Dr. Mehta discusses the state of women in urology

In this interview, Akanksha Mehta, MD, MS, discusses her recent publication, “The past, present and future of women in the Unites States urological workforce”.¹ Mehta is an assistant professor of urology and the director of male reproductive health at Emory University School of Medicine in Atlanta, Georgia.

Akanksha Mehta, MD, MS

Could you provide some background on this paper?

This particular manuscript is actually 1 of a series of manuscripts that are going to be published on the state of women in urology. Our manuscripts are focused on the women in the urologic work force as they currently stand, what our hopes are for the future, as well as discussing some strategies on how we maintain the current work force and attract more women urologists to the work force in subsequent years.

What does female representation in urology look like today?

Depending on the survey results that you look at, whether it's the AUA [American Urological Association] membership survey or some of the Medscape surveys that have come out recently, the current proportion of women urologists in the overall urologic work force is around 11% to 12%. This is already an increase over the last AUA census that measured this number, which is wonderful to see. Hopefully this is a trend that will continue to increase.

We still remain underrepresented as women in the urology work force, however, when you take into account the fact that our patients are nearly 50% women. We are caring for a variety of patients who do not look like the physicians who are providing care to them. That gender discordance is very important in making sure that we are providing appropriate care to our patients.

What are some of the future projections for the urologic work force, and what impact will women in urology have on that?

Even though the current proportion of practicing women urologists is around 11%, the proportion of trainees that are actively in urologic training programs across the country is much higher, somewhere between 25% and 30%, which is really promising and gives us a glimpse into what the future of urology will be 10 to 15 years from now when these trainees are established in practice. There's certainly going to be an increase in the number of women entering urology practice.

If we look at the current distribution of where women practice within urology, they tend to be more likely to be fellowship trained, so to have subspecialty expertise. They tend to be more likely to practice in academic training centers, so where they themselves are having an impact on the training of the future generation of urologists, and often providing very advanced subspecialty cutting edge care for their patients. They are engaged in research; they're engaged in device design and optimization. So, they're really at the forefront of our field.

It's our hope that this trajectory will continue as more and more women enter the field. It's going to be really important for us to be mindful of the strategies that we implement, not only to bring more women into the field, but also to retain and support the women that are already here within urology. The priorities for the women who are in training or the women who are in practice or even mid-career are very different. We need to be able to speak to all of those different priorities at those different stages in training or practice.

What are some strategies for recruitment and retention of women in the urologic work force?

Recruitment into urology is a challenge. [With] the way the current medical school curriculum exists across medical schools in the United States, many schools do not have a formalized introduction to the field of urology for their medical students. Students will complete 4 years of medical school, sometimes with just 1 or 2 hours dedicated to urologic education. Many students will never actually complete a clinical rotation in urology. So, it's not unusual for students to go through medical training having very little knowledge of what the field of urology encompasses. That's the first thing to change. And I think the AUA as an organization can take an instrumental role in that.

Of the folks that do find out about urology and are fortunate to be able to rotate in our departments, for them to choose urology as a career depends heavily on how they see their faculty practicing, how much they see their faculty and the trainees enjoying their field [and] their patients and deriving satisfaction from the practices that they have. To the extent that we can offer flexibility in the breadth of urology and the type of practice patterns that as a field we support, I think that can be very helpful.

For many of our women trainees, they are going through training at a time that's also the peak years for their reproductive planning, and I think that's always a concern. We know that women surgeons are at increased risk for a diagnosis of infertility and for fertility-associated complications, even if they do not struggle with infertility. That can be daunting. It is a big ask of a trainee to have them sign up for a field that is demanding in terms of training, but also demanding in terms of non-professional commitments that they would otherwise make to their family life and their personal life.

It's important for us as a field to be able to recognize that and to support our trainees, whether it's through the introduction of parental leave policies that many schools are doing [and] that the [Accreditation Council for Graduate Medical Education] has also mandated and now that the [American Board of Urology] is trying to mirror. That's one thing. But to also think outside of the box, to be able to support lactation for those female trainees who may have young children at home that they're trying to breastfeed to be able to support participation at academic meetings. And AUA, again, has made great strides in this in being able to offer babysitting and child support services at the meeting. That has been a tremendous help for some of our trainees. Sometimes, the need for a flexible work schedule, or a shortened work week, or unconventional work week that allows for work on campus, as well as remote work is helpful. COVID has forced us to think about that, to some extent, so many institutions and practices have been able to implement that. That needs to be on the forefront for us as well.

And then lastly, I would say that in addition to the clinical roles that many women urologists play, many of them are also tasked with administrative roles that have little recognition associated with them. They can be a time commitment and a time sink without any benefit, either related to academic promotion or pay increases. That's something we need to be very mindful of to make sure that those administrative tasks are being assigned equally to all urologists in the practice or the department, not disproportionately to the women. On that topic, I'll also say that pay equity in terms of gender equity has been an important problem for all of medicine, and urology is no exception to that. Transparent reimbursement policies [and] making sure that we are informing our physicians of how they are making money compared with their peers fosters that collegial work environment where women feel that they have pay transparency and the opportunity to have pay equity. That's really important.

Your paper also mentioned this idea of the “leaky pipeline” for women urologists. Could you highlight this concept in more depth?

We were trying to illustrate the idea that although more women are entering the field of urology and staying within academia disproportionately compared with private practice, they do not quite get that same boost in terms of career advancement that some of their male colleagues do in the world of academic medicine. For example, women are less likely to be promoted, both overall and certainly less likely to be promoted at the same rate as some of their male colleagues. They are less likely to hold leadership positions, whether that be program director positions, or chair positions, or division directors, or other leadership roles at their institutions. This can be very disheartening for qualified individuals who have been through the same training [and have] the same experience, and do not get those same opportunities for career advancement. It can certainly put physicians at risk for leaving that academic setting, just given the increased frustration with their lack of professional advancement, and it may even place some women at risk for leaving the field of urology altogether, which would be a shame.

Seeing women in positions of leadership is essential to be able to attract more women into urology. I never appreciated that as a trainee myself, at least when I was applying into urology, but definitely appreciated it more when I was towards the end of my training. And I certainly appreciate it now, as I try to mentor other women trainees to enter this field. If we do not see people that look like us in positions of leadership, that is not a field that we're going to want to enter.

Is there anything else that you’d like to add?

I would just say that, as a follow up to the initial comment I made, this paper is certainly a standalone paper on this topic, but it is really an essential part of that entire series on the state of women in urology, so I would encourage the readers to look at all of the papers together to have a comprehensive view on how we can do better.

Reference

1. Nam CS, Luckenbaugh AN, Mehta A. The past, present and future of women in the United States urological workforce. Nat Rev Urol. 2023. doi: 10.1038/s41585-023-00744-z.