ORIGINAL ARTICLE. areas has accelerated during the past several decades.

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1 ORIGINAL ARTICLE Practice of Otolaryngology Results of the Future of Education II Project David E. Tunkel, MD; William L. Cull, PhD; Ethan A. B. Jewett, MA; Sarah E. Brotherton, PhD; Carmelita V. Britton, MD; Holly J. Mulvey, MA Objectives: To define the practice of pediatric otolaryngology compared with general otolaryngology and to estimate pediatric otolaryngology workforce utilization and needs. Methods: Survey of members of the American Academy of s Section on Otolaryngology and Bronchoesophagology and the American Society of Otolaryngology and of a random sample of the membership of the American Academy of Otolaryngology Head and Neck Surgery. Results: otolaryngologists were more likely to practice in urban and/or academic settings than were general otolaryngologists. Children (age 18 years) comprised over 88% of the patients of pediatric otolaryngologists and 30% to 35% of the patients of general otolaryngologists. otolaryngologists were more likely to see children with complicated diseases such as airway disorders or congenital anomalies than were general otolaryngologists. otolaryngologists, unlike general otolaryngologists, reported an increasing volume of pediatric referrals, as well as increased complexity in the patients referred. The surveyed physicians estimated the present number of pediatric otolaryngologists in their communities as approximately 0.2 to 0.3 per people. Conclusions: Most children receiving otolaryngologic care in the United States receive such care from general otolaryngologists. The patient profile and practice setting of the subspecialty of pediatric otolaryngology differ from those of general otolaryngology. The demand for pediatric otolaryngologists appears to be increasing, but many general otolaryngologists do not believe there is an increased need. Arch Otolaryngol Head Neck Surg. 2002;128: From the Department of Otolaryngology Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Md (Dr Tunkel); the Divisions of Health Policy Research (Dr Cull) and Graduate Medical Education and Workforce (Mr Jewett), American Academy of s, Elk Grove Village, Ill; the Department of Data Acquisition Services, American Medical Association, Chicago, Ill (Dr Brotherton); The Children s Hospital, Albany Medical Center, Albany, NY (Dr Britton); and the Future of Education II (FOPE II) Project, Elk Grove Village (Ms Mulvey). THE DEVELOPMENT of medical and surgical subspecialty areas has accelerated during the past several decades. The field of otolaryngology head and neck surgery has seen the development of a number of subspecialties, including facial plastic surgery, otology and neurotology, head and neck surgery, and pediatric otolaryngology. Controversy exists regarding pediatric otolaryngology, usually centered around the appropriate practice setting for the pediatric otolaryngologist and the relationship of this subspecialist to the general otolaryngologist. 1-3 A large portion of the practice of otolaryngology concerns the care of children (age 18 years) with ear, nose, and throat disorders, and it is likely that most children who need such care are treated by general otolaryngologists. The diseases and types of surgical cases that are more appropriately handled by a pediatric surgical subspecialist have been debated. The most appropriate location of a pediatric otolaryngology practice has also been discussed, and many agree that such a subspecialist is most needed in a tertiary pediatric medical center. The need for postresidency pediatric fellowship training, the duration of such training, and the appropriate pediatric content of otolaryngology residency programs are subjects that are not settled. See also page 765 Workforce issues in pediatric and general otolaryngology involve the determination of the appropriate number and distribution of otolaryngologists and pediatric otolaryngologists to serve patient needs adequately. Workforce studies of otolaryngology 4-6 and pediatric otolaryngology 7 have projected these numbers. We obviously need to ensure that we are train- 759

2 METHODS QUESTIONNAIRE As part of the FOPE II Project, a 5-page questionnaire was developed to obtain information from a variety of medical and surgical specialists who treat children. This questionnaire was designed to be applicable to most physicians and collected information on several areas, including specialty training, competition, referral sources, and demographic characteristics. An additional 3-page questionnaire specific for pediatric otolaryngology was developed in collaboration with the American Academy of s Section on Otolaryngology and Bronchoesophagology (AAP Section). The pediatric otolaryngology questionnaire included questions on proportion of practice that involves care of children, the type and duration of pediatric otolaryngology training, the numbers of pediatric otolaryngologists in the community, referral patterns of children requiring otolaryngologic care, and the types of disease processes seen in them. These questionnaires were pretested by a small group of pediatric otolaryngologists. Questionnaires were revised based on comments received. SAMPLE The sample included 148 members of the AAP Section, 150 otolaryngologists who belong to the American Society of Otolaryngology (ASPO), and a random sample of 299 otolaryngologists who belong to the American Academy of Otolaryngology Head and Neck Surgery (AAOHNS). There was some overlap in membership; 21.3% of the sample belonged to both the AAP Section and ASPO. Less than 2% of the AAOHNS sample also belonged to ASPO. Five mailings of the survey went out between October 1997 and February 1998 to the 489 otolaryngologists. Each mailing contained the standard questionnaire and the pediatric otolaryngology questionnaire, a cover letter emphasizing the importance of the survey, and a return envelope. We received responses from 309 physicians, 63.2% of the sample. We received 26 responses that were excluded because the physicians indicated they were retired, did not treat children, were temporarily not practicing, or were in training. These were excluded from the sample size of 489, producing an effective sample size of 463. Our response rate is therefore 283 of 463 (61.1%). Respondents were divided into 2 groups for all statistical analyses. The first group consisted of 140 otolaryngologists with a pediatric focus. This group was operationally defined as those respondents who belonged to the ASPO, the AAP Section, or both, and will be referred to as the pediatric otolaryngologist group. The second group consisted of the 143 respondents who belonged only to AAOHNS and will be referred to as the general otolaryngologist group. For continuous variables, comparisons between the groups were made using independent group t tests. For categorical variables, comparisons between groups were performed using 2 analysis. P.05 was considered significant for all statistical tests, and all analyses were conducted using SPSS statistical software (SPSS for Windows version 9.0; SPSS Inc, Chicago, Ill). The number of cases for each analysis fluctuated slightly based on the number of missing values for the individual question. ing an appropriate number of otolaryngologists and subspecialty otolaryngologists to meet patient needs now and in the future. The Future of Education II (FOPE II) Project was a 3-year, grant-funded initiative of the entire pediatric community. As part of this project, key leaders in pediatrics addressed the future supply and training of pediatricians and pediatric specialists and the provision of pediatric care in the new millennium. 8,9 As was also done for 16 other medical and surgical subspecialty groups in the Survey of Sections Project of the FOPE II Project, we surveyed a group of otolaryngologists and pediatric otolaryngologists in an attempt to better define the practice of pediatric otolaryngology and to help estimate workforce needs. RESULTS DEMOGRAPHIC AND PRACTICE CHARACTERISTICS There were several differences in demographic and practice characteristics between the pediatric otolaryngologist and the general otolaryngologist groups. The mean age of pediatric otolaryngologists was significantly lower than that of general otolaryngologists (45 vs 48 years; P=.004). There was also a higher proportion of pediatric otolaryngologists who were women compared with the general otolaryngologist group (14.3% vs 4.9%; P=.007). The overwhelming numbers of pediatric and general otolaryngologists were white, non-hispanic (89.7% vs 85.2%; P=.26), and had graduated from US or Canadian medical schools (93.2% vs 90.6%; P=.42). There were also significant differences between the 2 groups concerning practice characteristics, such as the type (P.001) and location (P.001). As given in Table 1, one half of pediatric otolaryngologists practiced in an academic setting compared with less than 3% of general otolaryngologists. Nearly half of general otolaryngologists were in solo practice. Also as given in Table 1, 79.8% of pediatric otolaryngologists were located in urban settings compared with 41.3% of general otolaryngologists. Furthermore, 5 times as many general otolaryngologists (16.1%) were located in rural settings compared with pediatric otolaryngologists (3%). Table 2 shows that patient profiles and practice content also differed for pediatric otolaryngologists and general otolaryngologists. As expected, the percentage of pediatric otolaryngologists patients who were younger than 18 years was much higher than the percentage of general otolaryngologists patients for 760

3 Table 1. Practice Type and Community of and * Practice Characteristic Type Medical school/hospital Specialty group Multispecialty group Solo group HMO staff/group model Other Community Urban/not inner city Urban/inner city Suburban Rural *Data are percentage of pediatric or general otolaryngologists as specified. HMO indicates health maintenance organization. The distribution of responses for this variable differs significantly between the pediatric otolaryngologist and general otolaryngologist groups (P.05). Table 3. Referral Sources for and * Source of Referrals generalists Family physicians medical/surgical subspecialists Urgent care centers School districts nurse practitioners Community agencies Physician assistants internists Adult medicine subspecialists Obstetricians/gynecologists Other *Data are percentage of pediatric and general otolaryngologists as specified. Respondents could indicate multiple sources. The mean percentage for this category differs significantly between the pediatric otolaryngologist and general otolaryngologist groups (P.05). Table 2. Patient Characteristics for and * Patient Characteristic Age Office patients 18 y Surgical patients 18 y Condition Otitis media Adenotonsillar disease Sinonasal disease Airway/voice/swallow Congenital anomalies Otological problems (eg, SNHL and vertigo) Head and neck masses Trauma Other *Data are means of the estimated percentage of the practice volume reported by pediatric and general otolaryngologists as specified. SNHL indicates sensorineural hearing loss. The mean percentage for this category differs significantly between the pediatric otolaryngologist and general otolaryngologist groups (P.05). both office patients (88.8% vs 29.0%; P.001) and surgical patients (89.4% vs 35.6%; P.001). When we looked at the disease processes seen in children requiring otolaryngologic care, compared with general otolaryngologists, pediatric otolaryngologists had significantly lower percentages within their respective patient pools of patients with otitis media (36.7% vs 40.3%; P =.04), adenotonsillar disease (20.3% vs 27.8%; P.001), and trauma (1.8% vs 4.1%; P=.006). A higher relative percentage of the children seen by pediatric otolaryngologists had congenital anomalies (6.8% vs 1.6%; P.001) or airway, voice, and/or swallow problems (9.9% vs 4.1%; P.001). Otolaryngology Practice in Only s Fellowship Training in Otolaryngology Advertising Location of Established Referral Patterns Managed Care Affiliations Importance Rating (Mean Rank) REFERRALS Figure 1. The importance of factors that influence referrals of children for otolaryngology care. The mean values for all but the Managed Care Affiliations category differ significantly between the pediatric otolaryngologist and general otolaryngologist groups (P.05). were asked to describe the sources of their pediatric referrals. generalists and family physicians were named the most often by both groups of physicians (Table 3). Urgent care centers and school districts also were mentioned frequently. otolaryngologists were more likely to receive referrals from pediatric medical and surgical subspecialists and pediatric nurse practitioners, while general otolaryngologists were more likely to receive referrals from general internists. When asked to rank the importance of personal or community characteristics that influence referrals of children for otolaryngologic care in their community, pediatric otolaryngologists and general otolaryngologists had very different rankings (Figure 1). Although managed care affiliations and established referral patterns were considered influential by both groups, general otolaryngologists ranked the latter as a more important factor than did pediatric otolaryngologists. otolaryngologists also 761

4 Table 4. Shifts in Referrals and the Number of Patients Cared for in the Last 12 Months* Shift ranked practice location and advertising higher than did pediatric otolaryngologists. However, pediatric otolaryngologists reported that fellowship training and practice concentration in pediatric otolaryngology were more influential characteristics affecting referral of children. were asked about changes in the volume or complexity of pediatric referrals and shifts in the number of pediatric patients. As given in Table 4, there were several differences between the pediatric otolaryngologist and the general otolaryngologist groups. otolaryngologists were more likely than general otolaryngologists to report that in the last 12 months the volume of referrals had increased (35.8% vs 3.8%; P.001), the complexity of referrals had increased (34.1% vs 15.4%; P.001), and the number of pediatric patients cared for had increased (49.6% vs 6.5%; P.001). otolaryngologists were also more likely to report an increasing need in the community for pediatric otolaryngologists (34.1% vs 11.1%; P.001). These results reflect the greater emergence of pediatric otolaryngology within communities and the increased utilization of such services. WORKFORCE Shift in the volume of referrals in last 12 mo Increase No change Decrease Shift in the complexity of referrals in last 12 mo Increase No change Decrease Shift in the No. of pediatric patients cared for in last 12 months Increase No change Decrease Perception of shift in community need for pediatric otolaryngologists Increase No change Decreasing *Data are percentage of pediatric and general otolaryngologists as specified. The distribution of responses for this variable differs significantly between the pediatric otolaryngologist and general otolaryngologist groups (P.05). When asked about sources of competition for pediatric patients, the patterns of responses were very different for pediatric otolaryngologists and general otolaryngologists (Figure 2). otolaryngologists were more likely than general otolaryngologists to experience competition from other pediatric subspecialists (65.4% vs % Reporting Competition Subspecialists Adult Specialists ians Family Physicians Nonphysician Providers Urgent Care Center Figure 2. Source of competition for pediatric otolaryngologists and general otolaryngologists for pediatric patients. The distribution for all but the Nonphysician Providers category differ significantly between the pediatric otolaryngologist and general otolaryngologist groups (P.05). Table 5. Estimated Population Size and Number of for Otolaryngologist and Otolaryngologist Groups* Mean population size, No Mean No. of otolaryngologists Mean No. of tertiary pediatric otolaryngologists *The mean values differ significantly between the pediatric otolaryngologist and general otolaryngologist groups (P.05). 45.3%; P.001) and from adult specialists (53.7% vs 34.5%; P.001). otolaryngologists were less likely to experience competition from general pediatricians (12.5% vs 31.7%; P.001), family physicians (11.0% vs 28.1%; P.001), and urgent care centers (5.1% vs 15.8%; P.001). Information was also collected on the size of physicians communities and on the number of otolaryngologists providing pediatric care (Table 5). The average size of pediatric otolaryngologists communities was larger than that of general otolaryngologists communities (P.001). Accordingly, the number of general otolaryngologists who provide pediatric care (P.001) and the number of pediatric otolaryngologists (P.001) were also higher in pediatric otolaryngologists communities. The ratio of the number of general otolaryngologists to the number of pediatric otolaryngologists was fairly consistent across communities, 7.4 to 1 in pediatric otolaryngologists communities and 5.3 to 1 in general otolaryngologists communities. In the pediatric otolaryngologists communities, this translates into population ratios of 1.6 general otolaryngologists and 0.2 pediatric otolaryngologists per people. In the general otolaryngologists communities, this translates into population ratios of 1.8 general otolaryngologists and 0.3 pediatric otolaryngologists per people. 762

5 COMMENT This survey has detailed a number of the differences between the practices and the practitioners of general otolaryngology and pediatric otolaryngology. Of importance, we found that 30% to 35% of the patients seen by general otolaryngologists are children. Because this survey suggests that there are more general otolaryngologists than pediatric otolaryngologists in most communities by at least 6- to 8-fold, most children receive otolaryngology care from general otolaryngologists. otolaryngologists are more likely to be located in urban tertiary pediatric and/or academic medical centers. These centers are the most appropriate settings for the pediatric otolaryngologist to treat complex otolaryngologic disease in children or routine otolaryngological problems in children with complicated medical problems. The pediatric otolaryngology subspecialty practice included a greater percentage of children with the unusual, complicated pediatric head and neck problems, such as airway problems and congenital anomalies, and a small fraction of the otologic, sinonasal, and adenotonsillar disease that comprises the large portion of the general otolaryngology practice applied to children. Referral of children to general or pediatric otolaryngologists appears to come from the usual sources of specialty referral, the primary care providers. otolaryngologists were more likely to receive referrals of children from other pediatric subspecialists than were general otolaryngologists. subspecialists often share a common location in a pediatric medical center and provide integrated care for children who may require subspecialty otolaryngology services, which likely contributes to this referral pattern. otolaryngologists report an increase in patient volume as well as an increase in the complexity of pediatric referrals. The increase in patient volume may reflect an increase in referrals from primary care physicians, a shift in referral of children from other specialists (including the general otolaryngologist), or an increase in the incidence of ear, nose, and throat disease in children. The increased complexity of the medical conditions of children referred to pediatric otolaryngologists may be due to improved survival of severely ill neonates and other children, new technologies and techniques advanced by the subspecialty (eg, laryngeal reconstruction), later referrals of sicker children from primary care providers, or a shift of these patients from other specialists, including general otolaryngologists. It is not surprising that pediatric otolaryngologists reported a need for more rather than fewer pediatric otolaryngologists, since they had increasing numbers of patients including children with more complicated conditions. It is also not surprising that over 89% of general otolaryngologists believed that additional pediatric otolaryngologists were not needed in their community, since most of the general otolaryngologists surveyed had not experienced an increase in pediatric referrals or patient volume, and indeed one third reported caring for fewer pediatric patients than previously. However, based on anecdotal reports of employment opportunities seen by recent pediatric otolaryngology trainees and the growing number of advertisements for pediatric otolaryngologists in journals, the demand for pediatric otolaryngologists appears to be increasing. The estimates of the number of general otolaryngologists and pediatric otolaryngologists in a given community may help us assess workforce needs. It appears that most communities had approximately 1.6 to 1.8 general otolaryngologists per people. This number is lower than the figure of 3.36 otolaryngologists per obtained from the American Medical Association Masterfile in The number of general otolaryngologists in a community can also be compared with Miller s 4 otolaryngology workforce figures, estimated as 2.5 per for the year 1990 and projected to be 2.8 per for the year Our estimates may be lower because respondents may have overestimated the sizes of their communities, or the number of otolaryngologists may have been restricted by the specification in our question that otolaryngologists must provide pediatric care. Most communities had approximately 0.2 to 0.3 pediatric otolaryngologists per people. Obviously, it would be most useful to have the number of otolaryngologists per number of children in the community. The figures from the survey suggest that most communities have about 1 pediatric otolaryngologist for every 7 to 8 general otolaryngologists. However, the ratio of pediatric otolaryngologists to general otolaryngologists may be much smaller. The number of practicing otolaryngologists in 1997 in the United States was about 9000, 10 and the number of pediatric otolaryngologists in the United States as estimated by ASPO membership (220) and AAP Section membership (161) is no more than several hundred. 11 The limitations of this study are inherent in the survey format and design. The data consist of the opinions, impressions, and knowledge of the surveyed pediatric and general otolaryngologists. We defined pediatric otolaryngologist and general otolaryngologist based on membership in otolaryngology organizations (ASPO, AAP Section, and AAOHNS) and not on the percentage of practice comprised by children. There may be a group of otolaryngologists who see only or mostly children who do not belong to the ASPO or AAP Section. These subspecialty practitioners may have different practice settings and patient populations than the pediatric otolaryngologists as defined above. If we had defined a pediatric otolaryngologist as either (1) an otolaryngologist with a practice comprised by more than 80% children or (2) an otolaryngologist who completed a pediatric otolaryngology fellowship, our results might have been slightly different. One of the concerns expressed regarding pediatric otolaryngology as a subspecialty has been that the subspecialty-trained physician may develop an identical profile of pediatric patients and a practice setting identical to that of the general otolaryngologist, with subspecialty training used only as a marketing advantage. The current results, however, suggest that many differences in practice characteristics, patient conditions, referral patterns, and sources of competition exist between pediatric otolaryngologists and general otolaryngologists. Our study did not address the appropriate distribution of pediatric otolaryngologists. This distribution involves geography, location of tertiary medical centers, and 763

6 the percentage of children in a given local population. Workforce planning and policy efforts should take into account national, regional, and local needs for pediatric otolaryngologists. In particular, further studies could look more closely at the adequacy of tertiary medical centers in meeting the needs for pediatric otolaryngological services in the hospital referral regions they serve. The practices of otolaryngology and pediatric otolaryngology appear in many ways complementary rather than competitive. As with other otolaryngology subspecialists, the pediatric otolaryngologist should be a resource for referral of children with complicated medical issues out of the realm of general practice. Because a large proportion of general otolaryngology practice is the care of children with ear, nose, and throat disorders, otolaryngology residency programs must maintain an appropriate level of training in pediatric otolaryngologic diseases. otolaryngology fellowship programs must continue to provide advanced training for individuals committed to the unique practice characteristics of pediatric otolaryngology in the tertiary pediatric medical centers. The data presented here reflect solely the perspective of the specialists and subspecialists themselves. Additional studies should be undertaken from other vantage points. For example, household surveys or surveys of health plan members could be conducted to elicit information from a consumer-demand perspective on the availability and accessibility of pediatric subspecialty services. Equally valuable perspectives on this question could come from surveys of health plan administrators, teaching hospital executives, fellowship training program directors, and primary care physicians. Nevertheless, the views expressed by specialists and subspecialists through the Survey of Sections data of the FOPE II Project provide insight into the practice differences in the otolaryngologic care for children. Accepted for publication December 17, This work was supported by grants from the Center for the Future of Children of the David and Lucile Packard Foundation, Los Altos, Calif; the Maternal and Child Health Bureau, Rockville, Md (Project MCJ379381); the Association of Medical School Department Chairmen, Chapel Hill, NC; the American Board of s Foundation, Chapel Hill; and the American Academy of s, Elk Grove Village, Ill. We thank the members and staff of the FOPE II Project; Thomas M. Gorey, JD, Max M. April, MD, and Michael J. Cunningham, MD, from the AAP Section; the members of the AAP Committee on Workforce Subcommittee on Subspecialty Workforce; and the many physicians who responded to the survey for their essential contributions to this project. Corresponding author and reprints: David E. Tunkel, MD, Johns Hopkins Outpatient Center, Room 6231, 601 N Caroline St, Baltimore, MD ( dtunkel@jhmi.edu). REFERENCES 1. Bluestone CD. otolaryngology: past, present, and future. Arch Otolaryngol Head Neck Surg. 1995;121: Smith RJH. Is pediatric otolaryngology fragmenting otolaryngology? Bull Am Acad Otolaryngol Head Neck Surg. May 2000: Harris NJ. Is pediatric otolaryngology fragmenting us? Bull Am Acad Otolaryngol Head Neck Surg. March 2001: Miller RH. Otolaryngology manpower in the year Laryngoscope. 1993; 103: Goldstein JC. The current manpower situation in American otolaryngology head and neck surgery. Laryngoscope. 1995;105: Jafek BW, Slenkovich N, Sheikali S. Physician workforce in otolaryngology. Otolaryngol Head Neck Surg. 1996;115: Zalzal GH. Projected societal needs in pediatric otolaryngology. Laryngoscope. 1996;106: Task force of the Future of Education II (FOPE II) Project. Organizing pediatric education to meet the needs of infants, children, adolescents, and young adults in the 21st century. s. 2000;105(suppl 2): Stoddard JJ, Cull WL, Jewett EA, Brotherton SE, Mulvey HJ, Alden ER. Providing pediatric subspecialty care: a workforce analysis. s. 2000;106: Pillsbury HC, Cannon CR, Sedory Holzer SE, et al. The workforce in otolaryngology head and neck surgery: moving into the next millennium. Otolaryngol Head Neck Surg. 2000;123: Bull Am Acad Otolaryngol Head Neck Surg [informational box]. May 2000: