'We embrace diversity,' but must do more to compete

You’ve done some impressive work on diversity and the history of African-American urology. Tell me how you became interested in this topic and how you’ve developed a passion for it. 

I have always been very interested in history in general, and when I was interviewing as a urology resident applicant, it was really impressive for me to meet the thought leaders in the field. From there, through my introduction to the R. Frank Jones Urological Society, I have met other African-American urologists like myself. As I have aged, I believe it’s now my role to continue to make sure that the younger members of our community are aware of the history of African-Americans in urology and surgery in general.

Tell me about some of the key African-American urologists in the history of American urology and what they contributed.

It goes back to the name of our organization, the R. Frank Jones Urological Society. When we held our 2013 meeting in San Diego, I submitted an abstract to the history forum to talk about R. Frank Jones, who became the first board-certified African-American urologist in this country in 1936. He was known for several things, including doing a one-stage perineal prostatectomy. He made many other contributions, the most important of which was training 80% to 90% of African-American urologists in this country at that time point.

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Some of the current members of the society include W. Bedford Waters, the former president of the American Board of Urology; Cheryl Lee, who is at the University of Michigan; Curtis Pettaway, of MD Anderson Cancer Center; the society’s past president, Walter Rayford, who’s in private practice in Tennessee; current president, Kevin L. Billups, who is at Johns Hopkins; and many others.

What areas of interest do those urologists have?

Drs. Pettaway and Lee are both very well-respected oncologists. Dr. Rayford is in a very busy private practice in Tennessee, and does a lot of community outreach with educating large communities of African-American men about prostate cancer. Dr. Billups is the director of an integrative men’s health program.

Next: Current status of diversity in urology and how it compares to other specialties

Tell me what you think is the current status of diversity and integration in American urology and compare it to some of the other specialties.

I think it’s challenging. I would even step back and look at the number of students who start in medical school and come from diverse backgrounds, specifically the African-American background. Among medical students, African-Americans are predominantly female, much more than among any other ethnicity. The male-to-female ratio is closer to 50:50 among Caucasian Americans and Latino Americans, but among African-Americans, you may see one male student to four or five female students. While we are making strides in overall diversity, the African-American male student is being left behind.

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When I’ve looked at the data, the number of African-American applicants who apply to urology is very small. The number of African-American applicants who applied for urology between years 2008 and 2012 ranged from 31 to 39 applicants per year. While the number of women applying into urology remained a constant 24% to 25% in 2011 and 2012, the number of African-Americans is constant but much lower, at 7.2% to 7.7%.

I don’t know the number who matched, but it’s my opinion as a specialty that we need to not only keep track of the number of women and under-represented minorities that apply to urology residency programs, but have a plan to ensure a diverse work force.

To add on to that, I have looked at other specialties that are very similar in size to urology and also two competitive residencies-orthopedic surgery and radiation oncology. In orthopedic surgery, 5.3% of residency applicants are African-American and African-Americans represented 4% of the resident work force and 2.5% of the faculty work force. In the field of radiation oncology, 5.7% of residency applicants are African-American, and African-Americans represented 3.3% of the resident work force and 4.8% of the faculty work force. In our field of urology, African-Americans represent 4% to 5% of the resident work force and 1% to 2% of the faculty work force.

Let’s talk about the academic programs and departmental roles. How do we stack up in terms of diversity?

When you think about the end product-the faculty member who is fully invested, very similar to the opportunities I have been given at the University of Wisconsin-you see a drop-off. If you have 4% to 5% of residents who are African-American, that number gets smaller when you look at the faculty, and then when you look at tenured faculty, that number is even lower: 1% to 2% at best.

But based on this conversation and the kind of feedback that I have been given in my 11 years of practice, I do think that urology is very open minded and very much geared toward making sure that we are a diverse work force.

Next: "Hopefully we'll see more diverse leadership"

As you know, aside from the American Board of Urology, most organizations in urology today do not have either females or African-Americans on their boards or in leadership positions. Can you talk about why that might be and how we can change that?

Great question. I’m not sure I have the answers. Again, when you start with 31 to 39 applicants each year and fewer graduating residents nowadays pursuing careers in academic medicine, the pool of African-American role models in our field will remain very small. When I sent out a survey to the R. Frank Jones Urologic Society membership to determine practice type, we found out that 50% of African-American urologists in our society are in academic practice.

As for the lack of African-Americans in leadership positions, maybe we haven’t been given opportunities or perhaps there has not been an interest. For me, as an African-American urologist, I take a lot of pride in what several members of our society have accomplished and specifically Dr. W. Bedford Waters, who became the first African-American president of the American Board of Urology. That’s a point of pride. Hopefully we’ll see more diverse leadership and more opportunities for others, including myself.

You are the newly minted assistant dean of diversity and multicultural affairs at the University of Wisconsin. Tell us what your role is going to be there and what specifically you are going to try to do.

Thanks for the opportunity to comment on something I am incredibly excited about. Also, I would like to extend my congratulations to you, Dr. Nakada, on receiving the University of Wisconsin’s 2014-2015 Faculty Equity and Diversity Award, which recognizes a faculty member’s personal commitment and efforts to support a diverse and inclusive workplace.

My new appointment is an opportunity for me to make a small imprint on a very prestigious university with a long history of outstanding accomplishments. I will be helping to shape the leadership and vision of our university in recruiting more under-represented minorities to Madison, which not only includes African-Americans but also Native Americans, Latinos, and under-represented Asians/Pacific Islander people groups such as the Lao Hmong (second largest Hmong population per capita in the United States is in Wausau, WI). If we can establish a critical mass of diverse students in all health care sciences (medical school, physical therapy, physician assistant, pharmacy school, etc.), hopefully it can make us more competitive in recruiting students to our residency programs.

I was recruited as part of the University of Wisconsin School of Medicine and Public Health’s Centennial Scholars Program, which was established by our dean, Dr. Robert Golden. It is a way to recruit talented, under-represented minorities to the University of Wisconsin and then to support them through grant money to help them be successful. What is very imperative in my new role is to begin to establish  an effective pipeline of undergraduate students who are interested in careers in medicine to faculty who can serve as formal mentors and inspiring role models at our medical school. On most campuses, the students in training and faculty are both unaware that each group exists and can support one another.

Based on that, what does organized urology need to do?

I think the AUA should consider forming diversity work force committees or establishing a diversity office similar to what has been established in the American Academy of Orthopaedic Surgeons. I think the analogy of how master-planned residential communities are built is relevant. When master-planned communities are just in the conceptual stages, they determine how many grocery stores and restaurants to build and they know the exact demographics that they’re looking for to buy homes and live in that community. In the field of urology, we need to equally be as intentional in planning the steps to ensure a diverse work force.

Next: How much do patients direct need for diversity in urology?

How much do you think patients in the general public direct the need for diversity in our field?

I am not sure that patients articulate this to providers by what they say as much as what they do not share in a patient encounter. A diverse work force takes into account the differences in language, communication styles, cultural values, and attitudes in our patients.

The goal of each provider should be to establish a therapeutic alliance with each patient; hopefully, patients leave our offices with a clearer understanding of what we have recommended and a higher rate of patient compliance.

I believe we can learn from the work done in cancer centers, which utilize patient navigators to serve as patient advocates embedded within the clinical care practice. A recent study published in Cancer (online Jan. 6, 2015) analyzed the impact of patient and patient navigator race and language concordance on care after cancer screening abnormalities. Charlot and colleagues found that both language concordance and race concordance improved health care delivery. Specifically, Hispanic patients who had Hispanic navigators had an 80% or greater likelihood of having timelier resolution of cervical cancer screening abnormalities. African-American patients who had African-American navigators were 50% more likely to have timelier resolution of cervical cancer screening abnormalities.

This work highlights the importance of taking into account patient diversity and the impact a diverse work force can make in improving patient care outcomes.

Do you have any final words for the various constituents involved in diversity?

Diversity is more than just gender and race. It is also diversity of thought.

Diversity has made our country great, it’s made our specialty great, and I think we need to monitor diversity. I go back to the master-planned community approach, which shows that you are able to improve on things that you measure. Metrics are very important. We need to be very measured on our outcomes and know what urology will look like in 2030.

If we are not invested in that, it may look like we have very few under-represented minorities and women in urology and very little diversity. We are competing with others specialties, such as orthopedics and radiation oncology, so we need to be very much at the table and make a plan. That plan may include the creation of a formal office within the AUA to invest in those efforts.

Based on where you sit right now, do you feel the future for diversity in urology is bright?

I do feel that the future of urology is bright. It’s bright right now in terms of diversity. In our department alone, we have myself as a faculty member, we have graduated our first African-American female, and we have two African-American urology residents currently in our program.

Additionally, in a survey I conducted with the R. Frank Jones membership, I asked a very important question: Were there other African-Americans training with you at the time? I was astounded that over 50% said they were in training programs with other African-Americans. So I think the future of urology is bright in terms of diversity, but we need to continue to be competitive as we attract the best and brightest across all ethnic and gender groups.

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