BackTable Urology
Ep. 187 Urology Trends: AUA 2023 Census Report Highlights with Dr. Amanda North and Dr. Matthew Nielsen
Tue, 03 Sep 2024
Hot off the press! The results of the 2023 American Urological Association Census findings will likely surprise listeners. In this episode of the BackTable Urology Podcast, host Dr. Suzette Sutherland is joined by Dr. Amanda North (The Children’s Hospital at Montefiore) and Dr. Matt Nielsen (University of North Carolina) to dive deep into the census data and offer a call to action for all urologists. --- CHECK OUT OUR SPONSOR PearsonRavitz https://pearsonravitz.com/backtable --- SYNPOSIS The conversation covers noteworthy statistics on burnout, accessibility to mental health care, and practice patterns within the urologic community. The doctors also discuss the evolution in demographics amongst practicing urologists, improvement in diversity, equity, and inclusion initiatives, and the growing concern of workforce shortages. Finally, the episode explores the importance of this census data in informing AUA advocacy efforts to shape future government policies. --- TIMESTAMPS 00:00 - Introduction 06:04 - The AUA Census 11:20 - Demographics of Urologists in the U.S. 22:48 - Trends in Private Practice and Employment 38:00 - Burden of Prior Authorizations 43:17 - Addressing Burnout 45:29 - Diversity, Equity, and Inclusion 52:43 - Conclusion --- RESOURCES Pearson Ravitz https://pearsonravitz.com/ Photocure https://www.photocure.com/
This week on the Backtable Podcast. 85% of women in urology say that they have some sort of burnout. I mean, it's really bad, but only 17% are seeking professional help. And one of the things, again, this goes back to our advocacy efforts, is to understand the impact of state licensing requirements.
43%.
So we're working on a paper. We're looking at the data now. It's in the beginning stages to look at which states ask these types of questions on their licensing renewals. And if that specifically has an impact on whether or not people said that they were afraid for their state licenses, because every state is different and not all states ask those types of questions.
Hello and welcome once again to Backtable Urology Podcast, your educational resource for all things urological and then some. As a reminder, Backtable Urology offers many informative episodes that you can find on iTunes, Spotify, And of course, on backtable.com.
I'm your host today, Dr. Suzette Sutherland, and I'm super excited to have two guests today to talk to us about the 2023 AUA census data. We have Dr. Amanda North and Dr. Matthew Nielsen.
This is vital data about our urological community, about our urological workforce, and our practice patterns that really help us to inform our future directions for policy efforts and overall urological care as well. So again, super excited to be talking about some of the pertinent things that came out of the AUA census data with all of you here today.
So before we get started, I'm going to do a formal introduction, of course, of our two guests. They are very well known in the broader urological community already, but I'll go ahead and do the formal introduction nonetheless. First, we have Dr. Amanda North.
She is chair of the AUA Data Committee, so the committee that really was quite responsible for all of the data here, collecting it with the AUA census, putting it together, and then looking at what does it really mean. She's associate professor of pediatric urology, so that's her specialty, and she's division chief now at Children's Hospital at Montfiori in the Bronx, New York.
So welcome, Dr. Amanda North. Thank you so much for having us. Our next guest is Dr. Matthew Nielsen. He's chair of the AUA Science and Quality Council, so also was quite involved in the data and what does it mean for us. He's professor of urology and may know chair of urology at University of North Carolina in Chapel Hill, and his specialty is urologic oncology. Hello, Dr. Nielsen.
Thanks for being with us.
Thank you, Dr. Salomon. It's really terrific to be with you today.
So let's just dive in, shall we? We're going to talk, first of all, about the data itself, how it's collected, how it's acquired, and who it really represents. When we look overall, we do see some of the data that's in there that it really had a response rate of about 13.5%, I think, if that number is correct.
of our urological workforce that answered the surveys and whether you think that that's really an accurate representation, I mean, of who we are and how we use that information then to make some decisions in the future. So I'll just throw that out to both of you or maybe starting with Dr. Nielsen.
And with that also describing what were your roles in this process and your committees and how many other committees and if there are influential people that should be mentioned who should be given, you know, accolades for their work they did for all of this data?
Yeah, great. Thank you so much, Dr. Sutherland. So this work is, as you mentioned, housed primarily in the AUA's data committee. And AUA has a wide variety of committees covering the waterfront of the issues in our education and research mission, as well as public policy, advocacy, and all the areas touching urologic patient care and education.
Within the Science and Quality Council, we try to coordinate the activities across the Guidelines Committee, the Quality Improvement and Patient Safety Committee, and the Data Committee. And the census is one of the crown jewels of the Science and Quality Council and a really big effort of the Data Committee.
were excited this year to celebrate the 10-year anniversary since the census has started. Dr. North is one of the leaders of this effort who has been leading the way in the census for many years, even before she assumed her current role as chair of the data committee.
As a data committee member and as just an active leader in the AUA, she has been a driving force behind how this has grown over time. along with many others on the AUA staff and many other urologists across the country who have really come together to help us figure out what those important questions are. So we are really grateful to Dr. North and all of those who've led the efforts.
As the chair of the Science Equality Council, I am involved and supportive of this, but I think the credit for this work and the really detailed behind-the-scenes work that has made this such a valuable thing really is due to Dr. North and others who've been more focused in that data committee space.
Wonderful. Thank you, Dr. Nielsen. And thank you, Dr. Sutherland. So the census was originally the brainchild of Raymond Fang, who was the now retired head of statistical services at the AUA. And he brought the idea back in 2014 of doing a survey of all practicing urologists. And over time, the census has really grown. Originally, it was just looking at practicing urologists.
But now there are actually multiple censuses that get published every year. So the one that we're talking about is the 2023 Census of Practicing Urologists. But we actually publish... a census divided by AUA section. We publish a census with residents and fellows. We publish a census on advanced practice providers and also a census looking at international urologists.
So the census isn't just one thing. It's multiple publications and they are all available for free on the AUA website if you're an AUA member. So I'll just put a little plug there for that. And, you know, there's been a host of publications that have come out of these 10 years worth of census data. Going back to your question about 13.5% response rate and is that really representative?
This is a question that comes up a lot when we publish papers using census data. And my counterargument to that is, are there any other surveys that have 2,000 urologists responding every year? And while 2,000 urologists may only represent 13.5% of our practicing urology community, it is a huge number of doctors who are responding to the census. every year.
When the census data is published, it is weighted to represent all practicing urologists. And I, as a disclaimer, I am not a statistician, but we have people who are experts into statistical services who create the data that you see on the website, and it has been weighted to represent all practicing urologists.
So as a disclaimer, for those who want to just pull the census data off and publish based on that, doing their own statistics, it's actually not a good way to do it. It's better to get the data from the AUA, which you can do, because it has been weighted to try to represent our entire practicing urology community.
And so I think that's a really important disclaimer when we're talking about a 13.5% response rate.
So a question I have for you then is, when you look at those who do respond, is there something about the demographics of those who respond? Is it mostly academic urologists that end up responding or more community urologists? Or what did you find out?
Obviously, there's going to be a response bias. And it's hard to say who has the response bias. At least half of the responses to the census respond at the annual meeting every year. So every year at the annual meeting, we have stations set up with computers and AUA staff, and we strongly encourage people to come fill out the census by giving them little freebies. super cute t-shirts.
I have a pair of AUA census sunglasses that are to die for. I wear them every day. And so we bribe people to come fill out the census at the annual meeting. So we do skew slightly heavily towards whoever attended the annual meeting that year, which is also how we get a lot of our international respondents, by the way. And then, of course, there's word of mouth. So I'm sure that
People who are active on the platform formerly known as Twitter are getting constant reminders because we tend to tweet. I think we still call it tweeting. We tweet and retweet the link to the census. So there is a little bit of a bias towards that. Our partner organizations, for example, my friends and colleagues in SWOO, are very good at encouraging people to fill out the census.
So I wouldn't be surprised if we get a disproportionate amount of women because we really push the census through SWU, thanks to all my friends in SWU who have been helpful with that. So yes, there probably is a little bit of a bias.
We know that people who are truly disconnected from the AUA are going to be less likely to fill out the census, but it's still a pretty large number of respondents overall. So given that any survey is going to be somewhat biased, I think the census is the best we're going to do, at least for now. Has it been pretty consistent over the years?
So I actually looked back in preparation for our talk today. And back in 2014, we had 2200 US respondents. And in 2023, we had close to 2000 respondents. So it's been pretty consistent. I think around the time of COVID, especially when the annual meeting was virtual instead of in person, we definitely saw a dip. I think there was also some email and survey fatigue around that time.
So there was a little decrease in response when the meeting was not in person, which is to be expected. But we've been pretty consistent over the years.
Great. That was a great insight into that. Thank you. So let's dive into some of the data that we see in that. It was broken up initially into primary observations up front, some highlighted summaries. So clearly, you know, the committees that went through all of the data found that these were really the highlights or the take-home points. So We don't have enough time to talk about all of them.
Of course, this isn't meant to be exhausted, but I've picked out a few that I think people are pretty passionate about. And so we want to look at some of those. We'll start off, of course, just about what's the demographics, right? What do we look like, our urological community here in the United States?
It's a really sort of fascinating insight, and I think it's helpful for all of us to sort of see beyond what we're used to in our day-to-day routine, both for folks in academic practice and in community practice, to get a glimpse of what practice is like broader across the nation.
So about nearly 90% are in the bucket defined as actively practicing, which in the survey responses is practicing at least 25 hours a week. That recognizes that many people who are maintaining an active practice are in that category, but this is the way that the answer is coded there.
The urologists are distributed across the country in uneven ways geographically in terms of the urologist to population ratio with New York, Dr. North's home state, having 5.7 urologists per 100,000 population, and North Dakota having 2.75 urologists per 100,000 population. So Looking at the absolute populations of those states, the numbers are even more dramatic and profound.
I mean, that's really almost half, right? So a state like North Dakota has half of what New York does. That's amazing if you think about it in that term. So, yeah.
Right. And that, you know, that points back to information that, you know, we've seen from other data sources that the majority of U.S. counties do not have a urologist. So the distribution problem that we have in the specialty is something that these data highlight.
A lot of the workforce is getting into the later part of their career with the largest age group in the census being over 65, almost 30 percent of the urology workforce is There's also been some interesting changes over time in terms of as we have become a more diverse field, the number of women in the over 65 age group is relatively small.
But we're excited about the fraction of women in the younger cohort of the age group where we have about 25 percent among respondents less than 45 years old.
So as more people retire, I think there was some data too about the anticipated retirement age, which was about 67. And so as we look at that age group, as they're aging and they are retiring, and most of those are men, very few are women, but yet more women are coming in down the pike. Right. On the other end, it really is going to change our urological landscape a bit. Right.
And I would imagine also change some of the traditional priorities within urology, things like that. Maybe Dr. North, maybe you didn't notice I'm wearing my swoop in here. So maybe you can address some of those issues, too.
Yeah, this is something we've been looking at for a while. And interestingly, the percentage of women in urology has been flattening over the last couple of years. So we went from 7.7% when we did the first census. And then last year, it was 11.6%. And we only went up to 11.8%. And that could be a little concerning.
But when we see that 1% of urologists over 65 are women and 25% of urologists under 45 are women, we know that in about 5 to 10 years when that cohort of older men finally retire, we're going to jump up to 25% pretty quickly. And I feel pretty confident about that. But it's interesting because women in urology practice fundamentally differently from men.
And this is something I've been talking about for several years. Women are more likely to be fellowship trained. Now, younger urologists in general are more likely to be fellowship trained. But at every age group, women are more likely to do fellowship. Women are more likely to be in academic practice. Women are more likely to be in employed practice.
So even if they don't choose academic, they choose practice situations where they are employees instead of practice owners. And again... Younger urologists are more likely to be in employed practice, but at every age group, men are more likely to choose private practices where they may have ownership stakes in the practice compared to women.
In terms of what fellowships women do, we know pediatrics and female urology are the two most highest percentage of women in each of those specialties. Perhaps not surprising. I mean, we know in pediatric urology, the percentage of women is quite high now, especially compared to the overall urologic population.
And we know women see fewer patients each week, but they spend more time with each patient. And this we think is one of the contributing factors to the gender pay gap. That we talked about from the census a few years ago, we actually published a paper on that. And there are a lot of factors involved in the gender pay gap.
But the fact that women see patients who require a little bit more time, maybe a little more TLC may have an impact on their ability to see as many patients as their male counterparts.
Yeah, just to put some numbers on that, the census said that the average patient encounter per week, how many? For men was 74. The average overall was 73. But since there are more men, of course, then for men it was 74 and women was 63. So to your point, you know, some would look at that as a pretty big difference. But then when you also looked at how many minutes per encounter was 16 minutes per
for the men's encounters and almost 18, almost 19, I mean, minutes, right? So another two and a half to three minutes per encounter.
And then that also doesn't talk about some of the things that we have alluded to before about the amount of time spent not only face-to-face with the patients, but afterwards and phone calls or communicating with families, so on and so forth, that don't get into the actual encounter visit that women are also doing. So two-year point. Yeah. So it's good to put numbers.
And I also wanted to say one little caveat just for the listeners so they understand that when we're talking about these numbers, like the 25% of the people that are less than 45 are women, right? We're talking about The practicing urologists, we're not talking about trainees because we do know that that number is increasing too, right? The number of trainees that are women.
So we just want to make sure we're looking at that fairly to say, yep, it's also the number of people who are coming out of training and in practice. That's the 25% number that are women. So.
Absolutely. And it's been said that women maybe work fewer hours per week. And we've looked at that over the census over several years. And men and women urologists work the same number of hours per week. I want to be very clear on that. So this women are not seeing fewer patients because they're working fewer hours. They're seeing fewer patients because
because they're spending more time with each patient from the data we have in the census. And we can surmise from other publications that it may be that the women are seeing the more difficult and time-consuming patients, although we haven't been able to show that in the census yet.
I wanted to go back to the comment, and maybe Dr. Nielsen, you can comment on this then too, is this idea of fellowship. More people overall, men and women, more of our trainees coming out or feeling they need to do fellowships or they want to do fellowships. I shouldn't say need, want to do fellowships and not always necessarily going into academic practices, but feel they want to do fellowships.
And then what do you think that that says, though, about the landscape of our urology and the type of practices that people want when they're done with their fellowship? And what does that mean that we can offer to patients then when we get so super specialized?
Thank you very much.
And I perceive that an element of it is that to the extent that a urologist coming out of training has a particular interest in a certain subspecialty area, and many are going to communities that already have a relative abundance of urologists, that to be able to have that practice, it is challenging in a lot of communities for a person to have that subspecialty practice element without the fellowship.
Whereas the distribution of urologists is such that those who go into practice in a smaller community may be more inclined to do a little bit of everything just by nature of how it works. And I think it's a good question that, to my knowledge, we haven't really gotten into in the census. But these conversations always lead us to things that might be important questions for us to ask.
Because we're going to get in a little bit later into things like burnout and all that. But if somebody's not getting the practice that they thought they wanted because the demand is different, you know, what does that say about physician satisfaction about their practice? Right.
So we need to be thinking about that as we're training people to get out into the greater urological community, what the need is. So that's why this data is so important, too. Right. For us to find out what what the needs are.
Maybe you could also speak to the subspecialties, what the top subspecialties are when people are doing fellowships or versus, you know, how many of the what we consider subspecialties are really part of a general practice, how much people are doing these things, even though they're not specialized with the fellowships.
Yeah, I think that the information that we get at in the census asks the respondent what their primary area of practice is, and then also questions about are these subspecialty areas part of your practice. And so for the answer to the primary area of practice, 12% identify, 12.3% identify oncology, 6.7% identify pediatrics. and 5.1% identify endourology and stones.
But at the same time, as many of us know, one of the things that draws people to the field is the diversity and the opportunity to cover all these areas. So nearly two-thirds, 65% of respondents, have oncology and endourology and stones as part of their practice, and over half, 56%, have ED. Yeah. As part of their practice.
Yeah, they don't have ED. I got it.
Well, yeah, we don't know the answer for that. You didn't ask that. We didn't ask that specifically.
But, you know, to your point, you know, we're all at academic institutions. And how many mission statements have you read from, you know, four-year students? Medical students trying to get into urology that say the reason they really like urology is the diversity. And then so many people ultimately end up specializing and subspecializing at the end of the day. Right.
So it is really an interesting, interesting thing to watch and be careful of. Right. As time goes on. So I think another thing that was super interesting, and you already said something, Dr. North, about more women going into academics and just overall, but just bringing that into the conversation.
I was really interested to see that overall, almost 50% of urologists are still, however, in private practice. And so it showed that some of the more men are in private practice and more of the older men. Right. Older, I just say it says greater than 45. I don't consider that older, but it didn't break it down more than that that I saw.
And I think they're in that traditional practice that now is potentially changing as the landscape changes. Right. Was that a surprise to you to see still so many people in private practice?
Yes and no. We've seen a trend towards employee practice over time that's been really startling. Like two-thirds of urologists are employees. Now, if you define...
employee as being a hospital employee but still being in private practice I think it can be a little vague to people am I in private practice if I'm not an academic maybe but when we look at the traditional the old school solo practitioner that almost doesn't exist anymore.
And I tell the story all the time that when I was growing up, my pediatrician lived across the street and had an office attached to his house. And if we were sick, my mom would call him and he'd go run over and open his office and we'd go see him. Nobody does that anymore, right? Or almost nobody does.
And I think a lot of people who are in solo private practice are running more concierge practices rather than the traditional old school way of, you know, hanging up a shingle and opening your practice. There are a lot of policy reasons why that's happened over time. And so we've been following that trend since the census started in 2014.
And I think as we use our census data for advocacy purposes, the fact that so many urologists are now employees, and it's so hard. to be in certainly solo private practice, but in private practice at all is really interesting.
And, you know, it also has led us to ask more business related questions like regarding private equity acquisition of urology practices, for example, to try to understand how that's going to impact practice in the future, because it's something that we're starting to see now. And we need to be on the forefront of understanding what that means for the
Thank you so much. why are these the most important things, right? They're pretty specialized there, the questions. And I see why they're in themselves important, but there are lots of questions that weren't asked. I mean, so the first one, you know, dealing, there are two buckets I saw, endourology bucket and then the sexual health bucket. The first one was, you know, the use of double J stents.
that so many practicing urologists really prefer using double J stents when they do even a simple ureteroscopic procedure, they'd still lead up a stent rather than doing it stentless, right? That not many people in the country are doing it stentless yet. And was there anything in the data that, or your other discussions about why that was an important question? Yeah, to have that answered? Yeah.
Well, I'll take that one because it goes back to how we structure the census every year. So we actually have a spreadsheet with rotating clinical topics that get asked on a cyclical basis. And so endourology and stones was up for this year. And then we partner with the Endourological Society and the data committee members who do endourology to solicit questions that are specific to endourology.
So you'll see in addition to the question about double J stents was a question about laser acquisition and trying to understand how quickly practices across the country are picking up new technology? And are rural hospitals picking up new technology or only academic centers? So these specific questions came from our endourology colleagues.
But the idea to put stones on this year's census, it was... It was Stone's turn to be on the census. So you'll see that there are different clinical topics. We try to do some that are related to hot topics in urology. For example, we recently asked about transgender care because transgender care has been a hot topic that was on last year's census. We felt that it was time to ask more about that.
But Stone's, it was Stone's turn this year. So that's why Stone's is on this.
Well, that makes sense. There's always a rotating pecking order, right? And then to your point about newer technology, there were questions about how many people are using homium lasers versus if they're going to invest in some new laser. Are they transitioning to the thulium laser? I thought that was very interesting. You know, almost half.
of people were saying they were going to have a new purchase in the future and it was gonna be Thulium. So just showing the utilization of the newer technology that's here. So, and another interesting thing in the endourology bucket was how many people are using strings on their stents. Now I didn't see a timeline associated with that.
I know personally that determines for me if I'm gonna leave a string or not. You know, if I think it's gonna stay in 24 or 48 hours, string it. But if not, I'm not gonna have a string on it. But how many people really preferred doing a cystoscopic scent removal in the office rather than leaving any kind of a string? And even those who had a string still having the provider remove it, right?
Having them come into the office so that the provider can pull the string. It was about 25% versus 20% of the patient pulling it. So I think things like that are really interesting to see different practice patterns that people are doing. Is there anything more that you're looking at that you're going to use this data for?
Well, I think, to your point, there's a lot of research on practice patterns and a lot of health services research in the field. But there are many questions that people are just sort of curious about to have a sense of what is the sort of prevailing norm in the specialty that we really can't get at from other data sources.
So, you know, claims data, BMR, you know, things like that, even with our aqua registry, which is, you know, an incredibly rich resource. Some of these factors in terms of, you know, what kind of laser is being used, you know, what is the sort of specific way that you're managing this or that pretty common practice is an opportunity that we have in the census.
And so that's where, as Dr. North was saying, there, you know, this through this rotating cadence of subspecialty areas over the years. were able to cover a lot of different areas and get insights that are questions that can't be answered through other readily available data sets. One of the other applications and advantages of these kinds of unique data within the space was
are that those responses can then be mapped back to respondent characteristics. And so many people in the field have availed themselves of the census data as an opportunity to do research. And that has been a very productive thing for the field, has given us beyond the really, really rich resource that is the publication that comes out for the census every year, specific resources
Thank you so much for having me. And that program is an opportunity on an annual cycle for folks who have those sorts of questions to ask in CensusData or AquaData to put a proposal forward that could be an opportunity to do some research with support of AUA Statistical Services.
So that was a question I had. Who has access to this data? If they have an idea, is it hard for them to get some of the raw data to be able to look at? Or is there oversight of their utilization of the raw data?
So that's a great question. One of the things that I felt really strongly about when I became data chair was democratizing both the way that we create the census and the way that the census data is accessed by members. There was a feeling...
I had from having been a member of the data committee and having had unprecedented access to census data, that it probably wasn't fair that I had access to data that other people didn't. So there are two ways for people to access census data. Well, three, actually. One is there are committees in the AUA that get access to data to do publications. So I'll give you an example.
I'm on the AUA Workforce Workgroup, which falls under legislative affairs. And the AUA Workforce Workgroup gets two papers worth of data from the census in order to write papers that support the legislative agenda of the AUA. So I'll give you an example.
We published two papers looking at the impact of student loan debt based on census data, one for the resident fellow census, one for the practicing urology census that has now been used at the advocacy summit. many years in a row to support student loan debt forgiveness for urologists who practice in rural areas, right? And so we worked with the legislative affairs team.
We work with the advocacy team to come up with what topics they want on the census, but then to also publish papers. So we have peer-reviewed published data that we can bring to Congress and say, look, this is an issue. Here's good, strong data to support that issue. So you can join AUA committees and volunteer your time and have access to data.
But the other two ways to access data is you can apply for data through the AUA website. If you go to the census part of the AUA website, you will see that you can apply for data. They do charge a fee to access the data. Depending on whether you just want raw data or you want statistical services, you work with the data team and they will help you figure out how much that costs.
And the other way is the way that Dr. Nielsen just mentioned, which is to apply for the data research program, which we're in the middle of reviewing the letters of interest from the second round. We had six awards last year, and we're in the process. I finished my preliminary review of all of my letters that I had to read today.
And we will award four census grants and two ACWA-related grants by the end of this year. And so that's another way for people to apply for data. And what you get from that data research program is you get the full support. You not only get the data, but you get the full support of the statistical team at the AUA, as well as a small amount of travel money to disseminate your project.
So to like attend the annual meeting and present your abstract. And the AUA gives you a small amount of money for that also. So we've had six awardees from last year and we're planning to have six more this year. So for anyone who hasn't heard of our data research program, I'm really excited about it because it is a way for anyone.
And we really do try to get, you know, junior level people access to the data through that program.
Yeah, those are wonderful opportunities. I love what you said about I think the word you said is democratize the data. I love that. And it's also provides her more transparency. We know that with different statistics, people can manipulate data to say what it needs to say or things get left out. And this really provides for the ultimate transparency. And that's so important.
So let's look again at a little bit more of some practice patterns that are happening. One big topic is telehealth, right? And then how much that people are doing in the area of telehealth. There was so much during time of COVID that But now that we've all backed away from that, what's really happening in that domain?
How many people are still doing telehealth and how many people are willing to if they're not going to be reimbursed the same as an in-office visit?
Yeah, great question. And this is another topic that gets into what Dr. North was alluding to, how we try to use the census to help us inform our very effective advocacy work, bringing important topics like this to Capitol Hill in the Advocacy Summit every year, where we have data from this real-world practice sample that is the census.
So from this last year's 2023 data, about 10% of the total visits were video, was reported by about 23% of the urologists overall. And the rates of this are still, though those numbers are small, those are still significant. significantly higher than many of our colleagues in surgical specialties. And so I think it's also noted that a number of the visits, about 10%, were audio only.
And this is something that, you know, many of us encounter in our practice for a variety of different, you know, Patient technology barriers, broadband barriers, having the opportunity to be reimbursed for that time that is, you know, excellent patient care delivered over the phone is something that's still important to a lot of our members and their patients.
Work in this space, I think, gets into some of the opportunities we have as we think about and try to problem solve for the distribution problem we have with over-concentration of urologists in some communities and a real desert of urologists across much of the country, how we can keep that message on point of the opportunity for these telehealth modalities to provide access in a more equitable way across the country.
To that point, telehealth crossing state lines, right? I know here I am in the state of Washington and we, during the time of COVID, could cross state lines. We're part of the big whammy region, Wyoming, Alaska, Montana, you know, what's all the W's? Washington, Idaho. There, I got them. But suddenly now we're not right and we won't be reimbursed.
And it's like now you've established care for some patients. You can continue with established, but the new, you know, it and it just seems unethical to some degree, at least in my opinion. Right. And so we have a service that we're able to provide to people. We should be able to. do that without being penalized just because we won't be paid for it.
That just seems so, yeah, people that are championing for this policy work, doing advocacy work, it's so important. Thank you for doing that, for sure. Yeah. And then the idea, too, about the telehealth, if it's the reimbursement for it is reduced, how many people will actually then say, I'll still do it? There was less than 20 percent said yes. The vast majority said no way. Right.
A few people said maybe. But for the most part, I mean, it is our livelihood, too. And so it's hard. You set up that precedent. Yeah. And now that's what you're doing all day long and not getting paid for it. So yeah, working with the policy changers is what's so important. And also another one is the big burden of prior authorizations, right?
So we could just say real quickly, maybe Dr. North, you can speak to that. How many people that that really involves and what that means if we look at overall staff shortage issues, right? Absolutely.
And both telehealth and the prior auth questions, We work in collaboration with the Legislative Affairs Committee. There is a telehealth subcommittee at the AUA who comes to our census planning meeting every year to advocate for our telehealth questions. But Brad Stein, who does a lot of the advocacy work for the AUA, he's full-time staff at the AUA.
I've been working with Brad for at least 10 years on these types of issues. And the one phone call that I make before we finalize the census questions is to make sure that Brad's team is has the data they need for the work they do in Washington DC on behalf of all practicing urologists. And telehealth and prior auth are two topics that they really advocated for us to put on the census this year.
The prior auth questions came straight from Brad's team, word for word, based on some of their meetings with some of the other medical specialty groups with the kinds of questions they've been asking their members. And so just another plug for people to fill out the census. This data goes to Congress. period, hard stop.
This is the data that the AUA needs to fight for things that are gonna make our practice lives better. Lawyers get paid hundreds of dollars for a 10 minute phone call with a client and they wanna take away any payment for a telephone only telehealth visit that we're doing because our patients don't have access to the technology to do it on video, really? I don't understand that at all.
And so if you don't fill out these questions, we don't have the data that we need to go to Congress. And so with prior auth, the data is appalling. Over half of urologists said that prior auth at least moderately affects clinical outcomes. More than a third said severely. Peer-to-peer consultation is almost never with a urologist. I personally have never spoken to a urologist in a peer-to-peer.
And half of urologists are doing more than 10 prior auths in a typical week. This is a huge waste of everyone's time. It's bad for patient care. It is bad for patient care. It is bad for patient care. And if you spend any time on social media listening to patients deal with prior aughts from their end, it is horrific.
And so, again, this data is super important to our advocacy team because this is what they use to go to CMS. And I've attended meetings with CMS where we talked about prior auth. And I'm talking about five years ago before COVID. I was invited to some of those meetings. Prior auth is a huge burden on everyone in the health care system except the insurance companies who want to gatekeep.
And when the insurance companies are making millions of dollars and urologists are taking salary cuts – Something is wrong, right? Our patients should not be paying the price for this. And again, this data comes from all of you filling out the AUA census.
I really wanted to highlight a number that you said. You said it real quickly, but you said, you know, 54%, but, you know, more than half of urologists. It's not only a headache to the urologists and to their staff, but they said it affects the clinical outcome of the patient, right? And so when we put it in those terms, too, my goodness. We definitely need to make some changes.
So that's great data to have. That's wonderful. Yeah. And then if we look at the staff shortage, I was astounded. Of course, we all experience it to some degree in whatever kind of practice we're in. But what I was really astounded to see is that real high percentages of vacancies, not only of nurses and support staff, 56% vacancies or difficulties filling vacancies.
positions for nurses, for MAs or LPNs, same, close to 50%. Urologists, hard-filling urologist positions too, the MD, 55%. That one was for me a real eye-opener. So that brings me to this idea too about, you know, where are we sending our trainees? How are we training them? Where are they going? setting them up for success to go into some more rural communities.
And then also, I didn't see any specific questions about locums. And, you know, again, what this looks like for our urological workforce, as I think more people are just really jumping into the locums pool for a variety of reasons, right? And then what that makes our urological workforce look like. Yeah. So I know that's a hefty one. Locums is on our radar. Don't worry. Yeah. Yeah.
Locums and private equity are both on our radar. It'll be on next year's. Yeah. And then the other thing is that with all these shortages of the acknowledgement that 82 percent of urologists said that they actually significantly utilize support staff such as a nurse practitioner or a P.A., So there you go. In order to keep me moving, this is what I need.
And if I don't have that, you can't keep me moving. And there's our shortage, right? So, yeah, which then, of course, leads to the next big topic, burnout, right? Why don't you go ahead and talk about that, what you found in the census?
Well, we found, and as a caveat, we have asked the Maslach Burnout Inventory on the census. We ask every five years. So it was asked in 2016 and 2021. This was a quick question, are you experiencing burnout? So that we could then assess some of the factors associated with burnout, which was really the point of the burnout questions on this census.
These questions came to us from the Workforce Workgroup, who's been studying burnout for decades. almost a decade now. And 71% ever experienced burnout with one third saying they are currently experiencing it. And 12% experienced in the past, but are still experiencing it now. 85% of women in urology say that they have some sort of burnout. I mean, it's really bad. But only 17%
are seeking professional help. And one of the things, again, this goes back to our advocacy efforts, is to understand the impact of state licensing requirements. When our states ask us about whether or not we've had any mental health care, does that prevent people from getting mental health care? And it does, 43%. So we're working on a paper to try to look at this now.
We're looking at the data now. It's in the beginning stages to look at which states ask these types of questions on their licensing of renewals. And if that specifically has an impact on whether or not people said that they were afraid for their state licenses, because every state is different and not all states ask those types of questions.
But I do think it's a big state advocacy issue to be able to go to the state legislatures. And again, the AUA has a state advocacy team. And so we want to be able to give them this data to help fight for us to be able to get mental health care. without it stigmatizing our ability to practice urology. So this data is super important on a state level.
Yeah, it's hugely important or we won't be able to move forward, right? We know everyone needs a helping hand at times and being able to do that confidently and confidentiality you know, that's what we all need. And then the next area is for, you know, diversity, equity and inclusion, looking at discrimination, harassment in the workforce.
I was pretty astounded again to see, you know, the differences here, how many people have witnessed some type of a harassment or discriminatory event and how many people have experienced. Both were close to the 30 percent area. So a third of our urologists are experiencing and or you know, seeing it.
And for women, of course, the numbers are higher than for men, women more around gender and sexual harassment, men often around bullying and violence. It's just really astounding. You know, of course, now this is feeding into the burnout. You know, if you're doing the best you can during the day, Being the best person you think you can be and suddenly, you know, somebody's bullying you.
Yeah, it certainly, you know, makes you want to go home.
You know, these aren't even microaggressions, right? But we know that microaggressions have impact on people in their day to day lives. And I tell the story. I've been in practice 17 years and I still get asked questions. If I'm the nurse in the recovery room at the children's hospital on a pretty regular basis, which is kind of discouraging, given that I'm the chief of pediatric urology.
Now, you would think that that would come with some recognition, but no. But this kind of patient driven harassment is really upsetting. And I think there's a theory in our culture, I think, that people's behavior has gotten worse since COVID. We don't have data anymore. From earlier, these questions were submitted by Dr. Kathy Nam at Michigan as part of a grant that she's doing.
So she's going to be writing up these questions. They were included on the resident and fellow census and the advanced practice provider census also. So we should have some really interesting data from her in the future. But she had asked us if we would include them on the census as part of a grant she received, and we were happy to do so.
But it would have been interesting to know if this is spiraling out of control because we all stopped knowing how to behave when we stayed home from COVID for too long, or if this has always been the case. We do have older data on sexual harassment of women urologists back from the 2017 census. We asked those questions. It may have been 2018.
I may have my data wrong, but it was one of those two years we asked about sexual harassment. But it was specifically just sexual harassment. It wasn't specifically patient driven sexual harassment. So this is really interesting data. And I hope we're able to get follow up data in five years on this to see hopefully we're moving the trend in the right direction.
Yeah. And then the last area for us to talk about, we're running out of time here, but is the area of ergonomics. That's such a hot topic today. I had the privilege of hosting Dr. Kristen Krauser from the University of Michigan on a Backtable Urology episode that we entitled, I Love My Job, But It's Killing Me, and all the statistics around that.
So you were able to glean some statistics here too about the the impact the ergonomics has and people even retiring early because of musculoskeletal issues and what our trainees are telling us even, right? The young ones, we think it's the older ones that are having trouble and they're going to retire anyway.
But my goodness, Dr. Nielsen, you've been on practice longer and with your geo-oncology, probably do a lot of robotics. I noticed in the questions, it was laparoscopy and robotics that was pulled out. That maybe is a question for Dr. North, but why that versus, you know, I do a lot of vaginal surgery. I'm sitting, but I still have back issues, right? And because of the ergonomics.
But anyway, in your practice and what you've seen and with residents, so on and so forth, how big of an issue is it? And what kind of things do you do in your program to try and mitigate them?
Yeah, I think, you know, we were excited to have these questions in the censuses here. And I love that you had Dr. Krauser on this topic. She has just been such a great leader for our field and really bringing this to light. I mean, I honestly don't remember, you know, when I was going through training, anybody ever talking about it.
But I, you know, people had, you know, sore necks and sore backs and other, you know, other things that were reflecting the issues in play here. But I am excited for the field and for the next generation of the field to have this front and center and be able to get some information out there.
So, you know, so I think that we, with this have an opportunity to just, you know, just by raising awareness of it, and, you know, raising awareness and connecting people to the resources that are out there.
There's a society of ergonomics in surgery that is, you know, really thinking about this as, I mean, it's a patient access issue, you know, to the extent that we can take care of ourselves as surgeons and keep ourselves in the game that much longer, aside from our, you know, physical health, it's also for the good of our patients.
So I think it's a really important topic that we're excited to have as a part of this.
It is one that's great to have in conversation here with our residents as well and fellows, and they're the ones, I think, to your point, are really leading this, saying, hey, this is my future, and we want to have more formal training around this.
So they're really squawking at the ACGME to make it part of residency training, make a core curriculum out of this, which is wonderful that they're doing that. But it is really, really important as we look at our workforce shortage here And what are we doing to ourselves, right? We're making it even shorter if we can't get out of bed in the morning because we're too sore, right?
Yeah, it's such an important thing.
Well, and as we hop on the Dr. Krauser bandwagon, we've been teaching a course on burnout at the annual meeting. And a couple of years ago, we shifted the focus from burnout to wellness. And we added Dr. Krauser as an additional faculty member. And she actually helped us develop these questions for the census.
So it's funny that we all mentioned her, but she does deserve a lot of credit because she was involved in getting these questions on the census this year. Yeah.
So my question again for you then is that the questions were specific towards laparoscopic and robotic cases. Do you see that more with those cases? I mean, I've sat at the council too, but I also feel like standing up out over a body is just as taxing.
Well, and wearing loops too, right? As a pediatric urologist, we know that the traditional loops are terrible for your neck. There is a lot of concern that the ergonomics of the instrumentation for laparoscopic and robotic surgery is particularly poorly designed for smaller surgeons, which includes a lot of women. I'm a smaller surgeon myself with smaller hands.
And so I think one of the concerns was to really understand the impact of the instrument design. I know we don't get into it that much, deeply on this census, but the impact of those instrumentations on women. And as we see, the women had higher rates of ergonomic injury. Great.
Well, I think we hit, you know, most of the main take home categories there. Is there anything else we didn't hit that you were really passionate about wanting to discuss today, either one of you?
No, just a last minute plug for people to fill out the census this year. It will be open through the end of September. The census opens at the annual meeting every year and it closes on September 30th. We have a new head of statistical services at the AUA, Lex Hessel, who is amazing because she comes to us with a background in survey design.
And so she's been really helpful in terms of getting us to think about how to word questions in a way that will maximize the value of the responses we get. We've also democratized the way that we solicit questions so that there will be an email sent out with a form that people can fill out online if they have ideas for future census questions.
We do keep a rotating schedule of some of the topics that we think should be asked, but we're pretty open-minded and especially for hot topics. Prior authorization was a hot topic this year because our legislative affairs people wanted it. But as you mentioned, locums is another really hot topic that we're interested in.
So we love getting ideas from people from all various specialties and practice settings because I think it's really important for us in the future to have everyone's voice heard on the census, both in terms of the questions that we ask and then, of course, in responding to the census. So that'll be my little plug.
Yeah, good. And then with that rotating schedule, what are the additional topics that we can expect?
Yeah, so we just asked last year about OAB and stress incontinence. We are learning over time, because I've made all the mistakes you can make, that grouping topics together often makes sense. Hematuria and all of the cancers that come from hematuria have been grouped together. So kidney and Bladder cancer, for example, into one setting, trying to understand uptake of guidelines.
So are people, you know, there was a microhematuria guideline that came out recently. Are people following that? We'd like to know. So, you know, assessing the utility of AUA educational tools. We did ask last year about torsion treatment because we know in pediatric urology, Having patients transferred from long distances with torsion can be very detrimental to the future of their testicle.
So we do have a whole rotating schedule that our AUA staff does a really good job of keeping us on track with that for specifically for clinical topics. And then we do put some business and legislative related stuff in every year. So Maslach burnout inventory is every five years. So that'll next be on in 2026. So keep a lookout for that because that's always an important one. Thank you.
And Dr. Nielsen, any final thoughts or words of wisdom?
Yeah, I'd say, you know, thank you so much for the opportunity to come on. Dr. North, you know, just briefly alluded to it there, but just to sort of call it out, in addition to her amazing leadership and all the physicians who were on there, we're really grateful to the AUA staff who make the magic happen behind the scenes.
And so when you go to the annual meeting and fill out your census next year, please thank them as well, because this has been a great resource for us. It's really...
a unique data set that we control you know we can we can sort of you know think of these questions as dr north said a theme hopefully across the the conversation today is democratization both of access to data you know having people bring their good ideas you know we solicit questions every year and the the opportunity to do research on these uh data sets is there
And then finally, to the theme of burnout that we talked about towards the end, I just would encourage all of our listeners to really reach out and get involved with activities with the AUA. It's a nice antidote to burnout to be able to make friends across our subspecialty areas across the country. and make a difference for our field.
As Dr. North said, a lot of these things have impacted our policy and advocacy agendas and have given us really great insights.
So I would just encourage everybody out there to look at your AUA emails that give a constant stream of opportunities to get involved, either with our committees on the Science and Quality Council or elsewhere, because it is, at the end of the day, a really lot of fun, and we love our community of urologists.
Well, thank you. That was really wonderful. Most sincerely, thank you to both Dr. Amanda North and Dr. Matt Nielsen for sharing your vast expertise and experience with us about this AUA census. And we look forward to what the data tells us for next year. Maybe we'll hold another one and see what the differences were. It would be quite enlightening.
And thanks to everyone, to all our listeners, once again. Your support for these programs is really invaluable. We do hope that you find that these podcasts enhance your understanding of current issues in urology, and we strive to be your informative resource for all things urological. Until next time, I'm Dr. Suzette Sutherland, your host for Backtable Urology Podcast, signing off.
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