1 INTRODUCTION
The goal with writing this article is to help guide medical students, whether they are a 1st, 2nd, 3rd, or 4th year, navigate the entire process of exploring/applying/matching into urology. That path starts from the beginning step of learning “what is urology?” This naturally leads into determining how one goes about getting exposure to the field and understanding the steps of becoming a competitive applicant and giving oneself as an applicant the best chance at matching into residency.
The author has structured this article in an objective manner, but some of the advice contained below reflects the author's own personal opinion. It's important to note that there is no one-size-fits-all approach to matching into urology, there are several ways that have all found success. The path laid out here may not be the path all applicants will, or should, take.
2 LEARNING ABOUT THE FIELD OF UROLOGY
Before determining if urology is the right specialty for an applicant to apply for, it's important to figure out what urology does on a day-to-day basis.
2.1 What they do/a typical day
Urology is a medical and surgical subspecialty that focuses on the treatment of conditions of the male and female genitourinary tract (kidneys, ureters, bladder, and urethra) as well as the male reproductive organs (penis, testes, scrotum, prostate)[
1].
2.2 Subspecialties
To give a better idea of the full breadth of urology, here are some of the subspecialties that comprise the field[
2]:
– Pediatric urology
– Urologic oncology
– Urogynecology and pelvic reconstructive surgery (also known as female pelvic medicine and reconstructive surgery)
– Endourology and stone disease
– Andrology/men's health
– Reconstructive urology
– Minimally invasive (laparoscopic and robotic) surgery
– Gender affirming surgery
– Neurourology and voiding disorders
2.3 Training length
After graduation from medical school, residency training in urology must be completed, which is a minimum of 5 years[
3]. Some programs are 6 years, with one of the years being a research year usually. However, most training programs are currently 5 years in length.
A sample format of a residency program for both 5- and 6-year programs include:
5-year program:
Postgraduate year 1 (PGY1 or Intern): 6 months of nonurology rotations (3 months of general surgery and 3 months of additional surgical training, such as colorectal surgery, pediatric surgery, or surgical oncology) and 6 months of urology rotations.
Post-graduate year 2–5 (PGY2–5): A total of 4 years of various urology rotations (general urology, urologic oncology, pediatric urology, etc.)
6-year program:
A protected research year in addition to the above training may be conducted. This could be done at various points in the training timeline such as PGY-3 or PGY-4 year.
Afterward, should one choose to subspecialize, there are several fellowships available from the subspecialties listed above. These programs vary in length from 1 to 2 years.
2.4 Salaries
While salary can vary depending on academic versus private setting, geography, and a bevy of other factors, urology is generally one of the higher paid specialties. The 2021 Medscape report lists an average salary of $461 000, with other sources listing averages in a similar range, from $460 000 to $518 000[
4]. However, keep in mind these can vary greatly depending on type of practice, region, and other factors.
2.5 Hours/satisfaction
The hours worked as a urologist can also vary. The American Urological Association (AUA) Census can be a great source of evaluating current urologists’ attitudes and trends toward burnout, satisfaction, and so on. From the 2022 AUA Census, the median number of hours worked as a practicing urologist was 55 h per week, with over 35% of respondents indicating they work more than 60 h per week[
5]. The burnout rate, as reported in the AUA Census was 36.7%[
5].
3 EXPLORING UROLOGY
3.1 Shadowing in the clinic and/or operating room (OR)
As a medical student, aside from doing research online about urology (where there are several amazing resources, even on YouTube), there are other ways to get involved in the field to determine whether it is the right fit or not. This experience can also help students get to know urology residents, faculty, and staff at their medical school and serve as a great networking opportunity. Shadowing in the clinic to understand what a urology practice looks like in the outpatient setting is a great start. One of the unique privileges in urology is the patient interactions regarding what can be very sensitive health topics. As the clinic is a large portion of urologic practice, experiencing (and finding that one enjoys) the clinic can be a big steppingstone toward making a decision. It can be very gratifying to see a patient in the clinic, assess and diagnose their concern and then get them to the operating room for definitive treatment. Similarly, shadowing in the operating room can be a great way to help explore whether one enjoys operating in addition to exposure to the various surgical pathologies that urologists treat.
3.2 Research
Working on a research project can be a great way to network with urology residents and faculty at one's medical school program (or other programs), develop your academic interests, and help learn more about the specialty. It is important to remember that this should not feel like a checkbox. While the temptation to feel like that one has to do a certain “thing” to match into residency is certainly a very real feeling, passion for the things one chooses to pursue will shine through. Therefore, even within research, don't feel obligated to focus on a specific type (i.e., clinical, translational). If choosing to pursue a research project, one of the many great takeaways is the opportunity to present that work at conferences, as discussed further below.
3.3 Attending/presenting at conferences
Conferences can be a great way to network with fellow medical students as well as residents, faculty, and others involved in the field and at programs applicants may be interested in. They are also a wonderful avenue to stay abreast about new developments in the field. Traveling to conferences can be expensive, thus there exists a financial hurdle to accessing what is otherwise a fantastic networking opportunity. Some conferences offer discounted and even free registration for medical students. Additionally, some conferences offer travel scholarships/stipends, so be sure to check out the conference websites as well as their respective X accounts prior to registering or attending. If heading to a conference to present research, the faculty/department one is presenting on behalf of may have funds to cover the attendance. While not a guarantee, it is worth at least asking.
Some of these conferences include[
6]:
–American Urological Association Annual Meeting
–American Urological Association Annual Sectional Meetings
–Society of Urologic Oncology Annual Meeting
–Society for Women in Urology (SWIU) Annual Meeting
–Sexual Medicine Society of North America Annual Meeting
–American Society of Clinical Oncology Genitourinary (ASCO GU) Cancers Symposium
–Society of Urodynamics and Female Urology (SUFU) Annual Meeting
–American Society for Reproductive Medicine
4 APPLYING FOR UROLOGY RESIDENCY AS A MEDICAL STUDENT
4.1 How competitive is it?
The urology match rate can vary, but it is generally considered as a very competitive specialty to match into. Data are not as uniformly available versus other surgical subspecialties as the Urology Match operates through its own system versus the National Resident Matching Program (NRMP) for many of the other specialties. However, the AUA does release quite a bit of data post-match every year to give an idea of competitiveness (Table 1)[
7].
4.2 General application timeline
Medical school (MS) 3 year:
Mid-February–May: Apply to away rotations for Summer/early Fall.
MS4 year:
May–September: Home sub-internship (Sub-I), away rotations, (order can vary).
Late September: Application due.
Mid October: Interviews released.
November–mid-December: Interview season.
Early January: Rank list due.
Early February: Match day!
Listed below are some tips for the lead up to the above-listed application process, starting back as a 1st year medical student. This format follows a medical school with more of a traditional curriculum. For medical schools with accelerated preclinical and starting rotations earlier, such as in MS2 year, this may vary.
4.3 Tips for success as a 1st year medical student
o Establish study strategies during preclinicals, the adjustment to medical school is difficult—show oneself grace and know that one does not have to be perfect right off the bat.
o Try to do well in classes, especially should one's medical school have graded preclinicals (Honors/high pass, etc.)
o Consider shadowing various specialties (including urology) one has preliminary interest in, like in a urology clinic or operating room as mentioned above.
o If interested in research, starting on a project is a great way to get involved. Some medical schools have a summer break and offer paid research over that summer—this can be a great option too. Even if it's not in urology, developing research interests are more important than what specialty the project is in.
o Pursue genuine interests—it can be very easy to feel that one needs to follow a set “plan.” Philanthropy, volunteering, recharging during downtime—these are just some of the ways to spend breaks in medical school. Do not feel that there is a necessity to have to do any certain activity just because “it will look good on applications.”
o Adjusting to medical school and building good study habits is most important at this stage.
4.4 Tips for success as a 2nd year medical student
o If in a traditional preclinical curriculum, advice is like 1st year. Traditionally, this is around the time to take the United States Medical Licensing Exam (USMLE) Step 1 exam as well.
o Passing Step 1 is very important. The material learned for this exam (and other medical school exams), will help set the foundation for clinical experiences and eventually Shelf exams and USMLE Step 2.
o If interested in urology, shadowing in the clinic or operating room, and if at a medical school with rotations beginning in this year, rotating on urology will help provide ample exposure to the field.
o Begin or continue research or any other scholarly interests one finds fulfillment in.
o Finding a mentor should one's medical school have a urology home program.
4.5 Tips for success as a 3rd year medical student
o Rotating on the urology service as mentioned above, depending on the school's schedule format.
o Doing well on rotations as evaluations will all go into the Medical Student Performance Evaluation (MSPE) that residency programs will receive.
o Excelling on rotations and shelf exams will help subsequently building a solid foundation for USMLE Step 2 exam preparation.
Even if there are rotations that are not what one is planning to go into, there can be something to be learned from each rotation that will serve one well in training to become a well-rounded physician. Some of the best praise an applicant can receive on an evaluation is “Even though he/she is going into X (specialty of choice here), he/she was an excellent member of the team on X rotation.” That speaks to the type of person someone is and is reflective of someone a residency program wants on their team.
4.6 Tips for success as a 4th year medical student
o Applying for residency.
o Doing well on USMLE Step 2.
o Subinternships and away rotations.
o Getting the overall application ready.
4.7 Step scores
As Step 1 has moved to Pass/Fail, Step 2 will possibly be considered to a greater extent than previously as there are now no Step 1 scores to use. Some programs did previously have Step 1 cutoffs listed (an example cited here had a Step 1 cutoff of >230), and Step 2 cutoffs may also be listed on residency program websites[
8,
9]. While not definitive, 245–250 is generally listed as a “good” Step 2 score. A score below this should not dissuade one from applying, there is no definitive “magic” score.
4.8 Research years
A research year can be an excellent way to strengthen one's application. Consulting with mentors and advisors in deciding whether a research year would be the best fit is important. The timing of such research years can vary. Some students do it between 3rd and 4th year, some may do it after 4th year, either delaying graduation or doing it postgraduation, including if re-applying. There are several great research years at institutions across the country that will provide various opportunities for networking, research, mentorship, and so on.
4.9 Social media
In the era of social media, this has made it easier than ever to connect with and learn about urology residency programs[
10,
11].
Being on Twitter (now X) can be very helpful in gathering information regarding programs as well as updates on deadlines and other aspects of the application process as many of the programs have active social media presence. While it's not a necessity, if used correctly it's a great networking tool. Exercising smart social media etiquette is essential, as no matter how great of a resource it can be, it can also hurt applicants, so be smart about what is posted. One example of a post that can help with showcasing oneself includes highlighting a research presentation at a conference attended (Figure 1). One's social media presence does not have to be all urology, but for the purposes of networking to programs, amplifying involvement in the field in moderation can help.
If an applicant does not have a home urology program, Twitter/X can be a wonderful resource to help in his/her journey toward becoming a urologist[
12,
13]. Programs such as the Michigan Urology Academy can help put him/her in touch with mentors as well[
14].
4.10 Away rotation decision making
4.10.1 How to apply?
This has been changing, but during the author's application year most were through Visiting Student Learning Opportunities (VSLO). Few programs make you apply directly (if any these days). Different programs have different requirements. Check on immunizations/titers needed and take a headshot/photo that will be required for your application. Some medical schools offer a free headshot photo on campus with a photographer, but even done at home with your phone can work just as well.
Some require a letter of recommendation (LOR) and letter of intent/personal statement (PS). Some programs participated in a pilot program for a coordinated away acceptance release date (early/mid-May). This appears to be expanding which will make decisions regarding away selection more streamlined and centralized.
4.10.2 How to choose?
Location, potential LOR writers, type of program (big academic center versus community program versus private hospital), word of mouth from past students/rotators. These can all be things to consider. Geographic area that one prefers is also important. For instance, if one does all their away rotations in a specific geographic distribution, it can help signal to other programs in that area that this applicant may prefer to end up there. Some programs have published information in regards to interview selection, including that either attending medical school in their region or doing an away in that region will get applicants past their initial filter[
15].
4.10.3 How many?
As of the 2023 cycle, this had been opened back up following the restriction from prior cycles following the start of the coronavirus pandemic (one rotation maximum).
4.11 Subinternship/away rotation tips
As one enters the 4th year, it's a busy but exciting time. This is when applicants will complete urology subinternships. If they have a home program, they'll commonly do one rotation with them, as well as away rotations. Generally, students will do around two away rotations. Preparing for these rotations will be important as applicants likely have a strong initial interest in this program to do an away rotation there. Also, they may ask for a LOR following this rotation which will be used for residency application.
For preparation from a urology content standpoint, Hinman's Atlas of Urologic Surgery is extremely helpful[
16]. Some medical schools may allow free online access to the text, which includes a chapter for practically any surgery rotators may find themselves assigned to/scrubbing into. It includes indications for the procedure, positioning, surgical approaches, and associated literature with outcomes, and so on. If in clinic, another great resource is the American Urological Association Medical Student Curriculum and Core Curriculum[
17]. One way to impress on rotations is to show up prepared and these will definitely help accomplish that. For technical skills (i.e., during time in the operating room), the Duke Suture Skills video on YouTube covers many of the types of suturing students may be given the opportunity to do[
18]. Having practiced prior to being given this opportunity in the operating room can also help showcase oneself. Going through this video with a suture pad (a very basic one such as from Amazon is more than sufficient), can pay off huge dividends on rotations.
For financial assistance for away rotations, many programs offer scholarships. These were also advertised on Twitter (now X), and can help offset the financial burden of housing, travel, and other costs that come with completing away rotations (Figure 2).
4.12 Grand rounds presentation
Many times, on subinternships and away rotations, rotators will be asked to present a case or topic they came across during their rotation. This is another excellent chance to showcase oneself and the ability to present a urologic topic saliently and in front of the department you are rotating with. Each program may have different guidelines for their presentation, but adhering to the time limit, finishing the presentation in time to have faculty and/or residents review it, as well as anticipating possible questions one may get following it will set them up for success.
4.13 Signal preferences and tips[19]
Per the American Urological Association, during the author's cycle, applicants were not allowed to signal our home program or places where they did aways (it's assumed you have interest here). This may change in coming years, particularly as previously there were FIVE preference signals, but now is THIRTY. Unofficially, this may serve as a pseudo-application cap, which can help limit the number of applications you have to send out.
In terms of planning where to send signals, there are different strategies to use including places outside the geographic region that one has a specific interest in, “reach” schools, and so on.
4.14 The urology application, how to apply and how it differs from electronic residency application service (ERAS)
4.14.1 Uniform release day
• On one day, all programs are required to get back to applicants.
• Email will either be an Interview Offer, Waitlist, or Rejection.
4.14.2 Single date interview offers
• Unlike other specialties, generally will not receive the option to choose a date.
• Interview offer will say “We would like to offer you an interview on November 17” for example.
• If one can't make that date, he/she will have to drop that date and go on waitlist for the program's other date (no guarantee to get that new date + have dropped your original date). Most places have 2–3 interviews dates/year.
4.14.3 Accepting interview offers
• Will receive all offers on one day and then cannot accept until a subsequent designated day. It was not time sensitive if one responded on that specific day's window. If offered an interview invite, they must have a spot for that applicant no matter what time they accept in the window on that day.
• Can also reject/drop interview offer on that day as well.
4.14.4 “Flush” Day
• Usually that next day, now programs know how many interviewees accepted their offer so they can call people from waitlist.
• On this “Flush Day” if one gets off a waitlist, for example, for December 7, but they already had accepted an interview on December 7, they are allowed to drop the original one and take this new waitlist interview.
• After this Flush Day, one cannot drop interviews anymore. The only way to accept an offer off a waitlist after Flush Day is if they had that date free. If a program calls a week later with a waitlist (WL) offer but an applicant already has an interview on that day, they must decline the WL even if they wanted to attend it instead. This may change in the next few years.
4.14.5 Use ERAS to apply
• Just like most other specialties, same application.
• However, won't register for the NRMP match.
• There is a box on ERAS for your Urology/AUA ID# instead.
• Most programs will send interview invites via ERAS messaging.
4.14.6 Create a urology match account
• Will submit preference signals here (more on this in next slide)
• Will rank programs/create rank list here.
• This will provide applicants with an AUA # that will be needed for ERAS.
4.15 What is contained in the application (PS, hobbies, and so on)
For Urology Match, applicants will still fill out the ERAS application, as mentioned above. In terms of what's in the application itself, it aligns similarly to applications one may have filled out for medical school or college. From year to year, the ERAS application may change, so be on the lookout for any new additions/subtractions from the previous year's application.
The application is separated into three sections:
4.15.1 Application
Briefly, the overall applications generally comprise the following:
General information
Experiences
Research/publications
In the 2023 cycle, there was a unique section for hobbies. This is an aspect of one's application that can be brought up repeatedly, so it may be of benefit to integrate hobbies into the application if there is no standalone section for them to be listed. Programs want to see who an applicant is as a person, not just interests in urology/academic performance.
Documents
Within this group there are three dropdowns of Personal Statement, Letters of Recommendation, and Additional Documents. A benefit of this system is one can individually select what Personal Statements and/or Letters of Recommendation they assign to each school. So, for instance, if Program X allows up to 4 letters to be sent, one can assign four and then if Program Y only takes a maximum of 3, they can adjust which of the three letters to send to that respective school. Same goes for Personal Statement. If including a paragraph unique to one specific program as to reasons for wanting to attend, one can send that Personal Statement specifically to that program and assign their general PS to other programs.
Programs
This is where one can browse programs to apply to. This section will be used to search and apply for programs.
Interviews
While it varies from specialty to specialty, for urology, on interview release some programs may use the ERAS Interview tab for scheduling, but some programs may use other methods, including accepting via email response, Thalamus program, and so on.
Letters of recommendation
One of the most important parts of the application. Most places ask for three letters of recommendation but will accept up to a maximum of four. The author's medical school urology department wrote a Chair LOR for all applying. It is very helpful for all letters to be from urologists; however, applicants should prioritize those who know them best and can speak to what they offer/their strengths. Letters of recommendation can influence the geographic distribution of interview offers[
15].
4.15.2 Interview tips
Know one's curriculum vitae (CV), especially research! Know the program/attendings. Tailor questions and find connections based on the program. In the virtual interview era—background and lighting are very important. Invest in a webcam light and good internet connection, if possible. Medical schools may offer a room for applicants to be able to conduct interviews. Note that programs may shift to in-person interviews at some point in the future.
A virtual interview is generally structured:
1. Interview social to meet with the residents the night before (If can't make it due to another interview, usually a nice gesture to let the Program Coordinator know)
2. Interview day
• Overview of the program.
• Interviews (usually 12–15 min per room, 1–2 attendings or residents, number of these rooms can vary- from just a few to 10 or so)
Some possible questions to ask during interviews?
What drew you here/why have you stayed here?
What is clinic exposure like?
What do you look for in a resident?
Any major changes coming? How will change “x” affect training?
Dynamic with fellows?
Specific training regimens/schedules?
Experience/autonomy at Veteran's Affairs (VA)/county hospitals?
Opportunities to continue research?
What are you most proud of about the program?
Work/life balance, where residents live, cost of living, good bars/restaurants, and so on.
Do residents hang out together outside of work? Call schedule? Vacation?
One of the most common questions that will be asked during the cycle to applicants is:
“What questions do you have for me?”
Attempt to have thoughtful questions ready for this.
4.15.3 Ranking on the AUA portal/waiting for the big day…
After interviews have concluded, applicants will log on to the AUA Portal, where they will input ranking preferences and then submit them. Then begins the wait. A few weeks later, applicants will go to the portal where you will now see a tab that says Results. This will tell applicants where they have matched and are headed to for the next 5–6 years.
2024 The Author(s). UroPrecision published by John Wiley & Sons Australia, Ltd on behalf of Higher Education Press.
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