A recurring legislative priority at the AUA Annual Advocacy Summit has been increasing the urologic workforce in order to address the impending national physician shortage that is affecting all areas of medicine. The Association of American Medical Colleges has projected that the US will face an overall shortage potentially upwards of 100,000 physicians by 2034, with at least 50% of this being among specialty physicians.¹ Moreover, projections from the Department of Health and Human Services have found that the majority of sub-specialties will have a critical national shortage by 2025.²

For urology in particular, the growing demand for urologic care by our country’s aging population as well as the higher average age of practicing urologists create additional strains on the health care system and will contribute to delays in access and treatment. Given the absence of a corresponding medical specialty, relatively unique among surgical specialties, urology has opportunities to “think outside the box” to address access and quality concerns.

Efforts to expand the urologic workforce include advocating for legislation that establishes loan repayment programs to incentivize practicing in rural settings, increasing the number of Medicare-funded graduate medical education slots, and waivers for international medical graduates to practice in underserved areas of the US. While these are all important federal legislative initiatives that urologists should continue to advocate for, it is also prudent to look at means to ease the supply-and-demand burden on our specialty at the individual and health care systems levels. Enhanced interdisciplinary collaboration and education between urologists and primary care providers (PCPs) on urologic conditions could mitigate these issues.

A study at the University of Michigan looked specifically at collaboration between PCPs and urologists in managing men with low-risk prostate cancer on active surveillance. In a survey of primary care providers about their role in the management of patients on active surveillance, they found that 50.5% agreed that PCPs can provide cancer-related care, but many did express concerns about management strategy and the majority preferred a “shared care model,” which was defined as working collaboratively with urologists on active surveillance management.³ Furthermore, those PCPs who agreed that they are able to provide cancer-related care preferred a shared-care or PCP-led model over a urologist-led system for ordering PSA tests.⁵ Developing a broader suite of models of this nature could free up capacity in urology practices while assuring quality care for the population.

Another study demonstrates a mismatch in established guidelines on prostate cancer screening and adherence to these recommendations in clinical practice that can result in potentially worse clinical outcomes for patients, especially among underserved populations. In 2018, the USPSTF published a recommendation on prostate cancer screening that suggested that primary care physicians discuss the increased risk of developing and dying from prostate cancer with high-risk patients potentially eligible for PSA screening.⁴ However, a study conducted by the Council of Academic Family Medicine Educational Research Alliance found that among over 1000 academic family medicine physicians surveyed, less than one-third were consistently having discussions with their Black patients regarding their increased risk of prostate cancer, and only about half of the study’s respondents were engaging in shared decision-making with patients about prostate cancer screening, regardless of the patient’s race.⁵ Given the broad interest in addressing health disparities, new approaches are warranted.

These studies also highlight that establishing guidelines alone without concerted efforts to acknowledge the daily reality faced by our primary care colleagues often leads to a disconnect between practice recommendations and clinical care. When attempting to optimize guideline adherence and quality of care for urologic patients in primary care settings, it is essential that our proposed health policy solutions and clinical guidance are pragmatic in reflecting the realities of urologic and primary care practice. Importantly, we must engage our PCP colleagues with empathy and respect, acknowledging the challenges they face managing the proliferating space of guidelines and quality measures. As noted in a recent study in the Journal of General Internal Medicine, PCPs’ current workload hypothetically exceeds 26 hours per day.⁶

As Dr Helen Burstin, CEO of the Council of Medical Specialty Societies and a national thought leader in quality measurement, and Dr Eric Schneider, Executive Vice President of Quality Measurement and Research at the National Committee for Quality Assurance, state in a recent editorial in the Annals of Internal Medicine, “there is a gap between clinical guidelines and quality initiatives.”⁷ They underscore that effectively bridging this divide between clinical guidelines and quality measures will involve subspecialty societies, like the AUA, creating clinical guidelines that are “precise, evidence-based, and actionable,” in order to improve the implementation of guideline recommendations into high-quality care.⁹ For example, they recommend avoiding vague terms like “population at risk” and ambiguous statements on recommended screening intervals in order to minimize confusion that can hinder optimal management.⁹ On the other side, development of quality metrics must also be done with rigorous scientific methodology and data collection that will require researchers in both urology and primary care to focus on evaluation and validation of quality metrics that explicitly seek to integrate clinical guideline recommendations with quality improvement initiatives.⁹

Ultimately, PCPs serve a vital role in our health care system as frequent, long-standing, and trusted touchpoints for patients. Empowering PCPs to apply their expertise in chronic disease management to other long-term care strategies, such as urologic cancer screening, can help ensure that patients with or at-risk for urologic illnesses receive the highest quality care. These efforts may also help decrease health care disparities as PCPs often are more accessible for patients from underserved communities than subspecialty physicians.

However, establishing clinical guidelines is not enough; we must also be actively engaged in providing support to our PCP colleagues through educational materials, clear communication and documentation, novel approaches such as e-Consults,⁸ and triaged recommendations on when a patient should be referred for urologic intervention. By working to enhance practical, actionable decision-making tools for PCPs managing urological conditions, we can improve the access, quality, and delivery of urologic care to benefit our patients, practices, and the future of urology.