Read the Full Video Transcript

Ruchika Talwar: Hi everyone, and welcome back to UroToday's Health Policy Center of Excellence. My name is Ruchika Talwar, and today I'm joined by Ashley Appleton, who's a medical student at UCLA, and Dr. Simons, who's a fellow at the University of Michigan. We're going to be discussing a very important topic. This work was recently published in the Gold Journal, and it's entitled "The Future State of Race Ethnicity in Urology: A Workforce Projection From 2021-2061." Thank you both for being here today. I really appreciate it.

Efe Chantal Ghanney-Simons: Thanks for having us.

Ashley Appleton: Thanks for having us, and thank you so much, Dr. Talwar, for inviting us for this presentation today. I'm very excited to present our paper. It's titled "The Future State of Race Ethnicity in Urology: Urology Workforce Projection from 2021-2061." My name is Ashley Appleton, and I'm joined by my mentor, Dr. Simons. So, a bit of background and significance of this paper: By 2060, it's projected that 44% of the US population will identify with a race considered underrepresented in medicine. These racial groups include Black, African American, American Indian, Alaskan Native, Latinx, Hispanic, Native Hawaiian, and Pacific Islander. However, the rate of growth of underrepresented in medicine urologists has not kept pace with that of the US population. So now, with the increasing number of URiM-identifying patients on the horizon, aligning our urology workforce becomes very important, not just as a means of representation but really as a practical necessity.

There is extensive research highlighting the many benefits of diversity across many professional fields, and in medicine in particular, diversity has been linked to lower healthcare costs, increased patient satisfaction, better healthcare outcomes, and race-concordant patient-physician relationships have also been shown to help reduce healthcare disparities. So the objective of our study then is to assess the expected growth of representation of those who identify as URiM in urology under various scenarios and offer recommendations towards increasing diversity in the field over the next 40 years. For our paper, we instituted two models. One model we called the Stock and Flow Model. This model represents the current state of urology. We'll be projecting the number of URiM urologists by looking at historical trends. Then we had a selected scenario. For this scenario, we begged the question: what do we need to do to increase diversity in the graduating urology residents to reflect the racial and ethnic makeup of the US population?

So our team actually looked at pre-existing trends to predict the future trends in US Urology residency and practicing urologists, and we actually created an online interactive tool where you can play around with it and change the number of graduates per year and follow on with the rest of the presentation. So currently, the proportion of URiM urology residency graduates increases by 0.145% per year. So at this rate, we found that URiM urologists will likely make up 16% of urology residency graduates and 13.3% of practicing urologists. So these percentages will obviously constitute a continued under-representation of URiM urologists relative to the US population. For a selected scenario, we explored what it would take for us to reach that target of 44.2% of URiM urology graduates. We found that it will require an increase in the percentage of URiM graduates from 0.145% per year to 0.845% per year.

This will also result in 28.1% of the practicing urologists who will identify as URiM in 2061. And it's important to note here that though this does not achieve equitable representation among the practicing urology workforce, it does provide a stepping stone to reaching equitable representation in the workforce. So a conclusion of our study is URiM representation within the urology workforce is projected to remain disproportionately low compared to the US population. And so there is a need for concerted efforts to implement interventions that will help recruit, train, and retain URiM trainees. So some future directions in terms of recruitment, we can look at early exposure to the field and pipeline programs. Future research can look at if early exposure to the field inspires medical students to pursue urology, and pipeline programs like UReTER at UCSF or Urology Unbound or the R. Frank Jones Society have been around to help URiM students become familiar with the field and also help them apply in the field.

Training, every year many interested applicants go unmatched, and it's really just not because they're unqualified, but really because we simply don't have a lot of spots. Urology is one of the smaller specialties so an increase in GME funded residency positions could really truly help us move forward in achieving racial parity with the US population. In terms of inclusivity, we can think about whether our trainees, our residents, are learning and working in an environment where they feel safe and feel included in the culture. In terms of retainment, there is historically a higher attrition rate of Black surgical residents. We can perhaps see if this is something that also translates to urology and also see if this can help us develop those more inclusive environments for residents and possibly avoid any discrepancy in attrition rates.

And then opportunity for promotion, what is the track to tenure for URiM urologists? Is it a fair game or are there any discrepancies that we may need to address? I'd like to thank everyone for their attention and thank you to all my co-authors and a special thank you to my mentor, Dr. Simons. And please feel free to follow me on Twitter at @AAppletonMD2Be.

Ruchika Talwar: Thank you so much for such a great overview of your work. So first I just want to congratulate you both on this incredibly important study. Urology is facing a workforce shortage and it's going to disproportionately burden patients who identify with underrepresented minorities because often patients feel more comfortable, as you alluded to, seeing physicians who look like them. But more importantly, we have literature that tells us that the care provided is actually higher quality and outcomes are better. So we know that this is something that our field needs to focus on, as you've alluded to, and there have been several initiatives, but clearly I think why your study is so important is it shows us that we need to do better. Frankly, we need to do better.

We need to support our underrepresented minority trainees, students, and we need to frankly do a better job of recruiting people into the field of urology. And so I'm curious, Dr. Simons, how can we work towards this? Because these studies are important. They tell us where we are, they identify gaps, but I really want to focus on what the urologic community can take away from this study and how they can affect the way that they practice or train residents or teach students, et cetera.

Efe Chantal Ghanney-Simons: Absolutely. Well, first and foremost, thank you so much for the opportunity to speak with you all today and to share this work that we've done, and a special shout-out to Ashley, who is going to be applying to urology this coming season. So keep an eye out. I think this work is particularly important because not having a baseline assessment as to where we stand doesn't permit us to create targeted interventions. So the creation of this just happens to be a small subset of a larger collection of research projects that I've thrown myself into and engaged in. And really, what I've been trying to understand is what our pathway looks like. I've chosen to focus my area of research on the medical student, applicant, resident, and I would argue the trainee population to include fellows such as myself, and practicing urologists, and gaining an understanding of what the facilitators to entry into a profession are, and what are the facilitators to transition from one point to the next, I think, is particularly important.

And secondly, really gaining an understanding of what those barriers are to entry and successful progression. So in these collections of research projects, we're hoping to create a baseline assessment. And then the question becomes, what next? What are some of the interventions that can be created to achieve a shared outcome or shared goal? I would argue the urology community hasn't defined what it means to be a good urologist, what it means to be a good provider, what it means to be a good surgeon. There is no collective list of characteristics that we have at the specialty level, at the institution level when you think about the recruitment of potential trainees, and so what could happen with a given institution is when you're selecting your future candidates, we might tend to veer towards picking people who look like us or have shared interests because it's easier.

You feel more at home with those individuals. You have a shared history, a shared story. The issue with that is that we continue to perpetuate the differences that are so neatly described to us. So I think first and foremost, if we truly say that having a diverse urologic community is of importance to us, then we need to define how we measure an outcome that we can track in order for us to track our progress. So, it's all well and good to create these intervention programs because there have been other specialties that have demonstrated success, but for the world of urology, what characteristics should we be seeking that would define how we go about the inclusion of individuals into our field by way of the urology match?

And then the other piece would be, well, what if the people who are choosing to apply to urology already have had adequate access, but there's a full pool of individuals who are missing proximal to that? Well, then you have to ask yourself the question, and this is one of the things that we're looking at: are institutions that tend to have more underrepresented in medicine medical students less likely to have an affiliated urology residency program? And I can tell you, because I've looked at this, the answer is yes. If you consider the four medical institutions that are historically Black medical colleges, so that would be Meharry, Morehouse, Charles Drew, and Howard—those four institutions, with the exception of Charles Drew, which actually just broke away from UCLA so it's now its own independent medical school, the other three do not have an affiliated urology residency program.

So those medical students are not going to discover urology until much later, which sets them behind in terms of the ability to successfully enter the field. So those are the questions I think we should be asking. How is our system set up to ensure that we have an outcome of increased diversity? And I don't think we've asked that question.

Ruchika Talwar: Yeah, I think you've put it very eloquently. I agree with everything you've said. These are all the right discussions we need to be having and the right questions we need to be asking ourselves. I think we as urologists are very lucky to have people like you with this expertise and interest because it's only going to help make our field better and improve the quality of care that we provide for our patients. So thank you for doing this important work. And I know that I, personally, am very eagerly awaiting the results of your future studies that you've described, and we'll be sure to bring you back to do a deep dive once those are out. But to both of you, congratulations on this study. Thank you so much for taking the time to share it with our audience today because it is incredibly important.

Efe Chantal Ghanney-Simons: Thank you again for your time.

Ashley Appleton: Thank you so much for having us.

Ruchika Talwar: And to our audience, thank you so much for joining us for this discussion. I know I learned a lot, and I'm sure you all did too. We'll see you next time.