“A lot of surgical specialties have a counterpart in the medical specialty world… Cardiac surgeons have their colleagues in cardiology, urologists have their counterparts in nephrology, orthopedic surgeons have… rheumatology. In otolaryngology, there is no counterpart…. We look after all medical and surgical problems that exist in our particular area.Dr. Doug Angel on the important medical and surgical roles of otolaryngology
- Positions: Otolaryngologist (Eastern Health, St. John’s); Clinical Assistant Professor (Memorial University)
- Training: Head and Neck Oncologic Surgery and Microvascular Reconstructive Surgery Fellowship (Western); Head and Neck Surgery Residency (Western); MD (Memorial)
- Pitch: Hugely variable specialty that’s a great mix of medicine and surgery.
- Path: Had interest in medicine and surgery from a young age and fell in love with otolaryngology after working with an awesome mentor who loved his job!
- Personal: Many subspecialties in otolaryngology can be difficult and tedious but there is great camaraderie and it can be extremely rewarding.
- Philosophy: Find a mentor and something may click! Try to get a balanced medical education and try out different electives.
- “Specialty with huge variety of potential clinical problems and patients, very good mix of medicine and surgery”
- A lot of surgical specialties have medical counterparts but otolaryngology doesn’t – they look after both surgical and medical problems, allowing for huge breadth
- Not just “tubes and tonsils”!
- Otolaryngologists are a very easy-going, fun group
- He gets along really well with 7 other colleagues, socializing after work
Trainees’ stereotypes of ENT
- Conducive to good lifestyle but work could be routine or tedious
- Dr. Angel’s response:
- Things can be tedious if you look at microscopic level (literally and figuratively) because a lot of anatomy in head and neck (almost as much as entire rest of body combined!) – often do delicate, tedious operations on very small area
- Variable lifestyle but it is one of the more friendly surgical specialties (“easy nights and tennis”)
- After hour calls are less busy than gen surg or orthopedic surg
- All surgical specialties are realizing importance of life outside medicine so things might be changing
Referenced Material: Mayer AW, Smith KA, Carrie S. A systematic review of factors affecting choice of otolaryngology as a career in medical students and junior doctors. J Laryngol Otol 2019;133:836–842.
- Did bachelor of music in piano performance after high school (had medicine in the back of his mind but didn’t want a science degree – dogma back then)
- Actually had no science courses in his UG program!
- Father was a psychiatrist
- He didn’t expect to get accepted to med school but chose to give up music when he did
- There was an excellent shadowing program at Memorial where mentors were encouraging and willing to take on med students in clinics and surgeries
- Exposed at early stage to various specialties
- He was always interested in surgery
- Obsessed with surgery shows, piano and fine motor skills may have helped too!
- He also worked with a mentor who loved his job and Dr. Angel caught the contagious enthusiasm for the specialty!
- The very first day, he did a 12 hour base of tongue cancer surgery and came back the next morning to check on the patient because he was so interested
- Other specialties he considered were general surgery, neurosurgery, and plastic surgery as well as oncology (liked the gratification and positivity when dealing with cancer patients as med student and resident)
- Residency was hard but an overall positive experience (“not to see everything but to develop skills and critical thinking to be able to do things”)
- Advice: it’s important to have a balanced and rounded undergraduate medical experience (take a variety of electives)
- Work with 7 other otolaryngologists who are each trained in a different subspecialty
- St. John’s is a busy academic center but has no residency program
- Start at 7:30-8
- flat days- major head and neck cancer or reconstructive surgeries (10-12 hours) every few weeks
- Having these procedures early in week allows for (usually) a relaxing end of week
- Also do smaller general head and neck surgeries (thyroid, parathyroid, salivary gland, vocal cord)
- Mornings at multidisciplinary cancer center with radiation oncologists and medical oncologists where he sees new head and neck cancer patients
- He also has an office outside hospital for new consults and follow-ups and general ENT practice for “run of the mill” things like recurrent ear infections and sore throats
- Back in office and then half day clinic for small procedures (biopsies, thyroid) in afternoon
- Start a bit later at 9:15 so he can bring kids to school!
- Thursdays – OR days
- OR day every second week or half day clinic in office (consults, paperwork)
- Finish by 1-2 and early start to weekend
- He also has academic responsibilities with teaching for UG program and recording electives
- Day usually ends around 5 pm unless major surgery
- Call burden is easier as they are shared by 8 people but can be busy without residents (all inpatient management falls to staff)
- He loves being in OR with another surgeon – sense of camaraderie & patient care (seeing cancer patients come out of that is super rewarding!)
Different subspecialties in ENT:
- General otolaryngology (half of ENT residents don’t subspecialize)
- Tubes, taking tonsils out, chronic sore throat, sinus surgery, some ear surgeries (lot of outpatients)
- Head and neck cancer surgery and microvascular reconstructive surgery
- Patients with malignancies above the collarbone not involving eye or brain (larynx, pharynx, oral cavity, oropharynx, sinonasal, skin cancer, thyroid, etc.)
- Often need to remove huge portion and replace with microvascular reconstruction (transplanting piece of skin, tissue or bone)- good functional, oncological, and cosmetic result
- Patients with vocal cord issues (difficult to treat medically and surgically)
- Neurotology and otology
- Ear surgeries and large lateral skull base surgeries (technically difficult specialty)
- Rhinology and anterior skull base surgery
- Endoscopic sinus surgery
- Resection of large cancers of skull base
- Other sinonasal conditions
- Pediatric ENT
- Insertion of tubes, removing tonsils and adenoids
- Very complicated when dealing with kids with airway problems
- Rewarding to manage kids with congenital deafness
- Sleep surgery
- Surgery for obstructive sleep apnea
- Facial plastics
- Cosmetic surgery of face (face lifts, rhinoplasties)
- Also deal with skin cancers of face
*Please note: this may not be a comprehensive list but we hope highlights the variability of ENT.
“One of the first big operations I did, over five years ago… a lovely gentleman…. who had a fairly advanced tongue cancer… so he needed… a total glossectomy, which involves taking out the entire tongue down to the larynx…we reconstruct it with a free flap from his thigh… You can’t really recreate the function of the tongue because it’s a fairly complicated organ and muscle but… put something back there that allows the patient hopefully to get swallowing function back to some degree. So he’s now over 5 years out, and he’s just a lovely person. And he brings me a salmon, a whole salmon he catches every year!… He’s very grateful, and… from a cancer standpoint, he’s done remarkably well. He doesn’t have a feeding tube and has managed to swallow everything. He doesn’t have articulation as a result of having the entire tongue taken out, but he communicates well… I remember it being a pretty stressful operation at the time. I was pretty early on in my practice, less than 6 months in when I did this particular surgery… Medicine can get pretty overwhelming and you can have difficult patients on top of having pleasant patients, and… you have to treat everybody as best as you know how… It’s a nice feeling to see this particular individual.”
Takeaway: You have difficult and nice patients in medicine. Sometimes it can be really rewarding!
Note: While we tried to keep these transcriptions as true to the speaker as possible, some dialogue is paraphrased and/or edited for easier reading.
- Try to shadow and find a mentor – if it feels good, there’s something there.
- Mentors are great if they are in the specialty you’re aiming for, but even those in other specialties can be really helpful, too