Streamlined management for metastatic castration-resistant prostate cancer, greater autonomy for residents, and a better understanding of issues facing the VA are among changes urologists hope to see occur in 2015.
“For me, there are a couple things. Number one, with everything going on in the changing landscape of metastatic castrate-resistant prostate cancer, we need to find a way to streamline its management. The ordering of medications, treatments, whether you do docetaxel chemo first and then abiraterone and enzalutamide, or do you do that before. [We need] to find some way to say, ‘These are first line, these are second, then we proceed to third-line with chemo and other therapies.’
After chemotherapy, the studies sort of leave the choice up to the practitioner. The message seems to be, ‘OK, we’ve gotten to this point, now we don’t know.’ I hope we can clarify that in the next year or two.
Number two, as we have an aging population, we are seeing a lot more elderly women with recurrent urinary tract infections. I hope we get more of an optimal management scheme for them. You can’t put everybody on prophylactic antibiotics, and not everyone qualifies for Estrace cream or Premarin cream to reduce the risk of that. It would be nice to see if there any other therapies in the pipeline. I’m hoping some new literature comes out there too.”
Anish Shah, MD
Dr. Smith“I’ve been in education for a long time, both for the University of New Mexico and the VA. I’m concerned about the loss of autonomy for residents, which I don’t think is good for the country long-term.
There’s a notion that if you get care from a resident, there’s something wrong. The fact is, teaching hospitals have had excellent volume-care outcomes for many years. Residents are the strength of those programs. Each year, residents used to gain in autonomy so that by their final year, they were very independent-almost running their own service. Nowadays, there’s much more oversight and that’s not good for health care.
Also, training is becoming more fragmented by technology. When there were only a few choices, residents had to learn a few procedures really well; now you’ve got 18 million ways to skin a cat. Residents learn so many things that I worry they aren’t becoming expert in anything, or that their expertise is too limited. We see residents trained intensively in robotic surgery who can’t perform an open radical prostatectomy.
I think the number one problem for health care in America is that the process is becoming more important than care. There’s an ongoing transfer of dollars into the administration of care and fewer dollars devoted to direct care. That’s been going on for a long time and it’s going to continue.”
Anthony Smith, MD
“I’m semiretired and have been working in locum tenens at the Fargo VA. My hope would be that they could find a urologist who would work in Fargo full time rather than needing locum tenens doctors. That would be beneficial for the veterans. The problem is the VA is only willing to pay so much, and urologists can make a lot more money in private practice. So my hope would be that the VA could find competent urology coverage in the future.
I also hope for better understanding of issues facing the VA, because if you applied some of the same standards to private hospitals, you’d find areas that could be improved upon there too. I was in private practice for a long time and in the Air Force for 23 years, so I’ve seen urology from different viewpoints. I’d like to see better recognition of what’s actually happening in the VA, which in my experience is generally good care.
For medicine in general, it’s complicated. I would like to see a way of making health care financial issues clearer so the health care consumer really understands what they’re getting.”
Gary K. Hargrove, MD
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