Year : 2006 | Volume
: 22 | Issue : 1 | Page : 23--26
Are we ready for subspecialization and group practice in India?
J Chandra Singh
Department of Urology, Christian Medical College, Vellore, Tamilnadu, India
J Chandra Singh
Department of Urology, Christian Medical College, Vellore - 632 004, Tamilnadu
|How to cite this article:|
Singh J C. Are we ready for subspecialization and group practice in India?.Indian J Urol 2006;22:23-26
|How to cite this URL:|
Singh J C. Are we ready for subspecialization and group practice in India?. Indian J Urol [serial online] 2006 [cited 2021 Jan 28 ];22:23-26
Available from: https://www.indianjurol.com/text.asp?2006/22/1/23/24648
0"Would you tell me please," asked Alice, "which way I ought to go from here?" "That depends a good deal on where you want to get to," said the Cat. "So long as I get somewhere," Alice added. "Oh, you're sure to do that," said the Cat, "if you only walk long enough".
Ever since urology developed as a specialty from general surgery, there has been a tremendous improvement in the overall care of patients with urological diseases. There has been further growth by continually adding knowledge and by acquisition of techniques from other specialties. Today, the scope of Urology is such that one expert in the discipline cannot maintain expertise in all its specialties. This has resulted in the concept of subspecialization.
What is Subspecialization?
It was Hippocrates who coined this term 2,000 years ago when he said, "I shall not cut stone but leave it to those who are specialists in the art". Today we have the World Endourology Society and a journal dedicated to the management of stone disease. Whenever an individual or a hospital subspecialized in the management of specific disease entities, the results were always far superior to that of those who were involvement in the management of this disease along with other diseases. For example, the Shouldice clinic has been well known for hernia repair and the results have not been equaled by the modern techniques. The patients are so contented with the care that they even have an annual get together along with their check up. In our country high professional standard of international acclaim has been set by experts in various subspecialties of urology. ,,,
Growth of specialities in urology
It has been more than a century since urology developed as a specialty from surgery. The oldest urological association in the world, the American Association of Genito-Urinary Surgeons, was formed in 1886. Between 1896 and 1899, several National Associations of Urology were created and the discipline started to be considered an independent specialty. From its very beginnings, urology was considered as a medical and surgical specialty. The two main disorders that consolidated urology as an independent surgical specialty were stone surgery and prostatic surgery. Both were established successfully from the beginning of the twentieth century. The British Association of Urological Surgeons was formed just over 50 years ago with 66 surgeons. Today the specialty's separation from general surgery is complete, consultant expansion continues and many of the 470 urologists in the United Kingdom have developed subspecialty interests within urology (uro-oncology, reconstruction, endourology andrology, female urology, neurourology and pediatric urology).
Urography facilitated the recognition of a much greater range of genito-urological problems. Endoscopy, first as a diagnostic procedure and later as a therapeutic technique, endowed urology with a special prestige. In the mid 1950s, the urologist made major in roads into abdominal and intestinal surgery through vesical replacement and urinary diversion. Interest in renal pathology, kidney failure in all its variants and replacement therapy meant that urology was at the fore in the introduction of kidney transplantation and renal artery surgery. Minimally invasive procedures, later to be known as endourological, were developed. Percutaneous nephrolithotomy, served as a model for other surgical specialties and its instruments laid the basis for laparoscopic operations, which were, introduced in general surgery.
Impact of subspecialization
Within specialties there has always been concern about subspecialization and its splintering effects as well as its potential to increase the cost of health care delivery. Hinman's survey of urologists has revealed a similar opinion among urologists, but a study done by Snow et al showed the opposite is true. The cost of ureteroneocystostomy done on 184 children by general urologists and pediatric urologists was compared. They found that the hospital charges were significantly less ($1095 per patient) and the complication rates were fewer when pediatric urologists did the procedure. The same study showed that the time required to complete a bilateral procedure was much more for a general urologist as compared to a pediatric urologist. The complication rates were lesser when urologists with appropriate subspecialization performed the procedures. The probable reason for this is that operations performed frequently by an individual surgeon will be quickly and safely accomplished.
When all factors are considered, it is obvious that high quality care with minimal complications will be the most cost effective and that the least expensive inpatient care is rendered by full term subspecialists. Patients under the care of a subspecialist are likely to have maximum overall cost savings in similar instances with complication rates similar or even lower.
Pros and cons of subspecialization
Subspecialization provides better care, reduction in risk, decreased cost of care, progress in diagnosis and treatment, improvement in teaching and research, establishment of a domain for determining educational objectives, evaluation of training and competence and for competition with other specialties.
There are a few complaints against subspecialization. It includes loss of substantive relationship with the primary discipline, reduction in training material for residents, decrease in competence of general urologists in areas of subspecialization, possibly lower standards of care for those without access to a specialist and adverse effects on the cost of medical care from the expenses and duration of training. But certainly the benefits outweigh these accusations.
Subspecialization in urology is feasible in India
The growth and development in urology in India is comparable with other developed countries in subspecialties like endourology and reconstructive surgery. More patients are approaching specialists in the field and this implies that the expectations of the patients are more. The willingness to pay for it warrants the care which is more likely to be provided by subspecialists than by general urologists. Teaching institutions in India have the facilities to establish subspecialty care. Urology trainees are likely to gain better training in decision making, lateral thinking and operative skills when they are trained in departments with subspecialties and can develop further in the specialty of their choice, helping determine their future career. Apart from improvement in patient care, institutions that subspecialize in urology are able to progress academically, with publications in reputed journals. In his review of health care delivery in India, Hegde pointed that the standard of health care varies so much across the country that a single yardstick cannot be applied for the whole of India. Cost reduction is an important factor in health planning in India. Contrary to common belief, subspecialty care will reduce patient costs as observed in Snow's study.
Subspeciality training in urology
Training of the urologists should be planned to ensure that their training needs are met. The rotations should be designed to give trainees exposure to urologists who practice different specialized interests. Most urology trainees will have made their specialist choice by the time they become senior registrars. Their training rotation should then be planned to include at least two years work with the appropriate specialists. Training needs must have priority over service requirements if the next generation of urologists is to be provided with specialist skills. Attempts need to be made to define approximate numbers of trainees for the subspecialties and those making a career choice should be advised appropriately. The proportion of trainees in the shortage-subspecialties needs to be increased and a mechanism for this has to be established.
What is Group Practice
A medical group is defined as three or more physicians formally organized as a legal entity in which business, clinical and administrative facilities are shared. The concept of group practice evolved in the United States and it is being followed in other countries. Many benefits have been stated in favor of group practice to improve quality, efficiency, physician life style and income. Quality of care is improved by mutual education and consultation; measures to improve patient safety, care of chronic illnesses and preventive services. Efficiency is improved by better management and purchasing. Less business responsibility, administrative burden and better vacation coverage and profit from ancillary services are the potential benefits of group practice.
Evolution of group practice
Large multispecialty groups like the Mayo clinic, Palo Alto Medical Clinic, Scripps Clinic and Permanente Medical group were formed following the report of the Chicago committee in 1932 in the US. It was evident that they improved the quality of health care, decreased costs and provide a professionally desirable working environment for medical practitioners. Medical care has become increasingly complex and expensive. Awareness of medical errors has grown and the possibility for using organized processes to improve quality has been well studied. In this context, the role of group practice seems more relevant today.
Pros and cons of group practice
Cited advantages of group practice include potential to increase physicians' leverage with negotiating health plans, operational efficiency, improve quality and containing medical care costs. A prospective Community Tracking Study done by Casalino et al among physician groups, health planners and hospital administrators identified six important benefits and seven barriers.
Leverage with health plans and negotiating with health insurance schemes are useful indicators of group practice and were identified as the most frequently cited benefits in this study. Group practice has also been identified to be beneficial in purchasing, management and monitoring information systems. A New York specialty group administrator stated, "You just can't be a Mom-and-Pop corner store anymore in medicine. There are too many administrative issues to deal with; you need quality administrative staff that only a large group can provide". It was also observed that gaining leverage with hospitals was the next most frequently cited benefit. Improvement in the quality of life of the specialists, including lesser duties and more vacations was the other advantage.
Conflicts among members of a group may arise due to income division, call coverage and staffing, scheduling, titles, vacation policies and many other reasons. Andrea Molberg, an organizational psychologist in Rochester says, "My toughest clients are physicians, police officers and attorneys." She adds, "They're not accustomed to having their views challenged". Casalino also identified this as the most common barrier. Others include lack of capital investment and information systems. Lack of physician leadership was identified as the third most frequent barrier. It was attributed to the paucity of physicians with management skills and to physicians' reluctance to reward leaders who put time into creating a group and/or helping it operate efficiently. A large office brings additional expense, more staff and higher paid staffing consultants. A large office can be efficient only with highly skilled management.
The legal and human relations requirements for a group practice with large numbers of employees is substantially greater than in a small private practice setting. There is considerable difficulty in finding and evaluating experienced administrative personnel who have proven experience in this kind of practice.
Money is the root of most troubles. Cost allocation is a challenging area in group practice. According to Messinger, ancillary income is the glue that holds many groups together. If a medical group does not get at least 30 per cent of its income from ancillary services, it becomes difficult to sustain a group, as individual practitioners find it more advantageous to practice alone. Distribution of surplus money may be a contentious area. If the bonuses are not properly accounted for, it might result in judicial interference as in a recent court in the US.
Indian Health Scenario
The public has had more awareness about advanced health and wants the best possible treatment from specialists in the field. They are willing to spend for their health related expenses. There is growing awareness about consumer rights.
The health care system in India has had explosive growth in the last century in preventive, diagnostic and therapeutic measures. Unfortunately, the health sector is also perceived by the public as one of the most corrupt service sector in India. ORG-Marg Research did a household survey of 5000 citizens in India to assess the public's perception of corruption. It covered 10 sectors with a direct bearing on people's lives, including education, health, the police, the judiciary and power utilities. The respondents rated the police as the most corrupt sector, followed by health, power and education. But the impact of corruption is on a much larger scale in the health and education sectors. A quarter of the respondents had paid bribes for health services, compared with 18% in the power sector.
A survey of 500 private practitioners (general physicians, gynecologists, surgeons and others) in Ahmedabad found that there 84% had a satisfactory growth in practice. The reasons given were experience of the doctor, availability of specialized skills and technology, accessibility of private medical services, increasing demand for health care, promotion of private medical practice by private practitioners. Another study done by Muraleetharan among 73 private hospitals in Chennai explored into the possibilities of policies that would benefit both Government and Private sectors. One possible policy could be to identify specialties in high demand from private sector and develop specific measures to moderate their practice. Urology is one such specialty and its role can be improved by the introduction of Group Practice. An important determinant for the success of group practice is the availability of health insurance coverage and of late, there has been an increasing awareness and enrolment in health insurance schemes. A study done by Mathiyazhagan among 1000 households in Karnataka revealed that the rural population is well aware of the health insurance schemes and are willing to join and pay for rural health insurance schemes.
Group practice in Indian urology
Group practice could be a tool to promote quality care in urological practice in India. Contrary to those cited by Casalino, the greatest benefit in India will be in improved quality of care. Capital investment has been a hindrance in our specialty, as minimally invasive procedures require expensive equipment. In a group practice through common investment more equipment can be procured which will be available for all the members of the group. Shared care will enable each urologist to have more quality time for him or her. Having competent colleagues in the group will enable cover during vacations and also mutual consultation and education. As in most situations in life, the distribution of income and allocation of expenses can be a major source of conflict in a group practice. Unwillingness to adopt a common formula for income distribution and expense allocation will define individuals within the practice who adopt any group decision only if it is personally beneficial. Group consensus is difficult, but essential to obtain in a group practice.
The prospects for urology look good and the specialty has been able to adapt to major technological and pharmacological changes. Charles Huggins, noble laureate and Professor of Urology at the University of Chicago has called urology "the queen of the specialties". This is appropriate, as urology has many ramifications and it is interwoven with surgical anatomy, pediatrics, endocrinology, psychiatry, human dynamics and emotions.
Urology in India is a dynamic specialty that has changed incredibly during the past forty years. Subspecialization is the answer for further growth and refinement in the specialty and we have all the prerequisites for subspecialization in India. Pressures to improve quality, the need to cope with the changing health care scenario in India are the drivers towards group practice with three to six urologists serving a large population. Such a transformation with subspecialization and growth in group practice is likely to become the norm in India.
|1||Carroll L. Alice's Adventures in Wonderland. The Macmillan Co: New York; 1963.|
|2||Harrison N. Urological Surgery. BMJ 1998;317:1255-7.|
|3||Porrero JL, Hidalgo M, Sanjuanbenito A, Sanchez-Cabezudo C. The Shouldice herniorrhaphy in the treatment of inguinal hernias: A prospective study on 775 patients. Hernia 2004;8:60-3.|
|4||Asopa HS, Elhence IP, Atri SP, Bansal NK. One stage correction of penile hypospadias using a foreskin tube. Int Surg 1971;55:435-40.|
|5||Krishnamurti S. Penile dermal flap for defect reconstruction in Peyronie's disease: Operative technique and four years' experience in 17 patients. Int J Impot Res 1995;7:195-208.|
|6||Gupta NP, Gill IS, Fergany A, Nabi G. Laparoscopic radical cystectomy with intracorporeal ileal conduit diversion: Five cases with a 2 - year follow-up. BJU Int 2002;90:391-6.|
|7||Desai MM, Desai MR, Gill IS. Endopyeloplasty versus endopyelotomy versus laparoscopic pyeloplasty for primary ureteropelvic junction obstruction. Urology 2004;64:16-21.|
|8||Goodwin WE. The development of Urology as a scientific and clinical discipline. Am J Kid Dis 1990;14:563-7.|
|9||Barondess JA. The future of generalism. Ann Int Med 1993;119:153-60.|
|10||Hinman F. Subspecialization and General Urology. J Urol 1989;141:482-5.|
|11||Snow BW, Cartwright PC, Young MD. Does Surgical Subspecialization in Pediatrics Provide High-quality, Cost-effective Patient Care? Pediatrics 1996;97:14-7.|
|12||Gother M. Specialty training in Surgery. Br J Surg 1991;78:260-4.|
|13||Watkin DM. Sub-specialty training in Surgery: Are we producing what the hospitals need? Ann R Coll Surg Eng 2000;82:150-3.|
|14||Havlicek PL. Medical group practices in the US. American Medical Association: Chicago III; 1999.|
|15||Casalino LP, Devers KJ, Lake TK, Reed M, Stottard JJ. Benefits of and barriers to large medical group practice in the United States. Arch Int Med 2003;163:1958-64.|
|16||Moser M. The growth of Multispecialty Medical Groups 1982-1989. J Ambul Care Manage 1991;14:9-13.|
|17||Crane M. Ways to resolve conflicts within group practices. Medic Econ 1995;72:103-5.|
|18||Crane HS, Dennis DA. Risks of a Large Group Practice: A Personal Experience. Clin Ortho Rel Res 2003;407:67-70.|
|19||Terry K. Group Practice: The best way to divide income. Med Econ 2004;81:88-91. |
|20||Lowes R. Group practice. The IRS cracks down on bonuses. Med Econ 2004;81:60,63-4.|
|21||Kumar S. Health Care is among the most corrupt services in India. BMJ 2003;326:10.|
|22||Ramesh B. Characteristics of Private medical practice in India: A provider's perspective. Health Pol Planning 1999;14:26-37.|
|23||Muraleetharan VR. Characteristics and Structure of Private Hospital Sector in Urban India: a study of Madras city. Appl Res. Abbt assc. Inc.|
|24||Mathiyazhagan K.Willingness to Pay for Rural Health Insurance through Community Participation in India Int J H Plan Mang 1998;13:47-67.|
|25||Health Care Delivery in India Today. GM Hegde. JAPI 2002;50:425-7.|