Addressing Urological Care Challenges in the South - Lorie Fleck

May 30, 2023

In a UroToday discussion, Zach Klaassen hosts a conversation with Lorie Fleck about the challenges of providing urological care in the South, the growth of their department at the University of South Alabama, and the importance of training new urologists for underserved areas. Dr. Fleck emphasizes the issues of access and long travel times for patients in remote locations, especially considering the lack of urologists in small-town hospitals. The conversation delves into the development of their urology department and residency program, explaining how they achieved the required coverage of urology subspecialties and the necessary number of cases. Dr. Fleck reflects on her transition from private practice to academic medicine, highlighting the joy of teaching and influencing the future of urology. The discussion concludes by acknowledging the pressing need for more urologists due to the aging population and the hope that their program will help address this.


Lorie Fleck, MD, FACS, University of South Alabama, USA Health, Mobile, AL

Zachary Klaassen, MD, MSc, Urologic Oncologist, Assistant Professor Surgery/Urology at the Medical College of Georgia at Augusta University, Georgia Cancer Center

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Zach Klaassen: Hello, and thank you for joining us for this UroToday discussion. My name is Dr. Zach Klaassen. I'm a urologic oncologist at the Georgia Cancer Center in Augusta, Georgia, and I'm delighted to be joined by Dr. Lorie Fleck, who is an associate professor at the Department of Urology at the University of South Alabama in Mobile. Dr. Fleck. It's great to chat with you today. I'm looking forward to our conversation.

Lorie Fleck: It's wonderful to be here, Zach. Thank you for inviting me.

Zach Klaassen: Of course. So you guys recently just got your own department and basically your first residents are coming in I believe this summer. Is that correct?

Lorie Fleck: That's exactly right. I was in private practice here in Mobile for 23 years. I went to a medical school in Augusta where you are, and I did my urology residency there. I moved here and joined a private group in a long time ago, I won't say how many years, but a long time ago. And I was with the same group until I moved to the university. And I loved practice. I loved taking care of patients and periodically I would get a little exposure to teaching. I would have a student that would come work with me, but it was always a passion and just such great pleasure.

So about five years ago, a couple of us moved over to the university just to cover the urology. So it just started kind of as a private practice covering a university system. And over the past five years, we've grown from two urologists to eight urologists, and we decided we wanted to form a department and went through all that it takes. We can talk more about that. And it's part of residency program. So all those things have happened, and you're exactly right. This summer we get our first intern and then one of the surgery interns will be our second year urology resident. So we'll start with two.

Zach Klaassen: That's so awesome. And you're absolutely right. I want to get into that for sure. Just to start off though, both of us work in the south and there's some unique challenges to being a urologist in the south in terms of the under served care. For our listeners, just sort of break down what treating patients in the south may be different from being in a bigger city like Chicago or New York. How does that look in your guys' practice and generally in the southeast US?

Lorie Fleck: Okay, and that's a very good question. In this part of Alabama, the closest largest city is Montgomery, Alabama, which is about two and a half hours away. And then north of that would be Birmingham, which is about four and a half hours away. So there's not any other cities with hospitals of any size close to us. You could drive west to New Orleans or you can drive east to Pensacola, Florida, but there's nothing else around here.

So all of the people that live out in the small towns and the rural areas, they may have some small hospitals, but they don't have urologists. There are some outlying clinics and we'll try to go there to provide some coverage, but again, you can't do any intervention. So if there's a kidney stone or a patient in retention, you're really stuck. You can't give them the care. So they're driving hours sometimes to get care. We'll have patients that'll drive an hour for an office visit, which is a long way and that we do need more urologists, which is one reason why we really wanted to get this residency started to have more urologists that maybe want to stay in the southeast. And if we can do more outlying clinics and go cover these smaller hospitals, maybe we can help more people without them driving.

Zach Klaassen: Yeah. And you're right, an hour visit for somebody who's maybe below means or doesn't have a vehicle that's reliable or is taking care of their family member, that's a big deal. It's not like you and I hop in our car and we drive four hours to the beach. This is a big deal for these folks, right?

Lorie Fleck: It is. And usually the people that are coming aren't in the best of health. Like you said, they may have multiple medical problems and they have a local doctor to take care of those basic things like the high blood pressure and diabetes, but they're not in the best of health. And then having to drive long distances to get urologic care, which really impacts quality of life. It can be a cancer diagnosis or it can be an incontinence or a prolapse. It can be anything, but whether it's a life-threatening problem or a quality of life issue, it's a hardship on these people. So we do need more urologists in the southeast in, again, I know my area better, but it's in Alabama, once you're away from Birmingham, there's just a lot less coverage.

Zach Klaassen: Yeah, no question. So take us through that process of becoming a department. I know there's some excruciating details, but give us an overview of how long that process takes. What are some of the challenges of actually going through that process?

Lorie Fleck: Well, fortunately, our acting chairman of the department was in Tennessee at the University of Tennessee at Chattanooga, and they recently went through this process-

Zach Klaassen: Years ago.

Lorie Fleck: ... to develop a residency program. So a lot of that information, we were able to piggyback on that. Nice. So I do have access to the person with all of the knowledge. I only have a limited amount of knowledge, but becoming a department meant us going from being a semi-private group to joining the university. So it's all new contracts, all new payment scales, new time off forms to fill out. It's a whole different thing to be part of a medical school and then to be allowed to be a department. And I think what helped us with the department and the residency acceptance was that we have most of the different subspecialty urology covered. We have female pelvic and reconstructive surgery, we have pediatrics, we have cancer and robotics, we have endo-urology, and we have access to a male reconstructive surgeon.

So having all those covered, and we have a large number of cases. In order to get a residency, obviously you have to have the number of cases for your residents to do. But we had all of those. We had the big cases, the cystectomies and the stones and the pelvic reconstructive surgery. So we were able to meet all the criteria because you want your residents when they finish to be qualified to be able to go out and practice. They may want to go do a fellowship, but what if they just want to go practice good high quality urology and become board certified? We want to make sure that they meet the criteria, they can pass their boards and have all of the surgical skills that they need to practice. So I think we were ready for that and that's why we were approved for a residency.

Zach Klaassen: Yeah, that's fantastic. And the fact that you're now the second program in Alabama, if I'm not mistaken, right?

Lorie Fleck: Yes. So University of Alabama at Birmingham has been the only place for urology residency as long as I've been aware. I don't think there's been another program in the state. And then, so we're very excited to have this, and even though we're still small, sure, we have very good attendings and hands-on a lot of experience. The students are excited. We have several students each year that will go match in urology residencies around the Southeast or outside of the Southeast, and we're really proud of them too. So we're starting to make a little name for ourselves, even though we're young. We're a young program.

Zach Klaassen: Well we've had several of your students come rotate with us up in Augusta, and they've been fantastic. So I can only imagine once you guys have your hands on them for five years, they're going to turn out to be excellent urologists too.

Lorie Fleck: I sure hope so. And that's what we're hoping for. We're hoping for people that, maybe they want go do a fellowship, like I said, but what if you don't? I didn't go do a fellowship at that point. I just wanted to go practice medicine and learn from other mentors in my group. And so I joined a private practice group and got great experience, loved being here in Mobile. And there's a lot of urologists and Mobile, but again, we don't have people out in the outlying areas, so we still need more.

Zach Klaassen: No, for sure. So just from a personal standpoint, you mentioned, you got training here in Augusta, you went into private practice. How was that switch either from going to private practice to going to working at the teaching hospital, to now being basically an academic urologist how did that process play out? And I'll be honest, what kind of risks and benefits in your mind is there at this point? You got residents now, you're now an academic urologist.

Lorie Fleck: Yes, and again, it's still new to me to be an academic urologist after being a private practice urologist for so long. I think for me, part of, again, I loved private practice. I love the freedom and the independence to do whatever you want to do with your practice. Practicing medicine for any physician in this day and age is very difficult from a financial standpoint. The management issues, watching your statements every month and looking at your income at some point that weighs on you and takes away some of the joy. It did for me. It took away some of the joy at practicing medicine. I love my patients, I love the surgeries and the diagnostics and the patient interaction, but I didn't love looking at the financial statements every month. So again, we still look at that in academic medicine. We have to make sure that we're financially solvent, but some of the pressure is off and some of the joys of teaching and sharing. I had students with me today and yesterday, they're students who are not even going to go into urology.

They're third year students, but right now we don't have residents. So they work straight with us. And I taught how to do cystoscopy and we talked about anatomy and the urethra. And so I was able to share all that with them. That brings back the joy for me. So yes, there's the pressure of making sure that I provide accurate information. I think I'm smarter now overall than I was five years ago because I've got to be ready for the traumas. I've got to be ready for a gunshot through the abdomen, transecting a ureter. I've got to be ready for a pelvic fracture and things I didn't do five years ago. I've got traumas now, and we have really sick people that come to a tertiary hospital like this. So I've had to review all that. I'm giving a lecture to the first year medical students next week.

So I'm just trying to go through and make sure it's a good lecture. So I feel like I'm more up to date maybe on everything than I was because I've got to be able to answer questions and be smart and not just do female urology. And that's what I've did mostly the past 10 years. So for me, it's been a learning experience and it's been educational and it's made me a better urologist, a better, more well-rounded urologist and prepared to give lectures and talk and consults and all these things I wasn't doing before. So again, it is a big transition, but the benefits and the blessings of that outweigh the loss of some of the independence and freedom I had before. And sometimes I still wish I could hire anybody I want and pay whatever I want instead of going through HR. But again I can deal with those hardships for the enjoyment of all the rest of it.

Zach Klaassen: That's a great answer. And I think you hit on a couple good things there. When people say, "Do you like up operating more, do you like teaching or do you like writing or do you education?" And the answer is yes, and that's what makes you-

Lorie Fleck: All of it.

Zach Klaassen: ... feel good, right? And there's nothing against... There's a lot of folks out there that are working hard in private practice, but the reason you're talking about the enjoyment of the variety of the process, and I think I agree with you, I think it's that teaching and seeing somebody go from X to Y to Z over the course of five years is honestly, there's no feeling that you can describe when you see that person progress to that point.

Lorie Fleck: Yeah. I'm looking forward to that. Even with our students who have chosen to go into urology, watching them from the beginning of a sub internship at the end of the month, being able to go with you to see a consult and let them look at the data and them review the films and present that to you and seeing their progress, it's very exciting because you're doing something that's going to live into the future instead of just seeing a patient and doing your billing and coding and running an office. You're affecting the future of urology.

And to me, I'd like to leave a legacy. And so I think if I can get people interested in urology and get these students to go through the match and match in urology and then now train them here, hopefully I'm making a difference in the future of all people. I think about this, I'm a baby boomer, I'm very thin, but I am a baby boomer and our population, it's a large number of people in their sixties and seventies. So we need urologists to be there to take care of these people with the multitude of medical problems we'll have, especially in the urologic area. You and I both know that, so I want to keep training them and it does bring a different kind of joy.

Zach Klaassen: No question. I think hit on a good point. I think the fact that the population's getting older and the workforce urology isn't expanding as quickly as we need it to, having programs like yourselves come on board is tremendous. Because if you look at our program and your program, a lot of these folks will stay in the southeast. And not that there's no other needs across the country, whether it be the Midwest or rural parts of the Pacific Northwest, but because we both practice here, this is what we live, I think there's a high likelihood that they will stay in the south and contribute to that.

Lorie Fleck: And I agree, and you're right, they may not choose to stay here, but I think there is a higher likelihood they would, if you train in Cleveland, it's less likely you're just going to jump to a group in southern Alabama. If you've gone to medical school, maybe in the south and you end up training in the south. I think it's appealing that we have good weather, we have nice people. I think you're more likely to stay in the south. So hopefully we'll build up this group of young urologists coming along. I know that's why we're involved in a lot of the societies we're involved in too, like the southeastern section and other things to increase the interest in these students and the residents and help them love urology like we do.

Zach Klaassen: Absolutely. We've had a great conversation. I've really enjoyed it. I want you to wrap up with maybe anything we didn't touch on, a message for folks that maybe wanting to apply to USA, just what your goals are for your residents and basically just leave our listeners with a couple of take home points.

Lorie Fleck: Again, we are a very young program. We have very enthusiastic, cohesive attendings and we all get along very well. We're all different, but we like each other very well. I'm the oldest, and so all of the other ones are in their forties and thirties and they love surgery, they love teaching, they love their patients. We have a nice mix of office and surgery. So our goal is to train urologists, to practice good urology, to know what they need to know to handle all the problems, to be able to pass their boards. I think all of us want that and to have them feel competent to go out and take care of most urologic problems. I think all of us, we need a little support when we get out. It's nice to have a partner or someone you can call when there's a question. I still see things every day that I've never seen before, which makes urology really fun.

There's always something new and different. Like "Wow. Never seen that before." So it's a field that I think most urologists are happy with urology, not that practicing medicine is easy because you want everyone to do well and all your patients to turn out fine and not all the outcomes aren't good, but the practice of urology is just a wonderful field. And so that's our goal here. So anyone that's listening that would be interested, we would love to have them come rotate with us and come visit Mobile, Alabama. It's a nice city. I've chosen to leave Georgia and leave Tennessee and stay here in southern Alabama and we sold our property in Tennessee and bought a boat, so we're very happy.

Zach Klaassen: That's perfect. Dr. Fleck so much for your time. I really enjoy it. And thanks again.

Lorie Fleck: Thank you Zach. Thanks I enjoyed it. Thank you very much.

Zach Klaassen: Thanks.