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Tabaee A, Luong A, Fried MP. Fellowship Training in Rhinology: A Survey of Fellows From the Past 6 Years. Arch Otolaryngol Head Neck Surg. 2009;135(6):571–574. doi:10.1001/archoto.2009.48
To define the educational goals and determine the success of formal fellowship programs in rhinology.
An anonymous, Internet-based survey of current rhinology fellows and those from the past 5 years.
Main Outcome Measure
A 5-point ordinal Likert scale was used, with higher scores being more favorable.
Complete responses were collected from 46 of 70 eligible participants (66%), representing 19 fellowship programs. High overall satisfaction with the fellowship experience was reported (mean score, 4.7). Pooled scores for comfort levels with the management of medical issues (mean, 4.8) and surgical procedures (mean, 4.5) were also positive. Following completion of training, lesser levels of comfort were associated with craniofacial procedures (P <.001), frontal sinus obliteration (P <.001), and dacryocystorhinostomy (P = .002) compared with all surveyed procedures. Respondents reported a greater interest in (mean score, 4.3 vs 2.4; P <.001) and preparation for (4.3 vs 3.5; P <.001) a career in academic medicine compared with private practice.
The rhinology fellowship experience appears to be generally favorable in terms of meeting stated training goals and helping fellows achieve subjective comfort with medical and surgical management of rhinological disorders. Continued discussion of the goals of rhinology fellowship training is necessary.
Within otorhinolaryngology, the subspecialty of rhinology is rapidly evolving. This is based on a number of factors, including the development of advanced surgical procedures, increased understanding of the basic science and medical underpinnings of sinonasal disorders, and ongoing efforts by academic leaders. Inherent to the development of the subspecialty is the educational process, which distinguishes the core requirements of residency training from the advanced skills and knowledge attained during fellowship. The history of formal fellowship training in rhinology is brief. Although fellowships have existed for approximately a decade, there was no formal organization of the application process before 2006. During the past 3 years, a centralized match process has been created, and the numbers of applicants and programs have remained strong. For the years 2006, 2007, and 2008, there were 22, 29, and 34 registered applicants and 16, 18, and 19 registered programs, respectively (http://www.sfmatch.org). Despite the increasing popularity of postgraduate training in rhinology, there is currently no accreditation process or standardization of fellowships. Given its nascent history, an understanding of the educational goals and experiences of rhinology fellows is critical for further development.
The 19 rhinology fellowship programs, 18 in the United States and 1 in Canada, were identified through a search of the centralized match Web site (http://www.sfmatch.org). The e-mail addresses of current rhinology fellows and fellows from the past 5 years were obtained from program administrators. An anonymous Web-based survey was performed during a 1-month period between April 7 and May 7, 2008, and an invitation was e-mailed to prospective participants at the beginning of the survey period and again at the 3-week mark. The institutional review board at Beth Israel Medical Center determined that no approval was required for this study.
All survey responses were collected in a de-identified manner, and there were no personal demographic or program-specific questions. The survey inquired about the respondent's status (current vs past fellow), the number of faculty members in the fellowship program, and current practice type. A 5-point Likert scale was used for survey questions about the reasons for pursuing a fellowship, the fellowship experience, and comfort level with medical and surgical management of sinonasal disorders after the fellowship was completed. For respondents still in the fellowship program, the anticipated comfort level with medical and surgical management of sinonasal disorders after completion of the fellowship was queried. A higher score represented a more favorable response: 1, strongly disagree; 2, disagree; 3, neither agree nor disagree; 4, agree; 5, strongly agree.
The data were collected at a centralized Web site (http://www.surveymonkey.com) and then entered into a Microsoft Excel spreadsheet (Microsoft Corporation, Seattle, Washington) by one of us (A.T.). The data were statistically analyzed for differences in study responses. Separate analyses comparing current vs past fellows and programs with single vs multiple faculty members were also performed. The Mann-Whitney test was used, and statistical significance was set at P <.05.
A total of 46 of 70 eligible respondents (66%) successfully completed the survey and were included in the study. The sample included 13 current fellows (28%) and 33 former fellows (71%). The fellowship was directed by a single faculty member for 29 respondents (63%), by 2 to 3 faculty members for 14 respondents (30%), and by more than 3 faculty members for 3 respondents (7%). Among those who had graduated from the fellowship when the survey was conducted, the current practice was academic for 21 (64%), solo private for 7 (21%), and group private practice for 5 (15%) respondents. Responses to questions regarding the reasons for pursuing a fellowship are presented in Table 1. Pursuing training in allergy medicine was a less common goal than improving surgical skills (P <.001), medical management skills (P < .001), and didactic fund of knowledge (P <.001). Preparation for a career in academic practice was a significantly more frequent goal than preparation for private practice (P <.001). Data regarding whether the rhinology fellowship experience met stated goals are presented in Table 2. Pooled median responses to the individual questions and the overall fellowship experience were all positive. Respondents indicated there were significantly more clinical vs basic science research opportunities (P <.001). In addition, significantly more respondents agreed that they were prepared for a career in academic medicine vs private practice (P <.001). The reported comfort levels with management of sinonasal disorders were positive, with a pooled median score of 5 (mean [SD], 4.8 [0.4]) (Table 3). The reported comfort level with performing rhinological surgical procedures was also positive, with a pooled median score of 5 (mean [SD], 4.5 [0.9]) (Table 4). Compared with the pooled scores for all procedures, the reported scores for individual procedures revealed statistically significantly lower comfort levels with craniofacial operations (P <.001), frontal sinus obliteration (P <.001), and dacryocystorhinostomy (P = .002).
Lower scores for current fellows compared with past fellows were identified for the goal (median and mean [SD], 3 and 2.7 [1.1] vs 2 and 1.7 [0.8]; P = .006) and actual fellowship experience (4 and 3.8 [1.0] vs 3 and 2.7 [1.1]; P = .004) of preparation for a career in private practice. No other statistically significant differences were noted between the 2 groups. Comparison of responses from those attending programs with a single vs multiple faculty members failed to reveal any statistically significant differences in the survey responses.
The ongoing development of rhinology as a distinct subspecialty is perpetuated by the creation and proliferation of formal fellowship training. Increasing interest in the field's advanced clinical and research challenges has spurred interest in fellowships. Although the fellowship application process has recently become a formal match, the goals and actual experiences of rhinology fellows remain incompletely defined. Various goals of postresidency training, in general, have been described, including improving advanced surgical skills, increasing fund of knowledge, performing dedicated research, compensating for inadequate residency experience, promoting career advancement, attaining hospital privileges, and seeking protection from malpractice.1-4 Given the potential disparity in the structure of various fellowships, a degree of variability in the different experiences is likely.
The goal of the present study was to examine the rhinology fellowship experience from the perspective of recent fellows. The subjective reporting of the goals of and actual training received by current and past fellows highlights several interesting findings. Greater interest in improving surgical skills, medical management skills, fund of knowledge, and preparation for a career in academic medicine were noted, compared with allergy training and preparation for a career in private practice. In general, the reported level of satisfaction with the fellowship experience was high. These results support the conclusion that, overall, the current educational experience in rhinology is positive. Several questions with lower mean scores, including availability of basic science research opportunities and comfort level with craniofacial surgical procedures, frontal sinus obliteration, and dacryocystorhinostomy, highlight some potential disparities among the various fellowship programs. Given the breadth of the procedures mentioned in the survey and the infrastructure required for basic science research, a certain degree of variability is expected. However, the otherwise high scores for comfort level with the remaining procedures, including advanced endoscopic procedures for the frontal sinus, anterior skull base, and orbit, are notable and highlight the effectiveness of the fellowship experience. The results of the present survey also support the pursuit of rhinology fellowship as preparation for a career in academic medicine; a high percentage of former fellows are currently practicing academic medicine, and high scores were given to this goal and actual experience in fellowship. This finding is especially notable given the relatively recent recognition of rhinology as a distinct subspecialty within academic medical centers. The increasing interest in academic medicine is also indicated by significantly lower scores for preparation for a career in private practice as a reason for pursuing a rhinology fellowship for current vs past fellows.
A number of issues related to the proliferation of rhinology fellowships remain incompletely defined. These include the lack of a formalized process for fellowship accreditation, assessment of core competencies following training, and determining the minimum criteria for a fellowship program. These issues, combined with the potential for disparate experiences in the different fellowship programs, highlight the need for critical examination of the educational experience. A number of procedures in rhinology, including endoscopic sinus operations, remain an essential part of general otolaryngology. However, it is not clear which advanced procedures benefit from postresidency training. The number of future fellowship-trained rhinologists who can be supported by both the academic and health care communities is also unclear.4 The effect of rhinology fellowships on residency education was recently discussed in a survey of graduating chief residents. A greater availability of basic science opportunities and no negative consequences on the overall rhinology experience were noted in residency programs that had rhinology fellowships.5
Although the high overall response rate strengthens the findings of this study, several limitations are identified. It is possible that certain findings in this study that failed to meet statistical significance would have been significant with a higher response rate or larger cohort. In addition, any survey-based study is inherently limited by potential selection bias from the respondents. The subjective reporting of respondents' comfort levels is not validated by any objective measures of clinical or surgical competency. Similarly, the surgical experience was not examined in an objective way, such as with surgical logs. The study was not designed to examine ongoing issues regarding fellowship accreditation and formalized criteria for the educational experience, which both require continued discussion. Finally, the brief history of rhinology fellowship implies that the educational process will continue to evolve, supporting the future examination of the issues raised in this study.
This survey of current and past rhinology fellows indicates that, overall, the educational experience during fellowship training is positive. A high degree of comfort with medical and surgical management of rhinological disorders and a greater interest in academic medicine vs private practice were noted. The continued development of rhinology fellowship training and the subspecialty in general requires ongoing examination.
Correspondence: Abtin Tabaee, MD, Department of Otolaryngology, Beth Israel Medical Center, 10 Union Square E, Ste 4J, New York, NY 10003 (firstname.lastname@example.org).
Submitted for Publication: October 4, 2008; accepted November 13, 2008.
AuthorContributions: All authors had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Tabaee, Luong, and Fried. Acquisition of data: Tabaee and Luong. Analysis and interpretation of data: Tabaee, Luong, and Fried. Drafting of the manuscript: Tabaee. Critical revision of the manuscript for important intellectual content: Tabaee, Luong, and Fried. Statistical analysis: Tabaee and Luong. Administrative, technical, and material support: Park and Lee. Study supervision: Tabaee, Luong, and Fried.
Financial Disclosure: None reported.
Previous Presentation: This study was presented as a poster at the American Rhinologic Society Meeting; September 20, 2008; Chicago, Illinois.
Additional Contributions: The American Rhinologic Society Committee for Residents and Fellows provided support and guidance for this project.
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