The lack of diversity in medicine and surgery has been an ongoing discussion for several decades. Even with roughly equivalent recruitment of female and male applicants at the medical school level, structural inequities as well as system-level and implicit biases continue to limit enrollment of underrepresented minority individuals.¹

There are also differences in how individuals funnel into certain medical specialities. Women and people from minority backgrounds are less likely to pursue surgical subspecialties.^2,3 This disproportionate recruitment is not based on technical ability.⁴ In a large population-based study of male and female surgeons, patients operated on by women had at least equivalent surgical outcomes.⁵ Further, gender and race concordance has been associated with improved patient satisfaction, compliance with physician recommendations,⁶ participation in clinical research⁷ and patient outcomes.⁸

There are further discrepancies in trainee attrition with certain populations disproportionately more likely to slip away–the so-called “leaky pipeline.” Increased attrition from surgical training programs has been reported among female surgical residents.⁹ Although the cause of this is multifactorial, there is evidence to suggest a relationship between physician burnout and attrition. In a large study of over 7,000 general surgery trainees, residents who reported exposure to discrimination, abuse or harassment at least a few times per month were more likely to have symptoms of burnout.¹⁰

The experience of explicit and implicit bias may play a direct role in resident attrition. Some studies have suggested a difference in opportunity¹¹ and subjective evaluation of performance by supervising staff¹² based on gender and race during surgical training. Further, negative stereotypes are detrimental to the operative performance of stigmatized individuals.¹³ A randomized controlled trial studied the impact of confirming negative stereotypes (stereotype threat) on technical skill and performance among male and female general surgery residents in the U.S. Women who were determined to be more susceptible to stereotype threat based on pre-intervention assessment and who were randomized to the stereotype threat arm were more likely to demonstrate a reduction in technical performance. Conversely, susceptible women who were randomized to the protective arm exhibited technical performance that was equivalent to their male colleagues.¹³

While differences in clinical and academic demand by institution may contribute to burnout and attrition, there are clearly important environmental factors intrinsic to each organization that help to mitigate some of these experiences. In a prospective study of surgical interns, despite equivalent technical ability, female trainees needed more time to reach the same level of surgical confidence.¹⁴ This is an example of the importance of equity for promoting individual success during training. Being engaged in the unique educational needs of individuals and creating an environment that is conducive to tailored learning opportunities are critical to allow each person to meet their full potential. Equitable and inclusive work environments create an atmosphere of representation and enhance the sense of belonging for our trainees and ourselves.

Mentorship is also one of the most powerful tools in our arsenal that can be used to promote diversity and retention in our training programs. Mentors play a key role in professional development, career guidance, academic success and personal growth. Effective mentorship has positive effects on career progression for both the mentor and mentee. Within the urology community, several influential organizations should be commended for facilitating mentorship opportunities for trainees. This should be made a priority at each institutional level.

Diverse teams work better together with higher productivity, performance and innovation. Diversity in health care teams has also been linked to improved patient satisfaction and outcomes, yet there remain barriers to recruitment, retention and ultimately academic promotion of underrepresented minority individuals.¹⁵ Improving equity and diversity within our own institutions is critical for trainee recruitment, retention and success. We owe it to our patients to train and retain the best people in our field.