“To improve is to change, to be perfect is to change often,” said Winston Churchill. Urology experts must acknowledge that the spectrum of clinical options that we offer our patients has changed significantly, which commands us to readjust the ratio and specificity of both our procedural and cognitive skills.

One can simply review the most recent surgical logs from the American Board of Urology to understand that the volume of traditional “open” surgical cases, especially major cases, has significantly diminished.  The practicing urologist is clearly spending more time in the clinic and less time in the operating room.

Simultaneously, all third party payors, and most prominently the Centers for Medicare & Medicaid Services (CMS), have continued to further decrease physician reimbursement for all procedural CPT codes (which includes all surgical specialties). The so-called “doctor fix” of obviating the 27% SGR (sustainable growth rate) still looms before us, like the proverbial sword of Damocles. Undeniably, our population continues to increase in volume and with a disproportionate increase in the aged. Concurrently, prostate cancer patients will live longer for a multitude of reasons (advanced cardiovascular health as well as advancement in CRPC [castration-resistant prostate cancer] therapies). We also see shrinking clinician manpower. There is an ongoing need for providing an expertise for offering systemic therapies for advanced cancer therapies.

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Who will take care of this ever increasing population of patients with urological malignancies, especially those who fail localized therapies? The employment paradigm for the field of urology has changed in my career lifetime. Virtually no one finishes a residency and then goes out and hangs a “shingle”. For that matter, many younger physicians may be dumbfounded to define exactly what a shingle represents. Today, urologists are employed by larger groups or organized institutions, eg, medical centers or large multidisciplinary clinics. There exists a need for subspecialization.

Although it is essential for urologists to continue to work closely with all of our medical and surgical colleagues, we must recognize that our field’s future is predicated upon the avoidance of being marginalized as proceduralists, answering to the decision-making or triage by other medical personnel who may not be as knowledgeable regarding the particular urologic disease state or our patient’s specific needs. Urologists should not abdicate the option to care for patients with CRPC status, where 2010 to 2012 has ushered in a multitude of well-tolerated oral and infusion therapies that can be safely and comfortably given within the urologist’s clinic.

There is a need to better educate and demystify the administration and infrastructure needs for providing systemic therapies. We must understand that our clinical demands have changed, our patient population has changed, and thus our cultural mindset of procedural and cognitive care must change and thus avoid the risk of obsolescence.