Cross-training between paediatrics and otolaryngology – A strong message

Although ear, nose and throat (ENT) conditions are commonly seen by the general paediatrician, formal training by otolaryngologists has not been a routine part of paediatric residency. Similarly, patients of the paediatric age group constitute a significant portion of a general otolaryngologist's practice. Teaching by paediatricians during otolaryngology residency is also not a routine practice for many otolaryngology programs. This issue has been a topic of discussion for many years, both nationally and internationally. Before the publication of two studies (1,2), no formal research or recommendations have been carried out to date. Having personally trained and worked in both the fields of otolaryngology and paediatrics, I have seen firsthand the lack of cross-training and knowledge between the two specialties. I, however, needed to perform research in this area to obtain an unbiased opinion relating to this very important clinical issue. The cross-training referred to here can be defined as otolaryngology training for paediatric residents and paediatric training for otolaryngology residents. The pilot study involved Canadian paediatric and otolaryngology program directors, because they would be the individuals who would know exactly what the present curriculum entailed. In addition, in the event that change was needed, they would be the most important group involved in the implementation of curriculum modification. The response rate for the study was high and the sentiments strong. Both fields identified a cross-training deficiency and a desire for more interaction between the two specialties. Three modes of training were offered in the questionnaire: lectures, clinics and rotation. Paediatric program directors thought that, although otolaryngology training was lacking in all three areas, the most important mode was the clinic experience. The otolaryngology program directors desired more training by paediatricians as well, particularly in the didactic format (eg, lectures). Both groups were asked to identify topics they felt their residents needed to know more about. Based on the pilot study, I conducted a large national survey of practicing paediatricians and otolaryngologists. It was a similar format to the one-page survey used in the pilot study. The physicians were asked what mode of training they received, and what they desired. The modes were once again divided into lectures, clinics and rotations. They were asked about topics of importance, and some basic demographic data were collected and analyzed. The survey response rate – 70.6% for paediatricians and 76.2% for otolaryngologists – was exceptionally high, given that the average response rate of any survey is between 30% and 50%. The areas of deficiencies and desired modes of education expressed by the program directors were echoed by the practicing physicians of both specialties. Requested topics for cross-training were fairly broad, covering many important aspects of clinical practice. ENT topics of importance for paediatric residency included airway problems, wax cleaning, ear disease, hearing loss and nasosinus disease. Paediatric topics of importance for ENT residency included resuscitation, fluids and electrolytes, evaluation of the sick child, medications, genetics, immunology and developmental delay. There was no statistically significant difference between the responses from generalists versus subspecialists in both specialties. It appears there is a slight trend toward more cross-training for those who graduated more recently. These studies have demonstrated that both paediatricians and otolaryngologists feel that cross-training is important, and that there is a deficiency in this area. The most important mode of education appeared to be otolaryngology clinics for paediatric residents and paediatric lectures for otolaryngology residents. A broad range of topics identified in these studies need to be covered. The results were sent to all of the paediatric and otolaryngology program directors in Canada for their review and consideration of curriculum modification, under the condition that cross-training between the two specialties was not part of their program already. Certainly, the specific nature and amount of cross-training is up to the discretion of the program director, but based on these results, one can give some general guidelines. Consensus among program directors of both fields across Canada would be ideal. According to the survey, paediatricians believe that the clinic experience is the most beneficial, and, therefore, that it should be incorporated into their residency, either at a teaching hospital or with a community paediatric otolaryngologist. I believe that a one-month clinic experience (with or without a formal rotation on the ENT service, comprising of all aspects of paediatric ENT) would be ideal, although this commitment may be difficult to fit into an already intense paediatric residency. Two weeks on the ENT service, in my opinion, would be the minimum clinic experience that would be acceptable to attain the basic diagnostic and procedural skills. Otolaryngologists desire more didactic training, which would be easier to incorporate within the residency than within a clinical experience. Definite topics have been identified, as mentioned above, and should be instructed by paediatricians at some point during the otolaryngology residency. It is time for us to accept these strong sentiments from both specialties and move forward with curriculum modification. Ongoing continuing medical education would obviously be crucial for those of us beyond residency, and for those who so strongly conveyed this message in the survey. After all, it is about our children in Canada and abroad, and our ability to offer them the best medical care we possibly can.

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