Just wanted some opinions regarding the future of head and neck oncology. I'm 3rd year resident in ENT at a midwestern program and am facing the decision about what to do with my life. I really enjoy head and neck but am somewhat put off by the chemo-XRT trends in management. We've had some disasters as a result of treating chemo-XRT failures. Anyone out there currently in a H&N fellowship or have any insights? I'd greatly appreciate any input. Thanks!
Head & Neck
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Chemoxrt is definitely here to stay as far as treatment of some H&N ca is concerned, but H&N surgeons are still in high demand. Here is where H&N surgeons mainly do surgery on clean (no XRT) patients: Oral cavity, sinonasal, temporal bone, parotid, thyroid. Nasopharyngeal, oropharynx, hypopharynx are all often treated with XRT +/- chemo up front these days. Laryngeal ca can go either way. Operating on chemoxrt failures will continue to be a reality, though.
One of my good friends is in H&N fellowship right now and likes what he does. The surgeries are, at times, technically demanding and patients don't always "fly" after surgery. Those are the facts of life, and the reason why having residents for complicated patients is a necessity.
One of my good friends is in H&N fellowship right now and likes what he does. The surgeries are, at times, technically demanding and patients don't always "fly" after surgery. Those are the facts of life, and the reason why having residents for complicated patients is a necessity.
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I don't think H&N surgery is dead. Not by a long shot.
I think the issue with H&N is that it is becoming increasingly more painful as the years go by and the numbers of nonsurgical therapies start to increase. Maybe int he future there will be custom vaccines for every patient's H&N cancer. That is not today and it is not tomorrow.
Yes, chemotherapy and radiation therapy are showing numbers that appear to be equal to that of surgery and radiation in certain areas of the head and neck. However, there will always be a number of those patients who have recurrence, persistence, or new primaries. A surgeon will be required for that. The number of general otolaryngologists who are willing to reoperate a chemoradiated patient is dwindling. This will become the domain of H&N trained surgeons. Bigger failures require bigger surgeries with microvascular reconstruction. The demand will be there. If a patient fails chemoradiation and has surgery and then recurs -- well, he can always have more surgery.
There will be a dive, I suspect, in the number of people willing to do this type of surgery. The reasons are too complex to even analyze, but I suspect a large portion of that reason will have to do with the length of training required, the increasing cost of school and malpractice, and the declining reimbursements.
If you really love head and neck, there will be a university that will want you. Guaranteed.
I think the issue with H&N is that it is becoming increasingly more painful as the years go by and the numbers of nonsurgical therapies start to increase. Maybe int he future there will be custom vaccines for every patient's H&N cancer. That is not today and it is not tomorrow.
Yes, chemotherapy and radiation therapy are showing numbers that appear to be equal to that of surgery and radiation in certain areas of the head and neck. However, there will always be a number of those patients who have recurrence, persistence, or new primaries. A surgeon will be required for that. The number of general otolaryngologists who are willing to reoperate a chemoradiated patient is dwindling. This will become the domain of H&N trained surgeons. Bigger failures require bigger surgeries with microvascular reconstruction. The demand will be there. If a patient fails chemoradiation and has surgery and then recurs -- well, he can always have more surgery.
There will be a dive, I suspect, in the number of people willing to do this type of surgery. The reasons are too complex to even analyze, but I suspect a large portion of that reason will have to do with the length of training required, the increasing cost of school and malpractice, and the declining reimbursements.
If you really love head and neck, there will be a university that will want you. Guaranteed.
How (un)common is it for someone doing H&N to not be in a big academic or tertiary center?
Surely, the huge team effort involved must almost necessitate being in a large hospital system. Is there any way that H&N works in a large group private setting? I have just never heard of anything like that.
I'm referring to either of the following training pathways:
1) fellowship-trained
2) general ENT but then made their own "niche" to focus practice on H&N
Surely, the huge team effort involved must almost necessitate being in a large hospital system. Is there any way that H&N works in a large group private setting? I have just never heard of anything like that.
I'm referring to either of the following training pathways:
1) fellowship-trained
2) general ENT but then made their own "niche" to focus practice on H&N
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It is pretty rare to be a "real" H&N surgeon, doing free flaps, etc, without residents backing you up. That said, I know private practice guys who have residents supporting them who do free flaps.
That said, I have done an inferior maxillectomy and also a post chemoxrt radical neck in the last few months. I wouldn't want to do that every week, and I had to round for 2 weeks on the maxillectomy (who went into a-fib, had to get a trach, couldn't eat....), but I enjoy the occasional "real" H&N case. Of course, I do a fair number of thyroids and parotids, but they don't really count.
That said, I have done an inferior maxillectomy and also a post chemoxrt radical neck in the last few months. I wouldn't want to do that every week, and I had to round for 2 weeks on the maxillectomy (who went into a-fib, had to get a trach, couldn't eat....), but I enjoy the occasional "real" H&N case. Of course, I do a fair number of thyroids and parotids, but they don't really count.
It's good to hear that you can still get a few good head and neck cases in a small private practice setting.
I guess I was thinking that the big "super groups" like this one in Charlotte might be the type of private group practice that could feasibly handle the big cases routinely.
Apparently they only have one guy listed as doing H&N. I'm not entirely sure how much he does, but he has a pretty snazzy pedigree.
Edit: That guy does some work at Carolinas so I would imagine he might get some occasional help from the Gen Surg residents.
I guess I was thinking that the big "super groups" like this one in Charlotte might be the type of private group practice that could feasibly handle the big cases routinely.
Apparently they only have one guy listed as doing H&N. I'm not entirely sure how much he does, but he has a pretty snazzy pedigree.
Edit: That guy does some work at Carolinas so I would imagine he might get some occasional help from the Gen Surg residents.
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I interviewed at that Charlotte practice. Kicks butt in terms of their "power." There's more than just the one guy doing H&N there, even though the one you point out is the one that does the bigger stuff.
In Denver, there's a private group of 2 that do exclusively H&N. They're at a major hospital and have the support for a good tumor board. There's another private group of 2, also fellowship-trained H&N, that do about 75% H&N only and supplement with general ENT to keep busy.
It really depends on the area. You can do H&N as a private practice guy, but like Throat said, it's tough, especially without either residents or PA's/NP's.
Personally, I rarely do big H&N cancer surgery anymore. Mostly because I don't have the tumor board support I feel is appropriate. Partly, because I just don't have the time/desire to take care of that population. I have more than enough to do with thyroid and salivary gland cancer that I don't want to get busy in the world of SCCa too especially when I still love to do rhinology, laryngology, and peds stuff.
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You are right that you probably need to join a group where more than one person does H&N. Based on my experience, if you are the only person who does big H&N cases, you will also be on-call everyday for your patients. To explain, if the neuro-otologist or facial plastics guy is on-call and one of your post-op H&N cases crashes, believe me that they are going to call you to take care of it.
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Not to derail this thread, but I have a question a bit off topic. To those ENTs on this forum practicing in the small, private practice setting... can you quickly comment on why you chose that route as opposed to something more like the large group in Charlotte that was referred to previously. How does the compensation (generally) compare between the two set ups? Call schedule easier in a large group?
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I work in a small single-specialty group practice. There is just 2 of us. I like it because he and I get along. The larger the group, the greater the chance for personality conflicts and competing interests. Your "voice" is smaller. Call is not bad even though it is on average q2d... I probably get paged after hours about 2 times a month. When you are on-call for a large group, the patient population is MUCH larger and you will be very busy when on-call. Compensation is not so much dependent on group size, but rather location. If it is a undesirable location, you will be compensated more regardless of group size.
Thanks to everyone for the information thus far, albeit there was some digression in this topic
Anyway, I've been looking into fellowships and was wondering whether they are all through the American Head and Neck Society, or whether there are some outside this match? I'm a bit confused on this topic... Partly because the AAO-HNS website's fellowship search gives several which are NOT listed on the AHNS website. Any help would be greatly appreciated!
Anyway, I've been looking into fellowships and was wondering whether they are all through the American Head and Neck Society, or whether there are some outside this match? I'm a bit confused on this topic... Partly because the AAO-HNS website's fellowship search gives several which are NOT listed on the AHNS website. Any help would be greatly appreciated!
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Thanks to everyone for the information thus far, albeit there was some digression in this topic
If you are looking into fellowships, ask your H&N staff member. H&N is such a tiny field, many programs don't really care to be on websites. Getting into fellowships is very much based on "who" you know.
That said, programs seem to be really scrambling for H&N surgeons. The back of the white journal and the bulletin have a ton of ads for them.
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Are there still any H&N fellowships that take general surgeons? Is there a list anywhere?
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Technically, all the AHNS fellowships are open to general surgeons. But some of these require general ENT call and/or ENT clinic coverage at the faculty level, so they may not take general surgeons although they obviously don't advertise that. More info here:
http://www.headandneckcancer.org/residentfellow/fellowships.php
