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GLOBAL STATE OF UROLOGY Leadership Training as Transformative Education for Urology Residents: The Revolution Will Not Be Televised

By: Alexis R. Steinmetz, MD, University of Texas MD Anderson Cancer Center, Houston; Kit L. Yuen, MD, University of California, San Diego | Posted on: 18 Mar 2024

Residency programs around the world dedicate themselves to the time- and resource-intensive task of mentoring the next generation of urologic surgeons. The inaugural Global Residents Leadership Retreat, held at the 2023 AUA meeting, reflects a growing demand for formalized leadership training. With 40 representatives from 20 countries, the attendance was a microcosm of the AUA meeting at large: mostly American, but increasingly diversified.1

While residents noted considerable variation in urologic training in and between countries, unifying themes emerged. Trainees from around the world raised concerns about managing burnout, tackling the global workforce shortage, and navigating generational differences among team members. Whether it was while immersed in the final strategic game or huddled around coffee and pastries, participants formed an impressive sort of think tank. The ever-familiar small talk of young trainees that floated between circular conference tables (“What’s your favorite case?” and “How much robot time do you get?”) was woven into a larger discourse. Together, participants contemplated how to best lead increasingly diverse and multidisciplinary teams.

In recent years, the historically high levels of job satisfaction reported by urologists have been replaced by staggering burnout rates.2 Expanding administrative burdens coupled with increasing pressure to generate revenue and publish original research have been cited as contributors.3 Some residents surveyed go as far as to say they would not choose a career in urology again2—Hugh Hampton Young is surely rolling over in his grave. Fortunately, the caffeine-fueled sense of camaraderie shared among retreat participants fostered inquisition and buoyant hope over resignation. Did residents from countries with 40- to 50-hour work week caps feel it less than those with 80-hour weeks? Was anyone anxious that surgical cures (such as the prostatectomy, a case seemingly integral to our profession) would become obsolete? How should we move forward as a specialty?

An unsurprising buzzword at this year’s retreat: artificial intelligence (AI). This burgeoning technology is hypothesized to change the face of urology training (and the world). Unlike a sleep-deprived, postcall junior resident, AI won’t feel suffocated by the incessant barrage of inbox results and patient messages. Coding and billing compliance are not cringe-worthy phrases to AI, but merely parameters in its neural network architecture. Historically, it was reasonable to expect the urology intern to preround when the inpatient census included a handful of healthy nephrectomies. But it’s 2024—an intern today may cover 36 comorbid inpatients with med lists that read like extensive catalogs, from Xarelto to Ozempic (speaking of which, how long should this be held preop? Would ChatGPT know?). Without the risk of fatigue-related errors or duty hour violations, AI could automate daily patient reports and facilitate patient communications.4 Amidst the reality of shifting parental roles and the bureaucracy of medicine, chattering around AI offered light in a darkened tunnel. Are reinforcements to save us from burnout really on the horizon? Or will AI become a false prophet, stagnate in legislation while The New York Times argues over intellectual property law? This remains to be seen. In the interim, the sense of idealism regarding the future of AI in urology was certainly contagious.

AI may also help alleviate the strain of worsening urology workforce shortages. Retreat participants across geographical lines discussed how subspecialization has further concentrated expertise into urban academic hubs.5 Integrating technological platforms like AI into telemedicine could assist with patient triage, timely diagnoses, and treatment monitoring. This can be particularly impactful in rural and underserved communities, where the number of urologists per capita is disproportionately low.5 While prioritizing recruitment and retention of trainees is critical globally, effective remedies certainly require some country-specific nuance. Some trainees described requirements in their countries to practice in rural or district hospitals. In the United States, new legislation hopes to incentivize urologists to establish rural practices through loan repayment.5 Ultimately, the exchange of ideas during the workshop fostered a sense of forward motion toward effective, multifaceted solutions.

While distinct generational cohorts are a sociological construct, managing team members with different sets of values and communication styles was a universal challenge for attendees. A traditional one-size-fits-all top-down approach to leadership can contribute to frustration and dissatisfaction, particularly among younger team members. Participants at the retreat brainstormed strategies to navigate and leverage diversity (generational and otherwise). Effective chief residents do more than manage call schedule logistics—they inspire cohesion. These leaders are willing to understand and question their own unconscious biases, even if it is uncomfortable or inconvenient. They are flexible in their interactions with different team members, aware of how evolving societal norms impact team dynamics, and able to avoid the trap of relying too heavily on their own training experiences as the gold standard.

This could arguably be the greatest message of the Global Residents Leadership Retreat: how successfully we face the most pressing challenges of our profession—from burnout to workforce shortages—will be determined by how we lead. The revolution will not come from ChatGPT, posts and re-posts on X, or legislation for loan forgiveness. It will come from within—from how we relate to each other, and how rapidly we adapt our training models to the inevitability of change. This room of eager senior residents, scribbling on poster-sized notepads and working together to win the final strategy exercise, suggested that perhaps “the days of the giants” are still ahead. This type of transformative education combined with (potentially naïve) optimism is exactly what we need to rescue urology from the top of the burnout list.

Conflict of Interest Disclosures: The Authors have no conflicts of interest to disclose.

  1. American Urological Association. Global Residents Leadership Retreat. 2023. Accessed December 2, 2023.
  2. Marchalik D, Goldman CC, Carvalho FFL, et al. Resident burnout in USA and European urology residents: an international concern. BJU Int. 2019;124(2):349-356.
  3. Chouhan J, Jones A, Murray K. Assessing reasons for urologist burnout, its implications, and possible interventions. J Am Coll Surg. 2018;227(4):S279.
  4. Nedbal C, Naik N, Castellani D, Gahuar V, Geraghty R, Somani BK. ChatGPT in urology practice: revolutionizing efficiency and patient care with generative artificial intelligence. Curr Opin Urol. 2023;10.1097/MOU.0000000000001151.
  5. Ivan S. A resident’s guide to the rural urology workforce crisis. AUANews. 2023. Accessed December 14, 2023.