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Investigation of Disparity of Urologic Fellowship Match Rates by Gender and US Versus International Medical Graduates Over the Past Decade - Beyond the Abstract

In this study, we aimed to investigate trends in urological fellowship subspecialties, focusing on disparities among applicants based on their medical school location (international medical graduates [IMGs] vs. U.S./Canadian graduates) and gender (male vs. female).1 The Educational Commission for Foreign Medical Graduates (ECFMG) defines IMGs as individuals who obtained their basic medical degree from outside the United States and Canada. While we successfully collected match statistics for all five American Urological Association (AUA) subspecialties since 2010, a major limitation was the lack of granular data, such as adjustments for applicants' competitiveness.

We identified three notable trends:
  1. U.S./Canadian graduates have a fourfold higher match rate compared to IMGs.
  2. There is a growing proportion of female applicants and matched applicants annually.
  3. Females consistently achieve higher match rates than males.
Gender and medical school nationality significantly influence applicants, evident in residency and subspecialty fellowship match statistics. These factors - possibly in addition to race (data was not available) - underscore disparities among expert urologists globally.

We discuss significant challenges beyond institutions' control, affecting focus on IMG applicants. This includes but is not limited to the difficulty in obtaining licensing for international physicians to practice urology, even under full supervision (known as a limited medical license). Consequently, over 60% of subspecialty match programs in the U.S. do not accept non-U.S./Canadian graduates. This requirement compounds the already rigorous criteria of completing residency and passing all United States Medical Licensing Examination (USMLE) step exams, which are time-consuming and costly. Figure 1 illustrates the 2025 match cycle, showing that only 36% (68/189) of programs are potentially open to IMGs, with varying accessibility, notably, 24% of EUS and two of 30 GURS programs are outside North America, welcoming international applicants.


Figure 1: Illustrates the 2025 Match Cycle Potential Programs for IMGs. AUA - American Urological Association; IMGs - International Medical Graduates; EUS – Endourology; ASA – American Society for Andrology; SPU - Society for Pediatric Urology; GURS - Genitourinary Reconstructive Surgery; SUO - Society of Urologic Oncology

Fellowship programs in centers of excellence aim to disseminate global knowledge crucial for candidates from regions with limited educational infrastructure. However, low international participation hampers global urology training advancement. IMGs contribute significantly to workplace diversity, enhancing culturally competent care and enriching the training environment.

This complex issue involves stakeholders across various fields and political levels, influenced by state-by-state policies.2,3 Despite challenges, opportunities exist to expand trainee positions, including for international applicants. Engaging more academic teaching hospitals under the AUA umbrella in the U.S. and globally could enhance training environments and potentially alleviate the U.S. physician shortage. Ultimately, diversity in medical training enhances global patient care quality.

Urology's progress towards gender equality is exemplified by historical figures such as Mary Childs MacGregor, one of the first women to practice urology, and Elisabeth Pauline Pickett, the first board-certified woman in urology, who were pioneers in the field.4 Medicine, including urology, has historically skewed male-dominated, yet as of 2022, 11.6% of U.S. urologists are female, up from 7% in 2014,5 with increasing female interest in urology residencies. Out of 382 matched applicants in 2024, 45.2% were females, and expected to further promote equity in subspecialty and academic involvement within urology, as detailed in our manuscript.6

Illustrates_the_Males_Match_Rates_Per_Subspeciality_through_the_match_years_across_the_different_programs.jpeg
Figure 2a: Illustrates the Males Match Rates Per Subspeciality through the match years across the different programs. EUS – Endourology; ASA – American Society for Andrology; SPU - Society for Pediatric Urology; GURS - Genitourinary Reconstructive Surgery; SUO - Society of Urologic Oncology

Illustrates_the_Females_Match_Rates_Per_Subspeciality_through_the_match_years_across_the_different_programs.png
Figure 2b: Illustrates the Females Match Rates Per Subspeciality through the match years across the different programs. EUS – Endourology; ASA – American Society for Andrology; SPU - Society for Pediatric Urology; GURS - Genitourinary Reconstructive Surgery; SUO - Society of Urologic Oncology

We identified significant disparities in female interest across urology subspecialties, with pediatrics (M= 114:106) most sought-after and endourology (including minimally invasive surgery [MIS]) least favored (776:76). Recent studies highlight stagnation in female endourology society (EUS) fellowship applicants despite increasing residency participation.7

Further limitations include a lack of data on non-AUA match programs like the Society of Urodynamics, Female Pelvic Medicine, and Urogenital Reconstruction, which could reveal additional disparities.

Lastly, our manuscript poses critical questions for further exploration:
  1. How can we sustain and enhance female involvement in urology academia and subspecialties while ensuring fair competition?
  2. What strategies can increase spots for IMGs in AUA subspecialty matches?
  3. Should there be targeted efforts to create and fund spots specifically for IMGs?
  4. Can academic societies influence state health policies to support these efforts?
We express gratitude to AUA secretary associates for granting data access and invite you to engage in advancing this vital discussion by reading our manuscript.


Written by: Kamil Malshy,1 Sari Khaleel,1 Keith Rourke,2 Borivoj Golijanin,1 Simone Thavaseelan,1 Gyan Pareek,1 Dragan Golijanin1

  1. The Minimally Invasive Urology Institute, The Miriam Hospital, Warren Alpert Medical School of Brown University, Providence, RI.
  2. Division of Urology at the University of Alberta, Edmonton, Canada
References:

  1. Malshy K, Khaleel S, Rourke K, et al. Investigation of Disparity of Urologic Fellowship Match Rates by Gender and US Versus International Medical Graduates Over the Past Decade. Urology. Published online July 2024. doi:10.1016/j.urology.2024.06.065
  2. California O website of the S of. Medical Board of California. 
  3. Department NYSE. License application Forms for Physicians. 
  4. Yang JH, Donat SM. Elisabeth Pauline Pickett (1918-): opening the door for women in urological oncology. J Urol. 2007;178(5):1875-1877.
  5. Jackson EM, Sellke N, Rhodes S, et al. How Female Is the Future of Urology? Projecting Various Trajectories of the United States Urology Workforce. Urology. 2023;178:180-186. doi:10.1016/j.urology.2023.04.028
  6. Registered P, Lists PS, Matching P, et al. 2024 Urology Residency Match Statistics 2024 Urology Residency Match Statistics. 2024;6:1-6.
  7. Srinath M, Singh Z, Hare M, Beland L, Aro T. Endourology Fellowship: More Than a Stone’s Throw Away for Women. J Endourol. Published online July 2024.
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