Over the last several years, there has been an increasing emphasis on improving diversity of U.S. urology residency programs. We now see a greater representation of Black, Hispanic/Latinx practicing urologists,¹ but it is unclear if the increase in diversity within the urological workforce has been accompanied by an increase in resources to allow trainees to succeed.

Recruiting diverse residents is important for most programs, but the burden of these efforts often falls to historically underrepresented (HU) people. This is the minority tax. Residents and faculty who agree to tackle diversity, equity, and inclusion (DEI) efforts often receive no compensation for their time, and these roles are associated with less academic merit than other nonclinical activities.² In a 2020 cross-sectional study of U.S. medical students, HU students spent significantly more time on DEI-related activities, while receiving no additional mentorship. They reported feeling obligated to participate in DEI activities, but experienced more microaggressions and lower wellness scores.³ Additionally, Black medical students reported a significant decline in emotional and physical well-being during 2020, a period of intense racial unrest in the United States, at a time when academic productivity was expected amongst students entering into competitive fields such as urology.⁴ As we see growing diversity amongst U.S. residency programs, it is difficult to gauge whether HU residents feel supported by their institutions. We conducted several interviews with HU individuals about the barriers they’ve faced in their training and careers.

A woman who is now a urology professor at a top academic institution trained as the only female in a residency program of men. She described her evaluations to include many subjective measures of personality that did not show up in her male colleague’s evaluations. She was described as “bossy” and a “know-it-all,” despite conscious efforts to toe the impossible line between likeability and authority. She spoke to us about the emotional toll this feedback had—and how it caused her to doubt her abilities. It was only years later when she discussed her experiences with a group of female urologists that most others had similar stories.

Another individual who interviewed with us, the first Black female to graduate from her residency program, recounts numerous instances of sexist and racist remarks that were often recognized by others but not acted upon. She had several faculty leaders in her program witness flagrant racism by patients, nurses, and other ancillary staff. They would comment to her about how terrible they felt that she was experiencing this, and would try to empathize with her, but their efforts stopped there. She describes this silence as permission for the behavior to happen again and again.

Dr Ariana Smith, faculty at Penn Medicine and chief of urology at Pennsylvania Hospital, offered us the following words (which reflect her own views and not that of any institution):

“Those who have held the reigns for so long can either hold on for dear life or they can embrace the brave new world of Urology (and Medicine, in general) as we make up for lost time hearing and valuing the voices of those historically underrepresented in medicine.”

It is imperative that we do what we can, not only to diversify our field, but to offer tangible support to those who offer their voices to evoke change. Residency programs should consider offering compensation and/or official titles to residents and faculty who participate in DEI efforts. Majority students, residents, and faculty should also be encouraged and expected to participate in difficult conversations and shoulder the burden of diversity programming. Beyond recruiting diverse trainees, programs must hire, support, and promote diverse faculty. When evaluating HU residents, program directors must be aware of implicit bias, especially before delivering subjective feedback on personality, likeability, perceived aggression, bossiness, or introversion.

Most importantly, if you see something, say something. It is not enough to empathize with students who have been victims of sexism, racism, or other types of prejudice. Call out the behavior and set an example for others to do the same. Allow diverse applicants a safe space to voice their experiences and make active efforts to change the culture. Make the uncomfortable phone call, have the important conversations, do the work. In order for our field to truly commit to advancement in equity, we cannot fill our residencies with diverse applicants unless we fully support them. It will take a renewed commitment from all of us to create learning environments for all of our trainees, particularly our HU residents and fellows, to flourish.