The AUA Annual Census is about to celebrate its 10th year in 2023. The results from this important data source are published on the AUA website, available to all AUA members and the public. Besides The State of the Urology Workforce and Practice in the United States, which reports on practicing urologists in the U.S., there are other census reports for: Practicing Urologists Around the Globe, Urologists in Training: Residents and Fellows in the United States and Beyond, and Advanced Practice Providers for Urologic Care in the United States.

The AUA Annual Census includes both core questions—mostly related to demographics and practice patterns—and supplemental questions, which vary year to year. The AUA Data Committee, in collaboration with the AUA Workforce Work Group, selects and approves questions for the annual Census. A list of priority topics for each year is sent to all AUA stakeholders in late fall and questions are solicited through early January. The number of questions is limited to a reasonable level each year to create a positive user experience. All questions are then approved by the AUA Institutional Review Group (see Figure). The Census opens at the AUA Annual Meeting and remains accessible through the end of September. Results are reviewed by the AUA Data Committee and edited prior to publication on the AUA website. About 2,000 practicing urologists in the United States respond to the Census each year, representing over 15% of the workforce. As the Census is voluntary and self-reported, it is susceptible to recall bias, selection bias, and nonresponse bias, particularly from underrepresented groups in urology, which may preclude meaningful statistical analysis. The response rate is, however, in line with typical survey response rates and over the years has demonstrated statistical reliability. The Census also has no ability to survey urological patients and therefore must rely on urologists to assess the needs of those we serve.

The census was completed online through the AUA website from May to September 2021 via a multimodal dissemination campaign conducted by the AUA. Weights were applied at the individual physician level to generate a representative population of practicing urologists. Two data files were established. One file was a population file containing basic demographic, geographic, and certification information for all practicing urologists in the United States in the Census year. The other file was a sample data file containing a broad range of information collected from the Census. The population file and the Census survey sample file were linked through post-stratification factors to adjust for nonresponses and the contribution of each respondent in a Census survey by assigned sample weight. The post-stratification factors include gender, geographic location, certification status, and years since initial certification. These factors are used to develop stratification cells for calculating sample weights.

Despite its limitations, the Census serves as a critical tool for the urological community by tracking changes in both the urological workforce and urological practice patterns. This is beneficial in predicting future needs of both practicing urologists and their patients, as well as advocating for public policy measures that are relevant to the practice of urology. Furthermore, by its mere publication, the Census has proven to be a robust instrument for promoting diversity and equity in the field. When looking at demographic data, the Census has been used to document gender disparities in the urological workforce including the gender pay gap and promotional disparities in academic medicine. From a workforce perspective, Census data have documented lack of access to care in rural areas.

Changes in The Urological Workforce

The Census has been able to track changes in the workforce over time. Major demographic changes have included the aging of the urological workforce and the increase in women urologists. Practice pattern changes have included the shift of practice ownership to employment as well as the growth of telemedicine.

The urological workforce has gotten older. In 2014, the average age of a practicing urologist was 53 years; by 2021, that had increased to 54 years. In the context of the steady increase in number of residency positions and new graduates over the years (from 268 residency positions in 2010 to 365 in 2022), this 1-year age difference is notable. Perhaps more telling, the percentage of urologists who are still practicing beyond the “retirement age” of 65 increased from 22.9% in 2014 to 29.8% in 2021. The percentage of women urologists over the age of 65 also increased from 0.4% in 2014 to 1.1% in 2021. While the overall representation of women in urology increased from 7.7% in 2014 to 10.9% in 2021, more significantly the percentage of women urologists in the youngest age group (<45 years) increased from 18.7% in 2014 to 23.2% in 2021. Most recent AUA Residency Match statistics demonstrate women comprise roughly 30%-40% of entering classes over the past decade.¹ When the older group of urologists stops practicing, there will be a significant increase in the proportion of urologists who are women.

The urological workforce has mirrored the trend in medicine away from private practice in favor of employed practice. In 2014, 64.1% of urologists were in private practice. In 2021, this percentage had decreased to 51.9%. Older urologists are far more likely to be in private practice than younger urologists, and men in any age category are more likely to be in private practice than women. This shift away from private practice is likely driven by changes in our health care system and are not unique to urology. A concern about this trend is that it is likely associated with an increase in physician burnout due to the loss of autonomy that comes from being an employee.

Political Advocacy

One of the most important roles of the AUA Census is to help support the advocacy efforts of the AUA. By working with the Legislative Affairs Committee to design questions that support the advocacy agenda of the AUA, the Census is able to provide data to help policy makers understand our needs.

Telemedicine underwent a huge transformation due to the COVID-19 pandemic. During this time several waivers were implemented to make telemedicine more accessible, including waivers allowing payment for audio-only telemedicine and allowing physicians to virtually see patients across state lines. The Census has been able to track telemedicine utilization among practicing urologists, and these data are being used to advocate for continuing waivers in the years to come, with major implications for serving rural and underserved communities.

The Census data have been used to understand the burden of student loan debt among practicing urologists. Student loan debt disproportionately impacts Black and women urologists. These data have been used to advocate for a student loan forgiveness bill for medical specialists (including urologists) who practice in rural areas. Census maps have shown that a large number of counties in the U.S. have no practicing urologists. These data have been instrumental in getting congresspeople to support this legislation.

Conclusion

The AUA Census is very important to all practicing urologists. Data from the Census help the AUA to better understand the urological workforce in order to provide better support for the needs of practicing urologists. The Census data are also an important factor in promoting the legislative agenda of the AUA, advocating for our patients, and promoting diversity and equity within the field. Increasing participation in the annual AUA Census will provide better data for all of these efforts—so please fill it out!