So you want to be an ENT surgeon
Authors: Steven Powell
Publication date: 09 jun 2007
Omar Najim and Steven Powell rave about their specialty
ENT (or otorhinolaryngology-head and neck surgery) is a diverse and fascinating specialty. The special senses of hearing, smell, and taste as well as the crucial functions of speech and swallowing all fall within an ENT surgeon's territory. We deal with more body orifices than any other specialty. As a specialty we have come a long way from the days when a piece of red flannel tied around the neck could cure a sore throat. Currently, it is the third biggest surgical specialty in the United Kingdom.
ENT remains a mystery to those who have no experience of it. In a recent survey of undergraduates, only 54% had a formal ENT attachment, and this lasted on average a total of just seven and a half days. It is estimated that 15% of a general practitioner's workload is ENT related, and there is considerable overlap with maxillofacial surgery, plastic surgery, neurosurgery, and ophthalmology.
Attractions of the specialty
ENT is becoming increasingly popular and competitive. Two deaneries (Northern and West Midlands) that advertised specialist registrar numbers in September and October 2006 stated that they received 65 and 87 applicants respectively.
Otolaryngology is diverse in both patient mix and the types and complexity of procedures undertaken. It is a cradle to grave specialty, from neonates with airway problems to elderly patients with head and neck tumours. Otolaryngologists see more children than any other surgical specialty apart from paediatric surgeons. ENT surgeons also manage all the non-surgical care of their patients (as there is no sister medical specialty). Consultants have on average four clinics a week and can deal with a variety of problems. Audiology, allergy, sleep disorders, voice pathology, balance disorders, and rhinological disorders can all form part of a clinic workload. ENT examination is specialised and uses lots of gadgets. These range from a simple head mirror (which will always produce a laugh) to a microscope for examining ears.
Despite a common perception that ENT deals mainly with wax, snot, and spit, it is not widely realised that ENT has more separate surgical procedures than most other surgical disciplines. An operation can be as short as 30 seconds (inserting a grommet) or as long as 12 hours (major head and neck resection with reconstruction). Advanced technology forms an integral part of the modern ENT surgeon's armamentarium—from the use of laser surgery in laryngeal lesion excision to cochlear implants for hearing restoration.
ENT departments can be busy during the daytime when elective work takes place and most emergency patients are seen. Out of hours work is generally quieter than other surgical specialties, but emergencies can be dramatic and life threatening. The lifestyle that ENT offers makes it attractive to women and flexible trainees. Private practice work is available, but there is variation between regions.
As with any other specialties, otolaryngology is becoming more and more subspecialised. The common subspecialties are:
Otology, neurotology, and base of skull surgery
Head and neck surgery
Facial plastic surgery
Otolaryngology and Modernising Medical Careers
Modernising Medical Careers (MMC) is the biggest shake-up to medical training since the establishment of the NHS. MMC is evolving all the time and new information emerges weekly. What is certain is that the old system of spending a number of years as a senior house officer before deciding on a career path, then spending a variable amount of time waiting for a national training number will (in theory) be a thing of the past. The stages of entry into ENT within the MMC system are outlined below:
ST1 (for foundation year 2 doctors)—The person specification for entry to specialist training year 1 (ST1) is based on competencies achieved using assessment tools and portfolio. Audit, presentations, and publications will be used for fine tuning.
ST1-2 (for SHOs)—This year will witness the integration of the old SHO cohort into run-through specialist training. To get into ST1 the trainee will need no more than one year's experience at SHO level. Time spent as an SHO will be accepted as demonstration of foundation year 2 competency. For entry into ST2, SHOs will need less than 36 months' experience in training posts and do not need to have completed their exams for membership of the Royal College of Surgeons (MRCS). Once in specialist training trainees should be able to progress seamlessly through their training if they pass the necessary competencies and exams (see below).
ST3 (for SHOs)—Until the ST1 and ST2 trainees filter through the system, direct entry into ST3 for current SHOs will take place. MRCS and 12 months' experience in ENT are essential. Publications, research, teaching, courses, and presentations will be taken into account.
The current planned format is for every trainee to complete ST1 to ST6. The curriculum and competencies of each stage are outlined on the intercollegiate surgical curriculum project website. After completing the required competencies and passing the necessary examinations (see below) the trainee will be awarded the certificate of completion of training (CCT). What happens at ST7 and 8 is still being debated. These years will be subspecialist training (for example, head and neck) and it seems that they will be applied for on a competitive entry basis. There may be some generalists who complete their training at ST6 and a smaller number of specialists who complete at ST8. In the current changeover period ST3 is equivalent to specialist registrar (SpR) year 1.
Modernising Medical Careers: [Link]
Royal College of Surgeons of England: [Link]
Intercollegiate surgical curriculum project: [Link]
Royal College of Surgeons of Edinburgh: [Link]
British Association of Otorhinolaryngologists-Head and Neck Surgeons (ENT UK): [Link]
Association of Otolaryngologist in Training: [Link]
Previously many SpRs did fellowship periods abroad (often in Australasia or Canada) to complete their specialist training. How this will be affected by the programme remains to be seen.
Many new assessment tools are going to come in with the intercollegiate surgical curriculum project, and these can be seen on the website. The main check on these ongoing assessments will still be RITA (the record of in-training assessment). This occurs annually and includes assessment of clinical and academic progress and evidence of appraisal and target setting for the coming year.
The old MRCS exam will disappear and will be replaced by a modified version. Currently, many trainees sit the diploma in otolaryngology and head and neck surgery after taking the MRCS. This will probably be incorporated into the new exam. During ST1 and ST2, the new MRCS will be required to progress to ST3. This exam will have generic and specialty components, the latter to reflect the trainee's chosen specialty. The fellowship exam for the Royal College of Surgeons (FRCS (ORL-HNS)), which is the “exit exam,” can be taken at any time before ST6 with the support of the local programme director. In practice most trainees will still take it in ST5 to 6. A new format for the exam was introduced in January 2007, with multiple choice questions included alongside the clinical component.
The consultant employment situation in ENT has reversed dramatically within the past five years. Currently there is a deficit with over 35 ENT trainees who have completed their training without consultant posts. In 2005 there were 614 consultants in the United Kingdom and 295 SpRs. This means that there is roughly one consultant per 100000 of the population. This is one of the lowest consultants to population ratios in the Western world. ENT UK has proposed a ratio of one to 76000, which would require an extra 170 consultant posts.
Expansion in consultant numbers faces a number of challenges. Widespread NHS financial deficits are making trusts reluctant to invest in expanding senior medical staff. Two government initiatives also threaten traditional consultant roles. The expansion of independent surgical treatment centres and plans to take care in certain specialties “into the community” will mean a change in delivery from the current NHS hospitals based model.
The future may see the traditional consultant role being undertaken by fewer doctors, with more “specialists” taking on work on shorter term contracts, including theatre sessions at independent surgical treatment centres and clinics in the community. There is understandable resistance to this from within the specialty.
If you want to embark on a career that is constantly evolving and will always present new challenges then think about ENT. You need to be enthusiastic, reliable and diligent
Modernising Medical Careers and the European Working Time Directive are having a marked impact on the staffing of ENT units. Cross cover rotas are becoming more common. There will be less experienced doctors first and second on-call for ENT, which may result in an increased senior workload.
Is ENT for you?
If you are interested in a surgical career, but still want a balanced lifestyle, then ENT is for you. If you want to embark on a career that is constantly evolving and will always present new challenges then think about ENT. You need to be enthusiastic, reliable, diligent, and not easily disheartened by the level of competition.
In a recent hospital educational activity, one of the doctors from medicine pointed out that “it seems that all ENT people are cool, chilled, approachable, and very friendly.” In this physician's description of a surgeon the spirit of otolaryngology is captured perfectly.
- Johnson A. The ENT workforce—where are we now? ENT UK Membership list and Handbook 2006: 34-6.
- Doshi J, Carrie S. A survey of undergraduate otolaryngology experience at Newcastle University Medical School. J Laryngol Otol 2006; 120(9): 770-3.
- West Midland Deanery online career guide. [Link]
- Ribeiro B. Meeting the challenge. Ann R Coll Surg Engl (Suppl) 2005;87: 262-3.
Steven Powell SpR in ENT