Addressing urology workforce shortages in rural America

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Ruchika Talwar: Hello everyone, my name is Ruchika Talwar, and today we are at the 2024 American Urological Association Annual Meeting in San Antonio, Texas. Today I am joined by Dr. Nathan Grunewald, a urologist at Sauk Prairie Healthcare in Wisconsin. We’re going to talk about some particularly important health policy issues as they relate to labor shortages, especially in America’s rural areas. Dr. Grunewald, thank you very much for your time today.

Nathan Grunewald: Thanks for having me.

Ruchika Talwar: So let’s just set the stage for our audience. We have had a shortage of urologists in this country for several years, and the trends remain concerning as we project the numbers into the future. But in rural America, the workforce shortage is particularly stressed and is a major access issue for our patients. Tell me more about this from your perspective as a urologist practicing in a predominantly rural setting.

Nathan Grunewald: Yes, that’s an excellent question. The situation in rural America is truly shaky. The history and geographic size of the United States actually create clusters of population density. And so, according to the most recent US census in 2020, we have 20% of the US population living in an area classified as rural. Additionally, according to the most recent AUA census, 10% of the urology workforce works in rural America.

And furthermore, the disparity goes even further: the individuals who work in rural America as part of the urology workforce tend to be of an older demographic, near retirement, retired, or actually beyond what most people retire would go. simply because they are trying to meet the needs of the communities. So in addition to the fact that there is already a shortage in the number of individuals there, over the next five years, perhaps even ten years, there is a real risk that numbers will drop even further. And it really gets to an adequacy issue in rural America when it comes to not just access to care, but access to the entire health care framework beyond just urology. We are not the only ones with this problem.

Ruchika Talwar: Yes, yes, absolutely. It’s actually a cycle because it’s difficult to get patients connected when there’s a lack of specialists or perhaps even primary care providers, even a health care system within a hundred miles of where a patient lives. And so you’re compounding the problem if they don’t get preventative care, early detection, screening, etc. And they present at a much later stage in the disease process, whether it is a cancer-related process or a benign urological process. . And that then leads to a more complex situation, higher healthcare costs and higher costs for the patient. So there’s been a lot of focus on how we can address some of these issues in rural America.

So in your opinion, we have paved the way and we know there is a problem. We know the problem could get even worse over the next five to 10 years. What is the way forward? How do we attract young urologists to these underserved areas?

Nathan Grunewald: It’s a complex question and answer. There is no simple switch we can flip to solve our problem. The socio-economic problems associated with it are wide-ranging. And so when we think about what kinds of policies we can have and what we can’t, it really comes down to a matter of advocacy. And so I’m really pleased that we’re seeing movement within, this is a recognized problem within the American Urological Association, within our workforce, and so it’s nice to see that we’re starting to see policies being tightened to address the problem to take. .

From a broader perspective, perhaps from the federal government, we know that the Specialty Physicians Advancing Rural Care Act, which we have introduced now, is in its second or third legislative session, and that is one way that we are trying to incentivize individuals to pursue rural care to consider. . It involves providing loan repayments of up to $250,000 after six years. Every year there is a bit that is forgiven if you stay in the countryside. And we know that if people try it in rural areas and they can establish some roots, and if they do that generally for six years, they’re more likely to stay. So that’s one aspect of the advocacy efforts that are going on right now at the federal level. But we also see that, even within our own specialist association and the AUA, we are trying to attract more people from rural areas to even go into urology.

And sometimes we make that a bit difficult, because we are a difficult specialty to get into. And we also ask you to apply early. And many people don’t even know that urology goes to medical school. So we have a future program that explores how we can attract a broader demographic group that really reflects our patient population, both in terms of gender, race, ethnicity, all of that, but also geography. And so that’s an important part of bringing more people into the specialty and hopefully helping with some of that labor shortage. Doubtless.

Ruchika Talwar: Yes. You raise so many great points here, and I want to expand on them a little more. By attracting young talent and resident applicants and the like, the people who are more likely to return to rural areas are often those who grew up in rural areas and perhaps received their education in these more rural areas. Those urology programs may not have the resources to do extensive research, for example, like you see in some of the major academic medical centers. And when you create a situation where it’s a very competitive specialty, and a lot of people spend years in research and have all these diverse experiences, sometimes we put those rural candidates with those roots at a disadvantage.

And so it’s important to attract residents who may be interested in returning to rural communities. It is important to keep this in mind when assessing residence applications. And the other part of this is introducing those students to urology early. So in rural areas we have often talked about the fact that there are no urologists. So how can we raise awareness of this amazing specialty we practice in? What is the way forward to try to get rural medical students interested in our specialty?

Nathan Grunewald: Yeah, I mean it goes back to how do we communicate and get in at the medical school level? And that in itself is not an easy task. I mean, we’re a specialty here after post-medical school that we train individuals with. So taking the initiative, helping schools develop advocacy groups, helping students eliminate rotations, not making it… In some cases it can be difficult and discouraging, especially if you don’t have a local person. Even if you’re interested in urology, you’ve somehow come across our specialty and you think, ah, that’s an interesting one. You may not have the resources, as you said, to even go to someone and say, how do I do this?

And so maybe one way to do it is to help the medical schools and the program directors of institutions in the area, but also to help, find and maybe expand some of our traditional forms, like a lot of DO schools that don’t have urology where they are. And so it really comes down to an exposure problem. So they are stages of advocacy leadership. You have ignorant people who don’t even know urology exists. We have to get them to the stage of consciousness where they even know we exist, and then how can we help them when they say, Hey, I really want to take action on this. How do we get them to that point?

And this is not an easy question to answer, but I think it is feasible. Really and truly. And I think we’re seeing, even from the AUA, there’s clear encouragement right now. And even with our Diversity, Equity, and Inclusion Committee, this is an important task that we’re working on: How can we, across the board, geographically, help medical students get to know us?

And then if they think they want to come, how can we help them get there?

Ruchika Talwar: Yes. How do we support them? I totally agree. And one of the main reasons we asked you here today was to raise awareness of this problem within the urology community. So as we wrap up here, I want to ask: what are the key insights you want to give our audience? What can we all do to, frankly, help alleviate some of the crisis that we’re going to see in rural America?

Nathan Grunewald: Yes. First of all, whoever hears this, I am already grateful because it is a message that in some cases they are not aware of. Many, even if you are among the 90% of our workforce who live or work in an urban environment, feel this. And some recognize this because as rural facilities lose urologists, or lose health care altogether, that pressure is transferred to the urban centers, and they absolutely feel it. They see the patients arriving from three hours away, an hour away. And so they feel that.

So I think the problem of consciousness is important in itself. The action comes a little later on the question we ask for, how can you help us generate interest in our specialty? But additionally, if we have the interest, how can we help cultivate those individuals to get into the specialty and be successful in the specialty? And in the ideal scenario, we take them to rural areas, which in many cases requires exposure. What can they do, especially from a health care perspective, to highlight the benefits of rural areas? Working in a rural environment has benefits that some people may never have considered before. And so the healthcare systems have to think about that.

That’s one way we can attract specialist doctors there, even if they’re not confident in rural areas, giving them exposure. Our training programs. We’ve talked about this before, not you and I, but in general we talked about it at AUA: are there rural routes? Should we come up with a system for people who want to go to rural locations and practice there? Have some basic requirements and understanding of how to do things.

But what are those barriers? Some of them look like robotics. If you are trained to perform the majority of your abdominal surgeries with a robot and then you go to a rural location where there is no robot, there is some hesitation. Maybe that’s not even why you’re going. What do we think about that? So I suspect that rural tracks could be a piece of this puzzle.

Ruchika Talwar: Yessssssssssssssssssss.. It’s a complex problem, but the great thing is that we have dedicated individuals like you brainstorming, and this issue certainly has the interest of our wider specialist associations, such as the AUA. So hopefully we can all work together and make sure our patients get the access they need.

Nathan Grunewald: Yes, one hundred percent. That’s what it’s all about at the end of the day: improving our patient outcomes.

Ruchika Talwar: Absolute. Absolute. Well, thanks for spending some time with us today. We appreciate it.

Nathan Grunewald: Thank you.