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Urology resident AMA

Discussion in 'Medical Students - MD' started by DoctwoB, Nov 17, 2017.

  1. DoctwoB

    DoctwoB 7+ Year Member

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    I always found these helpful when I was a med student looking at specialties, and IMO few specialties are more overlooked then Urology. I’m a 4th year resident (out of 5) at a well known program in the Northeast going into general urology (no fellowship) and am happy to answer any questions.
     
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  3. azmd22

    azmd22

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    Why urology?
     
  4. Frogger27

    Frogger27

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    Thanks a lot for doing this! I'll start off with a couple questions that hopefully you won't mind answering:

    1) Why did you pick Urology?

    2) When did you begin to get exposure to it in med school? Is it important to begin making contacts early in Urology in order to maximize chances to match due to the early match?

    3) What Step score would be your cut off for competitiveness?

    4) Most important factors for matching?

    5) Do you have to enjoy Renal anatomy/management to be a good fit in Urology?
     
  5. Osteoth

    Osteoth Fake it till ya' make it 5+ Year Member

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    What would you say were the 3 most important factors in your application besides scores & research?

    Re: research, how much did you have?

    What looks better, 3 3rd author papers or 1 1st author paper?
     
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  6. Save a life

    Save a life 2+ Year Member

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    Thank you for doing an AMA thread, I'm an M1 that's very interested in urology. There has been one on here in a while.

    Question: As a 1st year medical student, what can I do now to start preparing myself for a successful match in urology? Should I focus on research, making connections with urology faculty, or maybe even start thinking about step 1 soon?
     
  7. Frogger27

    Frogger27

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    What’s your favorite dick joke?
     
  8. mcloaf

    mcloaf 5+ Year Member

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    What're some things applicants should pay attention to on the interview trail?

    Sent from my SAMSUNG-SM-G920A using SDN mobile
     
  9. Both of my classmates who went into urology were obsessed with drawing male anatomy, Superbad style. Is this a thing? Or was I just "lucky" to meet two separate people who were into the same thing?


    Sent from my iPhone using SDN mobile
     
  10. akuko2

    akuko2 2+ Year Member

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    I'm interested in the field, and have spent time with my home dept which is a pretty well known academic center. The attendings have pretty big names and are almost constantly travelling, presenting research, and self admittedly have no family life. Do you know if there is a big difference in the lifestyle of a community urologist vs one at a big academic center? I really like the subject matter and some of the procedures I've seen, and while I've done a fair amount of research I'd like to detach from that and get to a point in my career where I'm just focused on taking care of patients/doing procedures while having enough time to not be an absentee father. Is that reasonable? Because I have heard so many people outside of urology talk about it as a 'lifestyle specialty' and observed quite the opposite. I'm just an MSII so I have not had a chance to experience urology outside my home institution.

    Also, thanks for taking the time to do this!
     
  11. DoctwoB

    DoctwoB 7+ Year Member

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    1. I knew I wanted to do a surgical field, and spent time rotating through each of the surgical fields until I found the right one. Urology has a great variety of cases, across open, laparoscopic, robotic, endoscopic, and microscopic approaches. Patients generally do very well and many of our operations make a huge impact on their quality of life, such as relieving pain form kidney stones, letting them void from surgery for BPH, and so on. I found that I liked the bread and butter of Urology (stones, BPH, common cancers like prostate/kidney etc.) much more then I liked the bread and butter of some other surgical fields (e.g. spine for neurosurgery). I liked that there is a huge demand for Urologists to practice straight out of residency without needing to do a fellowship like most do in Ortho. Finally, while Urologists are surgeons and thus have some type A personalities, generally I felt that I fit in better with them personality-wise then some of the more intense surgical specialties.

    2. I was a relatively late arrival, and didn't get any Urology exposure until middle of third year. The earlier you can get to it, the better, as this gives you more time to do research, rotate with the department, set up aways, etc. We have some students who have been doing research with us since MS-1 and that definitely helps get them exposure to the faculty and can help with letters and matching, assuming you did a good job. That being said, we understand that many people (like me) don't arrive at Urology until late, so it's certainly not a major disadvantage.

    3. It's cliche to say, but for most places there is no strict step-1 cutoff and the whole application matters. For practical purposes, I'd say that below 240 is fine but you should have other strengths to show on your application, while above 250 is an asset to your application.

    4. Most places look at the whole package. Urology is quite competitive(67% match rate my year, gotten a bit better since then) and so programs have the luxury of looking for a well-rounded application. In some order (will vary by the program), they want to see good step scores, clinical grades, meaningful research, strong letters of rec from people they know (Urology is a tiny field, so in academics basically everyone knows everyone) as well as be personable and interview well. They want to see good performance on a home (and likely away) subi. Most applicants will do at least 1 away rotation.

    5. Renal anatomy is important, but much more from a gross perspective then the nephron anatomy that nephrologists focus on. We do a lot of renal surgery which involves knowing the vascular anatomy and surrounding retroperitoneal structures and how to approach them. Of course if you want to sub-specialize in infertility/microsurgery or female urology and never operate on a kidney again after residency, you certainly can.
     
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  12. DoctwoB

    DoctwoB 7+ Year Member

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    Clinical grades, letters, subi/away rotation. I had relatively little research, one medschool summer project, one ortho abstract (didn't realize I was doing Urology until after that), and then wrote up a urology case report on an away rotation.

    Generally more lines on the CV is better for research, but if you have one impactful article as a first author that can be huge. Depends on circumstances.
     
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  13. DoctwoB

    DoctwoB 7+ Year Member

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    First thing is just to focus on doing well in med school. Getting good grades, understanding the material, doing well on step1 is all key. If you are interested early though, I would definitely recommend getting involved with research in the department, which also is a great way to build connections with faculty. If there is a medical student or rotation coordinator, I might email them to ask who would be good faculty to start to work with. If the department has research meetings or grand rounds, you can attend those to show your face (and learn).
     
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  14. DoctwoB

    DoctwoB 7+ Year Member

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    There is such a thing as too much interest in anatomy.
     
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  15. Frogger27

    Frogger27

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    Thanks for the replies. What type of personalities do you feel tend to gravitate towards the field of Urology?
     
  16. Osteoth

    Osteoth Fake it till ya' make it 5+ Year Member

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    Awesome, thanks alot.

    Do you feel that people cared about clinical grades outside of surgery?
     
  17. CherryRedDracul

    CherryRedDracul Resident Sh!tposter Physician 5+ Year Member

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    Only thing I care about ITT.
     
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  18. sloop

    sloop 2+ Year Member

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    How many people do you piss off daily?
     
  19. Nysor_bttw

    Nysor_bttw Cheetah pictures: Accepted. 2+ Year Member

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    Good ol' Tejas.
    Howdy! 3rd year, been interested in Urology since working in a busy academic department before Med School. Just wondering, what programs have you seen/ interviewed at/ heard about that are based in academic urban hospitals and produce residents with strong technical skills? Starting to look for places to apply, and wanted your opinion on some great places to look out for
     
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  20. Elessar

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    +1 I'd also be curious to hear your take on the lifestyle of private practice urologists (as my experience has only been with those in academics). What kind of job offers are you seeing your fellow residents getting? Thanks for doing this!
     
  21. DoctwoB

    DoctwoB 7+ Year Member

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    As a gross overgeneralization, it tends to draw people who are still type A (we are still overachieving surgeons after all), but generally more relaxed and laid back then the typical surgeon. Given the subject matter, it takes a bit of a sense of humor to be a Urologist. Most of the faculty I've worked with are very personable and pleasant, even if they are very demanding in the OR.
     
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  22. DoctwoB

    DoctwoB 7+ Year Member

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    If you want an urban center with excellent operative training/technical skills focus, then look at hospital groups that tend to be the only gig in town. By that I mean they have minimal competition, and so draw a lot of cases from a large area of the country. The lack of local competition also allows attendings to be more hands off, as they don't feel that they're scrounging for cases like they may in NYC where competition is ridiculous. Becoming a good technical surgeon is all about repetition with graduated autonomy, and for that repetition you need operative volume. Good examples of this include places like Emory, UPMC, UTSW, Baylor (though they're in flux after losing methodist), Vanderbilt, Michigan, etc.

    The downside of this kind of program is that if you're operating a ton, it means you have a lot of patients on your service and your days and call nights are busier and hours are longer. I think that's a worthwhile trade off because you only get one shot at residency, but none of the programs on that list would be considered "cush"
     
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  23. DoctwoB

    DoctwoB 7+ Year Member

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    It's the patients who are pissing usually. Though our residents may or may not have had a competition on the uroflowmeter to see who had the best stream . . .
     
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  24. DoctwoB

    DoctwoB 7+ Year Member

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    Yes in that they cared about the overall level of your grades and AOA status. People won't ding you too much for that high pass in family med, but they want to see as much excellence across the board as possible.
     
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  25. DoctwoB

    DoctwoB 7+ Year Member

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    Urology can have a great lifestyle (as an attending) for a surgical field. If you're an attending in private practice, you basically set your own schedule. You can cram your clinic schedule will 60-70 patients in a day, work later, and make more money, or you can work at a more reasonable pace and have better hours. In academics, the lifestyle tends to be worse, as attendings are trying to put research, teaching, clinic, and operating into the same workday, so days are longer. Also in academics the cases are generally more complicated meaning longer hours in the OR, and the ORs at academic medical centers are much less efficient then your typical surgery center, so lag time between cases is greater. That being said, as academic surgeons go, their lifestyle is still pretty darn good compared to other surgical fields

    Most attendings I know in private life tend to work 8-5 type hours (earlier on days in the OR, as the OR starts at 630 or 7, not 8). Call is an unfortunate part of any field, but in Urology there are relatively few middle of the night emergencies that require you to come in. The most common would be things like infected obstructing kidney stones, testicular torsion, priapism, or fournier's gangrene, but those things are all much less common then the overnight issues that ortho, neuro, or general surgery have to deal with. The vast majority of consults can be triaged and seen the next morning. I'm a family oriented person, and the fact that I wanted to be a surgeon but also have a life outside of work and not be an absentee father was a major reason I chose Urology and I haven't had any cause to change my mind in that regard.

    With all that said, none of any of that applies to residency. Urology is a surgical residency and is extremely busy. You work surgeons hours (meaning you get there and round on all your patients before the OR starts), you see all the consults, of which there are many, stay late operating, and take a lot of call. Most Urology programs cover multiple hospitals, and thus you take "home call" where you are holding the pager but covering multiple hospitals from your house. This sounds better then in-house call, but it really isn't IMO. What it does mean is that after running around between hospitals for a lot of the night, you then don't have a post-call day and are up operating the next day. Our program is pretty good about sending home juniors who had a rough call the night before, but that isn't required by duty hours or expected at most places. Comparing my life to the general surgery residents at my program, I'd say its pretty comparable for the first 3 years, and maybe we actually have it a touch worse, but then our senior residency years are easier, as you are not going in as often on chief or backup call.
     
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  26. DoctwoB

    DoctwoB 7+ Year Member

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    Lifestyle I addressed above. The job market in Urology is one of the best in all of medicine. The population is aging so more of us are needed, and the number of Urologists is going down, as they sharply cut the number of spots in the 90s/2000s. Starting offers depends greatly on where you are looking. Average is probably around 350-400k with higher numbers in less desirable areas, lower numbers in the San Francisco's and NYCs of the world. A lot of PP groups or hospitals are desperate to hire someone and there are a lot of offers including signing bonuses, loan repayment, offering you a stipend during residency, etc. Especially as a general Urologist, you can really pick where you want to practice. The more specialized you get it does become trickier, like if you want to be an academic urologic oncologist you're limited to the jobs that are open at that given time. People still find good jobs, but it may not be a matter of picking where you want to be. However, some will do a fellowship and then do PP, which makes them even more desirable for a private group.

    For example: It's not a perfect indicator, but if you look on MDsearch.com or other job sites, there are about 900 postings for Urology jobs. We only graduate about 270 people a year, so the math looks pretty darn good. Compare that to say Cardiology (450 jobs for about 500 grads/year), Radiology (315 posts for ~900 grads/year), or even more in demand fields like Derm (700 postings for ~400 grads). Obviously all the people in those other fields will likely find good jobs, and many of the best jobs are never posted on these sites, but it just goes to show that there is a lot of pent up demand for Urologists.
     
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  27. Osteoth

    Osteoth Fake it till ya' make it 5+ Year Member

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    Would you say the job market in private practice is better for general urologists or urologists who are fellowship-trained? Speaking in terms of variety of openings + salary.
     
  28. Frogger27

    Frogger27

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    Interested to hear what the ballpark salary (I know there are many variables to this) is for a PP Urologist in the middle of their career
     
  29. DoctwoB

    DoctwoB 7+ Year Member

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    It depends what kind of job you are looking for. If you are willing to practice general Urology, then a fellowship can only only open additional doors for you, as you can get any job that a generalist could get plus some jobs that are specifically looking for a fellowship trained sub-specialist. If you are looking specifically to practice within your sub-specialty, then that limits you to practices that are looking to recruit someone in your subspecialty, which will vary based on the sub-specialty, geography etc., but overall will be a smaller market then for generalists.
     
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  30. Fracture

    Fracture

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    What other surgical fields do you guys work with the most? Any turf wars?
     
  31. DoctwoB

    DoctwoB 7+ Year Member

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    We work mostly on our own. In looking at specialties we collaborate with sometimes:

    Vascular surgery: We'll work with them for big renal tumors that invade through the renal vein into the IVC and we need to do a major IVC repair, or when we mess up and need a major vessel reconstruction

    Cardiac surgery: similar to vascular, but if the tumor thrombus extends all the way into the atrium and the patient has to go on bypass

    General surgery/surg-onc/colorectal surgery: We put in a fair amount of pre-op stents for them to help them identify ureters intraop, most commonly during sigmoid colectomies. We fix some of their issues when they injure a ureter or a bladder and we have to reconstruct it. They fix some of our issues when we injure the bowel or colon and they have to repair and/or bring up a fecal diversion. They'll also call us into the OR during trauma ex-laps for management of urologic issues. We'll also do some big pelvic exenterations with them where they take out the rectum and divert the the stool, we take out the bladder and divert the urine.

    Ortho: In rare pediatric cases like bladder exstrophy we need ortho to do pelvic ostetotomies to mobilize the pelvis enough to allow for closure, but most of the time we're in their OR is because they can't put in a foley. In recon cases if we need more urethral length we'll sometimes due an inferior or total pubectomy. Some attendings do those solo, some do them with ortho. In some patients with extraperitoneal bladder perforations with a pelvic fracture, we normally would leave them with a foley for a month and let the bladder heal on its own. If Ortho is putting in hardware in the pelvis though, they don't want urine bathing over it and infecting it, so we'll do a joint case where we close the bladder and they fix the pelvis.

    Neuro: they can't put in foleys.

    As for turf wars, there really are only a few for such a broad field.

    Pediatric urology butts heads with pediatric surgery regarding management of inguinal hernias and wilm's tumors. At my shop wilms are generally collaborative cases because they feel like they should be involved but we have the skill-set to do partial nephrectomies (which is very controversial in Wilm's) and more expertise in renal surgery. It will vary by institution. For hernias, they frequently are the ones who see the patients who come through the ER, but we see a lot of hernias in clinic through outpatient referrals or in association with undescended testis. There's plenty to go around.

    We share turf between female urology and urogynecology. To do female urology you do 5-6 years of urology and a 1-2 year female fellowship. They do 4 years GYN and a 3 year urogyn fellowship. We both treat stress incontinence and prolapse with slings, suspensions, anterior/posterior repairs. Once again this is an area where there is some turf wars at the big academic center, but in practice in the community there is a huge number of females with prolapse or leaky bladders and a relatively small supply of urogyns or female uros, so there are plenty of cases to go around. Female Urology is very much in demand. At my shop we're pretty collaborative, sometimes they will scrub with us and vice versa for interesting cases.
     
  32. TCSC13

    TCSC13 5+ Year Member

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    Are you still putting in 80 hour weeks in your last 2 years of residency or is it only a more relaxed call schedule? Residency seems daunting where you put life on hold for 5-6 years. Do you feel like that's been your experience or have you been able to somewhat keep up with hobbies and a life outside the hospital?

    Also thank you for doing this. Your replies have been incredibly informative.
     
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  33. DoctwoB

    DoctwoB 7+ Year Member

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    During our last two years we definitely average less then 80 hours, probably closer to 60 depending on the rotation. We have 1 or 2 chief rotations where you’ll definitely be pushing 80, but most are significantly less. Once again this will vary between programs, but our senior residency is definitely much easier due to the lack of primary call, relatively rare overnight surgical emergencies that require a chief (e.g the on call junior can easily do a Cysto-stent for an infected stone or detumesce a priapism), and not carrying the consult pager.
     
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  34. Elessar

    Elessar

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    As a general urologist, how often would you do robotic operations?
     
  35. DoctwoB

    DoctwoB 7+ Year Member

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    Depends on your practice set up. Despite their ubiquity in academics, not every hospital had a robot in the community, though more and more of them do. Many of the older Urologists never learned how to do robotic surgery, so the answer for many of them is never. As a new grad joining many small groups, you will be one of the more experienced if not the most experienced robotic surgeon, so some may shunt referrals your way which would increase volume. Most I’ve talked to that do some robotics without specializing in it do 1 robot day every week or two. A typical schedule might be 2-3 days of clinic/week, 1-2 days/week of cystoscopy cases (stones, bladder tumors, transurethral resection of prostate, etc), and 1-2 days of open/lap/robotics cases a week.
     
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  36. Ejm1

    Ejm1 2+ Year Member

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    How critical is having steady hands for surgical specialties? Are there any specialties in particular that would be next to impossible if I have slightly shaky hands? (mostly when nervous)

    Thanks in advance!
     
  37. number22

    number22

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    Do you have any idea how competitive urology is in Canada (taking my chance!)?

    What's expected from applicants, aside from step 1 scores in USA?
     
  38. DoctwoB

    DoctwoB 7+ Year Member

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    Everyone has some degree of an essential tremor, which becomes obvious when working under magnification. This can often be partially compensated through proper technique in resting your hands near where you are working, avoiding caffeine, training yourself not to get antsy/nervous, or even taking beta blockers. A severe tremor could certainly preclude one from being a surgeon at all. A mild to moderate one might preclude you from being a great micro surgeon, which in Urology is mainly in infertility work doing vasectomy reversals, varicoceles, and testicular sperm extractions under a microscope. Other fields that require a lot of microsurgery include plastics and neurosurgery.
     
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  39. DoctwoB

    DoctwoB 7+ Year Member

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    No idea about Urology in Canada, though I have heard the job market there for Uros is not great like it is in the USA. No idea how Canadian programs review applicants beyond likely wanting excellence across the board like US programs.
     
  40. Fission Chips

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    First off, thank you for doing this! I'm an MS2 attempting to pursue Uro. It has been a pretty difficult process to navigate the match process with the field being so small and intimate... These forums are pretty quite when it comes Urology. I have 2 questions for you.

    1) I've just submitted my first case report in Urology and I would love to get a couple more papers out before I apply, given the match rate last year. I really enjoyed writing the case report, and learned quite a bit about some very rare Urologic pathology in the process. Is it okay if most of my Uro research is writing case reports (maybe 3 total by application time,) or do I really need some other clinical research? I also have a first author basic science paper if that means anything, but it isn't in Urology. I don't believe I will have time to engage in another basic science project and get published before applications 4th year.

    2) The big PP Uro group in my city (~1 million people) is composed of around 10 Urologists and 1 Rad-Onc. It sounds like they own a fairly large ASC and are able to keep the prostate cancer in house, whether it be surgery or radiation. I believe partners share some level of profits (ASC, etc.) and it's Eat What You Kill after that. Any idea on whether it will be feasible to continue practices like this in the future? I realize the futility in trying to predict the future, but I figured that you, as a resident, have far more insight into this sort of thing than myself. Any concern with the Stark laws when you have a urologist teamed up with a rad-onc in the same group?

    Thanks again. Hopefully I'll see you at a CME meeting someday.
     
  41. number22

    number22

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    Makes sense. As a Canadian grad, how are my odds applying to US residencies in uro?

    Most residencies see us as equivalent (I believe?), but just making sure.
     
  42. DoctwoB

    DoctwoB 7+ Year Member

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    To be honest I don’t really know and I don’t want to provide misleading info.
     
    Last edited: Nov 22, 2017
  43. DoctwoB

    DoctwoB 7+ Year Member

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    1. Case reports are good and show interest and ability to publish, but a meatier, more long term project would certainly be better, even if it’s not done by application time, as it will build faculty connections and give you something to talk about on the interview trail. Basic science generally isn’t feasible unless you’re taking a year off.

    2. Practices like that are pretty common and seem to be thriving. The overall trend, however, will continue to be towards consolidation of groups or employment by hospitals (in all fields) to negotiate better rates with payers and navigate regulatory requirements. Many times these practices have multiple independent offices that act as seperate groups, but share a centralized billing/emr/compliance staff. There are stark laws preventing physician ownership of the capital equipment they refer to, but urorads (situations where a urology group that employs a radonc and owns a linac) are an exception or grandfathered in. They can be sketchy ethically, as generally IMRT pays better then surgery, so studies have shown those groups are more likely to recommend radiation over surgery, potentially to the patients’ detriment. Though I hear that IMRT reimbursement is down and may fall further with hypofractionation and that may be less the case these days. Practice ownership or partnership in an ASC is reasonably common though, perhaps more so in Urology than other surgical fields because a large number of our cases can be most efficiently done an ASC.
     
    Last edited: Nov 22, 2017
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  44. Osteoth

    Osteoth Fake it till ya' make it 5+ Year Member

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    What other specialties do you think will have a future in private practice/ASC going forward?
     
  45. Elessar

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    How much research do matched applicants tend to have? Would 3 manuscripts (one 1st author) and 3-4 abstracts/posters be considered competitive? Without any NRMP data it can be hard to gauge. Thanks!
     
  46. DoctwoB

    DoctwoB 7+ Year Member

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    That’s definitely a strong research resume and would be an asset on an application, once again in the overall context of the whole application. I had little research output, which was a relative weakness, but very good good grades and boards, so different strengths and weaknesses can get you to the same point.
     
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  47. DoctwoB

    DoctwoB 7+ Year Member

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    Any surgical fields that do a moderate to high volume of outpatient procedures, like Urology, ENT, some parts of general surgery (e.g breast, colorectal), Ortho, ophtho, GI, interventional pain, and so on.
     
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  48. Elessar

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    Thanks again for doing this, it really seems like such a cool field. What are your least favorite things about urology?
     
  49. DoctwoB

    DoctwoB 7+ Year Member

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    No layperson knows what you do or even that Urology is a surgical field. You get some curious looks when telling your non medical friends what field you want to go into. You stop caring pretty quickly, but it’s not a “sexy” specialty to the non medical folks.

    Also like any medical field we have some difficult patients: chronic testicular pain, chronic prostatis, bladder pain syndromes, etc are relatively poorly understood and very difficult to manage. While it can be rewarding as well to help patients with a difficult problem, they can be a rather difficult patient population with unrealistic expectations as there are no cureall pills or surgeries for them.

    Finally it seems like no one in the freaking hospital system knows how to put in a foley. As I’m no longer a junior it’s usually not my problem, but while we have many tricks for difficult catheter placement (different foley types, wires, scopes, etc), i’d guess about 90%of our difficult catheter consults are dealt with just using the standard catheter and proper technique. Once again this isn’t unique to Urology, just mention duotubes to ENT or ask a general surgeon how many G-tube consults they’ve seen, but it is annoying.
     
    Gurby, Osteoth, Elessar and 1 other person like this.
  50. kovalchuk71

    kovalchuk71 Classifieds Approved 7+ Year Member

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    931
    Jan 27, 2009
    Any recommendations on how to find research programs for people with no "home" urology department? I'm gaining interest in the field, and would like to find a research opportunity this summer (I am a first year DO Student).
     
    Osteoth likes this.
  51. DoctwoB

    DoctwoB 7+ Year Member

    1,503
    437
    Jan 10, 2010
    Also I might add that while the easy/boring consults like Foleys, urinary retention, etc. are rather annoying for a resident, for attendings they’re just easy money.
     
    Donald Juan, jcorpsmanMD and Elessar like this.

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