OSTEOPATHIC APPLICANTS
As an osteopathic medical student, there are some things you should consider before pursuing a career in otolaryngology. First, otolaryngology is known to be one of the more competitive specialties to match into for allopathic and osteopathic medical students alike; it is a small field with limited residency positions nationwide and attracts incredibly talented and high-achieving medical students. In 2021, 17 of 37 (46%) DO senior applicants across the country who applied to otolaryngology successfully matched. Second, the osteopathic profession is highly underrepresented in otolaryngology. In part, this stems from the fact that DO medical schools historically graduate primary care physicians, as the mission of many osteopathic schools is tailored more towards these specialties. In addition, osteopathic schools often lack direct exposure to otolaryngology through limitations in hospital based clinical rotations and clinical faculty presence. As a result, many DO students choose not to pursue a specialty like otolaryngology. Lastly, osteopathic students may face additional barriers — such as limited access to specialty mentorship, research opportunities, or early clinical exposure — when pursuing a career in otolaryngology. Notwithstanding, otolaryngology is an incredibly rewarding field and there exists a strong knit community of osteopathic otolaryngologists, from the community level to large center academic institutions, that actively contribute to this exciting field. Applying to otolaryngology is a competitive process; however with the right information and excellent preparation, matching is absolutely within reach.

PRECLINICAL YEARS
OSTEOPATHIC VS. ALLOPATHIC: So, what makes a DO different from an MD? The answer is complicated, but to simplify: the largest distinguishing characteristic of an osteopathic physician is the unifying approach and philosophy guiding clinical practice. DO physicians place a strong emphasis on preventative medicine, a holistic approach to care, and patient empowerment towards an optimal state of function and self-healing. This philosophy affords DO physicians a unique perspective regarding medical practice. Healthcare is currently shifting towards a team-based and patient-centered approach, which aligns with existing osteopathic values (Carey, 2003). Outside of the osteopathic philosophy, osteopathic medical education and training is conducted in a very similar fashion to allopathic medical education and training; both require completion of rigorous medical education including preclinical curriculum, clerkship training in core specialties, and successfully completing national board examinations with minimum passing scores. DO students receive additional education in osteopathic principles and practice, including training in hands-on osteopathic manipulative treatment (OMT). OMT is guided by the principle that the body is capable of self regulation and healing, so long as it is able to function within an optimized set of parameters.

BOOK WORK: Not different from your fellow MD counterparts, your preclinical grades are important. Aim to be in the top 20% of your class as data has shown correlation between preclinical grades and board exam performance (Zhong, 2021; Hu, 2016). Many osteopathic programs have a chapter of the Sigma Sigma Phi (SSP) Honor Society, which is somewhat equivalent to the MD version of the Alpha Omega Alpha (AOA) Honor Society. The criteria for induction into SSP varies from school to school, and thus selection committees know it may not be the most reliable indicator. While SSP membership will by no means guarantee residency placement, it shows your dedication to outstanding performance and commitment to the osteopathic profession, resultantly helping you stand out compared to your peers during the application process.

ACE THE BOARDS: Per NRMP data, matched otolaryngology applicants have some of the highest USMLE scores of all matched applicants. DO medical students are required to take the COMLEX board examination, but are not required to take the USMLE board examination. These two exams cover similar topics, but they are slightly different in testing style and content. While both exams are accepted by virtually all otolaryngology programs, it is common for osteopathic students applying to otolaryngology to also take the USMLE. By taking both exams, you demonstrate equivalency of knowledge and allow programs to compare “apples to apples,” (i.e. directly comparing your performance to that of allopathic medical students). Efforts have been taken to increase awareness and acceptance of the COMLEX exam and its scoring system; however, many allopathic otolaryngology residency programs remain partial to the USMLE due to greater familiarity. Thus, taking both exams as a DO student is not necessary but will likely increase your chance of successfully matching, especially if aiming to pursue training at an allopathic program. Notably, the USMLE Step 1 and COMLEX Level 1 board exams are transitioning to a pass/fail grading system as early as January 1, 2022. Regardless of the grading mechanism, you should study hard for these examinations, as this will benefit you in future standardized examinations within clinical rotations and beyond. It is likely that standardized examination grading and reporting will become increasingly complicated in coming years.

EXPOSURE TO OTOLARYNGOLOGY: Otolaryngology is a relatively smaller surgical specialty that, unfortunately, most medical students do not gain ample exposure to until their clinical years, if ever. For this reason, it is important to consider reaching out to your home institution’s otolaryngology program early on in order to access clinical and research opportunities near the beginning of your training. If you do not have an otolaryngology department at your institution, consider reaching out to a private practice otolaryngologist in the community. Most are more than willing to have an enthusiastic medical student work with them. Alternatively, you could reach out to an institution with an otolaryngology department in your region and ask the program coordinator if they allow medical students to shadow faculty members and/or residents within the department. This is a good opportunity to begin networking. If shadowing is not possible, you may be able to participate in virtual didactics or online lectures as well. Finally, consider checking out the “No Home Program?” page for more information.

MENTORSHIP: It is advised to establish a relationship with an ENT mentor as soon as you spark interest in the field. Having an ENT mentor whom you trust will ensure that you have more opportunities for clinical exposure, research experiences, and overall knowledge of the field. Ideally, this should happen as early on in medical school as feasible. Guidance from experienced mentors is key to being successful in the Match; however finding the right mentors can be challenging. This may be further complicated if there are no otolaryngologists at your home institution, no upperclassmen pursuing otolaryngology, or no alumni who recently matched. If you are fortunate to have a home otolaryngology program, start with upperclassmen and residents. The knowledge you can gain from them is invaluable. They may offer suggestions, tips to avoid “mistakes,” other connections, or even research opportunities. If there are no upperclassmen available at your institution, OtoMatch.com, in partnership with Headmirror, allows matched medical students to list their contact information should they be willing to provide assistance to interested parties. You can also reach out to recent alumni who successfully matched for further guidance. To find mentors outside of your institution or community, you'll need to be creative and tactful. Do not be afraid to reach out to programs in search of a mentor, you will be pleasantly surprised how willing otolaryngologists can be to mentor you. The American Academy of Otolaryngology-Head and Neck Surgery (AAOHNS) has developed a mENTor-mentee program; take full advantage of it. The American Osteopathic Colleges of Ophthalmology and Otolaryngology-Head and Neck Surgery (AOCOOHNS) is another wonderful resource. Another resource is the National Otolaryngology Interest Group of Headmirror (NOIG), which is a student-led interest group that aims to connect its members with mentors in otolaryngology. This should serve as a major resource for students and especially those facing barriers. Prior to meeting with a possible mentor, be sufficiently prepared to discuss the motivation for your interest, appropriately demonstrate that interest, and be well read on your mentor’s involvement in the field. The otolaryngology community is fairly small, and the osteopathic otolaryngology community even more-so.

RESEARCH: Given the decision to report the USMLE Step 1/COMLEX Level 1 scores as pass/fail instead of a traditional 3-digit score, research productivity may become a more prioritized metric for academic potential when residencies are evaluating applicants. In 2020, the mean number of abstracts, presentations, and publications of U.S. MD Seniors in otolaryngology reached 13.7 and 9.5 for matched and unmatched applicants, respectively. A 2021 study analyzing publication trends of otolaryngology graduates found that research publication output before residency correlated with fellowship training or the pursuit of a career in academic medicine (Johnson, 2021). In short, research is becoming increasingly important for those applying to otolaryngology, and especially for those pursuing academic otolaryngology. Because research projects can take a long period of time to complete, jump on any opportunity as early as possible. We encourage the interested reader to review two related Headmirror sections, Research Year, and Research, and also the accompanying podcast, Research and Publications: Why and How, for general tips regarding getting started in research. DO medical students interested in participating in research that do not have access to projects at their home institution can consider reaching out to other programs through the mentor opportunities listed above.

CLINICAL YEARS
CLINICAL GRADES AND BOARD EXAMS: It goes without saying you should do your very best on your clinical rotations. “Honoring” as many clinical rotations and especially general surgery, internal medicine, and any ENT elective are important for a strong application. As far as your second set of board exams, make sure you ace them (again)! As an osteopathic student, you must decide if you should take both USMLE Step 2/COMLEX Level 2 early enough for it to be considered as part of your application. There are pros and cons to this; taking them early and doing well will allow you to supplement your residency application with another appealing score. However, if you take them early and do not score well, you may decrease the strength of your application. If you decide to take the exams early, you should put effort into increasing your score by a substantial margin. An unofficial “holding par” goal is twelve points higher than your Step 1, when comparing cumulative averages of the two exams. If you can excel beyond this score, it can strengthen your application tremendously. If you do not take it early enough for it to be considered, opportunities may be missed. For those students who do not perform well on the USMLE Step 1/COMLEX Level 1 exams; taking the USMLE Step 2/COMLEX Level 2 exams early enough for consideration and scoring substantially higher can show perseverance and determination through identification of weaknesses in test taking and working to improve on them. With the transition to pass/fail scoring for USMLE Step 1/COMLEX Level 1, USMLE Step 2/COMLEX Level 2 scores may become increasingly more important in the future.

SINGLE ACCREDITATION SYSTEM: Previously, two residency accreditation systems existed — The American Osteopathic Association (AOA) and the Accreditation Council for Graduate Medical Education (ACGME). Formerly, DO students could apply to both AOA and ACGME residencies through two separate matches that occurred at different times of the academic year. Whereas allopathic medical students could only apply to ACGME residency programs. In 2014, the ACGME, the AOA, and the American Association of Colleges of Osteopathic Medicine (AACOM) agreed to move forward with a single system for accrediting residency programs. This merger took place on July 1, 2020. While the unification of graduate medical education has many benefits, it has added some additional stressors for DO medical students interested in pursuing competitive medical specialties such as otolaryngology. The ACGME merger contributed to several AOA program closures. It further removed the safety net of ‘protected’ DO residency positions, as MD students can now apply to several former AOA residencies. Overall, DO match rates in otolaryngology were poor prior to ACGME unification and continue to remain low. This situation potentially threatens the future of osteopathic physicians in otolaryngology (Craig, 2021). In an attempt to preserve the osteopathic philosophy and culture in the single accreditation era, programs may apply for Osteopathic Recognition. The designation of Osteopathic Recognition allows programs to teach and instill osteopathic principles at the graduate medical education level and even require training in osteopathic manipulative treatment in order to match.

AWAY ROTATIONS: Preparation for your away rotations will be key. Showing up to a surgical away rotation and not knowing how to close skin, or worse, not knowing basic head and neck anatomy will quickly diminish your competitiveness as an applicant. Take time to study anatomy, operative skills, etc. beforehand and make an effort to rotate with an otolaryngologist prior to your away rotations in order to gain exposure to common disease pathologies and presentations. Headmirror has excellent resources to help prepare you, including a video surgical atlas and podcasts, among others. With all the hard work you have poured into having the opportunity to audition, do not forget to validate why you’re the right candidate for their residency program. Demonstrate the 3 “A’s” of medicine: Available, Affable, and Able. Show up early and stay late. Offer to take call and round on hospital patients with the resident on call. Be personable, polite, and kind. How you fit in with the program and how the program fits you is what away rotations are all about. After all, the faculty and residents will have to work closely with you for the next 5 years and vice versa, making away rotations an important factor traditional DO programs use to rank their applicants.

Now, on to away rotations. Though not a hard and fast rule, most DO medical students conventionally do an away rotation with programs that were historically DO, with none to a few historically MD programs mixed in. This is likely due to the fact that a large number of historically DO programs tend to interview students who come and rotate with them. Another consideration is that a large portion of historically DO programs only offer two week rotation blocks, versus a more traditional four week block rotation available elsewhere. This often makes planning complicated when participating in multiple away rotations. Oftentimes, these block systems do not align with your institution's block system, which further complicates the issue. Programs are predominantly understanding and will be reasonably accommodating, but expect some headache with this process. Make sure you start early when scheduling and apply judiciously. Other helpful content regarding sub-internship preparation can be found in Headmirror’s Years 3 and 4 section.

LETTERS OF RECOMMENDATIONS: Should you get LORs from both DO and MD physicians? Why not! The recommendations from a DO are just as credible as a recommendation from an MD physician, and vice versa. The guidelines of LORs are mostly the same. Choose people who can write strong LORs and who are well known in the otolaryngology community. Otolaryngology, as we have mentioned before, is a small and tight-knit field. Obtaining meaningful LORs from recognizable names, such as program directors or chairmen and chairwomen, can open doors when it comes to interview season. Strive for quality over quantity. You will want your letter writers to have spent a considerable amount of time with you and know your character — this is how you will obtain an earnest and individualized LOR.

INTERVIEWS: Shine your shoes, it's interview time! All of your hard work for the past few years have led up to this point. Know your application inside and out, be prepared to discuss your research in depth or even your hobbies and have SPECIFIC answers for the questions: “why otolaryngology”, “why this program / city”, “what are our programs strengths / weaknesses from your point of view”, “why did you choose to go to an osteopathic medical school”, etc. Always maintain a positive viewpoint, never talk disparagingly about other programs, and be your enthusiastic self. Additional helpful tips regarding the interview process can be found on Headmirror’s The Interview section.

IN CLOSING: While this process is often somewhat stressful and the uncertainty of the future is disconcerting, try to enjoy the journey. If you do not match your first round, Headmirror has a dedicated section on how to navigate the several choices you still have if you go unmatched. The work ethic and perseverance required for top tier academic success, multiple research projects, and traveling across the country for various away rotations should not be underestimated. Given the many obstacles the average DO medical student faces while applying for a competitive specialty like otolaryngology, they often come out the other side stronger. We hope this guide serves you well in your quest to become an osteopathic otolaryngologist. Best of luck!

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