Urology resident AMA

[DoctwoB]

Hi!
I'm also having a question if you don't mind
I need to decide whether I wanna do an internship (for 6 months) in general surgery or urology. I'm a female though and that is what concerns me a little bit. And the hospital I wanna apply to has no female doctors for urology. How are your experiences with this matter? Are there a lot of female urologists where you're working and have there been problems with patients? Thanks!

My experience has been that I have worked with a lot of female residents/urologists and most of them haven’t had many issues except for the occasional inappropriate patient comments and the issues that all female doctors deal with (being called nurse, called by first name andnot having title used, etc).

My experience is just at a few academic centers with a lot of females training. I’m sure that there are “old boys” places that would be less accommodating but fortunately/hopefully these are becoming less common.

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[Medstudent1874]

Thanks so much for all your help and advice DoctwoB.

How much follow up do uro oncs generally have with their patients?

It seems to me that a lot of bladder ca and prostate ca require close urologic follow up for many years, but how about say kidney cancer? How frequent is it that a urologist resects a tumor and "hands-off" the patient to med/rad onc for the rest of the patient's treatment/possible end-of-life care?

Thanks so much!

 

[DoctwoB]

Thanks so much for all your help and advice DoctwoB.

How much follow up do uro oncs generally have with their patients?

It seems to me that a lot of bladder ca and prostate ca require close urologic follow up for many years, but how about say kidney cancer? How frequent is it that a urologist resects a tumor and "hands-off" the patient to med/rad onc for the rest of the patient's treatment/possible end-of-life care?

Thanks so much!

We definitely follow most of these patients long term. Prostate and bladder cancer patients require pretty frequent long term follow up. Some kidney cancer patients as well, though we’ve gotten more conservative about follow up imaging for small renal masses. There are a few cases where we “hand off” people after the post op period, such as doing a cytoreductive nephrectomy for metastatic disease then handing off to heme onc for systemic therapy, but on the whole we follow many of or onc cases long term.

 

[Medstudent1874]

In that vein, how often does the onc urologist transition patients to hospice or have end of life care discussions with patients?

 

[DoctwoB]

In that vein, how often does the onc urologist transition patients to hospice or have end of life care discussions with patients?

Relatively rarely, because by the time that a patient is nearing hospice status it is usually med-onc running the show. If you’re a uro oncologist that does bladder cancer, a reasonably large percentage of patients will progress to metastatic disease and then death. However while you are still involved in their care via managing any urologic issues that arise from their urinary diversion, the real decision at that point is additional Nth line chemo vs hospice or CMO, which is generally been driven by heme-onc.

Where we do have more end of life discussions tends to be on our own post ops that do very poorly for whatever reason and end up in situations with little chance of a functional outcome and we discuss conversion to CMO rather then continuing likely futile care. Fortunately this is pretty rare, but does happen.

 

[TheHaarpMD]

Are there any plastics-type procedures associated with Urology, either cosmetic or reconstructive in nature? Or would these cases go straight to plastic surgery?

 

[DoctwoB]

Are there any plastics-type procedures associated with Urology, either cosmetic or reconstructive in nature? Or would these cases go straight to plastic surgery?

Absolutely, there is the whole field of reconstructive urology which has a lot in common with plastic surgery. They perform a lot of grafts and flaps in reconstruction of trauma or urethral stricture disease. One example is augment urethroplasties where you harvest mucosa from the cheek lining and lay it on as a patch to a stenotic area of urethra that you open up. Gender affirming surgery (aka digging holes or building poles) is another growing area of urology that shares a lot of principles with plastics. Another is buried penis repair, basically performing a panniculectomy only of the fat pad entrapping the penis, which generally requires removal of penile skin and skin grafting.

Finally the whole field of pediatric urology involves a lot of reconstruction and “plastic type surgery” ranging from hypospadias repair to other less common congenital defects like exstrophy, gender affirming in ambiguous genitalia, etc.

 

[jcorpsmanMD]

As a 4th year urology resident are there any specific concerns you have when it comes to genital burn injuries? Or do you not see many cases related to burns or burn complications?

 

[DoctwoB]

As a 4th year urology resident are there any specific concerns you have when it comes to genital burn injuries? Or do you not see many cases related to burns or burn complications?

We don’t do much burn as that is typically handled by burn trained general surgeons. Fortunately GU burns aren’t all that common, and isolated GU burns are even more rare. When we’re involved it’s usually for assistance with SPT placement if urethra is involved or help with debridement.

 

[TheHaarpMD]

Is there any advantage to having 2 years of general surgery in a 6 year residency as opposed to doing just 1 year in a 5 year residency? Or is it just additional slave labor?

 

[dr zaius]

Is there any advantage to having 2 years of general surgery in a 6 year residency as opposed to doing just 1 year in a 5 year residency? Or is it just additional slave labor?

My program did 2 years of gen surg. Is there any advantage? As a PGY-2 if you're doing a lot of cases with only the attending or the chief resident, and you're really learning how to handle tissue, dissect, sew, see open anatomy etc. there is an advantage. I don't know that it will really make a difference in the long run, though. There were a few good rotations as a PGY2 that I thought were helpful such as transplant and vascular, but I look back on most of that year as treading water before diving into the sea of dongs.

 

[DoctwoB]

Is there any advantage to having 2 years of general surgery in a 6 year residency as opposed to doing just 1 year in a 5 year residency? Or is it just additional slave labor?

There are pros and cons. In a lot of programs PGY-2 gensurg is exponentially more operative then pgy1. My program is set up to give 8 months gensurg PGY 1 and 3 months pgy-2. The pgy2 months were some of the highest yield I had in junior residency and it would have been a shame to miss it. That being said every program is different so it’s hard to say.

Also it’s key to look at rotation schedules as programs are often not as described my the acgme. My program is officially 2 years gensurg according to acgme. We actually get 10-11 months of gensurg and the rest is urology.

 

[dr zaius]

Some urology during PGY2 would have been nice. We did 3 months as an intern and none as a PGY2 before being thrown into the uro1 year.

 

[Iris42]

While we're on this topic, are there any 6-year programs with 5 ACGME- accredited uro years ?

 

[DoctwoB]

Don’t quote me on it but I don’t believe so. I think all 6 year programs are 2+4 or 1+4 with unaccredited research year.

 

[Newyawk]

Is ob/gyn honors looked at particularly favorably? Is it worth it to do an elective in obgyn? Thanks!

 

[DoctwoB]

Is ob/gyn honors looked at particularly favorably? Is it worth it to do an elective in obgyn? Thanks!

Will vary based on program. My program cares most about grades in urology rotations/ subi, surgery, medicine, and OB as those are the “hardest” medical/surgical rotations. Is OB/gyn not a core clerkship for you guys? I wouldn’t do an extra rotation in it unless you are interested but it’s certainly worth seeing.

 

[Newyawk]

Will vary based on program. My program cares most about grades in urology rotations/ subi, surgery, medicine, and OB as those are the “hardest” medical/surgical rotations. Is OB/gyn not a core clerkship for you guys? I wouldn’t do an extra rotation in it unless you are interested but it’s certainly worth seeing.

Thanks!
We do have a core clerkship i was just wondering. Also i really enjoy being a part of deliveries so i thought maybe id do an elective if it would be looked at favorably anyway. But i guess not?

 

[DoctwoB]

Thanks!
We do have a core clerkship i was just wondering. Also i really enjoy being a part of deliveries so i thought maybe id do an elective if it would be looked at favorably anyway. But i guess not?

It won’t help with applications, but if you’ve already done core clerkships, Subi, and aways, and you want to then go ahead. Treat it just like any other elective.

 

[DoctwoB]

I am an incoming M1 with an interest in urology due to shadowing and kidney research background. My future school however does not have a urology residency program. Is it still feasible to match urology without a home program or would I be better off crossing urology off the list of specialties I look into?

You certainly don’t have to cross Urology off the list but it does make it a tougher proposition. If you think you may want to do Urology, in addition to all the usual things (do well in class, crush step 1, etc) you should reach out to other Urology departments to see if you can do research with them in the summer between M1 and M2. We’ve had med students from other medical schools do research with us over the summer before, generally if you’re pleasant and hard working people won’t turn down free help.

When application time comes around plan to do 3 aways and to do them early to get letters plus extra research opportunities.

 

[Fission Chips]

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.

I was talking with our chief Uro resident the other day, and he mentioned how he had become jaded with the whole process of residency. Granted, he was in a 6-year program that transitioned to 5 after his inception. I was wondering if you feel the same... How has residency changed you? Does the **** of your day carry over into your personal life? Are you burned out in your 4th (almost 5th) year?

Thanks for doing this, I've officially decided on pursuing a Uro residency (MS-III), and I couldn't be happier with my decision. Best field in medicine by far.

 

[DoctwoB]

I was talking with our chief Uro resident the other day, and he mentioned how he had become jaded with the whole process of residency. Granted, he was in a 6-year program that transitioned to 5 after his inception. I was wondering if you feel the same... How has residency changed you? Does the **** of your day carry over into your personal life? Are you burned out in your 4th (almost 5th) year?

Thanks for doing this, I've officially decided on pursuing a Uro residency (MS-III), and I couldn't be happier with my decision. Best field in medicine by far.

Residency definitely changes you, though how is hard to define. I’m more efficient, resilient, and independent then when I started, but the responsibility, hours, and other BS do wear over time. Loss of empathy is common, but most of time I dont feel that is the case for me, though I’ll admit I’m a lot less empathic to the patient calling at 2 AM with stent pain then the cancer patient in the office. I’m pretty good about leaving my work at work, but when i have a complication or a patient I’m worried about or just an extremely sad case I definitely dwell on it for a while. One great thing about urology is that we do lot of elective surgery that really improves patients quality of life, but that makes it harder to bear when the elective TURP, prolapse repair, stone case, etc has a bad outcome and would have been better off if they never met you. Family, exercise, etc. all help.

Burnout varies, I’ve definitely been burned out during residency at the end of rotations I didn’t like though I’d say I am not now. As a senior resident I’ve found the days are higher yield, the responsibility more fulfilling, the hours generally better, and the pending end of residency is starting to weigh that I need to learn everything now and soak up every opportunity. I’m not saying I’m over the moon to go to work every morning (especially clinic days) but I’m very happy that I went into Urology and excited rd about practice as an attending.

 

[md_doc]

Quick question about compensation of urologist is major cities (like NY, LA) and their surrounding suburbs. Do you have any idea what urologists starting salaries are in these areas for both hospital employed vs private practice? Also, what is compensation like in general (on average) in these areas after being in practice for 3-5 years or so - again in hospital employed vs private practice? I understand it obviously will depend on how hard you are working but just curious if you had any idea on any figures given a relatively busy practice while not killing oneself.

thanks.

 

[DoctwoB]

Quick question about compensation of urologist is major cities (like NY, LA) and their surrounding suburbs. Do you have any idea what urologists starting salaries are in these areas for both hospital employed vs private practice? Also, what is compensation like in general (on average) in these areas after being in practice for 3-5 years or so - again in hospital employed vs private practice? I understand it obviously will depend on how hard you are working but just curious if you had any idea on any figures given a relatively busy practice while not killing oneself.

thanks.

I can’t say about NYC in particular, but where I’ve looked in competitive CA suburbs and cities, hospital employed was starting in the low 400s with gradual rise over career while PP generally starts there or lower but with a much higher ceiling after partnership.

 

[Osteoth]

I can’t say about NYC in particular, but where I’ve looked in competitive CA suburbs and cities, hospital employed was starting in the low 400s with gradual rise over career while PP generally starts there or lower but with a much higher ceiling after partnership.

Kind of in the same vein, urologists saw their salary drop by 7% this last year per medscape's annual salary report. How do you reason out the salaries you've seen offered vs. what is reported nationally? What is a smart way to rationalize possible earning potential as an applicant?

 

[DoctwoB]

Kind of in the same vein, urologists saw their salary drop by 7% this last year per medscape's annual salary report. How do you reason out the salaries you've seen offered vs. what is reported nationally? What is a smart way to rationalize possible earning potential as an applicant?

View attachment 235823

The numbers in these surveys are quite small and the variance is large. If you look at MGMA data, which is generally seen as most accurate, the means are slightly higher then what I quoted but the standard deviations are about 200k. That means it doesn’t take too much variance given the limited N for the survey to skew up or down year to year. Don’t read too much into it.

The bigger thing to look at is if there were any major changes that would effect reimbursement, like When Medicare got rid of Buy and Bill for in office medications, many years ago, that was a bit cut to Uros who made a lot of money administering Lupron shots for prostate cancer. To my knowledge there haven’t been any major changes in the last couple years.

 

[Osteoth]

The numbers in these surveys are quite small and the variance is large. If you look at MGMA data, which is generally seen as most accurate, the means are slightly higher then what I quoted but the standard deviations are about 200k. That means it doesn’t take too much variance given the limited N for the survey to skew up or down year to year. Don’t read too much into it.

The bigger thing to look at is if there were any major changes that would effect reimbursement, like When Medicare got rid of Buy and Bill for in office medications, many years ago, that was a bit cut to Uros who made a lot of money administering Lupron shots for prostate cancer. To my knowledge there haven’t been any major changes in the last couple years.

Is there a way for students to get access to MGMA data? I've heard it tossed around as more accurate on here, but to my knowledge it's only available if you pay for it.

 

[Cyphix]

Kind of in the same vein, urologists saw their salary drop by 7% this last year per medscape's annual salary report. How do you reason out the salaries you've seen offered vs. what is reported nationally? What is a smart way to rationalize possible earning potential as an applicant?

View attachment 235823

Don't forget that the response rates for these are incredibly low, like ~1%

 

[DoctwoB]

Is there a way for students to get access to MGMA data? I've heard it tossed around as more accurate on here, but to my knowledge it's only available if you pay for it.

Not the latest data but if you search on sdn there is one from a few years ago.

 

[Dr. Scribe]

What advice would you have for a student who is interested in pursuing a surgical specialty but is worried that his/her procedural skills might hold back his/her career (i.e- he/she is not 'good' at surgery)?

 

[DoctwoB]

What advice would you have for a student who is interested in pursuing a surgical specialty but is worried that his/her procedural skills might hold back his/her career (i.e- he/she is not 'good' at surgery)?

I'd say to go for it. As a medical student you have no idea what your procedural skills are or could be. Assuming you don't have an uncorrectible physical deficit that could preclude surgery, not being a natural at the techniques you attempted as a medical student doesn't mean much.While there is a range in natural skill, surgery really comes down to practice and training. If you fall on the lower end of the natural talent spectrum may need to work harder and practice more then your colleagues, but should be able to get to the same place.

 

[Cyphix]

What advice would you have for a student who is interested in pursuing a surgical specialty but is worried that his/her procedural skills might hold back his/her career (i.e- he/she is not 'good' at surgery)?

During a preclinical med school lecture one of the thoracic surgeons gave a talk and said: "If you can tie your shoes, you can be a surgeon."

 

[Frogger27]

The most burned out (and happiest) doctors, according to Medscape

What do you think of these recent studies coming out about Urologiest being some of the most burnt out/unsatisfied physicians? Should this sway medical students from pursuing the field? This is definitely not what I have seen from the urologists in private practice I have worked with but it is concerning nonetheless.


I bumped @cpants AMA thread as well so maybe both of you could give insights on this on either thread.

Thanks!

 

[NotaCop]

I’m a student but I’ve done a bit of reading on this and my assessment is that the finding is marred by extremely low N for urologists in the study compared to other specialties. All studies done by AUA within the specialty have much higher N and show comparable burnout rate to that found in other specialties

 

[longshot1821]

Generally speaking is there a big difference in OR vs. clinic time in private practice vs. academics?

 

[DoctwoB]

The most burned out (and happiest) doctors, according to Medscape

What do you think of these recent studies coming out about Urologiest being some of the most burnt out/unsatisfied physicians? Should this sway medical students from pursuing the field? This is definitely not what I have seen from the urologists in private practice I have worked with but it is concerning nonetheless.


I bumped @cpants AMA thread as well so maybe both of you could give insights on this on either thread.

Thanks!

I (and others I've discussed it with) have found this survey quite surprising as it doesn't jive with our experience. The vast majority of Uros I know are very satisified with the field and would choose it again 100%. The complaints I hear tend to be the complaints of working in the medical field in general (EMR, metrics, admin, etc.) and not specific to Urology. Personally I wouldn't let it sway you at all if you like the field. Certainly small sample size could play a role, especially given that then the number responding to the survey is a small fraction of the total number of physicians it was sent to there is self selection in who fills out the survey.

 

[DoctwoB]

Generally speaking is there a big difference in OR vs. clinic time in private practice vs. academics?

The short answer is that specialization can change your clinic to OR ratio, but it will vary heavily depending on how you establish your practice and what kind of practice you are in. For example, if you're a busy and well established academic oncologist who has a wait list of 3 months to get an appointment, you can set up your clinic so you only see people who are likely to need surgery. On one extreme I know one oncologist who has one clinic day and 4 OR days a week, mainly because almost every patient he sees in clinic either needs surgery or is a post op visit. That being said, it is more typical for an academic oncologist, especially one starting out or in a competitive market to have 2-3 clinic days and 2 OR days. One can have a similar setup as a specialist in private practice, especially if you are in a mega group that will internally refer you a specific type of case.

The more typical scenario, however, if you are a general urologist who sees whatever walks in the door (or specialist still establishing their practice or in a competitive market) is that you'll see 10-20 patients for every one that needs surgery. A typical schedule may be 2.5 days in clinic, 1 day of cysto cases, 1 day of open/robotic cases.

 

[halfwaycrooks]

How often do people switch into urology via open positions outside the match?

 

[DoctwoB]

It happens but is pretty rare. There will be a few spots open after the match that fill through scramble. A few spots open up through people dropping out or programs backfilling after expanding residencies, most of these will be people that transfer in after a qualifying intern year (Gensurg or prelim surgery)

 

[sella.turcica]

Does it really hurt with 2 fingers?

 

[DoctwoB]

Does it really hurt with 2 fingers?

Use a single finger on exam, so couldn’t tell you there. A transrectal US probe that we use for prostate biopsies is about two fingers in diameter though. Patients don’t love it.

 

[OrthoTraumaMD]

Have you seen the ZdoggMD latest music video about urology?

 

[Elessar]

What specific resources do you recommend to prepare for urology sub-I's/aways? I've heard about Wieder's pocket guide, Hinman's atlas, and Campbells. Any particular favorites to prep for surgical anatomy for upcoming cases? Thanks!

 

[DoctwoB]

What specific resources do you recommend to prepare for urology sub-I's/aways? I've heard about Wieder's pocket guide, Hinman's atlas, and Campbells. Any particular favorites to prep for surgical anatomy for upcoming cases? Thanks!

Those are the big 3. Use wieders to quickly read up about the science side of a case (eg read about bladder cancer before a cystectomy), and Hinmans and/or Campbell’s for surgical steps/anatomy. Know the anatomical landmarks that determine what you’ll do next, e.g making an incision in anterior peritoneum immediately lateral to medial umbilical ligament towards vas deferens during robotic prostatectomy.

While all that is important, what is the biggest factor is work ethic and attitude. Get there early. Help the resident team in any way you can, get numbers for patients, have dressing supplies, do drains/Foley’s/staples. Find an inefficiency in how the team runs and help fill it. Be reliable and efficient. Be present without being annoying (toughest part)

 

[numbersloth]

Not sure if this thread is still active. What would you say the split is between male vs. female patients for a general urologist?

 

[DoctwoB]

Not sure if this thread is still active. What would you say the split is between male vs. female patients for a general urologist?

Probably about 70/30 or 80/20 depending on your referral patterns. Obviously that can go higher with specialization in female (all women) or stones (closer to 50/50)

 

[Cheeezcake]

I grew up in a small town, and would like to move back after residency. For urology, is there a sizable difference in compensation and scheduling hours between rural and urban practice? Also, whats the current demand like for rural urologist?

i’m an incoming med student and getting way ahead of myself.

 

[habibimarwan]

I grew up in a small town, and would like to move back after residency. For urology, is there a sizable difference in compensation and scheduling hours between rural and urban practice? Also, whats the current demand like for rural urologist?

i’m an incoming med student and getting way ahead of myself.

Insurance contract say how much you make. "Rural" area not great insurance. Urban not great insurance. Suburb has great insurance.

Only farm needs rural urologist, for animals!

 

[DoctwoB]

I grew up in a small town, and would like to move back after residency. For urology, is there a sizable difference in compensation and scheduling hours between rural and urban practice? Also, whats the current demand like for rural urologist?

i’m an incoming med student and getting way ahead of myself.

There is definitely a big need for urologists outside of urban center. Something like 60% (don't quote me on this, but a big number) of counties in the US don't have a urologist. And as a urology resident you will constantly be inundated with emails begging you to come to a job "2 hours from blank metro area" with great pay and hours etc.

The key, however, is many of these jobs will give you a high salary guarantee and then after a couple years your pay is based on production. The problem is you need enough volume to make that production. That town of 5k might love to have a urologist, but won't have enough volume to support one long term. So while it is definitely possible to be the Urologist for a less populated region, but you would need a large cachement area of patients coming to see you to be busy. Pay will depend on the situation and payor mix. Rural areas tend to have more medicaid which pays poorly, but the hospital may subsidize your salary to incentivize you to come out there or just employ you directly. Very much a your mileage may vary type situation. One concern if you're the only urologist is coverage for you during vacations, time off, illness, etc in which case they may need to hire locums. Definitely something to ask about when you're interviewing.

 

[DoctwoB]

Just wanted to give this old thread a bump in case any new folks had questions. To provide an update, I’ve now been out in private practice as a part of a large multi specialty group for few years doing general urology on the west coast. I definitely still think Urology is the best field in medicine.