United in Tulsa: Urologic Specialists of Oklahoma Is a Model of Collaboration

John Forrest, MD

The words “north” and “south” may conjure up images of the Civil War that divided, and then eventually reunited, the country. For Urologic Specialists of Oklahoma (USO) in Tulsa, the merging of north and south was free of such conflict and turmoil, yet still rooted in long-held personal ties and shared history.

USO co-founders John Forrest, MD, and Robert Bruce, MD, have known each other since the fourth grade. They both attended medical school at the University of Oklahoma and, after some time away from home, ultimately joined two different, well-established practices in north and south Tulsa

“Over time, we came up with the idea to merge our two large practices into one larger group,” Forrest explained. “It’s always been my feeling that with the changes in medicine, practicing in a larger, highly structured group was the wave of the future. It allows you certain positions in the marketplace in terms of how you practice medicine, how you respond to payers, and how you manage regulatory issues. We believed that being a large group would make us more agile to respond to changes in healthcare while providing a high level of expertise and service.”

The advantages of this model, Forrest explained, include shared, structured decision making; the ability to offer an array of ancillary services on site; and timely access to the latest healthcare management practices, such as electronic medical records.

USO formed in 1996 with nine doctors on the north side of town and four on the south side, housed in multiple locations, said Steve Dobbs, the practice’s CEO. In 2004, the 52,000-square-foot main campus was built, bringing the majority of the physicians and staff under one roof (the practice also maintains a small satellite office in another part of Tulsa). USO now has 20 physicians and will be welcoming two more later this year. Its areas of specialty include general urology, urologic oncology, pediatric oncology, renal transplantation, and a division devoted solely to female pelvic medicine.

Forrest and Dobbs spoke with Urologists in Cancer Care about how the practice came together, how it maintains its union, and why outreach is a major part of its expansion plan.

The Ties That Bind

Beyond Forrest and Bruce’s long-term friendship, USO has many connections that give the practice its united front. But getting to the point of cohesion did require some adjustment.

Dobbs joined USO in 2011 and checked in with some of the veterans of the practice to learn more about the challenges it faced when first merging. Not surprisingly, one of the main issues was integrating the different cultures of two independent practices that had been around since the 1960s.

The practice managers looked to one of the driving principles of real estate to circumvent any culture clash: location, location, location.

“When they designed [the current] building, they strategically put one doctor from the north side and one doctor from the south side next to each other in a pod,” Dobbs said. “That way, people would ‘click’ together. In fact, even now, in every one of our pods, there are physicians who came from the south side practice and doctors who came from the north side. Of course, after all these years, north and south is a non-issue, but it was a smart way to get everyone to start working together as a group.”

Steve Dobbs,CEO

In fact, USO physician-partners have taken that “all for one” philosophy even further with their salary structure. “We have a pooled income model,” Forrest said. “Basically, all of the full partners make the same amount of money. It’s not driven by patient volume, compensation formulas, or relative value units. We all subspecialize, but ultimately, our contributions are equal, so our income model reflects that.”

The shared income model is “all about doing the best we can for the patient,” Dobbs echoed. “If one of our physicians sees a patient, and determines that person would be better served by one of his partners, then that patient is referred. I see it happen every day.”

In addition to its central location and an egalitarian income model, the practice boasts other connections: Physicians David Confer, MD and Stephen Confer, MD are father and son, while physicians Oren Miller, MD and Curt Powell, MD served in the military together.

USO also includes many physicians with Oklahoma roots. “Of the two physicians we recruited this year, one grew up in Tulsa. So he’s coming into a community where many people have known him for years,” Dobbs explained. “The other is from a town about 60 miles away from here. He’s done a fellowship in urology trauma and he wanted to come into a practice where he could really use that knowledge. These are both people who we recruited from major training programs in the country, but who have a relationship with Oklahoma and want to give back to their community.”

Indeed, physician recruitment is an area where the practice has excelled. Forrest attributes that to the practice’s size, which he said offers it clout and an array of helpful contacts. The group’s success in recruiting new members is particularly notable at a time when there is a shortage of urologists due to more physicians opting to become hospital employees. Having been in the healthcare industry for nearly 40 years, including several as a hospital CEO, Dobbs acknowledges the appeal of the hospital model, but said he asks potential partners to look beyond the paycheck.

“So many doctors become hospital employees so they don’t have to worry about the business side,” he said. “I understand that. But I ask them to think, how do they want their partner relationship to work? Do they want to work with people who have their backs? In a dynamic, large group like ours, if you need help, your partners will step up and help you. In a hospital setting, those personal relationships aren’t always as easy to establish.”

Underserved Areas, Under-Recognized Risk

As part of its plans for expansion, USO will continue its outreach program to other towns in Oklahoma, either because those communities have no urologists or their urologists are about to retire.

As part of their routine, all USO partners participate in the outreach program, traveling to towns 20 to 100 miles away from Tulsa to provide general urology services.

“For instance, Vinita, Oklahoma, is about 60 miles away, and it did not have a practicing urologist in town or nearby,” Dobbs explained. “McAlester, which is a large city near the Choctaw Nation, is about 100 miles away, and that community of 20,000 has no full-time urologist. We usually partner with a local hospital so that we have a space to consult and treat these patients.”

From a clinical standpoint, outreach also includes talking to patients about their overall health and any associated risk for urologic disorders, including cancers.

“The biggest health challenge in the US now is the management of obesity, which is a risk factor for prostate cancer, stone disease, recurrent urinary tract infections, sexual dysfunction, and incontinence,” Forrest said. “But patients don’t always see those relationships, and that’s part of our job, to help them understand that.”

The outreach also includes helping to raise the awareness of patients and the general public about other urologic cancers that typically don’t gain as much attention as prostate cancer. For instance, a study presented at the 2013 American Urological Association meeting showed that testicular cancer rates have been steadily rising.¹ Yet public awareness of this disease is minimal, Forrest said.

The same holds true for renal cell carcinoma and bladder cancer, he pointed out. “The rate of finding renal cell cancer is up because of ubiquitous CT scanning; renal lesions are found earlier. But the rate of high-stage, renal cell carcinoma is still going up. In terms of bladder cancer, those rates are not going down, most likely due to smoking and some other environmental factors. It can take up to 20 years for that malignancy to show up, even in someone who has quit tobacco use.” Fortunately, urologists now have much better tools to treat these cancers, Forrest said, such as ablative techniques and laparoscopic or robotic partial nephrectomy. “Also, we’ve had the introduction of three to five new oral agents that have slowed the growth of metastatic renal carcinoma, adding years of survival to these patients’ lives,” he said.

In bladder cancer, preoperative chemotherapy prior to cystectomy has been refined over the years, while in early-stage testicular cancer, active surveillance is a viable option, he added.

Since the doctors at USO forge longterm bonds with their patients, they are able to present a variety of such options at the most appropriate times.

“What’s interesting about the practice of urology is that we take care of some of these patients for many years, so we watch their health change over time,” Forrest said. “Not many other specialties have the ability to make those connections.”

Reference

1. Nigam M, Shikanov S, Aschebrooke-Kilfoy B, Eggener S. The increasing incidence of testicular cancer in the United States from 1992 to 2009. Presented at: the American Urological Association Annual Meeting; May 4-8, 2013; San Diego, CA. Abstract 933.