What Allopathic Urologists May Not Know About Osteopathic Urology Applications

Recently, there has been a push toward standardizing the urology match for allopathic (MD) and osteopathic (DO) applicants alike, backed by the Society of Academic Urology.1 However, as these changes are implemented, programs must reassess their methods for evaluating applicants to determine their competitiveness and suitability. With the increasing demand for urologists in the United States, it is important to promote and advocate for the training of more urologists, including those from DO medical schools.2 For DO students, certain aspects of their application may not be widely understood within the urology community. These include (1) Comprehensive Osteopathic Medical Licensing Exam (COMLEX) board scores, (2) membership in Sigma Sigma Phi, an osteopathic honor society, and (3) letters of recommendation from nonacademic urologists. Currently, 25% of medical students are DO students, and correspondingly there has been a rise in osteopathic medical students applying to more competitive specialties.3 In 2019, data showed that 2.6% of practicing urologists identify as DO.4 In addition, before 2020, there was a separate American Osteopathic Association (AOA) urology match with 11 programs exclusively reserved for DO students.5 Then in 2020, the Accreditation Council of Graduate Medical Education merged MD and DO application process allowing both MD and DO students to apply to all urology programs, including those formerly AOA. Considering this recent change, MD students have been matching into formerly DO programs at higher rates, but the match data for DO applicants into MD programs has not been analyzed.5 It is likely that some urology programs may not be familiar with attributes unique to DO students. The aim of this editorial was to highlight these aspects for a more comprehensive review process of these aspiring urologists. COMLEX EXAMINATION DO students must pass the COMLEX to complete their licensure just as MD students must take and pass the US Medical Licensing Exam (USMLE). Most DO students pursuing competitive specialties, like urology, have been encouraged by mentors and medical school advisors to take both examinations to allow better assessment of their application. It was shown that most surgical residency programs required a USMLE score as an application requirement.3 This may present an issue for DO students who decide later in medical training to pursue urology as they may not have a USMLE score. Program directors unfamiliar with COMLEX may find it challenging to interpret the score, potentially leading to disregarding applicants’ submissions or deeming them incomplete without a USMLE score. A score calculator is provided on the National Board of Osteopathic Medical Examiners (NBOME) website at the end of each testing cycle to determine percentile standing.6 In addition, the NBOME website provides resources for program directors to help understand the examination competencies and the score.6 Using these resources may facilitate a fairer assessment of a DO student’s application especially if a USMLE score is not available. SIGMA SIGMA PHI While induction into the Alpha Omega Alpha (AΩA) honor society is a recognized achievement for MD students, DO students are not eligible for AΩA as DO schools do not have chapters.7 However, DO students have their own honor society, Sigma Sigma Phi (ΣΣФ), which holds similar prestige within the osteopathic community.8 ΣΣФ maintains a highly selective admission process, admitting no more than 25% of a class of students who demonstrate exceptional academic performance, active volunteerism, and a strong commitment to osteopathic medicine.8 Similarly, AΩA has similar requirements for membership and is limited to 20% of a class who demonstrate high academic achievement, service, and leadership.7 ΣΣФ and AΩA are both selectable boxes in the Electronic Residency Application Service (ERAS) application; however, for those unfamiliar with ΣΣФ, this may be overlooked when reviewing DO student applications. Being an AΩA member tends to be favored highly among urology residency programs because 30.3% of matched urology applicants in 2021 were members of AΩA.9 A DO student with distinction of ΣΣФ should be held in similar regard to an allopathic applicant with distinction of AΩA. LETTERS OF RECOMMENDATION There have been discussions encouraging the integration of standardized Letters of Recommendation (sLORs) into the application process.1,9 Other specialties have already embraced sLORs, and similar trends are beginning to emerge in urology applications.9 The adoption of sLORs may inadvertently exacerbate disparities among students without access to home programs, a scenario often encountered by the majority of DO students and some MD students. The majority of DO schools are not affiliated with a hospital with graduate medical education residency programs and hence they do not have home urology programs.3 Students without home urology programs may engage in rotations and establish relationships with community or private practice urologists, who may not be acquainted with standardized letter-writing practices. Consequently, this can lead to a failure to adequately highlight the applicant’s strengths with wordage used by those familiar with letter writing to describe their skills.10 It should remain that a sLOR should not be a requirement to urology residency, to allow for fairness to all applicants. CONCLUSION With the recent push to a more standardized urology residency application, it is imperative to holistically review urology applications to assess their competitiveness, surgical aptitude, and suitability. For DO students, this entails considering COMLEX scores, ΣΣФ status, and being open to an absence of a sLOR and nonacademic urologists’ letters of recommendation. As more DO candidates apply to programs with predominantly MD faculty and trainees, it is important to highlight distinctive aspects of DO applicants to promote a more holistic evaluation of aptitude for urology residency. The United States is facing an overall shortage of physicians that includes a growing shortage of urologists. Specifically, more than 60 percent of all US counties do not have a practicing urologist, and there have been significant declines in the number of urologists per capita, and the average age of a practicing urologist makes the specialty one of the oldest in the medical profession.2 As such, it is important to advocate for resources to train more urologists and understand unique qualifications of urology applicants including familiarizing ourselves with attributes specific to DO applicants. ETHIC STATEMENT This editorial does not contain any studies involving human or animal participants performed by any of the authors. CONFLICT OF INTEREST The authors know of no conflicts of interest associated with this publication. FUNDING This research did not receive any specific grant from funding agencies in the public, commercial, or not-for profit sectors.