Five decades ago, otolaryngology dealt primarily with infectious diseases of the head and neck. The quality of otolaryngology residency training programs was inconsistent and mostly determined by the institution and local faculty. The specialty flourished by developing new expertise in all facets of head and neck medicine and surgery through the leadership of outstanding clinicians and scientists in private practice and universities. Otolaryngology programs subsequently grew from weak divisions within a department of surgery with few faculty members to departments of otolaryngology with full-time, mostly fellowship-trained faculty. Teaching shifted from resident-to-resident to faculty teaching. Organized medicine encouraged systematic quality improvement and periodic review of programs for accreditation. Residencies were also bolstered through Medicare, Medicaid, and Veterans Administration hospitals, which provided funds for growth but limited flexibility of the faculty schedules. The American Academy of Otolaryngology/Head and Neck Surgery shouldered an enormous load of teaching and maintaining unity of the specialty from its birth to the present.
In 1950, conventional wisdom said that otolaryngology was a dying specialty. Otolaryngology was primarily concerned with otitis, mastoiditis, sinusitis, neck abscesses, tonsillitis, and their complications, and new antibiotics were curing more and more infections . At that time, head and neck cancer and thyroid surgery were commonly the purview of general surgeons, 1
1 Even into the 1960s, otolaryngology residencies were often limited in departments of surgery and could perform only partial or total laryngectomy, whereas other surgeons performed radical neck dissections and composite resections.and cosmetic surgery was generally performed by plastic surgeons. Even tonsillectomy might be performed by general practitioners, general surgeons, and some pediatricians. Approved otolaryngology residency slots were often unfilled, and the quality of otolaryngology training programs was inconsistent. A good otolaryngology research program was the exception rather than the rule. Otolaryngology was also just emerging from The American Academy of Ophthalmology and Otolaryngology as the new American Academy of Otolaryngology. 2
2 The American Academy of Ophthalmology and Otolaryngology was formed in 1896 as a foundation for continuing education. The two academies divided and otolaryngology became the American Academy of Otolaryngology. This academy was later renamed the American Academy of Otolaryngology/Head and Neck Surgery.
In perspective, medical students in 1950 seemed much less anxious about choosing a specialty than today’s students are. Residencies were plentiful and less competitive, and it was not uncommon to find medical school graduates returning after several years of general practice to what is considered today a “competitive” residency. Many medical graduates in the 1950s served “rotating internships” and then entered practice, and others made their final specialty decision during internship or during military service. A “match” was generally achieved by a single visit to a couple of residency sites. From the late 1950s to the middle of the 1970s, draft-eligible medical graduates were routinely called to 2 years of military service; in the 1960s and 1970s numerous physicians served in Vietnam. In response, residency programs customarily required applicants to have either completed their military obligations or to have an official deferment through the Berry Plan before being accepted in otolaryngology. 3
3 The Berry Plan granted a military deferment for specialty training in exchange for 2 years of service after completion of specialty training. Thus, the armed services were able to guarantee highly trained medical personnel for their forces.During this time period, residency directors labored to improve training; change was slow, however, and any change was normally driven by institutional factors rather than regulatory agencies. On the positive side, “paper work” in this environment was modest compared with today’s hours committed to documentation.
An otolaryngologist of 1957 would be astounded by the breadth and depth of the vibrancy of the specialty in 2007. This 1957 otolaryngologist (almost certainly a white male) would be impressed to see that otolaryngology is now the primary provider of head and neck surgical oncology and skull base surgery. In addition, otolaryngologists are now routinely becoming “super specialists” in neurotology, laryngology, facial plastic and reconstructive surgery, pediatric otolaryngology, rhinology, and otolaryngic allergy. What happened to bring this “challenged” specialty to such heights over the past 50 years?
Except for localized anecdotes from senior physicians, much of what has changed in the specialty is now remote, if not forgotten. There is the impression that the “chiefs of old” would neither be able to envision nor tolerate sitting passively while a room full of accomplished surgeons is chided by clerks over ICD-9 and CPT peccadilloes. Would these “chiefs” of the last century immediately equate codes and compliance regulations as symbols of quality care and good outcomes? Lamentably, reimbursement and “doctoring the chart” now often seem to take precedence over teaching, character, or performance. Physicians from 1957 would, however, be impressed with today’s computerized world and scientific technology that have led medicine to a “continuous quality improvement” in contemporary practice. They might be especially surprised to see women and minorities in leadership positions.
Otolaryngology has changed in countless ways since 1957, a change driven, in part, by an unprecedented exponential growth of knowledge and technology in the physical, biological, and behavioral sciences. Clinical advances occurred because numerous otolaryngologists responded to these developments with dedication and innovation. Otolaryngology has particularly benefited from these scientific advances partly as a consequence of otolaryngologists’ early expertise as microscopic surgeons and a keen interest in applying new knowledge in basic head and neck physiology and neurophysiology to clinical problems.
The knowledge explosion reshaped otolaryngology training in the United States, and the following are thought to be the significant internal and external forces that shaped the modern otolaryngology residency:
The improvement in faculty quality and quantity
The American Academy of Otolaryngology/Head and Neck Surgery’s supporting presence
The development of academic departments of otolaryngology
Medicare and Medicaid
The Veterans Administration (VA) hospitals
Accreditation Council of Graduate Medical Education (ACGME)
The American Board of Otolaryngology (ABOto)
The Residency Match Program
These forces of change are discussed briefly below.
Change factors within otolaryngology
Otolaryngology has been blessed with talented and tenacious innovators who overcame intimidating obstacles to develop and expand this specialty in many directions. It was a partnership of many: otolaryngology chairs, academic faculty, and numerous dedicated private practitioners all contributed to the effort. Over the past 50 years, many residency programs were kept alive solely because dedicated private physicians would not let them die. In many cases, the surge in otolaryngology excellence was because of academic private physicians such as John Conley, John Shea, William and Howard House, Jack Anderson, Paul Holinger, George Shambaugh, James Willoughby, and others who often donated their efforts. Herbert Rinkel was an internist, as was his associate James Willoughby, but they both supported the development of allergy and immunology by otolaryngologists. Academic chairmen such as Walter Work, Dean Lierle, Harold Schuknecht, Bobby Alford, Ron Bailey, Joseph Ogura, Paul Ward, and John Kirchner are but a few of the many who wrote extensively and helped inspire and challenge academic otolaryngology to excellence.
The American Academy of Otolaryngology has particularly supported resident education. The academy partnered with its members and the training programs to initiate a home study course, monographs, self-instructional packages, patient of the month, and an annual residency examination. In addition, the academy has maintained a research department that assists young academic investigators, and it acts as an agent and conduit for private and public funding. The academy’s Annual Meeting has continually brought national and international experts together so that residents could also experience a course by the expert and take notice of the latest in scientific presentations. From another perspective, the academy, through tact and compromise, has been a major factor for specialty unity despite the tension of widespread divergent interests from 50 years of subspecialization.
Fifty years ago, significantly fewer medical schools had an otolaryngology residency program; if they did it was usually a division of otolaryngology. These divisions often lacked autonomy, and they were often disadvantaged politically. “Turf wars” were common. Many academic otolarynologists were forced to risk their jobs to obtain departmental status over the years. Today, most otolaryngology programs are autonomous departments, and departmental status has been a vital force for the academic maturity now seen in this relatively small specialty. (Otolaryngologists represent less than 1% of physicians in the United States.)
With the complexity of newer procedures and pressure for excellent results, fellowship training for today’s academic otolaryngologists is almost an absolute requirement. The result is that residents receive the bulk of their procedural instructions and clinic instruction from fellowship-trained specialists or those who have additional experience. While one-on-one faculty-to-resident surgical training has increased under the new model, resident-to-resident teaching has decreased. (The mechanism of how the quality and quantity of faculty increased is discussed further in the section on external factors.) Besides the increases in number of faculty and increases in faculty specialization, another vital factor is the previously mentioned increased quality of otolaryngology residents. Otolaryngology is now viewed as a highly technical, fast-moving, forward- looking surgical field, resulting in a robust competition of residency applicants from the top of the bell curve.
Achieving departmental status and hiring talented faculty were important steps in transforming otolaryngology. In 1957, new hires could be difficult because capital was often lacking. Many residencies in the 1960s had only one or two full-time faculty and could afford no more—a situation that often forced residents to function with minimal faculty supervision. Senior residents trained junior residents, and commonly the faculty was augmented by private physician volunteers. Today, a full-time on-site faculty predominates. Several external developments helped provide the necessary funding to build the modern academic department of otolaryngology.