ENT in 20 years

[Kierkegaard's Bud]

M1 student here with high interest in ENT. I wanted to ask what are interesting trends in field that one should be on the lookout and/or excited for next two decades or so.

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[HighPriest]

The most interesting trend is that no one does anything in primary care anymore, so now you get to do it instead.

I think the future is ENT offices hiring PAs to do the work that the PA or NP in the primary car office didn’t do before they sent the patient to ENT (like prescribe even a single antihistamine, or try an antibiotic for a subacute sinus infection, or order an US for someone with a “big thyroid.” And actually our version of the Daily News (ENT Today) actually resleased an op ed where the editor said he thinks that’s the right way to go. To dilute medical accountability so significantly that no one knows who does what anymore.
If you don’t hire midlevels to watch out for the PCP midlevels, then you have to do it and that ends up being all that you do, so you’re a highly over-trained mid level and patients don’t benefit from your specific skill set.

But I imagine that probably true in other fields, not just ENT.

 

[HighPriest]

All of that being said, this is a systemic problem not confined to ENT.

ENT is, under ideal circumstances, a great field. Lots of interesting pathology, an amazingly broad range of different surgeries considering the portion of the body we work with, and when you’re managing medical care at an appropriate level it’s satisfying.

In terms of what to look forward to: 20 years is a long, long way off a medicine advances slowly (for a good reason). I suspect you’ll see better treatments for OSA, more effective cancer screening tools. I’m sure a lot will change but it’s hard to predict that far away. Everyone in the 60’s thought we would be living on the moon right now.

 

[Pir8DeacDoc]

There's been a rather dramatic change in my career so far away from surgical management of head and neck cancer and towards chemo/rads up front with surgical clean up if they fail. Downside for a general ENT Like myself- I'm not interested in salvage surgery. It's just exponentially more challenging and more prone to complications. So I function as a biopsy guy and do some T1/2 work in the oral cavity, Oropharynx, and sometimes larynx.
Other major change has been immunotherapy for nasals polyps. I used to have a subset of patients that would go to surgery every couple of years. Now, those patients really benefit from Dupixent. It's an amazing medication. I suspect there will continue to be advances in that area.
I'm sure there's more, but that's the first two things I think about.

 

[asrw77]

There's been a rather dramatic change in my career so far away from surgical management of head and neck cancer and towards chemo/rads up front with surgical clean up if they fail. Downside for a general ENT Like myself- I'm not interested in salvage surgery. It's just exponentially more challenging and more prone to complications. So I function as a biopsy guy and do some T1/2 work in the oral cavity, Oropharynx, and sometimes larynx.
Other major change has been immunotherapy for nasals polyps. I used to have a subset of patients that would go to surgery every couple of years. Now, those patients really benefit from Dupixent. It's an amazing medication. I suspect there will continue to be advances in that area.
I'm sure there's more, but that's the first two things I think about.

Are people worried about these monoclonal ab therapies eventually decreasing overall need for FESS? Bad for future rhinology market?

 

[OtoHNS]

Are people worried about these monoclonal ab therapies eventually decreasing overall need for FESS? Bad for future rhinology market?

I'm not. The price tag is astronomical, and these new meds are only for CRS with polyps. The only situation I would use one of these meds is in post-op FESS patients where the polyps aggressively recur within 1-2 years. Others may feel differently of course.

 

[HighPriest]

The drugs work well, but I’m with OtoHNS - they don’t fix everyone, they have limited indications, I don’t know that I’ve ever given them as a first line treatment (instead of surgery), and most of my patients tell me that can’t afford the allerflo at Costco let alone Dupixent.

They’re a tool. They work on some projects.

It’s just like people saying robotic surgery will replace everything, or balloons will replace FESS. Rarely is anything ever that simple.

 

[javksmith93]

I'm not. The price tag is astronomical, and these new meds are only for CRS with polyps. The only situation I would use one of these meds is in post-op FESS patients where the polyps aggressively recur within 1-2 years. Others may feel differently of course.

I’m a pgy3 trying to decide between Rhinology and otology my goal is to go back to LA (born and raised) I love both of those fields. Compensation wise would one be better then the other I. High saturation areas?

 

[HighPriest]

I think rhinology usually pays best amongst subspecialty trained docs.

The other thing I would consider is:

Almost everyone wants an otologist in their practice.

A lot of people don’t want a rhinologist.

The reason is that most people like doing sinus cases and sinus cases reimburse the best. So if I’m a general ENT and I hire a rhinologist, I’m likely going to have to give up a good share of my best cases to this guy so that I can support an occasional skull base mass.

A lot of people don’t like doing ear cases (or managing vertigo) so the opposite is true.

That has been my general experience, anyway. Since I got out of the Army, we have interviewed every otologist who has applied (even when we weren’t actively searching) and we’ve declined to interview every rhinologist. I have five rhinology trained docs within a two hour drive. I send them something once or twice a year. I just don’t need someone in house with that skill set.

This obviously would not apply to academic centers, or groups where everyone is fellowship trained (everyone has their schtick).

 

[OtoHNS]

Agree 100% with High Priest, though this is generalized advice. I think it is probably very accurate outside of the top 10ish metro areas. Huge cities may have their own unique dynamics though.

If you're focused on LA (or any other specific large city for anyone reading this in the future), I would speak with someone or a few different people who practice there to get a better idea of the landscape.

I'm not super familiar with LA, but I do know it's unique among US metro areas (except for NYC and maybe a couple others) in the large number of academic departments within the metro as well as having arguably the Mecca of otology there (House Clinic). I have no idea about the non-academic ENT situation there.

My recommendation: call up some ENTs there and ask your questions to them:
-People you personally know
-Alumni from your residency
-People your attendings know

You should be able to come up with at least 3 people this way who you have at least some connection with. They will give you better answers than anyone who does not practice in LA.

 

[HighPriest]

* almost all of my advice will be general advice if you’re applying to work in my practice, then it’ll be specific advice.
Otherwise, as OtoHNS said, always check the local landscape.

Honestly I wasn’t sure if you meant Los Angeles or Louisiana.

 

[Pir8DeacDoc]

I think rhinology usually pays best amongst subspecialty trained docs.

The other thing I would consider is:

Almost everyone wants an otologist in their practice.

A lot of people don’t want a rhinologist.

The reason is that most people like doing sinus cases and sinus cases reimburse the best. So if I’m a general ENT and I hire a rhinologist, I’m likely going to have to give up a good share of my best cases to this guy so that I can support an occasional skull base mass.

A lot of people don’t like doing ear cases (or managing vertigo) so the opposite is true.

That has been my general experience, anyway. Since I got out of the Army, we have interviewed every otologist who has applied (even when we weren’t actively searching) and we’ve declined to interview every rhinologist. I have five rhinology trained docs within a two hour drive. I send them something once or twice a year. I just don’t need someone in house with that skill set.

This obviously would not apply to academic centers, or groups where everyone is fellowship trained (everyone has their schtick).

well said. Exactly my experience as well.

 

[javksmith93]

* almost all of my advice will be general advice if you’re applying to work in my practice, then it’ll be specific advice.
Otherwise, as OtoHNS said, always check the local landscape.

Honestly I wasn’t sure if you meant Los Angeles or Louisiana.

Los Angeles. There’s always a stupid joke about Los Angeles elitism that we abbreviate it as LA and expect everyone to know which one we’re talking about and I’ve totally fallen into the trap haha sorry about that

 

[TonsilPlucker]

Los Angeles. There’s always a stupid joke about Los Angeles elitism that we abbreviate it as LA and expect everyone to know which one we’re talking about and I’ve totally fallen into the trap haha sorry about that

Otology if you want to practice in a big city in California. Everyone loves sinus. Everyone wants the thyroids and parotids. Very few people want to manage the recurrent choles that need CWD, subtotal/total TM perforations, 99% occlusive exostotic ears, vague ET dysfunction/patulous ET issues and of course all our favorites vertigo.

Honestly, you're probably better off practicing general ENT if you want to do PP. Seems to always be practices looking for those.

Probably the best advice is to not practice in any large city, especially in California. I know because I'm in one.

The reimbursements suck. the COL is high. The patient population (esp those with good insurance) are whiny and self-entitled.

Can't speak for academia but obviously fellowship is usually desired but not always.

 

[Pr1d3D0c]

Can anyone speak to the Northern AZ market? I am currently deciding between Head and Neck Fellowship and Facial Plastics. My heart is with the former, but my ultimate career goal is northern Arizona. I value most being able to live where I want to so can anyone weigh in on what is the best path to get to Northern AZ?