Transforming Lives in Transgender Surgeries as a Urologist

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SS 187: Transforming Lives in Transgender Surgeries as a Urologist

Session 187

Dr. James Hotaling is an academic urologist who specializes in men’s health and transgender surgeries. We bust some myths during our discussion of his experiences.

For more podcast resources to help you with your medical school journey and beyond, check out Meded Media. If you like the Specialty Stories and want to learn more about other specialties, go check out They’re very similar to Specialty Stories, but they’re being done live. We’re also covering cases which we don’t get to do here on the podcast.

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

[01:09] Interest in Urology

Although James’ parents are both physicians, they didn’t really force him to go into medicine. Then his mom passed away when he was 17. His mom was an adolescent psychiatrist, and his dad was a Navy combat pilot and then became a pediatric ENT surgeon.

James went to Dartmouth for college. He double-majored in physical chemistry and history and toyed with the idea of getting a PhD or MD/PhD. He did a full year of research and orthopedic surgery, thought about neurosurgery and ENT, and ended up doing urology having mentors who were urologists.

[02:47] The Biggest Myths or Misconceptions Around Urology

What a lot of people don’t know is that they perform a huge range of surgeries. They do diverse procedures from as simple as a vasectomy or a cystoscopy, to eight-hour transgender surgeries and complex robotic surgeries to microsurgical stuff. And a lot of medical students don’t really spend time with them because they never realized the scope of what they could possibly do in the specialty.

[04:00] Traits that Lead to Being a Good Urologist Specializing in Transgender Surgery and Men’s Sexual Health

James points out that you have to have a passion for it since patients can pick that up pretty quickly. You have to learn how to navigate that in a way that isn’t going to make people uncomfortable. Whether that’s with humor or realizing what the dynamics are with the partner if they’re there for a male fertility evaluation or erectile dysfunction.

'You have to have high emotional intelligence and be good with people skills because these are really sensitive issues.'Click To Tweet

James stresses the need for empathy when dealing with these patients, especially those within the trans community. Having that emotional connection and the capacity to understand patients going through whatever they’re going through is a big component.

[05:50] Typical Day

His typical week would be – Mondays are for academic stuff. Tuesdays, he’s either operating or doing academic staff, which is basically a bunch of zoom meetings and research. Wednesdays, he has a really big clinic of around 40 patients. Then he has a couple of nurse practitioners and a fellow who helps him. Thursday, he does operations And then Fridays, he does academic and administrative stuff with a lot of meetings.

For those students interested in physiology and anatomy but don’t trust their hands to become a surgeon, James says a lot of it can be taught.

One of his mentors used to tell them that residents can be broken down into three categories: the top 5% are the super technically gifted. They’d have no training and they’d end up being really good. The second group would be the vast majority of people. They have some aptitude. You can teach them and they will get progressively better. And the third group is a small percentage of those who just wouldn’t work out.

'One of the really good predictors of being a successful resident is being a fairly competitive athlete who did team sports.'Click To Tweet

[08:39] Taking Calls and Life Outside of the Hospital

James takes calls one to two weeks every six months. They have fellows and a bunch of faculty. In a typical week, he might be in the middle of the night, once or twice. While the rest of the stuff is semi-urgent, where it needs to happen in the next 24 hours.

In terms of life outside of the hospital, James explains it’s a balancing act. His wife is a dermatologist and they have a seven-year-old and a nine-year old. He used to do Ironman triathlons ,and now, he does a lot of backcountry skiing and mountain biking. Or he takes his kids backpacking with llamas once or twice a year.

That being said, it’s hard to balance things. But he learned to set time blocks for the things he needs to do.

[11:55] What Makes a Good Fellow

James describes a good fellow as someone who gets along well with people. Because they’re going to be with this person five days a week for a year or two. And if they have some major personality issue, that would come out pretty quickly.

He also likes someone who’s fun to be around, humble, hard-working, good with patients, and has good tactical ability, which can be taught. Some fellows want to just crank through clinical stuff, and others want to try to get NIH grants. So it’s certainly not one size fits all. He adds that a good fellow must also be coachable. There’s a lot of surgery, and at some point, it becomes muscle memory.

[13:13] The Training Path

You do three years of clinical and a year of research. James did research. In fact, their urology residency is among the most competitive specialties. And then residency is five or six years, although most of the programs are five years. The six-year programs usually have research. Following residency is fellowship. Most of the fellowships are one to two years. Some of the oncology fellowships are three years. 

If you just want to go through and go into private practice, it’s five years after med school. But if you wanted to do a fellowship, it’s anywhere from you six to eight years after med school.

James did male infertility for his subspecialty fellowship training. Other fellowship training include sexual medicine, reconstructive urology, female urology, oncology, pediatrics, and minimally invasive or robotic.

[16:35] Overcoming Bias Against the DOs

James explains DO students now go through the same match. And to be competitive, they have to be doing some research. The biggest problem that they see with med students trying to match into urology is they don’t have any urologists at their home program, which makes it hard.

James adds that a strong letter of recommendation is helpful considering that the subspecialty is very small. And so, you’re going to get a stronger letter if you worked with somebody for two years, and that letter carries a tremendous amount of weight. It’s a small community where phone calls can be made on the back-end between programs asking about the med students.

'From our standpoint, it's a big investment. These programs are taking two to four residents a year. So if you have one person who has a major issue, then that's a big problem.'Click To Tweet

[17:46] Message to Future Primary Care Physicians

James recommends watching those 30-minute videos of their surgeries they do. Understand the anatomy and what you’re dealing with because it’s very confusing for people to watch where things actually are.

Also, try to get a better understanding of things such as even the question of whether these trans women still have their prostate because James explains that they do. They could get prostate cancer, and he’s sure that at some point, some of them will.

And so, there are big issues that they haven’t totally figured out yet. Ultimately, it’s important to just understand the anatomy because it’s a big part of it.

[19:06] Other Specialties They Work the Closest With

Other specialties they work the closest with reproductive endocrinologists and OB-GYNs doing female infertility.

[19:50] What He Wished He Knew Before

James wished he had a much better understanding of the scope of it. Unfortunately, in our current training system, residents don’t really understand.

Also, looking at it on the other side being a faculty and an attending for eight years now. James explains that sometimes, there could be some complications and bad stuff happens no matter what you do. And so, you have to get to a point where you can learn what you can, deal with it appropriately, and move on, otherwise it can be really devastating.

[21:20] The Most and Least Liked Things

James explains how it’s much different on the male sexual health and reproductive stuff. The research stuff is fascinating. It has huge implications for the human race and health and other things. And they’re just getting to the point where they can treat some of it. They’re not there yet, but they’re getting closer on that with medical therapeutics.

On the surgical side, there’s microsurgery, which is suture finer than a human hair under the microscope. So it’s really delicate, intricate, and the end-product is a baby. And he finds it very rewarding to see patients sending him baby pictures.

On the transgender surgery side, he loves seeing how happy patients are once the dust settles, so to speak. So far, he hasn’t had a single patient they’ve done the surgery on who came back to say they regretted having the surgery.

He adds that they actually follow the standardized criteria that people have to meet to have surgery. So it’s not like people are coming in on a last minute decision. He admits though that he had talked to other surgeons who have had patients who’ve had regret, but he hasn’t experienced this personally.

On the flip side, what he likes the least is that his patients can be very demanding and they may have a lot of high expectations. For instance, when you are having elective surgery, you don’t tolerate anything going wrong and things very rarely go wrong. But things occasionally do. So that can be the hardest part for them, which is managing that aspect.

[25:07] Major Changes Coming to the Field

In the transgender space, the only big change could be depending on what happens politically. As of now, insurance is not covering those surgeries largely. And that could change, and that would have a drastic impact on their ability to do the surgery. James thinks that’s unlikely but it could be a possibility.

[26:09] Final Words of Wisdom

If he had to do it all over again, James says he would still have chosen the same specialty. But that being said, he’s also interested in the entrepreneurial side of things so he could have also been a serial entrepreneur on the side.

That being said, he enjoys taking care of patients. But the most rewarding thing for him is being able to work with fellows and residents, and even med students. And to see people who aren’t very good at something become really good at something is very rewarding.

Finally, to those who might be interested in urology, James recommends to go seek out somebody who could mentor you. Reach out to people, connect with people, develop relationships, and see where things go.


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