"Brothers in Arms"

Raoul Concepcion, MD

Editor-in-Chief of

Urologists in Cancer Care

Director of Clinical Research Urologic Surgeon Urology Associates, PC Nashville, TN

I am the third urologist in my family, having the good fortune to have both a father and older brother in the same field, albeit in different parts of the country (thankfully for them, they did not have to tolerate my idiosyncrasies on a daily basis). I recall being in medical school during the early 1980’s and my father getting involved with a partnership that involved joint ownership of a “stone machine” with other urologists in the central Ohio area. Unlike some of his other investment ventures, which were questionable at best and not an uncommon scenario for many physicians then and now, the lithotripsy partnership was an absolute home run and provided many years of financial stability to our family. Because the regulatory environment and the amount one could put away for retirement were much more restrictive than they are today, he was able to earn some extra income as a result, and retire a little earlier.

Our specialty has always been able to adapt and adopt new technology and ideas: Lithotripsy is one example from the past, and today that adaptability is evidenced by the evolution of large group practices, which are now becoming more commonplace. I believe much of this has to do with the personality types that enter into this great field, as well as the fact that many urologists across the country had positive experiences with forming successful business ventures with their colleagues, just like my dad, despite being in competitive groups in the same market or region.

For the most part, as classically trained surgeons, we are all über intense and strive to be the alpha presence in the room. As the old joke goes, if you ask a surgeon to name the three greatest surgeons in his field or area, he has no difficulty naming himself, but it is the other two he has problems identifying! Yet, because urologists recognized the need for a business model that allowed for state-of-the-art patient care and also provided financial return, lithotripsy partnerships were (and still are) successful. In forming lithotripsy partnerships, physicians had to relinquish some control to the management team and go against some of their natural tendency to always be the leader.

This holds true today as the urology community continues to adapt: As we evolve toward large group practices, not everyone can be the leader or president. But for the organization to be ultimately successful, which requires a mix of optimal patient management, integrated care, and financial stability, we are oftentimes forced to check our egos at the door and not micromanage and control every facet. This is very difficult for a surgeon to do, and thus not all urologists are suited to work well in a large group model.

But the ever-growing number of independent, large integrated practices in urology highlights the fact that for the most part, we as a specialty are very collegial and open to change. In fact, to my knowledge, no other specialty has a national network that equals what exists among large urology practices. Urologists realize that the biggest threats to our survival are not our urologic colleagues, but hospitals and insurance companies (and I would include the government in this latter category).

Times are changing rapidly in the healthcare environment. The days of walking into the operating theater, no H and P on the chart, telling the occasional off-color joke, uttering the occasional expletive, and having available to you whatever new instrument or latest greatest stent that just hit the market are long gone. They have long been replaced by not being able to even take the patient back to the operating room until the site-appropriate side has been marked, x-rays are available, and an accurate time out has been verbalized with all in agreement. This is all implemented for better, safer patient care, which is at the core of what we do.

In that same vein, we need to begin to migrate toward a system that embraces evidence-based medicine, and begin the development of protocols and the measurement of quality metrics. No longer can we continue to practice by “gestalt” or “feel,” without care for costs to the system or whether or not there is literature to support therapeutic and diagnostic plans. No longer can we say we practice better urology without outcomes data to back our claims. Payers are going to want to pay for quality and physicians who provide better care for the monies spent.

It is up to us as physicians, and not a bureaucrat or insurance executive, to define what those outcome metrics might look like. To that end, all of us, whether we practice in an academic setting, large group, or small solo practice, must work together as a specialty to help define and answer “What is good?” This solution requires working together as colleagues, just as we have done in the past. To borrow a song title from Dire Straits, we need to be “Brothers in Arms” to ensure survival of our chosen profession.