Physician work force advocate Dr. Cooper remembered

Richard “Buz” Cooper, MD, an outspoken figure on health care work force shortages, passed away Jan. 15, 2016, from complications related to cancer. He was 79.

Dr. Cooper, a hematologist/oncologist, founded the Cancer Center at the University of Pennsylvania in Philadelphia in 1971, according to a tribute from the university’s Leonard Davis Institute (LDI) of Health Economics. Later, he served as dean of the Medical College of Wisconsin in Milwaukee, where he established and led an academic center devoted to health work force research.

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Dr. Cooper later returned to the University of Pennsylvania as an LDI Senior Fellow, focusing on the future of the physician work force.

"His was a remarkable transformation from someone who was a leader in hematology/oncology to someone who became a forceful leader in the area of health policy. He was really a larger-than-life kind of character,” said David A. Aasch, MD, MBA, of the University of Pennsylvania.

In 2009, Dr. Cooper spoke with Urology Times Editorial Consultant Philip M. Hanno, MD, MPH, about the urologist shortage, a concern that persists today. In this interview, which follows below, Dr. Cooper discusses the urologist shortage, the increasing role of physician extenders, and what the future holds for an aging specialty.

Do we have enough physicians in the United States?

No, we certainly don’t. It’s being felt everywhere.

Do we have enough urologists in the United States?

No, we don’t. The situation is even worse for urologists than it is for physicians overall. During the 1980s and 1990s, when the overall number of physicians per capita was increasing, the number of urologists didn’t increase and the number of urologists per capita has actually fallen by about 10% over the past decade. It’s really astounding to look at what’s happened to the number of urologists, particularly when considering all the procedures and therapies that urologists now perform or prescribe. If you match urologists against the older population, which is increasing rapidly, the shortage is just devastating.

Next: "There’s just no question that urology in America can’t function in the future with only urologists."

The use of physician extenders appears to be a growing trend in medicine in general and urology in particular. How does this play into the urologist shortage?

Physician extenders are helping to improve the situation. They allow urologists to concentrate on what they do uniquely. Preoperative care, follow-up education and advice, follow-up phone calls, and even counseling on sexual function or other issues for which patients seek urologists’ advice are very effectively handled by nurse practitioners. Physician assistants aid certain procedures as well. There’s just no question that urology in America can’t function in the future with only urologists. Urologists need the assistance of non-physician clinicians.

How does the increase in the use of physician extenders affect the quality of care?

If anything, I think it increases the quality. It keeps everybody focused on what they’re interested in and what they do best. Doctors, like it or not, have never been terrific at patient education, but nurses are wonderful at it. There’s a lot of patient education that goes on in all physicians’ practices, and this certainly applies to urology. Nurses handle that whole aspect of care very effectively. As specialists (I’m a hematologist/oncologist), we focus on what we know and do best and what engages us most, so physician extenders make perfect sense.

Does the volume of surgery and procedures parallel the number of surgeons and urologists, in particular?

Yes. You would expect it to. Procedures can’t occur without physicians, and physicians tend to locate where there is a demand for what they do.

Next: "[Surgeons] locate where there is a demand for their services."

Haven’t there been studies showing that the number of surgical procedures is directly related to the number of surgeons and that the quality of health care doesn’t necessarily improve in the population based on the number of procedures?

Yes. The research you’re referring to has related the number of surgeons to the amount of surgery. Victor Fuchs published a classic paper showing a strong association, and he concluded that a greater number of surgeons was responsible for more surgery: supplier-induced demand. But David Dranove followed this with an identical study that assessed the association between the number of deliveries in a community and the number of obstetricians, and the results were identical: a strong association.

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The question, then, is did the obstetricians induce those pregnancies, or did the obstetricians go to a community where there was a demand for services? Clearly, it’s the latter, and the same is true for surgeons. They locate where there is a demand for their services.

Yet, it is likely that some physicians do induce the demand for unnecessary treatments. We all know physicians who do that, but it’s not commonplace and it’s not what drives the volume of medical care. The major drivers of medical care are the resources available in a community for medical services-the overall wealth of the community-and the demand for care in that community, which is greater among the wealthier segments of the community, but are increased two- to three-fold among the poorest.

Is population health directly or indirectly related to the number of physicians in first-world societies where a baseline number of physicians exist? Once you reach a certain baseline, do more physicians mean better health care?

That's a very difficult question to answer because a number of related factors are important to the health of a population. In the U.S., health care, health care outcomes, and health status are all better in states with greater affluence, primarily in the North and Midwest, and they are the poorest in poor states, primarily in the South. More affluent states with richer health care resources also have richer educational systems and richer social support systems. They tend to have fewer impoverished people, who have the worst outcomes. It's a combination of people, the society of which they're a part, and the health care, education, and social services that can be brought to bear on their lives.

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If you're simply relating the supply of surgeons and surgical services to population health in first-world countries, then yes, population health is better where there are more physicians. But at the level of population health, physicians play a rather small role. Education, nutrition, family support, and other factors are more important. The “outcomes” that are commonly talked about in health care reform discussion have relatively little to do with physicians, or even health care.

Next: Should more urology care be taken over by primary care providers?

Should more urology care be taken over by primary care providers?

That would not be a good idea. Patients are well served by nurse practitioners and physician assistants within the contextual framework of a urology practice. All the knowledge is there, it's passed back and forth, and all members of the team learn from each other. If you separate that culture in areas as complex as many urologic conditions are, it doesn't add quality.

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I believe that primary care is principally for first-line minor illness, prevention, and wellness. General medicine is for more complex patients, often with comorbidities. Diseases that are well demarcated are best handled within a specialty framework.

What is the optimal number of urologists per population, and how is that number determined?

It's really hard to get at the number. The number varies across the nation; more affluent states have more urologists, and less affluent states have fewer. The variation is not as striking as it is for medical specialists or for surgeons overall. Urologists tend to distribute across the country somewhat more evenly than other physicians. There's no “optimal” number; the number is based on the demand for services and the shifting needs and procedures that come along.

It seems that it would be much more efficient if major urologic surgical procedures were performed by specialists in those procedures in major medical centers. Fewer urologists could be more productive and more proficient by specializing. To some extent, this is already happening. Doesn't this change the ratios needed for optimal health care?

It probably does. More efficient facilities can have a much greater throughput. We're seeing that trend in the focused hospitals that are being set up in India to handle the tourist medical business. They're very focused on one particular activity, and they do it very well.

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There are centers in this nation where prostate cancer, for example, is a major focus of activity. They have a huge throughput, their surgeons have high skill levels, and they have outstanding outcomes. There's no question that the more technical the procedure, the better it is for that procedure to be performed in a dedicated facility, or what's been referred to as a “focused factory.” But we live in a vast nation with a widespread population. We're too big to focus everything in a few places. The needs are diverse, and the organization of medicine must be, too.

Next: Do you think the advent of laparoscopy and robotics suddenly made many urologists somewhat obsolete and created unexpected shortages?

Urology is an aging specialty: 45% of urologists are 55 or older. Do you think the advent of laparoscopy and robotics suddenly made many urologists somewhat obsolete and created unexpected shortages?

I don't have any first-hand familiarity with that subject, but it certainly makes sense. It's not uncommon for older surgeons across disciplines to say, “What would I rather do, the procedure I've been doing for 20 years or the new procedure that I'm not very familiar with?” That's a real problem.

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Of course, patients are going to prefer a newer, low-risk approach over an older approach that may not be as successful or may be associated with higher morbidity.

The evolution of surgery is rapid. Keeping current in all of this is a real challenge, particularly for older practitioners.

Is it the government, the market, or the specialty that ultimately controls the number of urologists?

There's no way for the government to control it because the government has never carried out an objective assessment of need. Government planners have traditionally been advocates for more primary care amidst an evolution to more specialty care, and all of their studies and recommendations have been grounded in this political belief. So deal the government out entirely. But it's also hard for the profession to control because we don't really know what the future holds in terms of new treatments and other developments. We are better at predicting the number of surgeons overall than the number in a particular subspecialty, like urology.

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Predicting the volume of care overall is easy because it's based on an economic formula. There will be as much care as the nation can buy, so if you predict how rich the nation will be, you can predict how much care will be given. It's a very simple formula. However, we don't know exactly what that care will look like 20 years hence, nor who will be giving it. We know that technologically driven care increases the most, so it is likely that the demand for urologists will be somewhat greater than for physicians overall.

Next: "I'd argue that urologists are worth more than a half a million dollars in today's society."

Our new resident graduates are commanding up to half a million dollars annually as they go into practice, which is simply astounding. Can this continue?

I don't know. It's what the market bears. Urologists are highly skilled and highly sought after. I'd argue that urologists are worth more than a half a million dollars in today's society. But the real message is that we're not producing enough.

How are medical schools adapting to the needs of the market?

They're not adapting enough. There are too few new medical schools. We should be expanding rapidly; we're expanding minimally. Worse than that, there are too few residency positions. Medicare funding for residencies was frozen in 1996, and because Medicare is a major source of funding, there have been few additional positions since then. In fact, that's the reason for the physician shortage. Even as we add more U.S. medical school grads, we don't necessarily add more doctors because the U.S. grads simply displace international medical graduates, who comprise about 20% of all residents.

What portion of the shortage problem can be attributed to maldistribution?

We don't really have maldistribution; we have variation in distribution. We will never have the same number of physicians in Mississippi as we will in Connecticut. The distribution of physicians on a population basis is the same as it was 50 years ago in relation to the relative wealth of the communities. We have more physicians in wealthy states and fewer in poorer states.

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You can refer to this as maldistribution, but that puts a value judgment on it. It's the way the world works. Wealthier areas have more of everything: K-12 education, social services, restaurants, physicians, everything. Call it maldistribution, which it is if you take the view that everybody in the world should be equal. But the world doesn't work that way, nor does America, and it's exceedingly hard to make health care work that way.

Health care is supported by the resources of a community, the employers, the tax revenues, and all the other resources. These resources vary from region to region. If you can make them all the same everywhere, I promise you health care will be the same everywhere. But to talk about the maldistribution of doctors when there's an equivalent variation in the distribution of everything else doesn't make sense.

Next: "We spend more in the North and have terrible outcomes in the South."

Why do you think the U.S. is 15th or 16th in the world in terms of health morbidity if we have so many more physicians and put so much into health care?

We are not a single nation; we're a nation of nations. We spend more in the North and have terrible outcomes in the South.

In America's poorest states, from West Virginia through Kentucky, Tennessee, Mississippi, and extending through the South, we spend less on health care. It's the poverty area, the Stroke Belt. There is a high frequency of hypertension, diabetes, and heart disease in these states. If you measure mortality in the Confederate states, they don't rank 15th or 16th; they are the worst developed in the world. But if you then measure mortality in the rest of the U.S., it's above average-much like Finland. Health outcomes are good where we spend on health care, and it's lousy where we don't. It's unfair to average the two.

What are your views on a single-payer system?

You can't have a single-payer system in a country that's not a single country. I divide the nation into nine regions, and the inputs and outcomes are different in those regions. If you look at the demographics, income, physician supply, health care spending, and outcomes in each region, they correlate with each other and they're different from each other. It's very hard to impose a single system on the entire country.

What is your view of misapplied incentives and their effect on the number of procedures performed?

It's very hard to measure the role of financial incentives. Most physicians are so overworked and have such long waiting times that it's hard to believe they've created these waiting times by doing a lot of unnecessary work. I know very few who I would say “churn the system.” It clearly happens, and we have to try to prevent it, but I really don't believe that unnecessary care is what is driving health care spending. It's technology, which leads to new ways to treat disease, many that were previously untreatable, and it's poverty, which creates an inordinate demand because poor people have a high burden of disease and often lack the knowledge and support systems that are necessary to make the best use of the best health care in the world.

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