A Cross-Sectional Survey Study Evaluating United States Medical School Curricula in Otolaryngology

Introduction

Undergraduate medical education curricula in the United States (U.S.) varies widely, with limited standardization. ¹ As the medical knowledge base and requirements for clinical training continue to grow, it becomes more challenging for medical schools to incorporate subspecialty education, like otolaryngology (OTO), into their curriculum. Despite OTO complaints making up to 25% of primary care visits in the U.S., ² medical school curricula around OTO is variable and frequently limited.^2,3 While 99% of U.S. medical schools require a surgery clinical clerkship, only 26% required a surgical subspecialty clerkship in 2019-2020. ⁴ Furthermore, international studies show that OTO is underrepresented in medical education^5-8 and that medical students and primary care physicians do not feel comfortable with OTO basics.^9-12 Thus, it is important to evaluate how U.S. medical school curricula incorporate teaching OTO in order to ensure the next generation of physicians are comfortable managing common OTO presentations.

Prior evaluations of U.S. OTO medical curricula are sparse, but support a similarly limited and variable exposure.^2,3 However, no prior study has evaluated medical school factors contributing to the extent of OTO teaching. We hypothesized that medical schools associated with OTO residency programs will have greater incorporation of OTO teaching in their core curricula and will have more opportunities for student rotations throughout clerkship years. We also hypothesized that larger medical school class size may be indicative of a larger school funding pool, and so may enable larger schools to better incorporate subspecialty teaching. Additionally, we examined the employment structure of OTO faculty to assess whether this may influence the extent of OTO teaching at the medical school. Therefore, this study provides an up-to-date assessment of the state of OTO teaching at U.S. medical schools, evaluates medical school factors contributing to the variability of subspecialty education, and provides recommendations on how medical schools can improve their teaching in OTO.

Methods

A cross-sectional survey study was designed employing a 48-question survey designed in coordination with the Society of University Otolaryngologists (SUO), aimed at evaluating the extent and practices of OTO teaching at medical schools (Supplemental Figure 1). This study was deemed Not Human Subjects Research by the Institutional Review Board of Boston Medical Center, Boston University, IRB Number H-40283. The survey comprised questions regarding the extent of OTO curriculum and resources at medical schools. The extent of OTO resources is evaluated in a concurrent paper.

In May 2020, a Jotform link to the survey was distributed by email to all 155 U.S. allopathic medical schools accredited by the LCME on or before 2020, with a follow-up survey link sent to non-responders in December 2021. Initial survey contacts were identified as otolaryngology program directors, otolaryngology department coordinators, or contacts within a department of medical education. Within the survey email, the contact was asked to forward the survey to the person they thought most appropriate, should they feel unqualified to answer the survey questions. In cases of non-responders, research assistants searched school websites for additional contacts, and on occasion called departments in order to obtain new contact information. To limit non-responder bias, the survey was then sent again to any non-responding school’s identifiable contact, which included otolaryngology program directors, otolaryngology department coordinators, clerkship directors, medical education coordinators, deans for medical education, and registrars.

Survey questions were aimed at measuring the extent and practices of OTO teaching in medical school curricula, notably: otolaryngologist involvement in teaching lectures and Head & Neck exams, presence of optional or required OTO rotations, and formal expectations of OTO knowledge in core curricula (Supplemental Figure 1). Survey questions also included general information about the school, including presence of OTO residency programs, OTO faculty employment structure, organization of subject blocks, and use of computerized or simulation resources. Class size was obtained from AAMC 2021 matriculant data.

Qualitative, open-ended responses were examined and standardized into common themes by multiple research assistants. For example, open-ended responses to describe the formal expectations for students rotating in otolaryngology were standardized into “learning objectives,” “readings,” “didactics,” “presentation/project,” “final exam,” “formal curriculum,” or “other.”

Results

Sixty-eight unique responses were received, representing 43.9% of allopathic medical schools in the U.S. Responding schools represented 33 states and the District of Columbia. Average medical school class size of the sample was 158 students per class (range 51-366), as reported by the AAMC 2021 matriculating class data, compared to an average class size of 146 students for all 155 allopathic U.S. medical schools (range 24-366). About 85.3% (n = 58) of responders had an associated OTO residency program, with an average self-reported size of 15.9 residents. Survey responders were anonymous. Descriptive statistics are outlined in Table 1.

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Table 1.

Descriptors of U.S. Medical School Otolaryngology Curricula.

Descriptor	N (Yes)	% Yes
Residency Program	58	85.3
Expectations for OTO knowledge	25	36.8
OTO teaching lecture	36	52.9
OTO teaching head & neck exam	33	48.5
Expectations for rotators	36	52.9
Optional Third Year Rotation	52	76.5
Optional Fourth Year Rotation	65	95.6

Abbreviations: N, number; OTO, otolaryngology/otolaryngologist.

Non-responding schools were evaluated in order to determine the extent of non-responder bias. The non-responding population consisted of 85 allopathic medical degree granting U.S. schools, representing 32 states and the District of Columbia. The average medical school matriculating class size for the non-responding school population was 136 students per class. 56% of the non-responding schools were affiliated with an otolaryngology residency program, while 44% were not.

Regarding OTO instruction in medical schools, 36.8% (n = 25) of schools reported that their core curriculum included formal expectations of what all students should be taught in otolaryngology. About 52.9% (n = 36) of schools reported having otolaryngologists teach basic science lectures, with lecture time ranging from 1 to 20 hours. The most commonly taught subjects by otolaryngologists included Anatomy, Physiology, Neurology, Intro to ENT, Pathology, Embryology, and Clinical Skills courses. 57.1% (n = 20) of these lectures were organized into discrete blocks. The Head & Neck Physical exam was taught primarily in years 1 and 2 (42.9% and 35.7%, respectively), with otolaryngologists teaching the exam at 48.5% of responding schools and teaching time ranging from 1 to 25 hours. 36.4% (n = 24) of schools used web-based or computerized resources to teach students about OTO, including video-based lectures and curricula, online reading material, and online question banks or quizzes. 38.8% (n = 26) of schools used simulation, augmented, or virtual reality for standardized patients, and anatomy models in conjunction with cadaver labs.

Only 1 school (1.5%) reported having a required OTO rotation, described as a 1-week, primarily outpatient rotation in third year. Optional third year clerkship rotations were available at 76.5% (n = 52) of schools, with the majority of clerkships being evenly split between clinic and operating room (OR) time (51.9%, n = 27). 38.5% (n = 20) of schools reported their third year rotation consisted of more OR time, and 5.9% (n = 4) reported more clinic time. 95.6% (n = 65) of schools provided an optional fourth year clerkship rotation, of which 53.8% (n = 35) were evenly split between clinic and OR time, 41.5% (n = 27) had more OR time, and 3.1% (n = 2) had more clinic time. Average annual student participation in OTO clinical rotations was estimated to be 25.6 students. 64.7% (n = 44) of respondents had formal expectations of rotating student knowledge, with 52.3% (n = 23) of those schools providing formal expectations during third and fourth year rotations, 29.5% (n = 13) during third year only, and 18.2% (n = 8) during fourth year only. Formal expectations were defined as a mix of formal curricula, learning objectives, readings, didactics, presentations/projects, and/or a final exam.

Presence of residency programs had a significant positive effect on the odds of schools incorporating OTO teaching into curricula (Table 2). Of total respondents, 85.3% of schools had an affiliated residency program while 14.7% of schools did not. Schools with residency programs were more likely to have otolaryngologists teach basic science lectures and the Head & Neck exam (OR = 13.7, 95% CI [1.86, 153.9] and OR = +infinity, 95% CI [3.35, +infinity], respectively), were more likely to offer an optional third year rotation (OR = 4.27, 95% CI [1.07, 16.99]), and were more likely to have formal expectations of rotating students (OR = 5.67, 95% CI [1.15, 27.71]) compared to schools without residency programs.

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Table 2.

Odds of OTO Curricula in Schools With an OTO Residency Program Compared to Schools Without an OTO Residency Program.

OTO curricula	Odds ratio	95% CI	P-value
Expectations for OTO knowledge	0.8514	0.2417 to 2.923	>.9999
OTO teaching lecture	13.7	1.857 to 153.9	.0046**
OTO teaching head & neck exam	+infinity	3.346 to +infinity	.0009***
Expectations for rotators	5.667	1.146 to 27.71	.0377*
Optional Third Year Rotation	4.273	1.069 to 16.99	.0474*
Optional Fourth Year Rotation	3.111	0.1947 to 28.25	.3843

Abbreviations: CI, confidence interval; N, number; OTO, otolaryngology/otolaryngologist.

*

Indicates significance level.

In contrast, there was no significant difference in the odds of having formal expectations of OTO knowledge in core curricula (OR = 0.85, 95% CI [0.24, 2.92]), or in the odds of providing an optional fourth year rotation (OR = 3.11, 95% CI [0.19, 28.25]), between schools with or without residency programs.

OTO faculty employment structure was also evaluated to assess how this may influence medical education in OTO. Faculty employment was grouped into 3 categories: “employed through an OTO or surgery department,” “not employed by the medical school, but employed by major teaching hospital,” or “not employed by school or hospital,” as outlined in Table 3. A school’s faculty employment structure had a significant effect on the incorporation of OTO curricula (Table 4). Among schools where faculty were employed through an OTO or surgery department, the faculty were significantly more likely to teach basic science lectures and the Head & Neck exam (OR = 5.67, 95% CI [1.15, 27.71] and OR = 11.08, 95% CI [1.51, 124.8], respectively), offer an optional third year rotation (OR = 4.27, 95% CI [1.07, 16.99]), and have formal expectations of rotating students (OR = 5.67, 95% CI [1.15, 27.71]). Schools in which faculty were employed through an OTO or surgery department were significantly more likely to have a residency program (OR = 42.78, 95% CI [7.47, 192]).

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Table 3.

Otolaryngology Faculty Employment Structure at U.S. Medical Schools.

Faculty employment structure	N	%
Employed through OTO or surgery department	58	85.3
Not employed by the medical school, but employed by major teaching hospital	2	2.9
Not employed by school or hospital	8	11.8

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Table 4.

Odds of OTO Curricula in Schools With Faculty Employed Through OTO or Surgery Department Compared to Schools With Other Faculty Employment Structures.

OTO curricula	Odds Ratio	95% CI	P-value
Expectations for OTO knowledge	2.629	0.5311 to 13.02	.3039
OTO teaching lecture	5.667	1.146 to 27.71	.0377*
OTO teaching head & neck exam	11.08	1.513 to 124.8	.0136*
Expectations for rotators	5.667	1.146 to 27.71	.0377*
Optional Third Year Rotation	4.273	1.069 to 16.99	.0474*
Optional Fourth Year Rotation	0	0.000 to 6.899	>.9999

Abbreviations: CI, confidence interval; N, number; OTO, otolaryngology/otolaryngologist.

*

Indicates significance level.

There was no significant difference in the odds of having formal expectations of OTO knowledge in general curricula (OR = 2.63, 95% CI [0.53, 13.02]), or in the odds of providing an optional fourth year rotation (OR = 0, 95% CI [0, 6.9]), between schools employing their faculty through an OTO or surgery department and schools employing through a major teaching hospital or who did not employ their faculty.

Medical school class size was evaluated as a potential explanatory factor. There was no significant difference in medical school class size between schools with and without expectations of OTO knowledge in general curriculum, otolaryngologists teaching basic science lectures, otolaryngologists teaching Head & Neck exam, optional third year rotation, optional fourth year rotation, formal expectations of rotating students, and faculty employment through an OTO or surgery department. Medical school class size was not associated with faculty employment through an OTO or surgery department (P = .24). However, schools with residency programs had larger mean class sizes compared to schools without residency programs (P = .0002). Simple linear regression revealed increasing mean class size significantly predicted presence of a residency program (β = .01205, P = .0021).

Discussion

Medical education should provide students with foundational knowledge of disease pathology, clinical skills, and residency preparation. However, with ever-increasing demands on medical schools and a growing fund of knowledge, medical schools struggle to incorporate subspecialty OTO teaching, which may in part explain decreased comfort levels in residents and primary care physicians in managing common OTO conditions.^9-12

A 2000 to 2001 evaluation of OTO curricula in 122 U.S. medical schools similarly demonstrated high variability of OTO teaching. ³ Two decades later, our survey study reveals the continued inconsistency of formal OTO education, with only 36.8% (n = 25) of schools having formal expectations of OTO knowledge in their general curricula and 52.9% (n = 36) having otolaryngologists teach lectures, and builds on previous studies by demonstrating the influence of residency program and faculty employment on the incorporation of OTO curriculum.

Clinical rotations in OTO are the ideal environment for developing clinical skills to evaluate common conditions. The 2000 to 2001 study by Haddad et al found that 33.6% of schools had a required OTO rotation. ³ In contrast, in 2020 to 2021, our study found that only 1 school (1.5%) reported having a required OTO rotation, with the majority of schools offering an optional third or fourth year clerkship rotation (76.5% and 95.6%, respectively). While differences in responders may have contributed to this discrepancy, our results may also reflect increasing pressures on curricula to incorporate more of an ever-increasing knowledge base, potentially leading to cuts in subspecialty content.

Stratifying for presence of residency programs revealed that schools with residency programs were more likely to have formal incorporation of OTO teaching in their curricula, including otolaryngologists teaching lectures and Head & Neck exams, optional third year rotations, and formal expectations of rotating students. Schools without residency programs may therefore be at a disadvantage in exposing their students to the field of OTO and teaching their students how to manage common OTO conditions.

This study reveals that faculty employment structure at medical schools is also associated with incorporation of OTO curricula. Schools that employed OTO faculty through an OTO or surgery department were more likely to offer an optional third year rotation and have formal expectations of rotating students. These schools were also more likely to have residency programs, which may in part explain the presence of increased OTO exposure in these schools’ curricula. However, similarities within schools employing faculty through an OTO or surgery department did not allow for sufficient statistical power to evaluate whether employment or residency program were the driving factor in the association with increased third year rotations and expectations of rotating students. Nevertheless, schools that employed OTO faculty through an OTO or surgery department were also more likely to have faculty teach lectures and Head & Neck exams. This may imply that faculty who are employed directly through an OTO or surgery department may be more engaged in undergraduate medical education through increased involvement in teaching and rotations.

Medical school class size was found to be positively associated with a school’s likelihood of having an OTO residency program. However, schools with larger class sizes were not more likely to have greater incorporation of OTO in their curriculum or rotations. Therefore, it is likely that presence of a residency program has a greater effect on the incorporation of OTO in medical school curricula than class size alone, although our study’s statistical power was too limited to test this hypothesis.

Limitations of this study include survey response rate, responder, and non-responder bias. Due to small sample size, with only 10 schools not affiliated with a residency program, the power for statistical analysis was limited. Non-responder bias was evaluated by examining the characteristics of the non-responding population, as described by Halbesleben and Whitman ¹⁴ While our study only received responses from 43.9% of the population of U.S. allopathic medical schools, our sample represented a large geographic area similar to the non-responding population. However, our sample only captured 10 schools without an OTO residency program, compared to 37 schools without a program in the non-responding population. This may indicate that schools without an OTO residency program may have been more hesitant to respond, or the proper survey contact may not have been identified. However, non-responder bias was limited by conducting 2 waves of data collection, and using publicly available data to supplement any knowledge gaps. Another limitation of this survey study is that the responding contact may not have had all of the information regarding how OTO is incorporated into medical education, as this topic generally spans multiple job titles and can be managed by persons within an OTO department, within a medical education department, or within the administration of the school of medicine.

Further studies should be conducted on the impacts of specific curricular methods on student career choices. Outcome measures like graduating student comfort level with common OTO presentations, were not included in this study. Future research could evaluate whether implementation of specific curricular methods influence student competency in OTO.

Conclusion

This study evaluated the extent and practices of OTO teaching at U.S. medical schools. Schools associated with residency programs and employing their faculty through an OTO or surgery department have more robust OTO curricula.

OTO conditions span a variety of medical specialties and are frequently managed by PCPs; therefore, competency in OTO is salient for all physicians. Despite the ubiquity of OTO complaints, this study and others show that incorporation of OTO knowledge into U.S. medical school curricula remains variable, and at times limited.

To provide appropriate exposure to common medical presentations, schools should incorporate OTO teaching into formal curricula to a greater degree than is currently being done. With multiple studies reporting poor overall comfort levels with OTO presentations in residents and practicing physicians,^9-12 it is important to identify ways in which institutions can better their teaching in foundational knowledge and clinical skills to provide more consistent exposure to common OTO presentations.

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Supplemental Material