In this article, Matt Donachie shares insights on the daunting yet enjoyable experience of starting as an ENT junior doctor, offering valuable advice.
Starting your first job as a junior doctor in any specialty in the UK can be a daunting experience but is especially true of beginning a rotation in ENT surgery. We have gathered the opinions of a number of recent ENT senior house officers (SHOs: FY2s, core surgical trainees, GP trainees and junior clinical fellows) with differing medical backgrounds and career aspirations, and from multiple ENT departments within Scotland, to explore their perceptions.
We hope that their experiences and advice can be used to inform future doctors starting out in ENT and to optimise the support provided by ENT departments to these doctors in the UK and beyond. We will also highlight some of the learning and teaching resources endorsed by these ENT SHOs to help smooth the road for any budding otolaryngologists.
The ‘ENT SHO’ job
Being new to ENT can be demanding for a number of reasons: the relatively brief teaching of ENT at medical school; the complexity of the anatomy of the head and neck and the special senses; the novelty of clinical examinations that are not routine in generalist medical and surgical rotations; the subspecialist surgical operations; as well as the wealth of procedural skills and new medical equipment that need to become familiar. The diversity of clinical expertise between SHO subgrades can compound the challenges for more junior members who strive to meet the expectations of SHO level.
"The diversity of clinical expertise between SHO subgrades can compound the challenges for more junior members who strive to meet the expectations of SHO level"
These challenges often come alongside the assumption of a greater degree of responsibility, too. Many will be expected to carry the on-call bleep or phone, triaging and assessing referrals, whilst also giving advice to GPs and secondary care colleagues (often for both paediatric and adult patient populations) on a diverse array of ENT issues. Furthermore, one might manage emergency outpatients in the ambulatory treatment room setting, whilst maintaining the more familiar responsibilities of inpatient ward care, outpatient clinic and the operating theatre. Junior doctors arriving in ENT should therefore be well-supported by senior staff (their registrars and consultants) to facilitate this transition.
Before the job
On asking junior doctors from a distribution of the common SHO grades, most had some degree of prior surgical experience, but this varied widely. Experience ranged from a single surgical-themed foundation job at one end of the spectrum to surgical electives, taster weeks and courses, such as basic surgical skills and care of the critically ill surgical patient (CCrISP) courses. At the other end of the spectrum, some of the core trainees had multiple years of surgical experience and had completed both parts of the Member of the Royal College of Surgeons (MRCS) examination.
The amount of prior ENT-specific experience was much more limited amongst all grades. There were a few who had undertaken ENT-themed electives or taster weeks, but the majority had no ENT experience since medical school – which could be as brief as a three-day attachment.
In terms of preparation for the job, very few SHOs did any self-directed reading or learning before starting. However, in the departments who sent out a handbook of common ENT emergency presentations, most read these prior to commencing the placement and found them helpful. Some continued to refer to their handbooks whilst on the job in their initial weeks.
"There were a few who had undertaken ENT-themed electives or taster weeks, but the majority had no ENT experience since medical school – which could be as brief as a three-day attachment"
All doctors received some form of induction session. This varied from a lecture and informal teaching on the ward on the first day to a combination of different teaching sessions, often spanning over multiple days. The most comprehensive inductions included a tour of the department, didactic teaching sessions and a dedicated practical skills session (demonstrating and allowing participants to practise flexible nasoendoscopy and otomiscroscopy, for example, as well as how to drain a peritonsillar abscess or how to manage an epistaxis). Some departments also organised simulated scenarios for the management of ENT emergencies (e.g. post-tonsillectomy bleed, epistaxis, tracheostomy emergency). Participants highlighted the practical skills and simulation sessions as particularly helpful in preparing them for the job.
During the job
About 2/3 of SHOs felt that it took between two and eight weeks to feel confident and comfortable on the job, although many felt it took longer than this and one in 10 felt it took more than four months (the typical length of an FY2 rotation).
Whilst identified as one of the main challenges at the beginning, most SHOs found the acquisition of practical and procedural skills to be one of the most satisfying aspects of the job. They found that seniors (especially registrars) were very open to teaching and supervising but that learning opportunities were highly variable if no formalised practical skills teaching was provided. Attending clinic and theatre provided valuable opportunities to consolidate knowledge and refine practical skills without the burden of emergency duties.
"Whilst identified as one of the main challenges at the beginning, most SHOs found the acquisition of practical and procedural skills to be one of the most satisfying aspects of the job"
Virtually all SHOs carried the on-call referrals bleep or phone during part or all of their emergency shifts. The majority found this frequently busy and stressful, especially when juggling the review of ambulatory patients in treatment rooms with inpatient ward care (with varying levels of ward-covering junior doctors between departments) or when receiving complex referrals (e.g. complex otology or from resus or ICU). This was generally less stressful in district general hospital settings compared to larger secondary or tertiary departments and improved with practice. Some departments shared the on-call bleep-carrying between the rest of the team (registrar and consultant). This approach was praised for giving SHOs exposure to triaging referrals whilst preventing them becoming overwhelmed.
After the job
On reflection, the large majority of SHOs acknowledged the steep learning curve but were very positive about their ENT experience and rated the job an average of 4.6 out of 5.
Aspects of the job that were particularly enjoyed were as follows:
- Relative independence and responsibility
- Practical skills and procedures
- Teamwork and friendly, approachable seniors
- Variety and complexity of patient presentations
- Running emergency clinic
- Mixture of medicine and surgery
- Capacity for training opportunities to attend clinic or theatre (even as an FY2)
- Variety of theatre cases (from simple procedures for SHO to perform to major head & neck operations)
Aspects that were not enjoyed were as follows:
- Cross-covering other specialties out-of-hours (in some units), often with minimal induction
- Receiving on-call referrals
- Being the only ENT doctor on-site for acute emergencies
- Early emergency clinic or treatment room sessions, if lacking supervision
- Limited SHO role in theatre for certain cases (confined anatomical spaces)
For those interested in surgery, their SHO experience encouraged a number to pursue a career in ENT whilst others found it very helpful in their pursuit of other surgical specialties (such as plastic, maxillofacial and general surgery). GP trainees were especially positive about their ENT jobs in preparing them for the management of ENT conditions commonly encountered in primary care and knowing who and when to refer. Even for those without surgical or GP career ambitions, they cited improved prioritisation and time management skills, and valuable experience managing both adult and paediatric patient populations, as positive influences on their future careers.
Advice
For new ENT SHOs
Take advantage of practising practical skills under supervision at the beginning before having to perform these alone out-of-hours. In the early days of holding the on-call bleep/phone, discuss referrals with seniors and remember you are not expected to be able to give advice for complex patients (or to clinicians with more experience who are calling to ask for help!). Seize training opportunities to attend clinic or theatre as these are less common on other placements.
For departments
Consider providing structured and formal teaching sessions for practical skills and equipment (being taught ‘on the job’ is more stressful and often competes with the clinical demands on the whole team). Consider sharing on-call bleep/phone responsibilities between team members.
Resources
- Departmental handbooks & guidelines
- Local policy, referral pathways and antibiotic or formulary prescribing - ENT UK Junior Doctors Induction Programme
- Combination of lectures, videos and self-assessment questions
- Available from:
https://www.entuk.org/professionals/training/
ent_uk_junior_doctors_induction_resources.aspx - Entsho.com
- Articles on common emergency ENT presentations by anatomical site, approach to referral triage by symptom, procedure and skills guides.
- Available from:
https://entsho.com - ENT4GP.com
- Symptoms-based resources, flowcharts and interactive case-based discussions aimed at the primary care setting
- Available from:
https://ent4gp.com - Headmirror’s ENT in a Nutshell podcast
- 20-40 minute podcast episodes on a wide range of more advanced otolaryngology topics
- Available from:
https://www.headmirror.com/toc-podcast - AOT ENT Education YouTube channel
- Association of Otolaryngologists in Training (AOT)’s collection of video lectures on more advanced otolaryngology topics aimed at UK ENT trainees
- Available from:
https://www.youtube.com/@aotenteducation9221/featured
All links last accessed April 2024.
Declaration of competing interests: None declared.
