So you want to be a urologist. You like the idea of dick jokes and, well, more dick jokes.
Let’s debunk the public perception myths of what it means to be a urologist, and give
it to you straight. This is the reality of urology.
Dr. Jubbal, MedSchoolInsiders.com.
Welcome to our next installment in So You Want to Be. In this series, we highlight a
specific specialty within medicine, such as urology, and help you decide if it’s a good
fit for you. You can find the other specialties on our So You Want to Be playlist. You guys
voted for it, so here it is. Make sure you’re subscribed if you want to vote for future
episodes.
What is Urology? Urologists are surgeons of the uro-genital
tract. If you need it to urinate or to reproduce, chances are urologists operate on it. This
includes the kidneys, ureters, bladders, prostate, urethra, testes, and more.
Urology also deals with some of the most sensitive parts of health, including sexual function,
fertility, urinary continence, and gender identity. For this reason, urologists are
well versed in having complex, quality of life conversations and delivering compassionate
care.
Many people have never even heard of the field of urology. But when you get intractable pain
from a kidney stone or a testis that has twisted on itself at 2AM, you’ll thank your stars
for the field of urology.
Contrary to popular belief, urologists are in fact real surgeons. They don’t just treat
STI’s all day. Urology residency involves rigorous surgical training and they are the
experts at operating on various structures within the pelvis.
Many also believe that urology only applies to men. Turns out many women seek treatment
from urologists for cancers of the urogenital tract and issues with voiding. In fact, there
are even some subspecialties within urology that treat women almost exclusively.
Although there is some overlap between OBGYN and urology, gynecologists focus primarily
on the female reproductive tract, whereas urologists typically focus on the male reproductive
tract and the urinary tract of both men and women.
Clinic vs Operating Room Urology is unique amongst surgical subspecialties
because of the blend between clinical medicine and surgery. Earlier on in a urologists career,
they may focus more on surgery, but it’s common for older urologists to phase out and
focus more on clinic, as they may be less enthusiastic about standing in the operating
room for hours at a time.
In clinic, urologists share many similarities with medicine doctors. They’ll be counseling
patients on lifestyle modifications for an overactive bladder, prescribing medications
to assist with erectile dysfunction, and working up the causes of recurrent kidney stones.
They may also perform small procedures in clinic, such as vasectomies and cystoscopies,
where they insert a camera through the urethra to visualize the bladder. Sounds comfortable.
In the operating room, the cases are varied. They can break up kidney stones or vaporize
prostates using lasers. Or use robots and laparoscopic procedures to remove kidney or
bladder cancers. Urologists also perform a variety of open surgeries with kidney transplants
or lymph node dissections.
Small vs Big Cases Urology has a high degree procedural variation.
One day, you may be performing a quick in-office vasectomy that takes less than 30 minutes.
And the next, a complex bladder reconstruction lasting several hours.
Some urologists may enjoy the complex, life-or-death surgeries where you carefully dissect all
around the aorta and vena cava, removing lymph nodes and curing a patient of cancer. Others
may like the quick but equally satisfying cases where you retrieve a large stone and
relieve a patient of some of the worst pain of their life — and all in under 30 mins.
You can be the cancer-slaying hero who saves the day or the quality-of-life captain that
helps a man stay continent, and everything between.
Academic vs Community Urologists that practice in academic settings
focus on research, teaching residents, and take care of patients inside and outside of
the operating room. Some academic urologists spend most of their time engaged with teaching
and clinical work while others may have just a half day of clinic and procedures per month
while the rest of the time is spent doing basic science research.
The practice of a community urologist can vary quite a bit — from mostly in the clinic,
to spending the majority of their days in the operating room. Regardless, these urologists
devote 100% of their time to patient care.
How to Become a Urologist After 4 years of medical school, urology residency
is an additional 5 or 6 years, depending on the program, as 6 year programs have a dedicated
research year built in.
In your first year of residency, also known as intern year, you’ll be developing fundamental
operating room skills, but the majority of your time will be spent learning how to manage
floor patients. As a PGY2 and PGY3, meaning postgraduate year 2 and 3, you’re a urology
junior resident, and you’ll be seeing urology patients that come in from the emergency department,
managing patients on the urology floor, and working on smaller cases. As a fourth and
fifth year, you’re now a senior resident, and you’ve paid your dues. Now it’s time
to shine and learn as much as you can in the OR. You’ll be doing larger open cases, like
kidney transplants and large reconstructive and oncologic cases. You’ll also be mastering
the use of the surgical robot to resect kidney, bladder, and prostate cancers. While it’s
much more fun, there’s also much more responsibility that comes with it. You’ll be the top level
resident, and as such there are additional administrative duties to make sure everything
within the urology service is running smoothly.
If a program has a research year, it’s typically done between the third and fourth year. However,
these are becoming less common as urology trainees are valuing the prospect of shorter
training and sooner independent practice.
There are several benefits to a research year, though. You can explore an intellectual curiosity,
whether it’s basic science research to understand how checkpoint inhibitors work in prostate
cancer, or develop a new device to address premature ejaculation. You can explore barriers
to healthcare access and many other facets applicable to urology. If you have a research
itch, this is your time to scratch it full time, for an entire year.
Research years are also often a much-appreciated pause from the rigorous and high intensity
surgical training that is the norm of residency. If you’re interested in a career in academic
medicine, a research year gives you an opportunity to publish additional papers, present at conferences,
and network with the top dogs in the field.
Urology is unique in that it participates in its own match, rather than the NRMP that
is the norm for other medical and surgical specialties. The application process is quite
similar, but you’ll be applying sooner than your NRMP colleagues, and you’ll match in
January or February, rather than March.
As I’ve covered in my Surgical Stereotypes video, urologists have the best jokes in the
business. A robust sense of humor is almost required to be a part of this field. After
all, a good part of your day is speaking with patients about their erections. The stereotypical
medical student applying to urology has a great sense of humor, doesn’t take themself
too seriously, and loves to be in the OR. These are the “happy surgeons”, some of
the kindest and most affable in the operating room. Unlike some other surgeons, you won’t
see them throwing instruments in the OR or having a temper tantrum with the scrub nurse.
Think of them as having the skills of a general surgeon, but the kindness of a family medicine
doctor.
In terms of competitiveness, urology is up there with other surgical subspecialties.
In 2020, 484 applied and 354 successfully matched. That’s a match rate of 73%. The
precise Step scores are not well defined since they don’t participate in NRMP. Estimates
for Step 1 and Step 2 are similar to those of something like ENT or orthopedic surgery,
around 245 to 250.
While board scores are important, letters of recommendation hold heavier weight than
usual. That’s because urology is a smaller specialty where urologists all know one another
more or less. A glowing letter from a prominent urologist can transform an applicant with
below average board scores into a more attractive applicant. For this reason, away rotations,
whereby medical students rotate for 1 month at an outside program, are quite important
in urology. This allows students to impress prominent leaders in the field and secure
strong letters of recommendation.
Subspecialties within Urology After completing urology residency, you can
subspecialize further with a 1 or 2 year fellowship.
Andrology/Infertility Little known fact - 50% of infertility in
couples is due to the man. Urologists specializing in andrology are men’s health champions
and specialists in fertility and sexual dysfunction disorders. The bread and butter is varied,
including varicocelectomies (surgically treating dilated veins near the testis which can compromise
fertility) , or even performing surgical sperm extraction while operating under a microscope!
If you want to get botox on your scrotum, also known as scrotox, then these are your
guys.
Andrology fellowship will also teach you how to perform penile prostheses, spermatic cord
denervation, and even reverse a vasectomy. This is a 1 year clinical fellowship, but
may also include 1 year of research as well.
Female Pelvic Medicine & Reconstructive Surgery (FPMRS)
Female pelvic medicine and reconstructive surgery, or FPMRS for short, is a fellowship
available to those who have completed either a urology or OBGYN residency. From urology,
it’s a 2 year fellowship, and if you’re coming from OBGYN, it’s 3 years.
These are the masters of reconstructive surgery of the urogenital region, including repairing
fistulas, reconstructing urethras, creating urinary diversions from the intestine, and
resolving vaginal prolapse, just to name a few.
Many FPMRS programs also offer training in gender affirming surgery for transgender patients.
Examples include metoidioplasties, or female-to-male surgery, whereby you reconstruct the lower
urogenital tract to create a small penis from the clitoris. Depending on the complexity
of the surgery, urologists may work alongside plastic surgeons during these cases. If you
want to learn more about plastic surgeons, including gender reassignment surgery, we’ve
covered that in a previous episode of So You Want to Be.
Transplant Transplant fellowship in urology, lasting
2 years, is relatively small compared to others, as most transplant surgeons come from general
surgery residency and are trained to perform other solid-organ transplants in addition
to the kidney.
The hours for this fellowship are intense, as you’ll be woken up in the middle of the
night to take a private plane or helicopter to harvest an organ and transplant it to a
new recipient. These are the adrenaline junkies and perfectionists of urology. After all,
every detail and every suture needs to be perfect to have a successful transplant.
Endourology/Robotics Endourology and robotics is a 1 year fellowship
dealing with the sci-fi of urology. You’ll hone your skills on the surgical robot, dealing
with some of the most complicated urology cases with minimally-invasive approaches.
There are even treatment modalities for benign prostate disease using lasers and water vapor.
Talk about futuristic.
Uro-oncology Uro-oncology is a 2 or 3 year fellowship,
often with a dedicated research year, where you’ll be specializing in the minutiae of
urological cancers. These surgeons have a reputation of being more on the serious side,
as their bread and butter is something life or death for their patient.
Urologic oncologists build long-term relationships with their patients, as they’ll follow a
patient’s cancer for several years before deciding to operate, and will continue to
follow their patients for the rest of their lives, as urologic cancers tend to recur.
Pediatric Urology Pediatric urology is a 2 year fellowship,
but don’t worry. It’s much more than just circumcisions. They deal with all the urologic
issues of children, including hypospadias repairs, whereby the urethra opening is on
the underside of the penis rather than at the tip. There are more complex cases too.
For example, children born with severe anatomical birth defects precluding normal urination
may need surgery that allows them to catheterize themselves from their belly button.
Peds urologists are especially meticulous and precise as they are dealing with smaller
structures than other urologists.
What You’ll Love About Urology There’s a lot to love about urology. First,
life as an attending has much better work/life balance compared to most other surgical specialties.
After residency, expect 40-60 hour work weeks.
Your patients will also love you because many of your interventions will have an immediate
and positive effect on their quality of life. Urology patients tend to suffer from sensitive
health issues for many years before they seek care, and they’re understandably incredibly
grateful when you can help them maintain a robust sex life or even help them be continent,
meaning not leaking urine, throughout the day.
There’s a great deal of variety in urology and you can adjust based on your preferences
over the course of your career. Younger urologists with more energy may choose to perform more
complex oncologic surgeries most days of the week. But as you get older, maybe you want
to transition to primarily a clinic-focused practice with some minor surgeries on the
side.
Compensation is also on the higher end, as it is with most surgical subspecialties, and
urologists make on average $408,000 per year.
What You Won’t Love About Urology While urology is an amazing field, it’s
not perfect. In fact, urologists have some of the highest burnout rates reported amongst
all of the medical fields. In a recent Medscape Burnout report, urologists topped the list
at 54%.
As with other surgical residencies, you can expect 80 hour work weeks as the norm during
your training.
Urology is also a specialty that has conditions requiring immediate and urgent treatment.
That means you can be called in during the middle of the night for a patient that is
septic from an infected kidney stone.
Although infrequent, urological complications can be some of the worst including gnarly
penile prosthesis infections and extreme electrolyte abnormalities that can be life threatening
in patients who have had their bladders or kidneys removed.
Should You Become a Urologist? If you want to work with your hands, enjoy
the pathophysiology of medicine, like building long-lasting relationships, love the operating
room, and are prone to making dick jokes, then urology may be a good fit for you.
If you want to be a surgeon but still have a healthy work-life balance, urology is unique
in being able to provide that. Urologists also love playing with new gadgets, lasers,
and toys in the operating room, as it’s a highly innovative field.
And in terms of personality, those who are happiest in urology have a great sense of
humor and don’t take themselves too seriously.
Lastly, because urology is a highly competitive field, you’ll need to crush your boards,
home and away rotations, and knock it out of the park with research too.
And who better to learn from and be mentored by than urologists themselves. Big shout out
to the urologists at Med School Insiders that helped me in the creation of this video. If
you need help acing your MCAT, USMLE, or other exams, our tutors can maximize your test day
performance. If you’re applying to medical school or urology residency, our urologists
can share the ins and outs of what it takes and how to navigate the competitive process
most effectively. We’ve become the fastest growing company in the industry, and it’s
no surprise. Our customers love us because we’re committed to delivering results, period.
Learn more at medschoolinsiders.com.
Thank you all so much for watching! If you enjoyed this episode, you may also enjoy our
Surgical Specialty Stereotype video or another So You Want to Be episode, like plastic surgery.
Much love, and I’ll see you guys in that next one.