One of the most important questions with which many otolaryngology residents struggle is whether or not to pursue subspecialty training. Since 2000, the number of medical and surgical resident graduates seeking subspecialty training has nearly tripled. And as with internal medicine and general surgery, the 5-year otolaryngology residency is becoming increasingly viewed as a gateway to subspecialization. As more residents are seeking fellowship training, the position of the general otolaryngologist is becoming challenged.

The immediate question that many residents raise is whether an extra year or two of training is really worth the “lost” time and wages. Otolaryngology residents often weigh this question particularly heavily since general training already requires five years and most are very eager to finish residency and actually start working. While this seems important at the time, it is critical to think long-term and see the big picture. You’ve already gone so far; if you are interested in fellowship training, finish strong! In the long run, one or two extra years will not matter. 

When deciding whether or not to pursue a fellowship, there are several more significant issues to consider such as personal and profession fulfillment, obtaining a competitive edge, job security, hospital privileges, and finally life-style considerations, including income potential and geography.

Most importantly, what is your passion? The days of being grandfathered into competitive subspecialties are nearing an end. If you truly enjoy microvascular free flap reconstruction, acoustic neuroma microsurgery, pediatric craniofacial repair or other advanced surgical cases then fellowship training is very important.

If you really love all of ENT and are reluctant to give up certain areas to develop a focused practice, then maybe additional fellowship training is not necessary. But even in this scenario there are several important points to realize. First, even if you are "doing it all", having pediatric, facial plastics, or rhinology certification will help you keep a competitive edge. While it seems sort of crazy, it is a fact that many parents believe that a pediatric otolaryngologist will do a better tonsillectomy than a general otolaryngologist, and that facial plastic surgeons should be sought for lymph node biopsy because they can close a neck incision more cosmetically than a general ENT surgeon. Unfortunately such misconceptions and misplaced priorities are a reality.  Another important point to realize is that for many residents pursuing a general otolaryngology practice, the chief year marks the pinnacle of their surgical skill for certain cases, and over time most general otolaryngologists slowly give up portions of their practice after becoming rusty or not having the appropriate infrastructure or support for complex cases.

Another important question is whether or not you received adequate training in residency to do the more complex cases safely and manage potential complications. Despite what we would like to believe, there are often tremendous disparities in training between residency programs. If you truly only drilled 5 mastoids during residency or never placed a cochlear implant, then you really need to have additional training if you want to perform otologic surgery. Beyond the issue of actual surgical competency, many hospitals require documentation to support hospital privileges for certain procedures or cases. With the increasingly litigious climate of medical care in the United States, it is likely that more hospitals systems will require subspecialty certification.

Another appealing aspect of fellowship training is the ability to become the “end-expert”, providing the definitive answers to questions related to your specialty. In the era of subspecialization, general fields such as internal medicine and emergency medicine are often viewed as triage specialties. This is even becoming true for general otolaryngology in larger cities or sizeable medical healthcare systems. Recognizing the importance of subspecialization, most positions in academic centers are reserved for applicants with fellowship training.

One important perk of fellowship that is commonly overlooked is that completing a fellowship inaugurates you into a club. You instantly become connected to a larger group of subspecialists that completed the fellowship before you, and if you are at the right fellowship program, you will be supported by your fellowship mentors for the rest of your career. These relationships can be immensely helpful to the new fellowship graduate, serving as a springboard to your career.

Last but far from least, lifestyle considerations must be evaluated, including any spousal or family needs. Will fellowship training grant you improved income potential or greater flexibility in job location? The short answer is… often, but not always. The answer largely depends on the size of the city you are working in, the catchment area of your center, and job saturation. As a general rule, the larger the city, the greater need there is for a fellowship-trained otolaryngologist. In a smaller community, a general otolaryngologist is usually preferable to a subspecialist with a niche interest. As a subspecialist in a smaller community, you may find it difficult to use your subspecialty training.

In summary, when deciding whether or not to pursue fellowship training, it is critical to know thyself. Evaluate your priorities, outline your long-term goals, and then determine if fellowship training makes sense for you. If you are interested in pursuing a fellowship, be sure to talk with recent fellowship graduates, program directors, and other mentors in the field. They can provide valuable insights into program selection, the current job market and the future of the field. Establishing these relationships early is also important for developing research projects related to the field and obtaining letters of recommendation for your fellowship applications.