The American Urological Association (AUA) recognizes that there is a growing national consensus that a physician workforce deficit exists. Whereas family medicine has successfully established their workforce needs within the minds of federal lawmakers through data-backed publications and advocacy efforts, the most recent data shows that, while there will be a shortfall amongst primary care physicians, roughly two-thirds of the physician workforce shortage will be among surgical and non-surgical specialties1. Several national surveys have identified urology as one of the specialties that is facing the worse future physician deficit. This deficit is compounded by an aging U.S. population that will require more urologic care and a desire to provide greater access to health care through the Affordable Care Act2. The recent AUA Census confirms that urology will see a significant decline in its physician numbers from 2016 to 2020 then remain at a new lower base number that will be significantly below the future projected need3. According to the AUA Census, the main reason for the steep decline in the next several years is because more than a quarter of currently practicing urologists are over 65 years of age. Like primary care, the shortfall of urologists is greatest in rural and nonmetropolitan communities4, 5.
Projecting the future urology workforce is complicated by a number of factors. The millennial generation desires to practice in urban areas and is often attracted to a physician employment over independent practice. When they choose independent practice the group practice is desired over solo practice. This is especially true of the rising number of female urology practitioners6. Younger urologists are more likely to see fewer patients per session and work shorter hours compared to older urologists. Older practicing male urologists and female urologists are more likely to desire part-time positions. Urologists have a high burnout rate according to a recent survey. Graduating urologists are more likely to undergo additional fellowship training. There is no way to predict how medical breakthroughs will impact future urologic care, and the impact that advanced practice providers provide in reducing the shortfall of future urologists is not clear. Adoption of telemedicine techniques also could affect future urology manpower projections. Addressing the lack of diversity in the urology workforce has important implications towards elimination of health disparities in our field.
Compounding the workforce shortages are the challenges facing urology graduate medical education (GME). In the 1970s, urology had just fewer than 400 residency positions and projections at that time suggested a surplus of urologists in the future. This resulted in efforts to balance the number of residency positions with the projected need, and by 1997, the number of residency positions had decreased to 200. The Balanced Budget Act of 1997 capped Medicare residency funding. Since then approximately 100 new residency positions have been added, funded primarily by hospitals, medical schools, and clinical income.
Over the past half-century, academic centers have had to rely on increasing clinical revenue to fund the academic centers. A recent Society of University Urologists survey showed a workforce shortage in academic faculty7. Faculty reported that the pressure to generate clinical revenue interfered with the ability to teach. Restrictions on work hours, adopting new techniques to properly teach the millennial generation, and needing to teach more material such as comprehensive competency-based training have provided challenges for the training programs. Approximately 60 percent of graduating urology residents go onto fellowship training. Current funding of residency training is under scrutiny with pressure from some to decrease or eliminate residency funding support8. Unfortunately, simply adding more residency positions will not address the issues outlined above.
The American Urological Association continues to endorse the 2015 Association of American Medical Colleges Statement on the Physician Workforce [pdf]. In addition, the American Urological Association makes the following declarations as they specifically pertain to the urologic workforce:
- The projected number of urologists-to-population ratio of the United States is inadequate to keep up with projected population growth.
- Existing shortages are exacerbated by inadequate numbers of residency positions and lengthening time of training. This has resulted in lack of workforce diversity, critical shortages in rural locations, and physician burnout. Instead of solely advocating for increased residency positions, a multifaceted approach is indicated, including improved training for advanced practice providers, exploring the use of telemedicine and tele-health technologies, improving diversity of the urology workforce, and increased utilization of part-time and less than full-time urologists.
- In order to meet urology’s workforce shortage, it has become necessary to meet the triple challenge of providing more urology training positions with more extensive training in a shorter duration of time. This requires developing a strategy to address the current unfunded urology training positions, resident faculty salary support, and development of innovative teaching techniques.
- Work must be done to move the national discussion away from focusing solely on primary care needs and advocate a new focus on the entire physician workforce.
- IHS Inc. (2015). The Complexities of Physician Supply and Demand: Projections from 2013 to 2025. www.aamc.org/data/workforce/reports/439206/physicianshortageandprojections.html
- Colby, S.L. and Ortman, S. L. (2015). Projections of the Size and Composition of the U.S. Population: 2014 to 2060. www.census.gov/content/dam/Census/library/publications/2015/demo/p25-1143.pdf.
- Fang, R., Gulig, S., Meeks, W., Rehring, P., Goldman, H. B., Donat, S., Anger, J., Shore, N., Breyer, B., Punnen, S., Loughlin, K. R., Saigal, C., Matlaga, B. R., Hubbard, H., Clemens, J. Q. (Unpublished Abstract). The American Urological Association, Linthicum, MD.
- Frye, T. P., Sadowski, D. J., Zahnd, W. E., Jenkins, W. D., Dynda, D. I., Mueller, G. S., Alanee, S. R., McVary, K. T. (2015). Impact of County Rurality and Urologist Density on Urological Cancer Mortality in Illinois. Journal of Urology, 193, 1608-1614.
- Odisho, A. Y., Cooperberg, M. R., Fradet, V., Ahmad, A. E., Carroll, P. R. (2010). Urologist Density and County-Level Urologic Cancer Mortality. Journal of Clinical Oncology, 28(15), 2499-2504.
- McKibben, M. J., Kirby, E. W., Langston, J., Raynor, M. C., Nielsen, M. E., Smith, A. B., Wallen, E. M., Woods, M. E., Pruthi, R. S. (2016). Projecting the Urology Workforce over the Next 20 Years. University of North Carolina, Department of Urology, Chapel Hill, NC.
- Gonzalez C. M. and McKenna P. (2013). Challenges Facing Academic Urology Training Programs: An Impending Crisis. Journal of Urology, 81(3), 475-479.
- IOM (Institute of Medicine). (2014). Graduate medical education that meets the nation’s health needs. Washington, DC: The National Academies Press.