Has Otolaryngology Subspecialization Gone Too Far?

CORONADO, CALIF.—As otolaryngology trends toward ever more specialization, a group of veterans in the field discussed the benefits and drawbacks of subspecialties in a panel session at the 2015 Triological Society Combined Sections Meeting held here Jan. 22-24.

One of the panelists, Jeffrey Harris, MD, PhD, chief of otolaryngology-head and neck surgery at the University of California, San Diego, set out to determine whether subspecialization in otolaryngology has led to more and higher quality research. He looked at the number of publications in the field to see whether the amount of research increased in a certain subspecialty area at the time when the subspecialty emerged. He found that, as an overall trend, the number of publications has grown over time but that there wasn’t a specific link between an increase in quantity and the beginning of a subspecialty area.

He looked at publications in the field of physical medicine and rehabilitation, an area of practice in which subspecialization is less predominant, and found a growing number of publications in that field. “Even though there’s much less interest in subspecialization in physical medicine and rehabilitation, they still showed that same graph,” Dr. Harris said. “It’s increasing over time, just like the other ones.”

He also looked at H-index—a measurement of the productivity and citation impact of an individual’s published body of work—and found a paper concluding that fellowship-trained neurosurgeons had a higher H-index than nonfellowship-trained neurosurgeons. So, he said, “there’s a little bit of suggestion through this paper that subspecialization and fellowship training will ultimately result in a higher impact of your papers.”

Also, he said, fellowship training increases the chances that you’ll end up working in a research-rich environment, giving rise to more research with greater influence. Subspecialization has also led to more interest in partnerships from industry, which sees a targeted audience.

Nonetheless, he wasn’t able to draw any definitive conclusions in his research. “I have not been able to determine, without a focused study, that subspecialization can with great certainty increase research productivity [or] the quality or quantity of our research,” he said.

The “Powerful Engine” of Subspecialization

Henry Hoffman, MD, professor of otolaryngology-head and neck surgery at the University of Iowa in Iowa City, who spent two years in private practice before entering academia, culled his own observations and those of others to give an assessment of subspecialization.

He began his talk with a quote from Byron Bailey, MD, chair emeritus for the department of otolaryngology at the University of Texas Medical Branch in Galveston, who said, “Specialization is a powerful engine for change—our real task is to manage the changes that are occurring in a manner that will lead to safer and more effective patient care.”

“From my perspective, subspecialization in otolaryngology is great for the field,” Dr. Hoffman said. “It advances research and technology, concentrates experience, [and is] great for the patient exposure to focused attention.” One suggestion, he said, would be to keep subspecialties under the otolaryngology umbrella but shorten the length of broad education to allow entry into further specialization earlier.

The Need for Generalists

Gerry Funk, MD, an otolaryngologist who recently joined Grande Ronde Hospital in a small town in Oregon after years with the University of Iowa, noted that, in many parts of the country, good general otolaryngologists are hard to find. “Subspecialization will further increase the divide between initial healthcare encounter and a competent specialist”—meaning a good general otolaryngologist.

Richard Waguespack, MD, clinical professor of otolaryngology at the University of Alabama in Birmingham (UAB) and immediate past president of the American Academy of Otolaryngology-Head and Neck Surgery, who spent 35 years in private practice before returning to the academic world, said that three years ago, approximately 60% of otolaryngologists self-reported as generalists. That number is now at 52%, indicating a trend away from general practice.

“There is an absolute need for subspecialization,” he said, particularly in the academic community. But the need for generalists cannot be ignored, he said. Patients will often self-refer to a specialist and, in otolaryngology, the physician they seek is a general otolaryngologist. Additionally, he said, “There are going to be communities that just simply, based on population … cannot support subspecialists in the way that we’ve been defining them.” Even in residency training, he said, it’s important to have some exposure to general otolaryngologists as role models.

Not only are there differences in the availability of subspecialists between large cities and small towns, but there can also be big differences in the number of subspecialists from one academic center to another. At many academic centers, there are no general otolaryngologists to see patients who might need that kind of a physician, and that means that physician assistants have more of a role in that regard.

“At UAB, we had three generalists, and now we’re down to one and we’re recruiting,” said Dr. Waguespack. “We are using physician assistants and nurse practitioners, and traditionally they have been locked in with the head and neck folks or they’ve been locked with otology. I think we’re trying to rethink that.”

Ultimately, the marketplace itself will help define how specialized otolaryngologists continue to become, said Dr. Waguespack. As subspecialization evolves, a sense of unity has to be retained, he added. “If [otolaryngologists] represent 1% to 1.5% … of U.S. physicians,” he said, “we have to speak with as much of a unified voice as possible.”

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Tom Collins is a freelance medical writer based in Florida.