Looking back, there is no real surprise that I chose general practice when considering which path to take after completing my undergraduate degree. I was by nature an inquisitive soul and had a fondness for exploring a multitude of topics across both science and the humanities. Rather than being limited to topics raised by my burgeoning understanding of medicine, I delved into whatever strayed across my path.
One area that stimulated my interest on a recurring basis was the evolving taxonomy for naming of the rapidly expanding number of specialty pathways then on offer when I was a junior house officer. Unlike other areas of the natural sciences, medical specialties and subspecialties were increasingly being defined across four separate archetypes rather than branching in the usual tree-like fashion. These archetypes were the three binaries of surgical versus internal medicine, diagnostic versus therapeutic, and organ versus technique-based, plus those based on the age range of patients. And of course, general practice did not really fit neatly anywhere in this system as the scope of practice, by its very nature, transcended these boundaries.
One of the most intriguingly named organ-based specialties is otorhinolaryngology or ear, nose and throat (ENT). This discipline began around 100 years ago when the otologist surgeons and the laryngologist physicians joined forces to create a new speciality.1 The otologist’s proud traditions included Eustachian tube catheterisation (1724), myringotomy (1724) and mastoidectomy (1774), while laryngology started with Benjamin Babington at Guy’s Hospital, London, with his mirrored instrument to view the vocal chords (1829).1 Perhaps it was the unlikely union of physicians and surgeons that ensured each continue to be represented in the speciality’s name. Interestingly, the specialty evolved over time to embrace the surgical stream and left the bulk of the internal medicine aspect to others, predominantly general practitioners (GPs), allergists and paediatricians.
My personal learning about ENT as both a student and trainee doctor always seemed to be relegated to a ‘special time’, as though the unique technical skills required were outside the realm of day-to-day clinical work. Back then, before the advent of halogen lights and fibre-optic scopes, special technical expertise was certainly required to visualise the larynx and, to a lesser extent, the eardrum. Interestingly, visualisation of the chords, by and large, appears to have remained an ENT-specialised skill.
All this seems somewhat surprising as ENT problems in the broadest sense (ie including upper respiratory tract infections) are incredibly common. Perhaps that alone has ‘crowded out’ from our education programs the less common and often more serious and sinister causes that are the core of modern ENT specialist practice. Yet ENT symptoms can be potentially ambiguous, leaving the GP with the challenge of selecting the few that require more intensive assessment from the vast majority that do not need referral. At times it may appear that the complexity of management, especially of chronicity, is proportionate to the prevalence of the condition. For ears, Phan, McKenzie, Huang, Whitfield and Chang2 discuss hearing loss in the elderly, while Kirkby-Strachan and Que-Hee3 provide an update on implantable hearing devices. Around the nose, Morcom, Phillips, Pastuszek and Timperley4 discuss sinusitis, and down in the throat Cooper and Quested5 consider the hoarse voice. We are also fortunate and proud to publish yet another important paper from the renowned BEACH team. This month, Henderson and her team shine their light on the rate of antibiotic prescribing for paediatric ear infections.6
The upper respiratory tract remains the anatomical region for the most common ailments leading to patients presenting to their GP. Despite our ever-present familiarity with this subject matter, new developments continue to make ENT an exciting and rewarding area of clinical practice.
Stephen A Margolis MBBS, MFM, MD, GEM, DRANZCOG, FRACGP, FACRRM, is the Senior Medical Editor of AFP; Professor, School of Medicine, Griffith University, Queensland; and Medical Officer with the Royal Flying Doctor Service.