On the Evolution of the Urological Species

By: Michael Schwartz, MD, Smith Institute for Urology, Zucker School of Medicine, Hofstra/Northwell, New York, New York; Hollie Brown, MD, Smith Institute for Urology, Zucker School of Medicine, Hofstra/Northwell, New York, New York; Louis R. Kavoussi, MD, Smith Institute for Urology, Zucker School of Medicine, Hofstra/Northwell, New York, New York | Posted on: 19 Sep 2023

The residency match process was born in 1952 with a mission “To match healthcare professionals to graduate medical education and advance training programs through a process that is fair, equitable, efficient, transparent and reliable.”1 Urology adopted this mechanism for filling residency positions in 1985.2 It is notable that the match process focuses on candidates and programs, not on patients or, more specifically, the skills and characteristics that patients want in their physician-surgeon. The competitive nature of our subspecialty has provided opportunity to select amongst the absolute best candidates. Debate has arisen surrounding which data to use in candidate selection as historically used metrics are evaporating or being realized as bootless. In consideration of all stakeholders and contemporary culture there is a need to reassess our traditional procedure.

Selection metrics have historically relied upon performance on the USMLE (United States Medical Licensing Examination) exams, medical school grades, in-person interviews, and recommendation letters. The National Board of Medical Examiners has eliminated scores from USMLE Step 1. Many medical schools have eliminated grades from preclinical courses, and some are adopting this practice for clinical rotations. Additionally, there is a lack of standardization among schools regarding what a given grade means with grade inflation in some and a paucity of differentiators in others.3,4 Letters of recommendation can also be difficult to interpret as there rarely are negative comments and the reader is left to assess degrees of approbation. Moreover, structured and unstructured interviews by faculty not trained in such processes are notoriously unreliable.5,6 Further clouding this process is the elimination of in-person candidate meetings in the aftermath of COVID. Programs are left with a system that poorly differentiates students in conjunction with the anodyne comfort of the traditional interview process.

How can our specialty continue to attract and cull the best candidates? It begins with what highly successful companies do when hiring: define what skills are needed for the job. There is no universal definition of qualities that are essential to create the ideal urologist. However, we can likely all agree that there are factors like intelligence, communication, problem solving, morality, and technical abilities to consider. It cannot be assumed that these are adequately screened for during the premedical process. Current urologists are products of this system and thus we accept that the general student enrolled in a medical school fulfills the basic needs criteria. The nature and methodology by which students are selected vary among schools. Interestingly, most focus upon undergraduate grades and Medical College Admission Test scores with ambiguous screening of additional important characteristics. There is irony in medical schools relying on grade metrics and not providing similar information to residency programs. Moreover, as students spend most of their schooling with cognitive practitioners, one questions the current methods of preparation for a surgical specialty.

After defining criteria, successful businesses objectively judge candidates on skills needed for the job. Organized urology must delineate methodology that accomplishes this goal. As such, specific testing needs to be created that evaluates each student’s potential to become the best urologist to serve society. For example, Bethel and associates utilized Lego exercises to assess team-based tasks.7 Our group in New York has utilized origami in a similar fashion to assess communication. There should also be a focus on identifying students with technical proclivity as patients want treatment from highly skilled surgeons. To provide this for society, there must be a focus on technical assessment. Over the years, the opportunity for independent surgical experience during residency has decreased. Regulations mandating strict oversite and work hour restrictions coupled with financial pressures on faculty to complete cases quickly have contracted hands-on learning opportunities. Many residents are electing to prolong training by taking fellowships to gain technical skill. Candidates with innate ability would require less resources to achieve the level of excellence patients expect. Shortening training could also help reduce current workforce shortages.

The Association of American Medical Colleges should embrace the importance of introducing early surgical training for those who show interest. Indeed, medical schools should investigate a parallel cultural and technical tract for individuals interested in a surgical career. This needs to include early intense skills training through all years as opposed to the current system where it is completely relegated to residency training. The AUA Boot Camp is an initial expedition in providing basic standard skills. This may serve as a template for collaborations among surgical specialties to create longitudinal parallel training during the entirety of medical school.

It is time to reassess our process for educating future surgeons and how we connect those individuals with graduate education programs. Urology should seize upon the opportunities provided by traditional data loss to ensure and improve upon the high quality of care our specialty provides. The goals of reengineering should align with all stakeholders including students, programs, patients, and society. The process involves defining core traits needed to be our best and creating a standardized, holistic methodology for appraising technical and non-technical skills. Deriving a solution requires the dedication of organizations such as the AUA and Society of Academic Urologists to take an active lead in identifying and mining meaningful assessment tools. Significant effort will be needed to overhaul the system as well as wean traditional beliefs about the current process that were created well before our candidates were born.

  1. National Resident Matching Program. About Us. Accessed August 4, 2023. https://www.nrmp.org/about/
  2. Weissbart SJ, Stock JA. The history and rationale of the American Urological Association residency matching program. Urol Pract. 2014;1(4):205-210.
  3. Visingardi JV, Inouye BM, Feustel PJ, Kogan BA. Variability in third-year medical student clerkship grades. J Urol. 2022;208(5):952-954.
  4. Association of American Medical Colleges. Curriculum Reports. Accessed August 4, 2023. https://www.aamc.org/data-reports/curriculum-reports/data/grading-systems-used-medical-school-programs
  5. Tuff G, Goldbach S, Johnson J. When hiring, prioritize assignments over interviews. Harvard Business Review. September 27, 2022. https://hbr.org/2022/09/when-hiring-prioritize-assignments-over-interviews
  6. Bohnet I. How to take the bias out of interviews. Harvard Business Review. April 16, 2016. https://hbr.org/2016/04/how-to-take-the-bias-out-of-interviews
  7. Bethel EC, Marchetti KA, Hecklinski TM, et al. The LEGO™ exercise: an assessment of core competencies in urology residency interviews. J Surg Educ. 2021;78(6):2063-2069.