So what's so great about otolaryngology anyways?

[MattMKL]

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[resxn]

So guys, I'd like to hear the straightforward answer to why you think oto is so great, and why you chose it/are considering it as a career.

What is it about life as an oto that attracted you so much?

Were there a lot of outpatient type procedures? Less sick patients? Less likely to get sued than in another surgical specialty like ortho?

How is the residency as compared to general surgery or internal medicine in terms of hours? Varies from program to program or is it pretty consistently less intensive (time wise) than gen surg?

What's the life like being an OTO in private practice?

What's the compensation potential like? Most of the survey's I've seen (Merritt Hawkins, etc.) usually put the otos at a lower median salary than other surgical specialties like ortho, optho, as well as rads, cardiology, and gastro. Is this a product of small sample size or do you think that's a pretty legitimate assessment?

Frank question: Is there an overarching theme in the type of personality ENT surgery tends to attract?

I'd just like you guys to be as straightforward as possible. If you like ENT because the hours are easy, just say so. If it's because the pay is actually out of the world, I'd like to hear it.

That's a big list of questions. I'll answer them in the order you asked. And I will answer them from the perspective of a general otolaryngologist, obviously a HNS is going to answer them differently.

1 - that will be answered throughout the other questions

2 - a) In my practice, 70% of my surgical volume is outpt, but in terms of time in OR, I'd say 45-50% is spent on inpt surgical procedures. b) "sick" is a very subjective word to use, but I'd say pt's typically present to a general ENT with less life-threatening conditions than they would to say a neurosurgeon or pulmonologist. Having said that, I see a fair share of patients with life-threatening cancers, trauma, etc. It's just not overwhelming in my practice. c) ENT's in general are less-likely to get sued than mostany other surgical specialities and that's why our malpractice is on average lower, but the threat remains high. There are a number of reasons for this which are outside the scope of this discussion. In general many of the surgical procedures in bread and butter ENT are for quality of life and not absolutely necessary unless the patients want it (septos, some tonsils, some FESS, all cosmetics, many middle ears, etc).

3 - The hours thing is a irrelevant comparison these days. There is an 80 hour work restriction regardless of speciality. I trained before the work hour restrictions went into effect. Only in my R-2 year did I routinely break that hour level anyway. R-3 and up I'd knock on the door frequently but rarely go over. In my internship, I rarely was under 80 and during CT surg for 2 months I did 130 or so hours a week taking call every other (40 on 8 off 40 on. . .). General slavery is worse for most programs than ENT but there are obviously exceptions.

4 - Life as a general private ENT is vastly different from practice to practice. It depends on whether you're solo, small single-specialty group, large single-specialty group, multi-specialty group, within an HMO, salaried or not, call schedule, number of hospitals covered, cover trauma or not, etc. You'd just have to ask individuals and find out what their respective experience has been.

5 - Compensation also varies greatly. Here is info from the 2004 American Academy of Otolaryngology/Head and Neck Surgery. For some reason, the link to 2005 is broken.
a - mean number of weeks/year worked = 48.64
b - mean number of pt office visits/wk - 90.65
c - how hours are divided per week = 27.6 in office, 10.9 in OR, 4.2 administrative activities, 3.7 hospital/ER rounds, 2.7 calling pt's
d - almost perfectly evenly divided 1/3 said their salary is higher, 1/3 said salary unchanged, 1/3 said salary increased from the previous 2 years
e - 2003 net median income by region = Pacific $240,150, Mountain $230,880, North Central $276,140, South Cenral $266,380, New England $247,500, Mid Atlantic $269,170, South Atlantic $248,330. I'm not going to wast my time looking up other specialties are even care what others make. The singular gold standard for salary and physician compensation comes from the MGMA data. Use that rather than salary.com or Merrit-Hawkins type places for your best info regardless of specialty. Most starting physician salaries is based on MGMA data.
f - Median overhead 50.91% (of which 42.0% is staff salary, 15.2% is office occupancy, and 9.2% liability insurance
g - median medical liability insurance premium = $22,591, mean = $28,038
h - median age of planned retirement 65.2

6 - ENT attracts well-rounded people who have lives signficantly active outside of medicine. They are among the smartest in their respective med school classes, but are also among the most well-liked. I'm sure this will offend some people who hate pigeon-holing personalities based on specialty, but I agree there is a personality associated with specialited. They don't have as severe the stereotypical ego associated with CT surgeons, Neurosurgeons, Plastics, and General Surgeons. They're not the gruff thick necks you hear about in orthopods. As one of the leaders in our field has said multiple times (Dr. Kennedy), "It's hard not to like an otolaryngologist."

7 - Straight-forward. I like the mix of medicine and surgery. I like that surgery involves some plastics, some cancer, some ortho, some endo, some peds, and some reconstruction. I like that for the most part my patients get better and I'm not just helping them linger on a little longer. I like that I make good money. I like my colleagues. I like that I have a life outside medicine. I love the anatomy. I love our gadgets. I like that there are new gadgets doing new things all year long. As a med student, I realized that ENT clinic was about the most interesting clinic in which I did things. That hasn't changed. I'd hate sitting in a medicine clinic all day handing out scripts and reviewing labs. I could not be as happy in any other specialty.

Geez, that was a book.

 

[MattMKL]

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[neutropeniaboy]

Thanks so much for typing all that out. Your input was extremely helpful. Quick question, you made a distinction between an general oto and a HNS. What exactly is the difference? Are HNS's the ones that do the fellowships and subspecialize into things like neurotology, working soley on surgery of the inner ear (for example)?

The terms "Head and Neck Surgery" or "Head and Neck Surgeon" typically are taken in two ways. Among surgeons and physicians in general, H&N refers to pretty much anything an otolaryngologist does (whether specialized or not). Within the field of otolaryngology, the term "head and neck" typically is used to describe those otolaryngologists that do head and neck cancer. Those that specialized are, of course, otolaryngologists; however, they tend to refer to themselves by their fellowship training (e.g., laryngology, rhinology, etc.).

 

[resxn]

Thanks so much for typing all that out. Your input was extremely helpful. Quick question, you made a distinction between an general oto and a HNS. What exactly is the difference? Are HNS's the ones that do the fellowships and subspecialize into things like neurotology, working soley on surgery of the inner ear (for example)?

Neutropeniaboy said it all. As an ENT, when I say HNS, I do indeed refer to those who take care primarily of head and neck cancer, most of whom these days are fellowship trained.

 

[salmonella]

6 - ENT attracts well-rounded people who have lives signficantly active outside of medicine. They are among the smartest in their respective med school classes, but are also among the most well-liked. I'm sure this will offend some people who hate pigeon-holing personalities based on specialty, but I agree there is a personality associated with specialited. They don't have as severe the stereotypical ego associated with CT surgeons, Neurosurgeons, Plastics, and General Surgeons. They're not the gruff thick necks you hear about in orthopods. As one of the leaders in our field has said multiple times (Dr. Kennedy), "It's hard not to like an otolaryngologist."

That's interesting...at the hospitals I rotated the ENT surgeons are well known for their arrogance and ego. They treated their medical students pretty badly, and are among the most unpleasant surgeons to work with. For the longest time I thought that was stereotypical of ENT surgeons.
Also, the job market seems concerning, especially in large cities. You have to be flexible in terms of location in order to obtain a good solid private practice position.

 

[MattMKL]

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[chirurgino]

Interesting...salmonella, did you rotate through the Yale system? Just a rumor I've heard about ENT from multiple surgical residents who went to medical school there.

It just stands to reason that the job market is tougher in the big cities--think about why you want to live there and you'll understand why everyone else wants to practice in NYC, LA, SF, Boston, etc. etc. It's not unique to ENT. I have heard of some people from the LA area going to practice for several years in OK or TN, where they can essentially double their salaries, and then trying to come back later. In big cities you'll make less money and face established competition--it's the hard reality of supply and demand. In the LA area, you always have the option of going north toward Oxnard or east to the Inland Empire...where I happen to know the market is MUCH better. Obviously much less desirable to live in (at least the Inland Empire), but you'll be close to LA.

 

[resxn]

That's interesting...at the hospitals I rotated the ENT surgeons are well known for their arrogance and ego. They treated their medical students pretty badly, and are among the most unpleasant surgeons to work with. For the longest time I thought that was stereotypical of ENT surgeons.
Also, the job market seems concerning, especially in large cities. You have to be flexible in terms of location in order to obtain a good solid private practice position.

Sorry to hear that. Honestly, one of the things I like most about my specialty was how personable the attendings were in general. I suppose there are outliers in every group. Again, though, I would hope no one uses academic programs to judge the personalities.

Second, the job market for ENT is one of the most favorable among surgical fields. The AAO/HNS is the 2nd oldest professional academy and has been commended on their tight control on the number of residents graduating each year. That has allowed for one of the more favorable job markets around. As is anywhere, the more desirable a city, the more people that want to move there.

For example, in Denver, it is a very desirable city and as such is supersaturated with ENT's. You can go there, though. In fact, there were 4 advertised openings in the metro area this year to join existing groups. However, it's all supply and demand. You will not make as much money there to start.

One of our attendings was big into the business aspects of medicine and said that the mountains are worth about 50K off your starting salary compared to averages. The ocean is worth 30K, the south and the ocean combined is worth 50K. Obviously opportunities exist at key moments. As someone who has just signed for a position this year, I'm well aware of the job market. You need, according to the academy, 1 ENT per 30-35K people. I found a great job in a big city for great money. I just happened to be the first one in when the opening was made.

At any given time, there is an estimated 2100-2300 jobs available for ENT's. With about only 250 graduating each year, that is a pretty good ratio I think.

 

[kilroth]

Neutropeniaboy said it all. As an ENT, when I say HNS, I do indeed refer to those who take care primarily of head and neck cancer, most of whom these days are fellowship trained.

How much head and neck cancer does a general ENT manage?

 

[resxn]

How much head and neck cancer does a general ENT manage?

As much as he/she wants is probably the best answer. I know general guys who do tons, including craniofacial resection stuff in concert with neurosurg, as well as free flaps and major procedures like that. And I know plenty of general guys who do none.

It all depends on the comfort level of the ENT and if he/she can deliver standard of care or better to the patient. Personally, because I don't have the multidisciplinary team I had in residency, I don't feel right caring for much more than the lower staged stuff. I miss composite resections and reconstructions, but I think that since I don't have a multi-disciplinary board at my facility (at least one with well-worn head and neck experience), I'd be doing the pt injustice to be the surgical provider. I do neck dissections when needed for thyroids and elective neck dissections for T1 SCCa of the oral cavity and things like that, but when chemorads, composite resections, and/or complex reconstructions are required, I typically refer them to the university head and neck service.

 

[TheThroat]

resxn: Get back to work! JK, you just seem to have more time to type on SDN than I do.

What I like about the lifestyle aspect of my job: usually can leave by 5 pm, very few emergencies, most patients are fairly healthy...could think of others, but don't have the time.

I think that oto attracts a fair variety of people. I have seen the super-arrogant, the country boy, the hard-as-a-knife gunner, and the girl with chip on the shoulder. Most are very easy to get along with, but some aren't. Same could be said for any specialty.

Agree with comments about big city. Its all supply and demand. I had no problem getting many interviews, though, and was specifically looking to work in the DFW metroplex and surrounding areas.

Compensation: I know of an oto who makes in the upper 6 figures. That is not common, but it is possible. I don't know of any private practice guys making <200K. Have spoken to a few who say that, once established in an area with a "good" demographic (read: little/no Medicaid), an oto should be able to make 500K without too much trouble, but that was just their opinion.

 

[resxn]

resxn: Get back to work! JK, you just seem to have more time to type on SDN than I do.

You forgot, I still am military for the next 6 months and am working on your tax dollar so I have all the time in the world on my hands. Wait, that means you pay my salary. Yes sir, I'll jump right back into seeing patients. I hate it when the boss catches me not racking up the RVU's.

 

[MattMKL]

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[resxn]

Thanks for your help guys. I was just wondering, how different is the life of a General ENT as opposed to the otos that subspecialize. I did some research with an OTO at UCLA Medical who worked mostly on the inner ear and he seemed extremely busy. It made me wonder why people considered ENT a "lifestyle" specialty. Is it a general rule that the ENTs that subspecialize are busier, or was my experience at UCLA just an outlier?

Again, that entirely depends on what your practice is when you get out. There are some fellowship-trained guys that work non-stop and there are some who work as much or less than their general ENT colleagues. I can't even break it down between academic and private practice, because I know ENT's who work ridiculously long hours in both and I know ENT's who work less than 50 hours/week in both practice types.

Choosing a fellowship is not a decision to make based on lifestyle, it's a decision to make based on the type of medicine you'd like to practice. And even then, I know several fellowship-trained guys that do mostly general ENT.

Determining the lifestyle you want will dictate where/how long you work. ENT provides an advantage in that you have the option of deciding. Generally, I don't think you'd find a neurosurgeon or orthopod who says they have as good of a control over their lifestyle as would an ENT.

 

[resxn]

Also here is a breakdown of salaries from MGMA data just released to public review from 2005. I got my hands on it from a published trade journal. There are 2 numbers, the first is the 2005 median, the 2nd is the 2005 Starting salary median. This is net income before taxes.

Anesthesiology 337,654; 267,000
Cardiology 363,081; 245,500
CT Surg 470,000; 292,700
Derm 306,935; 225,000
Dx Rads 400,000; 297,810
Emergency Med 248,271; 187,800
GI 344,200; 222,500
Gen Surgery 310,736; 210,000
Hospitalist 189,677; 146,790
IM 183,840; 130,000
Neurosurg 476,260; 360,085
Ophtho 281,112; 180,000
Ortho 409,518; 290,000
ENT 315,000; 202,000
Urology 349,811; 240,000


That should help you see that the discrepancy is not as great as you might have thought it to be.

 

[aggernodi]

Sorry if these comments have already been made... but I'm a general private practice ENT (working in a rural area) and have a few comments to make which I hope haven't been rehashed elsewhere.

Couple things I think improve quality of life for an ENT out in the real world:
1) Work for only one hospital (opposed to 3 or even 4 in urban settings)
2) Work for a hospital that is not a level 1 trauma center (which avoids all the facial trauma call)
3) Work for a small community hospital (less than 150 beds)...acuity overall is much decreased.
4) Work in a community that is about 2 hours away from a tertiary care center. I think that hits the sweet spot in terms of patients still coming to see you out of convenience, yet if an extremely complicated patient, can transfer out as well.
5) Work with someone who shares your vision, lifestyle desires, sense of fairness, and practice management.
6) You make more than your city-dwelling colleagues...even if they work even only 1 hour away from you.
7) You are IT... you provide a monopoly service (good or bad).

There are downsides working in a rural setting:
1) More bread & butter cases and decreased number of "interesting" cases, but you make your practice what you will.
2) More call days. I am currently q2d...but due to above reasons, call is 95% of the time quiet.
3) It is rural... but I personally prefer that over traffic, congestion, etc.
4) You are IT... you provide a monopoly service (good or bad).

I should also mention that I am a fellowship trained laryngologist. My practice mix is about 25% laryngology, 25% otology (not happy with this as I'm not an ear guy), and 50% everything else.

 

[TheThroat]

Sorry if these comments have already been made... but I'm a general private practice ENT (working in a rural area) and have a few comments to make which I hope haven't been rehashed elsewhere.

Couple things I think improve quality of life for an ENT out in the real world:
1) Work for only one hospital (opposed to 3 or even 4 in urban settings)
2) Work for a hospital that is not a level 1 trauma center (which avoids all the facial trauma call)
3) Work for a small community hospital (less than 150 beds)...acuity overall is much decreased.
4) Work in a community that is about 2 hours away from a tertiary care center. I think that hits the sweet spot in terms of patients still coming to see you out of convenience, yet if an extremely complicated patient, can transfer out as well.
5) Work with someone who shares your vision, lifestyle desires, sense of fairness, and practice management.
6) You make more than your city-dwelling colleagues...even if they work even only 1 hour away from you.
7) You are IT... you provide a monopoly service (good or bad).

There are downsides working in a rural setting:
1) More bread & butter cases and decreased number of "interesting" cases, but you make your practice what you will.
2) More call days. I am currently q2d...but due to above reasons, call is 95% of the time quiet.
3) It is rural... but I personally prefer that over traffic, congestion, etc.
4) You are IT... you provide a monopoly service (good or bad).

I should also mention that I am a fellowship trained laryngologist. My practice mix is about 25% laryngology, 25% otology (not happy with this as I'm not an ear guy), and 50% everything else.

Aggernodi, welcome to the Oto board! Always good to have another guy out of residency to give your take on things.

Couldn't agree more with you on the diff bw/ rural and urban oto. I am in the middle: work at medium-sized hospital in an urban area, so don't get as much bread and butter, BUT, my hospital is also not a big trauma center, so I don't get much trauma (yea!).

 

[nosugrefneb]

Lots o' words.

Thanks for that. As someone who's been thinking more seriously about ENT, this definitely makes it more appealing than I had thought.

 

[fongool]

I'm nearing the end of residency and have loved ENT.

For those of you out of residency - can you speak about how you found your job? How helpful were recruiters or recuiter type websites vs just calling up offices or using connections on your own?

 

[aggernodi]

I'm nearing the end of residency and have loved ENT.

For those of you out of residency - can you speak about how you found your job? How helpful were recruiters or recuiter type websites vs just calling up offices or using connections on your own?

I personally didn't use any recruiters or use any websites to find my job... I basically picked a place I wanted live around... Searched for every single ENT practice in the region through ENTlink.net as well as hospitals, and wrote dozens of letters with my CV enclosed asking if a position was available. I probably sent out about 30 letters, received 6 interview requests, and ultimately landed my dream job that way. If you haven't already been told, most desirable jobs are NOT advertised as it is expensive for practices/hospitals to use a recruiter. Those desperate, however, recruit, but than you have to wonder why they are that desperate...

 

[resxn]

I'm nearing the end of residency and have loved ENT.

For those of you out of residency - can you speak about how you found your job? How helpful were recruiters or recuiter type websites vs just calling up offices or using connections on your own?

Unlike Agger, I did use a recruiter and blitzed their websites frequently. However, I found their benefit being more of who they knew in their network rather than what they actually found for me.

The way I found my position, which I think is my dream job, was by having one recruiter contact me for a particular position. It sounded great but when the practice wanted to hire someone sooner than when I was available, the recruiter gave me the name of a hospital CEO 30 minutes away who was looking to hire an ENT in my timeframe. I contacted the CEO and the rest is history. (This was for a 285-bed hospital in a well-to-do suburb of Dallas so it's not like it was obscure.)

I agree that you should be wary of recruiters. Initially, 90+% of the time a recruiter contacted me it was for a rural practice in which I wasn't interested. After a month or so, I started to narrow down my preferences to a range of 20-30 minutes outside of a major metro area and only to single-specialty practices. The recruiters did honor those preferences and I only received e-mail and calls regarding those practice parameters. I found it to be very effective. I had plenty of inquiries from the cities in which I was interested: Phoenix, Dallas, Austin, Atlanta, Charlotte, Nashville, Denver, and Salt Lake. I probably accepted 8 phone interviews and went to 3 in-person interviews before making my ultimate decision.

I wasn't set on a particular city or location other than being somewhere south of I-70, so that was probably the best "shotgun" method for me. I do think that if you are set on one city, the best thing to do is exactly what Agger did and I actually planned on doing the same thing if my initial method was ineffective.

I just barely went through this process and am now just getting going on setting up my practice, but I'd be happy to provide more detail if you want. My situation is a little unique in that I'll be starting a brand new solo practice in a sizeable population from scratch, but there are others on this site that have rural practices as well as those who are more metro than me.

 

[fongool]

Thanks for the input.
One other question - what was the timeframe like? At what point did you interview?

 

[aggernodi]

Thanks for the input.
One other question - what was the timeframe like? At what point did you interview?

During my PGY3 and PGY4 year. I signed my contract the end of my fourth year. Remember that it takes about 6-8 months for hospital credentialling, licensing, malpractice insurance, etc, etc to go through so if you decide during your chief year, there is a chance you may not be allowed to practice medicine if all the paperwork hasn't been completed yet. In other words, you need your state medical license and DEA first which takes like 3 months before you can even apply for malpractice which can take another 3-4 months. After you get your DEA, state license, and malpractice coverage, than you can apply for hospital privileges which takes another 3-4 months. Once you get hospital privileges, than you can start working on getting on participating insurance plans to care for patients which can sometimes take up to 1 year (I'm still working on it in fact and I've been in practice for more than 1 year)!!! On this last point, you can bill under your partner's name...but going solo will be very tough for this last point.

In other words, plan ahead if you want to start working right away!!!

 

[resxn]

I put my CV out there on ENTCareers on Jan 1, 2006 and I had recruiters and practices calling me within days. I set up my first interview in February. As I said, I set up 3 in-person interviews, but had well over 50 inquiries requesting at least telephone interviews. This is because of my use of recruiting websites, though. It was kind of a pain at first until the firms understood what my criteria for a practice were. Then the number of inquiries was much more manageable. About 50% of the initial inquiries wanted someone sooner (summer 2006) than I was available. In late May or so it changed and then most everyone was looking for someone the following summer (2007).

I had my last interview in June and had a letter of intent from them within a week. I had my formal contract in hand a couple of months later.

Like Agger said, it takes forever to get your paperwork done. I applied this far in advance because I wanted 10 months to get all credentials set, obtain a state license, and to have a contract with as many payers as possible before starting. I have to do this since I'm going solo to start. Someone joining an existing practice still needs to be as ahead of the game as possible, but it's not as financially crucial as it is to the solo practitioner.

 

[THE armada]

2003 net median income by region = Pacific $240,150, Mountain $230,880, North Central $276,140, South Cenral $266,380, New England $247,500, Mid Atlantic $269,170, South Atlantic $248,330.

Is it just merely supply and demand that allows otolaryngologists to have above average salaries in the South Central region?

 

[resxn]

Is it just merely supply and demand that allows otolaryngologists to have above average salaries in the South Central region?

That, but more importantly is probably payer mix. Texas plays a large role in the south central area and in TX physician's are allowed to joing provider networks which negotiate for higher paying contracts with 3rd party payers. Essentially it acts like a union--one of only a few states that's allowed to do it.

The reason I bring that up is because there is probably a higher concentration of ENT's here than in the Mountain States region but we're still earning more. Just goes to show that there's more to it than simple supply and demand. Having said that, there is a relatively smaller concentration in the North Central region which at least partly accounts for their higher pay.

Essentially multiple factors, but those 2 are probably the biggest.

 

[otoeye]

Resxn: such an amazing reply. I concur, ENT by far are the coolest people I have met. They are fun loving and likeable people in general. I loved my ENT rotation in medical school and remember how passionate my mentors. your thoughtful reply in itself is a reflection of your attitude.

 

[entresearch]

. The Department of Otolaryngology of the GWU Medical Faculty Associates has one funded position for 12 months for formal training and mentored clinical research with Dr. Arjun Joshi.

This fellowship is ideally suited to medical students seeking a research year between the 3rd and 4th years, unmatched students, preliminary surgical interns, or residents in other specialties who are interested in training in Otolaryngology and are seeking to improve on their existing research experience in preparation for the Match. Candidates should come from U.S. accredited medical schools. .

. This research fellowship offers a unique opportunity to become involved in a variety of clinical research projects, all of which are conducive to obtaining peer-reviewed publications and presentations at national and international meetings. The successful Fellow will be expected to organize and carry out multiple clinical research projects throughout the year. This will involve study design, IRB submission, data collection (either through retrospective review of charts or prospective interactions with patients), data analysis and interpretation, and manuscript and presentation preparation. There may be multiple projects at various stages of completion in progress at any point in time. Excellent organizational and writing skills are required.

Your typical day will be spent seeing patients in clinic with Dr. Joshi and assisting him in the OR. There will also be opportunities to work with the other attending physicians in the clinic and OR settings as well. You may also be expected to attend lectures and journal club with the ENT residents.

Projects are predominantly clinical outcomes research in the areas of Head &Neck cancer and surgery, in-office sialoendoscopy, and ultrasound imaging; however, the scope of projects may also cover voice disorders, sleep surgery, skull base surgery, and sinus surgery. .

. The Fellow will primarily work with Arjun Joshi, MD, but there will be opportunities to conduct research under the supervision of the other attending physicians in the department. The successful applicant will join and benefit greatly from collaboration and interactions with outstanding clinicians and clinician researchers within and outside of this group. The fellowship begins July 1, 2012 and ends June 30, 2013. Interested candidates are encouraged to apply by sending a cover letter and a CV to:.
.
Contact: Arjun Joshi, MD
Assistant Professor .
. The George Washington University.
. Medical Faculty Associates
[email protected].