Why ENT? Choosing a specialty and what drew me to ENT

When you first enter medical school and begin to ruminate on your future specialty choices, there are two distinct camps which stand out.  The first are the captains of the sinking ship… the physicians who for whatever reason have become dissatisfied with their practice, and their pessimism can be contagious.  The second are the victims of luck… individuals who have stumbled into a field which seems to complete some deficit in their life and who love their job with every resonating electron shell in their body.  Both camps can provide an impassioned argument, and it’s not uncommon to find yourself alternating between empty despair and emboldened determination your first few years of medical school.  But I would argue that the gross majority of us are neither pessimists (we entered this field for the right reasons) nor lucky (it takes a little work to get what you truly want in life).  Some of the best advice I’ve received in regards to choosing a specialty lies somewhere in the middle.  One resident I interacted with for a brief period of time passed along a great anecdote which I think offers a great deal of insight.  She bought one of those massive white boards from Office Depot at the beginning of her medical school experience and created a list of the 18 different medical residencies, along with a “Strengths” column and a “Weaknesses” column.  She filled out each column for each field as she learned more about each specialty.  She also kept a log of the different aspects she wanted to have in her future practice, and different aspects she wanted to avoid.  For example, she wanted longevity of care with her patient base.  She enjoyed simple procedures but didn’t particularly yearn for anything beyond that.  As she proceeded in her years of study, she would reach a point where she could definitively say she did not want to go into a particular field, and it would get crossed off her list.  With her progression through medical school, she developed a good sense of the future physician she would become as her list became steadily pruned. 

I hold no stock in Office Depot, and am not saying everyone should go out and buy white boards.  But I think the process is a good one to practice, in whichever way is comfortable for you.  We all go through the same steps subconsciously in our own right, but it’s often helpful to have the proverbial “writing on the wall.”  For example, I found myself enjoying clinical medicine much more in medical school than I anticipated.  But I don’t think I could go into a field where I would never step in an OR.  For the longest time, these facts simply existed in me as feelings.  Feelings of unease at the hectic and sometimes superficial pace of general surgery clinic.  Feelings of boredom or futility that sometimes hit me as I saw patients in family medicine.  It wasn’t until I sat down and began to verbalize why I was having those feelings that I began to develop a sense of the sort of things I desire in my own future practice, and was able to develop those into criteria I could apply towards choosing a specialty.  Introspection takes time and work and can be difficult, especially in the hectic pace of medical school where it can often seem a lower priority then studying for your next exam or getting enough sleep before tomorrow’s rounds.  But it is an invaluable asset towards the decision making process. 


So what ended up drawing me to wanting to become a “snot doc”?  That is a difficult question to give proper lip service, but it’s a question I’ll be endlessly answering on the interview trail, so I’ll try to elucidate some of the factors that led me down this crazy path.  There’s a lot of reasons to consider ENT, these just happen to be a few of my own and my own experiences coming to those conclusions.  The first three reasons are what I consider the Pillars of ENT (must be said in dramatic movie trailer voice): 

(1) Is it medicine? Is it surgery? 

The divide between medicine and surgery goes back into the annals of time.  As a medical student, it’s easy to become indoctrinated into the school of thought that the two are mutually exclusive.  But with the explosion of outpatient and minimally invasive procedures and more specialists taking over procedures related to their respective practice, the line is more blurred than ever and a wide variety of fields offer the ability to both practice medicine and do procedures to varying degrees.  However, for some people (like myself) there is nothing that can compare to being in the OR.  From the ritual of the scrub and gown to the feeling of observing living, breathing anatomy spread open in front of you, the experience of the operating room can intense and immensely rewarding, almost spiritual.  And there’s often a (misguided, in my opinion) sense that to commit to the OR means to forsake the clinic.  ENT offers a truly unique niche where just as many, if not more, patients are managed as an outpatient as those that are treated with the knife. For me, it means having my cake... and eating it too. 

(2) Variety of procedures & practice 

When I say “ENT,” you say “tonsils.”  True, ENT may not be as sexy as, say, neurosurgery, but in the public eye it remains a largely hidden specialty.  As I learned more about otolaryngology as a specialty, I kept finding myself saying “they can do that?”  That’s the beautiful thing about ENT.  It’s a little bit minimally invasive surgery.  A little bit non-invasive procedures.  A little bit of plastics.  A little bit of orthopaedics.  A little bit of neurosurgery.  And a little bit of good old open dissection. A little bit of immunology, rhinology, family practice, pediatrics, infectious disease, oncology.  The advantage of having a specialty that is specialized on a specific anatomical region is the ability to treat the myriad of disorders associated with that region, regardless of the specific "discipline" of medicine it may fall into. 

(3) The anatomy 

This is a funny one to me, because I absolutely loathed head & neck when I slogged through anatomy as a fledgling first year medical student.  In the beginning of your training, it’s easy to feel overwhelmed by the learning process simply adjusting to the sheer volume of information.  And with my first interactions with head & neck anatomy, I was sufficiently overwhelmed with vein, artery, nerve that the region felt damn near impossible.  But hindsight is a funny thing.  As you build on your foundation of medical knowledge and master basic concepts, the nuances of the brilliance of the human body begin to reveal themselves.  By the time I rotated through general surgery as a third year, the anatomy of the abdomen had progressed from frustrating to boring.  Head & neck went from overwhelming to elegant.  The intricacy of our upper anatomy is both awesome and inspiring, especially when you consider how important the function of the region (from facial expression to voice to hearing) is to the basic human experience

In the not too recent history, I had breakfast with a faculty member in the ENT department at my medical school.  Of course, he posited the classic “why ENT?” question and I spent a few minutes discussing the above 3 reasons and how they shaped my interest in the field.  At the end, he smiled and said “Good.  Those are good reasons. *pause* You do realize that’s what everyone else is going to say on the interview trail too, right?”  We laughed, but the point is valid.  Interest in the scope of practice, types of procedures, and anatomy involved in ENT are so essential to what it means to practice in the field that that are somewhat proverbial prerequisites to have any sort of substantial interest in the field.  But what else about the field is unique or interesting?  Here’s three others that I’ve found that really get me going: 

(4) The toys
The first time I saw a surgery performed with a CO2 laser, I was geeked out beyond belief. Granted, a lot of that is likely rooted in my Star Wars Nerd childhood, but my love of technology and inner geek are two things I have tenderly fostered over the years (granted, more quietly at certain times than others – namely, high school).  One of the advantages of working with structures in the body which are accessible from one of its orifices is it provides such a unique access to pathology.  ENT is a field which has warmly embraced the cutting edge of technology.  The strides it has made in recent years are sometimes awesome to observe, and there’s no indication that the field has any intention of slowing down.  If you like gadgets, there’s plenty of things to keep your hands busy in ENT.  Plus, there’s something sexier about a flexible laryngoscope when compared to its colorectal brethren. 

(5) Surgeons that don’t want to operate? 

I am hesitant to paint entire areas of medicine with broad strokes of generalities, so I preface this section by stating: this is based on my own experiences and is part of my own story of what drew me to ENT.  While I was on my general surgery rotation, I was somewhat disconcerted with the flippant way in which some attendings would approach the decision to take their patient to the OR.  Clinic felt more like a screening process to determine if the patient was fit for surgery, rather than an assessment of if the patient truly needed the surgery.  I've seen enough complications from simple surgical procedures to have developed a healthy respect for the degree of stress that general anesthesia can place on the body.  At the first ENT rounds I ever attended, one of the attendings discussed a case where a patient suffered a permanent complication from a relatively straightforward and simple surgical procedure.  His take home point: "Surgery is still surgery.  Never be complacent when placing someone under the knife."  It's an attitude I've found to be consistent within the field.  One of the advantages to ENT, with a myriad of therapeutic and diagnostic procedures that can be done on an outpatient basis, is that there is there is a lot than can be done to treat patient's conditions which keeps them out of the OR.  One surgeon is particular I have worked with really enjoys the challenge of engineering new ways to effectively treat patients as outpatients.  Its a refreshing attitude within the surgical subculture, and one which I would hope to maintain in my own future practice.

(6) The personalities 

The stereotype of the gruff, domineering surgeon has been around for generations.  While it is dangerous to think solely in stereotype, and there are plenty of examples of exceptions to the rule, there is often a certain amount of truth hidden within stereotype.  Stories of surgeons throwing instruments in the OR often inspire terror in young medical students facing their first experience in the OR.  I personally had an experience on call where I watched a trauma chief publicly berate an ED attending in the middle of the emergency department, ending her tirade with "I'm the CHIEF of trauma surgery! That is beneath me!" I was told once by a cardiothoracic surgeon I preceptored under (a very gentle man who was very un-like the stereotypical surgeon) that "Surgery is full of ego.  Just because it is, doesn't mean you have to be egotistical.  But you have to be able to interact with colleagues who are to still enjoy your work."  The stereotype of ENT, from my interactions with docs in various areas of medicine, is that of the "nice surgeon," and like many stereotypes, I've found quite a bit of truth in that assessment.  The field tends to attract a kinder personality, and job satisfaction is very high comparative to other fields.  If people have told you that you are a nice person, and you enjoy working with other nice people in turn, you would not find yourself adrift in the field of otolaryngology.

These are just a few of my own personal reasons I've fell into ENT.  The website has also outlined several others in their "Why Otolaryngology?" page which I thought were very insightful.  In conclusion, there's three key things when it comes to choosing your specialty which I have learned are invaluable to ensuring you end up in a field which will bring you satisfaction in your professional life.  (a.) Be proactive.  Don't write off a field just because on first glance it doesn't like you would be interested in it.  Shadowing doesn't stop when you get into medical school.  Use the flexibility of your schedule the first two years of medical to get exposure to a wide variety of disciplines.  Don't depend on only your core clinical rotations to get you the exposure you need to determine your future.  There's a lot more out there than your medical school exposes you to.  (b.) Know your strengths and weaknesses, your wants and do-not-wants.  It's easy to fall into the trap of liking a field because you had a good rapport with one specific physician.  If you find yourself liking a specific clinical experience, ask yourself why.  And write it down; put it into words.  Same if you find yourself loathing one.  After enough time, you'll have a good sense of what aspects of practice are important to your future satisfaction and happiness.  (c.) Ultimately, you're in charge.  Be aware of other field's opinions of the fields you are interested in.  There is some truth to them.  But don't let other people tell you what you do and do not want to do.  When push comes to shove, you are the sole authority on yourself.  Don't let people tell you a field is too competitive to match into.  Don't let people tell you that you won't be happy in a specific field.  I'm a big believer in personal initiative and determination, and if you have your sights set on something, trust that with hard work and perseverance will get you where you need to go.

Best of luck, and until next time.