According to the 2020 American Urological Association Census, there are 13,352 practicing urologists in the United States, an increase from 11,703 in 2014, when the first AUA Census was conducted.¹ The urologist-to-population ratio has also increased from 3.70 per 100,000 in 2014 to 4.07 in 2020. However, despite this increase 62% of counties in the United States currently have no practicing urologists, and the majority of urologists, approximately 90%, practice in a metropolitan area compared to just 0.4% practicing in rural areas.

Though the increased number of practicing urologists has positive implications, the demographic makeup of the workforce presents concerns for a future shortage in the field. Specifically, a considerable and increasing proportion of practicing urologists are over 65 years of age, increasing from 23% of urologists over the age of 65 in 2014 to 30% in 2020. Furthermore, the percent of practicing urologists under the age of 34 years has decreased from 7.2% in 2014 to 5.4% in 2020. In combination with increased demand from an aging population, an aging workforce is cause for concern as the number of postgraduate training positions may not be enough to replace a rising number of retiring surgeons.

It is encouraging to see that increasing numbers of female trainees are entering the field. The percentage of female practicing urologists has seen a steady increase from 7.7% in 2014 to 10.3% in 2020. Additionally, the percentage of female practicing urologists under the age of 45 years has increased from 18.7% in 2014 to 21.3% in 2020, while less than 1% of urologists over the age of 65 are women. Encouraging women to pursue careers in urology, especially as women now make up the majority of medical school matriculants,² may combat the pressures of a workforce shortage.³

However, differences in how women and men practice may indicate ongoing inequalities that propagate unequal gender representation in the field. Male and female urologists worked an equal number of hours per week, on average (52.7 male vs 52.5 female), and it has been previously shown that there are no significant gender differences in weekly clinical and nonclinical hours worked.⁴ However, male urologists saw more patients per week (65 male vs 60 female) and female urologists spent more time on average with each patient (16.5 minutes male vs 19.2 minutes female). More female urologists practiced in academic medical centers (27.3% male vs 41.5% female), while more male urologists were in private practice (53.1% male vs 36.4% female). Longer clinical hours, more frequent and short-duration office visits, and private practice are all associated with higher pay, highlighting potential contributors to the gender pay gap between male and female urologists.

When asked about barriers that impacted professional success, 92.7% of females reported any barrier compared to 74.5% of males. Specifically, lack of control over staffing decisions or scheduling was cited as a barrier to professional success (24.1% males vs 46.2% females). This indicates that in practice rather than gendered differences being facilitated by the preferences of individual female urologists, they may instead reflect practice decisions that are out of their control.

Alarmingly, racial and ethnic diversity in the urological workforce continues to stagnate. The percentage of urologists who are Black or African American has remained virtually unchanged since 2014 (2.5% in 2014 vs 2.1% in 2020), and the same is true for urologists who are Hispanic or Latino (4.1% in 2014 vs 3.8% in 2020). These percentages are disproportionately low compared to the U.S. population as a whole, as 12.4% of people living in America identified as Black or African American and 18.7% of the U.S. population identified as Hispanic or Latino according to the 2020 United States Census data. The pipeline that begins with medical school, followed by residency, fellowship and faculty appointment, has multiple points at which applicants from underrepresented groups may be lost.⁵ For example, significant differences in the number of residency applications submitted per applicant based on race suggest potential disparities in applicant counseling. It has been suggested that multiple interventions be put in place throughout identified training milestones to mitigate barriers, such as structured mentoring programs and partnerships with student groups such as the Latino Medical Student Association and Student National Medical Association.⁶

In conclusion, examination of data from The State of Urology Workforce and Practice in the United States identifies areas of improvement as well as potential sources of ongoing inequality. The urology workforce continues to see an increasing number of female trainees. However, the workforce has not seen a significant improvement in its inclusion of racial and ethnic groups underrepresented in medicine. Thus, investment in programs aimed at diversifying the field of urology, and the medical field as a whole, is as important as ever.