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Geographic distribution of otolaryngologists in the United States

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June 14, 2016
by Thad W. Vickery, BA; Robbie Weterings, PhD; Cristina Cabrera-Muffly, MD

Abstract

We conducted a study to determine the demographic traits, training characteristics, and geographic distribution of otolaryngologists in the United States using publicly available data. We then correlated our findings with U.S. census data. Univariate analysis was performed to analyze results, with a p value of <0.05 determined as significant. We used data from the American Board of Otolaryngology's list of 18,587 board-certified allopathic otolaryngologists through 2013 and the American Osteopathic Colleges of Ophthalmology & Otolaryngology-Head & Neck Surgery's list of 428 osteopathic otolaryngologists. From these two databases, 9,642 otolaryngologists met inclusion criteria, which included an active practice in the United States and an age of 70 years and younger. This group was made up of 8,185 men (84.9%) and 1,449 women (15.0%); we were not able to identify the sex of 8 otolaryngologists (0.1%). The median age of the women was significantly lower than that of the men (54 vs. 48 yr; p < 0.001). A total of 8,510 otolaryngologists (88.3%) graduated from a U.S. allopathic medical school, and 8,520 (88.4%) graduated from a U.S. allopathic residency program. We determined that 25.9% of otolaryngologists established their practice in the same metropolitan statistical area where they completed their residency training. Older practitioners (p < 0.001) and women (p < 0.001) were significantly more likely to stay in the same area than younger physicians and men. In terms of population, 61.8% of the otolaryngologists practiced in metropolitan areas with more than 1 million residents; by comparison, these areas represent only 55.3% of the total U.S. population, indicating that otolaryngologists are over-represented in larger U.S. cities.


Introduction

Understanding the geographic distribution of the otolaryngology workforce is essential to directing policy and planning for increases in patient visits. Factors such as population growth and healthcare reform coupled with limited expansion of otolaryngology training positions are placing increasing demands on the current otolaryngology workforce.1,2 The authors of previous studies have concluded that there is an impending shortage of otolaryngologists nationally, but data to identify the specific geographic areas lacking otolaryngologists are either nonexistent or out of date.3-5 Furthermore, little is known about those specific personal characteristics of practicing otolaryngologists that have an impact on the location of their practices.

The Association of American Medical Colleges' 2013 State Physician Workforce report showed that 47.4% of all physicians practiced in the same state where they completed their residency training and that 38.7% practiced in the same state where they completed their undergraduate medical training.6 Retention statistics were not calculated for otolaryngologists specifically, but they are likely different since many otolaryngology residents must relocate to distant communities to pursue their careers.

Cannon et al estimated that 1 otolaryngologist for every 40,000 population is sufficient to provide comprehensive patient care.4 This information is useful for anticipating national shortages. However, it does not reflect the current workforce situation, since most otolaryngologists practice in cities, leaving rural areas in the United States lacking otolaryngologic care.

In this article, we describe our study to quantify the demographic and training characteristics of otolaryngologists in relation to the location of their practices. By comparing the geographic distribution of otolaryngologists with U.S. census data, we have attempted to better identify specific counties that have a shortage of otolaryngologists. These data are necessary for sound policy making because they can be used to develop strategies to deliver care to rural areas, where there are often proportionally higher numbers of uninsured and Medicaid patients.7


Methods

We reviewed the American Board of Otolaryngology (ABOto) public database and identified all board-certified otolaryngologists listed therein through 2013.8 Data from 2014 and 2015 were excluded from our analysis to account for recent graduates from residency programs who might relocate during the data collection period or who might pursue further fellowship training before settling at their final practice location. We also reviewed data from the website of the American Osteopathic Colleges of Ophthalmology & Otolaryngology-Head & Neck Surgery (AOCOO-HNS), which listed 428 osteopathic otolaryngologists.9

Data on the age, sex, training, subspecialty certification, and location of the current practice for each otolaryngologist were obtained from publicly available Internet-based physician databases (e.g., healthgrades and U.S. News & World Report's Doctor Finder) and from state medical board databases. This information was independently confirmed and supplemented with information obtained from institutional and individual otolaryngologist websites when available.

Exclusion criteria included graduation from medical school before 1965, age older than 70 years, and board certification before 1970. We also excluded otolaryngologists who were no longer practicing and those who did not practice in the United States.

Population data for each county and metropolitan statistical area in the United States-including Alaska and Hawaii-were compiled on the basis of the U.S. Census Bureau's 2013 estimates.10 Census data were also used to define metropolitan statistical areas and U.S. regions and divisions. The four census regions in the United States are the Northeast, Midwest, South, and West. Each region is divided into divisions, which is what we used to analyze the distribution of otolaryngologists. The nine divisions are New England and Middle Atlantic (Northeast); East North Central and West North Central (Midwest); South Atlantic, East South Central, and West South Central (South); and Mountain and Pacific (West).

Statistical analysis was performed with JMP 12.0 software. Univariate analysis was performed with a p value of <0.05 determined as significant.

Approval of the study protocol was granted by the Colorado Multiple Institutional Review Board.


Results

The ABOto database listed 18,587 board-certified otolaryngologists through 2013; of these, 9,233 otolaryngologists met our inclusion criteria. (The reason for the large exclusion rate is that the database included every otolaryngologist who had ever been board-certified since 1925, almost half of whom were deceased or no longer practicing.) Of the 428 osteopathic otolaryngologists listed by the AOCOO-HNS, 409 met our inclusion criteria. Data on sex, medical school, residency, year of board certification, and practice location were obtained for more than 99% of these otolaryngologists; only 84.1% of the subjects' ages were reported in the databases.

Age and sex. A total of 8,185 otolaryngologists (84.9%) were men (median age: 54 yr) and 1,449 (15.0%) were women; we were not able to identify the sex of 8 otolaryngologists (0.1%). The median age of the women was significantly lower than that of the men (54 vs. 48 yr; p < 0.001) (figure 1).


Figure 1. Graph shows the age and sex distribution of the 8,104 otolaryngologists for whom data on both age and sex were available.

Training. A total of 8,510 otolaryngologists (88.3%) graduated from a U.S. allopathic medical school, and 481 (5.0%) graduated from a U.S. osteopathic medical school; the remainder fell into other categories. Similarly, 8,520 (88.4%) graduated from a U.S. allopathic residency program, and 404 (4.2%) graduated from a U.S. osteopathic residency program, with the rest classified in other groups (table 1).

Table 1. Medical school and residency training characteristics of otolaryngologists

Medical school, n (%)

Residency, n (%)

U.S. allopathic

8,510 (88.3)

8,520 (88.4)

U.S. osteopathic

481 (5.0)

404 (4.2)

Military

87 (0.9)

529 (5.5)

Canada

136 (1.4)

112 (1.2)

Non-U.S./Canada

419 (4.3)

20 (0.2)

Missing

9 (0.1)

57 (0.6)

Total

9,642 (100)

9,642 (100)

Of the 8,407 otolaryngologists who completed both civilian medical school and civilian residency training in the United States, 2,825 (33.6%) served their residency in the same metropolitan statistical area where they received their undergraduate medical training. Older practitioners were more likely to have completed medical school and residency in the same area than were younger practitioners (p < 0.001), but there was no difference between the sexes (p = 0.77).

In terms of the regional divisions of the United States, otolaryngologists were just as likely to stay in the same division for residency training after medical school as to leave.

Current practice location. Of the 8,910 otolaryngologists who completed civilian medical school in the United States, 1,735 (19.5%) currently practiced in the same metropolitan statistical area where they completed medical school. Of the 8,794 otolaryngologists who completed a civilian residency program in the United States, 2,277 (25.9%) practiced in the same metropolitan area where they served their residency. Again, older practitioners (p < 0.001) were more likely to do so than their younger counterparts, and women were more likely to do so than men (p < 0.001).

On the larger scale, otolaryngologists were equally as likely to stay in a particular division for practice after residency as to leave. Again, older practitioners were more likely to stay in the same division after medical school (p < 0.001) and after residency (p < 0.001), but there was no difference in geographic retention by sex (p = 0.11 and p = 0.81, respectively).

Practice location according to population. A total of 5,961 otolaryngologists (61.8%) practiced in metropolitan areas with a population of more than 1 million, although these areas represent only 55.3% of the total U.S. population. Among the 3,142 counties in the United States, those with the greatest number of otolaryngologists were centered within or adjacent to major cities (figure 2). While heavily populated counties had the highest number of practicing otolaryngologists, 2,064 counties (65.7%) did not have a single otolaryngologist in practice (table 2).


Figure 2. Map shows the distribution of otolaryngologists by county in 2013.

Table 2. Number of otolaryngologists per county

Otolaryngologists, n

Counties, n (%)

Mean population

0

2,064 (65.7)

21,358

1

323 (10.3)

59,527

2 to 5

406 (12.9)

114,537

>5

349 (11.1)

595,130

Total

3,142 (100)

N/A

We also categorized the 3,142 counties into approximate quartiles based on population; the four categories were fewer than 10,000 residents, 10,000 to 24,999, 25,000 to 74,999, and 75,000 or more (figure 3). We then analyzed the number of otolaryngologists in each quartile. We found that 8,949 otolaryngologists (92.8%) practiced in the top population quartile (table 3). MD and DO physicians were similarly distributed among county population quartiles.


Figure 3. Map shows the number of otolaryngologists per 10,000 residents by county in 2013.

Table 3. Distribution of otolaryngologists by U.S. county population

Quartile

Counties, n

Population range

Otolaryngologists, n (%)

1st

733

≥75,000

8,949 (92.8)

2nd

875

≥25,000 to <75,000

626 (6.5)

3rd

832

≥10,000 to <25,000

63 (0.7)

4th

702

<10,000

4 (<0.1)

Total

3,142

N/A

9,642 (100)

The median population of all U.S. counties was 25,733. When we compared the number of otolaryngologists who were practicing in counties with more and less than 25,000 people, we found no significant difference between the two population groups in terms of age or sex.


Discussion

The main objective of our study was to quantify the demographic and training characteristics of otolaryngologists in relation to the eventual location of their practice. The second objective was to correlate the geographic distribution of otolaryngologists with population density according to census data to better identify current shortages.

Age. We were able to capture age information on 84.1% of the otolaryngologists in our dataset from either their state medical board listing or a Web-based physician database. Compared with the workforce data reported by Neuwahl et al,2 our data suggest that the mean age of otolaryngologists in the United States increased slightly between 2009 and 2013 from 44.4 to 49.2 years for women and from 52.0 to 54.0 for men.2 This may be partially explained by the aging of the workforce and the fact that this trend is not being fully offset by an influx of new otolaryngologists. However, most of the otolaryngologists for whom age information was unavailable had been board-certified within the previous 10 years. As a result, the actual average age of the otolaryngologist workforce is likely to be younger that what is reported here.

Sex. According to our findings, the percentage of women practicing otolaryngology increased from 11.6% in 2009 to 15.0% in 2013. While men continue to be over-represented in the otolaryngology workforce, these data show that the proportion of women practicing otolaryngology continues to increase.

Practice location according to training. Compared with physicians of all disciplines, we found that otolaryngologists were less likely to practice in the same metropolitan statistical area where they completed medical school (19.5% of otolaryngologists vs. 38.7% of all physicians), and they were less likely to remain in the same area where they completed their residency (25.9 vs. 47.4%, respectively).

The lower retention rate is likely explained by several factors. First, our specialty has a competitive residency match that drives applicants to apply broadly to programs all across the United States and forces many trainees to leave their school area. Second, there are only 100 allopathic otolaryngology residency programs in the United States. Third, based on the recommended ratio of 1 otolaryngologist to 40,000 population, 91 of these residency programs are located in saturated metropolitan areas, which provides no incentive for graduates to establish a practice there.

Practice location according to age and sex. The observation that older otolaryngologists are significantly more likely to remain in the same geographic division for practice as their residency training is likely multifactorial. Older individuals are also more likely to have completed medical school and residency at the same institution, which may explain their higher rates of retention within the same metropolitan statistical area. We believe the fact that younger otolaryngologists were more mobile reflects both the increased ease of long-distance travel over time and a greater willingness to pursue job opportunities in distant locations.

Women were just as likely as men to stay in the same geographic area when transitioning from medical school to residency, but more likely to stay for practice after residency. In terms of regional divisions, women were just as likely as men to practice in the same division as their residency.

The likelihood that an otolaryngologist would practice in a county with greater or less than 25,000 persons did not vary by age or sex. Despite the vast difference in the numbers of male and female otolaryngologists, when it comes to geography, the two sexes generally behave similarly.

Practice location according to population. Our finding that most otolaryngologists practice in cities is consistent with previously published data. Almost two-thirds of counties in the United States lacked a practicing otolaryngologist; the mean population of these counties was 21,358. Clearly, a significant percentage of the United States does not have access to a local otolaryngologist.

Previous studies have demonstrated the effectiveness of rural outreach and visiting consultants to expand access to surgical subspecialties in lightly populated areas.7,11 Our data are especially useful to states in order to quantify needs within individual counties and to develop ways of increasing access for residents of rural counties. Of note, we found that Kearny County (pop.: 3,923) in Kansas was the smallest county to have a practicing otolaryngologist, while Montour County, a fairly rural county in central Pennsylvania, was the most saturated county, with 8 otolaryngologists serving a population of 18,541 (ratio: 4.3:10,000).

Study limitations. Whereas other reports on the geographic distribution of physicians have been based on data from the American Medical Association's Physician Masterfile, our method provided a unique, independent datapoint by using alternate sources of publicly available information. However, since our data do not have any antecedent data collected by the same methods, we are unable to make any direct comparisons, which made it difficult to quantify any trends in workforce characteristics.

Our method of data acquisition was wholly dependent on information from various state medical boards and publicly available websites. Several states do not publish all the information that we desired. Also, our database did not include non-board-certified foreign-trained otolaryngologists who are practicing in the United States. This might have affected the density rates in our geographic analysis.


Conclusion

Our data provide a comprehensive and very recent snapshot of the geographic areas with the greatest need for otolaryngologic care. While other studies have suggested an impending shortage of otolaryngologists nationwide,3-5 our data suggest that there are significant areas of the United States with inadequate otolaryngology coverage now. This should prompt an immediate discussion of national funding for graduate medical education positions in otolaryngology, the current length of otolaryngology training, and new strategies for healthcare delivery to counties with small populations.



References

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  9. American Osteopathic Colleges of Ophthalmology & Otolaryngology-Head & Neck Surgery. http://www.aocoohns.org/health-resources/otolaryngology/find-an-otolaryngologist/. Published 2016. Accessed April 5, 2016.
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From the Department of Otolaryngology, University of Colorado School of Medicine, Aurora (Mr. Vickery [student] and Dr. Cabrera-Muffly); and the Department of Natural Resources and Environment, Naresuan University, Phitsanulok, Thailand (Dr. Weterings). The study described in this article was conducted at the University of Colorado.
Corresponding author: Cristina Cabrera-Muffly, MD, Department of Otolaryngology, University of Colorado School of Medicine, 12631 E. 17th Ave., Room 3110, Aurora, CO 80045. Email: cristina.cabrera-muffly@ucdenver.edu
Ear Nose Throat J. 2016 June;95(6):218-223