Urology vs orthopedic surgery for private practice

[Doc mu]

I am still between these two specialties and would like to know a few things to make the decision clearer:

1. Which is better suited for private practice and why?

2. What procedures do private practice urologists do? (A urologist said he can count on one hand the number of procedures he does in PP i.e. very little)

3. How much of urology is inpatient in PP?

4. Exactly how "resource-intensive" is urology in the sense of needing OR time, other personnel...etc

5. How much medical management is there in urology exactly? (is it just a few diseases here and there or can you decide not to do any procedures after residency and fare well)

6. Would Urology have a decent case load in a country with more youngsters and less elderly?

7. Do you regret choosing urology? (has a really the high burn out rate on medscape...)

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[DoctwoB]

I am still between these two specialties and would like to know a few things to make the decision clearer:

1. Which is better suited for private practice and why?

2. What procedures do private practice urologists do? (A urologist said he can count on one hand the number of procedures he does in PP i.e. very little)

3. How much of urology is inpatient in PP?

4. Exactly how "resource-intensive" is urology in the sense of needing OR time, other personnel...etc

5. How much medical management is there in urology exactly? (is it just a few diseases here and there or can you decide not to do any procedures after residency and fare well)

6. Would Urology have a decent case load in a country with more youngsters and less elderly?

7. Do you regret choosing urology? (has a really the high burn out rate on medscape...)

I'm a urologist in private practice (large multi specialty group). I can't comment on Ortho, but will give the urology side of things.

1. Urology is perfectly suited for private practice. Demand for the specialty is great in most areas of the country so if you set up a shop, most can get pretty busy.. It benefits from using its own ancillary services (ultrasound, office procedures like cystoscopy, prostate biopsy, etc) which being in private practice you collect the revenue from. It does involve some start up costs, more so then a primary care office for example, as scopes, prostate US machines, etc are not cheap.

2. As a private practice urologist, I do a ton of different procedures. I do stones (ureteroscopy, shock wave, pcnl), cancer with both open and laprobotic approaches (TURBT, radical and partial nephrectomy, radical prostatectomy, upper tract urotheleal carcinoma procedures), BPH (TURP, urolift, HOLEP, and variations therof), incontinence ( mid urethral slings, botox, sacral nerve stimulators, etc), female urology (anterior/posterior repairs, robotic sacrocolpopexy), Urethrla stricture work (dilations, DVIUs, urethroplasties) and Prosthetic surgery (AUS IPP). The only things I don't do that fall within urology are really big oncology whacks (RPLND for testicular cancer, radical cystectomy for bladder cancer, large caval thrombi with renal tumors) or complex prolapse work, And vasectomy reversals. since i hate them.

The short answer is you can have a ton of variety as a PP urologist. In a larger group, you may subpsecialize in a subset of those procedures. You can also choose to send many of those cases to the academic center or your partners and focus mostly on work in the office or minor procedures. I was well trained to practice the gamut of urology and that was how I wanted to set up my practice.

3. Relatively little inpatient work. Most of the cases above are done as an outpatient or maybe a one night inpatient stay. That means very little time spent rounding in the hospital which is great. Depending on your group set up, you may choose to take ER call or cover hospital consults, but not all groups do this (with the exception of covering your own patients). If you do cover ER call and consults, which I do, it is often well compensated.

4. You do need resources like almost all specialties. You will need MA or LVNs to room your patients and do minor procedures like bladder scans, cath changes, etc to keep your clinic moving. You will need access to an OR or surgery center to do your cases and they will need specific uro instruments like scopes, lasers, disposables, etc. You will need equipment for your office proceures like scopes, ultrasound machines, disposables, and ways to sterilize your equipment.

5. There is a lot of medical management in a general urology practice. A lot of patients with BPH, ED, incontinence, or low grade cancers are managed with medications and/or surveillance. As mentioned above, you can choose to have more of an office focused practice and send cases to your partners, who would generally be happy to have them. Many urologists do this as they wind down and get older.

6. With a younger patient population, you will see a different case mix, but still plenty of things. You'll see more stones, recurrent UTI, infertility, etc and less cancer/BPH, but still likely plenty.

7. No regrets whatsoever. I love my job, I make a big difference in my patient's lives, I have a great lifestyle, and am well paid for it.

 

[Doc mu]

I'm a urologist in private practice (large multi specialty group). I can't comment on Ortho, but will give the urology side of things.

1. Urology is perfectly suited for private practice. Demand for the specialty is great in most areas of the country so if you set up a shop, most can get pretty busy.. It benefits from using its own ancillary services (ultrasound, office procedures like cystoscopy, prostate biopsy, etc) which being in private practice you collect the revenue from. It does involve some start up costs, more so then a primary care office for example, as scopes, prostate US machines, etc are not cheap.

2. As a private practice urologist, I do a ton of different procedures. I do stones (ureteroscopy, shock wave, pcnl), cancer with both open and laprobotic approaches (TURBT, radical and partial nephrectomy, radical prostatectomy, upper tract urotheleal carcinoma procedures), BPH (TURP, urolift, HOLEP, and variations therof), incontinence ( mid urethral slings, botox, sacral nerve stimulators, etc), female urology (anterior/posterior repairs, robotic sacrocolpopexy), Urethrla stricture work (dilations, DVIUs, urethroplasties) and Prosthetic surgery (AUS IPP). The only things I don't do that fall within urology are really big oncology whacks (RPLND for testicular cancer, radical cystectomy for bladder cancer, large caval thrombi with renal tumors) or complex prolapse work, And vasectomy reversals. since i hate them.

The short answer is you can have a ton of variety as a PP urologist. In a larger group, you may subpsecialize in a subset of those procedures. You can also choose to send many of those cases to the academic center or your partners and focus mostly on work in the office or minor procedures. I was well trained to practice the gamut of urology and that was how I wanted to set up my practice.

3. Relatively little inpatient work. Most of the cases above are done as an outpatient or maybe a one night inpatient stay. That means very little time spent rounding in the hospital which is great. Depending on your group set up, you may choose to take ER call or cover hospital consults, but not all groups do this (with the exception of covering your own patients). If you do cover ER call and consults, which I do, it is often well compensated.

4. You do need resources like almost all specialties. You will need MA or LVNs to room your patients and do minor procedures like bladder scans, cath changes, etc to keep your clinic moving. You will need access to an OR or surgery center to do your cases and they will need specific uro instruments like scopes, lasers, disposables, etc. You will need equipment for your office proceures like scopes, ultrasound machines, disposables, and ways to sterilize your equipment.

5. There is a lot of medical management in a general urology practice. A lot of patients with BPH, ED, incontinence, or low grade cancers are managed with medications and/or surveillance. As mentioned above, you can choose to have more of an office focused practice and send cases to your partners, who would generally be happy to have them. Many urologists do this as they wind down and get older.

6. With a younger patient population, you will see a different case mix, but still plenty of things. You'll see more stones, recurrent UTI, infertility, etc and less cancer/BPH, but still likely plenty.

7. No regrets whatsoever. I love my job, I make a big difference in my patient's lives, I have a great lifestyle, and am well paid for it.

Thank you for the thorough answer!

This sounds awesome tbh, i remember seeing you in one of the old ortho vs uro threads going through the same decision as i am right now.

i am honestly leaning towards urology and one of the biggest reasons is the heavy sub-specialization reality in ortho where most orthos do fellowship and limit their scope to hand, F&A...etc.

do you think there is a similar trend in urology where we will have the cancer guy doing only cancers and the peds guy doing only peds cases with no general urologists doing a little bit of everything?

 

[DoctwoB]

Thank you for the thorough answer!

This sounds awesome tbh, i remember seeing you in one of the old ortho vs uro threads going through the same decision as i am right now.

i am honestly leaning towards urology and one of the biggest reasons is the heavy sub-specialization reality in ortho where most orthos do fellowship and limit their scope to hand, F&A...etc.

do you think there is a similar trend in urology where we will have the cancer guy doing only cancers and the peds guy doing only peds cases with no general urologists doing a little bit of everything?

Like all of medicine, there is definitely a trend towards sub specialization. If you want to work in an academic center, you will generally need a fellowship and focus on your specialty, maybe with a sprinkling of general urology thrown in. However in private practice it really comes down to you, what you feel comfortable/skilled at doing, and what the local referral patterns are. Plenty of urologists don't do fellowships and practice broad spectrum urology as I do.

 

[Doc mu]

Like all of medicine, there is definitely a trend towards sub specialization. If you want to work in an academic center, you will generally need a fellowship and focus on your specialty, maybe with a sprinkling of general urology thrown in. However in private practice it really comes down to you, what you feel comfortable/skilled at doing, and what the local referral patterns are. Plenty of urologists don't do fellowships and practice broad spectrum urology as I do.

Sorry for the rapid fire Qs but i was watching a few open urology procedures and i LOVED them, the anatomy, exposures, elegance...etc i just wanted to ask what % of procedures in PP are done open

 

[nymedstudent874]

Sorry for the rapid fire Qs but i was watching a few open urology procedures and i LOVED them, the anatomy, exposures, elegance...etc i just wanted to ask what % of procedures in PP are done open

most scrotal cases are open including IPP, AUS placement. Most onc cases are robot assisted now with the exception of radical cystectomy which is still mostly done open- but most urologists aren't doing these anyway.

 

[Doc mu]

most scrotal cases are open including IPP, AUS placement. Most onc cases are robot assisted now with the exception of radical cystectomy which is still mostly done open- but most urologists aren't doing these anyway.

So abdominal/pelvic incisions are no longer done and everything there is now done lap/robotically?

 

[DoctwoB]

So abdominal/pelvic incisions are no longer done and everything there is now done lap/robotically?

Nope. There are still plenty of reasons to do open abdominal or pelvic surgery in Urology. There are cases with no proven benefit to being done robotically or even possible harms, like radical cystectomy that most still do open. There are patient's who aren't great candidate for robotic or lap surgery due to prior surgeries/scar tissue/disaster bellies, so are better served with an open extraperitoneal incision. Very large renal masses, caval thrombi, large retroperitoneal tumors, RPLNDs, etc will continue to be done open. But as robotic skill and technology have improved, as well as training becoming more geared towards robotic surgery, more and more cases have moved in that direction. In my practice, I've done about 6 open abdominal surgeries in the last year,

Also as mentioned above, many of the non belly surgeries are done open. Prothetic surgeries like AUS or IPP are done through perineal or penoscrotal incisions. Reconstructive procedures like urethroplasties are usually done through open perineal incisions. Pediatric urology involves a lot of open inguinal or pelvic surgeries as in tiny babies the benefits of lap/robotics is minimal when your open incision is barely over a centimeter, for example at my instutition we did all our ureteral reimplants open

 

[HighPriest]

All depends which kind of bones you want to spend your time with.

 

[cpants]

I echo @DoctwoB and it sounds like we have very similar practice, although I am employed by a large system. The answers to your questions are....it depends, but urologists are so in demand that you can probably find the right mix for what interests you ranging from totally outpatient to totally hospital based. Great variety of procedures and subspecialties out there and you can tailor your practice to your interests. Generalists generally practice broadly and will share a lot of overlap with all of the subspecialties and send out the complicated stuff (eg. generalist does orchiectomy but sends patient out for RPLND, generalist does nephrectomies but sends out patients with vena cava thrombus, generalist treats most stones, but sends out a complicated PCNL, generalist will perform orchidopexy bet sends out intrabdominal testis for laparoscopic pexy).

In larger cities or academic centers, the abundant amount of subspecialists may box you in in terms of surgical diversity, but flip side of that coin is that generalists are SUPER in-demand in these settings and command high salaries. Professor Walsh the GU oncologist doesn't want to deal with overactive bladder, testicular pain, circumcisions, etc, and there aren't a lot of generalists that are willing to limit their surgical practices to simple stuff. Can make a great living seeing the new patients and feeding the subspecialists in a city/academic setting if it doesn't bore you. This is also a great opportunity as you get older and want to slow down operatively.

Overall, I have no regrets. Urology is a hidden gem. Ortho seems cool too, but the lifestyle is unacceptable to me.

 

[Doc mu]

I echo @DoctwoB and it sounds like we have very similar practice, although I am employed by a large system. The answers to your questions are....it depends, but urologists are so in demand that you can probably find the right mix for what interests you ranging from totally outpatient to totally hospital based. Great variety of procedures and subspecialties out there and you can tailor your practice to your interests. Generalists generally practice broadly and will share a lot of overlap with all of the subspecialties and send out the complicated stuff (eg. generalist does orchiectomy but sends patient out for RPLND, generalist does nephrectomies but sends out patients with vena cava thrombus, generalist treats most stones, but sends out a complicated PCNL, generalist will perform orchidopexy bet sends out intrabdominal testis for laparoscopic pexy).

In larger cities or academic centers, the abundant amount of subspecialists may box you in in terms of surgical diversity, but flip side of that coin is that generalists are SUPER in-demand in these settings and command high salaries. Professor Walsh the GU oncologist doesn't want to deal with overactive bladder, testicular pain, circumcisions, etc, and there aren't a lot of generalists that are willing to limit their surgical practices to simple stuff. Can make a great living seeing the new patients and feeding the subspecialists in a city/academic setting if it doesn't bore you. This is also a great opportunity as you get older and want to slow down operatively.

Overall, I have no regrets. Urology is a hidden gem. Ortho seems cool too, but the lifestyle is unacceptable to me.

Man this is tempting, I am very much leaning towards Urology for the variety, medicine/surgery mix, lifestyle and most importantly interest in the diseases (Ortho procedures are cool but the diagnostics/diseases bore me to death).
Is there some sort of list of procedures a generalist does and ones he sends out or like of the core urology procedures?

Ortho folks recently told me to suck it up and do Ortho because (according to them) Ortho procedures pay "far" more and Uro will become mostly medical management in the future with improved cancer therapy and medical therapy in general, i would like to know your opinion on this as a practicing Urologist

 

[DoctwoB]

Man this is tempting, I am very much leaning towards Urology for the variety, medicine/surgery mix, lifestyle and most importantly interest in the diseases (Ortho procedures are cool but the diagnostics/diseases bore me to death).
Is there some sort of list of procedures a generalist does and ones he sends out or like of the core urology procedures?

Ortho folks recently told me to suck it up and do Ortho because (according to them) Ortho procedures pay "far" more and Uro will become mostly medical management in the future with improved cancer therapy and medical therapy in general, i would like to know your opinion on this as a practicing Urologist

I would caution you about making decisions based on what outsiders view as the future of the specialty. Im no orthopod, but I wouldn’t be shocked if in 20 years we do 20% of the spine surgery and joint replacements we do today. Lot of progress being made on regenerative therapies. Or maybe not. Who knows.

It is true that medicine in general progresses towards less invasive therapies over time. We operate less on non aggressive prostate and kidney cancer then we used to. It is also true that the best BPH meds are only slightly more effective then placebo. There is no potentially curative medical therapy for any urologic cancer. Ditto for stress incontinence. Ditto for hydrocele/varicocele, recon procedures, and so on and so on. 40 years ago we had thiazides and potassium citrate to prevent stones. Now we have . . . Thiazides and potassium citrate.

One perk of urology is that as the doctors of the urinary tract we are the ones who remain in charge of care as it gets less invasive. For example, we now almost never perform open surgery for stones. But it is urologists who do the endoscopic or percutaneous procedures. When that happens in the heart it goes from CT surgery to cardiology. Or GI surgery to gastroenterology. If it happens in ortho it may move to rheum, chronic pain, pm&r, etc.

 

[cpants]

Man this is tempting, I am very much leaning towards Urology for the variety, medicine/surgery mix, lifestyle and most importantly interest in the diseases (Ortho procedures are cool but the diagnostics/diseases bore me to death).
Is there some sort of list of procedures a generalist does and ones he sends out or like of the core urology procedures?

Ortho folks recently told me to suck it up and do Ortho because (according to them) Ortho procedures pay "far" more and Uro will become mostly medical management in the future with improved cancer therapy and medical therapy in general, i would like to know your opinion on this as a practicing Urologist

Ortho definitely does pay more, but urologists aren't exactly starving out there. Impossible to predict what practice will look like in 20-30 years. Urology was way different 20-30 years ago -- 20 years ago no robotics and limited lap surgery, 30 years ago still doing a lot of open stone surgery. 30 years from now, who knows? I would just keep it simple and consider factors like lifestyle, compensation, surgeries/diseases managed, and the job market. IMO, can have a great career in either field, but you need to figure out what's important to you.

 

[HighPriest]

You’re not going to starve doin uro or Ortho. IMHO, your quality of life trumps the pay. Unless you’re particularly lazy you’ll still be in the top 1-2% of earners in your state either way.

 

[Doc mu]

I would caution you about making decisions based on what outsiders view as the future of the specialty. Im no orthopod, but I wouldn’t be shocked if in 20 years we do 20% of the spine surgery and joint replacements we do today. Lot of progress being made on regenerative therapies. Or maybe not. Who knows.

It is true that medicine in general progresses towards less invasive therapies over time. We operate less on non aggressive prostate and kidney cancer then we used to. It is also true that the best BPH meds are only slightly more effective then placebo. There is no potentially curative medical therapy for any urologic cancer. Ditto for stress incontinence. Ditto for hydrocele/varicocele, recon procedures, and so on and so on. 40 years ago we had thiazides and potassium citrate to prevent stones. Now we have . . . Thiazides and potassium citrate.

One perk of urology is that as the doctors of the urinary tract we are the ones who remain in charge of care as it gets less invasive. For example, we now almost never perform open surgery for stones. But it is urologists who do the endoscopic or percutaneous procedures. When that happens in the heart it goes from CT surgery to cardiology. Or GI surgery to gastroenterology. If it happens in ortho it may move to rheum, chronic pain, pm&r, etc.

Yeah that's why i thought I would ask what you guys' opinion on this would be, that last point you made is a pretty big plus for uro though in the same vain wouldn't all kidney medical management go to nephros and same for all the cancers wouldn't the oncologists do all the novel chemotherapy? i am sorry if i sound ignorant it's because i am, i have no idea how these things work

 

[Doc mu]

You’re not going to starve doin uro or Ortho. IMHO, your quality of life trumps the pay. Unless you’re particularly lazy you’ll still be in the top 1-2% of earners in your state either way.

Yeah honestly after interest in the subject matter, a very big part drawing me to Uro is that i hear it has a much better lifestyle than ortho, though one thing bugging me is that the surveys for hours worked / burnout have Uro as working even more hours than ortho / being more burned out so i am really not sure what to make of that...

Sources:
Medscape: Medscape Access (Uro at 49% burnout vs ortho at 33%)
Annual Work Hours Across Physician Specialties (Uro at 264 hours above FM vs ortho at 216)
Specialty Profiles (Uro at 58.1 hrs/wk vs Orho at 57 hrs/wk)

 

[HighPriest]

So much of that depends upon where you practice, and what your practice consists of, and how you choose to practice.

Once you’re done with residency, you get to decide (usually) whether you want to work 10 more hours a week based upon whether the money is more important than your sanity. Frankly, most people pick the money. And they often burn out.

I always tell med students to understand the fun, interesting stuff a specialty of interest does, but also make sure you understand what their bread-and-butter stuff looks like. Because if you love the complex, rare stuff but hate the basic stuff, you’re going to burn out. There are a lot of reasons for burn out, but hating the crap you spend most of your time doing is a big one, and it’s avoidable.

I’m not a urologist or an ortho, but as an example: if I hated tonsillectomies and outpatient hearing evaluations, I would hate my life no matter how much I like neck dissections.

You can do a fellowship to try to avoid some things, but even then there’s going to be some equivalent thing that you gotta do every day.

If you can love (or even like) the little stuff, you can be happy.

And also make sure you set some @&$king boundaries on your life. You can’t do that when you’re a resident and so many people grow up and keep practicing that way as a staff doc.
If you share a call pool, and you get called from the ER when you’re not on call - don’t answer the damned phone. That’s why you have a call pool. If you’re on vacation, be on vacation. Unless someone is dying, stop checking your email. People burn out because their professional life eats their personal life. Or because they never develop a personal life.

 

[Doc mu]

So much of that depends upon where you practice, and what your practice consists of, and how you choose to practice.

Once you’re done with residency, you get to decide (usually) whether you want to work 10 more hours a week based upon whether the money is more important than your sanity. Frankly, most people pick the money. And they often burn out.

I always tell med students to understand the fun, interesting stuff a specialty of interest does, but also make sure you understand what their bread-and-butter stuff looks like. Because if you love the complex, rare stuff but hate the basic stuff, you’re going to burn out. There are a lot of reasons for burn out, but hating the crap you spend most of your time doing is a big one, and it’s avoidable.

I’m not a urologist or an ortho, but as an example: if I hated tonsillectomies and outpatient hearing evaluations, I would hate my life no matter how much I like neck dissections.

You can do a fellowship to try to avoid some things, but even then there’s going to be some equivalent thing that you gotta do every day.

If you can love (or even like) the little stuff, you can be happy.

And also make sure you set some @&$king boundaries on your life. You can’t do that when you’re a resident and so many people grow up and keep practicing that way as a staff doc.
If you share a call pool, and you get called from the ER when you’re not on call - don’t answer the damned phone. That’s why you have a call pool. If you’re on vacation, be on vacation. Unless someone is dying, stop checking your email. People burn out because their professional life eats their personal life. Or because they never develop a personal life.

Thank you for the detailed reply, this clears a few things up

 

[nymedstudent874]

Urology is bomb, but so is ortho, my residency ortho friends love what they do. In urology I will say, there is extreme diversity both in pathology and in terms of lifestyle as a urologist. Some attendings are extremely busy seeing 50 patients a day and doing 5-6 big cases on their operative days, and on the other end of the extreme there are those seeing 10 patients a day five days a week with one OR day every 1-2 weeks. The money is definitely higher in ortho from the data i've seen but that shouldn't be a reason enough to choose a field. Call is definitely less annoying for urology but its definitely not nephrology or dermatology call. My attendings definitely come in more often than not and thats in an academic environment, depending on your practice setting you may be the one coming in initially too. I would recommend rotating in both and choosing what you enjoy more.

 

[Doc mu]

Urology is bomb, but so is ortho, my residency ortho friends love what they do. In urology I will say, there is extreme diversity both in pathology and in terms of lifestyle as a urologist. Some attendings are extremely busy seeing 50 patients a day and doing 5-6 big cases on their operative days, and on the other end of the extreme there are those seeing 10 patients a day five days a week with one OR day every 1-2 weeks. The money is definitely higher in ortho from the data i've seen but that shouldn't be a reason enough to choose a field. Call is definitely less annoying for urology but its definitely not nephrology or dermatology call. My attendings definitely come in more often than not and thats in an academic environment, depending on your practice setting you may be the one coming in initially too. I would recommend rotating in both and choosing what you enjoy more.

Yeah i am waiting for the rotations currently (COVID delayed everything again) and all orthos and uros i talked to seemed glad they chose the specialty and both would actively encourage me on doing it (while ****ting on the other specialty lol), so i think that regardless of what i chose after rotations i wouldn't be making the wrong choice

 

[DoctwoB]

Urology is bomb, but so is ortho, my residency ortho friends love what they do. In urology I will say, there is extreme diversity both in pathology and in terms of lifestyle as a urologist. Some attendings are extremely busy seeing 50 patients a day and doing 5-6 big cases on their operative days, and on the other end of the extreme there are those seeing 10 patients a day five days a week with one OR day every 1-2 weeks. The money is definitely higher in ortho from the data i've seen but that shouldn't be a reason enough to choose a field. Call is definitely less annoying for urology but its definitely not nephrology or dermatology call. My attendings definitely come in more often than not and thats in an academic environment, depending on your practice setting you may be the one coming in initially too. I would recommend rotating in both and choosing what you enjoy more.

No doubt, both are great fields. I thought about both myself. By all means try to rotate on both and see which pathology/physiology/cases interest you more. Lifestyle/money (ortho usually better money, usually worse lifestyle, YMMV) are close enough you should choose based on interest and fit.

Also see which culture fits you more. Ortho, for better or worse, likes to focus on only bones and tends to defer management of patients and their ancef pumps to medicine. Urology is more like general surgery in that we manage our patients post op, though will still consult when necessary.

 

[ChordaEpiphany]

I would caution you about making decisions based on what outsiders view as the future of the specialty. Im no orthopod, but I wouldn’t be shocked if in 20 years we do 20% of the spine surgery and joint replacements we do today. Lot of progress being made on regenerative therapies. Or maybe not. Who knows.

Science shocks me all the time, but I'm finishing up a biomaterials PhD now and I don't think any of this technology is anywhere close to prime time. You see some amazing things in journal articles, but if you saw what it required in the lab you'd see how far off we are. To do things far less impressive than required to put most of it to practice, post-docs are doing rain dances and appeasing the gods of science hoping their protocol published in Cell works even half the time. Ortho is going absolutely nowhere. Medicine has tended towards less invasive therapies throughout time, and that could threaten surgeons, but people doing less invasive therapy have mid-levels breathing down their necks drooling at the thought of picking up simple procedures and stealing away bread and butter. So I guess it's a pick your poison situation.

Lifestyle/money (ortho usually better money, usually worse lifestyle, YMMV)

Am I crazy or is this just a reflection of culture in a specialty? If lifestyle is good and money is medium, couldn't you swap the two if you really wanted? It's hard to gauge how much everyone is getting paid, but transparent California or other open payroll databases give some insight. Among clinical professors (i.e., non-research, mostly clinical faculty) any given specialty might have a $200-300K range in compensation. So there are urologists making $300K and others making $600K, all with the same title. I assume this is just a reflection of picking up wRVUs, where some people have carved out a particularly lucrative niche or have simply chosen to work light/insane hours and pick up pay accordingly.