Introduction

Women in urology are a growing proportion of the urological workforce yet continue to face disparities in practice patterns, compensation equity, and gender bias in the workplace. Optimizing the success of women in urology is critical to maximizing the potential, sustainability, and impact of women urologists. In the spring of 2022, the AUA developed a steering committee to develop and provide a platform for women in urology, to elevate awareness, and to provide professional development that focuses on career advancement and education. Funded by Urovant who provided an independent educational grant in support of this initiative, the Women in Urology initiative falls under the larger new AUA Institute for Leadership and Business that was launched in early 2022. Part of the steering committee’s role was to provide oversight and expertise into the development of a needs assessment survey that the AUA administered online to just over 3,000 women U.S. members in August 2022. Four hundred sixty members responded and identified current needs and gaps for education and training for women in urology across the career trajectory. Results from the survey indicated that the top areas of need overall were negotiation skills and self-advocacy, mentorship and sponsorship, and communication. As a result, the AUA has developed a live webinar as well as a series of 3 new podcasts on AUAUniversity focusing on mentorship, sponsorship, and coaching/self-advocacy. The content in this article summarizes the December 2022 AUA Webinar, Advancing Women in Urology: Negotiating for Success.

The median salary for women is $80,000 less than male urologists despite controlling for number or hours worked.¹ This gender pay gap is typical of nearly all industries and medicine at large² but more severe for surgical subspecialists and undervalues women in urology. This translates into a career loss of $2 million of lifetime compensation compared to male physicians.³ Strategies to address the gender pay gap must be multifactorial, systemic, and institutional and cannot rely only on women themselves to address and effect change in inequitable systems. Nevertheless, arming women with the training, basics, and resources of negotiation (see Figure) can influence their starting salary on entry into the workforce or during leveling up for new leadership opportunities.

Perception of Issue

Negotiation is critically important if women are to maximize their potential in medicine. The disparities women in medicine face in terms of initial salary, lifetime compensation, and access to the soft resources of staff, time, and system perks compound over time and clearly impact the success, sustainability, and impact of the talent women in medicine. Negotiation is key to becoming successful in one’s role—it allows women to be leaders, earn the money they deserve, and positions them for future roles. In addition, the other areas that they negotiate (eg, salary, support) reflect to themselves and others that women are accepted and belong in their positions, especially those in leadership. If women receive less than would a man in a similar position, what does that communicate about their worth to the organization? Women are not typically raised or expected to negotiate—they are socialized to exhibit communal traits and emphasize helping others; and in fact, face the unconscious bias in seeking to negotiate of the perception of being aggressive.⁴ The knowledge and skills that women bring to the table are worthy of recognition and compensation and should be valued. The practice of negotiation is often “people moving” in addition to problem solving and sometimes looks like failure. It requires practice in daily life before being used in high-stakes events. Negotiation can feel like risk taking and as such induce fear or discomfort or risk the woman being perceived as greedy, aggressive, or pushy when underlying gender bias is exposed.

What Should Be Considered When Negotiating

Apart from direct salary, there are many other potential opportunities to negotiate. These include paid time off, parental leave, relative value unit accommodations for lactation time, CME (continuing medical education) time, CME funds, operating room block time, scheduling, office space, computers, staffing (MA vs registered nurse, secretary), operating room equipment, scribes/chart prep, research support, benefits (health insurance, life insurance, disability insurance), retirement/matching moving expenses, signing bonus, loan forgiveness, tuition reimbursement, noncompete clauses, termination notice, entry point into partnership, and mentorship or leadership training. To be successful in a position, women need to have the appropriate resources. Placing a woman in a position of leadership without providing her with the needed resources is a recipe for failure. This can require negotiating not just for money but for their team and how they spend their time. A leader recruiting expects one to negotiate so you can tell them about your aspirations and plans for the job as an assessment of your leadership vision.

Often women feel there is a lack of transparency regarding compensation offers. Starting with the mindset that everything is in fact negotiable, obtain benchmark data when available. Consider using a coach or consult with a colleague who has accomplished this at another institution to ensure your strategy includes milestones/roadmap of prior successful attempts.

What Is Your Strategy for Preparing for Negotiations

The soft power of influence or informal power can be wielded to listen attentively, converse effectively, and persuade intelligently. This starts with self-awareness of your communication style and your approach to conflict and understanding your process of decision-making in order to assess your counterpart’s as well. For example, is your conflict style competing, collaborating, avoiding, compromising, or accommodating? As a decision maker, are you results driven and focused or cerebral and academic or disruptive and innovative or responsible and cautious or logical and detail-oriented? The next step is to assess both the conflict and decision-making style of your counterpart and curate and individualize your approach to complement your counterpart. For new positions and if negotiating for a new leadership position, thoroughly read the position description and understand the responsibilities and what some of the challenges could be. It’s also important to research similar positions in other organizations, as well as the responsibilities, staff support, and compensation that are provided elsewhere. Using a coach to plan your negotiation conversation can be helpful to role play and practice your asks and prime your internal response to “no” by working to reframe “no” as the idea or thought that your counterpart is not yet ready to agree or feels uncomfortable or wants or needs more information, rather than that the negotiation is over.⁵

What Is the Impact of Not Negotiating to the Individual, Institution, or Field?

You will not be successful if you do not negotiate—the leader expects you to negotiate so you can tell her/him about your aspirations and plans for the job. Without negotiating, you will not obtain the positions to which you aspire and the support that you need to be successful and achieve longevity in the position. It’s important to remember that what you offer as your needs/requirements for a position is the best that you will receive—the person with whom you are negotiating is unlikely to offer you more. Know your worth, as well as what others in similar positions elsewhere receive. If you don’t negotiate what you need, you will likely either not be in the position long or will burn out trying to make things work. This not only has a negative impact on you and your career, but also a negative impact on the institution, as replacing a physician is expensive. In addition, it can have a negative impact on the field, especially for women, as a woman is likely the first or only one of a few to hold a given leadership position. Losing a woman from leadership impacts gender diversity of the institution and the field.

Systemic Solutions

While preparing women to negotiate successfully is critical, systems-based solutions with institutional and leadership action are needed as well. This means deliberately making spacing for women to be included and heard, recognizing unpaid labor and citizenship, and seeking to share these citizenship burdens, creating policy that supports parental pursuits, developing awareness and gender intelligence, being deliberate and intentional mentors and sponsors for women in urology, and amplifying women by citing, promoting, mentoring, sponsoring, and hiring women in their spheres of influence. It requires leadership to give credit to women during meetings, at author attribution and in institutional outcomes, seek to recognize their bias, select women for leadership opportunities with direct financial or decision authority, avoid denying or rationalizing the reality of the gender pay gap, and to advocate for blinded review of salary equity and standardized pay structures.⁶ Practice managers, chief financial officers, and chairs can examine their practice’s gender equity though the lens of an ethical code of conduct for business practice; report the results of salary assessment by gender to all key partners; investigate causes of disparities; implement strategies to narrow the gap by analyzing compensation by gender, sharing uncompensated citizenship work and burdens, and maximizing such resources as block time, ancillary staff, extenders across genders; and finally track these outcomes and make the results transparent.