Urogynecology Attending AMA

[Dr G Oogle]

Third year fellow in a combined urology/gyn program (take both kinds of fellows) coming from gyn background, staying in academics

Will answer anything

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[ChrisTurkletonMD]

Why Urogyn over other surgery heavy paths like gyn onc?

What are the advantages of entering urogyn through gyn as opposed to urology? Disadvantages?

What is your bread and butter? Most interesting cases?

Thanks for doing this!

 

[Dr G Oogle]

Urogyn has a much better lifestyle than onc both in fellowship and after; MIGS is still a pretty fledgling specialty and it will likely find its legs soon, most MIGS jobs still include OB.

The main advantage of going the gyn route is your better at vaginal surgery from the get go; and often you don't get much of hysterectomy training if you do a urology-only fellowship, the disadvantage is you spend more than 50% of your time on OB so residency surgical training is limited, you don't learn much about neurourology and doing urinary diversion procedures though there are gyn trained urogyns doing those cases

the main advantage of urology is you do 5 years of surgical training and it is relatively easy to pick up the more "gyn" procedures like hysterectomy and AP repairs, so you are actually well ahead of the vast majority of gyn fellows when you start, though it pretty much evens out; it is also much easier to get an FPMRS fellowship out of urology than gyn because general urology is so lucrative and a decent amount of trainees feel competent in doing female procedures without doing a fellowship

Our bread and butter is correction prolapse (vaginal, robotic, laparoscopy) and incontinence (slings, fascial slings), neuromodulation
we also a decent amount of urethral surgery (like excision of prolapsing urethra, diveriticula), fistula repairs, in many places Urogyn is also doing a lot of bening gyn surgery (hysts for bleeding/fibroids etc) especially in places where there are no MIGS trained people

The most interesting cases for me by far are abdominal fistula repairs (usually vesicovaginal, have had a few vesicouterine and rectovaginal ones as well) and congenital anomalies; recently we performed a complex reconstruction on someone with a Mullerian anomaly and ectopic ureter and fixed a post-radiation trigonal fistula with reimplantation of both ureters

 

[Splenda88]

How salary is like for urogyn?

 

[Lawpy]

Third year fellow in a combined urology/gyn program (take both kinds of fellows) coming from gyn background, staying in academics

Will answer anything

1. Tips on shining in clinical years (i.e. as an MS3) in obgyn rotation? Would appreciate some specifics from your perspective even though it's probably rotation/school dependent.

2. Why academics?

 

[Dr G Oogle]

Depends: starting in academics can be 220-320 (highest I’ve heard) PP can be much higher; the AUGS salary survey has people reporting >500 K after 10 years

 

[Dr G Oogle]

1. Tips on shining in clinical years (i.e. as an MS3) in obgyn rotation? Would appreciate some specifics from your perspective even though it's probably rotation/school dependent.

2. Why academics?

1. Know your anatomy, volunteer to see consults and try to come with good ddx and tx plan (I especially like it when students come up with plans because it shows you’re thinking, even if you’re wrong or recommend something I wouldn’t do it opens up the door for teaching). One student in particular sticks out to me from when I was a resident, he went to every patient room politely introduced himself to the patient and asked if he’d be permitted to attend the birth, no one said know and everyone from that rotation still highlights him as a model of student behavior.

2. I do of research and want to have leadership positions in the future on a national level, can certainly do that in PP but easier in academics. Who knows, might jump ship and join a PP group.

 

[puahate]

If i am interested in uro is obgyn performance on rotations really important?

 

[Dr G Oogle]

If you mean as a Med student: then yes, you need to do well on obgyn to match into obgyn

If you mean as a resident: then also yes; You have do especially well on gyn and while you don’t have to deliver 500 babies on OB you should be engaged and a good team member

 

[puahate]

If you mean as a Med student: then yes, you need to do well on obgyn to match into obgyn

If you mean as a resident: then also yes; You have do especially well on gyn and while you don’t have to deliver 500 babies on OB you should be engaged and a good team member

What about matching into uro? Do you need to do well in obgyn?

 

[Dr G Oogle]

Generally you need to do well in everything. Boards and rotations; I don’t think you need to get an honors and stellar evals in obgyn but your certainly don’t want to come off as someone who doesn’t care. A pass won’t kill you if you’ve done everything else right.

 

[puahate]

Ok understandable. I just wasn't sure if uro had emphasis on obgyn. Like with surgical subspecialties i assume they want everything pass or honors but take a close look in surgery rotations. Wasn't sure if uro takes a close look in obgyn too.

Generally you need to do well in everything. Boards and rotations; I don’t think you need to get an honors and stellar evals in obgyn but your certainly don’t want to come off as someone who doesn’t care. A pass won’t kill you if you’ve done everything else right.

 

[Dr G Oogle]

I think the best policy is to try your best and not slack off and you’ll be fine

 

[akuko2]

Any geographical limitations with jobs after fellowship?

How competitive are the fellowships both applying from the uro and gyn side?

 

[Dr G Oogle]

You can’t really be a rural urogyn just yet so you are limited to large private practices and medical centers; you could probably still practice in more rural areas though you’d probably have to do OB and General office gyn and there are older generalists who do urogyn procedures though that’s getting less common and I suspect in the near future there will be more urogyn only opportunities in less populated areas.

Academic jobs are fairly limited but there are a decent number of people nearing retirement so there will be more openings in the future. And there seems to be more recognition that urogyns bring a desired skill set and generate a lot of RVUs for a hospital so more jobs will be available in the future especially as the surgical skill set of the generalist becomes more and more limited.

Last year for gyn the match rate was 90%, but I think it was a fluke; often it’s low to mid 70s; this year we reviewed 80+ apps for 16 interviews for 1 spot. There are about 44-50 spots available annually.

Uro match is less competitive but don’t know the exact numbers.

 

[numbersloth]

Not sure if this thread is still active but giving it a shot anyway.

Can you elaborate on lifestyle, both as a fellow and as an attending, of a urogyn vs. gyn onc? Did you know you wanted urogyn when you chose obgyn? If you had not done urogyn would you have done a different fellowship? If you could go back would you choose the same path? Finally, is having a child/family during fellowship feasible?

 

[Dr G Oogle]

I can only elaborate on Urogyn. Fellowships vary but you get some variant of 2 years clinical + 1 year research. Ours was integrated to 4 months clinical then 2 months research over 3 years. Lifestyle in Urogyn fellowship is great, few emergencies. We operate in Friday’s so have to round Saturday morning but I did that in early am and then had the full weekend with family. We did about 800+ majors in my fellowship and something like 2400-2500 individual procedures. My fellowship was a bit unique we had extentsive training in procedures of lower urinary tract, straight stick, robot and vaginal surgery And I am very comfortable in all of these areas. I did take GYN back up call 6 weeks a year and those could get hairy. Attending life is similar to fellowship, given where obgyn is going as a specialty Urogyn is getting more and more non Uro specific cases so I due a decent amount of general GYN surgery and come in to bailout generalists for surgical misadventures. Usually about 1-2x month, has mostly been during the day. Family life is great in both fellowship and attending life, you’re still a surgeon but an elective surgeon, generally hours are 7-5 and no weekends barring extenuating circumstances. I really like my job but if I had to do it over I’d probably do urology or general surgery and do ACS or colorectal fellowship.

 

[numbersloth]

I can only elaborate on Urogyn. Fellowships vary but you get some variant of 2 years clinical + 1 year research. Ours was integrated to 4 months clinical then 2 months research over 3 years. Lifestyle in Urogyn fellowship is great, few emergencies. We operate in Friday’s so have to round Saturday morning but I did that in early am and then had the full weekend with family. We did about 800+ majors in my fellowship and something like 2400-2500 individual procedures. My fellowship was a bit unique we had extentsive training in procedures of lower urinary tract, straight stick, robot and vaginal surgery And I am very comfortable in all of these areas. I did take GYN back up call 6 weeks a year and those could get hairy. Attending life is similar to fellowship, given where obgyn is going as a specialty Urogyn is getting more and more non Uro specific cases so I due a decent amount of general GYN surgery and come in to bailout generalists for surgical misadventures. Usually about 1-2x month, has mostly been during the day. Family life is great in both fellowship and attending life, you’re still a surgeon but an elective surgeon, generally hours are 7-5 and no weekends barring extenuating circumstances. I really like my job but if I had to do it over I’d probably do urology or general surgery and do ACS or colorectal fellowship.

So, if someone is interested in the surgical/gyn side of obgyn, would you recommend general surgery or a surgical subspecialty as primary residency instead of obgyn?

 

[Dr G Oogle]

If you want to do surgery I think a surgical subspecialty or gen surgery will be a better choice. Urogyn, onc and even MIGS are Uber competitive with match rates between high 60s to low 80s (latter is in less competitive years). So it’s a bit of a gamble. You can get to urogyn from urology; obgyn is experiencing a change in large and mid size metro areas it is getting less and less common for generalists to be doing surgeries and modern residency training only provides a median of about 100 hysterectomies (all routes) so as more MIGS and to some degree urogyns are trained the less generalists will be doing majors except in more rural areas, much like you still FP docs doing OB. If you are dying to do gyn surgery than go to obgyn and take your chances, focus on research and CREOGs. If you just like surgery then I suggest a residency that only focuses on surgery like gen surge, ortho, ent, Uro etc . There are some great general surgery community programs that are family friendly, will get you fellowship and don’t skimp in surgical experience

 

[numbersloth]

If you want to do surgery I think a surgical subspecialty or gen surgery will be a better choice. Urogyn, onc and even MIGS are Uber competitive with match rates between high 60s to low 80s (latter is in less competitive years). So it’s a bit of a gamble. You can get to urogyn from urology; obgyn is experiencing a change in large and mid size metro areas it is getting less and less common for generalists to be doing surgeries and modern residency training only provides a median of about 100 hysterectomies (all routes) so as more MIGS and to some degree urogyns are trained the less generalists will be doing majors except in more rural areas, much like you still FP docs doing OB. If you are dying to do gyn surgery than go to obgyn and take your chances, focus on research and CREOGs. If you just like surgery then I suggest a residency that only focuses on surgery like gen surge, ortho, ent, Uro etc . There are some great general surgery community programs that are family friendly, will get you fellowship and don’t skimp in surgical experience

Thanks so much - one more question: How saturated are the gyn subspecialties and urology? How hard is it to get a job in a major metro area?

 

[Dr G Oogle]

I think there will always be a need for urogyn and oncology and job market is decent. And as urogyn becomes a more known quantity more and more hospitals will want to recruit them. Urogyn also has another advantage which is that academic urology departments, hospitals and even large urology groups will higher urogyns. A few of my friends got PP jobs in urology groups and I am core faculty in a urology department. There are also a handful of female urologists employed by obgyn departments but it rarely goes in that direction only because you tend to make more money at least at the beginning in a urology department than an obgyn dept even though you are doing the same stuff. Urology itself Has a pretty decent job market because the produce a relatively small amount of urologists per year compared to the need. I can’t really speak to specific job markets but out of the last 5 years of urology residents I haven’t seen one have trouble getting a job where they want one. Same for general obgyn as a matter of fact.

 

[thedude001]

I think there will always be a need for urogyn and oncology and job market is decent. And as urogyn becomes a more known quantity more and more hospitals will want to recruit them. Urogyn also has another advantage which is that academic urology departments, hospitals and even large urology groups will higher urogyns. A few of my friends got PP jobs in urology groups and I am core faculty in a urology department. There are also a handful of female urologists employed by obgyn departments but it rarely goes in that direction only because you tend to make more money at least at the beginning in a urology department than an obgyn dept even though you are doing the same stuff. Urology itself Has a pretty decent job market because the produce a relatively small amount of urologists per year compared to the need. I can’t really speak to specific job markets but out of the last 5 years of urology residents I haven’t seen one have trouble getting a job where they want one. Same for general obgyn as a matter of fact.

I think there will always be a need for urogyn and oncology and job market is decent. And as urogyn becomes a more known quantity more and more hospitals will want to recruit them. Urogyn also has another advantage which is that academic urology departments, hospitals and even large urology groups will higher urogyns. A few of my friends got PP jobs in urology groups and I am core faculty in a urology department. There are also a handful of female urologists employed by obgyn departments but it rarely goes in that direction only because you tend to make more money at least at the beginning in a urology department than an obgyn dept even though you are doing the same stuff. Urology itself Has a pretty decent job market because the produce a relatively small amount of urologists per year compared to the need. I can’t really speak to specific job markets but out of the last 5 years of urology residents I haven’t seen one have trouble getting a job where they want one. Same for general obgyn as a matter of fact.

Hoping to bump this thread. Is Urogyn typically family friendly or is your situation a rarity? Does your salary suffer because of that? Has you seen any changes in practice setting/hours/pay in light of COVID? I’ve definitely heard that majority of surgical specialties like ortho are moving from private practice to hospital employment offering very reasonable hours. Is that an outlier in your opinion? Thanks so much!

 

[Dr G Oogle]

Urogyn is pretty family friendly. I take call once per 6 weeks and in the past 1.5 years have only been called in about 6 or 7 times and that’s with being on 24/7 call for the OB/gyns (they can handle most stuff but I’ll get called in for cesarean hysterectomy, intraop complications etc). I see between 20-30 patients a day at this point (2-3 days per week), do 7-8 cases per week and am usually home by dinner and spend vast majority weekends at home. And I’m quite happy with my salary. As far as COvID I think it made me busier because with people not being able to do stuff (fewer distractions) and restrictions on public restrooms more and more people were realizing they were having a problem.

I am not in PP but in academics, but you are correct more and more people are becoming employed. You will probably make less gross income as employed but not sure if take home changes as much since you don’t have any overhead as an employed physician. You might have less “freedom” but depends on where you work. I cover 2 regional hospitals and hardly ever go to the mothership hospital. People trip over themselves to help the surgeons, I needed more OR block time (difficult to get in any situation, and especially for junior people) and I emailed the president of one of the hospitals and got it from the following week on. I asked for an NP and got one who is also a first assistant when I don’t have a resident or fellow.

 

[Dr G Oogle]

PS changed the title from “fellow” to “attending”

 

[SurgeryAspirant]

Hi.

Can urogynecologists with backgrounds in urology perform hysterectomies where indicated or does that remain the domain of ob/gyns? What are the typical procedures that a urogynecologist can do?

Background: I'm a non-US surgery resident trying to decide on a future subspecialty. I live in a developing country and my uncle (and mentor) is a General Surgeon of old whom I shadow. He routinely performs hysterectomies, vesicovaginal fistula repairs, surgeries for pelvic organ prolapse, etc. in addition to typical bread-and-butter general surgery. Watching him has made me interested in gynecologic surgery, but I do not wish to swim through obstetrics to get there. I thought about pursuing the Urology -> Urogynecology route but its relatively new and I wanted to know what procedures a urogynecologist is legally entitled to perform.

 

[Dr G Oogle]

Hi.

Can urogynecologists with backgrounds in urology perform hysterectomies where indicated or does that remain the domain of ob/gyns? What are the typical procedures that a urogynecologist can do?

Background: I'm a non-US surgery resident trying to decide on a future subspecialty. I live in a developing country and my uncle (and mentor) is a General Surgeon of old whom I shadow. He routinely performs hysterectomies, vesicovaginal fistula repairs, surgeries for pelvic organ prolapse, etc. in addition to typical bread-and-butter general surgery. Watching him has made me interested in gynecologic surgery, but I do not wish to swim through obstetrics to get there. I thought about pursuing the Urology -> Urogynecology route but its relatively new and I wanted to know what procedures a urogynecologist is legally entitled to perform.

It depends on your training. Some programs are combined and take both gyn and urology fellows simultaneously, in these programs urology based fellows get a lot of hysterectomy training, many urology only fellowships don’t do enough hysterectomies to make someone Competent so in those cases you’ll had to do them with gynecology.

 

[Aryes]

Third year fellow in a combined urology/gyn program (take both kinds of fellows) coming from gyn background, staying in academics

Will answer anything

Hello, can you please highlight the differences between the two paths to urogynecology: urology to urogyn and ob/gyn to urogyn. Does one path benefit the physician more than the other? What are the advantages and disadvantages of each path? What are the salary differences between the two paths? Which path would you recommend, etc? Thank you

 

[Dr G Oogle]

Hello, can you please highlight the differences between the two paths to urogynecology: urology to urogyn and ob/gyn to urogyn. Does one path benefit the physician more than the other? What are the advantages and disadvantages of each path? What are the salary differences between the two paths? Which path would you recommend, etc? Thank you

Generally going through urology will give you a better basis of surgical fundamentals and understanding of neurourology and you’ll be able to do things like bladder augments and diversions if you choose, as well as more complex reconstruction of injured urethras and bladder; you’re salary might be higher in urology but that’s probably not as true anymore. You also don’t need to do any OB training in urology which is largely irrelevant to urogynecology. Also it is easier to match into fellowship out of urology because fewer people are interested in this field. In obgyn you might have a better understanding of female pelvic anatomy and i feel
Like as an obgyn I can provide more comprehensive care to a woman, like if someone comes in for incontinence and also has postmenopausal bleeding or cervical dysplasia i can deal with all of that for the patient. I am from the obgyn world but work in an urology department so I feel pretty comfortable making these comparisons. I would recommend going through urology unless you really want to do something unique to gyn like incorporate other gyn care (endo, AUB, etc) in your practice.

 

[GadRads]

Depends: starting in academics can be 220-320 (highest I’ve heard) PP can be much higher; the AUGS salary survey has people reporting >500 K after 10 years

Surprised the starting pay is in the low 200s for academics. Is this before bonuses?

 

[Dr G Oogle]

That’s just the base and it’s really easy to get to bonuses if you set up a favorable schedule with protected time. My first job I started in mid 200s but within 6 months I was able to get to mid 300s just by productivity and I was not that busy. But this is one of the reasons this isn’t as popular a field as some others. On the other hand there are almost no emergencies, patients are pretty great compared to other fields, no one is real sick, and QoL is probably better than in other fields

 

[ninanon]

Hi there! I am currently an OB/GYN PGY3 applying into FPMRS fellowships. I’m about to interview soon but I feel a bit lost as to how to evaluate the different programs. I was wondering if you could elaborate on things I should be looking for in a fellowship program in terms of their training and educational potential and how this could affect my career in the long run.

 

[Dr G Oogle]

Hi there! I am currently an OB/GYN PGY3 applying into FPMRS fellowships. I’m about to interview soon but I feel a bit lost as to how to evaluate the different programs. I was wondering if you could elaborate on things I should be looking for in a fellowship program in terms of their training and educational potential and how this could affect my career in the long run.

Depends on what you’re looking for. All programs will have more than sufficient numbers of cases but some do a ton of vaginal cases and almost no Sacrocolpopexy or vice versa, so you might want to look for one that has a nice balance. Ask to see the senior fellows cases and look at the breakdown. Don’t worry about things like fistulas and bladder neck closures and more esoteric stuff, most of the surgery we do translate to fixing the kind of fistulas urogyns take care of. I’m biased but I would also prioritize programs that are integrated urology and gyn, as a gyn you’ll benefit greatly from more urologic exposure and will also learn stents and finer points of UDS and management of neurogenic bladder, IC and neurourology (the urologists in these programs get better exposure to vaginal surgery, gyn disorders etc.) it makes you a more holistic person that can really handle anything between the bellybutton and the knees.

Everyone wants you to do research and also expects a certain level of productivity, and will complain if you don’t present at every AUGS and SGS and publish regularly. Not every program will have resources to support you or have good mentors. You can figure this out by asking the current fellows.

Ask about call. Many programs have fellows cover general gyn call, often it’s compensated but not always. Be weary of programs where it’s uncompensated and I personally would 100% stay away from programs that expect you to cover L&D without compensation. It has nothing to do with urogyn. On the other hand, inquire about moonlighting, it is usually L&D and usually fairly lucrative. I doubled my income as a fellow moonlighting and usually just chilled when I covered the community hospitals.

Beyond that, see what the vibe is. I’m happy to say the majority of urogyns are very chill and nice and I’d hang out with any one of them outside of work. But there are some people with pretty big personality disorders and they have positions of power and can make your life quite unbearable. You can also figure this out from talking to the fellows.

 

[ninanon]

Thank you so much for taking the time to answer my question! Some of these things were definitely not on my radar. This was very helpful 🙂

Now that you mentioned L&D call, in your experience, what proportion of attending urogynecologists have to take L&D call as part of their job? Again, thanks so much for your time!

 

[Dr G Oogle]

Thank you so much for taking the time to answer my question! Some of these things were definitely not on my radar. This was very helpful 🙂

Now that you mentioned L&D call, in your experience, what proportion of attending urogynecologists have to take L&D call as part of their job? Again, thanks so much for your time!

I am not sure, but I don’t think it’s very high. For the most part people do it because they want to, urogyn is a money maker for obgyn departments so most people don’t require you to take L&D call. I’d be weary of jobs that do require it because either they lack the volume (big red flag because pelvic floor disorders are super common and a minor effort of marketing you will have people beating down your door) or they don’t have enough generalists to cover (another red flag because they send a lot of patients your way)

 

[obgynres_]

Hello! PGY3 OBGYN resident from community program here with a recently developed strong interest in urogyn after being exposed as a PGY3. Planning to apply MIGS originally.
- is it worth it to apply urogyn now (late) in this year’s cycle, after the first round of fellowship interviews have already been released?
- from your experience, can MIGS-trained attendings proficiently perform urogyn procedures?
Thanks in advance!

 

[Dr G Oogle]

Hello! PGY3 OBGYN resident from community program here with a recently developed strong interest in urogyn after being exposed as a PGY3. Planning to apply MIGS originally.
- is it worth it to apply urogyn now (late) in this year’s cycle, after the first round of fellowship interviews have already been released?
- from your experience, can MIGS-trained attendings proficiently perform urogyn procedures?
Thanks in advance!

It will be challenging this year only because interviews are about to start, this time of year most programs, certainly the top ones have secured their list of people who they want to interview. I think working on your app, getting some research would help getting you lots of interviews next year.

Most of the MIGS people I know don’t do urogyn stuff, but certainly are capable from a mechanical standpoint. Particularly laparoscopic prolapse procedures. But prolapse is just a fraction of what we do. It’s more about understanding the diseases we treat, when to offer surgery, which treatments are the best etc. I don’t think MIGS fellowships covers this, especially the urologic component of urogyn in great enough depth. Similarly I got very good surgical training in endo because one of our attendings is MIGS and we spend almost 30% of our fellowship with them, but I never really got good training on counseling and management pre and postop, so unless people are coming to see me for this strictly for the removal (I.e. someone did all the counseling and is willing to manage it after surgery and sending them to me for the technical skill) I will refer every MIGS type patient out.

That being said, there are some MIGS fellowships that have a decent amount of Urogyn exposure (Mayo Az is one) and there’s no law that says you can’t fix pelvic floor disorders unless you’re Urogyn, at least not yet, if you fellow comfortable you could do it as a MIGS, and if you have good outcomes you’d continue to be able to do it.
Though It might be hard to get privileges if you haven’t don’e a lot of cases if you’re hospital employed and most academic programs want you to have a urogyn fellowship to allow people to do those procedures.

 

[obgynres_]

Exceptionally helpful response. Thank you kindly for your time and sharing your knowledge!!!