Subspecialization trends: Who’s doing what and where?

In this interview, Michael Palese, MD, discusses subspecialization, its benefits for clinicians and patients, and what the future “office urologist” may look like.

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.

Next:"We probably have to look at board certification again."Do you think that area of expertise is more important than your boarded specialty?

We probably have to look at board certification again. There are certain specialties, such as anesthesia, that have gotten rid of board recertification. Why would we continue to demand that urologists are proficient in all areas of urology like pediatrics or infertility when they will never practice or see these types of patients in the future? Perhaps we need to be thinking about recertification or boards that are subspecialty specific.


Has this subspecialization change been driven more by patients and social media or by urologists who want each patient to see the person best suited to treat their individual problem?

I think it’s a combination of the two. We know very well that the higher volume surgeon and the higher volume center tend to have fewer complications and fewer issues with morbidity and mortality. This has been shown over and over again, not only in urology but in other medical specialties as well. It’s just the evolution of health care.

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As we have grown, so the days of the individual physician working as a private practitioner with a shingle on the door are numbered, if not already dead at this point. It behooves you to be part of a large group, and so there are large practice groups and large academic groups. Because of that, we now have groups of anywhere from 20 to 40 or 100 or more urologists. It would make sense then to have a few individuals do certain things and those urologists would elevate a standard of care that is well above what was previously being done.

The other side of this is that as physicians are finding ways to compete against each other, social media certainly has played a role and patients are much savvier about trying to find physicians by looking at their Press Ganey scores and learning about their reputation online, so we have certainly become much more of a customer service-oriented industry than we’ve ever been before.


That makes it much harder for the person just going into practice who doesn’t have that backlog of cases when a patient asks: How many have you done?

Correct. It’s amazing how often we hear that in New York City, where patients can find experts within 20 blocks of each other. It’s one of the first questions we get from patients. That by itself has already created a situation where physicians really need to focus on one area in particular that they do well.


What advice would you give to a urologist who’s been in practice for 1 year and is asked that question?

I think you just need to be honest and say, “I’ve trained in this area, my mentor is so and so, and I’m in a high-volume center where we do ‘X’ amount of cases per year. I’m very comfortable doing this procedure and if there is a situation that arises, I have lots of back-up to help me out.”

Next:"We have people who are now subspecializing just in MRI-focused biopsy"Do you think this subspecialization trend applies now to non-surgical as well as surgical fields within urology?

Absolutely. We’re seeing this not only in inpatient volume but also in outpatient volume; for instance, infertility and pediatrics, and even areas that are a little more modern such as MRI-focused biopsy. We have people who are now subspecializing just in MRI-focused biopsy because it’s so labor intensive and there are complexities to it.


To what extent is this trend related to reimbursement per unit of care? For instance, cystectomy seems more and more to be relegated to academic centers of excellence, not only because the results are better but because it’s so time-consuming to operate and take care of these patients for the private-practice urologist that it almost becomes not financially viable. Do you think that’s a driving force?

Absolutely, that’s part of it. It’s not only a financial decision but also a resource decision. In a large academic center, we have many more resources to deal with these patients who tend to be very sick or have potential long-term complications or issues. For a private practitioner, spending 6 hours on a cystectomy instead of 6 hours in the office is a world of difference in terms of financial reimbursement. This is the future of urology; why train all of our urologists to do cystectomies when there are only a handful who are going to be doing them?


In the Urology study, you noted that in Germany, subspecialization within urology has led to the creation of the “office urologist” whose activity is restricted at the end of training to diagnosis and non-surgical treatments or a limited range of surgical treatments. This practice structure is also being explored in England. Do you see this happening in the U.S., or is this more the role of the nurse practitioner/physician assistant or physician extender by and large?

I think there will probably be a combination of such. What’s been happening is a lot of our more senior urologists who are less excited to go to the operating room every day have become more like office urologists, which is wonderful because we have an experienced urologist in the office who understands these cases. That’s the nice thing about urology; we have a lot of leeway in terms of how we can continue to practice well into our later years. Interestingly enough, some of the insurance companies are already looking at insuring urologists based on how many cases you do in an inpatient setting versus an outpatient setting as well as office-based volume.

Next:"There are so many complexities and split-second decisions that are made in surgery that I’m not sure a computer can accommodate just yet"We had an interesting lecture at Stanford on computers like Big Blue and their role in medicine. The speakers said that while computers may be able to take over many cognitive activities, it’s unlikely they’ll be able to operate on patients in the foreseeable future. The thrust of the lecture was that people who went into cognitive specialties would have more to lose to computers in the future than those who were in surgical specialties. What are your thoughts about that?

It’s very interesting. I saw a segment on “60 Minutes” on Big Blue where the supercomputer was used during a medical oncology tumor board. Big Blue searched the entire world for appropriate clinical trials and treatments. There’s no way that any individual person could possibly know all of those trials and treatments. That goes hand in hand with what we’re discussing.

I do believe that, yes, surgical skills are still going to be in the hands of surgeons. There will be assistance, just as we use robots and MRI-guided technology now, but ultimately, the final decision will continue to be with the surgeon. I see that continuing in the foreseeable future.

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There are so many complexities and split-second decisions that are made in surgery that I’m not sure a computer can accommodate just yet. That being said, there are probably ways for a computer to figure that out as well; for example, what the odds are for certain things to happen based on the anatomy, and the factors involved.


What effect do you think subspecialization could have on unnecessary surgical procedures? 

I think there’s always a risk for someone doing surgery when they don’t need to be doing so. Presumably, if someone is highly specialized in an area, they wouldn’t want to embark on a procedure that doesn’t make any sense. Subspecialization may be a way of making sure that surgeries are done for the right reasons. But like any procedure or any financially goal-oriented system, there are always going to be people who will take advantage.


Do you think that major changes in training with earlier subspecialization in mid-residency will be the way things move along?

I think we’re going to have to seriously consider it. It makes sense, certainly with the way we are providing health care and the way we’re using our resources. Look at what’s happened with bariatric surgery. You cannot perform bariatric surgery except in a center of excellence that’s been sanctioned to do so. I see robotic surgery not far behind this. I can’t imagine that it makes sense for every little hospital to own a $2- or $3-million robot to support surgeons who do five or six cases per year; the robot really needs to be in the hands of surgeons who do a lot of volume and understand how to move through the cases quickly and safely. The resources we have are limited, so why would we spend them on surgeons who, frankly, just shouldn’t be doing these cases?


How does subspecialization impact costs of care?

In a lot of ways, it may save quite a bit of money, because we are now creating a better outcome. Presumably, patients are getting the best care possible with minimal potential for morbidity and mortality based on the fact that the surgeons who are doing these procedures are well experienced. Again, why should a low-volume surgeon use up resources and presumably drive up the cost of something if another surgeon who can do the same procedure three or four times over in that same amount of time? We really need to look at this, and I think a lot of the operating rooms around the country are starting to look at how much time surgeons take, what kind of products they use in the operating room, how much each case costs them. This is the future of urology, no question.

Next: What do we lose by giving up the general urologist?What do we lose by giving up the general urologist?

Like everything else in life, as things become more complex and more complicated, we are going to have people who understand certain areas very, very well, and it’s going to be important to make sure that the general urologist still exists. That general urologist may not be a urologist anymore. It may be a nurse practitioner or a physician assistant. It may be a primary care doctor who delves into urology. Not so long ago, family practice doctors were doing cystoscopies in their offices. We’re seeing less and less of that now. But it existed in the past and I see a reason at some point it might come back to that.


So in the future, you could have a training path where someone goes through general medicine training and then does a year of urology.

Correct. They would get a basic urology background, which is not such a bad idea; you would have a physician who is trained in other areas, not just urology but in general medicine.

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I think as urologists we’re always worried about giving up certain procedures to other specialties, but as these things become more complex, it’s a natural evolution that we just embrace new technologies and new techniques. It’s not that we’re going to lose our specialty, we’re just going to make it better.


Is there anything else you would like to add?

One of the other areas my group has studied is patient travel (2015 AUA annual meeting study). Patients are much more willing to travel for care than ever before. We looked at studies back in the 1980s where if people were offered a really good doctor 5 minutes from their house or a really great doctor 30 minutes from their house, the majority of patients would go to the good doctor who is 5 minutes away because they felt that they would get a basic standard of care and it was more convenient for them to travel those 5 minutes.

It’s very different nowadays. The average patient will travel well over 100 miles to get to wherever they need to go, especially if they have a specialty issue. In our study, even if patients live in the tip of New York State, they would come down to New York City thinking that they’re getting better care there. I suspect this is a travel pattern that we’re seeing not just in New York State but in other areas of the United States. This reinforces the argument for subspecialization and regionalization of care to large-volume surgeons and centers.


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