Raoul S. Concepcion, MD, FACS
Raoul S. Concepcion, MD, FACS
Over the past few years, we have struggled with the continued physician shortage, especially in urology. Although it is forecast that by 2035 there will be a net increase in urologic providers (defined as MDs and advanced practice providers [APPs]), the number of physicians will drop to less than 9000. According to the American Urological Association’s (AUA) 2016 workforce report, the median age of urologists in the United States is 55 years, and 30% have been in practice for more than 30 years! Urology is truly the domain of older physicians.1
Now, a recently published survey indicates that 44% of physicians feel burned out and up to 15% have an element of depression.2
However, of physicians in 29 specialties polled or represented, urologists top the burnout list at 54% (the AUA reported 39% in 2016). All of us are keenly aware of the contributing factors: payment reform and diminished compensation; information overload, including more drug therapies, advances in genomic testing, and “Dr Google”; and practice burdens, such as electronic health record documentation, long work hours, and bureaucratic paperwork. With the aging population and the aforementioned urologist shortage, we are reaching a critical tipping point for our esteemed specialty. We need to continue to provide care across the board for our patients, but how do we keep our physicians engaged and stimulated in order to capitalize on their wealth of experience and established reputations in the community? These elements are so critical for continuity of care and mentorship of the up-and-coming generation of new doctors.
I would put forth that most of us entered this field to become surgeons. The beauty of the specialty has been the variability of the procedures one needs to master, depending on your clinical interests and type of practice you join. Clearly, though, our specialty has moved away from traditional open surgery toward minimally invasive procedures and active surveillance, which is counter to why many of us in my generation chose urology. This transformation is most acutely seen in surgical oncology where robotic surgery has become a cornerstone for even the most complex of procedures. As a direct result of their video game prowess, our younger colleagues have a distinct advantage with that technology.
However, for the most part, patients are referred for specific clinical signs or symptoms, and the cognitive aspect still is critical to practicing state-of-the-art medicine. This is even more true now, given all the advances that we are currently witnessing, whether in therapeutics, testing, or imaging. For the urologist who feels overworked and overstretched, these paradigm-shifting advances may represent an opportunity to stave off burnout, more effectively use clinical acumen gained over the years, and maintain practice engagement.
Here and in many other publications, urologists have discussed the need to embrace the management of advanced prostate cancer in the increasing number of patients who fail definitive therapy—specifically, by gaining a mastery of the delivery of care that although nonsurgical does require an extensive intellectual commitment. We know that the number of drugs currently approved in the castration-resistant prostate cancer space will continue to increase and numerous trials are demonstrating the relevance of these agents to specific disease subtypes. Additionally, it will become critical to understand the various predictive molecular tests that ultimately will be mandated to effectively layer these various therapies, as well as provide effective counseling for both patients and families. I truly believe that if more urologists can make this transition, they will find themselves challenged and perhaps less inclined to just walk away, knowing that there are opportunities that allow them to stay involved in the care of their patients and advance the science. Their roles, traditionally surgical, will become more diverse and important as disease management takes priority.
In his 2017 book Homo Deus: A Brief History of Tomorrow
, Yuval Harari stated, “The greatest scientific discovery was the discovery of ignorance.” As the information explosion saturates our world, we need to retain freshness of mind and avoid turning our backs on practice-advancing knowledge. Hopefully, the development of advanced therapeutic centers and identification of providers who want to fill these specific roles can result in better continuity of care, less burnout, and continuous involvement of the aging urologist, whose accumulated expertise is so valuable to the rising need for quality urologic care across the country.
- The state of the urology workforce and practice in the United States: 2016. American Urology Association. April 2017. www.auanet.org/research/research-resources/auacensus/ census-results.
- Kane L. Medscape national physician burnout, depression & suicide report 2019. Medscape website. medscape.com/slideshow/2019-lifestyle-burnout-depression- 6011056. Published January 16, 2019. Accessed February 26, 2019.