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Brutality of ENT residency

Discussion in 'Otolaryngology' started by StillChoosing, 03.24.12.

  1. StillChoosing

    StillChoosing

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    Last edited: 07.12.12
  2. Chakrabs

    Chakrabs

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    I'm not going into ENT, rather I'm going into a specialty that would send someone like you screaming - Neurosurgery. However, during med school I spent a month on the ENT service and they did work considerably long hours at my institution. We were a very busy program and there were plenty of consults to see. When we were not in the OR, we were in clinic seeing patients. I went to a state school so perhaps at private institutions the hours are different, but it was definitely 13+ hr days on a regular basis.
  3. neutropeniaboy

    neutropeniaboy Blasted ENT Attending

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    :boom:
  4. Valadi

    Valadi

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    As a general rule I've hard that for surgery and surgical subspecialties you should expect to be around that mark most weeks. This is different than IM which has ward months and then 'easier' subspecialty services, where they often are under 80hrs/week. Someone on here put it well awhile ago when they said that surgery is like doing a ward month, every month.
  5. resxn

    resxn

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    agree. students get pissed when we have this response. I can't believe they even ask it.

    My personal feeling is that if the thought of an 80hr work week is unappealing to you, don't do ENT. Certainly, get out of surgery. And consider getting out of medicine.

    I HATE this attitiude. However, to provide some perspective, I finished residency in my chief year when work hour restrictions first began, so for 4 years I worked at the discretion of my attendings often breaking 100 hrs/wk. I finished with over 3000 surgical cases under my belt which was in the upper 25%ile for residencies at the time and would now be in the 5th% I bet. I still felt I could have used more time.

    In his book, Outliers, Malcolm Gladwell demonstrates how it takes about 10,000 hrs of practice to become a master at something (whether it's a musical instrument, the stock market, writing, etc). Let's assume you average as a resident 8 hours of OR at least 3x/wk 52 weeks/yr for 5 years--you'll graduate with 6240 hrs in the OR. That's not considering a year of internship so you're really talking 4992 hrs of ENT surgery. That's less than 1/2 of what it takes to get to master something. Consider that those hours are divided over a number of different cases.

    If you think you really want to do surgery, but you are really concerned about family time or me time or golf time or whatever it may be, consider a different career or at least a different specialty. Your patients deserve someone who is committed to being a master of their craft. Just as you may think it's only fair to have family time, your patients consider it fair to have someone well-trained and proficient. Last thing I want is for my son to see a surgeon who graduated, is board-certified, but spent much of their residency trying to get home, rather than trying to get better in the relatively short time they have to train in the first place.
    Last edited: 03.26.12
  6. StillChoosing

    StillChoosing

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  7. neutropeniaboy

    neutropeniaboy Blasted ENT Attending

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    My recommendation to you, then, is to ask each program director and chair of every program that interviews you if you have to work hard (gasp, 80 hours) for 5 years straight or if you get some breaks along the way. Make sure you do it with a smile.
  8. StillChoosing

    StillChoosing

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  9. Butler

    Butler

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    Still, it seems to me that your question has been sufficiently answered, even if you may not like the response. Resxn made a point of noting that he still felt unprepared coming out of a residency program with MANY more cases under his belt than most graduating residencies are accumulating with the new restrictions. I believe their point is this: 80 hour weeks as it is do not do justice to current surgery residents, so as such students should be ready and willing to go above and beyond the call of duty to maximize their educational experience in the time they do have. If you don't see your future self able to satisfy that requirement, than they recommend you seek another specialty out. This is not meant as a personal attack on you, as there are many excellent physicians that could not or would not have been able to handle the intensity of a surgical residency program, but they made great physicians in their own right in a different field. Ask yourself what you like about Oto and what other fields might satisfy some of the your needs while maintaining your interest in your professional life.

    Neutro and Res, please correct me if I am wrong and have misunderstood your points.
  10. ZagDoc

    ZagDoc Ears, Noses, and Throats

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    I am glad you acknowledged the fact we hardly operate as interns.

    (only logged 130 cases this year, starting to get stir crazy)

    To the OP, the further you go along in training, the more you realize the sheer amount of things you should (and should want to) learn. As you start to stare down the barrel of the gun called independent practice, you start to feel that a 5 year residency, 80 hour weeks, and a couple thousand surgeries no way in hell adequately prepares you for being on your own practicing medicine or performing surgery. It can, but its not given to you. Personally I have petitioned the cosmos multiple times to slow the earth's rotation and add another dozen hours to the day, so I could use those hours to read more and practice more. But so far they haven't cooperated.

    The gist is- ENT is a surgical residency. Surgical residencies are a unique beast where you're given a finite amount of time to master both medical management and surgical technique. There's a certain mentality, almost an aggressiveness, about seeking out experience that's required to maximize a surgical residency. The number of hours spent performing clinical duties is important, but so is the time outside the hospital spent reading and practicing. Is time with family important? Absolutely. Being a good spouse and parent is one of the few noble things left in this world. And I know residents who are both excellent surgery residents and excellent family persons (yes, they are. their children recognize them when they get home and for all intents and purposes appear to be normally developing children, but I am a poor judge of character). Not to say that it is easy, it isn't. I think what concerns the attendings on this forum when asking about hours is that it conveys an attitude of looking to do "just enough." Doing "just enough" in a surgical residency isn't going to cut it as far as preparing you to be an adequate surgeon.

    And yes, if you add up the hours including clinic, OR, consults, didactics, reading for cases, studying for ABOto, prepping for weekly conferences, research, administrative chief stuff, etc I think around or over 80 hours a week for most weeks for all 5 years is safe to say (but hey, we get vacation!)

    Btw, its possible to have a vibrant life outside the hospital and still work long hours. One of my favorite chiefs as a student once told me "The hours never get better, but you get better at the hours." I think that's very true. We have residents who have found the time to train for marathons/ironmen, write a (non-medical book), go on multiple-state bike rides, climb mountains, close down bars (a favorite of my program), etc. Time is precious, sure, but 80 hours isn't some magical threshold where life stops when you arent at work.
    Last edited: 03.27.12
  11. StillChoosing

    StillChoosing

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  12. Arcan57

    Arcan57 Junior Member

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    That would be awesome if that last part was true. Patients who suffer adverse events secondary to incompetent care are not generally comforted by knowing that their doctor was in a good mood while maiming them.

    And I while I'm here, I just wanted to say that having worked in multiple cities that ENT docs have been consistently pleasant and responsive. Most of the time I'm just calling you to get follow-up for anterior epistaxis s/p packing, but the times I've needed an ENT STAT I've never gotten any response other than "I'm on my way in".
  13. RapidReview

    RapidReview MS-IV

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    Zagdoc,
    I'm actually going into urology (just wandered into this forum), but I just wanted to say how much I've appreciated your posts. I recall reading a few of your blog entries from the Step1 forum days. Hope intern year is treating you well!
  14. plauto

    plauto

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    To the OP...it's definitely not an easy residency. Depending on where you are, it might be a little less intense than GS, or just as hard. Be ready to go up to 80 hrs/week routinely.

    After residency, it can be a lot cushier, depending on where you want to be, or just as bad as residency if not worse.
    The upside is that ENT tends to attract people much nicer than the other surgical specialties (despite some smartasses ;)) and working with them is pretty sweet.
    While I understand your fear about spending time away from your family, you need to do what makes you happy. I'd be so unhappy doing radiology 8-5PM everyday. I'd take the intensity of a surgical residency over that any time (easy for me to say since I haven't started yet!). Bottom line is, if you are not happy doing what you are doing, it does not matter if you get to be home earlier.
  15. resxn

    resxn

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    One of the tenants to which I hold dear is the following stated by one of my favorite leaders, "No other success can compensate for failure in the home."

    Family is first. However, if your family cannot tolerate you maximizing your opportunity to learn a lifetime of care in 5 years, a surgical specialty may not be right for you and your family. I have posted on numerous occasions on this forum how hard it was on my wife and I during residency. However, we both recognized that I couldn't adequately do what I do now and do it as well as I do, without sacrificing family time for those 5 years. The time invested then now allows me to do something I love and do it well enough that I have time to spend with my family. 5 years of suffering for an hopefully lifelong career of family time. I make an income that allows me to take 2 half days off a week to be with family. Let me know how many PCP's do that. Also, while you're checking, see how many ENT's went through residency with a plan on getting a lifestyle simply doing the B&B cases and can make a reputation grand enough to gain the respect they need to garner the referrals they need to support the practice they desire to have the time off they want. I'm guessing that will be the exception, not the rule.

    In my day, we spent most rotations at or above 80hrs. Our Children's rotation was busier than H&N and we often came close to 100 on the former, 90 or so on the latter. The VA rotation was lightweight and we hit 60 far more than 80.

    I can't even imagine a rotation where you'd work 40 hrs/wk and have it be worth anything. I can't. I suppose there may be a few primary care rotations where it is possible, but I think my face would melt off if I ever heard of a surgical resident of any specialty having a 40hr work week at a respectable (read accredited) program.

    While you may be correct that long hours has a negative effect on a relationship with family, so too does having a lifetime of working more than you had planned with less off time than you desire to make up for what you failed to invest in during residency. If there's serious risk to your family in the 5 years of a surgical residency, don't do it. However, I think despite all the trials and missed time with my family during those 5 years, I've been lucky enough to get back in spades what I wouldn't be able to do without having worked my tail off in residency. Moreover, we've gone through the refiner's fire. There is very little that faces us now that we can't get through because we've run the gauntlet. We've conquered it. We're stronger for it and I can't foresee a trial that we are not better prepared for now because of our strength having come through residency together.

    I feel that I can offer if not the best, then equalling the best, ENT care any of my patients can receive any where in my neck of the woods. I can only state that because of the quality and quantity of my residency (in that order). I also feel now that with that success, I can offer my family more time than I ever would have if I didn't build a successful practice. Lots of luck, lots of blessings for sure, but none would have come without hard work and sacrifice up front.

    It all goes back to hours. I could potentially be the world's greatest violinist, but if I don't put in the practice time, I may only be good enough to entertain friends and familiy at reunions and parties. If I practice, I can become a master.

    So it boils down to this: do you (and your wife) want to sacrifice time now for time later so that you can be a master of your craft and then work on family with all the resources that come with success? Or would you like to choose something that doesn't require those kinds of hours so that you can be the master of fatherhood and marriage now without the same career prestige/success/financial resources later? Or do you want to try to ride the fence and be mediocre at both?

    Whatever your goal, family or career, you can't expect to live in the 95th percentile and invest at the 50th percentile to get there.
    Last edited: 03.27.12
  16. kstreet

    kstreet

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    The responses in this thread are great in illuminating the challenge and desire needed in becoming a master of the craft. Awesome work and thank you!
  17. Chakrabs

    Chakrabs

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    I lobby Resxn's post be made into a sticky for pretty much every surgical specialty. Damn good advice for anyone who has questions regarding balancing surgical residency and family.
  18. Leforte

    Leforte Member Moderator Gold Donor

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    I personally have no issue with medical students asking if ENT is an easier surgical specialty. I have no problem with them asking how many hard months are there, what are the easier rotations and what programs are "hard" so they can avoid them. Honestly, I think it allows me to know which students to avoid placing on our rank list, and allows me to adjust any LOR.

    I've also commented to the students who ask these types of questions that when the time comes to seek out an OB for their partner or themselves - ensure that they seek out the one who met the minimal requirements for graduation, yet had plenty of time at home during their residency. I am sure that the experience of the OB has no relationship to obstetrical bad outcomes...

    Should their child need ear surgery - it is important that the ENT have had plenty of time at home during their training - 80 hours per week is clearly far beyond what is needed to train a surgeon. Although current graduates have performed far less mastoidectomies than previous trainees, I am sure they can read about the surgery and be competent if hours were reduced even further. I mean - if the surgeons home life is good, the surgeon is happy and the patient is happy. Who cares about facial paralysis from mastoid/parotid surgery, vocal cord paralysis from thyroid surgery, etc. While it is well known that the best surgical outcomes come from the more experienced surgeons - I am sure patients will accept less than ideal outcomes if their surgeon has a happy home life.

    If you have asked about how "hard" is ENT, if you have to work close to 80 hours during your training and disagree with any of the comments above, then, honestly, I think it would be best to pick another non-surgical career - unless, of course, you have a narcissistic, perhaps slightly psychopathic personality that desires personal satisfaction and gain at the expense and potential harm of others. If you want to become a safe, competent, compassionate surgeon who understands the time requirements to obtain this in 5 years - and is willing to work the hours required, then please apply to ENT. Until the AAO-HNS increases the length of residency to 6-7 years, I do not see how we can train competent surgeons with continually reduced hours. Quite honestly, there is talk to mandated any complex surgery to the realm of the sub specialists - which may be the direction the field may need to go.... Perhaps like the German model, where people are trained in basic ENT operations (basic FESS, PE tubes, tonsils, septum's etc) - and anything even mildly complex - tympanoplasties (much less mastoids), laryngology, and H&N, facial plastics, etc is referred on....
    Last edited: 03.28.12
  19. AMSZ

    AMSZ

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    :thumbup:
  20. THE FUROR

    THE FUROR feel the furor...

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    Do you guys have on-call days in the US? I mean staying in the hospital overnight after completing your daytime duties.
    Or you just take night floats alternating between residents??
    How are the hours?
    I'd like to know, just for curiosity...
  21. Leforte

    Leforte Member Moderator Gold Donor

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    Some places have in house call for the junior years and back up call from home in the senior years. If you take in house call - you should be home by noon the next day, and no primary responsibility after 24 hours continuous duty.

    Others have home call throughout the ENT years (that is, you take call from home, and only the hours you are in the hospital count towards the 80 per week maximum). The new rules ask for a certain amount of time for sleep while on call - and if this is not met, to consider the time to be similar to in house call. I think most residents and attendings would agree that if you were up all night, you should go home the next day - it is a patient safety issue.
  22. OtoHNS

    OtoHNS ENT Attending

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    Interesting discussion here.

    Yes, the majority of people don't want to spend all their time at work and never see their families. However, you do have a limited amount of time to learn how to do surgery while someone is dedicated to supervising you and teaching you. I agree with the other attendings above that you need to take full advantage of the opportunities to learn surgical technique during residency. Sometimes that means sacrificing time with family and friends.

    If you can't handle that, think about doing derm, rad onc, rads, EM, path, etc where you can do your shift and then go home.

    Once you are done with residency, your hours are more under your control if you choose to do private practice. Obviously, you have to see enough patients to stay profitable (and build/maintain your reputation), but other than that you do have the power to choose how many patients you see a day and what types of cases you will do.
  23. Ibn Alnafis MD

    Ibn Alnafis MD

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    This, by far, is the best of what I've read on SDN. Thanks for sharing your wisdom.
    ommu88 likes this.
  24. KWTRCSI

    KWTRCSI

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    Dear Leforte
    Dont you agree that its more about quality of time rather than quantity of time ?
    I mean what is the point of doing 200 hours per week if you end up performing same number of surgeries as in 80 or less hours per week ?
    JUST WONDERING:confused:
  25. THE FUROR

    THE FUROR feel the furor...

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    Thanks Leforte... Always helpful :thumbup:
  26. neutropeniaboy

    neutropeniaboy Blasted ENT Attending

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    There are only 168 hours in 1 week.

    Being an otolaryngologist is not solely about how many people you operate on. You have to learn how to see patients in clinic. You have to learn how to evaluate and manage patients both nonoperatively and operatively. You have to learn how and when to take a person to the operating room. You have learn how to operate on that person and as many variations of that person as possible. You have learn how to avoid mistakes and how to recover from mistakes. You have to learn how to talk to family members and the patient about a mistake you make and how to assure them that you are doing everything you can to get to the bottom of the error and to put into place a system that will help you avoid it in the future. You have to learn how to manage a patient once he gets out of the operating room and is recovered or is in his hospital bed. You have learn how to manage problems that arise in the immediate post-operative period that occur 24 hours per day. You have to learn how to think straight when you are awoken from your sleep at 3am in the morning to deal with a sometimes very serious issue. You have learn how to discuss with a family a bad outcome or a hospital-acquired problem. You have to learn how to talk to a family when your patient dies or is about to die. You have to learn to determine the conditions of discharge. You have to learn the appropriate course of follow-up. You have to learn how to manage patients long after their surgeries and when you can safely discharge them from your clinic.

    And that's just the beginning . . ..

    You can't learn this **** in <80hr per week and expect to flourish in any type of practice.
  27. resxn

    resxn

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    The two are not mutually exclusive. You can't have quality without some baseline amount of quantity. I argue, per Malcolm Gladwell's assertion, that you can't master our specialty in a residency. And if that's the single greatest exposure to general ENT without the burden of running a practice, how can you be expected to be a great surgeon if you try to cut corners on your exposure to it then?

    I'm not saying you can't be adequate, but when's the last time you heard a patient say, "Hey, do you know of any adequate surgeon's I can bring my wife to?"
  28. WDeagle

    WDeagle

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    I just dont see how I could possibly learn how to do all this in 5 years. Do you think I should aim for a fellowship even though I want to do a variety of things in my practice?
  29. KWTRCSI

    KWTRCSI

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    Aaahh neutropeniaboy i wish you were my attending:xf:
  30. StillChoosing

    StillChoosing

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    Last edited: 07.12.12
  31. neutropeniaboy

    neutropeniaboy Blasted ENT Attending

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    As alluded to already, otolaryngology may be headed that way. Internship hours are now cut. It is conceivable that resident hours will be cut even further.

    If so, you face three possibilities:
    1. Discharging residents into practice who are not prepared
    2. Increasing the length of residency
    3. Having a core residency program in which you are certified to do a, b, and c procedures when you graduate and if you want to do x, y, and z procedures, you will need to pursue a fellowship for advanced training.

    To answer your question, you should pursue a fellowship because you wish to go the academic route or because you want to limit your practice. Doing a fellowship so that you can become more experienced at something to you can put another feather in your cap doesn't make sense to me. People do it, but it doesn't make sense to me.
  32. neutropeniaboy

    neutropeniaboy Blasted ENT Attending

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    You never know....;)
  33. chidoman

    chidoman

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    Last edited: 04.29.12
  34. resxn

    resxn

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    Chidoman, sometimes subtlety is not obtained with a sledgehammer. There may be a very good reason why I didn't say who it was (such as a quiet shoutout to those who would already understand), but thanks, Sherlock, for the stunning sleuthing. Actually, the original author of that quote, though, is James Edward McCulloch. Pres McKay borrowed the phrase in two separate GC talks in April of 1935 and 1964. He, indeed, is the leader to whom I referred.
  35. neutropeniaboy

    neutropeniaboy Blasted ENT Attending

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    Love it!:thumbup:
  36. chidoman

    chidoman

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  37. nacholibre

    nacholibre

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    i'm honestly perplexed by the responses from the attendings on this thread. You have been almost consistently level headed and quite sympathetic, and then all of the sudden a nerve was hit. No one reading this thread is an idiot (assumption of course) why is it wrong for me to worry about my ability to balance my family life and residency. Would you rather I blindly run in and then have a nervous breakdown PGY-2?!?

    If asking you what the hours are going to be like is going to make you think less of me - you're obviously very proud of what you have accomplished and have become disconnected from the feelings that I am very certain you once felt when thinking about making this decision.

    I am scared to death about the hours, and not entirely certain how I am going to get through it with a wife and son, but that has no relationship to my work ethic or my ability to become good at what I do. I hope that my attendings and program directors are more prone to encourage and help me see the possibilities rather than trying to scare me out of proceeding.
  38. neutropeniaboy

    neutropeniaboy Blasted ENT Attending

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    Some of us have been around for 7-10 years. A lot of the attendings were students when this forum was started, and one thing that all the attendings (who post regularly on this forum) share is a solid work ethic.

    There's not a single one of us who hasn't stressed that hard work is necessary in order to complete a surgical residency. There isn't a single one of us who has NOT advocated making the most you possibly can out of the 5 years of training. There's not a single one of us who hasn't said it before: if you don't think you can dedicate the time, don't start what you can't finish.

    I'm sure no one in this forum believes it is bad to balance work and home life. In fact, I'm sure we'd all agree that you must achieve a work-home balance in order to be successful.

    However, there's a right way and a wrong way to figure out how difficult this can be. Try to discern the differences between these two posts:

    1. I have some questions for the attendings and experienced residents out there with families. I'm really pushing for an ENT residency. I have a wife and two children. What ways have you managed to balance your home life and work life while at the same time achieving all you can possibly achieve in residency?

    2. I have some questions for the attendings and exprienced residents out there with families. How often do you actually work 80 hours? Are there easy ENT rotations? When you are off call, are you really off call? What's harder: ENT or Urology? Lifestyle and family are very important to me.


    :cool:
  39. StillChoosing

    StillChoosing

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    :thumbup::thumbup::thumbup:
    Last edited: 05.06.12
  40. OtoHNS

    OtoHNS ENT Attending

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    Status:
    Attending Physician
    SDN 2+ Year Member
    Gold. Couldn't agree more with Neutropeniaboy.

    To the OP and other med students: Thousands and thousands of surgical residents with families have successfully completed the process before. It's not always going to be easy, and sometimes call, patient care, and yes, your surgical education are going to come before spending time relaxing with your family. I think ENT on average is going to be less demanding than specialties like Gen surgery or Neurosurgery, but it's no cakewalk.

    Most people want to know what they are getting into before starting a surgical residency. None of us blame you for that.

    The ways to find out are 1. to experience it for yourself during your surgery and ENT rotations as a student and 2. to ask attendings and residents.

    If you're asking us, you'd be wise to frame your question along the lines of NPboy's #1 above, not his #2. If residents or attendings think you are lazy and want to avoid working hard (doesn't matter if it's true or not), it's the kiss of death for your chances of matching at that program.
  41. resxn

    resxn

    Joined:
    10.02.06
    Messages:
    900
    Status:
    Attending Physician
    SDN 7+ Year Member
    NPB and OtoHNS are right.

    You hope that you don't get attendings like us who respond aggressively to someone who asks how hard our residency life was. We hope we don't get you, a student who we perceive to be lazy, in our specialty.

    If you frame the question as #1 (I'm dedicated to be an ENT--help me prepare to balance my life so that I can try to make the best of some tough years) we will welcome you with constructive advice. However, if you frame it as #2 (I'm thinking about ENT--I want the coolness of the specialty without the hard work) you're going to get the response you did. If you don't understand the difference, you'll always be a #2.

    As a former interviewer for several years in 3 academic programs, I welcomed those students with attitude in #1 and cross-haired the students with attitude #2. And I still 100% think it's the right thing to do to protect my specialty and ENT patients.

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