American Laryngological Association
Guest of Honor Speech

Socioeconomic, Political, and Scientific Predictions for Otolaryngology and Laryngology by the Year 2000

Paul H. Ward MD

Let me express my deep appreciation to our President, Dr. Byron Bailey, and the American Laryngological Association for this happy occasion of being selected Guest of Honor. My address is merely an appendage to President Bailey's. He has asked me to gaze into my crystal ball and come up with some socioeconomic, political, and scientific predictions for the next decade.

I'm reminded of the drunk who came home as the sun was rising. His wife was irate and wanted to know where he had been. He informed her he came home late in the evening, stopped to rest in the hammock, and fell asleep. She said she had taken down the old hammock 3 weeks ago. His reply was, "Well, that's my story and I'm sticking with it." What I am going to guess may or may not occur, but it is my story and I'm going to stick with it! It has about the same potential and may be as accurate or inaccurate as the expensive think tank studies commissioned by the government and other private organizations.

We now have almost 1/2 years of Clinton presidency under his and her belts and a Congressional majority of Democrats in both the House and Senate. The milieu is preset for the most dramatic changes in society since the passage of the Social Security Act 60 years ago and that of Medicare in 1965. The President and Congress were elected upon their campaign promises to fix the broken health care delivery system. A system that is excessively expensive. A system where many of the poor have no access, where even the employed middle class with medical problems are only a pink slip away from the loss of their medical insurance because of a preexisting condition, and where corporate employers who are responsible for their employees' medical bills change their insurance carriers, leaving the employee without access to his or her physicians.

No one, of course, knows what will happen to the Clintons' plan for universal medical care, how it will be modified, or whether an alternate plan will be submitted by Congress.

Health care consumed over 14% of our gross national product in 1993, a figure predicted in 1989 to be reached in 1996. The current expenditure is increasing by 1% of our GNP every 35 months. Currently, the major automotive companies expend $750 to $1,000 on health insurance for every automobile produced. The President feels health care reform is essential if we are going to get our economy on the move again.

Passage of the Clinton plan or a modified version of a competitive managed care plan appears probable unless a single-payer nationalized plan is passed by Congress. I have a strong feeling that we will go through the experience of a competitive managed care health process first. When the insurance companies, health maintenance organizations, and other private health care corporations have wrung the system dry, then we will witness buyouts, takeovers, and failures of many corporations such as we saw with Maxi Care a few years ago. At this point, with the difficult cost-cutting accomplished, the administration and Congress will introduce and pass a single payer universal program. These experiences have already happened in California and will soon happen in your state. A single-payer initiative is already on the California ballot for November.

Let me return to the main topic of how these socioeconomic changes impact the future of otolaryngology-head and neck surgery. Since the government's stated objective is to increase the number of primary care providers, which include general physicians, internists, nurse practitioners, and physician's assistants, the impact will be a programmed decrease in the numbers of all practicing specialists, in our case otolaryngologist-head and neck surgeons.

Your American Board of Otolaryngology is intensifying its manpower study to provide reasonable estimates of the numbers of specialists in our field who will be needed during the next decade based on prevalence of various diseases and the number of physicians who will be practicing in the specialty in the coming years. This also includes predicting how many residency positions are needed to meet these expectations. These figures are expected to be avail able this summer.

Well, here are my calculations based upon existing knowledge. There are currently approximately 8,000 otolaryngologists, of which 6,000 are, board-certified. Fourteen hundred otolaryngologist-head and neck surgeons are currently 55 years old or older. Most of this group have established their retirement nest eggs, likely will not adapt to the loss of autonomy, and abhor governmental or corporate bureaucracy. I predict many of them will retire-something we have already witnessed.

The 92 residency (some 5-year and others 6-year) programs produce around 262 residents yearly. This means there are approximately 1200 to 1300 residents in the training pool. In some programs, particularly in the big Eastern cities, residents serve primarily to provide service to indigent populations, learning by experience with minimal supervision. As a matter of fact without this care, many of the patients in the county, city, and veterans hospitals would have even more difficulty than they currently experience in receiving their basic care. This must be considered in our calculations. Will patients with a Clinton Care Card still frequent their current service providers, or will they enter the system through local primary care gatekeepers who will refer them to their group's specialist? The latter appears more likely and has the potential for tremendous changes in our training of students, residents, and paramedical personnel and a shift in the characteristics of our practice. The current 8,000 physicians (including residents) functioning as otolaryngologists are excessive for the 257 million population that is increasing at a projected 3 million per year. In order to meet the cost cap, general physicians, nurse practitioners, technicians, and other less experienced paramedical personnel will be trained to take care of sore throats, colds, otitis media, and laryngitis. The primary care physicians and others will remove cerumen, perform flexible and rigid telescopic examinations, and perform biopsies on appropriate lesions of the head and neck.

We can assume that residents currently in training and most otolaryngologists under 55 will work until age 65 or older because of lower-salaried incomes, delayed acquisition of adequate retirement benefits, and anticipated greater longevity.

According to my calculations, we will require only 5000 to 5500 otolaryngologists to care for the expected 285 to 295 million population in the year 2004.

Residency positions must be reduced 30% to 35%, from 262 annually to 156 to 189. This is not cheerful news to residency directors and academicians who rely heavily upon residents to help them care for patients in return for teaching and research time. Since residency positions are primarily paid for by governmental funds, limiting the positions funded easily controls the numbers. Determining how and which residency positions and programs are to be deleted is a more difficult problem. Problems with geographic distribution of both primary care and specialist physicians will be solved by differential incentive remuneration.

Some of these predictions sound dire to the older generation of practicing otolaryngologists, but the specialty has blossomed into one of the most dynamic in medicine. Almost three times the number of highly qualified applicants seek residencies in otolaryngology as there are residency positions. We can predict that the dynamic breadth of the field, from the microsurgery of the ear, sinuses, and larynx to radical head and neck and reconstructive surgery, will continue to expand. There will appear new innovative diagnostic and therapeutic modalities almost beyond our imagination. Laryngology, neurolaryngology, and voice diagnosis and therapy will emerge as a recognized specialty.

The next decade is perhaps the most promising ever for all of medicine. The current generation of young people entering medicine and otolaryngology do so because of the new challenges. Their attitude is one of diminished expectations for monetary rewards but with enhanced expectations and excitement about current and developing technological, medical, and surgical advances.

The maturation and introduction of molecular biology offers the prevention and correction of many genetic and acquired diseases through genetic engineering. This past year the French reported completion of the genome bank, beating out our national competitive efforts to be first. They have shared these data with the world, and the next few years will provide the laborious sequencing of the 100,000 genetic pieces. Gene therapy, genetic engineering, and splicing already offer promise of prevention and correction of several diseases (for example, cystic fibrosis). I predict we will finally see prevention and cure of some head and neck cancers by this technology (viral-induced papillomata and carcinoma of the larynx, congenital defects of the larynx such as subglottic and tracheal stenosis).

Other positive aspects of the restructuring of the health care delivery system as it applies to otolaryngology will be the elimination of most ineffectual treatments, be they medical or surgical. Unnecessary surgery and ineffectual medicines simply will not be paid for with our tax dollars. Wasteful, inadequate, and inferior hospitals, medical schools, and residency training programs will become extinct. The 6 year residency will be reduced to 5 years. Residencies will be shortened to minimize lengthy, marginally effective service requirements, and stress will be placed upon intensified training. In the medical centers the teaching and education of medical students, paramedical personnel, and residents will be elevated to a level of recognition equal to research. The abundance of recently proliferating preceptor fellowships will vanish.

Those who desire to go into otolaryngology-head and neck surgery will find it even more competitive and will do so because of a specific desire and love for the specialty. Those who continue on to more restricted fellowships will do so in search of personal knowledge and satisfaction, since they will receive little if any extra financial remuneration.

It seems safe to predict that like it or not, the private practice of medicine as we have known it will cease. Patients will be cared for by a pyramid of medical personnel providing basic medical care to all citizens of our great nation. A few staunch physicians may hold out, as they have with Medicare, and provide their services only to the wealthy. The wealthy can always care for themselves, but our poor can no longer go without. I continue to reassure the students and residents that physicians will always be at the top of the heap. They deserve a good living for their intellect and lengthy training. If they care for society, then society will continue to care for and reward them. What is most important is to contribute to the health and happiness of our fellow citizens. To seek intellectual challenge and restore the confidence that has led to the high esteem, respect, and prestige of physicians. We have a bright future. Let's focus and work on making it better. I predict higher self-satisfaction and greater freedom of time allotments with more time for family and other personal activities.

In summary, what will be the overall effects of these changes? I believe in the importance, dignity, and the art and science of otolaryngology-head and neck surgery. Our place in American medicine is secure. William Faulkner, in his 1950 Nobel laureate's address, addressing the fear and doom of a nuclear holocaust that permeated society, stated, "I refuse to accept this. I believe that man will not merely endure, he will prevail." Paraphrased, I refuse to accept the decline of our devotion to the highest principles of otolaryngology. I believe that they will not only endure but will prevail and will continue to make us one of the most intellectually challenging and dynamic fields of medicine.