Rethinking the Otolaryngology Workforce

The Rust Belt has garnered unfortunate attention these last few years. Our recent election cycle made its job losses, poor alternatives, and lowered wages abundantly clear. While the economic benefits of free trade and technology to our society as a whole should be celebrated, we failed to hedge against the downsides. The United States continues to rank far below other developed economies in terms of money invested in labor markets, including retraining, according to 2017 data from the U.K.-based Organisation for Economic Co-operation and Development.

While it may be easy to dismiss this phenomenon as unique to manufacturing, these market forces have now turned their focus onto physicians.

An inefficient market with pressing needs, inelastic demand for services, and profitability is an attractive target for technological disruption; healthcare is one such market. Technological advancements have moved medicine forward, expanding our capabilities to provide better care; however, technological advancements seem to have an ever-increasing potential to displace physicians rather than to assist them. The arc of coronary artery bypass grafting (CABG) is a cautionary tale of what can result from inefficient resource allocation in the face of technology. CABG was the dominant form of coronary revascularization for decades. Training programs boomed to supply the proliferation of financially lucrative “heart disease” centers at hospitals, driving down hospital volumes of CABG surgery, even as percutaneous coronary intervention (PCI) was showing increasing benefits and rapidly surpassing CABG in volume (Health Aff. 2007;26:162-168).

What followed were early retirements and an overabundance of trainees with not enough jobs, according to a 2015 analysis published by the American College of Cardiology . Otolaryngology may be following the same path in some respects. What some have predicted will be an undersupply of physicians may be anything but (Laryngoscope. 2016;126:S5-S11). Moreover, instead of the market adjusting price to accommodate any supply/demand mismatch, some of us may be unable to find work in our current capacity.

New pharmaceuticals show remarkable effectiveness against hepatitis C, one of the leading causes of hepatocellular carcinoma and cirrhosis (Ann Epidemiol. 2015;25:183-187). Hepatic and transplant surgeons will invariably become displaced as these drugs dramatically reduce the liver disease burden. More recently, Enlitic, a software company specializing in artificial intelligence, designed an algorithm to detect cancer on chest radiographs. In a trial against three expert radiologists working together, the algorithm was superior at classifying malignant lung tumors and had a better false-negative rate (Economist. June 25, 2016.).

Cancer treatment trials using CRISPR/Cas9, a ground-breaking gene-editing technique, are already underway (Nature. 2016;539:479). Other examples abound, particularly in the primary care realm, with the use of big data, diagnostics, and mobile applications.

Technological advancement is inevitable and will naturally eliminate some jobs for the sake of broader gains. Physicians with a narrower focus bear the greatest risk. Generalists have a superior ability to manage idiosyncratic risk than do subspecialists. We have but one choice: how we choose to adapt. In order to do so gracefully, we must have adaptive capabilities able to satisfy two criteria—efficient resource allocation and speed.

Technological advancement is inevitable and will naturally eliminate some jobs for the sake of broader gains. Physicians with a more narrow focus bear the greatest risk. We have but one choice: how we choose to adapt. In order to do so gracefully, our adaptive capabilities must be able to satisfy two criteria—efficient resource allocation and speed.

Subspecialization

Our specialty has become increasingly subspecialized, with approximately 50% of graduates pursuing fellowship training. While the availability of more subspecialists theoretically offers patients better access to safer care, at some point there is a dilutive effect on case volume, which impairs future training. This is bad for our trainees and patients. Concern has been raised about current and future levels of neurotologist supply in this regard (Otol Neurotol. 2013;34:755–761). As technology has provided for less invasive management, surgical treatment of vestibular schwannoma, Menière’s, and other cranial base tumors have been on the decline, even as our trainee supply has remained stable (Otol Neurotol. 2013;34:755-761; Otolaryngol Head Neck Surg. 2015;153:822-831). Unless a paradigm shift occurs, bucking the trend of less-invasive management, we may suffer the same fate as cardiothoracic surgeons at the turn of the 21st century.

Workforce Projections and Retraining

We should also take a more nuanced approach to workforce projections, moving away from per capita goals. These numbers don’t account for variance of subspecialty utilization over time, use of subspecialty skills in practice, lifestyle preferences, inefficiencies in geographic dispersion, or productivity gains we may have achieved by use of second-level providers or operational improvements. Whether we are meeting a public need will be reflected in trends with wait times for office visits and surgery as well as outcome data. We need to know our own specialty-specific data in order to make efficient workforce decisions.

We then must combine our data with projected effects of technological advances to maximize efficient resource allocation with alacrity. Subspecialty societies, led by a diverse group of constituents, could publish regular medium- and long-term workforce projections, incorporating their nuanced utilization data to signal demand to prospective fellows. Learning geographic or inter-subspecialty skill utilization variance and projected subspecialty workforce needs may be enough to allow for more efficient fellowship selection, or none at all.

Additionally, plans should be put in place for retraining, should those with a narrow focus become displaced by technology. For example, if a drug, genome editing, or nanotechnology eliminates squamous cell carcinoma, we should first cheer this accomplishment, but then be ready to bring our head and neck cancer colleagues displaced by such advancements back into the workforce.

Efforts to this end will be challenging, but we must be committed to learning from the pains of our fellow Americans in the Rust Belt and our changing healthcare landscape. Our diversity as a specialty and the absence of an imminent threat protects us better than most, which represents an ideal opportunity to begin planning. These changes are essential to ensure that we are both efficiently responding to the public need and protecting ourselves from obsolescence.

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Dr. Tompkins is the department head of otorhinolaryngology–head and neck surgery at the Naval Hospital Jacksonville in Florida.