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To preface my thoughts, I would first like to stress that clearly there are many great otolaryngology training programs-our specialty is particularly strong in this regard. Accordingly, your forthcoming decision will likely be one of choosing between very good and even better options. I point this out because in my praise of our program, I do not wish to come across as arrogant or condescending. If for whatever reason you decide that Mayo Clinic is not for you, all is certainly not lost!

Drum roll please….

1. The early start:
As you may know, the bulk of experience in most programs is heavily "back-loaded"-that is, most of the intensive operative experience is obtained in very busy senior and/or chief resident year(s). Our program is absolutely different than nearly all others in this respect. If there is one thing that I could tell you that really sets this program apart from many others is that here at Mayo you will start doing complex cases very early-as in your PGY 2 year! You will be granted all 5 years to learn otolaryngology. The general approach in this department is to utilize all five of these years (not just the last 1 or 2) to teach you how to operate.

Your experience will begin immediately as an intern while you spend a 3-month quarter in ENT. In addition to learning how to deal with the otolaryngologic problems most frequently seen in the ER (epistaxis, peritonsillar abscess, airway distress, deep neck space infections, facial trauma), you will jump right in and perform numerous tonsillectomies, tracheotomies and PE tube placements while still an intern. As an intern I logged nearly 20 tracheotomies-all but 5-6 as primary surgeon. By doing so, you are ready to hit the ground running in ENT after you finish your intern year having already attained general proficiency with the basics.

As a PGY-2 resident, I literally performed several mastoidectomies, a ½ dozen neck dissections, numerous pediatric surgical airway endoscopies, and lots of FESS-all as primary surgeon. When I say primary surgeon, I mean start to finish, skin to skin, or however you prefer to say it! All of this was done along with LOADS of other bread and butter ENT.

So why is it important to start early? I have found that the sooner I have actually done a given surgical case, the sooner I am truly able to internalize my reading and study of it (making the subsequent conferences, study time, and even time assisting in the OR more significant). There are subtleties that you cannot grasp unless you have actually done things yourself. Anatomy and pathophysiology will come alive after having dealt with it yourself in the OR.


2. The unique structure:
So how is the early operative experience made possible? While you are paired with a staff consultant (what they call attending physicians here), you work and interact with them very closely in an individualized manner. In doing so, you are given "claim" among residents to whatever surgical cases they list-no matter what it is and no matter what level of training you have. The apprenticeship model works under the philosophy that residents are allowed to actively participate in a given surgical procedure to the full extent that their skill and experience will allow. If you are new to a particular procedure, consultants walk you through more and more steps each time you perform it. Here, you will rarely be told that you cannot do whatever case because it is a "Sr. or Chief-level case"-these terms, to some extent, do not exist or apply here. It is not appropriate for a more senior resident to step in and try to take your interesting cases….this is not accepted.

Other benefits of the apprenticeship model include early decision-making autonomy as the only resident caring for set patients (no need to run the routine patient care plans by more senior residents) as well as lots of direct interaction/teaching from consultants. It also means no endlessly repetitious rounds every morning!!-usually YOU decide when to show up to round on your patients--no endless "re-rounds" with the Sr, then the chief, then finally the consultant.

3. The operative experience:
The operative experience here in our program is truly tremendous. At most interviews you will be quoted the number of cases that the chief residents will have done by graduation-much is made by some of the total number of cases that residents complete during their training (of course how these cases are counted seems to differ person-person from place to place). As was outlined during the interview presentation-the total volume of cases performed by our residents is VERY large. However, the most impressive thing about our operative experience is its breadth. If you have the chance to peruse one of our resident logs you will note extensive experience with both the "bread and butter" as well as the complex. Indeed, the number of complex cases seen here is staggering. Some programs "pad" their total operative experience with a disproportionate number of tonsils, PE tubes, and endoscopy-here, the experience truly covers ALL aspects of ENT. You will be exposed to the entire specialty--from skull-base surgery to facial plastics.

The volume of cases coming through this department is huge-it is certainly one of the busiest otolaryngology departments in the country. As a result, interesting cases are less of a "big deal" here as compared to some places. A stapedectomy or neck dissection for example raises few eyebrows-these are not a perceived as big ordeals at all. As a result, you won't have loads of residents jammed into the OR every time something cool comes around.

Now obviously there are lots of wonderful programs that support fellowships and there are surely exceptions to my criticism. Our department could certainly support fellowships in several areas; however, I personally feel that it is a very good thing that they choose not to. This is one of the only so-called "top-shelf" departments in ENT that has a no-fellowship policy.

4. The "hands-on" approach:
Possibly someone, somewhere along the line has warned you that Mayo residents don't operate. There are many possible explanations for why such uninformed views exist-misunderstanding of what Mayo Clinic really is, the fact that maybe some of the other surgical departments here may have been this way at some time (who knows). I can, however, tell you such misconceptions usually come from those who in reality know little about our program and/or have never been to Rochester-hearsay. Believe me when I tell you that this notion that we don't actually get to operate is absolutely ludicrous! As residents we routinely laugh about this noting that nothing could be further from the truth. I would be shocked if you were able to find someone that claims Mayo residents don't operate that has actually spent time in the department.

First of all, Mayo is not a place were your patients are all millionaires or VIPs from foreign lands-this describes at most 5% of who we see up here. 95% of our patients are regular folks from all around the upper mid-west (and some referred from beyond)-lots of farmers;). Or ER takes Medicare/Medicaid patients like anywhere else. The overwhelming majority of patients here simply do not come unwilling to see residents-in truth, I personally had more of a problem with this at the county and VA hospitals where I went to medical school than I have here. It really is a non-issue. If anything (this is key), when patients come here to Mayo Clinic, they generally assume that they will receive top-notch health care-Mayo's reputation precludes most from questioning the system.

Additionally, I would clarify that we don't just provide exposure for the attending to perform the critical maneuvers. We actually get to take out tumor, dissect facial nerve, free carotid, remove stapes, enter the frontal sinus, drill cochleostomy and/or most any other critical maneuver you can think of. I personally have sewed the microvascular anastomosis on a few free flaps! (a classmate of mine with an interest in microvascular reconstruction has harvested, in-set and sewn the anastomosis in a double-digit number of flaps). Our staff is basically on a set salary that is not affected by the type or number of surgeries done or patients seen-so they do not have any financial ties to whether or not surgery is done by a resident.

Please talk to the other residents if this is a concern of yours-it really should not be. If you choose not to come to Mayo for fear that you will not operate, you are making a misinformed mistake. I can almost guarantee that you will not hear a single resident complain about not operating here-most all of them, I believe, will tell you that we get to do at least as much as the residents from where they came. When I interviewed here, I actually left with the impression that the program here was very "hands-on." Now that I am here, I can tell you that I was correct in this supposition. OK already, you get my point!

5. The call schedule:
Admit it, this is fairly key. You won't be disappointed. With 4 residents per year, thankfully call gets spread fairly thin. In-house call at St Marys Hospital is split between the intern and all four 2nd year residents. It averages out to every 5th night in-house. In addition to this, Jr residents split weeknight home call for Rochester Methodist Hospital (no in-house call at RMH). Fortunately, we make the call schedule (not department secretaries who are less in tune with your daily scheduling needs) so there is a ton of flexibility. Generally, we will take a run of a few q3 or q4 calls in a row and then have a week or so of almost nothing. After PGY-2, no in-house. On days after call in-house, the department has a strict policy of sending the post-call resident home by 12 noon. Adherence to the new ACGME 80 hr work week has already been adopted within our department.

3-4th year residents take occasional weekend call from home for Rochester Methodist Hospital and round on all in-house ENT patients. What this means, is that unless you are on call, you have every weekend off (only on call 1 in 4-6 weekends after PGY2). Chiefs take back-up call from home 1 week in 4. Mostly, they just answer Jr resident questions by phone. Although, some programs offer no in-house call, when you consider our intern year into the equation (see below) here we aren't too far removed from that. I should note, however, that the 2nd year is very busy in regards to call.

6. The intern year:
In some programs you basically have to kiss one year of your life good-bye as an intern with a full year of q3 call-not here. We are not completely handed over to the wolves…err general surgeons for a year spent on the transplant and cardiac surgery wards. The educational value of our PGY-1 year is quite good in that it is mostly all relevant to ENT. In addition to 3 months of ENT, our intern year consists of : 6 wks Plastic Surgery (easy time), 6 wks Endocrine/General Surgery (easy time), 6 wks Surgical ICU (not bad), 3 months ER/Trauma, 6 wks Vascular Surgery.

You will definitely get to spend a lot of time in the OR and actually operate quite a bit as an intern-I was very pleased. You will not be trapped on the wards all year. In my opinion, internship here is either a feast or famine situation in that life can be either absolutely wonderful (on ENT) or very tough (vascular surgery/trauma & critical care). Luckily, the absolutely difficult portion only entails the 6 wks of Vascular and 1of the ER/Trauma months for a total of 2 ½ really difficult months…with basically no life-however, I must say that I think that the lessons learned on these services make them very worthwhile. Otherwise, the rest, while certainly hard work, really are not at all too bad. My wife was very pleasant ly surprised.

7. The flexibility:
Private practice vs academics? Truly no pressure whatsoever to go one way or the other. Whichever way you choose, the only concern among faculty is that you simply be committed to excellence. This program will prepare you equally well for either direction. Historically, Mayo has turned out a lot of facial plastic surgeons, but recent graduates have landed top fellowships in most areas. There is a 6-month dedicated research block in the 3rd year funded by the department. Most residents find it a nice break from clinical duties. Also, chief residents have reported that the Mayo name has been like gold in private practice job-seeking activities.

8. Strong diverse faculty:
Our department includes experts in all areas of ENT including: Otology/Neurotology (Drs. Beatty, Driscoll, and Neff), Head & Neck Oncologic Surgery and Reconstruction (Drs. Olsen, Kasperbauer, Moore, and Price), Facial Plastics (Drs. Moore and Friedman), Rhinology/Sinus (Dr Pallanch, Dr. Gustafson), Pediatric Otolaryngology (Drs. Orvidas, Thompson, and Cofer), Laryngology/VoiceRestoration (Drs. Maragos and Ekbom). There are also many others from Jacksonville and Scottsdale. The diversity of faculty allows us to learn different ways to perform the same procedure or care for the same problem. We enjoy a very good rapport with our entire faculty (no, really-we do). This is definitely not at malignant program AT ALL in terms of resident/faculty relations.

9. The atmosphere:
I don't mind saying that we have an extremely laid-back, fun group of residents-definitely not a bunch of angry people here. Fortunately, the structure of the program minimizes "case stealing" or competition amongst us. Many of us are married and some of us have children (as of summer 2005, 11 of our 20 residents are married, 9 are single). Many of our spouses/significant others and children have become a tight-knit group as well. With 4 residents per year, there are enough of us to be able to cover for each other when needed. Our department sponsors several social activities per year-along with other frequent parties and get-togethers. Hopefully at the reception you had a chance to meet most of us-if so, hopefully you will agree that we have a cool group.


Other issues/important points:
What about Rochester? This city is what it is….a very clean, family-oriented small mid-western city. If your happiness hinges on weekly trips to the opera, surfing, great sushi, or lets face it, a serious nightlife, this place is probably not for you. However, if you want to buy a nice house, drive 5-10 min to work with no traffic, live with essentially no crime, send you kids to very good public schools, camp, hunt/fish, bicycle, golf and/or enjoy middle America, Rochester is your place. Have realistic expectations-this is not NYC. Rochester was named Money magazine's best American small city several times in the 90's. Depending on whom you ask there are anywhere from 5-6 to 9-10 good restaurants around town-in addition to many of the common chains.

Real estate is affordable, but has risen in recent years-to the point where I wouldn't necessarily classify property here as being cheap, but still quite affordable-your opinion of this will depend on where you are from. Nearly every resident owns a home. For a city of its size (~100K), it has much more to offer than you might expect--it is now the 3rd largest city in Minnesota behind Minneapolis and St. Paul. Other than Mayo, IBM is the main employer. My wife works for an employment recruiting agency here in town-per her, the employment market in Rochester is much better than most of the country. DO NOT assume that your spouse or significant other will not be able to find employment here as the job market is larger than you probably think. Fortunately, my wife's job search was very easy.

The Twin Cities are a just over a 1-hour drive away-which is nice for good shopping, sporting events, dining, etc. Again, if your happiness depends on your ability to make it to the big city lights every weekend-consider yourself warned, this will not happen. I have been happy here so far. Check out www.rochestercvb.org , www.rochestermn.com., and www.rochestersquare.com. Also, if you are into the great outdoors, "up North" in the wild part of the state you will find many truly spectacular places to hike, camp, canoe, fish, and much more. Check out www.exploreminnesota.com

What about the cold weather? This too is what it is…no way to sugarcoat bitter cold. There are basically 5-6 months of winter. I will say it again…it's cold here. If you absolutely cannot deal with cold weather, maybe you should look elsewhere. Of course, you should realize that it is only somewhat colder than Chicago up here (not that this comforts a Texan like myself). The flip side is that other than a few hot weeks in Aug, the remaining weather up here is absolutely beautiful-including a glorious autumn. When I moved here from the boiling Texas heat, I thought I had died and gone to heaven; of course, when winter set in……

How hard do you work? Make no mistake, if you want to come to Mayo Clinic for the "country club" residency experience, you will be very disappointed. We work quite hard here (like most programs). There is a sub-set of applicants that chose ENT because they view it as a kinder, easier version of surgery-somewhere near the land of dermatology. While to a certain extent this may be the case (we don't get worked like the poor neurosurgeons-thankfully), don't be mislead into thinking that this program is any sort of a vacation. While the efficiency of the clinic itself minimizes scut to a certain extent, there is still plenty of work to do-lots of operating. On the difficulty scale, there are certainly easier programs out there, but then probably more difficult ones as well. Face it, learning takes time and effort.

One of the nice things about an ENT program in a place like Rochester is that we are not constantly beat-down by facial trauma calls (the curse of many big-city programs-just ask most residents how they feel about facial trauma). On the flip side, if there were one weakness in the operative experience here, it would be facial trauma-specifically mandibular trauma. To augment this, we spend 6 wks in at the Hennepin County Medical Center in Minneapolis during our Chief year. While somewhat of a pain, it beats being overworked by trauma for 5 years.

Well now, it seems that I have said quite enough-and then some. Hopefully this has been helpful.