Natalie Hartman is a chief resident at Loyola University Medical Center and the Edward Hines Jr Veterans Affairs (VA) Hospital. She served as the chief resident in quality and safety for surgery at the Edward Hines Jr VA Hospital during her research year, a federally funded quality improvement fellowship. She participated in an international urology rotation at Fundació Puigvert in Barcelona, Spain, to learn the inner workings of a single-payer system abroad and spur new ideas for quality improvement efforts within the VA (Figure 1). She will be joining the Sacramento VA next fall. For the Global State of Urology issue, she shares a comparative perspective on American and Spanish training.

What Does Urology Training Look Like in Your Country?

In the US, trainees complete 4 years of college and 4 years of medical school prior to residency. The residency application process starts with audition rotations at outside institutions as a fourth-year medical student. The application itself consists of a written component (personal statement, grades, and letters of recommendation), and then programs offer a small pool of applicants an interview. Once interview season is completed, programs and applicants participate in a match system.

For comparison, Spanish students complete a combined 6-year undergraduate/medical degree. Urology residency spots are determined by a national test and points-based selection process; candidates with the highest application score pick their program first, analogous to having a top draft pick.

What Do You See as the Greatest Opportunities in Your Specialty in the Next 5 Years?

COVID-19 ushered in a telehealth boom. While phone visits were initially performed out of necessity, the virtues of telehealth visits—convenience, improved access, privacy—made it a tool worth using even outside of pandemic constraints.

Legislative support for continued telehealth reimbursement remains uncertain past December 2024, but urologists are uniquely poised to demonstrate the advantages of telehealth and help cement its permanence as a tool. Diagnosis and management of many urologic conditions are not predicated on physical exam findings and lend themselves to virtual counseling. A large proportion of urology patients are elderly or have limited mobility, and making in-person appointments can be challenging. Offering the option to take an appointment from home can remove logistical/transport barriers, particularly if the patient lives in a remote location or relies on familial assistance for appointments. Lastly, even for patients without mobility obstacles, telehealth may offer a more private and reassuring avenue to receive care. Patients with sexual dysfunction may be intimidated by an office visit but willing to seek care if it can be done from the privacy of their home. More cost studies are needed to demonstrate a concrete economic benefit and incentivize continued government support, but I am optimistic that urologists can champion efforts to sustain coverage for this modality.

At Fundació Puigvert, at least one-third of clinic visits I observed were audio-only telehealth calls, and the modality was supported by the government for similar convenience and access reasons.

What Are the Biggest Challenges Facing the Specialty?

I joke that urologists care for “grumpy old men who can’t pee,” and while that is flippant, it is true that our general urology patient population tends to be older. According to US Census data, the decade of 2010 to 2020 was the largest ever growth in the > 65-year-old demographic, with an increase of 15.5 million individuals. Despite the rising senior population, US urology residencies only graduate up to 386 surgeons per year. While no one can argue we don’t have job security, our aging population is outpacing the number of graduating urologists able to care for them and calls into question the need to expand training opportunities.

How Has Connecting With Other Residents Around the World Shaped the Way You Think About Urology and Global Medicine?

Rotating in Barcelona exposed me to new technology, alternative applications of existing techniques, and different patient care pathways. As someone who is planning to work within a single-payer system (the VA), it was fascinating to see a different nationalized system at work and what is possible with that setup.

The majority of Spanish patients are covered by the public health system, which sets parameters for how soon individuals with particular conditions need to be seen in clinic or have surgery (30 days for new consults or bladder cancer, 60 days for prostate cancer, etc). Attending physicians at Fundació Puigvert are collaborative in meeting these standards. If a patient needs surgery, they are added to a pool of cases that need to be completed within the government’s diagnosis-specific windows. Each Friday, attendings divvy up cases for the following week. Patients often see one physician in clinic but have surgery with a different urologist. This model differs from academic practices within the US, where patients typically have a longitudinal relationship with one surgeon, but patients were happy and received timely, quality care.

While robotic cases are performed, regular laparoscopy is the most common approach for major cases like nephrectomies and even prostatectomies. I did see the Medtronic Hugo RAS robot for the first time, which consists of separate arms docked individually, allowing the surgeon to move a port without needing to redock the entire setup (a solution for nephroureterectomies!). Cutaneous ureterostomies were also used liberally for more frail individuals who required cystectomy; this would avoid a bowel anastomosis and minimize anesthetic time.

Fundació Puigvert is a urology/nephrology hospital only; it is affiliated with St Pau Hospital up the street, which has all other subspecialties (Figure 2). Patients who need admission for urologic issues come through a minitriage/urology-only emergency room staffed by urology residents. The system doesn’t always work perfectly as it relies on patients to correctly identify their issue as urologic (sometimes “flank pain” is actually atypical chest pain), but it largely enabled smoother admissions. This wouldn’t necessarily be replicable in the US, but their setup did spark ideas for alternative ways to triage urology patients.