Portuguese Version

Year:  2004  Vol. 70   Ed. 1 - (0º)

Editorial

Pages: 02 to 03

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About the medical residency program and Otorhinolaryngology in the future...

Author(s): Henrique Olival Costa

For some time now we have been discussing the general status of both national and international Otorhinolaryngology concerning vocation, skills and perspectives for the future. The latter will be the focus of this editorial, since good perspective provides prospect platform and determination to move ahead.

One of the main aspects of a prospect platform for the future is the capacity a medical system has of forming specialists in the present to reach the professional level we have in mind for the future.

This is a complex issue and it has evolved slowly in meetings with resident physicians and coordinators of Medical Residence Programs, organized by the Brazilian Association of Otorhinolaryngology and Head and Neck Surgery. We have noticed that there are two issues involved in the discussion, and even though they are not opposite, they cannot be implemented simultaneously, to wit: a decision of what is the "standard otorhinolaryngologist " and the definition of the minimum criteria for professional training.

In an editorial in 2003, we discussed what was exactly the specialty known as Otorhinolaryngology, both in Brazil and abroad, and we were amazed to see that the specialty advocators may have come from different paths of the profession, from both clinical and surgical settings, surgeons who operated on the face, neck region and skull base. It may be electrophysiologist, plastic surgeon, oncologist, pediatrician, as well as a master in the insides of the areas between the skull base and the scapula. However, which is the one that is more representative of the specialty? This definition can be simplistic and follow what is said of Otorhinolaryngologists in Brazil, since when the first centers were organized in the 19th century, that is, clinicians who deal with the ear, nose and throat and surgeons that treat infectious-inflammatory diseases of these areas. But the definition can also follow a harder and more complex path and try to define a specialist who is not that all specialist, but rather a professional who has broader area of activity and performs everything that is done in a diversified and non-systematic form, incorporated into a coherent and rational way. This is a decision that has to be made by the community, since what we will be in the future has to be decided right now.

To present, we have been concerned about having homogenous, uniform and well-balanced services provided by teaching facilities of Otorhinolaryngology, accredited by the Brazilian Association of Otorhinolaryngology. To that end, we created an adjusted model to what would be the minimum requirements for training specialists; However, if we closely analyze the model, we can see that it looks like a tasting experience: much hors d'oeuvres waiting for the main course. "The minimum duration of Otorhinolaryngology training shall be of 3 years, comprising basic knowledge of Otology, Rhinology, Bucco-pharyngoscopy, Laryngology, Orthodontic, trauma, esthetical and recovery surgeries of the face, Snoring and Sleep Obstructive Apnea, Head, neck and skull base affections, Otoneurology, Otoneurosurgery, Microsurgeries, Allergy, Phoniatrics, Diagnosis and Endoscopy." - Committee of Teaching, Training and Residence.

SBORL 2003

The fact is we have not prepared this dish. We do not even known what type of restaurant it is. As a result of a menu as long as these it could easily be an international restaurant: "Committee of Teaching, Training and Residence in Otorhinolaryngology - 2003, Surgeries to be performed by resident physicians in ENT: perioral endoscopy, abscess drainage, adenotonsillectomy, uvulopalatopharyngoplasty, septoplasty, turbinectomy, and turbinoplasty, maxillary sinusectomy, Caldwell Luc and intranasal, external and intranasal ethmoidectomy, external and intranasal frontal sinusectomy, sphenoidectomy, partial and total maxillectomy, paracentesis, myringotomy for ventilation tube, tympanoplasty, tympanomastoidectomy, stapedotomy, partial and total temporal bone resection, rhinoplasty, otoplasty, bhlepharoplasty, other esthetical facial surgeries, removal of submandibular gland, parotidectomy, removal of congenital neck lesions, removal of benign neck tumors, neck dissection, mouth and pharynx tumor resection, partial and total glossectomy, marginal and segmental mandibulectomy, tracheal intubation, tracheostomy, larynx microsurgery, laryngotracheoplasty, endoscopic cordectomy, thyroplasty, partial laryngectomy, total laryngectomy, nasal cleft, maxillary fractures, mandible fractures, zygomatic arch disorders, facial nerve surgeries, cranial-facial dysfunction".

This puzzle deserves better delineation of the main objectives of the specialty: what were the real vocation and motivation that drove its formation? We will probably not come to conclusions about the reasons why we were formed, but if we define a safe and coherent path, we will at least learn where to arrive at.

We are concerned that we might have taken a too bureaucratic route when defining the minimum attributions for specialists in Residence Programs. There is no doubt of what the final results would be. Once the objectives were defined, we would come up with a curriculum not only to define minimum requirements, but also to envision what would be the maximum or ideal curriculum.

Throughout the history of ENT we have already won and lost crucial opportunities - we knew about clinical audiology, auditory rehabilitation, plastic and facial surgery, we dealt with cranial nerves and immunology, but we lost because of the formation of new specialists and careers, we fought to maintain our space in routine practice. Now, are we preparing younger people to maintain the same spirit?

Otorhinolaryngology has in our days the possibility of being an area of great importance, since it deals with problems that affect our daily lives such as headaches, cough, upper airway inflammations and infections, vertigo, tinnitus, digestive disorders, swallowing, facial trauma, speech, hearing. and at the same time, we can perform prevention and treatment of highly specialized areas of radiology, endoscopy, electrophysiology, non-invasive surgery, microscopic surgery, and neck and facial major surgeries. Should we trade these possibilities on behalf of the uniformity of the specialty or could we possibly devise a plan providing deeper and more specialized knowledge at least to some of our colleagues?

The issue is it may be a solution but at the same time it generates a problem of execution.

We know that our medical schools have their own assumptions, conditions and limitations. The definition of minimum criteria for accreditation of a Medical Residence Program by the Brazilian Association of Otorhinolaryngology and Head and Neck Surgery makes us assume that many cannot reach the optimal level. But which of them would reach the ideal status? Is there any center that gathers all conditions to form Otorhinolaryngologists with top excellence? Probably not. Therefore, are we simply a patchwork specialty or can we start a joint action to work as a large area, working hard to train the Otorhinolaryngologist of the future, even if it requires external support? Looking around us, we can notice that we have moved towards that thanks to the activities of the supra-specialty teaching centers and their regional training courses, as well as internships in less popular areas such as facial traumatology. However, it would be a shorter and more efficient path if we could assume our institutional limitations and created Inter-institutional Residence Programs. They would complement each other by sharing candidates for residence programs as well as facilities, faculty, skills and vocations. The resident would know that the program comprised two, three or four schools and the training would be conducted by each of them stressing different curriculum areas. This format would also allow the resident to know that in three years he would have obtained training of excellence, though no complete yet. If so decided by the resident and available by the institution, it would be complemented by 4 more years in head and neck, allergy, skull base, otoneurology, etc.

This is the design of a large area with dimensions of a specialty, in which the specialist would be an Otorhinolaryngologist specialized in Otology, Rhinology, Head and Neck, Pediatrics, Otoneurology, etc.
Nothing but thoughts, but the future is imposing itself on us.

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