The day-to-day work of a urologist is mystifying to most new medical students. Genitourinary issues can be uncomfortable to discuss with family and friends, and without personal connections or shadowing opportunities, many medical students are not exposed to a career in urology until late in their medical education.

The continuous growth of basic medical sciences, coupled with the earlier onset of clinical rotations, has crowded the preclinical curriculum; currently 50% of medical schools do not require urology lectures or coursework.¹ Moreover, during third-year clerkships, students will typically rotate in only one surgical subspecialty, of which urology may not be an option. Simultaneously, urology, like many surgical specialties, has become an increasingly competitive match. More than 500 applicants competed for 386 positions in the 2023 Urology Residency Match, with only 75% successfully matching.² Additionally, 15% of applicants in the 2023 Urology Match were previous graduates, up from 11% in the previous year.² This increasing number of re-applicants concurs with the observation that urology is a highly desirable field but often requires a research portfolio to match successfully.

Deciding during clinical rotations that you are attracted to the field makes it difficult to build a competitive resume before applying to the match. The average matched urology applicant in 2021 had 4 published articles and 9 other research items.³ For many students, their only option is to take a year off to conduct research to increase their likelihood of matching, further delaying the start of their lengthy residency training and subsequent career.

At Sidney Kimmel Medical College (SKMC), our urology interest group, the Jefferson Urology Society (JUS), has attempted to address these issues by providing opportunities for exposure to the field during the preclinical years. In 2020, we initiated a 2-week Winter Externship for first- and second-year medical students interested in urology. The Winter Externship is a 2-week rotation occurring when third-year clerkship students are on winter break. This allows first- and second-year students to interact directly with residents and attendings and gain a realistic understanding of the field. This past winter, 5 first- and second-year students at SKMC participated. During their externship, students were able to scrub into a range of cases from robotic-assisted prostatectomies to percutaneous nephrolithotomies and penile prosthesis implantations. On days when students were not assisting in the operating room, they had the opportunity to shadow in the clinic. With access to attendings in reconstructive surgery, neuro-urology, and urologic oncology, students were able to observe many subspecialties within the field, helping to dispel the misconception that urology is a narrow field. The externship also helped students develop relationships with attendings and residents, resulting in several ongoing research projects. The feedback from participants has been overwhelmingly positive.

Comments from participants included:

“We were surprised to see the diversity in the field. Before the externship, my understanding of urology was limited to treating kidney stones or UTIs; seeing prostatectomies and trauma reconstructions showed us the breadth involved.”

“I was impressed by the technological innovation; I was able to observe while an attending skillfully used a daVinci robot to navigate around the obturator nerve.”

“Spending time with the residents exposed us to the lively personalities that urologists are known for and increased my attraction to the field.”

Medical schools with a mandatory clinical rotation in urology match more students than those that do not, as do medical schools that include a preclinical urology course in their curriculum.⁴ Urology interest groups also are correlated with increased numbers of urology residency applicants.⁵ However, groups such as JUS exist at only 21% of medical schools.⁶

For many urology departments, the framework to implement a winter externship is already in place because it is designed to mimic a third-year rotation. Based on the experience of the JUS, there are 2 key factors to implementing a similar program. The first step is to outline the program goals. In our program at SKMC, we wanted to give students the same experience as a third-year student on rotation, so the JUS leadership met with the program director for advice on how to accomplish this endeavor. Because the fourth-year student members of JUS already had completed their rotations, they took the lead on teaching the students how to use the hospital electronic medical record system and how to scrub into cases. The JUS student leadership then led an orientation day in which they taught basic suturing skills and explained the common procedures occurring in the operating rooms. Practical steps that needed to be taken included ensuring all participants had access to scrubs and that their badges allowed them to swipe into the operating rooms. The second factor is that it is essential to build a good working relationship with the urology residency leadership (ie, program director and associate program director(s), program coordinator, and chief residents) to facilitate the program’s implementation in the department. It should be perceived as a win-win for all parties involved. Participants come away with increased interest in the field and greater preparation for their rotations and sub-internships in the near future.

In summary, medical student exposure to urology often is limited. Studies of the factors influencing medical students’ decision to pursue a career in urology support the importance of early exposure to the field.⁶ Medical schools with a mandatory clinical rotation in urology match more students than those that do not, as do medical schools that include a preclinical urology course in their curriculum.⁴ Urology interest groups play an important role in stimulating interest in the field and helping to navigate the application process. Implementing programs, such as the SKMC Urology Winter Externship, can promote early commitment and maximize the chance of matching in this dynamic and increasingly competitive specialty.