Modeling the importance of physician training in practice location for Ohio otolaryngologists

Methods

Results

This study analyzed a total of 361 otolaryngologists practicing in Ohio (Table 1). Of the 361 physicians, 140 (38.9 %) went to medical school and 151 (41.8 %) went to residency in Ohio. Moreover, 83 (22.9 %) otolaryngologists performed their medical education and residency in the state of Ohio. The proportion of otolaryngologists that performed their medical school, residency, and/or fellowship in the state of Ohio was statistically significant (p<0.01).

Of the 140 otolaryngologists who went to medical school in Ohio, 83 (59 %) continued their residency in the state. Thus, going to medical school in Ohio significantly increases the odds of going to an otolaryngology residency in the state (p<0.001). However, going to medical school or residency in Ohio did not increase the likelihood of otolaryngologists performing a fellowship in the state (p=1.0).

Thirteen of the 88 counties (15 %) were considered to be in southeast Ohio, and 32 of the counties (36 %) were in the Appalachian region (Figure 1) [36]. The subset of 13 counties in southeast Ohio are all classified as Appalachian. Although more osteopathic otolaryngologists practiced in the Appalachian region than allopathic otolaryngologists (17.4 % vs. 11.1 %), the difference was not statistically significant (p=0.3) (Table 2).

Figure 1:

Map of Ohio with the Appalachian region highlighted, as defined by the Foundation for Appalachian Ohio. The Southeast Ohio region consists of the following 13 counties: Athens, Gallia, Hocking, Jackson, Lawrence, Meigs, Morgan, Perry, Pike, Ross, Scioto, Vinton, and Washington [36].

There was a significant difference (p<0.01) in the proportion of osteopathic and allopathic otolaryngologists who practiced in southeast Ohio (13.0 % vs. 2.9 %). Additionally, the mean population (p<0.001) and percent rural (p<0.001) of counties were significantly different between osteopathic and allopathic physicians. Osteopathic medical graduates practiced in counties with an average of 28.2 % rural (standard deviation [SD]=25.3), whereas allopathic medical graduates practiced in counties with an average of 12.7 % rural (SD=18.9).

The number of practicing otolaryngologists increased with the recency of medical school graduation (Figure 2). Specifically, more than 90 % of otolaryngologists in Ohio graduated medical school after 1983, and approximately 15 % graduated between 2008 and 2014.

Figure 2:

The number of otolaryngologists practicing in Ohio sorted by medical school graduation year, with a cumulative line curve identifying the total proportion of otolaryngologists.

In total, 390 Ohio medical school graduates completed residency training in otolaryngology. Multivariate logistic regression prediction models depicted the relationship between performing medical training (medical school, residency, and fellowship) in Ohio and practicing in the Appalachian or southeastern region for these 390 medical graduates (Table 3). Going to medical school and/or residency in the state was a significant predictor of practicing in Appalachia (p<0.001) or southeast Ohio (p<0.001). Moreover, between medical school and residency, medical school was a significantly better predictor of otolaryngologists practicing in Appalachia (ΔBIC>10) and southeast Ohio (ΔBIC>10). For the continuous prediction models of percent rural and median household income, performing medical school in Ohio was a better predictor than residency (ΔBIC>10). Performing residency in state was a better predictor for county population than medical school (ΔBIC>10). Combining these predictor variables yielded the best results. The multivariate model of medical school and residency was significantly better than either predictor alone for population (ΔBIC>2).

However, the optimal model for all five response variables included the addition of fellowship to medical school and residency (ΔBIC>10). The model of fellowship, medical school, and residency omitted otolaryngologists who had not done fellowship training.

Practicing in Appalachia and southeast Ohio was predicted with the same binary variables of medical training (medical school, residency, and fellowship), with the addition of osteopathic education (Table 4).

The addition of DO to the various models did not significantly improve the prediction strength of Appalachia or southeast Ohio (p>0.05). All models predicting percent rural were significantly improved with the addition of DO (ΔBIC>10). Models including medical school and residency to predict the median household income of counties were enhanced with the addition of DO (ΔBIC>2).

Similar to the models without DO, the optimal model for all five response variables included the addition of fellowship to medical school and residency (ΔBIC>10).

Discussion

The goal of this study was to identify factors that impacted what specific locations otolaryngologists practice in, and if GME had any influence. The hypothesized belief, as stated before, is that the more training that otolaryngologists receive within the state of Ohio, the more likely they would be to practice in an underserved portion of the state.

One of the strongest correlations that came from this study was between attending medical school or residency in state and practicing in Ohio. These results show that otolaryngologists will likely practice in the same state as their training. A study supported this finding and discovered that nearly 80 % of participants who completed medical school and GME in Michigan also went on to practice in Michigan [37]. This trend occurred across all specialties, demonstrating that it is a phenomenon that is not unique to Ohio or to otolaryngologists.

The present study did not find this connection to remain true for fellowship. The state of Ohio has numerous fellowship opportunities (more than 20) offered through institutions such as: The Ohio State University Wexner Medical Center, University of Cincinnati, University Hospitals in Cleveland, and the Cleveland Clinic [38], [39], [40], [41]. Among the otolaryngologists who practice in Ohio, approximately 15 % fewer did their fellowship in state when compared to medical school or residency. One possible explanation is that physicians frequently change from their original job after fellowship. Specifically, “physicians who completed training in the last six years stayed in their first jobs for an average of only two years.” [42] This is a unique finding for younger physicians, and several variables have been hypothesized, including the impact of the COVID-19 pandemic as well as a general shift in generational views [42]. There are also other factors that could play a role, including long hours and workloads that are too burdensome [43].

In 2023, there were 493 applicants for 373 available residency positions in otolaryngology, according to the National Resident Matching Program (NRMP) [44]. Among the 373 available residency positions, 371 positions were filled [44]. By increasing awareness of the specialty earlier in the medical school process, more students may be encouraged to pursue otolaryngology, potentially reducing the number of unfilled positions in the future. The federal government offers financial support for GME and has taken measures to address the shortage of physicians in all specialties. However, although some specialties have witnessed considerable growth in the number of residency positions, otolaryngology has not experienced a commensurate increase in comparison to other specialties [10]. As with any field, the number of applicants continues to increase at a disproportionately fast rate, with more applicants than there are residency positions. This puts the pressure, instead, on the number of residency spots, which continues to be the limiting factor in the competitiveness of an otolaryngology residency spot.

Studies have shown that there is a wide-ranging shortage of physicians, which is affecting the care for people of all ages. This shortage tends to have a disproportionate impact on rural areas. Rural areas commonly lack specialists like otolaryngologists [2]. This leads to primary care physicians needing to take up a larger set of responsibilities that frequently go beyond their traditional scope of practice. Previously, higher rates of burnout were believed to correlate with increased demands on rural family physicians, as compared to their metropolitan counterparts. However, one study found that roughly 25 % of rural family physicians experienced burnout, whereas 51.4 % of family physicians practicing in metropolitan areas experienced burnout [45]. Hence, although rural physicians frequently have less help, they report significantly higher rates of job satisfaction. One explanation could be due to feelings of freedom regarding the ability to change careers easier than physicians in city centers, but it does not address the organization or coordination of care. Coordination of care is predicted to worsen in rural settings because of higher patient-physician ratios and large numbers of responsibilities of all kinds [45].

Ohio is a unique state in many ways. Its diverse geographical landscape allows physicians to seamlessly move from a city to a rural setting and continue working with little to no change in their work dynamic. Ohio University Heritage College of Osteopathic Medicine (OU-HCOM) has three campuses across the state of Ohio: Cleveland, Dublin, and Athens. Between these three campuses, OU-HCOM had an enrollment of 1,001 students in 2023 [46]. This made OU-HCOM the largest medical school in the state [46]. Thus, Ohio residents may be more likely to experience care from a DO and to view the DO as an equally prevalent part of the healthcare team.

The mission of the AOA as well as all doctors of osteopathic medicine is to treat the whole patient, employing the belief that the person is equally mind, body, and spirit, and the natural self-healing mechanisms of the body should be guided instead of interrupted. Just as central to that mission is the importance placed on caring for underserved populations in a primary care setting. According to the AOA, 57 % of DOs practice in primary care [47]. Although the number of DOs practicing in primary care decreased in years past, it is still significant enough to make this study two-fold. The physician participants in this study were divided into doctors of allopathic medicine (MD) and DOs. This offers an opportunity to examine whether DOs have a stronger predilection towards rural, underserved areas. The study does not create a binary distribution regarding whether an area is rural. Instead, each county was classified as a certain percentage of rural or urban. As previously stated, studies have shown a clear link between more rural areas and an increase in poor health outcomes with a concomitant decrease in access to care [2].

Our study found that osteopathic physicians were more likely to practice in southeast Ohio, Appalachian Ohio, and in counties with a roughly 15 % higher rate of rural communities, although not all of these were clinically significant. It has long been believed to be true that DO physicians are more likely to practice in a rural setting than their MD counterparts, but that was historically only examined in the primary care setting and then extrapolated. There is reason to believe, though, that these rates could differ for a surgical subspecialty such as otolaryngology due to their differing lifestyle and patient populations. One study showed that osteopathic ophthalmologists from Michigan are much more likely to practice in rural settings than allopathic ophthalmologists [16]. This finding, paired with the results in the present study about otolaryngologists in Ohio, strengthens the understanding that osteopathic physicians, no matter the specialty, hold to their mission statements and tend to practice in more rural settings.

The multivariate logistic regression prediction models looked at the connection between in-state medical education and practicing in southeast or Appalachian Ohio. The connection was significant with medical school and residency alone, but it was the strongest when all three variables (medical school, residency, and fellowship) were combined. This omitted the otolaryngologists who did not complete a fellowship. This is interesting, and it makes sense from a social point of view. If a physician completes his or her medical school, residency, and fellowship all within the same state, then he or she has built a very strong base and is likely to continue to practice in that state. With the DO variable added in, the predictive models for practicing in a rural area (% rural) were increased. Models predicting the population of counties were also enhanced with the addition of DO. This may be due to the osteopathic mission to practice in underserved areas.

Conclusions

There exist substantial differences in the overall health and availability of healthcare between differing geographic areas. The otolaryngology subspecialty, in particular, has far fewer physicians practicing in these rural areas, with the majority of physicians practicing in areas of higher socioeconomic status. This study aimed to determine if the location of an otolaryngologist’s training throughout medical school, residency, and fellowship had a predictive value to the geographical area where that same physician will practice after their medical education. It also investigated whether a physician being licensed as an MD or a DO had a significant effect on their future place of practice.

The findings of this study reveal that the location where physicians complete their medical training (medical school, residency, and fellowship) has a significant impact on predicting their future place of practice. This study found that the location of such training has a positive predictive nature as to whether that physician will practice in a rural and underserved area in the future. Notably, the addition of being licensed as a DO also increased the probability of that physician practicing in a rural and underserved area.