Inspired by Academic Pediatric Otolaryngology


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SS 152: Inspired by Academic Pediatric Otolaryngology

Session 152

Dr. Max April is a pediatric otolaryngologist who has been out of training for a while now. He is also the Program and Fellowship Director at NYU. We have an amazing conversation about pediatric otolaryngology, what brought him to the specialty, what he looks for in applicants to the pediatric otolaryngology fellowship and so much more!

For more information on this specialty, check out the American Society of Pediatric Otolaryngology.

For more podcast resources to help you along your journey to medical school and beyond, check out Meded Media.

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

[01:17] Interest in Otolaryngology

In Boston University, where he attended undergrad, he joined the MMEDIC program that allowed them in their last two years at the undergraduate level to take one course a semester at the medical school.

Unlike the six-year program where you shave off years of medical education, this was still eight years. But by taking some of the courses at medical school in your last two years of undergrad, when you got to the first year of medical school, then you could explore what you would like to do going forward. And this was exactly how he got into otolaryngology.

Max took biochem and micro and had about 50% of his first year as an elective. Being a big sports person, Max felt lucky as a fourth-year undergrad to go twice in the operating room with Dr. Bob Leach, the chairman of Orthopedics at Boston University who was also the team doctor for Boston Celtics. He was also the team doctor in the Olympics in the 70s and 80s.

He applied to be able to go to his office two days a week over the six months of the first year of medical school. At that time, he knew he wanted a career in orthopedics. But the doctor’s schedule was too filled that didn’t allow him to have time so he had to rescind the offer.

So the Assistant Dean recommended Dr. Stuart Strong, another famous person at Boston University, an ENT. And to Max, it was just love at first sight. So Max got to follow him two days a week for the first six months of medical school and that was how he got into otolaryngology.

Max recommends you have to keep your eyes open to everything. He has never heard of ENT until he got introduced to his mentor and so mentors can help pave the path for students.

“A mentor can pave the way for your future.”Click To Tweet

[09:01] The Training Path

Otolaryngology is a five-year residency. Max ended up doing a one-year fellowship training, which is now either one or two years of pediatric otolaryngology after five years of residency.

“One of the beautiful things about otolaryngology is you can take care of newborns and premature babies up to a person during their last days of life.”Click To Tweet

There are so many different specific specialties in otolaryngology but Max is giving us the five main categories. 

The first two are Pediatric Otolaryngology and Rhinology and Skull Base Surgery (the sinuses and the end anterior skull base).

Head and neck surgery (which is always a favorite of medical students) is usually oncology. But it can be thyroid surgery, parathyroid surgery, salivary gland surgery, parotid and submandibular gland.

Otology is for ear-related problems. A subspecialty of otology is neuro-otology, where earlier colleges and neurosurgeons work together on acoustic neuromas and other tumors of the lateral skull base.

The last is Facial Plastic Surgery, which has had a lot of increase more recently. In people being interested,

[11:13] Interest in Pediatric Otolaryngology

When Max finished his residency in 1990, the subspecialties at that time would mean seeing patients of all ages but you only stick with that specific part like rhinology, or neck cancer, or facial plastics.

The thing that drew Max to pediatric otolaryngology is that he can do ear surgery, or nasal surgery, or neck surgery, or plastic surgery. He can do all breadth of otolaryngology in pediatrics. His oldest patient might be in the early 20s.

“You can practice all that you saw in your five years of residency training and apply it to pediatrics.”Click To Tweet

And at that time, pediatric otolaryngology was the newest specialty so another reason that drew him into the field is the innovation. He likes thinking about newer ideas, newer techniques, newer treatments. He thought that pediatrics and pediatric otolaryngology allowed him to do that.

Most importantly, why he loves pediatric otolaryngology is the children, and being able to connect with them brings him certain joy.

He admits it makes him happier dealing with nononcologic things. Not that it always ends up perfectly, but at least the prognosis is better. In pediatrics, you can see how children go through really difficult times and how they can respond and get back to where they should be well.

[15:23] Traits Of Good Pediatric Otolaryngologist

In pediatric otolaryngology, your patient is the child, but you need to be able to not only converse with parents but also understand what the problem is. And that is not always so easy.

And the more we get into the digital age and the more and more information that is available to parents, it makes that job even worse. Because they would suggest whatever things they’ve found on the internet. And to Max, he finds this frustrating. So they have to deal with the parents and answer their questions.

“In a lot of ways, when we're dealing with certainly younger children, they can't tell you what the problem is and that you look at signs versus symptoms.”Click To Tweet

Pediatric otolaryngology is a very small group of practitioners across the country, with only 12 of them in New York. Especially when surgery is being contemplated, it’s a potential challenge. So their group meets up every year and they have a whole day for residents. They’d be presenting cases to improve our collegiality and discussions about newer topics and trending ways to deal with problems.

[19:32] Typical Day

Max explains that it’s different for everybody.

In heart-related problems, you have cardiology as a medical specialty and cardiothoracic surgery. In kidney problems, you have urology surgical and you have nephrology medical. In GI, endoscopy is performed by medical doctors and GI surgery by general surgeons. So in every specialty, except ophthalmology and otolaryngology, you have a medical and a surgical specialist.

In medical school, the amount of anatomy, physiology, and function of the ears, the nose, and throat is probably the smallest you get to learn about. Because it takes special instruments to look into the ear in a good way. Everybody has an otoscope but nobody has a microscope in the office to look in the nose. Everybody has a flashlight, but nobody has an endoscope to look at the larynx. You can’t even do it unless you have a flexible or rigid scope.

“Nobody will encroach into otolaryngology because there's no other specialty that can perform the physical exam.”Click To Tweet

As to whether you want to do operations or not, that can change whatever your choice is after residency. Some of his colleagues only do medical oncology. They don’t operate at all and are just diagnosticians. They may be even in otolaryngologic but are only office-based and never go to the operating room. You can be a head and neck oncologic surgeon and be in the operating room four days a week and only see patients one day a week. The patient will be in the operating room for 8-10 hours or whatever is necessary. So pediatric otolaryngology happens to be right in between.

As for Max, he spends either two or three days a week and it alternates in the operating room and the rest in the office. He does about 60% in the office and 40% in the operating room.

Then as you age and as you mature and maybe want to start slowing down a little bit, you can reduce the amount of time that you are in the operating room if you like.

[23:50] Taking Calls and Life Outside Of The Hospital

“Call for an otolaryngologist revolves around two things: foreign bodies and airway obstruction.”Click To Tweet

When he started training, they would get called for epiglottitis, maybe once a month, once every other month. Then a vaccine for Haemophilus influenzae came around in the 90s and we never saw epiglottitis again. They haven’t seen an infectious reason for epiglottitis in at least 10 years. You can get epiglottic swelling from medication but that has taken away one of the most serious emergencies pediatric otolaryngologists dealt with. 

That was a real-life and death situation when the epiglottis would swell within hours from infection and they’d be involved either in doing an emergency tracheotomy or at least getting the child intubated to secure the airway.

Max says that around 30% to 40% of pediatric otolaryngologists go into private practice and without academic responsibilities. He thinks you can certainly come up with a practice that allows for an outside activity for sure. And it depends on how big the group is and the call coverage. etc. In academics, there are other teaching responsibilities, for courses, for papers, and other academic pursuits that impact upon your time.

[27:50] How to Be Competitive for Matching

This year is unique because you’re not having any in-person interviews. Everything will be virtual. That’s going to create some challenging times for the committee that’s responsible for ranking the residents.

But he would certainly encourage that every school curriculum is different. Otolaryngology fits into somewhere they get to take a one-week or maybe two-week elective on their 12-week general surgery block that allows them to see what otolaryngology is.

Max says that if you’re interested in a surgical subspecialty, check out otolaryngology. Because it is something that is probably not on many people’s radar before you get to see it in the operating room or the office.

Number two, it is one of the more competitive residencies to obtain. So you should try to make your CV or your resume better, as good as you possibly can. Some residencies, including NYU, are interested in academic pursuits and publications and research. And when they review applications, they do take that into account.

“Some residencies are interested in academic pursuits and publications and research. And when they review applications, they do take that into account.”Click To Tweet

There happens to be an increasing number of medical students that are taking a year off between their third and fourth years. So if you’re interested, get to know so much more about otolaryngology once you’ve done your third-year rotation and some small amount of electives.

[30:55] Message To DO Students And Residents

In pediatric oncology specifically, there are about 40 spots every year. For instance, at NYU, they have one spot but at Cincinnati Children’s, they have four spots. Then Boston Children’s will have four spots. So when you add it all up, they’re 40 spots. They’re not 40 institutions, but 40 spots. 

In the past, they have always had around 60 applicants this past year. And for the first time this year, they had 19 applicants for 40 spots. So it was a buyer’s market, not a seller’s market, and nobody matched. So a lot just depends on the year and who’s applying.

So at the fellowship meeting, they were trying to figure out why that happened. And some of the reasons are that it’s been so competitive in the past that people thought they may not get a spot so they don’t do it.

[33:06] Message to Primary Care Providers

Max is a big believer in communication. You need to listen. Specialists see the child once that pediatrician has seen that child depending on how old they are. They have a relationship with the family that you will never, ever have. If you don’t enlist the pediatrician and have them see your perspective, then your ability to treat that child and help that family is much less so.

These days, Max thinks that a lot of templated medical records are not helpful. For the pediatricians, they get a three-page templated note and they’re not going to read it. Max is a little bit old school in that respect. That either if it’s a significant problem that needs to be dealt with right away. He’d pick up the phone and get the pediatrician on the phone with the parents and the child in the room because they need to make a decision one way or another quickly. If it’s much more of an elective thing, then a letter to the pediatrician explaining the conversation he had with the parents will go a long way.

In general, what primary care providers, especially pediatricians for pediatric patients need to be aware of is the need to identify sleep problems. 

“Children's sleep apnea has been under-appreciated. Because if the child isn't sick, the child isn't coming to the pediatrician.”Click To Tweet

You need to explore your child’s sleep and how they’re snoring. Is there restless sleep? Is your child tired during the day? These are questions that might come up in a yearly checkup but it also might be missed and parents think that if the kids snore, that’s okay.

[34:54] Most Liked Things

As he already alluded to earlier, Max likes the ability to do so many different things and it’s always different. And another thing he likes is innovation. Max is privileged to invent and make instruments that have been helpful for pediatric otolaryngologists.

Max adds that you need to keep an open mind. And of the issues he found, not just in their field, but also applies across all walks of medicine is that people practice the way they were trained and don’t learn new things, unfortunately.

“People practice the way they were trained and don't learn new things, unfortunately.”Click To Tweet

And so Max likes talking about just human behavior and getting just so wrapped up in the day to day that you don’t have time to step back and look at the big picture again.

[43:04] Final Words of Wisdom

If this is something you’re interested in, Max recommends that you take that one or two-week block during your 12-week core rotations to see otolaryngology. And if it’s not going to be the specialty you choose, you will at least get a better and clearer perspective about the very important senses of hearing, smell, taste, and breathing.

Certainly improve your resume to the best of your ability, whether that’s more research in the summer, or taking a year off and just hook up with life. I’ll just add your medical school to just maybe see patients in the office one day and get a feeling for that.

And then when you get to apply to residency, learn everything because if you want to do all of the otolaryngology, and you don’t want to be a general otolaryngologist, pediatric otolaryngology allows you to do that.

Links:

Meded Media

American Society of Pediatric Otolaryngology

MMEDIC program

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