DR NICK SCHNITZLER’s survey confirms a gap in otological examination skills among junior doctors in Australia and identifies a strong desire for more structured ENT training.
By Dr Nick Schnitzler
Ear-related conditions are a common presentation in primary care and emergency settings, ranging from benign wax impaction to potentially serious infections. Accurate ear examination, particularly otoscopy, is an essential skill for junior doctors, enabling appropriate diagnosis and treatment of common ear pathologies. Misdiagnosis or missed diagnosis can lead to unnecessary use of antibiotics or delayed treatment, contributing not only to individual harm but also to the broader issue of antimicrobial resistance.
Our study aimed to evaluate the competency of junior doctors in basic otological examination and to understand the extent of Ear, Nose, and Throat (ENT) exposure received during their medical school and post-graduate training.
We assessed the ability to perform otoscopy, identify ear pathology, interpret tuning fork tests, and analyse audiograms. The survey-based, cross-sectional study also sought to explore the correlation between exposure to ENT training and confidence in clinical ear examination.
Study design and objectives
Participants in the study included recent medical graduates working in public hospitals in New South Wales and the Australian Capital Territory. The survey focused on several key competencies: knowledge of ear anatomy, recognition of common pathologies seen on otoscopy, as well as interpretation of tuning fork tests and basic audiogram analysis.
The primary aim was to assess the current state of ear examination skills among junior doctors. The secondary aim was to identify whether there was any relationship between perceived or demonstrated confidence and the level of ENT exposure during undergraduate and post-graduate training.
Key findings
We received responses from 83 junior doctors. The findings highlighted several areas regarding clinical competence in otology:
• Only 50% of respondents were able to correctly identify pathology from otoscopic images.
• Just 10% could correctly identify anatomical landmarks of the ear.
• Those who had undertaken an ENT rotation during pre-vocational training were three times more likely to correctly identify pathology compared to those with no ENT exposure beyond medical school.
• 74% of respondents had less than one week of ENT experience during medical school.
• Almost all respondents agreed or strongly agreed that more ENT exposure was needed during their undergraduate education.
• Only 50% could correctly interpret tuning fork tests.
• Less than 30% were able to correctly identify all forms of hearing loss on an audiogram.
Implications and discussion
These findings underscore a significant gap in training and clinical exposure to ENT-related skills during both undergraduate medical education and early postgraduate years. Given that ear complaints are frequently encountered in general practice and emergency departments, this gap has the potential to impact patient outcomes through misdiagnosis, delayed treatment, or over-prescription of antibiotics.
A lack of confidence in interpreting audiological data such as tuning fork tests and audiograms may also result in missed referrals for patients requiring specialist hearing assessments or further investigation.
Potential solutions
Given the logistical and resource constraints within medical education, a full ENT rotation for every student is not always feasible. Many hospitals, particularly in rural and regional areas, do not have dedicated ENT departments. As such, alternative educational strategies must be explored and implemented.
One solution is to embed structured ENT teaching in the medical curriculum, with a focus on core otological skills. This could take the form of interactive workshops, online modules, and anatomy tutorials that emphasise visual pattern recognition for otoscopic findings.
Including simulation-based learning and virtual reality training tools may also bridge the gap by allowing students to practise otoscopy in a controlled, repeatable, and scalable way.
For junior doctors, ENT education can be incorporated into pre-vocational training, regardless of whether they are based in a hospital with an ENT department. Virtual or remote teaching sessions, run by ENT specialists or registrars, could ensure consistent access to otology teaching. These could cover common presentations, red flags for urgent referral, and practical diagnostic techniques.
Additionally, the development of standardised teaching resources, potentially shared across universities and training hospitals, could support a uniform baseline of competency in ear examination.
Our study confirms a substantial gap in otological examination skills among junior doctors in Australia and identifies a strong desire for more structured ENT training. Addressing this shortfall is crucial to ensuring early career clinicians are confident and competent in managing common ear-related presentations.
ABOUT THE AUTHOR: Dr Nick Schnitzler is an unaccredited ENT registrar working in NSW.
The study was published in the Australian Journal of Otolaryngology online on 29 October 2024.
