There is a current and worsening workforce shortage of urologists in the United States.¹ This is attributable to limited residency training positions, an aging population (leading to greater demand for health care services), and retirement, aging, and burnout of active urologists (leading to a diminishing supply).^1-4 The shortage is expected to worsen over the next 20 years, with a greater than 15% decrease in urologists per capita.¹ This is especially concerning as the demand for urologic services increases with age.² Without intervention, this shortage threatens to delay urologic evaluation and treatment, exacerbate burnout among providers, and worsen patient outcomes.

One potential solution to the workforce shortage may be found in the growing ranks of advanced practice registered nurses (ie, nurse practitioners) and physician assistants. Collectively regarded as advanced practice providers (APPs), this clinician workforce is growing at a rate much faster than that of physicians. Growth in full-time equivalent physicians is approximately 1% annually, while nurse practitioner and physician assistant growth is projected at 6.8% and 4.3%, respectively.⁵ As many physicians are working less than full time, considering workforce contribution by hours per week leads to growth estimates for APPs that are 10-fold higher than for physicians.⁶ While sometimes associated with primary care settings, APPs have been employed in surgical practices considerably more often in recent years.⁷ In fact, over 75% of practicing urologists worked with at least one APP in 2021, demonstrating promise as a workforce opportunity.⁸

The role of APPs within urology clinical practices continues to increase, and in many environments now includes inpatient consults, emergency room consults, and assisting in surgery. Additionally, prior work demonstrates significant growth in the performance of independent urologic procedures by APPs (Figure).⁹ However, there is a lack of standardized training or supervision for independent urologic procedures by APPs. Summary data from the AUA Census APP report suggest considerable variation in the use of APPs for procedural care.¹⁰ Our study, generously supported by the AUA Data Research Program, will aim to characterize the variation in APP independent procedural care, which can help identify individual characteristics and practice settings in which procedural care is more often delivered by APPs.

Like urologists, APPs in urology suffer from professional burnout. Analysis of AUA census responses by APPs suggests a high rate of professional burnout but without clear findings as to its underlying causes.¹¹ One possibility, supported by studies outside of urology, is that APP autonomy and independence lead to increased job satisfaction and are protective against burnout.¹² This study will aim to understand the relationship between independent procedural care by urologic APPs and salary, job satisfaction, and burnout. We hypothesize that APPs who perform more independent procedures will have better job satisfaction and reduced burnout.

This analysis of procedural tasks and responsibilities of nurse practitioners and physician assistants in urologic practice can help improve our understanding of the division
of labor and the potential for a team-based approach to urologic care. To increase access for patients, urology practices will need to identify tasks that can be shared with APPs to generate available time for urologists to provide care for which they are uniquely qualified (eg, surgery). Ultimately, better models for integrating APPs into urologic practices may allow for increased access to timely and high-quality care for patients. Improving a collaborative team model for patient care, as endorsed by the AUA,¹³ may also maximize job satisfaction for physicians and APPs and create efficiencies to mitigate the ongoing workforce shortage in urology.