Is there a difference between MD and DO in urology?

Introduction

The education of physicians in the US currently falls into 2 pathways: allopathic (for an MD degree) and osteopathic (for a DO degree). Over the past 10 years, the number of students graduating from osteopathic programs has increased by approximately 3000, representing a growing percentage of the physician workforce.¹ Based on 2024 Association of American Medical Colleges data, osteopathic physicians comprise approximately 11.5% of the 1,010,892 actively practicing doctors.² An even smaller percentage of these physicians pursue a career in urology, with an estimated 3.0% of the 10,747 practicing urologists having a DO degree.²

"Despite the overall underrepresentation of osteopathic urologists in the field, they play a crucial role in providing care in regions that lack subspecialty services," write the authors.

Discrepancies between the 2 training pathways extend beyond residency, with differences in both practice patterns and physician demographics. Research across various specialties and with diverse cohort sizes has demonstrated that osteopathic physicians are more likely to practice in rural areas compared with their allopathic counterparts.^3-5 For example, Gronbeck et al analyzed the practice trends of DO and MD dermatologists nationally and found that a significantly higher proportion of osteopathic dermatologists worked in low-income, nonmetropolitan areas with a relative shortage of dermatologists compared with the population.³ Given this context, our current study hypothesized that DO urologists differ significantly from their allopathic counterparts regarding their demographic background, fellowship training, and practice patterns.

Methods

To test this hypothesis, we reviewed American Urological Association (AUA) Census data from 2018 to 2022 to compare the aforementioned variables of demographics, training, and clinical practice information between osteopathic and allopathic urologists.The AUA Census is a voluntary annual survey created by the AUA Data Committee that is distributed to all AUA members, in addition to any urologists who have participated in AUA educational courses or annual meetings. The survey includes questions on respondents’ background, education, and practice settings. To address the discrepancy in sample sizes between the 2 cohorts, we analyzed the 2022 data for allopathic urologists (n=1849) alongside the information for osteopathic urologists from 2018 to 2022 (n=154), thereby maximizing the sample size and available data for the DOs. A χ2 analysis was used to evaluate for significant differences between cohort responses.

Results

A greater proportion of osteopathic urologists were female compared with the allopathic group (26.0% vs 17.4%, respectively; P = .008). Additionally, osteopathic urologists were more likely to pursue general urology compared with fellowship training (65.6% vs 53%; P = .003). Lastly, osteopathic urologists were more likely to work in private practice (58.4% vs 49.8%; P = .038) and in rural/nonmetropolitan areas (16.2% vs 8.7%; P = 0.002). The Table summarizes these findings.

Discussion

This study examined potential differences in physician demographics, fellowship training, and practice patterns between MD and DO urologists. The DO cohort was significantly smaller than the MD cohort, even when combining 5 consecutive years of DO cohort data. DO urologists were more likely to pursue general urology rather than additional fellowship training, and they tended to practice more frequently in private settings as well as in rural and nonmetropolitan areas. Additionally, our data showed a higher proportion of female DO urologists. 

The disparity in DO and MD cohort sizes is linked to organizational changes that have affected DO applicant participation in the urology match. Before the transition to single accreditation of US graduate medical education in 2020, there were only 11 urology residency programs participating in the American Osteopathic Association (AOA) match, with 22 intern positions offered annually.⁶ To evaluate urology residency admissions since the merger, each publicly available residency program website was reviewed, and the reported medical degrees of residents were recorded. Based on these data, 6 out of the 11 formerly AOA programs (54.5%) have accepted MD residents. Excluding the 6 urology programs established since 2020 and former AOA programs, 41 out of 131 (31.3%) allopathic programs have accepted DO residents. Most recently, in the 2025 urology match, only 30 DO applicants successfully secured positions out of the 403 available vacancies (7.4%).⁷ Overall, these trends continue to support a lower entry rate of osteopathic physicians into the field of urology, the reasons for which are likely multifactorial and warrant further attention and characterization.

Given the bottleneck effect of DO students who successfully match into urology residency, it is not surprising that a similar effect can be seen regarding fellowship training. The present study shows that significantly fewer DO urologists pursue fellowships, and, although the literature on why this exists in urology is sparse, possible causes can be extrapolated from similarly competitive surgical subspecialty studies. Orthopedic adult reconstruction fellowship match data from 2012-2023 found that DO graduates were ranked lower by programs and were significantly less likely to match than their MD counterparts.⁸ DO urologists may also decide not to pursue fellowship to provide comprehensive general urology care to smaller rural communities. Osteopathic medical schools place a high priority on rural health care access, with 56% of osteopathic schools intentionally located in health professional shortage areas designated by the federal government.⁹ This principle may continue to guide practice patterns as DO urologists more commonly practice in rural areas of the US.

Studies analyzing AUA Census data have begun to show that planned earlier retirement age and decreased productivity of practicing urologists will intensify the existing shortage.¹⁰ In particular, a 2022 study examining the rural urology workforce showed that 76.1% of respondents were older than 55, and only 31.9% planned to be in the same practice with the same clinical volume in 5 years.¹¹ With 63% of American counties having no practicing urologists when these data were published, it is reasonable to estimate that the decreasing workforce will continue to be a concern for access to urologic care across the country, particularly in rural communities. Appreciating the unique practice niche that osteopathic urologists serve is thus critical in strategizing to address projected subspecialty workforce needs.

This study is not without limitations. Our data are based on voluntary AUA Census participation. Therefore, responses only make up a percentage of the urology workforce and may not accurately reflect the entire population. Another limitation is the considerable difference in sample sizes between the MD and DO cohorts, which necessitated the aggregation of DO data for comparison with current allopathic information. This methodology introduces potential bias and can affect the generalizability of the results.

Conclusion

The current study uses AUA Census data to highlight significant differences between contemporary DO and MD urologists. The results indicate DO urologists are more likely to practice as generalists and in rural/nonmetropolitan areas; additionally, there is a relatively higher proportion of female osteopathic urologists compared to their allopathic counterparts. Despite the overall underrepresentation of osteopathic urologists in the field, they play a crucial role in providing care in regions that lack subspecialty services. Further research is needed to validate these significant workforce trends among MD and DO practitioners in contemporary and comparably adjusted cohorts.