The expanding role of PAs and NPs in otolaryngology

FigureImagine a patient in a remote community struggling with chronic sinusitis. After months of ineffective treatment through primary care and telemedicine, the patient is finally referred to an otolaryngology (ENT) service. However, instead of traveling hours to the nearest metropolitan center, the patient receives care locally from a trained physician associate (PA) or nurse practitioner (NP). This scenario is becoming increasingly common as the roles of PAs and NPs expand within ENT. Access to ENT care remains challenging, particularly in rural areas, due to workforce shortages and geographic barriers. However, strategies including use of telemedicine, rural-urban partnerships, and structured training programs for PAs and NPs can bridge these gaps and improve patient outcomes. THE CHANGING ENT WORKFORCE The United States is facing a growing shortage of otolaryngologists, with demand expected to outpace supply in the coming decades. This shortage is particularly acute in rural areas, where specialists are often hard to find. Meanwhile, the number of PAs and NPs entering the field has risen significantly, transforming the ENT workforce. Between 2013 and 2024, the number of PAs practicing in ENT more than tripled, rising from 483 to 1524.1,2 During the same period, the per capita number of otolaryngologists declined, highlighting the growing reliance on PAs and NPs. Medicare data from 2012 to 2017 show that although the number of otolaryngologists increased by only 2.2% in that time frame, the number of PAs and NPs in the field surged by 51% (Figure 1).3 Consequently, the proportion of new patient visits managed by PAs and NPs rose from 4% to 7%, whereas established patient visits increased from 11% to 15%.3FIGURE 1.: Growth of PAs and NPs in ENTTHE ROLE OF PAs AND NPs IN ENT PAs and NPs in ENT play a key role in both procedural and diagnostic services. Common procedures include cerumen removal, flexible nasolaryngoscopy, and diagnostic nasal endoscopy. More specialized interventions, such as laryngeal video stroboscopy and sinus debridement, have also experienced significant increases in PA and NP involvement.4 Although the median number of procedures per provider has remained stable, the expanding workforce of PAs and NPs has had a substantial overall impact on patient care. GEOGRAPHIC DISTRIBUTION AND ACCESS TO CARE The geographic distribution of ENT providers underscores the role of PAs and NPs in addressing healthcare disparities. Studies indicate that most otolaryngologists practice in urban centers, whereas a larger proportion of PAs and NPs serve in rural counties (Figure 2).5 This distribution is particularly significant given that rural populations often experience higher rates of poverty and an aging demographic, both of which contribute to an increased demand for specialized ENT care.5 By strategically placing PAs and NPs in underserved areas, healthcare systems can greatly enhance access to otolaryngologic services.FIGURE 2.: Geographic distribution of PAs and NPs in ENT vs physicians in ENTCHALLENGES AND TRAINING CONSIDERATIONS Despite these promising trends, challenges continue to exist. Most PAs and NPs enter the ENT specialty through on-the-job training, as formal postgraduate training programs are still limited. Although some PA and NP fellowship programs have been established, their impact on patient outcomes and workforce retention needs further analysis.6 Integration into team-based care models is another critical success factor. Evidence from institutions such as Dartmouth-Hitchcock demonstrates that incorporating PAs and NPs into multidisciplinary teams increases patient access, shortens wait times, and enhances surgeon productivity.7 These findings suggest that expanding the roles of PAs and NPs in structured, collaborative environments benefits both patients and healthcare providers. POLICY AND FUTURE DIRECTIONS To fully realize the potential of PAs and NPs in ENT, several steps must be taken: Develop standardized core competencies specific to PA and NP practice in ENT. Expand training opportunities, including structured postgraduate programs, to ensure proficiency in advanced procedures. Advocate for policy reforms that empower PAs and NPs to practice at the top of their licenses while maintaining high standards of patient care. Promote integration into team-based care models, ensuring that PAs and NPs complement and enhance ENT services rather than replace physician-led care. As the healthcare system evolves to meet the needs of an aging population and the increasing demand for specialty care, PAs and NPs are well-positioned to play an essential role in the future of ENT services. Ensuring adequate training, regulatory support, and strategic workforce deployment is necessary to maximize their impact. By embracing these changes, the ENT specialty can advance toward a more accessible and patient-centered model of care.