Brand T, Mitchell K, Quallich S et al: Current state of advanced practice providers in urological practice. Urol Pract 2021; 9: 1.

A workforce shortage of 65,000 physicians is projected by the year 2025.¹ In 2018, there were 3.89 urologists per capita, which is among the most severe specialty shortages. Urology has the second oldest surgical subspecialty workforce with an average age of 52.5 years.² According to the 2018 census, 72.5% of urologists used an advanced practice provider (APP) in their practice, and APPs accounted for 41% of an MD/DO full-time equivalent.³

Figure. App white paper infographic.

To that end, the AUA published the 2020 update to the 2015 Consensus Statement on Advanced Practice Providers titled the “Current State of Advanced Practice Providers in Urologic Practice,” with new content on inpatient utilization, procedural data and compensation.⁴ An abbreviated version was just published in Urology Practice®.⁵ This document was created by an ad-hoc group of urological providers formed by the AUA board of directors.

Urologists work with APPs frequently, but many may not know the most efficient way to incorporate them into their practice. This document examines APP integration from a regulatory and practice management approach, as well as provides information on inpatient utilization, procedural data and compensation.

The AUA endorses the use of APPs in the care of patients through a formally defined, supervised role with a board certified urologist under the auspices of applicable state law.⁶ This physician-led, team-based approach provides the highest quality urological care.

Most APPs primarily work in general urology while nurse practitioners are more likely than physician assistants to work in urology specialty areas such as oncology and pediatrics. Specialty areas in which APPs are more likely to work are erectile dysfunction (61.4% of physician assistants and 53.4% of nurse practitioners), oncology (52.3% of physician assistants and 37.8% of nurse practitioners) and endourology/stone disease (47.2% of physician assistants and 34.3% of nurse practitioners).⁷

Supervision/collaboration is a process in which an APP works with one or more physicians to deliver health care services within the scope of the practitioner’s expertise with medical direction and appropriate supervision as supported by jointly developed guidelines or other mechanisms as indicated by the law of the state in which the services are performed. This requires that each party share responsibility for care. Supervision/collaboration is an interactive process involving trust, excellent communication, mutual goals and common direction in practice as well as a dynamic process dependent upon the skills and competencies of both the APP and physician. An important component of collaboration requires professional relations that foster the best patient outcomes and the optimal use of individual skills. This team model is an efficient way to provide high-quality medical care.

The role of APPs in a urology practice is dependent upon many factors, including academic vs private practice, large vs small group, APP experience, facility and practice needs, physician comfort level, and state laws. The supervisory/collaborative model may be described as delegated autonomy. This model fosters an appropriate growth in autonomy time as the physician and the APP become accustomed to working together.

This working group supports the AUA’s policy statement that in a team based approach with a board certified urologist in a supervisory role, APPs contribute to the care of the patient with genitourinary disease and, therefore, encourages the proper use of APPs.