It was so uplifting to see so many colleagues and friends back in person attending the AUA 2023 Annual Meeting. We had tremendous response to the call for abstracts submission in the Diversity, Equity & Inclusion (DEI) space, which yielded 4 poster sessions and 1 podium session. Discussion of the entire body of AUA2023 presentations in the Increasing Representation in Urology space is beyond the scope of this article; nonetheless, all these abstracts signify valuable work. This publication will concentrate on the take home messages for the Increasing Representation in Urology. The Health Care Disparities summary will be shared in its dedicated Health Care Disparities Take Home Messages article.

Several notable themes emerged, including Pipeline and Mentorship, Equity and Inclusion, and additional body of work specific to Gender Equity. Abstract numbers will be listed in parentheses for reference and can be readily accessed in The Journal of Urology^®, volume 209, supplemental issue (No. 4S, April 30, 2023).

I would like to start by highlighting the work that overlaps several DEI themes by Imam and colleagues: A New Barrier in the Urology Residency Application Process for Students: Growth of U.S. Medical Schools Increasingly Outpaces the Development of Urology Programs (MP57-10). The authors analyzed the data on the number of MD and DO medical schools and urology residencies in the U.S., with the year of establishment sourced from the Association of American Medical Colleges, American Association of Colleges of Osteopathic Medicine, Doximity, and individual programs’ websites. Data were tabulated and stratified by year of establishment (either before 2000, or 2000 or later). Prior to 2000, nearly 80% of medical schools had an associated urology residency. That number has fallen to 67.9% in the past 2 decades. All AUA Sections experienced a decrease in the percentage of medical training sites in their region with a urology residency, except for the Mid-Atlantic and New England Sections. The authors point out that equity is one of the pillars of the AUA’s DEI initiatives; however, students at one-third of medical training sites lack local urological mentorship, leading to disadvantages in pursuing a career in urology.

On the theme of Mentorship and Pipeline, Goh and colleagues reported on students’ experience with diversity-focused pipeline programs in their abstract, Michigan Urology Academy (MUA): Initial Results From a Diversity Focused Pipeline Program (MP-57-06). The program was piloted in June of 2020 through 2022 and included a 2-day virtual mentorship targeting M1-M4 URiM (underrepresented in medicine) students interested in urology. The program hosted 208 students from 104 medical schools. Participants identified as 46% (n=96) male, 53% (n=110) female, and <1% (n=1) gender nonconforming. In total, 42.3% (n=88) identified as African American/Black, 15% (n=31) Hispanic/LatinX, 12.5% (n=26) White, 19.2% (n=40) Asian/Indian, and 7.7% (n=16) Middle Eastern/North African. Most participants (54%) were in their fourth year of medical school, with 21.6% in the third, 20.7% in the second, and <1% in the first year. Postgraduate trainees comprised 2.9% of participants. Echoing Imam’s work described earlier in this publication, one-third of participating students indicated that they did not have a home urology training program. All students reported a high degree of satisfaction with the program and would recommend the program to a peer. At 3 months of follow-up, respondents noted that the MUA was most useful for finding a mentor (27%), networking with other applicants (44%), and serving as an introduction to the field of urology (23%). Overall, fourth-year MUA participants from 2020-2021 (N=73) matched at a higher rate than the national average (76.1% vs 70%), although this was not statistically significant. This work underlines the importance of mentorship and earlier exposure to the field of urology.

On a similar note, Gonzalez and colleagues highlighted the importance of early exposure to urology, the impact of diversity, and mentorship throughout the residency application process and training years in their work, Recruiting and Retaining Latinx Residents in Urology: The Trainee Experience (MP57-08). They also pointed out challenges unique to first-generation trainees, such as family understanding of urological training and self-navigating spaces.

Within the theme of Equity and Inclusion, Holten and colleagues reported on Racial and Gender Diversity on AUA and European Association of Urology Guideline Panels (MP57-11). Panel composition of voting members was largely male (median: 83.3%; IQR: 72.7%, 92.9%) and White (median: 88.2%; IQR: 83.3%, 92.9%). About 1 in 5 guideline panels did not include a single female (11; 21.6%) or racialized individual (10; 19.6%). Only 11 of 617 (1.8%) voting members were racialized women. When comparing oncology- and nononcology-related guidelines, female (26.4% vs 25.8%; P = .129) and non-White representation (21.9% vs 28.4%; P = .129) was similar. For AUA and European Association of Urology guideline panels, female representation was similar (26.1% vs 25.8%; P = .946), whereas racialized individuals were more frequent on AUA guidelines (29.3% vs 20.9%; P = .048). The authors conclude that female and racialized individuals are underrepresented on guideline panels of the 2 major professional organizations, and stress the need for transparency in the panel member selection process and intentional efforts to promote gender parity and diversity.

On a similar note, Wang and colleagues presented a thought-provoking analysis of AUA2021 Census data in their work, Factors Related to Differential Treatment and Practice Limitations Amongst Urologists: A Report of AUA2021 Census Data (MP57-15). Their analysis shows that female and non-White urologists are more likely to experience both differential treatment in their practice and limitations in the scope of their practice. Specifically, women were more likely to both have experienced differential treatment in practice (75.0% vs 10.2%, P < .001) and to be limited in seeing certain patients/diagnoses (27.0% vs 3.7%, P < .001). Similarly, respondents who self-identified as non-White were more likely to both have experienced differential treatment in practice (30.4% vs 14.1%, P < .001) and to be limited in seeing certain patients/diagnoses (12.8% vs 5.0%, P < .001; see Table in abstract). The authors recommend further studies to understand if these experiences of discrimination in urologists’ practices are driven by patients, other providers, or a combination of both factors.

There were numerous stellar presentations reporting on the state of gender equity in urology. This includes the analysis of the Society of Women in Urology Census and the AUA Workforce Workgroup reports.

McMurray and colleagues in their abstract, Sexual Harassment in Urology: Society of Women in Urology (SWIU) Census Findings (MP 57-01), report that sexual harassment of women urologists is ubiquitous and grossly underreported. There were 379 total female respondents with an average age of 43 (SD 18.6) years old. Of these, 75.0% were urologists in practice, 15.1% residents, and 9.8% fellows. Specifically, 62.5% reported experiencing sexual harassment in training or in practice. Of those who reported experiencing sexual harassment, 70.9% described patient-perpetrated harassment, 59.5% had been harassed by a physician colleague, and 33.3% had experienced harassment from both sources. Although the majority of respondents were younger urologists, only 16.0% of respondents who had experienced sexual harassment chose to report it. This begs the question of whether we are encouraging a safe space for reporting and addressing these issues.

Hennig, Danforth, and colleagues reported on gender gap in urology and other surgical specialties from resident demographics and match statistics through ACGME (Accreditation Council for Graduate Medical Education) and the AUA 2017-2022 (MP57-16). Data show that the rate of female/nonbinary/transgender-identified individuals matching into urology was significantly higher over the past 5 years (1.3% per year vs 2.9% per year, respectively; P = .014); the number of female/nonbinary/transgender-identified residents was highest in general surgery and with the greatest overall increase of 7.4% over 5 years. Urology, neurosurgery, and orthopedic surgery had the lowest percentages overall, but all increased ∼3% over 5 years. The proportional increase from 2017, however, was higher in neurosurgery and orthopedic surgery (17.2% and 19.7%, respectively) than urology (11.9%).

Teplitsky, Harris, and colleagues reported an Update on Professional Burnout and Conflict—Work From the AUA Workforce Workgroup (MP57-02). The workforce metrics data from the past 5 years were derived from the AUA Annual Census. Results show that in 2021, 36.7% of urologists reported burnout, compared to 36.2% in 2016. When assessing by gender, burnout in men decreased from 36.3% to 35.2%, but increased in women from 35.3% to 49.2%. When examined by age, the largest increases in burnout were seen in the <45 years old group, increasing from 37.9% to 44.8%, closely followed by 45-54 years old, increasing from 43.4% to 44.6%. Those over age 55 either had decreased or stable burnout. When asked about the effect of COVID-19 on burnout, 54% of urologists didn’t feel COVID-19 impacted burnout. When considering work-life conflicts, 25.0% of men and 4.6% of women reported no conflict between work and personal responsibilities, while 25.7% of men and 44.7% of women resolved conflicts in favor of work or were unable to resolve them; 22.5% of men and 37.1% of women responded they were dissatisfied with their work-life balance. The authors conclude that further action is needed to substantiate the causes of burnout.

While this summary calls attention to several areas of improvement, numerous submissions in the Increasing Representation in Urology space and selected projects highlighted in this article convey a positive message that our membership is invested in DEI in our profession. We hope that these take-away points raise awareness of ongoing issues that many of our colleagues and students face on a daily basis, and encourage collaborative efforts with stakeholder organizations, specialty societies, and the AUA at large to take intentional steps toward improving representation in urology.