Selecting a Urology Residency Program: What Really Matters?

When I was applying for urology residency years ago, UrologyMatch.com served as a valuable resource in my search for the “right” residency program. This website has comprehensive program reviews and helpful program director surveys on residency training.  However, what I found most interesting is the anonymous forum as it often captures prospective applicants, residents, and even faculty relaying important program information, interview experiences, and the “inside-scoop” on residency programs.

I still browse the Urology Match forums several times a year and have noticed that many forum threads make some of the following statements:

“____________ is a top ten residency training programs” OR

“____________ is a top-tier training program” OR

“The residents at ____________ have great case logs/experiences.” OR

“The residents at ____________ have great autonomy.” OR…

You get the picture. The mostly anonymous nature of the Urology Match forums makes it difficult to contextualize and validate the basis for some of these comments. In fact, the methodology utilized by oft-quoted rankings of urology programs such as the US News and World Report have been highly scrutinized and have been shown to be arbitrary, unreliable, and flawed.[1] More importantly, subjective comments such as the ones above really make me question what criteria prospective residency applicants currently utilize when deciding how to rank programs prior to the Match.

I remember quite vividly the stressful process I undertook years ago when creating my rank list. Reflecting on my experience, I believe that a fair number of medical students currently face the same difficulty in ranking programs. Ultimately, the majority of programs offer more than adequate training to become a well-rounded urologist, and the programs themselves appear similar on interview day, as it is often difficult to find any “weaknesses.”

I am writing this editorial in an effort to help objectify the stressful process of assessing a residency program. Certainly, many of the criteria that I have outlined below come with an admitted bias from my end, but I have tried to describe my reasoning for each point and hope to bring some clarity when deciding on your rank list. I would also like to thank many of my colleagues around the country from various programs who have helped me in formulating my thoughts. Lastly, I hope the reader understands that I have considered the points below with the understanding that the most important goal to achieve following residency training is to become a qualified, capable, and independently functional general urologist.

 The Importance of ‘Autonomy’ and ‘Independence’

In contrast to many of my mentors who trained over several decades ago, current ACGME standards strongly emphasize the importance of resident supervision in the training process.[2] Nevertheless, the best way to know if one could practice as an independent urologist following residency training is to be given the opportunity to make independent decisions during residency training. This concept seems simple enough as many, if not all, programs claim to offer such autonomy. So, how does a medical student distinguish these qualities in a training program on interview day?

 In general, residency programs that have a county hospital or a VA hospital rotation probably offer the best chance for residents to make independent decisions in clinic and in the operating room. Alternatively, some residency programs may have rotations with specific attendings who allow chief residents to “take” junior residents through difficult cases on a consistent basis. From my personal experience, I was best able to gauge my abilities when given the opportunity to perform a radical cystectomy and urinary diversion with a junior resident assisting me (rather than when I was assisted by an attending physician). Expecting each accredited residency program to offer such experiences is probably unrealistic and maybe even unfair, but I believe assessing for such opportunities during the interview process is completely reasonable and extremely helpful as medical students “stratify” programs on their rank list.  

Robotics During Residency: What Counts?

Robotic surgery within the field of urology is here to stay. Similar to the dissemination of ureteroscopy over twenty years ago, robotic procedures for indications such as “straight-forward” prostatectomy or partial nephrectomy will likely shift from the hands of fellowship-trained specialists to the general urologist. As a result, obtaining adequate training in all components of robotic procedures will probably become mandatory during residency, as it currently is not.[3]

All residency programs that have embraced robotics training for residents offer case exposure during the chief year. However, in order to perform robotics cases independently as a general urologist out of training, immersion with robotics for more than one year is probably necessary. As programs become aware of this need, several institutions have already established robotics curricula with graduated responsibility by resident training year in order for residents to gain the necessary skills prior to the completion of training.[4] As a take-home point, residency programs that offer only chief resident-level immersion for robotics will probably become increasingly inadequate. 

How Important is Geography?

In my discussions with colleagues around the country, it is evident that residents from both small and large urban programs obtain similar experiences in terms of clinical and operative experience. Although some differences may exist in types of patients seen (e.g. urban programs may treat many penetrating traumas while rural programs manage more blunt traumas), clinical and surgical competency for most programs at the completion of training is probably comparable. Medical students should consider the geographic location of programs based on individual preferences, the preferences of spouses/significant others, or the presence of any nearby family/friends for an adequate support system.

Prospective candidates should note that many residency graduates practice near the place of residency training for a variety of reasons. However, obtaining a private practice job in a metropolitan city or surrounding suburb far from the location of residency training may be challenging and it is important to note that “local” residents from programs in surrounding areas may have an “inside-edge” to these opportunities. After all, residents from nearby programs often work with faculty members that have established referral patterns from local urologists and will thus be willing to support their residents to land these jobs. On the other hand, residents interested in academics probably do not face similar hurdles as many urology departments are happy to interview candidates based on the input of fellowship mentors, the fellowship program completed, and academic characteristics of the job candidate (e.g. strength of CV). 

Mentorship 

Many medical students interested in academics searching for “top” programs may look for academic leaders who are “well-known” (e.g. “Program A” has renowned urologists in oncology, female urology, etc.). However, it is probably more important to assess exposure to all fields of urology rather than assess the influence of any individual faculty within residency programs (e.g. Are there faculty in Female urology? Infertility? Endourology?). Sufficient exposure to the various fields within urology is probably more valuable since it provides the best opportunity for a comprehensive experience necessary to be a fully functioning general urologist.  Also, fame does not necessarily translate into good mentorship. One should be careful in selecting a program based solely on “reputation,” as goals following training are different for each individual.

Residents who are interested in pursuing additional training will absolutely benefit from faculty mentorship to assist in obtaining fellowship positions, and renowned faculty may influence a candidate’s “chances” of obtaining desirable fellowship training. However, most residency programs have faculty mentors who will support a resident’s desire to pursue fellowship training even if the chosen field is different from that of the faculty mentor! Additionally, the majority fellowship program directors seem to respect the enthusiastic backing from a resident’s faculty, irrespective of the area of subspecialization of the supporting faculty member.

A Word About Fellows…

Fellowship training within urology is becoming highly prevalent, as many programs have recently initiated accredited or non-accredited fellowships in oncology, robotics, reconstruction, andrology, and infertility. Although some candidates worry that the presence of fellows may dilute the clinical experience for residents, this belief may be an over-generalization in many instances. While the presence of fellows may result in fewer cases for residents in certain programs, the presence of fellowship programs may otherwise indicate advanced exposure to certain disease processes other programs without fellowships may not experience. Bottom line: it is important to have each program clearly delineate the working relationship between fellows and residents during the medical student’s interview day.

Looking to the Future

It is important to note that many of my recommendations regarding residency programs are in the context of providing overall training to become a qualified, independently functional general urologist. However, certain medical students lean strongly or whole-heartedly towards a career in academics. As a general rule of thumb, academic faculty positions at the overwhelming majority of programs require fellowship training and are difficult to obtain directly out of residency. For residency candidates that may be interested or have not yet decided to pursue a career in academics, search for residency programs that require residents to contribute to research projects during residency. Programs with such requirements often have established research curricula that greatly assist residents in “building a CV” prior to applying for fellowships. Other programs that simply remark, “You can be as busy as you want to be from a research standpoint…” usually do not have established research opportunities for residents. While participation in research during residency may sound tedious and unnecessary to some, it nevertheless remains a requirement for many fellowships following residency training.  

The Importance of “Second Looks”

While some of the above recommendations may help narrow the field, it still may be difficult to draw strong conclusions regarding a given program from any close observations made during residency candidate interviews. After all, programs and applicants alike put their respective “best foot forward” on the day of the interview and any program “weaknesses” are rarely discussed at length. Sometimes, applicants may even feel that what they are hearing/seeing on interview day sounds “too good to be true.” I generally feel that the role of program second looks should be reserved for candidates to confirm any perceptions made on interview day. Alternatively, applicants could use the second look to clarify any doubts they may have had regarding a program’s assertions during formal interviews. However, I must also caution applicants to remember that while you as an applicant may “bump up or down” a program after closer inspection, the program may choose to do the same to you!

I hope my reflections and recommendations serve as a guide to ranking programs as prospective residency candidates near submission of their rank list.

In Summary

• Assess the graduating residents’ “readiness” for independent practice with carefully crafted questions. Simply asking if they “feel ready” is not good enough. Try to gauge their independence and autonomy, especially in mentoring and teaching junior residents. Make sure you ask where graduates go, whether the program discourages private practice jobs, etc.
• Robotics is quickly becoming mainstream and should not require fellowship training for basic competence. Therefore, programs that don’t offer adequate exposure throughout training may lack in adequately preparing you.
• While it may be worth moving wherever “the best training program” is, consider where you may want to be once you have graduated… Geography might be important.
• “Renowned” faculty does not equal good mentorship nor does it guarantee adequate hands-on training.
• Fellows aren’t necessarily a negative – you may find you will learn more from someone fresh out of residency and potentially have exposure to more complex cases
• “Second looks” go both ways.
• Be sure you feel like you fit in.

 Good luck!

 

 

References

1.         Kutikov, A., et al., Academic ranking score: a publication-based reproducible metric of thought leadership in urology. Eur Urol, 2012. 61(3): p. 435-9.

2.         Whalen, T. and G. Wendel. New Supervision Standards: Discussion and Justification. 2011  April 26, 2014]; Available from: http://visibl.es/WA7Zpz.

3.         Daskivich, T.J. Case recording of robotic and urologic ultrasound cases. 2013; Available from: http://visibl.es/1qy2cxb.

4.         Tausch, T.J., et al., Content and construct validation of a robotic surgery curriculum using an electromagnetic instrument tracker. J Urol, 2012. 188(3): p. 919-23. 

Jay Simhan, MD (@JSimhan)

Director of Urologic Trauma, Reconstruction and Prosthetics for the Fox Chase/Einstein Urologic Institute and an Assistant Professor of Urology at the Fox Chase Cancer Center.