Supplementary Online Content

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1 Supplementary Online Content 1 Bell JR, Ruch-Ross H, Hotaling AJ. Practice patterns and projections for the US pediatric otolaryngology workforce. JAMA Otolaryngol Head Neck Surg. Published online June 16, doi: /jamaoto efigure. The 2014 AAP Workforce Survey - Section on Otolaryngology This supplementary material has been provided by the authors to give readers additional information about their work.

2 2 efigure. The 2014 AAP Workforce Survey - Section on Otolaryngology This survey asks for information about your career and educational and training issues. The survey is organized into three sections: a general section, which is asked of all pediatricians and physicians who care for children; a section with questions that pertain to surgical specialties; and a section which is specific to your subspecialty or AAP section. Please answer all of the questions to the best of your ability. Please consult records concerning number of patients seen, procedures performed, and so forth. For the purposes of this survey, "specialty" refers to your initial training (i.e., the specialty in which you completed your residency training). A "pediatric subspecialist" is a physician who treats children, either through training in a pediatric medical subspecialty or surgical specialty, or through training in an adult specialty AND pediatrics. As an example, if you are a pediatric otolaryngologist, then your specialty training might be internal medicine and your subspecialty could be adult otolaryngology, with a second subspecialty in pediatric otolaryngology. Please direct questions or concerns about this survey to Holly Ruch-Ross,ScD, research and evaluation consultant, at hruchross@aol.com.

3 This section of the survey asks for specific information about your specialty training and certification What is your professional degree? M.D. 2. What is the primary, or first, specialty or subspecialty in which you have been trained? For example, if you are a neonatologist, then your specialty training would be pediatrics with a subspecialty in neonatology. You would enter "pediatrics" here, and you will be able to enter "neonatology" on a subsequent question. Please enter only one response; you will be asked about additional specialties later. 3. In what YEAR did you complete your training in [Q2]? 4. Are you board certified in [Q2]? No * 5. Did you train in an additional specialty/subspecialty? No [TO Q14] 6. What is the second specialty or subspecialty in which you have been trained? Please enter only one response; you will be asked about additional specialties later. 7. In what YEAR did you complete your training in [Q6]?

4 8. Are you board certified in [Q6]? 4 No * 9. Did you train in an additional specialty/subspecialty? No [TO Q14] 10. What is the third specialty or subspecialty in which you have been trained? Please enter only one response. 11. In what YEAR did you complete your training in [Q10]? 12. Are you board certified in [Q10]? No 13. Please list any additional specialties or subspecialties in which you have been trained. Specialty/Subspecialty Specialty/Subspecialty Specialty/Subspecialty Specialty/Subspecialty

5 14. Are you enrolled in Maintenance of Certification? Please check all that apply. No, I have lifetime certification 5 No, my initial certification is still current No, my certification has lapsed, in my primary specialty/subspecialty: [Q2], in my second specialty/subspecialty: [Q6], in my third specialty/subspecialty: [Q10], in another specialty or subspecialty Other (please explain below) Other (please explain) 15. Please indicate your main employment site, that is, the setting in which you spend the most time. Solo practice Non-profit community health center or health dept Pediatric group practice Specialty group practice Multi-specialty group HMO staff/group model Uniform Health Services clinic Medical school/hospital (or parent university) Community/staff model hospital Other (please specify below) 16. Are you a hospitalist? No

6 6 17. What is the zip code of your main employment site? U.S. zip code (5 digits) Canadian zip code Other 18. How would you describe the community type of your main employment site? Urban, inner city Urban, not inner city Suburban Rural 19. During a typical work week, what is the total number of hours you usually work? Hours worked

7 20. During a typical work week, what percent of your time do you spend in the following professional activities? If you do not spend any time in a particular activity, please indicate zero (0) in the appropriate space. Note that your responses should total 100. As a resident or fellow in training - % 7 Direct patient care (include time spent on patient-related record keeping and other office work) - % Administration (include activities related to planning/managing services in hospitals or other health facilities) - % Teaching - % Clinical research - % Basic science research - % Health services research - % Other medical activities not involving the direct care of patients (e.g., committee work, consulting with agencies) - % Other - % * 21. Do you provide direct patient care? No [TO Q31]

8 22. What proportion of your direct patient care time is spent in primary care pediatrics and in subspecialty care? Please note that responses should total 100. primary care pediatrics - % 8 pediatric medical subspecialty (specify area below) - % pediatric surgical specialty (specify area below) - % another specialty, including adult (specify area below) - % 23. Please specify specialty areas in which you provide direct patient care. Pediatric medical subspecialty Pediatric surgical specialty Another specialty (including adult) Other * 24. Do you receive referrals for pediatric patients? No [TO Q28]

9 25. From which sources do you receive referrals? Please check all that apply. Pediatric generalists 9 Family physicians General internists Obstetric/Gynecologists Adult medicine subspecialists Pediatric medical subspecialists/surgical specialists Pediatric nurse practitioners Non-pediatric nurse practitioners Physician assistants Others (please specify below) 26. Do you receive referrals from any of the following sites? Please check all that apply. Urgent care centers Community agencies School districts None of these sites 27. Do your pediatric referrals come from only within your own practice or managed care network? No No, not in a network * 28. Has the volume or complexity of pediatric referrals that you have received in the last 12 months changed compared to previously? No, neither has changed [TO Q31]

10 29. What has changed in the last 12 months? 10 Increased Decreased Not changed Volume of referrals has... Complexity of referred patients has To what do you attribute the change in referrals in the last 12 months? Please indicate below which and how conditions have changed in your area. Please check one for each response. Likelihood of general pediatricians and other generalists to treat LESS complex subspecialty patients has... Likelihood of general pediatricians and other generalists to treat MORE complex subspecialty patients has... The amount of competition with other pediatric subspecialists has... The amount of referrals from adult subspecialists to me has... The number of inappropriate or questionable referrals has... The incidence or severity of illnesses/conditions in my community that I treat has... Other (please specify below)... Increased Decreased Not changed * 31. Do you face competition for your pediatric subspecialty services in your geographical area? No [TO Q35]

11 32. From whom do you face competition for your pediatric subspecialty services? Please check all that apply. General pediatricians 11 Family physicians Other pediatric medical subspecialists/surgical specialists Physicians trained in adult medicine in my subspecialty Non-physician medical personnel (e.g., advanced practice nurses, chiropractors) Related health personnel (e.g., psychologists, nutritionists) Urgent care center Retail based clinic(s) Others (please specify below) * 33. Have you modified your practice as a result of competition with others? No [TO Q35]

12 34. How have you modified your practice as a result of competition with others? Increased Decreased No change 12 Office hours Fees Number of support staff and/or their responsibilities Number of advanced practice nurses employed Number of physician assistants employed Number of physicians for practice Amount of research/administrative activities Other (please specify below) 35. What is the typical waiting time for a non-emergency appointment for a new patient in your principal practice site? Same day 1-2 days 3-7 days 8-14 days 15 days-4 weeks More than 4 weeks to 8 weeks More than 8 weeks to 16 weeks More than 16 weeks

13 36. Have you used telemedicine/telehealth as a part of consultation with another physician or nonphysician clinician? Please check all that apply., for convenience 13, for a group consult, to obtain a second or expert opinion, to provide expert opinion, for patient(s) in a rural area, due to unacceptable wait times No If yes, please specify the types of physicians or non-physician clincians involved, and the format of the consultation. * 37. Have you ever taken an extended leave of absence or sabbatical from the clinical practice of medicine? No [TO Q40] 38. How long were you away from medicine when you took your extended leave? Less than 2 years 2-5 years 6-10 years More than 10 years Please feel free to share any comments you have about your leave.

14 39. Did you engage in any of the following activities to prepare yourself for your return to clinical practice? Please check all that apply. I have not returned to clinical practice 14 Assessment/evaluation program Continuing medical education (CME) courses Mentoring by or shadowing another physician(s) Volunteer activities Formal physician reentry program or mini-residency Other (please specify below) 40. Are you a member of any of the following professional organizations? Please check all that apply. American Academy of Pediatrics (AAP) AAP Section on Otolaryngology - Head and Neck Surgery (SOOHNS) American Society of Pediatric Otolaryngology (ASPO) American Academy of Otolaryngology - Head and Neck Surgery (AAOHNS) American College of Surgeons (ACS) The Society for Ear, Nose and Throat Advances in Children (SENTAC) Other professional society related to otolaryngology (please specify)

15 41. Why did you choose to go into a pediatric subspecialty? Please check all that apply. Enjoy working with children 15 Good match for personality Diversity and scope of practice (i.e., interesting cases) Personally rewarding (i.e., making a difference in children s lives) Influence of mentors Income potential 42. Are you currently practicing pediatric otolaryngology?, practicing pediatric otolaryngology full-time or part-time No, practicing another pediatric subspecialty No, fully retired [TO Q54] Other (please specify below)

16 43. How important was each of the following factors in choosing your current job? What percentage of your practice is clinical? % clinical: 45. What percentage of your clinical volume do you consider to be primary care (care that a general pediatrician should be able to provide)? % primary care:

17 46. What percent of your clinical practice is comprised of adult patients (over the age of 18)? 17 % adult patients: 47. How many surgical procedures do you perform in a typical month, and how many hours in surgery do you spend? If you do not perform surgical procedures, please write "N/A". # procedures/month: # hours/month: 48. How would you describe your current practice? Full-time clinical service (office, hospital) Full-time clinical with research, teaching, and administrative duties. Part-time clinical Part-time clinical with research, teaching, and administration Retired Other (please specify below) 49. How would you describe your current income structure? Salary without a bonus Salary with a bonus Collections based Hourly wage Other (please specify below)

18 50. Are you currently looking for an associate in your practice? 18 No 51. How many colleagues/partners do you have in your group? # colleagues/partners: 52. In the next 5 years, do you plan to: No Don't know Cut back on workload in my surgical specialty Retire from my surgical specialty Move into a non-clinical role in medicine Pursue a different specialty Pursue a career outside of medicine Fully retire 53. If you plan to reduce or leave your surgical specialty practice in the next 5 years, what would be the most important reasons for your leaving? Please rank up to three. Physical wear Emotional stress Lack of job opportunities Inadequate reimbursement Change of professional interest Increased clinical demands Decreased research and/or teaching opportunities Family needs Other (please describe below) Most important Second most important Third most important 54. In your opinion, are we training the correct number of pediatric specialists in your specialty area to meet patient care needs for the next five years? Too few

19 Just the right amount 19 Too many 55. Have you ever been sued? No [TO Q59] 56. How many times have you been sued? Number of times 57. How many of the times you have been sued did the case end up in court? Number of times 58. In how many court trials was a decision made in favor of the plaintiff? Number of decisions 59. What has been the greatest challenge in your relationship with adult/general providers in your subspecialty? * 60. Do you see pediatric patients? No [TO Q98] 61. What percentage of your practice is pediatric otolaryngology? Office (%): Surgery (%): 62. What was the overall length (in months) of your residency training?

20 20 Residency - months 63. How much of your otolaryngology residency training was in pediatric otolaryngology? Months of otolaryngology residency training Proportion in pediatric otolaryngology - % 64. Are you fellowship trained in pediatric otolaryngology? No [TO Q67] 65. How long (in months) was your pediatric otolaryngology fellowship training? Pediatric otolaryngology fellowship - months 66. Which of the following best describes your opinion regarding your pediatric otolaryngology training? My training in pediatric otolaryngology was insufficient My training in pediatric otolaryngology was sufficient My training in pediatric otolaryngology was excessive 67. Which of the following was the most important to you in your pediatric otolaryngology training? 68. How many years have you been in practice? Years in practice 69. How many more years do you plan to be in practice? If you don't know, please write "don't know".

21 21 Planned additional years of practice 70. Do you consider that you currently work full-time or part-time? Full-time Part-time 71. How many residents do you work with? How many fellows do you work with?

22 Many pediatric otolaryngologists divide their time among multiple practice sites. Please provide the zip codes of up to 5 of your practice sites. Please enter the zip code in which you spend most of your time first, and the zip code in which you spend the least amount of your time last. 1 (I spend most of my time here) What is the size of your community (number of individuals who live in the area)? <100, , , , ,999 1,000,000-4,999,999 5,000,000 or more 75. How many otolaryngologists provide care to pediatric patients in your community? Don't know 76. In your opinion, is the number of otolaryngologists providing pediatric care in your community too few, too many, or just right? Too few Too many Just right 77. How many pediatric otolaryngologists provide tertiary pediatric otolaryngology care in your community? 1

23 Don't know 78. In your opinion, is the number of pediatric otolaryngologists who provide tertiary care in your community too few, too many, or appropriate? Too few Too many Just right 79. Is the need for pediatric otolaryngologists in your community stable, increasing, or decreasing? The need is stable [TO Q82] The need is increasing The need is decreasing [TO Q81] 80. Why is the need for pediatric otolaryngologists in your community increasing? Please choose all that apply. The number of children is increasing/has increased There are fewer general otolaryngologists in the community General otolaryngologists are seeing fewer children There are fewer pediatric otolaryngologists in the community There is a greater incidence of ENT disease Other 81. Why is the need for pediatric otolaryngologists in your community decreasing? Please choose all that apply.

24 The number of children is decreasing/has decreased 24 There are more general otolaryngologists in the community General otolaryngologists are seeing more children There are more pediatric otolaryngologists in the community There is a lower incidence of ENT disease Other 82. What do you think the opportunities for employment in your community for a fellowship-trained pediatric otolaryngologist will be over the next three years? Opportunities will be numerous Opportunities will decrease, but jobs will be available Opportunities will be limited to a few positions Opportunities will be extremely limited 83. What do you think the nationwide opportunities for employment of a fellowship-trained pediatric otolaryngologists will be over the next three years? Opportunities will be numerous Opportunities will decrease, but jobs will be available Opportunities will be limited to a few positions Opportunities will be extremely limited 84. In the last 12 months, has the number of children cared for in your practice increased, decreased, or stayed the same? Increased [TO Q86] Decreased Stayed the same [TO Q86]

25 85. What do you believe is the primary reason that the number of children cared for in your practice has decreased over the past 12 months? Please choose one response. Fewer referrals from pediatric primary care providers 25 More competetion from general otolaryngologists More competition from pediatric otolaryngologists Lower incidence of ENT disease in children Personal choice in modifying my practice 86. With respect to the factors that most influence the referral of children in your community, please rank the following in order of importance (1 = most important). To rank, drag and drop the response options into the appropriate order. Managed care affiliations Established referral patterns Location of otolaryngologists/practice Advertising Fellowship training in pediatric otolaryngology Otolaryngology practice limited to pediatrics Reputation Other

26 87. Do you use ancillary personnel to evaluate pediatric patients in your practice? 26 No [TO Q91] 88. How many of the following ancillary personnel do you employ? Nurse Practitioners Physician Assistants Nurses Other (please specify below) 89. If you chose "other", please specify the type and number of additional ancillary personnel you employ here: 90. During the last 12 months, has your total use of ancillary personnel increased, decreased, or stayed the same? Increased Decreased Stayed the same 91. Please estimate the proportion of your pediatric patients in the following areas of pediatric otolaryngology. Please ensure that responses are entered as whole numbers, and that percentages total 100. Otitis media - % Other otologic problems (e.g., SNHL, vertigo) - % Sinonasal disease - % Adenotonsillar disease - %

27 Congenital anomalies (Down's, craniofacial disorders, cleft lip palate, syndromes) - % 27 Airway, voice, swallowing - % Head and neck masses - % Trauma - % Special needs/medically complex/technology-dependent - % Other (please specify below) - % 92. If you chose other, please specify here: 93. Do you believe that the American Board of Pediatrics (ABP) should offer a Certificate of Added Qualifications (CAQ) in pediatric otolaryngology? No Unsure 94. Do you take ER call? No [TO Q97] 95. Are you paid for ER call? No

28 96. At what age does your practice allow you to stop taking ER call and at what age do YOU plan to stop taking ER call? 28 Practice stops call requirement - age in years YOU plan to stop taking call - age in years 97. Why did you choose your current job? Please check all that apply. Reasonable work hours Leadership opportunities Reasonable call responsibilities Interesting patient population Intellectual stimulation Compensation/salary Academic setting Teaching opportunities Research opportunities Quality of the department/partners Ability to define scope of my own practice Geographic location Prestige/reputation of the hospital/medical center Spousal influence Only job available Other Work-life balance You are almost finished! Please take one more moment to answer a few questions about yourself. 98. What is your sex? Male Female 99. Are you of Hispanic, Latino or Spanish origin? No

29 100. What is your race? Please check all that apply. 29 Asian Native Hawaiian or Other Pacific Islander Black/African American American Indian or Alaska Native White Other 101. In what year did you graduate from medical school? 102. What is the location of your medical school? U.S. Canada Other 103. Is there anything else you would like to tell us about your experience in the practice of pediatric otolaryngology or about the future of pediatric otolaryngology training or practice? Thank you for participating in the AAP 2014 Workforce Survey. We appreciate your time!