By Kevin R. Loughlin MD, MBA
February 14, 2018
Health care issues continue to receive extensive coverage in the lay press, however the current and future physician manpower issues which significantly impact patient care have been largely ignored. I would like to review the urologic workforce issues and their consequences.
A recent American Urologic Association survey reported that 52% of practicing urologists are 55 years of age or older.1 This suggests that perhaps half of the urologic workforce will retire from active practice within the next decade. Compounding the “graying” of urologists is a maldistribution of urologists. The same survey verified that 72% of United States counties have either one or no urologist.1
Implications for Care of the Elderly
A large portion of urologic practice is treating diseases of the elderly. Concurrent with the aging of practicing urologists will be the aging of the American population. In 2010, 13% of the population was aged 65 or older, by 2030 this will increase to 19%.2 Complicating the challenges of caring for an aging population is the fact that the elderly require more urologic care. According to CDC data, in 2010, 51% of all urologic visits were in patients over the age of 65.3 CDC data further show that in the 45- to 64-year-old group, there is an average of 8 urologic visits per 100 patient years. This increases to 22 visits per 100 patient years in the 65- to 74-year-old group and to 30 visits per 100 patient years in the 75-year-old and above group.
Facing Economic Realities
One response to an aging workforce facing increased patient demands would be to train more urologists. However, there are economic realities to consider. The Balanced Budget Amendment of 1997 was passed by Congress in an attempt to control the expanding national debt. This resulted in restraints of federal funding for post-medical school residency training. Despite the current and anticipated urology shortage, there has been only a modest increase in the number of annual graduating urology residents.4,5
The Older Urologist: Cognition and Productivity
The aging of the urology workforce presents additional issues including cognition and the productivity of the caregiver. The AUA Census reports that urologists who continue to practice beyond age 65 see fewer patients than their under 65-year-old colleagues. Specifically, using 100 patient visits per week as a gauge of high office volume, only 8.2% of urologists over 65 years old see that threshold compared to 24.3% and 22.2% of urologists in the 55 to 64 and 45 to 54 age groups , respectively.6
In addition to productivity issues, there are cognition issues to consider in older urologists. This is a complex and controversial topic as not all individual experience cognitive decline at the same rate. Nevertheless, Stanford Health Care has initiated a Late Career Practitioner Policy which involves peer reviews of physicians over the age of 75.6
The Female Urologist: Balancing Family and Career
For many years, urology was primarily a male domain. Fortunately, there have been marked changes in recent years and now many urology training programs have more female than male residents. It is forecasted that the number of female urologists will increase from 7% in 2015 to 18.6% in 2035.7 Some studies suggest that female urologists are likely to work fewer hours than their male counterparts.8,9 However, Lightner et al. provided a contrasting view and reported that female urologists are not more likely to pursue part-time work than male urologists, and the number of hours worked did not correlate with the number or age of their children.10 The ultimate impact of an increasing female workforce remains uncertain.
The Millennial Urologist: Different Priorities
Recent urology graduates, the millennial urologists, have undergone their training during the 80-hour work week era. Many of them have expressed a greater interest in work-life balance. Although it may be attributable to multiple factors, the 2017 AUA Census reports that urologists under the age of 45 see fewer patients per week than any other age group, including urologists over 65.1 It remains unclear whether this pattern will persist as they progress through their careers, but it may exacerbate the urologist shortage even further.
The Rural Urologist: Geographic Maldistribution
Demographics confirm that the United States is becoming a more urbanized society. Projections forecast that from 2010 to 2030, the number of Americans living in urban areas with populations of over 300,000 will increase from about 180 million to 220 million.11 As mentioned, the AUA reports that currently 72% of U.S. counties have one or no urologist.1 Compounding this urban maldistribution is the fact that younger urologists and female urologists are less likely to settle in rural areas. Approximately 7% of urologists under age 45 practice outside metropolitan areas compared to 9–14% of urologists in other age groups.1 Add to this, that women urologists are also less likely to practice in rural areas and the urologist maldistribution is likely to become more intense in future years.
The Advanced Practice Provider (APP): The Imminent Solution with Caveats
Given the reality that it is unlikely there will be an infusion of federal money to support an expansion of urologic training, and given the reality that the demand for urologic services will increase as the population ages, what is the most practical solution? It appears that in the near future there will be increasing reliance on advanced practice providers (physician assistants, nurse practitioners, and advanced practitioner registered nurses) to deliver significant portions of urologic care. Data from the AAMC predict that access to all specialties will evolve, and the MD to PA ratio will decrease from 7.2:1 in 2015 to 3.5:1 in 2030, and the physician to APRN will similarly decrease from 3.6:1 to 1.9:1 during the same period.12
However, the inevitable increased reliance on urologic APPs has to be introduced in a thoughtful manner. Currently, the training, licensing, and scope of practice of APPs is heterogeneous among states.13 Urologists throughout the country have identical training requirements and take standardized exams for board certification. The same type of standardized training and certification must be introduced for APPs. Urologists must embrace, as their responsibility, becoming actively involved in the formulation of curricula and certification of APPs. It is clear that in the future MDs and APPs will be partners and that urologists must be responsible for insuring the quality and competence of all urologic health care providers.
- The State of the Urology Workforce and Practice in the United States, 2017. American Urological Association, Linthicum, Maryland. [PDF]
- The Next Four Decades: The Older Population in the United States: 2010-2050, Population Estimates and Projections, United States Census Bureau, Issued May 2010. [PDF]
- National Ambulatory Medical Care Surgery Fact Sheet-Urology. Center for Disease Control. [PDF]
- ACGME Data Resource Book 2007-2008, pg. 89
- ACGME Data Resource Book 2016-2017 pg. 92
- Lagnado L. When Are Doctors Too Old To Practice? WSJ. 6/25/17
- McKibben MJ, Kirby EW, Langston J et al. Projecting the Urology Workforce Over the Next 20 years. Urology 2016;98:21
- Spencer ES, Deal AM, Pruthi NR et al. Gender differences in compensation, job satisfaction and other practice patterns in urology. J. Urol. 2016; 195:450
- Pruthi RS, Langston J, Kirby EW et al. Workforce survey for practicing urologists. In development with the assistance of AUA marketing, government relations, and practice management departments, 2014
- Lightner D, Terris M, Tsao A et al. Status of women in urology: based on a report to the society of university urologists. J.Urol. 2005;173:560
- US Urban Area Population 1950-2030. Newgeography. Retrieved from: http://www.newgeography.com
- The Complexities of Physician Supply and Demand: Projections from 2015-2030. Final Report, 2017 Update prepared for: The Association of American Medical Colleges. Submitted by HIS Markit Inc. February 28,2017
- Nurse Practitioner Scope of Practice Laws. Barton and Associates. Retrieved from: https://www.bartonassociates.com/locum-tenens-resources/nurse-practitioner-scope of practice
Kevin R. Loughlin MD, MBA is a Professor of Surgery (Urology) Emeritus at Harvard Medical School and practiced urologic surgery at Brigham and Women’s Hospital for 35 years. He holds degrees from Princeton University (A.B.), New York Medical College (M.D.) Boston University (M.B.A.) and Harvard University (M.A.,Hon). He is a former trustee and vice president of the American Board of Urology. He received the Alumnus Gold Medal Award from New York Medical College in 2003 and the Lifetime Achievement Award from the New England Section of the American Urological Association in 2008. Dr. Loughlin has published over 250 articles in the medical literature and is the author or editor of 11 books.
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