Urologic training in the United States has been slowly reshaping over the years. Historically, urology training was a 6-year endeavor, combining 2 years of general surgery training with 4 years of dedicated urology time. While there is variability from institution to institution, urologic training has largely transitioned into 5 clinical years, with residents spending at least 6 months on general surgical rotations and the remainder in dedicated urological training. Some programs offer a 6-year residency with an additional year-long research track. The reduction in general surgery time and the expansion of dedicated urology training underscores the transition of urology from merely a subspecialty under surgical departments to its own discipline requiring unique skills and knowledge, driven largely by technological advances such as urologic endoscopy and robotic surgery.

Perhaps the most critical issue that faces urology as a specialty in the United States is the projected workforce shortage. As of 2022, there were 365 vacancies for first-year urology residents, demonstrating a 55% growth from 2006.¹ Despite this growth in vacancies, a recent article by Nam et al projects that by 2060 there will be a decrease in per capita urologists as compared to 2020, with this burden falling especially on patients aged 65 and older.² While there have been several proposed changes to help meet the demands of both an aging population and a shrinking urologic workforce, including expansion of graduate medical education spots and increased utilization of advanced practice providers, there also lies an opportunity to rethink the very nature of urologic training in the United States.

While variation does exist, the general trend for urologic residents in the United States follows a similar course. The junior years are dedicated to the mastery of perioperative care and urologic consultation, along with developing proficiency in endoscopic and basic open surgical skills. The senior years are dedicated to more complex operations and exposure to the various urologic subspecialities. The culmination of urologic residency training is the chief year, where during the last year of training residents work closely with faculty to perform large, complex major operations. Yet, when looking at the most recent AUA Census, the training paradigms may not match what graduated residents are doing once in practice. In the 2022 census, only 26.8% of urologists performed 10 or more major inpatient operations in a typical month, which is consistent with about 2 to 3 major operations a week.³ Additionally, 22.5% of those surveyed reported not doing any major operations in a typical month. Conversely, 68.4% of all surveyed saw more than 50 patients in the clinic in a typical week.³ While other factors such as age and geographic locale certainly play a role, these statistics suggest a transition of a urologist’s time away from the inpatient operating room and into the outpatient setting.

The evolution of the urologist out of the inpatient setting can be attributed to a wide variety of factors, including pressures from payors, evolving technology allowing for more outpatient and in-office procedures, and centralization to centers of excellence for complex operations. Whatever the reasons may be, this does present a unique opportunity to rethink the training of urologic residents. It is clear that not all trainees go on to perform major cases with regularity, and those that do often do so after pursuing further subspecialization following residency training. Obtaining further fellowship training after residency can be prohibitive to some residents, particularly those with families or from nontraditional paths to medicine. Possible solutions to this problem include the creation of enfolded fellowships in training, as is currently done for neurosurgical trainees, or the creation of an expedited path to practice for those trainees who desire more clinic- or office-based urology. Modernizing training would not only allow residents to hone their skills and interests earlier in their career, but also serve to train more high-quality residents in a shorter time interval, thereby addressing workforce needs among the current urologic community. Creating an alternative “clinical urology” pathway may likewise attract trainees who may initially have avoided urology given the relatively longer training duration or emphasis on inpatient surgical management. Much as there is a push towards personalized medical care, there ought to be a transformation to personalized medical training.

As a participant in the recent Global Residents Leadership Retreat, I can attest that workforce concerns were primary among the issues identified by other residents affecting their own urologic communities. This experience taught me that while there may be nuances across national boundaries, core issues affecting urologic practice and training are often similar. Developing a well-trained workforce is paramount in ensuring the best care for patients, a sentiment shared among all the trainees I met at the retreat. Urology has always been a dynamic field, constantly evolving in its clinical practice and use of technology. To continue our persistent march forward, we must also rethink our training paradigms and understand how we can better serve both our trainees and patients. While challenges do exist and can seem overwhelming, it is an exciting time to be in this field to help create and influence change for the better.