Trends in the otolaryngology workforce in the U.S.

The American health care system is evolving at an increasingly rapid pace. The structure of health care delivery is moving toward larger and more integrated systems. The traditional pattern of independent practice for physicians is being supplanted by contracted arrangements among large groups of clinicians. The financing of medical care is undergoing changes due to federal legislation as well as pressures from payors to remain competitive. Financing systems are evolving toward “bundles” and disease-based reimbursement with the anticipation that patient outcomes will one day form the basis for payment. These trends all have implications for the supply of health care professionals as they choose to enter medicine and surgery.

The practice of otolaryngology and many other surgical specialties has changed significantly over the past three decades. For instance, vascular surgery barely existed in the early 1980s and is now an independent specialty. New procedures, unheard of even 20 years ago, are now performed by a variety of surgical specialists. The practice of head and neck oncologic surgery, skull base surgery, neuro-otology, head and neck endocrine surgery, and pediatric otolaryngology has developed over this time period, increasing the demand for otolaryngologists to perform procedures that have been newly developed to treat cases that are referred to them by general surgeons. New technology, new procedures, and changes in surgical training pathways and certification have resulted in a redistribution of the division of labor within all the surgical specialties and an increasing proliferation of specialty surgeons of many types, including otolaryngologists.

This article is based on a fact sheet that was developed as part of a series of policy briefs produced by the American College of Surgeons Health Policy Research Institute (ACS HPRI) illustrating surgical workforce trends. The aim of these brief reports is to provide decision makers with descriptive data on the workforce that can be used to inform health policy. This fact sheet focuses on trends in the otolaryngology workforce since 1981.

Key findings

Relative to population, the supply of otolaryngologists increased from 1981 until 2001, was stable between 2001 and 2006, and then began to decline between 2001 and 2006. Furthermore, between 2000 and 2009 the number of otolaryngology residents becoming certified by the American Board of Medical Specialties (ABMS) dropped 19.3 percent. As supply has contracted, distribution also has become problematic. Between 2004 and 2009, one in five (641) counties lost otolaryngologists relative to population. Of these, 88 counties lost all their otolaryngologists. More than half (59.8 percent, n=1,858) of all U.S. counties had no otolaryngologists in either 2004 or 2009.

In addition, we found that otolaryngology is more male-dominated than most surgical specialties. Female otolaryngologists are disproportionately represented in hospital settings. In the last decade, the number of solo practice otolaryngologists in rural counties decreased significantly.

The number of otolaryngologists in active practice in the U.S. (excluding residents in training) increased 60 percent between 1981 and 2009 (see Table 1). However, the ratio of otolaryngologists per 100,000 population increased from 1981 until 2001, was stable between 2001 and 2006, and then began to decline between 2006 and 2009 (see Table 2). Although this recent decline in supply is not as dramatic as those in thoracic, general, and urologic surgery during the same period, the decreasing number of residents seeking board certification in otolaryngology will likely accelerate the decline in supply in the near future.

Training in otolaryngology

According to ACGME data, from 2001 to 2009, the number of otolaryngology residents increased by 23 percent.¹ The number of otolaryngology training programs held steady at 103 during this period. However, otolaryngology residents receiving ABMS certifications declined by 19.3 percent from 2000 to 2009.²

Geographic distribution of otolaryngologists

As supply has contracted, distribution has also become problematic. To examine geographic variation in the supply of otolaryngologists, we analyzed practitioner and population data for all U.S. counties from 2004 to 2009. In 2009, otolaryngologists practiced in 37.4 percent (1,161) of U.S. counties, representing an increase of 20 counties from 2004. From 2004 to 2009, 20.6 percent of U.S. counties (641) lost otolaryngologists relative to population, and 88 counties (2.8 percent) lost all otolaryngologists (see Figure 1). During the same period, 13.3 percent of counties (412) gained otolaryngologists relative to population, and 108 counties (3.5 percent) that had no otolaryngologists in 2004 gained at least one otolaryngologist by 2009. Slightly more than 59.8 percent of counties (1,858) had no otolaryngologists in 2004 or 2009.

Age and gender of the workforce

With an average age of 51.4 years in 2009, otolaryngologists in active practice are slightly older than the average age for all surgical specialties (50.9 years). In 2009, 15.1 percent were older than 65 compared with 14.2 percent for all surgeons. This represents more than a 4 percentage point increase in otolaryngologists 65 and older since 1981, when the 65 and older age group comprised 10.8 percent of the workforce. This increase is roughly equal to the average rate of aging of the overall surgeon workforce.

Women have been entering the surgical workforce with increasing frequency since 1981, although at different rates in different specialties. Since 1981, the number of female otolaryngologists has grown from 111 to 1,158, an increase of nearly 10 percentage points (see Figure 2). Nonetheless, men continue to account for a large majority of otolaryngologists, representing 88.4 percent of the workforce versus 80 percent for all surgeon specialties combined.

Since 1981, the age gap between male and female otolaryngologists has remained steady, with males being an average of eight years older than their female counterparts. In 2009, female otolaryngologists were 44.4 years old on average and males were 52.0 years old. Among all active surgeons in 2009, males were slightly older at 52.5 years old. Female surgeons on average are approximately the same age as female otolaryngologists. As Figure 2 indicates, more female otolaryngologists have recently entered the otolaryngology workforce.
In 2009, otolaryngologists practicing in rural areas (average age 52.6) were 1.7 years older than those in urban areas, a trend that has reversed since 1981 (see Figure 3).

Movement from solo to group practice

Following trends for all practicing surgeons, otolaryngologists are increasingly likely to practice in a group (see Figure 4).³ The proportion of the otolaryngologist workforce in group practice increased from 37.8 percent in 2001 to 53.4 percent in 2009. As the number employed in group practices increased, there has been a corresponding decline in the percentage of surgeons self-employed in solo practice. In 2001, slightly more than 30.1 percent of otolaryngologists were in solo practice compared with one in four (25.1 percent) in 2009. The percentage of surgeons employed by HMOs, nonhospital government, and other entities (defined in Figure 4 as “other setting”) also declined substantially between 2001 and 2009. In 2009, otolaryngologists in solo practice were on average 6.7 years older than otolaryngologists in group practice.

Not surprisingly, urban otolaryngologists have chosen to practice in groups proportionally more often than rural otolaryngologists. From 2001 to 2009, the number of urban otolaryngologists in group practice increased by 52.2 percent, while rural otolaryngologists increased by 34.1 percent. Also, the number of urban otolaryngologists in solo practice decreased by 15.3 percent, while rural otolaryngologists decreased by just 6 percent. The decrease in rural solo practice for surgeons in general was much larger (16 percent).

Most female otolaryngologists practice in a group setting (49.6 percent), and a slim majority of males choose group practice (53.9 percent). Although females make up just 11.6 percent of the otolaryngology workforce, they represent 18 percent (in 2009) of the otolaryngologists practicing in a hospital, an increase from 11.7 percent in 2001. Overall, otolaryngology saw larger increases in hospital practice in both urban and rural areas than surgeons in other specialties.

Data and methodology Surgeons were identified as surgeons and classified into surgical groups using a combination of American Medical Association (AMA) primary and secondary self-reported specialties and American Board of Medical Specialties (ABMS) certifications. This analysis only included active, nonresident, nonfederal surgeons. “Active surgeons” are under the age of 80 and report working in administration, direct patient care, medical research, medical teaching, or other nonpatient care activities, or who have an “unclassified” activity status. Active surgeons exclude those who are classified as retired, semi-retired, temporarily not in practice, or not active for other reasons. “Urban-Rural” was defined as a county’s Metropolitan Statistical Area status as defined by the Office of Management and Budget.

Implications

Work by Kim and colleagues demonstrated an increasing concentration of neck dissections at high-volume centers from 2000 to 2006.⁴ Urban otolaryngologists more often chose group practice than their rural counterparts. If otolaryngologists continue to concentrate in fewer locations, new models of care, such as the “medical mission” used in developing countries, may improve access to otolaryngology care in rural U.S. areas where proportionately more Medicaid and uninsured patients reside.⁵

Although the distribution of otolaryngologists may foreshadow geographic problems with access, research has shown that practitioners are taking on a greater workload.⁶ This trend may have effects on entry into the specialty as graduating medical students assess the relative burden of practice in rural versus urban communities.

Although the otolaryngology workforce increased by 20 percent per 100,000 during the period 1981–2009, the trend has recently reversed. Bhattacharyya’s predictions about an increasing workload due to the aging U.S. population suggest the need for close monitoring of the otolaryngology workforce.6 Otolaryngology currently relies less on international medical graduates (11.7 percent) than the surgeon population in general, and has trended away from international medical graduates since 1981. Hence, the U.S. graduate medical education system will likely play a larger role in the otolaryngology workforce than other surgical specialties.

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References

1. Brotherton SE, SI Etzel. Graduate medical education, 2008-2009. JAMA. 2009;302(12):1357-1372.
2. American Board of Medical Specialties. 2010 ABMS Certificate Statistics. Chicago, IL: American Board of Medical Specialties; 2010:1-48.
3. Poley ST, et al. Independent Practice Becoming Increasingly Rare Among Surgeons. ACS HPRI Fact Sheet, 2011. Available at: http://www.acshpri.org/documents/ACSHPRI_FS6.pdf. Accessed February 16, 2012.
4. Kim EY, et al. Neck dissections in the United States from 2000 to 2006: Volume, indications, and regionalization. Head Neck. 2011;33(6):768-773.
5. Winters R, Pou A, Friedlander P. A “medical mission” at home: The needs of rural America in terms of otolaryngology care. J Rural Health. 2011;27(3):297-301.
6. Bhattacharyya N. The increasing workload in head and neck surgery: An epidemiologic analysis. Laryngoscope. 2011;121(1):111-115.