Racial and ethnic minorities are the primary seed for the growth of our nation. According to the U.S. Census Bureau projections, “Minorities will be the source of growth in the nation’s youth and working-age population, its voters, its consumers, and its tax base as far into the future as we can see.” By 2060, the Hispanic/Latinx community will comprise 32% of the population under 18 years, while Whites will comprise 36%.¹

As our nation undergoes these changes in its demographic landscape, we observe how structural racism, divisive political events and a devastating pandemic expose our existing health care system’s inequity. Improving health inequity is not only a social justice issue–it is an important economic issue. If our health care system will live up to the standards of health equity for all those who reside in our nation, we must put our boots to the ground and ensure our health care workforce reflects the rich diversity of our patients. We must expand our Latinx urological workforce, from early investment in youth and science, technology, engineering and mathematics (STEM) education to recruitment, retainment and promotion of Latinx surgeons, health care leaders and innovators. Herein, we share a framework to begin reaping the benefits of diversity.

There is no universally accepted term for the population we describe as Hispanic, Latino or Latinx. Latinx (pronounced La-TEE-necks) is used as a gender-neutral neologism referring to Latin American cultural or ethnic identity in the United States. Hispanic includes Spaniards and emphasizes a shared language, whereas Latino includes Brazilians, underscoring a Latin American origin. People who identify as Hispanic, Latino or Spanish may be of any race or combination of races. Therefore, Latinx is considered an inclusive term that represents many cultures and nationalities within one broad umbrella. From here on, we will utilize Latinx as defined above.

Unique aspects of this patient population. Currently, 18% of the U.S. population is Latinx, with some states having a higher proportion than others of this growing population (see figure). Latinx patients have unique medical, cultural and socioeconomic considerations. Mexican Americans and Puerto Ricans make up more than two-thirds of the Latinx population.² The Latinx population is younger relative to other minority groups and is growing at a faster rate. Despite this population boom, the Centers for Disease Control and Prevention (CDC) reported that 18% of Latinx were uninsured in 2017 compared to 9.1% of the total population.³ This is the highest rate of uninsured status of any minority group. There are several reasons for this inequity. First, the U.S. health care system assumes that most individuals will obtain health insurance through their employer. However, 9 million of the 11 million Latinx who do not have health insurance live in a household where at least one person is employed.⁴

Figure. Total Hispanic population growth in the U.S. from 1970 to 2019. Source: https://www.pewresearch.org/fact-tank/2020/07/07/u-s-hispanic-population-surpassed-60-million-in-2019-but-growth-has-slowed/ Accessed Feburary 16, 2021.

A large portion of the Latinx community is made up of immigrants (most often legal residents or citizens, sometimes undocumented). Immigration status can be prohibitive for employment with insurance benefits, even if the individual is not undocumented. Limited English proficiency and the lower rate of formal U.S. education mean that many Latinx have jobs that don’t offer health insurance. While the Affordable Care Act improved access, many in the Latinx workforce still experience significant cost barriers and fears due to the public charge rule, immigration status and fear of deportation, which prevent them from seeking coverage. As a result, many of these patients are cared for in ways that are frequently overstretched and under-reimbursed.⁵ There is a documented 50% higher death rate from diabetes, 24% higher likelihood of having poorly controlled hypertension, 23% likelihood of being obese and 28% lower likelihood of undergoing colorectal screening.² Despite their overall underrepresentation in the physician workforce, Latinx and minority physicians account for the overwhelming majority of providers delivering care to this underserved population.

More Latinx physicians, urologists (community and academic), and National Institutes of Health (NIH)-funded researchers are needed to address health inequity. The Association of American Medical Colleges (AAMC) in 2018 reported that 5.8% (53,526) of the physician workforce and only 3.2% (5,734) of U.S. medical school faculty are Latinx.⁶ As of 2019, the American Urological Association (AUA) reported that 3.9% (495) of practicing urologists in the United States are Latinx.⁷ Finally, the National Institutes of Health reported that in 2018 Latinx researchers held roughly 4% of all funded R01 grants. With this background, we propose several action items for the urological community (see Appendix).

We must nurture an early pipeline of Latinx students to pursue careers in urology.⁸ Pipeline programs are required to increase the number of qualified urology applicants from diverse backgrounds, starting with high school exposure or earlier. Despite a 2009 task force to increase diversity among medical school applicants, underrepresentation has not changed significantly. In 2018–2019, the AAMC reported that 6.2% (3,297) of all medical student applicants were of Latinx origin. Providing mentorship to Latinx and underrepresented students is a priority.⁹ For the urology workforce to reflect the Latinx population, we would need to match 77 Latinx applicants yearly for 20 years with no workforce attrition.⁷ Funded research and/or clinical shadowing opportunities for Latinx students throughout undergraduate or medical school training are opportunities for the AUA and specialty organizations. Also, attention must be paid to a rich network of medical schools in Puerto Rico, for example, which boasts 4 Accreditation Council for Graduate Medical Education (ACGME)-accredited medical schools that graduate hundreds of Latinx students a year, most of whom are fully bilingual U.S. citizens. Many establish themselves in the mainland United States to undergo residency training.

Anti-racism training, continued mentorship, and clinical support are essential to recruit and retain diverse faculty. Latinx physicians are a multiracial population and very likely to experience racism and stereotyping at their institutions, leading to lower job satisfaction and lower promotion rates. Recruiting, retaining and promoting Latinx physicians require concerted efforts, including the involvement of champions from outside the Latinx community. Latinx urologists taking care of Latinx patients may require additional resources. Depending on insurance, they may be reimbursed less for having a predominately uninsured patient population, with fewer resources with which to practice.¹⁰ For example, additional support may be needed to ensure that research and clinical trials include a diverse patient population and reflect patient-centered aims.

Partnering with existing organizations that mentor Latinx trainees will nurture the workforce pipeline. The Latino Surgical Society (https://www.latinosurgicalsociety.org) was started by a group of Latinx surgical residents to advocate for Latinx surgeons’ issues and now has representatives from different subspecialties. The R Frank Jones Urology Interest Group, along with nonprofit organizations like Urology Unbound, has worked tirelessly to mentor Latinx students and faculty. Several Twitter groups have recently started to mentor, highlight and support future Latinx trainees (follow @LatinxUro and @UroForEquity). Building a professional organization to advance the agenda of Latinx urologists and our patients is the next essential step for success.

In summary, we must provide our patients an inclusive, equity-driven urological workforce that represents the communities we serve. This is our call to action to you, fellow urologist: YOU can improve diversity and inclusion within your community and institution. Identify inequity and address it. Our specialty will be better for it.