The American Board of Otolaryngology was incorporated in 1924, a few years after the precursor to the American Board of Ophthalmology, and many training programs in that era taught both specialties. It was not until 1940 that requirements for board eligibility in otolaryngology specified 1 year of a general internship and 1 to 2 years of otolaryngology-intensive instruction. Up to 1959 a combined residency in otolaryngology and ophthalmology was an allowable pathway to examination by the American Board of Otolaryngology, but thereafter the current 5-year postgraduate training period was adopted, initially encompassing a year of internship, a further year of general surgery training, and 3 years of otolaryngology, and gradually evolving to 1 year of a general surgery internship followed by 4 years in otolaryngology. Whereas the training requirements for the otolaryngology component are highly detailed and cover the breadth of the specialty, those for the intern year (PGY-1) have been deferred to the discretion of the general surgery program director, and have resulted in a highly variable experience across this country for otolaryngology-bound interns. The reasons range from the otolaryngology-bound trainee participating in only the first year of a structured 2-year introduction to general surgery, to the “cannon fodder” rotations that some specialty residents endure during their sole year on a general surgery service. In too many instances, trainees are arriving at the PGY-2 year inadequately prepared for otolaryngology training that is growing progressively more complex with the evolution of our subspecialties. Indeed, the goal for a more uniformly prepared PGY-2 recently prompted the Residency Review Committee (RRC) for Orthopedic Surgery, under the aegis of the Accreditation Council on Graduate Medical Education (ACGME), to acquire control of the PGY-1 year from the RRC for General Surgery, and such change was also successfully pursued by the Otolaryngology RRC this February. A survey by the Residents and Fellows Section of the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) in 2003 had ascertained that over one-half of otolaryngology-bound PGY-1s were missing rotations in anesthesia and emergency medicine, and that Section requested the Board of Directors endorse the transfer of control of the PGY-1 year from the General Surgery to the Otolaryngology program directors. Such position was also supported by the American Board of Otolaryngology, and by 77% of Otolaryngology program directors subsequently surveyed. The new program requirements incorporate the PGY-1 year into a 5-year otolaryngology residency, specifying PGY-1 year rotations in anesthesia, critical care medicine, emergency medicine, and neurosurgery, plus at least 5 further months on services such as general surgery, thoracic surgery, pediatric surgery, and plastic surgery. Such should greatly diminish the possibility of a “nightmare” internship year of little relevance to subsequent otolaryngology training, and eschew the necessity of some PGY-2 otolaryngology residents having to postpone clinical rotations in our specialty to take rotations in anesthesia or the like that were missed during the PGY-1 year.
Another recent change affecting training in all surgical specialties is the new duty hour work rules mandated by the ACGME as of July 2003. Such are a less stringent version of the restrictions in effect in the state of New York, and were initiated by the ACGME when it became apparent that federal and/or state agencies were going to regulate resident work hours if organized medicine did not do so of its own volition. Basically, the duty hour rules involve an 80-hour weekly limit, in-house call no more frequently than 1 in 3 nights, and 1 in 7 days free from all clinical duties, averaged over a 4-week period. An “exception” for up to an additional 8 hours per week (88 hours total) can be requested by any program director. Although the surgical RRCs expected many such “exception” requests, during the first year of the new duty hour rules only 3 of 119 Otolaryngology program directors (102 residencies, 17 fellowships) applied, and this current year only 2 programs have done so. Current otolaryngology residents seem to be averaging only 75 to 78 duty hours per week. For a frame of reference, the 2003 survey of AAO-HNS active Fellows tabbed their average work week at 50 to 51 hours. Note that all surgical RRCs still have concerns regarding as-yet-undocumented (we have only 1 year of data available to date) untoward effects of duty hour restrictions on resident training, and have petitioned for an increase in the allowable work hours for chief residents; it is during that final year of training that a resident participates as surgeon in the more complex cases, and such is also a transition year to private practice when a “by-the-time-clock” approach to patient care is inappropriate.
On a final note, the program requirements of the two subspecialties of otolaryngology currently certified by the ACGME, namely neurotology and pediatric otolaryngology, are being altered to pare overlap with those of the core curriculum of an otolaryngology residency. As examples, tonsillectomy, adenoidectomy, and myringotomy enumerations have been dropped from the pediatric otolaryngology fellowship, as have tympanoplasty and mastoidectomy from those of neurotology. In June, the ACGME approved a new subspecialty fellowship in sleep medicine, sponsored jointly by 5 Residency Review Committees, including Otolaryngology. This 1-year fellowship encompasses the evaluation and conservative management of sleep disorders, but neither airway endoscopy nor surgical interventions will be taught, and such should diminish overlap between a sleep medicine fellowship and an otolaryngology residency.
