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At Urological Associates of Southern Arizona, "collaboration" is not just a buzzword, it's part and parcel of the daily practice.
On an early Tuesday morning, when many businesses are just ramping up, practice administrator John O’Rourke is wrapping up a briefing with a staff member. Their discussion includes the practice’s plan to begin administering Provenge, the prostate cancer vaccine, to their patients.
During the time that our publication Urologists in Cancer Care spent at the more than 40-year-old practice, appointments with two of its senior physicians required rescheduling because both were called to consult in the operating room. Not to worry; two other partners graciously stepped in to discuss topics ranging from the establishment of the practice to the changing needs of urologic cancer patients in Tucson and beyond.
“The physicians here will help each other out, whether it’s consulting in a patient exam room or in the operating room,” O’Rourke explained. “They consult each other constantly, despite the fact that the reimbursement system has made collaboration very complicated.”
That’s no doubt one reason that in 2011, seven of the 11 top urologists in Tucson who were voted The Best Doctors in America were based at Urological Associates of Southern Arizona.
In terms of urologic cancer care, the practice has also kept its eye on collaboration, seeking to form alliances with its fellow cancer specialists. The practice is in a unique position: Tucson is a microcosm of the rest of the United States, with a graying population that carries a higher cancer risk. And given its long history, the practice has seen many milestones reached for urologic cancer, particularly prostate cancer.
O’Rourke and some of the physician partners shared their vision for their practice and how they are planning to thrive in an increasingly complex medical climate.
Urological Associates of Southern Arizona was founded in the mid-1960s by Donald Gleason, MD, who came to Tucson from the East Coast. During that era, Tucson saw its population double, and the local medical community followed suit. Tucson became known as a “specialist” town, with the highest number per capita of board-certified physicians in the country. More than 850 physicians were serving the community of 200,000 residents in the 1960s.
After Gleason established the practice, he called Robert J. Riley, MD, to join him. Practice lore has it that desert-based Gleason rang up his colleague from poolside on Christmas day, while Riley took the call in snowbound Connecticut.
Thomas Hicks, MD
Throughout the next three decades, Riley and Gleason saw their practice expand, often merging with single practitioners like Thomas Hicks, MD, who joined in 1998.
For Hicks, who spent six years as a solo practitioner, being a part of a large group held practical and professional appeal. “The physicians in this practice were interested in research, and I wanted to get more involved in research,” he said. “Joining a larger group practice also [offers] an efficiency of administration. For a solo practitioner to establish contracts is difficult, because you don’t have the leverage, so that’s another benefit of being in a larger group practice. The resources here and the collegiality of the physicians here appealed to me.”
A wealth of resources has meant that the practice has been able to reach beyond the city: opening satellite clinics in the small southern Arizona towns of Safford and Willcox; acting as a teaching facility for urology residents from the University of Arizona School of Medicine (Stanley Suffecool, MD, serves as the practice’s clinical instructor); partnering with not one but three major hospitals in town; and conducting clinical trials.
Curtis Dunshee, MD
Curtis Dunshee, MD, joined the practice in 1993 and serves as one of the principal investigators of in-house clinical trials (Susan Kalota, MD, is the other PI). In fact, the practice is currently involved in a clinical trial of MDV3011, an investigational drug for men with metastatic castration-resistant prostate cancer that has progressed after treatment with docetaxelbased chemotherapy.
The practice now boasts 12 full-time physicians, one nurse practitioner, and two physician assistants, based at two main Tucson locations.
For urologists, treating cancer has always been a part of their specialty. After all, many urologic cancers are treated surgically or hormonally, and that’s been the domain of the urologists. “Only in the last few years have medical oncologists gotten the tools to take care of prostate cancer patients,” Hicks pointed out. “The same with renal cell carcinoma (RCC); in the last 10 years, medical oncologists have gained the tools to treat this disease. So before that, these cancers were taken care of primarily by urologists. We have the benefit of long-term experience with treating these cancers.”
The physicians agreed that prostate cancer makes up the majority of the urologic cancer cases that they see now, followed by bladder cancer and RCC. It’s in the area of prostate cancer treatment that these urologists feel they have made the greatest strides.
Sanjay Ramakumar, MD
One advance was bringing Sanjay Ramakumar, MD, who came from the University of Arizona in Tucson, into the practice in 2007 (the year Riley retired). There, Ramakumar performed one of Tucson’s first laparoscopic prostatectomies in 2003. Since then, he has done nearly 500 such procedures.
“Minimally invasive surgery has become so integrated into urology that you really can’t be a urologic oncologist without training in this area,” Ramakumar said. “Now prostate cancer patients are routinely offered [laparoscopic prostatectomy], and that’s a great advancement for them.”
The widespread use of minimally invasive surgery for prostate cancer is just one area where urology has shown impressive progress, Ramakumar and Dunshee agreed. Another is the ability to offer treatment options for advanced prostate cancer.
“The man who failed primary therapy, either radiation or surgery, had very few options,” Ramakumar said. “The main option was hormonal therapy, but it was of questionable benefit and came at such a high cost.”
Partners at Urological Associates have made it a point to incorporate newer treatment methods into their armamentarium. For instance, Terry F. Favazza, MD, trained in brachytherapy in 2003. Partner Tristan T. Berry, MD, now specializes in robotic surgery for kidney cancer.
And within the clinical trials, Dunshee has opted to reach out to a population that is often excluded from major research. “Ten years ago, I would have never considered enrolling a 90-year-old in a clinical trial,” he said. “But now I have a couple of [older patients] on clinical trials for castration-resistant prostate cancer who are doing well.”
Healthcare reform has caused some physicians to circle the wagons, afraid of relinquishing turf and losing their livelihood. But Urological Associates has made it a point to reach out to other physicians and remind them that, as a profession, they will sink or swim together.
One example of this came in 2011 with the US Preventive Services Task Force (USPSTF) recommendation against routine prostate cancer screening with prostate-specific antigen (PSA) testing. After the recommendation came out, Urological Associates saw a drop in the number of patients referred to their practice. So they sent letters to all of the primary care physicians in southern Arizona, urging them to continue with PSA screening.
“We said, ‘It is a mistake to take the only screening tool we have for the number one cancer diagnosis in US men, and the number two cause of cancer-related death, and stop screening with it,’” Ramakumar explained. “The task force is not speaking untruths, but how you look at the data, and how that data impacts a practice and the patients on a day-to-day basis, are two different things. Perhaps the agenda of the government is not the same as the agenda as a clinician who cares for patients who die of prostate cancer.”
It’s this type of communication that Ramakumar and his colleagues want to see happen in all specialties, and especially among all the doctors who treat urologic cancers. Given the multiple options that prostate cancer patients now have for their disease, coordination of care is vital, he explained.
“Compartmentalized medicine has worked in the past, but that can lead to duplication of services,” he said. “We need to really think integrated care. If you have two specialists performing the same test, it’s a waste. It’s not that we are going to start doing chemotherapy, but we are going to coordinate with those physicians who do. This is a solution to deal with rising healthcare costs.”
O’Rourke came to Urological Associates in 2010, when the healthcare reform movement was in full swing. One of his first tasks was to determine how to make sure that the practice was ahead of the curve.
“There’s an emphasis in healthcare today on cost-effectiveness and cost cutting,” he said. “Some people feel the price for more efficiency is patient care. One thing I’ve done is look to best practices in other industries and start making little adjustments to bring ourselves into line with those best practices.”
One thing I’ve done is look to best practices in other industries and start making little adjustments to bring ourselves into line with those best practices”
One area that O’Rourke drew inspiration from was Six Sigma, a business management strategy that emphasizes quality management control and eliminating errors. To that end, the practice’s focus in 2012 will be the implementation and streamlining of systems and tools, he said.
ï»¿“Our goal has been to make the systems that surround the patient more efficient,” he said. “For instance, we are in the process of introducing a wireless tablet system into our check-in process. This will facilitate faster patient intake and enhance the communication system outside of the exam room between the staff and the physicians.”
The benefit here is that once the systems are working efficiently, the patientdoctor experience can play out exactly how it needs to in the exam room. “Each patient is unique, and there’s no point in trying to pigeonhole patients into some kind of formula,” O’Rourke said. “But if we build a more efficient system, then we have the best of both worlds: cost-effective care along with putting the patient first.”
In cancer care, the practice has two major projects under way. First, there’s the introduction of Provenge (sipuleucel-T) for patients with early-stage metastatic prostate cancer. Before offering the vaccine to patients, practice nurses will undergo training in the infusion process at a facility that already delivers Provenge.
The second project is to set up a bone health clinic for their prostate cancer patients. Putting the program in place will be a group effort, but once the clinic is a go, its administration will be turned over to the people who are best equipped to manage it.
“I firmly believe in finding the one person in a practice who is passionate about a particular project and letting them be the strongest advocate for it,” O’Rourke said. “So that’s what we are doing with the bone health clinic. Once we’ve established the clinic with everyone’s input, and set up the clinical pathway for running it, we’ll turn it back over to the physician assistants and nurse practitioners to manage.”
Last year, the practice renovated its older office, relocating all of the administrative offices to an offsite location, and then converting the space into more exam rooms. “We are in the business of patient care, so we needed to emphasize that with our physical location,” O’Rourke stated.
With multiple projects, locations, and physicians to manage, O’Rourke said he makes it a point to keep everyone in contact with each other, through Web conferences, clinical roundtables, and, when possible, face-to-face meetings.
Without a spirit of collaboration, the practice will not continue its success. O’Rourke recalled recently seeing an example of what happens when the shareholders in a practice are completely disengaged from one another.
“I was recently at a conference where I watched the CEO of a very large East Coast practice address the physicians— they had about 20 doctors and at least that many locations—and I could just see that there was a complete disconnect between her and the doctors,” he said. “These were very good doctors, and she was a good CEO, but they just weren’t communicating and working as a whole. That kind of disconnect is ultimately going to breed inefficiency in a practice, and the patient experience will suffer.”