As far back as 2009, ACGME (the Accreditation Council for Graduate Medical Education) has meticulously documented the gender distribution of current urology residents each academic year.¹ Similarly, the AUA has publicly reported the gender distribution of urology residency applicants since 2008. This transparency regarding gender distribution of the upcoming urology workforce has led to ongoing dialogue and strategies to increase the representation of women in urology, spearheaded by organizations such as the Society of Women in Urology. Using the work in gender representation as a model in our research study, we sought to query the trends in race/ethnicity distribution of urology residency applicants over time, recognizing that a problem not acknowledged is a problem destined to remain unsolved. This question is particularly salient given that the average percentage of African American/Black practicing urologists has remained stagnant at 2.2% from 2015 to 2019, as has that of Latinx practicing urologists (3.9%) during that same time frame.²

Table. Descriptive summary of urology applicants stratified by race/ethnicity for 2018-2019, 2019-2020 and 2020-2021

In this study, we partnered with the Society of Academic Urologists and the AUA to review urology residency applicant data and to disaggregate demographic data by race/ethnicity. Beyond that, we aimed to determine if differences exist across race/ethnicity in outcomes of the Urology Match (see Figure). Unlike gender, data regarding the racial/ethnic identities of applicants were not included in the application for urology residency until 2018, allowing for the analysis of only 3 years’ worth of data.

The primary outcomes of interest were:

• number of applications, interview invitations, and programs on each applicant’s rank list
• being truly ranked to match (ie in the top 5 spot on program’s rank list) vs practically ranked to match (ie ranked higher than the last matched person)
• match status, applicant position on program’s rank list, and vice versa

Our first set of findings harbor implications for match equity. Overall, Black and Latinx urology applicants were the least likely applicants to successfully match into urology. Compared to their White and Asian peers, Black and Latinx urology applicants were more likely to get fewer interview offers and were less likely to be ranked higher than or equal to the last matched person, ie practically ranked to match. Interestingly, although Black urology applicants were the most likely to rank in the top 5 positions of a urology residency program’s rank list, they still were less likely to match compared to their Asian or White peers (see Table). Given that the data captured by the AUA in the urology residency application did not include academic performance metrics such as USMLE (United States Medical Licensing Examination) Step scores, clerkship grades, and research publications, it is difficult to assess if and how these metrics play a role in explaining the differences observed across race/ethnicity. In the gender representation literature, findings such as these led to further studies, ranging from differences in letters of recommendation and personal statements to differences in academic performance metrics such as USMLE Step scores and clerkship grades.^3–5

Our findings shed light on possible recruitment strategies for Underrepresented in Medicine (URiM) individuals into the field of urology. Our study revealed that there was no difference across race/ethnicity for whether a urology applicant attended a medical school without an affiliated urology residency or a urology interest group. Additionally, compared to their non-URiM peers, Black and Latinx urology applicants were less likely to be DO (osteopathic medicine) students. As the world of urology has collectively gained a heightened awareness of racial disparities within our ranks, there has been a concerted effort to promote more equitable recruitment into our field. These efforts have included intentional proactive recruitment initiatives from organizations such as Urology Unbound and UReTER (UnderRepresented Trainees Entering Residency) as well as institution-specific initiatives to improve exposure and mentorship for URiM applicants. It will be important to continue to evaluate the individual and collective impact of these efforts to inform recruitment strategies and improve representation within our field.

The appointment of the inaugural AUA Chief Diversity Officer signals to the larger urology community that an investment in intentional strategies to promote equity remains of utmost importance. In addition, 2 of the 10 charges of the AUA Diversity and Inclusion Task Force are focused on enhancing diversity in the urology workforce and providing annual reporting of Urology Match statistics including race/ethnicity. Our work marks the beginning of such efforts and serves as a foundation for transparent reporting of data to inform targeted interventions to increase representation within the urology workforce.