PAs address shortage, but their role can be controversial

There has been and remains a shortage of urologists in the United States that is expected to worsen, and experts inside and outside of urology generally agree that physician assistants (PAs) will be called upon increasingly to help shoulder the burden of a declining work force. The remaining question-and a frequently contentious one-is, what specific tasks should these men and women be allowed to carry out.

That is the question Aaron Milbank, MD, and Ken Mitchell, MPAS, sought to answer in their Saturday morning address to colleagues attending the Large Urology Group Practice Association annual meeting held in Chicago.

"There are a variety of roles PAs can fill, but some are controversial because there are procedures that urologists feel fall entirely within the scope of their clinical specialty," Dr. Milbank told Urology Times. Dr. Milbank and Mitchell practice at Metro Urology in Minneapolis, the largest urology group in Minnesota, with 19 physicians, five PAs, and two advanced practice registered nurses.

"Our goal is to have PAs help us maximize our 'triple aim' performance. That is to say, they help maximize cost, quality, and patient experience," Dr. Milbank said.

"We are here to help. We can be integral to relieving the work force shortage. The population we serve is growing faster than there are providers for their care," said Mitchell, a certified PA with more than 17 years of clinical experience. He specializes in male sexual dysfunction at Metro Urology.

Dr. Milbank noted that among the many services a PA can offer are providing assistance during in-office surgeries, conducting hospital rounds, sitting on hospital committees, taking initial calls, conducting community outreach, and serving on hospital committees and national association boards.

"And then there are the procedures, some of which are controversial," said Dr. Milbank. These include diagnostic cystoscopy, pessary fitting, percutaneous tibial nerve stimulation, and in-office treatments (bacillus Calmette-Guérin administration, depot administrations, intracorporeal injections, and chemotherapeutic or immunotherapy administration). Assisting on vasectomies and transrectal ultrasound biopsies are also on the list.

"There is a knowledge gap about the scope of a PA’s skills and abilities,” Mitchell said. “A lot of doctors are not necessarily aware of the procedures that can be done by PAs. My area is sexual medicine. So I perform penile Doppler ultrasounds, testosterone pellet implants, penile injection training, and other associated procedures.”

Despite their ability to contribute to success, PA utilization is not uniform across practice settings. A work force survey conducted by an AUA ad hoc committee in 2008 found that 74% of academic institutions employ PAs compared to 22% of solo urology practices. The Medical Group Management Association reports that PAs generate income far in excess of their costs. Urology PAs see an average of 70 to 100 patients per week, according to data presented by Dr. Milbank and Mitchell. (Also see, “PAs in urology: Vital statistics.”)