ENT Workforce in the Future

Article:
Jin Suk C. Kim, Richard A. Cooper, and David W. Kennedy
Otolaryngology–Head and Neck Surgery Physician Work Force Issues: An Analysis for Future Specialty Planning Otolaryngology -- Head and Neck Surgery February 2012 146: 196-202, doi:10.1177/0194599811433977

Accompanying Commentary:
Shannon P. Pryor, Linda Brodsky, Sujana S. Chandrasekhar, Lauren Zaretsky, Duane J. Taylor, Kathleen L. Yaremchuk, and Harold C. Pillsbury III
Commentary on “Otolaryngology–Head and Neck Surgery Physician Workforce Issues An Analysis for Future Specialty Planning” by Kim, Cooper, and Kennedy Otolaryngology -- Head and Neck Surgery February 2012 146: 203-205, doi:10.1177/0194599811433979

For my first post, this seems like a good place to start: An analysis of the ENT workforce over the next 10-15 years. The article by Kim et. al. adress two major issues: 1. The increase in demand for ENT related services in 2025, and 2. The corresponding supply.

By way of a quick summary, the study does the following:
Estimates future demand for otolaryngologists with various techniques including:
1. A population based model relying on current demand levels per 100,000 pop.
2. A GDP based model which gives an estimate of demand and medical growth based on
These are the main techniques in use with some variation.

The study then predicts future supply of otolaryngologists using several factors:
1. Current number/stability of ENT residency/fellowship programs
2. Average age of retirement based on current trends
3. "Social" and "Lifestyle" factors of the new/younger generation of otolaryngologists
4. Percentage of women in the specialty and a gereral historical discrepency in hours worked for males vs. females.

Although differing methods of prediction and differeing variables result in sizeable range of values, they estimate that demand for otolaryngology services in 2025 will increase from the current number of roughly 8,600 practitioners to 11,127.

They report that there is likely to be a deficit in physicians given the factors I've listed above and that supply will be 2500 practitioners short of demand.

Suggestions they give suggestions for increasing supply to meet demand include
1: "The number of mid-level providers could also be increased with additional training and recruitment. Therefore, the development of an appropriate training program is strongly recommended."
2. "Considerations should be given to either a 4-year residency or a 3-year residency providing training in basic medical and surgical otolaryngology, followed by a 2-year subspecialty fellowship, for those individuals wanting to train in advanced comprehensive otolaryngology or a variety of subspecialty fields."
3. "An alternative consideration to address the workforce shortage may be to develop a medical otolaryngology/primary care specialty."


The associated commentary that I posted above really rips this article for pretty much everything they did. Their abstract alone states, "The authors of this comment have concerns about the article’s assumptions, design, and recommendations. Kim et al attempt to extrapolate data from other specialties and other countries to the US otolaryngology workforce, use that data in modeling methods without demonstrated validity, and based on their analysis, they recommend drastic changes to otolaryngologic training and practice in the United States. Particularly troublesome are (1) the emphasis placed on gender and part-time work and (2) the measurement of productivity defined as hours worked per week. Before redefining our specialty, more thorough and systematic data acquisition and review are necessary to meet the needs of our patients now and in the future." They go on to states, "Physician workforce issues are at the forefront of the health care reform debate. Widespread physician shortages are predicted. Many possible causes are being cited, along with potential solutions. Unfortunately, the extant data regarding factors contributing to this shortfall and the feasibility and effectiveness of the proposed countermeasures are inadequate at best or inaccurate at worst."

MY REACTION:
I thought the original article was interesting. I agreed with much of the criticism the commentary offered, specifically with it's issues regarding the originals article's use of data gathered from specialties outside of ENT and it's comparison to the specialty in other countries. ENT in America is a unique field of medicine with unique demands and demographics. It seems to me that generalized application of historical data for future analysis is likely to be proven inaccurate in the not so distant future.

One issue I found interesting was current trends in younger physician toward working fewer hours. Additionally, Kim et al cite a growing percentage of females in otolaryngology and state that, "although there are no otolaryngology- specific data for lifetime work expectations, there is evidence demonstrating that, on average, women physicians have worked fewer hours." Pryor et al attack this statement as well as it's implications. It will be interesting to see in the future if female otolaryngologists do in fact work fewer hours than their male counterparts. Pryor et al do cite some interesting statistics regarding women in medicine:
"The career arcs of women are different from those of men, with greater career gains more often in the last third of their careers.4 The work habits of female physicians seem to be different, with 10% more time being spent with each patient and safer practices being noted in many studies.5,6 American data on female otolaryngologists’ work effort are notably absent. However, what is known with certainty is that, controlling for hours worked, number of patients seen, and so on, women physicians make 20% less money than male otolaryngologists7 and start off at a $32,000-plus disadvantage when coming out of residency.8 "

Pryor et al mention an assumption stated in the original article that I had taken for granted: More hours worked translates directly into productivity. This of course is not a true assumption. There are great differences from one physician to the next in time seeing patients vs. charting, for example. Presumably less experienced individuals are less efficient with their time than those with more experience.
It will be interesting to see how the newer generation of physicians will use their time given the general trend toward desiring improved life style. I'm also interested to see how work ethic has or will change.

Kim et al suggest maintaining the current number of residency positions while decreasing ENT residency from 5 years to 4. This is the first time I have personally heard of this suggestion. Given the problems Pryor et al point out with the original article, I agree with them that it is premature to start reorganizing the residency requirements for the specialty. I would like to see Kim et al's suggestions for changes in curricurulm if they have any. The obvious questions this suggestion presents are 1. What would be lost in training with this change and 2. What would be the competency level for new trainees?

Pryor et al.'s biggest issue, in my opinion, is that the original article uses too much assumption and too little peer reviewed, evidence based data/analysis. This is certainly a valid criticism. If the data cannot be trusted, how can we trust the recommendations that flow from that data? However, I believe this points to a larger trend in medicine that I do take issue with. I don't believe it is beneficial for change within medicine to be crippled by incomplete information. Certainly, there is a reason we use evidence to inform our decisions. But to gather every last scrap of evidence can be extremely time consuming and when the larger problem looms, awaiting resolution, delay can be harmful.

In summary, this article raises several issues that are as yet unanswered and require further investigation (has any article ever been published that didn't call for 'further investigation'?). Though their underlying assumptions may be suspect, the relatively static number of residency training positions and increasing population do indicate that there will be a physician shortage. To what extent remains to be seen.

What's the immediate solution? Give me a residency position!