Do you think this subspecialization trend applies now to non-surgical as well as surgical fields within urology?
Absolutely. We’re seeing this not only in inpatient volume but also in outpatient volume; for instance, infertility and pediatrics, and even areas that are a little more modern such as MRI-focused biopsy. We have people who are now subspecializing just in MRI-focused biopsy because it’s so labor intensive and there are complexities to it.
To what extent is this trend related to reimbursement per unit of care? For instance, cystectomy seems more and more to be relegated to academic centers of excellence, not only because the results are better but because it’s so time-consuming to operate and take care of these patients for the private-practice urologist that it almost becomes not financially viable. Do you think that’s a driving force?
Absolutely, that’s part of it. It’s not only a financial decision but also a resource decision. In a large academic center, we have many more resources to deal with these patients who tend to be very sick or have potential long-term complications or issues. For a private practitioner, spending 6 hours on a cystectomy instead of 6 hours in the office is a world of difference in terms of financial reimbursement. This is the future of urology; why train all of our urologists to do cystectomies when there are only a handful who are going to be doing them?
In the Urology study, you noted that in Germany, subspecialization within urology has led to the creation of the “office urologist” whose activity is restricted at the end of training to diagnosis and non-surgical treatments or a limited range of surgical treatments. This practice structure is also being explored in England. Do you see this happening in the U.S., or is this more the role of the nurse practitioner/physician assistant or physician extender by and large?
I think there will probably be a combination of such. What’s been happening is a lot of our more senior urologists who are less excited to go to the operating room every day have become more like office urologists, which is wonderful because we have an experienced urologist in the office who understands these cases. That’s the nice thing about urology; we have a lot of leeway in terms of how we can continue to practice well into our later years. Interestingly enough, some of the insurance companies are already looking at insuring urologists based on how many cases you do in an inpatient setting versus an outpatient setting as well as office-based volume.