Philip M. Hanno, a Urology Times editorial consultant, is professor of urology at the University of Pennsylvania, Philadelphia.
In this interview, Sarah E. McAchran, MD, discusses the need for urology-gynecology collaboration, the background behind the ABMS recognizing the female pelvic medicine and reconstructive surgery subspecialty, and how barriers to full integration of providers treating pelvic floor disorders can be overcome.
Sarah E. McAchran, MDIn this interview, Sarah E. McAchran, MD, discusses the need for urology-gynecology collaboration, the background behind the ABMS recognizing the female pelvic medicine and reconstructive surgery subspecialty, and how barriers to full integration of providers treating pelvic floor disorders can be overcome. Dr. McAchran is associate professor of urology with a dual appointment in the departments of urology and obstetrics and gynecology at the University of Wisconsin School of Medicine and Public Health, Madison. She is also medical director of Women’s Pelvic Wellness Clinic at the University of Wisconsin. She was interviewed by Urology Times Editorial Consultant Philip M. Hanno, MD, MPH, clinical professor of urology at Stanford University School of Medicine, Stanford, CA.
In the past, there were tremendous turf battles between gynecology and urology. When one tried to impinge on the other’s territory, it was usually the dean who became involved. What do you think drove the change to cooperation we see now?
I think one of the main factors was each specialty realizing that neither one could completely “own” this set of clinical problems and that we need each other. Urology would need the OB/GYN expertise, and OB/GYN would need the urology expertise to make any progress in terms of research, patient care, and professional training.
At my institution, Dr. Laurel Rice, chair of the OB/GYN department, and Dr. Stephen Y. Nakada, chair of the urology department, have created an atmosphere where we could move forward to create a collaborative rather than a competitive approach. It’s important to have the mindset from the administration that it’s better for everyone to collaborate. It’s better for our medical students, it’s better for our trainees, and it’s better for our patients if we have a collaborative rather than a competitive approach.
Pelvic floor disorders, including pelvic organ prolapse, urinary incontinence, and fecal incontinence, affect over 20% of adult women. In 2010, an estimated 560,000 women underwent surgical repair of pelvic organ prolapse or stress incontinence. The demand for services is increasing. Do you think this is one of the factors that pushed urology and urogynecology to collaborate?
Several factors are driving collaboration. I think that demand, the need for research-driven data, the need for patient quality outcomes, and patients themselves are driving collaboration. In the current market, patients view themselves as consumers. Our health care system views them as consumers. Patients are no longer going to be satisfied with trying to seek the answer to their multi-system problem from multiple places; they want easy-to-navigate care for these problems. That’s what we’re trying to do at the University of Wisconsin: create a one-stop shop where we come to the patient rather than sending the patient out to multiple places.
Kirby has estimated that 3,735 pelvic floor disease specialists will be needed, or one per 100,000, in the next 15 years (Am J Obstet Gynecol 2013; 209:584.e1-5). That means adding 2,300 specialists given that in 2013 there were 1,400 members of the American Urogynecologic Society (AUGS). The prevalence of female pelvic disorders is expected to experience 45% growth in the next 20 years. Up to half of U.S. women experience one or more symptoms of pelvic floor disorders during their lives. One in nine will undergo surgery for female pelvic floor dysfunction by age 80. Do you think there’s a need to increase the number of providers-urogynecologists, female urologists, nurse practitioners-to meet this demand?
There’s clearly a need. The way we’re going to meet that is twofold: by increasing interest and increasing training opportunity. Increasing interest starts at the medical student level. When I was a second-year medical student at Vanderbilt, I went to a panel discussion on women in surgery and Dr. Jenny Franke, Vanderbilt’s female urology specialist at that time, was one of the speakers. I thought everything she said sounded incredibly interesting. So I focused on rotating through urology in my third year, working with Dr. Franke in my fourth year, and ultimately went into urology with the hopes of doing what I’m doing now.
At UW, we have a fourth-year rotation for the medical students in urogynecology that satisfies their surgical rotation. We have exposure to urogynecology in the OB/GYN rotation that is done during the third year. Increasing that exposure is really important. That continues on into residency training as well. All of the residents in urology and in OB/GYN have some exposure to female pelvic medicine and reconstructive surgery (FPMRS) at our institution.
In addition, for institutions that don’t have such a strong faculty presence in that, the Society of Urodynamics, Female Pelvic Medicine, and Urogenital Reconstruction (SUFU) runs the Resident Preceptorship program every August, which sponsors residents from all of the different urology programs in the country to come to Chicago for a “mini-fellowship” in female urology with specialists from across the country. That’s another way that we can generate interest in pursuing this as a career.
Can you discuss the history of the American Board of Medical Specialties recognizing the subspecialty of female pelvic medicine and reconstructive surgery?
As I understand it, SUFU and AUGS, which were the urology- and the OB/GYN-based subspecialty societies that were interested in this, wanted to make FPMRS a more formalized training program and so began accrediting postgraduate training programs in that around 1998. That means that the trainees have finished a fellowship but they are neither certified nor examined. To be certified and examined, you have to be recognized by the American Board of Medical Specialties (ABMS). It took until 2011 for that to happen. Once you’re recognized by the ABMS, your fellowships have to be accredited by the Accreditation Council for Graduate Medical Education, which is an entirely separate application process. That was completed in 2011 as well.
In 2013, the first certified examination was given; that was a written examination. Both grandfathered and fellowship-completed examinees were allowed to take that exam. Going forward, only those applicants who have completed an accredited fellowship may sit for the exam.
What do you see as barriers to full integration of all physicians involved with full-time care of patients with pelvic floor disorders?
In 2000, Dr. Jerry Blaivas wrote an editorial called “Herding cats” that covered this exact issue (Neurourology and Urodynamics 2000; 20:1). The two big barriers he identified were territory and money. While these are not as problematic today as they were then, they are still problems going forward.
Territory is difficult because you have to navigate the waters between the generalist and the specialist within urology and within GYN and then navigate between urology and GYN. If there’s limited territory, that can be challenging. But as we discussed earlier, the territory is really expanding in this field. There are lots of patients with these problems.
Dr. Blaivas thought the money problem could be solved by having us work together and share income the way we do within our individual departments now. That would be the ideal way for that to happen, but in an academic medical center, where funds flow along departmental lines, that’s challenging. It’s challenging to figure out how providers are going to be reimbursed, how physicians will be compensated, and how to gather resources, space, and staff.
There are also practical barriers. How do we take call for each other? If I’m a urology practice and I want to expand my FPMRS services by hiring a gynecologist who has finished an accredited training program, how do I fit that person into my call schedule?
How would the conversion of the volume-based model of financing U.S. health care into a value-based model in which quality indicators will lead the path for financial incentives benefit female pelvic medicine?
There are data from other diagnoses that have multi-system effects-multiple sclerosis, spina bifida, obesity, and diabetes-demonstrating that a multidisciplinary approach to those problems is beneficial in terms of quality outcomes. Pelvic floor disorders certainly apply to that. I think that female pelvic organ reconstructive surgery is well poised to do this because the goal of such collaborations as the Pelvic Floor Disorders Network and the Urinary Incontinence Treatment Network was to work together to develop large, prospective data-driven answers to some of the key questions. Because we have a history of doing that, we’re going to be well poised to figure out the quality indicators for our specialty going forward.
UW is one of the pioneer sites for the AUGS Pelvic Floor Disorders Registry, which is a multicenter, prospective cohort study looking at surgical versus medical treatment of patients with pelvic organ prolapse. It examines effectiveness, quality of life, and safety of therapy. I wouldn’t be able to participate in that if I wasn’t in a multidisciplinary program. Having that collaborative approach really helps.
A multidisciplinary program seems like a great fit if you’re going to pay based on quality rather than volume; the multidisciplinary group would squeeze out providers who are not in the group because their quality is going to be so much higher.
Absolutely. In the study from Kirby that you mentioned, while demand for care increased over the time covered by the study, the number of surgeries actually didn’t increase commensurate with that, which I think goes to show that surgery is not always the quality answer. In a volume-based model, surgery is always the answer.
How does the new generation of fellowship-trained urologists and gynecologists who are trained in cross-disciplinary programs in which the message of collaboration and integration is increasingly advocated serve as a positive force to help institutions fully integrate the FPMRS service line?
To have an FPMRS service line, first and foremost you have to have the human capital. You have to have physicians who want to work in that type of situation and who understand the benefits of working in that type of situation; if you don’t, you can’t get anywhere. Having trainees come out of programs where they’ve been exposed to that is incredibly beneficial. My fellowship training was at Cleveland Clinic, where we had multidisciplinary conferences and research, and we served on each other’s services throughout the training. I absolutely understood the benefit of that, and it has always been my goal at UW to create a similar environment. All of my partners in urogynecology came from similar backgrounds. That really helps.
Where do we stand now with integration and training, and what benefits have become apparent? Is there a geographic difference in harmonization?
There are 56 fellowships that are accredited, and by my estimation about 32 of them accept both urology and gynecology backgrounds in the fellowship program. I think integration is there and I think it’s hard-wired going forward. To be an accredited fellowship, you have to have a urologist and a gynecologist background as part of your program. Exposure to that is part of your training.
One of the very specific benefits I can talk about in our multidisciplinary program is increased patient compliance. We compared compliance with prescribed pelvic floor physical therapy in patients who were seen in our multidisciplinary clinic by both a physician and a pelvic floor therapist with patients who were prescribed that treatment option from a physician-only clinic. We found that compliance was much better with patients seen at the multidisciplinary clinic.
I don’t know that there are geographic differences. The real issues are resources and commitment, the human capital. Those are the barriers to this getting fulfilled.
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