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Editor, -I enjoyed your editorial in CME Urology. You ask readers to send you their thoughts regarding the future of urology, so here are mine.

It is both likely and right that subspecialisation in urology should increase. The whole of urology is clearly too large for any single person to be expert at everything. The questions to be answered are:

a. How narrow should subspecialisation be?
b. How should the totality of a urology service be delivered?
c. How can skills and interests be maintained for a lifetime of practice?
d. What will become of — “one disease surgeon” if scientific advances produce a medical rather than a surgical treatment for the condition?

I believe the answer to most of these questions can be found if all urologists have a general training in urology making them able to achieve an accurate diagnosis and decide the broad strategy of treatment for almost all conditions. In addition, all urologists should have a higher level of competence in the management of one or two conditions. This would enable every urologist to receive all sorts of referrals but after initial diagnosis and simple treatment, more complex patients would have to be passed on to a colleague with suitable expertise but any individual would keep patients in his speciality and expect similar referrals from his colleagues.

From a patient’s point of view, this provides an efficient first tier of management as well as a skilful second tier.

Proper delivery of a urological service will clearly depend on larger units. A minimum of five consultants would be needed to cover the common specialities (prostatic cancer, kidney and bladder cancer, stones, uro-gynae, complex reconstruction). A full range of backup services including MRI, ICU, lithotripsy
etc. would clearly be needed. These larger “units” need not necessarily be on one geographical site but interdepartmental referral would have to be the norm.

Although the subspecialists would spend at least 50 % of their time in the high-tech hospital, there is no reason why the other 50% should not be spent at smaller community hospitals, seeing initial referrals and sorting them out. 1 would guess 75 % of patients would never need to get beyond the first stage
and 25 % would need interdepartmental referral.

Skills would be maintained because each specialist could expect to see numbers of patients well in excess of the “critical mass”. In addition, the unhappy surgeon who finds himself shipwrecked by scientific advance would not find it difficult to retrain provided his broad basic knowledge is maintained and also provided it is agreed, well ahead of time, that a period of in-service retraining is likely to be necessary once or twice during a consultant’s career.

This system, if it could be made to work, solves a lot of problems and, importantly, avoids the production of ” second class urologists”. Everybody is a specialist in something, everybody has access to high-tech. glamorous facilities but in return, everybody has to accept they have to do a certain amount of bread and butter urology and donkey work for their colleagues.

These are my thoughts; if you think they are silly, put them in the bin but if you think they are sensible, I look forward to receiving my Nobel Prize before long.

Andrew Pengelly
72 Berkeley Avenue
Reading Berks.
RG1 6HY
Tel. 0118 9553452
Fax: 0118 9588110

Reference

1. Editorial- CME Urology 1999; 1: 31.