The State of the Workforce: Advanced Practice Providers in Otolaryngology
Learn how the growing presence of APPs is reshaping otolaryngology practice while raising important questions about training, oversight, and scope of practice.
Andrew J. Tompkins, MD, MBA, Chair, on behalf of the Workforce Task Force
The integration of advanced practice providers (APPs) into otolaryngology care, their scope of practice, and impact on our healthcare system always generates diverse and passionate opinions. Regardless of individual positions on these matters, APPs have become a significant and growing part of our otolaryngology workforce. The 2022 and 2023 workforce reports have shed light on these facts—which we will explore below—but practical and philosophical questions remain regarding oversight and future directions.
Current Workforce Numbers
Although precise estimates of the otolaryngology workforce in the U.S. remain challenging owing to database limitations, we can use the American Medical Association Physician Professional Data (AMA PPD) to provide a rough estimate for establishing APP workforce numbers. The AMA PPD estimates we had 10,178 actively practicing (defined as working at least 20 hours per week) otolaryngologists in the United States in 2023.1 Using the practice environment breakdowns from our 2023 report2 and ratios of APPs to otolaryngologists in those settings from our 2022 report,3 we can derive a rough estimate of the APP workforce.
This rough calculation reveals that we have over 3,000 APPs in the otolaryngology workforce, which represents approximately one-third of the otolaryngologist workforce. Even if the AMA PPD workforce numbers are inaccurate, the ratio of APPs to otolaryngologists and relative APP workforce approximation still holds. Further, this number may have increased given the continued intent to hire more APPs4 since those ratios were established in our 2022 report. The upshot is that APPs are a substantial percentage of our workforce and otolaryngology care delivery.
Figure 1. Plans to add APPs(s) to practice in next 12 months by practice type.
Practice Patterns and Productivity
The workforce is trending towards academic settings,5 where productivity is lowest in terms of clinical days worked per week6 and patients seen per day.7 All else equal, this shift equates to less patient throughput over the average otolaryngologist’s career. APP utilization acts as a counter to this productivity decline as well as other effects such as time to fill out electronic medical records (EMR). Depending on the practice setting, APPs are employed in 31% to 90% of practices.8 The vast majority of APPs perform in-office procedures9 and see a median of 15–19 patients daily when seeing patients independently,10 which almost all APPs do regardless of practice setting.11 These productivity gains increase the total time available for each otolaryngologist, which has the effect of decreasing wait times for our patients.
Table 1. When performing procedures, percentage of APPs performing given procedures by practice setting.
Geographic Distribution and Access
The geographic distribution of APPs and their effect on distance-based access is more nuanced. Some data suggest a slight tendency towards APPs practicing in rural environments,12,13 though, like otolaryngologists, their practice environments are overwhelmingly urban. Rural APP employment tended to be more varied than in urban environments, with a larger percentage of rural practices either not employing APPs at all or having a higher APP to otolaryngologist ratio than urban counterparts.14 Whether through APP employment, graduate medical education (GME) changes, telehealth, or other creative solutions, we should strive to address the rural access gap, especially as more residents complete fellowship, which has a significant predisposition to urban concentration.
Financial Considerations
On the financial front, APPs can offset decreasing revenue from declining Medicare reimbursement. Physicians can only see so many patients before experiencing the effects of burnout, negatively affecting patient care. Employing APPs can not only help with patient access but also relieve physician burnout while providing benefits. Physicians are not always in the office, whether in the operating room or on call. In situations when an otolaryngologist is unavailable, the assets of the practice (e.g., real estate, procedural assets, and medical assistant time) are not being put to productive use. Further, excess capacity may allow for future growth. In a strict financial sense, APPs’ ability to see patients in times of physician absence, or when excess capacity exists, increases the return on investment of a practice’s assets. We showed this objectively in our 2022 report, where higher ratios of APP employment correlated significantly with higher income in a multifactorial analysis.15
Training, Credentialing, and Oversight
Despite the increasing involvement of APPs in our field, it is reasonable to have a healthy debate about practice standards. We are all keenly aware of the training pathway to become an otolaryngologist and the associated licensing, credentialing and board certification requirements. Some would argue that this crucible puts us in the best position to have oversight—that is, direct and individual accountability for the APPs who work with us. Others might argue that without standardization, we have not defined what competence in our field looks like for APPs. Both points are valid.
Physician assistants (PAs) and nurse practitioners (NPs) have dissimilar training requirements and varied independent practice potential depending on the state in which they practice. Institutions have attempted to fill the void of training standardization either through core curricula or one-year fellowship programs. Despite these efforts, most otolaryngologists do not send their APPs for training.16 The vast majority of training occurs in the practice itself, followed by training received elsewhere prior to joining the practice.16 The time until an APP reaches competence in the specialty is seen as bi-modal, with most otolaryngologists citing either a six- or 12-month period of training to achieve competence in otolaryngologic care.17
Figure 2. How APPs are trained by practice type.
Implementing a core curriculum, such as the AAO-HNSF Otolaryngology Core Curriculum (OCC) developed recently for resident education, would benefit practices from an educational perspective. For hands-on training and clinical judgment, otolaryngologists seem to want to take an active role in this—which makes sense, given that the care being delivered is ultimately a reflection of that practice. Since most APPs perform in-office procedures, a combination of educational tools to ensure competence (and confidence) and individualized oversight appears justified, considering the variable time to achieve competence and the costly, inflexible nature of formal accreditation standards.
Scope of Practice Concerns
Some, rightly, have concerns about scope of practice expansion. NP organizations have made consistent efforts to expand their ability to practice independently. Professionals previously referred to as “physician assistants” have now undergone a name change to “physician associates”, represented by the American Academy of Physician Associates (AAPA), a change that occurred in 2021. These maneuvers by PAs at the national level go beyond superficial name changes. The AAPA now defines an “optimal team practice” as having no “legal requirements for a specific relationship between a PA, physician, or any other healthcare provider.” As a result of legislative advocacy to this end, the governor of Montana, for example, signed legislation eliminating supervisory requirements after PAs complete 8,000 clinical hours.19 The AAPA’s goal is to establish similar, if not looser standards, in every state. None of these actions respect the physician as the team lead.
To learn more about the AAO-HNS state-level advocacy initiatives and how you can get involved, visit the Academy’s Advocacy pages and sign up as a State Tracker for regular access and updates to legislation introduced in your state, including those related to scope of care.
Physician Leadership and Collaborative Care
While the loosening of historical supervisory standards generally undermines physician leadership and clinical expertise, these moves are, regrettably still, more of a direct threat to our colleagues in primary care. Our competitive advantage remains our ability to take a patient to the operating room when needed, and the associated credentialing requirements to that end. APPs are smart and accomplished professionals. Their employment not only helps our practices and patients in many ways but can also maximizes practice potential. But scope of practice and standardization concerns are real. Otolaryngologists, regardless of how they choose to employ, train, and work with APPs, should continue to be the leaders of otolaryngologic care in our communities. With effective physician leadership, we can thread the needle to optimize patient safety and access.
References:
1. “U.S. Physician Workforce Data Dashboard,” AAMC, accessed March 4, 2025, https://www.aamc.org/data-reports/report/us-physician-workforce-data-dashboard.
2. Figure 5.1, “Practice Type Distribution of Respondents,” from The 2023 Otolaryngology Workforce, published by the American Academy of Otolaryngology – Head and Neck Surgery, 2024.
3. Page 65, “Mean APP to Otolaryngologist Ratio by Practice Type,” from The 2022 Otolaryngology Workforce, published by the American Academy of Otolaryngology – Head and Neck Surgery, 2023.
4. Figure 6.2, “Plans to Add APP(s) to Practice in Next 12 Months by Practice Type,” from The 2023 Otolaryngology Workforce, published by the American Academy of Otolaryngology – Head and Neck Surgery, 2024.
5. Page 30, “Relative Practice Setting Dispersion for Largest Practice Setting by Decade,” from The 2022 Otolaryngology Workforce, published by the American Academy of Otolaryngology – Head and Neck Surgery, 2023.
6. Table 7.2, “Clinical Days Worked Per Week by Practice Type,” from The 2023 Otolaryngology Workforce, published by the American Academy of Otolaryngology – Head and Neck Surgery, 2024.
7. Figure 7.4, “Patients Seen Independently of APP/Resident/Fellow during Full Workday,” from The 2023 Otolaryngology Workforce, published by the American Academy of Otolaryngology – Head and Neck Surgery, 2024.
8. Figure 6.1, “APP Use by Practice Type,” from The 2023 Otolaryngology Workforce, published by the American Academy of Otolaryngology – Head and Neck Surgery, 2024.
9. Figure 6.4, “APPs Performing In-Office Procedures by Practice Type,” from The 2023 Otolaryngology Workforce, published by the American Academy of Otolaryngology – Head and Neck Surgery, 2024.
10. Figure 6.6, “Patients Seen by APPs Independently During Full Workday by Practice Type,” from The 2023 Otolaryngology Workforce, published by the American Academy of Otolaryngology – Head and Neck Surgery, 2024.
11. Figure 6.5, “How APPs See Patients by Practice Type,” from The 2023 Otolaryngology Workforce, published by the American Academy of Otolaryngology – Head and Neck Surgery, 2024.
12. Patel RA, Torabi SJ, Kasle DA, Pivirotto A, Manes RP. Role and Growth of Independent Medicare-Billing Otolaryngologic Advanced Practice Providers. Otolaryngol Head Neck Surg. 2021; 165(6): 809-815.
13. Liu DH, Ge M, Smith SS, Park C, Ference EH. Geographic Distribution of Otolaryngology Advance Practice Providers and Physicians. Otolaryngol Head Neck Surg. 2022; 167(1): 48-55.
14. Page 68, “Ratio of APPs to Otolaryngologists, Urban vs Rural,” from The 2022 Otolaryngology Workforce, published by the American Academy of Otolaryngology – Head and Neck Surgery, 2023.
15. Page 77, “2021 Clinical Income $525k-$1M,” from The 2022 Otolaryngology Workforce, published by the American Academy of Otolaryngology – Head and Neck Surgery, 2023.
16. Figure 6.9, “How APPs are Trained by Practice Type,” from The 2023 Otolaryngology Workforce, published by the American Academy of Otolaryngology – Head and Neck Surgery, 2024.
17. Figure 6.10, “Months Until APP Achieved Full Otolaryngology Competency,” from The 2023 Otolaryngology Workforce, published by the American Academy of Otolaryngology – Head and Neck Surgery, 2024.
18. “Optimal Team Practice,” AAPA, accessed March 4, 2025, https://www.aapa.org/advocacy-central/optimal-team-practice/.
19. “Montana Governor Signs Law Removing Supervision Requirement,” AAPA, accessed March 4, 2025, https://www.aapa.org/news-central/2023/04/montana-law-removes-collaboration-requirement-for-pas-with-8000-practice-hours/.