Growth and popularity of urology as a specialty among residents in India

In India, to practice urology, a surgical resident is required to enter into a training program and acquire one of two equivalent degrees; Magister Chirurgiae (MCh) or Diplomate of National Board (DNB). Both government and privately run medical colleges/universities may be accredited to offer either of these two degrees. Some of the government run institutions, designated as Institute of National Importance (INI), can also award these degrees after admitting students to their training program through an entrance examination separate from other institutions. To register for urology training, a student who has completed a 3-year training program in general surgery, has to appear in an all India entrance examination called the National Eligibility-cum-Entrance Test Super Specialty (NEET-SS) conducted by the National Testing Agency. As there are a total of 4285 seats for pursuing residency in general surgery (including Master of Surgery [MS] and DNB Surgery),[1] more than 4285 students are eligible to appear in the entrance examination for surgical super-specialties (including urology) each year including some who may qualified in earlier years. While taking the NEET-SS exam, till 2021, all eligible students could opt to take the exam for upto two super-specialties. Furthermore, till 2021, the exam for admission to urology included questions primarily from the field of urology. Similarly, a student who appeared for neurosurgery had to answer questions based on the subject of neurosurgery. In 2022, however, the question paper pattern was changed, and now the entire examination, for all the super-specialities, tests the students knowledge of general surgery only. In India, urology as a specialty was first started in 1965 by the University of Madras.[2] Subsequent progress was slow and only a handful of departments offered urology training, mostly at the national institutes. Although robust data are lacking, by 2006, there were approximately 20–25 centers that awarded the MCh degree and around 10–12 centers offered DNB courses in urology.[3] Today, there are 96 institutes with M.Ch programmes in urology, including 53 government run and 43 privately run colleges. This translates into a total of 309 seats for MCh urology, 181 in the government and 128 in the privately run medical colleges. Besides, there are nine INIs with a total of 31-MCh seats. 70 centers offer a DNB in urology, with a total of 126 seats throughout the country. The number of available seats and their growth in the past 7 years (between 2016 and 2022) for some common surgical super-specialties is shown in Table 1. The largest increase, of 223 seats, is seen in the field of urology. Typically, the number of seats in a specialty reflects its popularity, mirroring the phenomenon of demand and supply. By that yardstick, urology has witnessed the maximum increase in the number of available seats.Table 1: Year-wise total number of seats (Magister Chirurgiae and Diplomate of National Board combined) in some surgical subspecialtiesTable 1 also shows the number of students who appeared for different surgical super-specialty examinations from 2018 to 2021. Of all the super-specialities, the highest number of students appeared for gastrointestinal surgery (GI surgery), urology, and surgical oncology. The sum of students who appeared in the different NEET SS MCh examinations is higher than the actual students who appeared in the NEET SS MCh because many students chose to appear for two subjects. Another parameter which assesses the popularity of any specialty is the number of students appearing in the examination of that particular specialty. Based on this metric, it seems that GI surgery is most popular among students, with urology marginally behind it, as is evident from the data between 2018 and 2021. Furthermore, the number of students who appeared for surgical oncology was also almost comparable to urology, indicating a popularity similar to that of urology. However, a closer scrutiny is warranted to understand why such a high number of students appear for GI surgery and surgical oncology. Both the Indian Association of Surgical Oncology (IASO) and Indian Association of Surgical Gastroenterology (IASG) are a part of the Association of Surgeons of India, while urology has an independent association, the Urological Society of India (USI) with its own subspecialties. The IASO came into being in 1977,[4] and the IASG came into being in 1988,[5] while the USI was established in 1961.[6] Naturally, most established medical colleges and institutes have a well-established department of urology whereas the departments of surgical oncology and GI surgery are still lacking. Consequently, at the majority of the institutes, the patients who seek GI surgery and surgical oncology consultations are managed by the department of general surgery. Understandably, most students who complete their residency in general surgery are well-versed with the principles of GI surgery and surgical oncology, while they lack in-depth knowledge of the field of urology. Similarly, neurosurgery, plastic surgery, pediatric surgery, and cardiothoracic surgery are also typically considered as distinct subjects, and a student of general surgery is inadequately exposed to these fields and has limited knowledge of these subjects. All students have the option to appear for any of the two super-specialties, and the majority do so. A student who is interested in pursuing urology, neurosurgery, cardiothoracic surgery, plastic surgery, or pediatric surgery has to read and prepare for these subjects (as these are inadequately taught during the general surgery training); hence, the number of students who appear for these subjects reflects the true popularity of these subjects. However, the number of students who appear for surgical oncology or GI surgery includes not only those students who want to pursue these subjects, but also those who opted to appear for them as a second choice, as they had “at least some knowledge” of these two subjects, having read them thoroughly during their general surgery curriculum. Thus, we believe, that using the number of applicants as the sole metric to evaluate the popularity of any super-speciality is inappropriate. Ray and Nundy highlighted the popularity of GI surgery in India based on the number of applications alone and thus their claim may not reflect the actual popularity of GI surgery, as a significant portion of these applicants might have opted for it as the second choice.[7] We calculated the ratio of students who appeared for urology entrance examination and the number of seats available. For 2020 and 2021, this ratio was about 5.5 students for every seat. At face value, it appears that the competition for pursuing a residency in urology is not tough. Till year 2000, there were only a handful of centers that offered residency programme in urology and about 100–150 students used to appear for 1 seat (not documented).[3] At that time, getting into the urology residency programme, especially at the national institutes, was like winning a tennis Grand Slam! With the exponential growth in the number of medical colleges and the emergence of newer subspecialties, the competition for urology has gone down. In 1960 (the USI started in 1961), there were 60 medical colleges in India,[8] which has grown to 595 by 2022,[9] and the most rapid growth is seen in the past decade.[10] We believe that the growth in urology is likely to continue,[11] which will reflect in the growth of its subspecialties and better access to urological services even in smaller towns. Financial support and sponsorship: Nil. Conflicts of interest: There are no conflicts of interest.