The mission of the American Board of Urology (ABU) is to act for the benefit of the public by establishing and maintaining standards of certification for urologists and working with certified urologists to achieve lifelong learning to ensure the delivery of high-quality, safe and ethical urological care. Unwritten within this mission is the ABU’s commitment to fostering and sustaining a diverse workforce to fully serve every individual with a urological condition. As part of its strategic goals, the ABU has committed itself to inclusive excellence by integrating diversity, equity and inclusion into the fabric of its organizational structure in pursuit of certifying urologists capable of achieving real health equity in our field.

In 2021, the ABU established the Committee for Diversity and Inclusion (CDI) to craft and advance Board policy and foster diversity and inclusive excellence in governance and in the credentialing process. An important goal of the CDI is to provide greater transparency of the governance structure of the ABU.¹ As a Board, there is keen interest in identifying a diverse group of members to inform Board decisions and policies that support and oversee urologists across 50 states and to execute the committee assignments necessary to fulfill the process of board certification. Consequently, the composition of the ABU committees is scrutinized closely. In consideration of committee member selection, the Board takes many factors into account including each candidate’s geographical location (AUA Section), subspecialty expertise, home institution or site of practice, institution of residency training and fellowship, gender, race and ethnicity. At a minimum, the Board seeks to match the current AUA census to ensure adequate representation from numerous stakeholders.

The ABU consists of 3 major committees: the Board of Trustees, and the Written and Oral Board Examination Committees. The demographic patterns of each committee as of June 2021 are summarized in tables 1–3. The ABU nomination committee processes are actively informed by these data as it seeks broad representation from the field to execute the business of the Board. Moreover, the ABU has strongly encouraged its 6 nominating bodies (the American Urological Association, the American Association of Genitourinary Surgeons, the American College of Surgeons, the American Association of Clinical Urologists, the Society of Academic Urologists and the Societies for Pediatric Urology) to provide a diverse slate of candidates for committee selection. Each year 2 nominating bodies put forth trustee candidates. Other bodies also suggest members for the Written and Oral Examination Committees. After the annual AUA Census is released, the CDI compares the ABU committee composition to the census composition and reports the findings to the full Board. This iterative process allows the ABU to regularly consider the demographic shifts in the field of urology and further guide the development of its pipeline from nominating organizations.

Another important initiative of the ABU is to continually ensure that the certification process is fair and equitable. Specifically, the Board appreciates the need to minimize individual implicit biases in its examination processes. Implicit bias reflects the attitudes or stereotypes that affect our understanding, actions and decisions in an unconscious manner. Concerns about bias may emerge when demographic factors are associated with certification outcomes. Recently, in an observational study of 662 categorical general surgery trainees, associations were observed between race, ethnicity and family status and American Board of Surgery qualifying and certifying examination outcomes.² Hispanic trainees were less likely to seek certification; married examinees with children were more likely to fail both the qualifying and certifying examinations and White examinees were more likely to pass the qualifying examination on the first attempt.

The CDI is also driven to provide greater transparency of the certification process and its outcomes. Beginning in 2021, the ABU began collecting data on examinee race and ethnicity to facilitate a better understanding of the impact of these factors in the certification process. Contemporary data on ABU examination pass rates by gender reveal no evident bias (table 4). Although implicit and explicit biases have been reported infrequently within specialty certification processes^2,3 or within objective structured clinical examinations,⁴ we must continually work to mitigate bias from entering the examination environment.

This year, the CDI was charged with the development and implementation of implicit bias training for all written and oral board examiners. The inaugural training session for oral examiners was conducted on February 19, 2022. Sixty examiners undertook the training which consisted of 1) a publicly available video reviewing implicit bias and its impact, 2) the completion of 1 module of the Harvard Implicit Association Test,⁵ 3) a review of the current literature concerning implicit bias in the specialty certification process and 4) a discussion of bias mitigation strategies. Although implicit bias may be difficult to completely eliminate, one can work to consciously reduce the impact of bias in key situations, such as candidate assessment. Capers et al have successfully applied implicit bias training and mitigation strategies to medical school admissions processes to enhance and sustain a diverse medical school environment.⁶ An awareness of one’s own personal implicit bias is a key aspect of their interviewer training in addition to the use of bias mitigation strategies immediately prior to medical school interviews.

In the ABU implicit bias training, we also assert the importance of personal bias awareness through the use of the Harvard Implicit Association Test.⁵ When confronted with a situation when bias may emerge, the PAUSE method of bias mitigation provides a framework to 1) slow down and Pay attention, 2) Acknowledge one’s assumptions, 3) Understand one’s perspective, 4) Seek different perspectives and 5) Examine all available options to make a good decision.⁷ The ABU is committed to delivering this training to all of its committee members in the coming months and surveying participants to learn from and improve this implicit bias curriculum. Full integration and application of these principles into the certification process will take time, but the ABU will continue striving for inclusive excellence through a concerted and iterative process of self-assessment and continuous improvement.