The declining urology workforce situation in America is a matter that is most acutely pressing for rural communities. According to the AUA Census report, in 2022 only 20.1% of urologists in America practiced in designated nonmetropolitan areas (defined as a population size < 50,000).¹ Taken from another perspective, only 37% of all counties nationally were identified to have a practicing urologist.^1,2

This situation is also a disparity matter, related to the fact that—as a group—patients residing in rural communities are commonly older, poorer, sicker, and more remotely located from health care services than patients living in urban areas.² Frankly stated, optimal health care delivery is not readily afforded individuals in rural America. The relative lack of a urological workforce in these communities is a contributor to health care disparity.

To evaluate for urology workforce trends, a team of investigators participating in the AUA Leadership Program Class of 2022 conducted a retrospective analysis of AUA Census survey data over a 5-year time span (2016-2020).³ These investigators found that age and years in practice for urologists in nonurban areas, relative to their urban counterparts, had increased.³ Their investigation also determined that nonurban urologists had less fellowship training than urban urologists and they more frequently worked in solo practice, multispecialty groups, and private practice, in contrast to their urban counterparts, who worked more frequently in single-specialty group practices and academic practices.³ These demographic and clinical practice trends cast further sobering news of the impending shortfall of urologists over time in America, with particular relevance for rural communities.

Given the urgency of this urological workforce issue, a clarion call to action was given by AUA leadership. A need was identified to examine more deeply the factors related to the disparate trends in the rural and urban urological workforce.

A new team of investigators, participants in the AUA Leadership Program Class of 2024, took on this assignment as their team capstone project. Team members were Kathleen Kieran, MD, of the University of Washington; Candace Granberg, MD, of Mayo Clinic Rochester; Paul Chung, MD, of Thomas Jefferson University; and Chris Deibert, MD, of the University of Nebraska; and I was privileged to be their team mentor. This distinguished group designed and implemented a specialized survey instrument based on information derived from interviewing urologists who practice in a nonmetropolitan setting. The survey was then distributed to nonmetropolitan urologists listed in the AUA directory. This exercise was meant to obtain granular information about the day-to-day conditions and challenges of urologists practicing outside urban areas, beyond that learned by prior reports.

There were several illuminating findings. Foremost, difficulties with practice manpower and resource support were described. Various stressors of practice were identified along with reports of high burnout. This team of investigators also explored solutions to the barriers in the practices of nonmetropolitan urologists. Discussion centered on making changes in urology residency programs to increase resident exposures to and training in rural practices, revising systems-based platforms that better integrate rural and urban practices, and improving resources for nonmetropolitan practitioners including telemedicine support and financial reimbursement equity.

A formal report of the team’s findings has been finalized for publication, an output achieved uniformly by Leadership Program teams upon completing their projects. This work product will present details of the findings of the investigative effort for readers to examine and review further. It offers a purposeful next step forward toward acting on the concern of a diminishing rural urology workforce along with addressing a matter of health care disparity.