Rethinking the Otolaryngology Workforce

Cancer treatment trials using CRISPR/Cas9, a ground-breaking gene-editing technique, are already underway (Nature. 2016;539:479). Other examples abound, particularly in the primary care realm, with the use of big data, diagnostics, and mobile applications.

Technological advancement is inevitable and will naturally eliminate some jobs for the sake of broader gains. Physicians with a narrower focus bear the greatest risk. Generalists have a superior ability to manage idiosyncratic risk than do subspecialists. We have but one choice: how we choose to adapt. In order to do so gracefully, we must have adaptive capabilities able to satisfy two criteria—efficient resource allocation and speed.

Technological advancement is inevitable and will naturally eliminate some jobs for the sake of broader gains. Physicians with a more narrow focus bear the greatest risk. We have but one choice: how we choose to adapt. In order to do so gracefully, our adaptive capabilities must be able to satisfy two criteria—efficient resource allocation and speed.

Subspecialization

Our specialty has become increasingly subspecialized, with approximately 50% of graduates pursuing fellowship training. While the availability of more subspecialists theoretically offers patients better access to safer care, at some point there is a dilutive effect on case volume, which impairs future training. This is bad for our trainees and patients. Concern has been raised about current and future levels of neurotologist supply in this regard (Otol Neurotol. 2013;34:755–761). As technology has provided for less invasive management, surgical treatment of vestibular schwannoma, Menière’s, and other cranial base tumors have been on the decline, even as our trainee supply has remained stable (Otol Neurotol. 2013;34:755-761; Otolaryngol Head Neck Surg. 2015;153:822-831). Unless a paradigm shift occurs, bucking the trend of less-invasive management, we may suffer the same fate as cardiothoracic surgeons at the turn of the 21st century.

Workforce Projections and Retraining

We should also take a more nuanced approach to workforce projections, moving away from per capita goals. These numbers don’t account for variance of subspecialty utilization over time, use of subspecialty skills in practice, lifestyle preferences, inefficiencies in geographic dispersion, or productivity gains we may have achieved by use of second-level providers or operational improvements. Whether we are meeting a public need will be reflected in trends with wait times for office visits and surgery as well as outcome data. We need to know our own specialty-specific data in order to make efficient workforce decisions.

We then must combine our data with projected effects of technological advances to maximize efficient resource allocation with alacrity. Subspecialty societies, led by a diverse group of constituents, could publish regular medium- and long-term workforce projections, incorporating their nuanced utilization data to signal demand to prospective fellows. Learning geographic or inter-subspecialty skill utilization variance and projected subspecialty workforce needs may be enough to allow for more efficient fellowship selection, or none at all.