Urology work force faces gender pay gap, shortage

Angela B. Smith, MD, MSMultiple recent studies point to a shortage in the urologist work force. In addition, while the number of women entering the field is growing, their compensation is not commensurate with that of their male colleagues. In this interview, Angela B. Smith, MD, MS, discusses two work force problems in urology, discrepancies in male and female urologist compensation, and solutions for these issues. Dr. Smith is assistant professor of urology at the University of North Carolina, Chapel Hill. She was interviewed by Urology Times Editorial Consultant Stephen Y. Nakada, MD, the Uehling Professor and founding chairman of urology at the University of Wisconsin, Madison.

Is there a work force problem in urology?

Yes, there are two problems. The first problem is that the supply of urologists has not kept pace with population growth-something that may be exacerbated by an aging urology work force. The second problem is the declining number of urologists practicing in rural settings. More than half of counties in the United States are without a urology provider, and rural urologists are less satisfied and less likely to choose medicine again, according to a recent work force study. The lack of rural urologists is likely to worsen since young urologists are more likely to work in urban and suburban areas. This is a clear gap highlighted in the AUA Annual Census.

Is the fact that not all urologists work full time an issue?

I don’t see this as an issue if we are smart about maximizing our current work force potential. It’s true that in the last decade, there has been more of an emphasis on quality of life compared to hours worked-both among men and women. A recent study found that less than 20% of the female urology work force work part time, and over 70% work more than 50 hours a week (Urology 2016; 91:1-5), and the AUA Census reported equal median work hours of 55 for both men and women. Looking at this singularly, less work hours could translate to expedited work force shortages. However, fostering an environment that allows for part-time work may increase overall job satisfaction. An increase in job satisfaction, especially in an era of serious physician burnout, will be vital for maintaining our work force. Part-time physicians can be a vital addition to addressing workforce shortages-filling in much-needed gaps in care, especially in rural settings.

Next: "We found that women were being compensated by about $76,000 less than male urologists."

Please provide an overview of the status of the urology work force with respect to gender.

My collaborators and I recently published a paper looking at how job satisfaction and work force issues differ between male and female urologists (J Urol 2016; 195:450-5). We surveyed practicing urologists in the United States and had a little over 700 urologists respond, of whom 90% were men and 10% were women (which reflects the current demographic makeup of the urology work force). In this survey, we wanted to get a sense of job satisfaction and differences in job type, as well as compensation.

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First, we found that female urologists were younger than male urologists, reported fewer years in practice, and were more likely to be employed in a practice or academic setting, findings consistent with that of the AUA Census. We wanted to study how these variables impacted compensation and whether there were differences between men and women when controlling for these additional factors. Previous studies had shown that women are compensated less, but this was believed to be secondary to younger age, practice type, and hours worked. When we controlled for a number of key variables such as these, we found that women were being compensated by about $76,000 less than male urologists. But this wasn’t the total picture-because despite these differences in compensation, job satisfaction was preserved and equivalent between men and women.

This is an important and timely topic right now because if you look at differences between the 2014 and 2015 AUA Census, women are a growing proportion of the urology work force. Approximately 18% of practicing urologists under age 45 are women, whereas only 8%-10% from 45-55 years and beyond that 3%. We’re seeing this rise because there’s a higher percentage of women in urology residencies now. According to a recent study published in Urology, about 25% of urology residents are women, which is a big difference from even a decade ago, when it was less than 10% (Urology 2016; 92:20-5).

What are some of the ways to correct this compensation differential?

The very first step is creating awareness and promoting compensation transparency. A lot of people ask me if I was surprised by our results, and my answer is no-because the literature in other fields of medicine and non-health care professions clearly show compensation differences between men and women. But it did come as a surprise to many others. Employers need to understand this differential exists. Even if unconscious bias is the root of the problem, being open to transparency in compensation (and determinants of compensation) will promote fairness and equality.

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Second, I think there are issues with how women negotiate as well as how women are perceived when they do negotiate. That has been borne out in the literature as well. A study of graduates applying for their first job found that 60% of men negotiated for their salary, whereas only 7% of women did the same (Psychol Bulletin 2015; 141:85-104). In that same study, when negotiators had negotiation experience, the gender differences favoring men were reduced. In my opinion, part of it is understanding how to negotiate as a woman and some of it is awareness and transparency among employers.

Next: Role of training programs

What role do you think training programs can play in ameliorating problems in both work force and gender?

That’s a good question. There’s a lot of value in working in rural communities, and I don’t think that is emphasized in urologic residencies because many of them are academic centers, in urban areas where research is emphasized. Research is certainly important, but equally important is serving the community, and there are certainly urologists who, if encouraged, would seek that opportunity. It would be beneficial if residents were somehow exposed to this opportunity-whether it be a short rotation, mentorship by practicing rural urologists, or understanding how to set up a practice in this setting.

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With regard to gender problems, I believe that good mentorship is critical. The value of having a mentor who can guide female urologists in the area of professional development can’t be overstated. Strategies of negotiation, confidence building, styles of communication-all of which can be different between men and women-are valuable life-long skills that can be developed during training.

Do you think that these are elements that you could have assessed when you were looking at residencies?

Looking back, I think it’s very difficult to assess these elements during residency interviews. One good clue, though, is whether a formal mentorship program exists within the residency. Formal mentorship is a great sign (although not the only sign) that you will have support to realize your career potential. I also think that programs that provide a diverse clinical experience (perhaps a rotation in the private as well as academic setting) can be very useful when deciding on what fits your career preferences.

How about when you took your first job? Were you able to look at those parameters at that level?

Quite honestly, I didn’t look into these parameters-I didn’t realize then how important they are. Fortunately, I ended up with co-workers who offer valuable mentorship and support transparency in compensation. I also have received quite a bit of mentorship and attended several professional development seminars that have strengthened my negotiation skills. Even if you’re in a job that doesn’t offer mentorship, there are ways to gain that experience on your own.

Next: How would you advise a young urologist who is female to pursue these types of opportunities?

How would you advise a young urologist who is female to pursue these types of opportunities?

The very first thing I would recommend is to educate yourself. There are excellent books about negotiation, time management, and about advocating for yourself and understanding the job that you want to create for yourself. Coming in prepared to your interview so that you understand what to ask ahead of time can increase your self-confidence and make you appear more confident to others. The preparation allows you to advocate for the things that are necessary to advance your career. For example, if you’re interested in research, understand what kind of start-up funds you might want to request. Understand the salary and how it might change over the course of the first 5 years of your faculty position. Ask about how junior faculty are mentored, supported, and developed.

What can urology department chairs do to make this more equitable?

Again, awareness is key-and understanding that unconscious bias exists. Transparency is a great place to start because it lays everything out on the table. In many cases, I think compensation differences surprise people because there is no transparency. With most positions, you won’t know what your peers make unless you ask. Understanding the reasons why compensation is different (eg, work relative value units, grant funding) goes a long way toward promoting equity and trust among faculty. I also would encourage chairs to be open to negotiation while understanding that unconscious bias exists based on gender. Unfortunately, when women negotiate, they can be sometimes viewed as ungrateful. When men negotiate, it is often seen as a strength. Simply being aware of this unconscious bias can eliminate some of these stereotypes right off the bat.

Next: Short-term, long-term future for work force and gender in urology

What do you think the short-term and long-term future holds for the work force and gender in urology?

I’ll tackle gender first. I think we’re narrowing the gap. I think things are improving. We are getting a better sense of what the issues are, and we’re discussing them openly. Our entire work force is changing, and the proportion of women in urology is rising. We need to show that we value women so we can create a diverse work force that’s able to keep up with patient demand. If 25% of our work force will be women, based on urologic residency projections, then we need to do a better job of valuing that demographic starting with fair and equal pay. We also need to be open to part-time physicians and recognize the value that they provide to our work force.

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With regard to the overall work force, we need to get a better sense of average hours worked and anticipate that these may decrease with time. We need to stay ahead of this by brainstorming creative solutions to keep up with patient demand. While solutions may include training more residents or employing non-physician providers, additional solutions could be the use of telemedicine so that we can better stretch our resources across the demand. Telemedicine could address the shortage of rural urologists by providing urologic care to this underserved patient population.

Could non-physician providers have an impact on the work force shortage?

Absolutely. In our study looking at the work force, a majority of urologists used physician extenders, and the biggest growth in providers overall were in the physician extender category. However, we need to get a better sense of how we best envision their role. Are we going to have them perform certain procedures? Are we going to have them work in clinic or consultations in the inpatient setting? Can they be used as extenders for rural satellite settings with rotating physician oversight?

Given the number of different possible roles for physician extenders, we need to set forth guidelines on how to effectively train these providers so that we’re confident in their ability to provide the same quality of services provided by urologists. Ensuring consistent and reliable training will be critical to understand how we incorporate them in a systematic and uniform way across the United States.

It seems like you think there’s a light at the end of the tunnel here. Is that right?

Yes, I think that we’ll adapt. I think that we are already ahead of the curve by administering the AUA Census and understanding these issues before they get out of control. If we can highlight work force gaps now and figure out solutions, I think that we will be able to get to where we need to be 10 years from now.

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