Of all topics pertaining to medicine, perhaps none is more consequential than our workforce. It affects our ability to meet patient needs in a competent manner, speaks to how we interact and compete with one another, shows the adequacy of our training systems and how they change over time, and handles what may be required of us in the future. The otolaryngology workforce is also a factor in our ability to sustain a rewarding practice and provide for our families. Because its health affects all of us in serious ways, it requires a careful and routine analysis.
Explore This IssueMay 2022
This three-part series is my attempt to provide an updated analysis of where the health of our workforce is headed. In this first part, we’ll examine some evidence from published studies and updated supply models about what’s really happening when it comes to supply and demand in our workforce. Our specialty was initially worried about whether we would have enough otolaryngologists when we perhaps should have been worrying about whether we might have too many.
Historical Supply Figures
To understand our current situation, we need a historical understanding of our workforce supply. While other studies preceded this, the Academy of Otolaryngology–Head and Neck Surgery (AAO-HNS) commissioned a workforce study in the late 1990s. Among many important findings in this study was that in 1997 we had 9,017 otolaryngologists, or 3.36 otolaryngologists per 100,000 population. It was thought that this overage would correct itself over the ensuing 20 years to the managed care demand range estimate of 1.8 to 3 otolaryngologists per 100,000 due to the aging of the workforce and population growth (Otolaryngol Head Neck Surg. 2000;123:341-356).
A follow-up study was commissioned and published in 2004. The authors made some interesting observations—in particular, that the workforce supply trends were the opposite of those that had previously been projected. The total number of otolaryngologists and number per 100,000 population were increasing in all areas of the country. We had risen from 3 otolaryngologists per 100,000 in 1995 to 3.2 per 100,000 in 2002 (Otolaryngol Head Neck Surg. 2004;131:1-15). An American College of Surgeons Bulletin article in 2012 also supported the idea that our supply per 100,000 was increasing, with 2.72 otolaryngologists per 100,000 population in 1981 rising to 3.32 per 100,000 in 2006 (ACS Bulletin. March 1, 2012). A slight decline to 3.26 was noted around 2009. And it was then that the shortage narrative surfaced.
Several studies peering into the horizon sounded alarm bells about the otolaryngology supply. While the American Association of Medical Colleges (AAMC) issued attention-grabbing headlines, starting in the 2010s, about looming shortages of tens of thousands of physicians, we had specific studies highlighting our apparently dire situation.
Predictions of severe specialty shortages over the next 20 years began as early as 2002 (Acad Med. 2002;77:761-766). New modeling forecast a shortage of between 1,600 (HRSA. 2016;1-14) and 2,300 (Otolaryngol Head Neck Surg. 2012;146:196-202) otolaryngologists per 100,000 by 2025, and 2,500 by 2030 (Ann Surg. 2009;250;590-597). New demand estimates from the 2012 paper also showed that we now needed 3.11 otolaryngologists per 100,000 population, which accounted for part of our expected shortfall.
One of the more recent analyses of our workforce supply, published in 2016, showed that we had 10,522 otolaryngologists in 2011 and 10,800 in 2014 (Laryngoscope. 2016;126:S5-S11). Despite these supply increases, we were still projected to have a shortfall. What struck me about this last study is that we were edging closer to the time periods of predicted supply shortfalls, yet our supply (and supply per 100,000 population) was increasing. I began to question the supply numbers we’d been relying on. Every study, save this most recent study, had used American Medical Association (AMA) supply data.
This begged the question as to whether AMA data are even accurate. I believe there’s reason to be skeptical.
To try to understand the accuracy of the AMA supply data, I looked at the American Urological Association (AUA) census data, which has been gathered since 2014. The AUA uses two internal databases implying some level of active practice (AUA roles and board certification data) as well as the NPI file data to construct a list of possible practicing urologists and then further ensures ongoing practice by confirming names on at least two of these databases. Physicians not meeting this criteria are then systematically checked to ensure each individual is still practicing—if physicians aren’t found, they aren’t included. The AAMC publishes a specialty data report every other year using the AMA physician master file that most of the previous studies used. Data were available for recent odd years for comparison.
The total urology workforce was approximately 28% greater than the AMA numbers would suggest. The AMA supply data are based on an “actively practicing” definition of 20+ hours of work per week. The AUA also calculates “actively practicing” urologists, although their criteria for active practice is more stringent at 25+ hours per week. And, under these more stringent definitions, the AUA workforce supply analysis was still between 1% and 11% greater than the AMA supply numbers over the three comparison years (Table 1).