Both urology and proctology are surgical specialties that deal with the organs and processes involved in eliminating human waste. To be successful in either of these fields, physicians need to have utmost sensitivity and compassion, as well as exceptional fine-motor skills. Patients who see urologists or proctologists often have problems of a highly personal nature, such as incontinence, unrelenting pain or itching, and sexual issues.
Practicing these specialties provides a desirable balance between office and operating room. Urologists and proctologists not only get to know their patients but also fix their problems.
Their whole-patient approach to care and deep understanding of the interrelationship between structure and function make osteopathic physicians particularly well-suited to urology and proctology. Requiring top-notch communication skills, urologists and proctologists interact with many other physicians, including primary care specialists, internal medicine subspecialists and other types of surgeons.
Both specialties are also on the front lines of detecting and treating cancer, but the two differ significantly in their training requirements and career options.
Urology offers variety, high pay, time for family
Not to be confused with nephrologists, internal medicine subspecialists who concentrate on the kidney, urologists are surgeons who focus on diseases of the male and female urinary system and the male reproductive system.
Urology and urological surgery refer to the same discipline. The nine AOA-approved programs in the field are designated as urological surgery residencies, while the 125 programs accredited by the Accreditation Council for Graduate Medical Education (ACGME) are listed as urology residencies. But the terms are interchangeable.
Because of the small number of openings each year in osteopathic and allopathic programs and the discipline’s many desirable practice qualities, urology is one of the most competitive medical specialties. Students match into the five-year residencies from their fourth year of medical school.
Tied with anesthesiologists as the third highest-paid medical specialists, according to a Medscape survey, urologists make $309,000 a year on average.
Though extremely busy, urologists can maintain some equilibrium between their professional and personal lives, says Dawn M. Bodell, DO, who chairs the urology discipline for the American College of Osteopathic Surgeons.
“My father was a general surgeon, so I knew at a young age that I wanted to be a surgeon. But I wanted a field that would allow me time to have a family,” Dr. Bodell says. “With general surgery, you get called in for almost every instance of abdominal pain. With urology, patients usually see you because they want a better quality of life. There are fewer emergencies.”
Most urologists, moreover, are in single-specialty group practices and share responsibility for being on call.
The opportunity to have relative work-life balance in this specialty also attracted Gregory V. McIntosh, DO, who directs the metropolitan Detroit urological surgery residency program associated with the Michigan State University College of Osteopathic Medicine (MSUCOM). “I like that urology is not as chaotic as most other surgical specialties,” he says. “And I like the mix of surgery and office-based practice.”
Dr. Bodell, who is fellowship-trained in female pelvic reconstruction and voiding dysfunction, appreciates the diversity of conditions urologists address. “I see pelvic prolapse, urinary incontincence, bladder cancers,” she says. “Other urologists in our group have their own areas of interests, whether it be prostate or kidney surgeries or vasectomies.” Kidney stones, overactive bladder and male erectile dysfunction are among the other conditions urologists commonly address.
Interpersonal skills are a must for urologists. “Usually people who do urology love to operate but also love to talk to patients,” says Dr. Bodell, who practices in Springfield, Ore. “You need compassion, and you need to be able to listen.”
At times, Dr. Bodell sees patients who have experienced sexual abuse. They may be talking about their traumas for the first time when they answer her questions.
Applicants to AOA-approved urological surgery residencies need good grades and strong scores on the Comprehensive Osteopathic Medical Licensing Examination of the United States (COMLEX-USA). In 2011, those who matched into urological surgery as their first-choice specialty had an average score of 550 on Level 1, the fifth highest among all specialties, and an average score of 568 on Level 2, tying for third highest, according to a report by the American Association of Colleges of Osteopathic Medicine.
But the weight given to board scores and grades is program-specific. Dr. McIntosh, for example, does not require a high class rank or use a minimum COMLEX-USA percentile score to winnow down his list of candidates, even though he received 54 applications for one opening last year.
“We look for applicants to be in the top half of their class,” he says. “And we expect them to have successfully passed everything the first time around. Anyone who has failed a class or failed a board exam on the first attempt usually will not be invited to be interviewed.”
Program director Anthony M. Grimaldi, DO, who generally has some 40 applications for one opening, likes urology candidates to have above-average COMLEX scores, preferably in the top quartile. But he cares more about their interest in urology and their performance while rotating with his program, which he requires.
“I expect students to have read at least the basics in urology before they start,” says Dr. Grimaldi, who leads the urological surgery residency in suburban Chicago associated with the Midwestern University/Chicago College of Osteopathic Medicine. “They will move right into our program where I’m training interns and residents.
“Students will be asked to give a presentation on a urologic topic while they are here. They will be in the office and surgery with me. They will also attend our academic conferences, our tumor boards, our morbidity and mortality meetings. I will evaluate how they fit into our program, whether they are genuinely interested in urology, and how they relate to house staff, other students and patients.”
James Patrick Tierney, DO, who directs the urological surgery residency at Charleston (W.Va.) Area Medical Center, says he strongly prefers candidates who have rotated in his program. “We have just 10 residents—two each year—so we need to make sure that any potential new resident fits in,” he says.
Dr. Tierney closely observes students’ hand-eye coordination when they’re on rotation. “We tell them before they get here that they have to be able to put their sterile gloves on and their sterile gown on without any help,” he says. “Before starting their rotation, they should know how to hold the scissors and the pickups and put in a suture or two, as well as how to put in a catheter.”
Dr. McIntosh requires applicants to have served elective rotations in urology but not necessarily at one of the three hospitals in MSUCOM’s Detroit-area urological surgery consortium. However, those who’ve rotated at a consortium site do have an advantage and typically land an interview unless they performed poorly.
Although Dr. McIntosh looks at letters of recommendation, he delves much deeper into applicants’ performance. He wants to ascertain whether they excelled not just on their urology rotations, which he expects, but also on rotations in other specialties.
“I want to see how the candidates did on rotations unrelated to urology, in which they were not that interested in the specialty, so I will call rotation sites and ask questions about each applicant,” Dr. McIntosh says. “ ‘Did the student fulfill his or her assignments? Was he or she willing to learn?’
“When students do their best even in situations where they’re not gunning for a future residency spot or enjoying what they are learning, that speaks to their well-roundedness and their character.”
Being well-rounded is essential for urologists because all aspects of a patient’s health affect the urogenitary system and treatment outcomes, Dr. Bodell notes.
“For example,” she says, “if I treat a patient whose body mass index is too high, I will try to get her to lose weight so she can have a successful surgery. You have to look at the overall patient in urology.”
When Dr. Tierney asks students on rotation why they are interested in urology, he sometimes hears the right answer: “Because I just love it.”
“What they love is the variety,” he says. “It’s a broad specialty with niches for everybody.”
Proctology—a lesser-known osteopathic niche
Because they focus on diseases of the anus, rectum and sigmoid colon, proctologists are sometimes the “butt” of jokes. Indeed, proctologists themselves are given to puns about their field.
“You need a sense of humor for proctology,” says David Harrison, DO, who directs the proctology residency program at Community Westview Hospital in Indianapolis. “You can’t imagine the foreign bodies we sometimes see. For example, one of my residents was on call when a guy came in who had a full-size Maglite stuck up there. One of the gag gifts we gave her at graduation concerned that.”
But most patients who seek help from proctologists have genuine, persistent, frustrating medical conditions that often have been misdiagnosed.
“Proctology is really the best of both worlds. You get to do medicine, including working on irritable bowels and inflammatory bowel disease. But you also do some surgery.”
“When people come to see us, they are very embarrassed,” says Shiva Golian, DO, who served her residency under Dr. Harrison and now practices as his partner. “We might be the fourth or fifth physician they’ve gone to. They don’t know how to get their problem fixed. We can really help them and make a big difference in their lives.”
“I find the field so gratifying because our patients are very appreciative, and they recommend us to family and friends,” Dr. Harrison adds.
Along with neuromusculoskeletal medicine, proctology is a uniquely osteopathic specialty. This is because the allopathic medical profession years ago absorbed the role previously performed by proctologists into the specialty of colorectal surgery. Becoming a colorectal surgeon requires completing a five-year general surgery residency followed by a one-year fellowship in colon and rectal surgery, of which the ACGME lists 55 programs.
In contrast to the six years required for colorectal surgery, the two AOA-approved proctology residencies are three-year programs. Osteopathic proctologists do surgical procedures in the anus and rectum and perform colonoscopies, but they don’t perform colectomies, colostomies and other major gastrointestinal surgical procedures.
Proctologists say they are an invaluable bridge between primary care and general surgery or colorectal surgery.
“We’ve done really well in communities with smaller hospitals that don’t have colorectal surgeons because we are feeders for the general surgeons,” Dr. Harrison says.
Like many proctologists, Dr. Golian developed her interest in the specialty when she was already serving another residency in family medicine. “I didn’t have any proctology lectures in medical school,” she says, noting that the specialty suffers from a lack of awareness among medical students.
A results-oriented individual who enjoys preventive medicine, Dr. Golian loves doing procedures and thwarting colon cancer through screening colonoscopies. “I like getting things done,” she says. “I need problems to be resolved.”
Many patients who come to see her erroneously think they have hemorrhoids, she says. One patient recently referred to her from the emergency department had been diagnosed with a thrombosed hemorrhoid but actually had a rectal tumor.
“Unless you see this stuff a lot, you don’t really know what’s going on down there,” she says. “A lot can happen.”
Proctologist Michael D. Adelman, DPM, DO, JD, also discovered his flair for the field by accident. Then a family physician in Florida, he had been seeing many elderly patients with rectal problems and referring them to a local proctologist. On more than one occasion, the proctologist would compliment Dr. Adelman for referring a patient early enough that a cancerous polyp could be removed in time. His interest piqued, Dr. Adelman had lunch with the physician, who told him more about the field.
“I learned that proctology is really the best of both worlds,” Dr. Adelman remembers. “You get to do medicine, including working on irritable bowels and inflammatory bowel disease. But you also do some surgery—colonoscopies, abscess removal, hemorrhoid surgery. I had previously done surgeries as a podiatrist and missed it.”
“What’s more, as a proctologist I could spend more time with each patient than I could as a family physician.”
Dr. Adelman practiced proctology for a dozen years and still maintains his AOA board certification, though he no longer has time to see patients as the president of the West Virginia School of Osteopathic Medicine (WVSOM) in Lewisburg. As a med student, he didn’t have any exposure to proctology, so he makes a point of introducing WVSOM students to the specialty through lectures. He also requires students to complete a four-hour lab course on colorectal screening in which they learn how to perform flexible sigmoidoscopy on mannequins.
“I always have students who ask me for information on proctology residency programs,” he says.
Students can learn more about the specialty by visiting the website of the American Osteopathic College of Proctology and by attending the specialty society’s meetings.
Although good grades and decent scores on COMLEX-USA are desirable, having true interest in the specialty and empathy for patients is more important.
Students and graduates who are interested in proctology need to serve an elective rotation in the targeted program.
“We require that potential candidates come in and rotate with us for a month because it takes a special personality to do proctology,” Dr. Golian says. “You need to be good with patients. You need to be able to make nervous, embarrassed patients feel at ease.”
Proctology candidates also need to have good hands. “We need to see that you are able to handle the colonoscope and do the procedures,” Dr. Golian says.
Proctologists take a holistic approach to examining patients and often try less-invasive techniques, such as injection therapy for hemorrhoids, before performing surgery, Dr. Golian says. They also sometimes perform osteopathic manipulative treatment.
“A lot of times, patients will have some kind of sacral issue going on that we can alleviate with OMT,” she says.
Proctologists can practice in solo, small group or multispecialty group practices, and they are sometimes employed by clinics and hospitals.
“It’s a field where you can practice anywhere,” Dr. Harrison says. “Because you’re not being called in every night, you can have a solo practice with proctology.”
Overall, proctologists are able to achieve better work-life balance than physicians in most other specialties, says Dr. Golian, who has an infant and young twin boys.
“To me, being a proctologist is a dream job,” she says. “If I had to start all over again, I wouldn’t choose anything else. It provides a good lifestyle and good pay. It’s interesting work. And it’s very fulfilling. Every single day, I feel like I’ve helped at least one person.”