Diversity in the urological workforce is critical to our specialty reflecting the patients we serve. Although urology continues to be male dominated, the proportion of women in urology is growing. According to recent AUA Census and ACGME (Accreditation Council for Graduate Medical Education) data, 10.3% of practicing urologists and 28.5% of urology residents are female. Racial representation among urologists is more severely lacking, with only 2.1% of current practicing urologists identifying as Black/African American and 3.9% as Latinx/Hispanic. These proportions have remained stagnant over recent years, as has the percentage of urology residents currently underrepresented in medicine (URiM).^1–3

Diversification in our specialty necessitates exposing students to urology early in their education, with mentorship and support throughout medical training as they consider a career in urology. Mandatory urology rotations among U.S. medical schools have declined to 5% in recent years.⁴ Familiarizing students, particularly URiMs, with urology as a specialty early in the academic journey is of utmost importance. An introduction to urology for high school and college students could be offered on the local, regional and national stage in the form of pre-medical studies organizations, summer clinical immersion and research fellowships, and pipeline programs supported by the Society of Academic Urologists and the AUA. Current initiatives such as Urology Unbound, Michigan Urology Academy and the UnderRepresented Trainees Entering Residency (UReTER) mentorship program can be complemented and supported by parallel national efforts. These programs should include URiM urology faculty to empower and mentor young recruits.

Furthermore, informational sessions on the specialty of urology should be a mandatory element of career development in U.S. medical schools. Urology rotations may be promoted as part of the core surgical clerkship for medical students and offered as an elective at all medical schools. Medical schools with no home urology program can partner with neighboring urology residency programs to establish clerkship positions. Partnership with the AAMC (Association of American Medical Colleges) is essential to bolster these efforts.

As we encourage more medical students from diverse backgrounds to enter our specialty, the urology residency applicant selection process must be fair, equitable, and free of discrimination and bias. In our relatively small academic community, letters of recommendation carry substantial weight when contemplating an interview offer. Letter writers must thoughtfully select verbiage not only to support applicants, but also to avoid introducing bias that could affect an applicant’s candidacy.^5,6 Based on research in successful letters of recommendation for advancement, tenure and awards, the American College of Surgeons Women in Surgery committee has designed a Letters of Recommendation Guide and Resource Bank highlighting general principles, notable words and phrases, things to avoid and examples of successful letters of recommendation.⁷ Recent use of standardized letter templates in urology helps selection committees concentrate on outstanding characteristics of the applicant.⁸ Letter-writing workshops outlining evidence-based best practices in endorsing diverse residency candidates could be considered a next step offered on a national scale.

Much emphasis has been placed on objective measures such as United States Medical Licensing Examination^® (USMLE^®) scores and medical school grades in the urology residency application review. With USMLE Step 1 and many medical school grading systems moving to pass/fail, transcripts provide even less information about an applicant’s ability to succeed in residency and beyond. The AAMC advocates holistic review of residency applications.⁹ In this, selection processes take into consideration experiences and attributes in addition to academic performance. The intent with this approach is to create a richly diverse interview pool and residency workforce with emphasis on diversity in demographics, personal attributes and experiences. Holistic review may involve blinding selection committee members to photos, ethnicity, USMLE scores and grades to limit implicit bias.¹⁰ Residency programs should include diverse faculty with respect to gender and URiMs on their selection committees. Additionally, committee members should participate in implicit bias training to recognize their own biases and focus on not only attitudes, but also behavior.

As our patient population continues to grow increasingly diverse, so should we. Eliminating discrimination and bias through conscientious initiatives in all phases of the recruitment process will grow the proportion of women and UriMs in urology. A diverse urology workforce brings multiple perspectives and experiences, broadening our views as a profession while ensuring delivery of comprehensive, culturally sensitive and compassionate care.