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Re: Imaging Use Among Employed and Self-Employed Urologists
LETTERS TO THE EDITOR/ERRATA
1989
some debate. At academic centers the patient profile is much different. Because a substantial percentage of these patients come complete with an evaluation and diagnosis, further imaging is not required. It would be interesting to know the ratio of surgery scheduled per patient visit. I believe it would show that employed urologists are more likely to schedule surgery. Surgery is far more expensive than testing. Does this imply that employed urologists are more likely to advocate surgery in similar situations? My belief is that some surgical patients elect to go to university medical centers because they have a problem, a diagnosis and a desire to undergo surgery there. It is crystal clear the authors wrote this article with an agenda in mind. I believe they thought that urologists who have ownership interest in ancillary imaging order more testing because of laziness, incompetence or greed. This allegation is insulting and wrong, and unbefitting The Journal of Urology. Respectfully, Paul N. Kaufman Columbus, Ohio
To the Editor: I am compelled, for the first time in a 25-year urological career, to write this Letter to the Editor. The authors, using NAMCS data from 2006 and 2007, report differences in imaging ordering between employed and self-employed urologists, and conclude that differences are due to financial motivations. However, the authors fail to account for differences between employed and self-employed urologists available in the NAMCS data, and draw conclusions unsubstantiated by the data regarding physician imaging ownership and financial motivation for imaging ordering. Readers should first note that only 125 urologists (more than 9,000 urologists in the United States) responded to the survey. In addition, the survey was over-weighted to self-employed urologists (82% self-employed vs 18% employed). There was no accounting for what percent of employed urologists were in academic or tertiary referral centers. It is widely known by many of us at tertiary referral centers that many patients arrive with outside imaging obviating the need for additional imaging ordering, thus possibly reducing the image ordering of employed urologists. The authors claim there is no difference in patient populations between employed and selfemployed urologists. However, table 2 shows that more than 73% of self-employed urologist patients were older than 55 years vs only 47% of employed urologist patients. Considering the large number of images ordered for BPH (possibly bladder ultrasound for post-void residual), the difference in patient age could significantly affect the need for imaging ordering. The authors document in table 3 that Doctors of Osteopathy (DOs) order 2 times more imaging studies than Doctors of Medicine (MDs) but fail to report the distribution percentage of DO and MD urologists in the employed and self-employed groups. Perhaps the difference in imaging ordering reported by the authors is due to training and not to ownership. Lastly, the authors provide no data regarding imaging ownership but assume that selfemployed urologists own imaging equipment and employed urologists derive no compensation for imaging ordering. Further examination of the few responding urologists may reveal that many self-employed urologists do not own imaging equipment and that many employed urologist compensation models include production incentives including imaging. The authors’ assumption regarding imaging ownership and financial remuneration for imaging ordering lead to unsubstantiated conclusions based on conjecture. In the future the editors of The Journal of Urology should apply the same academic scrutiny to socioeconomic articles that it has historically applied to scientific and clinical articles, and reject articles with incomplete data analysis and unsubstantiated conclusions. Respectfully, Peter M. Knapp, Jr. President, Urology of Indiana Volunteer Clinical Associate Professor Urology Indiana University School of Medicine Indianapolis, Indiana
1989
some debate. At academic centers the patient profile is much different. Because a substantial percentage of these patients come complete with an evaluation and diagnosis, further imaging is not required. It would be interesting to know the ratio of surgery scheduled per patient visit. I believe it would show that employed urologists are more likely to schedule surgery. Surgery is far more expensive than testing. Does this imply that employed urologists are more likely to advocate surgery in similar situations? My belief is that some surgical patients elect to go to university medical centers because they have a problem, a diagnosis and a desire to undergo surgery there. It is crystal clear the authors wrote this article with an agenda in mind. I believe they thought that urologists who have ownership interest in ancillary imaging order more testing because of laziness, incompetence or greed. This allegation is insulting and wrong, and unbefitting The Journal of Urology. Respectfully, Paul N. Kaufman Columbus, Ohio
To the Editor: I am compelled, for the first time in a 25-year urological career, to write this Letter to the Editor. The authors, using NAMCS data from 2006 and 2007, report differences in imaging ordering between employed and self-employed urologists, and conclude that differences are due to financial motivations. However, the authors fail to account for differences between employed and self-employed urologists available in the NAMCS data, and draw conclusions unsubstantiated by the data regarding physician imaging ownership and financial motivation for imaging ordering. Readers should first note that only 125 urologists (more than 9,000 urologists in the United States) responded to the survey. In addition, the survey was over-weighted to self-employed urologists (82% self-employed vs 18% employed). There was no accounting for what percent of employed urologists were in academic or tertiary referral centers. It is widely known by many of us at tertiary referral centers that many patients arrive with outside imaging obviating the need for additional imaging ordering, thus possibly reducing the image ordering of employed urologists. The authors claim there is no difference in patient populations between employed and selfemployed urologists. However, table 2 shows that more than 73% of self-employed urologist patients were older than 55 years vs only 47% of employed urologist patients. Considering the large number of images ordered for BPH (possibly bladder ultrasound for post-void residual), the difference in patient age could significantly affect the need for imaging ordering. The authors document in table 3 that Doctors of Osteopathy (DOs) order 2 times more imaging studies than Doctors of Medicine (MDs) but fail to report the distribution percentage of DO and MD urologists in the employed and self-employed groups. Perhaps the difference in imaging ordering reported by the authors is due to training and not to ownership. Lastly, the authors provide no data regarding imaging ownership but assume that selfemployed urologists own imaging equipment and employed urologists derive no compensation for imaging ordering. Further examination of the few responding urologists may reveal that many self-employed urologists do not own imaging equipment and that many employed urologist compensation models include production incentives including imaging. The authors’ assumption regarding imaging ownership and financial remuneration for imaging ordering lead to unsubstantiated conclusions based on conjecture. In the future the editors of The Journal of Urology should apply the same academic scrutiny to socioeconomic articles that it has historically applied to scientific and clinical articles, and reject articles with incomplete data analysis and unsubstantiated conclusions. Respectfully, Peter M. Knapp, Jr. President, Urology of Indiana Volunteer Clinical Associate Professor Urology Indiana University School of Medicine Indianapolis, Indiana