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Experts share advice on growing out men’s health program within a urology practice

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"Men's health, as a sort of separate discipline or a sub discipline within urology, is definitely growing," says Andrew Y. Sun, MD.

On April 13-15, 2023, Specialty Networks held its spring 2023 national conference in Boston, Massachusetts. In this interview, Andrew Y. Sun, MD, and Michael D. White, PA-C, summarize key takeaways from the presentation, “The Men's Sexual Health Program: Where to Focus, How to Invest,” which was given on April 15 at the conference. Sun is director of the Center of Men’s Health at Urology Partners of North Texas, Arlington, and White is a physician assistant at Urology Partners of North Texas.

Please summarize the key takeaways from "The Men's Sexual Health Program: Where to Focus, How to Invest" discussion at the Specialty Networks Spring 2023 National Conference.

Andrew Y. Sun, MD

Andrew Y. Sun, MD

Sun: UroGPO—and urology as a whole—have been very oncology focused. Men's health, as a sort of separate discipline or a sub discipline within urology, is definitely growing, as there's a bigger and bigger population need for things like erectile dysfunction treatment, testosterone management, and a lot that general urologists don't do as much. So UroGPO organized this talk, to basically have those of us that do men's health discuss the value of creating a men's health program within a urology group and how to logistically do so.

We have our Center of Men’s Health, and we take care of a concentrated number of issues. You can create a program that delivers excellent care, and also drive a lot of value for your organization. We approached that from a few different angles. Xiaflex [collagenase clostridium histolyticum] treatment for Peyronie's disease is one of the big angles because it's a very under diagnosed disease process, and a lot of general urologists don't do it that much. That was a big focus. And the other side is ways to optimize that within a practice, such as dispensing medications like Viagra [sildenafil citrate] and Cialis [tadalafil], or testosterone management, which is the bane of existence for a lot of regular urologists. But we manage a lot of this, and there are ways to do it efficiently, and profitably, I guess you could say. It was a really nice conversation; we talked a little bit about what we do, and then we had a lot of great questions from the audience.

One of the biggest takeaways was that a lot of men's health kind of piggybacks on to the treatment of prostate cancer. And for an organization and a field that is so focused on prostate cancer, a discussion of prostate cancer management is very much incomplete if you don't talk about the lifestyle effects that prostate cancer treatment can have. They're so focused on overall survival, and how do we do this cool surgery, but these guys get erectile dysfunction, low testosterone, and urinary incontinence, and you have to talk about that. And so if you can roll a program in for the lifestyle things, in addition to the prostate cancer treatment, that's better. So the plan would be for the next conference to bring that up main stage as part of the main prostate cancer discussion as well.

Michael D. White, PA-C

Michael D. White, PA-C

White: One of the things that we've implemented from an advanced prostate cancer standpoint with UroGPO is having a navigation system set up. This is something that had never been done before: seeing where that fallout was, in terms of the patients that were not being identified, that were not being treated, or fell out of treatment. One of the conversations that we had 6 months ago, at an advanced prostate cancer discussion was, why are we not utilizing this same system that's also being utilized in overactive bladder with men's health, because there are a lot of patients that are coming through the door, that are not being asked, or if they are being asked, are not following up, or they haven't been called. Maybe this patient didn't pick up their medication, maybe they didn't get the refills, maybe they weren't followed back in terms of a patient called about Peyrone's disease as a referral, and we never reached back out to him. And so, if we can input this into a navigation system, the fallout would be much less.

Please provide an overview of your own practice.

Sun: Our group is quite large. We have 29 doctors and approximately 12 to 15 advanced practice providers [APPs]. We have general urologists, we have oncology-focused providers, we have incontinence-focused providers and then we have me and my group, which is basically the men's health team. I would say our diagnoses primarily are erectile dysfunction, Peyronie's disease, low testosterone, male infertility, and male scrotal testicular issues—hydroceles, pain, anything like that. Most of the time, either somebody else will see a patient and prescribe Viagra and tell the patient to go see the Men's Health Center, or they'll just call and come in directly, or they'll get referred after being initially identified with something like Peyronie's disease. Another nice element is that we have it so that all of our patients in our group that are undergoing pelvic surgery, prostatectomy, cystectomy, or prostate cancer radiation, they basically get a preoperative appointment with the men's health center, where we discuss quality-of-life considerations—how to rehabilitate the penis after prostate cancer surgery. So they have someone on our side that's they know is on their team. So instead of just the oncologist, they have the team of the cancer guy and then the quality-of-life guy. I guide them through that process—post op, vacuum, Cialis, whatever they need, so that they have someone in their corner and a better outcome and someone to talk to about these things that maybe their oncologist either doesn't want to talk about, or is not as well versed in.

I do a lot of talking. I just talk to people and decide plans, but then executing is basically all Michael. And we have a group of APPs that basically do that, whether it's Trimix injections, or penile ultrasounds, or Xiaflex injections, basically anything but surgery. And it kind of goes back and forth, because maybe they come to see me for ED, and I prescribe a pill and tell them to follow up with Michael. He manages them for a while, they fail the pills, they get to injections, they do the injections for a while. Then 1 day, 3 years later, they need a penile implant, then they come back and see me, but they've been in the system the whole time.

White: We always use the word "team." When the patient comes in, we talk about this as a team approach, so they understand they're not just being handed off. The first thing that we always emphasize with patients as soon as they walk in the door is, "We're going to get you from point A to point Z. Now, how that might happen, we'll go whatever pathway you need to go in terms of your treatment model." And so we make sure they understand from the very, very beginning, that we have 15 ways to do things; it just depends on which pathway they choose.

What advice or best practices can you share for practices looking to establish a men’s health center?

White: I think one of the things from an APP standpoint that I try to push all the time is getting it out into the public—doing community health talks. Before COVID, we used to really take a lot of time going in and talking about prostate cancer, organic impotence, and Peyronie's disease. We also go into primary care, because they just don't have the time anymore. Now that we have the Baby Boomers coming into the golden years, if that's what you would like to call it, they don't have the time in their office to really discuss ED, Peyronie's disease, low T. It's a headache. I tell them, instead of you having to deal with that, let us be the gatekeeper for that. We would love for you guys to refer that over to us so we can take those patients that need to be treated. And I think that whenever we've talked—we have APP breakout meetings with UroGPO—trying to get the APPs involved in terms of seeing those patients that are coming through the door, understanding what a best practice is, having a protocol set up. These are conversations that we have with Nashville Urology and Indiana Urology. What does a protocol look like? So there's a whole lot less opportunity for failure in terms of mistreating a patient. That way, the patient understands that we've got an entire plan for them so they feel a little more comfortable in walking into the door.

Sun: So much of it does happen on the APP level. I mean, most primary care patients are seen chronically not by the doctor anymore, but by an NP or a PA, right? And most primary care doctors are not going to say, "The number 1 thing that I care about is erectile dysfunction." I mean, they're going to manage their diabetes or high blood pressure. It's the APP that's seeing them every 6 months, and having the time to chat with them that they might bring up, "How's everything else going," then that comes out, and then that referral, honestly, often gets made directly from their APP to Michael, and then he'll eventually treat them and then send them to me for surgery. That's 1 thing.

Number 2, there are advanced men's health things you can do. We have our own pharmacy, so I dispense Viagra, vacuum erection devices, sex instruments and all these kinds of things. But that takes a lot of set-up, so one of the easier things you can do is, everybody has somebody treating prostate cancer. Identify a champion, somebody who really wants to make men's health their thing; then the other doctors who don't want to deal with it don't have to deal with it. That person then becomes the holder of that disease process. And you start with a preprostatectomy or a periprostatectomy lifestyle management protocol, where you have somebody that's dedicated to managing that stuff. It's a relatively easy thing to get a group to start to do. The first thing you have to do is convince people that these diagnoses—low T, ED—instead of being a burden or something uninteresting, are not only straightforward, revenue generating, helpful to patients' psychological and physical and mental health, and easy to do. Then you identify somebody who wants to do that as their champion. And then you realize that all of the other patients that you're already sitting on—patients with kidney cancer, patients with overactive bladder, patients with benign prostatic hyperplasia—every single male patient in your practice, probably also has some degree of erectile dysfunction or maybe Peyronie's disease, but you never asked them about it because you're monitoring their kidney. But if you care, and if you have an APP especially and they just asked that question, you'll bring out these diagnoses that were simmering under the surface that people aren't there primarily to see, and you'll help the patients, you'll take care of them. It's good for the practice. It's interesting for that person who wants to do it. And it doesn't even require going out and getting new patients because you're already sitting on all of these patients; you just haven't asked them the right question.

Is there anything else you would like to add?

White: There's an SMSNA [Sexual Medicine Society of North America] APP committee now. And the AUA [American Urological Association] has done a very, very good job of bringing in the UAPA as they started seeing a rise in APPs over the past 5 to 10 years. They've done a very good job of kind of grandfathering in that organization. But there needs to be a tie-in too for those APPs in that very select men's health section, getting more involved with SMSNA. So we've really tried to push that more and more. That's what we've talked about at UroGPO. And then that's something that will be brought up in the next couple of days at the AUA. So our goal at the AUA too is for those people that are trying to get into this new wave therapy—which is not that new wave, it's just been taboo in a lot of instances—we want to give them an outlet for them to get involved.

Sun: It's definitely a growing field. There are more applicants to sexual medicine fellowships now than there were before. Ultimately, there's tremendous value in the men's health patient. Those patients have other issues that they're already being seen for: BPH prostate cancer, elevated prostate-specific antigen level, etc, and if you can create an efficient system to treat those processes, you can help people and you can also do it well for your practice, right? That's kind of the thrust of the UroGPO talk. And I think a lot of the cancer-treating providers in the audience felt, "Oh, wow, I didn't think about it this way." A lot of practice administrators came up to us afterwards and they want to send delegations of people down to us to see how we do it because they want to learn this whole other piece of a urology practice, which is awesome.

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