Abstract
Background:
Evidenced-based models should be used to predict future implications of the single accreditation system for graduate medical education. Compared with other states, Pennsylvania has a relatively high number of osteopathic physicians (ie, DOs) and may be used as a model for a health care system with an increased DO presence.
Objective:
To compare the geographic distribution of otolaryngologist DOs with otolaryngologist allopathic physicians (ie, MDs) in Pennsylvania and identify differences in community size (urban, urbanized, and rural) in which these physicians practice.
Methods:
A list of otolaryngologist practice locations in Pennsylvania was developed using Centers for Medicare and Medicaid Services data, the American Osteopathic Colleges of Ophthalmology and Otolaryngology–Head and Neck Surgery Masterfile, and the American Medical Association Physician Masterfile. The United States Census data were used to document the general population of those locations. The samples of individual otolaryngologist DOs and MDs were then analyzed by determining where each otolaryngologist practiced, identifying the type of community in which they practiced, and then comparing the percentage of otolaryngologist DOs and MDs who practiced in each community type (urbanized area, urban cluster, and rural). A χ2 analysis was used to determine whether a difference existed in practice location between otolaryngologist DOs and MDs.
Results:
Of the 47 otolaryngologist DOs, 32 (70%) practiced in cities with a population of 49,999 or less. More than half (120 of 238) of the otolaryngologist MDs practiced in cities larger than 50,000, and 96 of 238 (40%) practiced in cities with a population of at least 200,000. χ2 analysis showed a significant difference in the geographic distribution of otolaryngologist DOs and MDs (P=.012).
Conclusion:
A correlation exists between the practice location of otolaryngologists in Pennsylvania and the medical degree they hold.
Pennsylvania has 9 medical schools, 2 of which are osteopathic institutions. The state graduates a higher proportion of osteopathic physicians (ie, DOs) than most other states in the country.
1 The Philadelphia College of Osteopathic Medicine currently has the highest active alumni of all osteopathic medical schools, and the Lake Erie College of Osteopathic Medicine, including its satellite campuses, is the largest osteopathic medical school in the nation. Furthermore, Pennsylvania is home to 6 allopathic otolaryngology residencies and 2 of the 18 total osteopathic otolaryngology residencies in the United States.
2 As the demand for physicians increases and the number of osteopathic medical schools and graduates increases, analysis of the geographic distribution of physicians in Pennsylvania may help to predict the trends and geographic distribution of DOs across the country.
Lack of access to physicians in rural areas, including access to trained otolaryngologists, may negatively affect health care outcomes for patients.
3 Although recent trends in medicine have been to incentivize primary care, there remains a constant push toward supplying rural communities with qualified physicians in all specialties.
4 Over 20% of the US population lives in rural areas that are underserved not only in terms of primary care physicians, but also surgeons and other specialists.
5
In 2012, Fordyce et al
6 determined that the distribution of primary care DOs differed from their allopathic (ie, MD) counterparts, in that a higher percentage of primary care DOs practiced in rural locations (20.5% vs 14.9%, respectively). No such data exist for otolaryngologist DOs; however, based on otolaryngology workforce data, 20.6% of counties in the United States have lost otolaryngologist practices from 2004 to 2009, partly due to merging of private practices and establishment of group practices and partly because fewer otolaryngologists were willing to practice in rural areas.
7 Furthermore, the average age of the practicing otolaryngologist has increased since 1981, and the number of residents seeking otolaryngology board certification began declining in 2006.
6
There has been some criticism regarding potentially negative implications of the single accreditation system for graduate medical education (GME). With the single accreditation system, MD graduates will be allowed to enter GME positions with osteopathic recognition. In 2014, a total of 2988 osteopathic first-year funded positions were available,
8 but the fate of these positions has been questioned. Some believe that several current osteopathic residency positions will cease to exist because standards of the Accreditation Council for Graduate Medical Education (ACGME) do not accommodate community-based residency programs, giving preference to large, nonosteopathic medical centers. Concern also exists regarding the fate of subspecialties for DOs, such as ophthalmology, orthopedic surgery, and otolaryngology.
9
Otolaryngologists represent a small subset of DOs, and there have been few DO students accepted into allopathic otolaryngology programs.
10,11 With the fate of otolaryngologist DOs in question, evidence-based research is needed to help guide policy makers in future decisions regarding approval of otolaryngology residency programs and how to protect specialty residency programs that are available to DOs. The aim of this study was to compare the geographic distribution of otolaryngologist DOs and MDs in Pennsylvania to identify differences in the community sizes (urban, urbanized, and rural) in which these physicians practice. We established the null hypothesis that otolaryngologist DOs and MDs do not significantly differ in geographic distribution of practice location. By comparing trends in geographic preference, we can make an argument that DOs are helping alleviate specialty shortages in more rural areas.
Using public Centers for Medicare and Medicaid Services data from 2015 (the most recent year available), the total population of otolaryngologists in Pennsylvania in that year was identified. The list was then cross-referenced with the American Medical Association Physician Masterfile and the American Osteopathic Colleges of Ophthalmology and Otolaryngology–Head and Neck Surgery Masterfile for validity of practice location. This information allowed for the exclusion of residents, fellows, and nonclinical health care professionals. Then, using the most current government census data available (2010), the population of the city in which an otolaryngologist was practicing was documented for our dataset of otolaryngologists in Pennsylvania. The dataset was then reorganized to separate otolaryngologist DOs and otolaryngologist MDs for statistical analysis.
The US Census Bureau separates urban areas into 2 categories:
urbanized areas (population >50,000) and
urban clusters (population between 2500-49,999).
12 Rural areas are defined as having a population of fewer than 2500.
12 Using these definitions, we aggregated the number of otolaryngologist DOs and MDs into these categories and pulled the percentage of the total number of otolaryngologist DOs and MDs in Pennsylvania in each population group. A χ
2 analysis was performed to determine significance in the categorical dataset. Statistical significance was defined as
P<.05.
The percentages of otolaryngologist DOs and MDs were aggregated into smaller groups based on the following population groups: below 3125; 3125 to 6249; 6250 to 12,499; 12,500 to 24,999; 25,000 to 49,999; 50,000 to 99,999; 100,000 to 199,999; and 200,000 or more. This larger distribution stratified the current practice location of otolaryngologist DOs and MDs.
A dataset of 46 otolaryngologist DOs and 238 otolaryngologist MDs was developed. Of the total otolaryngologist population in Pennsylvania, 46 of 284 (16.2%) were DOs. The
Figure shows the geographic distribution of otolaryngologist DOs and MDs by population of the area. We found that 14 of 46 otolaryngologist DOs (30.4%) in Pennsylvania practiced in urbanized areas, compared with 120 of 238 otolaryngologist MDs (50.4%); 29 of 46 otolaryngologist DOs (63%) practiced in urban clusters, compared with 111 of 238 otolaryngologist MDs (46.6%); and 3 of 46 otolaryngologist DOs (6.5%) practiced in rural areas compared with 7 of 238 otolaryngologist MDs (2.9%). When aggregate data were further broken down into smaller population groups, we found that otolaryngologist MDs were more likely than otolaryngologist DOs (40% vs 13%, respectively) to practice in urbanized areas. However, otolaryngologist DOs were more likely to practice in urban clusters than otolaryngologist MDs (28% vs 13%, respectively). χ
2 analysis revealed a difference in the practice city population of otolaryngologist DOs and MDs (χ
2=8.93,
P=.012).
Pennsylvania has a higher percentage of otolaryngologist DOs than the national average.
1 If the single accreditation system has any negative effect on the availability of osteopathic GME, specifically in surgical subspecialties, Pennsylvania may be among the first states to experience the consequences. As more physicians leave private practices to seek employment in larger medical groups or hospitals,
3 smaller communities may have an inadequate supply of physicians. The presence of an otolaryngology residency tends to retain otolaryngologists within a hospital region and may improve otolaryngology access in rural communities with low populations.
13
Our data demonstrated that a correlation exists between practice location of otolaryngologists and type of medical degree (ie, DO or MD). If the otolaryngologist population in Pennsylvania was used to predict otolaryngologist practice location trends at a national level, it may be concluded that an overwhelming majority of DOs would practice in smaller suburban communities or rural areas, and the majority of MDs would practice in larger, urban areas. This potential trend could provide an evidenced-based example to support the expansion of the DO workforce in such communities and show that the discontinuation of osteopathic surgical residencies may decrease health care access in communities with low populations.
Our dataset did not include ages and was not adjusted for sex of the physicians because previous studies have demonstrated that age and sex of otolaryngologists do not significantly influence practice location.
10 However, one limitation of this study was the accuracy of the populations. Using population-based categorization, smaller cities (that are actually suburban and not geographically isolated) may have been unintentionally categorized as rural. Because otolaryngologist DOs in Pennsylvania already represent a small sample size, trying to regroup the populations into smaller groups would have yielded insignificant sample sizes for calculation. Rather, it was decided that by applying population as the main parameter to both samples equally, cities with smaller populations that are considered suburban or semiurbanized would be represented equally between the 2 samples. For the purpose of the current study,
rural was defined by the US Census Bureau in terms of population, not access to care. Therefore, we do not claim that otolaryngologist DOs are more likely to practice in more underserved areas.
The American Medical Association Physician Masterfile and the American Osteopathic Colleges of Ophthalmology and Otolaryngology–Head and Neck Surgery were used for our dataset, which led to some limitations because we relied on the validity of the data provided by those organizations. We concluded that any health care professional who was in our dataset billed Medicare and represented a physician. A limitation is that we were unable to stratify those criteria in GME. Legally, otolaryngologist DOs have equal rights and access to GME positions and thus any differences in practice locations among the populations represent valuable health care information. While research
11,13 has been done on the geographic distribution of otolaryngologists, quality research elucidating whether differences between DO surgical specialists and MD surgical specialists exist is lacking.
As the single accreditation system moves forward, its implications are unknown. The fate of the approval of current osteopathic residencies remains in the hands of the ACGME. Given the differences between the practice location of otolaryngologist DOs and MDs in Pennsylvania, Pennsylvania's otolaryngology population may serve as a useful model for future study of physician subspecialties. A higher percentage of DOs than MDs practice in rural locations, and, therefore, otolaryngology residency programs are needed in these locations. Based on our data, we concluded that the lack of approval or discontinuation of osteopathic surgical residencies may decrease health care access in less-populated communities. The ACGME, AOA, American Academy of Otolaryngology–Head and Neck Surgery, and government-regulating bodies should take this into consideration as they continue to improve health care access in the United States.
We thank Sanket Patel, BS, for contributions toward the literature review.