Introduction

Diversity in the U.S. population has shown a steady increase in the last decades followed by an increased interest in diversity in healthcare to reflect the population that is served.¹ Care from providers who share similar background, including gender for urology female patients but also racial and ethnic concordance in physician-patient relationship has been associated with higher patient satisfaction, decreased reports of patient mistreatment, and improved patient decision making.^1-3 Despite awareness and interest, the increase in diversity in the U.S. population has rapidly outpaced the Urology workforce in the country. In the 2019 US Census, 18% of the population was Latinx/Hispanic.^3,4 The most recent data from the American Urological Association (AUA) Census in 2020 showed that 497 (3.8%) of practicing urologists, both male and female, were Latinx/Hispanic.⁵ Representation of women in the AUA Census increased since 2019, with a 10.3% of practicing women from 2% in 1980, to 7.7% in 2013 and 10.3% on the most recent AUA census.^5,6 However, the census does not provide a breakdown of Latina women currently practicing in the United States.⁷

Other than ethnic/language congruence between patients and physicians than serve them, there are other benefits of diversity in the healthcare workforce. Diverse teams may have better outcomes and are more innovative.⁷ There is an impetus to improve representation of women and underrepresented minorities in medicine. Having said that, urology is lagging other fields in medicine in racial and ethnic diversity.^3,8

Women in urology residency in the U.S

Even though women representation in Urology has shown a slow growth throughout the years, urology has traditionally been a male dominated field. Back in 1980, women represented less than 2% of the residents in training.⁶ Recently, Ghanney Simons et al. investigated the diversity in graduate medical education in Urology in the U.S. with a total of 5.7% Latinx/Hispanic urology residents. They highlight a key point in that diversity in the physician-scientist population will improve and ensure diversity in patient recruitment for research trials. This may be due to the innate trust that is easier to foster when the physician population mirrors the communities they serve.⁷

Marthi et al. evaluated the available data from the Accreditation Council for Graduate Medical Education (ACGME) from 2019 and 2020 and compared the information to the national racial, ethnic and gender distribution from the 2019 U.S. Census. This estimated that 60.7 million of the U.S. population were Hispanic/Latino, representing 18% of the total population. By calculating the percent differences in representation in urology residency programs in the U.S., the authors found that from 1734 urology residents, 27% were female and 14% were URM. When analyzing this data, results showed that women and URMs were significantly underrepresented in urology residency programs with a negative difference of 14%.³

Diversity in other medical specialties with greater Hispanic/Latinx representation include psychiatry, family medicine, obstetrics and gynecology, general surgery and internal medicine.^3,9 Potential causes of underrepresentation from URM in urology can be explained by lack of URM mentors and structural barriers limiting URM from entering competitive specialties like urology. The shortage in URM urologists in academic leadership positions has been documented, with 96% being Non-Hispanic and 79.9% men.¹⁰ Additionally, there is a higher percentage of women physicians in the URM applicant pool, and women, too, are underrepresented in urology.^3,11

One other potential explanation for underrepresentation of URM and women in the urology match can be related to a different experience interacting with urology trainees and faculty before and during the application process.¹² An anonymous survey of 136 applicants of the 2020 Urology Match showed that among 85% of applicants from URM reported that URM residents, faculty or leadership at an institution had a favorable impact on their rank list. Most importantly, URM ethnicity was an independent predictor for URM students ranking a program higher due to a higher proportion of residents, faculty or leadership.¹²

International Medical Graduates in Urology

Halpern et al. examined Urology Match data from 1987 to 2015 to evaluate the trends of international medical graduates (IMG) representation within urology and compared it to other specialties.¹³ Match rates for U.S. medical graduates are between 68-90% compared to 6-33% for international medical graduates (IMG). Interestingly, the proportion of IMG in other specialties remained stable throughout the years, but in Urology there was a significant decline from 27% to 5% over three decades. The authors discuss different options to explain this decline, including the increase in U.S. medical graduates, also explained by the 17% expansion in U.S. Medical Schools. They also highlight the fact that Urology has become a highly competitive surgical specialty and the high cost of the match process. As part of the selection process, program directors place importance on the prestige of an applicant’s medical school, and many of the prestigious international institutions may not be well known in the U.S. by those involved in the selection process.^13-15

IMGs also face challenges beyond training, including isolation or insensitivity at work, as well as different degrees of discrimination. The authors highlight four areas where IMGs face challenge during residency: simultaneously navigate dual learning curves as immigrants and residents; insensitivity and isolation in the workplace; migration personal and global costs and specific IMG needs to complete residency training.¹⁶

IMGs play a key role contributing to diversity in the workforce particularly in academic research and help decrease the gap between the high demand for urologists in the country as the US population continues to grow.¹³

Strategies

Dai et al give an insightful perspective on strategies to improve recruitment and retention of URM and women in Urology. Focusing on increasing early exposure and opportunities for medical students, fostering networks, creating career mentorship during and after residency support the professional development of female urologists of URM.¹

Early mentorship, a diverse faculty and residency cohorts that medical students can identify with has been associated with an increased number of students who match into urology.^1,17 Continuing these strategies throughout residency that support URM and female urology residents during their surgical training will also impact retention of trainees.¹ In the past couple of years, increasing research in the topic of diversity in graduate medical education has shed light on this important topic raising significant awareness. As a result, new initiatives have been built around the topic and are widely available for Hispanic women training in the U.S.¹⁸

Urologists for Equity, a group centered leadership was developed in order to create a community to propel meaningful changes in diversity, equity and inclusion in our field.¹⁸ Society of Women in Urology, which started in 1980 by five female urologists, is currently a large and key group for women at all levels of training in urology. It comprises the largest and strongest mentorship group of female urologists. An active society that offers an annual meeting with multiple opportunities for women and URM to network and share research ideas. But most importantly has opened a formal space for mentorship, grant funding and advocacy.^1,18 The Society of Academic Urologists created a task force in 2018 called “Recruitment and Retention of Women and Underrepresented Minorities in Urology LatinX in Urology,¹⁸ created by two Latina medical students in 2020 who seized the opportunity offered by social media to connect LatinX urologists in the United States in order to create mentorship, celebrate LatinX urologists and in that way motivate other medical students of URM to pursue a career in urology.¹⁸

The R. Frank Jones Urology Interest Group ran by Urology Unbound are increasing national awareness and provide mentorship to women and URMs.¹⁸ The Under Represented Trainees Entering Residency (UReTER) program is a formal mentorship program developed in 2020 at the University of California, San Francisco (UCSF) as a resident led mentorship program that matched URM residents and fellows with URM medical students interested in urology during the residency application journey.¹⁰

Ongoing efforts of building a clinical and academic environment that welcomes a diverse group of trainees and urologists will increase the representation of URM women in urology and will attract and recruit more women to this field.¹ Mathis et al highlight that there needs to be deliberate and active recruitment of diverse applicants and established effort to limit and prevent implicit bias when reviewing women and URMs residency applications and during the interview process.³ The authors in this study call for program directors and faculty to actively diversify their programs and also suggest training on implicit bias during resident application review and also provide a safe environment for female and URM students, residents, fellows and staff to provide networking, mentorship and collaboration.³ The value of increasing the Latina population in urology serves to achieve congruence between physicians and patients to provide better care, recruit diverse populations into clinical trials, and to continue innovation in urology.

Academic training institutions need to be more than “mindful” of diversity, equity and inclusion (DEI) which has been a recent tagline. Recruitment and advancement should be an active process. URM faculty need support to have time and resources to serve as mentors to medical students and trainees. Hospitals and clinics serving URM communities should seek healthcare providers who are congruent with the populations that they serve; this creates a demand that will encourage training of women and URM. In the last decades, there has been and increasing number Latina women in urology that have earned leadership positions in the U.S, opening a new door for younger generations as exemplary role models.

Awareness of international training standards and institutions should help program directors evaluate more fairly IMGs for consideration into urological training. Structural barriers like United States Medical Licensing Examination (USMLE) STEP scores becoming “pass fail” should favor consideration of other important factors like academic productiveness in research, community outreach and advocacy. There is no logical or scientific reason why the urology workforce should not mirror the population of the U.S.