25: An Academic Urologist Shares His Thoughts on the Field

Session 25

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

[00:50] Academic Practice

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 available in most community practices. Second, he enjoys working in training residents. He has been practicing for seven years now.

Peter started residency training in general surgery, which at that time most programs would require you to two years of general surgery prior to four years of urology. So he decided during his intern year to do urology, which was his second rotation as an intern and it was he deemed would fit him and his personality rather than general surgery. It took a while to get into a urology program but he kept doing general surgery and did the two required years before switching.

[02:05] A Better Fit to 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 (at least as a resident where they often encountered issues that are extremely serious, extremely acute, and very challenging.) Urology, on the other hand, has a very broad spectrum of different things they dealt with ranging from simple issues to very serious and life-threatening and everything in between, something Dr. Steinberg was looking for.

Secondly, he noticed the personalities of the residents and the attending physicians matched his personality a lot better than a lot of the surgeons in terms of having a healthy work-life balance, good sense of humor, being jovial and collegial. And this speaks to the issues they're dealing with which are a little bit less stressful. He add that because of the nature of some of the problems, you have to deal with them with a little sense of humor with issues relating to people's sex lives and genitals.

As to getting a sense of what community general surgery was, 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 issues like hernia, gall bladder issues, and some serious issues occasionally. But  he saw a different pace as opposed to an academic center.

Dr. Steinberg stresses that the Venn diagram of overlap between training and practice can be very small depending on what you're interested in doing. He reminds med students and residents that 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 and doing quick procedures with not a lot of complexity.

[05:49] Traits Leading to a Good Urologist

Dr. Steinberg describes Urology as 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 mentality where you're going to be dealing with people longitudinally where you have to get used to having rapport with people, building some trust, and dealing with them over time.

For instance, Dr. Steinberg does a lot of kidney stone work and a lot of nephrology where he deals with people with tinkering medications and their diet where he has to deal with them over the years. He also deals with them 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 and dealing with them over time or they get another urologic problem over time.

Dr. Steinberg says you need to have a little bit of the longitudinal kind of primary care doctor personality and interest in dealing with the medical side of things but also some of the traits that go with being a surgeon in terms of being decisive and knowing when to and when not to operate on people.

Other traits he thinks would make a good urologist is having a good sense of humor that helps with everything in life, being loose, and being used to hearing things like sex lives and how they go to the bathroom. You need to have some degree of not taking things too seriously otherwise you'll have a hard time dealing with just how people describe their chief complaints and histories.

[08:40] Types of Cases, Typical Day, and Calls

Dr. Steinberg describes his mix of cases and patients with about two-thirds of his practice consisting of kidney stones, falling into general urology. The third is straight up general urology, encompassing issues like those having trouble urinating, 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 testicle such as trouble with the foreskin, pain in the genitals, pain and swelling of the testicles, etc. This is the big bulk of 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. As with Dr. Steinberg, he will have a day consisting of office in the morning, a two to three-hour procedure in the afternoon, or in the office all day seeing a mix off new and returning patients and doing some office-based procedures such as stethoscopy or endoscopic checks of the bladder, vasectomies, biopsies of the prostate under ultrasounds. 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 of those in a day.

He sees around 1,500 patients a year and he does around 150-200 operations. He is a referral provider for other people sending in complex things. So it's a small percentage of the people he sees end up getting operated by him.

In terms of taking calls, Dr. Steinberg describes urology calls not to be horrendous. Most of the issues can be dealt with by emergency room physicians or some basic techniques known to other types of providers. In the group he's in, there are five of them taking calls so they are on call basically one week night and they have a larger group of people that take calls over the weekends so they're on call one weekend a quarter, a little less on the weekend than an average person but it really depends on the group size. Peter thinks most times, urologists are on call. If they do get called, they can have things the can deal with over the phone or things they need to be dealt with urgently or straightforward, as opposed to calls in other fields where calls deal with a lot of operations and doing a lot of stuff in the middle of the night. Basically, calls are very heavily phone, triage-based.

[14:37] Work-Life Balance

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 meetings each year, about three to four of them which allow him to get away from work. Their national meeting is usually around May and regional meeting in the Fall. the subspecialty meeting is close to the end of year. 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 meetings which he finds relaxing.

During his free time, he does things he enjoys such as skiing, sailing, and surfing. And living in Boston, he works around a lot.

[15:50] Residency Training Path and Competitiveness in Matching

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

In terms of matching, Dr. Steinberg describes Urology as a very competitive field to get into. There are a couple of things unique about it. One, it has its own separate match and not part of the conventional match. It's one of the early match programs such as ophthalmology and plastic surgery and it's run by the American Urological Association. It's highly sought after now because of the work-life balance a lot of people find within the field. A typical urology applicant nowadays has a strong resume in terms of academic achievement in college and the basic science part of medical school. They have good marks on rotations like surgery and medicine and 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 doing an underserved clinic or traveling to the third world to bolster their resume.

Additionally, something very critical in matching into urology is doing away rotations at programs you're highly interested in matching in and performing well there. Most of these are pretty standard in terms of competitive programs having students come from other medical schools and you function as a sub-I on the service. Generally speaking, you're graded on a couple of things such as your performance day-to-day. Most programs make you give a big sum-up talk at the end of your rotation, a big area you're graded upon. Dr. Steinberg thinks most 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.

[20:03] Bias Towards Osteopathic Physicians

This was a big debate about a decade ago, having concern at the higher levels of organized urology about things like extending board-certification to osteopaths. But his has mellowed and there's been much more embracing of osteopaths within the field. There are some osteopath-specific programs out there such as Michigan State. Peter is not seeing any huge bias towards it but he thinks most osteopaths still currently congregate towards a couple of the more osteopath-specific training programs. This may improve in the future but for the time being, a lot of osteopaths going into the field 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 and PCOM (Philadelphia College of Osteopathic Medicine) was around so they were used to having osteopathic colleagues on rotations and as residents and faculty because there were so many PCOM graduates in Philly. He remembers the best anesthesia resident he ever worked with was a PCOM grad. So Dr. Steinberg thinks it's still somewhat regionalized given the fact that osteopathic schools tend to be regionalized. So a urology training in Philadelphia or Michigan is still that way to some extent.

[22:25] Message to Primary Care Physicians

Dr. Steinberg has actually been waiting for this to be asked for three years now. He sees three things that are routinely issues and backed up by the data people have acquired. He sees tremendous reluctance on the part of house officers and even attending physicians in practice to not do a genitourinary exam, a pelvic exam, or a rectal exam. They teach this to the second year medical students at Harvard where they do a half-day session on these skills. He finds it remarkable how often they get consulted and there's no documented genitourinary exam in the chart. The same goes with outpatient referrals.

He emphasizes that you have to learn how to do those exams as 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 some basic skills in medical school and residency to put a Foley catheter in. You're not always going to have a urologist close by where you're going to be. It's not that complicated. There are times when you need a urologist to help you do it and there are certain things to look for there 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, working up an elevated PSA, a urinary tract infection, and just the basic things. If you're confused about the basic work up, 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. Dr. Steinberg recommends seeking the guidelines from some of these subspecialty areas to get some basic information on evaluation of hematuria, kidney stones, etc. So just know some basic things about what imaging tests you need, doing a good exam, and being able to put a Foley catheter in would go a long way and this would put you at the cream of the crop of internists in terms of dealing with these things.

[25:10] Working with Other Specialties and Subspecialty Opportunities

Dr. Steinberg is a bit unique in a way that he does a lot of complex kidney stone work so he deals with interventional radiologists and this is true for a lot of radiologists doing a bigger practice. Interventional radiology and radiology in general is going to be one area where you work very closely together.

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.

Moreover, fellowship opportunities are rampant within Urology including oncology, endourology, minimally invasive surgery and robotics, pediatrics (a separate board-certification now), female urology and incontinence, voiding dysfunction in men, reconstructive urology (urethral stricture disease), sexual dysfunction, andrology, male infertility and doing vasectomy reversal. Obviously, there is a variety of areas of subspecialization you can pursue.

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 residency training, there is tremendous ability to carve out your niche in the team like you could be the incontinence person in the group or the kidney stone, etc.

Dr. Steinberg explains that gender re-assignment is extremely subspecialized and that most of the male to female full reassignment is 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 that tends to be pretty heavily done by plastic surgeons. There are a few urologists involved in that and if you did want to get into that as a urologist, there is tremendous opportunity out there to be involved with that. Peter thinks it's a very under-served area without a lot of people with good skills. He adds that If you did reconstructive fellowship, you will immediately have a two-year wait list for operative patients if you went out into practice.

[29:05] Special Opportunities

Dr. Steinberg says there are ample opportunities to do things that are not direct patient care such as research in an academic setting or in any industry. There are tons of innovation within urology especially devices like for kidney stone, robotic surgery, incontinence surgery and pharmacologic work on things like the bladder, prostate, and in oncology.

There are tremendous opportunities in hospital administration and 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 to work with investment firms to figure out would certain areas be good investments. You can be a typical healthcare consultant. You can also do medical legal work as an expert witness.

[30:30] Most and Least Liked about the Job and Major Changes in the Future

What he likes most about his job is taking people who are feeling really unwell and getting them back to normal health. The least think he likes about being a physician in general is a lot of metrics in bureaucracy is making daily patient care more challenging. The focus of large healthcare organizations is getting slightly off-track from patient care and physician empowerment. Although Peter thinks the pendulum is going to swing the other way a little bit on this but it's his biggest gripe.

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. Another big thing is the change in how care is delivered within the specialty in terms of people becoming employed by hospitals, larger groups forming, fewer small, private practices, and the consolidation of physicians together.

If he had to do it all over again, Dr. Steinberg would still have chosen Urology as the field suits him very well and he thinks it's an excellent choice for people with his personality and interests.

[33:50] Final Words of Wisdom

Dr. Steinberg leaves us with an advice that if this something you want to do, you will find a way to get into it. If you've got some deficiencies in your application in some ways, it's very easy to make up for problems with low board scores or some bad rotations. You can make up with it 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, by being affable, and by being a good team player, it can be achieved if that's what you really want to do.

Links:

MedEd Media Network

UROPAC

American Urological Association