Efforts to increase diversity in the medical workforce have become a focus of health institutions, as these efforts align with goals of improving care and reducing health disparities within marginalized communities.¹ While diversity is multifactorial and can be viewed holistically, the American Association of Medical Colleges identifies racial or ethnic populations that are underrepresented in medicine (URM) as a particular focus for increasing diversity in the workforce.^2,3 Despite its importance, increasing racial/ethnic diversity in graduate medical education remains a challenge, one to which pediatric urology is no exception. There are 27 pediatric urology fellowships that on average accept 1 applicant per year, and pediatric urologists comprise 7.5% of all practicing urologists.⁴ As a subspecialty within a small, competitive field, pediatric urology programs face a secondary challenge of recruiting diverse trainees from an even smaller, less diverse applicant pool. In this context, we sought to characterize what strategies were instituted at pediatric urology fellowship programs to recruit URM trainees, and if these recruitment strategies were effective.

To assess current recruitment efforts and barriers to recruitment of URM pediatric urology fellows, we designed a 20-question REDCap survey to distribute to 27 program directors (PDs) of ACGME (Accreditation Council for Graduate Medical Education)-accredited pediatric urology fellowships. The survey consisted of 4 sections of questions focused on (1) PD demographics, (2) program demographics, (3) program priorities regarding diversity, and (4) program recruitment efforts. Likert-scaled questions were valued 1-5, with 1 being “strongly disagree,” 3 “neutral,” and 5 “strongly agree.” Agreement (4-5), disagreement (1-2), and neutrality (3) were assessed.

Twenty PDs responded to the survey (74%), including 3 incomplete responses. PD and program demographics are detailed in Table 1. Of respondents, 68% (13/19) were in their role as PD for 5 years or more and 89% (17/19) were at least 40 years old. A majority were male (68% 13/19), White (79%, 15/19), and heterosexual (95%, 18/19). Respondents were from nearly all AUA regions. Most PDs (70%, 14/20) reported their program size as 5-10 full-time pediatric urologists, and 50% (10/20) of PDs reported no full-time faculty of color in their practice group. When asked about trainees, 45% (9/20) reported they had trained no URM fellows in the last 3 years (Table 2).

Table 1. Demographics of Program Director (Respondents) and Program

Table 2. Program Director–reported Demographics of Pediatric Urology Fellows Over the Last 3 Years

Although 60% (12/20) of PDs identified their program as being racially/ethnically representative of the surrounding patient population, 75% (15/20) reported their program was less diverse than the patient population served. While PDs agreed their program valued faculty and trainee diversity (88% and 76%, respectively), the majority of PDs (53%, 9/17) reported not having methods in place for diversity recruitment (Figure 1). Of those reporting a recruitment method, mentorship was most common (35%, 6/17). When asked about recruitment barriers, 59% (10/17) reported that no barriers existed to recruiting URM fellows. The most common barrier among those reporting one was an overall limited applicant pool (18%, 3/17). Other responses included lack of expertise/education, time, funding, undiversified patient population, or disinterest by faculty/trainees (Figure 2).

Figure 1. Recruitment strategies utilized by pediatric urology fellowship programs to recruit underrepresented in medicine (URM) trainees. Other responses included funding for URM applicant interview expenses (6%) and designating 1 fellowship position for abroad applicants (6%).

Figure 2. Reported barriers to underrepresented in medicine (URM) recruitment. Other responses included funding (6%), lack of education (6%), disinterest by trainee (6%), disinterest by faculty (6%), and patient population not diverse (6%).

Our study suggests that despite valuing diversity, few programs are consistently training URM trainees, few PDs have mechanisms in place to recruit racially/ethnically diverse trainees to their programs, and, paradoxically, most see no barriers to recruiting URM trainees.

From 2014-2021, the percentages of Black and Latinx urologists have remained stagnant at 2.2% and 3.9%, respectively.⁴ While the 2023 AUA urology residency match reflects encouraging increases in the number of matched applicants from these backgrounds, the proportions of URM trainees still fall below that of the national census data.^5,6 Therefore, we recommend active and intentional efforts to increase URM recruitment in pediatric urology through formal and informal structures both at the program and national level.

1. Mentorship was often reported as a method of recruitment in our study, and we view this as an opportunity to use an existing recruitment method in a strategic, targeted manner to increase the number of URM applicants. Early mentorship is critical to increase exposure to both urology and pediatric urology, and to develop deeper, longitudinal mentorship relationships built on trust. While concordance between mentors and mentees can potentially enhance a mentoring relationship,⁷ this should not be a limitation in creating new opportunities for mentorship of undergraduates, medical students, and residents from URM backgrounds. We urge both individuals and programs in pediatric urology to identify early mentorship programs in which they can participate, or create new ones.
2. Representation at the faculty level can impact a trainee’s decision to train in a field or at a specific institution.⁸ Accordingly, pediatric urology programs should prioritize recruitment and retention of URM faculty to increase visible representation for URM trainees. Increased support and recognition of work performed by URM faculty who may take on an expanded role in their department mentorship programs, institutional committees, and local/regional/national professional society diversity efforts is a crucial component. Evaluation of institutional promotion criteria and providing promotional credit to a broader range of activities and contributing roles outside of traditional research productivity is one such strategy.⁹
3. In addition to institutional efforts to engage medical students early in training, we recommend increased presence at national conferences and forums created for URM students. Annual conferences hosted by the Student National Medical Association and the Latino Medical Student Association are examples of opportunities to engage with students from diverse institutional settings and geographic regions and to create visible presence of pediatric urology in early-stage medical trainees from URM backgrounds.

We urge pediatric urologists to not only take an active role in existing national, institutional, departmental, and divisional URM recruitment efforts, but to lead the charge for new or renewed efforts as well. In doing so, pediatric urologists in academic centers can increase their visibility, broadcast their commitment to diversity, form relationships with trainees earlier in their training, and increase opportunities for mentorship and early exposure to the field. With intentional efforts towards recruitment, the applicant pool and the diversity of the pediatric urology workforce can better reflect patients and communities served, encouraging improved health outcomes.