There is an established gap in promotion of women across all specialties in medicine. To quote the New England Journal of Medicine article, “Among all the cohorts, the percentages of women graduates who were promoted to associate or full professor were lower than expected across nearly every academic department.”¹ Urology is no different, but it is perhaps more glaring in a field where women are so obviously a minority. In this article we seek to identify contributing factors to the gap in promotions for women and suggest potential solutions to mitigate obstacles that women face.

Lack of Female Mentors

Although young female residents and faculty do not require a female mentor, having one can be invaluable. Female urologists more advanced in their career will have unique insights on how to handle microaggressions that occur day to day, set boundaries when gender inequities occur, negotiate for salary or practice infrastructure without incurring backlash, and lead without being perceived as “bossy.” That is not to mention advice on how to handle a career in tandem with unique female experiences such as pregnancy, childbirth, maternity leave, and lactation.

Lack of Leadership Opportunities

Leadership experience is an important part of the promotion process. In 2017, women represented 2.5% of advanced leadership positions in urology nationally, despite making up 7.7% of the workforce.² As recently as 2021, women were found to be underrepresented on the boards of directors of major AUA subspecialty societies.³ A recent review study examined strategies to improve the representation of women in health care leadership. Successful organizational strategies included increased career flexibility, family-friendly policies such as flexible meeting design, renumeration strategies to enable and fund participation of women, and promotion of women role models. Formal mentorship and networking with high-status men benefited women.⁴

Lack of Proportional Representation for Speaking Panels and Awards

“Manel” is an easy example of the phenomenon. Teoh et al found that 63.5% of speakers in meeting sessions at major urological meetings from 2019-2020 were composed of all men.⁵ While this is not shocking given the high proportion of men in urology, what is more concerning is that when comparing speakers in the upper quartile of publications and with similar h-indices, women had fewer speaking sessions than men. There are qualified female urologists in every possible subspecialty. Certainly, some subspecialties are particularly male dominated, hence the term “proportional representation.” Speaking opportunities are crucial to demonstrate the regional and national reputations required for promotion. Equally important are awards given by professional societies such as the AUA. Wenzel et al demonstrated that the bulk of prestigious AUA awards given to women were in fact presidential citations and young urologist of the year.⁶ Furthermore, 39.5% of awards given to women were to professionals who were not clinical urologists.⁶

More Uncompensated Activities

Gender norms lead to women participating significantly more in uncompensated activities such as institutional citizenship, education, direct patient contact, or in the electronic medical record. Gendered expectations of patients, nurses, colleagues, referring doctors, and administrators all play a role in this problem. This burden contributes to both the gender pay gap as well as the promotional gap for women. Female patients seek physicians who are empathetic listeners and spend more time with their patients. The patients of women doctors are likely to speak more and disclose more psychosocial issues. Women doctors see more women patients and more patients with complex psychosocial issues. This may contribute not only to women urologists having more burnout, but also spending more time with each patient and therefore seeing fewer patients each week, which in turn lowers their RVU (relative value units).⁷ Women doctors also spend more time on electronic medical record documentation than men. This increased clinical burden will consume time and consequently decrease the time available for academic pursuits.⁸

In addition to increased time spent in clinical care, women physicians have an increase in citizenship duties and are often expected to perform nonphysician duties due to gender norms. In a qualitative study almost half of women physicians felt that they participated in more citizenship activities than their male colleagues, more than two-fifths felt obligated to volunteer for these types of tasks, and more than one-third believed they were asked to participate because of their gender.⁹ Citizenship activities include things like leading the physician extenders, telehealth efforts, making the call schedule, or clinic optimization. Women surgeons have been shown to have a different relationship with nurses (who are predominantly female) compared to their male colleagues. Women surgeons may feel the need to help transfer patients off the operating table or get their own supplies within the operating room so they are seen as cooperating with the nursing staff.¹⁰ While these seemingly small behaviors take equally small increments of time, they often feel compulsive and collectively not only lead to undermining the authority of women surgeons, but also take time away yet again from academic pursuits.

Lack of Clear Promotional Criteria

In a recently published qualitative review of female urology faculty opinions on the barriers to promotion and the interplay of pregnancy and parenthood, the most commonly cited barrier was nebulous promotional criteria—nothing to do with gender or childbearing at all.¹¹ The problem with unclear criteria is that they leave room for interpretation so that rules may be more stringently applied to one group than another, and essentially a form of gatekeeping happens. When is your scholarship enough? How many speaking opportunities defines a regional or national reputation? How much grant funding do you need? Further compounding the difficulty is that these criteria vary widely from institution to institution—so even advice from trusted colleagues may be incorrect.

Conclusion

A delay in promotion exists for women in academic medicine and urology in particular. The etiology is clearly multifactorial, and numerous inequalities collectively contribute to the delay. Steps may be taken by the women themselves, their male allies, and institutions to offset this delay (see Table).