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Opportunities for the Urologist in Small Communities1
OPPORTUNITIES FOR THE UROLOGIST IN SMALL COMMUNITIES1 PAUL M. BUTTERFIELD From the Department of Urology of the Cape Cod Hospital, Hyannis, Mass.
The saturation point for the urologist has long since been reached in our great cities. In New York, for example, there are approximately 150 members of the American Urological Association. These and a hundred more belong to the New York Section. In addition there are probably a hundred men who are practicing urology in whole.or in part. So that the total number approximates 350. Hence there is 1 urologist to about 17,000 people. It is very likely that the same situation obtains in our other large cities. Inasmuch as a population of at least 50,000, and better still 100,000, is required for a practice in urology yielding sufficient income to maintain an office, home and family in comparative efficiency and comfort, it is apparent that the young resident, coming out of a hospital well prepared for his work and not provided for by urban or institutional contacts, must seriously consider location in a smaller community. Following their discharge from the Medical Corps of the Army in 1918 large numbers of men decided it was an opportune time to enter some special field in medicine or surgery. I have no doubt that the same thing will happen at the conclusion of the present war. Further, it is not unlikely that shifts of population toward smaller cities and towns will take place in the near future. It is the object of this paper to show that opportunities for the urologist do exist in small communities by citing my own experience in a community of 35,000 people, increased in summer to 100,000, served by a hospital of about 60 beds. In a little less than a year and a half about 200 patients have been referred by 30 doctors (60 in the area). A survey of the cases cited and the work done will show that a wide knowledge of urological diagposis and surgery is needed even in the country. The cases coming under my care were as follows: Bladder, calculus, 2; carcinoma, 10; diverticulosis, 2; fibrosis vesical neck, 12; hemorrhage (radium slough), 1; post-resection, 1; incontinence (pituitary tumor), 1, malnutrition, 1; papilloma, 1; retention (large bowel surgery), 1, Kidney, calculus, 9; ptosis, 5; pyelonephritis, acute, 10, chronic, 14; pyonephrosis, 1; rupture, 1; tumor, 2. Penis, acute cavernositis, 1. Perineum, abscess, 1; multiple fistulae, 1; phlegmon, 1. Prepuce, balanitis, 1; paraphimosis, 2. Prostate, carcinoma, 2; hypertrophy, 33; prostatitis, 6. Scrotum, epididymitis, acute, 2, chronic, 5; hydrocele, 2; orchitis (traumatic), 1; varicocele, 2. Ureter, calculus, 3; periureteral abscess, 1; stricture, 6. Urethra, caruncle, 2; contusion, 1; gonorrhea, 3; rupture, 1; stricture, 25; total, 176. In addition 18 cases of extra-urinary tract disease giving rise to urinary tract 1 Read at annual meeting, American Urological Association, New York, N. Y., June 1, 1942. 133
134
PAUL M. BUTTERFIELD
symptoms were seen in consultation. This is an important group and is shown in table 2. Table 1 shows the number and character of the surgical procedures. Considering the number and type of cases coming under observation a larger number of operations might have been done. I have, however, avoided any high pressure salesmanship. It seems to be less necessary and effective in the small community. Table 3 shows the number of deaths to which you may add your own comment. TABLE
1.-Surgical procedures
Calicectomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Caruncle resection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 fulguration..... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Cystoscopies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 Cystograms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Cystourethragrams................................................................. 5 Cystostomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 Dorsal slit......................................................................... 2 Endoscopy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 External urethrotomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 N ephrectomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 N ephrotomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Perinea! abscess. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Periureteral abscess................................................................ 1 Prostatectomy perinea!.......................................................................... 2 suprapubic....................................................................... 11 Pyelograms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Pyelotomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Repair suprapubic sinus............................................................ 1 Resections endoscopic bladder tumor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 vesical neck. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 cystostomy (radon seeds in cases of bladder tumor). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 surgical (bladder tumor). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Vasotomy.......................................................................... 2 Ureteral dilatation................................................................. 7
That the specialist is most welcome in the small hospital group there is little room for doubt. The access to skilled opinion, so easy in the city, is wanting at a distance and while many of the local doctors are men of large experience and sound judgment the presence of specialists in various fields is a valuable asset to the institution. In the selection of a location many factors come into the picture. Localities near the home town or areas which, for various reasons, are well known and well liked by the seeker will appeal to the majority. The presence of friends or old patients makes certain towns attractive. Locations near large cities should be
UROLOGISTS AND SMALL COMMUNITIES
135
popular as here one can attend meetings and clinics from time to time. Be assured that you should do so. These advantages are offset by the loss of patients to the city but in general this is not a serious consideration. The crux of the situation lies in the hospital. Given a good one in which to work, the rest should be fairly easy. In seeking a hospital appointment it would TABLE
2.-Extra urinary tract disease giving rise to urinary tract symptoms PATHOLOGICAL CONDITION
84 29 sss 35 GC 28 WMB 62 WT 54 TET 72 AAW 77 BH 37 FED 70 MH 50 RIH 37 ES 75 JAM
MD
JB
32
GMM 30 RM 7 LVB 65 wso 52
M ..... F ..... M ..... M ..... M ..... M ..... F ..... F ..... F ..... M ..... F ..... F ..... F ..... F ..... F ..... M ..... M ..... M .....
Pneumonia Acute appendicitis Acute appendicitis Acute appendicitis Acute enteritis Coronary Cholecystitis Cholelithiasis Cholelithiasis Diabetes Endocrine Endocrine Ovarian cyst Ovarian cyst Pelvic abscess Regional enteritis? Retroperitoneal tumor Undiagnosed TABLE
JHP
75 M. . . . . . Carcinoma of bladder
GNH 66 M. . . . . . Carcinoma of prostate
GFB
68 M. . . . . . Prostatic hypertrophy
BN
78 M. . . . . . Prostatic hypertrophy
SPK
69 M. . . . . . Prostatic hypertrophy
RG
70 M. . . . . . Prostatic hypertrophy
URINARY TRACT SYMPTOMS
Acute retention Pain left flank Pain left flank Pain right flank, hematuria Right renal colic Pain left flank Pain right flank Pain right flank Pain right flank Frequency, urgency Frequency, urgency, plastic vagini tis Frequency, urgency, deficiency Pain left flank Frequency, urgency Pain left flank Pain right flank Pain and mass left flank Pain left flank, anuria, death
3.-Deaths Died 3 months after cystostomy of inoperable ca. Died sixth day after total perinea! prostatectomy, cardiac. Had early pulmonary atalectasis with bronchoscopic treatment Died coronary heart disease prior to any surgical procedures Died, uremia, sixth day after second stage suprapubic prostatectomy Died, pneumonia, fourth day after second stage suprapubic prostatectomy Died, third day after cystostomy, pulmonary embolism
be a move of great wisdom to secure it through the staff and be recommended by it to the Board. The approach should be through the staff and not the other way round. Be wary of an appointment via the powers that be. This is no criticism of the hospital board. What you are looking for is staff co-operation and it is more likely to be gained in this way. I find small hospitals to be unusually generous in the matter of purchasing
136
PAUL M. BUTTERFIELD
special supplies. There is usually a small amount of urological equipment on hand but you would do well to have instruments of your own for routine cystoscopic and pyelographic work. Our carpenter built us a formaldehyde sterilizing cabinet, which is as satisfactory as any I have ever seen, at a cost of about $10. One of my well-to-do patients who needed a resection of the bladder neck bought the outfit for the hospital. Opportunities for research are limited only by the paucity of one's imagination. My own experience with the staff and board and superintendent in my present location has been extraordinarily pleasant. The avoidance of any mortality of consequence in the early months of hospital work is advised. The bad risk had best be postponed for a time. This puts off the evil day until you can safely and legitimately lose a few. My present hospital has such an amazingly low death rate in appendicitis and in obstetrical work that it behooved me to be very conservative. There are several practical points I might impress on the tyro for whom this article is written. (I might add, in passing, that some of the older men may be impressed by these opportunities, as I have been. They will find many compensations in country life.) Have your home and office near the hospital, preferably within walking distance (I didn't). Give all your cystoscopic patients a real anesthesia, preferably spinal. I have not seen a single spinal headache in my series. Do not expect to do cystoscopic examinations on many children. The word has not yet reached all doctors that children need and deserve all the diagnostic and curative measures that are available to adults. In relation to joining golf clubs and local organizations, if you do not already know what to do about them you do not belong in urology. The limitation of your work to your special field is much the wiser course. In leaving the city you will leave friends, magnificent hospitals and splendid staffs and you will find them all in miniature in the country. I have reason to be grateful to my present staff and Board for their co-operation and their permission to use my material in this paper; my gratitude also goes to the nursing staff which took up new duties and gadgets and diets with interest and competence, and to the X-ray department which co-operated fully in all the fantastic demands of the work.
Harwich, Mass. REFERENCE Ross, W. L., JR.: J. Urol., 44: 753, 1940.
The saturation point for the urologist has long since been reached in our great cities. In New York, for example, there are approximately 150 members of the American Urological Association. These and a hundred more belong to the New York Section. In addition there are probably a hundred men who are practicing urology in whole.or in part. So that the total number approximates 350. Hence there is 1 urologist to about 17,000 people. It is very likely that the same situation obtains in our other large cities. Inasmuch as a population of at least 50,000, and better still 100,000, is required for a practice in urology yielding sufficient income to maintain an office, home and family in comparative efficiency and comfort, it is apparent that the young resident, coming out of a hospital well prepared for his work and not provided for by urban or institutional contacts, must seriously consider location in a smaller community. Following their discharge from the Medical Corps of the Army in 1918 large numbers of men decided it was an opportune time to enter some special field in medicine or surgery. I have no doubt that the same thing will happen at the conclusion of the present war. Further, it is not unlikely that shifts of population toward smaller cities and towns will take place in the near future. It is the object of this paper to show that opportunities for the urologist do exist in small communities by citing my own experience in a community of 35,000 people, increased in summer to 100,000, served by a hospital of about 60 beds. In a little less than a year and a half about 200 patients have been referred by 30 doctors (60 in the area). A survey of the cases cited and the work done will show that a wide knowledge of urological diagposis and surgery is needed even in the country. The cases coming under my care were as follows: Bladder, calculus, 2; carcinoma, 10; diverticulosis, 2; fibrosis vesical neck, 12; hemorrhage (radium slough), 1; post-resection, 1; incontinence (pituitary tumor), 1, malnutrition, 1; papilloma, 1; retention (large bowel surgery), 1, Kidney, calculus, 9; ptosis, 5; pyelonephritis, acute, 10, chronic, 14; pyonephrosis, 1; rupture, 1; tumor, 2. Penis, acute cavernositis, 1. Perineum, abscess, 1; multiple fistulae, 1; phlegmon, 1. Prepuce, balanitis, 1; paraphimosis, 2. Prostate, carcinoma, 2; hypertrophy, 33; prostatitis, 6. Scrotum, epididymitis, acute, 2, chronic, 5; hydrocele, 2; orchitis (traumatic), 1; varicocele, 2. Ureter, calculus, 3; periureteral abscess, 1; stricture, 6. Urethra, caruncle, 2; contusion, 1; gonorrhea, 3; rupture, 1; stricture, 25; total, 176. In addition 18 cases of extra-urinary tract disease giving rise to urinary tract 1 Read at annual meeting, American Urological Association, New York, N. Y., June 1, 1942. 133
134
PAUL M. BUTTERFIELD
symptoms were seen in consultation. This is an important group and is shown in table 2. Table 1 shows the number and character of the surgical procedures. Considering the number and type of cases coming under observation a larger number of operations might have been done. I have, however, avoided any high pressure salesmanship. It seems to be less necessary and effective in the small community. Table 3 shows the number of deaths to which you may add your own comment. TABLE
1.-Surgical procedures
Calicectomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Caruncle resection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 fulguration..... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Cystoscopies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 Cystograms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Cystourethragrams................................................................. 5 Cystostomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 Dorsal slit......................................................................... 2 Endoscopy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 External urethrotomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 N ephrectomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 N ephrotomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Perinea! abscess. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Periureteral abscess................................................................ 1 Prostatectomy perinea!.......................................................................... 2 suprapubic....................................................................... 11 Pyelograms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Pyelotomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Repair suprapubic sinus............................................................ 1 Resections endoscopic bladder tumor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 vesical neck. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 cystostomy (radon seeds in cases of bladder tumor). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 surgical (bladder tumor). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Vasotomy.......................................................................... 2 Ureteral dilatation................................................................. 7
That the specialist is most welcome in the small hospital group there is little room for doubt. The access to skilled opinion, so easy in the city, is wanting at a distance and while many of the local doctors are men of large experience and sound judgment the presence of specialists in various fields is a valuable asset to the institution. In the selection of a location many factors come into the picture. Localities near the home town or areas which, for various reasons, are well known and well liked by the seeker will appeal to the majority. The presence of friends or old patients makes certain towns attractive. Locations near large cities should be
UROLOGISTS AND SMALL COMMUNITIES
135
popular as here one can attend meetings and clinics from time to time. Be assured that you should do so. These advantages are offset by the loss of patients to the city but in general this is not a serious consideration. The crux of the situation lies in the hospital. Given a good one in which to work, the rest should be fairly easy. In seeking a hospital appointment it would TABLE
2.-Extra urinary tract disease giving rise to urinary tract symptoms PATHOLOGICAL CONDITION
84 29 sss 35 GC 28 WMB 62 WT 54 TET 72 AAW 77 BH 37 FED 70 MH 50 RIH 37 ES 75 JAM
MD
JB
32
GMM 30 RM 7 LVB 65 wso 52
M ..... F ..... M ..... M ..... M ..... M ..... F ..... F ..... F ..... M ..... F ..... F ..... F ..... F ..... F ..... M ..... M ..... M .....
Pneumonia Acute appendicitis Acute appendicitis Acute appendicitis Acute enteritis Coronary Cholecystitis Cholelithiasis Cholelithiasis Diabetes Endocrine Endocrine Ovarian cyst Ovarian cyst Pelvic abscess Regional enteritis? Retroperitoneal tumor Undiagnosed TABLE
JHP
75 M. . . . . . Carcinoma of bladder
GNH 66 M. . . . . . Carcinoma of prostate
GFB
68 M. . . . . . Prostatic hypertrophy
BN
78 M. . . . . . Prostatic hypertrophy
SPK
69 M. . . . . . Prostatic hypertrophy
RG
70 M. . . . . . Prostatic hypertrophy
URINARY TRACT SYMPTOMS
Acute retention Pain left flank Pain left flank Pain right flank, hematuria Right renal colic Pain left flank Pain right flank Pain right flank Pain right flank Frequency, urgency Frequency, urgency, plastic vagini tis Frequency, urgency, deficiency Pain left flank Frequency, urgency Pain left flank Pain right flank Pain and mass left flank Pain left flank, anuria, death
3.-Deaths Died 3 months after cystostomy of inoperable ca. Died sixth day after total perinea! prostatectomy, cardiac. Had early pulmonary atalectasis with bronchoscopic treatment Died coronary heart disease prior to any surgical procedures Died, uremia, sixth day after second stage suprapubic prostatectomy Died, pneumonia, fourth day after second stage suprapubic prostatectomy Died, third day after cystostomy, pulmonary embolism
be a move of great wisdom to secure it through the staff and be recommended by it to the Board. The approach should be through the staff and not the other way round. Be wary of an appointment via the powers that be. This is no criticism of the hospital board. What you are looking for is staff co-operation and it is more likely to be gained in this way. I find small hospitals to be unusually generous in the matter of purchasing
136
PAUL M. BUTTERFIELD
special supplies. There is usually a small amount of urological equipment on hand but you would do well to have instruments of your own for routine cystoscopic and pyelographic work. Our carpenter built us a formaldehyde sterilizing cabinet, which is as satisfactory as any I have ever seen, at a cost of about $10. One of my well-to-do patients who needed a resection of the bladder neck bought the outfit for the hospital. Opportunities for research are limited only by the paucity of one's imagination. My own experience with the staff and board and superintendent in my present location has been extraordinarily pleasant. The avoidance of any mortality of consequence in the early months of hospital work is advised. The bad risk had best be postponed for a time. This puts off the evil day until you can safely and legitimately lose a few. My present hospital has such an amazingly low death rate in appendicitis and in obstetrical work that it behooved me to be very conservative. There are several practical points I might impress on the tyro for whom this article is written. (I might add, in passing, that some of the older men may be impressed by these opportunities, as I have been. They will find many compensations in country life.) Have your home and office near the hospital, preferably within walking distance (I didn't). Give all your cystoscopic patients a real anesthesia, preferably spinal. I have not seen a single spinal headache in my series. Do not expect to do cystoscopic examinations on many children. The word has not yet reached all doctors that children need and deserve all the diagnostic and curative measures that are available to adults. In relation to joining golf clubs and local organizations, if you do not already know what to do about them you do not belong in urology. The limitation of your work to your special field is much the wiser course. In leaving the city you will leave friends, magnificent hospitals and splendid staffs and you will find them all in miniature in the country. I have reason to be grateful to my present staff and Board for their co-operation and their permission to use my material in this paper; my gratitude also goes to the nursing staff which took up new duties and gadgets and diets with interest and competence, and to the X-ray department which co-operated fully in all the fantastic demands of the work.
Harwich, Mass. REFERENCE Ross, W. L., JR.: J. Urol., 44: 753, 1940.