Raoul S. Concepcion, MD
As many of you know, my father emigrated from the Philippines in the mid-1950s after medical school and completed a general surgery and urology residency. At the American Urological Association (AUA) meeting last year, my friend, colleague, and fellow Filipino, Jim Sylora, MD, was instrumental in allowing me to deliver a presentation at the first joint meeting in the United States of the Philippine Urological Association (PUA) and the AUA. During that gathering, I had the good fortune to meet a number of our colleagues from the Philippines, and when the opportunity presented itself to speak at their national meeting on the topic of advanced prostate cancer last November over the Thanksgiving holiday, it was an invitation I could not decline.
For those of you who have traveled overseas and had the good fortune of interacting with our international colleagues, it is really quite an educational and cultural experience. We are all quite aware of the manpower shortage of urologists in the United States and this is, unfortunately, a ubiquitous problem faced by many countries. The PUA offers only 15 accredited spots for residents in urology annually. This is for a country of 98 million inhabitants. (Compare that with the United States, where we matriculate approximately 300 residents every year with a total population of 320 million people.) The ingress of technologic advances and therapeutics is very limited. Thus, the inability to care for their patients in a fashion that we are accustomed to is quite striking.
However, what is laudable, especially as it pertains to oncologic management, is that the urologist delivers and controls the therapies for prostate and bladder cancer. As previously mentioned, although they may not have approval or access to some of the agents we routinely use, especially in metastatic castration-resistant prostate cancer (mCRPC), it does fall to the urology community for overall delivery. Their search for knowledge and how to better diagnose and manage these patients was quite evident.
One solution that has been put in place to better share information, and is not just relegated to medical care, is the creation of the Association of Southeast Asian Nations (ASEAN). Founded in 1967, this consortium consists of 10 member countries including Brunei, Cambodia, Indonesia, Laos, Malaysia, Myanmar, Philippines, Singapore, Thailand, and Vietnam. From the urologic perspective, they would like to function very much like our brethren in the European Association of Urology (EAU). Getting there, especially in light of the limited economic resources of many of these nations, is going to be a very steep hill to climb. However, their desire and willingness to further educate themselves in order to raise the standards of care and better manage urologic disorders cannot be questioned.
I think it is incumbent on all of us to make real attempts to fill the vast lacuna of knowledge that exists in urology across all of our disease states. We discuss this constantly as it relates to the complexity of urologic malignancies and therapies that have exploded upon us over this past decade. The promotion of physician champions, whether it be for prostate/bladder cancer, overactive bladder, pelvic health, benign prostatic hyperplasia, etc, is becoming the norm. With the introduction of new technologies and panomic testing, it is virtually impossible for us to be renaissance urologists and expect that we can master every aspect of urology and provide state-of-the-art care.
Certainly, this becomes more important in the post-MACRA (Medicare Acess and CHIP Reauthorization Act of 2015) world where outcomes and quality of life for our patients comes with a premium. We have encouraged the creation of centers of excellence within community practice, very much akin to the environment that our academic colleagues have created. There is a realization that at some point our residency programs will need to be revamped as our specialty becomes less invasive. I will also submit, given that we live in the most advanced healthcare country in the world and have access to cutting-edge technology, we owe it to the rest of the world to advance and educate their providers, as well.