Otolaryngology as Told By a Residency Director

Session 103

Dr. Cristina Cabrera-Muffly is an ENT residency Program Director at the University of Colorado who has been out of training for 10 years now.

Cristina is also the host of the new podcast called Otomentor that provides mentorship for your Otolaryngology career. Listen to it on iTunes and Spotify.

Whether you’re interested in ENT or not, today’s topic isn’t only specific to ENT as she gives great advice with regards to every residency that you’re going to be applying for. Also, we talk about women in the operating room, pathologies in otolaryngology, life as a resident, and more!

Be sure to check out all our other podcasts on Meded Media for more resources!

Listen to this podcast episode with the player above, or keep reading for the highlights and takeaway points.

[01:30] Interest in ENT

Cristina went to medical school with an open mind. Her dad is an OB/GYN. She had volunteered at the hospital and had followed him to the OR and shadowed a few times. She liked the OR environment. She liked how it was meticulous and detail-oriented, as well as the camaraderie of working with the team to get a patient outcome.

When she got to medical school, she considered Surgery, but she fell in love with her Pediatrics rotation. This was initially a shock to her as she didn’t consider herself to be a kid person. She loved the continuity of care and working with the kids.

She then did an Otolaryngology Pediatrics elective and that was when she knew it was what she really wanted. It had the best of both worlds. She could see both adults and kids. She could do surgery. She could treat her patients medically.

'It's one of the few surgical fields where you can actually see kids without a long fellowship afterward.'Click To Tweet

The surgical electives were urology, orthopedics, ENT, anesthesia and most of them were at the main hospital. The medical school she went to had one at the pediatrics hospital for ENT specifically. Cristina thought it was providence that led her to ENT.

Since then, things have changed for medical student electives. At the University of Colorado, they recently lost the ability for medical students to do an Otolaryngology elective at all.

They have to do a full rotation when they’re on their fourth year. But they don’t get to experience any Otolaryngology unless they shadow on their own time during their surgery block.

[04:33] Traits that Make a Great Otolaryngologist

Cristina says you have to be able to relate to people. Otolaryngologists see patients in clinics. So you have the ability to establish great rapport to patients.

Most people can be surgically trained. It’s usually more of the ability to synthesize the knowledge and translate that into who will need surgery and who doesn’t.

'In our field, especially, people have trouble communicating. We do more with communication than almost any other field.'Click To Tweet

In their field, they see people with communication problems – people with impaired hearing or those who have lost their ability to speak. It’s important to be able to interact with people that may not be able to communicate with you.

[06:05] Types of Patients and Typical Day

Otolaryngology is a very anatomically specific field but wide-ranging otherwise. Possible pathologies include jawbone/mandible fracture, hearing loss, deviated nasal septum, or vocal chord dysfunction (for stroke patients with trouble verbalizing). It’s pretty diverse set of skills.

If you can’t choose one thing, you can decide to do everything in one particular anatomic area.

As a generalist, Cristina sees more patients in the clinic than some of her other subspecialist colleagues. For instance, a head and neck surgeon who sees cancer patients is going to spend a lot more time in the operating room as they have to do12-hour procedures.

While Cristina’s cases are generally 1-3 hours long. Her typical week is 2-3 days of clinic and 1-2 days of operating room time. She does bread and butter ENT like tonsils, ear tubes, sinus surgery, septum surgery, and excisional biopsies.

Basically, it really depends on what want to do, whether you want to do ear surgery or laryngology surgery.

Cristina’s decision to stay as a generalist is mainly because she enjoys multiple parts of Otolaryngology. She didn’t want to just do nasal surgery or just ear surgery or just laryngeal surgery. She wanted to be able to do all of it.

As she continued to practice, she had narrowed down her focus so she no longer does some of the more gigantic procedures.

'It's a very satisfying thing to be able to treat multiple things at once.'Click To Tweet

When she does clinic at the main campus, all of her partners are subspecialists. So when a patient comes who, for instance, complain about all three issues of the ear, nose, and tongue. Cristina can actually treat all at once without having to see three different people.

She has the luxury of being a generalist in a university practice. So if there’s something which she thinks is better served by a subspecialist then she can always refer to her partners.

[09:55] Academic vs Community Setting

Cristina’s first job was at an academic center. She chose general because she really likes general cases and not just one thing. But also, she was getting to the time of her life when she wanted to start having a family. So she didn’t want to have another year of fellowship.

Instead of going to fellowship, she followed her husband (who is a surgeon) to his fellowship. Then she got an academic job at the same hospital where he did his fellowship.

This opened her eyes to academic practice. She fell in love with it. It wasn’t initially something she considered or thought out. But she found it to be very satisfying. She ended up being an associate program director while they were there.

'This is something that I can do to make a difference for future generations.'Click To Tweet

Moreover, Cristina wants to leave this legacy of being able to train multiple people who would go on to treat more patients than she could ever treat in a lifetime.

[11:40] The Training Path

'ENT continues to be one of the most competitive specialties to get into.'Click To Tweet

Being a very competitive field, Cristina stresses the importance of having great clinical rotation grades or the Step 1 score or research opportunities to be able to attain a position.

Over the last 20 years, ENT has always been known as very competitive and the Step 1 scores have gone up every year. It wasn’t until five years ago that it hit a peak where they had a mean of 250.

Three years ago, they had 14 unmatched positions in 2017 and 12 unmatched positions in 2018. This was unheard of as they’ve never had more than 1-2 unmatched positions. This was on a national level. So there’s about 300 positions every year.

The reason for the opening in those two years is that fewer people applied. Instead of having 400 applications, they only had 300 applications for two years straight.

For this past cycle, the pendulum swung again and they had about 450 applicants for 2019. There were a lot of unmatched applicants. This is unfortunate for applicants who actually deserve a position and they could have interviewed at least 300-350 applicants.

Cristina believes the reason ENT is so competitive is because of the supply and demand issue.

[01:30] Interest in ENT

'It's one of the few surgical fields where you can actually see kids without a long fellowship afterward.'Click To Tweet

Since then, things have changed for medical student electives. At the University of Colorado, they recently lost the ability for medical students to do an Otolaryngology elective at all.

They have to do a full rotation when they’re on their fourth year. But they don’t get to experience any Otolaryngology unless they shadow on their own time during their surgery block.

[04:33] Traits that Make a Great Otolaryngologist

Cristina says you have to be able to relate to people. Otolaryngologists see patients in clinics. So you have the ability to establish great rapport to patients.

Most people can be surgically trained. It’s usually more of the ability to synthesize the knowledge and translate that into who will need surgery and who doesn’t.

'In our field, especially, people have trouble communicating. We do more with communication than almost any other field.'Click To Tweet

[06:05] Types of Patients and Typical Day

If you can’t choose one thing, you can decide to do everything in one particular anatomic area.

Basically, it really depends on what want to do, whether you want to do ear surgery or laryngology surgery.

As she continued to practice, she had narrowed down her focus so she no longer does some of the more gigantic procedures.

'It's a very satisfying thing to be able to treat multiple things at once.'Click To Tweet

She has the luxury of being a generalist in a university practice. So if there’s something which she thinks is better served by a subspecialist then she can always refer to her partners.

[09:55] Academic vs Community Setting

Instead of going to fellowship, she followed her husband (who is a surgeon) to his fellowship. Then she got an academic job at the same hospital where he did his fellowship.

'This is something that I can do to make a difference for future generations.'Click To Tweet

Moreover, Cristina wants to leave this legacy of being able to train multiple people who would go on to treat more patients than she could ever treat in a lifetime.

[11:40] The Training Path

'ENT continues to be one of the most competitive specialties to get into.'Click To Tweet

Being a very competitive field, Cristina stresses the importance of having great clinical rotation grades or the Step 1 score or research opportunities to be able to attain a position.

Over the last 20 years, ENT has always been known as very competitive and the Step 1 scores have gone up every year. It wasn’t until five years ago that it hit a peak where they had a mean of 250.

The reason for the opening in those two years is that fewer people applied. Instead of having 400 applications, they only had 300 applications for two years straight.

For this past cycle, the pendulum swung again and they had about 450 applicants for 2019. There were a lot of unmatched applicants. This is unfortunate for applicants who actually deserve a position and they could have interviewed at least 300-350 applicants.

Cristina believes the reason ENT is so competitive is because of the supply and demand issue. There are only 320 positions and a lot of people want to do it. She also thinks they’re the “nice” surgeons.

[15:45] How to Be Competitive for Residency Application

You do not have to have a 250. It helps if you do, but if you don’t, you need to have other aspects of your application that can help you shine. This can be in the form of your clerkship grades.

'We look at the general surgery clerkship and the internal medicine clerkship as the key ones that really tell us how you've been doing.'Click To Tweet

A lot of medical schools have done the pass/fail system now so you can’t always tell how people did in their clerkships. However, the dean’s letters can give some insights. The thing is, they’re often cultivated to be the most positive of the positive comments.

In the last 5 years, the research output of applicants applying to Otolaryngology has gone up astronomically. They used to see people who had one oral presentation or one poster or one publication. Now, many people applying have multiple publications. They’re not necessarily in Otolaryngology. They can be in Orthopedics or General Surgery or even nonsurgical fields. It’s interesting to see that evolution over the last several years.

No matter how high your board score is, but if you don’t have volunteer activities or haven’t participated in any research projects, and your letters are mediocre, the admissions committee is going to take a pass.

[18:30] How They’re Narrowing Down Applicants

300 out of the 400 applicants have those pieces of the application in some form. So to try to narrow that down, they interview approximately 60 people every year for their 4 positions and this can be very difficult for them.

Additionally, they sometimes rely on geography as well. They currently have only one resident in their program who is from the Northeast. So if someone is from the Northeast and another one is from Oklahoma, they’re probably going to interview the person from Oklahoma. And that’s because they’re more likely to look at the school as an option for their training.

Each program has its pros and cons. Each program has its strengths.

For instance, too, there may only be 5 programs in the country that offer cleft palate training in their pediatric hospitals. So this may signify that you’re more interested in a specific school because of that. Conversely, it can be hard for them to really tell if it’s your real interest or you’re just trying to put it in there to get in.

'You do what you need to do to get to where you want to go. But it's also tricky from this end to really know what people's motivations are.'Click To Tweet

[21:25] How Students Should Evaluate Programs

Cristina doesn’t personally think there is a lot of information to help you make that decision. A lot of applicants apply based on geography. Either they have family in the area or it’s somewhere they want to be for other reasons.

That being said, how people decide where to apply is an interesting process. In Otolaryngology, there are very few programs that are better than other programs.

There could be challenges along the way in terms of key people leaving or recruitment issues. But when you have a competitive specialty, almost all of our 120 programs are actually amazing.

'99% of our programs will give you excellent amazing training.'Click To Tweet

Hence, it can be hard to tell what applicants should be looking for since they’re all very similar. And Cristina doesn’t think you won’t really have an idea of what a program is truly about until you go there. See how you fit with the culture and the residents and the faculty.

[23:15] The Application Process

It used to be a separate intern year, but now it’s combined. Most of their interns are actually happy about this. They get to do 6 months of ENT (which used to be a complete general surgery year).

They generally just apply for a categorical position which is for 5 years. Then they arrange the other 6 months of internal rotations with other departments.

'It's actually very prescriptive through the ACGME as to what rotations interns can do.'Click To Tweet

Most programs will have a research block during their training. This is usually somewhere between 4 and 6 months during their third or fourth year.

Other than that, you will be doing clinical work the entire time. As a junior resident, you’re going to do more clinic at most programs. As a senior resident, you’re going to spend a lot more time in the operating room.

It’s a really progressive autonomy experience as well. As a junior resident, you’re going to have a backup call person that’s there for your questions. As a senior person, you’re going to be the main person assessing the patient.

[25:00] Taking Calls

Calls would depend on the program. All of the programs Cristina has been a part of (except for one) were home calls. This is the trend because they generally cover several hospitals at once.

At their program, they cover four institutions. There’s a junior resident on primary call, who is the first person to get called. Then the senior resident is there to back them up in case something needs to go to the operating room.

'It's very rarely a home call. It's actually a car call because you're driving to the hospitals all the time.'Click To Tweet

Additionally, they’ve arranged call rooms for the residents at various hospitals since they’re there most of the time. So if they’re waiting for the operating room and the case is going, they’d have some space they can stay in to take a nap.

[27:05] Doing Elective Rotations Away From the Home Program

Cristina published an article about this. Two years ago, she did a study with one of her residents at that time. They sent out a survey asking applicants about away rotations.

They found that 90% of people actually thought the rotation was valuable. Not because they matched, but because they’ve learned so much about the field and about another program. This way, they could compare it to their home program.

'Doing an away rotation is a double-edged sword.'Click To Tweet

You’re interviewing for a month and this is harder to do than an interviewing for a day. So you’re going to be probably judged more harshly for that month. But if there’s someplace that you really want to go, having an away rotation is pretty much your only guaranteed way of getting an interview there.

With the way that selection goes, it’s a little bit random as to what interviews you’re going to get. So if there’s a place you really want to go to, Cristina advises you do an away rotation.

'If there's a place you really want to go, I would highly recommend that you do an away rotation.'Click To Tweet

Moreover, this influences the rank list. So a lot of people who do away rotation and do a great job matched at that away rotation.

Cristina adds that doing an away rotation gives you insights into how a different department operates and how residents interact with each other at different places.

You could hone in on this during your one-day interviews. See what you’re looking for in that way. See what kind of fit you’re looking for and what kind of questions to ask that you may not have thought of because you only had this one experience at your home program.

[29:38] What Makes a Good Future Resident

Cristina says they could tell if someone can be a great resident if the applicant shows up on time and shows up early. They carry around supplies like tongue depressors, flashlight, etc.

It’s someone who really wants to be there, is asking intelligent questions, is volunteering to do some of the things that are tough to do like talking to the patients and making them feel heard.

For Cristina, what the residents have to say is more important to her than what the faculty has to say. Every year, there is an applicant who comes and they are two different people. They act one way with the faculty and then act a completely different way with the residents. This is a huge red flag.

'If the residents really don't think you're a hard worker and you just try to sneak under the radar, and the faculty all love you, I don't want that type of resident in the program.'Click To Tweet

[31:10] How Osteopathic Applicants Can Stand Out

Last year, the ACGME incorporated the DO programs into the NRMP match. They actually went from 110 programs to 120 programs.

The number of positions increased by 20 positions. Again, this is very rare to be increasing that much for a year. This is because they incorporated a lot of the DO ENT programs.

Cristina thinks this is going to change significantly having one standardized process for application. There is going to be a lot of crossover over the next 5-10 years.

Like any applicant, if someone has an excellent application, great board score, great clerkship grades, good letters of recommendation, research, then they would be evaluated in the same way as an allopathic applicant.

[32:25] Major Changes in Otolaryngology

As technology advances, there will be even more interesting toys to play with. They currently have endoscopes and binocular microscopes. This is going to advance even more.

'Ultimately, the ability to interact with patients is not going to change.'Click To Tweet

As we go to a more lifestyle-based with bigger practices and less mom-and-pop shop physician offices, that’s really the barrier they need to address.

They need to have that patient connection and patients feeling they’re heard and taken care of by each provider in a way that feels more one-on-one.

[34:05] Message to Female Physicians

Cristina explains that part of the reason she’s staying in the field is that she believes in showing female applicants that it’s possible to have a life and a career.

Having women in surgical fields is important. Some patients find that they want their doctors to look like them – whether that’s a gender thing or racial-ethnic thing.

Cristina thinks that Otolaryngology is behind the times as far as both gender disparities and racial-ethnic disparities.

'It's important to have a diversity of physicians in our field.'Click To Tweet

The main thing is to realize that while surgery is not as predictable as a nonsurgical field, you can make that into what you want by choosing the right job after residency.

Residency is always difficult no matter what field you go into. Surgical specialties are generally longer than nonsurgical specialties. That’s going to be the toughest few years of your life from a work standpoint.

But if you have accomplished all the knowledge and skills that you need, you can have a lot of room to decide what you want in your life to look like afterward.

Based on personal experience, Cristina is married to another surgeon. She has two small children. And she makes it work. She may not be at home every single night for dinner but she makes sure she’s home five nights a week. She makes this a priority. She gets help. They have a nanny and a person who cleans their house.

'It's not something you can do alone and you have to have support. But it's definitely possible.'Click To Tweet

[36:50] Final Words of Wisdom

Seek out a mentor. It can be someone who is on the application committee, the program director, or the associate program director in your institution. If you don’t have an otolaryngology program in your institution, seek out one in a nearby area or institution and talk to them about the reality of applying.

'If you feel like you didn't get the score you wanted. it doesn't mean that the dream is over.'Click To Tweet

If you didn’t get the score you want, it means you need to have other things that make you an amazing candidate. Having a mentor to help you through that process is really critical. So don’t be hesitant because you feel like you’re going to be a bother.

Don’t use a Step 1 score to judge yourself or your potential. Meet someone and get real advice about what else you need.

[38:54] A New Podcast About Otolaryngology

Cristina just launched a podcast called Otomentor that provides mentorship to the Otolaryngology field. It’s a one-on-one interview-based format where she talks to other otolaryngologists about different topics.

She gives real advice to medical students, residents, and eventually junior faculty such as how to advance in your field.