The evolution of urology has trended toward subspecialization, with a smaller number of urologists performing the majority of certain procedures. In this interview, Michael Palese, MD, discusses subspecialization, its benefits for clinicians and patients, and what the future “office urologist” may look like. Dr. Palese is chair of the Sol and Margaret Berger Department of Urology at Mount Sinai Beth Israel and Mount Sinai Downtown as well as professor of urology at the Icahn School of Medicine at Mount Sinai in New York. He was interviewed by Urology Times Emeritus Editorial Consultant Philip M. Hanno, MD, MPH, clinical professor of urology at Stanford University School of Medicine, Stanford, CA.
Back in 1980, when I finished my fellowship, the beauty of going into urology was that you could get a handle on virtually the entire field and feel comfortable doing almost anything. What do you think has happened since then in terms of subspecialization?
I think it’s a dramatically different environment for urologists in training. Our residents are certainly exposed to many areas of urology, but many of them will go on to practice and never do these areas again. This is going to be an issue going forward. We’re training our newest doctors to handle cases that they probably will never want to do or even have the ability to do in the future simply because the practice of health care is changing so dramatically. We are subspecializing so much with our areas of interest that it becomes impossible to do these kinds of cases.
How did you come to study this topic?
This is a topic that I was looking at when my colleagues and I were reviewing a New York State health care database called SPARCS (Urology 2016; 98:64-9). It’s a very unique database in that it has information from all carriers—Medicare, Medicaid, commercial carriers, etc. It allows us to look at the practice patterns of urologists, and all physicians for that matter, over the last 30 years. We have not only inpatient data but also outpatient data and even emergency room data. With these data, we were able to see and track physicians and patients through those 30 years and figure out exactly who’s going where and who’s performing what surgeries.
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Although New York State is not the entire United States, it is still a microcosm of what happens in health care now. I think a lot of the patterns we’re seeing can be applied to what’s happening around the U.S.
What did you find in this study?
For starters, we looked at what are considered the major inpatient cases: radical prostatectomy, partial nephrectomy, radical nephrectomy, and radical cystectomy. These are the types of cases that still require an inpatient stay if not 24 hours then potentially 2 or more days. The way that health care has changed dramatically in urology is that more and more of these are being pushed into ambulatory or 23-hour stay situations. A lot of cases are actually even going to the office.
We looked at the last 30 years to see who is performing these surgeries and at what level and what volume. Interestingly, we found that even though the volume has increased, the number of surgeons in general has gone down. That means that the number of cases each surgeon is doing has gone up dramatically. For instance, looking at prostatectomy, the top 5% surgeons in the state of New York in terms of volume do almost 50% of all prostatectomies currently. That top 5% represents maybe 10 to 12 surgeons.
Do you think this applies internationally as well?
We don’t have any international data simply because this is a state-based database. I suspect that internationally we’re starting to see some of these patterns changing as well, because the amount of time that you need to get very good at a certain procedure, the amount of time you need to master a certain technique and use the technology appropriately, is changing. The ability to do these cases and pick them up right out of residency is falling by the wayside. You really have to specialize, do a fellowship, do extra training. It’s becoming tougher and tougher for the community urologist to do these types of cases.
That leads me to my next question. What are the implications for training programs? Is it worthwhile to train everyone to do everything?
That’s one of the things we looked at in this study. If we only have a small handful of urologists to do these major inpatient cases, why should we put our resources into training everybody to do them? Perhaps we should be thinking about making “mini-fellowships” within our residency programs much the same way that plastic surgery and vascular surgery have done. You would have “general urology” time, but then you would branch out during the last 2 or 3 years of your residency, so it’s already a specialization within our specialty.