After a cancelled 2020 meeting, the American Academy of Otolaryngology–Head and Neck Surgery (AAO-HNS) held its annual meeting live at the Los Angeles Convention Center in October. There were 1,800 registrants, down from the normal 12,000 to 15,000, but their presence was felt—not so much in the hotel lobby bars or crowding around the vendor hall, but in the meeting rooms in support of the presenters. And as one of the registrants, especially one who debated about whether or not to go all the way up to the meeting date, I can say it was a great experience and one I’m glad to have attended.
During the pandemic, many AAO-HNS activities have been detailed in monthly magazines and episodic emails. But it’s different to hear about it live, and I was interested in listening to some of the academy’s plans for the upcoming years:
- The “125 Strong” program is a fundraising effort to celebrate AAO-HNS’s 125 years and support a new strategic plan, which places an emphasis on mentorship, inclusive diversity, and clinical excellence.
- Incoming president Ken Yanagisawa outlined his plans to focus on the business of medicine, including the creation of the Private Practice Study Group. Sponsored by the board of directors of the academy, the group will be tasked with engaging private practitioners around the country, will focus on issues pertinent to their work lives, and will identify the academy’s next private practice leaders. (It’s needed and, I hope, will help us address an elephant in the room.)
As this last item suggests, we’re at a crossroads when it comes to employment models. In full disclosure, I’m the chair of an academic department, and I hope what comes next won’t be overly colored by my personal bias.
Over the past decade, the percentage of employed otolaryngologists has markedly increased. In response to the expansion of academic and employed staff, many private practices have come together to form “super groups,” mainly for the purpose of contracting and decreasing overhead costs. Similar to what has already happened in the fields of dermatology and ophthalmology, private equity firms are now omnipresent to help invest in these super groups. There are obvious advantages and disadvantages to a model in which a practice is owned and governed by an entity dedicated to maximizing profits and revenue. Time will tell if this will be the norm, but in the meantime smaller practices and rural practices have been left out, and many of them have become discouraged with what’s happening.
So how do we all coexist and thrive in what feels like a fish bowl with limited resources and surgical patients? To compete with the academic groups in town, many super groups are actively hiring their own subspecialists, keeping many of the tertiary cases that the academic groups rely on to train their residents and fellows. Academic groups, needing the clinical revenue to fund research and educational activities that don’t fund themselves, end up hiring generalists to compete with the private practitioners for primary care referrals. Instead of working together, in many regions the academic and super groups are in direct competition with each other, further fragmenting the otolaryngology community.
Otolaryngologists and their departments are leaders in many of the academic medical centers across the country. The faculty serve as role models for the best and brightest of students, and those same people are becoming driven residents and practitioners who are changing our specialty. But many of these high-achieving students end up becoming attending otolaryngologists who choose to stay in urban environments or go on to fellowship and eventually join a super group or academic practice.
As a result, rural and small group practices have a hard time recruiting and, because of their size, often get the squeeze from insurers. Many of these practices are vital to the communities they serve, and they enjoy the autonomy of running their own practice. Now, they’re at risk. Where do they best fit in this fish bowl?
I’m optimistic that the academy’s focus on the business of medicine will help all of us out—decreasing the need for pre-authorizations and fighting for greater reimbursement will benefit all practitioners. But we haven’t yet addressed the workforce issue. Is private equity good for our specialty? Are academic and super groups getting too big? Why aren’t we focusing on rural practices and encouraging some residencies to have rural health tracks? And when the future points to us being a less surgical-heavy specialty—biologics for sinus inflammatory disease are on the rise, immunotherapy is gaining traction in head and neck cancer, there are improvements in hearing aid technology, and the scope of audiologists is increasing—are we selecting the right medical students who will adapt comfortably to this new future? Will they have the research acumen and drive to improve our specialty but possess the same passion for a specialty that may be less surgical and more medical?
These are tough questions, and I’m not sure who has the answers. But when I think of the future of otolaryngology, this is what weighs heavily on my mind. Thanks for reading, and stay safe.