish educational standards for fellowship training, take steps to accredit fellowships, and study the effect of fellowships on residency education. Finally, he advised that we develop a method to certify/credential fellows and define the content of general otolaryngology–head and neck surgery . Fellowship training in otolaryngology has gone through many changes over the last 15 years, and to varying degrees these admonitions have been heeded.
Who does a fellowship and why?
Fellowship training is important in the academic setting. Academic programs at tertiary care institutions are burdened with caring for complex, difficult cases, and a subspecialty-trained faculty is most capable of caring for these patients. Academic departments with residency training programs also are charged with training residents in the depth and breadth of the field of otolaryngology–head and neck surgery. A complement of faculty trained in the various subspecialty areas is crucial to expose otolaryngology residents to the myriad highly specialized diagnostic and treatment strategies within the broader field of otolaryngology. It is no surprise that a survey by Nadol of young academics in 1997 found that 71% had done a clinical fellowship after residency. It should be remembered, however, that many of the prominent fellowship mentors around the country, and those who have pioneered many of the techniques of subspecialty otolaryngology, were not themselves fellowship trained. So fellowship training is not a requirement for an academic career and, in fact, general otolaryngologists within academic faculty can serve as effective role models for most residents who eventually enter careers in general otolaryngology.
The motivations for pursuing fellowship training are many and various. In a 1994 survey study of fellowship-trained otolaryngologists, various motivations were uncovered . The primary reason for taking a fellowship was a perceived inadequate operative case load in the subspecialty area during residency. This was followed by a perceived need for an extra year of training to secure an academic position and a need for an extra year of training to enhance private practice. Interestingly, 87% of respondents, all of whom completed fellowships, felt that the number of fellowship slots should not be increased. This study was published in 1994, and 80% of survey respondents finished their fellowship since 1980, demonstrating the relative novelty (at the time) of fellowship training. Miller studied the attitudes of residents about fellowship training. In his 1994 survey study, 32% thought that taking a fellowship would be necessary for success in their careers, whereas 44% thought it unnecessary. He suggested that residents may seek fellowship training because of a perceived inadequacy of their residency. Other reasons included the desire to develop a subspecialty practice, enhance academic progression, avoid malpractice suits, gain more hospital privileges, improve competitiveness for patients, and increase income .
Various benefits accrue for otolaryngologists who pursue fellowship training. Spending even a single year concentrating on one aspect of otolaryngology with the exposure to increased numbers of higher complexity surgical cases can be a valuable investment. Surgical expertise comes with the performance of large numbers of specialized procedures; for some procedures this experience is not available in residency. A broad, diverse education in otolaryngology often does not allow a resident to perform the numbers of cases in some subspecialty areas that are required to achieve a high level of expertise. There is also the invaluable experience of learning under the guidance of fellowship mentors.
A common reason that most residents decide against fellowship training is their desire to practice general otolaryngology and the fact that they feel adequately trained by their residency program. This reason differs from a prevalent problem in the past, when most residents who went into fellowships did so because of inadequate training and teaching. Undoubtedly, modern residency programs are doing a better job of training residents; consequently, the motivation for additional training has shifted. We agree with Dr. Bailey that “there is no place in the fellowship world for remedial fellowships” and that the purpose of fellowship training always should be to achieve a higher level of mastery in a given subspecialty, for the benefit of patients and the public as a whole. Fellowships should not make up for inadequacies within residency training but should enrich a physician’s career, whether it be in academic or private practice.
What fellowships are available?
Currently, fellowships are available in the following subspecialties: facial plastics, head and neck oncology, pediatric otolaryngology, otology/neurotology/skull base surgery, rhinology/sinus surgery, and laryngology/voice. Otolaryngologists are also eligible to participate in the newly accredited sleep medicine fellowships. The subspecialties of rhinology, facial plastics, neurotology, and pediatric otolaryngology all participate in a formal match through the San Francisco Match (SFMatch) program, whereas the programs in head and neck oncologic surgery participate in a separate match that is sponsored by the American Head and Neck Society (AHNS). Laryngology fellowships and some other nonaccredited fellowships do not participate in a formal match. The following section details the current fellowship training options.
Sleep medicine
Currently, more than 50 sleep medicine fellowships are available as listed on the American Academy of Sleep Medicine Web site . Of these fellowships, 43 are Accreditation Council for Graduate Medical Education (ACGME) accredited ( Box 1 ). Sleep medicine fellowships prepare otolaryngologists to provide comprehensive medical care to patients who have disordered sleep. Additional education is provided in the basic sciences related to normal sleep and sleep disorders, organ system physiology in sleep, advanced diagnostic and management skills (eg, the interpretation of polysomnography,) pharmacology and medical management, and the whole range of sleep disorders (ie, insomnia, parasomnias, sleep-related movement disorders, and hypersomnia). Most of these fellowships are mentored by non-otolaryngologists and are 1 year in duration. A fellowship in sleep medicine can be a useful training experience for individuals who wish to focus their practice on the medical and surgical management of sleep disorders or plan to operate a sleep laboratory.
University of Florida
University of Iowa
Rush University
Beth Israel (Boston)
Hennepin County Medical Center, Minnesota
Washington University (St. Louis)
Dartmouth-Hitchcock Medical Center
Albert Einstein University
New York University
Ohio State University
Temple University
Vanderbilt University
University of Vermont
Medical College of Wisconsin
Northwestern University
University of North Carolina
Duke University
University of Louisville
Johns Hopkins University
Mayo Clinic
University of Mississippi
Seton Hall University
University of Buffalo
Case Western Reserve University
Drexel University
University of Pennsylvania
UT Southwestern University
University of Washington
University of Michigan
Long Island Jewish Hospital
University of Cincinnati
Brigham and Women’s Hospital
Wayne State University
University of Missouri
University of Nebraska
University of New Mexico
Winthrop University
Cleveland Clinic
Thomas Jefferson University
University of Pittsburgh
University of Utah
University of Wisconsin
Henry Ford Hospital
A sleep medicine certification program was developed recently by the American Board of Otolaryngology (ABOto) in conjunction with the American Board of Internal Medicine, American Board of Pediatrics, and American Board of Psychiatry and Neurology. For ABOto purposes, a sleep medicine specialist is a board-certified otolaryngologist who has been prepared by an ACGME-accredited sleep medicine fellowship or who meets the alternative pathway requirements and has passed the ABOto sleep medicine certification examination. This special certification for sleep medicine first became available in 2007. The alternative pathway is valid through 2011 for people without 12 months of dedicated sleep training and is based on practice experience with sleep medicine and interpretation of polysomnograms or prior certification by the non–American Board of Medical Specialties/American Board of Sleep Medicine. More detailed information can be found at www.aboto.org .
Neurotology
The neurotology fellowship program is the most developed subspecialty fellowship in otolaryngology. Fellowship training in otology/neurotology spread across the United States as otolaryngologists trained by Howard House started their own fellowships and promulgated the neurotologic techniques they had learned at the House Clinic . By 1990, there were 31 known neurotology programs . Neurotology certainly has been the leader among the otolaryngology subspecialties to demand accreditation through a governing body such as the ACGME. Through a long and difficult process, leaders at the American Otologic Society, American Neurotologic Society, and American Board of Otolaryngology forged a vision for otology/neurotology as a distinct specialty in medicine. Over a period spanning more than a decade, these leaders navigated through uncharted waters to achieve a series of accomplishments.
In 1992, otology/neurotology became the first American Board of Medical Specialties–approved subspecialty of otolaryngology. A 2-year fellowship plan with detailed curriculum and requirements was then submitted to the ACGME and finally approved in 1995. The first training program was approved by the ACGME in 1997. The ABOto approved a certificate of added qualification in 2002, and the first subspecialty examination in neurotology was administered by the ABOto in 2004 . To obtain this certificate of added qualification, an individual must complete one of the accredited fellowship training programs or meet the criteria spelled out in the alternative pathway. The alternate pathway to neurotology certification will be available until 2012. It requires 7 years of clinical practice in neurotology, submission of 2 years’ operative experience, and documentation of at least ten intracranial exposures in the last 2 years.
Currently, there are 15 ACGME-accredited programs in neurotology, all of which require 2 years of training. The Joint Residency Committee of the American Otologic Society and American Neurotologic Society sponsors the matching process and restricts programs listed through the SFMatch program to approved programs. Because of the requirements of the ACGME, the fellowship is designated as “neurotology residency” . The neurotology residency provides advanced education beyond that provided in otolaryngology residency in the basic sciences related to the temporal bone and lateral skull base, communication sciences, neurophysiology, advanced audiologic and vestibular testing, and diagnostic evaluation and management, including advanced surgical management of diseases of the auditory and vestibular system, temporal bone, cerebellopontine angle, lateral skull base, and related structures. Of the 2-year experience, a maximum of 6 months is dedicated to protected time for research. The neurotology residencies are subject to the same strict curricular requirements that are standard in otolaryngology residency, including work hour restrictions, a dedicated didactic program, and instruction and evaluation based on the six competencies.
The AAO-HNS directory lists 15 otology/neurotology and 7 neurotology/skull base fellowships ( Box 2 ), some of which are not ACGME-accredited fellowships. These other nonaccredited fellowships are usually 1 year in duration, and their quality and content are unregulated. Current and future participants in these nonapproved fellowships are not eligible to obtain the certificate of added qualification in neurotology unless they also complete an ACGME-accredited neurotology residency.
Stanford University
University of California San Diego
University of Southern California
Jackson Memorial Hospital (Miami, FL)
University of Iowa
Northwestern University
Massachusetts Eye and Ear (Harvard)
Johns Hopkins University
Michigan Ear Institute/Wayne State University
University of Michigan
New York University
Ohio State University
Vanderbilt University
Baylor College of Medicine
University of Virginia
Rhinology
Fellowships in rhinology provide additional training in the diagnosis and medical and surgical management of sinonasal disease. These fellowships have proliferated with the introduction of endoscopic sinus surgery and development of endoscopic techniques to address pathology of the anterior skull base. Fellowships are usually 1 year in duration, and a formal matching program was initiated in 2006. Currently, no specialty organization or accrediting body provides oversight or quality control for these fellowships. Although the American Rhinologic Society sponsors the rhinology fellowship match through the SFMatch program and provides a directory of programs, it does not monitor or certify any rhinology training program. In the June 2007 match for rhinology, there were 18 participating programs with 18 positions offered. Further information about the rhinology match can be found at www.american-rhinologic.org/fellowship.phtml .
Pediatric otolaryngology
Pediatric otolaryngology is a subspecialty defined by the age of the patients and the training of the physicians. Pediatric otolaryngologists are expected to have education and experience that exceeds that afforded in otolaryngology residency. Pediatric otolaryngologists manage neonates and children with complex otolaryngologic problems who often have significant comorbidities. ACGME-accredited fellowships must be based at tertiary care children’s hospitals. The ACGME-approved “pediatric otolaryngology residency” must provide educational experiences in the diagnosis and treatment of complex congenital and acquired conditions that involve the ear, nose, throat, head and neck, and aerodigestive tract. Additional education is also provided in management of disorders of voice, speech, language, and hearing. Currently, five “pediatric otolaryngology residencies” are ACGME accredited, each fellowship being 2 years in duration ( Box 3 ). ACGME-accredited pediatric otolaryngology residencies are subject to the same stringent educational requirements mandated of otolaryngology residency programs, including a formal curriculum, monitoring of case numbers, nonclinical educational experiences, work hour restrictions, and instruction and evaluation in the six competencies. Most pediatric otolaryngology fellowships are not accredited by the ACGME, however. Overall, 21 programs are listed in the American Society of Pediatric Otolaryngology directory, and there are approximately 26 positions available per year. Fifteen programs participated in the most recent match in May 2007. The nonapproved fellowship programs last from 1 to 2 years .
