EDITORIAL

Diversity in Urology: If not Now When?

He was a prominent New York City urologist and urologists of a certain age will recognize his name for the prostatic retractor he designed. Nonetheless, to most urologists today, the words of Oswald S. Lowsley published in January of 1943 are reprehensible. He wrote, ”Gentlemen-it is true that a gentleman is a gentleman in every language, and there are gentlemen in Japan, a large party of them, but they have been entirely submerged by the military gang of cut-throats who have control in Japan at present. I know Japs. I was born in California and have traveled in Japan on two occasions. They are a barbaric people at heart with a veneer of civilization. They are truly, unreliable and fanatically brave in battle….the only country whose military officials declare a whole district to be a brothel and every woman in it a prostitute regardless of her color. I don’t like Japs!”1

Even though this article was published a little over 6 months after the major Pacific naval battles of the Coral Sea and Midway, it in no way justifies the overt racism expressed by Doctor Lowsley. Urologists should be cautioned that although these words were uttered in a different era, the disease of racism and bias is just as palpable today as it was 80 years ago. One only has to look to a Boston Globe article, ‘White Supremacist Group Marchers Move Through Boston’, which recounts the demonstration of a white supremacist group on the Freedom Trail during the July 4th weekend.2 These cowards demonstrated with their faces covered with gaiters, sunglasses and baseball caps while holding a banner that read, “Reclaim America.” They allegedly assaulted a black man.

The struggle for diversity and equality continues in our society and unfortunately in urologic practice as well. The 2019 census reported 10% of practicing urologists as women, 3.9% as Latinx and 2% as black.3 From 2007- 2008 to 2019-2020 while the proportion of Latinx/Hispanic urology applicants increased by 0.38% per year, their proportion in the urology resident population remained unchanged. During the same period, there was a decrease in the proportion of Black urology applicants (-0.13%/per year).4

Obviously, racial discrimination is just part of the problem. Like most surgical specialties, urology has traditionally been a male dominated domain. Chyu et al5 provide a compelling review of the current state of the urology workforce as well as some tangible recommendations for improvement. They argue persuasively for the economic benefits of women in leadership roles that have been achieved in non-medical companies. Studies by McKinsey and the Credit Suisse Research Institute demonstrated a 33% to 47% higher return on equity between companies with the most women on their executive boards compared to those with none.6,7

With respect to all medical specialties, women represent only 15% of departmental chairs. The number is even lower in surgical fields with women serving as department chair in approximately 3% of general surgery and urology programs.8,9 In 2016, a survey of academic urology programs revealed that women comprised 3.3% of chairs, 4.5% of vice chairs, 7.9% of division directors, 9.4% of fellowship directors, 8.1% of residency directors and 27.4% of medical clerkship directors.5 The presence of female urologists on urologic editorial boards continues to range from 2.1% to 4.8%.10

Beyond race and gender, diversity is lacking in urologic representation in the LGBTQ community. Griebling and others have led the AUA DEI (Diversity, Equity and Inclusion) Task Force to begin to address this issue.11 Besides addressing this constituency in the workforce, their task is to promote a greater understanding of the urologic problems unique to this group of patients.

Although our specialty has begun to address diversity, we have a long way to go. Diversity needs to start at least as early as in medical student education, if not earlier.12 As urologists, we need to be aware of the need to improve diversity, equity and inclusion in urology residency recruitment.13 Our leadership organizations, like the American Board of Urology, need to continue to support these efforts throughout urologic practice.14

In this issue of The Canadian Journal of Urology, an analysis of diversity within academic urology leadership should serve to crystalize the challenge before us.15 As we proceed deeper into the 21st century, one truth is becoming obvious. Whether it is a society, a profession or a specialty, the greatest success awaits for those groups who best utilize the full talents of all its members. If the existential threats of our era, global warming and pandemics, have taught us anything, it should be that we are all on this journey together.

Like most human endeavors, success in achieving diversity in urology rests with leadership. Equality and fairness in any aspect of life is not easy, but our specialty can and will achieve equality for ourselves and for our patients. If we do anything less, it is at our own peril. Let us be guided by the words of Martin Luther King, “Whatever affects one directly, affects all indirectly.”

Kevin R. Loughlin, MD Associate Editor Harvard Medical School Boston, MA, USA

References

1. Lowsley OS. The role of the urological surgeon in the Armed Forces. J Urol 1943;49(1):192-194.

2. Crimaldi L, Stoica N. White supremacist group marchers move through Boston. Boston Globe, 7/3/22. Pg. B3.

3. 2019 AUA Census, auanet.com.

4. 4 Simons ECG, Arevalo A, Washington SL et al. Trends in the racial and ethnic diversity in the U.S. urology workforce. Urology 2022;162:9-19.

5. Chyu J, Peters CE, Nicholson TM et al. Women in leadership in urology: The case for increasing diversity and equity. Urology 2021;150:16-24.

6. Kersley R, Klerk E, Boussie A et al. The changing face of companies. Credit Suisse, 2019.

7. McKinsey & Company. Women matter, 2 October/media, 2008. https://www.mckinsey.com/media/McKinsey/Business/Functions

8. Cooper-Patrick L, Gallo JJ, Gonzalez JJ et al. Race, gender and partnership in the patient-relationship. JAMA 1999;282(6):583-589.

9. Rock D, Grant H. Why diverse teams are smarter. Harvard Business Review, November 4, 2016.

10. Henderson AA, Murray KS, Ahmed H. Female representation on journal editorial boards-is urology behind the times? J Urol 2019;201(2):237-238.

11. Recent initiatives for LGBTQ and Health Care in Urology. Tomas Griebling, posted Apr. 1, 2022, auanet.org.

12. Slaughenhoupt FB, Ogunyemi O, Giannopoulos M et al. An update on the current status of medical student education in the United States.

    Urology 2014;84(4):743-747.

13. Kraft KH, Brown J, Pruthi RS. Improving diversity, equity and inclusion in urology residency recruitment. AUA News 4/1/22.

14. Husmann DA, Terris MK, Lee CT, Thrasher JB. The American Board of Urology: In pursuit of diversity, equity and inclusion. Urology Practice 2021;8:583-588.

15. Casals RK, Overholt TL, Matthews CA et al. An analysis of diversity within academic urology leadership. Can J Urol 2022;29(4):11204-11208.

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© The Canadian Journal of Urology™; 29(4); August 2022