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Ruchika Talwar: Hi everyone, my name is Ruchika Talwar, and today we're at the American Urological Association's 2024 annual meeting in San Antonio, Texas. Today I'm joined by Dr. Nathan Grunewald, who is a urologist at Sauk Prairie Healthcare in Wisconsin. We're going to be talking about some particularly important health policy issues as it relates to the workforce shortages, especially in rural areas in America. Dr. Grunewald, thank you so much for your time today.

Nathan Grunewald: Thanks for having me.

Ruchika Talwar: So let's just set the stage for our audience. We have had a shortage of urologists in this country for several years, and the trends just continue to look concerning as we project out numbers in the future. But in rural America, the workforce shortage has been particularly stressed and it's a major access issue for our patients. Tell me more about this from your perspective as a urologist who practices in a predominantly rural setting.

Nathan Grunewald: Yeah, that's an excellent question. It really is a tenuous situation in rural America. The history and the geographic size of the United States really create population density clusters. And so we have, according to the most recent US census in 2020, 20% of the US population living in an area that's designated as rural. On top of that, according to the most recent AUA census, 10% of the urology workforce works in rural America.

And on top of that, the disparity goes even further, those individuals who work in rural America as part of the urology workforce tend to be of an older demographic, nearing retirement, are retired, or are actually beyond what most people would retire at, simply because they're trying to serve the needs of the communities. So on top of already having a shortage of the number of individuals there, the likelihood over these next five years, maybe even 10 years, there's a real risk for the numbers declining even more. And it really gets to an adequacy issue within rural America when it comes to not just access to care, but access to the whole healthcare framework goes beyond just urology. We're not alone in this issue.

Ruchika Talwar: Yeah, yeah, absolutely. It's really a cycle because it's hard to get patients plugged in when there's a lack of specialists or perhaps even primary care providers, just even a healthcare system within a hundred miles of where a patient lives. And so you're compounding the problem further when they're not getting preventative care, early detection, screening, etc. And they present at a much later stage of the disease process, whether it's a cancer-related process or a benign urologic process. And then that leads to a more complex situation, higher healthcare costs, and greater costs to the patient. So there's been a lot of focus on how do we tackle some of these issues in rural America.

So in your opinion, we've set the stage, we know there's a problem. We know over the next five to 10 years, the problem may even get worse. What is the path forward? How do we attract young urologists to these underserved areas?

Nathan Grunewald: It's a complex question and answer. There is no simple switch we can flip that's going to solve our problem. The socioeconomic issues associated with it are broad. And so as we think about what types of policies we can enact and whatnot, it really comes down to an advocacy issue. And so I'm really happy that we're seeing traction within, this is a recognized issue within the American Urological Association, within our workforce, and so it's nice to see that we're beginning to see policy being pushed towards addressing the concern.

From a larger, maybe federal government standpoint, we know that the Specialty Physicians Advancing Rural Care Act, we've introduced it now, this is the second or the third legislative session, and that's one way we are trying to incentivize individuals to consider rural. It goes by providing loan repayment up to $250,000 after six years. Every year there's a piece that gets forgiven if you stay in rural. And we know that if people try rural and they can put some roots down and six years generally does that, they're more likely to stay. So that's one aspect of the advocacy efforts that are currently ongoing on the federal level. But we're also seeing, even within our own specialty society and the AUA, we are trying to attract more individuals from rural to even go into urology.

And at times we make that a little difficult because we're a tough specialty to get into. And on top of that, we ask you to, hey, you got to apply early. And many people don't even know about urology coming into med school. So we have a future program that's looking towards how can we attract a broader demographic that really mirrors our patient population, both from gender, race, ethnicity, all of that, but also geography. And so that's an important piece to bring in more people into the specialty and hopefully help with some of that workforce shortage. No doubt.

Ruchika Talwar: Yeah. You bring up so many great points here, and I want to dig in a little bit. From attracting young talent and resident applicants and things like that, a lot of times people who are more likely to go back to rural areas are those who were raised in rural areas and perhaps did their education in these more rural areas. Those urology programs may not have the resources to conduct, for example, extensive research like you see at some of the big academic medical centers. And when you create a situation in which it's a very competitive specialty, and a lot of people are doing research years and have all these varied experiences, we are putting those rural applicants with those roots at a disadvantage sometimes.

And so it's important as we look to attract residents who might be interested in going back to rural communities, it's important to keep that in mind as we evaluate residency applications. And so the other piece of this is getting early exposure to urology for those students. So a lot of times in rural areas, we just talked about the fact that there are no urologists. So how do we get the word out about this awesome specialty in which we practice? What's the path forward to try to get rural medical students interested in our specialty?

Nathan Grunewald: Yeah, I mean, it goes back to how do we communicate and get in at the medical school level? And that's not an easy task per se. I mean, we're a specialty here after post-medical school that we're training individuals with. So getting boots on the ground, helping schools develop interest groups, helping students do away rotations, not make it... In some cases, it can be difficult and daunting, especially if you don't have a local person. Even if you have an interest in urology, somehow you kind of stumbled upon our specialty and you're like, ah, that's an interesting one. You might not have a resource, as you mentioned, to even go to someone to say, how do I do this?

And so helping the medical schools and the program directors at institutions nearby maybe is one way to do it, but also helping, looking, maybe expanding some of our traditional forms, like plenty of DO schools that have no urology where they're at. And so it really comes down to an exposure issue. So it's stages of advocacy leadership. You've got unaware people who don't even know urology exists. We need to move them to the awareness stage where they even know we exist, and then how do we help them when they say, Hey, I really want to take some action on this. How do we get them to that point?

And this is not an easy issue to answer, but I think it's doable. I really do. And I think we see, even from the AUA, there's definite encouragement going on right now. And even with our diversity, equity, and inclusion committee, this is an important task that we're working on is how can we, across the board geographically, how can we help med students find out about us?

And then when they think they want to come, how do we help them get there?

Ruchika Talwar: Yeah. How do we support them? I totally agree. And one of the big reasons we asked you to be here today was to just increase awareness about this problem within the urologic community. So as we wrap up here, I want to ask, what are the biggest takeaways that you'd like to impart on our audience? What can we all do to try to help alleviate, honestly, some of this crisis that we're going to see in rural America?

Nathan Grunewald: Yeah. Well, first, whoever's hearing this, I am already thankful because it's a message that in some cases they aren't aware of. Many, even if you are like 90% of our workforce that lives or works in an urban setting, feel it. And some of them recognize it because as rural facilities lose urologists or they just lose healthcare altogether, that pressure gets transferred over to the urban centers, and they absolutely feel it. They see the patients coming from three hours away, an hour away. And so they feel that.

So I think the awareness issue in and of itself is important. The action comes a little bit later on where we're asking for, how can you help us with garnering interest in our specialty? But on top of that, when we have the interest, how can we help cultivate those individuals to get into the specialty and be successful in the specialty? And in an ideal scenario, we're bringing them into rural areas, which requires exposure in many cases. Certainly from a health system standpoint, what can they do to highlight the benefits of rural? There are benefits to working in a rural environment that some people maybe have never considered before. And so health systems need to think about that.

That's one way we can attract specialty physicians back there, even if they aren't sure about rural, getting them exposure. Our training programs. We talked about this before, not you and I, but in general in AUA, we talked about are there rural tracks? Should we devise a system for people who want to go into rural locations and practice in those locations? Have some baseline requirements and understanding on how to do things.

But what are those barriers? Some of them are like robotics. If you're trained how to do most of your abdominal surgery with a robot and then you go to a rural location that doesn't have a robot, there's hesitation there. You might not even go simply because of that. How do we think about that? So I suspect that rural tracks might be a piece of this puzzle.

Ruchika Talwar: Yeah, yeah. It's a complex problem, but the great thing is we have dedicated individuals like yourself brainstorming, and certainly this issue has the interest of our broader specialty societies, such as the AUA. So hopefully we can all work together and ensure that our patients do have the access they need.

Nathan Grunewald: Yeah, a hundred percent. That's what it's all about in the end, improving our patient outcomes.

Ruchika Talwar: Absolutely. Absolutely. Well, thanks for spending some time with us today. We appreciate it.

Nathan Grunewald: Thank you.