Monica Derevjanik

Changes in the nation’s population affect the medical profession to varying degrees. Between 1970 and 2006, the average age of hospital patients jumped over a decade, from 41 years old to 53, according to the Centers for Disease Control and Prevention. As the population ages, more patients are flooding not only hospitals but the offices of physicians, including urologists. In turn, these growing pains contribute to the urologist shortage, says Rick Rutherford, director of practice management at AUA.

"The aging of the baby boomers, coupled with the potential retirement of a significant number of urologists in the next decade, represent a 'perfect storm' scenario where demand could exceed supply for urology health care," Rutherford told 

To address this gap, some urology practices have to turned to physician extenders, also known as midlevel providers. The number of urology physician assistants almost doubled between 2003 and 2008, according to the American Academy of Physician Assistants. Nurse practitioners in the field grew by 1.1% between 2003 and 2008, survey data from the American Academy of Nurse Practitioners shows. In 2003, there were 106,000 urology nurse practitioners; in 2008, the field expanded to 125,000. Urology Times’ 2009 "State of the Specialty" survey found that more than half of urologists (58%) expect their use of physician extenders to increase 5 years from now.

Urologists who have worked with physician extenders say the extra hands can be valuable to their practice. However, a number of factors need to be weighed when hiring-and before hiring-a physician extender, according to practicing urologists, practice executives, and extenders themselves.

Recruiters can access talented physician extenders through typical job recruitment channels: career service departments at medical and physician assistant schools, newspaper ads, and social networking. Physician extenders also have their own networks of colleagues and friends that employers can tap into.

Regardless of the method, however, it’s important to determine your practice’s needs before starting your search, says Bob Asinof, MS, chief executive officer of the Urology Center of Colorado in Denver.

“We identify a need in terms of whether we have the patient volume and the type of services we want to provide,” said Asinof, whose practice hired a skilled nurse practitioner to assist with robotic radical prostatectomies.

It is also essential that the midlevel practitioner’s skills fit the tasks assigned to him or her, Kathleen Kobashi, MD, head of the section of urology at Virgina Mason Hospital in Seattle, points out.

"We’re not going to put them beyond their scope of practice or beyond their scope of comfort either," Dr. Kobashi said. "If you’ve got a physician extender that has been in practice with you for 15 years, they know a lot about urology. The independent decision making will come with practice."

Urology’s specialized nature requires a commitment to providing quality care for conditions that patients may find embarrassing or difficult to address. For this reason, a physician extender’s personality is just as important to his or her success as training and experience.

"Everyone across the board in urology... has to be a people person because there are very sensitive issues that folks are going to come to us for," Dr. Kobashi said.

"It’s different than [treating] a man who has a heart attack," said Diane Newman, RNC, MSN, a certified nurse practitioner who is co-director of the Center for Continence and Pelvic Health at the University of Pennsylvania Medical Center, Philadelphia, who notes that not all clinicians are qualified to handle sensitive matters such as incontinence and erectile dysfunction.

Although Newman recommends finding a candidate who is an independent, life-long learner, the best physician extenders exhibit a combination of social skills and strong training. A candidate can gain field experience from traditional schooling or work in other fields, whether through completing a certification program, working as an emergency medical technician, or even pelvic exam training with a gynecologist. Keep in mind that while surgical experience is helpful, many midlevel providers come without that background and can learn procedures on the job.

Ultimately, the goal in hiring a physician extender is to boost physician productivity in procedural and clinical work, urologists say.

"While we’re tied up in the operating room, the physician extenders are truly that-they extend us," Dr. Kobashi said.

Urologists can forego seeing a patient when they first come in and use an extender to obtain a patient’s history or perform a physical exam. Nurse practitioners and physician assistants can then share the patient’s information with the doctor, saving the physician time while providing immediate, symptom-focused treatment for the patient.

Physician extenders can listen to a patient’s needs or answer previously asked questions, which can help out a urologist who is juggling the demands of his workload, Dr. Kobashi notes.

In addition to freeing up a doctor’s clerical workload, extenders can also offer surgical assistance, depending on their interests and expertise. Knowing that its urologists wanted to better allocate the time they spent in surgery, the Urology Center of Colorado recruited a nurse practitioner with years of experience to assist during surgeries.

"He makes our surgeons much more efficient," Asinof said, "because instead of having two surgeons in the operating room for our da Vinci prostatectomies, it only requires one."

Despite the usefulness of physician extenders, be cognizant that their addition to your staff may interfere with the training of urology residents.

"I have to always consider if I am going to take things away from my residents that they need to learn," said Anthony Smith, MD, professor and chief of urology at the University of New Mexico, Albuquerque.

Although hiring new physicians can be expensive, using an extender instead comes at its own cost.

"It is more difficult to get paid for the [work done by a] physician extender," Asinof said. "Some insurances will not reimburse or the reimbursement rates are lower. And you have to get the person credentialed with the insurance plan."

The downward spiral of reimbursement and professional fees have forced physicians to double their workload to maintain their incomes of 10 years ago. Physician extenders can increase the number of operative patients a surgeon can see, thereby increasing their revenue, explains Steven C. Hortopan, PA-C, MPH, the lead physician assistant at the Brady Urological Institute at John Hopkins Hospital, Baltimore.

But if insurance companies don’t reimburse for physician extenders, practices have to pick up the tab. This, says the Urology Center’s Asinof, is a price some practices are willing to pay.

"If your doctors can do more surgeries, if they can see more patients with the assistance of a nurse practitioner, then even though the nurse practitioner doesn’t get reimbursed very much, you’ve improved the productivity of the doctor," he said.

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To address the gap between the increasing number of urologic patients and decreasing number of urologists, some urology practices have to turned to physician extenders, also known as midlevel providers.

Author | Monica Derevjanik

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