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 (SP) 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 freeing time for the physician to attend to more complex patient care suited to his or her level of expertise. Highly skilled APPs are eligible for this indirect supervision. Given the specialty nature of urology and the lack of intensive curricula in NP or PA programs, the supervision/collaboration model likely promotes the best patient care outcomes in urology. In most instances, prior urology experience is limited, and for that reason, sound problem solving and decisionmaking skills will mature with time. Delegated tasks must be mutually understood and agreed upon. As such, it is important 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 frequent physician-APP communication and a period of direct supervision and orientation. Models of team-based integrative care should be 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. Outreach clinics can also be staffed by experienced APPs, and preoperative and postoperative educational classes conducted by APPs can increase patient satisfaction and patient retention. In the hospital setting, consultations, history and physical examinations, and difficult bladder catheterizations can be performed by APPs. Allowing APPs to perform these types of tasks enables the physician to dedicate more time to more complex urologic patients within the practice. In the clinic setting, some procedures, such as prostate ultrasound, urodynamics, cystoscopy, vasectomy, and stent removal, have been performed by APPs; however, this is an area of controversy requiring 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 to maintain the highest quality urologic care and patient safety.
9. DIVERSITY AND INCLUSION IN UROLOGY The following is a reprint of an article originally published in the April 2021 issue of AUANews, authored by Fenwa Famakinwa Milhouse, MD, Denise Asafu-Adjei, MD, and Ashanda R. Esdaille, MD. Read the entire April 2021 Diversity and Inclusion focus issue of AUANews at AUAnet.org/DiversityIssue. Microaggressions in Medicine In the wake of the gruesome murder of George Floyd and the disproportionate impact of COVID-19 on communities of color, America is facing a reckoning over race and the historical inequities that underrepresented minorities have endured. Our institution of medicine has been forced to look inward and evaluate its own role in perpetuating these inequities. Casual discrimination occurs in our classrooms, hospitals, operating rooms, doctors’ lounges, clinical workspaces and board rooms in the form of microaggressions. “Microaggressions” was coined by African American Harvard psychiatrist Dr. Chester Middlebrook Pierce.1 This term was used to convey the everyday verbal and nonverbal slights, snubs or insults that communicate hostile, derogatory or negative messages to degrade Black Americans. In modern times, the definition has been expanded to include the subtle denigration of any marginalized group, whether intentional or unintentional. Microaggressions stem from implicit bias: the attitudes, assumptions or stereotypes we hold subconsciously towards members of a particular group. None of us is immune to implicit bias. Therefore, we are all capable of perpetrating microaggressions. In fact, microaggressions are often perpetrated by individuals with good intentions. Yet it is not the intent but the impact that matters. Committing a microaggression is not necessarily a reflection of one’s values, but evidence of the dominant culture or point of view that is so deeply entrenched in society. Microaggressions can be divided into 3 types, as defined by Dr. Derald Wing Sue.2 Microinsults are comments or actions that are unintentionally discriminatory. Examples of microinsults include assuming a person of color or woman is not the doctor and statements to minorities such as “you are so articulate” or “you are a credit to your race.” These convey that minorities, women or members of a discriminated group are typically less capable. Microinvalidations are comments or actions that invalidate the experience of marginalized
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