Christopher Gonzalez, MD, MBA
For medical students, matching to their chosen residency is a rite of passage – a pivotal moment in their just-starting careers. For many in the medical community, it is also a stark reminder of critical shortages in the physician workforce.
We recently sat down with AUA Public Policy Council Vice Chair Dr. Christopher Gonzalez to discuss the issue of graduate medical education (GME) funding and its effects on the urology community and our healthcare system as a whole.
Q: Around the country, doctors of all specialties are talking about a workforce shortage. What are the key factors that led to this crisis? What is its impact on urology?
Urology has the second-oldest surgical subspecialty workforce with an average age of 52.5 years. Forty four percent of the urology workforce is over the age of 55 with 18 percent age 65 or older and 7.4 percent over the age of 70. Another concerning trend is the higher density of urologists practicing in urban as compared to rural areas (7:1 ratio), leaving many counties in the United States without the services of a urologist. Couple these statistics with the fact that, by 2030, it is estimated that nearly 20 percent of the US population will be age 65 or older. Furthermore, it has been established that elderly patients require three times the rate of surgical services the general population uses. (Williams 2010, US Census Bureau 2000 – 2050). To meet these population demands, the U.S. Department of Health and Human Services (HHS) projects a need for 14,000 urologists by 2015 and 16,000 urologists by 2020. Currently there are more than 10,000 urologists practicing in the United States. Other independent analysis indicates that by 2030, urology will face a 32 percent (3,884 urologists) shortage in the number of providers necessary to care for a projected 364 million U.S. citizens. (Williams et al 2009)
These shortages, in combination with the 1997 freeze on GME funding at 170 funded urology residency slots, has led to a very precarious situation for our specialty to train high quality urologists for the future. This past year, there were 285 PGY1 slots in the 2014 match, which means that 115 slots were funded with non-GME money. In a recent Society of University Urologists survey, clinical revenue and hospital funding appear to be the main financial support engines for faculty salary, resident education, dedicated resident research rotations and proficiency training (surgical training skills labs). This is not a sustainable model. The current system of GME funding for urology residency programs requires fundamental change as its impact has contributed to a significant shortage in the supply of urologists in the United States. An ad hoc Institute of Medicine committee has been assembled to study the governance, finance, and regulation of GME in the United States. A final report is expected from this independent advisory commission in the fall of 2014.
Shadowing these workforce trends and the existing cap on GME funding for residency training, are the new Accreditation Council for Graduate Medical Education (ACGME) mandated requirements which include an increased emphasis on didactic teaching along with resident duty hour restrictions. These requirements coupled with the increasing use of organized proficiency training labs and surgical simulators have proven costly to urologic academic training programs, and are not supported by existing GME funds. In essence, there is much more to teach and less time to teach it with increasingly expensive resources required.
Q: Tell us about the impact of the "residency bottleneck" on future matches.
We are fortunate to attract the best and brightest medical students into our subspecialty and, as result, the Match has become extremely competitive. Reinforcing this is the fact that there were no open positions following the last two matches in 2013 and 2014. Although the number of available residency slots has slightly increased from 259 positions in 2009 to 285 positions in 2014, many extremely qualified candidates do not match. The gap between qualified applicants and available urology residency positions will continue to widen if legislation to increase GME funding cannot be passed.
Q: In your opinion, what are the key barriers to effecting change?
There is a physician workforce shortage across all of medicine. The AAMC has estimated that a deficit of 65,000 physicians in both primary care and non-primary care will be evident in the year 2025. The AUA recognizes the workforce shortage in primary care but also continues to keep specialty and urology workforce as one of its top legislative priorities. A united front to legislative reform of the GME system is necessary and coalition building is crucial. The AUA works closely with the Alliance of Specialty Medicine and the American College of Surgeons on this issue, and continues in its efforts to engage and work with the American College of Physicians and the American Academy of Family Practice to synergize our advocacy efforts.
Q: How is the urology community coping with the shortage?
The use of advanced practice nurses (APN) and physicians assistants (PA) is becoming more widespread in urology practices around the country. In a 2013 AUA survey on workforce and compensation trends, Dr. Raj Pruthi and his health policy research group at the University of North Carolina showed that 62 percent of urologists had an APN/PA in their practice. This was highest amongst academics at 80 percent and lowest amongst self-employed urologists at 52 percent. According to the surveyed urologists, APN/PAs account for 41 percent of an MD/DO FTE, with 75 percent of their work related to the ambulatory clinic, 14 percent inpatient services, and 9 percent procedural.
The AUA recognizes the importance of the APN/PAs as part of the urology care team and has developed a strategic plan focused on non-physician providers. This plan involves outreach to APN/PA organizations to discuss synergy of patient care resources, creation of an APN/PA educational committee to assess educational needs and develop an APN/PA focused curriculum, establish an AUA non-physician provider membership committee, and launch a new membership category for APN/PAs called Advanced Practice Provider. Finally, the AUA, in conjunction with the UAPA and SUNA, continue their work on a consensus statement regarding the integration of APN/PA into the urology practice.
Other ideas to address the urology workforce shortage involve telemedicine and robotic remote presence technology, mostly in rural areas. These ideas are under development and will be addressed in the AUA consensus statement on the integration of APN/PA into the urology practice.
Q: What is the AUA doing in this space in terms of advocacy?
The AUA continues to work with the AACU, the ACS, and the Alliance of Specialty Medicine to advocate for an increase in GME funding. In April 2013, the AUA led the Alliance of Specialty Medicine Roundtable on Workforce Shortage. This event included Representative Aaron Schock, who acknowledges the workforce shortage in urology and spoke about the importance of increased funding to establish more residency slots, specifically in the area of specialty medicine.
There are currently three active pieces of legislation on GME funding which the AUA advocates for and supports: the "Training Tomorrow's Doctors Today" Act (H.R. 1201) sponsored by Representative Schock; the "Resident Physician Shortage Reduction" Act (H.R. 1180), supported by Representative Joseph Crowley; and the "Resident Physician Shortage Reduction Act of 2013" (S. 577), supported by Senator Bill Nelson. All three bills allot for 3,000 more residency slots over each of the next five years, of which half would be reserved for specialty medicine. Each piece of legislation also calls on the Comptroller General to study the workforce issue and to identify specialties where there is a shortage.
Learn more about AUA advocacy efforts on Workforce/Graduate Medical Education.
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