Introduction

Urology is one of the most competitive specialties with a historically low match rate, reaching as low as 2 of every 3 applicants in the 2022-2023 cycle.^1,2 Competitiveness is related to the abundance of applicants (∼600) vying for a limited number of positions (∼380), resulting in hundreds of highly qualified applicants going unmatched annually.¹ Additionally, those participating in the 2023-2024 Urology Match will confront complex variables, including being the first to apply without Step 1 board scores and the first to utilize novel preference signaling guidelines.³ Moreover, interviews will remain entirely virtual. We hope to present strategies for navigating these changes and provide guidance for a successful Urology Match.

Board Scores

Since its inception in 1992, Step 1 of the United States Medical Licensing Examination had been a cornerstone of a successful applicant’s resume.⁴ However, Step 1 moved from a numerical score to a binary pass/fail in 2022.⁵ With Step 1 no longer serving as a metric for program directors, applicants find themselves wondering how to quantitatively distinguish themselves when applying to competitive fields like urology. Effects of this may disproportionately impact students from less prestigious medical schools, those from low socioeconomic backgrounds, and those with fewer resources, such as limited access to research opportunities and mentorship.^6,7 Some speculate that the emphasis on scores will simply shift to Step 2, but there has been no official announcement from the Society of Academic Urologists (SAU) or directly from programs to advise students on this aspect of their application.

Overall, pass/fail Step 1 has potential to improve the match process by encouraging medical students to focus on holistic personal growth, clinical exposure, and meaningful research rather than fixating on a 3-digit score. Furthermore, many argue that a numerical Step 2 score is a more representative metric for evaluating clinical decision-making, since it focuses on patient-centered knowledge and experiences that students gain throughout rotations. Key strategies to help students navigate the change in Step 1 scoring would be to seek early urology mentorship, identify research projects of interest, engage in community outreach/volunteering, and build strong clinical skills through hands-on experiences in urology.

Students with urology programs at their home institution are encouraged to reach out to faculty at their university, while students without home programs are tasked with exploring alternative avenues. The AUA extends several opportunities for medical student scholarships, such as the Summer Medical Student Fellowship, as well as mentorship programs like the Urology Scientific Mentoring and Research Training Academy. Additionally, other urologic groups offer opportunities for medical students, such as the Endourological Society, which offers an annual Summer Student Scholarship. Furthermore, students lacking home programs can participate in the Michigan Urology Academy (MUA), tailored exclusively for students in this situation. The MUA facilitates the application process by hosting discussions led by nationally recognized urologists and residents who successfully matched, originating from diverse backgrounds. In terms of hands-on experiences, students with established programs at their home institutions can reach out to their respective faculty to gain exposure in urology clinics and operating rooms. Conversely, students without a home program are encouraged to connect with mentors through avenues such as the AUA, MUA, and local private-practice urologists in their communities, who are often eager to provide mentorship to enthusiastic medical students.

Virtual Interviews

The SAU has announced they are requiring that programs continue to conduct interviews virtually for the 2023-2024 cycle.³ A survey of the 2022 Urology Match cohort found that over half of the applicants expressed satisfaction with virtual interviews.^3,8 While this format can save applicants thousands of dollars in traveling expenses, students (particularly those with strong interpersonal skills) are concerned about the disservice of virtual interviews. Furthermore, it is difficult to pick up on the intangibles—a gut feeling for a program—without experiencing the program’s physical and social environment. Away rotations remain as great opportunities to gain insight into whether a program is a proper fit for an applicant. Unfortunately, most medical schools limit students to 2 to 4 visiting rotations, and away rotations are, again, cost prohibitive.

Programs have enhanced the quality of their open houses/meet-and-greets to bridge this gap.^3,8 The SAU website has a standardized calendar reporting the dates of programs’ virtual open houses to offer applicants a glimpse into their programs. Most programs also use social media platforms like X/Twitter to announce these events, which occur after business hours or on weekends during the summer and fall. This enables students to attend regardless of geographic location or clinical obligations. Although applicants are not physically at the program, these meet-and-greets serve as an opportunity for applicants to screen programs for fit by asking any pertinent questions about the program before submitting applications. These events often offer breakout sessions which promote discussions with faculty and residents separately so that applicants have the freedom to ask questions without the fear of impacting their candidacy. Moreover, most medical schools are offering mock virtual interviews, enabling students to practice and receive feedback on their performance so that official interview day is not the first time they are asked certain questions. Attending open houses and signing up for mock interviews are key strategies for putting your best foot forward during the match cycle.

Preference Signaling

The preference signaling process was changed substantially by the SAU for the 2023-2024 cycle, with an increase from 5 to 30 preference signals per student.⁹ The goal of this modification was to slow the recent trend of over-applying to urology residencies; in the 2022-2023 cycle, an average of 82 applications were sent per applicant, up from 77 the previous year.¹ Current applicants’ concern about this change revolves around the evidence-based belief that they are unlikely to get an interview at a program they do not signal. Pilot studies from other specialties suggest that applying beyond the 30 signaled programs demonstrates a pattern of diminishing returns. For instance, in the 2022 orthopedics match, where applicants were allotted 30 signals, students who applied but did not signal a program only had a 0.92% chance of receiving an interview at that program.¹⁰ In other words, applying to 100 unsignaled programs would, on average, yield just 1 additional interview. While applicants who signaled programs had a 24.4% chance of securing an interview, a 1% interview chance at a nonsignaled program is concerning for students seeking to expand their outreach beyond 30 programs. Thus, rising urologists are now strongly encouraged to identify their top 30 programs prior to applying.⁹

The decision to apply to more than 30 programs also hinges on the associated costs, which can be substantial. Applying to 30 programs will cost a student $519. A total of 144 programs are listed on the Electronic Residency Application Service, amounting to $3597 if a student were to select all.¹¹ Applicants grapple with this dilemma because applying to only 30 programs constitutes a 63% decrease from the previous year, but available data suggest a poor return on investment when applying to more programs.¹⁰ Given the realistic anxiety that going unmatched is possible, discerning the correct number of applications to submit is distressing. Over-applying is likely a financial waste for already indebted medical students, but under-applying may result in an unsuccessful cycle and the opportunity costs associated with delaying the start of residency. Without seeing the results from this year’s match cycle, it remains difficult to predict if the additional applications beyond the 30 signaled programs will be worthwhile. We suggest paying careful attention to the match results released by the AUA from the 2023-2024 cycle to best strategize.

Conclusions

The urology application process is stressful for students, without a clear path for guaranteeing a successful outcome. In addition to being a competitive field, the 2023-2024 application cycle is complicated by significant changes from the SAU. Our advice would be to seek out strong mentors in senior medical students, junior residents, and faculty members closely involved in the match. These individuals can help applicants strategize based on their specific strengths. Each year comes with new changes in the hopes of improving the process—do not hesitate to ask questions, as this experience is novel for everyone involved. Medicine, especially surgical subspecialties like urology, is full of unanticipated events that demand prompt and decisive action, similar to the challenges that applicants may encounter in this year’s unique application cycle.