Urologists must refocus on medical care, broaden scope

The specialty of urology is evolving dynamically. With changes in techniques and treatment protocols have come significant practice challenges, including a declining work force, an increased focus on procedures, and competition from other specialties, according to J. Stuart Wolf, Jr, MD. Dr. Wolf, who has researched these issues, discusses what he calls "the expansion and contraction of urologic practice, past, present, and future" in this exclusive interview. Dr.Wolf is the David A. Bloom Professor of Urology and director of the division of minimally invasive urology at the University of Michigan,Ann Arbor. He was interviewed by UT Editorial Consultant Stephen Y. Nakada, MD, professor of urology and professor and chair of the division of urology at the University of Wisconsin, Madison.

Q. Among the practice concerns facing urologists today is the number of people entering and leaving the specialty. Is there a shortage of urologists, and if so, how serious is the problem?

Q. What do you see as some of the solutions to the problem?

A. Certainly, we need to think about increasing the number of urologists. I do not mean to lay too much blame on our specialty, since everyone miscalculated.

AUA has similar problems. In the mid-'90s, the AUA commissioned a report that predicted manpower needs for our specialty, and it recommended that the number of trainees be decreased. That, in fact, happened, and has led in part to the current predicament.

The problem, of course, is that we can't just snap our fingers and suddenly increase the number of residency spots. The graduate medical education program is capped, so adding a resident at an institution means it must come from some another specialty that's giving it up or it will be an unfunded position.

But increasing our numbers in some way is one way to address this. We need to extend our practices. We're already doing that in many settings with physician extenders, such as nurse practitioners. I also think we need to think about changing the scope of our practice so that we don't work ourselves into a corner and make our specialty too small.

Q. What measures should practicing urologists consider when trying to expand or maximize their practice opportunities?

A. We need to recognize that procedures currently make up the vast majority of our practices. If you look at CPT claims, about 20% of a urologist's claims are for procedures done in the office and about 20% are for procedures done in the operating room. But if you look at actual income, 75% of our income is derived from procedures. We have become proceduralists; we have become technicians. Urologists were forced to do this to maintain their income in the face of declining reimbursement. However, if this trend progresses, we risk becoming technicians and risk losing our expertise in the medical aspects of urologic care.

I see several very bad outcomes from that. Number one, most urologists went into urology because they like medicine and surgery, and as we become proceduralists, I think we're going to lose our own professional satisfaction.

Number two, as we lose expertise in the medical aspects of urologic care, we're going to lose our expertise in the urologic disease processes in general. For example, in prostate cancer, if we become just the clinicians who perform the biopsies and take out the prostates, we're not the ones managing the disease anymore. The medical oncologist may be managing the disease. We need to be concerned about this trend.