INKLINGS Is it about business, education, or patient care? There is an increasing trend in medicine toward subspecialization, and even further subspecialization of the subspecialty. When I started residency training, most urologists were generalists and practiced all areas of urology, including men and women, adults and children, as well as benign and malignant diseases. At that time, the only board certification was in urology. There were no subspecialty boards, even though some people focused on particular areas of urology. Today the field is quite different; there is subspecialty board certification in pediatric urology. Female urology training has now been combined with urogynecology to produce female pelvic floor medicine and surgery fellowships that allow residents who completed either urology or obstetrics and gynecology residencies to enter and become board certified in this subspecialty. Subspecialization has happened for a reason that has much to do with the volume of knowledge required to give top-notch patient care. As medicine and science have advanced, so has the volume of publications and information. Focusing on a subspecialty allows the practitioner to become a master of one area. This same process has occurred in every field in medicine. Male reproductive medicine and surgery fellowships developed as a result of the increased knowledge base and advanced surgical skills required for up-to-date state-of-the-art patient management. The field of reproductive endocrinology and infertility (REI) has narrowed over the years as other subspecialties have developed. These include minimally invasive surgery and pediatric and adolescent gynecology. In addition, there has been encroachment of other fields into conditions such as polycystic ovary syndrome and menopause. As a result, surgical procedures have become less and less a component of those who specialize in REI. Although surgical logs of fellows completing fellowships may make low surgical volume an undeniable fact, it is not clear why this is necessarily a problem and that having reproductive endocrinologists evaluate men is a solution. The practice of medicine is a many-faceted activity. To a great extent, it is a business. Is the problem with current REI practice a business problem, that is to say, are there not enough patients to support REI practices? Certainly encompassing male infertility would increase patient volume and, therefore, revenue flow. Thus, if the problem with current REI fellowships and practice is financial, then it is certainly possible that broadening REI practice to both sexes may be considered by some to be a solution. One of the stated deficiencies of the current REI fellowships and subsequent practice is the lack of surgical volume. Unlike our REI colleagues, male reproductive urologists have continued to practice both medicine and surgery. Techniques such as vasoepididymostomy and microdissection testicular sperm extraction are rarely performed by non–fellowship-trained physicians. In addition, most reproductive urologists also deal with male sexual dysfunction and associated surgical procedures, such as implantation of penile prostheses and correction of Peyronie disease, that are commonly used for that patient population. Finally, many reproductive urologists still practice some general urology, which also helps to maintain their surgical skills. One VOL. - NO. - / - 2014

reason for this is that many male reproductive issues result from other urologic problems that the urologist is uniquely trained to manage. The field of male reproductive urology has not seen the loss of turf that seems to be a problem in the field of REI. Therefore, if the problem with current REI practice is a lack of surgery, certainly entering the male field would increase the surgical breadth of the REI specialty. Although this may be the case, it does not necessarily follow that this makes sense from a quality-of-care point of view. A major reason why many subspecialties developed is that those people who practiced that specialty were better at it than others. The argument to change the REI fellowship training to encompass the male partner can not be credited to the lack of a male reproductive specialty, because that already exists. Encompassing male reproduction into the REI's breadth of care does not arise because the general field of medicine does not have specialists in that area, whereas most currently established specialties arose from a lack of expertise in a particular area. This, therefore, does not seem to be an educational or training argument. Finally, we should turn to the most important characteristic that should be examined when suggesting changes to medical education and practice, that is, the effect on patient care. Is this a model that will improve patient care? It has been suggested that the REI is better equipped than the general urologist to deal with male infertility issues. Although that opinion may arise from anecdotal experience, there are no substantial data to suggest such a conclusion. While there is no doubt that those of us in the reproductive field have seen patients mishandled by other physicians in many specialties, that does not mean most couples are mishandled, and therefore, there should be substantial changes in education and practice. Many of us that practice male reproductive medicine have had patients referred to us by reproductive endocrinologists who have had a multitude of inappropriate tests done before referral. Thus, one could argue that there should be less involvement of REIs in the infertile male evaluation and management. The solution to this is not to incriminate all REIs. Similarly, we have all seen couples who may have had inappropriate management by general gynecologists. However, again, the solution is not to have the urologist start managing the female partner. The solution is to make sure that the couple gets the best medical care available by those trained in those areas. Currently, there is some exposure of REI fellows to the evaluation of the man in most fellowship programs. A proposal might be that REIs should be trained in basic male evaluation, and only those cases deemed to be difficult should be sent on to reproductive urologist. This is no different than suggesting that general practitioners or family practitioners manage all medical problems except those they deem to be too difficult to manage themselves. The obvious problem with this approach is that it assumes that it is clear when cases are too difficult to manage alone and that referral actually occurs. All of us who are subspecialists realize that many diagnoses are missed unless the evaluating physician is an expert in that field and identifies the clues leading to a proper 1

INKLINGS diagnosis. If the REI fellowship did incorporate some male infertility training (beyond what is currently incorporated), do we really think that these new fellowship-trained physicians will feel that they have a need to continue to refer men for a male evaluation at all? In this instance, one can envision that less appropriate evaluations may be performed on many patients. We all have seen cases of men who have undergone attempts of sperm retrieval when that approach may not have been the most appropriate. This certainly has the potential to result in worse, not better, patient care. It may also be argued that there is a paucity of male reproductive specialists, and therefore that many patients get no treatment at all. Although this was certainly the case in the 1980s, the number of reproductive urologists has increased dramatically. The issue may not be that there is no available expertise, but rather a willingness to find and utilize available expertise. Maintenance of education is an important component of specialty training. There are currently a variety of organizations that are critical to dealing with male reproduction beyond the American Society for Reproductive Medicine. These include the Society of the Study of Male Reproduction, the Sexual Medicine Society of North America, and the American Society of Andrology. Is it realistic to think that REI fellows, after training, will have time to attend additional meetings beyond those needed to maintain REI skills? While a proposal to broaden the REI training to include male reproduction has many important weaknesses, it does raise the question of what would be the best training that may result in improved patient care. The obvious example that comes to mind is the combined female floor and reconstructive medicine and surgery fellowships. The experience with these is quite early, and only time will tell how they work out. However, there are important differences between the management of female voiding dysfunction patients and the management of male and female infertile patients. In the first case, urologists and urogynecologists already dealt with female voiding dysfunction, and fellowships existed under each specialty. In addition, the basic training of residents before entrance into the fellowships included female pelvic floor conditions. This is not the case for male and female reproduction. Urologists deal with both men and women as part of their urology residency training. Gynecologists, for


the most part, have no or limited male exposure during training. They are not trained in the physical exam of or the surgical procedures for the man. They are not exposed to the complications of the male reproductive surgery or to the relationship between general urologic disorders, male sexual dysfunction, and male reproduction. Similarly, urology residents, though quite familiar with female urinary anatomy and pathophysiology, have minimal exposure to female reproductive issues. Thus residents coming from the two separate fields would have greatly differing knowledge bases. Whether a combined fellowship could be devised that would bridge this gap is an interesting point for discussion. In the past it has been suggested that the areas of male and female sexual dysfunction should be combined into a new residency to allow better care of medical conditions that clearly involve both partners. The same can be said for male and female infertility. Whether this is best accomplished by restructuring residency training to have male reproductive and sexual residencies may warrant further discussion in the future. As medicine continues to advance, our willingness to look at how well we are doing in meeting our patient's needs and what the best approach is for training to meet those needs should be continually reexamined. It also remains important, when evaluating possible changes, to look at the rationale for doing so. We must not confuse what is best for business with what is best for education and patient care. Mark Sigman, M.D. Division of Urology, Brown University, Providence, Rhode Island You can discuss this article with its authors and other ASRM members at Use your smartphone to scan this QR code and connect to the discussion forum for this article now.* * Download a free QR code scanner by searching for “QR scanner” in your smartphone’s app store or app marketplace.

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Is it about business, education, or patient care?

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