Managing the Increasing Primary Care Burden in Otolaryngology

Since the start of COVID-19, otolaryngologists have been seeing many patients who would normally be taken care of by primary care doctors, a situation that causes problems with scheduling and care for patients who most need specialists. “This influx of patients isn’t sustainable, as it dilutes the patient population being seen that requires otolaryngologic care,” said Sarah Bowe, MD, a pediatric otolaryngologist in San Antonio, Texas. “I think this trend is multifactorial and, quite possibly, that it will continue to worsen.”

Multiple Drivers

“There were already existing concerns regarding a primary care shortage prior to the pandemic. Now, the added strain on the healthcare system and providers may accelerate the retirement timeline for many of those in active practice,” Dr. Bowe said. “During the pandemic, we saw negative impacts on access to care due to some of the safety requirements imposed by COVID-19. Now, we may continue to see challenges in access to care and, subsequently, timely management of certain disease states.”

Even before the pandemic, many otolaryngologists were seeing patients who could have been cared for by primary care offices, either due to patient preference for specialized care or lack of access to primary care professionals, said Michael J. Brenner, MD, associate professor in the department of otolaryngology–head and neck surgery at the University of Michigan Medical School in Ann Arbor. “During the pandemic, labor shortages and capacity strain rippled through the workforce, disrupting both primary care and specialist practice. What we’re seeing is a confluence of factors that involve not only a shortage of primary care professionals but also too few nurses and office staff, with pent-up demand for care,” Dr. Brenner said.

What we’re seeing is a confluence of factors that involve not only a shortage of primary care professionals but also too few nurses and office staff, with pent-up demand for care.

—Michael J. Brenner, MD

Many primary care physicians shifted to telemedicine during the pandemic. “As such, and because you cannot examine an ear or really look inside a nose or palpate the neck via telemedicine, they may be asking their patients to see otolaryngologists more frequently than before,” said Sujana S. Chandrasekhar, MD, a partner at ENT & Allergy Associates in New York City.

Along with reduced access to primary care, there’s an increased prevalence of symptoms relating to real and perceived effects of COVID-19 and its variants.

“COVID-19 has wreaked havoc in the ear, nose, and throat region, and this has driven demand for our services, as patients are more aware [of] and concerned regarding the long-term consequences of infection,” said Eugene Brown, MD, an otolaryngologist in Charleston, SC. “I think that fear of long-term viral complication has driven demand for otolaryngologic services. Concerned patients are seeking specialty advisement early to try to minimize complications.”

Karen A. Hawley, MD, an otolaryngologist in Albuquerque, New Mexico, also cited limited access to primary care physicians and COVID-19 symptom crossover, adding that patients often neglected care or were denied a clinic visit during the pandemic. Access was challenging throughout 2020 and 2021, “So people are coming out of the woodwork needing help for issues that may have been more easily managed if they hadn’t waited a year or two to be seen,” such as head and neck cancer. (For more information on head and neck cancer guidelines, see the sidebar “Head and Neck Cancer Care.”)

Managing the Trend

To cope with the increased demand for otolaryngologic services, some practices are increasing the use of advanced practice providers (APPs), such as physician assistants and certified registered nurse practitioners, for primary care-type visits.

“One of the enticing things about working in otolaryngology is the diversity of a practice type,” explained Dr. Hawley. “It’s a true mix of medical and surgical problems. Our residency training and true subspecialty expertise, however, are geared toward surgical management and procedures. Much of what we do in clinic could be managed by a nonsurgical physician.” She added that many practices use APPs who are trained by otolaryngologists to help with simple conditions such as recurrent otitis media, sleep-disordered breathing, sinus complaints, globus, and dysphagia.

[Medical otolaryngology fellowships are] an excellent opportunity to build up on the knowledge base and skillset of well-trained family physicians or internists. —Sujana S. Chandrasekhar, MD

Other otolaryngologists are opening extra clinic slots for patients with urgent conditions, such as those with head and neck cancer or sudden sensorineural hearing loss. “We’re seeing more patients individually to try and meet demand,” Dr. Brown said. “We continue to add advanced practice providers within our practices to help meet the demand for ambulatory care. While this strategy isn’t embraced by everyone, it’s very popular for patients who appreciate having greater access to care.”

According to Dr. Brenner, the approach needs to consider the context, understanding why such challenges are arising and the options available to the practice.

“Simply trying to accommodate the added load through extra workload is unlikely to be sustainable over the long term,” he said.

“There’s a need to look upstream at what’s causing the change in practice,” Dr. Brenner noted. “The trend is structural and therefore likely requires structural solutions. Otolaryngologists can create more stringent referral criteria and prioritize care, but these are temporizing measures that will neither stem the tide of new patients nor allow for timely access to care. A different approach, expanding the practitioner base, is needed.”

The Future

While some of the short-term challenges created by COVID-19 (backlog of services and deferred care, for example) will likely become less acute as the pandemic recedes, other changes represent secular shifts, Dr. Brenner said. Expansion of the workforce is needed and could include primary care physicians or APPs.

“Whereas the number of otolaryngologists has been essentially flat for many years, the number of advanced practice providers has steadily risen over the past decade,” he explained. “Several studies have documented the tendency of physicians, particularly specialists, to concentrate in urban areas. So, the long-term solution will require expanding the workforce so that patients who most need a specialist can receive timely, appropriate care.”

“Advanced practice providers will be vital to creating greater access into our practices,” said Dr. Brown. “These are bright, well-trained professionals who flourish under our guidance, with our tutelage, and under our supervision. They can see many of our return patients, especially for cerumen impactions, and many of our acute care patients, creating revenue for our challenged practices and allowing surgeons to practice at the top of our licensure.” He added that, “with mounting economic pressures, I don’t predict that the higher-cost physician model will achieve as much traction. The advanced practice provider model is successful, and their employment is growing logarithmically within otolaryngology practices today.

“Rural specialty practice is a challenge for not just otolaryngology but for the ‘house of medicine’ overall,” Dr. Brown continued. “Rural ENT doctors tend to be older, and most describe recruitment of next generation otolaryngologists as ‘impossible.’ Our footprint in rural settings will continue to contract. This subspecialty vacuum will challenge small, rural hospitals and medical communities. Ultimately, I think that this will create opportunities for successful practices to serve this population with telehealth, weekly/monthly clinics, and advance care provision.”

Otolaryngology Fellowships

According to Dr. Chandrasekhar, if otolaryngology organizations, such as the American Academy of Otolaryngology– Head and Neck Surgery and the Triological Society, provide education for primary care counterparts in terms of clinical practice guidelines and clinical consensus statements, especially for common otolaryngological issues that often present to primary care, it will help improve patient care.

“There are a handful of medical otolaryngology fellowships for primary care physicians interested in joining otolaryngology practices or departments,” she said. “I think that this is an excellent opportunity to build upon the knowledge base and skillset of well-trained family physicians or internists to provide comprehensive otolaryngologic office care, with referrals to otolaryngologists within the practice when needed. This is still in its infancy, however.

“Even if expanding opportunities for clinical otolaryngology one-year fellowships for primary care physicians cannot be done, encouraging the senior trainees in your area in family practice or internal medicine, or the new graduates, to shadow you in the office for a significant but small amount of time, will really help cross-pollinate knowledge,” added Dr. Chandrasekhar. She noted that practices that are comfortable using physician extenders should continue to do so, with the caveat that patients understand “when they are being seen by a physician and when they are being seen by someone who isn’t a physician but who has the skillset needed.”

Dr. Hawley agreed that otolaryngology is a specialty that could support a nonsurgical/medical fellowship. “Residents could graduate from pediatrics, internal medicine, family medicine, or emergency medicine and enter a ‘medical otolaryngology’ fellowship, perhaps for one to two years, to learn to better manage medical conditions of the head and neck and then refer to an otolaryngologist for surgery if needed. These fellows could learn to scope patients—nasal endoscopy and flexible laryngoscopy are examples of simple procedures that offer an immensely more detailed exam and often are the sole purpose of an otolaryngology consult. They could also learn simple procedures like [performing] peritonsillar abscess drainage, packing epistaxis, or using a microscope in clinic to remove a foreign body or cerumen. They could also offer specialized services in a rural community, whether it be primary care or in the emergency room. They could also work within an otolaryngology department and help offload clinic patient load. This would help reduce the referral to the surgically focused otolaryngologists (as most of us are) and improve patient access to much of their needs. “

A fellowship-trained medical otolaryngologist would have no shortage of work,” Dr. Hawley added. “These MDs would have a much better foundation and regimented fellowship training than what our advanced practice providers are currently providing.”

Citing Katy Milkman, PhD, the James G. Dinan Professor at The Wharton School of the University of Pennsylvania, Dr. Bowe said, “Landmark events, such as the coronavirus pandemic, that demarcate the passage of time, can initiate a ‘fresh start effect,’ motivating aspirational behaviors and spurring improvement efforts. I think that now is a great time to explore different methods of training. Some of these altered training paradigms have already been started, such as with pilot studies looking at competency-based training in plastic surgery. Perhaps there are different alternatives that could be explored with otolaryngology as well.”

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Katie Robinson is a medical freelance writer based in New York.