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Practice of Pediatric Otolaryngology
Results of the Future of Pediatric Education II Project
David E. Tunkel, MD;
William L. Cull, PhD;
Ethan A. B. Jewett, MA;
Sarah E. Brotherton, PhD;
Carmelita V. Britton, MD;
Holly J. Mulvey, MA
Arch Otolaryngol Head Neck Surg. 2002;128:759-764.
ABSTRACT
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Objectives To define the practice of pediatric otolaryngology compared with general
otolaryngology and to estimate pediatric otolaryngology workforce utilization
and needs.
Methods Survey of members of the American Academy of Pediatrics Section on Otolaryngology
and Bronchoesophagology and the American Society of Pediatric Otolaryngology
and of a random sample of the membership of the American Academy of Otolaryngology–Head
and Neck Surgery.
Results Pediatric otolaryngologists were more likely to practice in urban and/or
academic settings than were general otolaryngologists. Children (age <18
years) comprised over 88% of the patients of pediatric otolaryngologists and
30% to 35% of the patients of general otolaryngologists. Pediatric otolaryngologists
were more likely to see children with complicated diseases such as airway
disorders or congenital anomalies than were general otolaryngologists. Pediatric
otolaryngologists, unlike general otolaryngologists, reported an increasing
volume of pediatric referrals, as well as increased complexity in the patients
referred. The surveyed physicians estimated the present number of pediatric
otolaryngologists in their communities as approximately 0.2 to 0.3 per 100 000
people.
Conclusions Most children receiving otolaryngologic care in the United States receive
such care from general otolaryngologists. The patient profile and practice
setting of the subspecialty of pediatric otolaryngology differ from those
of general otolaryngology. The demand for pediatric otolaryngologists appears
to be increasing, but many general otolaryngologists do not believe there
is an increased need.
INTRODUCTION
THE DEVELOPMENT of medical and surgical subspecialty areas has accelerated
during the past several decades. The field of otolaryngology–head and
neck surgery has seen the development of a number of subspecialties, including
facial plastic surgery, otology and neurotology, head and neck surgery, and
pediatric otolaryngology.
Controversy exists regarding pediatric otolaryngology, usually centered
around the appropriate practice setting for the pediatric otolaryngologist
and the relationship of this subspecialist to the general otolaryngologist.1-3 A large portion of the
practice of otolaryngology concerns the care of children (age <18 years)
with ear, nose, and throat disorders, and it is likely that most children
who need such care are treated by general otolaryngologists.
The diseases and types of surgical cases that are more appropriately
handled by a pediatric surgical subspecialist have been debated. The most
appropriate location of a pediatric otolaryngology practice has also been
discussed, and many agree that such a subspecialist is most needed in a tertiary
pediatric medical center. The need for postresidency pediatric fellowship
training, the duration of such training, and the appropriate pediatric content
of otolaryngology residency programs are subjects that are not settled.
Workforce issues in pediatric and general otolaryngology involve the
determination of the appropriate number and distribution of otolaryngologists
and pediatric otolaryngologists to serve patient needs adequately. Workforce
studies of otolaryngology4-6
and pediatric otolaryngology7 have projected
these numbers. We obviously need to ensure that we are training an appropriate
number of otolaryngologists and subspecialty otolaryngologists to meet patient
needs now and in the future.
The Future of Pediatric Education II (FOPE II) Project was a 3-year,
grant-funded initiative of the entire pediatric community. As part of this
project, key leaders in pediatrics addressed the future supply and training
of pediatricians and pediatric specialists and the provision of pediatric
care in the new millennium.8-9
As was also done for 16 other medical and surgical subspecialty groups in
the Survey of Sections Project of the FOPE II Project, we surveyed a group
of otolaryngologists and pediatric otolaryngologists in an attempt to better
define the practice of pediatric otolaryngology and to help estimate workforce
needs.
METHODS
QUESTIONNAIRE
As part of the FOPE II Project, a 5-page questionnaire was developed
to obtain information from a variety of medical and surgical specialists who
treat children. This questionnaire was designed to be applicable to most physicians
and collected information on several areas, including specialty training,
competition, referral sources, and demographic characteristics. An additional
3-page questionnaire specific for pediatric otolaryngology was developed in
collaboration with the American Academy of Pediatrics Section on Otolaryngology
and Bronchoesophagology (AAP Section). The pediatric otolaryngology questionnaire
included questions on proportion of practice that involves care of children,
the type and duration of pediatric otolaryngology training, the numbers of
pediatric otolaryngologists in the community, referral patterns of children
requiring otolaryngologic care, and the types of disease processes seen in
them. These questionnaires were pretested by a small group of pediatric otolaryngologists.
Questionnaires were revised based on comments received.
SAMPLE
The sample included 148 members of the AAP Section, 150 otolaryngologists
who belong to the American Society of Pediatric Otolaryngology (ASPO), and
a random sample of 299 otolaryngologists who belong to the American Academy
of Otolaryngology–Head and Neck Surgery (AAOHNS). There was some overlap
in membership; 21.3% of the sample belonged to both the AAP Section and ASPO.
Less than 2% of the AAOHNS sample also belonged to ASPO. Five mailings of
the survey went out between October 1997 and February 1998 to the 489 otolaryngologists.
Each mailing contained the standard questionnaire and the pediatric otolaryngology
questionnaire, a cover letter emphasizing the importance of the survey, and
a return envelope.
We received responses from 309 physicians, 63.2% of the sample. We received
26 responses that were excluded because the physicians indicated they were
retired, did not treat children, were temporarily not practicing, or were
in training. These were excluded from the sample size of 489, producing an
effective sample size of 463. Our response rate is therefore 283 of 463 (61.1%).
Respondents were divided into 2 groups for all statistical analyses.
The first group consisted of 140 otolaryngologists with a pediatric focus.
This group was operationally defined as those respondents who belonged to
the ASPO, the AAP Section, or both, and will be referred to as the pediatric
otolaryngologist group. The second group consisted of the 143 respondents
who belonged only to AAOHNS and will be referred to as the general otolaryngologist
group.
For continuous variables, comparisons between the groups were made using
independent group t tests. For categorical variables,
comparisons between groups were performed using  2 analysis. P<.05 was considered significant for all statistical
tests, and all analyses were conducted using SPSS statistical software (SPSS
for Windows version 9.0; SPSS Inc, Chicago, Ill). The number of cases for
each analysis fluctuated slightly based on the number of missing values for
the individual question.
RESULTS
DEMOGRAPHIC AND PRACTICE CHARACTERISTICS
There were several differences in demographic and practice characteristics
between the pediatric otolaryngologist and the general otolaryngologist groups.
The mean age of pediatric otolaryngologists was significantly lower than that
of general otolaryngologists (45 vs 48 years; P =
.004). There was also a higher proportion of pediatric otolaryngologists who
were women compared with the general otolaryngologist group (14.3% vs 4.9%; P = .007). The overwhelming numbers of pediatric and general
otolaryngologists were white, non-Hispanic (89.7% vs 85.2%; P = .26), and had graduated from US or Canadian medical schools (93.2%
vs 90.6%; P = .42).
There were also significant differences between the 2 groups concerning
practice characteristics, such as the type (P<.001)
and location (P<.001). As given in Table 1, one half of pediatric otolaryngologists practiced in an
academic setting compared with less than 3% of general otolaryngologists.
Nearly half of general otolaryngologists were in solo practice. Also as given
in Table 1, 79.8% of pediatric
otolaryngologists were located in urban settings compared with 41.3% of general
otolaryngologists. Furthermore, 5 times as many general otolaryngologists
(16.1%) were located in rural settings compared with pediatric otolaryngologists
(3%).
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Table 1. Practice Type and Community of Pediatric and General Otolaryngologists*
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Table 2 shows that patient
profiles and practice content also differed for pediatric otolaryngologists
and general otolaryngologists. As expected, the percentage of pediatric otolaryngologists'
patients who were younger than 18 years was much higher than the percentage
of general otolaryngologists' patients for both office patients (88.8% vs
29.0%; P<.001) and surgical patients (89.4% vs
35.6%; P<.001). When we looked at the disease
processes seen in children requiring otolaryngologic care, compared with general
otolaryngologists, pediatric otolaryngologists had significantly lower percentages
within their respective patient pools of patients with otitis media (36.7%
vs 40.3%; P = .04), adenotonsillar disease (20.3%
vs 27.8%; P<.001), and trauma (1.8% vs 4.1%; P = .006). A higher relative percentage of the children
seen by pediatric otolaryngologists had congenital anomalies (6.8% vs 1.6%; P<.001) or airway, voice, and/or swallow problems (9.9%
vs 4.1%; P<.001).
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Table 2. Patient Characteristics for Pediatric and General Otolaryngologists*
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REFERRALS
Otolaryngologists were asked to describe the sources of their pediatric
referrals. Pediatric generalists and family physicians were named the most
often by both groups of physicians (Table
3). Urgent care centers and school districts also were mentioned
frequently. Pediatric otolaryngologists were more likely to receive referrals
from pediatric medical and surgical subspecialists and pediatric nurse practitioners,
while general otolaryngologists were more likely to receive referrals from
general internists. When asked to rank the importance of personal or community
characteristics that influence referrals of children for otolaryngologic care
in their community, pediatric otolaryngologists and general otolaryngologists
had very different rankings (Figure 1).
Although managed care affiliations and established referral patterns were
considered influential by both groups, general otolaryngologists ranked the
latter as a more important factor than did pediatric otolaryngologists. General
otolaryngologists also ranked practice location and advertising higher than
did pediatric otolaryngologists. However, pediatric otolaryngologists reported
that fellowship training and practice concentration in pediatric otolaryngology
were more influential characteristics affecting referral of children.
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Table 3. Referral Sources for Pediatric and General Otolaryngologists*
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Figure 1. The importance of factors that
influence referrals of children for otolaryngology care. The mean values for
all but the "Managed Care Affiliations" category differ significantly between
the pediatric otolaryngologist and general otolaryngologist groups (P<.05).
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Otolaryngologists were asked about changes in the volume or complexity
of pediatric referrals and shifts in the number of pediatric patients. As
given in Table 4, there were several
differences between the pediatric otolaryngologist and the general otolaryngologist
groups. Pediatric otolaryngologists were more likely than general otolaryngologists
to report that in the last 12 months the volume of referrals had increased
(35.8% vs 3.8%; P<.001), the complexity of referrals
had increased (34.1% vs 15.4%; P<.001), and the
number of pediatric patients cared for had increased (49.6% vs 6.5%; P<.001). Pediatric otolaryngologists were also more
likely to report an increasing need in the community for pediatric otolaryngologists
(34.1% vs 11.1%; P<.001). These results reflect
the greater emergence of pediatric otolaryngology within communities and the
increased utilization of such services.
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Table 4. Shifts in Pediatric Referrals and the Number of Pediatric
Patients Cared for in the Last 12 Months*
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WORKFORCE
When asked about sources of competition for pediatric patients, the
patterns of responses were very different for pediatric otolaryngologists
and general otolaryngologists (Figure 2).
Pediatric otolaryngologists were more likely than general otolaryngologists
to experience competition from other pediatric subspecialists (65.4% vs 45.3%; P<.001) and from adult specialists (53.7% vs 34.5%; P<.001). Pediatric otolaryngologists were less likely
to experience competition from general pediatricians (12.5% vs 31.7%; P<.001), family physicians (11.0% vs 28.1%; P<.001), and urgent care centers (5.1% vs 15.8%; P<.001).
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Figure 2. Source of competition for pediatric
otolaryngologists and general otolaryngologists for pediatric patients. The
distribution for all but the "Nonphysician Providers" category differ significantly
between the pediatric otolaryngologist and general otolaryngologist groups
(P<.05).
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Information was also collected on the size of physicians' communities
and on the number of otolaryngologists providing pediatric care (Table 5). The average size of pediatric
otolaryngologists' communities was larger than that of general otolaryngologists'
communities (P<.001). Accordingly, the number
of general otolaryngologists who provide pediatric care (P<.001) and the number of pediatric otolaryngologists (P<.001) were also higher in pediatric otolaryngologists' communities.
The ratio of the number of general otolaryngologists to the number of pediatric
otolaryngologists was fairly consistent across communities, 7.4 to 1 in pediatric
otolaryngologists' communities and 5.3 to 1 in general otolaryngologists'
communities. In the pediatric otolaryngologists' communities, this translates
into population ratios of 1.6 general otolaryngologists and 0.2 pediatric
otolaryngologists per 100 000 people. In the general otolaryngologists'
communities, this translates into population ratios of 1.8 general otolaryngologists
and 0.3 pediatric otolaryngologists per 100 000 people.
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Table 5. Estimated Population Size and Number of Otolaryngologists
for Pediatric Otolaryngologist and General Otolaryngologist Groups*
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COMMENT
This survey has detailed a number of the differences between the practices
and the practitioners of general otolaryngology and pediatric otolaryngology.
Of importance, we found that 30% to 35% of the patients seen by general otolaryngologists
are children. Because this survey suggests that there are more general otolaryngologists
than pediatric otolaryngologists in most communities by at least 6- to 8-fold,
most children receive otolaryngology care from general otolaryngologists.
Pediatric otolaryngologists are more likely to be located in urban tertiary
pediatric and/or academic medical centers. These centers are the most appropriate
settings for the pediatric otolaryngologist to treat complex otolaryngologic
disease in children or routine otolaryngological problems in children with
complicated medical problems. The pediatric otolaryngology subspecialty practice
included a greater percentage of children with the unusual, complicated pediatric
head and neck problems, such as airway problems and congenital anomalies,
and a small fraction of the otologic, sinonasal, and adenotonsillar disease
that comprises the large portion of the general otolaryngology practice applied
to children.
Referral of children to general or pediatric otolaryngologists appears
to come from the usual sources of specialty referral, the primary care providers.
Pediatric otolaryngologists were more likely to receive referrals of children
from other pediatric subspecialists than were general otolaryngologists. Pediatric
subspecialists often share a common location in a pediatric medical center
and provide integrated care for children who may require subspecialty otolaryngology
services, which likely contributes to this referral pattern.
Pediatric otolaryngologists report an increase in patient volume as
well as an increase in the complexity of pediatric referrals. The increase
in patient volume may reflect an increase in referrals from primary care physicians,
a shift in referral of children from other specialists (including the general
otolaryngologist), or an increase in the incidence of ear, nose, and throat
disease in children. The increased complexity of the medical conditions of
children referred to pediatric otolaryngologists may be due to improved survival
of severely ill neonates and other children, new technologies and techniques
advanced by the subspecialty (eg, laryngeal reconstruction), later referrals
of sicker children from primary care providers, or a shift of these patients
from other specialists, including general otolaryngologists. It is not surprising
that pediatric otolaryngologists reported a need for more rather than fewer
pediatric otolaryngologists, since they had increasing numbers of patients
including children with more complicated conditions. It is also not surprising
that over 89% of general otolaryngologists believed that additional pediatric
otolaryngologists were not needed in their community, since most of the general
otolaryngologists surveyed had not experienced an increase in pediatric referrals
or patient volume, and indeed one third reported caring for fewer pediatric
patients than previously. However, based on anecdotal reports of employment
opportunities seen by recent pediatric otolaryngology trainees and the growing
number of advertisements for pediatric otolaryngologists in journals, the
demand for pediatric otolaryngologists appears to be increasing.
The estimates of the number of general otolaryngologists and pediatric
otolaryngologists in a given community may help us assess workforce needs.
It appears that most communities had approximately 1.6 to 1.8 general otolaryngologists
per 100 000 people. This number is lower than the figure of 3.36 otolaryngologists
per 100 000 obtained from the American Medical Association Masterfile
in 1997.10 The number of general otolaryngologists
in a community can also be compared with Miller's4
otolaryngology workforce figures, estimated as 2.5 per 100 000 for the
year 1990 and projected to be 2.8 per 100 000 for the year 2010. Our
estimates may be lower because respondents may have overestimated the sizes
of their communities, or the number of otolaryngologists may have been restricted
by the specification in our question that otolaryngologists must provide pediatric
care.
Most communities had approximately 0.2 to 0.3 pediatric otolaryngologists
per 100 000 people. Obviously, it would be most useful to have the number
of otolaryngologists per number of children in the community. The figures
from the survey suggest that most communities have about 1 pediatric otolaryngologist
for every 7 to 8 general otolaryngologists. However, the ratio of pediatric
otolaryngologists to general otolaryngologists may be much smaller. The number
of practicing otolaryngologists in 1997 in the United States was about 9000,10 and the number of pediatric otolaryngologists in
the United States as estimated by ASPO membership (220) and AAP Section membership
(161) is no more than several hundred.11
The limitations of this study are inherent in the survey format and
design. The data consist of the opinions, impressions, and knowledge of the
surveyed pediatric and general otolaryngologists. We defined "pediatric otolaryngologist"
and "general otolaryngologist" based on membership in otolaryngology organizations
(ASPO, AAP Section, and AAOHNS) and not on the percentage of practice comprised
by children. There may be a group of otolaryngologists who see only or mostly
children who do not belong to the ASPO or AAP Section. These subspecialty
practitioners may have different practice settings and patient populations
than the pediatric otolaryngologists as defined above. If we had defined a
pediatric otolaryngologist as either (1) an otolaryngologist with a practice
comprised by more than 80% children or (2) an otolaryngologist who completed
a pediatric otolaryngology fellowship, our results might have been slightly
different.
One of the concerns expressed regarding pediatric otolaryngology as
a subspecialty has been that the subspecialty-trained physician may develop
an identical profile of pediatric patients and a practice setting identical
to that of the general otolaryngologist, with subspecialty training used only
as a marketing advantage. The current results, however, suggest that many
differences in practice characteristics, patient conditions, referral patterns,
and sources of competition exist between pediatric otolaryngologists and general
otolaryngologists.
Our study did not address the appropriate distribution of pediatric
otolaryngologists. This distribution involves geography, location of tertiary
medical centers, and the percentage of children in a given local population.
Workforce planning and policy efforts should take into account national, regional,
and local needs for pediatric otolaryngologists. In particular, further studies
could look more closely at the adequacy of tertiary medical centers in meeting
the needs for pediatric otolaryngological services in the hospital referral
regions they serve.
The practices of otolaryngology and pediatric otolaryngology appear
in many ways complementary rather than competitive. As with other otolaryngology
subspecialists, the pediatric otolaryngologist should be a resource for referral
of children with complicated medical issues out of the realm of general practice.
Because a large proportion of general otolaryngology practice is the care
of children with ear, nose, and throat disorders, otolaryngology residency
programs must maintain an appropriate level of training in pediatric otolaryngologic
diseases. Pediatric otolaryngology fellowship programs must continue to provide
advanced training for individuals committed to the unique practice characteristics
of pediatric otolaryngology in the tertiary pediatric medical centers.
The data presented here reflect solely the perspective of the specialists
and subspecialists themselves. Additional studies should be undertaken from
other vantage points. For example, household surveys or surveys of health
plan members could be conducted to elicit information from a consumer-demand
perspective on the availability and accessibility of pediatric subspecialty
services. Equally valuable perspectives on this question could come from surveys
of health plan administrators, teaching hospital executives, fellowship training
program directors, and primary care physicians. Nevertheless, the views expressed
by specialists and subspecialists through the Survey of Sections data of the
FOPE II Project provide insight into the practice differences in the otolaryngologic
care for children.
AUTHOR INFORMATION
Accepted for publication December 17, 2001.
This work was supported by grants from the Center for the Future of
Children of the David and Lucile Packard Foundation, Los Altos, Calif; the
Maternal and Child Health Bureau, Rockville, Md (Project MCJ379381); the Association
of Medical School Pediatric Department Chairmen, Chapel Hill, NC; the American
Board of Pediatrics Foundation, Chapel Hill; and the American Academy of Pediatrics,
Elk Grove Village, Ill.
We thank the members and staff of the FOPE II Project; Thomas M. Gorey,
JD, Max M. April, MD, and Michael J. Cunningham, MD, from the AAP Section;
the members of the AAP Committee on Pediatric Workforce Subcommittee on Subspecialty
Workforce; and the many physicians who responded to the survey for their essential
contributions to this project.
Corresponding author and reprints: David E. Tunkel, MD, Johns Hopkins
Outpatient Center, Room 6231, 601 N Caroline St, Baltimore, MD 21287-0910
(e-mail: dtunkel{at}jhmi.edu).
From the Department of Otolaryngology–Head and Neck Surgery,
Johns Hopkins University School of Medicine, Baltimore, Md (Dr Tunkel); the
Divisions of Health Policy Research (Dr Cull) and Graduate Medical Education
and Pediatric Workforce (Mr Jewett), American Academy of Pediatrics, Elk Grove
Village, Ill; the Department of Data Acquisition Services, American Medical
Association, Chicago, Ill (Dr Brotherton); The Children's Hospital, Albany
Medical Center, Albany, NY (Dr Britton); and the Future of Pediatric Education
II (FOPE II) Project, Elk Grove Village (Ms Mulvey).
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4. Miller RH. Otolaryngology manpower in the year 2010. Laryngoscope. 1993;103:750-753.
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