I was wondering what the negatives are ENT, as in what bugs you guys particularly about your field. Any specific gripes? Things like patient population, types of surgery, encroachment by other fields, etc? Thanks in advance.
Problems in ENT
- Thread starter Dr.CCM
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this is probably institution-based, but i think it's really annoying that some other services think that ENT is a tracheostomy service and that we can just jump at the snap of their fingers and do trachs same day or next day. they're not very accepting of the fact that sometimes we have 6 ORs going at once and have cases that are 15 hours long...
also, the issue of splitting facial trauma call between other services like plastic surg and OMFS. despite the fact that these services at my hospital have decided to split face call "evenly" every 3rd night, the other services like to cherry pick which "parts" of the face they will cover. i understand that OMFS doesn't work with ears much and if there is a complex ear lac, they are more comfortable getting our advice. but, it shouldn't be the same for plastic surgery. i think if you perform otoplasties you should be able to drain a small auricular hematoma and put a bolster on it...
anyway, that was my rant. i love everything else about ENT. it's a very unique field and the breadth within ENT itself is really wide-ranging.
also, the issue of splitting facial trauma call between other services like plastic surg and OMFS. despite the fact that these services at my hospital have decided to split face call "evenly" every 3rd night, the other services like to cherry pick which "parts" of the face they will cover. i understand that OMFS doesn't work with ears much and if there is a complex ear lac, they are more comfortable getting our advice. but, it shouldn't be the same for plastic surgery. i think if you perform otoplasties you should be able to drain a small auricular hematoma and put a bolster on it...
anyway, that was my rant. i love everything else about ENT. it's a very unique field and the breadth within ENT itself is really wide-ranging.
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Considering post-residency life, the #1 thing that our specialty faces is division among the ranks. There is sub-certification in otology. Peds is pushing for it. Laryngology wants it. Each group then ends up pursuing their own agenda and the group as a whole suffers. Perfect example is how the rhinologists (behind closed doors, mind you) lobbied for new codes to be used for balloon sinuplasty. You see, balloon sinuplasty ate into the rhinologists market because it allowed access to treat difficult frontal sinuses that were only the realm of the rhinologist before. So they successfully got the codes changed so that balloons reimburse less than doing standard microdebrider or cold steel work on the frontal sinus. Totally bogus, but it fed the egos and it hurts the specialty.
Other than that, there really is no particular downside for ENT that all of medicine is not already facing--declining reimbursement in the face of more scrutiny and administrative hoops to jump through. Not to mention the hard core push for fee-for-performance. It's not getting any prettier.
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How bad is this issue? If this becomes the norm, does this mean that you would have to be certified in peds to do peds cases? Or oto for oto cases:
Part of the reason I am interested in ENT is because there is a lot of variation. So this is a bit concerning.
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In my opinion one of the interesting things about our field is the patient populations we serve. There are a lot of normal folks but also some real odd balls.
The dizzy patients and sinus patients can me maddening. I absolutely love the cancer patients but they are their own sort of thing, generally heavy smokers and drinkers and live on the fringes of society. Peds is generally great but for the occasional parent (any pedi field has this problem).
Overall I would say ENT is a great field. It's really quite broad, which is something I didn't truly appreciate until I get deeply into it. Good luck!
The dizzy patients and sinus patients can me maddening. I absolutely love the cancer patients but they are their own sort of thing, generally heavy smokers and drinkers and live on the fringes of society. Peds is generally great but for the occasional parent (any pedi field has this problem).
Overall I would say ENT is a great field. It's really quite broad, which is something I didn't truly appreciate until I get deeply into it. Good luck!
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I agree with this entirely. I certainly see it among people in my subspecialty. Many are fellowship trained while others are not. There's an undercurrent of animosity there because of what it implies now and what it could potentially imply later on down the road. It already implies to patients that somehow a fellowship trained neurotologist is better than a neurotologist who is not fellowship trained. In the future, with certification (almost certainly anyone in the game long enough is going to want to be "grandfathered"), now you will have certified and "noncertified" surgeons. Push it even further, you can't do a procedure unless you are fellowship trained and board certified, regardless of how good you are.
On the flip side of that, the specialty at least gets to see some (potentially) standardization in the training. ACGME accredited residencies and fellowship must have certain standards that are met. Otherwise, you could pretty much do a X fellowship, spend your year doing Y, and come out calling yourself Z. That's a point of contention as well.
I "hear" what you are saying, but I disagree with you. That's like saying a patch myringoplasty should have the same RVUs as a post-auricular approach tympanoplasty with OCR. Having done balloon sinuplasty and watched some of my colleagues do frontal surgery -- real frontal surgery -- I have to agree with them on this one. I think they're upset that 1) it's turned non-frontal surgeons into "frontal surgeons" and 2) those doing sinuplasty are getting paid the same amount for a 5 minute procedure what a rhinologist is getting paid for the 20-30 minute frontal procedure (no, no one gets reimbursed for 22 modifiers...I've never gotten extra either). I also hear that patients who wouldn't otherwise need frontal surgery are getting it because using the balloon is so easy and relatively free of maintenance.
This will be big in the future. With the increasing difficulty I have getting people approved for surgery, there is going to be a fee assessed to each patient based on the the surgical procedure. Whatever the insurance doesn't cover, the patient will have to.
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As we agree on most things, NPB, one thing I can say is that there is a far cry from a myringoplasty and tympanoplasty but not with approaches to the frontal sinus. Entirely different approaches, entirely different post-op recoveries, difficulty levels, methods, and to some degree risks. However, a balloon is a tool not a procedure. It's like if you had a device that allowed you to perform a tympanoplasty in half the time with the same results and with reduced risk. Everyone would migrate to that device once proven. Problem is that with the balloon you use the same approach, put the device in the exact same spot, take the same risks (some would argue and probably correctly that there are fewer with balloon), and have the same recovery, same post-op need for debridement, etc.
No one I know would argue that a Draft III is far more complicated than a frontal approach whether using a balloon, microdebrider, or Blakesly. But of the latter 3, they are all just tools to do the exact same thing. Because one is more efficient, shouldn't count against reimbursement.
I do think that it is reasonable to consider differences in reimbursement when ballooning the maxillary as that is an entirely different philosophy regarding retaining or removing the uncinate and far more compatible with the ear surgery analogy.
As far as addressing badasshairday's question regarding the future of procedures. The same guys that are anti-balloon are pushing for a seismic shift in residency training. They are saying that they want to have a 3 year general ENT residency where you get trained and certified to do only the basic garbage--essentially tubes, tonsils, myringoplasties, skin lesion excisions, biopsies, turbinate reductions, septoplasties. If you want to do anything beyond that, you will need to go into a 2 year fellowship in the field of your choice. That means if you go otology, you can't do FESS, and vice versa. I can't see this taking hold, but there is a push there. In my opinion, it's a ridiculous idea.
The current idea is that the subcertification will not prevent the general ENT from performing all aspects of Oto/HNS that they'd like, but it may eventually become harder for them to compete with those who have board certification to do so. It could become tough within your career, but not likely in the next 5-10 years will it be a tough climate.
