An Academic Urologist Shares His Thoughts on the Field

Session 25

Academic Urology is a mix of medicine and surgery. Today Dr. Peter Steinberg discusses what drew him to the specialty, whether you and your personality would mesh with this field, and what you can do to be a competitive applicant given that urology is one of the more competitive fields out there.

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

[00:50] Choosing Academic Urology

Dr. Steinberg chose academic practice over a typical community practice for two reason. First, he wants to have a more sub-specialized focus in his practice than what is available in most community practices. Second, he enjoys working on training residents. He has been practicing for seven years now.

Peter started residency training in general surgery. At that time most programs would require you to two years of general surgery prior to four years of urology. He decided during his intern year to do urology, which was his second rotation as an intern. He deemed that urology would fit him and his personality better than general surgery.

Urology was a better fit for him and his personality than general surgery.Click To Tweet

It took him a while to get into a urology program, but he kept doing general surgery, and he finished the two required years before switching.

[02:05] Urology Fits His Personality

Dr. Steinberg cites a few things that make him fit to be in urology. First, the types of problems you encounter in urology involve a greater variety of issues compared to other fields like general surgery. Urologists see a very broad spectrum of different problems, ranging from simple issues to very serious and life-threatening.

Urologists see a very broad spectrum of different problems, ranging from simple issues to very serious and life-threatening.Click To Tweet

Secondly, he noticed the personalities of the urology residents and the attending physicians matched his personality a lot better than a lot of the surgeons. They had the healthy work-life balance he wanted, they had a good sense of humor, and they were jovial and collegial. And this reflect the issues they’re dealing with, which are a little bit less stressful. You need to have a little sense of humor when relating to people’s sex lives and genitals.

Community Practice vs Academic Medicine

Dr. Steinberg actually did a community general surgery rotation towards the end of his second year as a trainee, where he spent three to four months at a community hospital. They dealt with hernias, gall bladder issues, and some serious issues occasionally. But he saw a different pace than in an academic center.

The Venn diagram of overlap between training and practice can be very small depending on what you’re interested in doing. In whatever job or field you’re in, you can get it. It may not be exactly what you want, but whatever you want to construct in the medical field, someone somewhere will let you practice it. So seeing the community general practice was eye-opening for Peter, where they seemed much less stressed, doing quick procedures with not a lot of complexity.

The Venn diagram of overlap between training and practice as a physician can be very small depending on what you're interested in doing.Click To Tweet

[05:49] Traits That Make a Good Urologist

Urology is a mix of medicine and surgery, like EENT (Eye, Ears, Nose, & Throat), and that you need to have a couple of different aspects to your personality. You need some of that surgeon mentality of seeing problems that can be fixed and dealing with them rapidly and decisively. You also need a little bit of that family-practice doctor type of mentality where you’re going to be dealing with people longitudinally. Ultimately, you need to be able to build rapport with people, building some trust, and deal with your patients over time.

Being a urologist requires a bit of a surgeon's mentality and a bit of a family doctor's mentality, too.Click To Tweet

For instance, Dr. Steinberg does a lot of kidney-stone work and a lot of nephrology. In these cases, he may need to work with a patient, adjusting their medications and their diet over the course of years. He also deals with patients who have acute and surgical issues. You can have a multi-year relationship with someone where you go from doing some basic things to operating on them. Or you deal with patients who develop multiple urological problems over time.

Other traits he thinks would make a good urologist is having a good sense of humor. That helps with everything in life. You need to get used to hearing about things like sex lives and how they go to the bathroom. You need to have some degree of not taking things too seriously as a urologist. Otherwise, you’ll have a hard time dealing with how people describe their problems.

You can't always be taking things too seriously as a urologist.Click To Tweet

[08:40] A Day in the Life of a Urologist: Types of Cases

Two-thirds of Dr. Steinberg’s practice consists of kidney stones. He also deals with other issues in general urology, including patients having trouble with urination, blood in the urine, urinary tract infections, prostate issues, and other urinary complaints. He also deals with pain or complaints related to the penis and the testicles, such as trouble with the foreskin, pain in the genitals, pain and swelling of the testicles, etc. This is general urology.

A typical week for a general urologist is somewhere between two and four days in the office and then one and two OR days. For Dr. Steinberg, sometimes he will have a day consisting of office in the morning and then a two- to three-hour procedure in the afternoon.

Sometimes he will be in the office all day seeing a mix of new and returning patients and doing some office-based procedures, such as endoscopic checks of the bladder, vasectomies, or biopsies of the prostate under ultrasound. Some days he will be in the OR all day doing 30-60-minute outpatient kidney-stone procedures and other endoscopic procedures, where he will do five or six in a day.

He sees around 1,500 patients and does 150-200 operations per year. Only a small percentage of the people he sees ends up getting operated on by him.

Taking Call as a Urologist

In terms of taking call, Dr. Steinberg describes urology not to be horrendous. Most of the issues can be dealt with by emergency room physicians or with basic techniques known to other types of providers. In the group he’s in, there are five of them taking call, so they are on call basically one weeknight each week. They have a larger group of people who take call over the weekends, so they’re on call one weekend a quarter.

Often when urologists do get called, it can be dealt with over the phone. This is opposed to call in other fields, where you can end up doing a lot more operations in the middle of the night. Basically, taking call as a urologist is very phone-based.

When you're taking call as a urologist, issues can usually be dealt with over the phone. This is opposed to other fields, where you can end up doing a lot more operations in the middle of the night. Click To Tweet

[14:37] Work-Life Balance and Lifestyle as a Urologist

Dr. Steinberg says he has a good work-life balance. First, he takes all his vacations. Secondly, he enjoys going to medical meetings and he has found a good way to attend a variety of different conferences each year, about three to four of them, which allow him to get away from work. Their national meeting is usually around May and their regional meeting is in the Fall. His subspecialty meeting is close to the end of the year.

Dr. Steinberg says he has a good work-life balance as a urologist.Click To Tweet

He likes to ski, so he also finds a ski meeting he goes to in the winter. So on top of going on vacation, he also gets away from work to go to these events, which he finds relaxing. During his free time, he does things he enjoys, such as skiing, sailing, and surfing. So he is really satisfied with his lifestyle as a urologist.

[15:50] Residency Training and Early Match Programs for Urology

Urology residencies have increasingly become five-year programs, which now include one year of general surgery internship and then four dedicated years of urology. More urologists go to fellowship now because a lot of times, they’re not getting all the skills they want in a particular subspecialty during their residency training.

Urology is a very competitive field to get into. There are a couple of things unique about it. One, it has its own separate match, and it’s not part of the conventional match. It’s one of the early match programs, along with as ophthalmology and plastic surgery, and it’s run by the American Urological Association.

Competitiveness of Matching into Urology Residency

Many people want to match into urology now because of the lifestyle and work-life balance. A typical urology applicant nowadays has a strong resume in terms of academic achievement in college and the basic sciences in part of medical school. They have good marks on rotations like surgery and medicine, and they often get very good board scores, which is often the screening tool that programs use to pick out who they’re going to interview. A lot of people have research experience or some other type of unique clinical experience, such as working in an underserved clinic or traveling to the third world to bolster their resume.

Urology is a very competitive field to get into.Click To Tweet

Something very critical in matching into urology is doing away rotations at programs you’re highly interested in matching into and performing well there. You function as a sub-I (sub-intern) on the service. Your grades largely will depend on your performance from day to day. Most programs also make you give a big sum-up talk at the end of your rotation, and this talk also affects your grades. Most residency programs pretty heavily weigh people’s performance on those types of away rotations as far as their rank list goes.

Lastly, letters of recommendation go a very long way in this field because it’s a small field. There are only so many training programs.

Letters of recommendation go a very long way in urology because it's a small field.Click To Tweet

[20:03] Bias Against Osteopathic Physicians in Urology

This was a big debate about a decade ago. Some people were concerned about extending board-certification to osteopaths. But his has mellowed out, and there’s been much more embracing of osteopaths within the field. There are some osteopath-specific programs out there such as Michigan State.

Most osteopaths still currently congregate toward a couple of the more osteopath-specific training programs. This may improve in the future, but for the time being, a lot of DOs going into urology end up in the more osteopath-oriented residency programs.

Although Peter doesn’t have osteopathic physicians as colleagues at their academic center, he thinks this is somewhat regionalized. He went to medical school in Philadelphia, near PCOM (Philadelphia College of Osteopathic Medicine). So they had plenty of osteopathic colleagues there. He remembers the best anesthesia resident he ever worked with was a PCOM grad.

Is there a bias against DOs in urology?Click To Tweet

So in different areas of the country, you might see different attitudes toward osteopathic physicians. If there is an osteopathic medical school in the area producing a lot of graduates, then people in the area are seeing the quality graduates and becoming more accustomed and accepting of DOs.

[22:25] Message to Primary Care Physicians from a Urologist

Dr. Steinberg sees tremendous reluctance on the part of some primary care physicians to do a genitourinary exam, a pelvic exam, or a rectal exam. Sometimes these skills are only taught very briefly in medical school. He finds it remarkable how often they get consulted and there’s no documented genitourinary exam in the chart.

He emphasizes that you have to learn how to do those exams. They’re not that complicated. In fact, any urologist would be happy to show you how to do these things if you don’t know how.

Secondly, Dr. Steinberg says that people need to learn the basic skills in medical school and residency to put a Foley catheter in. You’re not always going to have a urologist close by to do it for you. It’s not that complicated. There are times when you need a urologist to help you do it because there are certain things to look for, but it’s a very important basic skill for everyone to learn.

Diagnostically, he thinks it’s almost embarrassing how he feels like people have lost sight of how to do some basic work-ups of common problems we see such as hematuria, kidney stones, elevated PSA, and urinary tract infections. If you’re confused about the basic workup for any of these, especially when it comes to imaging for certain problems, the American Urological Association and other associations have tremendous guidelines on how to deal with basic problems.

So just knowing some basic things about what imaging tests you need, being able to do a good exam, and being able to put a Foley catheter in would go a long way. This would already make you the cream of the crop of internists in terms of dealing with these things.

[25:10] Working with Other Specialties

Dr. Steinberg is a bit unique in a way because he does a lot of complex kidney-stone work. So he deals with interventional radiologists. Interventional radiology and radiology in general is going to be one area you work very closely with if you’re doing this kind of work with kidney stones.

Other specialties a urologist might work with include pathology (if you do a lot of prostate biopsies, prostate cancer, bladder cancer, kidney and testes issues), medical oncology, gynecologic oncology, gynecology, obstetrics, colorectal surgery, nephrology, and pelvic surgery.

Subspecialty Opportunities Within Urology

Fellowship opportunities are rampant within urology. These include oncology, endourology, minimally invasive surgery and robotics, pediatric urology (a separate board-certification now), female urology and incontinence, voiding dysfunction in men, reconstructive urology (urethral stricture disease), sexual dysfunction, andrology, male infertility, and vasectomy reversal.

In addition, if you go into practice and your group is big enough, usually people will tend to subspecialize to some extent. Even with urology, just with the residency training, there is tremendous ability to carve out your niche in the team. You can become the incontinence person in the group or the kidney stone person, and so on.

Subspecializing in Gender Reassignment Surgery

Gender reassignment is extremely subspecialized, and most of the male-to-female full reassignment is actually done by plastic surgeons. Some urologists will do male-to-female surgery because it’s less technically demanding and does not require microvascular or microsurgical skill, but plastic surgeons handle the majority of that work.

Gender reassignment is extremely subspecialized, and most of the male-to-female full reassignment is done by plastic surgeons. Click To Tweet

There are a few urologists involved in it, and if you do want to get into that as a urologist, there is tremendous opportunity out there to be involved with gender reassignment surgery. Peter thinks it’s a very underserved area without a lot of people with good skills. He adds that if you did a reconstructive fellowship, you would immediately have a two-year wait list for operative patients once you went out into practice.

[29:05] Nonclinical Opportunities in Urology

There are ample opportunities to do things as a urologist that are not direct patient care. This includes research in an academic setting or in any industry. There is a ton of innovation within urology, especially with devices like for kidney stones, robotic surgery, incontinence surgery. There is also pharmacologic work on things like the bladder, for prostate, and in oncology.

Tremendous opportunities exist in hospital administration, and there are a lot of leadership opportunities within urology. You can do legislative work and advocacy. They have a political action committee called UROPAC. There’s a congressman in Florida who’s a urologist.

You can also do consulting, working with investment firms to figure out whether certain areas would be good investments. You can be a typical healthcare consultant, and you can also do medical-legal work as an expert witness.

[30:30] What’s the Best and Worst Part of Being a Urologist?

What Dr. Steinberg likes most about his job is taking people who are feeling really unwell and getting them back to normal health.

The thing he likes least about being a physician is all the bureaucracy making daily patient care more challenging. The focus of large healthcare organizations is getting slightly off-track from patient care and physician empowerment. Peter thinks the pendulum is going to swing back the other way a little bit on this, but it’s his biggest gripe presently.

How the Field of Urology Is Changing

Dr. Steinberg thinks we’ve been in a drought for the last five to ten years, and he thinks we’re due for something. He’s not sure where it’s going to be, but he thinks urology is definitely due for something.

Urologists are finding employment more often in hospitals now, and they are forming larger groups. We’re seeing fewer small, private practices, and there is more consolidation of physicians together.

If he had to do it all over again, Dr. Steinberg would still choose urology. The field suits him very well, and he thinks it’s an excellent choice for people with his personality and interests.

If he had to do it all over again, Dr. Steinberg would still choose urology.Click To Tweet

[33:50] Final Words of Wisdom from an Academic Urologist

If urologist is what you want to do, you will find a way to get into it. If you’ve got some deficiencies in your application, it’s very easy to make up for problems with low board scores or some bad rotations.

You can make up for weaknesses very easily with a strong research program, picking a program where you want to go and becoming a known entity there through research and away rotations.

Don’t be discouraged. With some embellishment of your CV, being affable, and being a good team player, it can be achieved if that’s what you really want to do.