Introduction

In the wake of crises such as the COVID-19 pandemic and the murder of George Floyd, urologists have revived discussions about workforce diversity. In this article, we will discuss why workforce diversity remains essential for delivering high-quality urological care, and present a theoretical framework for evaluating and improving workforce diversity in urology. We will conclude with recommendations, including creating a national database to house information about urological diversity equity and inclusion (DEI) initiatives, promote collaboration and identify under-targeted domains in the urological workforce pipeline.

The Case for Diversity in the Workforce

In the Healthy People 2020 report, the Department of Health and Human Services (DHHS) identified workforce racial and ethnic diversity as essential health care infrastructure.¹ Research shows that health outcomes, quality, patient safety and patient satisfaction improve within a race concordant patient-provider relationship.^1-4

To better serve an increasingly diverse U.S. population (fig. 1),⁵ the urology community must prioritize increasing diversity at every level within our workforce. There remains a large gap between the percentage of U.S. minority citizens, minority urology residents and independent urologists (see table). Unfortunately, data from the Accreditation Council for Graduate Medical Education demonstrate that the percentage of urology residents considered underrepresented in medicine (URM) by the Association of American Medical Colleges⁶ has remained stagnant over the past decade, averaging just 9.3% from 2011 to 2020.⁷

Figure 1. Projected demographic changes in U.S. racial and ethnic composition.

Increasing the number of URM physicians entering the urological workforce is critical. However, first we need a framework for identifying strengths and weaknesses in our existing workforce strategies. Therefore, we propose a framework to understand where and how the urological community can influence the URM Trainee-to-Urologist Pipeline.

URM Trainee-to-Urologist Pipeline Framework

Like any workforce pipeline, the key to increasing the diversity of the urologist workforce is maximizing matriculation while minimizing attrition. We have conceptualized a URM Trainee-to-Urologist Pipeline that includes 4 targetable domains: pre-medical education, undergraduate medical education, graduate medical education and independent urologists (academic faculty, private practice physicians). Within each of these 4 domains, there are 5 categories of strategic interventions, consisting of recruitment, retention, mentorship, professional development and promotion (fig. 2).

Conventionally, increasing URM representation relies heavily on recruiting residents into the pipeline. For example, the resident recruitment fair held at the American Medical Education Conference (AMEC) serves to recruit URM students from the undergraduate medical education level into the graduate medical education domain. While recruitment events like AMEC are underutilized, they present an opportunity to bolster the number of trainees entering urology residencies. However, a lack of initiatives for retaining, developing and promoting those in the higher domains of the pipeline can lead to attrition.

Keeping URM in the pipeline is essential because of a concept termed the “snowball effect.”⁸ Laursen and Weston analyzed trends in productivity and diversity in top-50 U.S. chemistry departments. Their qualitative interviews revealed that once a program reached a critical mass of diverse students, recruiting and retaining future students became easier. The authors noted that the most successful departments coupled their student recruitment efforts with specific plans for the retention and development of students after they matriculated, emphasizing the need to keep individuals in the pipeline.

While Larsen and Weston described a “snowball effect” for students, we think the snowball effect is even more potent for faculty. Faculty, particularly senior faculty, have the unique ability to affect all domains of the pipeline. Additionally, the presence of diverse senior faculty demonstrates that an institution affords URM faculty opportunities to rise within the system, enhancing passive recruitment, and is notably attractive for residents and junior faculty. Since only 2.3% of full professors in urology identify as racial and ethnic minorities,⁹ there is an enormous opportunity to increase senior URM faculty.

(Incomplete) Catalog of Current Interventions

Figure 2. Individuals entering pipeline travel through various domains to become independent practicing urologists. Undergraduate medical education (UGME) domain (domain II) comprises undecided and urology committed students since DEI strategies may differ for these groups. At each domain level, there are opportunities to strengthen pipeline through application of multiple DEI strategies. Strategy (a) increases number of pre-medical and undecided UGME students entering pipeline. AMEC is highlighted as it presents national opportunity to target urology DEI efforts at pre-medical level. Strategies (b)–(e) decrease attrition. Red “promotion valve” depicts transition from junior faculty to senior faculty. Color gradient depicts “snowball effect,” with increasing color saturation implying larger “snowball effect.” GME, graduate medical education.

Several organizations aim to target one or multiple domains in the URM Trainee-to-Urologist Pipeline with a combination of strategic interventions. The UReTER (UnderRepresented Trainees Entering Residency) mentorship program at the University of California San Francisco (UCSF) and UroVersity at the University of Michigan are geared toward mentoring URM trainees in the undergraduate medical education domain (domain II). LatinX in Urology is an independent social media-driven platform targeting the pre-medical education (domain I), undergraduate medical education (domain II), graduate medical education (domain III) and independent practitioner (domain IV) domains with recruitment and mentorship strategies. The R. Frank Jones Society is a professional society serving multiple domains, including URM residents and physicians. Urologists for Equity is a new organization with a broad mission that includes publishing urological disparities data and developing metrics for evaluating DEI efforts. Groups like these are continuously growing and evolving to meet URM urologists and trainee needs. However, this list is incomplete, broad knowledge about these groups is limited and we lack a centralized repository to publicize DEI initiatives.

Developing a National DEI Repository

As the number of programs combating the lack of diversity in urology grows, it is imperative that a national body like the AUA publicize what resources and DEI initiatives exist. Housing this information on an easily accessible website will increase collaboration, distribute best practices and reduce labor duplication. Each initiative may be cataloged using the URM Trainee-to-Urologist Pipeline domains and strategies (fig. 2), providing a structured means to understand how an intervention improves diversity in the workforce. Furthermore, users could be asked to upload outcomes data for national recognition of their DEI efforts.

Conclusion

There is broad agreement that diverse providers are needed within all fields of medicine to increase the quality of care delivered to minority communities, which affects the entire health system. As a urological community, we can work actively to diversify our workforce by intentionally targeting the pipeline. This first requires utilizing a framework such as the URM Trainee-to-Urologist Pipeline model to assess where current efforts are concentrated and guide future interventions. Since many programs already focus on attracting trainees into the pipeline, new initiatives to recruit, retain and develop faculty are particularly needed. Housing information about these initiatives on a publicly accessible website would facilitate greater DEI effort coordination within the urological community.