Twenty percent of Americans live in nonurban areas,¹ and rural-urban disparities in health care provision are well documented for numerous conditions.^2-4 Urology continues to struggle with an aging and understaffed workforce: nearly two-thirds of American counties have no urologist, the median age of urologists nationally is 55 years, and only 20% of urologists work in nonmetropolitan areas.^5-7 Burnout continues to be a challenge for urologists: 45% of those younger than 45 years old meet the criteria for burnout.⁶ Together, these challenges threaten the continued provision of local urologic care in rural areas, potentially widening urban-rural health disparities. We undertook this study to identify the reasons urologists were attracted to practice in nonmetropolitan areas and describe what they perceive as the most significant challenges in rural practice.

Using data from the 2022 Annual Census as a starting point, we created a secondary survey aimed at Census respondents who self-identified as being in rural practice. Of the 552 urologists receiving surveys, 20.5% responded. Most respondents (92.9%) were male, and 58.0% had been practicing urology for over 25 years. Nearly half (48.5%) reported burnout more than once a month, only 31.9% anticipate being in their current practice at the current pace in 5 years, and 40% indicated that call burden was the primary reason they were considering leaving their practice. Respondents were drawn to practice in nonmetropolitan areas by the lifestyle and the desire to live in a particular geographic area (72.5%), with financial incentives such as loan forgiveness (7.7%) or a signing bonus (6.6%) less important.

Daily stressors for urologists practicing in nonmetropolitan areas (Table) included recruitment challenges, patient access in clinic (especially for patients with urgent issues seen on call), support from other surgical subspecialists, frequency of call, and limited hospital resources. Most urologists in nonmetropolitan areas reported that tertiary care centers were helpful in caring for complex patients through either partnership or transfer, but several respondents reported that tertiary and quaternary systems were not consistently respectful to them during care coordination.

Table. Nonmetropolitan Urologists Describe Their Most Significant Practice Challenges

Respondents offered proposed solutions to what they perceived as their greatest challenges to providing consistent and high-quality patient care. Among these were tailored care guidelines that acknowledge the differential resources available to nonmetropolitan urologists, implementation of national and section meeting educational material specifically directed at nonmetropolitan urologic care, and consistent advocacy for reimbursement and workforce strategies that benefit rural providers. Respondents also highlighted the importance of communicating the different yet still valuable role of the nonmetropolitan urologist in the ecosystem of holistic urologic care. In particular, residency and fellowship training programs should offer exposure to urologic care in these settings and commit to education on respectful interactions between colleagues in various clinical settings.

As a group, we found the responses from nonmetropolitan urologists enlightening: not only was there clear passion for and dedication to the provision of high-quality urologic care in the community, but respondents also identified and prioritized actionable ways to promote and sustain this care. For example, rural urology rotations during residency and financial incentives such as signing bonuses and loan forgiveness are often touted as “draws” to underserved and underresourced areas. However, our respondents found daily challenges more likely to impact their decision to stay or leave nonmetropolitan practice. This work is an initial step in opening the conversation to identify ways to engage all urologists in promoting high-quality care in all clinical settings.

Acknowledgments

We would like to thank Rosemary Frasso, PhD, CPH, and Richard Hass, PhD, from the Jefferson College of Population Health, Thomas Jefferson University, Philadelphia, Pennsylvania, and Todd Carrick and William Meeks from the AUA, Linthicum, Maryland, for their invaluable assistance with questionnaire guidance and development (R.F., R.H.) and questionnaire distribution and data collection (T.C., W.H.).