What Does Practicing in Urology and Men’s Health Look Like?

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Session 179

Dr. Petar Bajic is an academic doctor practicing urology with a focus on men’s health. Listen for a peek into common diagnoses, procedures, and his lifestyle. To know more about this specialty, check out the American Urological Association.

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

[01:27] Interest in Urology and Male Sexual Dysfunction

Petar went to medical school without any preconceived notions about what he wanted to do. And it was a coincidence that he ended up in urology when he decided to room with one of his friends from college who was a year ahead of him in school. He had a roommate who was a fourth-year med student at that time and doing kidney transplant research. And the transplant team where he went to medical school was all urologists. He recognized it was an easy way to get involved in research by just asking his roommate if he could work with them and so they brought him on board. 

For him, he found the specialty fit his personality as he enjoyed being around urologists. Nevertheless, he still went through all his rotations and just ruled things out until he found urology was the only thing he liked.

Petar says a good fit for the specialty would be people who feel comfortable talking about some of the difficult things to talk about, have a good sense of humor, and are easygoing. But at least, that was the case for him.

'It's important to be able to laugh and enjoy yourself at work.'Click To Tweet

He found himself so serious in some of the other rotations he did and the people just had a different tone. That’s not to say they’re not handling serious cases, but it’s important to be able to maintain a positive attitude.

[04:20] The Biggest Myths or Misconceptions Around Urology

One of the misconceptions around their specialty is that everything urologists do is gross. So you have to have a tough stomach to deal with some of this stuff. But Petar clarifies that’s necessarily the case for urology, even comparing to other specialties.

He adds that you can have a great career in urology even if you’re somebody that might be more squeamish. He admits he almost passed out the first time he was in an operating room. And some people think that means he can’t be a surgeon. But that’s not the case. He learned he just had to eat breakfast and he was fine.

And just like med students going through anatomy. The first time you see a cadaver, you get grossed out. But a couple of months into anatomy, you’re thinking about what you’re going to eat for lunch and you’re dissecting a cadaver.

Another misconception is that urology is only for men. In fact, the people currently in training and the incoming residents are becoming much more diverse with a lot more women and people of color. So it has become a much more diverse field nowadays than it has been historically. And that’s been a very positive change.

'Historically, it's been a very male-dominated field. But there's been a lot of effort to make it more diverse.'Click To Tweet

Lastly, in urology, you’re not just dealing with prostate checks and urine all day. There are plenty of ways you can sub-specialize in whatever area you’re most interested in. You can choose to do major abdominal cancer surgery or focus on fertility helping couples have children. There’s also the pediatric urology aspect as well as the very fine reconstructive surgery. So there are a lot of different ways you can go.

[06:56] Traits that Lead to Becoming a Good Urologist

For Petar, the most important thing is being able to make the patient feel comfortable, and being able to make them feel comfortable talking to you about some of the most intimate and private aspects of their life.

Petar’s primary focus is male sexual dysfunction and guys really don’t like going to the doctor. So sometimes, it takes some serious trust-building before somebody will open up to you about some of these issues that can really be psychologically and physically debilitating for them.

People with incontinence, etc. are looking for somebody that will listen to them and can offer them solutions to some of these problems they might not feel comfortable talking to anybody about.

[07:54] Typical Day

He spends roughly half of his time in the clinic and the other half in the operating room, although that varies week to week.

“Nowadays, many procedures in urology can be done under local anesthesia. It's definitely one of the more high-tech fields.”Click To Tweet

One of the things that drew him to the field is how high-tech the field is. Nowadays, many procedures in urology can be done under local anesthesia. He does a lot of in-office treatments for BPH or prostate enlargement, and a lot of male genital reconstructive surgery done in the operating room.

And then in the clinic, he sees follow-up patients and manages conditions like erectile dysfunction, Peyronie’s disease or penile curvature, and low testosterone. He also sees a lot of general urology that includes male voiding dysfunction, kidney stones, etc.

Other procedures they do in the office include cystoscopy prostate biopsies. He does a lot of penile Doppler ultrasound, so it’s very varied as well as vasectomies.

[09:48] Diagnosis vs. Treatment

In terms of patients coming to him for diagnosis versus treatment, Petar says he sees a wide variety of things.

For example, somebody that comes to him with voiding dysfunction, the gut thought for most providers in a 60-70-year-old man with some urinary complaint is that it’s the prostate. And usually, that’s probably the case. But he also pays very close attention to whether there could be something else going on. 

He explains there are variable phenotypes of urinary dysfunction. Some guys have more of the overactive bladder. And a subset of those men may actually have their voiding dysfunction stem from spinal pathology.

Petar says he has diagnosed several patients with spinal stenosis just based on their genital urinary complaints. He sees a lot of men for genital and testicular pain, a lot of times, those end up being something else going on.

“You have to have a holistic view. And it's not just about the genitourinary tract. So there's definitely a lot of Sherlock Holmes thing for many of these diagnoses.”Click To Tweet

Another he likes about urology is that it’s not like one of these fields where they have a surgical problem, you fix it, and then you never see them again. In urology, your patients become your lifelong patients. So even if you see somebody for something nonsurgical, there’s a chance that somewhere down the road, something may come up that does require a procedure.

[12:22] Taking Calls

Being part of a big academic center, Petar is at the main campus at Cleveland Clinic so he takes calls about every 13 weeks, I take a week. They also have great residents who do the majority of the heavy lifting for them. So he’s just available to deal with transfers and surgical cases and takes some calls just to help out at one of their community hospitals. But the visits aren’t that many and he also doesn’t have to go in the middle of the night.

But if he would have to go in, types of urology emergencies he would have to deal with are the ones when there’s an obstructing kidney stone in the presence of an infection. It’s a true emergency that all urologists can probably be expected to do at some point. Other cases would be necrotizing infections like Fournier gangrene. People come in with blood in the urine quite frequently and sometimes they might have to go to the operating room.

“Nowadays, the urology training is very robust. All urologist programs he has been exposed to are comfortable dealing with the everyday stuff that they encounter on call.”Click To Tweet

[14:29] Life Outside of the Hospital

Petar says he’s generally home by 5 or 6 pm. This means he has already finished his charting. If he has a sick patient in the hospital and he’s not on call, he sometimes goes to check on them. But with calls as infrequent as it is, he has a good amount of rest on the weekends.

'The work-life balance component of the surgical specialties, urology is one of the best.'Click To Tweet

[15:30] Interest in Men’s Health

Petar trained at a residency program where they did a lot of major cancer surgery. Although he loved it, he just knew it wasn’t for him in the long-term. He felt like the big operations, day-in and day-out were taking a toll on his body. He just couldn’t imagine himself doing it for the next 20-30 years.

The other thing was that seeing all those cancer patients and how they tried to get back to the quality of life. Once their cancer was treated, he saw a big unmet need. And they had some absolutely wonderful urologists where he trained and that was the focus of their practice. They were restoring sexual function after prostate cancer treatment or restoring continence after people becoming incontinent because of their treatment.

So he found it incredible to watch people get that quality of life back. That’s why he decided it was what he was going to become passionate about which is to focus on Men’s Health.

[16:51] The Training Path

After medical school, you basically enter into residency. All urology training programs bundle-in the intern year. The intern year can range from between six months to about a year of general surgery.

Every program is a little different. There may be some still out there that do two years of general surgery, although that’s becoming pretty rare. There are programs that are five years total and others are six years total. The residency program he trained at was six years because it included a research year, which was his fifth year of residency.

Petar’s guess is that probably about half of people choose to do a fellowship although that varies based from program to program and city to city. But there are a number of different fellowship options available.

'Many people choose to just go straight into training and practice general urology because there's a huge unmet need for urologists around the country.'Click To Tweet

Petar adds that it’s probably a lot easier to find a job out in the community without being super-specialized because they need people to do the general urology stuff. Kidney stones, BPH, and those kinds of stuff are so common, and with the baby boomers and the aging population in general, there’s a huge unmet need.

[19:55] His Decision Going Down the Academic Route

Petar initially thought he was going to do general urology private practice and doing his research late in his training. And it wasn’t until his research that he started falling in love with research that he decided he wanted to do academics. He had already interviewed at a number of private practice jobs around the community before he totally did a 180-degree shift and decided to do academics. And then after that, he decided he was going to do a fellowship.

Petar stumbled into a basic science lab where they were studying the genital urinary microbiome during his research year, and he got really into it. He got really interested in not only the science part, but also, the writing part – papers, grants, and getting the funding to do more research. It’s very time-consuming but he loves doing it.

He also found it very difficult to apply for NIH grants as somebody in private practice. There’s pressure on productivity and very little ability to have any sort of carved-out time or PhDs and labs supporting you. So ultimately, Petar decided he wanted to be part of an academic center.

Even as a private practice general urologist, he had wanted to focus on men’s health because he was confident his training was robust enough. But after talking to some of his mentors that he was going to apply for academic positions, they actually suggested he did a fellowship. Otherwise, somebody without a fellowship in an academic position may have to see other things that they might not be focused on.

So doing a fellowship allowed him to carve out a niche while still getting to do the research and getting to teach the residents. And that was a huge part that he felt he would have missed out on in private practice. So all of that played into the ultimate decision to do academics and to do a fellowship.

[22:11] How to Be a Competitive Applicant to Match

At their residency program, they take a very holistic approach to evaluating each and every application. Unfortunately, board scores are important, although they’re not a deal-breaker. So you need to make sure that you put forth an adequate effort to prepare for the Step exams, although Step 1 is doing pass-fail by 2022.

“Unfortunately, board scores are important, although they're not a deal-breaker.'Click To Tweet

That being said, Petar advises students to do their due diligence. Work hard to honor your surgery rotation. And if you’re going to do either an elective or a sub-internship, make a good impression. Get some good letters.

Beyond that, you need to be the whole package in a very well-balanced way. You don’t need to win a Nobel Prize but you should show you’ve made an effort to be involved in research to contribute to the field. Show that you made a contribution to your community through volunteerism.

[24:55] Bias Against DOs

Petar believes there are still some systematic biases historically, unfortunately. But with more and more programs taking a more holistic view of applications, it’s becoming less and less of an issue. 

Many of his greatest mentors through training were DOs. So he certainly doesn’t hold those biases. Unfortunately, there are probably some people at some programs that have unfair views. His hope is that more and more programs will look just as closely at osteopathic candidates as they do at allopathic candidates.

[25:52] What He Wished He Knew Before About the Field

Petar admits he wished he would have focused less on where he was going, and more on where he was at the time. There is a lot to enjoy at every step of the way. And he was always somebody that was thinking five or more years down the road or how it was going to set himself up for x, y, and z.

You’re only in med school once. You’re only in training once, unless you change specialties. You’re only an intern once.

Once you become an attending, and you face the burden of having your own patients, the liability, etc., you realize it’s very different. And it makes you miss when you were a resident where you get to share that responsibility for those patients with others.

“There are certain things that are bad about each of those stages. But there are also things that you don't necessarily appreciate that are good about them.”Click To Tweet

So Petar encourages people to really enjoy every step of the way. Work hard. Try not to stress out too much about where you’re going to be five years from now and really just focus on the moment and learn as much as you can at every step of the way.

[27:38] The Most and Least Liked Things

His primary area of interest in both clinically and research-wise is Peyronie’s disease and erectile dysfunction – basically male sexual health.

'It's really cool to be the last stop of the train for people with a specific issue.'Click To Tweet

He finds it rewarding to be able to just give them the whole “lay of the land” for their condition, the different treatments available. And being able to take that journey with them from the beginning until the end where they’re satisfied with the result.

Petar also likes the very private and intimate nature of men’s health. And he feels he’s good at developing a type of friendship with his patients where they can feel like they can tell him anything.

It’s important for patients to know that everything they talked about stays confidential. Some people are ashamed of certain things. And so, they really appreciate that. So he finds it very rewarding when somebody comes back to you just to tell you how much they appreciate you listening to them and the impact you’ve made on their life.

Some of the sexual health concerns can have huge massive implications on people’s quality of life and their mental health. Unfortunately, they go a little ignored when it comes to insurance coverage.

There’s a lot of jumping through hoops that patients have to go through to get the care that they deserve. And that includes sometimes switching to different insurance, etc. Petar finds this very frustrating just watching them try to navigate the very complex system.

[31:03] Major Changes in the Future

The broader change that’s happening in medicine across the board, specifically in men’s health is the increasing utilization of telehealth, which even amplified during COVID. And there’s also this tendency of men to gravitate towards these direct-to-consumer Men’s Health platforms. And so, the whole face of men’s health care is evolving.

Petar explains that many of the alternative health care delivery systems are not necessarily offering high-quality care. They’re not offering evidence-based, or guidelines-based care.

So we’re seeing an evolution of the current healthcare system to try to meet some of the needs of these men who are embarrassed to talk about what’s going on with them to their doctor. They want to remain anonymous as much as they can. They want their medications delivered to their home and to be seen virtually from the comfort of their own home. And he’s just excited to see how men’s health is going to deliver that care to them in a high-quality and legitimate way. 

One of the things that also drew him to urology is robotic surgery, which over time, has become exceedingly less and less invasive. To the point where people are going home the same day for major abdominal surgeries.

[36:21] Final Words of Wisdom

If he had to do it all over again, Petar would still have chosen to do men’s sexual health urology. He has no regrets doing it and he loves what he does.

Finally, to students or residents thinking about going into this field, his last piece of advice is to look around and go on your rotations. Meet people even outside of your rotation. Do your search and find your tribe of people you feel comfortable around. These are the type of people that you’re going to be around for many years of training, and then in the many years of your career.

'With how much time we spend in medicine focused on careers, we become a certain persona, and part of that is what specialty we chose.' Click To Tweet

You need to make sure those people you’re spending your time with are people that you can get along with and that you’ll be happy spending time with them. Because you’re probably going to spend as much time with them as your own family.


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