Urology Attending AMA

[Durty-Trixxx]

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Is uro routinely consulted for every stone case that comes in the ER ?

I had a kidney stone about 15 yrs. ago and the ER doc just gave me a shot of Toradol and sent me home with a strainer. Colic went away within 24 hrs. and about two weeks later the stone flew out when I was taking my morning pee. I still got that little SOB in a Ziploc sandwich bag 😛

 

[cpants]

Is uro routinely consulted for every stone case that comes in the ER ?

I had a kidney stone about 15 yrs. ago and the ER doc just gave me a shot of Toradol and sent me home with a strainer. Colic went away within 24 hrs. and about two weeks later the stone flew out when I was taking my morning pee. I still got that little SOB in a Ziploc sandwich bag 😛

Depends on the ER, but I would say in most cases we are not involved.

 

[Fission Chips]

Young urology attending in the NE. 2 years out of training in private practice.

I saw some other specialties have threads like this, and thought I would put myself out there if you guys want any questions answered about urologic or surgical training or practice.

If we apply with an average app (step 1 250's, 6-7 posters/pubs, good LORs) but don't match, do you have any advice if you really want to do urology and not gen surg/IM/anything else? I know a couple of people who didn't match this year, they seemed like decent applicants and pretty normal too (I'd think they interview just fine). Sounds like the peyronie's just bent the wrong way for them.

Also, out of curiosity, what did your RVU numbers look like over the last 2 years? Did you feel stressed about reaching your goals coming out of residency? I've seen the average number around 7500/year, how hard (lifestyle wise) is it to push over 10k/year?

 

[cpants]

If we apply with an average app (step 1 250's, 6-7 posters/pubs, good LORs) but don't match, do you have any advice if you really want to do urology and not gen surg/IM/anything else? I know a couple of people who didn't match this year, they seemed like decent applicants and pretty normal too (I'd think they interview just fine). Sounds like the peyronie's just bent the wrong way for them.

Also, out of curiosity, what did your RVU numbers look like over the last 2 years? Did you feel stressed about reaching your goals coming out of residency? I've seen the average number around 7500/year, how hard (lifestyle wise) is it to push over 10k/year?

I don't think many people with those stats will have a very hard time matching assuming they apply to an appropriate number of realistic programs. My guess is that the people you know who didn't match were not very competitive for some reason--most likely low boards or grades. How many interviews did they get? In my experience, medical students frequently either lie or just don't talk about their scores with other students.

If you get asked in an interview what you will do if you don't match, the answer is always do what you can to improve and then reapply. However, that's not really the advice I would give for most people. If you don't match, you need to take a hard look at your application and figure out why. It's not usually a big mystery. Then you need to sit down and talk to the program director or someone in academic urology you trust and honestly assess whether you can improve that application or correct what deficits are there. For most people there just is not a way they can fix what's wrong with a year of research or clinical work. The match rate for reapplicants is very very low. So my advice would be to seriously consider other specialty options. If you are going to go for broke with urology, there used to be one prelim uro spot at Emory I think or you could consider a research year. But again, your reapplicant chances at uro are very low, and digging yourself deeper into that hole may jeopardize your chances at another satisfying option.

I anticipate logging about 8000 wRVU's this year. I have a pretty good lifestyle. Pushing over 10k/year is likely going to come with some pretty big lifestyle sacrifices.

 

[DubbiDoctor]

Why did you decide to pursue private practice rather than academics?

 

[cpants]

Why did you decide to pursue private practice rather than academics?

It was a tough call. I wasn't interested in doing a fellowship, and in most academic settings fellowship will either be required or you will be pigeon-holed into doing only the most basic cases as a generalist (scrotal/minor open/ and basic stones). Since I'm interested in lap/robotics, even with a fellowship the job market is very tight in academic settings (places where you could do only oncology for example). Overall, I'm happy with decision, though I do miss working with residents and students.

The job market for general urologists is fantastic.

 

[Newyawk]

I dont really know what i mean by this question but whats the most impressive uro research?

 

[cpants]

I dont really know what i mean by this question but whats the most impressive uro research?

Uhh I guess a first author double-blind RCT in the NEJM?

 

[Newyawk]

Uhh I guess a first author double-blind RCT in the NEJM?

haha good one. but forreal. what kind of research tends to impress and what is kinda just there?
for e.g. 3 posters vs 1 pub. clinical vs basic science? etc

 

[cpants]

haha good one. but forreal. what kind of research tends to impress and what is kinda just there?
for e.g. 3 posters vs 1 pub. clinical vs basic science? etc

Papers>>Posters/presentations. More quantity helps but hard to generalize. If you have very high quality research and you are a primary author, you don't necessarily need a ton of stuff on there.

 

[LeeroyJenkins4]

Any advice for medical students on their sub-i and away rotations?

 

[Frogger27]

How many publications on an app would make you call that a "strong research" application?

 

[cpants]

Any advice for medical students on their sub-i and away rotations?

Show up on time. Be polite, friendly, professional to everyone -- a secretary or scrub tech can very easily get you black-balled. Read on high yield topics before the rotation and prepare for every case. Practice basic surgical skills like wound closure and knot tying before rotation.

Avoid any entitled attitude. Try to help the residents as much as you can. Never leave early.

This is basically an audition to see how pleasant you are to work with.

 

[cpants]

How many publications on an app would make you call that a "strong research" application?

I would say several posters or abstracts is a minimum requirement at this point. Doesn't necessarily have to be in urology.

Strong would be several first-author high quality articles in good journals in addition to this basic requirement.

When I applied 8 years ago, I think I had 1 review article and 7 abstracts at regional meeting. It definitely helped my chances with mediocre board scores.

 

[PatchAdams25]

Do you think a student with low board scores (230-235), decent clinical grades but strong research (5+ pubs) can match Urology?

At my school they make it seen like you have to be 245+, Top quartile, AOA, etc to have a chance

 

[cpants]

Do you think a student with low board scores (230-235), decent clinical grades but strong research (5+ pubs) can match Urology?

At my school they make it seen like you have to be 245+, Top quartile, AOA, etc to have a chance

Yes, I think you have a good chance if you apply broadly, do well on aways, and have good letters. I’m sure 245 is close to the average but that means plenty match below there.

 

[badasshairday]

What do you think of PCNU for extrinsic compression?

 

[Fission Chips]

Young urology attending in the NE. 2 years out of training in private practice.

I saw some other specialties have threads like this, and thought I would put myself out there if you guys want any questions answered about urologic or surgical training or practice.

What is the most difficult thing for you in your job (maybe certain surgeries, dealing with pts or insurance)? Are there any procedures/surgeries that get your BP up from the risks?

 

[cpants]

What do you think of PCNU for extrinsic compression?

Are you talking about a a percutaneous nephroureteral stent? Not sure what you are asking. I usually place a retrograde stent first because it's less invasive and less infection risk, but percutaneous NU stent is a good option if you are concerned the patient will fail a stent like in some cases of malignant compression. Then you can just unclamp the nephrostomy if they don't fly.

 

[cpants]

What is the most difficult thing for you in your job (maybe certain surgeries, dealing with pts or insurance)? Are there any procedures/surgeries that get your BP up from the risks?

Certainly more difficult lap, robotic, or open cases will get my sphincter tone up, because there is not a lot of backup in a community hospital. If I rip a big hole in the IVC during a RP node dissection, there isn't a vascular surgeon in the next room to bail me out. I try not to be a hero and send the more difficult cases out.

Dealing with insurance is always frustrating. Spent 25 minutes on hold and disconnected once for a peer-to-peer for MRI preauth yesterday -- the reason for the denial ended up being "We denied it because it was a duplicate request -- the study was already approved last week." That kind of stuff can drive you nuts.

Entitled patients get me angry. People who show up late. "Can we do my yearly follow up over the phone so I don't have to pay a copay"

 

[Durty-Trixxx]

Dealing with insurance is always frustrating. Spent 25 minutes on hold and disconnected once for a peer-to-peer for MRI preauth yesterday -- the reason for the denial ended up being "We denied it because it was a duplicate request -- the study was already approved last week." That kind of stuff can drive you nuts.

This is probably why artificial intelligence (AI) and robots need to replace humans ASAP. I'd rather be on on the golf course or at the beach tanning and let the AI machine handle all these stupid tasks.

Entitled patients get me angry. People who show up late. "Can we do my yearly follow up over the phone so I don't have to pay a copay"

Again, let's make AI robots a thing like really quick! Entitled people are much easier to tolerate when your paycheck doesnt depend on them.

 

[cpants]

This is probably why artificial intelligence (AI) and robots need to replace humans ASAP. I'd rather be on on the golf course or at the beach tanning and let the AI machine handle all these stupid tasks.

Again, let's make AI robots a thing like really quick! Entitled people are much easier to tolerate when your paycheck doesnt depend on them.

At least until AI can take a kidney out, I will still have a job.

 

[mntrzl]

What are your thoughts on male reproductive medicine? How does the compensation compare to general urology in PP/academics, what is the patient population like, how is the job market relative to gen uro, onc, etc, and how is the lifestyle/how much operating do they do? Can you maintain a male reproductive medicine practice in PP or do most also supplement their practices with general uro?

 

[cpants]

What are your thoughts on male reproductive medicine? How does the compensation compare to general urology in PP/academics, what is the patient population like, how is the job market relative to gen uro, onc, etc, and how is the lifestyle/how much operating do they do? Can you maintain a male reproductive medicine practice in PP or do most also supplement their practices with general uro?

Very interesting field. It can be very lucrative in private practice--lot's of cash pay patients and procedures. In academics and hospital employed settings it is not as lucrative, because you typically get paid based on wRVU's. A vasovasostomy, for example, which can be paid around $5,000 cash professional fee in PP, only has about 8.5 wRVU's assigned to it--in many employed settings resulting in about $500 payment to you (keep in mind these are very rough estimates).

I suspect most supplement with general urology practice. Male factor infertility that requires surgery just isn't that common. You need to live in a medium to large city with excellent referral base of general urologists and reproductive endocrinologists to exclusively practice infertility. If you do a lot of hormonal treatment and ED work that can cover a lot of ground.

 

[Inspired Chaos]

What are your thoughts on ED in young men? Do you personally observe it to be on the rise? Do you believe porn plays a role in ED in younger men?

Do you think female students are at an advantage, a disadvantage, or neither in securing residency spots?

Thanks in advance for answering!

 

[anbuitachi]

I'm in a kind of weird PP/hosp employed hybrid. I basically already am a partner. I anticipate max of about 500K.

As far as starting salary, I was offered 220k - 340k. Keep in mind, starting offer is not the most important variable when considering offers. Much more important is income potential and likely income a few years in.



All research counts. Urology-specific is obviously better, but they understand that interests change over time.

My favorite is being in the OR. Urologists are surgeons, and I think most surgeons in all fields would answer the same. I have a broad general urologic practice including onc/robotics.



Very congenial.



The NE is usually on the lower side for salary.

Med school name counts minimal after you match for residency. Sure it helps to have Harvard on the CV, but 99% of employment decisions will be based on your skill set, recommendations, and relevant work experience.



1. In about 5-530, almost never out before 7-730. It was a grind.
2. One where you operate a ton. This is your only chance to learn surgery.
3. Stone cases, transurethral resection of the prostate and bladder tumors, open scrotal and penile cases, office stuff like cystoscopy, vasectomy, and TRUS biopsy.
4. My favorites are probably lap radical nephrectomies or radical orchiectomies. Very satisfying.

how do these robotic prostate guys make so much? saw in the news the top urologist earner made 7+++M in nyc a year a few years ago. do insurance companies pay that much more for robotic cases?

 

[cpants]

how do these robotic prostate guys make so much? saw in the news the top urologist earner made 7+++M in nyc a year a few years ago. do insurance companies pay that much more for robotic cases?

"These robotic prostate guys" don't make that much. Robotic surgeons make on average what nonrobotic urologists make.

David Samadi's income is not achievable by pretty much any other urologist or physician.

Medicare reimbursement for a robotic prostatectomy is about $1500. $7M/1500 = 4667 prostates per year. Yes, his volume is very high, but there is obviously some other math at work here. He's not doing 20 prostates per day despite his running multiple rooms at the same time.

Federal prosecutors launch investigation of prominent surgeon who double-booked operations - The Boston Globe

 

[anbuitachi]

"These robotic prostate guys" don't make that much. Robotic surgeons make on average what nonrobotic urologists make.

David Samadi's income is not achievable by pretty much any other urologist or physician.

Medicare reimbursement for a robotic prostatectomy is about $1500. $7M/1500 = 4667 prostates per year. Yes, his volume is very high, but there is obviously some other math at work here. He's not doing 20 prostates per day despite his running multiple rooms at the same time.

Federal prosecutors launch investigation of prominent surgeon who double-booked operations - The Boston Globe

so its probably achievable if most of your patients have good insurance. im guessing the 1500 is for the procedure itself. what about rounding on them on floor? you can bill for those too right.

 

[cpants]

so its probably achievable if most of your patients have good insurance. im guessing the 1500 is for the procedure itself. what about rounding on them on floor? you can bill for those too right.

No, it's not achievable. Definitely not by doing robotics. It could be possible if you: figure out what the next big thing in urology is, then become the best at it and do thousands of them, then be the guy that does it in NYC, then figure out how to get paid a lot more than what you bring in in professional fees. A good comparison would be saying that if you play basketball in college, it's achievable to become Lebron James.

Even for patients with "good insurance" you are only going to get a multiplier of medicare rate depending on your deal with the company -- usually something like 130% of medicare fee. So maybe you could get $2,000/prostate if all of your patients have good insurance. That's still 3500 prostates in a year.

No you cannot bill for rounding on postop prostatectomies. Google "global period".

If you are medical student, I would focus more on finding a field that is a good fit for you than what the highest paid members of a certain specialty make.

 

[CyrusHabs7695]

What are your thoughts on ED in young men? Do you personally observe it to be on the rise? Do you believe porn plays a role in ED in younger men?

Do you think female students are at an advantage, a disadvantage, or neither in securing residency spots?

Thanks in advance for answering!

 

[Inspired Chaos]

Haha is this question stupid or for some reason off-limits? It's a genuine curiosity of mine. Maybe it's not as related to the field of urology as I thought?

 

[BirdiePutt]

What kind of opportunities are there for Pharma/Device consulting in PP vs academics? I've read that research and the financial incentives through Pharma/Device companies is starting to expand to the PP setting? Assuming maybe that's something you would see in larger group practices?

Second, I've read that it's more beneficial (as far as billing goes) to crank out a bunch of in-office procedures versus big whacks. Any truth to this?

 

[cpants]

What are your thoughts on ED in young men? Do you personally observe it to be on the rise? Do you believe porn plays a role in ED in younger men?

Do you think female students are at an advantage, a disadvantage, or neither in securing residency spots?

Thanks in advance for answering!

I have no insight into whether the incidence of ED is rising in younger men. Most of the time it is more of a psychological problem in young men, unless there is a history of trauma or unusual comorbidities. Porn may play a role in some cases -- eg. porn addiction, but I think that is still mainly a psych issue.

I don't think there is an advantage or disadvantage to being female.

 

[cpants]

What kind of opportunities are there for Pharma/Device consulting in PP vs academics? I've read that research and the financial incentives through Pharma/Device companies is starting to expand to the PP setting? Assuming maybe that's something you would see in larger group practices?

Second, I've read that it's more beneficial (as far as billing goes) to crank out a bunch of in-office procedures versus big whacks. Any truth to this?

The opportunities are there. It depends what you mean be "research and financial incentives". Are you talking about giving some dinner talks and receiving an honorarium? Can probably do that in PP or academics if you are high volume and the right fit for what they are selling. Are you talking industry funded trials run out of your office? Easier in an academic setting, but have seen some pharma trials out of PP setting.

 

[BirdiePutt]

The opportunities are there. It depends what you mean be "research and financial incentives". Are you talking about giving some dinner talks and receiving an honorarium? Can probably do that in PP or academics if you are high volume and the right fit for what they are selling. Are you talking industry funded trials run out of your office? Easier in an academic setting, but have seen some pharma trials out of PP setting.

Was kinda asking about both - thanks for your reply!

 

[DoctwoB]

Couple questions from the perspective of a resident about looking at transitioning into a general urology practice.

1. How long did it take you to “get busy”? Did it take much extra legwork (self promotion, detailing pcps, covering extra ERs, etc). Or was there pent up demand? Is this in a more or less saturated area?

2. What is your clinic/OR breakdown? I’ve heard 2-3 clinic, one cysto, one major day/week is somewhat typical, but curious to hear your take. How do you manage major cases from a first assist standpoint? Do you use a PA, scrub tech, have a partner join you etc?

3. Any extra skills you wish you had picked up in residency when you had the chance?

4. Any factors you wish you had considered more in job selection or general job search tips?

Thanks!

 

[cpants]

Couple questions from the perspective of a resident about looking at transitioning into a general urology practice.

1. How long did it take you to “get busy”? Did it take much extra legwork (self promotion, detailing pcps, covering extra ERs, etc). Or was there pent up demand? Is this in a more or less saturated area?

2. What is your clinic/OR breakdown? I’ve heard 2-3 clinic, one cysto, one major day/week is somewhat typical, but curious to hear your take. How do you manage major cases from a first assist standpoint? Do you use a PA, scrub tech, have a partner join you etc?

3. Any extra skills you wish you had picked up in residency when you had the chance?

4. Any factors you wish you had considered more in job selection or general job search tips?

Thanks!

Good questions.

1. This will be very dependent on the area you are practicing in and how many urologists there are. Simple supply and demand. I ramped up fast because the area where I live was already undersaturated and I was replacing a retiring partner (ideal scenario). Also, brought skills to the table that my older partners don't have, so I get lots of internal referrals. Impossible to answer this in general, but this is definitely something you should be asking about and considering when interviewing for jobs. How will I get busy? How are referrals handled? Who do referrals come from?

2. When I first started I was 1 day in OR every 2 weeks. Now 2 years later I am averaging 1.5 days in OR and 3.5 days in clinic. Mix of mostly minor/endo cases and some bigger cases (RP, nephrectomies, PCNL's). I have used hospital employed PA's, and if it's something very challenging will have one of my partner's scrub with me. Any minor case goes unassisted which is pretty typical. Our scrub techs are good at helping with cysto stuff and open minor cases.

3. Yes. Spend time learning to do TRUS biopsies and vasectomies well. These procedures aren't that easy and the patient is awake. I graduated residency a lot more comfortable doing a nephrectomy than I was doing a vasectomy.

4. General tips: Spend some time soul searching on what you want your practice to be like before you start the search. If you are OK not doing big cancer cases, you have a lot more options on where to go and how much you can make. Focus on a geographical area and make an Excel sheet of all the practices, names of partners, whatever other criteria are important to you, and keep it updated (ie. called practice on 5/15, waiting for callback...). Don't be scared to just cold call practices. Many/most practices would consider hiring someone even though they may not be advertising. A lot of places have just given up. Ask your faculty for help -- urology is a very small world, and you would be surprised how many of your faculty know urologists all over the country. A phone call of introduction is a MAJOR door opener.

 

[harkas]

You may or may not have an answer for this but how difficult is it to get into sexual medicine (not just ED but gender reaffirming/transgender medicine) ? Does it require a fellowship or is it really just based on the experiences your residency institution gives you?

 

[cpants]

You may or may not have an answer for this but how difficult is it to get into sexual medicine (not just ED but gender reaffirming/transgender medicine) ? Does it require a fellowship or is it really just based on the experiences your residency institution gives you?

I'm not sure I would consider transgender/gender reaffirming work "sexual medicine". That generally refers to ED, peyronies, and other sexual dysfunction work.

There really are no fellowships that I know of which would train you in this area. I certainly think there is an opportunity to open a practice specializing in this area. Move to a medium to large size city and get the word out somehow that you have an interest. They will show up. This is a highly underserved patient population.

How are you going to learn to do gender reassignment? Probably you are going to have to mostly teach yourself. The only urologist I know who does this work is at a major academic center and is basically self-trained through books and videos.

 

[harkas]

I'm not sure I would consider transgender/gender reaffirming work "sexual medicine". That generally refers to ED, peyronies, and other sexual dysfunction work.

There really are no fellowships that I know of which would train you in this area. I certainly think there is an opportunity to open a practice specializing in this area. Move to a medium to large size city and get the word out somehow that you have an interest. They will show up. This is a highly underserved patient population.

How are you going to learn to do gender reassignment? Probably you are going to have to mostly teach yourself. The only urologist I know who does this work is at a major academic center and is basically self-trained through books and videos.

Thank you for your input. I honestly don’t know. I worked at an institution that had a Sexual Medicine group that included gender reaffirming surgery (as well as everything you mentioned) with trained urologists as well as Endo and ID. I was in another department so couldn’t get a good idea of what they did on a regular basis.

 

[DoctwoB]

You may or may not have an answer for this but how difficult is it to get into sexual medicine (not just ED but gender reaffirming/transgender medicine) ? Does it require a fellowship or is it really just based on the experiences your residency institution gives you?

The few people I know of that do a lot of work in this field did sort of a mini-apprenticeship, where they started working as a junior partner with someone who does a high volume of these surgeries and picked t up through experience.

 

[cpants]

Thank you for your input. I honestly don’t know. I worked at an institution that had a Sexual Medicine group that included gender reaffirming surgery (as well as everything you mentioned) with trained urologists as well as Endo and ID. I was in another department so couldn’t get a good idea of what they did on a regular basis.

Why ID?

 

[harkas]

Why ID?

My knowledge is limited but I would say probably for the higher risk of HIV infection among transgender groups.

 

[badasshairday]

for stone access are you willing to accept lower pole access if that is were the stones are? also what do you thick of intercostal access between ribs 11 and 12?

 

[cpants]

for stone access are you willing to accept lower pole access if that is were the stones are? also what do you thick of intercostal access between ribs 11 and 12?

Yes. Posterior lower pole access is preferred for most stones.

Intercostal access is not preferred due to higher risk of pneumothorax, but sometimes necessary.

 

[bommer1389]

1. TRANSURETHRAL RESECTION OF BLADDER
2. MEATOPLASTY URETHRA
3. CYSTOSCOPY URETHROTOMY
4. MICROSURGICAL VARICOCELECTOMY

Any thoughts on these operations? I will be shadowing in the OR and am hoping to gain a little more insight into what I will be seeing. Should I just google these surgeries and see what I can learn? Thanks.

 

[cpants]

1. TRANSURETHRAL RESECTION OF BLADDER
2. MEATOPLASTY URETHRA
3. CYSTOSCOPY URETHROTOMY
4. MICROSURGICAL VARICOCELECTOMY

Any thoughts on these operations? I will be shadowing in the OR and am hoping to gain a little more insight into what I will be seeing. Should I just google these surgeries and see what I can learn? Thanks.

These aren't topics I can really explain to you in this setting.

I would at a minimum google them. If you want to impress, then read the chapter on the pathology from Campbell's or at least Smith's prior to OR.

 

[kalf]

Tips and tricks for residents to prepare for their transition to private practice? Would a MHBA degree help at all?

 

[TheHaarpMD]

What is the longest operation you perform on a regular basis, and how long does it usually take?

 

[atomi]

Do you operate on Gleason 8 prostate cancer without sending them to radiation oncology first?
Do you agree that surgery is inappropriate initial management for high risk prostate cancer?