Perspectives of osteopathic medical students on preclinical urology exposure: a single institution cross-sectional survey

Methods

This study was approved and deemed exempt by Nova Southeastern University’s Institutional Review Board (NSU IRB Study: 2023-391). A survey-based methodology was utilized for this study. Twenty multiple-choice questions were created on Research Electronic Data Capture (REDCap), a secure web-based software, containing categorical variables in the answer choices, as shown in Supplementary Table 1. Survey questions were designed to assess osteopathic medical students’ interest in and perception of urology and preclinical exposure. The first two questions asked for the respondent’s medical school year and gender. The next four questions pertained to the respondent’s perspectives regarding overall medical specialty decisions. The final 14 questions gauged the respondent’s attitudes and perspectives on urology interest and preclinical exposure.

The survey was disseminated through university email lists to all current first-, second-, third-, and fourth-year osteopathic medical students enrolled at Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine. A total of 1,645 students at both campuses (Davie and Tampa) were included. Responses were voluntary and anonymous. Between August 2023 and September 2023, five emails were sent. Responses that respondents completed that took them more than 1 min and also had all questions answered were included in the final analysis. If the respondent answered the questions in less than 1 min, these responses were excluded from analysis to mitigate against responses that did not have time for thoughtful consideration.

Results

A total of 152 responses were received, and the response rate was 9.2 %. One was excluded due to an incomplete response, and another one was excluded due to a survey completion time of less than 1 min. Therefore, 150 responses were included in the study for analysis, of which 53 (35.3 %) respondents identified as male, 96 (64 %) respondents identified as female, and 1 (0.7 %) respondent identified as other (Table 1). When looking at the distribution of respondents’ current year in medical school, 54 (36 %) were M1, 61 (40.7 %) were M2, 19 (12.7 %) were M3, and 16 (10.7 %) were M4 (Table 1). Among the respondents, 62 % indicated personal interest and passion as the most important factors when deciding a medical specialty, whereas 34.7 % of respondents indicated lifestyle and work-life balance as the most important factor (Table 1).

Preferences and attitudes toward preclinical urology exposure

A significantly greater percentage of preclinical students (56.5 %) are considering urology compared to clinical students who are actively on rotations (28.6 %) (p=0.0064). A greater percentage of males (64.2 %) are considering urology compared to females (42.7 %) (p=0.0164). Although not statistically significant, a greater percentage of M1 (63 %) are considering urology compared to M2 (50.8 %). Among the respondents, 89 % believe that early urology exposure is useful in deciding whether to pursue urology as a specialty. Furthermore, among the students who are considering urology, 98.7 % believe that early urology exposure is useful. This was significantly greater than that of respondents not considering urology (78.7 %) (p=0.0001) (Figure 1).

Figure 1:

The proportion of preclinical urology exposure among respondents considering urology. Considering urology, n=75; not considering urology, n=75. ***p=0.0001; ****p<0.0001.

In evaluating the inclination to pursue a preclinical urology elective if offered the opportunity, individuals considering urology (77 %) exhibit significantly greater interest compared to those not considering urology (32 %) (p<0.0001) (Figure 1). Similar responses were observed between male and female groups, as well as among M1 and M2 participants. When asked whether or not to include a core urology course as part of the preclinical curriculum, 56 % would include one. No differences were observed in male and female responses. However, a significantly greater percentage of M1 (68.5 %) would include a core urology course compared to M2 (49.2 %) (p=0.0395). Moreover, among those who are considering urology, 73.3 % believe that a core urology course should be included, compared to only 38.7 % of those not considering urology who share the same view (p<0.0001) (Figure 1).

Discussion

The current study assessed osteopathic medical students’ perspectives on preclinical urology exposure and interest in approaches to increase exposure. While there was significant interest in early urology exposure among those considering urology as a specialty, more than 75 % of those not considering urology also expressed interest, suggesting that early exposure is generally valued by students. The findings also indicate that personal interest and passion, as well as lifestyle and work-life balance, are considered to be of the greatest importance when choosing a medical specialty. This result aligns with findings from studies in the literature. One study found that specialty appeal was the most chosen factor, and family time with fewer on-call duties was also important [12]. Another study found that job satisfaction and “lifestyle following training” were the highest-rated considerations when choosing a specialty [13]. While the present findings support previous results on overall medical specialty choice, the present study expands the scope by further investigating urology-specific perspectives.

Upon assessment of respondents’ familiarity with and consideration of urology, a greater percentage of first-year students lacked familiarity compared to second-year students. This discrepancy may be attributed to the fact that first-year students have not yet covered the material in their curriculum, considering that this survey was disseminated during their initial semester of medical school. The current urology curriculum at the institution examined consists of a renal course that goes into kidney, bladder, and male reproductive physiology, pathology, and clinical applications. This is taken at the start of the second year of medical school. Further, a clinical procedures portion of the curriculum that teaches students how to place Foley catheters is also concurrent with the renal course. Interestingly, a study found that medical students in their first month of school have already contemplated a medical specialty preference despite minimal exposure [13]. However, these students were open to considering other specialties. Concurrently, the present findings reveal that a lower proportion of osteopathic medical students currently in their clinical years are considering urology compared to those in the preclinical years. The response rate from students in their clinical years was lower than that of students in their preclinical years. An explanation for this is that students in their clinical years may have already decided on whether or not they want to apply to urology residency programs. Thus, clinical students who are not interested may have bias and opt to not complete the survey, and the interest is likely even lower than the rate of those interested in urology presented herein. This result underscores the significance of early exposure to urology during the preclinical phase.

Among the respondents who are considering urology, more than half lacked awareness of urology’s scope and 84 % had no preclinical discussions with urologists. This result highlights the need to increase preclinical urology exposure. Studies have corroborated this finding by indicating that urology interest groups, research opportunities between first- and second-year students, and mentorship are strategies to encourage medical students’ interest in urology [9]. While urology is heavily research-driven field, a study found that osteopathic medical students face barriers to attaining research experiences that can make them less competitive and also affect the specialty in which they ultimately want to select [14]. The present results indicate that among those considering urology, inclusion of preclinical urology elective, core urology course, extracurricular urology-related workshops, and a urology mentorship program is of high interest. These results may provide a basis for designing the preclinical medical education curriculum, aiming to enhance urology exposure among osteopathic medical students. This initiative may contribute to reducing the disparity in urology match rates between osteopathic and allopathic medical students.

Such an initiative could include a national mentorship program in which attending urologists are paired with preclinical students to engage in urology-related research, because findings suggest that few expressed interests in taking a course or attending a workshop. Similarly, an option would be a resident mentorship program in which urology residents are matched with preclinical medical students to either participate in scholarly activities or discuss strategies for matching into urology, serving as guides for the students. However, attaining enough mentors may be challenging if there is a large number of interested mentees. To the authors’ knowledge, such programs currently do not exist for osteopathic medical students. Additionally, including more hands-on learning at the college of osteopathic medicine level, such as urology-based procedures through virtual reality during students’ preclinical years may generate more understanding and interest in the specialty. These skills can include the basics of cystoscopy, a robotic surgery introduction, and lithotripsy. Employing contemporary virtual reality technology may not only help overcome barriers in student access to operating rooms to observe these skills and procedures, but also simulation-oriented training is very effective in transferring skills to the operating room [15].

When examining the gender cohorts, the data reveal similarities in the responses between male and female participants. Notably, a statistically significant higher proportion of males express an inclination toward urology compared to their female counterparts. Although urology is one of the most male-dominated subspecialties, females exhibit a considerable interest in this specialty and gender disparities currently exist. Among practicing female surgeons, urology had one of the lowest representations, and the growth rate for entering female urology residents falls behind compared to most specialties [16]. A study found that females are more interested in pursuing OB/GYN and pediatrics than surgery [17]. According to the 2021 AUA census data, females represent 10.9 % of practicing urologists in the United States, with 8.1 % of them in the southeastern section of the United States [18]. The present study contributes to the existing literature by emphasizing that there are inherent barriers for female individuals pursuing urology and that targeting these barriers at the medical school level is crucial. It is important to note that our study only included one respondent identifying as “Other,” preventing us from discerning perspectives from nonbinary gender-identifying individuals. Further investigation may be warranted to better understand potential barriers in medical education for this demographic.

There are several limitations inherent to the present study. Firstly, the investigation exclusively captured the perspectives of students from a single osteopathic medical institution located in Florida, and the response rate was under 10 %. Considering that there are currently 37 osteopathic medical schools in the United States and only two in Florida, there may be distinct institutional experiences that could yield contrasting results compared to this study. Additionally, regional variations, particularly in the number of practicing urologists, could contribute to differences in the level of exposure that students receive at their respective institutions. Based on the 2021 AUA census data, there were 13,790 urologists practicing in the United States, with 81.9 % in the northeastern section and 59.5 % in the southeastern section of the United States [18]. Therefore, the level of exposure reported in our study might be influenced by these regional disparities. Another limitation is that a majority of the respondents were preclinical students, which may not entirely encompass the perspectives of those in their clinical years. However, given that the survey questionnaire was designed to ascertain experiences specific to past or current experiences during the preclinical years, this is adequate to gain insights into perspectives on urology exposure during this particular phase of their education.

An avenue for future research involves exploring the perspectives of osteopathic medical students regarding preclinical urology exposure on a longitudinal scale. Such a study could shed light on how individual viewpoints evolve as students transition into their clinical rotations and how their exposure to urology in the preclinical years might influence their choice of specialty during the application process. Given our findings of high interest in urology among preclinical students, urology interest reinforced at an earlier time in medical school may provide further insight into the urology match rate for DO students.

Conclusions

Currently, there is a disparity in the representation of osteopathic and allopathic urologists. Insight into the perspectives of osteopathic medical students’ urology preclinical exposure is important for identifying barriers to pursuing urology and strategies to enhance urology exposure prior to clinical rotations. Results show that there is a lack of familiarity and knowledge of urology among osteopathic medical students considering urology in the preclinical years and that early preclinical exposure to urology is important. Increased efforts should be made at the preclinical curriculum level to engage female individuals in urology exposure. Targeted early preclinical educational strategies are also needed to provide access for heightened urology mentorship and urology research opportunities for osteopathic medical students. Additional longitudinal research is needed to determine the sustained impact of early preclinical urology exposure on clinical rotation elective choices and residency match outcomes of osteopathic medical students.