being discouraged about entering urology...

[gooze]

hey guys,

so i was all pretty much set about applying to urology since i do feel that it's a great field that offers a lot of variety, etc. however, recently in my urology rotation, i've met a couple of attendings that have been certainly less than enthusiastic about the future of urology, especially in terms of reimbursement rates and all, and have pretty much told me to consider going into another field. they said that medicare rates get cut every year and that urology is one of the main field that is affected by such cuts since urologists have a lot of medicare pts. they say that a lot of urologists have been forced to come out of private practice because they can't afford the overhead anymore, etc....so now, i'm stuck, i don't know what to do...i like urology but nonetheless do feel that it's important to think about the future of the field as I make my decision now. would appreciate any of your thoughts...thank.

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[badasshairday]

dude that is the issue with every field except for peds. But then they have to deal with medicaid, which is worse paying then medicare.

 

[Enkidu]

hey guys,

so i was all pretty much set about applying to urology since i do feel that it's a great field that offers a lot of variety, etc. however, recently in my urology rotation, i've met a couple of attendings that have been certainly less than enthusiastic about the future of urology, especially in terms of reimbursement rates and all, and have pretty much told me to consider going into another field. they said that medicare rates get cut every year and that urology is one of the main field that is affected by such cuts since urologists have a lot of medicare pts. they say that a lot of urologists have been forced to come out of private practice because they can't afford the overhead anymore, etc....so now, i'm stuck, i don't know what to do...i like urology but nonetheless do feel that it's important to think about the future of the field as I make my decision now. would appreciate any of your thoughts...thank.

Gooze, dental urology is quite a niche field and the prospects are hard to predict. I say go for it and report back on how things are.

 

[tiger816]

I'm a little surprised since I've read the average salaries in this field are increasing. Any thoughts?

 

[gooze]

haha, i actually am using my brother's account to post this...and he's a dental student. i was actually being serious in my original post. any thoughts would be appreciated.

 

[FunnyCurrent]

Gooze, dental urology is quite a niche field and the prospects are hard to predict. I say go for it and report back on how things are.

Dental Urology? No you go to jail for that

 

[Taurus]

Key panel will urge men to skip prostate screening, reports say

 

[Taurus]

Treating patients with prostate cancer is a highly profitable business in the United States, and much of the practice of urology is dedicated to this fight. If men no longer get screened routinely, urologists will see a steep decline in patient visits and income.

 

[Valadi]

This doom and gloom is plastered all over every specialty and has been for the last 20 years. Even the plastic surgeons are crying it.

Bottom line, if you're in a surgical subspecialty you're likely going to be faring better than your average doc. If you're a doc, you're generally going to be more well off than the average citizen.

 

[bronx43]

Treating patients with prostate cancer is a highly profitable business in the United States, and much of the practice of urology is dedicated to this fight. If men no longer get screened routinely, urologists will see a steep decline in patient visits and income.

I don't understand the urologists' argument... well, I do, but it makes no sense. They can't argue that stopping the PSA recommendation will do more harm than good if the PSA test has zero data to show that it extends life on a macro level.

 

[Taurus]

I don't understand the urologists' argument... well, I do, but it makes no sense. They can't argue that stopping the PSA recommendation will do more harm than good if the PSA test has zero data to show that it extends life on a macro level.

I'm more interested in the future of the field. If the govt and private insurance companies stop paying for the tests, most men won't pay out-of-pocket for it. Fewer screenings means fewer surgeries. If prostate surgery is the bread and butter of urology, then urology will take a huge hit. What will the interest in urology be 5 years from now? 10 years? Unlike breast cancer, I don't think there will be much grassroots efforts to reverse it. If I were a 4th year med student, I would think long and hard about these things.

 

[bronx43]

I'm more interested in the future of the field. If the govt and private insurance companies stop paying for the tests, most men won't pay out-of-pocket for it. Fewer screenings means fewer surgeries. If prostate surgery is the bread and butter of urology, then urology will take a huge hit. What will the interest in urology be 5 years from now? 10 years? Unlike breast cancer, I don't think there will be much grassroots efforts to reverse it. If I were a 4th year med student, I would think long and hard about these things.

Oh, totally agreed. This will be a hit to rad onc too.

 

[DoctwoB]

I'm more interested in the future of the field. If the govt and private insurance companies stop paying for the tests, most men won't pay out-of-pocket for it. Fewer screenings means fewer surgeries. If prostate surgery is the bread and butter of urology, then urology will take a huge hit. What will the interest in urology be 5 years from now? 10 years? Unlike breast cancer, I don't think there will be much grassroots efforts to reverse it. If I were a 4th year med student, I would think long and hard about these things.

Most private practice Uro's I've talked to say that the more and more of the money comes from in-office procedures, not the OR. This will definitely lower the income ceiling for uro, where you could get rich by owning a combination uro-radonc center and employ radiation oncologists, buy your own machines, and collect the technical fees, but for the avg. urologist it might not have that big an impact.

 

[gooze]

any residents/attendings that could comment on how they think the new recommendation will affect urology in the near and far future? thanks in advance. appreciate any thoughts/insight.

 

[Taurus]

where you could get rich by owning a combination uro-radonc center and employ radiation oncologists, buy your own machines, and collect the technical fees

Let's think about this for a moment. If you have fewer screenings, then there will be fewer incidences of prostate cases. Fewer cases of prostate cancer = fewer procedures for you and the rad-onc guy, no matter where the setting is. So your logic is incorrect unless you like to do a lot of vasectomies in-office.

What I want to know is, how far does the logic go? If the govt is basically saying that don't screen because most prostate cancers are very slow growing and don't kill, then why stop at PSA tests? You can argue that prostate bx's, surgery, chemo, and XRT shouldn't be reimbursed either or put a lot of restrictions and guidelines before you can get reimbursed. I wouldn't be surprised if this is where we are headed.

 

[DoctwoB]

Let's think about this for a moment. If you have fewer screenings, then there will be fewer incidences of prostate cases. Fewer cases of prostate cancer = fewer procedures for you and the rad-onc guy, no matter where the setting is. So your logic is incorrect unless you like to do a lot of vasectomies in-office.

What I want to know is, how far does the logic go? If the govt is basically saying that don't screen because most prostate cancers are very slow growing and don't kill, then why stop at PSA tests? You can argue that prostate bx's, surgery, chemo, and XRT shouldn't be reimbursed either or put a lot of restrictions and guidelines before you can get reimbursed. I wouldn't be surprised if this is where we are headed.

Which is why I said the income ceiling would go down. These all in one prostate centers, which were previously extremely lucrative would be by far the hardest hit.

 

[ScubaStarved]

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[ScubaStarved]

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[Taurus]

http://www.msnbc.msn.com/id/47505948/ns/health-mens_health/

A top panel of U.S. medical experts has issued a final decision on a long-debated men’s health controversy, concluding that no man of any age should routinely be screened for prostate cancer using the popular PSA test.

The U.S. Preventive Services Task Force gave the prostate-specific antigen test a grade of D, saying that the risks of population-wide screening outweigh the benefits.

 

[KinasePro]

http://www.msnbc.msn.com/id/47505948/ns/health-mens_health/

A top panel of U.S. medical experts has issued a final decision on a long-debated men’s health controversy, concluding that no man of any age should routinely be screened for prostate cancer using the popular PSA test.

The U.S. Preventive Services Task Force gave the prostate-specific antigen test a grade of D, saying that the risks of population-wide screening outweigh the benefits.

Seems like urologists are suggesting to start earlier (age 40), screen LESS frequently, and don't treat low-risk patients. Meanwhile, the USPSTF want's to abandon screening altogether for a curable cancer (2nd most-frequent affecting men...). Have to side with the urologists on this one, I think.

Also, re: urologist's income declining based on these guidelides, I'm doubtful that would happen for three reasons: 1) data shows that these recommendations aren't readily adopted by PCPs, 2) medicare will continue to reimburse for screening anyway, and 3) even if screening stopped altogether, the predicted shortage of urologists over the next two decades is enormous. There is a growing excess of patients needing urologic procedures, and urologists will be as busy as they so want to be for the foreseeable future.

 

[gooze]

can a currently practicing urologist comment on the recently passed statement of the USPSTF on psa screening? how do you see if affecting urologists now and in the future in terms of demand, compensation, etc?? thanks so much.

 

[DocEspana]

No one cares about the USPSTF ("The Task Force") recommendations except for the news media. The task force is assigned with trying to find a way to cut healthcare costs at every single venue. It's hard to cut procedures dramatically as they tend to be highly tailored to the patient presentations. Its much easier to aim your cuts in spending at screening tests. While they make total sense from a medical point of view, the economics of performing a test (That may induce other tests) on a populations regardless of their signs/symptoms at some preset time frame.... well economically it looks like a huge waste of money on 99% of the people who get it. So they pretty much always come down on screening tests. And medicine pretty much always ignores them. Especially since its usually screening tests for cancers, which would make their recommendation unpopular with both physicians and the general populace.

If the USPSTF wants to come down on a screening test for a rapidly growing or highly fatal cancer... then sometimes they are right (or close to right). Because in those cases you can screen all you want. The number of people you'll catch early enough to save is very low. Mostly you'll catch it in time to tell the patient what they will die from. Ovarian cancer comes to mind here. Its not an ideal situation so you stop screening all together since knowing before you have symptoms is no different than waiting til you have symptoms, if you can't do much to change mortality in either case.

A screen that can find cancer in early and super treatable stages (PSA and mammograms): needs to stay regardless of the Task Force's recommedations. The societies (e.g. AUA, Gyne society) simply need to find a way to slightly streamline the cost, rather than accepting the task force's somewhat reckless hack job. It's why you should almost never report a USPSTF recommendation to your attending (this is advice from a 4th years POV). They will laugh at you and tell you no one really cares about the USPSTF, only the <insert specialty society here> recommendations.

 

[lazers]

No one cares about the USPSTF ("The Task Force") recommendations except for the news media. The task force is assigned with trying to find a way to cut healthcare costs at every single venue. It's hard to cut procedures dramatically as they tend to be highly tailored to the patient presentations. Its much easier to aim your cuts in spending at screening tests. While they make total sense from a medical point of view, the economics of performing a test (That may induce other tests) on a populations regardless of their signs/symptoms at some preset time frame.... well economically it looks like a huge waste of money on 99% of the people who get it. So they pretty much always come down on screening tests. And medicine pretty much always ignores them. Especially since its usually screening tests for cancers, which would make their recommendation unpopular with both physicians and the general populace.

If the USPSTF wants to come down on a screening test for a rapidly growing or highly fatal cancer... then sometimes they are right (or close to right). Because in those cases you can screen all you want. The number of people you'll catch early enough to save is very low. Mostly you'll catch it in time to tell the patient what they will die from. Ovarian cancer comes to mind here. Its not an ideal situation so you stop screening all together since knowing before you have symptoms is no different than waiting til you have symptoms, if you can't do much to change mortality in either case.

A screen that can find cancer in early and super treatable stages (PSA and mammograms): needs to stay regardless of the Task Force's recommedations. The societies (e.g. AUA, Gyne society) simply need to find a way to slightly streamline the cost, rather than accepting the task force's somewhat reckless hack job. It's why you should almost never report a USPSTF recommendation to your attending (this is advice from a 4th years POV). They will laugh at you and tell you no one really cares about the USPSTF, only the <insert specialty society here> recommendations.

The people who won't be laughing and who WILL be taking USPSTF recommendations seriously are the PCPs who actually order the screening tests. You're dismissing it without even knowing its implications. I guarantee you that these recommendations will be taken seriously by the FP and IM doctor who will subsequently not order the PSA which will ultimately result in the patient with a low-risk prostate cancer to not be seen by you and therefore not cut upon unnecessarily. The far majority of patients who get treated for their prostate cancer never should have been treated in the first place.

I just realized you're a medical student and obviously too early in your career to have known what I just said.

 

[DocEspana]

The people who won't be laughing and who WILL be taking USPSTF recommendations seriously are the PCPs who actually order the screening tests. You're dismissing it without even knowing its implications. I guarantee you that these recommendations will be taken seriously by the FP and IM doctor who will subsequently not order the PSA which will ultimately result in the patient with a low-risk prostate cancer to not be seen by you and therefore not cut upon unnecessarily. The far majority of patients who get treated for their prostate cancer never should have been treated in the first place.

I just realized you're a medical student and obviously too early in your career to have known what I just said.

Haha. I'm not too early in my career to understand what you said. It makes total sense. I believe your point was the exact fear I was dissuading and you just re-rose it. It is entirely valid and could 100% be what happens. But history says it wont. The USPSTF has been very ineffective in having any penetrance to their best practice guidelines when the specialty society disagrees. The most direct equivalent was the USPSTF recent (~2-2.5 years ago) decision on breast cancer screening. The various gyncologic societies told them that they are right about saving money, but wrong about saving lives (ignoring the USPSTF's morbidity argument entirely). Breast screening with mammography is more frequent than ever, PCPs have not changed their recommendations to patients, Those under 45 are still imaged at rates massively exceeding realistic risk, and patients are still trained to self-assess for lumps; all of which the USPSTF recommended against explicitly.

Again: you could be 100% right. Especially given the USPSTF dropped a two-fer on urology because they also released a study showing conservative non-surgical care has equivalent fatality to prostatectomy in various low-level cancers. I dont know of any examples of them dropping a double hammer on a field for overtreatment. But I would say "if youre a betting man" to bet heavily on it not impacting the practice of urology or the referrals from PCPs. There is plenty of historical evidence that when the USPSTF decides to save money on cancer protocols, the PCPs do not respond as a trend (neither do the specialists). They decide to side with the overly expensive and morbid protocols that prevent mortality (which this may not even prevent mortality.. but thats the second report). Maybe this time will be different, then yea, it will have an impact.

I won't debate if they should or shouldnt be treated. Because I know the student who was in on the USPSTF on that very report. He's convinced me that they are 100% right and have overwhelming data to support their decision.... but I still want to believe the AUA is right on this. And my willingness to overlook a wall of solid data about how much morbidity there is and how much it costs to prevent so few deaths just makes me a very poor person to weigh in on the merits because I *want* to believe the data is wrong. haha.

 

[lazers]

AUA is obviously caring quite a bit about the money its members will lose when patients no longer recieve psa tests

 

[Taurus]

The most direct equivalent was the USPSTF recent (~2-2.5 years ago) decision on breast cancer screening. The various gyncologic societies told them that they are right about saving money, but wrong about saving lives (ignoring the USPSTF's morbidity argument entirely). Breast screening with mammography is more frequent than ever

Maybe you should stop pulling things out of your butt. Breast screenings dipped around 3% after the USPSTF recs. It took a huge lobbying campaign from women's groups and an act of Congress to block insurance companies from denying annual screenings. Make no mistake. The USPSTF for PSA will hurt a lot more than their recs for breast screenings because you don't have an equivalent group of breast activists and survivors. The only question is how much will the dip in PSA screenings be. Over time, I think it will be large, 20-30% or more, especially when insurance companies refuse to reimburse for it.

 

[DoctwoB]

Results from Screening and Prostate-Cancer Mortality in a Randomized European Study (AKA the best prospective RCT on prostate cancer screening)

RESULTS
In the screening group, 82% of men accepted at least one offer of screening. During a median follow-up of 9 years, the cumulative incidence of prostate cancer was 8.2% in the screening group and 4.8% in the control group. The rate ratio for death from prostate cancer in the screening group, as compared with the control group, was 0.80 (95% confidence interval [CI], 0.65 to 0.98; adjusted P=0.04). The absolute risk difference was 0.71 death per 1000 men. This means that 1410 men would need to be screened and 48 additional cases of prostate cancer would need to be treated to prevent one death from prostate cancer. The analysis of men who were actually screened during the first round (excluding subjects with noncompliance) provided a rate ratio for death from prostate cancer of 0.73 (95% CI, 0.56 to 0.90).

While these numbers sound bad at first glance, the number needed to screen to prevent one death (NNS) of 1410 is quite comparable to colonoscopy for colon cancer (NNS of 1250) and mammography for breast cancer (~800-1000), and a PSA is much less invasive and expensive then a colonoscopy or mammogram. The USPTF recommendations, if followed, are going to kill people, plain and simple.

 

[g8orlife]

Maybe you should stop pulling things out of your butt. Breast screenings dipped around 3% after the USPSTF recs. It took a huge lobbying campaign from women's groups and an act of Congress to block insurance companies from denying annual screenings. Make no mistake. The USPSTF for PSA will hurt a lot more than their recs for breast screenings because you don't have an equivalent group of breast activists and survivors. The only question is how much will the dip in PSA screenings be. Over time, I think it will be large, 20-30% or more, especially when insurance companies refuse to reimburse for it.

Just to update this topic, I just called my mom who's a FP at a VA hospital in Florida and asked her about this. She said that ever since the USPSTF, the VA does not allow annual PSAs to be ordered anymore. She said that the VA only allows her to order PSAs ONLY if a pt is symptomatic or the pt requests a PSA.

I don't know how the oganizations in the rest of the country is changing due to the recommendations, but this is ridiculous. It looks like Taurus is going to be closer in his predictions b/c PCPs are definitely cutting back.

Anyone know how this may affect Urology in the future?

 

[KinasePro]

Just to update this topic, I just called my mom who's a FP at a VA hospital in Florida and asked her about this. She said that ever since the USPSTF, the VA does not allow annual PSAs to be ordered anymore. She said that the VA only allows her to order PSAs ONLY if a pt is symptomatic or the pt requests a PSA.

I don't know how the oganizations in the rest of the country is changing due to the recommendations, but this is ridiculous. It looks like Taurus is going to be closer in his predictions b/c PCPs are definitely cutting back.

Anyone know how this may affect Urology in the future?

There are a lot of groups that are starting to collect data to answer this question. If you get plugged into the urology twitter-verse (which is surprisingly active, btw), you will find a lively ongoing debate about the actual effects of the USPSTF guidelines.

This is a pretty sad story, IMO. We're gonna see far more PCa mets with the USPSTF guidelines. Not sure how urology will be affected, but I'm not worried. There is plenty GU pathology around to keep the stream team busy.

 

[DoctwoB]

Just to update this topic, I just called my mom who's a FP at a VA hospital in Florida and asked her about this. She said that ever since the USPSTF, the VA does not allow annual PSAs to be ordered anymore. She said that the VA only allows her to order PSAs ONLY if a pt is symptomatic or the pt requests a PSA.

I don't know how the oganizations in the rest of the country is changing due to the recommendations, but this is ridiculous. It looks like Taurus is going to be closer in his predictions b/c PCPs are definitely cutting back.

Anyone know how this may affect Urology in the future?

It's simple: fewer PSAs => fewer prostate Ca diagnosis + a higher percentage of cases with inoperable mets => fewer prostatectomies. This will be partially offset by the expanding elderly population, and IMO the PSA guideliens won't stick given the results of the ESRPC study and with longer follow up on existing studies.

 

[Taurus]

Just to update this topic, I just called my mom who's a FP at a VA hospital in Florida and asked her about this. She said that ever since the USPSTF, the VA does not allow annual PSAs to be ordered anymore. She said that the VA only allows her to order PSAs ONLY if a pt is symptomatic or the pt requests a PSA.

I don't know how the oganizations in the rest of the country is changing due to the recommendations, but this is ridiculous. It looks like Taurus is going to be closer in his predictions b/c PCPs are definitely cutting back.

Anyone know how this may affect Urology in the future?

Two key takeaways:

1) It takes time for change to trickle down. After the USPTF recommendations, it may take 5 years before you start seeing it impact the # jobs and salaries. Therefore, medical students going into a field because they don't see any changes immediately will get a nasty surprise later.

2) It is my understanding that prostate is the bread and butter of urology. Sure, you may still have kidney stone or renal cancer work, but it's the bread and butter stuff that keeps the lights on and pays your salary.

Bottom line, urology needs to urgently find new growth areas to replace the prostate work.

 

[cpants]

Two key takeaways:

1) It takes time for change to trickle down. After the USPTF recommendations, it may take 5 years before you start seeing it impact the # jobs and salaries. Therefore, medical students going into a field because they don't see any changes immediately will get a nasty surprise later.

2) It is my understanding that prostate is the bread and butter of urology. Sure, you may still have kidney stone or renal cancer work, but it's the bread and butter stuff that keeps the lights on and pays your salary.

Bottom line, urology needs to urgently find new growth areas to replace the prostate work.

Not really. There is a huge shortage of urologists already and it's only getting worse. We are making less than half of the urologists we need each year. Even with the new guidelines there will be plenty of work including plenty of prostatectomies. We did lots of prostatectomies before PSA even existed.

 

[stems]

STARK laws will be also be enforced and loopholes closed in the next 5 years preventing urologists from co-owning radiation centers.

 

[FootballFoot]

Do any urologists have updates on how reimbursement has panned out in 2016?

 

[Medstart108]

hey guys,

so i was all pretty much set about applying to urology since i do feel that it's a great field that offers a lot of variety, etc. however, recently in my urology rotation, i've met a couple of attendings that have been certainly less than enthusiastic about the future of urology, especially in terms of reimbursement rates and all, and have pretty much told me to consider going into another field. they said that medicare rates get cut every year and that urology is one of the main field that is affected by such cuts since urologists have a lot of medicare pts. they say that a lot of urologists have been forced to come out of private practice because they can't afford the overhead anymore, etc....so now, i'm stuck, i don't know what to do...i like urology but nonetheless do feel that it's important to think about the future of the field as I make my decision now. would appreciate any of your thoughts...thank.

Do something you love, these reimbursements change and also, your attendings will complain whenever their pay is cut its only natural, but if you start at a lower salary you won't notice the difference.

 

[cpants]

The sky hasn't fallen yet.