INTERNSHIP
Although each program’s schedule is different, starting in 2016, the ACGME will require that 6 months of internship will be spent within the Otolaryngology department, and the remainder with anesthesia, general surgery, neurological surgery, neuroradiology, ophthalmology, oral-maxillofacial surgery, pediatric surgery, plastic surgery, and/or radiation oncology.
Each of these rotations offers an opportunity to learn important surgical principles and skills. Also, Otolaryngologists frequently have combined operative cases with Neurosurgery and Thoracic Surgery, and learning their approaches will help establish good teamwork in the future. Try to identify a few key goals or things you would like to learn from each rotation before you start, such as anatomy and tissue planes of the mediastinum on Thoracic Surgery, or how a Neurosurgeon approaches temporal bone CSF leaks.
Lastly, remember that when rotating outside of Otolaryngology, it is important to put your best foot forward and be an ambassador for your department - it will help you down the road when you are working with your colleagues in combined cases.
FIRST YEARS IN OTOLARYNGOLOGY
Your first month in Otolaryngology as an intern and the start of your PGY2 year will be both an exciting and overwhelming experience. Finally, you are dedicating all of your efforts and time in mastering your chosen craft. Every small task seems slightly less tedious and more relevant. But as you spend more time within the field, it is very common to be overwhelmed by the vastness of the specialty and how little you actually know. There is a reason why it takes 5 years to reach competency in this field, and you will get there, but it takes time and effort. Below are a few key concepts that will help you during your early years:
OWN YOUR PATIENTS – As an intern or junior resident, you will usually be working with and reporting to senior residents during patient care. This supervision is important, both for you and your patients, but you will learn exponentially more if you take an active role in patient care rather than just seeking out and following orders. When seeing an inpatient consult or a patient in the Emergency Department, get the entire history, do a full physical exam including nasopharyngoscopy or bringing the patient to an otomicroscope room if need be. Then, sit down and think about the patient for a few minutes. Formulate a differential diagnosis, either in your head or on paper, and then a plan for further diagnostic tests, imaging and/or treatments. If during this process you discover that you didn’t get a key piece of history or didn’t examine something that would be useful to know about, go back to the patient. When you present the patient to your senior resident or attending physician, present the patient and then offer your impression of the most likely diagnosis, some other diagnoses to consider, and what your plan is. They will appreciate your efforts, and these attempts will open the door for teaching. This process will be much more valuable than simply regurgitating an H&P and waiting for instruction.
Similarly, when caring for inpatients, treat each patient as though you are their only physician. Are there any signs of a potential postoperative complication? Does that Doppler signal sound a little bit different than it did yesterday afternoon? If it’s not an emergency, consider what you would do about it if you were the only one around. If you aren’t sure what to do, look it up. Then talk to your senior about it.
If you keep this mindset about the patients you interact with, you will get so much more out of the early years of training than your peers.
READING – Probably the best learning comes from patient interactions, but reading textbooks is also important to expand your knowledge outside of what comes through your doors. One could approach reading as starting at page one and then finishing a book slowly but surely, or could jump around and read a chapter here and a chapter there. Learning styles vary, but probably the most practical and worthwhile approach is to focus on a particular topic in which you are personally invested at the time, such as a patient you saw that day or are currently caring for as an inpatient.
Set a realistic goal such as reading for 15-30 minutes 5 days a week. Which books should you read? Early on, your reading should be more generalized and then as a senior resident you can get into the more nitty-gritty. For outline-based books, Pasha, K.J. Lee, and Goldenberg are all good options. For more paragraph style, Lalwani has a good mix of breadth and depth for junior residents. Later on, you will spend more time in Cummings, Bailey’s and the primary literature.
PREPARING FOR THE NEXT DAY – Being prepared for the next day helps you be more efficient in your work, learn more effectively, and gives you more free time. Before an OR day, it is imperative that you look up your patient’s history, recent clinical notes, look at their imaging, review the relevant anatomy, and read on how to perform the operation if you do not already know the steps. This will expedite your surgical learning tremendously. To learn the steps of an operation, some good resources are searching in the journal “Operative Techniques in Otolaryngology-Head and Neck Surgery”, textbooks like Myers or Cohen, or the University of Iowa Head and Neck Protocols website.
The same principle applies to clinic as well. Spend a few minutes looking up the new patients for tomorrow’s clinic and see what their chief complaints are if possible. See two patients on the schedule tomorrow with Meniere’s Disease? Well tonight is the perfect night to read about treatment options of Meniere’s. This approach will help solidify what you read and make you more efficient in clinic.
OPERATIVE LOGS AND NOTES – Another approach that will help as you are learning in the OR is to keep a surgical notebook. Some people use small physical notebooks that they carry with them and have a few pages dedicated to each common operation or perhaps a subspecialty in which they can jot down notes to remember. Others have had good success with online tools such as Evernote.com and creating new notes for each operation. Writing down the steps will help you learn them faster and serves as a good reminder if it’s been a while since you’ve done a certain operation. These resources can evolve to include the nuances of how you like the room set up for a certain case or the little tricks that your attending does that make certain moves seem effortless.
PREPARING FOR YOUR FUTURE
Although now you are trying to keep your head afloat and learn the basics of the specialty, you will need to start thinking about your future starting around PGY3. At this stage, don’t get too worried about deadlines, but as you spend time in each of the various subspecialties, consider if it is something to which you would like to dedicate your career. Contemplate if you are more interested in academia or the community and what that might mean for your future.
Research can be a good way to get your name out there and also can bring the opportunity to attend national meetings and conferences as an oral or poster presenter. These conferences are good ways to meet others in the field, gain exposure to other viewpoints and methodology, and to begin networking. Attending conferences is especially important if you would like to continue in academics or if you are interested in a more competitive sub-specialty.
DO OTHER THINGS
Over the next 5 years, residency will occasionally be overwhelming and it will seem as if you have no time for family, friends, or other pursuits. Just like you set goals for reading, research, or mastering the art of mastoidectomy, you should also set goals for your personal life. Find time to exercise and continue your hobbies, even if to a smaller degree than you used to, and call your friends to stay in touch. Make dinner time with your spouse or significant other a “protected time” where you don’t think about medicine or have your laptop open. Get at least 6 hours of sleep. It’s important to keep some balance in your life, and as much as residency will try to creep into other areas of your life, it’s good to have some barriers to prevent this.