Area Sylvan Stool

Sylvan Stool (EUA)
IAPO´s president 1995-1997

Reflections

SYLVAN E. STOOL, MD, Denver, Colorado, 1996

I have been asked several times to recount my own experiences in becoming a pediatric otolaryngologic specialist. Like many others, I fell into the field. “Within my medical education, I acquired training that later gave me the expertise required to become a pediatric otolaryngologist. I have watched and participated in the development of pediatric otolaryngology, and I am confident that this field will continue to grow. Moreover, I believe that many of my experiences are similar to the experiences of my colleagues.

After a 2-year rotating internship and residency in general practice, I responded to an advertisement in the Journal of the American Medical Association and went to the Children´s Orthopedic Hospital in Seattle to be a fellow in pediatric surgery. In 1949 the hospital had many difficulties recruiting house staff, primarily because no one knew what the specialty was, even though Herb Coe and his young associate Alexander Bill had established a service and had started a training program. When it was not possible to get further training in surgery, I decided to go into pediatrics, although the skill I had gained through Coe´s training later helped me to become a competent pediatric otolaryngologist.

When Korean War broke out, I served my duty in the Far East and worked for 2 years with Jack Hartman, who previously had been the chief resident from Children´s Medical Center in Boston. After my discharge, he helped me receive an appointment as an unpaid fellow in the outpatient department in Boston. As luck would have it, the otolaryngology resident there came down with hepatitis, and there was no one to replace him because in 1953 otolaryngology was considered a dying field. Charles Janeway, the professor of pediatrics, asked me if I would like to cover the service because I had some surgical experience. This position also allowed me to stay in the house officers´ quarters and eat two meals a day – free. Carlyle Flake and Edward Ferguson had an office in the children´s hospital, where they performed tonsillectomy and adenoidectomy, endoscopy, and dilated esophageal strictures.

The chief of the service was Flake, who had earlier started and audiology department. I worked with Ferguson, who was model for me; he had started his career with William Ladd. Ladd is considered the father of pediatric surgery and has devoted many years to the care of children. I witnessed Ferguson´s efforts at forming a group devoted entirely to pediatric otolaryngology. He participated in many national organizations but received little recognition for his proposed specialty simply because there was little interest. However, he did edit a two-volume book on the subject with Edward Kendig. Although I was offered a position to continue in the sick resident´s place, I could not afford more training.

After leaving Boston, I went to Denver General Hospital and practiced pediatrics in the outpatient department. As I worked, I treated a large number of children with ear problems and started an informal ENT clinic. Realizing that I needed more training, when a new otolaryngologist was appointed at the University Hospital I asked him about training. Victor Hillyard immediately offered me a residency position because he had a conditional approval and no other candidates. I applied for a special fellowship from the National Institutes of Health to develop a career in teaching and research and started as the only otolaryngology resident at the university. This was an exciting time in otolaryngology. We performed many stapes surgeries, and many other procedures were being developed. Because of my pediatric background. I was able to attract many patients from that service.

In 1993 I received an inquiry from the Children´s Hospital of Philadelphia to help establish a rehabilitation center with Mary Ames to serve children with multiple defects. Philadelphia presented a much different atmosphere from that of the West, which was difficult to understand. The Easterners seemed so much more set in their ways and tended to be resistant to changing established medical fields. For instance, only the Jackson-trained bronchoesophagologists did endoscopy. The concept of an age-related specialist in otolaryngology was difficult for the community to accept. This is similar to Koop´s experiences when he started performing pediatric surgery.

Koop related that he had many obstacles to overcome in pediatric surgery. One of these obstacles was the instruments. The idea had not yet caught on that small patients needed smaller instruments. This was especially true in anesthesiology. Koop was forced to invent the equipment he used to anesthetize patients, sometimes the day before surgery. One such night, he stayed up late creating “endotracheal tubes out of red rubber catheters, filing the edges with emery boards to prevent injury to the tracheal mucosa, boi [ing] them over a bent wire, [and] hoping that they would retain some curved memory. “By today´s standards, these techniques might seem crude, but at that time it allowed pediatric surgeons of all specialties to perform surgeries that were not imaginable before because young patients could not properly be anesthetized.

After a few years, the training programs in the city recognized there were opportunities in pediatrics, and their residents requested rotations at the children´s hospital. David Myers, who was chief of the graduate school, suggested that we have a symposium on pediatric otolaryngology. Accordingly, we organized the first symposium of its kind in the nation. The symposium was not only very well received, but it also enabled members in the fields of hearing, speech, and airway problems to come together and discuss their fields.

Recognizing the growing interest in the field, Marvin Culbertson and I posted a notice at the 1968 meeting in Las Vegas inviting all those interested in pediatric otolagyngology to a cocktail party. About 20 otolaryngologists and audiologists came. This meeting made it possible to establish important contacts, such as Seymour Cohen from Los Angeles, who had been working in pediatrics for years. The following year in Dallas we took the next step in developing a group for pediatric otolaryngology. The result was the formation of the Society of Ear, Nose, and Throat Advances in Children – SENTAC, in Atlanta. Today, this group is in its twenty-second year.

It was my opinion that unless pediatric otolaryngology achieved academic recognition and the ability to train fellows, it could never be established as a specialty. Because this recognition seemed impossible to achieve in Philadelphia. I accepted an offer from Eugene Myers and Charles Bluestone to join them in Pittsburgh. I also accepted appointments from Tim Oliver, chairman of pediatrics, to come to Pittsburgh as a professor of pediatrics and di
rector of education in pediatric otolaryngology. The hospital funded a fellow for 1 year, and in 1985 the National Institutes of Health made it possible to fund a fellow for the second year through a training grant. This grant enabled fellows to do research and pursue graduate studies. We have now trained more than 40 fellows, most of whom are in academic centers and are professors or associate professors. One of these fellows is currently the vice-president of the Academy, and several others are being considered for appointments as department chairmen.

We wanted to form a section of otolaryngology in the Academy of Pediatrics to establish a presence with that group because they required 20 dues-paying members. Bluestone and Myers arranged a meeting in Pittsburgh to form a study group and to apply for admission to the Academy of Pediatrics as a section of otolaryngology and bronchoesophagology (Fig.1). this group has been very successful in establishing a liaison between the pediatricians and the otolaryngologists. Today, the Section of Pediatric Otolaryngology and Bronchoesophagology of the Academy has many more members than its original 20. interest and membership in this subspecialty increases every year. As these interests grow, new aspects of the interrelationship of pediatrics and otolaryngology develop. For instance, a patient´s psychologic health has become important in pediatrics because many of our patients have psychosocial problems. By working in concert, we can identify and help to provide better patient care for those with otolaryngologic disorders.

Recently, Pediatric Otolaryngology, the textbook I edited with Dr. Bluestone, appeared in its third edition. The first edition had 89 chapters; the second edition had 107 chapters. Although not all of the chapters are written by pediatric otolaryngologists, the topics reveal the diversity of interests that doctors from all specialties have concerning children. With this background, I think it is safe to say that pediatric otolaryngology will continue to gain support and recognition. I am hopeful that those who have received, and are now receiving, training that once was not possible at one single institution, if anywhere, will use their expertise to advance pediatric otolaryngology.

I would like to thank Kristen Jafek for manuscript preparation.

REFERENCES
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