Although NRMP data indicates that otolaryngology has become a bit less competitive over the past 3 years, it continues to attract far more applicants than available positions. In deciding whom to interview, programs will use a variety of residency selection criteria. In the 2021 NRMP survey of otolaryngology residency program directors, "grades in clerkship in desired specialty" was cited as an important factor by 82.1% of programs. It received a mean importance rating of 4.0 on a scale of 1 (not at all important) to 5 (very important).
It can be argued that rotation performance is even more important if you consider that 96.4% of program directors cited "letters of recommendation in the specialty" as an important factor in making interview decisions. These letters are often largely based on a student's performance during the rotation.
Given the importance of the otolaryngology rotation in the residency selection process, I am often asked for advice on how medical students can stand out. Below are recommendations that I have gathered from attendings and residents over the years.
Know How to Evaluate Common Symptoms Encountered in Otolaryngology
Although a small number of patient symptoms account for the majority of encounters in otolaryngology, these symptoms are infrequently encountered by medical students prior to the otolaryngology rotation. Therefore, many students begin the rotation unsure of how to approach patients presenting with these complaints. Fortunately, some preparation on your part in advance of the rotation can help you become familiar with the workup of these complaints. Focus your efforts on the following symptoms or problems:
Epistaxis
Nasal obstruction/rhinitis
Hoarseness
Sore throat
Hearing loss
Tinnitus
Dizziness/Vertigo
Neck mass
Oral lesions
Snoring
Stridor
Ear pain
Headache/Facial pain
Dysphagia
Sinus pain
Change in taste/smell
Review How to Perform a
Head and Neck Physical Exam
How comfortable are you with the physical exam of the head and neck? If you feel that your clinical skills are lacking in some respect, you're in good company. In one study assessing the comfort levels of junior medical students in performing the head and neck exam, students reported an average comfort level of 2.1 on a scale of 0 (not comfortable to 5 (extremely comfortable).
Your otolaryngology rotation will provide you with many opportunities to improve your skills in this important area. The American Academy of Otolaryngology - Head and Neck Surgery has created an excellent series of instructional videos on how to perform the head and neck exam (see below).
The ENT Exam: Ear Exam
The ENT Exam: Oral Cavity and Neck Exam
The ENT Exam: Face and Nose
The ENT Exam: Nasopharynx and Larynx Exam
Present Patients Powerfully
"It is critical to be able to make an informative, accurate and complete patient presentation on rounds," writes the Department of Otolaryngology at SUNY Downstate. Presentations should follow the SOAP format. The most common mistakes made by students include the following:
Presenting information out of order
Providing unnecessary or superfluous information
Skipping relevant parts of the physical exam
Delivering an inadequate assessment and plan
The latter mistake is particularly common, and usually due to inexperience or lack of sufficient time to process information collected during prerounds. In order to come across as more than just a reporter of information, set aside enough time so that you can put your thoughts together before morning rounds.
Another valuable tip involves reflecting on your patients when you go home each and every night, and anticipating what may happen the following day. For example, let's say you have a postoperative patient who is receiving analgesic therapy. What will you do the next day if your patient's pain is not well controlled? Thinking about different possibilities when you have the luxury of time (at home) will help you to develop more thoughtful assessment and plans.
Remember to seek feedback on your oral case presentation skills. If something is lacking in your presentations, don't hesitate to ask the resident or attending to assist you in this very important area.
Look for Ways to Improve the Team's Efficiency
The patient census is often high on the otolaryngology service, and anything you can do to increase the team's efficiency will score you points. Some examples:
Having supplies or materials ready for basic procedures during rounds (dressing changes, removal of drains/staples/sutures, trach suctioning/changes)
Gathering vital signs and other pertinent information before afternoon rounds
Searching the literature to answer a clinical question pertaining to a patient on the service, and reporting the findings to the team
Having films or imaging studies ready to review (hard copy or on computer) with team during rounds
Read and Then Read Some More on Otolaryngology Diseases
My recommendation is to be well read on every aspect of your patient's problem or condition. In fact, I would take it even one step further. Try to be well read on all patients on the service. This will allow you to make the most of your learning opportunities in the clinics, on the wards, and in the operating room. "One of the most effective teaching methods in medicine is asking questions, whether this is on morning rounds, in the operating room, in conference, or in clinic," writes the Department of Otolaryngology at the University of North Carolina. "We use this method liberally, so please read and be prepared."
Shine in the Operating Room
Never enter the operating room without having a strong understanding of the patient's presentation, indications for surgery, possible complications, and postoperative considerations. Although you won't be expected to know the individual steps of the surgical approach, you'll be asked questions about surgical anatomy. It's also a good idea to brush up on some basic surgical skills, as you may have opportunities to assist the surgeon. "In the operating room...students will be able to demonstrate and sharpen skills in basic surgical techniques such as knot-tying, suturing and limited dissection," writes the Department of Otolaryngology at the University of Washington.
Make a Favorable Impression in the Otolaryngology Clinic
To meet the needs of your faculty preceptor, be sure to ask about expectations and responsibilities in the clinic. How many patients will you be expected to see? How much time should you take with each patient? Should you see the next patient on the list or will you be assigned patients? Are there any particular preferences with respect to the oral case presentation? Does the attending want you to observe him before venturing out on your own? Fortunately, most attendings will initiate this discussion with you. But if it doesn't happen, don't be afraid to ask these questions. You'll be glad that you did.
In the otolaryngology clinic, you'll typically be given the opportunity to see patients independently. Your goals in performing this evaluation include the following:
Review the medical chart
Establish rapport with the patient
Obtain a relevant history
Complete a focused exam
Present the patient to your otolaryngology attending or resident, including the assessment and plan
Decide on the next course of action (further diagnostic tests, treatment)
Implement the plan
Educate the patient
Document the encounter (if allowed)
Strive to do as much as possible in the above areas.
Demonstrate Superb Interpersonal Skills and Professionalism
Medical students should view the entire rotation as one extended interview. Every interaction or encounter with residents or attendings is an opportunity to demonstrate the interpersonal skills and professionalism valued in the field. Otolaryngology faculty members have also been known to seek the opinions of the entire team when assessing student performance. Dr. Richard Scharf, program director of the ENT residency program at St. Barnabas Medical Center, solicits opinions from colleagues, residents, nurses, office staff, and even patients. "We find out how the individual is in terms of seeing patients," says Dr. Scharf. "And if a student is disrespectful to office staff, we'll hear about it right away."
For more information on how to succeed in rotations, please check out our other posts in this series:
Dr. Samir Desai is the co-creator of the online course The Residency Interview 101 and the author of The Successful Match: Rules to Succeed in the Residency Match. He has been a faculty member in the Department of Internal Medicine at the Baylor College of Medicine for over 20 years, and has been the recipient of numerous teaching awards
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