It is no secret that otolaryngology is a highly competitive specialty that attracts talented and high achieving students. Given that otolaryngology is a small niche surgical specialty, it is often highly suggested to have the support of faculty within otolaryngology who can “vouch” for you, otolaryngology specific research experiences, and mentorship; however, students without home otolaryngology programs often face an uphill battle in finding this support and other opportunities that are critical to match. We acknowledge that there are many ways to get to the same place; therefore, this is not a perfect nor exhaustive guide, but general tips and advice gathered from former students that have done it and the wisdom of faculty mentors along those journeys. We hope this guide encourages those in this situation to follow their passion and to be creative in ultimately reaching their goals.

PRE-CLERKSHIP EXPOSURE
The earlier you discover this incredible field, the better, but it’s also not too late to start, especially if otolaryngology fits with your interests and personal & career goals. Headmirror is a wonderful resource to begin to understand what this field is all about!

Shadowing: If you don’t have otolaryngologists at your institution, then reach out to a private practice physician in the community! They are often enthusiastic to have a medical student work with them. If feasible, reach out to an institution with an otolaryngology department in your region and ask the program coordinator if their department allows medical students to shadow faculty within the department. This is an easy opportunity to begin networking and possibly conducting research as well. Alternatively, there are other specialties that have plenty of overlap with otolaryngology that could also give you a glimpse of the field such as oral maxillofacial surgery (OMFS), endocrine surgery, and plastic surgery.

MENTORSHIP
Finding mentors is a vital aspect for guidance and success, however it can be quite challenging, especially if there are no otolaryngologists at your institution.

Be creative: You will have to be proactive in seeking mentorship. A good start is reaching out to alumni from your institution who matched into the field. They can often be very helpful in giving advice and paving the way for you. As previously mentioned, contacting a local institution with a department/division/program may be worthwhile to attempt to coordinate clinical time shadowing and/or research opportunities. Ultimately, even cold emailing faculty from across the country is something that can be fruitful. We suggest identifying individuals who share your research interests, who serve in roles dedicated to mentorship (clerkship directors, program directors (PD), assistant PDs), and/or individuals that you have a common connection. The worst thing that can happen is not getting a response, which is exactly where you were before you started. Once you have a connection with a faculty member, it benefits you to keep in contact with them, periodically giving updates and asking for advice as appropriate – just remember to be polite and respectful of their time as to not come across as overeager.

URMs: there are a number of incredible resources referenced in the Diversity & Inclusion section of Headmirror. We encourage you to take advantage of these opportunities whether it is coordinating a weeklong rotation during 3rdyear or reaching out to faculty members who have volunteered to serve as diversity liaisons!

RESEARCH
Research is a great surrogate marker to identify candidates that may be future leaders in the field and those that possess work ethic and commitment to finishing tasks. Broadly speaking, it is extremely important to conduct quality research during medical school. When having no home program, otolaryngology specific research can be extremely difficult. Thus, we have outlined three key tips on conducting research:

Clinical research with a twist: Having no otolaryngology faculty at your medical school will make it seem impossible to conduct any form of otolaryngology research, however, that is not necessarily true. “ENT” problems are often also handled by other specialties since the head and neck is a region of the body (e.g. general surgeons and tracheostomies, OMFS and facial trauma, radiation oncology and head and neck cancer patients). Therefore, consider reaching out to any faculty that deal with otolaryngology related pathology. (Other examples include emergency medicine, radiology, plastic surgery, pediatrics, audiology, surgical oncology, pediatric surgery, head & neck medical oncology, & sleep medicine.)
Non-clinical research with a twist: Venture past clinical research. Recall that the field of otolaryngology also benefits from advances in public health research such as vaccination efforts in at risk communities (e.g. HPV), medical education research (e.g. residency training), community outreach (e.g. smoking cessation), patient education (e.g. readability studies), impact of social media (e.g. otolaryngology-related Twitter use) and many other topics. Be creative – there is always a way to build a project that you are passionate about even if your mentor is not an otolaryngologist.
Research outside of your medical school: There are multiple paths on how to obtain opportunities for research at other institutions - summer programs, research fellowships, away rotations, society scholarships, and sometimes just e-mailing faculty. If you are unable to obtain clearance at the respective institution for patient related research there is always the option for case reports, survey-based studies, database studies, systematic reviews, and meta-analyses.

Having ambition, drive and grit are crucial to successfully completing tasks and especially research. However, always be mindful in regard to your availability (don’t over commit!) when obtaining research opportunities, especially during away rotations.

ENT ROTATIONS & LETTERS OF RECOMMENDATION
Once you have committed to applying, away rotations in otolaryngology and recommendation letters are vital for your application; you must be very thoughtful and strategic in your planning.

The away rotation: Most students with home programs will do their home rotation first and at least one other away rotation. We advise doing 2-3 away rotations. Some people may choose to do more; however, it is important to know that rotations require significant preparation, hard work, and energy to succeed; therefore, some down time between rotations is advised so you do not burn out and underperform. Choosing the right programs to spend a month with is often challenging and a source of stress. Asking mentors or people who went through the process for their advice is a good first start, as they may have knowledge of programs and help you connect with faculty before you arrive. Reaching out to residents from a program of interest can also be valuable, as they can be frank and provide information regarding what a rotation with them is like. We recommend choosing a diverse set of programs (e.g. small vs. big, research heavy vs. more clinically oriented, multiple hospital sites vs. more centralized rotations, fellows vs. no fellows, etc.). Having a diverse experience will help you determine what you value in your future training and also will make ranking programs easier for you. Additionally, it may be in your best interest to target programs that take a limited number of rotators per block, known to take rotators as residents, and those that have a strong reputation for a friendly culture. The earlier these rotations take place before ERAS submission, the more time you have for potential letter writers to complete their work, which takes a lot of time and effort.

Rotations in otolaryngology are challenging, especially for students with limited background in the field. We strongly advise preparing weeks in advance by learning the anatomy of the head and neck as much as possible, especially for common procedures you may encounter (e.g. neck dissections, sinus surgeries, mastoidectomies). Some popular resources are referenced under the Study Links page in the Resident section of this website. It behooves you to practice, practice, and practice simple deep dermal and interrupted suturing as well as two-handed and single-handed knot tying – being able to competently perform these skills in the operating room or in the ED for laceration repairs is a great first step for impressing and for a career in surgery! Once you arrive, you must have the mindset that you are going to give everything you have. Think of this as a month-long interview. Never arrive unprepared. Never arrive late. A few negative interactions can impact an entire month of hard work and leave an unfavorable impression. This means preparing each day for the clinic or the OR. If you are scheduled in a clinic, it is wise to read up on all of the patients scheduled for that day and write down a few notes for that patient, come up with differentials in advance, and possible ways to manage them. For the OR, you must know the patient's history, indication for surgery, possible complications, pertinent anatomy, basic pathophysiology and management principles of the disease – these are all free game to be asked. Feel free to ask questions – but ask thoughtful questions – that show that you read and wish to understand the nuances, while limiting the questions that you can easily look up. When rounding with the team in the mornings, have common supplies ready in a small, easily accessible bag or in the pockets of your white coat such as tongue blades, cotton tip applicators, kerlix, tape, gauze, flashlight, etc. Find ways to be helpful without stepping on anyone’s toes and without getting in the way (very tricky!). It may take a few days for you to realize how you can be helpful and find a role within a team of residents. Ask the residents for feedback. Some programs and rotations are set up to involve students more than others – be flexible! Ultimately, people want someone who works hard and gets along with the team.

Letters of Recommendation (LORs): We find this part of your application to be one of the most important. LORs showcase who you are, why programs should interview you, and why you will make a great otolaryngologist. You need at least three LORs, but many people submit four. Try your best to obtain three LORs from otolaryngology faculty with at least two of the three being from academic physicians (non private practice). The “home” letter can be your fourth letter and should be from a surgical faculty member that knows you well (e.g. an endocrine surgeon, OMFS, general surgeon). Medicine letters may be valued less, but if you did a particularly rigorous unique medicine sub-I, then this can be included. Also, if you conducted a meaningful research fellowship or joint degree, your mentor could be another source for your “home” or fourth letter.

LORs from away rotations can be challenging, as you may not spend significant quality time with the same faculty members, especially at bigger programs. Begin by asking residents and/or the program coordinator/PD early on who are faculty members that would be willing to write good letters for you – they are often in tune with this type of information. Being upfront with the person who makes your weekly schedule (chief resident or program coordinator) about your interest in working with a specific attending can be beneficial, if they can be flexible. Oftentimes, PDs or Chairs are the individuals most commonly asked and are open to these requests. Sometimes, they gather information from the residents who you work with intimately, therefore, it is important to always be sharp, friendly, and hardworking. In an ideal world, you want to target faculty who are respected leaders in the field, publish frequently, and/or are in the associate or professor role, as they are often well known and will therefore carry more weight in your application. The caveat being that sometimes these individuals are busy and/or may not be as invested in students; you have to be aware of this because you do not want an empty, stock letter, which may inadvertently hurt your application. It is wise to ask faculty who you worked with a few times and therefore should be able to judge your performance. If possible, ask for a letter in the middle of your rotation so you can give your letter writer time to think of things to write about you as you work with them further and to gather information from residents. NEVER ask by email. Try setting up a meeting with them in person. Ask them if they think they know you well enough to write a strong LOR for you – if they cannot do this for you, then it’s better to know at that moment than be surprised later. You should come prepared to this meeting by being intentional with your request and with a packet of information, to make their job easier. This includes having your personal statement ready, your CV, and consider having a short list of patient encounters during your rotation that showcase your skills. Show gratitude to your letter writer, such as writing them a handwritten thank you letter.

THE “X” FACTOR
What makes you outstanding and unique? Through your grades, LORs, and scholarly activities you have shown the residency review committee that you are well prepared. However, a residency program is searching for future leaders. Therefore, show them what you are passionate about. The two main ways to showcase your uniqueness or your “X” Factoris by revealing your passion through your extracurricular activities and hobbies. Having a common theme that can tie in your activities, research, and/or life story can be a bonus, such as caring for underserved populations or being passionate about medical education.

Extracurricular Activities: Whether it is community health education, medical education, health equity, mentorship or any other topic, these should be included in your application. Also, if you have been working, particularly if committed to the same organization over an extended period of time, definitely include this. In our opinion, it is more important to dedicate substantial effort to quality experiences that you are passionate about rather than crowding your application with numerous short experiences you do not really care about. If you dedicate time to initiatives or projects you are enthusiastic about, you will be able to innovate, excel, and become a leader in that area. All of this will shine through in your application and during your interview.
Hobbies: We are not just medical students - hobbies allow you to express methods of relaxation, interests, and will often be great conversation starters during your interviews. Examples include: sports, writing, cooking, traveling, playing an instrument, singing, or even your trending blog on terrariums. There is a section of your application for hobbies – don’t underestimate the importance of this!

ADDITIONAL TRAINING PATHWAY
There are a number of otolaryngology applicants each year that pursue a yearlong research experience during or post medical school. However, it is important to note that there are several paths for “time off”; including, obtaining an additional degree, conducting research, or other scholarly activities. Preparing for such activities is crucial and you should seek out advice from your mentors on how to excel during that time and whether it is the right decision for you, as there is significant cost and it may not be in the best interest of everyone. The option to obtain additional training can allow for increased exposure in otolaryngology, connecting with valuable mentors, obtaining quality letters of recommendation, and conducting meaningful research. It is important that you come out of this year being productive because a year with incomplete projects may only hurt you. Choosing the right program is a difficult decision; we suggest considering the strength of your application to the caliber of the institution, so that you may have a higher potential to match at that program.

Additional training pathways include: graduate degrees, formal research fellowships, informal research fellowships, joint degree programs, and leadership fellowships. The following list is not exhaustive, but can serve as a starting point.

THE COVID ERA
The public health situation of 2020 has drastically changed the way undergraduate and graduate medical education is structured. Students without home programs face a unique disadvantage since they will have limited opportunities for rotations leading to even more barriers in terms of accessing potential mentors, obtaining LORs, and gaining valuable exposure to residency programs. During this unique time, it is imperative that you are proactive.

Tips: Attend otolaryngology virtual seminars, apply for virtual rotations, follow programs through social media, and e-mail prospective programs about opportunities to speak to residents or faculty. Visit websites of the programs you are interested in and join their virtual events to learn more about otolaryngology as a whole, as well as specifics about those programs.

WHAT IS IN MY CONTROL?
As an applicant without a home program, you cannot change the fact that access to otolaryngology exposure, mentorship, and research is limited to you. However, you can definitely maximize what is in your control.

Excelling during pre-clerkships and performing well in USMLE exams
Excelling during clerkships and away rotations
Obtaining quality LORs
Performing quality and meaningful research
Highlighting your “X” Factorthrough your extracurricular activities and hobbies

Ultimately, if you are able to successfully navigate through this challenging process, you will demonstrate to programs that you are proactive, resilient, and relentless to reach your goals, which will actually set you apart from your co-applicants. This process is very stressful and sometimes may seem impossible to do, but with careful planning and thinking outside the box to find opportunities, you can succeed!

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