Young Urologist Manual | 2020

5TH Edition

AUA YOUNG UROLOGISTS COMMITTEE

Transitioning from Residency to Practice Manual

WHAT'S NEW: Entering a Competitive Market Academic Urologic Practice 2020 CPT® Codes

PREFACE:

TRANSITIONING FROM RESIDENCY TO PRACTICE Navigating your new career path?

Questions about transitioning into practice?

The American Urological Association’s (AUA) Young Urologists Committee (YUC) has prepared this manual to guide residents and young urologists during the transition from training to independent practice.

While questions such as, “which type of practice should I enter?” “how do I negotiate a contract?” and “how do I get paid?” are critically important as you navigate your new career path, they may not have been top of mind to ask faculty mentors when working through the rigors of residency and fellowship training.

This manual should not only serve as a guide as you determine what type of practice to enter, but can also help you consider important factors when deciding where you would like to practice as well as provide information on the job search process, contract negotiations, and physician compensation models. Most importantly, this guide also offers wellness tools to help optimize work-life balance and combat burnout.

This year’s edition includes two important additions. The first addresses challenges young urologists face when entering a competitive market such as a large metropolitan area or a subspecialty that is saturated.

In this section, Drs. Sammy Elsamra, Adam Kadlec and Jay Simhan provide practical tips to help young urologists overcome the unique challenges associated with establishing a practice in these complex and challenging markets. The second addition focuses on entering into an academic practice. Drs. Elsamra, Kyle Richards and Benjamin Ristau discuss how entering academia offers both advantages and disadvantages over other practice models as well as relevant tips on how to succeed in an academic environment regardless of subspecialty or practice location. Finally, both the Financial Management and Military Urology sections have been revised to include new and updated information.

I would like to thank the entire Young Urologists Committee, especially Chair-Elect Dr. Kyle Richards, for their hard work and commitment to this Committee and to the AUA. Additionally, the activities of this Committee would not endure were it not for the hard work and commitment of Ms. Sarah Loughlin, the YUC’s AUA staff liaison, to whom we are all incredibly grateful.

I wish each of you great success and fulfillment in your early careers and beyond. Please feel free to email your comments, questions and feedback to youngurologists@AUAnet.org. Updates to this manual are made annually, and we rely on your input to make it better each year.

Steven J. Hudak, MD Young Urologists Committee Chair (2019-2020)

Additional resources, including podcasts, webinars and more for early-career urologists and trainees can be found here: • Young Urologists section of AUAnet.org: www.AUAnet.org/youngurologists • Residents and Fellows section of AUAnet.org: www.AUAnet.org/rfc

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TABLE OF CONTENTS 1. DETERMINING WHAT KIND OF PRACTICE TO ENTER........................................................................................................ 5 2. APPLYING FOR THE POSITION.......................................................................................................................................... 6 3. NEGOTIATING CONTRACTS............................................................................................................................................ 11 4. PHYSICIAN COMPENSATION MODELS........................................................................................................................... 12 5. FINANCIAL MANAGEMENT............................................................................................................................................ 14 6. DEFINING YOURSELF...................................................................................................................................................... 18 7. WORKING WITH ADVANCED PRACTICE PROVIDERS (APPs)........................................................................................... 20 8. WOMEN IN UROLOGY: UNIQUE CHALLENGES............................................................................................................... 22 9. WELLNESS FOR UROLOGISTS......................................................................................................................................... 26 10. CONTINUING EDUCATION & PRACTICE MANAGEMENT.............................................................................................. 27 11. UNDERSTANDING PUBLIC POLICY AND GOVERNMENT ADVOCACY............................................................................ 31

Appendix A. PRACTICING IN A COMPETITIVE MARKET..................................................................................................................... 32 B. MORE ABOUT ACADEMIA.............................................................................................................................................. 34 C. MORE ABOUT RESEARCH.............................................................................................................................................. 35 D. PERSPECTIVE: PRACTICE TYPE AND LOCATION............................................................................................................. 37

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AUA Young Urologists Committee Transitioning from Residency to Practice Chief Editor: Steven J. Hudak, MD

Members of the 2019-2020 AUA Young Urologists Committee: Steven J. Hudak, MD – Chair Kyle A. Richards, MD – Chair-Elect Sero Andonian, MD, MSc, FRCSC, FACS – Immediate Past-Chair Clint Cary, MD – American Medical Association Liaison Sammy E. Elsamra, MD – New York Section Erik Grossgold, MD – Society of Government Service Urologists (SGSU) Liaison Bruce Jacobs, MD – Northeastern Section Forrest Jellison, MD – Western Section Adam Kadlec, MD – North Central Section

Kevin Koo, MD, MPH, MPhil – Residents and Fellows Committee Liaison Mark Memo, DO – Doctor of Osteopathy Representative Jay Raman, MD, FACS – American College of Surgeons Liaison Julie M. Riley, MD – South Central Section Ben Ristau, MD – New England Section J. Patrick Selph, MD – Southeastern Section Jay Simhan, MD – Mid-Atlantic Section Tricia Zubert, MSN, APRN, CNP – APP Membership Committee Liaison Sarah Loughlin – AUA Staff Liaison

Contributing Authors: Nathan Grunewald, MD

Mathew Sorensen, MD

Todd Lehrfeld, MD

Russell Williams, MD

Dima Raskolnikov, MD

Jonathan Wingate, MD

Acknowledgement: This guidebook has been adapted from the original AUA Young Urologists Guide, “Transitioning from Residency to Practice” and includes content from the “Business and Communication” section of the AUA Core Curriculum. Unless otherwise stated, content in the guide should be viewed as opinions and perspective from the authors, and not as official positions of the AUA or professional career, legal or financial advice.

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1. DETERMINING WHAT KIND OF PRACTICE TO ENTER Academia? Large group? Small group? Hospitalbased? Decide what fits best for you.

Practice types are generally divided into four broad categories – hospital-based, private practice, academia and military practice. Read more about each below.

NOTE: Three young urologists share their personal perspective on practice type and more in Appendix D.

1.1 Hospital-Based Salaried employment as a hospital-based physician can be seen as a way to escape the increasing administrative burdens of the profession and/or achieve a more satisfactory lifestyle – especially in a health care environment that is in flux.

Advantages: • Guaranteed salary (typically with an incentivized plan) • Built-in retirement plans • In-house management of administrative affairs (e.g., human resources oversight, billing and collecting, rent and overhead, daily operations management, etc.)

Challenges: • Not being in charge • Patient population defined by the needs of the hospital system • Possibility of compensation changing and/or being evaluated on pre-determined metrics (e.g., quality and patient satisfaction measures) as part of your overall compensation plan Unique opportunities in this practice type include the ability to climb the career ladder to manage multiple practices or become a leader within the organization.

Hospitals may be a stand-alone entity or part of a hospital network such as Kaiser Permanente, Mayo Clinic, Cleveland Clinic, Veterans Affairs, an HCA (Hospital Corporation of America) affiliate, etc.

If considering employment at a hospital, become familiar with the satisfaction level of the physicians employed there. Consider reaching out to current contracted physicians at the hospital for a better understanding of their satisfaction level with their contracts. Reaching out can also provide you with an opportunity to ask questions and seek advice that may help in negotiations.

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1.2 Private Practice Private practices can be organized as a corporate model (where physicians are shareholders) or where one or more physicians owns the practice and employs other physicians or providers. Physicianpractices are often incorporated for tax benefits as well as to protect owners from liability. Owners generally take a salary draw, split any receipts after all expenses are paid, and typically distribute receipts monthly or quarterly; it is often an “eat what you kill” model. This practice type can include solo practices, small or large single-specialty groups, or a multi-specialty group.

Advantages: • Often provides more control over how one individually practices, including the physical set up, management of the electronic health record (EHR)/health informatics system(s), employee selection and what type of patients are seen and how they are treated • Generally allows for decisions to be based on the interests of the owners/stakeholders versus those of an entire health care system • Partial ownership in the corporation can provide financial incentives separate from those received when caring for patients in the clinic, hospital, or operating room Challenges: • Compromising with the interests of partners that may differ from yours • Nurturing referral sources and partnering with hospitals for mutually beneficial outcomes • Partial ownership usually requires an initial investment of time and/or capital to “buy in” to the corporation. This requires the new urologist to acquire a certain amount of fiscal risk

1.3 Academic Practice Academic urologic practice typically entails being hired by a medical school, cancer center, or large hospital system as part of an academic department or division of urology (often the primary site of a sponsoring residency program). One will generally have a rank position within a university or academic structure (clinical instructor, assistant professor, associate professor, professor, etc.) with responsibilities of (and resources for) research, education, and administration. Academic practices still rely on clinical productivity in order to provide salary and benefits unless grant funding subsidizes

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a portion of your salary (depending on the budget approved in the grant).

While most academic practices are administered by the division or department of urology within a medical school or cancer center, they can also exist as employed positions within large tertiary care medical centers with an academic affiliation (perhaps a secondary rotation site of a residency program).

Working in a county hospital or VA medical center may also be part of an academic career, as these faculties often participate in the academic affairs of the sponsoring university.

Hybrid academic positions also exist at private practice groups that service academic medical centers. While opportunities outside of an academic medical center to educate trainees and conduct research certainly exist, academic medical centers typically offer the ability to provide specialized tertiary urologic care in an environment where research and education are prioritized. A hybrid position may be advertised as being able to provide an “academic appointment and academic career,” but unless the setup supports attending conferences, conducting and presenting research, and plays an integral role in the education of medical students, residents, and/or fellows, those critical academic functions may be sacrificed for clinical productivity as required by the practice.

In addition to a busy clinical practice, most academic urologists have the ability to shape the future of urology through research and/or teaching the next generation of urologists. For most (but not all) academic positions, fellowship training and sub-specialty practice is becoming the norm. It is important to look for programs that have a need for your specific area of expertise and interest.

More about this practice type can be found in Appendix B. In addition, more about research as a job function (including funding, clinical trials and more) can be found in Appendix C.

1.4 Military Practice Practicing urology while serving your country offers a breadth of rewarding practice opportunities, as well as chances to go places and do things you would not otherwise have had the opportunity to do within civilian medicine. Military urology positions can range from single-urologist practices at smaller military hospitals in the U.S. and abroad to academic tertiary care hospitals associated with large military installations. Many of these positions are filled by individuals who attended medical

school on a military scholarship program and/or completed residency training at a Military Treatment Facility (MTF), although direct accession into the active or reserve military force is possible. Interested individuals should contact a recruiting office (Army, Navy, Air Force) and ask to speak specifically with a recruiter well-versed in physician recruitment as well as one or several military urologists.

Residents and fellows preparing for a military medical career should become familiar with their service branch’s strategic needs related to fellowship opportunities and practice locations available after training. Military urology leaders differ for each branch of service (Navy Specialty Leader; Army and Air Force Consultant to the Surgeons General).

These leaders ultimately determine assignments for each of the urologists within the active force.

Thus, it is vital to proactively engage these leaders years before assignments are made to ensure the preferences of the young urologist can most closely align with the needs of the service. It is also critically important to convey any special requests (e.g., family health considerations, civilian spouse employment, etc.) so that they may be considered as assignments are made. Once in practice, these service leads will remain an important resource for information about career advancement, military-unique training opportunities, and alternative practice locations. It is also helpful to engage other practicing military urologists to seek career guidance and overall professional support.

After fulfilling one or several active duty service commitment(s), most military urologists transition to civilian urology practice. Federal agencies such as the Department of Veterans Affairs, the Indian Health Service and Military Reserves have programs that credit the time in service, which applies the active duty service towards a federal retirement plan.

Each program is specific and is subject to change.

It is essential to investigate these benefits before transitioning from military service, while future contracts are being negotiated.

2. APPLYING FOR THE POSITION 2.1 Location A key factor to consider when applying for jobs is geographic location. Research the areas that interest you. Is there a high density of urologists? Are the competitive markets already saturated with urologists (note: more about practicing in a competitive market can be found in Appendix A)? Are there less competitive areas with fewer urologists? What

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AUA JobFinder THE ONLINE SOURCE FOR CAREERS IN UROLOGY

The AUA JobFinder is free for all job seekers! We offer a variety of features and resources to help make your job search easy: APPLY ONLINE Search and apply for job openings directly from the site and use the confidential option to maintain your privacy.

FREE AND CONFIDENTIAL RÉSUMÉ POSTING With our enhanced career profile builder tool, confidentially upload a copy of your Curriculum Vitae or Résumé and choose if you’d like recruiters to contact you.

AUTOMATIC EMAIL

NOTIFICATIONS Select your search

criteria for Job Alerts that match your preferences sent right to your inbox.

FIND YOUR NEXT OPPORTUNITY TODAY! AUAnet.org/JobFinder

are the typical payer mixes for these regions? What types of insurance do the patients have?

In addition to these factors, it’s also critically important to consider whether or not the city or practice location is desirable from a personal perspective. If applicable, is the location desirable/ offer employment opportunities for your spouse/ partner? Become well versed with the social opportunities in the vicinity if that is important to you. Dining, night/family life, and school systems can all play a significant role in choosing a location to practice.

NOTE: Three young urologists share their personal perspective on location and more in Appendix D.

2.2 The Job Search In today’s medical job market, urologists are in high demand. A tightening workforce in urology has caused the demand for well-trained urologists to skyrocket. It’s not uncommon for a graduating urologist to receive 9 to 12 job offers prior to selecting a location to practice. Still, it’s important for graduating trainees to begin the job search early.

As in all fields, networking and connections can oftentimes lead to job opportunities. Personal recommendations via networking can be one of the best ways to start your job search. Groups looking to hire will often contact program directors in search of graduating residents or fellows. Leverage your attendings, advisers or program director to see if they know of a job opportunity that aligns with your goals. Even if they don’t, they may be able to direct you to someone else who does.

Academic positions are often not widely advertised, but come about by word of mouth. If pursuing an academic position after fellowship, your fellowship director or mentor will often be able to identify available positions via their own network. You’ll also want to rely on your own contacts within professional associations/societies. Many times, preliminary interviews happen at major urologic conferences (e.g., AUA Annual Meetings or AUA Section meetings) or at sub-specialty meetings.

In addition to networking, consider the number of other ways to find a job that best suits your needs.

Career fairs can be a good way to begin the job search, as they provide an opportunity to engage with numerous employers, recruiters and groups in a relatively short period of time. Working with a recruiter is another way to learn about job opportunities: a good recruiter will consider your

needs and recommend you accordingly to employers who seem to be a good fit. In addition, the AUA’s online career center (JobFinder) and classified advertisements in medical journals and publications such as JAMA, The Journal of Urology® and Urology Times also publish job postings. Lastly, don’t be afraid to leverage social media: Doximity, LinkedIn, Twitter and Facebook provide an opportunity to network while being mobile.

Job Search Resources • JobFinder: AUA’s Online Career Center www.AUAnet.org/Jobfinder • Veterans Affairs Job Postings www.va.gov/jobs

2.3 The Curriculum Vitae Doctors use a Curriculum Vitae (CV) to apply for employment. More common in the academic world and within international medical communities than a résumé, a CV is typically longer than a résumé and provides more detailed, relevant information to employers about your achievements as a physician.

To be effective, a CV should be as up-to-date as possible, be flexible enough to speak to any opportunity for which you are applying, and include your achievements, experience, skills, education, special research projects and publication credits.

Below is a formula you might consider when crafting your CV. [https://www.wikihow.com/Write-aDoctor's-Curriculum-Vitae] 1. Begin with contact information. On the top of your first page, list your full name and credentials, address, phone number(s), pager number, fax number and email address(es).

2. Write a brief objective or career statement. This should be a one or two sentence summary of your current position and your professional goals.

Example: I have completed a fellowship in minimally invasive surgery and have extensive experience in robotic surgery. I am seeking a position in the private practice environment as a urologic cancer surgeon.

3. List any board certifications, including the dates national examinations were taken and passed.

Include a list of states where you are licensed.

4. List your educational history and your professional experience. Share your educational credentials by starting with the most recent institution you attended, and list the schools, degrees and years of attendance. Include any relevant activities you participated in while

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a student/resident/fellow. List all awards and honors you have received.

5. Include a section for professional successes. List any research you have conducted, publications you have written, any teaching you have done for the American Urological Association and awards you have received.

6. List the names and contact information of three or four professional references. It is very important to ask your references if they can be included on your CV and provide them with a copy of your CV in case they are contacted.

7. Include memberships of professional organizations or associations, along with leadership roles held.

8. If you have any gaps in your education or training, it is recommended that you explain the breaks as it may come up in your interview. It is better for you to take control of the gap than to leave it without an explanation.

9. For first time job seekers, it is suggested that you include information about your residency and any relevant volunteer experience.

10. Share all languages that you speak, including your level of fluency.

Tip: Always have an updated CV published and accessible online.

2.4 The Cover Letter A cover letter can be an important part of the application. If the letter doesn’t attract the attention of the person reading it, your entire application package could be discarded. Tips for successful cover letters include the following: 1. Address the letter to a specific person (e.g., the hiring manager or hiring physician) when possible.

2. Use bullet points to differentiate yourself as someone who can excel in the position. Clearly define yourself and your unique skills. Example: As an experienced male infertility and erectile dysfunction expert, I routinely: • Perform microscopic vasal anastomoses • Perform penile prosthesis surgery • Treat Peyronie’s disease with synthetic and auto grafts • Work with a reproductive endocrinologist for assisted fertility cases

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• Market and promote Andrology to the community and to potential referring physicians • Publish articles in peer-reviewed literature on these topics 3. Underscore your commitment to the position by including that you will be calling the hiring manager at a specific time (within a week of submitting your application) to follow-up.

4. In the signature block, along with your name and credentials, include the following: • Phone number • Email address • Any relevant social media handles (i.e., LinkedIn, Twitter, etc.)

2.5 The Interview Congratulations, you’ve been invited for an interview! Now what?

The interview process and site visit allow both the candidate and employer the unique opportunity to not only meet face-to-face, but also to determine if the proposed relationship is a good match for both sides. Nothing can influence an interview more – either negatively or positively – than the interviewee’s preparation or lack thereof. A candidate interviewing for a position should know some of the institution’s history and be familiar with the individuals already in the practice and their area of interest or specialization. Much of this information can be found easily online.

It’s a good idea to practice for the interview before you “go live.” If possible, schedule mock interviews with colleagues who are in the same position. If you currently work at a hospital, ask the human resources department to practice with you for an interview. Most departments will be happy to accommodate you and help you with interview preparation.

Anticipate what questions may be asked during the interview (e.g., “What can you or your skill set bring to the practice that we don’t already have?” or “Why do you think this practice would be the best fit for you?”). Rather than memorizing a scripted answer, prepare three or four talking points so you can respond naturally.

If necessary, take care to also prepare responses to address anything that could be perceived as negative that may come up in a background check (e.g., a past DUI citation, arrest or other previous punitive

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actions). As nearly every practice does a background check as part of the interview process, it’s important to be truthful and upfront about such incidents.

Offering a transparent explanation for gaps in your training or work experience is also important. It is far better to offer a truthful account with a positive spin (i.e., what have you learned from the experience?) than trying to conceal it.

If interviewing at a hospital, a candidate is likely to meet primarily with the physician recruiter who serves as the liaison during the interview and negotiation process. You may also visit with the Chief Executive Officer, Chief Operating Officer, Chief Financial Officer, Chief Nursing Officer, OR supervisor, OR specialist (urologist) and/or members of the marketing department. Be prepared for each of these interactions.

When interviewing for an academic position, giving a Grand Rounds-style lecture during your interview period is typical. While preparing for your interview day, reflect on the factors that interest you in academic practice. Are you a researcher? If so, what kind of research do you want to do (e.g., bench vs. translational vs. clinical trials vs. big data)?

Are you interested in education? If so, what kind of education (e.g., undergraduate medical education, graduate medical education, etc.)? The answers to these questions can help provide the program with a sense of what you bring to the table. Remember, you are interviewing the program as much as they are interviewing you: be sure to ask questions about the kind of support you think you will need for your non-clinical academic interests.

During the interview itself, make an effort to connect with the interviewer on some level. This connection could be anything related to the job itself or a particular interest in the medical practice.

It could also be a personal connection such as a mutual interest in a particular hobby or time spent outside of work. Connecting with the interviewer can differentiate you from other candidates as well as demonstrate your sincere interest in the position.

Additional Tips: • While this may be obvious, take care to arrive early to the interview. Never show up late. Dress appropriately. If there is a question about the attire, it is better to dress too formal than appear too casual.

• Follow the cardinal rule of interviewing: never say anything negative about your former institution, colleagues, residents or students.

• Highlight yourself as a team player. Provide positive examples of your participation in team sports, clubs or societies. Any leadership positions held in any of these activities are certainly worth emphasizing.

• Smile. Sit up and lean slightly forward to convey interest. Be enthusiastic. It is desirable to be remembered, but you want to be remembered in a positive light, so avoid being “over the top” when trying to impress or making a statement if it’s not an authentic reflection of your personality.

• Although salary and benefits are important, it’s not advisable to bring up salary as the first question you have. An employer will expect to answer this question but avoid making it your first question or concern. However, do your research: most of the time, you can get a pretty good idea of salary ranges and benefits from publicly available documents. The benefits package for most universities will be clearly delineated and, likely, non-negotiable. In public institutions, base salaries are a matter of public record (although bonuses and incentives may not be). Salary ranges may be a little more difficult to determine for a private institution where the data is not necessarily made public, but comparing salaries at nearby public institutions can give you a solid idea. Read more about compensation models in Section 4.

At the conclusion of the interview, ask for contact information (such as a business card) for each of the interviewers. Send a thank you or follow-up letter to each individual either via a mailed, hand-written note or by email. Include specific information that was discussed during the interview; including a memorable anecdote or connection can also be helpful.

A successful interview will lead to an employment agreement from the practice or group. Read more about Contracts and Negotiations in Section 3 and before accepting, consider visiting the location again.

If you have a significant other and/or family, discuss having them visit as well. Become familiar with the neighborhoods and the areas’ housing market. After all, this will be your new home.

If you aren’t finding success or direction with your job search, another option is to consider working as a locum tenens physician for a while. Locum tenens provides the opportunity to experience a range of practice conditions and locations, and can help determine what the best job for you actually is. Other advantages include good pay, lodging that is usually provided, and some locum tenens jobs include the option for permanent

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placement if the “fit” is good.

3.1 Needs/Requests

2.6 Resources

Consider the following and whether or not they should be included in your contract:

• JobFinder: AUA’s online career learning center offers free resources and videos on the topics of Standing Out by Building Your Brand, Networking for Job Search and Career Success, Avoiding Job Search Sabotage, Acing the Interview and more.

• Equipment ° Office-based equipment (laptop or desktop computer, flexible cystoscope, ultrasound, etc.) ° Hospital-based equipment (full complement of flexible and rigid endoscopes, surgical instruments, etc.)

https://careercenter.auanet.org/jobseekers/ resources/blueskyLMS/

° Special equipment (surgical robot, ultrasound equipment, operative microscope, surgical LASERs, etc., and an appropriate amount of dedicated surgical “block time” for use)

Job Search Timeline for Residents and Fellows

MARCH/APRIL

• Personnel Requirements ° In your office: nursing and ancillary staff members

Prior to your final year of training (i.e., fourth year of a five-year residency or first year of a two-year fellowship)

° In the hospital: Will they provide appropriately-trained personnel for surgical procedures? It’s especially important to be staffed with a qualified assistant for procedures such as robotic surgery, ESWL and microsurgery.

Schedule a few “meet and greet” sessions with colleagues to discuss job opportunities, locations and types of practices during the AUA Annual Meeting in May.

AUGUST/SEPTEMBER

3.2 Understand Compensation

Begin interviews and hospital/practice visits.

Typically, a hospital will guarantee your salary for one to two years. A suggested negotiated length of an initial contract is three years with frequent evaluations and/or meetings to track progress toward target productivity endpoints.

JANUARY/FEBRUARY

Key questions to consider include:

During your final year of training

During your final year of training Complete contract negotiations and finalize employment selection.

• Does your contract specify that you’ll be evaluated on a quarterly basis?

• Will you be reimbursed based on your work Relative Value Units (RVUs)?

Figure 1: It is extremely important to follow this timeline to avoid scrambling for a job. Limited options weaken the ability to negotiate effectively.

3. NEGOTIATING CONTRACTS You nailed the interview and received an employment agreement contract – congratulations!

What’s the next step? Many physicians recommend hiring an attorney to assist in contract negotiations.

Remember, any contract you sign is a legal document, so having your own legal counsel (or two) review the contract in detail to protect your interests is to your advantage.

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° NOTE: Though contracts will vary, the RVUs are based on national guidelines with an average RVU production of 9,000-10,000 per year. Academic positions generally have a lower RVU requirement to accommodate research activity.

• Will you be paid additionally on a quarterly basis?

• How will you be compensated if you exceed expectations? ° One suggestion is that the physician is paid 75% of any overage of professional fees collected with the hospital keeping 25%.

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Be aware of the billing and collections process, as a hospital may have several other physicians in different subspecialties on their payroll. Therefore, be mindful of the following: • Ensure billing and collections for you is handled promptly and that appeals to third-party payers are processed in a timely fashion.

• Review and audit your own surgical case logs and RVUs. Read more about compensation models in Section 4.

3.3 Contract Renewal Review the policy for continuing your contract.

Contracts can be terminated based on factors such as performance, professionalism or surgical outcomes. It is important to have a 90-120 day termination notice in your contract to have enough time to relocate and move to a new practice location if necessary. While contracts usually suggest a 30-60 day window, this may be inadequate.

3.4 Vacation/Time Off Contracts typically provide 15-20 vacation days per year and national holidays off as part of its time-off package. Be sure this is included in your contract. Emergency room coverage and home call assignments should be clearly defined: you should know if inpatient, ER, and home-call responsibilities will be shared with other urologists on staff or if you are expected to be continuously on call. Weekend obligations should be clearly defined as well. For example, will the “on call” urologist covering your practice round on (and provide care for) your patients currently admitted (i.e., patients who have recently had surgery), or will you need to make weekend rounds on your inpatients even when not on call?

The contract should also state exactly which hospital(s) you cover for call, how often, and whether call coverage is included in your reimbursement package or if call is paid separately on a per diem basis. Additionally, some hospitals do not require urologists to be on call once they have reached 60 years of age, so determine how/if that could impact your call schedule (based on your age and the age of the other urologists in your call pool).

3.5 Malpractice Coverage Malpractice insurance for doctors comes with tail or without tail. “Tail” is coverage that takes effect once you leave a place where you were employed and

practicing. This insurance covers any lawsuit that is submitted to the court on behalf of a patient you treated from the time of you leaving this job until the statute of limitation runs out for a lawsuit to be submitted to the court. This type of coverage can get quite expensive depending on the state, so be sure you know who is expected to cover this.

Once you’ve signed your contract, begin the credentialing process for the hospital as soon as possible. Credentialing can take up to six months to complete. Many hospitals have a separate credentialing process for surgical LASERs and robots. Obtaining credentials in these areas usually requires documentation of platform-specific training and submission of a 12-24 month caselog. Proactively save documentation supporting your training/experience and notify your program director and/or department chief that they may be contacted to validate your credentials in these areas.

Additionally, be aware that each insurance carrier has its own credentialing process. You should be fully credentialed by the time you start your practice so that you can immediately treat patients and thus generate revenue. Be aware of additional state or medical board requirements including fluoroscopy, LASER, or jurisprudence certification.

4. PHYSICIAN COMPENSATION MODELS Most providers are reimbursed for services through several “payers,” including federal and state government programs (e.g., Medicare, Medicaid) and insurance programs offered through employment and individual plans.

Reimbursement usually involves a payment as a percentage of the total bill received and is often impacted by standards set by Centers for Medicare and Medicaid Services (CMS) as well as by negotiations between the provider and regional insurance companies that the provider is contracted with. A co-payment is a small percentage of the bill paid directly by the insured patient. A premium is a monthly charge to the patient in order to stay covered.

There are two basic compensation models with variations: pure productivity and base plus bonus.

Guaranteed total salary is not common, but several healthcare systems (e.g., Kaiser Permanente), government positions (e.g., Veterans Administration), and/or academic positions may offer this. The various payment structures are described below.

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4.1 Fee-for-Service vs. Value-Based Care The fee-for-service model compensates physicians based on the amount of services provided to a patient and is a common payment structure seen in both private and public practices. This varies from other payment structures such as the concept of capitation, which involves paying a provider a fixed amount of money per patient over a pre-specified period of time.

Potential issues that arise with each of these payment methods relate to the possibility of incentivizing providers to “overtreat” or “undertreat” patients.

CMS is promoting payment models that pay for performance in lieu of service. These models tie bonus payments to the quality of patients’ care rather than to how many or how few services are provided. CMS’s primary program is the Quality Payment Program, which was launched in 2017 and features two tracks: (1) Merit-based Incentive Payment System (MIPS), and (2) Alternative Payment Models (APMs).

MIPS is composed of four categories (Quality, Cost, Promoting Interoperability, and Improvement Activities), and participants must complete required components from each category. Participants receive a score based on the amount and quality of reporting they complete. Those scoring above the minimum threshold will receive a bonus of some degree; however, those that do not achieve the minimum threshold will be penalized.

While MIPS moves away from fee-for-service, APMs do so to an even greater extent through value-based payments. Participants must be part of entities set up to share both the costs and risks associated with serving patients. CMS requires the use of technology and metrics to be able to measure the value of the care given as well as the amount of risk the entity must bear. If successful, the financial benefit of being in an APM is more than that of MIPS participation.

However, at this point, as it is difficult to qualify for APMs, there may be limited options for participation in this track.

CMS amends both MIPS and APMs each year, so it is important to monitor changes to the programs and look to the AUA for resources.

4.2 Relative Value Units There are many models currently based on Relative Value Units (RVUs). These are pay-for-performance models where the physician’s training, skillset and time expended to provide a given service are taken into account when establishing compensation.

Compensation based on RVUs provides a model AUAnet.org

that focuses on value-based healthcare more so than the fee-for-service, volume-based model attached to the number of patients a provider sees or the amount of revenue the provider bills for or collects.

RVUs are part of the system Medicare uses to decide how much it will reimburse physicians for each of the services and procedures covered under its Physician Fee Schedule, and which are assigned Current Procedural Terminology (CPT) code numbers. The dollar amount for each service is determined by three components: 1. Provider’s work effort 2. Practice expenses associated with producing the service 3. Professional liability insurance expense Each of these three components is assigned an RVU; to account for variations in living and business costs across the country, each of the three components is multiplied by a factor known as the Geographic Practice Cost Index (GPCI). The three components are added together and the resulting sum is multiplied by a dollar amount known as the conversion factor set by CMS on an annual basis to arrive at the reimbursement dollar figure.

RVUs are determined as part of the Resource Based Relative Value Scale (RBRVS), a system to describe, quantify and reimburse physician services relative to one another. A panel of physicians representing every sector of medicine, known as the Relative Value Scale Update Committee (RUC), reviews the values in the RBRVS scale periodically.

The primary purpose of work RVU compensation models is to align the provider’s compensation to the productivity (as measured by work RVU). This is completed with the use of independent compensation surveys and analysis of expected productivity. The most commonly used “government endorsed” surveys to accomplish this task are: • American Medical Group Association (AMGA) Medical Group Compensation and Financial Survey • Medical Group Management Association (MGMA) Physician Compensation and Production Survey • Sullivan Cotter and Associates, Inc. (Sullivan Cotter) Physician Compensation and Productivity Survey The most common methods of clinical compensation arrangements utilizing work RVU are:

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1. Compensation per work RVU: Also known as an “eat what you kill” model. Providers are paid a set dollar conversion rate for each work RVU generated.

Example 1.

Work RVU

$/Work RVU

8,000

$50

Compensation $400,000

2. Graduated scale: Under this model, providers are paid dollar conversion rates per work RVU based on a graduated scale.

Example 2.

Work RVU Scale

$/Work RVU

$/Work RVU

Compensation

0 - 2,666

2,666

$45.00

$119,970

2,667 5,333

2,666

$50.00

$133,300

5,334+

2,666

$55.00

$146,630

APPROXIMATE TOTAL: $400,000

3. Base guarantee plus productivity bonus: Under this model, providers are paid a base guarantee and receive incentive/productivity compensation for every work RVU generated above a predetermined threshold.

Example 3.

Base Salary

Threshold

$266,650

$/Work RVU $50.00

5,333

Bonus $133,350

Work RVU 8,000

Compensation $400,000

4.4 Resources •

https://www.amga.org

•

https://www.sullivancotter.com

•

https://innovation.cms.gov

• https://qpp.cms.gov

5. FINANCIAL MANAGEMENT This section was authored by Dima Raskolnikov, MD, Jonathan Wingate, MD and Mathew Sorensen, MD. Note from the authors: this text does not constitute professional financial, accounting, legal, or any other advice; we recommend consulting a professional if such services are desired. The products referenced below are meant as examples and are not specifically endorsed by the authors or the AUA. The purpose of this section is to provide a framework for you to consider critical aspects of financial management during an important time in your career. It is not meant to be exhaustive. Just as it wouldn’t be possible for you to decide whether academic medicine or private practice is a better fit solely by reading this manual, so too with decisions related to personal finance. Instead, this section is meant to serve as a guide for further reading and discussion. We hope that you find it helpful.

Census data suggests that you now earn – or are likely to soon earn – approximately $350,000 annually. What should you do with this money?

The right answer involves a combination of the ideas described below, tailored to your specific circumstances, goals and values.

4.3 Bundled Payments

5.1 Emergency Fund

The Bundled Payments for Care Improvement (BPCI) initiative was developed by the Center for Medicare and Medicaid Innovation (Innovation Center). The Innovation Center was created by the Affordable Care Act to test innovative payment and service delivery models that have potential to reduce Medicare, Medicaid, or Children’s Health Insurance Program (CHIP) expenditures while preserving or enhancing the quality of care for beneficiaries.

Provider and hospital expenses are linked to make a single payment for an episode of care with bundled payment models. There are several bundled payment models, including the Oncology Care Model. In this model, oncology practices receive monthly care management fees and are eligible for bonus payments if they lower overall Medicare spending and meet quality goals for episodes of chemotherapy and related care.

How would you fund living expenses if you lost your job, had a medical emergency, or were unable to see ambulatory patients due to practice restrictions placed during a global pandemic? This is the point of an emergency fund. Before considering saving for retirement or any other long-term goal, set aside 6 months’ worth of living expenses in an account that you can access quickly and without penalty. The amount you select depends on your other financial needs and risk tolerance. Emergency funds typically take the form of a savings or money market account.

Such accounts do not earn significant interest, but that is not their point. Instead, emergency funds allow you the flexibility to invest other money in necessarily higher risk ways. For example, you will likely purchase stocks or mutual funds as part of your retirement portfolio. If an emergency struck and you were forced to sell while the market was low to cover living expenses, you will have lost money.

14 The American Urological Association

This is entirely avoidable. Emergency funds have the added benefit of helping you – and potentially a more risk-averse spouse/partner – sleep more comfortably, irrespective of how your money is otherwise allocated. Do not skip this step.

5.2 Debt If you have consumer debt such as high-interest credit cards, pay them off immediately and plan on never carrying high-interest consumer debt again.

Such debt is usually costly (due to high interest rates), not tax deductible, harmful to your credit rating, and ultimately the end result of spending more on a monthly basis than your income allows.

The transition from residency/fellowship to attending is likely the only time in your career where you will see such a dramatic increase in your income.

Using this income to pay off unhealthy debt before increasing your discretionary spending is an important first-step toward financial independence.

A full discussion of the pros and cons of auto loan and home mortgage debt is beyond the scope of this manual. However, it is important to remember that banks will commonly loan you more money than you should borrow, especially as a high-income earner. So how much should you borrow? A good starting point is to keep your debt-to-income ratio (calculated as the ratio of the total of your monthly loan payments to your gross monthly income) well below 1:3. Keeping a low debt-to-income ratio will, much like an emergency savings fund discussed above, provide a cushion of security in the event an unexpected expensive event occurs.

Student loan debt is largely unavoidable. American Association of Medical College (AAMC) data suggest that you may have upwards of $200,000 in education debt. A clear plan for paying this off should be a high priority. Broadly, there are two ways to do this. The first is to seek loan forgiveness.

Many borrowers holding federally guaranteed loans are eligible for income-based repayment. If you made small payments on your loans during residency, it was likely through one of these programs. Payments made through such programs while employed by a non-profit institution (e.g., academic medical centers, VA, and other public hospitals) for 10 years may qualify you for a federal program known as Public Service Loan Forgiveness (PSLF). After 10 years of payments, the balance of your loans is forgiven.

This program has some risk. While it may exist in its current form indefinitely, multiple recent federal

AUAnet.org

budgets have proposed sweeping changes. You may also choose partway through these 10 years to leave for a private employer. However, PSLF could also substantially reduce the amount of debt that you ultimately pay back. Consider a trainee who makes payments during 5-6 years of residency and 1-2 years of fellowship through one of the qualifying federal programs such as Pay As You Earn (PAYE). In a best-case scenario, these payments would be based on a relatively low trainee salary for 8 years and higher attending salary for 2 years. While you could begin making such payments even after training, this will expose a higher salary to the income-based repayment calculation.

Strategies exist to mitigate the effects of PSLF changing or ending if you do pursue this program.

For example, you could set money aside in a personal “PSLF side fund” while making minimum payments. If the program ends prematurely, you could use this fund to pay off your loans. If your loans are forgiven, you’ll have a lump sum with which to invest. Whatever you choose, becoming an expert on student loan repayment options can save you thousands of dollars if you have large amounts of educational debt.

Second, and more reliably, you could just pay off the loans. You may choose to first refinance to secure a lower interest rate, for which you qualify now that you earn an attending salary. Quickly paying off your loans is one of the only forms of tax-free, guaranteed returns. Some argue that this is unwise because you could earn a higher rate by investing in the market. Why pay off $200,000 in debt at 5% interest if you could earn 10% by investing in stocks? These arguments are mathematically sound but ignore both market and behavioral risk. You will not earn greater than 5% on your money if the market drops, or if you forget to invest and instead buy yourself a new car. The freedom and peace of mind that result from eliminating debt are harder to quantify, but are also valuable. You may ultimately leverage this freedom to change jobs, work fewer hours, or otherwise improve your well-being in ways that you might not consider if still heavily in debt.

5.3 Retirement & Investing Of all of your long-term financial goals, retirement is perhaps the most important because it is both inevitable and expensive. How much should you save? The answer is ultimately, “it depends.”

Recognize that by virtue of starting your peak-

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earning years later in life than non-medical professionals, you have already fallen far behind.

As a general rule, to eventually replace a reasonable fraction of your pre-retirement income, anticipate saving 20% of your gross attending salary each year for retirement alone. Begin this practice as early as possible, ideally during residency with a smaller amount. Not only will this establish a useful habit, but it will also ensure that you receive your employer’s retirement contribution match.

This money should preferentially be used for investments within tax-advantaged retirement accounts such as 401(k), 403(b), 457, IRA, Health Savings Account (HSA), and so forth. Each of these accounts has unique advantages that can help maximize the growth of your investments. For example, 401(k) (private, for-profit employers) and 403(b) (nonprofit and government employers) plans allow pre-tax contributions of up to $19,500 (for tax-year 2020). This money grows tax-deferred, enabling you to pay the income tax at the time of distribution (upon retirement at age 59.5 or older), at a rate which is likely to be a lower marginal rate compared to when the funds were initially earned.

While uncertainties will always be present (future tax rates, inflation, status of the financial markets, etc.), failure to educate yourself about, or effectively utilize tax-advantaged retirement programs may cost you hundreds of thousands of dollars over the span of your career.

The good news is that investing is less complicated than many would have you believe. Once you understand the different types of programs and accounts that are available, all that is left is to purchase a combination of investments (e.g., stocks, bonds, and funds thereof) that match your goals and risk tolerance. Low cost, passively managed index funds such as Total Stock or Total Bond Market index funds are likely the best way to do this for most investors. This is particularly true for those saving for retirement who wish to simplify their portfolios. Target date funds or “lifecycle funds” are low-cost mutual funds that track stock and bond indices, changing the ratio of these assets to decrease risk as you approach retirement (i.e., the target date).

If you do nothing more than invest 20% of your salary in such a fund from now on, you will be far ahead of many of your peers in retirement planning.

It does not need to be more complicated. By modifying asset allocation, a similar strategy may be used to save for other long-term financial goals such as a home or your children’s college education.

Some argue that investing is too complicated for you to do on your own and that you should leave this to a financial professional. There are certainly benefits to this approach. If you are not willing to spend time educating yourself on personal finance and investing, or if the alternative is simply that you would not plan or invest, you will benefit immensely by paying someone else to do this for you. Just as importantly, a financial planner may help protect you from yourself. Whatever you pay in fees could pale in comparison to the losses you sustain if you panic and sell inappropriately during a market downturn.

However, recognize that even seemingly small investment management fees can have dramatic effects on your account balance over time. Consider two urologists, both earning $350k per year and saving 20% of their incomes in tax-advantaged retirement accounts. One has educated herself about personal finance and manages this money independently; she pays 0.2% annually in fees for index funds. The second pays 2% annually in fees to a financial planner to invest the money for him. Both portfolios grow at 7% per year. After 30 years, these accounts will hold $6.4M and $4.7M respectively, a difference of $1.7 million dollars, or 30%. What sounds like a small fee results in a very large difference in account balances over time. Moreover, by the time you have educated yourself sufficiently to judge the value of professional advice that you might purchase, you will likely know enough to invest the money yourself. One option to mitigate this effect is to pay a financial planner episodically on an hourly basis to re-evaluate your investment plan. Spending even $500-$2,000 for such advice could ensure that you are on track without resulting in a substantial drag on your annual investment returns.

5.4 Budgeting It will be very difficult to meet any of the above goals without keeping a budget. Free or inexpensive software such as Mint (www.mint.com) or You Need A Budget (www.youneedabudget.com) are available online to help you track and plan your spending.

You may think that your salary is so high that this is unnecessary, but you are wrong. Consider the countless stories of professional athletes making multiples of your salary who manage to declare bankruptcy. No matter how much you earn, it is always possible to spend more. If this idea is too daunting, start by just tracking your spending. Even this simple task will likely encourage you to save and spend more effectively. A common refrain is to “live like a resident” for a few years after training. If

16 The American Urological Association

you can manage to avoid growing into your entire attending salary immediately, you will be able to use this money to pay down debt, save for retirement, fund a house down payment, or achieve any of the other major financial goals that you have likely been neglecting during residency. The other commonly used adage is to “pay yourself first.” This is the concept that you use automatic deposit/transfer processes to contribute to short, intermediate, and long-term savings and investment accounts. This ensures these accounts are appropriately funded before you have a chance to spend the money on discretionary items which have less long-term value (e.g., restaurants, clothing, recreation, etc.). Living by this mentality helps ensure you meet your longterm goals and simplifies your budget because if followed consistently, the money will have been deposited before it was even available to budget for discretionary use in the first place.

5.5 Insurance Consider how life, disability and other insurance can impact your financial wellness.

Life Life insurance should be the simplest insurance to buy because it is conceptually simple and for most young urologists, relatively inexpensive: if you die while you hold the policy, the insurance pays your beneficiaries a lump sum. That’s it.

A typical policy features a 20 to 30-year term, meaning that the insurance company guarantees the payment over that time. You want this term because 20-30 years from now you will hopefully have saved enough money that your dependents would use that instead of your lost future income to support themselves should you die. If you reach this point of financial independence sooner, cancel the policy. In the meantime, opt for a term policy in the range of $2M - $5M. Another option is to “layer” multiple term policies (e.g., $1.5M 30 year term + $1M 20 year term + $500k 10 year term). This provides the greatest benefit when it is needed most (early in your career when you have little in your investment accounts and, if applicable, your children are likely still financially dependent on you), but saves on cost compared to a single high value, long-term policy.

You should be wary of policies such as “whole life insurance,” which are sold under a variety of confusing names and seek to combine aspects of insurance and investing. They are almost never the best option for either of these purposes and are sold by agents who stand to earn high AUAnet.org

commissions if they can convince you otherwise.

Disability Consider that you may have a 30-year career ahead of you. Not accounting for inflation or changes in reimbursement structure, this may amount to $10.5M of earning potential over the span of your career ($350k x 30 years). If you currently owned a fragile item worth $10M, would you not insure it? That’s what people without disability insurance are doing. Disability insurance is expensive because people frequently submit claims for these policies. Recall all of the patients that you have seen throughout your training with illness or injuries that restrict their ability to work. Now think of all of the ways that you depend on your health to optimally function as a urological surgeon: you must be able to think rapidly and clearly, have the stamina to stand for several hours at a time, and retain excellent gross and fine motor function. It is not difficult to imagine how a decline in any aspect of your health could restrict your ability to earn a high salary during your peak working years. High-quality disability insurance policies will protect you if this happens. You should look for an own-occupation, specialty-specific, individually owned disability insurance policy.

Purchase this policy as soon as you can afford it – ideally in residency – or run the risk that new medical conditions you develop will be considered pre-existing and thus uninsurable.

Other Review the coverage that you have selected on your existing insurance policies, including things like car, renter’s, or home. Now that you can more easily afford it, you may wish to increase the liability limits on these policies. Even if you currently have a negative net worth, your profession may make you a target for litigation.

You should further expand coverage by opting for umbrella insurance that kicks in when an existing policy reaches its coverage limits.

For example, consider a car insurance policy with a personal liability limit of $500k. A $5M umbrella policy would cover you for claims between $500k -$5M, even if such coverage is not offered by the car insurance company itself.

Additionally, even large umbrella policies are relatively inexpensive, given the very unlikely possibility of a claim under them. Importantly, umbrella insurance does not cover malpractice, so be sure to review these policies with your employer separately.

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We hope that this section is helpful to you as you navigate the financial transition from training to practice. Fortunately, there are many excellent resources to which you may turn for further reading. Online communities such as The White Coat Investor and Bogleheads, along with a book published by the former, are both terrific places to start. Good luck and congratulations.

6. DEFINING YOURSELF As a junior member of your practice/department, it’s important to establish yourself as a capable and hardworking urologist to your new colleagues while also building a rapport with your patients and local community. Relationships are vital. Get to know your referring physicians. Introduce yourself to colleagues. Identify senior colleagues who you trust to act as mentors. Other ways to build relationships include volunteering to speak at local health advocacy groups and/or joining hospital committees.

Below are some things to think about as you begin to establish these important connections.

6.1 Examine Yourself • What is your niche? Is there a unique clinical area that you would like to commit a large amount of time and effort to?

• What can you provide that is currently lacking at your new practice? What skills do you bring to your group that can address these areas?

• Are there ways you can support your group in a nonclinical capacity (e.g., leadership, business acumen, research, etc.)?

• What untapped revenue streams exist in your community?

• Are you willing and/or able to take on complex and difficult cases that others may not wish to tackle?

6.2 Develop a Referral Base • Take exceptional care of your patients. There is no substitute for safe, high-quality medical and surgical care delivered in a patient-centered, wellcommunicated manner.

• Introduce yourself to key leaders in the medical group (this can usually be facilitated by the practice manager).

• There is nothing better than face-to-face interaction. Hospitalists often take care of inpatients and few primary care doctors round

on patients during the day. As such, the “esprit de corps” has changed in the hospital and it has become more difficult to meet colleagues.

Some hospitals have “liaisons” to assist in these introductions. However, going out to meet referring doctors on your own can also be well received. Offering your personal email and cell phone contact information demonstrates that you are serious about addressing patient concerns swiftly.

• Be kind to everyone. Remember, everyone talks.

One bad interaction will spread much further than several good interactions. Your reputation is gold, and can be impacted by early negative interactions. Exercise caution when posting on social media, especially when posting both personal and professional experiences.

• Let the operating room staff know your specific area of expertise and set up lectures to demonstrate. Those referrals will grow quickly!

6.3 Staff Selection Everything that happens to your patient while under your care reflects back on you, so it’s critical to surround yourself with a high quality support staff, including: • Advanced Practice Providers (Physician Assistants, Advanced Practice Registered Nurses) Read more about working with APPs in Section 7.

• Nurses (RNs, LVNs) • Medical office assistants • Administrative assistants

6.4 Publicity • Your highest degree of visibility will come from patients talking about you to their friends, family and their other doctors. However, when building a practice, you can further define yourself with publicity. Either the hospital or your group can advertise your arrival with mailings to the community, patients and affiliated physicians.

• Another way to introduce yourself is with scheduled lectures (i.e., “grand rounds”) at your hospital(s). Some larger medical groups have their own lunchtime talks that can often be a great introduction to referring physicians.

• Speaking with local advocacy groups, patient support groups and even the local high school can also assist in getting your name out there.

• Hospital public relations staff often publicize

18 The American Urological Association

accepted abstracts of academic urologists that result in free press.

• Consider volunteering at patient support groups (e.g., Us TOO).

• Participate in research projects or mentorships at local colleges.

• When given the opportunity, participate in interviews and review articles in magazines and journals.

6.5 Leadership and Mentorship Opportunities Take advantage of the many leadership opportunities and programs for young urologists.

AUA Leadership Program The AUA Leadership Program is a twelve-month leadership experience for Active members of the AUA who are interested in future leadership opportunities within the organization. Launched in 2004, the program seeks applicants who are fifteen years or less out of training interested in developing their leadership skills, expanding their network to accelerate their professional growth, learning about AUA's operations and reach and being mentored by Past AUA Presidents and Board Leaders.

Early-career urologists with an interest in AUA involvement should strongly consider applying for the program.

Benefits of the Leadership Program • Expand your professional network to include program mentors who are leaders in the field and have served in leadership roles such as an AUA President or Board Member, as well as Leadership Program alumni and current leaders across the organization.

• Learn about the AUA's sphere of influence and its impact on urology worldwide.

• Evaluate and understand your leadership capabilities to develop opportunities to address any leadership gaps you may have.

• Collaborate with Leadership Program participants under the guidance of a mentor to develop projects that will enable you to make significant contributions to the AUA. Learn more about the Leadership Program at www.

AUAnet.org/Leadership.

Gallagher Health Policy Scholar Program The Gallagher Health Policy Scholar Program is a one-year program that offers a unique opportunity to AUAnet.org

participate in a variety of health policy activities that affect urology practice. Each year, the AUA selects one Gallagher Health Policy Scholar. As part of the program, the awardee: • Participates in the Executive Leadership Program in Health Policy and Management at Brandeis University • Receives intensive training on a wide variety of health policy issues, including mentoring from seasoned physician volunteers • Participates in key conferences – including the Annual Urology Advocacy Summit – and other relevant meetings with agencies and lawmakers Previous Gallagher Scholars are now among some of the AUA's top health policy leaders, and point to their participation in this program as a key step in making the transition into leadership roles.

Learn more about the program at www.AUAnet.org/ advocacy.

Science and Quality Fellow Program The Science and Quality Fellow Program is designed to advance the fields of guidelines, quality and data. Open to AUA residents in their research year, fellows, and first-year post-graduates, program highlights include: • Participation in the AUA Quality Improvement Summit • Participation in the Brandeis University Executive Leadership Program in Health Policy and Management • Participation in a Guidelines panel meeting • Attending the AUA Annual Meeting, the Science and Quality Council meeting, three committee meetings and the AQUA Forum • Attending the Epidemiology and Population Health Summer Institute at Columbia University (online course) Learn more about the program at www.AUAnet.org/ advocacy.

H. Logan Holtgrewe Legislative Fellowship Open to AUA residents in their research year, fellows, and first-year post-graduates, the H. Logan Holtgrewe Legislative Fellowship program provides unique opportunities to be involved on Capitol Hill and in policy issues impacting urologists and their practices. The Holtgrewe Fellow completes a four- to six-week fellowship with a legislative office in Washington, D.C., participates in the Annual

19

Urology Advocacy Summit on Capitol Hill and attends the Alliance of Specialty Medicine fly-in event. Fellows also attend the American College of Surgeons Executive Leadership Program in Health Policy and Management at Brandeis University and are actively involved in the AUA's Public Policy Council and related committees.

Learn more about the program at www.AUAnet.org/ advocacy.

“advanced practice providers (APPs).” The term “allied health professional” includes nurses, medical technicians, and assistants. All must be working in a urology-based setting for at least one year to obtain these respective designations. The AUA endorses the use of APPs in the care of genitourinary disease through a formally defined, supervisory role with a board-certified urologist under the auspices of applicable state law.

International Exchange Programs

7.1 Defining the Nurse Practitioner (NP) Role

The AUA's Academic Exchange Programs provide promising young urologists the opportunity to gain a global perspective in urology while broadening their cultural horizons. These reciprocal programs include a 2-4 week educational experience at an academic institution(s) and attendance at the national society's annual meeting. During the exchange, participants observe urologic surgeries/procedures, attend clinics, present lectures and take part in staff activities.

“APRN” is a term that covers four distinct roles: certified nurse practitioner, certified nurse midwife, clinical nurse specialist, and certified registered nurse anesthetist. Each APRN has obtained a Bachelor’s of Science in Nursing (BSN) prior to admission to a graduate program; some students may have additional undergraduate and graduate degrees.

The student APRN then undergoes a broad-based education at the graduate level and sits for a national certification examination to assess competencies of their specific core and at least one population focus area (such as adult-geriatrics or pediatrics). After passing the certification examination, individuals are licensed as independent practitioners subject to the specific regulation of a state board of nursing.

Licensing implies congruence between certification, licensure, and population focus; an APRN cannot be licensed only in a specialty area, such as urology, but must first be certified in one of the four generalist APRN categories. The academic degree granted is either a Master of Science in Nursing (MSN), a Master of Science (MS), or a Doctorate of Nursing Practice (DNP), depending on the individual program. The role of the NP includes diagnosis and treatment of both acute and chronic conditions.

This extends to comprehensive history and physical examination; preventative screening and health assessment; ordering and interpreting laboratory and imaging studies; and prescribing medication, physical and occupational therapy, and durable medical equipment.

The AUA offers academic two-way exchange programs with the following countries/regions: • Brazil • Europe • Japan Learn more about the program at www.AUAnet. org/education/global-academic-exchanges/exchangeprograms.

7. WORKING WITH ADVANCED PRACTICE PROVIDERS (APPs) Content in this section is taken from the AUA’s 2013 Consensus Statement on Advanced Practice Providers. The full and most updated version of the statement can be accessed at https://www.auanet.org/advocacy/comment-letters-andresources/advanced-practice-providers.

A workforce shortage of 65,000 physicians is projected for both primary care and specialty medicine by the year 2025. Similarly, the supply of urologists per capita in the United States continues to decrease, a trend that started in 1991 and continues to accelerate. In 2009 there were only 3.18 urologists per 100,000 in the population, which is a 30-year low and amongst the most severe specialty medicine shortages. This is compounded by the fact that urology has the second oldest surgical subspecialty workforce with an average age of 52.5 years, of whom greater than 18% are age 65 years or older.

As of February 2014, the AUA recognizes advanced practice registered nurses (APRN) and PAs as

7.2 Defining the Physician Assistant (PA) Role The PA is a medical professional who is a graduate of an accredited PA program who is also nationally certified and state licensed to work with the supervision of a physician. PAs undergo training based on the medical model with a focus toward primary care, including courses in pathophysiology, pharmacology, physical diagnosis, laboratory science, and microbiology. Specific rotations in

20 The American Urological Association

diverse environments such as family medicine, internal medicine, pediatrics, general surgery, and obstetrics comprise clinical rotations for PAs and emphasize primary care, office practice, or longterm care facilities. Prior to admission to a PA program, students have various undergraduate and graduate degrees, with a minimum of two years of college courses in basic or behavioral sciences.

The academic degree granted after completing a PA program is usually a master’s degree, and they must pass a certification examination for licensure.

In clinical practice, the role of the PA is as part of a team practicing medicine with physician supervision, and is frequently described as delegated autonomy.

The PA model of education emphasizes disease prevention, elimination of health disparities, and promotion of health and healthy behaviors. The PA provides care for patients across the health continuum, and functions in diverse settings that can include internal medicine subspecialties and acute care environments. This extends to comprehensive history and physical examination skills; preventative screening and health assessment; ordering and interpreting laboratory and imaging studies; prescribing medications; and assisting in surgery.

7.3 APPs in Urology Practice The official position of the AUA is that APPs work in a closely and formally defined alliance with a urologist that serves in a supervisory role. This physician-led, team-based approach provides the highest quality urologic care. As the physician-led, team-based approach evolves, so do the definitions of supervisory and collaborative models of care between physicians and APPs. The role of the APP in a urology practice is dependent on many factors, including academic versus private practice, large versus small group, APP experience, physician comfort level, and state laws. The supervisory/collaborative model in urology may be described as delegated autonomy. This autonomy process has a natural growth over time as the physician and the APP become accustomed to working together, which leads the team to provide the highest level of quality urological care.

Although the physician is responsible for the overall care of the patient, the concepts of supervision and collaboration do not require that the supervising physician be present with the APP during APPprovided care. As the physician-APP relationship grows and evolves, the duties delegated to the APP are designed to deliver quality health care while reserving the physician to attend to more complex AUAnet.org

patient care suited to his or her level of expertise. A highly skilled APP will be eligible for this indirect supervision.

Supervision/collaboration is a process in which an APP works with one or more physicians to deliver healthcare services within the scope of the practitioner’s expertise, with medical direction and appropriate supervision as provided for in jointly developed guidelines or other mechanisms as provided by the law of the state in which the services are performed. This requires that each party share responsibility for care. Supervision/collaboration is an interactive process involving trust, excellent communication, mutual goals, and common direction in practice. It is a dynamic process dependent upon skills and competencies of the APP and physician.

An important component of collaboration requires professional relations that foster best patient outcomes and the optimal use of individual skills.

In most instances, prior urology experience will be limited, and for that reason sound problem solving and decision-making skills will mature with time.

Delegated tasks must be mutually understood and agreed upon. As such, ensuring that team members realize their potential for efficiency and high-quality care requires appropriate support, encouragement, and training tailored to the experience level of the APP. Newly graduating APPs and APPs new to urology will require strong physician-APP communication and a period of direct supervision and orientation. This team model is an efficient way to provide high-quality medical care.

Models of team-based integrative care are based on the needs of the particular practice. Examples can include: assisting in surgery, seeing postoperative patients, hospital consults, emergency room consults, and overflow office patients. This allows the physician to see more complex urologic patients.

Outreach clinics can also be staffed by experienced APPs. Preoperative and postoperative educational classes that can be conducted by APPs can increase patient satisfaction and patient retention. In the hospital setting, consultations, history and physical examinations, and difficult bladder catheterizations also can be performed by APPs. In the clinic setting, certain procedures such as prostate ultrasound, urodynamics, cystoscopy, vasectomy, and stent removal have been performed by APPs; however this remains an area of controversy that requires further study. Factors such as APP education level, APP proficiency with procedures, state scope of practice laws, and the level of comfort for the supervisory/ collaborative physician must be considered in order

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to maintain the highest quality and patient safety for urologic care.

State laws governing APP supervision can have subtle differences between states. States that have restrictive language regarding the physician’s delegating authority are challenged and modified regularly. The purpose of these challenges is to improve the physician’s ability to extend access to care through physician-APP teams. More and more states use language that defines supervision more broadly and look to repeal laws that require physicians to be present at their practices for a set number of hours.

The most effective physician-APP team practices provide optimum patient care by designing a practice model in which the skills and abilities of each team member are used most efficiently. Ideally, physicians are not involved in care best provided by APPs and similarly, APPs do not undertake tasks best provided by physicians. Studies consistently find enhanced quality of care in settings that fully integrate physician-APP practice.

7.4 Resources For additional information, please refer to the following resources: • AUA Consensus Statement on Advanced Practice Providers (www.AUAnet.org) • American Academy of Physician Assistants (www.AAPA.org) • American Association of Nurse Practitioners (www.AANP.org) • Society of Urologic Nurses and Associates (www.

SUNA.org) • Urological Association of Physician Assistants (www.UAPAnet.org)

8. WOMEN IN UROLOGY: UNIQUE CHALLENGES TO WOMEN IN THEIR EARLY CAREERS This section was authored by Julie Riley, MD, Assistant Professor and the Director of Endourology, and Director of Urologic Research at the University of New Mexico.

While gender equality is steadily improving in the U.S., it is important to remember that women in urology are still relatively new, with the first becoming board certified in 1962. Currently, 9.2% (1,167) of practicing urologists are women – but with women accounting for a quarter of urology residents

(and 22% of female practicing urologists 45 years old or younger1), the number is steadily increasing.

Furthermore, in the 2020 Urology Match, there was a record high match rate for women at 86%.2 It’s also important to note that there are currently an equal number of male and female medical student admissions.

8.1 Practice Patterns When entering a practice, women can oftentimes be pigeon-holed into seeing the female patients – even if this isn’t necessarily the desire of the physician.

While this may be a much-needed role to fill within the practice, it is important to consider that these cases can often result in non-operative conditions that could potentially lead to decreased earnings.

Suggestions to help with practice patterns: • Prior to joining a practice, discuss your targeted patient population with partners and consider adding clauses to contracts to note this.

• Market to your target population.

• If your target population is female patients, ensure your compensation reflects the work you do given that the RVUs and operative case potential may not compare to other subspecialties.

• Ensure that those who schedule for you understand your desired patient population.

The front staff can have significant influence on the patients scheduled into clinic. Some schedulers, for example, may ask patients if they mind seeing a woman. While non-malicious in intent, this question can be a very subtle way in which your practice can be dramatically affected.

You may need to be involved in scripting the language used by schedulers, front staff and even Advanced Practice Providers within your practice who may refer patients.

8.2 Work Life Balance The term “Work Life Balance” is a bit of a misnomer. There is no magical, harmonious balance between work and life. There are moments when life outside your profession will become priority and others when work will. Feeling guilt for prioritizing one over the other can distract from both productivity and satisfaction. Be present in what is happening in the moment and realize it is a give and take: no one is perfect; stop feeling guilty about it. Evaluate and prioritize your time and stick to it.

Suggestions include the following:

22 The American Urological Association

• Keep a unified calendar for your work and personal life.

• Determine which events are important well in advance like family commitments or work events and put them on the calendar. Calendared events could include school schedules, spouse/partner/ family schedules, celebrations/milestones such as birthdays, anniversaries, etc.

• Set time limits on activities and do not do anything else (such as check email, take phone calls, etc.). When the time is up, move on to the next activity.

• Ask for help when you need it. If you don’t have the support staff you need, ask for it (particularly if your male counterparts have this help).

• Streamline or simplify household duties like using a house cleaning and/or laundry service if it will help.

• Schedule 20 minutes periodically for yourself (really, schedule it). A happier doctor is a more productive doctor. Remember, you would never miss a day in the operating room because there “just wasn’t enough time in the day.”

Another issue more prevalent for women can be the inability to say no and/or the strong desire to please those around them. It is important when you say yes to something that it is meaningful and you do what you say you will do. It is important to say yes to some things (particularly things you are passionate about), otherwise the opportunities will begin to dwindle. On the other hand, taking on too much can be counterproductive and lead to decreased satisfaction and quality overall. Consider having two or three close friends to vet out a new offer. If the offer is not desirable, practice a professional way to say no. Make sure that whenever you do say yes to something, you do it and take credit for it.

8.3 Burnout Women are disproportionately affected by burnout.

In 2017, Medscape reported that 70% of women urologists suffer from burnout compared to 49% of men.3 These numbers have been increasing over several years. Women usually experience burnout differently than their male counterparts. The first stage for women is emotional exhaustion. The belief is that women tend to support others in their lives and there is only so much emotional support to go around. The second stage for women is depersonalization and cynicism. This is a way to detach from the stress and overwhelming nature AUAnet.org

of medicine. It is usually short lived for women and often leads to the third stage of reduced accomplishment or a sense that one’s work doesn’t matter. Men more often start with depersonalization followed by emotional exhaustion. Rarely do men reach the third stage of feeling like they are a bad doctor. Because genders typically experience burnout differently, the presentation is also different. Women tend to first feel a lack of energy and inability to recover even with time off, followed by cynicism and blaming patients, which can lead to subsequent feelings of inadequacy. Men, on the other hand, tend to present first with blaming patients and cynicism, followed by exhaustion. It should be noted that younger physicians are more likely to suffer from burnout. This makes early-career women urologists particularly susceptible.

Unfortunately, burnout can lead to depression and even worse, suicide. Male physicians have about a 1.41 relative risk of suicide to the general population. Compare this to female physicians who have about a 2.5 relative risk to the general population. In addition, women physicians have a suicide completion rate comparable to their male counterparts, which is in contrast to the general population where completion rates are lower for women.4 This has not been specifically studied in urologists.

One of the best treatments for burnout is social support. This has been shown to be more effective than even counseling or therapy. Reach out when feeling even the first signs of burnout and reach out to others when it is recognized in colleagues and friends. Other suggestions to decrease burnout include exercise, meditation, mindfulness, setting boundaries, getting more sleep and even just simply pausing and taking a deep breath. See Section 10 for further resources on wellness.

8.4 Gender pay gap There is a gender pay gap in the United States. As of 2015, women are paid 20% less than men for equivalent work. While the gap has significantly improved since the passage of the Equal Pay Act in 1963 (when women earned 31% less than men), at this rate, it will take until the year 2152 to totally erase the gap.5 Urology has not been spared from this. In fact, in 2017, urology had the third largest gender pay gap among all medical specialties and the widest gap among surgical specialties. Women urologists on average were found to make 20% less than male counterparts. This equated to $84,799 less per year.6 Maintained over the course of a career,

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this represents a nearly $3 million loss to women.

While other factors such as less hours worked, more part-time work, maternity leave and others have been attributed to the pay gap, women urologists were still found to make approximately $76,000 less than men when variables that would affect take home pay were controlled.7

After a break of up to three months or more, many surgeons will be rusty on surgical skills. This is a good time to consider scheduling less complicated, shorter cases while readjusting. If doing longer/larger cases, consider having a senior partner backup in case a break is needed for pumping or simply to take a little stress off.

See Section 8.6 for information on negotiating.

Unfortunately, there may be unavoidable discrimination related to maternity leave, even if unintended. The good news is that maternity leave has been taken by many successful female surgeons throughout their careers; reach out to those who have done this before and take advice. If your particular practice hasn’t had experience with maternity leave, checking out groups on social media and online for advice may be helpful.

8.5 Maternity Leave There is no standard parental leave for men or women in the United States, so it’s important to research a potential employer’s policy for maternity leave as well as the Family and Medical Leave Act (FMLA), paid sick leave, unpaid sick leave and vacation (all of which may be required for time with a new child). When planning for maternity leave: • Consider when you’d like to tell your institution; letting your institution (not just clinic or OR schedulers) know early can help ensure all necessary paperwork is completed prior to leave. Being upfront about your needs and plans can also translate to more being offered when your group/institution/partners have time to accommodate.

• Learn what paternity leave consists of to understand what your male counterparts are receiving.

• Discuss call coverage prior to starting leave.

• If you are in private practice, you will likely need to continue to pay overhead so consider saving money for this. In addition, understand how maternity leave affects partnership, equipment buy in, etc.

• For academia or employed practice models, know what effect this leave could have on promotion and incentives and have everything in writing. There are options of prorating RVU requirements if you ask for this. Consider this in negotiating with a potential employer if this may be a concern in the future.

• Ask for the maximum allowed time off; you can always choose to return early or have the occasional urgent patient visit if necessary/ desired.

Coming back from maternity leave can also be stressful. Hospitals are legally required to have lactation rooms, so do your research to ensure there is adequate space for this and block off time to pump (if necessary) several times throughout the day.

8.6 Negotiating There is a body of evidence to suggest that women do not negotiate as often as men. A recent study showed that 68% of women accepted the salary they were offered and did not negotiate as compared with 52% of men.8 Though a sensitive subject, more and more, physicians are willing to share about salaries.

Research potential partners and compensation in a desired location. The first step is to know what fair compensation within the market is.

Negotiating is more than just salary; everything is negotiable. Consider support staff, office space, time off, professional funds, titles, administrative time, equipment, etc. Consider that negotiating for ease of practice can sometimes be more meaningful at the end of the day than simply a base salary, particularly if you aren’t able to directly reinvest the money into your practice (academia, hospital-based practice).

8.7 Imposter Syndrome Imposter Syndrome is the phenomenon of feeling like you do not belong and/or are not qualified.

While these feelings can serve to motivate, they can also lead to anxiety, stress and prevent career advancement. Imposter Syndrome is more commonly seen in minorities within professional fields, particularly women. There are many reasons female physicians can be susceptible to this: staff and patients referring to a woman by first name but male counterparts as “Doctor;” patients asking a woman physician who the doctor is that will be operating on them after a consultation has been completed – or worse, when the doctor will be seeing them. So many subtle factors can predispose women physicians to feel inadequate. Imposter Syndrome causes doctors

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to feel that their success is from an external force or luck rather than internal forces like hard work, diligence and intelligence. Long-term effects can be burnout, depression, decreased productivity, career sabotage and being less likely to ask for promotion or leadership roles.

Suggestions to overcome Imposter Syndrome include: • Writing down accomplishments and referring to them often until they are internalized

women in academia advance to full professor compared to 33% of men. In addition, there are three female Department Chairs (1.3% of female urologists) in contrast to 441 male chairs (26% of male urologists).10 14.6% of Program Directors are women and while better than the overall percentage of women in urology, this falls short of the representation of current female residents in urology.

This is certainly multifactorial, but there remains a difference between genders.

• Getting rid of the word “just” in your vocabulary (e.g., “I am just a general urologist;” “I just do slings and manage incontinence,” etc.)

Within leadership of the AUA, there has been increasing numbers of women. However, while 75% of committees included at least one woman in 2017, only 75% were urologists (relative to 95% of men on AUA committees).11 In 2020, there is one woman on the AUA Board of Directors and two women trustees on the American Board of Urology, which is representative of the AUA and practicing urologists as a whole (approximately 8% of the board). The AUA is making a conscious effort to increase women in leadership positions.

8.8 Mentors

8.10 Resources

Finding a mentor can be difficult. In fact, a third of female urologists were dissatisfied with the limited opportunities for mentorship and 25% of women who have left academia stated it was due to lack of mentorship.9 There is little formal training for mentors and few advanced career women within urology.

• Society of Women in Urology

• Using support systems to remind yourself how qualified you are to be in your role • Naming the Imposter Syndrome and recognizing when you are suffering from anxiety related to it • Taking credit for the work you do and trying hard to not self-depreciate those accomplishments

That said, mentorship can be invaluable to women (and men) when starting in practice (and throughout one’s career). While it is often encouraged to seek multiple mentors, there is utility for women to have female mentors. Many of the challenges that can be unique or approached differently as a woman can be navigated more easily with a female mentor. However, it is certainly not a necessity to have a female mentor, and it may be challenging to find one. The important thing is to have someone supportive who listens to your individual needs and is honest and approachable. Seek people who are knowledgeable in the area in which guidance is needed such as research, leadership, practice management, etc. Mentorship relationships can be short lived or over a career; don’t be afraid to move on if the advice is no longer relevant.

8.9 Leadership/Promotion On the academic side, women have been shown to have decreased publications and decreased rates of promotion.9 As of 2017, only 11% of AUAnet.org

https://swiu.org • The Secret Thoughts of Successful Women: Why Capable People Suffer from the Imposter Syndrome and How to Thrive in Spite of It by Valerie Young • Women in Surgery Committee of American College of Surgeons www.facs.org • Association of Women Surgeons

www.womensurgeons.org

• Being a Woman Surgeon: Sixty Women Share Their Stories by Preeti R. John • Ask For It: How Women Can Use the Power of Negotiation to Get What They Really Want by Linda Babcock and Sara Laschever Acknowledgments Thank you to all of the women urologists who gave advice and input to this section and special thanks to Drs. Jessica Ming and Frances Alba.

References 1. American Urological Association. The State of the Urology Workforce and Practice in the United States. 2017.

2. American Urological Association. 2020 Urology Residency Match Results. 2020.

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3. Peckham C. Medscape Urologist Lifestyle Report: 2017: Race and Ethnicity, Bias and Burnout. Jan 2017.

4. Schernhammer ES, Colditz GA. Suicide rates among physicians: a quantitative and gender assessment (meta-analysis). Am J Psychiatry.

2004 Dec; 161(12):2295-302.

5. Sanfey H, Crandall M, Shaughnessy E, et al.

Strategies for Identifying and Closing the Gender Salary Gap in Surgery. J Amer Coll Surg. 2017 Aug; 225(2): 333-8.

social functioning. Increasing wellness and resiliency amongst physicians can lead to less stress and better engagement with their patients, as well as higher quality care.

9.1 Specialty-Related Stressors Some potential reasons why urology has become one of the most stressed specialties include: • Drive for Relative Value Units (RVUs), resulting in physicians being pressed to see significantly more patients in significantly less time

6. https://blog.doximity.com/articles/doximity2018physician-compensation-report

• An aging population resulting in urologists being busier than ever

7. Deal A, Pruthi NR, Gonzalez CM, et al. Gender Differences in Compensation, Job Satisfaction and Other Practice Patterns in Urology. J Urol.

2016 Feb; 195(2):450-5.

• Rising patient and public expectations and intolerance of complications and/or unsatisfactory outcomes

8. Glassdoor Survey. 3 in 5 Employees Did Not Negotiate Salary. 2017.

9. Awad MA, Gaither TW, Osterberg EC, et al.

Gender Differences in Promotions and Scholarly Productivity in Academic Urology. Can J Urol.

2017 Oct; 24(5): 9011-6.

10. Mayer EN, Lenherr SM, Hanson HA, et al.

Gender Differences in Publication Productivity Among Academic Urologists in the United States.

Urology. 2017 May; 103: 39-46.

11. Cancian M, Aguiar L, Thavaseelan S. The Representation of Women in Urological Leadership. Urology Practice. 2018 May; 5(3): 228-32.

9. WELLNESS FOR UROLOGISTS The amount of time physicians spend delivering direct patient care has diminished due to increasing administrative responsibilities from greater regulatory pressures and evolving payment and care delivery models. Increasing responsibilities and stress can lead to physician burnout, which plagues more than half of the U.S. physician workforce.

Furthermore, urology has the distinction of being one of the most burned-out specialties in medicine today (https://www.medscape.com/slideshow/2019lifestyle-burnout-depression-6011056?faf=1#1).

Increasing rates of suicides, depression and burnout and decreasing personal and professional satisfaction among physicians emphasize the importance of creating a wellness culture within the health care profession and its organizations. Wellness consists of multi-dimensional aspects that in combination lead to optimal levels of health and emotional and

• Fear of litigation, investigation by medical boards or, worse, prosecution for “gross negligence manslaughter” • Busy after-hours call • Added clerical burden associated with electronic medical records • Having to manage overflow office-based urologic conditions • Nationwide shortage of urologists • Decreased reimbursement • Outcomes-based pay and government regulatory outcome reporting and mandates • Gender-based pay discrepancy

9.2 Effects of Burnout Stressful work conditions and burnout can lead to: • Increased clinician errors • Reduced empathy for patients • Reduced patient satisfaction • Decreased patient adherence to treatment recommendations • Increased physician intent to leave the practice • Increased malpractice claims • Poor physician mental health: depression, anxiety, relationship stress, substance abuse, suicide, etc.

9.3 Assessment Tools The following are tools intended to assess if a physician is at risk of burnout.

• Maslach-Burnout Inventory™: recognized as

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a leading measure of burnout, the Inventory measures burnout as defined by the World Health Organization (WHO). https://www.mindgarden.com/117-maslachburnout-inventory • Well-Being Index: measures six dimensions of distress and well-being. https://www.mededwebs.com/well-being-index • Mini Z Survey: comprised of 10 items and one open-ended question; assesses satisfaction, stress, burnout, work control, chaos, values alignment, teamwork, documentation, time pressure, excess electronic health record (EHR) use at home, and EHR proficiency. https://edhub.ama-assn.org/steps-forward

9.4 Wellness Activities Suggested activities to help establish a culture of wellness include: • Sleep • Exercise, such as running, yoga, etc.

• Movie nights or dinners • Holiday potlucks • Ballroom or other dance classes that include spouses and significant others • Charity work (e.g., volunteering at a homeless shelter) • Mindfulness and meditation classes to promote stress reduction • Sporting events (e.g., playing in a recreational league, watching a televised match or attending a university game) • Painting or pottery classes • Exploring the local culture

9.5 Resources • Mayo Clinic's 5-Pillar Anti-Burnout Remedy www.urologytimes.com/editors-choice-ut/beyondburnout-how-stay-engaged-and-thriving • Stanford Medicine WellMD Center (first of its kind)

http://wellmd.stanford.edu/healthy/stress.html

• American Medical Association www.STEPSForward.org • www.jeffsmithmd.com • www.TheHappyMD.com AUAnet.org

10. CONTINUING EDUCATION & PRACTICE MANAGEMENT 10.1 Certification The following text is from the American Board of Urology (ABU) website as of April 2020. For more information, please visit www.abu.org/certification.

The purpose of awarding certification to individuals who meet the qualifications of The American Board of Urology is to assure the public that an individual has: (a) received appropriate training, and (b) has a level of urologic knowledge to practice safe and effective urology. The American Board of Urology strives to provide the urologic community with an examination process which is relevant and fair to all who take it.

Certification includes all domains of urology, including but not limited to pediatric urology, endourology, female urology, andrology, oncology, urolithiasis, and general urology. All certified urologists are trained to evaluate and treat all patients with urological disorders.

All US chief residents who have completed their training and residency requirements may apply for admission to the certification process. Canadian and international medical graduates may be eligible to apply if they have satisfied the training and residency requirements.

Applicants approved by the Board to enter the certification process must successfully complete a Qualifying (Part 1) Examination. After meeting certain specific criteria including unrestricted medical licensure, assessment of clinical practice through practice logs, acceptable peer review, and the 16-month practice requirement in a single community, the applicant must successfully complete the oral Certifying (Part 2) Examination to become certified.

Certification is valid for a period of ten years, subject to Lifelong Learning (LLL).

Candidates have six years from the end of residency to complete the components of the certification process to become a Diplomate. An applicant will have no more than three attempts to pass the Qualifying (Part 1) Examination and no more than three attempts to pass the Certifying (Part 2) Examination. If a candidate fails the Qualifying Exam for the third time the Board may consider individual requests to re-enter the process. These requests will be assessed on a case-by-case basis. The applicant will be required to undergo a professional

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competency and/or educational assessment in a program approved by the ABU. If a candidate fails the Certifying Exam for the third time or fails to pass the exam within the required window of six years from residency (with any approved variances), the Board may consider individual requests to reenter the process. The applicant will be required to undergo a professional competency and/or educational assessment in a program approved by the ABU. For either exam, evaluations will be performed at the expense of the candidate. Specific CME activity or other evaluation may also be assigned.

If re-entry criteria are met, the applicant will be allowed to apply to re-take the exam. Approved re-entry applicants for either exam will generally be expected to take the exam at the next available time it is administered. Failure to do so requires a written excused absence from the ABU, and only one such excused absence will be allowed. The candidate will be expected to successfully complete the entire process (QE and CE) within four years from reentry.

10.2 Life Long Learning The following text is from the American Board of Urology website as of April 2020. For more information, please visit www.abu.org/lifelong-learning/faq.

Maintenance of Certification (MOC) was an initiative of the American Board of Medical Specialties (ABMS) aimed at ensuring quality patient care from certified physician specialists through an ongoing process of professional self-improvement.

A ten-year cycle, MOC entailed four levels and these basic components: licensure and peer review; continuing medical education; practice log, Practice Assessment Protocols (PAP), and modules for patient safety and professionalism/ethics; and a computerized, multiple choice exam. Completion of these components allowed Diplomates of the ABU to maintain their general certification in urology and any urologic subspecialty certification. Responding to Diplomate feedback, in 2017, the ABU dismantled its MOC program and created, instead, the Life Long Learning program as a certification requirement.

Life Long Learning (LLL) is a 2017 initiative of the American Board of Urology aimed at ensuring quality patient care from its certified urologists through an ongoing process of professional selfimprovement. It is a retooled version of the former Maintenance of Certification (MOC) program.

A ten-year cycle, LLL is comprised of two Levels and these basic components: licensure and peer

review; continuing medical education; practice log, Practice Assessment Protocols (PAP), modules for patient safety and professionalism/ethics, videos for patient safety; and a computerized, multiple choice knowledge assessment. Completion of these components allows Diplomates of the ABU to maintain their general certification in urology and any urologic subspecialty certification.

10.3 Resources There are a number of excellent resources to remain current with the practice of urology. AUAUniversity (www.AUAnet.org/university) offers yearround access to a growing repository of valuable information through live and online educational opportunities. Other resources include: • AUA Oral Board Review Course

www.AUAnet.org

• AUA Clinical Guidelines www.AUAnet.org/guidelines • NCCN Guidelines www.nccn.org/professionals/physician_gls/default. aspx • AUA Coding and Reimbursement Resources www.AUAnet.org/practice-resources/coding-andreimbursement/coding-resources-and-information • Patient Education from the Urology Care Foundation

www.urologycarefoundation.org/order

10.4 Medical Coding and Billing Staying current on key coding issues, particularly as they relate to the yearly changes from Current Procedural Terminology (CPT®) is important.

Using outdated books can lead to unnecessary denials or may result in delayed reimbursement. See the new codes for 2020 below. These will be updated again in November for January 2021.

New and Revised CPT Codes for Urology Effective January 1, 2020 There are a number of Current Procedural Terminology (CPT®) code changes that urologists should understand that became effective as of January 1, 2020, including changes to the orchiopexy code, new codes for biofeedback (with elimination of the old code), a new Category III code for Transurethral ablation of malignant prostate tissue by high-energy water vapor thermotherapy with a new parenthetical to CPT 53854, and four new Category III codes for Percutaneous implantation

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or replacement of integrated single device neurostimulation system, including electrode array and receiver or pulse generator.

Revision under Urinary System/Bladder/ Introduction

this code descriptor.

Biofeedback: new and deleted codes New CPT codes:

Parenthetical Change

90912 Biofeedback training, perineal muscles, anorectal or urethral sphincter, including EMG and/or manometry, when performed; initial 15 minutes of one-on-one physician or other qualified health care professional contact with the patient.

In accordance with the deletion of code 0377T in the surgery section, the parenthetical note following code 51715 has been deleted. Refer to the codebook and the Background for code 0377T for full discussion of the changes.

90913 . . . each additional 15 minutes of oneon-one physician or other qualified health care professional contact with the patient (List separately in addition to code for primary procedure)

(For anoscopy with directed submucosal injection of bulking agent for fecal incontinence, use 0377T)

51715 Endoscopic injection of implant material into the submucosal tissues of the urethra and/or bladder neck

Orchiopexy: revised description Old CPT code descriptor: CPT 54640 - Orchiopexy, inguinal approach, with or without hernia repair New CPT code descriptor: CPT 54640 - Orchiopexy, inguinal or scrotal approach (For bilateral procedure, report 54640 with modifier 50) (For inguinal hernia repair performed in conjunction with inguinal orchiopexy, see 49495-49525) Background: CPT Code 54640 has been revised by deleting the words “with or without hernia repair” and adding “or scrotal” to the descriptor language.

This new description eliminates the previously confusing language to confirm the allowance of reporting the separate work of hernia repair if significant and medically necessary if performed concomitantly with orchiopexy. In addition, the term “or scrotal” was added to the descriptor to better identify all approaches inherently included for the orchiopexy procedure. Code 54640 originally included language that conflicted with instructions in a parenthetical note following the code listing which noted that inguinal hernia repair performed in conjunction with inguinal orchiopexy may be reported separately. As a result, the term “with or without hernia repair” was removed to provide better instruction to users regarding report of 54640 in conjunction with hernia repair codes 49495-49525.

In addition, the term “or scrotal” was added to the descriptor for 54640 to ensure that all approaches intended as part of the procedure are reflected within AUAnet.org

►(Use 90913 in conjunction with 90912)◄

(For testing of rectal sensation, tone and compliance, use 91120) (For incontinence treatment by pulsed magnetic neuromodulation, use 53899) Deleted CPT code: 90911 Biofeedback training, perineal muscles, anorectal or urethral sphincter, including EMG and/or manometry; Background: CPT Code 90911 was created in 1994.

Since that time, biofeedback training for pelvic floor weakness has evolved and the amount of time spent with patients varied for each session. For this reason, code 90911 was deleted because the code did not truly represent the amount of time for biofeedback training for pelvic floor weakness performed by the physician or other qualified health care professional.

It was determined that reporting biofeedback training for pelvic floor weakness should be time-based.

CPT Codes 90912 and 90913 describe 15-minute increments of one-on-one physician or other qualified health care professional contact with the patient for biofeedback training of the perineal muscles, anorectal sphincter, or urethral sphincter. EMG and/ or manometry is included, when performed. Related parenthetical notes were moved from deleted code 90911 and added following code 90913.

New Category III Code for Transurethral ablation of malignant prostate tissue by highenergy water vapor thermotherapy, including intraoperative imaging and needle guidance New Category III CPT Code: 0582T - Transurethral ablation of malignant prostate tissue by high-energy water vapor thermotherapy, including intraoperative imaging and needle guidance

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(Do not report 0582T in conjunction with 52000, 72195, 72196, 72197, 76376, 76377, 76872, 76940, 76942, 77021, 77022) (For transurethral destruction of prostate tissue by radiofrequency-generated water vapor thermotherapy for benign prostatic hypertrophy [BPH], use 53854) Revised CPT code parenthetical: 53854 Transurethral destruction of prostate tissue; by radiofrequency generated water vapor thermotherapy (For transurethral ablation of malignant prostate tissue by high-energy water vapor thermotherapy, including intraoperative imaging and needle guidance, use 0582T) Background: A new Category III code 0582T has been established for reporting transurethral ablation of malignant prostate tissue by high-energy water vapor thermotherapy, including intraoperative imaging and needle guidance. Parenthetical notes have been added to provide guidance on the appropriate reporting of code 0582T. Currently, code 53854 is used to report the indirect application of radiofrequency (RF) energy in the form of water vapor thermotherapy to ablate prostate tissue. New code 0582T is used to report transurethral ablation of malignant prostate tissue by high-energy water vapor thermotherapy, including intraoperative imaging and needle guidance. Exclusionary parenthetical notes were added restricting the use of code 0582T with other codes in the CPT code set.

New Category III code(s) for Percutaneous implantation or replacement of integrated single device neurostimulation system including electrode array and receiver or pulse generator, including analysis, programming, and imaging guidance when performed, posterior tibial nerve New Category III CPT Codes: 0587T Percutaneous implantation or replacement of integrated single device neurostimulation system including electrode array and receiver or pulse generator, including analysis, programming and imaging guidance when performed, posterior tibial nerve.

(Do not report 0587T in conjunction with 64555, 64566, 64575, 64590, 95970, 95971, 95972, 0588T, 0589T, 0590T) 0588T Revision or removal of integrated single device neurostimulation system including electrode array and receiver or pulse generator, including analysis, programming, and imaging

guidance when performed, posterior tibial nerve (Do not report 0588T in conjunction with 64555, 64566, 64575, 64590, 95970, 95971, 95972, 0587T, 0589T, 0590T) 0589T Electronic analysis with simple programming of implanted integrated neurostimulation system (e.g., electrode array and receiver), including contact group(s), amplitude, pulse width, frequency (Hz), on/off cycling, burst, dose lockout, patient-selectable parameters, responsive neurostimulation, detection algorithms, closed-loop parameters, and passive parameters, when performed by physician or other qualified health care professional, posterior tibial nerve, 1-3 parameters (Do not report 0589T in conjunction with 64555, 64566, 64575, 64590, 95970, 95971, 95972, 0587T, 0588T, 0590T) 0590T Electronic analysis with complex programming of implanted integrated neurostimulation system (eg, electrode array and receiver), including contact group(s), amplitude, pulse width, frequency (Hz), on/off cycling, burst, dose lockout, patient-selectable parameters, responsive neurostimulation, detection algorithms, closed-loop parameters, and passive parameters, when performed by physician or other qualified health care professional, posterior tibial nerve, 4 or more parameters (Do not report 0590T in conjunction with 64555, 64566, 64575, 64590, 95970, 95971, 95972, 0587T, 0588T, 0589T) Background: New Category III codes 0587T, 0588T, 0589T and 0590T have been added to report percutaneous implantation or replacement and revision or removal of integrated single-device neurostimulators with analysis and programming and separate simple or complex electronic analysis of implanted integrated neurostimulator system devices. In addition, parentheticals have been added within the Surgery/Neurostimulator and Medicine/ Neurostimulators subsection and Category III code section to provide additional instruction regarding reporting of other neurostimulator electrode or generator implantation, removal, replacement, revision, imaging for placement and programming for these integrated devices.

Codes 0587T and 0588T have been established to report percutaneous implantation or replacement and revision or removal of integrated single-device

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neurostimulators with analysis and programming.

These codes have been added to identify the efforts of implanting or replacing (0587T) or revising or removing (0588T) an integrated, single-device neurostimulator. These neurostimulation devices are comprised of an electrode array and integrated receiver in a single unit/device and are used at the posterior tibial nerve (lower leg) to treat overactive bladder and refractory urge incontinence. The implant is placed via a single percutaneous approach, is permanent, and is powered by a generator (which is externally worn by the patient). The difference in the make-up of the device (i.e., use of a single device that incorporates components that have typically been utilized and inserted as two devices – an electrode array and a receiver or pulse generator) changes the work that is necessary for the placement, removal, and revision procedures as no single code appropriately identifies the placement of the electrode and the creation of the pocket for the receiver portion of the device.

As a result, the new codes have been added to account for the differences necessary to perform these services.

Imaging, programming, and analysis have been included as part of the placement procedure (as noted in the code descriptor). Therefore, these services are inherently included as part of the procedures and not separately reported. Separate codes have been established to identify electronic analysis with simple (0589T) and complex (0590T) programming. These codes are intended to be used when programming services are performed independent of placement and revision/removal services. Guidance for this has been included within the exclusionary parenthetical that follows each code. Other parentheticals within the Category III section for these codes and in other sections of the code set provide additional direction regarding the intended use for the new codes. These include exclusionary parentheticals that restrict reporting of placement and programming services and cross-references that direct users to the new codes for placement/replacement, revision/removal and programming services for percutaneous implantation or replacement of integrated neurostimulation system for the posterior tibial nerve.

If you have any questions, you may contact the AUA Coding Hotline at 1-866-746-4282 (Opt 3) or via email at codinghotline@AUAnet.org.

11. UNDERSTANDING PUBLIC POLICY AND GOVERNMENT ADVOCACY With a long history of promoting legislation and regulation that positively impacts a urologist’s AUAnet.org

ability to provide quality patient care, the AUA is a leading advocate for the specialty of urology and maintains a consistent presence in Washington, D.C., working with lawmakers and regulators to promote and preserve the interests of urologists.

The AUA’s advocacy efforts are varied to ensure that the interests of members are made known to a wide array of decision makers. Whether contacting lawmakers on Capitol Hill or federal officials in government agencies, the AUA is supporting and defending the practice of urology. In addition to independent advocacy activities, the AUA often joins with other likeminded organizations and specialty societies to collaborate on issues of mutual interest and concern. These efforts are especially important in both legislative and regulatory matters and member involvement is critical to advocacy.

The Public Policy Council of the AUA is comprised of several committees and workgroups that protect the interest of urology health care professionals.

Component committees of the AUA Public Policy Council include, but are not limited to, the following: • Coding and Reimbursement Committee: serves as urology’s representative in the area of coding, terminology development and reimbursement, as well as seeks new and updated codes to ensure accurate identification of urologic diseases and procedures.

• Legislative Affairs Committee: provides feedback on the continual refinement of the federal legislative agenda and its execution, provides advice and guidance regarding new opportunities for urology’s involvement, and represents the AUA to the federal government.

• State Advocacy Committee: provides feedback on the continual refinement of the state legislative agenda and its execution, provides advice and guidance regarding new opportunities for urology’s involvement, and represents the AUA within state capitals.

• Practice Management Committee: evaluates, investigates and advises on initiatives designed to improve the overall business operations of the urology practice.

• Research Advocacy Committee: advocates for public, private and philanthropic support of urologic research, engages with urology stakeholders, including patient advocates, to ensure funding for urologic research is protected and communicates with federal and non-federal agencies to ensure urology is represented on advisory boards and strategic planning initiatives.

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11.1 AUAPAC The American Urological Association, Inc. Political Action Committee (AUAPAC) was established in late 2018 to further raise the house of urology's profile and foster relationships with members of Congress in Washington, D.C., as well as in their home districts, thereby providing opportunities to engage lawmakers and strengthen advocacy networks.

AUAPAC represents the voice and broad interests of the AUA’s domestic membership, which reflects all facets of the urology community. Learn more at www.myAUAPAC.org.

Angeles, Houston or Boston? Okay, of course the metropolitan lifestyle doesn’t appeal to everyone. But living in a major metropolitan area does offer many unique advantages: easy access to arts and culture, lively and diverse social scenes, diverse selections of dining, ease of national and international travel, etc.

If city life is up your alley, you are not alone – which can make seeking jobs in such a market extremely competitive and present a set of unique challenges when looking for your first job. Consider some of the information below if you think practicing in a competitive market is right for you.

11.2 Health Policy Terms

A.1 Start Your Networking Now

ACO: Accountable Care Organization

If you’ve already identified a specific metropolitan area you’d like to practice in, consider applying to complete some of your training there. Being a resident or a fellow in the city you want to ultimately practice in can increase your chances of hearing about positions that aren’t always formally advertised.

APM: Alternative Payment Models developed by the Centers for Medicare & Medicaid Services to replace current payment system.

ICD-10-CM: International Classification of Diseases – 10th Version – Clinical Modifications. Listing of diagnostic and procedure codes developed by the World Health Organization and modified for use in the United States medical community.

MAC: Medicare Administrative Contractor (local Medicare carrier) MedPAC: Medicare Payment Advisory Commission Medicare Part A: hospital, SNF, hospice coverage Medicare Part B: physician services, lab, imaging services, and office medications Medicare Part C: proper ties to Medicare advantage plans (HMO) Medicare Part D: drug coverage MIPS: Merit-based Incentive Payment System QPP: Quality Payment Program RUC: Relative Value Scale Update Committee (AMA) 11.3 Additional Resources Learn more about the many resources that are available to assist you in better understanding health policy and government advocacy by visiting www.

AUAnet.org/advocacy/get-involved.

APPENDIX A: PRACTICING IN A COMPETITIVE MARKET Competitive job markets are typically located in areas with high desirability – often, a major metropolitan area with appealing amenities and a well-diversified economy. Who doesn’t want to live in a major metropolitan area like New York City, Los

Using your network of colleagues, friends and family can be very important when looking to secure a job in a competitive market. Having an “in” can provide you with sometimes difficult-to-find information on compensation, group culture, and what you might expect regarding patient load, case mix, etc. Leverage relationships you have from childhood, college, medical school and residency – tapping into your network can give you an edge on the competition.

Consider the following if you were unable to train in the city you want to practice in and don’t have an “in:” • Reach out to academic departments, hospitals, and large urology group practices in the area to offer Grand Rounds presentations.

• Get involved at AUA Section meetings or regional conferences in your desired location.

Often, such meetings (e.g., New York Section of the AUA or the Philadelphia Urological Society) are small, intimate meetings that may allow you to connect with potential employers.

A.2 Be Adaptable Plans to be the robotics expert in the big city where there are already thirty experts in the area may not pan out. Consider some compromise. Are you open to researching an unmet need and then providing it in the big city?

As it relates to case mix and practice building, be open to taking advantage of any needs you see in the group or market – perhaps the group has a need for

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an expert in minimally invasive BPH surgery, or the market has a need for a prosthetic urologist. Don’t be afraid to reinvent yourself to accommodate; this could just be the “edge” you need to gain a foothold in the market (many experienced urologists will tell you that their “niche” came from somewhat random circumstances!).

As with any job, there will be growing pains. In the first few years, many young urologists in competitive markets may feel alone in facing the challenges of early practice. Be purposeful about meeting other urologists in the area – even those in “competing” groups. They are going through much of the same experiences you are, and you may end up working with them one day! Plus, as you build your niche, you will want to have contacts who trust you and send you challenging cases.

A.3 Cost of Living Considerations Living in a non-competitive market can often offer a urologist a higher salary with a lower cost of living. Competitive markets, however, can be just the opposite. Competitive markets tend to have a high cost of living – combined with lower compensation, this can have a significant impact on lifestyle. Housing costs are the largest expense for most people in the early stages of their career, and urologists are no different. Frugality in a house can go a long way – renting for 1-2 years can be a good move in a competitive market to allow savings for a down payment and avoid “locking in” to a situation that could turn out to be a poor fit.

“Hitting it big” in the big city doesn’t happen often.

Sure, if you open up the right office for the right disease at the right time with the right reputation, you could earn much more than standard rate for your profession. But don’t count on it. It’s much more realistic to plan on living within your means and understand that the desirability of a metropolitan area can come with some costs.

A.4 Initial Negotiation and Non-Compete In a competitive market, applicants have less negotiating power when it comes to important factors such as compensation, case mix and allocation of resources. Do your research on compensation in your desired specific market for a realistic idea of what is reasonable. Realize that starting salaries tend to be lower. Often, hospital employed groups and large private practice groups use physician compensation calculators, such as the MGMA, AAMC, etc. The type of practice you may want to initially develop may also be less negotiable.

AUAnet.org

Many metropolitan areas are populated with wellestablished urologists, so it may take several years to build a “niche” practice in areas like robotics, reconstructive surgery, female pelvic medicine or complex stone disease.

Non-compete clauses bear special mention in competitive markets. If you are taking a job with location as the leading (or one of the leading) factor, chances are you’re probably looking to stay in that location for a substantial amount of time. Overly restrictive non-compete clauses (e.g., clauses that include long periods of time or large geographic areas) could present a big problem if you are dissatisfied with your job. Sometimes, a non-compete clause is very negotiable – other times, especially if you are looking to work for a big system, it may not be negotiable at all. Again, do your research on what is reasonable, and carefully consider the potential future impact of the clause before you agree to the job.

Oftentimes, a non-compete clause has a washout period, so if you’re willing to move out of the area, consider a job in the suburbs or doing locum tenens for a year. Sometimes, if you have a desirable enough reputation or skill-set, the competing hospital may buy out your non-compete.

A.5 Stay True to Yourself While competitive markets tend to give the applicant less negotiating power in general, do not let your desire to live in a certain area or take a certain job blind you to an overly negative situation. Even in an ideal location, enough negative work-related factors will lead to dissatisfaction. Try to find the right balance – reasonable pay in an established group with senior partners who take a sincere interest in mentorship and practice development for younger physicians. Do your due diligence on physicians who have left the practice – a pattern of younger physicians leaving the group within the first few years of practice can be a red flag.

A.6 Conclusion While entering a competitive market is not for everyone, jobs in competitive markets may be the only realistic option for some young urologists due to family/spousal concerns, geographical preference and/or cultural factors. Setting yourself up for such a job includes exposure that allows access to a job, knowing your core set of values while remaining adaptable and being able to navigate the finances associated with working and living in a big city.

Using your network and keeping your eye on long-

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term goals, in combination with a good dose of patience and a willingness to “pay your dues,” will be assets in the process. Good luck!

APPENDIX B: MORE ABOUT ACADEMIA B.1 Time Allocation Employees in an academic system are responsible for one “full-time equivalent” (FTE) position. How this time is allocated depends on your academic interests and the ability of your employer to provide what amounts to salary support in non-clinical domains.

The default position is usually 100% clinical (i.e., 1.0 FTE for clinical work).

If you are interested in developing a research career, the time for research is ultimately covered by funded grant support. It is not uncommon to be offered non-clinical “protected time” to get your research off the ground (up to 50% or 0.5 FTE in some places) when first starting. Be aware that this time usually has a clock associated with it (1-3 years) at the end of which the time will go away. If it does, you will probably be expected to cover the remainder of your time with clinical work if you have not attained grant support. For more on research as career, see Appendix C. There are additional ways to receive time for non-clinical work in the domains of education and administration. Urology residency Program Directors (PDs), for example, have a demanding job and their clinical productivity requirements/targets can be decreased by 20%. In fact, the ACGME mandates 0.2 FTE to fulfill the responsibilities of a PD. Similarly, Division Chiefs or Department Chairs have non-clinical time allocated to complete administrative responsibilities.

B.2 Academic Tracks In most systems, you will enter your first academic position as an Assistant Professor. The first decision to be made is whether you will pursue a tenure track or a non-tenure track position. The vast majority of urologists coming out of training will be offered non-tenure track jobs. While a full discussion of tenure is beyond the scope of this section, suffice it to say that most urologists will be expected to focus on clinical productivity (even in academics) rather than the types of academic pursuits that typically result in tenure.

Within the non-tenure track position, there are a number of different tracks that determine how you will be promoted (e.g., from assistant to associate and from associate to full professor). These vary widely from institution to institution. Try to get a sense of

what these tracks entail during your interview and certainly early in your employment so that you know what will qualify you for promotion. Generally speaking, promotion to associate professor requires demonstrating evidence of publication or program development in a given subject area along with development of a regional reputation (as evidenced by invited talks or patient referral base).

B.3 Early Academic Career Asking a hundred urologists would likely net you a hundred different answers to this question: what should I do early in my academic career? This is because every academic environment has its own nuances and “success” is measured differently from individual to individual and institution to institution. However, it is difficult to imagine having a successful career as an academic urologist without first taking superb care of patients. The first couple years of independent practice are daunting for even the most confident of young urologists. It can be easy to get caught up in the multitude of competing interests vying for your time. Let the patients be your rudder and take excellent care of them. If you find yourself interested in a certain clinical discipline (e.g., robotics), target extra-mural activities within your hospital, local/regional society, and even the national society that are in line with your interests (e.g., hospital robotic steering committee, moderator/ scientific program coordinator for your AUA Section meeting, or AUA national committees that are relevant to robotics). Activities such as these will help you get your name recognized. While you have accomplished a ton throughout four years of undergraduate studies, four years of medical school, 5-6 years of residency, and a 1-2 year fellowship, remember: no one knows who you are. Another way to “get your name out there” is to join a hospital governance committee or policy committee.

However, if you commit to doing something, make sure that it gets done. Do not overcommit. If you don’t have the bandwidth to do something, it is better to say “no” than to make commitments you cannot fulfill in a timely and high quality manner.

Mentorship is critical in order to navigate the complex systems of academia, large hospital systems and societies. Ideally, you should have a mentor within your academic department and an external local mentor to help provide you with a non-urologic perspective of both local academic and hospital matters. Relying on mentors within your subspecialty will be critical for navigating your respective society.

Be sensitive of your mentor’s time. You should have a good sense of what your mentor can provide you

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with in terms of time, resources and advice. Take care not to abuse such relationships by reaching out unnecessarily or not following through on advice provided if relevant (measure your questions ahead of time and anticipate the recommendations).

Stay active in your subspecialty society and attend your subspecialty society meeting. While mentorship can be time consuming and somewhat difficult to foment, sponsorship is a lesser form of support that can be critical for promotion within a society. While a mentor is someone you may call to ask a question regarding a clinical or academic matter, a sponsor can be someone who may nominate or recommend you for a certain task or opportunity within a society.

Know that you will not be handed a plenary session presentation just because you did a fellowship and work at an academic medical center. Such speaking opportunities come with relentless research submission and specialty section participation along with support from leadership within the society. Be friendly and social at your meetings and connect with some sponsors!

B.4. Conclusion Academic urology can be an extremely rewarding career path. It basically boils down to a focused clinical/research interest that you then promote within your division, hospital system and society by way of clinical practice and research and presentation. For those interested in additional reading regarding a career in academic medicine, consider Dr. Joseph V. Simone’s work, “Understanding Academic Medical Centers: Simone’s Maxims” (Clinical Cancer Research 1999; 5(9): 2281-2285).

APPENDIX C: MORE ABOUT RESEARCH The field of urology prides itself on being a champion of medical progress. Urologists have received two Nobel Prizes and have made significant advances in the understanding of diseases and applications of novel technologies.

In fact, contemporary urologic research takes on many forms: basic science, translational science, clinical research, and health sciences/comparative effectiveness research are just some areas of scientific investigation that urology surgeon-scientists pursue.

C.1 Rewards and Challenges Participating in research is central to the job satisfaction of many physicians. The opportunity to advance medicine, be on the cutting-edge of clinical care and immersed in the world of ideas AUAnet.org

clearly satisfies some of the intrinsic rewards that many physicians sought when entering medicine.

Furthermore, success in research also affords opportunities for leadership roles within one’s institution and professional groups, and often offers a seat at the table with policy makers and industry leaders. Importantly, physician researchers continue to remain leaders in training the next generation of practitioners. Participation in research clearly has its well-known challenges, such as decreased funding, a smaller number of like-minded peers, “publish or perish” pressures and a limited number of role models and mentors. In addition, the research community is increasing outside of urology and, in some instances, conducting research requires foregoing income from clinical activities. As such, individuals motivated to establish a dynamic research career must be well informed and well prepared for the challenges ahead.

C.2 Research as a Job Function After completing residency/fellowship, the new practicing urologist interested in pursuing research is faced with a new challenge: how to efficiently and productively manage both a clinical practice and a research program and best prepare for long-term success.

Two major goals of a clinical practice are to make sure one can provide effective and safe care as well as be available to patients and their families. One of the major objectives of a research program is to pursue discovery that will impact current knowledge while contributing to the future well-being of patients.

Nonetheless, both areas have to be financially viable and sustainable long-term.

When considering a career with a significant research component, junior faculty members should have a clear understanding of several factors that are critical to success: • Finding a mentor, or better yet a collection of mentors with strengths in different areas, is the first and probably most important step. Mentors are individuals who have “been there and done that” and can provide crucial career and research guidance to you.

• Know exactly what type of institutional support/ commitment each potential job is willing to provide (e.g., startup funds, cost-sharing of salary short falls, etc.).

• Assess the types of resources that are available.

For example, will you have to start your own tumor bank or can you draw on an existing one?

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Is there a database already established or will you need to build one on your own?

• Independent Research Scientist Development Award (K02)

• Surveying potential collaborations available institutionally or regionally (e.g., other institutes, industry, etc.) is key. The strength of each must be weighed against the type of research you want to pursue as well as your ultimate career goals.

• Mentored Clinical Scientist Research Career Development Award (K08)

C.3 Obtaining Funding

• Mentored Patient-Oriented Research Career Development Award (K23)

Numerous public and private sources support scientific studies and young researchers. These include the National Institutes of Health (NIH), the nation’s largest funder of academic research, the U.S. Department of Defense Congressionally Directed Research Programs, U.S. Department of Veterans Affairs, and private funders such as foundations, societies (e.g., American Cancer Society or urology societies), advocacy organizations, and other funding groups.

In addition to the federal and private foundation sources, there are local research grants (your own academic institution, local charities and organizations, health insurance companies/payers), industry (pharmaceutical and medical device) and private donors (endowments, gifts, etc.) as well as crowdsourcing platforms.

The AUA is committed to supporting urologic research through funding, education, and advocacy.

Through the Rising Stars in Urology Award, the Research Scholar Awards, and the Residency Research Awards – as well as other internal and external funding awards – the AUA and Urology Care Foundation have been providing support to young urology researchers for 45 years. More information can be found at https://www.AUAnet. org/research/research-overview.

The NIH Guide (grants.nih.gov) is a comprehensive resource for funding opportunities and materials to guide researchers through the process. The Research Project Grant (R01) is the original and, historically, oldest grant mechanism used by NIH. The R01 provides support for health-related research and development based on the mission of the NIH. R01s are submitted in response to program announcements (PA) or requests for applications (RFA).

The following NIH research awards are also typically available for early-career investigators, although each NIH institute may not offer all of these mechanisms: • Mentored Research Scientist Career Development Award (K01)

• Clinical Scientist Institutional Career Development Program Award (K12) • Career Transition Award (K22)

• Small Grant Program (R03) • Academic Research Enhancement Award (R15) • Exploratory/Developmental Research Grant Award (R21) • Clinical Trial Planning Grant (R34) • Research Program Project Grant (P01) Grant applications are peer-reviewed by standing or ad hoc review groups and scored based on significance, investigator credentials, innovation and research approach and environment. Funding decisions are determined by the score, the “fit” with the mission of the institute and approval of the institute’s Advisory Council.

Critically important to applying for research funding is being prepared to submit a grant application that has the best chance of success. Therefore, physician scientists in particular, who typically have less exposure to grant writing than their PhD-trained peers, would do well to participate in courses that focus on urology grant writing and grantsmanship.

The AUA provides the following courses on these subjects: • Early Career Investigators Workshop (a 2.5-day workshop held at the AUA headquarters that includes one-on-one mentoring by NIH-funded faculty) https://www.AUAnet.org/research/ research-education-and-events/early-careerinvestigator-workshop • Writing a Successful Career Development Award Application, an online course available on AUAUniversity. https://auau.AUAnet.org/content/ writing-successful-career-development-awardapplication-2018

C.4 Clinical Trials Clinical trials to evaluate new drugs, tests and devices have traditionally been carried out in academic institutions, but private medical practices or healthcare organizations with little or no academic affiliation are also often involved.

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Dedicated staff is needed to provide support for the activities that will be performed. It is also necessary to have certain equipment and space, both of which vary depending on the nature of the clinical trial. The requirements for management of data, regulatory and institutional review board concerns, marketing, patient recruitment and documentation of clinical visits are different for clinical trials compared with clinical care.

APPENDIX D: PERSPECTIVE: PRACTICE TYPE AND LOCATION The Young Urologists Committee posed the following questions to the AUA Young Urologists Online Community: What factors did you consider when deciding where you would settle and practice after training? What ultimately made you decide to practice there?

Below are some of the responses received. They are being published with permission of the authors.

Note that all opinions are those of the responder and do not reflect those of the American Urological Association. Responses have been lightly edited for clarity.

DR. TODD LEHRFELD – EGG HARBOR TOWNSHIP, NJ: What I usually tell residents/applicants about transitioning to practice is to first settle on location.

When applicable, the first question should be, "where will my spouse be happy?" If your spouse/ partner needs to be in a particular city, then you need to take a job there – period. If that is not an issue, identify a location where you’ll be happy, but don’t forget to consider the cost of living.

Urologists (and doctors in general) have the advantage of location arbitrage; often times, betterpaying jobs are in lower cost-of-living cities – quite different from our tech and law colleagues. Unless you feel you MUST live in a high cost-of-living area, consider choosing a nice (livable) area, and visit the NYC-type places with the extra money you will make/save.

After you know the general area you wish to live, it’s time to find a practice (NOTE: if you're going into academics, you will probably know by now. Your mentor will send you on interviews and tell you where to go. Go where you are told!).

Decide your level of entrepreneurial acumen; this can be quite difficult to do prior to entering the "real world." You'll need to decide between private practice or hospital employment.

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Hospital Employment I know I am biased, but my advice is: realize that the hospitals are NOT your friends; you are a commodity to them, and they will do everything they can to disempower you. The trend is moving toward hospital-employed doctors; realize that any offer made likely has an expiration date, at which point your pay will likely suffer and you may even lose your job (which I've seen happen all too often).

If you are lured in by a hospital, I recommend splurging for the best health care contract lawyer you can find; make sure you are PROTECTED. I wholeheartedly agree that practicing without a hospital (or at least minimizing its impact on your practice) is ideal for many/most urologists. Hospitals can be incredibly inefficient; the moment you walk into one, your productivity drops at best by 75%, and your liability and agitation skyrocket compared to that of your office.

Hospitals NEED us, but we have very little need for THEM. In the past, it was considered "an honor and a privilege" to be on staff at a hospital; older doctors even took call for free! The times have indeed changed, and our generation is so very different than the urologists of yesteryear. We are now starting to wise up enough to see the economic impact of being an extremely high-demand, low-supply specialty.

Hospital administrators are now learning that the free ride is over. If they feel it is important for them to have access to urologists 24/7, they will have to reimburse us at a level that is congruent with "27 years of schooling plus being in the top 1% of your med school class" to convince us to walk into their facilities.

If you do practice at a hospital, payment should be at least equal to the amount of productivity you are projected to lose plus a factor to account for the agitation of dealing with their bureaucracy, plus a factor to account for your time and possible loss of the next day's productivity if you are taking call.

The one confounding factor is that many surgical centers require active hospital privileges. There may be some creative ways around this, such as the use of urologic hospitalists or having other groups cover your portion of call (or just negotiating with the hospital CEO for a fair enough reimbursement/ salary for you to take some call and have the next day off with pay).

Private Practice It's very difficult to hang a shingle and start your

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own practice; I recommend finding a "like-minded" group of other urologists you can join. Feel out the groups and their leadership, and find out if they have similar interests as you; factors I deem crucial include: • Age of partners: You are young. You will have far more in common with other young urologists.

What percentage of the group is over 50 years old? If it's high, that may be a red flag. Older urologists have very different goals than you will.

In general, find young, like-minded people to work with.

• Quality of life: I believe this is the most important factor. Determine what type of lifestyle you wish to live. You've gone through hell and back – maybe you like living like that, but you will probably want to have a "normal family life" at some point. Does the group you are looking at stress quality of life? How many days per week do the partners work? A group that works more than 4 days a week would be a red flag to me.

Does the group force its partners to take call? If so, how much, how busy is it, and how much do the hospitals pay you for coverage? If you do take call at multiple hospitals, how far apart are they? How much driving is involved? (I've seen large groups whose members drive more than 90 minutes for night call! Another red flag.) Do they give you the following day off?

• Economics: How does the group do financially vs. MGMA average? Are there ownership opportunities? More specifically – are there ownership opportunities for YOU? (I've seen large groups that only offer things to the older partners – see Age of Partners above.) If you are truly considering the group, have them spell out ownership of various items such as surgery centers, radiation machines, ESWL, etc. in the contract. And again, pay to have a GOOD health care contract lawyer review anything before you consider signing. It will pay for itself many times over.

To summarize, find the right area to live for you, then find a group with young, business-savvy urologists who believe in a great quality of life with minimal (well paid) hospital-based call.

DR. RUSSEL WILLIAMS – HOUSTON, TX: I remember this stage well and have been exposed to

many different scenarios throughout my career: I’ve had years to observe large group practices, hospitalbased practices, solo traditional practices and am now in solo (soon to be small group) entrepreneur Urology practice. And, while I’ve practiced in a large city for the duration of my own career, I did a locum rotation in a small rural hospital/medical community.

I also have many close friends who are urologists in the academic setting.

For me, the strongest consideration in deciding where to practice (aside from practicing in an ideal city) was the people. I asked myself: • Who would have the greatest influence/control over me? Would it be the hospital administrator?

• Would I be placed in a political role and needing to manage relationships?

• Would I be asked to be on committees?

• Would I be responding to a large group administrator wanting me to perform “non-ideal clinical duties?”

• Would I be covering call for multiple physicians with in-house patients with prolonged weekend rounds?

Keep these things in mind!

Quality of life, family life and longevity of practice requires you to find a practice setting where you can minimize stress and be excited about being a physician.

I agree with the comment that hanging a shingle to open up practice is difficult. It’s not that you "do not have the skills," but rather the insurance contracts can be very poor when starting a new practice as a solo doctor. The best scenario is a small group practice that is established with like-minded, considerate physicians who seem to control their business environment.

I now practice in a non-hospital based, patientto-patient referral, community outreach referral, ambulatory Urology practice. Yes, this still exists and if you are interested in "how," you are welcome to reach out to me.

When considering location, think about educational opportunities for your children if you have or expect to have a family. I have seen many physicians leave their practice, move cities and start over because they had educational concerns for their children in their first practice location.

38 The American Urological Association

To end on a positive note: remember, you are in demand and thus have choices! Godspeed!

DR. NATHAN GRUNEWALD – PRAIRIE DU SAC, WI:

covering (how many locations, hospitals, etc.), who are you covering (number of partners, what are you/they doing case-wise?), triage available (when does a patient actually get you?), volume (is trauma included?)

Here is what I usually tell folks when they ask. This assumes private practice.

o Number of partners and cases

• Take a few minutes to make a list of what you and your partner want in life. Consider family, career (work/life balance), pleasure, etc.

o Hospital beds covered o Community and travel times

• Look ahead with a long-term focus. Your life has been dominated by school friends forever. You'll still have those, but the circle you keep will likely change.

o OR access (block time option), Ancillary access (IR, imaging, hospitalists)

• Kids, new money, real job responsibilities, debt, free time - prioritize these items. Write them down. Save it. Look back on it as you seriously consider contract options.

• It is a job seeker's market right now. Urologists are in MAJOR demand and will be for the foreseeable future. Your pay should reflect that, so don't sell yourself short. There is plenty of data out there regarding reasonable pay expectations. o Be careful as you inquire. People will be upset if you don't choose them/their group. Express appreciation, but leave options open until the contract is signed. Thank them afterwards.

Know your friends.

o Clinic and support staff assistance

o Pay (guarantee vs. production, sign on, production bonus) o Contract term (many don’t stay in their first job) o Competition restrictions o Payer Mix I am personally hospital employed in a solo setting of a small (35 bed) rural hospital with a superb surgeon base and hospitalists. This is a new service line for the hospital, so I had to start from scratch for them.

If that interests you, feel free to message me and I'll explain how I set it up and how I created work/life balance. Good luck!

• When evaluating a Urology job in general terms, think about the following: o Call requirements: how often, what are you

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