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MANPOWER NEEDS IN UROLOGY IN THE TWENTY-FIRST CENTURY
TECHNOLOGIC ADVANCES IN UROLOGY: IMPLICATIONS FOR THE TWENTY-FIRST CENTURY
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MANPOWER NEEDS IN UROLOGY IN THE TWENTY-FIRST CENTURY David L. McCullough, MD
Much of this article comes from material developed at the Strategic Planning Committee Workshop in San Diego, California, in 1995. Some comes from the AUA Workforce Committee evaluation. Special thanks are due to Drs. Logan Holtgrewe and Rod Taylor, as well as to many others who have supplied ideas and information for this manuscript. This is not a scientific paper; rather, it is more a compilation of my own impressions about the topic as listed. CHANGES IN UROLOGY MANPOWER
The number of urologists increased from around 9000 to 9900 between 1987 and 1997. The total number in academic urology has nearly doubled during that time. According to Dr. William Steers at the University of Virginia (personal communication), notes that there were 515 full-time positions in academic urology in 1993 and that approximately 10 retire each year. In 1997, 183 jobs were available. Most were in oncology, neuro-female urology, calculus/endourology, general urology, infertility/impotence, pediatric . urology, and transplant, in that order. Most of the positions were open in the North Central, Southeast, and West, which also corresponds to the
fact that these are the largest sections of the AUA. The New England Section had the fewest job opportunities and members. In 1975, there was approximately one urologist per 35,000 population. In 1995, there was approximately one AUA urologist for 31,000 population. There are approximately 1000 fewer AUA urologists than there are urologists in the United States, where about 86% of urologists presently belong to the AUA. In areas where managed care has achieved high penetration, the average need is purported to be one urologist per 50,000 population. No states have this ratio, however. States with the highest ratio of urologists per population are the District of Columbia, with 1:10,000, and Maryland, Florida, Connecticut, and New York with approximately 1:25,000. States with the lowest ratio are Idaho, with around 1:44,000; Maine, 1:42,500; and Utah, Iowa, and Mississippi, with around 1:40,000. A geographic redistribution of urologists is occurring. Market forces are distributing urologists to various sites in the United States at a rate not previously seen. This certainly is good for the public and may or may not be good for urologists. However, one has to balance the quality of life versus income possibilities and survival as a urologist. All of these factors affect geographic distribution.
From the Department of Urology, Bowman Gray School of Medicine of Wake Forest University, Winston-Salem, North Carolina
UROLOGIC CLINICS OF NORTH AMERICA VOLUME 25 * NUMBER 1 * FEBRUARY 1998
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MANAGED CARE PENETRATION BY STATE
Managed care penetration by state ranges from a high of around 40% down to a low of about 0%. In Massachusetts, California, Maryland, and Minnesota, between 35% and 40% penetration is seen. This ranges down to 0% penetration in 1993 in Alaska, Vermont, West Virginia, and Wyoming. Also, very low penetration is seen in North Dakota, Iowa, Montana, Arkansas, and South Dakota, ranging from around 1%to around 3%.
seniors planning certification for specialty groups in the United States, around 30% plan to go into both the medical and the surgical specialties. This is a fairly level percentage entry. A rising percentage are going into generalist specialties, over 30% at present, and a declining percentage are going into support specialties, such as radiology and anesthesia. This percentage currently has dropped below 18% from about 21% in 1991.13 In the same questionnaire, it was interesting that the median educational debt of graduates from private medical schools is around $90,000; from all schools, the median debt is around $70,000.
CHANGES IN UROLOGIC PRACTICE
In the past, urologic practice was paid for by indemnity insurance, traditional Medicare, and patient out-of-pocket payments. The services provided included cognitive services and minor surgery, which account for most of the income for most urologists. Services include benign prostatic hyperplasia (BPH) management, urinary infections, routine prostate check-ups, stone disease follow-ups, cancer follow-ups, and prostatectomies. A smaller percentage consists of such diagnostic procedures as cystoscopies, ultrasounds, radiology, laboratory studies, and urodynamics. A significant percentage, but less than 50%, was represented by major surgery. In the future, in terms of managed care, urologists may well lose a piece of this pie, with cognitive services being eroded by primary care physicians, PAS, and RNs. The diagnostic procedures may be partially taken away by radiologists and central laboratories. Major surgery appears to be stable. The question arises “will this loss of turf and changing urologic practice patterns affect future workforce needs in urology?” The answer is that fewer urologists will be needed to provide services that only urologists can provide, such as major surgery, certain diagnostic procedures, and consultations. However, urologists can take steps to minimize this erosion. GENERAL PRACTITIONER DATA
Another interesting fact is that the percentage of general practitioners in a population (which many think is an important piece of data) is around 50% in Canada and the United Kingdom, but only 12% in the United States. Regarding percentages of graduating
UROLOGY MANPOWER CONTROL
The number of urologists per capita around the world ranges from 1 to 16,000 in Japan to around 1 to 27,000 in the United States, 1 to 250,000 in Great Britain, and 1 to 2.5 million in Ghana. There is a huge variation in training, equipment, and practice patterns. Who determines the number in training? Program Directors have the predominant role. The Residency Review Committee can control the numbers to a lesser degree by establishing more or less stringent criteria for approval of residency slots. The American Board of Urology, the AUA, and the American Medical Association (AMA) have little to do with manpower. It used to be thought that the federal and state governments had nothing to do with manpower control, but this is not the case at present. This lack of control is eroding, and, as will be shown later, both state and federal governments are affecting urology manpower control. In 1994, urology program directors were surveyed, and 44% thought that the number of urologists currently in training was about right, approximately 55% thought the number needed to be decreased, and 2% thought the number needed to be increased. In this same survey, the Residency Directors responded to the question ”Within the next 5 years, do you plan to voluntarily change the number of residents in training?” Eighty-nine percent said no change, 8% said a decrease, and 3% said they planned to increase. Academic urology faces a number of challenges at present. One is how to address the whole issue of manpower. The ”but not my program” mentality is another issue, as are legal issues. Reductions in the number of trainees is a dangerous area to discuss in
MANPOWER NEEDS IN UROLOGY IN THE TWENTY-FIRST CENTURY
terms of antitrust activities. The Residency Review Committee and Deans of the Medical Schools also are areas of concern for Program Directors. DEMAND FOR GRADUATING RESIDENTS An interesting study appeared in the lournal of the American Medical Association in 1996.5 The percentage of resident graduates in the June 1994 class who did not find positions in their specialty by January 1, 1995 included pathology (around llY0), plastic surgery (loo/,), anesthesia (7%), pulmonary medicine (6%), orthopaedics (6%), and ophthalmology (6%). The "good times" specialties whose graduates found jobs more readily included urology (100% of residents finding positions); emergency medicine (over 99%); and obstetrics/gynecology, psychology, family practice, and internal medicine, with around a 98% or greater success rate. Of the urology residents who graduated in 1994, 87% went into full-time community practice, 12.3% went into full-time academic practice, and fewer than 1%went into temporary employment. In terms of where the graduates entering community practice went, 56% went into urban and suburban practices, 22% went into practices in towns of less than 50,000 population, and around 8% went into closed-panel HMOs.
OVERPRODUCTION AND UNDERPRODUCTION OF UROLOGISTS
There are numerous consequences from overproduction of urologists, including a reduced volume of surgery and, perhaps, reduced quality, and greater complications and costs. Also, "make-work cognitive services are possible. Lack of bargaining power with managed care organizations because of greater numbers of urologists could occur, including a loss of control of practice, reduced incomes, and possibly low morale. It is certainly difficult to decrease the supply of urologists once they are trained. There are also consequences of underproduction of urologists. These include patients lining up for care and GU surgeries by nonurologists that could result in lower quality and more complications and costs. Also, loss
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of turf to nonurologists could occur. Enhanced bargaining power with managed care companies might be seen if there were a fewer number of urologists to bargain with. There also might be fewer "make-work services." There could be higher morale, but possibly lower morale might occur with overwork. It is relatively easy to increase supply, but one needs a 5- to 7-year lead time between recognizing the demand and coming up with additional supply. RESIDENCY MATCH STATISTICS
As far as the urology residency match is concerned, there was a 27% reduction in applicants from 1985 to 1995. The number of applicants dropped from 404 in 1985 to 293 in 1995, and the number of residency positions increased from 229 in 1985 to 249 in 1995 (Joseph Corriere, MD, AUA Office of Education, personal communication) (Table 1). However, it is interesting to see that there has been a recent stepwise reduction in the number of positions offered, from 253 in 1994 to 249 in 1995, to 237 in 1996, to 220 in 1997 (which came from 104 programs). The number of applicants dropped from 317 in 1994 to 293 in 1995 and increased to 294 in 1996, increasing further to 340 in 1997. My own thought is that a number of these applicant reductions resulted from fear that the Clinton Health Care Plan might be enacted. Also, a number of factors led to the low number of positions offered in 1997, including downsizing and reductions from 6- to 5-year programs, but the trend is definitely down in terms of positions offered. The percentage of foreign versus U.S. graduates who have matched urology residency programs has ranged from 3% in 1986, down to 2% in 1990, and back up to 4% in 1995. This does not appear to be a significant issue in urology. Table 1. UROLOGY RESIDENCY MATCH 1985 TO 1995* Year
Vacancies
Applicants
1985 1988 1990 1992 1994 1995
229 233 239 246 253 249
404 353 314 336 317 293
*27% reduction in applicants 1985-1995
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CURRENT UROLOGY MANPOWER STATISTICS (1995)
In 1995 the total number of urologists in federal, nonfederal, United States, and its possessions was around 9900, of whom 244 were women. There were around 9600 in patient care and around 8000 in office-based positions. There were 1100 hospital-based residents and fellows in 1995 and 532 hospital staff-based urologists. Other categories included administration, 101; teaching, 78; research, 60; and “other,” 22. It is interesting that 273 of the total of 9900 urologists in 1995 were federal, including 55 residents and fellows (Table 2). A personal communication from Dr. David McLeod, April 1997, stated that there had been a drop in the military resident slots per year from 15 recently down to 12, and probably down to 9 positions per year by 1998. The system definitely is changing and is reacting to trends in medicine.
RECENT ACTIONS ON MEDICAL RESIDENCY TRAINING
AUA POSITION ON MANPOWER
The AUA position on physician workforce, planning, and graduate medical education in 1994 was as follows. It endorsed the American Association of Medical Colleges (AAMC) and AMA position statement to study the needs, number, and mix of specialists. It also felt that any body established to conduct planning should be outside of and staffed independently of existing government agencies. There should be an all payers system (national funding pool) for graduate medical education. Transition funds to hospitals losing residents should be available. Also, schools should try to influence more students to become generalists. Table 2. UROLOGY MANPOWER STATISTICS (1995): FEDERAL, NONFEDERAL, UNITED STATES, AND POSSESSIONS Overall total (244female, 9642 male) Patient Care Off ice-Based Hospital-Based Residents, Fellows Physician Staff Other Administration Teaching Research Other
9886* 9625 7991 1102 532 101 78 60 22 273
“Of the above total, 273 are federal, including 55 residents, fellows.
A recent consensus panel response to oversupply included the AMA, the American Association of Colleges of Osteopathic Medicine, American Osteopathic Association, Association of Academic Health Centers, the AAMC, and the National Medical Association. It validated the previous AMA and AAMC statements mentioned above and concluded that federal funding should be aligned more closely with the number of US.medical graduates. There should be expanded training in inner city and rural settings. Graduate medical education training should be offered to foreign-born and foreign-trained physicians, but the program should not allow them to stay in the United States. It also observed that fewer than 50% of U.S. medical graduates enter specialty residencies but that the majority of international medical graduates do.8
On February 18, 1997, an Associated Press article, ”Scalpel: Hospital Staffs That Cut Back Will Get $400 Million,” was published in the Winston-Salem, NC Journal, page A3.2 After reading this article, I would classify this as the Health Care Financing Administration (HCFA)medical ”soil bank.” In the mid-1950s and 1960s in the United States, the Agriculture Department paid farmers not to grow tobacco, cotton, and other crops. Today we have the HCFA paying medical schools and hospitals not to train physicians. In New York City, there will 2000 fewer physicians, a 20% reduction over 6 years. This will decrease yearly over a 6-year period. Presently these hospitals obtain $87,000 per year per slot according to the above-cited article. By spending $400 million, it is thought that the government will save $300 million. This is a pilot program and may go nationwide. It will have a major effect on international medical graduates by reducing their participation. In terms of specialty choices of U.S. medical school graduates in 1996, more than 50% matched in the primary care residencies, and our conclusion is that there are more generalists in the pipeline, which will raise the 12% in general practice considerably in future years.8 Accreditation Alert, Vol. 3, p. 70, 1996,’ included an interesting graph. In 1981, there
MANPOWER NEEDS IN UROLOGY IN THE TWENTY-FIRST CENTURY
were 153 urology residency programs; by 1996, there were 122. This has now dropped to 120. The number of residents in training was 1136 in 1994. In 1995, there were 1094. There is a stepwise reduction going on in terms of urology programs and the number of residents in training. Further discussion on this trend will follow later in this article. In 1956,99% of third- and fourth-year medical students rotated through urology. This dropped to 48% in 1978 and to 38% in 1994. Ten per cent to 15% have never been exposed to urology, with no lectures and no rotation^.^ RECENT HCFA ACTIVITY TWOTIERED UROLOGY TRAINING
Recently, HCFA proposed changes that could affect urology manpower needs. They proposed a greater than 30% decrease in most surgical fees. It is my impression that this sort of decrease would certainly lessen the number of surgical procedures. At the same time, HCFA advocated increasing officebased fees, and I believe that this will certainly increase office activities. The effect on manpower needs remains to be seen. I do think it will, in effect, accelerate a two-tiered medical system: one composed predominantly of surgeons who do urologic procedures and another, predominantly officebased, who do not do any significant volume of surgical procedures outside their offices. The question is, do we need such a system? Do we have such a system? A personal communication from one of the American Board of Urology members stated that many applicants have fewer than 36 major cases on their logs presented for consideration for sitting for the oral examination of the American Board of Urology. In effect, it would seem that we are already moving into such a two-tiered system. Should we try such a system on a pilot basis? I think we should, perhaps in 10 institutions widely spaced geographically across the United States. However, this would be a nightmare for the Residency Review Committee and the American Board of Urology who must construct tests and examinations for such trainees. Is there a demand by residents for such a two-tiered system? I am not sure, but I think there probably is. One difficult problem would be to how to select who does which procedures in a given residency and at what volume? And what procedures (surgical) ex-
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posure would one need for these two-tiered positions? One might propose 1 year of general surgery and 2 or 3 years of urology with operative exposure to a number of procedures, perhaps not as primary surgeon but mainly as an assistant to understand what the procedures entail. One could have office-based urologists who perform primarily diagnostic and office procedures, such as cystoscopies, vasectomies, biopsies, and evaluation and management. This now occurs in Germany, and could provide a big deterrent to encroachment by primary care physicians, physician assistants, and nurse clinicians. Such a two-tiered system would result in fewer hours worked by the office-based urologist. It could, but not necessarily, result in less pay, better quality of life, more family time, and less hassle and stress. Would there be greater job satisfaction? I think there would be in many cases. Also, the question of whether surgeons or nonsurgeons could live in peace would be a real issue. I think they could, with each group having a niche. CHANGES IN SURGICAL SUBSPECIALTY NUMBERS
The AMA Physician Characteristics Distribution in the U.S., 1996-19979 reported in 1990 to 1995 changes in manpower in various surgical specialties that were both interesting and varied. Plastic surgery increased by 207'0, otolaryngology increased by 12% (as did neurosurgery), orthopaedics by l6%, and urology by 5.5%. General surgery decreased by 2.1%. So the average increase in numbers of urologists was a little over 1%per year during 1990 to 1995. Obviously, the general population increased significantly during that time. A number of factors presently are decreasing the number of residents training in urology. There are fewer programs, mergers of institutions are occurring, and many medical schools are mandating more primary care. Government-mandated decreases in residency slots appear to be a trend, as mentioned earlier. In the military and in the VA, positions in urology are planned to be decreased at least 30% according to some authorities. The University of California is mandating a 25% decrease in residents by the year 2000, and New York State may reduce the number of residents as well. Earlier we discussed the government "soil bank" pilot pro-
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gram in New York City. There may be tighter Residency Review Committee requirements, which also would decrease the number of resident slots available. Regarding pediatric urology manpower, Retik and Kingloand Shapiro12reported on a questionnaire sent to pediatric urologists. There was an 87% response rate. It was noted that 70% of pediatric urologists are less than 50 years old, 81% are in full-time pediatric practice, and about half are university-based. The conclusion was that the pediatric urology community was training 10 to 15 fellows a year; if that trend continues there would be an excess of 40 to 90 pediatric urologists in 10 years. A personal communication from Dr. Terry Hensle states that there are now fewer than nine fellows training per year, and this should not be a problem. The system is correcting. WILL UROLOGY SURVIVE?
This is a real question, but I feel that the answer is “Yes, we will.” Urologists are very ingenious as demonstrated by the development of ESWL, endourology, PSA testing, ultrasound of the kidneys and prostate, prostate biopsies, changes and improvements in radical prostatectomy, minimally invasive therapy of BPH, urodynamics, improved techniques of node dissection in testis cancer (which has vaulted this back into a popular way of treating this disease), and impotence evaluation and therapy. We have an aging population in which incontinence, cancer, and BPH will become more prevalent. I think that brachytherapy will note an increase because of HCFA decreased funding of radical prostatectomies and the fact that urologists can deliver such therapy. Also, in terms of medical therapy of BPH, I think a number of deferred or delayed procedures now being “warehoused” ultimately will result in some procedures being done on the patients. Even if that does not occur, urologists still treat many BPH patients medically. It would appear that the numbers of radical nephrectomy, orchiectomy, cystectomy, and prostatectomy remain stable. Female urology could be lost if we are not careful. Transplantation and some aspects of infertility already have been lost to other specialties. It is obvious that managed care cannot outlaw diseases that are going to occur and increase in frequency. There appears to be a
national backlash over the lack of specialty referral in many managed care programs, and the public does not seem to be accepting the rationing of care well. I predict that there will be an increase of provider service networks (PSN) in which the middleman is eliminated and the consumer will get more ”bang for their b u c k by having the third-party payors negotiate directly with the providers, both physician and hospital-based. My opinion is that urology will survive. HIGHLIGHTS OF THE AUA STRATEGIC PLANNING COMMllTEE REPORT
The Strategic Planning Committee of the AUA, Chaired by David L. McCullough, MD, met in San Diego, California, in November 1995.‘jThis was thought to be a suitable city because it had the reputation of being the ”Bosnia” of managed care. At that meeting we had input from HMOs, the AUA Gallup Poll, the U.S. government, the AUA Workforce Committee, and reports by a number of consultants, including a report entitled “The National Supply and Demand for Urologists 1995 to the Year 2020” by Harlan Menkh7 We also had legal input on the antitrust issues. One has to be careful when discussing the possibility of limiting manpower, and we were careful with this sensitive issue. We attempted to obtain the best possible information in the range of needed urologists based on variables that became evident during the Committee proceedings. We were made aware that there were about 6350 voting members of the AUA and around 8400 members in practice. At present, we see that there are around 9900 urologists. This is from the recent AMA data.4 We also noted that the average urologist retires at age 68; around 200 urologists recently have been retiring yearly. To keep the present number of AUA urologists in practice to the year 2020, 270 per year would need to graduate. We are substantially below that level at present. If 260 graduate per year, the total number of urologists in 2020 would be 9165, substantially below the 9900 we have now, and the AUA members certainly would be fewer than today. Patients 65 years old and older account for 46% of office visits and only 13% of the population. Baby boomers will need more care. The U.S. population is slated to increase from
MANPOWER NEEDS IN UROLOGY IN THE TWENTY-FIRST CENTURY
263 to 323 million between the years 1995 and 2020. This 60 million increase in population is the equivalent of dropping into the United States population pool the equivalent of the population of the United Kingdom or France. The number of Medicare patients will increase from 34 million to 54 million, or 20 million more than at present. Weiner et all4 made recent observations on Medicare population increases and implications for the necessary number of urologists to serve them. Medicare patients average 184 visits per 1000 population versus 72 per 1000 population per persons aged 45 to 64, the age group immediately below the Medicare group. If the number of urologists remains stable and the population increases by 60 million, there would be 6315 more patients per urologist, and one third of these would be Medicare patients. The ratio of urologists to population is now around 1:27,000. If the ratio were changed to 1:34,500 by the year 2000, or the present California ratio, we would need fewer than 250 graduates per year. We are now down to that level. As mentioned previously, some HMOs allegedly require only one urologist for 50,000 population. If this penetration occurred across the United States, and I doubt it will, we would need fewer than 150 graduates per year. The number of urology chief graduates per year has undergone a stepwise reduction from 278 in 1992, to 253 in 1996, and it now is down to 250. This is over a 9% decrease in 5 years and already below the 260 mentioned above. If we continue a 9% 5-year attrition rate, we would be down to 230 graduates by the year 2001 and 209 by the year 2006. The system is definitely adjusting. AUA WORKFORCE COMMITTEE CONCLUSIONS
Thomas J. Rohner, MD, Chair of the Workforce Committee, reported to AUA in May 1996, and this report is summarized briefly below." The Committee believed 'that it was difficult to gauge the percentage of urology work to be performed by primary care physicians or RNs. They also noted that technology would decrease the number of procedures, especially open procedures, in the years to come. They believed that residency training should increase emphasis on office practice economics and decrease the present emphasis
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on surgery. They also found from the AUA Gallup survey that 18% of groups representing 2900 urologists were seeking another urologist, or 530 physicians. They also found that 68% would hire a newly graduated resident, or 360 positions. This is 110 more positions available than there are new graduates at present. The committee found that if more than 225 urology residents were graduating in the year 2010, or over 150 in the year 2020, there would be an oversupply. They thought it would be helpful to try to persuade the ACGME to aim for a reduction to 200 to 250 graduates per year until the year 2000 and then to restudy the situation. As mentioned above, we are down to 250 graduates per year already, and it is only 1997. ACGME DATA*
In 1989, 60% of the programs were 5-year programs. This dropped to 33% in 1994. The trend reversed in 1997 and is presently at 37.5%. The number of 6-year programs is the flip side of these statistics. In 1997, there are a total of 120 programs, down from 125 in 1994. The program compositions are as follows: 2 years of general surgery and 3 years of urology in 24 programs; 1 year of general surgery and 4 years of urology in 21 programs; and 2 years of general surgery and 4 years of urology in 75 programs. There is considerable movement to the 1-in-4 configuration: 1 year in general surgery and 4 years of urology. This probably relates to the potential funding of residents in residency training programs and the feeling by some that 2 years in general surgery (often with few surgical procedures performed) is neither necessary nor desirable. Resident Slots Deleted Because of Closings or Mergers. In 1994, two programs closed and six resident slots per year were eliminated. In 1995, there was one closure and one resident slot per year deleted and one merger that resulted in no resident slots deleted. This does not include military downsizing. The total number of urology residents has shown a stepwise reduction in the last 4 years. In 1994, 125 programs had 1135 residents in training in urology. In 1995, this had dropped to 122 programs with 1034 residents. *Provided by Doris Stoll, PhD, 4/97, ACGME, personal communication.
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In 1997, there were 120 programs with 971 residents. These statistics represent a 4% decrease in the number of programs and a 15% decrease in the number of urology residents in training. The system is definitely adjusting. SUMMARY Physician supply factors are based on a number of variables. These include the base supply and retirements, which presently show that around 200 urologists are retiring per year. Death rates of both patients and physicians are significant. The rate of entry of graduating residents is important. Population changes (which certainly will continue to increase in the United States) are important. Needs-based projections, demandneeds based projections, and benchmarked projections are important issues. The immigration of physicians is important. So far, I think we have seen little emigration of physicians from the United States. A number of confounding variables can have impact and are almost impossible to predict at present. These include technology changes, disease patterns, and methods of care delivery. The Strategic Planning Committee thought we should aim for a band of 200 to 250 chief residents finishing one per year. We have already reached the 250 level. At 200 finishing per year, we would have 2300 fewer urologists in the year 2020 than we presently have. At 225/year, we would have 1700 fewer urologists. At 250 (our present level), we will have 1100 fewer than now. These 8800 urologists would be caring for 60 million more patients, of whom 20 million would be Medicare patients. These patients would provide over 500 additional patient visits/year/urologist. I hope that I have convinced you that the
system is correcting and responding to multiple market forces. I predict that urologists in practice in 2020 will be busy and that we will not have too many urologists i f the graduating numbers are kept stable. If they drop much more, we could well have too few. References 1. Accreditation Alert: A publication of Nixon, Hargrave, Devans, and Doyle, Vol. 3, 1996, p 70 2. Associated Press: Scalpel: Hospital staffs that cut back will get $400 million. Winston-Salem Journal, February 19, 1997 3. Benson GS: The decline of urological education in United States medical schools. J Urol 152:169, 1994 4. Dickey Nw: Building consensus, protecting our future. American Medical News: February 24, 1997, P 33 5. Miller RS, Jonas HS, Whitcomb ME: The initial employment status of physicians completing training in 1994. JAMA 275:708-712, 1996 6. McCullough DL: Report of the Strategic Planning Committee to the American Urological Association, Inc, April, 1996 7. Menkin HL: National supply and demand forecast for urologists 1995-2020. The Center for Health Policy Studies-West Health Demographics and the Health Forecasting Group. Prepared for American Urological Association, December 1995 8. Mitka M: Doctor ranks grow 17% in 5 years. American Medical News: February 24,1997, p 55 9. Randolph L, Seidman B, Pasko T Physician Characteristics and Distribution in the US, 1996-97. Chicago, American Medical Association, 1997 10. Retik AB, King LR: Editorial comments. J Urol 156:490491, 1996 11. Rohner TJ: Report of the Workforce Committee Meeting to the American Urological Association, May 8, 1996 12. Shapiro E: Pediatric urology manpower report 1995. J Urol 156:488-490, 1996 13. Szenas P: Graduates’ interest in generalist specialties continues to rise, along with educational debt. American Association of American Medical Colleges Reporter 6:1, December 1996/January 1997 14. Weiner DM, McDaniel R, Lowe FC: Urologic manpower issues for the 21st century: Assessing the impact of changing population demographics-Urology 49~335-342, 1997
Address reprint requests to David L. McCullough, MD Department of Urology Bowman Gray School of Medicine of Wake Forest University Medical Center Boulevard Winston-Salem, NC 27157
0094-0143/98 $8.00
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MANPOWER NEEDS IN UROLOGY IN THE TWENTY-FIRST CENTURY David L. McCullough, MD
Much of this article comes from material developed at the Strategic Planning Committee Workshop in San Diego, California, in 1995. Some comes from the AUA Workforce Committee evaluation. Special thanks are due to Drs. Logan Holtgrewe and Rod Taylor, as well as to many others who have supplied ideas and information for this manuscript. This is not a scientific paper; rather, it is more a compilation of my own impressions about the topic as listed. CHANGES IN UROLOGY MANPOWER
The number of urologists increased from around 9000 to 9900 between 1987 and 1997. The total number in academic urology has nearly doubled during that time. According to Dr. William Steers at the University of Virginia (personal communication), notes that there were 515 full-time positions in academic urology in 1993 and that approximately 10 retire each year. In 1997, 183 jobs were available. Most were in oncology, neuro-female urology, calculus/endourology, general urology, infertility/impotence, pediatric . urology, and transplant, in that order. Most of the positions were open in the North Central, Southeast, and West, which also corresponds to the
fact that these are the largest sections of the AUA. The New England Section had the fewest job opportunities and members. In 1975, there was approximately one urologist per 35,000 population. In 1995, there was approximately one AUA urologist for 31,000 population. There are approximately 1000 fewer AUA urologists than there are urologists in the United States, where about 86% of urologists presently belong to the AUA. In areas where managed care has achieved high penetration, the average need is purported to be one urologist per 50,000 population. No states have this ratio, however. States with the highest ratio of urologists per population are the District of Columbia, with 1:10,000, and Maryland, Florida, Connecticut, and New York with approximately 1:25,000. States with the lowest ratio are Idaho, with around 1:44,000; Maine, 1:42,500; and Utah, Iowa, and Mississippi, with around 1:40,000. A geographic redistribution of urologists is occurring. Market forces are distributing urologists to various sites in the United States at a rate not previously seen. This certainly is good for the public and may or may not be good for urologists. However, one has to balance the quality of life versus income possibilities and survival as a urologist. All of these factors affect geographic distribution.
From the Department of Urology, Bowman Gray School of Medicine of Wake Forest University, Winston-Salem, North Carolina
UROLOGIC CLINICS OF NORTH AMERICA VOLUME 25 * NUMBER 1 * FEBRUARY 1998
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MANAGED CARE PENETRATION BY STATE
Managed care penetration by state ranges from a high of around 40% down to a low of about 0%. In Massachusetts, California, Maryland, and Minnesota, between 35% and 40% penetration is seen. This ranges down to 0% penetration in 1993 in Alaska, Vermont, West Virginia, and Wyoming. Also, very low penetration is seen in North Dakota, Iowa, Montana, Arkansas, and South Dakota, ranging from around 1%to around 3%.
seniors planning certification for specialty groups in the United States, around 30% plan to go into both the medical and the surgical specialties. This is a fairly level percentage entry. A rising percentage are going into generalist specialties, over 30% at present, and a declining percentage are going into support specialties, such as radiology and anesthesia. This percentage currently has dropped below 18% from about 21% in 1991.13 In the same questionnaire, it was interesting that the median educational debt of graduates from private medical schools is around $90,000; from all schools, the median debt is around $70,000.
CHANGES IN UROLOGIC PRACTICE
In the past, urologic practice was paid for by indemnity insurance, traditional Medicare, and patient out-of-pocket payments. The services provided included cognitive services and minor surgery, which account for most of the income for most urologists. Services include benign prostatic hyperplasia (BPH) management, urinary infections, routine prostate check-ups, stone disease follow-ups, cancer follow-ups, and prostatectomies. A smaller percentage consists of such diagnostic procedures as cystoscopies, ultrasounds, radiology, laboratory studies, and urodynamics. A significant percentage, but less than 50%, was represented by major surgery. In the future, in terms of managed care, urologists may well lose a piece of this pie, with cognitive services being eroded by primary care physicians, PAS, and RNs. The diagnostic procedures may be partially taken away by radiologists and central laboratories. Major surgery appears to be stable. The question arises “will this loss of turf and changing urologic practice patterns affect future workforce needs in urology?” The answer is that fewer urologists will be needed to provide services that only urologists can provide, such as major surgery, certain diagnostic procedures, and consultations. However, urologists can take steps to minimize this erosion. GENERAL PRACTITIONER DATA
Another interesting fact is that the percentage of general practitioners in a population (which many think is an important piece of data) is around 50% in Canada and the United Kingdom, but only 12% in the United States. Regarding percentages of graduating
UROLOGY MANPOWER CONTROL
The number of urologists per capita around the world ranges from 1 to 16,000 in Japan to around 1 to 27,000 in the United States, 1 to 250,000 in Great Britain, and 1 to 2.5 million in Ghana. There is a huge variation in training, equipment, and practice patterns. Who determines the number in training? Program Directors have the predominant role. The Residency Review Committee can control the numbers to a lesser degree by establishing more or less stringent criteria for approval of residency slots. The American Board of Urology, the AUA, and the American Medical Association (AMA) have little to do with manpower. It used to be thought that the federal and state governments had nothing to do with manpower control, but this is not the case at present. This lack of control is eroding, and, as will be shown later, both state and federal governments are affecting urology manpower control. In 1994, urology program directors were surveyed, and 44% thought that the number of urologists currently in training was about right, approximately 55% thought the number needed to be decreased, and 2% thought the number needed to be increased. In this same survey, the Residency Directors responded to the question ”Within the next 5 years, do you plan to voluntarily change the number of residents in training?” Eighty-nine percent said no change, 8% said a decrease, and 3% said they planned to increase. Academic urology faces a number of challenges at present. One is how to address the whole issue of manpower. The ”but not my program” mentality is another issue, as are legal issues. Reductions in the number of trainees is a dangerous area to discuss in
MANPOWER NEEDS IN UROLOGY IN THE TWENTY-FIRST CENTURY
terms of antitrust activities. The Residency Review Committee and Deans of the Medical Schools also are areas of concern for Program Directors. DEMAND FOR GRADUATING RESIDENTS An interesting study appeared in the lournal of the American Medical Association in 1996.5 The percentage of resident graduates in the June 1994 class who did not find positions in their specialty by January 1, 1995 included pathology (around llY0), plastic surgery (loo/,), anesthesia (7%), pulmonary medicine (6%), orthopaedics (6%), and ophthalmology (6%). The "good times" specialties whose graduates found jobs more readily included urology (100% of residents finding positions); emergency medicine (over 99%); and obstetrics/gynecology, psychology, family practice, and internal medicine, with around a 98% or greater success rate. Of the urology residents who graduated in 1994, 87% went into full-time community practice, 12.3% went into full-time academic practice, and fewer than 1%went into temporary employment. In terms of where the graduates entering community practice went, 56% went into urban and suburban practices, 22% went into practices in towns of less than 50,000 population, and around 8% went into closed-panel HMOs.
OVERPRODUCTION AND UNDERPRODUCTION OF UROLOGISTS
There are numerous consequences from overproduction of urologists, including a reduced volume of surgery and, perhaps, reduced quality, and greater complications and costs. Also, "make-work cognitive services are possible. Lack of bargaining power with managed care organizations because of greater numbers of urologists could occur, including a loss of control of practice, reduced incomes, and possibly low morale. It is certainly difficult to decrease the supply of urologists once they are trained. There are also consequences of underproduction of urologists. These include patients lining up for care and GU surgeries by nonurologists that could result in lower quality and more complications and costs. Also, loss
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of turf to nonurologists could occur. Enhanced bargaining power with managed care companies might be seen if there were a fewer number of urologists to bargain with. There also might be fewer "make-work services." There could be higher morale, but possibly lower morale might occur with overwork. It is relatively easy to increase supply, but one needs a 5- to 7-year lead time between recognizing the demand and coming up with additional supply. RESIDENCY MATCH STATISTICS
As far as the urology residency match is concerned, there was a 27% reduction in applicants from 1985 to 1995. The number of applicants dropped from 404 in 1985 to 293 in 1995, and the number of residency positions increased from 229 in 1985 to 249 in 1995 (Joseph Corriere, MD, AUA Office of Education, personal communication) (Table 1). However, it is interesting to see that there has been a recent stepwise reduction in the number of positions offered, from 253 in 1994 to 249 in 1995, to 237 in 1996, to 220 in 1997 (which came from 104 programs). The number of applicants dropped from 317 in 1994 to 293 in 1995 and increased to 294 in 1996, increasing further to 340 in 1997. My own thought is that a number of these applicant reductions resulted from fear that the Clinton Health Care Plan might be enacted. Also, a number of factors led to the low number of positions offered in 1997, including downsizing and reductions from 6- to 5-year programs, but the trend is definitely down in terms of positions offered. The percentage of foreign versus U.S. graduates who have matched urology residency programs has ranged from 3% in 1986, down to 2% in 1990, and back up to 4% in 1995. This does not appear to be a significant issue in urology. Table 1. UROLOGY RESIDENCY MATCH 1985 TO 1995* Year
Vacancies
Applicants
1985 1988 1990 1992 1994 1995
229 233 239 246 253 249
404 353 314 336 317 293
*27% reduction in applicants 1985-1995
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McCULLOUGH
CURRENT UROLOGY MANPOWER STATISTICS (1995)
In 1995 the total number of urologists in federal, nonfederal, United States, and its possessions was around 9900, of whom 244 were women. There were around 9600 in patient care and around 8000 in office-based positions. There were 1100 hospital-based residents and fellows in 1995 and 532 hospital staff-based urologists. Other categories included administration, 101; teaching, 78; research, 60; and “other,” 22. It is interesting that 273 of the total of 9900 urologists in 1995 were federal, including 55 residents and fellows (Table 2). A personal communication from Dr. David McLeod, April 1997, stated that there had been a drop in the military resident slots per year from 15 recently down to 12, and probably down to 9 positions per year by 1998. The system definitely is changing and is reacting to trends in medicine.
RECENT ACTIONS ON MEDICAL RESIDENCY TRAINING
AUA POSITION ON MANPOWER
The AUA position on physician workforce, planning, and graduate medical education in 1994 was as follows. It endorsed the American Association of Medical Colleges (AAMC) and AMA position statement to study the needs, number, and mix of specialists. It also felt that any body established to conduct planning should be outside of and staffed independently of existing government agencies. There should be an all payers system (national funding pool) for graduate medical education. Transition funds to hospitals losing residents should be available. Also, schools should try to influence more students to become generalists. Table 2. UROLOGY MANPOWER STATISTICS (1995): FEDERAL, NONFEDERAL, UNITED STATES, AND POSSESSIONS Overall total (244female, 9642 male) Patient Care Off ice-Based Hospital-Based Residents, Fellows Physician Staff Other Administration Teaching Research Other
9886* 9625 7991 1102 532 101 78 60 22 273
“Of the above total, 273 are federal, including 55 residents, fellows.
A recent consensus panel response to oversupply included the AMA, the American Association of Colleges of Osteopathic Medicine, American Osteopathic Association, Association of Academic Health Centers, the AAMC, and the National Medical Association. It validated the previous AMA and AAMC statements mentioned above and concluded that federal funding should be aligned more closely with the number of US.medical graduates. There should be expanded training in inner city and rural settings. Graduate medical education training should be offered to foreign-born and foreign-trained physicians, but the program should not allow them to stay in the United States. It also observed that fewer than 50% of U.S. medical graduates enter specialty residencies but that the majority of international medical graduates do.8
On February 18, 1997, an Associated Press article, ”Scalpel: Hospital Staffs That Cut Back Will Get $400 Million,” was published in the Winston-Salem, NC Journal, page A3.2 After reading this article, I would classify this as the Health Care Financing Administration (HCFA)medical ”soil bank.” In the mid-1950s and 1960s in the United States, the Agriculture Department paid farmers not to grow tobacco, cotton, and other crops. Today we have the HCFA paying medical schools and hospitals not to train physicians. In New York City, there will 2000 fewer physicians, a 20% reduction over 6 years. This will decrease yearly over a 6-year period. Presently these hospitals obtain $87,000 per year per slot according to the above-cited article. By spending $400 million, it is thought that the government will save $300 million. This is a pilot program and may go nationwide. It will have a major effect on international medical graduates by reducing their participation. In terms of specialty choices of U.S. medical school graduates in 1996, more than 50% matched in the primary care residencies, and our conclusion is that there are more generalists in the pipeline, which will raise the 12% in general practice considerably in future years.8 Accreditation Alert, Vol. 3, p. 70, 1996,’ included an interesting graph. In 1981, there
MANPOWER NEEDS IN UROLOGY IN THE TWENTY-FIRST CENTURY
were 153 urology residency programs; by 1996, there were 122. This has now dropped to 120. The number of residents in training was 1136 in 1994. In 1995, there were 1094. There is a stepwise reduction going on in terms of urology programs and the number of residents in training. Further discussion on this trend will follow later in this article. In 1956,99% of third- and fourth-year medical students rotated through urology. This dropped to 48% in 1978 and to 38% in 1994. Ten per cent to 15% have never been exposed to urology, with no lectures and no rotation^.^ RECENT HCFA ACTIVITY TWOTIERED UROLOGY TRAINING
Recently, HCFA proposed changes that could affect urology manpower needs. They proposed a greater than 30% decrease in most surgical fees. It is my impression that this sort of decrease would certainly lessen the number of surgical procedures. At the same time, HCFA advocated increasing officebased fees, and I believe that this will certainly increase office activities. The effect on manpower needs remains to be seen. I do think it will, in effect, accelerate a two-tiered medical system: one composed predominantly of surgeons who do urologic procedures and another, predominantly officebased, who do not do any significant volume of surgical procedures outside their offices. The question is, do we need such a system? Do we have such a system? A personal communication from one of the American Board of Urology members stated that many applicants have fewer than 36 major cases on their logs presented for consideration for sitting for the oral examination of the American Board of Urology. In effect, it would seem that we are already moving into such a two-tiered system. Should we try such a system on a pilot basis? I think we should, perhaps in 10 institutions widely spaced geographically across the United States. However, this would be a nightmare for the Residency Review Committee and the American Board of Urology who must construct tests and examinations for such trainees. Is there a demand by residents for such a two-tiered system? I am not sure, but I think there probably is. One difficult problem would be to how to select who does which procedures in a given residency and at what volume? And what procedures (surgical) ex-
19
posure would one need for these two-tiered positions? One might propose 1 year of general surgery and 2 or 3 years of urology with operative exposure to a number of procedures, perhaps not as primary surgeon but mainly as an assistant to understand what the procedures entail. One could have office-based urologists who perform primarily diagnostic and office procedures, such as cystoscopies, vasectomies, biopsies, and evaluation and management. This now occurs in Germany, and could provide a big deterrent to encroachment by primary care physicians, physician assistants, and nurse clinicians. Such a two-tiered system would result in fewer hours worked by the office-based urologist. It could, but not necessarily, result in less pay, better quality of life, more family time, and less hassle and stress. Would there be greater job satisfaction? I think there would be in many cases. Also, the question of whether surgeons or nonsurgeons could live in peace would be a real issue. I think they could, with each group having a niche. CHANGES IN SURGICAL SUBSPECIALTY NUMBERS
The AMA Physician Characteristics Distribution in the U.S., 1996-19979 reported in 1990 to 1995 changes in manpower in various surgical specialties that were both interesting and varied. Plastic surgery increased by 207'0, otolaryngology increased by 12% (as did neurosurgery), orthopaedics by l6%, and urology by 5.5%. General surgery decreased by 2.1%. So the average increase in numbers of urologists was a little over 1%per year during 1990 to 1995. Obviously, the general population increased significantly during that time. A number of factors presently are decreasing the number of residents training in urology. There are fewer programs, mergers of institutions are occurring, and many medical schools are mandating more primary care. Government-mandated decreases in residency slots appear to be a trend, as mentioned earlier. In the military and in the VA, positions in urology are planned to be decreased at least 30% according to some authorities. The University of California is mandating a 25% decrease in residents by the year 2000, and New York State may reduce the number of residents as well. Earlier we discussed the government "soil bank" pilot pro-
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McCULLOUGH
gram in New York City. There may be tighter Residency Review Committee requirements, which also would decrease the number of resident slots available. Regarding pediatric urology manpower, Retik and Kingloand Shapiro12reported on a questionnaire sent to pediatric urologists. There was an 87% response rate. It was noted that 70% of pediatric urologists are less than 50 years old, 81% are in full-time pediatric practice, and about half are university-based. The conclusion was that the pediatric urology community was training 10 to 15 fellows a year; if that trend continues there would be an excess of 40 to 90 pediatric urologists in 10 years. A personal communication from Dr. Terry Hensle states that there are now fewer than nine fellows training per year, and this should not be a problem. The system is correcting. WILL UROLOGY SURVIVE?
This is a real question, but I feel that the answer is “Yes, we will.” Urologists are very ingenious as demonstrated by the development of ESWL, endourology, PSA testing, ultrasound of the kidneys and prostate, prostate biopsies, changes and improvements in radical prostatectomy, minimally invasive therapy of BPH, urodynamics, improved techniques of node dissection in testis cancer (which has vaulted this back into a popular way of treating this disease), and impotence evaluation and therapy. We have an aging population in which incontinence, cancer, and BPH will become more prevalent. I think that brachytherapy will note an increase because of HCFA decreased funding of radical prostatectomies and the fact that urologists can deliver such therapy. Also, in terms of medical therapy of BPH, I think a number of deferred or delayed procedures now being “warehoused” ultimately will result in some procedures being done on the patients. Even if that does not occur, urologists still treat many BPH patients medically. It would appear that the numbers of radical nephrectomy, orchiectomy, cystectomy, and prostatectomy remain stable. Female urology could be lost if we are not careful. Transplantation and some aspects of infertility already have been lost to other specialties. It is obvious that managed care cannot outlaw diseases that are going to occur and increase in frequency. There appears to be a
national backlash over the lack of specialty referral in many managed care programs, and the public does not seem to be accepting the rationing of care well. I predict that there will be an increase of provider service networks (PSN) in which the middleman is eliminated and the consumer will get more ”bang for their b u c k by having the third-party payors negotiate directly with the providers, both physician and hospital-based. My opinion is that urology will survive. HIGHLIGHTS OF THE AUA STRATEGIC PLANNING COMMllTEE REPORT
The Strategic Planning Committee of the AUA, Chaired by David L. McCullough, MD, met in San Diego, California, in November 1995.‘jThis was thought to be a suitable city because it had the reputation of being the ”Bosnia” of managed care. At that meeting we had input from HMOs, the AUA Gallup Poll, the U.S. government, the AUA Workforce Committee, and reports by a number of consultants, including a report entitled “The National Supply and Demand for Urologists 1995 to the Year 2020” by Harlan Menkh7 We also had legal input on the antitrust issues. One has to be careful when discussing the possibility of limiting manpower, and we were careful with this sensitive issue. We attempted to obtain the best possible information in the range of needed urologists based on variables that became evident during the Committee proceedings. We were made aware that there were about 6350 voting members of the AUA and around 8400 members in practice. At present, we see that there are around 9900 urologists. This is from the recent AMA data.4 We also noted that the average urologist retires at age 68; around 200 urologists recently have been retiring yearly. To keep the present number of AUA urologists in practice to the year 2020, 270 per year would need to graduate. We are substantially below that level at present. If 260 graduate per year, the total number of urologists in 2020 would be 9165, substantially below the 9900 we have now, and the AUA members certainly would be fewer than today. Patients 65 years old and older account for 46% of office visits and only 13% of the population. Baby boomers will need more care. The U.S. population is slated to increase from
MANPOWER NEEDS IN UROLOGY IN THE TWENTY-FIRST CENTURY
263 to 323 million between the years 1995 and 2020. This 60 million increase in population is the equivalent of dropping into the United States population pool the equivalent of the population of the United Kingdom or France. The number of Medicare patients will increase from 34 million to 54 million, or 20 million more than at present. Weiner et all4 made recent observations on Medicare population increases and implications for the necessary number of urologists to serve them. Medicare patients average 184 visits per 1000 population versus 72 per 1000 population per persons aged 45 to 64, the age group immediately below the Medicare group. If the number of urologists remains stable and the population increases by 60 million, there would be 6315 more patients per urologist, and one third of these would be Medicare patients. The ratio of urologists to population is now around 1:27,000. If the ratio were changed to 1:34,500 by the year 2000, or the present California ratio, we would need fewer than 250 graduates per year. We are now down to that level. As mentioned previously, some HMOs allegedly require only one urologist for 50,000 population. If this penetration occurred across the United States, and I doubt it will, we would need fewer than 150 graduates per year. The number of urology chief graduates per year has undergone a stepwise reduction from 278 in 1992, to 253 in 1996, and it now is down to 250. This is over a 9% decrease in 5 years and already below the 260 mentioned above. If we continue a 9% 5-year attrition rate, we would be down to 230 graduates by the year 2001 and 209 by the year 2006. The system is definitely adjusting. AUA WORKFORCE COMMITTEE CONCLUSIONS
Thomas J. Rohner, MD, Chair of the Workforce Committee, reported to AUA in May 1996, and this report is summarized briefly below." The Committee believed 'that it was difficult to gauge the percentage of urology work to be performed by primary care physicians or RNs. They also noted that technology would decrease the number of procedures, especially open procedures, in the years to come. They believed that residency training should increase emphasis on office practice economics and decrease the present emphasis
21
on surgery. They also found from the AUA Gallup survey that 18% of groups representing 2900 urologists were seeking another urologist, or 530 physicians. They also found that 68% would hire a newly graduated resident, or 360 positions. This is 110 more positions available than there are new graduates at present. The committee found that if more than 225 urology residents were graduating in the year 2010, or over 150 in the year 2020, there would be an oversupply. They thought it would be helpful to try to persuade the ACGME to aim for a reduction to 200 to 250 graduates per year until the year 2000 and then to restudy the situation. As mentioned above, we are down to 250 graduates per year already, and it is only 1997. ACGME DATA*
In 1989, 60% of the programs were 5-year programs. This dropped to 33% in 1994. The trend reversed in 1997 and is presently at 37.5%. The number of 6-year programs is the flip side of these statistics. In 1997, there are a total of 120 programs, down from 125 in 1994. The program compositions are as follows: 2 years of general surgery and 3 years of urology in 24 programs; 1 year of general surgery and 4 years of urology in 21 programs; and 2 years of general surgery and 4 years of urology in 75 programs. There is considerable movement to the 1-in-4 configuration: 1 year in general surgery and 4 years of urology. This probably relates to the potential funding of residents in residency training programs and the feeling by some that 2 years in general surgery (often with few surgical procedures performed) is neither necessary nor desirable. Resident Slots Deleted Because of Closings or Mergers. In 1994, two programs closed and six resident slots per year were eliminated. In 1995, there was one closure and one resident slot per year deleted and one merger that resulted in no resident slots deleted. This does not include military downsizing. The total number of urology residents has shown a stepwise reduction in the last 4 years. In 1994, 125 programs had 1135 residents in training in urology. In 1995, this had dropped to 122 programs with 1034 residents. *Provided by Doris Stoll, PhD, 4/97, ACGME, personal communication.
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McCULLOUGH
In 1997, there were 120 programs with 971 residents. These statistics represent a 4% decrease in the number of programs and a 15% decrease in the number of urology residents in training. The system is definitely adjusting. SUMMARY Physician supply factors are based on a number of variables. These include the base supply and retirements, which presently show that around 200 urologists are retiring per year. Death rates of both patients and physicians are significant. The rate of entry of graduating residents is important. Population changes (which certainly will continue to increase in the United States) are important. Needs-based projections, demandneeds based projections, and benchmarked projections are important issues. The immigration of physicians is important. So far, I think we have seen little emigration of physicians from the United States. A number of confounding variables can have impact and are almost impossible to predict at present. These include technology changes, disease patterns, and methods of care delivery. The Strategic Planning Committee thought we should aim for a band of 200 to 250 chief residents finishing one per year. We have already reached the 250 level. At 200 finishing per year, we would have 2300 fewer urologists in the year 2020 than we presently have. At 225/year, we would have 1700 fewer urologists. At 250 (our present level), we will have 1100 fewer than now. These 8800 urologists would be caring for 60 million more patients, of whom 20 million would be Medicare patients. These patients would provide over 500 additional patient visits/year/urologist. I hope that I have convinced you that the
system is correcting and responding to multiple market forces. I predict that urologists in practice in 2020 will be busy and that we will not have too many urologists i f the graduating numbers are kept stable. If they drop much more, we could well have too few. References 1. Accreditation Alert: A publication of Nixon, Hargrave, Devans, and Doyle, Vol. 3, 1996, p 70 2. Associated Press: Scalpel: Hospital staffs that cut back will get $400 million. Winston-Salem Journal, February 19, 1997 3. Benson GS: The decline of urological education in United States medical schools. J Urol 152:169, 1994 4. Dickey Nw: Building consensus, protecting our future. American Medical News: February 24, 1997, P 33 5. Miller RS, Jonas HS, Whitcomb ME: The initial employment status of physicians completing training in 1994. JAMA 275:708-712, 1996 6. McCullough DL: Report of the Strategic Planning Committee to the American Urological Association, Inc, April, 1996 7. Menkin HL: National supply and demand forecast for urologists 1995-2020. The Center for Health Policy Studies-West Health Demographics and the Health Forecasting Group. Prepared for American Urological Association, December 1995 8. Mitka M: Doctor ranks grow 17% in 5 years. American Medical News: February 24,1997, p 55 9. Randolph L, Seidman B, Pasko T Physician Characteristics and Distribution in the US, 1996-97. Chicago, American Medical Association, 1997 10. Retik AB, King LR: Editorial comments. J Urol 156:490491, 1996 11. Rohner TJ: Report of the Workforce Committee Meeting to the American Urological Association, May 8, 1996 12. Shapiro E: Pediatric urology manpower report 1995. J Urol 156:488-490, 1996 13. Szenas P: Graduates’ interest in generalist specialties continues to rise, along with educational debt. American Association of American Medical Colleges Reporter 6:1, December 1996/January 1997 14. Weiner DM, McDaniel R, Lowe FC: Urologic manpower issues for the 21st century: Assessing the impact of changing population demographics-Urology 49~335-342, 1997
Address reprint requests to David L. McCullough, MD Department of Urology Bowman Gray School of Medicine of Wake Forest University Medical Center Boulevard Winston-Salem, NC 27157