Received: 8 May 2019 Revised: 26 December 2019 Accepted: 10 January 2020

DOI: 10.1002/hed.26084

ORIGINAL ARTICLE

Trends in head and neck fellowship graduates in the

United States from 1997 to 2017

Yufan Lin BS | Dhruv Patel BS | Tam Ramsey MD | Neil Gildener-Leapman MD

Department of Otolaryngology, Albany

Medical Center, Albany, New York
Correspondence
Tam Ramsey, Department of Surgery,
Albany Medical Center, Otolaryngology/
MC-191, 50 New Scotland Ave, Albany,
NY 12208.
Email: ramseyt2@amc.edu
Section Editor: Jonathan Irish
Abstract
Background: We investigated whether the supply of head and neck fellowship
graduates matches head and neck cancer trends.
Methods: Graduates between 1997 and 2017 from the American Head and
Neck Society (AHNS) and United States Otolaryngology fellowship program
webpages were identified. Trends in graduates were compared with head and
neck cancer incidence obtained from the Center of Disease Control.
Results: Of 538 fellows, 428 were from the United States. Of fellows practicing
in the United States, 24.14% were female. Most practice locations were urban
(98.44%). AHNS fellowship positions from 1997 to 2017 increased by nearly
1.82 per year (P < .00001). Graduates in academic positions increased by 1.03
per year (P < .00001). Concomitantly, the age-adjusted incidence rate of oral,
oropharyngeal, and laryngeal cancers decreased (P = .0115).
Conclusion: There is important geographic variability in the practice loca-
tions of Head and Neck Oncologic Surgeons in the United States and our data
may be helpful in matching clinical supply and demand.

KEYWORDS
fellowship trends, gender disparity, head and neck fellowship, surplus, underserved areas

1 | INTRODUCTION to a lower cancer patient caseload per surgeon. In a

According to the American Head and Neck Society
(AHNS), there were 48 head and neck fellowship pro-
grams available in North America in 2018 including three
in Canada and four American endocrine surgery pro-
grams. Compared to 1997, when the total number of
accredited head and neck fellowship programs was seven,
this is considerably higher.1 This upward trend parallels
trends in opening additional medical schools and otolar-
yngology residency positions over the years.2,3 However,
head and neck cancer fellowship graduates typically need
an academic affiliation with a high-volume center to
safely perform ablative and reconstructive surgery for
patients with mucosal head and neck squamous cell car-
cinoma.4 A surplus of head and neck surgeons might lead
recent study by Sturgis et al, the incidence of oral squa-
mous cell carcinoma and laryngeal cancers-two predomi-
nant cancers in head and neck oncology-decreased, while
the incidence of oropharyngeal cancer increased due to
HPV related cases.5 This present study sought to identify
trends in head and neck cancer fellowship graduate
employment in comparison to trends in the combined
incidence of oropharyngeal, oral cavity, and laryngeal
cancers. These mucosal head and neck cancers inci-
dences were considered a good surrogate for cases that
ablative and reconstructive head and neck surgeons are
uniquely qualified to manage. In the United States, the
supply of endocrine surgeons is more complex, involving
general otolaryngologists, general surgeons, as well as
head and neck surgeons. For this reason, we have not

1024 © 2020 Wiley Periodicals, Inc. wileyonlinelibrary.com/journal/hed Head & Neck. 2020;42:1024–1030.
LIN ET AL.
included thyroid cancer in this study. Furthermore, cuta-
neous malignancies were not included in this study due
to their management being handled by a multitude of
specialties and not being limited to head and neck cancer
surgeons. We also investigated whether a geographic mis-
match exists regarding the distribution of head and neck
surgeons trained in the United States after 1997 and the
incidence of new head and neck cancers by individual
state. These research questions have not been addressed
in the literature and there is a significant need for exami-
nation to guide resource allocation for training, optimiza-
tion of patient outcomes, as well as plans for prospective
fellowship applicants.
2 | METHODS
A list of head and neck fellowship programs in North
America was obtained from the AHNS in 2018 excluding
endocrine fellowships. The number of fellowship posi-
tions and the duration of each fellowship were collected.
We also obtained a list of past head and neck surgery
graduates between 1997 and 2017 from the AHNS
website as well as fellowship program-specific webpages.1
Graduates from 2002 were excluded as no names were
provided by AHNS for that year and a complete list of
graduates was not obtainable elsewhere. An internet sea-
rch using Google search engine was performed using
combinations of terms including: “name, otolaryngology,
head and neck, surgery, residency, fellowship” for each
AHNS fellowship graduate. The following were collected:
year of fellowship; gender; name, state and region of fel-
lowship; name, state and region of residency program;
and name, academic status, state and region of the cur-
rent practice. Academic practice was defined as residency
and/or fellowship training program affiliation with a
rank of at least assistant professor. Graduates who were
found in two different continuous years but at the same
program were listed in the latter year. The number of the
head and neck fellowship graduates was plotted from
1997 to 2017. The distribution of the AHNS fellowship
program graduates' current practice locations was
mapped. Referencing the United States Department of
Agriculture Rural-Urban Commuting Area Codes, ZIP
codes of current practice locations were then categorized
as urban areas or rural areas.
The age-adjusted rate of oral, oropharyngeal, and
laryngeal cancer incidence from Centers for Disease Con-
trol and Prevention between 1999 and 2015 was collected
and added together to trend over time. The new cases
(incidence counts) per state were recorded and used to
(a) graph the distribution of new cancers throughout the
United States (b) determine the number of patients per
1025
graduate in each state by dividing the incidence counts
by the total of graduates residing in that state (only fel-
lows who graduated from 1997 to 2017 were included).
Descriptive and simple linear regression analysis was
used to determine statistical significance of fellowship
and head and neck cancer rate trends.
3 | RESULTS
There were 48 head and neck fellowship programs in
North America including 4 endocrine programs and
3 Canadian programs. The 41 programs in the United
States, excluding endocrine only fellowships, offered a
total of 50 positions. The majority of the programs (32 out
of 41) currently offer one-year-training fellowships. Eight
other programs offer the option of either one- or two-year-
training fellowships. However, additional research years
are also common. A total of 24 states had at least one head
and neck fellowship program: Pennsylvania (5 programs),
Ohio, California, and New York (4 programs per state),
Michigan and Florida (3 programs per state), North Caro-
lina (2 programs), Alabama, Georgia, Illinois, Indiana,
Iowa, Kansas, Maryland, Massachusetts, Nebraska, Mis-
souri, Oklahoma, Oregon, South Carolina, Tennessee,
Washington, Wisconsin and Texas (1 program per state).
There were three programs in Canada; 45 of
59 (76.27%) fellowship graduates trained in Canada
received training at the University of Toronto. Of
538 graduates who did fellowship in the United States,
428 (79.55%) were from the United States, 107 (19.89%)
were from foreign countries, while 3 had unknown back-
grounds. Nearly one-third of foreign graduates were from
Canada (34). Lebanon (11), England (9), and India (9)
each contributed to nearly one-tenth of the total past for-
eign fellowship graduates. The remaining fellows were
from Singapore (7), Puerto Rico (6), Turkey (4), Israel (4),
Chile (3), Scotland (3), Australia (3), New Zealand (3),
Greece (2), Ireland (2), Netherlands (1), Syria (1), Taiwan
(1), Switzerland (1), Sweden (1), Egypt (1), and Jordan (1).
A total of 71 of 107 (66.34%) fellows from foreign coun-
tries currently work in their home countries or in
another foreign country, and 33.66% continue to work
in the United States.
The number of fellowship graduates rose steadily
from 1997 to 2017 at the rate of nearly two fellows per
year (P < .00001, r = 0.9278, regression slope of 1.82) in
accordance with the AHNS website which identifies
AHNS certified programs (Figure 1). There were only
seven graduates in 1997 while there were 43 graduates in
2017. When excluding graduates currently residing in for-
eign countries, the increase in fellowship graduates was
1.62 per year (P < .00001, r = 0.9107) (Figure 1). The
1026
F I G U R E 1 Trends of American head and neck fellowship
graduates from 1997 to 2017. The solid line and circle markers
represent all graduates from American fellowships regardless of
background (P < .00001, r = 0.9278, regression slope 1.82). The
dotted line and the diamond markers represent American head and
neck fellowship graduates who completed residency at
U.S. programs (P < .00001, r = 0.9107, regression slope 1.62)
distribution of current practice location for graduated fel-
lows is presented in (Figure 2). We were not able to iden-
tify the current locations of three fellowship graduates.
Of those with identifiable locations excluding those prac-
ticing in foreign countries (538 past fellows minus
3 unidentifiable locations minus 71 practice in foreign
countries), 75.86% (352 out of 464) were male and 24.14%
(112 of 464) were female. Over 70 % (327 out of 464) of
graduated fellows currently practice at academic institu-
tions, of which 23.24% (76 of 327) were female. Nearly
25 % (114 out of 464) practice in the same state as their
fellowship location, and 33.84% (157 of 464) practice in
the same state as their residency location. There was no
statistical significance in academic participation trends
for all the graduates or female graduates over the studied
period (P = .9592 and P = .3763, respectively). The vast
majority (98.44%) of practice locations were categorized
as urban areas.
There was a total of 112 female graduates in the stud-
ied period. In comparison to 71.79% (252 out of 351) of
male graduates who joined an academic practice, 67.86%
(76 out of 112) of female graduates joined an academic
practice. The number of fellowship graduates in aca-
demic positions increased by 1.03 per year over the
period of the study (P < .00001, r = 0.9001, regression
slope of 1.0309) (Figure 3). The proportion of females by
fellowship year ranged from 5.56% to 41.18% with 13 of
20 studied years demonstrating female participation of
less than 20.00%. The last 3 years of the study, 2015 to
2017, showed the highest rate of female participation in
head and neck fellowships (33.33% in 2015, 41.18% in
2016, and 32.56% in 2017). Over the 20-year period of the
study, there was a statistically significant positive trend
LIN ET AL.
F I G U R E 2 Geographic distribution of American Head and
Neck Society fellowship graduates of period 1997 to 2017. The darker
shade represents a higher distribution ranging from 0 to 54. The
number of graduates practicing in each state: (Arkansas 5, Alabama 5,
Arizona 9, California 50, Colorado 5, Connecticut 9, Florida 23,
Georgia 12, Hawaii 5, Illinois 16, Indiana 4, Iowa 4, Kansas 3,
Kentucky 5, Louisiana 9, Maryland 10, Massachusetts 16,
Michigan 19, Minnesota 9, Mississippi 1, Missouri 10, Nebraska 5,
Nevada 1, New Jersey 10, New Mexico 4, New York 54,
North Carolina 10, Ohio 19, Oklahoma 6, Oregon 5, Pennsylvania 28,
South Carolina 4, South Dakota 1, Tennessee 7, Texas 35,
Utah 8, Virginia 12, Washington DC 5, Washington 7,
West Virginia 4, Wisconsin 4. The remainder states have 0) [Color
figure can be viewed at wileyonlinelibrary.com]
F I G U R E 3 Trends in academic positions currently held by
head and neck fellowship graduates between 1997 and 2017
(P < .00001, r = 0.9001, regression slope: 1.0309)
in female participation in head and neck fellowship
(P = .0090). However, this trend fails to reach signifi-
cance when inspected in the 10-year period of 2007 to
2017 (P = .1020).
There is a downward trend in the age-adjusted total
incidence of oral, oropharyngeal, and laryngeal cancers
(P = .0115, r = 0.5524, regression slope = −0.0194)
(Figure 4). The distribution of head and neck fellowship
graduates in the United States was analyzed. The states
with the highest concentration of the graduates were
New York (54), California (50), and Texas (35). The
LIN ET AL.
Northwest region has the lowest number of graduates
residing (Figure 2). The incidence of head and neck can-
cer in 2015 in descending order by region was: Southeast,
Midwest, West, Northeast, and Southwest. The incidence
rate of head and neck cancer cases in 2015 is depicted by
state (Figure 5). Ten states (Utah, Hawaii, New Mexico,
New York, Nebraska, Connecticut, Massachusetts, Penn-
sylvania, Maryland, and Michigan) had less than
100 new cases per graduate while six states (South Caro-
lina, Virginia, Wisconsin, Indiana, Nevada, and Missis-
sippi) had more than 250 new cases per graduate. Ten
states had a complete absence of identifiable graduates
(Wyoming, Idaho, Montana, Alaska, North Dakota,
Delaware, Vermont, Rhode Island, Maine, and New
Hampshire) (Figure 6).
F I G U R E 4 Trends of age-adjusted incidence rate of total oral
and oropharyngeal and laryngeal cancers from 1999 to 2015
(P = .0115, r = 0.5524, regression slope = −0.0194). Data collected
from Center for Disease Control and Prevention
F I G U R E 5 Geographic distribution of oral, oropharyngeal,
and laryngeal cancer incidence in 2015. Darker shades indicate
higher rates, ranging from 8.5 to 18.5 per 100 000 population [Color
figure can be viewed at wileyonlinelibrary.com]
1027
F I G U R E 6 Geographic distribution of patient with cancer
head and neck cancer per American Head and Neck Society
fellowship graduates of 1997 to 2017. Darker areas represent a
lower patient to physician ratio while lighter colors represent a
higher patient to physician ratio [Color figure can be viewed at
wileyonlinelibrary.com]
4 | DISCUSSION
While the total number of AHNS fellowship positions in
the United States has been increasing linearly by nearly
two fellows per year since 1997, the combined incidence of
oral, oropharyngeal, and laryngeal cancers has been slowly
decreasing since 1999 (Figures 1 and 4). A significant por-
tion of the increase in AHNS fellowship positions is likely
from previously nonaccredited fellowships joining AHNS,
which makes conclusions about the overall workforce
numbers difficult. Further, non-AHNS fellowship gradu-
ates were not included in the scope of this study.
Previous studies analyzing trends in head and neck
cancer cases using the US Surveillance and Epidemiology
and End Results (SEER) database showed a steady
decline at a rate of 0.22% per year between 2002 and
2012,6 as well as an overall decrease of head and neck
cancer incidence between 1973 and 1999.7 This was spec-
ulated to be in part caused by the decreasing trends in
tobacco use, especially among younger populations.5
Stagnation in oropharyngeal cancer improvement was
attributed to HPV widespread prevalence.5 In 2018, the
FDA approved the use of the HPV 9-valent vaccine for
men and women up to the age of 45.8 More widespread
implementation of HPV vaccination may provide an
opportunity to decrease the incidence of oropharyngeal
cancer in the upcoming decades.9 For now, the impact of
this epidemiological level change remains to be observed
as it may take decades between exposure and incidence
of cancer.
On the other hand, there continues to be an abundant
interest in pursuing fellowship sub-specialization in head
1028
and neck oncology among U.S. otolaryngology residents.
Based on the most recent survey by the American Acad-
emy of Otolaryngology-Head and Neck Surgery Section for
Residents and Fellows-in-Training in 2016, 45.7% of sur-
veyed residents and fellows intended on future academic
practice and 46.0% of residents intended on pursuing fel-
lowship. Head and neck oncology remained the most pop-
ular fellowship of choice at 23.6% of subspecialty plans.5
While the reasons for the increasing number of prospec-
tive head and neck subspecialists is multifactorial, previ-
ous articles have cited an increased level of interest in
overall fellowship training overall due to the 2008 reces-
sion leading to a perceived decrease in general otolaryn-
gology job opportunities10 and decreased general training
due to work-hour restrictions.11
Our study revealed an uneven geographic distribution
of head and neck physicians who graduated between
1997 and 2017. Six states had more than 250 new cases
per graduate, and 10 states had a complete absence of
graduates. From a patient care perspective, this is con-
cerning as it can mean disparities across the country in
distance traveled to receive medical care. Zeng H et al
found that the further away patients with head and neck
cancer were to the cancer centers, the lower their survival
rate.12 This is likely due to the need for frequent follow
up for recurrence surveillance in head and neck can-
cers.13 Therefore, incentives for new graduates to move
to these deficient areas might be considered. Our study
indicated that a significant percentage of graduates in
academic settings chose to practice in the state they were
trained (24.57% for fellowship location, and 33.84% for
residency location). Residency location was a better pre-
dictor of final practice location than fellowship location,
possibly because of the relative abundance of choices for
residency and the amount of time spent in training
(5 years residency vs 1-2 years fellowship). Therefore, if
additional otolaryngology residency and head and neck
oncology fellowship positions are planned, consideration
should be given to programs in underserved areas to
improve physician retention in those areas.
Over 98% of practice locations in this sample were
classified as urban by the United States Department of
Agriculture Rural-Urban Commuting Area Codes. Fur-
ther, nearly all urban locations were metropolitan and
over half of rural locations were micropolitan (population
size 10 000-49 999) as defined by the United States Cen-
sus Bureau. This data supports the idea that a critical
population size is required to support the infrastructure
required for a head and neck practice. While establishing
physical practices in low population density areas may be
less feasible, innovations in telemedicine may help cross
geographic boundaries by decreasing time to establish-
ment of patient-physician relationship and facilitate ease
LIN ET AL.
of travel for long term postoperative follow-up.14 Beswick
et al piloted the feasibility and impact of involving ter-
tiary care hospitals in the remote workup of head and
neck cancer patients seen at Veteran Health Affairs hos-
pitals. Using on-site tissue diagnosis, imaging, and
nasopharyngoscopy which was broadcasted via real-time
audiovisual teleconferencing, the authors found improve-
ments in time from referral to operation as well as total
traveling time.15 Regardless, challenges still remain for
care requiring physical infrastructure such as in office
procedures or surgeries.
Our study also found that 19.89% of head and neck
graduates were from foreign countries. The intention of
training foreign graduates are twofold: sharing and
exchanging knowledge with other providers around the
globe and/or retaining physicians to meet the healthcare
needs of American patients. This relationship is reciprocal
as American graduates have participated in fellowship
training in foreign countries as well. It is our view that
American fellowship programs should continue to wel-
come foreign graduates and be a part of this global
exchange of otolaryngology knowledge and quality of care.
While an argument can be made for training more
American-based fellows for physician retention, our study
shows that training more American head and neck surgery
fellows might not solve the problem of health disparity as
most graduates practice in few concentrated geographical
locations.
Espinel et al showed that 54.7% of the pediatric otolar-
yngology fellowship graduates worked in academic set-
ting.10 Our study demonstrated a higher rate of academic
practice for head and neck graduates at 70.47%. This is no
surprise as head and neck cancer surgeries are generally
more extensive, requiring postoperative care and multi-
disciplinary coordination that is often only available at ter-
tiary academic centers. The practice patterns of the
remaining 30% of AHNS fellows outside of academic cen-
ters are not well characterized. Our data show that the rate
of increase in academic positions for head and neck fel-
lowship graduates does not match the rate of new fellow-
ship graduates. During the study period, the number of
AHNS fellowship graduates practicing in an academic set-
ting increased by approximately one per year while 1.8
AHNS fellowship positions were added each year. Due to
limitations in the data, it is unclear whether this difference
indicates a scarcity of academic positions, whether the
demand for academic practice has decreased, or whether
this difference is attributable to an overestimation in the
rate of fellowship growth due to absorption of previously
non-AHNS accredited fellowships.
Medicine has seen a significant increase in female
physicians over the last decade. In 2017, more than half
of U.S. medical students were female.16 In 2018, more
LIN ET AL.
than half of medical school applicants were female.17
This prospect has not yet translated to otolaryngology. A
study of medical school faculty in Otolaryngology showed
that only 14% of professors and 2% of academic chairs
were female in 2017.18 A national resident survey in 2011
reported that while female residents were initially more
interested than their male peers in completing a fellow-
ship and academic practice, these sex differences were
eliminated or reversed by the end of training.19 Our study
showed that only 23.24% of head and neck physicians
practicing in academic centers who graduated from 1997
to 2017 were female. Interestingly, the rate of female par-
ticipation (67.86%) in academic practice was similar to
the rate of male participation (71.79%) in academic prac-
tice. Our study also demonstrated an upward trend in
females pursuing head and neck surgery fellowships over
a 20-year period with the highest rate in the last 3 years.
This is encouraging; however, efforts should continue to
provide opportunities for more females to advance in the
field of head and neck oncology.
One of the major limitations of the study was the data
source. We used the AHNS and fellowship program-
specific websites as our sources for fellowship graduates
and current job status. Even though they are reliable, it is
possible that some programs did not post their past fel-
lows on these two websites. The total number of AHNS
certified and non-AHNS certified head and neck fellows
graduating each year is likely higher than what our data
shows, adding to the competition for both academic and
nonacademic positions. The rate of growth of total fel-
lowship positions, however, is likely overestimated. In
earlier years, fellows may have been trained at programs
not accredited by AHNS; non-AHNS head and neck fel-
lowships were not accounted for, and many of these fel-
lowships were later converted to AHNS certified
fellowships. More recently, the difference between the
number of graduating head and neck fellowship trained
surgeons from all programs and AHNS-certified pro-
grams has grown smaller and smaller. Exclusively using
AHNS fellowship data will more accurately reflect true
growth rates and the total number of head and neck fel-
lowship positions/graduates over the next 20 years in
comparison to the previous 20 years.
Another limitation with the data is that we used the
Center of Disease Control and Prevention database to col-
lect oral, oropharyngeal, and laryngeal cancers incidence
as a surrogate for overall head and neck cancer volume.
Trends in thyroid and cutaneous malignancies were not
considered due to their management by other specialties
but can certainly impact overall caseload for a head and
neck surgeon. There are also lower volume cases which
were not included such as sarcomas, vascular mal-
formations, and advanced endocrine lesions that would
1029
benefit from the expertise of a head and neck surgeon.
Instead, the comparison between the rise in the number
of head and neck surgeons is made against the total
cumulative decline in incidences of oropharyngeal, oral
cavity, and laryngeal cancers. While the total incidence
of oral, oropharyngeal, and laryngeal cancer cases is
decreasing, the incidence of oropharyngeal cancers alone
has increased due to HPV related cases.20 Importantly,
there are now more indications for surgical treatment of
oropharyngeal cancers such as primary resection for T1
and T2 squamous cell carcinomas with transoral robotic
surgery that may ultimately serve to increase average
number of procedures per patient.21 Another limitation
with this approach is that patients often travel great dis-
tances and cross state lines for treatment, which does not
consider well-entrenched referral patterns.
Despite limitations, we believe that this is a useful
cross section of current practice patterns and patient
demand for the evolving workforce of head and neck sur-
geons, particularly regarding cancer trends. Future studies
could trend head and neck cancer procedure case volume
and geography to more accurately investigate the supply
and demand of head and neck fellowship graduates.
5 | CONCLUSION
Our study demonstrated geographic discrepancies in
head and neck cancer trends (oral, oropharyngeal, and
laryngeal cancers) and AHNS head and neck fellowship
graduate trends over the last two decades. The combined
incidence of oral cavity, oropharynx, and larynx cancers
has decreased while the number of AHNS fellows per
year continues to increase. As a portion of this growth
may be attributable to the absorption of nonaccredited
programs, this trend should be followed. Additionally,
the distribution of head and neck graduates favors areas
of concentrated health care markets. This may have
important implications for competition, surgeon case vol-
ume, and quality of patient care. Fellowship applicants
may consider geographic need and patient need when
making career plans.
CONFLICT OF INTEREST
The authors declare no potential conflict of interest.
ORCID
Tam Ramsey https://orcid.org/0000-0002-1027-3286
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How to cite this article: Lin Y, Patel D,
Ramsey T, Gildener-Leapman N. Trends in head
and neck fellowship graduates in the United States
from 1997 to 2017. Head & Neck. 2020;42:
1024–1030. https://doi.org/10.1002/hed.26084