Improving diversity in the field of urology

Even in the year 2021, urology remains a field of medicine that struggles with diversity, equity, and inclusion. In a recent interview, recipient of the Society of Women in Urology’s 2021 Outstanding Resident Award, Efe Chantal Ghanney Simons, MD, discusses the improvements that are needed for women in urology. Specifically, she addresses common stigmas and misconceptions associated with women in this field as well as why female medical students and residents should consider pursuing this subspecialty amidst the active gender gap. Ghanney Simons is a PGY5 urology resident physician at the University of California, Los Angeles.

What does the Outstanding Resident Award mean to you?

It means a lot because of how I won it. Last year I was in my fourth year of urology residency at UCLA, andwas on my research year. And during that time, I really had been intentional about seeking out mentorship for my professional development but also about providing mentorship to women, particularly women of color who were interested in urology and who were applying into urology. These women got together and wrote excerpts on their lived experiences in navigating urology and how the mentorship I had offered had helped them during the application season. This award is deeply personal but also very much communal because it does not represent my individual achievements as a resident but rather serves as a platform to highlight how challenging the process of applying to urology can be for individuals who typically have not had access to the table. These women are now dear friends.

What prompted you to pursue urology as a specialty?

Urology was not my first pick! I had thought of myself as being a future geriatrician. I thought I was going to go into palliative care. That's how I had fallen in love with medicine to begin with. However, come third year, on my surgery rotation I absolutely fell in love with the operating room. And I knew that the operating room was a space I wanted to be in. Actually, the day this realization dawned on me, I remember going back home, calling my mother who was in Ghana, and just crying and saying, "My life [is] over. I'm going to be a surgeon. I'm never going to be a good mother like you were to me." And then I took a step back from the theatrics and realized that there was a way for me to be able to take care of the patient population that was so near and dear to my heart, and still be able to be a surgeon. With that in mind, I rotated through every single surgical subspecialty my medical school had to offer (except Orthopedic surgery) and urology was it. In part, because a lot of our patients are old. Not all of them, but a good proportion of them. Urology allowed me to care for the patients I was so drawn to and still become an excellent surgeon.

On a separate note, I have always known that one of my callings was to be a conduit of resources and education between the institution I establish a career at here in the United States, and my home country of Ghana. My hope was to be able to actively engage in a field of medicine where I would be a part of closing a need gap. If we are all tools in a toolshed, then I would be a connector of sorts. At the time I was contemplating urology, there were only eight urologists in the entire country of Ghana, which had a population of 30 million people! All eight urologists were men!

Although women are becoming increasingly prevalent in urology, they are still outnumbered by men. What challenges do you face as a woman working in a specialty that is mostly male, when it comes to both working with colleagues and seeing patients?

I had thought that there would be more pushback from patients. In Urology we have the privilege of carrying out extremely sensitive discussions ranging from fertility and erectile dysfunction to issues related to voiding. I had had the misconception as a medical student that those intimate conversations meant that patients may be uncomfortable with me as a woman providing their care. I've been pleasantlysurprised at how infrequent that occurrence has been. It happened once when I was a med student, and I want to say maybe twice as a resident, and I'm currently a fifth-year resident. I think a large contribution to the challenge of urology training as a woman comes from systemic issues that are not necessarily related to the specialty itself. For instance, we happen to be a longer training program and UCLA, in particular, is 6 years instead of the traditional 5. This length of training poses restrictions if you're one who wanted to start a family for instance. Think aboutmaternity leave, and how feasible or not it is for a trainee. On a separate note, I think that sometimes there can be instances where there's a bit of the ‘old boys’ club’ when it comes to career development. If you're not around when conversations are being had about the new trendy research project, or if you don't have that 1-on-1 guidance, it can be challenging navigating things like applying for fellowship or applying for a job. I've been very fortunate that most of my mentors in my residence program have been incredibly supportive. Most of them have been men so it certainly is not a mutually exclusive situation. I can imagine though that not every single female trainee has the level of sponsorship that I have received particularly from my faculty advisor, Dr. Christopher Saigal, and my department chair, Dr. Mark Litwin.

What sorts of steps are needed to improve diversity and equity in urology?

Diversity tends to speak of a numbers game.When you look around the room, is there a variety of individuals who are present? If you start thinking about recruitment at the medical school level or university level, we're probably a bit too late. Early engagement of the world of urology with high school, with middle school, with college, [and] getting people to know the field is [very important]. Using myself as an example I did not discover what urology was until I was a third-year medical student. We can be proactive about exposing our specialty to individuals, particularly [in] medical schools that don't have departments represented, or just getting young folks excited about medicine quite early on. If we're talking specifically about gender, however, we've started to see a shift in medical school where, at this point, I believe there are more women going to medical school than there are men. If that's the case, it's a little troubling that within the field of urology, we still have such a low representation. But that number is rising. I believe 27% of residents this past year were women, and that's in contrast to 9.1% of practicing urologists being women. So, I imagine that over the course of the next several years, our demographics will change.

But numbers aside, the real big shift would be inclusion and equity. Inclusion is creating an environment where people feel as if they belong. That's a tough call because that really requires interpersonal change: how we interact with people, how we speak with one another, how we are considerate with one another. And those cultures tend to be something that have to be initiated from the top down.

When it comes to equity, if you want to have more female trainees, it probably is a good idea to have support in place for things like maternity leave. Same is true for paternity leave, but I think especially so for women. Those are some of the things that we can start to have open conversations about and not stigmatize. There are places where people make exceptions when the one resident gets pregnant but creating a system where an individual has to advocate for these rights when they are in a unique situation, makes that individual an outlier and can result in that person being stigmatized for the burden they place on an underprepared system.. The logistics of call coverage and case coverage when not addressed ahead of time may create tensions within the department that the trainee may have to bear often in isolation. If the status quo however is, "This is our policy. This is how it's done," so that a resident is not having to ask, you've automatically created an environment that's more inclusive. That is my challenge for residency programs. How can you create systems where a resident is not having to push to advocate for basic human needs, and that the system has established that pregnancy, a normal human function that we all are dependent on for ongoing life, is within the realm of norm and not an outlier?

What advice would you give a female medical student who might like to pursue urology?

Urologyis such an incredible field! It's the hidden gem of medicine. We all talk about how it's the best specialty ever, but it's the best surgical specialty for sure. And you can do it if you want to.There are so many misconceptions about whether or not you can do it because of board scores or STEP scores, whether or not you can do it because patients won't let you, whether or not it'll be weird if you're the 'male doctor'. First of all, men and women have kidneys. They have bladders too; they get kidney stones. So, you're not pigeon-holed to a specific patient population if you became a urologist. And there's also the misconception that if you're a woman and you're a urologist, then you're only going to see women because they're all going to flock to you. To some degree, that is true. But at the same time, I want to challenge that mindset because I think more and more, we're living in a world where people are understanding that skill matters, empathy matters, and if you have that, I think you are equally going to be able to treat men and women. Lastly, don’t be your own barrier is what I would say. If this is something that you even have an inkling of an interest in, explore it. And then if you decide you don't want to, at least you made an informed decision.