A Serendipitous Journey Into Pediatric Urology

SS 132: A Serendipitous Journey Into Pediatric Urology

Session 132

Dr. Thomas Lendvay, Pediatric Urology Residency Director at the University of Washington, tells us why his specialty is a perfect fit for the variety junkie. Thomas has been out of training for 14 years now so he’s able to give valuable insights into this specialty.

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[01:05] Interest in Pediatric Urology

Thomas was first interested in pediatric urology when he did a rotation on it in his third year of medical school. It was part of a urology rotation that he did as a medical student. He was exposed to a variety of patients and he was enamored by the specialty.

Plus, he found it energizing to work with children. At that point, he knew was gearing towards a surgical profession and urology, being one of the two possibilities.

Within urology, he was working with a set of patients that he was energized every time he came home from work. 

[02:30] Traits that Lead to Being a Good Pediatric Urologist

First, it’s good to have a good sense of humor and that you can relate with children. You have to be able to get into their mental plane to be able to convey how you’re going to care for them and why you’re caring for them. 

'You have to be comfortable treating three people – the primary patient or the child, plus their care providers.'Click To Tweet

Most medical students really enjoy working with children. But what becomes a little more challenging at times is that you’re not just taking care of the child. You’re taking care of the care providers as well. If you can do this, then this is a great place for you.

These care providers are emotionally invested for their loved ones and so they’re much more than normal patients because they’re worried about their little ones.

[04:00] Urology Rotation in Medical School

When you’re on your general surgery rotation, you have the option to take an elective within that. 

At that time, it was a 12-week rotation for general surgery. Part of that time can be spent in an area of surgery different than general surgery. It could be trauma, vascular surgery, ENT. Thomas chose urology primarily because he was interested in the big abdominal surgeries.

“Urology is another profession where you can have a lot of exposure in that type of area. It's similar to general surgery and you might find that those surgeries are also interesting.”Click To Tweet

So he chose urology as a sub rotation within the general surgery rotation in his third year of medical school.

Thomas wasn’t initially interested in urology. He thought he was going to be a nephrologist or a gastroenterologist. His choice of where he did his surgery rotation was driven more about getting it out of the way. He chose a community hospital over a big university where one had to get recommendation letters from the big wigs.

Ultimately, it was just Thomas and a private practice general surgeon. They did a one-on-one for eight straight weeks. He was basically his first assistant so he got exposed to all the cool stuff of general surgery.

He got to cherry-pick the best parts of the clinical rotation in general surgery. Because of this, he became very inspired by what was available. 

[08:05] Myths and Misconceptions Around Pediatric Urology

The thought of students early in medical school is that pediatric urology is taking care of urinary tract infections in children. This is a medical subspecialty, which is not because this is a surgical subspecialty.

They do manage urinary tract infections but they’re usually in patients that they’re managing their surgical disease so it’s a minority of their focus.

'This is a surgical subspecialty.'Click To Tweet

[10:15] Types of Patients

As pediatric urologists, they take care of patients aged 0-21 years of age. They deal with issues of birth defects of the urinary tract and reproductive tracts through reconstruction.

For instance, they take care of hypospadias and other common pediatric urologic issues. 1% to 3% of people have the condition have urinary reflux where your urine can go backwards up from the bladder to the kidneys. Through surgery, they reconstruct how the ureters drain into the bladder.

Another procedure is for kidney obstruction. Children can be born with or over time can acquire narrowing where the kidney drains into the ureter. It can cause severe pain or a compromise to the kidney function. It’s a plumbing surgery where they reconstruct or open up the narrowing.

'Much of the surgeries we do are plumbing surgeries. The goal is to figure out how somebody can store and drain urine.'Click To Tweet

They also take care of kidney stones. When you think of a urologist, and adult surgeon, people pretty much think of it as kidney stones. Kidney stones are a growing problem in children.

They treat children born with Differences in Sexual Development or DSD conditions. What used to be called ambiguous genitalia or hermaphrodites are terms no longer used.

These are children with this discordance between their genetic makeup and how they’re designed anatomically in the reproductive tracts. That’s the pediatric urology domain to care for. Those patients are approached collaboratively with endocrinologists and genetics counselors and psychiatrists.

Historically, the surgeons are just going to assign you gender-wise because it’s very difficult to do the reconstruction. Now, they’ve realized that having shared-decision making with patients and their families provides much better care for them. Those are multi-disciplinary scenarios.

The other children are spina bifida patients who have problems with their urinary tract in terms of bladder function. They are either constantly leaking or they don’t empty well. they do interventions to help get the bladder drained or keep the bladder in safe pressure so they don’t put that pressure back on to the kidneys.

'Children with undescended testes is the most common birth defect in males in the urinary reproductive tract.'Click To Tweet

About 3% of all boys in the United States have surgeries to bring their testes down into their scrotum. They also take care of pediatric hernias, complications from circumcision, or children with infected foreskins.

Pediatric urologists also deal with a lot of girls. There are many anatomic birth defects that girls are born with involving their vagina and urethra.

There are also girls born without the insides like the uterus and fallopian tubes and the top parts of the vagina. They actually don’t have a vagina they can use when they become sexually active. So they do the reconstruction to build vaginas.

Additionally, they are in this circuit of trauma care for pediatrics. One of the most common injuries they see is children with vaginal lacerations or injury down there that they have to fix.

[16:40] Cancer and Transplants

If you’re interested in oncology or cancer, there are urologic malignancies that they’re taking care of such as Wilms’ tumor or sarcoma to the bladder, prostate, and vagina. These are not common but if you’re interested in having oncology leaning to your practice, this is something you can be involved in.

Another area you can get into is Transplants. They’re involved with many kidney transplants in children. If the kidneys aren’t right in a child, frequently it’s because of a urologic problem that they had.

So they’re working with transplant surgeons in some of the reconstruction when they get new kidneys. They specifically have to manage that portion of the system that gets plugged into the bladder.

[17:50] Typical Week

A typical week for a pediatric urologist will be some time in clinics and other times in the operating room managing some additional things.

Typically, you’re taking care of not only surgical patients but also medical patients who never have to go to surgery such as bedwetting issues. They work alongside advanced practice providers in some of these nonsurgical areas.

'Because of the high surgical needs of a lot of patients, we now have a shared system in many practices.'Click To Tweet

In Thomas’s practice, he finds it very engaging to balance his clinical with his research and education thrusts. He is the Program Director for the pediatric urology fellowship at the University of Washington at the Seattle Children’s Hospital.

He is heavily involved with the education and the training curriculum for the residents that also rotate through there. He has specifically gravitated towards technical skills training. He is creating simulation modules to help train their trainees.

They’re working on novel technologies to assess the skill of surgeons and to accelerate learning curves. In their work, he’d typically spend a day a week just on the education and research side of things in addition to the clinical aspects of his career.

[21:29] Can Manual Dexterity Be Taught?

'Most trainees, if given the right environment and time, can technically advance to a level that makes for a safe, proficient surgeon.'Click To Tweet

There are some circumstances that things can get challenging. Somebody who has very little spatial relations capabilities might find some procedures to be very difficult.

One of the problems with medical training is that it’s still kind of a one-size-fits-all type model. What we’re learning more and more about how people learn is decades-old data in the psychology of education is that it’s not one-size-fits-all.

And even in technical skills, somebody can grasp a technique faster than somebody else.  Having said that, you can still bring a person who takes a little longer up to the same proficiency level that just requires a different approach. They just might require more repetition or more one-on-one time with faculty.

[23:50] Taking Calls

On his urology rotation, the faculty in urology was just much more fun to be around. It was a culture that Thomas personally thought was aligned more with who he is.

Additionally, he observed that call was not as bad as general surgery. He saw that a urologist would come in for certain things related to trauma. Trauma is usually the thing that brings you in the hospital in the middle of the night. But it’s not nearly as much as general surgery.

'If you want to be the type of provider where the buck stops with you in a hospital, be a general surgeon. But that also means you are working a lot at night.'Click To Tweet

Kidney stones are also a legitimate surgical emergency at times but there aren’t that many cases.

When you go to pediatric urology, you can almost list in a single hand the things they will call you in. These include obstructing kidney stone, twisted testes on its blood supply threatening to die, scrotal or vaginal laceration, and perforation of the bladder in a child who has had previous reconstructive surgery on the bladder.

In Thomas’s experience, he’d probably get called in 1 in 8-10 for the nights he’s on call. And they’re on call for a week at a time including the weekend and then they’re off for a couple of months. This tells you that they’re not that called very often.

[26:45] Life Outside of the Hospital

For Thomas, this question is very dependent on how you learn to say no through your career.

If you’re in private practice, you have to balance the drive to earn a living with your quality of life. In academics, you have to balance the drive to discover and do research with your family life. These are the things competing against each other.

It requires you to be honest with yourself about how much do you want to crush it.

'You have the ability to decide how you want to structure your life but it does require that you say no to some things.'Click To Tweet

That being said, Thomas has noticed that urology has a better work-life balance while he was still deciding on general surgery.

Pediatric urology is even a milder culture than urology in general. Everybody working at their hospital is so invested in the children. And so the pediatric hospital is a totally different breed of culture. Everybody is happier in general and energized.

[29:15] The Training Path

After medical school, you go to a general urology residency program. This consists of a year or a year and a half of general surgery. Now, there are only 9-12 months of general surgery rotations as an intern.

Then urology residency is a five to six-year endeavor. Most programs are five years and the six years have a year of research embedded within the program. They are both in community settings and academic medical centers.

There are just over 120-125 urology residencies in the United States. Some take 2-5 residents a year.

Then you go onto doing a two-year pediatric urology fellowship. For the most part, it’s a year dedicated to clinical.

'It's actually the only one in urology that's ACGME-accredited. All the other fellowships are not ACGME-accredited.'Click To Tweet

The second-year is either all research or a hybrid of research and clinical practice. There are a few three-year pediatric urology fellowships and they spend two years doing basic science research in those nonclinical years.

You can do transplant fellowship in addition to your pediatric urologist thrust.

If you’re interested in oncology within the pediatric urology, you can put a premium on fellowship programs that tend to have a very strong leaning towards the oncology practice.

In some programs, many of the tumors are taken by the pediatric general surgeons. And in other programs, it’s the pediatric urologist that does them. So you can identify programs that would give you training in the oncology piece.

Beyond that, every program is very good at giving you that kind of well-rounded experience. The fact that it’s ACGME-accredited means that the bar is already set high. 

[34:00] Message to DOs

To be competitive to get into a pediatric urology fellowship, just go to a regular urology residency and perform well. So there’s no barrier for a DO.

Moreover, when you do your urology residency, usually you spend a quarter of your time doing pediatric urology rotations.

'Many residencies will have you exposed as a junior resident or a senior resident so you can really understand whether this is a profession for you.'Click To Tweet

[35:35] Working with Primary Care Providers and Other Specialties

One of the things they try to convey to pediatricians is that they are open anytime there’s a question of what seems like a pediatric urologic issue. When in doubt with a surgical issue, just refer them to a pediatric urologist so they can at least lay their hands on the child.

This can be very challenging for pediatricians as there are complex cases and so they are definitely open to partnering with them in the care of these children.

Other specialties they’re working very closely with include pediatric nephrology for kidney stone problems. They work with general surgery for birth defects issues and endocrinology, genetics, and psychiatry for DSDs. They also collaborate with the infectious disease people for treating urinary tract infections, and orthopedics and neurodevelopment for spina bifida.

[41:00] Special Opportunities Within the Field

Pediatric urology really allows for an individualized career pathway as well as work-life balance. There is a lot of latitude in how you can structure your career.

You can do private practice and even within that realm, you can choose to work as much or as little as you want. You just have to decide what you want your lifestyle to be. In academics, there are so many different areas that you can research and go into.

'You can create the career path you want.'Click To Tweet

[44:11] The Most and Least Like Things

Thomas enjoys being able to fix things for children so that they have 90-100 years ahead of them. He likes fixing, reconstructing, and rebuilding things that pediatric urology has really honed in on this particular area of surgical skills.

There’s the ability to apply novel technologies. His subspecialty within pediatric urology is minimally invasive surgery including robotic surgery and laparoscopy.

It requires some creativity to be able to afford patients with the same advanced technology applications that they would use on adults. 

On the flip side, what he likes the least is the administrative side to medical care that has expanded over time for providers.

'If you pick a reconstructive surgery profession, you're going to be needed for our society for the foreseeable future.'Click To Tweet

[47:40] Final Words of Wisdom

Don’t be discouraged by the fact that it’s additional training as this can be discouraging for some people. It’s not as intense of a training as the urology aspects of the residency were.

Don’t go into urology necessarily knowing for sure that you’re going to do pediatric urology. Keep an open mind because there may be other things that really interest you.

Lastly, if you’re interested in working with kids, your pediatric urology rotation is only going to reinforce that.

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