Projecting the Urology Workforce Over the Next 20 Years

Accepted Manuscript Title: Projecting the Urology Workforce Over the Next 20 Years Author: Maxim J. McKibben, E. Will Kirby, Joshua Langston, Mathew C Raynor, Matthew E Nielsen, Angela B Smith, Eric M Wallen, Michael E Woods, Raj S Pruthi PII: DOI: Reference:

S0090-4295(16)30451-4 http://dx.doi.org/doi: 10.1016/j.urology.2016.07.028 URL 19941

To appear in:

Urology

Received date: Accepted date:

6-4-2016 22-7-2016

Please cite this article as: Maxim J. McKibben, E. Will Kirby, Joshua Langston, Mathew C Raynor, Matthew E Nielsen, Angela B Smith, Eric M Wallen, Michael E Woods, Raj S Pruthi, Projecting the Urology Workforce Over the Next 20 Years, Urology (2016), http://dx.doi.org/doi: 10.1016/j.urology.2016.07.028. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

Projecting the Urology Workforce over the Next 20 Years Maxim J. McKibben MDa, E. Will Kirby MDa, Joshua Langston MDb, Mathew C Raynor MD, FACSa, Matthew E Nielsen MD, FACSa, Angela B Smith MD, FACSa, Eric M Wallen MD, FACSa, Michael E Woods MD, FACSa, and Raj S Pruthi MD, FACSa

a

Department of Urology, University of North Carolina, Chapel Hill, North Carolina b

Department of Urology, Eastern Virginia Medical School, Norfolk, Virginia

Corresponding Author & Address: Maxim J. McKibben, MD University of North Carolina, Department of Urology 170 Manning Drive, 2115 Physicians Office Building, CB#7235 Chapel Hill, NC 27599-7235 [email protected] 617-216-8495

Manuscript Word Count: 2,940

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Keywords: Urology workforce; female workforce; nurse practitioner; physicians' assistant; workforce shortage; forecast model

Disclosures: McKibben, Kirby, Langston, Raynor, Woods, Pruthi: Nothing to disclose Dr. Nielsen reports personal fees from Grand Rounds, Inc, outside the submitted work; Dr. Smith reports personal fees from Photocure, grants from AHRQ K-08, outside the submitted work; Dr. Wallen reports personal fees from MDX Health, outside the submitted work;

Abstract Objectives: To forecast the size and composition of the urologist and urology advanced care provider (ACP; nurse practitioner, physicians’ assistant) workforce over the next 20 years. Methods: Current urologist workforce was estimated from the American Board of Urology (ABU) certification data and the 2014 American Urological Association (AUA) Census. Incoming workforce was estimated from ABU and AUA residency match data. Estimates of the ACP workforce were extracted from the 2012 AUA Physician Survey. 2 Page 2 of 24

Full-time equivalent (FTE) calculations were based on a 2014 urology workforce survey. Workforce projections were created using a stock and flow population model with multiple alternative forecast scenarios. Results: Slight growth in overall (urologist + ACP) workforce FTEs is expected, from 14,792 in 2015 to 15,160 in 2035. A significant decline in urologist FTEs is likely, from 11,221 in 2015 to 8,859 in 2035. ACPs should increase markedly, from 8,710 in 2015, to 15,369 in 2035. Female urologists should increase by 2035, from the current 7.0% to 18.6% of urologist workforce. Alternate scenarios were evaluated, with forecasted FTEs in 2035 ranging from 14,066 to 17,675. In 2035, workforce shortage predictions range from 12% to 46%. Conclusions: With a decrease in urologists over the coming decades, urologists and ACPs may not meet future demand. This forecast highlights the need for discussion and planning among leadership in the field to find creative solutions for this impending workforce shortage. Introduction The demand for urologic care in the United States will reach unprecedented levels in the coming decades due to an aging population with increased prevalence of nephrolithiasis, benign prostatic hyperplasia, and urologic malignancy.1 Adults >65 use urologic services at a three-fold higher rate than the general population, and this segment is expected to increase from 14.9% of the population in 2015, to 21.4% by 2035.2 The very old will also increase substantially, with a doubling of centenarians by

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2030.2 Previous analysis forecasts a 37.5% increase in the demand for urologic services between 2001 and 2020.3 In light of the impending need for increased urologic care, the composition of the urology workforce should concern us. With a median age of 53, urology represents the second oldest surgical specialty.1, 4 A recent estimate of supply and demand suggests a urologist shortage of 32% by 2030, primarily due to attrition of older physicians.5 Compounding this problem, the urology training pipeline has been relatively stagnant. The Balanced Budget Act of 1997 froze Medicare funding of residency positions at 1997 levels, making it difficult to significantly increase the number of graduating urologists. The current GME budgetary constraints suggest flattened growth or even contraction of residency positions in the future. The gender composition of the workforce is changing as well, with women now accounting for a much larger proportion of the workforce than previous.6, 7 Studies suggest that female physicians tend to work fewer hours than their male counterparts, potentially affecting productivity.8, 9 In addition, young physicians of both genders desire more work-life balance with fewer work hours than the previous generation.5, 10 The expanding role of advanced care practitioners (ACPs: Nurse Practitioners, Physician Assistants, and Clinical Nurse Specialists) will dramatically change the face of urologic care, and their effect has yet to be quantified. As we enter a new era of health care, with greater accessibility to subspecialists, increased emphasis on quality of care, and more administrative demands on practitioners, we must understand supply and demand for urology services in order to 4 Page 4 of 24

intelligently structure the practice and policy decisions that address these challenges. In the present study, we aim to define the current urology workforce, using both population trends and recent survey results to guide assumptions, and to provide a forecast range of the urology workforce over the next 20 years.

Methods

Current Workforce Licensure data from the American Board of Urology (ABU) and the 2014 AUA census were used to establish the baseline number and demographics of practicing urologists in the United States. The 2014 AUA Census provides an estimate of the percentage of the workforce that is not ABU-certified, and the baseline number of urologists was adjusted based on this figure. Approximately 11,116 urologists are in practice in the US, with a median age of 53. Reported mean weekly work hours by age group were used to adjust FTEs accordingly (TABLE 1).11 New Urologists From 2009 through 2015, a mean of 241 urologists were annually ABU-certified. Based on 2014 AUA Census, 20% of the urologist workforce is not ABU-certified.4 The annual number of “new urologists” in our adjusted baseline model is 301. We assume no baseline growth in the number of urology residency positions.15 Alternate growth models assume changes in GME funding for residency positions. Downside scenario assumes

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a GME funding decrease of 5% over three years, which would then stabilize through the rest of the model (Deficit Reduction Commission proposal),16 and an upside scenario is a 15% increase over 5 years with subsequent stabilization (Nelson, Schumer, Reid proposal). Female Workforce Currently, about 93% of urologists are men, but 16% of newly ABU-certified urologists and 25% of urology residents are women.6, 7, 17 We assume that the 25% female resident graduation rate will persist into the future. Alternate forecast scenarios of 30% and 20% female residency graduates were also evaluated. Women work 8.3% fewer clinical hours than male counterparts, based on self-reported figures from a recent urologist survey.11 An alternate scenario based on the 2014 AUA census decreases female FTEs 16.7% relative to men.4 Among different age cohorts, FTEs were calculated based on urologist survey responses comparing hours worked.11 The estimates were applied to male urologists, and the previously-mentioned 8.3% decrease was applied to women in addition to these FTE figures. Physician Retirement The median age of planned physician retirement in 2014 is 67, which we assume continues.4 There are approximately 2,000 current practicing urologists over the age of 67, with a median planned retirement age of 75.4 In our model, we assume that this cohort is working at 0.5 FTEs, and will retire at age 75. Our model also runs an alternate 6 Page 6 of 24

scenario where urologists work four more years past usual retirement age at 0.5 FTE, simulating “semi-retirement”, or part-time work. ACP Workforce ACPs in urology were estimated from a 2012 AUA survey,12 and adjusted to 2015 with a 3.97% annual growth rate based on ACP forecast estimates.13, 14 This calculation yielded a baseline figure of 8,710. Future growth was held constant at 3.97% annually, before decreasing to 2% annually in 2025.13, 14 A urologist survey provides an estimate of ACP efficiency (ACP=41% of urologist FTE).11 Forecast Sensitivities To evaluate the possible forecast range, multiple alternate scenarios were modeled (TABLE 2). Changes in GME funding with differing numbers of annual residency graduates were based on recent proposed legislation. An upside and downside range of female residency graduates was based on the current percentage of women in urology residency positions. A scenario of delayed retirement simulates a situation where urologists are incentivized to continue working part-time beyond the usual retirement age, a model drawn from the general surgery literature.10 Alternate ACP growth rates were also evaluated due to the uncertainty of longitudinal trends in this group. The above data were used to build a stock and flow population model using Microsoft Excel® (Microsoft Corporation, Redmond, WA). All key assumptions are outlined in TABLE 1.

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Demand Forecast To forecast demand for urology services, we benchmarked based on current per capita urologist and ACP figures, and projected static per capita demand using US Census Bureau population projections.2 Results

Forecast Outputs The forecast model projects minimal net change in urology workforce FTEs comparing 2015 (14,792) to 2035 (15,160) when considering both physicians and ACPs (Compound Annual Growth Rate (CAGR) 0.12%, FIGURE 1). For urologists, there will likely be a sizable decrease in FTEs, from 11,221 in 2015, to 8,859 in 2035 (CAGR 1.17%, FIGURE 1). Conversely, we project the ACP workforce to increase substantially over the next two decades, from 8,710 in 2015, to 15,369 in 2035 (CAGR 2.88%). Women as a proportion of the urologist workforce should increase as well, from the current 7.0% to 18.6% by 2035 (CAGR 4.29%). Alternate forecast scenarios yielded a range of FTEs from a minimum of 14,066 to a maximum of 17,675 by 2035 (FIGURE 2). Demand Projection If demand for urologic services remains at current per capita levels, our forecast demonstrates that urologist supply in 2035 will be 46% below need. With ACPs included in the supply/demand projections, the supply shortage decreases to 12% (Supplementary Figures 1 and 2).

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Discussion Our forecast model suggests that the urology workforce will remain largely static in terms of overall FTEs from urologists and ACPs, with a substantial decline in the number of practicing urologists and per capita urology providers by 2035. This trend has appeared in other surgical specialties. It will likely be compounded within urology due to an aging population that disproportionately uses urologic services, a stagnant urology training pipeline and an aging workforce. The US Department of Health and Human Services projects that urology will have the greatest increase in need by 2020 compared to other surgical subspecialties. 16,000 urologists will be needed then, compared to the approximately 11,000 currently in practice. Our forecast suggests that some demand will be met by the burgeoning ACP workforce, but the limits of their capacity relative to urologists are unknown. The future workforce will not sustain current per capita provider levels, and with a higher proportion of population >65 years old in the future, per capita demands will likely increase. The cause of the coming supply/demand imbalance is multifactorial, so multiple issues must be addressed when considering possible solutions. Aging Workforce With the median age of 53 years, a large bolus of urologists will either retire or significantly decrease work hours in the coming decade.1, 4 While retirement is inevitable, some novel approaches could mitigate the impending shortage. Part-time 9 Page 9 of 24

(PT) employment of physicians is increasingly desired and accepted, especially in medical specialties with a large proportion of women.18-20 While the concept is less mature in surgical specialties, there has been an increase in locum tenens and PT general surgeons over the last decade.20 In a forecast examining the effect of delayed retirement with an additional 10 years of PT employment of general surgeons at 0.5 FTEs, the authors estimated 50% of surgeons choosing this avenue would decrease the general surgeon shortage by 28.3% by 2050.20 A survey of physicians over 50 years old suggests that 42.6% would consider working past retirement age if part-time work were available.21 Concerns about PT surgical work include inability to maintain surgical and clinical skills, difficulty in credentialing due to case volume, relative cost of liability insurance, increased patient handoffs, and diminished cognitive and physical abilities with aging. Many of these concerns have been addressed in other contexts. In primary care, PT physicians perform as well or better than full-time physicians, but such data do not exist for surgeons.22 Though PT practice is not common in the surgical specialties, urology should consider implementing a pathway allowing older urologists to work part-time, as keeping a fully trained urologist in the workforce, even at reduced capacity, is far more efficient and feasible than growing the workforce through new residency training positions. Declining Supply Over the last three decades, the number of urologists per capita in the US has decreased significantly, more than all surgical specialties except general surgery and 10 Page 10 of 24

thoracic surgery.1 Despite a 7% increase in the number of ACGME-accredited urology residency positions from 2001 to 2009, the annual number of new ABU certifications increased only 2% from 2004 to 2013 (256 to 262).23 The modest increase in the number of incoming urology residents in recent years (268 in 2010 to 296 in 2015) will not offset the rate of retirement. The primary barrier to addressing the urologist shortage is the Balanced Budget Act of 1997, which froze the number of Medicare-funded US residency positions at existing teaching hospitals and has not been amended to account for population growth or changes in need. All hospital-level increases in residency size come with no attendant funding increase from Medicare.24 Numerous efforts to reform GME funding have failed, and nearly 20 years after its passage, its effects are being felt more acutely. Attempts to overcome this barrier include hospital funding of residency positions and the creation of new teaching hospitals and residency programs, which are not subject to the residency cap and therefore eligible for new Medicare funding.24, 25 In the current environment of federal healthcare restructuring, GME funding of residency positions is certainly ripe for change, for better or for worse. When addressing issues of healthcare access across specialties, policymakers should consider removing the cap on GME-funded positions, which would allow all medical specialties to recalibrate to appropriate per capita levels. Cost concerns will make this change politically challenging, but unified advocacy by urologists and other specialties can increase the likelihood of substantive improvements in GME funding. Increase in ACPs

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The most readily apparent way to mitigate the impending workforce shortage is with ACPs. Today an estimated 8,710 ACPs work full-time in urology.12 Firm longitudinal trends are unclear, but ACPs in urology have been increasing rapidly, and soon will likely outnumber their urologist colleagues. The ACP role has increased in recent years in urology. For example, ACPs see office patients and perform procedures such as prostate biopsy, office cystoscopy, and vasectomy.11 ACP presence in the office and on the wards frees the urologist to spend a greater proportion of time in the operating room and with complex patients. These two areas may see the greatest increased need in the coming years. The effect of ACPs seeing patients autonomously in clinic has not yet been evaluated. The model has been studied more intensively in primary care, where ACPs often act as primary providers. A criticism of this model is that ACPs lack the depth of knowledge of physicians, and that patient care may suffer. However, numerous studies have failed to validate this concern; in many studies, patient satisfaction with care is higher, and care quality is equal.26 An important aspect of ACPs in urology is standardization of urology-specific training and education, with a gradual increase in autonomy and patient complexity as skills increase. ACPs in training have an expected progression of core competencies similar to the Urology Milestone Project for urology residents, but no required urology-specific curriculum yet exists for ACPs (Supplementary Table 1). Recognizing the need and demand for ACP-focused urologic education, the AUA has created educational modules for overactive bladder, urologic oncology, stone disease, and female sexual dysfunction 12 Page 12 of 24

targeted towards ACPs.15 Educational materials and suggested core competencies are a step forward in standardizing training of ACPs. However, because specific educational materials and standards are not currently mandated, levels of urology-specific training vary widely. Some institutions have created fellowships for ACP training in urology prior to implementation within a practice, which may be a helpful model to emulate. ACPs are vital partners in providing quality care to patients, and their roles in all care settings will likely continue to expand with increased need, but a lack of standardized urology education or certification makes this a heterogeneous workforce with potential for optimization. Increased Female Workforce Urology has historically been a male-dominated specialty, with men comprising about 93% of the workforce. However, about 25% of current urology residents are female, which will greatly alter workforce gender demographics in the coming years. Recent studies have addressed these changing dynamics. Female urologists are equally as satisfied with their career choice as men, despite being paid significantly less after controlling for many factors such as work hours.9 The cause of this income disparity is not entirely clear, but several factors likely contribute. A number of studies have demonstrated that female physicians prefer flexible or part-time work hours, which may decrease income.27, 28 Within urology, recent studies have demonstrated that female physicians work 8.3% to 16.6% fewer clinical hours than their male counterparts. 4, 11 However, other studies suggest that women tend to underreport work hours relative to men, so the work hour disparity is not entirely clear.29 13 Page 13 of 24

Our forecast model projects an overall decrease of 149 FTEs by 2035 due to fewer clinical work hours by women, a difference of less than one percent relative to the overall workforce. The improved gender diversity within urology will undoubtedly have a positive impact on patient care and comfort, but with more flexible work hours and possibly more part-time work among women, there may be a small decrease in overall workforce productivity. The Millennial Effect Recent residency graduates have expressed a greater interest in “work-life balance” than physicians of the baby boomer generation, which will have implications for the physician workforce. Female physicians have historically been responsible for much of the PT work, but men are increasingly interested in PT practice. A survey of physicians found that while women preferred PT work more frequently than men, 44% of male physicians indicated a strong preference towards PT work.19 Surgical subspecialties with a greater proportion of women are likely to be most strongly impacted by the millennial effect of a larger PT workforce, but urology will also be affected, as younger physicians of both genders are decreasing total work hours. Limitations The results of this workforce model are reliant on a number of assumptions previously mentioned. Minimal longitudinal data exists for certain assumptions, such as the growth of ACPs in urology, so future trends that differ greatly from our projections could substantially change the forecast outputs. We provided multiple alternate scenarios to

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account for this uncertainty, but there will be unforeseen scenarios. Actual workforce dynamics are much more nuanced than can be modeled, and unaccounted-for variables may change results significantly. Future demand for urology services remains unanswered, and our per capita projections oversimplify these calculations. Electronic medical records, telemedicine, aging patients, use of ACPs, and changing disease management patterns (i.e. increase in active surveillance) will likely change per capita urology provider demand, but we cannot yet measure their impact. Additionally, urologist distribution is geographically varied, with a higher per capita concentration of urologists in urban settings, and this national workforce forecast does not address the potential disparities in need among different regions.

Conclusions With the rapidly growing and aging US population, demand for urologic care will increase in the coming decades. An older urology workforce, coupled with a stagnant pipeline due to funding limitations, will likely result in a sizable gap between physician supply and demand. Other factors, such as a proportionally larger female physician workforce and a generational preference for reduced work hours, may further decrease urologist productivity. The need to train more urologists will require increased funding of residency positions via Medicare or another novel source. In the meantime, encouraging delayed retirement of urologists, such as a pathway for part-time work after usual retirement age, would effectively mitigate some of the demand gap. ACPs play an increasingly important role in provision of urologic care, and their contribution should be 15 Page 15 of 24

expanded in the future, but their urology training needs to be more standardized to ensure top quality care for patients. Bibliography 1. Pruthi RS, Neuwahl S, Nielsen ME, et al: Recent trends in the urology workforce in the United States. Urology 82: 987-994, 2013. 2. US Census Bureau: US interim projections by age, sex, race, and hispanic origin. Available at: http://www.census.gov.libproxy.lib.unc.edu/population/projections/data/national/2014 /summarytables.html. Accessed 1/7/2015. 3. Etzioni DA, Liu JH, Maggard MA, et al: The aging population and its impact on the surgery workforce. Ann Surg 238: 170-177, 2003. 4. American Urologic Association (AUA): State of the Urology Workforce and Practice in the United States - 2014. 5. Williams TE,Jr, Satiani B, Thomas A, et al: The impending shortage and the estimated cost of training the future surgical workforce. Ann Surg 250: 590-597, 2009. 6. Association of American Medical Colleges: 2014 Physician Specialty Data Book. Available at: https://members.aamc.org/eweb/upload/Physician%20Specialty%20Databook%202014. pdf, Accessed 6/2/2015.

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7. AUA: 2015 Urology Match Statistics. Available at : https://www.auanet.org/common/pdf/education/specialty-match/2015-Urology-MatchStatistics.pdf, Accessed 9/2015. 8. AAMC: Complexities of Physician Supply and Demand: Projections through 2025. Available at: http://www.innovationlabs.com/pa_future/1/background_docs/AAMC%20Complexitie s%20of%20physician%20demand,%202008.pdf. Accessed 1/7/2015. 9. Spencer ES, Deal AM, Pruthi NR, et al: Gender differences in compensation, job satisfaction and other practice patterns in urology. J Urol 195: 450-455, 2016. 10. Satiani B, Williams TE, Ellison EC: The impact of employment of part-time surgeons on the expected surgeon shortage. J Am Coll Surg 213: 345-351, 2011. 11. Pruthi RS, et al: Workforce survey for practicing urologists. Developed with the assistance of the AUA Marketing, Government Relations, and Practice Management Departments. 2014. 12. American Urologic Association (AUA): AUA Consensus Statement on Advanced Practice Providers. Available at: http://www.auanet.org/common/pdf/advocacy/advocacy-by-topic/AUA-ConsensusStatement-Advanced-Practice-Providers-Full.pdf, 2014. Accessed 7/2015. 13. US Department of Health and Human Services: Projecting the supply and demand for primary care practitioners through 2020. Available at:

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http://bhpr.hrsa.gov/healthworkforce/supplydemand/usworkforce/primarycare/projecting primarycare.pdf. Accessed 7/2015. 14. Hooker RS, Cawley JF, Everett CM: Predictive modeling the physician assistant supply: 2010-2025. Public Health Rep 126: 708-716, 2011. 15. American Urologic Association (AUA): Education for APN/PA/Allied Health. 2016,. Available at: https://www.auanet.org/education/education-for-allied-health.cfm. Accessed 6/6/2016. 16. National Commission on Fiscal Responsibility and Reform: The Moment of Truth: Report of the National Commission on Fiscal Responsibility and Reform. 2010. Available at: https://www.fiscalcommission.gov/sites/fiscalcommission.gov/files/documents/TheMome ntofTruth12_1_2010.pdf. Accessed 1/2016. 17. American Board of Urology: ABU Board Certification Data. Report obtained directly from ABU 9/2/2015. 18. Buddeberg-Fischer B, Stamm M, Buddeberg C, et al: The impact of gender and parenthood on physicians' careers--professional and personal situation seven years after graduation. BMC Health Serv Res 10: 40-6963-10-40, 2010. 19. Heiligers PJ, and Hingstman L: Career preferences and the work–family balance in medicine: gender differences among medical specialists. Soc Sci Med 50: 1235-1246, 2000.

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20. Satiani B, Williams TE, Ellison EC: The impact of employment of part-time surgeons on the expected surgeon shortage. J Am Coll Surg 213: 345-351, 2011. 21. Association of American Medical Colleges: The Complexities of Physician Supply and Demand: Projections from 2013 to 2025. Available at: https://www.aamc.org/download/426242/data/ihsreportdownload.pdf?cm_mmc=AAMC_-ScientificAffairs-_-PDF-_-ihsreport, Accessed 8/2015. 22. Jennings N, Clifford S, Fox AR, et al: The impact of nurse practitioner services on cost, quality of care, satisfaction and waiting times in the emergency department: A systematic review. Int J Nurs Stud 52: 421-435, 2015. 23. Elsevier: 2013-2014 ABMS Board Certification Report. Available at: http://www.abms.org/media/84770/2013_2014_abmscertreport.pdf, Accessed 8/2015. 24. Scally CP, Gauger PG, Dimick JB: The Institute of Medicine Report on Graduate Medical Education Funding Implications for Surgical Training. Ann Arbor 1001: 48109, 2015. 25. Nuss MA, Robinson B, Buckley PF: A Statewide Strategy for Expanding Graduate Medical Education by Establishing New Teaching Hospitals and Residency Programs. Acad Med, Sep;90(9):1264-8, 2015. 26. Stanik-Hutt J, Newhouse RP, White KM, et al: The quality and effectiveness of care provided by nurse practitioners. The Journal for Nurse Practitioners 9: 492-500. e13, 2013.

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27. Viola KV, Bucholz E, Yeo H, et al: Impact of family and gender on career goals: results of a national survey of 4586 surgery residents. Archives of Surgery 145: 418424, 2010. 28. Mayer KL, Ho HS, Goodnight JE: Childbearing and child care in surgery. Archives of Surgery 136: 649-655, 2001. 29. Akers MD, and Eaton TV: Underreporting of chargeable time: The impact of gender and characteristics of underreporters. J Manage Issues: 82-96, 2003.

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FIGURE 1: Urology Workforce Forecast

16,000 Full Time Equivalents (FTEs)

14,000 12,000 10,000

15,160

14,792 11,221 10,508

8,859

8,000

7,210 6,301

6,000 4,000

3,571

2,000 -

1,649

712 2015

2020

2025

2030

2035

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FIGURE 2: Sensitivity Analysis of Alternate Forecast Assumptions

Full Time Equivalents (FTEs)

20,000 18,000

17,675

16,000 15,160 14,066

14,000 12,000 10,000 8,000

2015

2020

2025

2030

2035

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TABLE 1: Key Forecast Assumptions Variable Baseline practicing urologists Age and gender breakdown New urologists annually

Key Assumption 11,221 7% female, 93% male Median age 53

Source(s) ABU certification data 2014 AUA Census4, 17

301 0% baseline growth

AUA match data ABU certification data 2014 AUA Census4, 7, 17

Retiring urologists

Age 67

2014 AUA census4

Women in urology

Current (7.0%) Peak (25%) FTEs = 0.917 relative to men

AUA match data ABU certification data 2014 AUA Census 2014 Urologist Survey4, 7,

“Millennial effect”, FTEs by age group

Under 37 = 0.917 FTE (55 hr/wk) 37-45 = 0.917 FTE 46-54 = 1 FTE (60 hr/wk) 55-64 = 1 FTE 65+ = 0.83 FTE (50 hr/wk)

2014 Urologist Survey11

ACPs in Urology ACP FTEs

8,710 FTEs = 0.41 urologists 3.97% annual growth

2012 AUA survey 2014 Urologist Survey USDHHS 2013 Hooker 201111-14

11, 17

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TABLE 2: Alternate Forecast Scenarios Scenarios 5% decrease in GME funding over 3 years 15% increase in GME funding over 5 years Delayed retirement 4 year (working 0.5 FTE) Peak female residency graduates 30% Peak female residency graduates 20% Female = 0.84 FTE Downside ACP growth (1% in 2025) Upside ACP growth (3% in 2025) All combined negative scenarios All combined positive scenarios

Legend GME down GME up Retire +4 Female 30% Female 20% Low Female FTE ACP down ACP up Low High

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