Pediatric Urologist’s Day in the Life and Typical Patients

Session 162

In this episode, Dr. Courtney Rowe takes us through what she sees in her specialty and how Pediatric Urology differs from Urology. She is a pediatric urologist at Connecticut Children’s Hospital. And I have a great conversation with her about her non-traditional path to becoming a physician and the mentor that guided her and exposed her to pediatric urology.

For more information about this specialty, check out the American Association of Pediatric Urologists.

For more podcast resources to help you along your journey to medical school and beyond, check out Meded Media.

Listen to this podcast episode with the player above, or keep reading for the highlights and takeaway points.

[01:12] Interest in Pediatric Urology

Medicine is Courtney’s second career. She did interactive computer sculpture in undergrad and graduate school and recognized that it was not the right fit for her. She wanted something a little bit more concrete in terms of how to help people. So she ended up going back to medical school although she had never really thought about a surgical specialty.

She had this stereotype of surgeons in her mind being male. So she never really saw herself as a surgeon. She had done a lot of work with her hands, specifically a lot of electrical work, soldering, and building things.

Ultimately, she was introduced to a urology mentor, during her physical diagnostics class in her second year of medical school. She offered for her to shadow her in her urology clinic to see some surgeries and procedures and she loved it since then. It was a combination of diagnosis and small procedures. She found it to be an engaging way to practice medicine that was also very tech-heavy.

Courtney felt she was a weak applicant for urology not having any traditional medical school background and research. So when she decided she wanted to apply to urology, she knew she needed to get some more research experience. And at the time, her mentor was at just a community hospital so she was advised to reach out to the local Boston Children’s Hospital that will be able to support her research.

She ended up cold-calling the head of Boston Children’s Urology by mistake, and she told him her life story. He then connected her with a translational researcher at Boston Children’s in pediatric urology. So she spent about a year and a half at the end of medical school doing work with him, and spent a full year in between medical school and residency, running his lab for him. And this gave her the pediatric urology bug.

'It's a very small specialty. And when you're looking at a smaller specialty, you have to know that you love the content, because in some ways it's doing it over and over again.'Click To Tweet

You also have to recognize that the job opportunities are going to be a little bit more challenging. So it took her awhile to get around to the idea of just committing to pediatric urology, where she did apply to fellowship in the third or fourth year of residency and she never looked back.

Courtney felt lucky to have a female mentor who’s very supportive of her. Urology might be the worst in terms of the gender divide. But the women in urology try to make more of an effort because they know that.

[05:53] The Biggest Myths or Misconceptions Around Pediatric Urology

'Most people don't know what pediatric urologists do.'Click To Tweet

Pediatric urologists take care of congenital conditions that hopefully are fixed once they’re done with the child. But most people think that a pediatric urologist takes care of prostate problems. They assume that adult urologists only really deal with prostates and things like that. But urologists do all of the DU organs – the kidneys, the bladder, and the genitalia. Therefore, pediatric urologists have plenty of work to do.

[06:42] Types of Patients

Their bread-and-butter cases include differences in testicles, like undescended testicles, and differences in kidneys like hydronephrosis. In the category of hydronephrosis, they see ureteropelvic junction obstructions, which are basically blockages when the kidney is draining. They see urinary reflux, which is urine going from the bladder up to the kidney. Other bread-and-butter stuff includes hypospadias and other penile differences. And then there’s the rare stuff like bladder exstrophy, spina bifida, clinical anomalies, all kinds of just sort of differences that kids can be born with affecting that part of the body.

'Difference doesn't necessarily mean it's bad or wrong. And there's a lot that comes from how you phrase things when you talk to families and a lot that they carry with them afterward.'Click To Tweet

Courtney believes that accidental judgment is really going to affect the parent, that family, and that child eventually. So they have to be very careful with their language.

[08:15] Key Traits that Lead to Becoming a Good Pediatric Urologist

There’s a physical aspect to it. Personality-wise, you have to be pretty relaxed. You’re talking about a part of the body that a lot of other doctors and people in the public find embarrassing or distasteful. It’s something they don’t want to talk about, look at, or touch. So for you to go into urology in the first place, don’t take yourself too seriously. They kind of joke around a little bit. Pediatric urologists take that to the next level.

Patience is also important especially with families because again, these are things that they’re embarrassed with. They sometimes don’t tell family members, even if it’s something as simple as an undescended testicle. Nobody talks about this stuff.

“Undescended testicles are incredibly common, and they've never heard of it. They think that something is absolutely terrible with their child and they're embarrassed and ashamed.”Click To Tweet

So as a pediatric urologist, you have to be patient when it comes to that. You have to be very understanding and be able to take your time.

Then there’s the physical aspect of it. The clinic is only a portion of what Courtney does. The other portion is surgery. They tend to be open surgeons so they all use either loops or microscopes. The robots are working on really small delicate things. And to be a good microscopic surgeon, which is what pediatric surgery often is, at least in urology, you have to be patient. You have to have good hand-eye coordination and move carefully and with precision.

[10:40] Can Manual Dexterity Be Learned?

They certainly care about function, but you’re also talking about some aesthetic components when it comes to reconstruction genitals. You have to be a little bit of a perfectionist and a little bit obsessive about that aesthetic component to do a good job.

“Dexterity or hand-eye coordination is a skill that can be learned. But you have to love it. If you don't love working with your hands, you're not going to practice and get better.”Click To Tweet

Anybody who walks into this profession who come in gifted thinks more about how they can apply those gifts. And as with anything surgical, it matters most what you choose to do.

You can be the most technically brilliant surgeon but if you make the wrong choices, you’re not going to have good outcomes. Therefore, that love for that technical aspect is necessary for pediatric urology. That being said, you don’t have to have an automatic and instant natural aptitude. You just have to be willing to work at it through practice.

[11:55] Diagnosis vs. Treatment

Pediatric urologists are more of the fixers. They certainly do the diagnosis stuff. There are some diagnostic uncertainties in their world, but very few.

'Pediatric urology tends to be a specialty involved in finding a solution more than it is in finding a diagnosis.'Click To Tweet

Most of where their conversations are at would be around which treatment path to take – whether that’s surgical, non-surgical, behavioral, medical – there are many treatment choices.

[12:49] Typical Day

Courtney does 50% clinical and 50% research. Her day depends on what kind of day she’s having. On her lab day, she’s usually writing grants, checking on experiments at the lab, and having Zoom meetings.

A typical clinic day would be seeing new patients, follow-ups, reviewing ultrasounds, maybe some small procedures in the morning. She also sees people pre-op or post-op. Her surgery days are much longer. And she could go back and forth between the more bread and butter cases.

Courtney does a lot of reconstructive cases. And those will be a whole day affair, sometimes with the team of surgeons over a long involved, interesting complex case.

[13:57] Is Going into an MD/Ph.D. Program Necessary?

Absolutely not. Courtney collaborates with a Ph.D. at the University of Connecticut. She does not have the experience or time to have a clinical. She had also looked at some grants that were submitted with no clinical person and you can really see the difference.

A lot of great work can be done out there in basic science. But when you’re talking about translational research, which is what Courtney does, they bring things out of the basic science lab. Then into kind of the clinical world, you need that clinical perspective. So having some of the basic science things is really helpful. Courtney reviews papers all the time. She has lots of friends with Ph.D.s who ended up not doing research.

'Going into a research career has more to do with if you want to dedicate your time to that because it's a lot of work.'Click To Tweet

With clinical work, if you put in the time, and work hard and do a good job, your patients will have a good outcome. You will be successful and things will go well.

On the other hand, research involves luck. You can work incredibly hard and be incredibly talented. You can have a great idea. If you miss the timing on where the funding is coming from or if you’re not part of a case that is in motion, you will not succeed in your research career. So there’s a level of uncertainty that you have to be willing to undertake.

For Courtney, it’s nice to go back and forth between the research and the clinical. Because sometimes in the clinical, it feels a little bit more formulaic where you’re doing the same thing over and over again. It’s lovely to get good outcomes, but it’s still a little bit repetitive. And then she can go into the research side where things are more exciting and more thought-provoking. But then when you start to hit your head up against a wall, because you’re not getting anywhere, you can always go back to the clinical side.

[17:05] Taking Calls and Work-Life Balance

There are not a ton of pediatric urologic emergencies. They typically take a week of call at a time. Courtney does inpatient and outpatient. She feels lucky to work with residents.

They occasionally have the occasional surprise emergency surprise newborns with something unexpected. But it’s pretty manageable. She finds that pediatric urology families are great people. They’re really appreciative of the care they’re getting. And so if they’re calling her on a Saturday, it’s a pleasant conversation.

Courtney feels work-life balance as a pediatric urologist is harder. Urology, in general, has a little bit more flexibility for work-life balance just because the types of emergencies they get are few and far between. And adult urologists have usually larger groups and with bigger call pools. So you’re on call less often, even though the call might be a little bit busier. With pediatric urology, because they tend to be a smaller group in the call pool. they are on call more frequently.

[18:51] The Training Path

They’re adult urologists first. And that’s actually a misconception of their pediatric colleagues. All the surgeons come from the adult surgical specialties and then specialize in pediatrics. Courtney did five to six years of general urology, which does include pediatric urology, and then a two-year fellowship.

'Many of the pediatric nonsurgical subspecialists are pediatricians first and then specialized.'Click To Tweet

If you want to still do adult urology as you grow, it basically depends on your job. Most hospitals and most larger organizations are going to want pediatric-specialized urologists.

To keep her pediatric sub-specialization, she needs to see 70% of pediatric patients. There are well out there who are practicing a more mixed population. But when you think about the fellowship-trained pediatric urologists, there are not that many of them, maybe just about 500 in the country.

Most of them are pretty dedicated to pediatrics. If you’re going to go through that two-year fellowship, you will mostly do kids. In terms of seeing the more general things, this is where being in a larger academic institution is really helpful. Courtney’s institution is not typically seeing the bread and butter cases. So by the time the kids get to them, it’s usually a little bit of a higher level and they get the more complex things. They are the more difficult referrals that aren’t doing well in the community for whatever reason.

[21:14] How to Be Competitive for Residency

Sometimes, there are way more applicants and spots, and sometimes, there are way more spots than applicants.

'It's a complete guessing game any particular year.'Click To Tweet

Depending on the climate, how people are talking about pediatric urology, or the mentors that you have, and the people you run into, they will either get a glut of applicants or they will get very few.

But the job market is the same. There are plenty of jobs out there, but it depends on the kind of job you’re looking for. So if you’re very specific about the type of job you want, or the location, it can be harder to find a job. Then again, there are always openings, there are always people looking.

[22:04] Message to Osteopathic Students and Primary Care Physicians

DO students just have to be good in the same way as an MD would be good.

'By the time you're in a urology residency, nobody really cares where you went to medical school.'Click To Tweet

Moreover, Courtney feels bad for the generalists in general, because recommendations are constantly changing.

The way you would practice pediatric urology 10 years ago is not how you practice it now. Hopefully, our new breed of pediatricians would be patient with the ever-changing recommendations.

In pediatrics, when it comes to research and being data-driven, it’s really hard to get data. So try to gather the best data and try to make the best choices. Also, it can be very confusing for people who are referring to them. So hopefully, they don’t feel bad if they refer to them for one thing and it ends up being wrong.

Also, it’s almost impossible to keep up with the recommendations and the constant changes, so it’s important for them to reach out to specialists.

[23:30] Specialists They Work the Closest With

As pediatric urologists, specialties they work the closest with include pediatric neurosurgeons because of their spina bifida kids, and the pediatric orthopedic surgeons for bladder atrophy.

[23:56] What She Wished She Knew that She Knows Now

Courtney feels lucky to have so many mentors who were at different points in their career. And so, she was able to avoid some pitfalls along the way. During her residency, she really thought she could burn the candle on both ends and do research and be very clinical, and do really well.

When it came to negotiating the position, she’s very careful to ensure that her goals and the structure in the job she took were aligned. And that has been very helpful. And this advice is not only specific to pediatric urology.

'If you don't have the support around you to do what you love, then you will find yourself constantly doing things that you don't love as much.'Click To Tweet

Even during the pandemic, the resources are scarce. Because Courtney has a contract that really protects and supports the research, it has allowed her to hold on to that even in a pandemic.

[25:37] Most and Least Liked Things

Courtney loves the kids and patients. And they’re the highlight of her day. She admits it’s really hard for her to be a doctor without also being a mom. It’s always very easy for her to put herself in the shoes of that parent.

'For these parents, it doesn't matter if it's the littlest thing in the world, it is a big deal.'Click To Tweet

You have to be able to put yourself in their shoes and say, this is a big deal to them. And even if it’s not a big deal, your job is to explain why it isn’t a big deal and what’s going to happen. Then give them all the reassurance in the world or guide them along a path.

On the flip side, what she likes the least just like all specialties is how medicine is becoming almost like commerce. She didn’t come into medicine wanting to see patients as consumers. She sees them as working together for the health of the child.

So the move towards more of a commercial bent to medicine is what frustrates her the most. She wants to see her patients afterward and have conversations beforehand about the pros and the cons. She wants to be thoughtful about making choices.

[28:30] Major Changes Coming Into the Field

'Pediatric urology is a very young field.'Click To Tweet

The field has just been around maybe a little less than 20 years. And they only got their subspecialty certification maybe 15 years ago. And as time goes on, they are getting more and more aware of pediatric urologists.

There’s going to be more demand from patients and from families for a pediatric urologist.

Also, more kids with congenital differences are being born and surviving and kind of growing up into adulthood. There’s been a big shift towards translational pediatric urology, basically taking care of these congenital differences, as the children are now in their 20s and their 30s in their 40s.

The demand for pediatric urologist is going to increase. And they’re going to shift slowly away from the younger population and more up from surgical intervention to more of a management and a long term relationship.

[29:38] Final Words of Wisdom

If she had to do it all over again, Courtney would still have chosen the same specialty. If this is something you’re interested in, go and meet some pediatric urologists. Read all you want and listen to what you like. Shadow somebody in the field and this will give you incredible insights, especially into pediatric urology.

[30:25] How eShadowing Can Help You

The exposure to a mentor showing someone their path to a specialty is something that seems to come up over and over again. And obviously right now, as I’m recording this, we’re in COVID times. So it’s really hard to get out there and find a mentor.

But we have learned that life continues even in a virtual world, which is why I set up eShadowing.com. It’s a platform to track the hours or the minutes that you’re watching. We also have a quiz and if you watch enough and you pass the quiz, then you can get credit. We’ll have a system to automate sending you a certificate at the end of each shadowing or when you need to apply to medical school so that you can at least get some “shadowing hours.”

Every medical school is going to be different from how they accept these hours but they understand that shadowing is non-existent. Virtual shadowing hours are going to be better than no shadowing hours right now.