Objectives: To determine the factors affecting the residents’ fellowship choice in the Saudi Program of Otorhinolaryngology and Head and Neck Surgery. Design: Cross-sectional survey-based studyPlace and Duration: Six hospitals conducting Saudi residency program of Otorhinolaryngology and Head and Neck Surgery in the Riyadh region from January 2014 to October 2014.Subjects and Methods: All 41 residents completed a questionnaire of 50 close- ended questions. Results: Of the 41 residents, a majority (78%) was males and 56% married. Most had taken Rhinology, Otology, Pediatric ENT and Head and Neck rotations. Rotations had 2.4% – 17.1% positive influence of fellowship selection. Influence of mentors was more pronounced in Rhinology (41.5%), Otology (14.5) and Pediatric ENT (17.1%). Future job prospects were more frequently a reason for joining or continuing in Rhinology (29.3%), Facial Plastic Surgery (26.9%) and Otology (21.9%). Financial consideration positively inclined most of the residents towards Rhinology (24.4%) and Pediatric ENT (17.1%). Data were analyzed with the help of SPSS version 20.Conclusions: The study concludes that the influence of mentors, financial reasons, and future job availability are major factors affecting the selection of ENT fellowship among residents of Saudi Program for this medical specialty. Rhinology is most favorite fellowship among the residents of Saudi Program for ENT specialty. Keywords: Otorhinolaryngology; fellowship choice; residents; Saudi Arabia.Introduction:The trends of sub-specialty expansions have made the choice of a medical graduate’s field of specialization a very important and rapidly growing concern 1. Ill-planned sub-specialty selection may results in oversaturation in some of the specialties, a lack of skilled staff in another specialty and an overall misbalance for community needs in addition to decreased financial and work satisfaction for the residents, the future consultants. Assessing how resident doctors choose their areas of specialization is essential to achieve a balanced distribution of doctors among all specialties and is important for educators and policy makers to plan the supply of specialists.2 As the medical students learn clinical skills, acquire exposure to different specialties, recollect their personal ambitions and weigh them against the requirements of various fields and regularly interact with their fraternity: consultants, residents, patients and fellow medical students, they get more avid and driven towards their profession, with a lot more vigor and ambition to excel 3,4 . According to literature, the most important factors influencing the career choice of medical doctors include financial gains, reputation in public, hospital-based private practice and better patient outcome 5experiences during specialty rotations, inspiration by mentors, working hours and flexibility of job and lifestyle factors6,7. Personal likings and career opportunities in nearest possible places also play some role in specialty choice3. Moreover, a recommendation from within the family and friends or advice by practicing specialists may also influence students in deciding their future specialty8.Subspecialty choice for the residents of a medical specialty is a daunting task and a challenging decision and otolaryngology (ENT) is not an exception. This decision is usually influenced by several factors with a variable significance of each as sketched briefly above. Determining the factors influencing ENT residents’ decisions of fellowship choice in Kingdom of Saudi Arabia is the first attempt of its nature and it will also depict whether these factors are modifiable to some extent. The results of the current study may help in attracting the brightest trainees to most suitable specialties in need, thus bridging the gap between needs and potential and it will benefit all, the trainees, the institutes and the patients. MethodsIt was a cross-sectional survey-based study carried out on residents of the Saudi Program of Otorhinolaryngology and Head and Neck Surgery in the Riyadh region. It was conducted from January 2014 to October 2014. A total of 41 residents were included in the study after formal approval of the study from Institutional Review Board.Informed consent was obtained from each of the participating residents.The otolaryngology residency in Saudi Arabia follows a program of 5 years. The 1st year or the R1 the residents concentrates mainly on outside specialty rotations: General Surgery 12 weeks, Intensive Care Unit (ICU) 8 weeks, Anesthesia 8 weeks, Plastic Surgery 8 weeks, Neurosurgery 4 weeks, Thoracic Surgery 4 weeks and Emergency Room (ER) 4 weeks. 2nd year to 5th year the residents are allotted to different subspecialty in different hospitals of a region.R2 is for orientation and the residents are trained in General otorhinolaryngology, Otology, Rhinology, Head and Neck Surgery 12 weeks each. R3, R4, and R5 are the main Clinical Rotations years for the residents. During the first 2 years they are trained in Head and Neck Surgery, Otology, Pediatric Otorhinolaryngology, and Rhinology, Facioplastic and Reconstructive surgery 12 weeks each. In the final year, the R5 residents select the rotation for their preferred subspecialty to peruse their career. All the residents from R1 to R5 were given a structured 50 close- ended questionnaire. All the residents participated and none refused. The questionnaire contained columns about their age, gender, level of training, marital status, number of children, their consideration of specialty before joining the Saudi Program of Otorhinolaryngology and Head and Neck Surgery and at the present moment, their rotations in various subspecialties of the program, duration, affiliations and influence of such rotations. They were also asked about the factors which were most relevant to their decisions about fellowship choice and the factors which make the fellowship in an institution more acceptable to them. The last question was whether they liked to choose according to the institution they were employed at or they liked to choose the institution according to their favorite fellowship. All the data was entered and analyzed with the help of SPSS version 20 (IBM Inc., Armonk, NY). Percentage and frequency were calculated for all the variables as all of these were qualitative or rank-scale and none was a pure quantitative variable. Data were presented as tables and graphs. Tests of statistical significance were applied where appropriate.Results:A total of 41 residents participated in this study. Three (7.3%) residents were the first year, 13 (31.7%) each in second and third year, 8 (19.5%) in fourth year and 2 (4.9%) in fifth year of their residency in addition to 2 (4.9%) residents who did not mention their level of residency training. Their demographic profile is shown in Table 1. Table 1. Demographic characteristics of ENT residentsCharacteristic Groups Frequency (%)Age(years) 25-27 4(9.8) 28-30 22(53.7) 30-32 7(17.1) 33 > 6(14.6)Gender Male 32(78) Female 7(17.1) No answer 2(4.9)Marital Status Single 16(39) Married 23(56.1) No answer 2(4.9)Children One 6(14.6) Two 8(19.6) Three 2(4.9) None 7(17.1)Region Central 36(87.8) Eastern 2(4.9) Southern 1(2.4) No answer 2(4.9)Out of 41, 22 (53.7%) considered one or more subspecialties in otolaryngology before starting their residency however currently 25 (61.0%) were considering one or more subspecialties of otolaryngology as their future as shown in Table 2. Table 2. Fellowship choice of ENT residents before and after joining residency programFellowship Before After Change(+,-,%)(+,-,%)Otology 12 (29.3) 16 (39) +, 9.7Rhinology 15 (36.6) 22 (53.7) +, 17.1Pediatric ENT 07 (17.1) 08 (19.6) +, 2.5H N Surgery 08 (19.6) 08(19.6) 0Facial Plastic Surgery 05 (12.2) 06 (14.6) +, 2.4 Laryngology 01 (2.4) 02 (4.9) +, 2.5None 07 (17.1) 02 (4.9) -, 12.2It was found that more than 70% of residents do go for a rotation in each of the Rhinology, Otology, Head and Neck Surgery and Pediatric ENT whereas the trend to take a rotation in Facial Plastic Surgery and Laryngology was less frequent (~40%). Most of the residents took their rotations in multiple centers and their rotations did affect their choice of fellowship selection as shown in Table 3. Table 3. Rotations into various ENT subspecialties by the participating residents PedENTN(%) RhinologyN(%) OtologyN(%) Head NeckN(%) Facial PlasticN(%) LaryngologyN(%) Frequency of rotation 29 (70.7) 35(85.4) 31(75.6) 32(78) 15(36.6) 16(39) Length of rotation 1-2 M 7 (17.1) 5 (12.2) 3 (7.3) 1 (2.4) 9 (22.6) 4 (9.8) 2-4 M 8 (19.5) 16 (39) 12 (29.3) 10 (24) 6(14.6) 10 (24) 4-6 M 11 (26.8) 13(31.7) 13(31.7) 17(41.4) 0 1 (2.4) Other 0 0 0 0 0 1 (2.4) Center for rotation KAAUH 2 (4.9) 1 (2.4) 4 (9.8) 4(9.8) 7 14 KFMC 5(12.2) 1(2.4) KAMC 5 (12.2) 2 (4.9) 2 (4.9) 1(2.4) 2 (4.9) 1 (2.4) PSMMC 6 (14.6) 2 (4.9) 2 (4.9) 1(2.4) 1 (2.4) SFH 7 (17.1) 1 (2.4) KFSHRC 2 (4.9) 3(7.3) 1 (2.4) Multiple 1 (2.4) Effect on decision 20 (48) 28 (68.3) 22 (53.7) 17 (41.4) 10 (24.4) 13 (31.7) Interest 11 (26.4) 23 (56.1) 23 (56.1) 10 (24.4) 10 (24.4) 7 (17.1) Ped = Pediatric, Rhinol = Rhinology, H = Head & Neck, Laryngo = LaryngologyThe reasons of interest for a particular fellowship are shown in Table 4. It indicates that influence of mentors was more pronounced in Rhinology, Otology and Pediatric ENT. Job opportunities were more frequently a reason for interest in Rhinology, Facial Plastic Surgery, and Otology. Financial consideration inclined most of the residents towards Rhinology and Pediatric ENT and so on.According to the residents, institutional support for fellowship (27), availability of fellowship at their institution of employment (23), a balance between workshop and lifestyle (20), backup by senior colleagues (18) and financial advantage (15) were the most powerful influencers for their fellowship choice. Most (38) of them would like to choose an institution according to their favorite fellowship and only 2 (4.9%) would like to choose fellowship according to their institution. Table 4. Factors Influencing Decision to pursue a particular fellowship in ENTFactors Ped ENTN(%) Rhinol N(%) Otology N(%) H N(%) Facial PlasticN(%) LaryngoN(%) Directed by Hospital 8 (19.5) 9 (21.9) 7(17.1) 4(9.8) 2(4.9) 3(7.3) Lifestyle 3 (7.3) 0 0 0 1 (2.4) 1 (2.4) Interest 6 (14.6) 7 (17.1) 6 (14.6) 3(7.3) 3 (7.3) 3 (7.3) Mentors 7 (17.1) 17(41.5) 10 2(4.9) 6(14.6) 4 (9.8) Procedures 3 (7.3) 6 (14.6) 4 (9.8) 2(4.9) 3 (7.3) 1 (2.4) Earning potential 7 (17.1) 10(24.4) 4 (9.8) 5(12.2) 4 (9.8) 1 (2.4) Job Opportunity 3 (7.3) 12(29.3) 9 (21.9) 5 (12.2) 11(26.9) 1 (2.4) Satisfaction 3 (7.3) 7 (17.1) 3 (7.3) 1 (2.4) 4 (9.8) 1 (2.4) Others 0 4 (9.8) 1 (2.4) 1(2.4) 2 (4.9) 4 (9.8) Ped = Pediatric, Rhinol = Rhinology, H = Head & Neck, Laryngo = LaryngologyThe most common reasons for no interest were demanding a lifestyle of Head and Neck Surgery and Pediatric ENT to those who didn’t like these specialties. Financial issues also negatively affected Head and Neck Surgery. The unsatisfying outcome was more common in Head and Neck, Facial Plastic and Pediatric ENT. Too many cases affected mainly Head and Neck Surgery. Opportunities of job didn’t negatively affect most of the residents.Table 5. Reasons of losing interest in a particular fellowship.Factors Ped ENTN(%) Rhinol N(%) Otology N(%) H N(%) Facial PlasticN(%) LaryngoN(%) Demanding lifestyle 21 3 (7.3) 3 (7.3) 26 (63.4) 2 (4.9) 7 (17.1) Financial 3 (7.3) 1 (2.4) 0 9 (21.9) 1 (2.4) 2 (4.9) Unsatisfying outcome 9 (21.9) 6 (14.6) 5 (12.2) 22 (53.7) 13 (31.7) 12 (29.3) Job Opportunities 5 (12.2) 5 (12.2) 3 (7.3) 1 (2.4) 4 (9.8) 1 (2.4) Stressful 8 (19.5) 2 (4.9) 4 (9.8) 19 (46.3) 1 (2.4) 5 (12.2) Others 4 (9.8) 6 (14.6) 8 (19.5) 1 (2.4) 10 (24.4) 7 (17.1) Ped = Pediatric, Rhinol = Rhinology, H = Head & Neck, Laryngo = LaryngologyDiscussionThe fellowship choice made by ENT residents of Saudi Program of Otorhinolaryngology and Head and Neck Surgery and factors influencing these choices are of prime importance to workforce planners especially in times of oversupply or undersupply of medical doctors and future provision of health care to the Saudi population. These choices are thought to be influenced both by the resident’s inclination before entering the residency program as well as exposure to a number of things during training and rotation to different subspecialties. The current study reveals that residents got pronounced positive inclinations toward rhinology and otology; whereas small positive inclination was observed in Pediatric ENT, Facial Plastic, and Laryngology. Head and Neck Surgery was unchanged from the onset of residency until the time of the study were conducted. Those residents who were not considering specialty before joining the program figured out their preference afterward, however, a tiny percentage of residents remained indecisive about their future subspecialty even after joining. It is widely reported in the literature that exposure to the skills and techniques of a particular subspecialty may improve the decision making of residents9,10.Another important thing worth mentioning here is the observation made during a current study that the majority of residents had taken one of the four major subspecialty rotation viz. Rhinology, Pediatric ENT, Head and Neck, and Otology but Facial Plastic Surgery and Laryngology rotations were taken by fewer numbers of the residents. There comes the role of opportunities. As the role of mentorship and support of colleagues may help them make their decision which is a documented fact11,12. It is also reported that with the advent of training in newer subspecialties or disciplines, the resident apprehensions also diminish13.The observations of current study identified that influence of mentors was more pronounced in three subspecialties in descending order viz. Rhinology, Otology and Pediatric ENT. Future job prospects were more frequently a reason for joining or continuing in Rhinology, Facial Plastic Surgery, and Otology. Financial consideration positively inclined most of the residents towards Rhinology and Pediatric ENT. Thus, the current study showed that influence of mentors, job opportunities, and financial reasons were most powerful tools among the ENT residents in making their choices for fellowship. A recent report compared the net present value of general otolaryngology and its subspecialties to measure the impact of financial pursuits in the subspecialty choice of ENT disciplines in USA and found that NPV of general ENT was $4.73 million / year and it was decreased by $ 339 for otology, $288 for laryngology, $191 for head and neck, $176 for pediatric otolaryngology, $ 139 for facial plastic surgery. Whereas the NPV for rhinology was increased by $ 28514. Similarly, the role of mentors in the specialty selection is widely reported15-17. Bennet and Philip have shown that future job prospects have a significant role in specialty selection18. Research so far done has identified several factors that affect career selection such as demographics, academic performance, income social status and personality attributes, duty hour requirement and expected income from practicing the selected specialty19. While a body of literature from around the world including countries such as the United States20, Europe 21, China 2 address factors affecting medical graduate specialty choice, there is little data regarding influences on Saudi medical doctors in general and ENT residents in particular. Our study revealed that inspiration during the clinical rotation in a particular subspecialty, job prospects, and financial considerations were the most influencing factors during subspecialty selection. the current study, the most common reasons for no interest were demanding a lifestyle of Head and Neck Surgery and Pediatric ENT to those who didn’t like these specialties. Financial issues also negatively affected Head and Neck Surgery. The unsatisfying outcome was more common in Head and Neck, Facial Plastic and Pediatric ENT. Too many cases affected mainly Head and Neck Surgery. According to the residents, institutional support for fellowship (27), availability of subspecialty at their institution of employment (23), a balance between work and lifestyle (20), backup by senior colleagues (18) and financial advantage (15) were the most powerful influencers for their subspecialty choice.Most (38) of them would like to choose an institution according to their favorite subspecialty and only 2 (4.9%) would like to choose subspecialty according to their institution. A study conducted in Kuwait has shown that patient outcome has a huge influence on specialty selection22. A study from Pakistan highlighted that better job opportunities, reputation and prestige, financial rating and surgical skills acquisitions also influence the choice of specialty23.This study has several limitations, as it was conducted on residents of only one province, thus it may not reflect the whole country. The study only concentrates on the subspecialties of ENT so its findings may not be generalized to subspecialty selection in other specialty fields of medicine and surgery. Although authors tried their best to include maximum participants a total sample size of 41 is not enough. Moreover, the influencing factors were given in the close-ended questions which might have overlooked some other unidentified factors. Recall bias can be another limitation of this study as it is possible that the participants could not answer the questions correctly regarding the influencing factors that led to the decision of present specialty. Further research is highly recommended which should include a greater number of institutions, longitudinal design and with open-ended questionnaire or interviews which will help recognize the unidentified influencing factors.ConclusionsIn conclusion, our study has shown that influence of mentors, financial reasons and future job availability are major factors affecting the selection of ENT subspecialties among residents of Saudi Program for this medical specialty. Rhinology is most favorite subspecialty among the residents of Saudi Program for ENT specialty.