As new technologies and therapies emerge and treatment of urological cancers becomes more complex, opportunities for urologists to practice within a community setting diminish. Garden State Urology, an independent urology group based in Morris County, New Jersey, has risen to meet this challenge by offering a broader range of care, from screenings to cuttingedge therapies, while striving to ensure patients stay connected with their urologists throughout the treatment path.

Garden State Urology, which formed in 2008 through the merger of 5 urology practices and is affiliated with Atlantic Health System, has 14 locations that strive to offer the same level of care as large medical centers. “We’re trying to bring more and more of this therapy out of the large hospital center and introduce the ability for patients to receive advanced therapies, whether it’s immunotherapy or radiation therapy, in the community, which is far more convenient for patients,” said Sandip M. Prasad, MD, MPhil, the surgical director of genitourinary oncology at Garden State Urology.

As Garden State Urology expands, its physicians try to maintain the personal touch of a community clinic. Keeping patients connected to their original urologist is not always possible when advanced therapy or specialized expertise is required. “If you send a patient to a medical oncologist, then that patient loses track of the urologist, or if that patient gets referred to an academic medical center, the patient isn’t seen back in the community setting—really where they live and where their care has been&mdash;for a long time,” Prasad said.

The practice has been able to maintain these relationships by keeping communication at the forefront of its patient-first treatment protocol. Garden State Urology practitioners believe that patients value the relationships they have built with their providers over years, if not decades, of visits. Implementation of an integrated practice model, in which in-house and outside referrals are available, has enabled Garden State Urology to continue to provide patients with high standards of care while maintaining the familiarity of a communitystyle clinic.

“I think there is value in patients maintaining relationships with the providers who take care of them; and for prostate cancer and bladder cancer, those physicians may have provided care for 2 to 3 decades. Those relationships are deep and strong and should be maintained,” Prasad said.

Making this happen takes careful planning and coordination. “It’s something we actively work on both in terms of communication and design so that patients feel that their doctors are being involved in the plan and they are aware of what is going on,” Prasad said. “And the trust primarily rises from that long-standing relationship, and that’s why patients allow us to continue to care for them.”

Having a network of providers with different backgrounds and burgeoning in-house options allows the practice broad flexibility of care, he said. “We can access novel therapies, whether it’s clinical trials or other agents on the market, and enable providers to refer patients for advanced therapies but also maintain general management of care for their own patients.”

For the past decade, Garden State Urology’s commitment to meeting the needs of any patient who walks through its doors has meant not only growth in specialty care but technological and business expansion as well.

The practice can provide prostate cancer and bladder cancer treatments ranging from immunotherapies to minimally invasive robotic surgeries, including advanced intensity-modulated and image-guided radiation therapy with tomotherapy. Garden State Urology’s determination to keep patients within its network means staying on top of the latest advances and adapting to new treatments, which may require increasing the subspecializations of the provider team.

As part of this effort, the practice has developed an advanced prostate cancer program led by Prasad and Adam Berman, MD. Patients continue to consult with their primary urologists, while doctors in the advanced prostate cancer program handle the day-to-day management of novel therapies.

Prasad explained that this program also teaches providers when to refer patients so that patients are given access to clinical trials or offered new oral agents early in their care, before their disease becomes castration resistant or metastatic. “Historically, those patients have been maintained by their existing provider, but we want them to see us in advanced specialty clinics earlier,” Prasad said.

Providing quality care comes with challenges, such as the transition to and adoption of electronic medical records. To compensate for the increased workload, Garden State Urology has taken steps to build up its back-office staff to ensure physicians do not lose time with patients, Ayal Kaynan, MD, said.

The practice also improves its quality of care by adding physicians who are proficient in diagnosing complex disease and administering the most advanced therapies. Kaynan, who is Garden State Urology’s chief of the section of urology and director of robotic urologic surgery, and his colleagues recognize that bringing in new talent helps to stay on top of new advances, consult on difficult cases, and treat more complicated problems within the discipline of urology. In addition, monthly tumor and radiology review boards are standard practice for the group. The network of medical oncologists, radiation oncologists, primary urologists, and other specialists regularly consult with one another and discuss complex cases. “We bring all the talent in 1 room and get to review difficult cases and discuss controversies in management and create meaningful plans that are, hopefully, useful and productive,” Kaynan said.

“When you have all these heads under 1 roof, you have everybody to tap into and you keep the patient at the center of all that attention. You may be seeing somebody who has several urological problems. You’re especially proficient in handling most of it or 1 very isolated part of it, and somebody else in your group is better equipped to handle the intricacies associated with that care,” Kaynan concluded.

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Implementation of an integrated practice model, in which in-house and outside referrals are available, has enabled Garden State Urology to continue to provide patients with high standards of care while maintaining the familiarity of a community style clinic.

Comprehensive Urology Care Does Not Mean Sacrificing Community Connection

Over the past few years, we have struggled with the continued physician shortage, especially in urology. Although it is forecast that by 2035 there will be a net increase in urologic providers (defined as MDs and advanced practice providers [APPs]), the number of physicians will drop to less than 9000. According to the American Urological Association’s (AUA) 2016 workforce report, the median age of urologists in the United States is 55 years, and 30% have been in practice for more than 30 years! Urology is truly the domain of older physicians.

Now, a recently published survey indicates that 44% of physicians feel burned out and up to 15% have an element of depression.

However, of physicians in 29 specialties polled or represented, urologists top the burnout list at 54% (the AUA reported 39% in 2016). All of us are keenly aware of the contributing factors: payment reform and diminished compensation; information overload, including more drug therapies, advances in genomic testing, and “Dr Google”; and practice burdens, such as electronic health record documentation, long work hours, and bureaucratic paperwork. With the aging population and the aforementioned urologist shortage, we are reaching a critical tipping point for our esteemed specialty. We need to continue to provide care across the board for our patients, but how do we keep our physicians engaged and stimulated in order to capitalize on their wealth of experience and established reputations in the community? These elements are so critical for continuity of care and mentorship of the up-and-coming generation of new doctors.

I would put forth that most of us entered this field to become surgeons. The beauty of the specialty has been the variability of the procedures one needs to master, depending on your clinical interests and type of practice you join. Clearly, though, our specialty has moved away from traditional open surgery toward minimally invasive procedures and active surveillance, which is counter to why many of us in my generation chose urology. This transformation is most acutely seen in surgical oncology where robotic surgery has become a cornerstone for even the most complex of procedures. As a direct result of their video game prowess, our younger colleagues have a distinct advantage with that technology.

However, for the most part, patients are referred for specific clinical signs or symptoms, and the cognitive aspect still is critical to practicing state-of-the-art medicine. This is even more true now, given all the advances that we are currently witnessing, whether in therapeutics, testing, or imaging. For the urologist who feels overworked and overstretched, these paradigm-shifting advances may represent an opportunity to stave off burnout, more effectively use clinical acumen gained over the years, and maintain practice engagement.

Here and in many other publications, urologists have discussed the need to embrace the management of advanced prostate cancer in the increasing number of patients who fail definitive therapy—specifically, by gaining a mastery of the delivery of care that although nonsurgical does require an extensive intellectual commitment. We know that the number of drugs currently approved in the castration-resistant prostate cancer space will continue to increase and numerous trials are demonstrating the relevance of these agents to specific disease subtypes. Additionally, it will become critical to understand the various predictive molecular tests that ultimately will be mandated to effectively layer these various therapies, as well as provide effective counseling for both patients and families. I truly believe that if more urologists can make this transition, they will find themselves challenged and perhaps less inclined to just walk away, knowing that there are opportunities that allow them to stay involved in the care of their patients and advance the science. Their roles, traditionally surgical, will become more diverse and important as disease management takes priority.

, Yuval Harari stated, “The greatest scientific discovery was the discovery of ignorance.” As the information explosion saturates our world, we need to retain freshness of mind and avoid turning our backs on practice-advancing knowledge. Hopefully, the development of advanced therapeutic centers and identification of providers who want to fill these specific roles can result in better continuity of care, less burnout, and continuous involvement of the aging urologist, whose accumulated expertise is so valuable to the rising need for quality urologic care across the country.

The state of the urology workforce and practice in the United States: 2016. American Urology Association. April 2017. www.auanet.org/research/research-resources/auacensus/ census-results.

Kane L. Medscape national physician burnout, depression & suicide report 2019. Medscape website. medscape.com/slideshow/2019-lifestyle-burnout-depression- 6011056. Published January 16, 2019. Accessed February 26, 2019.

For the urologist who feels overworked and overstretched, paradigm-shifting advances may represent an opportunity to stave off burnout, more effectively use clinical acumen gained over the years, and maintain practice engagement.

April 2019 | Oncology Live Urologists in Cancer Care®

Comprehensive Urology Care Does Not Mean Sacrificing Community Connection

Avoiding Urologist Burnout