A career in audiovestibular medicineBMJ 2012; 345 doi: https://doi.org/10.1136/bmj.e5544 (Published 30 August 2012) Cite this as: BMJ 2012;345:e5544
- Louisa Murdin, academic clinical fellow in audiovestibular medicine1,
- Breege Mac Ardle, consultant in audiovestibular medicine2
- 1National Hospital for Neurology and Neurosurgery, London, UK
- 2Royal National Throat, Nose and Ear Hospital, London
Louisa Murdin and Breege Mac Ardle outline what’s entailed in being an audiovestibular physician
If you meet another medic and tell them you’re an audiovestibular physician, you may well hear one of these responses: “Isn’t that a technician’s job?”; “That’s a very specialised area, I’ve never heard of it”; or “I didn’t think you could really do anything to treat patients. Isn’t it all just hearing aids and prochlorperazine?”
So what is audiovestibular medicine? It is the branch of medicine that deals with hearing and balance in patients across the age range from birth to old age. We are different from audiologists, who are non-medical clinical staff with training in doing diagnostic audiovestibular tests and the technical aspects of rehabilitation.
The conditions we deal with aren’t obscure; they are common and often highly disabling, with a big impact on people’s lives. By the age of 60, one third of us will have had a balance disorder. One in seven people in the United Kingdom has a hearing problem, and more than one in 1000 newborn babies has a permanent hearing loss.
A number of treatment strategies employed by audiovestibular physicians use rehabilitation to induce neural plasticity. Many common audiovestibular conditions such as migraine and benign paroxysmal positional vertigo have specific and effective medical and physical treatments.
Much of the scientific and clinical basis underpinning audiovestibular medicine will be new to trainees when they start, but there are areas of overlap with other specialties, including neurology; care of older people; psychiatry; developmental paediatrics; immunology and allergy; ophthalmology; genetics; and ear, nose, and throat surgery. The importance of knowledge in these areas of medicine is reflected in the specialty training programme.
What do audiovestibular physicians do?
Audiovestibular physicians work in multidisciplinary teams that see child and adult patients with problems such as dizziness, hearing loss, tinnitus, imbalance, hyperacusis, auditory processing difficulties, speech disorders, and abnormalities in eye movement.
Some audiovestibular physicians have a role in assessing and managing patients who may benefit from cochlear implants, a procedure that is potentially life transforming. Many assess children with hearing loss identified through the national Newborn Hearing Screening Programme. Some audiovestibular physicians see mainly children and others mainly adults, while some manage both groups.
What are the advantages and disadvantages of audiovestibular medicine?
Doctors who work in audiovestibular medicine report satisfaction in providing an effective service in an area of high demand. The specialty has huge scope for medical discoveries and clinical research, and doctors are encouraged to study for the diploma or MSc in audiovestibular medicine and are supported in studying for higher research degrees.
As an outpatient based specialty audiovestibular medicine is mainly a nine to five job and lends itself well to less than full time training. Also, there is scope for private practice and medicolegal work.
On the downside, there is limited geographical flexibility for a junior doctor because only two deaneries offer training in audiovestibular medicine. The lack of out of hours work means no banding supplement for trainees. Many doctors in this specialty find that there is a lack of awareness among colleagues and the public about the service they offer.
What qualities do audiovestibular physicians need?
Audiovestibular physicians must have excellent communication skills, especially with deaf and disabled people, and be competent in working with children and their families as well as with adults. These doctors need a sound medical knowledge base and an ability to adapt to change and implement new and more effective and efficient services and treatments.
Case studies: specialty training
Vasuky Sriskandarajah (specialist trainee (ST) year 6, Pan Thames rotation)
I came to audiovestibular medicine from a neurology background. My knowledge and clinical skills from my neurology training placed me in a good position to manage patients with complex central vestibular disorders. Having not had to deal with children as patients since medical school, I found the paediatric clinics initially quite daunting. However, I quickly became aware of the pivotal role that we play in the early crucial stages of diagnosing, counselling, and investigating a child with permanent hearing loss.
Simone Walter (specialist registrar year 5, Pan Thames rotation)
I came to audiovestibular medicine from paediatrics, attracted by the mix of general and specialised paediatric work, spanning from the community to tertiary level. I did the MSc in audiovestibular medicine provided by University College London part time (one day a week) over two years and enjoyed getting to grips with the underpinning science of my specialty and the opportunity to do research.
Ann Large (new certificate of completion of training holder, Northern rotation)
My background before audiovestibular medicine was in ear, nose, and throat. I enjoyed the audiology/otology areas of ear, nose, and throat, and although I liked theatre I preferred being in clinic, so audiovestibular medicine seemed the logical progression. I also like being able to practise with both adults and children.
Julian Ahmed (ST3, Pan Thames rotation)
In audiovestibular medicine we use a lot of diagnostic tests that I’d not come across before I started, such as auditory evoked brainstem responses and eye movement recordings. Essentially it’s like learning to read an electrocardiogram. To start with it’s a bit baffling but eventually it becomes clear. Audiovestibular medicine is also the only specialty I know of where you can justify buying a Wii or full size gyroscopic chair arcade simulator (SEGA Afterburner) for treatment and research purposes.
Case study: working as a consultant
Breege Mac Ardle (consultant, Royal National Throat, Nose and Ear Hospital)
Working as a consultant in an ever changing NHS is challenging and rewarding, with high levels of job satisfaction. Vestibular medicine is an important and developing aspect of our specialty. We also spend time educating colleagues and the general public about what we do and how we add value to patient care.
Physicians in audiovestibular medicine work hard and have significant clinical caseloads but this is balanced by no acute on-call shifts. In addition, we teach and are involved in research.
We are a relatively “young” specialty; currently, there are 48 consultants in the United Kingdom. The Newborn Hearing Screening Programme has resulted in a moderate expansion of new consultant posts in audiovestibular medicine.
How can I get into audiovestibular medicine?
Entry to audiovestibular medicine is at ST3 level (see figure). The requirements for entry are: core medical training and membership of the Royal College of Physicians; or completion of core training or equivalent in paediatrics with membership of the Royal College of Paediatrics and Child Health; or completion of core training in general practice with membership of the Royal College of General Practitioners.⇓
Entrants from core surgical training require membership of the Royal College of Surgeons and will acquire core medical competencies during ST3 and ST4. At present, they are expected to obtain membership of the Royal College of Physicians, although the need for this qualification is under review.
Two training rotations exist. One is in the London Deanery, where there are 14 training slots, and one is in the North Western Deanery, which rotates between Manchester, Cardiff, and Nottingham, where there are five training slots.
Audiovestibular medicine is a rewarding and flexible specialty that offers the opportunity to become an expert in the management of common but often neglected clinical problems and provides good opportunities for research and clinical practice. Audiovestibular physicians are likely to have a leading role in coordinating specialist hearing and balance services, mostly at the tertiary level, and will lead the way in implementing new technologies in diagnostics and therapeutics in the field.
You can find your nearest audiovestibular physician on the website of the British Association of Audiovestibular Physicians (www.baap.org.uk), as well as other useful information about the specialty. Taster days are organised annually and are advertised on the website.
Information is also available from the Joint Royal Colleges of Physicians Training Board (www.jrcptb.org.uk/trainingandcert/ST3-SpR/Pages/Audiological-Medicine.aspx) and the Royal College of Physicians (www.rcplondon.ac.uk/specialty/audiological-medicine).
Competing interests: None declared.