Of the 14,000 practicing urologists in the US, 28.5% are 65 years of age or older.¹ Comparing US population trends, estimated urology retirement rates, and new graduating residents each year, the number of urologists per capita for patients 65 years and older is expected to drop 34% by 2035.² As a whole, the thinning urology workforce and a growing patient population will strain urologic care in the coming years. However, this strain will be distributed quite differently throughout the country.

While nearly 20% of the US population lives in nonmetropolitan areas (population <50,000), only 10% of urologists practice in such locales.³ These rural urologists tend to be older and delay retirement compared to their urban counterparts, which is indicative of the difficulties they face in finding replacements.^4,5 Additionally, the number of graduating residents pursuing fellowship continues to increase, with 63.9%/71.7% (male/female) of urologists younger than 45 years having completed a fellowship compared to 32.5% and 58.8% of those older than 45.¹ Fellowship training correlates with employment in areas of higher population density, with 42% of urban urologists having completed a fellowship compared to only 13% of rural urologists.⁴ The result is an aging urology workforce particularly concentrated in rural areas with new members of the urology workforce who appear less likely to fill the void. How should we as urology residents and fellows address this?

One obvious solution is to provide opportunities for more graduating urology residents to gain experience in nonmetropolitan areas during training. When surveyed, current residents indicated that rural rotations during residency (67.3%) or specific recruitment of medical students interested in rural practice (51.2%) may increase interest in this area. Unfortunately, in 2021, only 16.2% of urology residents reported a rotation or exposure to rural urology in residency. According to the same survey, only 4% of urology trainees planned to pursue rural practice. This lack of exposure could make it difficult for many to even consider rural urology as a viable career path.⁶

Could additional incentives encourage urologists-in-training to consider rural practice? Most residents felt that government legislation would be an effective draw to rural practice (73.2% of respondents).⁶ A recent AUANews article by Harris et al reviewed the SPARC (Specialty Physicians Advancing Rural Care) Act, reintroduced to Congress in March 2023.⁷ This bill would provide loan forgiveness to specialty physicians in rural areas up to $250,000 over 6 years. Furthermore, the Resident Physician Shortage Reduction Act of 2023 would seek to increase resident training capacity throughout the US by 14,000 over 7 years.⁸ This is also a reintroduction of similar language that did not meet a vote in 2019. Though the AUA and the Association of American Medical Colleges continue earnest advocacy of such measures, legislation has yet to advance, and this problem may materialize before federal help arrives.

Another option to address the looming lack of access to rural urologic care is to evolve in our delivery of care to these patients. The use of telehealth may allow us to expand our footprint as displayed by Ferari et al, who connected 3 rural advanced practice provider (APP) staffed satellite clinics by telehealth to their urban West Virginia pediatric urology practice.⁹ Using this arrangement, they calculated travel savings of 4 hours and 46 minutes and decreased financial burden of $173.88 per patient. As trainees, we will benefit from learning to embrace and effectively utilize the assistance of both telehealth and APPs.

Similarly, there is a growing push from our general surgery colleagues to train rural surgeons. As urologists and trainees, we can provide mutual benefit by actively participating in training curricula for rural general surgeons. At our institution, we have worked with our department of surgery to integrate a urology rotation into the rural surgery program, focusing on common urologic emergencies that may be effectively triaged by a community surgeon (eg, ureteral stent placement, difficult catheter placement, testicular torsion, priapism, and hematuria management). In the same vein, several institutions are now offering genitourinary medicine fellowships for internal medicine or family medicine physicians seeking to learn office-based urology. If done well, and with attention to applicants interested in rural practice, this could also help address the impending workforce shortage.

As urology trainees we are poised to enter a workforce strained for urologic care, specifically in already under-resourced rural areas. We must proactively take measures to address this by improving exposure to rural urology, advocating for effective government legislation, becoming adept at integrating telehealth and APPs into practice, and even assisting in appropriate education of our nonurology colleagues who may practice in communities without immediate access to a urologist (Table). It is imperative that we act now to navigate the workforce challenges that we as residents and fellows will soon face.

Since 2002, the AUA Residents and Fellows Committee has represented the voice of trainee members. The Committee’s mission is to address the educational and professional needs of urology residents and fellows and promote engagement with the AUA. The Committee welcomes your input and feedback! To contact us, or inquire about ways to be involved, please email rescommittee@AUAnet.org.