Paediatric and otolaryngology cross-training

Abstract

I read, with interest, Dr Fabian’s editorial (pages 283 to 284), as well as his two referenced studies (1,2), on the need for increased cross-training between paediatrics and otolaryngology. He performed two studies to document this need – one involving a survey of Canadian paediatric and otolaryngology program directors, and the other a survey of practicing paediatricians and otolaryngologists. Ten paediatric program directors responded to the three questions on the first survey. All 10 indicated that teaching by otolaryngologists would be beneficial for paediatric residents. Five of the programs already had a clinic experience, seven had lectures or rounds, and one program had an otolaryngology rotation. The areas identified by program directors as being important were airway problems, ear disease, hearing loss and sinus disease. Dr Fabian received responses to his second survey from 343 practicing paediatricians. All respondents felt that some training by otolaryngologists would be appropriate. Of these respondents, 72% reported receiving some formal training from otolaryngologists. The respondents were asked to choose which ear, nose and throat (ENT) topics should be taught by otolaryngologists during residency. Five topics were listed: airway problems, wax cleaning, ear disease, hearing loss and nasosinus disease. Each was chosen by at least 50% of the respondents. Dr Fabian concludes in his editorial that paediatric program directors and practicing paediatricians believe there is a deficiency in their otolaryngology training. This deficiency appeared to be less for recently certified paediatricians. He concludes that this has an impact on patient care. In his studies, he states that one-third of visits to a paediatrician are related to otitis media. The reference for this statement is an American study. General paediatricians in the United States have three years of residency and are considered primary care physicians (3), while in Canada we require four years of training, and our residents become consultant general paediatricians. According to the Canadian Paediatric Society Web site Caring for Kids , which is directed toward parents, paediatricians are described as “specialists in child and youth health”. They are said to “provide a wide variety of services for children, youth and their families. Their work with patients runs the gamut from taking care of a seriously ill newborn baby to treating a teenager who’s been involved in a car accident”. Sounds like a tall order, especially when all of this knowledge must be gained in only four years of residency training! Amazingly, a survey of paediatricians (4), certified by the Royal College of Physicians and Surgeons of Canada (RCPSC) between 1999 and 2003, reported that 96% believed they were “adequately” or “very well” trained for practice. Areas in which general paediatricians, in particular, reported “less than adequate” training were behavioural paediatrics, child development and child psychiatry. This may be because consultant paediatricians see a greater number of children with developmental or behavioural disorders, rather than otitis media and other acute infectious diseases, which, in Canada, are more likely to be treated by their primary care provider. However, Dr Fabian is correct in his assertion that paediatricians do require training and expertise in diagnosing and managing many otolaryngology disorders. The RCPSC, in their document Objectives of Training and Specialty Training Requirements in Pediatrics (5), lists four areas of knowledge, three skills (including curettage) and 17 common problems in otolaryngology (including all the topics identified by program directors and endorsed by practicing paediatricians) in which a paediatric resident is expected to be competent by the end of training. The RCPSC does not specify how the resident acquires this competency, or who should teach these skills. These competencies may be acquired in a variety of settings. Residents will see children with acute ENT conditions, such as otitis media, mastoiditis and airway obstruction, during their rotations in emergency medicine. In fact, they are more likely to encounter these conditions in the emergency room than in an ENT clinic. Many of the other areas of competency required by the RCPSC will be acquired during residents’ other rotations, such as developmental paediatrics, in-patient general paediatrics, community paediatrics and paediatric surgery. Dr Fabian recommends a one-month clinic experience with a paediatric otolaryngologist, and that two weeks should be the minimum. In an ideal world, where residency training was unlimited, this would be possible. In the real world, with only four years of training (complicated by clinical time lost to academic half-days and post-call days), we have to be more flexible, because virtually every service and subspecialty wants more exposure to the residents. Paediatricians need these skills, and our residency programs need to provide an opportunity for residents to acquire them. We do need to work with our paediatric otolaryngology colleagues to ensure that the opportunities provided are of the best quality, if not the ideal quantity, to meet these needs.