The Ask Is MORE, the Opportunity Is LESS: Promotion for Women in Urology

Women are promoted more slowly compared to their male counterparts in urology, particularly from assistant to associate professor.¹ The delay is multifactorial. Janet Bickel argued that rather than a “glass ceiling,” the lack of progress for women in academic medicine is better attributed to “cumulative career disadvantages.”² In other words, death by a thousand cuts, all of which are small but together systemically slanting the playing field against our success and promotion.

The “MORE”

More administrative tasks/departmental housekeeping: Women are conditioned societally as nurturers to take care of what needs to be done and as younger professionals may not feel they can say no to administrative tasks or committees that take up valuable time. Making call schedules, championing telehealth, overseeing medical student rotations and managing physician extenders are some of the many tasks that have been cited as time intensive tasks offered to women with poor translation into equity toward promotion. In addition to the global/departmental asks of more, there may be more day to day. In a qualitative study at the University of Michigan on barriers to promotion, one participant said, “If my clinical support is asking me to do 10% or 15% more than they would ask the male colleagues to do, then that’s 10% to 15% of my time that I have to spend doing the clinical work that I don’t have for other things.”³

More potential bias against promotion: Promotional committees often lack female representation due to the slow generational shift of accepting women in medicine and/or delayed promotion. Additionally, lack of transparency in the process leads to non-uniform application of the requirements. In the 2018 AUA census, 30.1% of women vs 0.2% of men answered affirmative that “my professional growth is limited because of my gender.”⁴

More duties at home: Women more often have spouses with full time careers and share in household responsibilities if not taking on a larger role. More than double the number of women urologists reported primary responsibility of day-to-day household duties compared to men (19.6% vs 7.9%), and double the number of male urologists reported their partner was primarily responsible (48.8% vs 24.6%) in the 2018 AUA census.⁴ Similar numbers of men and women respectively reported a shared responsibility (38.9% vs 42.1%), but the degree to which that responsibility is shared was not queried.⁴ Further, this is reinforced by the fact that 81.6% of female urologists report a spouse who works while only 46.1% of male urologists report the same.⁴ A spouse who manages the household (of any gender) inherently contributes to the success of their surgical counterpart.

More leave for childbearing: If a woman urologist takes maternity leave in practice it is typically 8–12 weeks. Most faculty are hired as assistant professors between the ages of 31 and 35 years old, which coincides with the age of childbearing for women urologists as reported by Lerner et al in 2009 (average age of 32.6 years for first child, 35.1 for second child, 36.5 for third child).⁵ The time out of work alone could delay promotion, even ignoring the demands of motherhood such as breastfeeding and fatigue with nighttime waking that might make academic productivity difficult.

The “LESS”

Less respect: Women are commonly and repeatedly invalidated with the assumption that they are a trainee, nurse or physician extender. When women assert a position of authority in accordance with surgical culture, they can be deemed “aggressive” or “difficult to work with.” These professional reputations then go on to influence promotional committees. The University of Michigan study cited above identified difficult interpersonal relations with both supervisors and clinical support staff as a barrier to promotion.³

Fewer role models/sponsors: People tend to favor mentees who resemble themselves, which is problematic since there are few women who hold leadership roles in urology. Successful women urologists also have unique insight on balancing the demands of home/work as well as navigating the complex gender interactions within a department. Women may be in particular need of mentoring due to self-imposed limitations, ie imposter syndrome vs the external expectation that they will be less successful due to their gender.

Less grant funding: A mean of $39,106 less was awarded in National Institutes of Health funding to first time female principal investigators as compared to their male colleagues.⁶

Fewer opportunities for national recognition: A recent examination of plenary panels at the AUA meeting shows that the majority were composed of all men (59%), and between the years of 2017 and 2019 there was no increase in female representation.⁷ During the same time the number and proportion of female moderators at the plenary decreased each year.⁸ Female representation on editorial boards of the 4 highest impact journals has only increased from 2.2% to 4.8% between 2000 and 2018.⁹

Less salary: Both baseline salary (∼$76,321 per year discrepancy after adjusting for hours, call, age, practice type and setting) and industry-sponsored payments have been shown to be lower for female urologists.^10,11 How does money correlate? Money creates the opportunity to outsource the previously mentioned home duties (ie housekeeper, nanny), thus indirectly creating time to focus on publications. Many in academic medicine write publications on nights and weekends, time which is scarce for women with children.

In summary, these additional expectations combined with less mentoring and resources affect women to varying degrees depending on institutional culture and the individual’s age, demeanor, spouse and childbearing status. As biases and the resulting disparities are difficult to quantify, further research will be crucial in identifying the barriers experienced by women. While no single factor is responsible for the delay in promoting women, the myriad inequalities make promotion an uphill battle for women in urology. Suggestions to address this imbalance include equal pay, active mentorship/sponsorship of women, increased visibility of women in leadership positions, equal distribution of administrative tasks between genders and promoting paternity leave for male urologists.