Urologist Hiring Practices: Data from the American Urological Association 2020 Census

By: Christina Shin, BA; Justin Loloi, MD; Andrew M. Harris, MD; Amanda C. North, MD | Posted on: 05 Oct 2021

Due to the increased demands of an aging American population in the setting of a concurrently aging urologist workforce and a limited pipeline of new urologists, multiple estimates suggest an impending shortage of urologists.^1–3 Though urology continues to be a male-dominated specialty, there has been a dramatic increase in the number of female urologists, who now make up 10.3% of practicing urologists.⁴ Given the dynamic nature of the urology census, a need for thorough review of current urology hiring practices is pertinent. Therefore, we sought to better describe census-reported factors concerning urologist recruitment and hiring, financial changes over time and barriers to success in an effort to identify areas to support future urologists.

Of the 13,352 practicing urologists making up a total of 4,223 practices in 2020, 1,972 (14.8%) completed the American Urological Association (AUA) Census.⁴ With respect to hiring, 23.3% of urological practices reported hiring or were anticipating hiring; notably, the rate of hire/anticipated hiring was greater in the Northeast (39.9%) and lower in the Western Section (20.5%; table 1). Of these practices 46.8% were academic medical centers, 32.3% private groups, 22% private and public hospitals, and 8.6% solo practices. The initial contract term breakdown was: 3 or more years (31%), no fixed term (24.2%), 1 year (22.9%) and 2 years (21.9%).

Table 1. Specialty requirement in recruitment by AUA section

AUA Section	No. Practices*	Practices Hiring or Anticipating Hiring in 2020
		Hiring Practices		Specialty Requirement†
		No.	%	General Only		Specialized Only		Both
		No.	%	No.	%	No.	%	No.	%
Mid-Atlantic	325	88	27.2	40	45.6	20	22.6	28	31.8
New England	219	72	32.8	30	41.7	14	18.8	28	39.5
New York	352	81	23.1	47	57.8	23	28.0	12	14.3
North Central	750	164	21.9	83	50.9	51	31.2	30	18.0
Northeastern	157	63	39.9	42	66.6	10	15.9	11	17.5
South Central	655	137	20.9	80	58.2	30	22.3	27	19.5
Southeastern	932	207	22.2	119	57.7	48	23.2	40	19.1
Western	833	171	20.5	79	46.3	37	21.5	55	32.3
Total	4,223	983	23.3	520	52.9	233	23.7	230	23.4
*Estimated numbers of practices by practice setting are slightly different from what were reported in the 2020 AUA Census report. The former utilized half of the samples in the module covering hiring questions while the latter utilized the full samples from all modules. † The totals (counts and percentages) may not be equal to the sum of the subtotals due to rounding errors.

Based on the Census data, hiring preferences tended to differ between academic medical centers and solo practices/private groups. A majority (87.5%) of solo practices were looking for a General Urology provider, possibly suggesting the relative lack of need of specialty training for resident-graduates entering the non-academic setting (table 2); furthermore, 66.7% of private groups did not have a fellowship requirement in considering hire. Conversely, academic medical centers sought fellowship-trained providers (57%); 54.7% and 38.6% of medical centers preferred or required fellowship training, respectively (table 3). Noticeably, 69 of 81 (86.1%) of New York section practices preferred a fellowship-trained urologist (Table 4). The following represents the specific hired sub-specialists: Urologic-Oncology (25.5%), Female Pelvic Medicine and Reconstruction (22.0%), Robotic Surgery (13.1%), Endourology/Stone Disease (12.7%), Men’s Health (10.8%) and Pediatrics (10.8%).

Table 2. Specialty requirement in recruitment by practice setting

Practice Setting	No. Practices*	Practices Hiring or Anticipating Hiring in 2020
		Hiring Practices		Specialty Requirement^†
		No.	%	General Only		Specialized Only		Both
		No.	%	No.	%	No.	%	No.	%
Solo practices	1,264	108	8.6	95	87.5	5	4.7	8	7.8
Private groups (2 or more urologists)	1,394	451	32.3	259	57.5	67	14.9	124	27.6
AMCs	460	215	46.8	45	20.9	123	57.0	47	22.1
Non-AMC hospitals	860	190	22.0	111	58.8	31	16.3	47	24.9
Other settings	245	19	7.8	10	53.4	7	35.0	2	11.6
Total	4,223	983	23.3	520	53.0	233	23.7	230	23.4
AMC, academic medical center.
*Estimated numbers of practices by practice setting are slightly different from what were reported in the 2020 AUA Census report. The former utilized half of the samples in the module covering hiring questions while the latter utilized the full samples from all modules. † The totals (counts and percentages) may not be equal to the sum of the subtotals due to rounding errors.

Table 3. Fellowship requirement in recruitment by practice setting

Practice Setting	No. Practices*	Practices Hiring or Anticipating Hiring in 2020
		Hiring Practices		Fellowship Requirement Known†
		No.	%	Not Required		Preferred		Required
		No.	%	No.	%	No.	%	No.	%
Solo practices	1,264	108	8.6	32	29.8	61	56.0	15	14.2
Private groups (2 or more urologists)	1,394	451	32.3	286	66.7	102	23.7	41	9.5
AMC	460	215	46.8	14	6.7	116	54.7	81	38.6
Non-AMC hospitals	860	190	22.0	134	71.6	40	21.4	13	7.0
Other settings	245	19	7.8	10	55.7	8	44.3	0	0.0
Total	4,223	983	23.3	477	50.0	326	34.2	151	15.8
AMC, academic medical center.
*Estimated numbers of practices by practice setting are slightly different from what were reported in the 2020 AUA Census report. The former utilized half of the samples in the module covering hiring questions while the latter utilized the full samples from all modules. † Practices without known fellowship requirement were excluded in the calculation. The totals (counts and percentages) may not be equal to the sum of the subtotals due to rounding errors.

Table 4. Fellowship requirement in recruitment by AUA section

AUA Section	No. Practices*	Practices Hiring or Anticipating Hiring in 2020
		Hiring Practices		Fellowship Requirement Known^†
		No.	%	Not Required		Preferred		Required
		No.	%	No.	%	No.	%	No.	%
Mid-Atlantic	325	88	27.2	45	52.8	31	36.4	9	10.8
New England	219	72	32.8	29	42.2	20	28.1	21	29.7
New York	352	81	23.1	0	0.0	69	86.1	11	13.9
North Central	750	164	21.9	82	50.2	47	28.5	35	21.3
Northeastern	157	63	39.9	35	56.1	24	38.4	3	5.5
South Central	655	137	20.9	72	53.0	40	29.1	24	17.9
Southeastern	932	207	22.2	121	63.5	48	24.9	22	11.6
Western	833	171	20.5	92	55.5	48	29.3	25	15.2
Total	4,223	983	23.3	477	50.0	326	34.2	151	15.8
*Estimated numbers of practices by practice setting are slightly different from what were reported in the 2020 AUA Census report. The former utilized half of the samples in the module covering hiring questions while the latter utilized the full samples from all modules. † Practices without known fellowship requirement were excluded in the calculation. The totals (counts and percentages) may not be equal to the sum of the subtotals due to rounding errors.

The majority (66.2%) of practicing urologists reported having a contract or salary guarantee. Those in the private practice setting experienced higher rates of contract or salary guarantee (40.6%) when compared to those at academic centers (23.2%). When negotiating contracts, 46.6% of urologists did not use any benchmark data, which was closely followed by Medical Group Management Association (40.6%), American Medical Group Association (10.2%), Other (7.4%), Merritt Hawkins (3.8%) and Sullivan Cotter (3.7%).

Of urologists, 91% reported their income either remained the same or increased as compared to the year prior. Those in the academic setting described a higher rate of salary increase (47.1%) than did those in private practice (37.6%). Furthermore, a lower number of academics reported decreases in salary (6.4%) compared to those in private practice (14.5%). The most common compensation determination factors amongst practicing urologists were individual relative value units (56.4%), followed by group/practice relative value units (17.7%), administrative work (16.9%), patient satisfaction scores (13.9%), research productivity (9.8%) and equipment/real estate ownership (3.8%).

Concerning barriers to professional success, lack of time was reported as the most considerable barrier (32.9%), followed by lack of autonomy, education and other (17.2%); lack of control over scheduling (15.9%) and lack of control over staffing decisions (10.3%).

Focusing on gender-related differences, approximately 93% of female urologists reported barriers to professional success compared to their male urologist counterparts (74.5%). The most cited barrier for females was lack of control over staffing decisions or scheduling (46.2%), whereas the most cited barrier for males was lack of time (33.7%).

The findings of this analysis illustrate variability in hiring practicing, financials, negotiation and barriers to success in the workplace. With a better understanding of these specific variables, we can offer more targeted avenues of support for future urologists, including assistance and guidance in negotiating initial contracts, promoting contract or salary guarantees, and alleviating barriers to professional success. The latter seems to be a particular context-sensitive issue depending on practice type and provider gender

Further study is warranted to further understand these issues and to determine how best to support urologists in navigating hiring practices and professional success. A more thorough understanding will help in identifying concrete areas for structural change or advocacy.

Acknowledgements: We would like to acknowledge Raymond Fang and William Meeks for their help in data management and statistical analysis

Pruthi RS, Neuwahl S, Nielsen ME et al: Recent trends in the urology workforce in the United States. Urology 2013; 82: 987.
McKibben MJ, Kirby EW, Langston J et al: Projecting the urology workforce over the next 20 years. Urology 2016; 98: 21.
Loughlin KR: The confluence of the aging of the American population and the aging of the urological workforce: the Parmenides fallacy. Urol Pract 2019; 6: 198.
American Urological Association: The State of the Urology Workforce and Practice in the United States 2020. Linthicum, Maryland: American Urological Association 2021. Available at https://www.auanet.org/research/research-resources/aua-census/census-results. Accessed July 15, 2021.