2019 HSC Section 2 - Practice Management

Wilson et al

caseload in subspecialty area during residency, and the second most common reason cited was the perceived need for extra training to secure an academic position or enhance private prac- tice. The difference in training during that time (programs were either 3 or 4 years of otolaryngology training) vs current pro- gram structure limits applicability to today’s residents. Also important to note, the PGY-5 class of 2008 was the first class to complete their entire residency under then 80-hour workweek rules instituted in 2003. While our survey did not give need for additional training as a set option when residents were asked to rank the reason(s) they chose a subspecialty fellowship, resi- dents today often are choosing a subspecialty based on the sur- gical cases and clinic nature of that field. Both Raynor 12 and Eloy et al 13 have looked at the per- centage of fellowship-trained physicians in otolaryngology academic departments. Raynor 12 noted that in 2006, 67% of otolaryngologists in academic departments were fellowship trained. In a 2015 study, Eloy et al 13 noted that 63% of chairpersons, 67% of vice chairpersons, and 84% of pro- gram directors were fellowship trained. Both authors note that if the more senior otolaryngologists, who trained when fellowships were much less common, were excluded, the percentage of academicians with fellowship training would be higher. Many speculate that perceived need for fellow- ship training to secure academic and leadership positions increases residents’ desire to pursue fellowship training. The data presented in this study show educational debt to be negatively correlated with pursuance of subspecialty oto- laryngology fellowship training. Hull et al 14 looked at the financial impact of fellowship training showing that except for rhinology, skull base surgery, and allergy and immunol- ogy, fellowship-trained otolaryngologists have decreased net salaries over a 30-year career. The correlation between a resi- dent’s current educational debt and perceived future earnings as a generalist vs subspecialist has not been determined. In orthopedics, there is a very high rate of fellowship training. A study looking at the number of job advertisements seeking an orthopedic generalist vs a fellowship-trained sub- specialist demonstrated that in 1984, 16% of job postings specified need for fellowship training, with the number increasing to 50% in 1994 and to 68% in 2009. 15 Although no studies to our knowledge have looked at this in otolaryn- gology, it is possible that this same trend could be occurring. General surgeons collected similar data from 1993 to 2007 through a survey during the American Board of Surgery In-Training Examination (ABSITE) examina- tion. 16,17 While the survey is optional, the examination is obligatory, and therefore high response rates of 88% to 94% are obtained with the ability to track individual residents each year of training. In this cohort of residents during this time period, the percentage of residents planning to pursue fellow- ship was 38% to 46% in PGY-1, increasing to 69% to 75% in PGY-5. The authors raise concerns that the increasing subspe- cialization will result in medical students who are examining the field to view the ‘‘general surgeon’’ as disappearing and therefore have reduced interest in the residency program. Similar concerns have been brought up in the ophthalmology

Table 2. Demographic Information for All Survey Respondents (N = 2422).

Characteristic

No. (%)

Age, y (n = 1990) 25-29

815 (41) 895 (45) 199 (10)

30-33 34-37

38

81 (4)

Sex (n = 2397) Male

1620 (68) 777 (32)

Female

Year of training (n = 2403) PGY-1

344 (14) 930 (39) 900 (37)

PGY-2/3 PGY-4/5 PGY-6 1

59 (3)

Fellow

170 (7)

Educational debt (n = 2128) None

360 (17) 242 (11) 246 (12) 374 (18) 417 (20) 216 (10)

\ $50,000

$50,000-100,000 $101,000-150,000 $151,000-200,000

. $250,000

Abbreviation: PGY, postgraduate year.

that on multivariate logistic regression analysis, increased age, increased training level, educational debt, and desire to pursue a nonacademic career were all negative predictors of pursuing fellowship training. The results of this analysis are useful for both residents and residency and fellowship pro- gram leadership in evaluating patterns in resident demo- graphics and resident plans. While not every resident completes the survey, with an open invitation for all resi- dents to participate and over 2000 respondents, the data here represent a large sample of residents. Over the past several decades, multiple opinion and editorial publications have attempted to explain why otolaryngology resi- dents choose subspecialty training or not. 1,4,5,7-10 Few data-driven studies have sought to determine these reasons for choosing a specific path. Goulb et al, 11 in 2010, surveyed all otolaryngology residents and also noted that interest in fellowship training decreased from 62% in PGY-2 residents to 58% in PGY-5 resi- dents. They did note that for PGY-2 residents, more women (69%) than men (60%) were interested in fellowship training, but for PGY-5 residents, more male residents (59%) than female resi- dents (54%) anticipated fellowship. However, this was a single- year survey and was not able to track the same group throughout residency. Goulb et al 11 also found residents not planning to pursue fellowship usually desired a private practice setting (94%), whereas in residents pursing fellowship training, 53% planned to pursue an academic career. In a 1994 survey of fellowship-trained otolaryngologists, 2 the primary reason for fellowship training was inadequate operative

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