Pediatric Otolaryngology in the United States: Demographics, Workforce Perceptions, and Current Practices

Objectives  To evaluate self-reported workforce needs and demands, professional activities, and the clinical practices of pediatric otolaryngologists in the United States for the purpose of better understanding the pediatric otolaryngology workforce and predicting manpower needs.

Design  A Web-based survey was sent to all members of the American Society of Pediatric Otolaryngology (ASPO). It achieved a 39.3% response rate, with a total of 99 US member respondents. We compared this sample to the overall US ASPO membership to determine if our respondent cohort was representative of ASPO demographics.

Participants  All members of ASPO.

Main Outcome Measures  Responses were categorized by demographics and nature of respondent practice (academic vs private practice).

Results  Respondents were representative of the US ASPO membership. Most of the respondents practiced in an academic setting (n = 70; 70%). Academicians reported seeing a higher percentage of patients with Medicaid public insurance than did private practitioners (34% vs 25.0%) (P = .03). Academicians spent a greater portion of their time than private practitioners on research (14.4% vs 6.6% of time) (P < .001) and teaching (26.9% vs 12.8% of time) (P = .002). With the exception of choanal atresia repair, there were no differences in the types of airway, otologic, head and neck, and plastic and reconstructive surgery performed by the 2 groups. Although fewer than half of the respondents (47%; n = 44) believed that there presently is a shortage of pediatric otolaryngology manpower, most (68%; n = 63) (P = .01) believed that there would be a shortage in 5 years.

Conclusions  Pediatric otolaryngologists predict an increased demand for their services in the near future. The only differences in the clinical practices of academic and private pediatric otolaryngologists are patient payer mix and the amount of time devoted to teaching.

Pediatric otolaryngology is now an accredited discipline for training, with fellowships accredited by the Accreditation Council on Graduate Medical Education. Controversies remain centered on the content of the pediatric otolaryngology practice as well as the actual workforce needs for such subspecialists. Legitimate concerns exist over competition between general otolaryngologists and pediatric otolaryngology subspecialists for the more common pediatric diagnoses and treatments involving otitis media and adenotonsillar disease.¹ The diseases and types of surgical cases that are most appropriately handled by the pediatric otolaryngologist in a pediatric medical facility are also a subject of debate. These concerns are tempered by the fact that most pediatric otolaryngologists practice in urban tertiary referral centers in large metropolitan areas, and most general otolaryngologists practice in smaller centers. The scopes of general otolaryngology and pediatric otolaryngology practices have been found to differ in 1 report.²

The manpower required to provide appropriate pediatric otolaryngology care now and in the future has not been established. The hospital-based model described by Zalzal³ (1) assumes that most, if not all, pediatric otolaryngologists will be based in academic situations or in children's hospitals with an active pediatric practice and (2) estimates that a total of only 382 pediatric otolaryngologists are needed to staff all free-standing children's hospitals and residency programs in the United States. However, concerns exist that as more pediatric otolaryngologists are trained, some will move away from the academic setting into community-based private practices and into direct competition with general otolaryngologists.¹

The present study was performed at the request of the American Society of Pediatric Otolaryngology (ASPO) board to get a sense of the workforce demographics of the subspecialty and its future needs. The study was designed specifically to render a current description of pediatric otolaryngologists in the United States, their perceived workforce needs and demands, professional activities, and types of clinical practices, particularly private vs academic practices. The results of the study will answer questions about scope of practice and perceived manpower needs.

A 4-item, 11-question survey was developed to obtain information from pediatric otolaryngologists about their demographics, practice setting, the clinical-surgical mix in their practices, and estimated workforce needs (Table 1). The questionnaire was reviewed by a small group of pediatric otolaryngologists and revised based on comments received.

The Web-based questionnaire was sent as a uniform resource locator (URL) Web link via e-mail by the ASPO Webmaster to all of its US members. Three separate e-mails inviting members to participate in the survey were sent between July 2006 and October 2006. Each e-mail contained a cover letter emphasizing the importance of the questionnaire. Respondents had to link to the Web page containing the questionnaire to answer the items. Average response time was 9 minutes, 5 seconds. We received responses from 99 US ASPO members, 39.3% of the membership. Demographic characteristics of the respondent group were compared with those of all of the ASPO membership to determine if our sample was demographically representative of the membership.

For statistical analysis, we categorized the respondents by practice setting, private or academic, and whether they had completed a pediatric otolaryngology fellowship or not. For continuous variables, comparisons between groups were performed using 2-tailed independent t tests. For categorical variables, comparisons between groups were performed using χ² tests. Significance level was set as P < .05. The number of respondents fluctuated slightly based on missing answers for individual questions.

In line with the overall US ASPO membership, most respondents were aged 36 to 50 years (67%; n = 66) and male (75%; n = 74). Most had completed a pediatric otolaryngology fellowship (85%; n = 84) and practiced in an urban area (98%; n = 97), in most cases with a larger than 1 million population size (77%; n = 76). The distribution of respondents was generally equal across national regions (Northeast, Midwest, South, and West). There were no statistical differences between our respondents' demographic characteristics and those of the US ASPO membership (sex, 75% men in our group [n = 74] vs 79.7% in overall US ASPO) (P = .33), practice area population (77% in our group [n = 76] vs 69.8% US ASPO practiced in areas with >1 million population) (P = .19), or regional distribution (26% Northeast [n = 26], 28% Midwest [n = 28], 24% South [n = 24], and 21% West [n = 21] in our group vs 28.6% Northeast, 26.6% Midwest, 27.8% South, and 17.1% West in US ASPO) (P = .33).

Also reflecting the US ASPO membership data, most of the respondents identified their practice setting as academic (70%; n = 70). Although a higher percentage of respondents who practiced in an academic setting were in the younger age group (36-50 years) compared with the respondents who practiced in a private setting (71% [n = 49] vs 59% [n = 17]), this difference was not statistically significant (P = .19).

We determined the identifiable differences in the professional activities and clinical practice composition of academic vs private practice respondents. Academicians reported seeing a significantly higher percentage of patients with Medicaid public insurance compared with private practitioners (34% vs 25%) (P = .03). Conversely, academicians also reported seeing a significantly lower percentage of patients through a preferred provider organization (19.7% vs 27%) (P = .02). There were no statistically significant differences reported by academicians vs private practitioners in the proportion of patients seen as part of a health maintenance organization (23% vs 29%) (P = .09), with private indemnity insurance (18% vs 14%) (P = .18), or as self-payers (5% vs 6%) (P = .63). The reported percentage of time devoted to research and teaching was significantly higher for academicians than for private practitioners (14.4% vs 6.6% of time devoted to research) [P < .001] and 26.9% vs 12.8% of time devoted to teaching [P = .002]).

Overall, survey respondents reported that general otolaryngology cases made up the largest proportion of their practices (48.8%), followed by pediatric airway cases (17.2%), otology cases (9.8%), head and neck cases (7.6%), and finally plastic and reconstructive cases (4.1%). There were no differences in the surgical case mix of academicians and private practitioners (Table 2). Academicians reported seeing more general otolaryngology patients with complex comorbidities than did private practitioners (38.6% vs 25.1%) (P = .004). Within rhinology cases, academicians reported a significantly higher proportion of choanal atresia cases (11.5% vs 6.9%) (P = .03). However, there were no other differences between responding academicians and private practice physicians in airway, otology, head and neck, or plastic and reconstructive cases.

Similarly, when comparing the survey answers of those respondents who reported completing a pediatric fellowship (85%; n = 84) vs those who did not (16%; n = 15) there were no differences in the proportions of airway, otology, head and neck, and plastic and reconstructive cases reportedly performed overall by the 2 groups.

Approximately half (50%; n = 46) of all survey respondents felt that they were not currently meeting the pediatric otolaryngology needs of their institutions and communities because their practices were too busy. Fewer than 5% of respondents felt that their practices were not busy enough (n = 4). The remaining 47% of the respondents felt that their practices were adequately meeting the institutional demands (n = 43). Responses for meeting the referral area needs roughly paralleled those pertaining to the institutional needs. There were no differences in these responses between academicians and private practitioners.

Most practitioners responded that their practices were currently seeking to hire a physician and/or a physician extender (92%; n = 90). Over two-thirds of respondents stated that they were currently seeking an additional pediatric otolaryngologist (68%; n = 66) and roughly one-quarter were trying to hire a general otolaryngologist (24%; n = 23). For those hiring nonotolaryngologist physicians and physician extenders, 38% were hiring a nurse practitioner (n = 37), 20% a physician assistant (n = 19), 18% a registered nurse (n = 17), and 5% a primary care physician (n = 5) (Table 3).

Mean wait times reported by respondents for scheduling in their practices were 6 weeks for routine appointments and 5.2 weeks for surgery. Academicians reported a longer mean wait time for routine appointments than private practice pediatric otolaryngologists (6.4 vs 4.8 weeks) (P = .047). There was no difference in the average wait time for surgical scheduling between the 2 groups.

The respondents were asked to estimate the status of the overall workforce supply in pediatric otolaryngology. Half of respondents felt that the workforce is adequate to meet the current health care community demands (n = 46); 47% felt that there is currently a shortage of pediatric otolaryngologists (n = 44), while only 3% felt that there is a surplus (n = 3). When asked to predict the workforce needs in 3 years, the responses were similar: 47% of respondents felt that the demands would be adequately met at that time by the pediatric otolaryngology supply (n = 44) and 48% felt that there would be a shortage (n = 45), while only 4% felt that there would be a surplus (n = 4). However, when compared with the current workforce estimates, a higher percentage of respondents felt that there would be a shortage of pediatric otolaryngologists in 5 years (68%; n = 63) (P = .01). Academicians were more likely to respond that presently there are, and in 3 years there will be, shortages in pediatric otolaryngology supply manpower compared with predictions of private practitioners (Table 4); but these differences were not statistically significant. In 5 years, most of both academicians and private practice otolaryngologists agreed that a pediatric otolaryngology manpower shortage will exist.

The main objective of this study was to present a description of the current characteristics of pediatric otolaryngologists in the United States, describing their perceived workforce needs and demands, professional activities, and clinical practices. We sought to compare the practices and attitudes of pediatric otolaryngologists in practice in private and academic settings. This analysis investigated whether private pediatric otolaryngologists are engaged in a more general based practice and so might be more likely to erode the practice of general otolaryngologists.

The results of our survey mirror ASPO membership information and the findings of American Academy of Pediatrics–sanctioned survey by Tunkel et al² in that most respondents practice in a large, urban, academic environment. The demographic characteristics of our respondents were not different than those of the US ASPO membership. Most respondents were male (75%; n = 74), had completed a pediatric otolaryngology fellowship (85%; n = 84), and practiced in a well-populated urban area (77%; n = 76), most usually in an academic setting (70%; n = 70). Respondents were distributed generally equally across national regions. Almost all respondents in the younger group (<50 years) had completed a pediatric otolaryngology fellowship. This finding makes sense because it reflects that younger physicians joining ASPO are doing it solely on the basis of fellowship training, and no further “grandfathering” into ASPO is occurring. Also reflected in our respondent demographics is the fact that most female pediatric otolaryngologists are in the younger age group (<50 years).

Our survey found few differences between academic and private pediatric otolaryngologists as far as the make up of their clinical practices. Not surprisingly, academicians reported seeing a higher proportion of patients covered with Medicaid public insurance. These responses likely reflect the payer mix of large academic urban health centers^4-6 and the possibility that some patients are being transferred or referred to academic practices in part on the basis of their insurance status. As might be expected, given the nature of academic medicine, academicians reported spending double the proportion of time in research and teaching activities.

When clinical-surgical case mix was addressed, approximately half of the clinical-surgical practice involved general otolaryngology cases. Within this case mix category academicians were more likely to report seeing patients with complex comorbidities, although the percentage of patients with general otolaryngology problems but complex comorbidities reported by both academicians and private practitioners was relatively high (>25%). Except for choanal atresia cases, there were no other significant differences when comparing the subtypes of airway, otology, head and neck, and plastic and reconstructive cases reportedly performed by the academician and private practitioner survey respondents, including proportion of open airway reconstructive procedures. The results of our survey therefore do not demonstrate major differences in the overall proportion of clinical-surgical case practices of academicians vs private practitioners. Similarly, there were no differences in the proportion of subtypes of cases reported by those who had completed a pediatric fellowship and those who had not, also including open airway procedures and cochlear implants. Thus, pediatric otolaryngologists in private practice do not appear to have less complex, more general based practices than academicians.

However, the results of our study must be interpreted with caution. The overall response rate was low. Only 26 total private practitioners responded to our survey, and it is quite possible that those private practitioners who primarily engage in general otolaryngology work elected to not respond to the survey. Furthermore, the survey did not include self-designated pediatric otolaryngologists who are not ASPO members. Future surveys that include a broader range of pediatric otolaryngologists and community general otolaryngologists would be useful to help demonstrate how their pediatric practices differ from those reported by pediatric otolaryngologists in the present survey.

The demand for pediatric otolaryngologists continues to increase, at least as perceived by pediatric otolaryngologists. This workforce need seems to be increasing in future projections. In fact, half of respondents felt that currently their practices were too busy to meet the demands of their institution and referral area. This perception is reinforced by the fact that 92% of all respondents indicated that they were currently in the process of hiring a partner into their practice (n = 90), and it reflects the finding that wait times are currently 6 weeks for new appointments and 5.2 weeks to schedule surgery, arguably too long for managed care plans and good patient care. Furthermore, the use of physician extenders among pediatric otolaryngologists appears to be growing. Finally, the finding that the academic pediatric otolaryngologists are able to spend only 40% of their time with research, teaching, and administrative functions further advances the argument that the workforce needs to be expanded.

It is difficult to estimate what the exact figures of pediatric otolaryngologists needed per 100 000 people are. Miller⁷ estimated that there would be a need of 2.8 general otolaryngologists per 100 000 population in the year 2010. Estimates along the same lines are lacking for pediatric otolaryngology. In 1996, Zalzal³ concluded that 382 total pediatric otolaryngologists would be needed in the United States to staff all tertiary institutions and that this need was likely to be met in 7 years. The model at that time assumed that 2 pediatric otolaryngologists would be needed per children's hospital and 1 per residency program. However, clearly not all pediatric otolaryngologists are based at academic or children's hospitals. Presently there are 46 freestanding children's hospitals and 73 children's hospitals within primary teaching hospitals that are members of the National Association of Children's Hospitals and Related Institutions (NACHRI). According to NACHRI and ASPO membership information, 97 ASPO member pediatric otolaryngologists (63%) staff 29 of the 46 freestanding children's hospitals and 35 ASPO members (30%) staff 22 of the 73 children's primary teaching hospitals. Twenty-eight ASPO members staff non-NACHRI university teaching hospitals. Thus, given that we only sampled ASPO members, our survey did not capture a large portion of otolaryngologists providing pediatric services. Whether those NACHRI institutions that are not currently being staffed by pediatric otolaryngologists are having their pediatric otolaryngology needs met adequately is a question that should be addressed in future studies that attempt to estimate pediatric otolaryngology manpower needs.

The limitations of the present study are evident in the survey format and design. The responses merely reflect opinions and estimates and are not based on objective data. Our US ASPO member response rate was low (<50%). There may be a group of otolaryngologists who define themselves as pediatric otolaryngologists but do not belong to ASPO. Our survey did not analyze or study the appropriate distribution of pediatric otolaryngologists and only compared those defining themselves as academic vs private to make inferences about potential practice conflicts with general otolaryngologists. Future studies should analyze more closely and objectively the adequacy of the current workforce in meeting the needs for pediatric otolaryngology in the hospital referral areas they serve. Surveys of groups of patients and consumers, referring physicians such as family practice doctors and pediatricians, and hospital administrators may provide additional useful information about pediatric otolaryngology workforce needs.

In conclusion, pediatric otolaryngologists predict an increased demand for their services in the near future. Over 90% of survey respondents were hiring partners or physician extenders into their practices (n = 90). The only differences in the clinical practices of academic and private pediatric otolaryngologists are patient payer mix and the amount of time devoted to teaching.

Correspondence: Diego Preciado, MD, PhD, Division of Pediatric Otolaryngology–Head and Neck Surgery, Children's National Medical Center, 111 Michigan Ave NW, Washington, DC 20010 (dpreciad@cnmc.org).

Submitted for Publication: February 4, 2008; final revision received April 21, 2008; accepted April 23, 2008.

Author Contributions: Dr Preciado had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Preciado, Tunkel, and Zalzal. Acquisition of data: Preciado. Analysis and interpretation of data: Preciado, Tunkel, and Zalzal. Drafting of the manuscript: Preciado. Critical revision of the manuscript for important intellectual content: Preciado, Tunkel, and Zalzal. Statistical analysis: Preciado. Administrative, technical, and material support: Preciado. Study supervision: Zalzal.

Financial Disclosure: None reported.

Previous Presentation: This study was presented at the 2008 American Society of Pediatric Otolaryngology Scientific Program; May 4, 2008; Orlando, Florida.