Karen Nash is a medical reporter and media consultant based in Monroeville, PA.

Karen Nash

“That’s a fair question, but I’m not sure how you define the right amount. There’s a lot of research. Industry does a lot in the field of voiding dysfunction and incontinence in men and women—that’s my specialty. I think they have done a nice job. I can’t really comment on kidney stones and bladder infections, but there’s no question that probably, head-to-toe, cancer gets a lot of research and financial emphasis, and maybe it should. There is, of course, is a lot of basic science research more affiliated with oncology than perhaps other disciplines.

As far as industry goes, I think they’re becoming more biased toward things that third-party payers have difficulty in saying no to, that they have to cover them. So there’s a lot of emphasis on oncology treatments vs quality of life therapies.

As I say, industry has to make money, and I only know my specialty. They go after what they would perceive, I’m assuming, can [affect] the customers— the patients and the doctors, but also what will drive economics based on the current market and demand.

I’m sort of spoiled. I do a lot of neuromodulation and overactive bladder [cases], and it appears there’s a lot of emphasis on that right now, so I’m pretty happy.”

“It’s a great question. The world of cancer certainly attracts research dollars and focus…Bladder cancer—there are genomics and testing and other types of chemical instillations for bladder cancer that’s refractory to BCG. So other genitourinary cancers get their due in terms of attention and research dollars.

Alternatively, to be honest, there’s a lot of attention, time paid, and investment in what I would call the lucrative, office aspect of urology…because that helps boost the urology bottom line.

Robotic surgery is costly, in time, for the doctor and the hospital. So [although] it’s important to cure cancer, that’s not what’s carrying practices. Practices are carried by smaller, more lucrative, less time-consuming items that have plenty of research and interest in corporate industry investment.

For marginal problems such as interstitial cystitis, which doesn’t have a high interest among urologists, you’re not going to get a lot of interest or research dollars into that because basically it’s a pain. You’re not curing cancer, and it’s not a big moneymaker. If you’re not [curing cancer or bringing in a lot of money], you’re not going to get a lot of interest.

The science of stones is well-studied, so I don’t think it’s true that prostate cancer sucks up all the oxygen in the room. It’s very common, so you have a lot of [investigators] interested because they could make a name for themselves.

But there are many aspects of urology that get equal attention. Cancer will always attract attention and dollars, but it’s trickier to solve.”

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"There are many aspects of urology that get equal attention. Cancer will always attract attention and dollars, but it’s trickier to solve," says 1 urologist.

With all the attention paid to prostate cancer research and treatment, do other aspects of urology get the research they need?

“Idaho is in crisis standard-of-care [mode]. COVID-19 is finally decreasing in our hospitals, but PACUs are still being used for COVID-19 wards, so not all hospitals are resuming normal operations.

In our practice, we’ve had a nurse position open since August that nobody’s applied for. Adult urology has had a position open for a year. There is a big shortage.

Nurses, MAs, and LPNs left because they didn’t want to get vaccinated, a requirement now to work in our hospitals. In Boise, every hospital except 1 requires it. When cases started ramping up in September, people walked off the job to avoid vaccinations. They ‘don’t believe in them, don’t think they’re researched enough, don’t want government telling them what to do.’ As a result, traveling nurses were hired to prepare for the shortage.

Luckily, at Children’s Hospital, we have a float pool that helps. Actually, when ORs [operating rooms] shut down, nurses assigned to the OR floated up to keep our clinics going.

We’ll see what happens when ORs reopen. We may have to see fewer clinic patients so we don’t burn our current nurses out.

As deaths increased, there was another push to get people vaccinated. I’m very outspoken. When people ask, ‘What can we do to make sure our child can get surgery?’ I tell them, ‘Get vaccinated, get your neighbors vaccinated.’ Some people do; others refuse.

Traveling nurses are great, although they get paid so much to stay. In a good way, it will probably raise nursing salaries, but it could have an effect on medical inflation.”

“Staffing isn’t as much of an issue here as in other practices. Our hospital doesn’t have a [COVID-19 vaccination] mandate. A mandate would cost us a handful of nurses. We’re pretty isolated, providing care for a 2½-hour radius. We can’t go down the street and hire new nurses.

Several of our nurses had [adverse] effects, including myocarditis, from their first [COVID-19] shot and hesitate to get another. Technically, they’re not fully vaccinated. A mandate could make some walk. Hospital administrators considered how many they would lose with the mandate.

The administration looked at mandates because a potential penalty is through [the Centers for Medicare & Medicaid Services (CMS)], and we can’t afford a CMS penalty because our Medicare population is too high.

Like a lot of places in the South, we had a pretty bad COVID-19 spell earlier this summer. It slowed us down surgically because we had major staffing issues. Since then, it hasn’t been a problem. We don’t want it to happen again.

COVID-19 came through our office early last year. We had to shut down for a short period because pretty much everyone in our office had it. Most of our staff and I feel this is what we signed up for in medicine. We’re exposed to things all the time and have to protect ourselves.

Going back to your original question, we’re OK on staffing because we got hit by COVID-19 early, before the vaccine was available. Our symptoms were fairly mild, and it desensitized us to the whole thing. Not that we can’t get it again, but we hope we developed antibodies from the virus itself. And the people we’re surrounded by, our elderly, high-risk patient population, is maybe 80% to 90% vaccinated, providing further protection.”

“We’re definitely seeing health care worker shortages—certainly in ORs [operating rooms]. It’s difficult just adding a case. We haven’t had many nurses leave our clinic but it’s a big issue within the hospital ORs. Where we generally did 10 cases a day, now we do maybe 8 or 9, so patients must wait a little longer.

In Pittsburgh, people are jumping ship to the other hospital system in town because everyone’s short-staffed. Hospitals are offering sign-on bonuses to entice people to switch. Remaining staff feel underappreciated because there are no retention bonuses. So they’re going 10 minutes across town to another hospital.

It’s interesting. I just did a case with a new circulator nurse and a new scrub tech recruited came from another hospital. The case before that I had a CRNA who’s leaving to go to the other hospital.

With the dependence on traveling nurses, people where I used to work feel underappreciated. They’ve been there 10 to 20 years. Travelers come in—they still live locally but had quit their job and came back as travelers—and make 3 times what they did when on staff and what their coworkers make.

We use more medical assistants than nurses in our clinic. There doesn’t seem to be as much burnout. They’re well-compensated and have a good work life.

To cope with the staff shortages, a smaller hospital here is being innovative, getting more surgical patients in and out the same day. Physical therapists are taking patients straight from PACUs to therapy units.”

"Our hospital doesn’t have a [COVID-19 vaccination] mandate. A mandate would cost us a handful of nurses," says 1 urologist.

Are pandemic-related worker shortages affecting your urology practice?  

“Administrators can improve the patient experience, but we have to make sure it also improves the physician experience. Does it lead to better patient care? This job doesn’t really leave you 24/7, so this could help fuel burnout and make it more difficult for us to get our work done.

Patients also don’t understand that urologists are actually surgeons. They expect an almost immediate response to texts, but we’re in the OR [operating room] for hours on end. Without any real data [showing] that this improves anything, it just makes us too accessible.

Texting appointment reminders is fine, but what can you safely send? You have to make sure your messaging service is HIPAA [Health Insurance Portability and Accountability Act) compliant. Someone changes their phone number, hasn’t updated it, and you send out health information. How can you confirm the right person gets the message?

It’s another push by outside players to make physicians more accessible, as opposed to a physician-driven component to improve patient care.

I just got a MyChart message saying, ‘Now texting your physician’s office is as easy as texting your friends.’ Currently, that means texting my nursing staff, but with the worker shortages even that could create an overload from excess communication. Other questions: billing-wise, where does this leave us? What other business allows this much access in terms of being able to text a professional directly? I think our medical portal probably meets the need.

“It hasn’t been propagated at my hospital. I don’t know any providers at my hospital who text with patients, although I know other urologists who do.

It seems intrusive for the provider. That would be my impression if I were asked to do it. Of course, the patient would have to agree to it and be interested in opening that line of communication.

The hospital texts patients with appointment confirmations and reminders, so that’s commonplace. As for provider and patient communication, it would be intrusive, at least with my practice, because I’m essentially a solo provider. I have a partner but we don’t share calls or patient responsibilities so there’s no one covering for me. Even though I don’t take calls for my hospital, my hospital calls me all the time. The ER [emergency room] calls if a patient ends up there with urological issues because I’m the urologist who works there. That’s the nature of my practice. So since I’m sort of always available, making myself more available isn’t something I’d be interested in.

If I were in a practice with 30 urologists, I would understand the expectation to respond to patient text messages. It’s reasonable in that sort of practice. So it’s practice specific is my answer.

I’m not afraid of being inundated during working hours. I’ve been working at my hospital for 6 years, so I understand the nature of the area. I don’t work in a large population center where you’ll see more volume. I know my volume and the amount of inquiries my patients have. So I wouldn’t be worried.”

“I’m in a unique situation because I work part-time at 2 different institutions. There’s no institutional policy I am aware of for physicians to text patients. I have developed communication patterns over the years, determining what meets the patient’s needs with safe and effective care without miscommunication that can result in mistakes.

Personally, I don’t text with patients, yet there are a number of patients, particularly those at higher risk, to whom I give my cell phone number and tell them to call me if they have issues. I never suggest texting.

If somebody has a problem, I want to know about it. Going through my staff is always better. With so much information coming through, you’ll get numb to it. You’ll start getting texts about what someone heard on the news or asking whether they should keep an appointment. I want those to be screened by my staff. Patients can’t tell what’s important or not. I want to be immediately available for the important things. My office staff can call me anytime, anywhere for anything that’s important. They know that.

Trying to figure out over the years how to lessen the chance of problems while serving the patient’s needs is a fine line.

You’re talking to somebody who’s never been on Facebook, Instagram, or TikTok. I hope to use technology for my benefit, to make sure patients have access to help, but that shouldn’t be directly from me most of the time.”

"Without any real data [showing] that this improves anything, it just makes us too accessible," says one urologist.

What are your thoughts on proposals that physicians should communicate with their patients by text?

“Pandemic 2 is far worse. The only good news is that we planned for this originally, so we have options for delivering care. Our intensive care unit [ICU] is 100% full, so we turned our recovery room into another ICU. Luckily, we haven’t had to go to the next level and set up a ward in the auditorium.

The [US] Air Force came to help with things that don’t require medical skill—like screening guests at the door.

Pandemic 2 really locked us up. It’s much worse than before. Individuals were coming back to the office; now they’re retreating home to do patient care.

A lot of us—oncologists particularly or ones, like me, who do female medicine—must examine patients. I can’t do much surgery because mine is mostly elective.

Patients started coming out with the vaccine but now they’re retreating. It’s difficult to get individuals to follow up.

Many elderly patients aren’t computer literate, so they can’t do virtual visits. I won’t do new patients on the phone. You can’t form a therapeutic relationship over the phone—I’m sorry. Face-to-face, there’s more opportunity to establish a connection.

During emergencies like this, the VA [Veterans Affairs] reaches out and takes civilian patients. The VA provides tertiary clinical care when the university can’t.

I treat patients with multiple sclerosis [MS]. During the first phase, we had no losses. The MS population did awesome. Now, however, we’re getting secondary cases; I’ve had people hospitalized. It makes me sad because they’re doing everything right. Now, they’re evidently quite susceptible to Delta [variant] and we’re almost 100% Delta in this state. It spread fast because we have so many unvaccinated.”

“The resurgence hasn’t affected us too much here in Virginia. Because of precautions, we aren’t getting hit as hard.

One impact is the hospital’s seeing a staff shortage, especially nurses. Our hospital system went out of the country to hire nurses from different countries because they can’t get enough here.

It affects us because it’s hard to find staff for the right job. We have high turnover. It’s hard to find somebody with experience. We hire somebody, train them, and after a few months some of them are overwhelmed by the work and leave. Then we must do it again. Health care is hard because you have contact with patients. That increases your risk.

Urology is a bit different because patients come in for a specific need. They have symptoms that simply cannot wait—a staph infection, bleeding, or stones. Those patients really can’t delay.

Patients who need medication for ED or other medication refills don’t have to come in. Their needs are met without risking exposure in the office.

We are affected financially, however, because much of what urologists do are procedures, like cystectomies. Telehealth appointments aren’t as beneficial to the practice because often patients are charged based on time spent and the complexity of the visit. We lose a lot of revenue because we’re not doing a cystoscopy- or urodynamics—all of which make money, maybe 30% to 40% of practice revenue. We had to stop doing them, so practice income is affected.”

“Nashville is getting hit really hard. Fortunately, or unfortunately, we got hit hard the first time. We learned a lot, so we were able to quickly transition back to telemedicine where appropriate. We also canceled our more elective cases when it got bad.

Vanderbilt [University Medical Center] had to do strategic redeployment of providers of all specialties to help accommodate overflow intensive care units [ICUs], and critical care doctors who are caring for patients with COVID-19.

I’m more likely to get with patients who are following up for routine care over the phone or our online portal instead of them coming in.

Patients are more wary of undergoing surgery. I’ve had several who decided to hold off until COVID-19 is under better control.

ICUs are overwhelmed, between providers getting sick themselves or the number of patients they’re caring for. They’re asking other providers to assist in the ICU, just to have manpower.

We’re continuing with high-priority patients with cancer, important or life-threatening cases, but the truly, purely elective cases are being held off.

We look at it on a day-to-day basis. It’s not just a blanket shutdown. We look at the census; talk to the surgery board; look at how many and types of beds are available. The day before surgery, we coordinate with all the surgical specialties, shutting down a room, cancelling cases as necessary, if staffing’s unavailable.

Patients in the community may hesitate to go to Nashville because of the larger population and the way COVID-19 is. They prefer to stay in their smaller town or in the country.”

"Patients started coming out with the vaccine but now they’re retreating. It’s difficult to get individuals to follow up," says 1 urologist.






Karen Nash

Articles

With all the attention paid to prostate cancer research and treatment, do other aspects of urology get the research they need?

Are pandemic-related worker shortages affecting your urology practice?

What are your thoughts on proposals that physicians should communicate with their patients by text?

How has the resurgence of the pandemic affected your urology practice?