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Pediatric Urology Manpower Report 1995
0022-6347/96/15624488$03.00/0
Vol. 156,488-491, August 1996 Printed in U.S.A.
Ike JOURNAL OF UROLOGY Copyright 0 1996 by h m c m U R ~ ~ I C ASSOCv\nON, AL hC.
PEDIATRIC UROLOGY MANPOWER REPORT 1995 ELLEN SHAPIRO ON BEHALF OF THE AMERICAN ASSOCIATION OF PEDIATRIC UROLOGISTS From the Department of Urology, New York University School of Medicine, New York, New York
ABSTRACT
Purpose: The quality and emciency of any health care system depend on a n appropriate level of manpower. The manpower issues of tomorrow will be influenced by the number of physicians and specialists trained today. The objectives of this manpower survey of pediatric urologists in the United States were to determine anticipated manpower requirements and provide caveats related to the practice of pediatric urology. Materials and Methods: A manpower questionnaire was distributed to pediatric urologists at the American Urological Association meeting in Las Vegas, Nevada in April 1995. Of the 234 distributed questionnaires 204 (87%)were completed and entered into a computer program. Results: Of responding pediatric urologists 70%were younger than 50 years, 81%practiced full-time pediatric urology and 45% were university based. The rates of respondents indicating t h a t their present workload was too busy, appropriate or not busy enough were 10,70 and 20%, respectively. A total of 71% of respondents indicated that they would discourage a newly trained individual from setting up a practice in their area. Of practicing pediatric urologists 26% intended to retire within the next 10 years. I n April 1995,80 respondents (39%)representing 67 practices were considering adding a n associate within the next 10 years. By the end of 1995 only 56 practices will remain that will add a n associate within the next 10 years. A total of 82% of respondents believed that there was a n excess number of pediatric urology training programs. Conclusions: The pediatric urology community presently trains 10 to 15 pediatric fellows per year. Based on the 1995 manpower survey, if this trend continues a n excess of 40 to 90 pediatric urologists will be trained in the next 10 years. The conclusion that there is a n overabundance of pediatric urologists in training is supported by the general consensus of practicing pediatric urologists. Policies related to the training of pediatric urology fellows and urology residents should depend, not on the manpower needs a t individual medical centers, but on the collective needs of our specialty and the patients whom we serve. K E Y WORDS:
manpower; pediatrics; urology; specialties, medical; education, medical
In 1991 the American Association of Pediatric Urologists initiated its first manpower study.' The American Association of Pediatric Urologists includes pediatric urologists who completed pediatric urology fellowship training after 1981. The initial survey was distributed to members of the Society of Pediatric Urology and American Academy of Pediatrics Section on Urology. The primary recommendation derived from this initial survey was that the availability of job opportunities for pediatric urologists in fellowship training per year must be determined before offering fellowship positions. The survey indicated that between 1991 and 2001, 95 positions would become available for fellowship trained pediatric urologists. Therefore, training 8 to 10 individuals each year would meet anticipated manpower needs for the next 10 years. It was also recognized that manpower needs may be changing depending on population growth, health care policies and referral patterns, and retirement plans of older pediatric urologists. In 1993 the second manpower study showed that the age distribution of pediatric urologists was evenly distributed among the 3 consecutive decades of 31 to 60 years. The majority of respondents practiced 100%pediatric urology and were between 31 and 50 years old. The questionnaire captured many caveats related to pediatric urology practice in the United States. Of the respondents 74% practiced fulltime pediatric urology, including 48% who were university based and 19% who were in private practice. A change in practice trends between 1991 and 1993 included an increase in the number of individuals in a combination university and Accepted for publication February 9, 1996.
private practice position from 25 to 42%. The study also addressed the attitudes of pediatric urologists toward other pediatric urologists seeking job opportunities in their geographic practice area. Of the respondents 8%indicated that they would welcome another pediatric urologist settling in their area, 33%would consider taking him or her as a partner and 50%would discourage settling in their area. When asked whether their current practice load was satisfactory, approximately 65%of respondents believed that i t was appropriate. According to 40% of the respondents an acceptable workload was a n office practice of 31 to 50 patients weekly, and the majority treated between 6 and 15 new patients weekly. A median of 6 operations was performed weekly. Importantly the 1993 manpower survey determined that within the next 10 years 92 pediatric practices anticipated adding a n additional pediatric urologist. A disturbing trend was that there appeared to be a n increasing number of fellowship training positions in pediatric urology in the United States and Canada. At the time of the 1993 study approximately 14 pediatric urology fellowships were offered annually. If the number of fellowship positions remained constant for the next 10 years, it was predicted that there would be 140 new pediatric urologists trained for only 92 anticipated positions. This information stimulated discussions among the fellowship directors in the United States and Canada about the need to develop a plan to decrease the number of fellowship positions. As a result of this manpower study, several programs withdrew from the fellowship match for a year. Since concern exists about the excessive number of fellows entering the job market yearly as well as the limited avail-
488
489
PEDIATRIC UROLOGY MANPOWER
ability of appropriate job opportunities, an abbreviated survey was sent to pediatric urologists who started new positions in July 1994 and July 1995. The survey inquired about the number of potential opportunities as well as the number of programs visited. In addition, the survey captured whether the number of job opportunities was believed to be sufficient and whether fellows were able t o choose the appropriate practice type, that is academic versus private practice. The survey also inquired about the availability of jobs in desired geographic regions as well as whether salary ranges were satisfactory. During this period 13 of 20 individuals completing a fellowship pursued a pediatric urology position. In July 1994, 2 individuals entered the military with obligations of at least 2 years. In 1995,4 individuals in training did not enter the pediatric urology job market since 2 entered the military, 1 returned to a foreign home and 1 entered a plastic surgery training position. In 1994 and 1995 an average of 3 jobs was offered to each fellow. Half of the individuals thought that there were sufficient positions available while half did not. Only half of the individuals were able to enter into their practice type of choice. A total of 75% of the individuals were not able to locate a job opportunity in the preferred geographic area and only half believed that the salary range was acceptable. Overall about 60% of respondents believed that finding a position was moderately to very difficult. With the continuing increase in the number of pediatric urology fellowship positions, and the expressed attitudes and concerns of recently trained fellows entering the job market we embarked on the 1995 manpower study. In addition to inquiring about the general information of individuals practicing pediatric urology, an effort was made to capture attitudes related to individuals settling in their areas, retirement plans and plans to add an associate. Furthermore, the 1995 manpower study critically evaluated the types of positions that would become available in the next 10 years. In addition, since health care trends have changed dramatically in the last 5 years, the survey ascertained the general impact of managed care on clinical practice and whether these effects were confined to specific geographic regions. Respondents were requested to comment personally on the effect of managed care as well as on the large number of fellowship positions, since these problems have been articulated by many practicing pediatric urologists. We also asked for written comments for the executive board members of the American Academy of Pediatrics Section on Urology and Society of Pediatric Urology, which may be useful in further understanding membership concerns.
TABLE1. Age distribution
of
pediatric urologists % Practice Activity
No. Urologists (%)
Age
100
3140 41-50 51-60 61-70 Older than 70 Totals
73 (35) 71 (34) 46 (23) 13 (7) 1 (1) 204
5 6 3 6 I
-
lfi6
50
75 9 3 7
7 5 4
6 2 3 5
2 -
1A
25
-- 16
1 1 2 -
4
TABLE2. Pediatric urolom Dractice trends % Practice
No. Urologists
Activity
(%I
100 75 50 25
183 (82) 19 (8) 16 (7) 4 (2)
Practice Type University
Private
University’ Private
83 9 2 1
44 7 11 3
47
2 1 -
fellowship trends in the United States. The figure illustrates the number of pediatric urology fellows in training each year between 1955 through 1995. The 1995 manpower study also addressed clinical workload of the respondents. A total of 19 respondents (10%)had practices that were believed to be too busy, 135 (70%)indicated that their practice load was appropriate and 38 (20%) thought that their practice was not busy enough. The number of patients and new patients seen weekly, and surgical procedures are shown in tables 3 and 4, respectively. An average of 6 or 7 surgical procedures was performed by those who believed that their practice was satisfactory. The survey inquired whether respondents would encourage or discourage another pediatric urologist to settle in their area. The 1991 questionnaire had a significant no response rate, while the 1995 questionnaire indicated that 3% of respondents would encourage an individual to settle in their area and 20%would consider taking him or her as a partner, while 71% would discourage someone from entering their community. The 1995 manpower study revealed that 53 practicing pediatric urologists (26%) planned to retire within the next 10 years. In April 1995, 80 respondents (39%)representing 67 practices were considering adding an associate within the
1995 MANPOWER SURVEY
The 1995 manpower study was distributed at the AmeriN can Urological Association meeting in Las Vegas, Nevada in April 1995. As of October 1995, 234 questionaires were dis- U tributed, and 204 (87%) were completed and entered into a M computer program. The geographic distribution of practicing pediatric urolo- B E gists in the American Urological Association included 7% in the Northeastern, 5% in the New England, 10%in the New R York, 12% in the Mid-Atlantic, 13% in the South Central, 16%in the Western, 18%in the North Central and 21%in the Southeastern sections. Age distribution of pediatric urologists is shown in table 1 with 70% distributed equally between ages 31 to 40 and 41 to 50 years, while the remaining I third were between 51 and 70 years old. The majority (81%) 55 60 65 70 75 80 85 90 95 of pediatric urologists responding to this survey practiced 100% pediatric urology with 45% in university based pracYEARS tice, 24% in private practice and 25% in a universitylprivate 1955 to 1995 Practice (table 2). Of the 183 urologists who practiced 100% pediatric urology 39% were sole practitioners while 55% had Number of pediatric urology fellows in training each year between a t least 1 associate. In the 1991 study we carefully examined 1955 and 1995. A
490
PEDIATRIC UROLOGY MANPOWER TABLE3. Pediatric urology patients seen weekly No. h. No. Urologists Total: Less than 10 5 11-30 31-50 51-70 71-100 New: 5 or Less 610 11-15 1620 21-25 26-30 Greater than 30
54 62 49 22 12 61 50 41 17 6 5
TABLE 4. Operations performed by pediatric urologists weekly No. Owrations
No. Uroloeists
8 Greater than 8
2 10 11 20 33 22 14 29 50
next 10 years. By the end of 1995, 56 practices remain that will add an associate within the next 10 years. Interestingly of the 139 pediatric urologists (71%) who would discourage someone from entering their community 60 (43%)responded that they planned to add a n associate to their own practice within the next 5 years. A total of 64% of respondents believed that managed care would affect their practices adversely, including 24% who indicated that only patient referrals would decrease, 20% who thought that income would be reduced and 20% who noted a negative effect of managed care on patient referrals and income. Of the 17 who responded that their practice had decreased in the last 2 years 13 (76%) noted that it was due to managed care directing patients to others and to an excess number of urologists caring for pediatric patients. A potential consequence of managed care is the increase in misdiagnoses, or inappropriate or unsuccessful surgery should urologists primarily practicing adult urology treat difficult pediatric urology cases. These concerns are based on previous experience before the development of our specialty. Of the respondents 82% thought that there was an excess of fellowship programs and that programs must be significantly reduced to about half the current number.
;pecialty practices. It is apparent from. the responses that nany individuals anticipate seeing a n increased volume of 3atients with a decrease in reimbursement. In addition, ac3demicians will see fewer patients since many patients with : o m o n problems will be sent to adult urologists. This will Impact severely on our ability to train urology residents in large academic centers. Private practitioners may find it increasingly difficult to maintain surgical skills at a high Level. A concern is the return to a pre-1950s era when individuals performed urological procedures that they had seen only occasionally, which will likely increase the numbers of complex surgical complications that are ultimately referred to the pediatric urologist and be the antithesis of costeffectiveness for the health care system. There was an overwhelming consensus that too many pediatric urology fellows are being trained, which is supported by the manpower surveys performed within the last 5 years. We are optimistic that this information will be useful in future decisions related to regulating the number of fellowships. Most importantly the survey has given pediatric urologists the opportunity to request that all fellowship programs be credentialed. There has also been a plea from pediatric urologists to the American Board of Urology to issue a Certificate of Specialty Competency in Pediatric Urology. Certification would ensure that managed care does not bypass pediatric urologists. Managed care requires that urologists provide care to patients of all ages and with all types of problems but many pediatric urologists are not willing to treat adult urological problems. Therefore, pediatric urologists may be excluded from contracting with some of these groups. This will have a major effect on patient volume, academic training centers and the subsequent effectiveness of fellowships as well as urology residency training. At the summer meeting of the American Board of Urology it was decided that no certification in pediatric urology would be offered at this time. However, a select committee of the board has been appointed to review the matter of urological specialization. CONCLUSIONS
An excess of pediatric urologists poses many serious problems for the pediatric urologist and children with pediatric urological disorders. The pediatric urologist loses bargaining power with managed care providers if there are well trained practitioners desperate for work who will underprice the market. In addition, the surgeon loses proficiency with more complex cases when the case load is sporadic. In the modern era of medicine the health care system has eroded the autonomy and influence of the physician. In many ways we have lost control of our destiny. As a specialty, we control 1 element of our destiny, that is control of the number of pediatric urologists whom we train. We will be optimistic that our DISCUSSION specialty leadership will base decisions on fellowship trainDuring the last 50 years pediatric urology has evolved into ing programs, not on the number of fellows needed t o manage a surgical specialty that is recognized and respected by pe- the manpower at our individual medical centers, but on the diatricians and family practice physicians for excellence in collective needs of our specialty and the patients whom we care provided to neonates, infants, children and adolescents. serve. Due to the growing popularity of this specialty many excelREFERENCE lent urology residents are choosing careers in pediatric urology. Unfortunately these talented individuals may soon have 1. Shapiro, E. and Hatch, D. A. on behalf of the Pediatric Urological difficulty finding a position in a large academic center or Manpower Committee of the American Association of Pediatprivate practice. The overwhelming majority of academic ric Urology: Pediatric urological manpower report. J. Urol., part 2 , 1 5 0 675, 1993. centers presently have adequate pediatric urology manpower. Of the 56 new positions that will become available within the next 10 years about two-thirds are in a university EDITORIAL COMMENTS or university/private practice setting. If the pediatric urology This manpower report describes in detail what we have known for community continues to train 10 to 15 pediatric urology a considerable time: we have trained and are continuing to train too fellows yearly, there will be an excess of 40 to 90 pediatric many pediatric urologists. The survey shows that we are a young urologists in the United States by 2005. This oversupply specialty (70% younger than age 50 years) and only about a quarter occurs as managed care is also impacting on patient access to of pediatric urologists plan to retire within the next decade. With 56
PEDIATRIC UROLOGY MANPOWER estimated new positions available during the next 10 years if we continue to train 10 to 15 fellows per year, there will be an excess of a t least 50 pediatric urologists in this country by 2005. With 20% of the surveyed pediatric urologists claiming that they are not busy enough now and approximately 6 0 8 of the fellow applicants responding t o the previous 1994-1995 survey believing that finding a position was moderately to very difficult, we have a distressing situation. The inevitable decreased accessibility to specialty care and reimbursement will only magnify the problem. Already a number of fellows graduating in June 1996 are accepting positions in clinics and practices where they will not be practicing full-time pediatric urology and will be competing with those committed to full-time pediatric urological practice. What have we done and what can we do about the impending glut of pediatric urologists? A number of programs are now offering fellowships in alternate years and several may not offer fellowships at all in the future. In addition, I think that it is critical for fellowship programs to be careful in selecting fellows who will be practicing pediatric urology on a full-time basis. Program chairmen are well aware of the problem, and continue to meet and devise more aggressive methods to help with the solution.
Alan B . Retik Division of Urology Children’s Hospital Medical Center Boston, Massachusetts Manpower reports have been useful. Chief residency positions in urology were reduced relatively painlessly by almost 100 per year, and we now graduate about the number of urologists needed. In subspecialty training the numbers thought to be needed depend on perceptions and premises. About 10% of urological surgery involves children. If there are 6,000 urologists, one- might estimate
49 1
oflhand that 600 would be needed. In the not too distant past pediatric urologists tended to be teaching hospital based to a much greater extent, dealing with complex cases, medicare and perhaps setting standards in pediatric urological surgery. According to this report the majority of pediatric urologists are in private practice and unquestionably more are competing for all pediatric patients. Is this good or bad? A pediatric urologist on the West Coast just told me that his last 3 exstrophy cases had been closed by different urologists working in managed care plans. Dehiscence occurred in all cases. This serious complication is not uncommon but it is clearly more likely when the surgeon has had little previous experience. It is true that last year there were few new job opportunities after fellowship but that is changing rapidly. Many large groups are seeking a pediatric urologist to be more competitive in bidding for managed care contracts, and the positions offered will probably be primarily in the private sector in the next few years. Pediatric surgeons have generally been supportive of urologists practicing only pediatric urology. However, pediatric surgery has recently doubled the number of graduates to 32 per year. They treat many emergencies and tend to practice together. There are large areas that have no pediatric surgeons, and the same is true of pediatric urologists. When families do not know that there is such a thing as a pediatric urologist, they are unlikely to seek such a surgeon. I do not think that we are training too many pediatric urology fellows. I encourage my fellows to obtain post-residency training in other areas as well because we need a cadre of pediatric urologists with a diversity of skills, and special abilities help to jump start a career.
Lowell R. King Section of Pediatric Urology Duke University School of Medicine Durham, North Carolina’
Vol. 156,488-491, August 1996 Printed in U.S.A.
Ike JOURNAL OF UROLOGY Copyright 0 1996 by h m c m U R ~ ~ I C ASSOCv\nON, AL hC.
PEDIATRIC UROLOGY MANPOWER REPORT 1995 ELLEN SHAPIRO ON BEHALF OF THE AMERICAN ASSOCIATION OF PEDIATRIC UROLOGISTS From the Department of Urology, New York University School of Medicine, New York, New York
ABSTRACT
Purpose: The quality and emciency of any health care system depend on a n appropriate level of manpower. The manpower issues of tomorrow will be influenced by the number of physicians and specialists trained today. The objectives of this manpower survey of pediatric urologists in the United States were to determine anticipated manpower requirements and provide caveats related to the practice of pediatric urology. Materials and Methods: A manpower questionnaire was distributed to pediatric urologists at the American Urological Association meeting in Las Vegas, Nevada in April 1995. Of the 234 distributed questionnaires 204 (87%)were completed and entered into a computer program. Results: Of responding pediatric urologists 70%were younger than 50 years, 81%practiced full-time pediatric urology and 45% were university based. The rates of respondents indicating t h a t their present workload was too busy, appropriate or not busy enough were 10,70 and 20%, respectively. A total of 71% of respondents indicated that they would discourage a newly trained individual from setting up a practice in their area. Of practicing pediatric urologists 26% intended to retire within the next 10 years. I n April 1995,80 respondents (39%)representing 67 practices were considering adding a n associate within the next 10 years. By the end of 1995 only 56 practices will remain that will add a n associate within the next 10 years. A total of 82% of respondents believed that there was a n excess number of pediatric urology training programs. Conclusions: The pediatric urology community presently trains 10 to 15 pediatric fellows per year. Based on the 1995 manpower survey, if this trend continues a n excess of 40 to 90 pediatric urologists will be trained in the next 10 years. The conclusion that there is a n overabundance of pediatric urologists in training is supported by the general consensus of practicing pediatric urologists. Policies related to the training of pediatric urology fellows and urology residents should depend, not on the manpower needs a t individual medical centers, but on the collective needs of our specialty and the patients whom we serve. K E Y WORDS:
manpower; pediatrics; urology; specialties, medical; education, medical
In 1991 the American Association of Pediatric Urologists initiated its first manpower study.' The American Association of Pediatric Urologists includes pediatric urologists who completed pediatric urology fellowship training after 1981. The initial survey was distributed to members of the Society of Pediatric Urology and American Academy of Pediatrics Section on Urology. The primary recommendation derived from this initial survey was that the availability of job opportunities for pediatric urologists in fellowship training per year must be determined before offering fellowship positions. The survey indicated that between 1991 and 2001, 95 positions would become available for fellowship trained pediatric urologists. Therefore, training 8 to 10 individuals each year would meet anticipated manpower needs for the next 10 years. It was also recognized that manpower needs may be changing depending on population growth, health care policies and referral patterns, and retirement plans of older pediatric urologists. In 1993 the second manpower study showed that the age distribution of pediatric urologists was evenly distributed among the 3 consecutive decades of 31 to 60 years. The majority of respondents practiced 100%pediatric urology and were between 31 and 50 years old. The questionnaire captured many caveats related to pediatric urology practice in the United States. Of the respondents 74% practiced fulltime pediatric urology, including 48% who were university based and 19% who were in private practice. A change in practice trends between 1991 and 1993 included an increase in the number of individuals in a combination university and Accepted for publication February 9, 1996.
private practice position from 25 to 42%. The study also addressed the attitudes of pediatric urologists toward other pediatric urologists seeking job opportunities in their geographic practice area. Of the respondents 8%indicated that they would welcome another pediatric urologist settling in their area, 33%would consider taking him or her as a partner and 50%would discourage settling in their area. When asked whether their current practice load was satisfactory, approximately 65%of respondents believed that i t was appropriate. According to 40% of the respondents an acceptable workload was a n office practice of 31 to 50 patients weekly, and the majority treated between 6 and 15 new patients weekly. A median of 6 operations was performed weekly. Importantly the 1993 manpower survey determined that within the next 10 years 92 pediatric practices anticipated adding a n additional pediatric urologist. A disturbing trend was that there appeared to be a n increasing number of fellowship training positions in pediatric urology in the United States and Canada. At the time of the 1993 study approximately 14 pediatric urology fellowships were offered annually. If the number of fellowship positions remained constant for the next 10 years, it was predicted that there would be 140 new pediatric urologists trained for only 92 anticipated positions. This information stimulated discussions among the fellowship directors in the United States and Canada about the need to develop a plan to decrease the number of fellowship positions. As a result of this manpower study, several programs withdrew from the fellowship match for a year. Since concern exists about the excessive number of fellows entering the job market yearly as well as the limited avail-
488
489
PEDIATRIC UROLOGY MANPOWER
ability of appropriate job opportunities, an abbreviated survey was sent to pediatric urologists who started new positions in July 1994 and July 1995. The survey inquired about the number of potential opportunities as well as the number of programs visited. In addition, the survey captured whether the number of job opportunities was believed to be sufficient and whether fellows were able t o choose the appropriate practice type, that is academic versus private practice. The survey also inquired about the availability of jobs in desired geographic regions as well as whether salary ranges were satisfactory. During this period 13 of 20 individuals completing a fellowship pursued a pediatric urology position. In July 1994, 2 individuals entered the military with obligations of at least 2 years. In 1995,4 individuals in training did not enter the pediatric urology job market since 2 entered the military, 1 returned to a foreign home and 1 entered a plastic surgery training position. In 1994 and 1995 an average of 3 jobs was offered to each fellow. Half of the individuals thought that there were sufficient positions available while half did not. Only half of the individuals were able to enter into their practice type of choice. A total of 75% of the individuals were not able to locate a job opportunity in the preferred geographic area and only half believed that the salary range was acceptable. Overall about 60% of respondents believed that finding a position was moderately to very difficult. With the continuing increase in the number of pediatric urology fellowship positions, and the expressed attitudes and concerns of recently trained fellows entering the job market we embarked on the 1995 manpower study. In addition to inquiring about the general information of individuals practicing pediatric urology, an effort was made to capture attitudes related to individuals settling in their areas, retirement plans and plans to add an associate. Furthermore, the 1995 manpower study critically evaluated the types of positions that would become available in the next 10 years. In addition, since health care trends have changed dramatically in the last 5 years, the survey ascertained the general impact of managed care on clinical practice and whether these effects were confined to specific geographic regions. Respondents were requested to comment personally on the effect of managed care as well as on the large number of fellowship positions, since these problems have been articulated by many practicing pediatric urologists. We also asked for written comments for the executive board members of the American Academy of Pediatrics Section on Urology and Society of Pediatric Urology, which may be useful in further understanding membership concerns.
TABLE1. Age distribution
of
pediatric urologists % Practice Activity
No. Urologists (%)
Age
100
3140 41-50 51-60 61-70 Older than 70 Totals
73 (35) 71 (34) 46 (23) 13 (7) 1 (1) 204
5 6 3 6 I
-
lfi6
50
75 9 3 7
7 5 4
6 2 3 5
2 -
1A
25
-- 16
1 1 2 -
4
TABLE2. Pediatric urolom Dractice trends % Practice
No. Urologists
Activity
(%I
100 75 50 25
183 (82) 19 (8) 16 (7) 4 (2)
Practice Type University
Private
University’ Private
83 9 2 1
44 7 11 3
47
2 1 -
fellowship trends in the United States. The figure illustrates the number of pediatric urology fellows in training each year between 1955 through 1995. The 1995 manpower study also addressed clinical workload of the respondents. A total of 19 respondents (10%)had practices that were believed to be too busy, 135 (70%)indicated that their practice load was appropriate and 38 (20%) thought that their practice was not busy enough. The number of patients and new patients seen weekly, and surgical procedures are shown in tables 3 and 4, respectively. An average of 6 or 7 surgical procedures was performed by those who believed that their practice was satisfactory. The survey inquired whether respondents would encourage or discourage another pediatric urologist to settle in their area. The 1991 questionnaire had a significant no response rate, while the 1995 questionnaire indicated that 3% of respondents would encourage an individual to settle in their area and 20%would consider taking him or her as a partner, while 71% would discourage someone from entering their community. The 1995 manpower study revealed that 53 practicing pediatric urologists (26%) planned to retire within the next 10 years. In April 1995, 80 respondents (39%)representing 67 practices were considering adding an associate within the
1995 MANPOWER SURVEY
The 1995 manpower study was distributed at the AmeriN can Urological Association meeting in Las Vegas, Nevada in April 1995. As of October 1995, 234 questionaires were dis- U tributed, and 204 (87%) were completed and entered into a M computer program. The geographic distribution of practicing pediatric urolo- B E gists in the American Urological Association included 7% in the Northeastern, 5% in the New England, 10%in the New R York, 12% in the Mid-Atlantic, 13% in the South Central, 16%in the Western, 18%in the North Central and 21%in the Southeastern sections. Age distribution of pediatric urologists is shown in table 1 with 70% distributed equally between ages 31 to 40 and 41 to 50 years, while the remaining I third were between 51 and 70 years old. The majority (81%) 55 60 65 70 75 80 85 90 95 of pediatric urologists responding to this survey practiced 100% pediatric urology with 45% in university based pracYEARS tice, 24% in private practice and 25% in a universitylprivate 1955 to 1995 Practice (table 2). Of the 183 urologists who practiced 100% pediatric urology 39% were sole practitioners while 55% had Number of pediatric urology fellows in training each year between a t least 1 associate. In the 1991 study we carefully examined 1955 and 1995. A
490
PEDIATRIC UROLOGY MANPOWER TABLE3. Pediatric urology patients seen weekly No. h. No. Urologists Total: Less than 10 5 11-30 31-50 51-70 71-100 New: 5 or Less 610 11-15 1620 21-25 26-30 Greater than 30
54 62 49 22 12 61 50 41 17 6 5
TABLE 4. Operations performed by pediatric urologists weekly No. Owrations
No. Uroloeists
8 Greater than 8
2 10 11 20 33 22 14 29 50
next 10 years. By the end of 1995, 56 practices remain that will add an associate within the next 10 years. Interestingly of the 139 pediatric urologists (71%) who would discourage someone from entering their community 60 (43%)responded that they planned to add a n associate to their own practice within the next 5 years. A total of 64% of respondents believed that managed care would affect their practices adversely, including 24% who indicated that only patient referrals would decrease, 20% who thought that income would be reduced and 20% who noted a negative effect of managed care on patient referrals and income. Of the 17 who responded that their practice had decreased in the last 2 years 13 (76%) noted that it was due to managed care directing patients to others and to an excess number of urologists caring for pediatric patients. A potential consequence of managed care is the increase in misdiagnoses, or inappropriate or unsuccessful surgery should urologists primarily practicing adult urology treat difficult pediatric urology cases. These concerns are based on previous experience before the development of our specialty. Of the respondents 82% thought that there was an excess of fellowship programs and that programs must be significantly reduced to about half the current number.
;pecialty practices. It is apparent from. the responses that nany individuals anticipate seeing a n increased volume of 3atients with a decrease in reimbursement. In addition, ac3demicians will see fewer patients since many patients with : o m o n problems will be sent to adult urologists. This will Impact severely on our ability to train urology residents in large academic centers. Private practitioners may find it increasingly difficult to maintain surgical skills at a high Level. A concern is the return to a pre-1950s era when individuals performed urological procedures that they had seen only occasionally, which will likely increase the numbers of complex surgical complications that are ultimately referred to the pediatric urologist and be the antithesis of costeffectiveness for the health care system. There was an overwhelming consensus that too many pediatric urology fellows are being trained, which is supported by the manpower surveys performed within the last 5 years. We are optimistic that this information will be useful in future decisions related to regulating the number of fellowships. Most importantly the survey has given pediatric urologists the opportunity to request that all fellowship programs be credentialed. There has also been a plea from pediatric urologists to the American Board of Urology to issue a Certificate of Specialty Competency in Pediatric Urology. Certification would ensure that managed care does not bypass pediatric urologists. Managed care requires that urologists provide care to patients of all ages and with all types of problems but many pediatric urologists are not willing to treat adult urological problems. Therefore, pediatric urologists may be excluded from contracting with some of these groups. This will have a major effect on patient volume, academic training centers and the subsequent effectiveness of fellowships as well as urology residency training. At the summer meeting of the American Board of Urology it was decided that no certification in pediatric urology would be offered at this time. However, a select committee of the board has been appointed to review the matter of urological specialization. CONCLUSIONS
An excess of pediatric urologists poses many serious problems for the pediatric urologist and children with pediatric urological disorders. The pediatric urologist loses bargaining power with managed care providers if there are well trained practitioners desperate for work who will underprice the market. In addition, the surgeon loses proficiency with more complex cases when the case load is sporadic. In the modern era of medicine the health care system has eroded the autonomy and influence of the physician. In many ways we have lost control of our destiny. As a specialty, we control 1 element of our destiny, that is control of the number of pediatric urologists whom we train. We will be optimistic that our DISCUSSION specialty leadership will base decisions on fellowship trainDuring the last 50 years pediatric urology has evolved into ing programs, not on the number of fellows needed t o manage a surgical specialty that is recognized and respected by pe- the manpower at our individual medical centers, but on the diatricians and family practice physicians for excellence in collective needs of our specialty and the patients whom we care provided to neonates, infants, children and adolescents. serve. Due to the growing popularity of this specialty many excelREFERENCE lent urology residents are choosing careers in pediatric urology. Unfortunately these talented individuals may soon have 1. Shapiro, E. and Hatch, D. A. on behalf of the Pediatric Urological difficulty finding a position in a large academic center or Manpower Committee of the American Association of Pediatprivate practice. The overwhelming majority of academic ric Urology: Pediatric urological manpower report. J. Urol., part 2 , 1 5 0 675, 1993. centers presently have adequate pediatric urology manpower. Of the 56 new positions that will become available within the next 10 years about two-thirds are in a university EDITORIAL COMMENTS or university/private practice setting. If the pediatric urology This manpower report describes in detail what we have known for community continues to train 10 to 15 pediatric urology a considerable time: we have trained and are continuing to train too fellows yearly, there will be an excess of 40 to 90 pediatric many pediatric urologists. The survey shows that we are a young urologists in the United States by 2005. This oversupply specialty (70% younger than age 50 years) and only about a quarter occurs as managed care is also impacting on patient access to of pediatric urologists plan to retire within the next decade. With 56
PEDIATRIC UROLOGY MANPOWER estimated new positions available during the next 10 years if we continue to train 10 to 15 fellows per year, there will be an excess of a t least 50 pediatric urologists in this country by 2005. With 20% of the surveyed pediatric urologists claiming that they are not busy enough now and approximately 6 0 8 of the fellow applicants responding t o the previous 1994-1995 survey believing that finding a position was moderately to very difficult, we have a distressing situation. The inevitable decreased accessibility to specialty care and reimbursement will only magnify the problem. Already a number of fellows graduating in June 1996 are accepting positions in clinics and practices where they will not be practicing full-time pediatric urology and will be competing with those committed to full-time pediatric urological practice. What have we done and what can we do about the impending glut of pediatric urologists? A number of programs are now offering fellowships in alternate years and several may not offer fellowships at all in the future. In addition, I think that it is critical for fellowship programs to be careful in selecting fellows who will be practicing pediatric urology on a full-time basis. Program chairmen are well aware of the problem, and continue to meet and devise more aggressive methods to help with the solution.
Alan B . Retik Division of Urology Children’s Hospital Medical Center Boston, Massachusetts Manpower reports have been useful. Chief residency positions in urology were reduced relatively painlessly by almost 100 per year, and we now graduate about the number of urologists needed. In subspecialty training the numbers thought to be needed depend on perceptions and premises. About 10% of urological surgery involves children. If there are 6,000 urologists, one- might estimate
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oflhand that 600 would be needed. In the not too distant past pediatric urologists tended to be teaching hospital based to a much greater extent, dealing with complex cases, medicare and perhaps setting standards in pediatric urological surgery. According to this report the majority of pediatric urologists are in private practice and unquestionably more are competing for all pediatric patients. Is this good or bad? A pediatric urologist on the West Coast just told me that his last 3 exstrophy cases had been closed by different urologists working in managed care plans. Dehiscence occurred in all cases. This serious complication is not uncommon but it is clearly more likely when the surgeon has had little previous experience. It is true that last year there were few new job opportunities after fellowship but that is changing rapidly. Many large groups are seeking a pediatric urologist to be more competitive in bidding for managed care contracts, and the positions offered will probably be primarily in the private sector in the next few years. Pediatric surgeons have generally been supportive of urologists practicing only pediatric urology. However, pediatric surgery has recently doubled the number of graduates to 32 per year. They treat many emergencies and tend to practice together. There are large areas that have no pediatric surgeons, and the same is true of pediatric urologists. When families do not know that there is such a thing as a pediatric urologist, they are unlikely to seek such a surgeon. I do not think that we are training too many pediatric urology fellows. I encourage my fellows to obtain post-residency training in other areas as well because we need a cadre of pediatric urologists with a diversity of skills, and special abilities help to jump start a career.
Lowell R. King Section of Pediatric Urology Duke University School of Medicine Durham, North Carolina’