Urology's identity crisis: Two tracks or one?

These were the first two papers presented on the meeting's opening day, and both examined data on recent candidates for certification and recertification by the American Board of Urology. Both showed that, while urology remains a surgical specialty to some extent, major surgery now constitutes a small portion of what urologists do.

Open surgical procedures accounted for 19% of the procedures performed by certification/recertification candidates during 2003-2005, whereas endoscopic procedures accounted for 62% of all procedures. Laparoscopy accounted for only 2% of the cases performed; extracorporeal shockwave lithotripsy, for 9%; and outpatient procedures, for 7%. An overwhelming majority of CPT claims-91%-came from the office, and only 9% came from the hospital.

The data must be viewed with caution, the authors note, as the sample size was relatively small, and not all major surgical categories were studied. Nevertheless, it's no secret that these studies were designed to answer vital questions about how urologists may be trained in the future and, significantly, how the specialty will define itself.

The highly charged issue in question is whether urology should formally become a two-tier or two-track specialty in which one group of general urologists would be trained to focus primarily on office-based care and a second group would be trained to handle major surgical cases. This contentious issue raises difficult questions:

Would medical students be attracted to a urology program in which surgery was limited? A recent study showed that 28% of urology applicants pursued the specialty because of its mix of medicine and surgical procedures (J Urol 2005; 174:1953-7).

Would a two-track system make sense financially? At current reimbursement levels, it is unrealistic for the average urologist to perform such major procedures as cystectomy, while reimbursement for many office-based procedures is considerably higher.

Would such a system improve outcomes? Studies show high-volume surgeons achieve better outcomes than low-volume surgeons when performing complex procedures.

Would general urologists compete effectively with general practitioners? With many urologic conditions now amenable to treatment with effective, easy-to-use drug therapies, primary care physicians already have made inroads into the care of urologic patients.

The ABU, AUA, and various certifying bodies are currently wrestling with these and many more questions that will shape urology's future identity. These groups, along with representatives of the private practice community, held a weekend meeting in April, and a paper outlining their conclusions will be issued soon.

It's clear that a two-track system of urology is already in place in the United States, as evidenced by the ABU data. It's also clear that change is inevitable, and that urology and its training requirements must evolve and adapt to the forces of reimbursement, technology, and competitive pressures.