Is the SLOR in Otolaryngology Residency Applications Contributing to Rural Disparities?

Rural otolaryngology patients experience disparities relative to their urban counterparts. These disparities range from lower rates of tonsillectomies among children with sleep-disordered breathing and longer periods of profound hearing loss before cochlear implantation to greater mortality from head and neck cancer (Otolaryngol Head Neck Surg. doi: 10.1177/0194599821993383; Otol Neurotol. doi: 10.1097/MAO.0000000000001197; Otolaryngol Head Neck Surg. doi: 10.1177/01945998211019278). Reasons for these disparities are multifactorial and are influenced by various socioeconomic factors (Otolaryngol Head Neck Surg. doi: 10.1177/01945998211068822).

While we cannot address all factors that contribute to rural otolaryngology disparities, a potential area we can take ownership of is rural access to otolaryngology care. Unfortunately, a disproportionately low number of otolaryngologists practice in rural settings compared to cities (Laryngoscope. doi: 10.1002/lary.30809). Data indicate this inequity is likely to worsen, with 2.9 otolaryngologists per 100,000 population forecasted to practice in major cities in 2030, while the availability of rural otolaryngologists is forecasted to decline 0.2 to 0.7 per 100,000 (Laryngoscope. doi: 10.1002/lary.30809).

Disparities in rural communities are unlikely to improve and could worsen if the availability of otolaryngologists continues to decline. What then is causing this lack of rural otolaryngologists, and what can be done to address this problem?

Clinical, academic, financial, personal, regional, and training factors all influence where an otolaryngologist practices. We cannot address all factors that influence whether an otolaryngologist chooses to practice in an urban or rural setting. Residency programs can recruit trainees interested in practicing in rural, underserved areas, however. Recruiting some residents interested in rural otolaryngology is a simple, actionable item that residency programs can implement to potentially address this shortage.

Unfortunately, there may be bias in the otolaryngology resident selection process that dissuades programs from matching such applicants. Of particular interest is the standardized letter of recommendation (SLOR), which includes an emphasis on whether an applicant is likely to pursue an academic career. The focus of this commentary is to discuss how the SLOR may be influencing the growing shortage of rural otolaryngologists.

Rural communities require comprehensive otolaryngologists to diagnose, triage, and treat a broad spectrum of pathologies, although the scope of an individual rural otolaryngologist is influenced by the specific needs of the community they serve. A comprehensive rural otolaryngologist may contribute to research by evaluating their clinical experience. Due to logistics often accompanying rural practice and the growing shortage of rural otolaryngologists, however, these surgeons are unlikely to contribute the same degree of time and resources to research as otolaryngologists at urban, academic centers. This is supported by the findings from the 2022 Otolaryngology Workforce Study, where nearly all academic otolaryngologists practiced in urban settings (The 2022 Otolaryngology Workforce. https://tinyurl.com/2mvaczrn). Unfortunately, analysis of the SLOR indicates that the residency selection process may be promoting the recruitment of academic-focused and, therefore, more fellowship-trained and urban-based otolaryngologists instead of the comprehensive otolaryngologists that rural areas need.