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Advanced Practice Providers, Urology Workforce Challenges, and Reviews in Urology

Kenneth A. Mitchell, MPAS, PA-C1

1Pazona MD Urology, Brentwood, Tennessee, and GUYnecology Men’s Health, Murfreesboro, TennesseePazona MD Urology, Brentwood, Tennessee, and GUYnecology Men’s Health, Murfreesboro, Tennessee

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In 2015, the American Urological Association published the Consensus Statement on Advanced Practice Providers (APPs) with the goal of providing up-to-date information on the training of APPs, the scope of practice legislation, and examples of APPs in urologic practices.1 This statement was co-written by an experienced team of physicians and APPs whose purpose was to provide a unique and collaborative perspective on urology APPs. The paper was inspired by a report from an American Urological Association ad hoc committee assembled in 2008, which concluded that there were substantial workforce shortages in urology and that physician assistants and advanced practice registered nurses would provide the “best solution” for the declining urology workforce.2 In 2009, reports estimated that there were 3.1 urologists per 100 000 people in the United States and that urology was the second-oldest surgical subspecialty, with a workforce median age of 52.5 years.2 A published update in 2021, which used data from 2018, revealed that there were 3.89 urologists per 100 000 people in the United States, with 65% of urologists reporting that they were “interested” in the integration and use of APPs; 72.5% of urologists reported already incorporating an APP into their practice, accounting for nearly 41% of a physician (ie, MD or DO) full-time equivalent.2 More recent data showed the use of APPs was lowest in practices with the youngest and oldest subgroups of urologists and was highest in urban urology practices, which represent groups most likely to be affected initially due to the disproportionate geographical urology patient population density.

Urology APPs have historically been trained using an on-the-job approach because APPs receive limited urologic training before being hired. Urology APPs and their practices are consequently providing urologic care in unique and creative ways to

  • meet the challenge of increasing clinical and patient demands;
  • ensure quality patient care;
  • support urology physicians’ workload; and
  • add financial value to the economic clinical and administrative model.

Published data, however, demonstrate that training APPs to perform urologic procedures such as cystoscopy, transrectal ultrasound, prostate biopsies, and injections of onabotulinumtoxinA independently as well as billing for reimbursement of these procedures, which APPs perform routinely in many urologic practices, remain controversial.3

In a data-driven world, there is a paucity of published data on the positive or negative impact of patient care that urology APPs provide that goes beyond scope of practice or financial performance. Decisions involving urology APPs are therefore based on data that may not be relevant or provide the necessary insight to create effective solutions for the many challenges of the practice model. For example, published data describing compensation models based on the production of work relative value units—that is, the metric used to measure the amount of work a health care professional does for each patient procedure or examination—may be considered in the development of APP compensation packages within a practice. An APP working within this model who sees a large volume of postoperative patients within the global period would not be compensated in a manner reflective of the work being performed. An APP seeing a large number of postoperative patients is likely to support the urologist’s workload so the physician can perform a greater number of higher-level relative value units; this supportive work therefore requires a more creative compensatory solution.

Abbreviations

APP advanced practice provider

Here is where I believe Reviews in Urology can make a difference. Reviews in Urology and, more specifically, its APP section, provides an outlet for information regarding all urology APPs and urologic practice models.

The collective voice and contributions of APPs, physicians, and practice administrators to the APP section of Reviews in Urology can help develop global solutions for practices with urology APPs. Access to wider perspectives will enable clinicians to identify and acknowledge specific threats, such as the increased demand for urology services, the lack of urologists to meet this demand, and the lack of urology training for APPs entering the workforce. It is hoped that Reviews in Urology’s APP section will address the misconception that APPs want to take urologic care away from physicians. Given the expected decline in the workforce and the parallel expansion of the aging population, most APPs strive for a more ecumenical approach, including a clinical implementation shift led by physicians in partnership with APP leaders that develops actionable strategies for urologic care demands, ensures patient safety and quality care, provides sustainable solutions to their practices, and incorporates and implements effective training while fostering urology APP professional growth.

Now more than ever, the voices of APPs are needed to help urologic practices navigate the rapidly changing health care landscape. I encourage all APPs, physicians, and practice administrators to contribute to Reviews in Urology in the hope that doing so will yield effective and sustainable solutions provided by urology APPs.

References

1. Gonzalez CM, Brand T, Koncz L, et al; AUA Ad Hoc Work Group on Advanced Practice Providers. AUA Consensus Statement on Advanced Practice Providers: executive summary. Urol Pract. 2015;2(5):219-222. doi:10.1016/j.urpr.2015.05.001.

2. Brand TC, Mitchell K, Quallich S, et al. Current state of advanced practice providers in urological practice. Urol Pract. 2022;9(1):1-7. doi:10.1097/UPF.0000000000000278

3. Langston JP, Orcutt VL, Smith AB, et al. Advanced practice providers in US urology: a national survey of demographics and clinical roles. Urol Pract. 2017;4(5):418-424. doi:10.1016/j.urpr.2016.09.012

Article Information

Published: July 8, 2024.

Conflict of Interest Disclosures: K.M. is a consultant for Marius Pharmaceuticals and is a member of the Endo Pharmaceuticals Speakers Bureau.

Funding/Support: None.

Author Contributions: K.M. is responsible for the design, drafting, and editing of this article.

Data Availability Statement: None.

Acknowledgments: Thanks to Susanne Quallich, PhD, ANP-BC, NP-C, CUNP, CMHE, FAUNA, FAANP; Ashley Tapscott, DO; Josh Langston, MD; and Anand Shridharani, MD.

Citation: Mitchell KA. Advanced practice providers, urology workforce challenges, and Reviews in Urology. Rev Urol. 2024;23(2):e55-e56.

Corresponding author: Ken Mitchell, MPAS, PA-C, GUYnecology Men’s Health, PO Box 11267, Murfreesboro, TN 37129
(kmitchell@learnguynecology.org)

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