The Growing Fragmentation of Otolaryngology—Head and Neck Surgery
Are general otolaryngology practices being “cannibalized” by subspecialization? Is fellowship training for all an inevitable reality, or can we keep this from being divisive? Is there too much overlap between the services that subspecialists and generalists perform, and is it fragmenting the profession? These questions are an increasingly pervasive source of contention among all medical disciplines. Many will argue that subspecialization is an evolution that occurs in response to the ever-increasing growth in medical knowledge. It is estimated that 60 percent of residents feel the need to further their education by securing a fellowship. Does this create better doctors or allow those with additional training to secure market share and dilute the relevance of the general otolaryngologist? Subspecialists within otolaryngology typically perform services that are outside the confines of a general otolaryngology practice. Head and neck oncologists perform more difficult resections and reconstructions, neurotologists perform more complicated otologic and intracranial surgeries, and pediatric otolaryngologists perform airway procedures that require specialized training and experience. Yet there is often a degree of overlap between the services offered by these subspecialists and general otolaryngologists. These areas of overlap typically do not present a conflict between subspecialists and generalists because the major volume of the subspecialist care is not the same as the generalist. As a neurotologic surgeon, I would never ask a generalist colleague to stop doing tympanoplasties, mastoidectomies, or stapes surgery, when his or her outcomes are good. On the other hand, we would probably agree that a general otolaryngologist would not be inclined to perform vestibular schwannoma surgery, the fourth revision of frontal sinus disease, a free flap or laryngotracheoplasty on a 3-year-old. Competition for patients is a reality, not only between the generalist and specialists but also between competing generalist and subspecialty groups. Although no one in the AAO-HNS would argue that a fellowship-trained specialist is any more qualified than a general otolaryngologist to treat such problems as tonsillitis, chronic serous otitis media, sinusitis, or chronic suppurative otitis media, patient referral patterns cannot be mandated or legislated, and there may be a natural affinity for pediatricians and parents to gravitate toward pediatric subspecialists. We can argue that subspecialization is fragmenting medicine today, although I would suggest that this is a canard. In reality, it is market forces and local/regional referrals that create this chasm. There is a need for continued subspecialization within otolaryngology—HNS, but this evolution need not herald the demise of the generalist. Rather, the existence of the one can strengthen the other. A study that evaluated quality and efficiency (Berry, et al1) concluded: “Specialist physicians should do less of what generalist physicians can do.” This study was based on the Institute of Medicine’s Quality Guidelines, which defines six aspects of care that should be maximized; safety, effectiveness, patient-centeredness, timeliness, efficiency, and equitability2. Given that effectiveness, patient-centeredness, and equitability are likely similar between care provided by a generalist and subspecialist for specific conditions, the differences arise in safety, timeliness, and efficiency. If subspecialists are routinely performing surgeries at a distance from their home institutions and without the ability to provide local emergency care, safety is compromised and care is better provided by a local generalist. It can be argued that because subspecialists will invariably perform general otolaryngology procedures, and because waiting times are typically shorter to see a generalist, the care is also timelier. Thus, perhaps for some conditions and situations, a general otolaryngologist is capable of delivering better quality than a subspecialist as defined by the Institute of Medicine’s goals. In other cases, the presence of a subspecialist in the geographic area may help the generalist offer care for more, and more complex, patients. A concern has been raised in one state; and although controversial, it appears that in some specific situations, subspecialists are performing a large volume of general otolaryngology procedures and, in essence, eroding the general otolaryngologist practice. This seems to be a significant problem where hospital administrators have created satellite locations to compete with general otolaryngology practices. But it is also concerning that surgery is being performed in some areas without local call coverage. There can be a point in which there is too much overlap between services provided by subspecialists and general otolaryngologists. To paraphrase, 3 our existing healthcare system was created considering patients with acute conditions that required immediate attention. This is not the case today and the majority of our patients have chronic conditions such as cardiovascular disease, diabetes, obesity, cancer, and chronic degenerative diseases. By the time our patients need a subspecialist, you could argue that conventional medicine has failed the patient. Thus across all areas of medicine there is an important role for both the generalist and subspecialist to collaborate in order to provide quality care to our patients. References Berry LL, Seiders K, Wilder SS. Innovations in access to care: a patient-centered approach. Ann Intern Med 2003;139:568 –74. Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Washington, DC: National Academy Press; 2001. Henderson, J. Marcus Welby and the relentless growth of specialization. www.kevinmd.com/blog/2011/01

Are general otolaryngology practices being “cannibalized” by subspecialization? Is fellowship training for all an inevitable reality, or can we keep this from being divisive? Is there too much overlap between the services that subspecialists and generalists perform, and is it fragmenting the profession? These questions are an increasingly pervasive source of contention among all medical disciplines.
Many will argue that subspecialization is an evolution that occurs in response to the ever-increasing growth in medical knowledge. It is estimated that 60 percent of residents feel the need to further their education by securing a fellowship. Does this create better doctors or allow those with additional training to secure market share and dilute the relevance of the general otolaryngologist?
Subspecialists within otolaryngology typically perform services that are outside the confines of a general otolaryngology practice. Head and neck oncologists perform more difficult resections and reconstructions, neurotologists perform more complicated otologic and intracranial surgeries, and pediatric otolaryngologists perform airway procedures that require specialized training and experience. Yet there is often a degree of overlap between the services offered by these subspecialists and general otolaryngologists.
These areas of overlap typically do not present a conflict between subspecialists and generalists because the major volume of the subspecialist care is not the same as the generalist. As a neurotologic surgeon, I would never ask a generalist colleague to stop doing tympanoplasties, mastoidectomies, or stapes surgery, when his or her outcomes are good. On the other hand, we would probably agree that a general otolaryngologist would not be inclined to perform vestibular schwannoma surgery, the fourth revision of frontal sinus disease, a free flap or laryngotracheoplasty on a 3-year-old.
Competition for patients is a reality, not only between the generalist and specialists but also between competing generalist and subspecialty groups. Although no one in the AAO-HNS would argue that a fellowship-trained specialist is any more qualified than a general otolaryngologist to treat such problems as tonsillitis, chronic serous otitis media, sinusitis, or chronic suppurative otitis media, patient referral patterns cannot be mandated or legislated, and there may be a natural affinity for pediatricians and parents to gravitate toward pediatric subspecialists.
We can argue that subspecialization is fragmenting medicine today, although I would suggest that this is a canard. In reality, it is market forces and local/regional referrals that create this chasm. There is a need for continued subspecialization within otolaryngology—HNS, but this evolution need not herald the demise of the generalist. Rather, the existence of the one can strengthen the other. A study that evaluated quality and efficiency (Berry, et al1) concluded:
“Specialist physicians should do less of what generalist physicians can do.”
This study was based on the Institute of Medicine’s Quality Guidelines, which defines six aspects of care that should be maximized; safety, effectiveness, patient-centeredness, timeliness, efficiency, and equitability2. Given that effectiveness, patient-centeredness, and equitability are likely similar between care provided by a generalist and subspecialist for specific conditions, the differences arise in safety, timeliness, and efficiency.
If subspecialists are routinely performing surgeries at a distance from their home institutions and without the ability to provide local emergency care, safety is compromised and care is better provided by a local generalist. It can be argued that because subspecialists will invariably perform general otolaryngology procedures, and because waiting times are typically shorter to see a generalist, the care is also timelier. Thus, perhaps for some conditions and situations, a general otolaryngologist is capable of delivering better quality than a subspecialist as defined by the Institute of Medicine’s goals. In other cases, the presence of a subspecialist in the geographic area may help the generalist offer care for more, and more complex, patients.
A concern has been raised in one state; and although controversial, it appears that in some specific situations, subspecialists are performing a large volume of general otolaryngology procedures and, in essence, eroding the general otolaryngologist practice. This seems to be a significant problem where hospital administrators have created satellite locations to compete with general otolaryngology practices. But it is also concerning that surgery is being performed in some areas without local call coverage. There can be a point in which there is too much overlap between services provided by subspecialists and general otolaryngologists.
To paraphrase, 3 our existing healthcare system was created considering patients with acute conditions that required immediate attention. This is not the case today and the majority of our patients have chronic conditions such as cardiovascular disease, diabetes, obesity, cancer, and chronic degenerative diseases. By the time our patients need a subspecialist, you could argue that conventional medicine has failed the patient. Thus across all areas of medicine there is an important role for both the generalist and subspecialist to collaborate in order to provide quality care to our patients.
References
- Berry LL, Seiders K, Wilder SS. Innovations in access to care: a patient-centered approach. Ann Intern Med 2003;139:568 –74.
- Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Washington, DC: National Academy Press; 2001.
- Henderson, J. Marcus Welby and the relentless growth of specialization. www.kevinmd.com/blog/2011/01