INTRODUCTION
Unarguably, ear , nose, and throat (ENT) courses offered during medical school are underutilized at the current stage of undergraduate medical education .[ 1 ] Despite this lack in course offerings, a surprising 25% of adults and 50% of pediatric patients attending primary care clinics have ENT complaints, most commonly hearing loss, vertigo, tinnitus, sore throat, nasal obstruction, and hoarseness.[ 2 ] Therefore, it is crucial for all graduating medical students , regardless of their intended specialty, to recognize and manage basic ENT disorders and assess the need for referral to a specialist.[ 3 , 4 ] Especially for students aiming to pursue a career in primary care, this education is important as they reported the lower levels of confidence when dealing with common ENT complaints.[ 4 , 5 ] Previous literature showed that the prevalence of otolaryngologic presentations in general practice does not match the extent of teaching and exposure in undergraduate medical education . Considering that the course duration does not exceed 3 weeks in many medical schools, the lack of knowledge is reflected by students’ diagnostic abilities and management skills.[ 5 ]
As stated, all graduating physicians will be dealing with patients with ENT cases regardless of their specialties. Therefore, medical schools’ curriculum developers should be obligated to enrich students with basic ENT knowledge , describe the variety and the complexity of the field, and when to refer in case of problems surpassing the knowledge of physicians of different specialties.[ 6 ]
To the best of our knowledge at the time of writing this manuscript, this the first multi-institutional study in Saudi Arabia that aims to assess medical students ’ basic ENT knowledge on a national level to estimate their competency in approaching and managing common ENT cases regardless of their intended specialty in future. This includes comparing Saudi medical students to the level of competency of undergraduate medical students in the United States.
METHODS
A quantitative, cross-sectional study was conducted in June 2020, and it included 1,124 medical students from the third year until internship from all public universities in Riyadh City, Saudi Arabia. The universities included are Imam Muhammad Ibn Saud Islamic University (a total of approximately 1,082 medical students , both male and female), King Saud University (2,345 medical students ), Princess Nourah Bint Abdulrahman University (630 female medical students only), and King Saud bin Abdulaziz University for Health Sciences– Riyadh (1,886 medical students from both genders). Sample size estimation was calculated through Raosoft online software, suggesting a sample size of 361 students using 5% margin of error and a 95% confidence interval. Data were collected through an online questionnaire using the help of trained data collectors at each university. Institutional Review Board (IRB) approval has been obtained from the IRB committee at Imam Muhammad Ibn Saud Islamic University. Written informed consent was obtained. The identity of the participants has been kept anonymous and confidential.
A validated questionnaire from a similar previously published study was used after obtaining permission from the authors to measure the medical students ’ basic ENT knowledge .[ 7 ] The questionnaire consisted of two parts: The first part measured the demographic data of participants (gender, university, academic level, intended specialty, the level at which head and neck examination was taught and how comfortable participants are in conducting it, the level of comfort diagnosing and identifying conditions related to head and neck, and how much time was spent and the setting of ENT services).
The second part includes nine ENT cases that test the following topics: Identify mastoiditis, initial management of hematoma, identify peritonsillar abscess, management of epistaxis, initial management of sudden unilateral deafness, identification and function of the obturator, management of benign paroxysmal positional vertigo, initial treatment of allergic rhinitis, and treatment of laryngopharyngeal reflux.
Intended specialties were grouped into primary care, according to the Association of American Medical Colleges’ definition, which includes internal medicine (categorical), family medicine, pediatrics, and internal medicine-pediatrics (combined). Surgical specialties were grouped according to the American College of Surgeons and include general surgery, thoracic surgery-integrated, obstetrics and gynecology, neurological surgery, ophthalmology, orthopedic surgery, otolaryngology, plastic surgery (integrated), urology, and vascular surgery (integrated). Analyses were also conducted with otolaryngology specialties, grouped separately from surgical specialties. The remaining specialties were separated into the “other” category for our purposes. Knowledge of competently managing basic ENT cases was calculated by the average percentage of attempted questions to those answered correctly.
Statistical analysis was performed using R v 3.6.2. Counts, and percentages were used to summarize the categorical variables. For checkbox questions (e.g. setting of time on ENT service), the percentage for each choice was calculated from the total number of respondents. The knowledge score was summarized using mean ± standard deviation. The Chi-square test of independence was used to assess the association between the categorical variables. Spearman’s correlation was used to assess the association between knowledge score and comfort with diagnosing conditions related to the head and neck, as well as comfort with performing a head and neck examination. One-way ANOVA was used to assess the association between knowledge scores with the categorical variables. Post hoc pairwise comparisons were performed using unpaired t -tests with correction for false discovery rates. Kruskal − Wallis’s test was used to assess the association between the categorical variables and confidence in diagnosing and managing ENT conditions, recording comfort levels on a scale from 1 to 5, with a higher number indicating a higher level of confidence. Mann–Whitney’s test was used for post hoc pairwise comparisons. Hypothesis testing was performed at a 5% level of significance.
RESULTS
The study sample included 1,124 medical students (63.1% female and 36.9% male). More than half of the included students did not spend any time on an ENT service in office as part of clinical education (58.5%), while the remaining 466 spent varying times doing so, ranging from 1 to 2 days (3.83%) to 3–4 weeks (12.3%). The majority of students were taught head and neck examinations. Regarding the setting, 439 medical students (94.2%) completed ENT rotations, and 312 students (67%) spent time in the outpatient office. Primary care was the most common specialty (44.8%), followed by the surgical specialty (40.2%) [Tables 1 and 2 ].
Table 1: Demographic and practice-related characteristics of the study sample
Table 2: Distribution of respondents by academic year in medical school and intended specialty
Results showed varying levels of confidence in performing activities related to head and neck. Only 6.9% and 24.8% of the medical students were very comfortable or comfortable with performing head and neck examinations [Figure1 ]. Regarding comfort in diagnosing and recognizing conditions related to head and neck, only 3.6% and 18.9% were very comfortable or comfortable, respectively [Tables 3 and 4 ].
Figure 1: Comfort in performing activities related to head and neck
Table 3: Comfort in performing activities related to head and neck
Table 4: Clinical setting of ear , nose and throat exposure of respondents
Results showed that the percentages of correct answers did not exceed 60% for any of the questions. The question related to identifying mastoiditis was answered correctly by 57.6% of the medical students . Questions related to the initial management of hematoma and identifying peritonsillar abscess were correctly answered by 26.2% and 28.4% of the medical students , respectively. The percentages of correct answers did not exceed 25% for any of the remaining questions. The average percentage of correct answers was 22% ±20% [Figure 2 ].
Figure 2: Rate of correct answers for the proposed clinical scenarios
Results showed a statistically significant positive association between knowledge score and comfort with diagnosing or recognizing conditions related to head and neck (r = 0.18, P < 0.001). Similarly, there was a statistically significant positive association between knowledge score and confidence with performing a head and neck examination (r = 0.161, P < 0.001) [Table 5 ].
Table 5: Correlation between knowledge score and comfort in diagnosing and managing ear , nose and throat case
One-way ANOVA showed that there was a statistically significant difference in the average knowledge score across medical years. Post hoc pairwise comparisons showed that the average knowledge score was higher with medical interns compared to all other medical students (P < 0.05). The average knowledge score was higher in fifth-year medical students compared to third-year medical students (P < 0.05) and fourth-year medical students (P < 0.05). Also, the knowledge score was higher in fourth-year medical students compared to third-year students. Kruskal-Wallis’s test showed a statistically significant difference in the mean rank for comfort in diagnosing or recognizing conditions related to the head and neck (P < 0.001). A statistically significant difference was also observed in the mean rank for comfort with performing a head and neck examination (P < 0.001). Post hoc pairwise comparisons showed that the mean rank for comfort in diagnosing and recognizing conditions related to head and neck was higher in third-year and fifth-year students compared to fourth-year students. The mean rank was higher in medical interns compared to all remaining medical students . Regarding comfort with performing head and neck examinations, the mean rank was not significantly different between third-year and fourth-year students (P > 0.05). However, it was significantly higher in fifth-year students and medical interns (P < 0.05). The mean rank was higher in medical interns compared to the remaining three academic levels (P < 0.05) [Table 6 ].
Table 6: Association between medical year, knowledge , and comfort in performing ear , nose and throat related activities
Results showed that the average knowledge score was significantly higher in students that were taught head and neck examinations, compared to those who were not (P < 0.001). There was a statistically significant difference in the mean rank for comfort with diagnosing or recognizing conditions related to head and neck (P < 0.05). Similarly, there was a statistically significant association between head and neck education and comfort with performing examinations (P < 0.001). These results support a positive association between head and neck education and knowledge regarding ENT, as well as comfort in performing ENT activities [Table 7 ].
Table 7: Association between HN education, knowledge , and comfort in performing ear , nose and throat related activities
Linear regression analysis showed that the average knowledge score was significantly different in males compared to females (B = −3.73, P < 0.001), which indicates that the average knowledge score is lower by 3.73% in males compared to females. Higher academic levels were associated with higher knowledge regarding ENT. The average knowledge score increased consistently with the increase in the academic level, with medical interns showing the highest difference in knowledge score compared to third-year students (B = 18.05, P < 0.001). Similarly, time spent on ENT services was significantly associated with better knowledge regarding ENT. The higher knowledge difference was observed in medical students who spent 3–4 weeks in ENT service compared to those who never spent any time (B = 13.31, P < 0.001). The average knowledge score was higher by 4.91% in medical students who were taught head and neck examinations compared to those who were not (B = 4.91, P < 0.001) [Table 8 ].
Table 8: Linear regression analysis for factors associated with knowledge regarding ear , nose and throat
Results showed a statistically significant difference in the average knowledge score between various intended specialties (P < 0.001). The average comfort level with performing head and neck examinations was significantly higher in participants who were interested in the ENT specialty, compared to those interested in all other specialties. The average comfort with diagnosing and recognizing head and neck conditions was also significantly higher in participants who were interested in the ENT specialty, compared to those interested in all other specialties [Table 9 ].
Table 9: Association between intended specialty, knowledge , and comfort in performing ear , nose and throat related activities
DISCUSSION
Undergraduate otolaryngology-head and neck surgery curriculum should be designed to provide medical students with the required knowledge and clinical skills to deal with basic ENT problems in real clinical practice.[ 8 ] In this study, the majority of the students were not able to answer the questions correctly. Students who achieved higher scores are more comfortable in handling Otorhinolaryngology cases, as well as performing head and neck exams. Also, students who had longer courses were more knowledgeable than those who attended shorter ENT courses, which is almost the same when compared to the American medical students .[ 7 ]
Time allocated to ENT rotation also plays a significant role in students’ knowledge and comfort level in conducting an ENT examination. More time spent correlated positively with knowledge and skill, and this finding was also supported by another national study.[ 9 ]
Medical students who intend to enter the ENT specialty achieved a higher score, comfort level, and competency in managing ENT clinical problems than others, which is remarkably similar when compared with American students.[ 7 ] There was no significant difference in this study in the knowledge , comfort level, or competency between students aiming to choose other specialties, such as primary care, surgical specialties, etc. This finding from Saudi medical students mirrored that of American medical students .[ 7 ] Furthermore, in contrast, previous studies showed that students who aim to pursue primary care specialties had subpar ENT knowledge .[ 5 , 6 ] Innovative approaches have been shown to improve otolaryngologic knowledge , such as E-learning, which is beneficial in enriching and grounding basic otolaryngologic knowledge .[ 6 ]
Gender can play a role in the performance level; in our study, female students scored higher than their male counterparts. The female undergraduate students’ performance was found to be better than male undergraduates. Saudi female students demonstrated superior academic performance compared to male students in preclinical courses at medical colleges.[ 10 ]
Among the subjects tested, students were able to identify mastoiditis correctly when compared to the other common conditions. Of the students tested, 25% identified the peritonsillar abscess picture as an enlarged lingual tonsil, but when asked about the management of epistaxis, more than 50% suggested observation as a management option. Regarding the distribution of the students’ answers about most of the questions, the majority chose the “I don’t know” option rather than guessing an alternative answer; this contrasts American medical students who tend to guess answers rather than choosing the “I don’t know” option.[ 7 ] This attitude can be looked at in a positive way, considering learning is a lifelong process and knowing the fact that the lack of certain information will drive the person to pursue that knowledge . This is further highlighted in our study, showing that medical interns and fifth-year medical students had higher knowledge scores than third-year and fourth-year medical students .
Both Saudi medical students and American students showed a deficiency regarding treating laryngeal reflux (89.9% of Saudi students answered incorrectly) and the initial treatment of allergic rhinitis (86.9% of Saudi students answered incorrectly). However, American students were superior in regard to identifying the use of the obturator compared to Saudi students, with 93.4% of Saudi medical students failing to identify the use of the instrument.[ 7 ]
Our study also showed that most students who participated faced some discomfort in assessing the ENT cases. This can be attributed to the fact that the teaching of ENT history and how to perform a comprehensive general physical examination was not given adequate time early in the medical curriculum . This shortcoming might be solved by introducing specialized head and neck examination sessions that have been shown to improve clinical head and neck examination skills.[ 6 , 11 , 12 ] An alarming finding from this study showed that 29.9% of participants were not taught the head and neck examination; this is extremely worrisome due to the high volume of ENT cases that are prevalent in primary health care clinics.[ 3 , 4 ] Also, this study showed that a higher knowledge score was associated with students who were taught the head and neck exam, further stressing the importance of head and neck examination teachings.
From the results of this national study of undergraduate otolaryngology teaching, it would appear that medical students often receive very little focused clinical training in otolaryngology, and it is very apparent that there is enormous variability in the experience of otolaryngology that is offered to medical students .
The fact that the bulk of ENT cases is quite high among patients visiting primary health care centers indicates that there is a need to assign more lengthy ENT courses in either the undergraduate curriculum or the postgraduate residency training program for primary health care to overcome this current deficiency in the undergraduate curriculum .
CONCLUSION AND RECOMMENDATIONS
This study demonstrated that participants who spent more time in an otolaryngology service had better knowledge scores than those with less time, which indicates the need for a longer, more focused, better-structured otolaryngology curriculum for medical graduates to be more efficient in handling ENT cases.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
Acknowledgments
We would like to thank Abdulaziz Saeed Alshahrani, Abdulaziz Sami Aljasser, Khalid Abdullah Aleisa, Rakan Jahaz Almetary, and Waleed Suliman Alanazi for their valuable contributions as data collectors.
REFERENCES
1. Sataloff RT. Consistency of medical student education in otolaryngology.
Ear Nose Throat J 2009;88:714.
2. Hu A, Sardesai MG, Meyer TK. A need for otolaryngology education among primary care providers. Med Educ Online 2012;17:17350.
3. Lennon P, O'Donovan JP, O'Donoghue S, Fenton JE. The otolaryngology, head and neck training appraisal questionnaire:A national general practice perspective. Ir J Med Sci 2013;182:609–14.
4. Naples JG, Canfarotta M, Tabtabai R, Sparks D, Parham K, Falcone T. Otolaryngology interest groups:A potential solution to the residency match crisis. Laryngoscope Investig Otolaryngol 2019;4:24–9.
5. Doshi J, Carrie S. A survey of
undergraduate otolaryngology experience at Newcastle University Medical School. J Laryngol Otol 2006;120:770–3.
6. Fung K. Otolaryngology –Head and neck surgery in
undergraduate medical education :Advances and innovations. Laryngoscope 2015;125 Suppl 2 S1–14.
7. Pasick LJ, Benito D, Zapanta P, Sataloff RT. Assessing medical student basic otolaryngology
knowledge :A multi-institutional study.
Ear Nose Throat J 2019;98:44–9.
8. Error ME, Wilson KF, Ward PD, Gale DC, Meier JD. Assessment of otolaryngic
knowledge in primary care residents. Otolaryngol Head Neck Surg 2013;148:420–4.
9. Alroqi A, Alkurdi A, Almazrou K. The attitude of
medical students toward otolaryngology, head and neck surgery. Saudi J Otorhinolaryngol Head Neck Surg 2012;14:76.
10. Al-Mulhim A, Elsharawy M, Awad N. The influence of gender on Saudi students performance in the
undergraduate surgical examination. Surg Sci 2012;3:206–9.
11. Kuan EC, Badran KW, Passy V, Armstrong WB.
Medical students 'comfort levels with performing the basic head and neck examination in practice:Follow-up during the core clerkship year. J Surg Educ 2015;72:117–21.
12. Wu EC, Passy V, Armstrong WB. Preliminary evaluation of junior
medical students 'exposure and comfort with performing the basic head and neck examination. Laryngoscope 2011;121:1431–5.
