For those of us lucky enough to have medical students attached to our teams at some time during their undergraduate training, the opportunity undoubtedly represents a refreshing chance to teach well-educated and enthusiastic clinicians at the very start of their careers. It is often a reminder of our own past (reflecting a time when enthusiasm and hope outweighed any feelings of negativity). It is an entirely positive experience. However, such episodes are often few and far between and teaching often squeezed in (as if as an afterthought) between surgical, radiological or medical specialities.
For many of us it seems a missed opportunity. Many of us would argue that the opportunities and exposure to medicine and surgery in its broadest sense is best achieved in a urology placement. However, it would appear that those currently designing the curriculum have a limited understanding of the potential they miss – and ultimately disadvantage undergraduates in what represents a very short period of time for training.
Here, two undergraduates (now successfully qualified and working in foundation programmes) provide a personal view to undergraduate urology exposure – both having elected to undertake a special skills module in urology. Their views will no doubt resonate with many – and hopefully will go some way to redressing the balance in undergraduate urology exposure.
Tim Lane, Editor (2012-2015), Urology News.
For medical students, urology has always remained a grey area in the syllabus – a hinterland subject tucked into another specialty or neglected altogether. Being students at a prestigious London medical school, one might assume that we would have gained experience in all major areas of medicine and surgery in preparation for practice, and, for the large part, this has been the case. However, one area of the curriculum that is conspicuous by its absence is urology.
Some argue that urology as a specialty is of little relevance to core training because of its relatively limited scope. The impression amongst medical educators would suggest that it is regarded as a niche subject along with the likes of ENT and ophthalmology. However, in this brief article we will argue that the current treatment of urology in medical education is not only unfair, but also detrimental to undergraduate teaching.
Current surgical teaching for undergraduates at most medical schools revolves around orthopaedics and general surgery, interspersed with taster weeks in ENT, ophthalmology and urology; for those who have never experienced these brief exposures to an unfamiliar specialty, we can assure you that you are expected to learn all the common presentations and emergencies of a surgical area, whilst also experiencing general ward work, clinics and surgery. This is something that most would agree is rushed, insufficient and jarring, disrupting another placement for five days packed with facts and experience; essentially, it is a brief whirlwind of activity where both students and doctors are unbalanced by rapid turnover and unfamiliarity both with each other, and the set-up.
This means that weeks that could be spread more fairly amongst equally deserving specialties are instead dominated by general surgery and orthopaedics. This conclusion is in no way intended to detract from the aforementioned subjects, but rather points out a failure in the education system for medical students.
To complicate this murky situation further, there is the random apportionment of students to one sub-specialty within the major one; is a month of hepatobiliary surgery a useful education in general surgery? Is four weeks of foot surgery a good reflection of orthopaedics as a whole? And why do medical students only see one facet of the specialty? In amongst an excess of bunions, urology is assigned a single week; one month of hallux valgus repairs, and one week for the entirety of urology. It could be argued that this constitutes a failure to teach medical students fairly when it comes to surgery, and those interested in the neglected specialties are forced to find extracurricular experience, or run the gauntlet of trying to explain to your consultant why you chose to visit the urology clinic instead of theirs.
Even amongst students at the same medical school there is a difference in the experiences offered dependent on the site where you are placed. Between the two of us, one of us received double the amount of urology teaching, two whole weeks, as compared to the other. This is confusing, and further reinforces the current surgical educational hegemony where anything other than the two behemoths of the field is cast aside and its role ignored.
Furthermore, it is worth considering why urology is the specialty we have singled out as being the most disused, and why it deserves a more central place in medical education? According to the Royal College of Surgeons of England, urology is the third largest surgical specialty, after general surgery and orthopaedics; however, when we look at the data more closely, general surgery accounts for 12 separate sub-specialties, ranging from breast to bariatric, and orthopaedics accounts for 10. None of these is truly therefore representative of a ‘general’ education, whereas urology, although it is divided into six specialties, excluding paediatric urology, is predominantly populated by general urologists, almost 30% in fact. Thus it begs the question as to which surgical specialty is best suited to provide the wide ranging and balanced education medical students require.
Urology is also especially appropriate for medical instruction as it is an area where everything is covered by the surgeons, meaning chronic follow-up, acute surgical cases, emergency treatment, elective procedures and oncology, to name but a few. It is a truly diverse area that we feel could be utilised so much better within the medical syllabus. The aim of the medical degree is arguably the production of safe, sensible and sensitive junior doctors, equipped with the knowledge base and empathy required to be a successful junior doctor. Conversely, this may not be reflected in the surgical experience gained whilst studying. The greatest strength urology possesses in its putative assertion of neglect is that it can provide all the surgical variety required to produce well rounded junior doctors.
To clarify this point, we argue that, from a clinical stance, the plethora of different clinics and conditions means that urology can demonstrate to medical students everything from the acute, emergency presentations, rapid and efficient, to the subtle emotional intricacies of delivering an oncological diagnosis. This is not only good preparation for surgical practice in the future, but also general practice placements. Urology entails a large amount of lifestyle modification and the increasing numbers of patients with urological diagnoses in the community mean that for the half of the graduates who will become GPs, urology will be a feature of their practice. Prostate cancer is the second most common malignancy in the UK, something almost every junior doctor will encounter regardless of specialty, highlighting once again the need for greater amounts of cohesive urological teaching.
Urology has been somewhat constricted in its image amongst medical students due to the educational system currently in place. Many of us are unsure of the place of female urinary tract pathologies with regard to whether this is an area monopolised by the gynaecologists or urologists. This has so far resulted in all female urological problems being exclusively taught by gynaecologists. Few of us are ever given the opportunity to experience female urology, something that is blinkered considering the many urological problems affecting women, and the many urologists who manage them. Urology is a mixed gender specialty yet teaching is only given pertaining to one gender, which contributes to the ongoing issue of reduced female recruitment into the specialty.
The pervading zeitgeist must be modified, and the first step to rectifying this altered perception is through improved urology tuition. Urology is also immensely useful in the preparation for general practice and medicine as there is a large amount of chronic management of patients, often involving sensitive lifestyle changes. Urology may be amongst the most embarrassing issues for patients, involving discussions about sensitive subjects such as incontinence, and intimate examinations. This not only necessitates high quality communication skills, but a trustworthy and empathetic rapport with the patients. These are skills that are honed through practice and ameliorated further by watching senior colleagues in their practice; urology is perfectly positioned to provide that kind of important education for the doctors of tomorrow.
“…urology can demonstrate to medical students everything from the acute, emergency presentations, rapid and efficient, to the subtle emotional intricacies of delivering an oncological diagnosis.”
This brings us to our next point concerning transferrable skills; as mentioned above, urology contains a diverse variety of situations both clinical and surgical that will be useful for other areas of practice for the junior doctor. Why, therefore, is it so truncated within the medical curriculum? The many skills gained in urological practice can be applied to other specialties far more than the current system allows. The hierarchy has meant that these are not exploited and medical education has suffered as a result.
To bolster this standpoint, and considering the range of surgical techniques used in urology, it is inefficient to underuse the multitude of opportunities offered by urology for medical students. Urological surgery ranges from endoscopy to cutting edge robotic procedures. Medical students could not only gain from viewing endoscopic procedures for their anatomical learning, but also witness the many techniques and surgeries now carried out endoscopically. Robotic surgery simulation provides a wonderful taster into the future of surgery, and gives students a chance to engage in surgical practice, to heuristically learn aptitude, and nurture any surgical ambitions a student might hold. The laproscopic procedures available in urology are equally as valid and engaging as any other specialty may offer and allow for the main focus of practical surgical education: scrubbing in to assist.
The feeling of partaking in a surgery is substantially greater than the equivalent whilst surveying from the outside; not only does the student feel useful, but they are able to learn far more accurately about surgical procedure and acumen. The wide range of non-emergency urological surgeries lends itself to this kind of unique teaching experience, not excluding the many experiences additionally available in open urological surgeries. This unique mix and variety really demonstrate how the paucity of time provided to medical students in urology is detrimental to both themselves, and the specialty.
It could be said that to an extent the medical degree acts as a solid basis for safe practice, but also as a snapshot of each specialty, an interactive advertisement upon which many students will base their career choices. The short period of urology experience results in many students overlooking urology as a specialist area, and considering this could be their only time working in urology it can be soured by the brevity of the experience. This pedestrian detour into urology fails adequately to show the many advantages of urology as a career, and drives many away, as they do not feel any particular connection with it. To ensure the next generation of urologists is discovered and encouraged, the essential change that needs to be made is the raising of urology’s profile in medical schools nationwide. There should be more time apportioned to it, and the variety and depth of its qualities fully demonstrated to the next generation of doctors, through education.
To conclude, we feel that urology is a specialty that has been unjustly sidelined and is grossly underutilised in modern medical education. Urology is a specialty that not only provides a wide range of surgical experience and a plethora of techniques, but also allows for a smorgasbord of allied experiences ranging from oncology to elective surgery. Urology allows students to experience both chronic and acute surgical management and the gamut of challenges facing the modern surgeon. To borrow the motto of the British Association of Urological Surgeons, maybe it is time to demonstrate that ‘United Strength is Stronger’, and to improve the role of urology and its profile; both medical students and medical professionals need to co-operate to restore urology to the core of medical education.
Declaration of competing interests: None declared.
