The way I see it
The value of cross specialty training
Authors: Babar Vaqas, Charlie Giddings
Publication date: 27 Aug 2008
“Why ENT—I have always wanted to be a neurosurgeon?” Recent reforms of training have formalised exposure to allied specialties. Many trainees were arranging this independently before but also spending five years in the senior house officer grade. But when I attained my specialty training year 2 run-through for neurosurgery I found unexpectedly that I was to have six months of training in ear, nose, and throat surgery (ENT), something I may well not have considered if independently arranging stand alone posts. However, as I have progressed through training I have realised it is just one of many allied specialties (box 1).
Box 1: Specialties relevant to neurosurgery trainees
Sharing ideas between ENT and neurosurgery is not new. In 1906 the Austrian otolaryngologist Herman Schloffer pioneered the transnasal approach to the pituitary. Between 1910 and 1925 Harvey Cushing refined this technique with a series of 231 patients and introduced it to the neurosurgical world.
Greater cross disciplinary awareness has given me exposure to related medical conditions and different ways of working, which is important when making and triaging interspecialty referrals. Attempts to shorten and condense training have made a broad base unfashionable. Yet it is difficult to commit a lifetime to a specialist career without appreciating the variety on offer. Fostering excellence should include encouraging future specialists to know more than just the confines of their specialty.
Although initially the association between neurosurgery and ENT seemed strange, I found and many new skills that have benefited me as a neurosurgical trainee (box 2).
Box 2: Relevance of ENT training to neurosurgery
Anatomy and physiology of related structures (cranial nerves, temporal bone, and ear, sinus, and neck anatomy)
Surgical approaches to spine via neck and oropharynx; skull base approaches via any existing hole in the head
Understanding vestibular causes of dizziness; diagnosis and management of acoustic neuroma; and the importance of joint clinics
Familiarity with using microscopes, headlights, and loupes during operations
Elective and emergency airway management—especially tracheostomy care
Acquiring skills in endoscopic techniques relevant in transphenoidal hypophysectomy and ventriculoscopy
Management of cranial nerve palsies; cerebrospinal fluid otorrhoea and rhinorrhoea
Liaison with speech and language therapists, audiology, and audiological physicians
Understanding of intracranial sequelae of ENT diseases (management of cholesteatoma and sinus pathology)
One particular example is my better understanding of the anatomy of the neck with regard to the anterolateral approach to the spine. This is commonly used in cervical discectomies and prosthesis placements. Working in a unit that specialises in benign head and neck conditions and oncological endocrine surgery, I have learnt the relevant anatomy of the recurrent laryngeal nerve and the techniques used to avoid injury. Nerve monitoring of the recurrent laryngeal nerve is routinely used in thyroid surgery in our unit; this is not yet the case in many neurosurgical centres.
Relevance of ENT skills
The use of microscopes is commonplace in otology and provides an excellent opportunity to become accustomed to the basics of microsurgery. It is, however, a skill that takes time to develop. I have found that removal of foreign bodies from ears and debriding mastoid cavities are excellent practice for manual coordination using a microscope and understanding the anatomy of the ear. Endoscopic nasal procedures also take time to learn, but if you begin with cautery in epistaxis your ability increases and you can then tackle basic sinus surgery procedures and hopefully transphenoidal surgery later.
The increasing focus on specialisation from an early stage in the Modernising Medical Careers pathway does not necessarily mean highly focused and narrow clinical exposure during training. Being required to work in this allied specialty has given me a valuable opportunity which I might otherwise have not taken and may inspire others to change career paths. I have seen how one surgical specialty is indebted to another for certain techniques and ideas, which were transferred only through cross specialty cooperation.
Competing interests: None declared.
- Tooke J. Aspiring to excellence: findings and recommendations of the independent inquiry into Modernising Medical Careers. Interim report . MMC Inquiry, 2007. www.mmcinquiry.org.uk.
Department of Otolaryngology and Head and Neck Surgery, Royal Free Hospital, London
Charlie Giddings Department of Otolaryngology, Royal Free Hospital, London