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Sam Chang: Hi, my name is Sam Chang. I'm a urologist at Vanderbilt University Medical Center in Nashville, Tennessee, and I have the great honor and pleasure of being here today with Simone Thavaseelan. Simone I have known for actually just a few years. She's the associate professor at Brown University and is the program director there, and we spent some time together working on an AUA task force, but we want to focus on a course that you just started I think last year. And I want you to tell us a little bit about the course and kind of how it started, and then we can start talking about the nitty-gritty of what that course actually attempts to try to tell us what's going on.

Simone Thavaseelan: Sure. I so appreciate the invitation to be here. The genesis of our course was really to move the needle on gender equity in urology. So our goal is to bring to the forefront a discussion about what are the experiences women are having as the workforce in urology changes. I think we're all aware that the vast majority of urologists in the country are men, over 90%, and we've just crossed that threshold into 10 to 11% of urologists are women. But the story is very different when we look at the training population. In residencies now, we've recruited up to 20 to 30% of the residency workforce to be women. And the success of our subspecialty relies on the fact that we want women who go on to become urologists to be successful in practice, to be able to bring their expertise and their training, their knowledge to the care of urology patients, patients who are not just women but men as well.

For us to be able to realize the talent, the expertise, the impact of women in urology, there are certain disparities that women face in their practice that we want to be able to both fix at the level of women advocating for themselves, but also for men in urology to be allies in order to achieve equity. And so part of my work, among the many things that I do, the different hats I wear is in education, as a program director. It's also in clinical work. I'm a stone surgeon and endo urologist, but also through professional societies, be it the AUA or the Society of Women in Urology, which is an affinity organization that seeks to advance the issues that are critical to women, is to advance that agenda of achieving greater equity for women so that they may be successful in their practice, so that they can potentially change the field of urology, and fundamentally improve the care of the patients that they're going to go on to take care of.

Sam Chang: Right. I think there's no question, I think in knowing you in a short period of time, this is an attempt to make this a win-win. This is not in any way, I know in terms of the emphasis of points that you've raised. This is an attempt for everyone to succeed for the betterment of patient care. And so along those lines, let's start off with the current inequities. In terms of, from what I can tell, clearly the percentage of women that go into urology has increased greatly. I'm sure in your program, in our program, it's more than 50%. It's changed significantly. Tell me what you think has led to some of those improvements and how can we, it may never get to 50/50 or 60, but tell me why you think that trend has started, and then what can urologists or our discipline do to help improve that or even better increase those initial opportunities?

Simone Thavaseelan: We have a rising representation of women in urology, but I'd love to make the point that representation does not equal inclusion. And so how we bring these women into urology and make them successful becomes super critical. Now, why do I think women are choosing urology? I think it's the same reasons that anyone else would choose urology. We have a great subspecialty, we deal with disease, both the medical and surgical aspects, and we make a difference in patient's lives.

And that spans the gamut from pediatrics to female urology to recon to oncology. So there's such a variety. Now, I think women in general, when they're called to choose a surgical subspecialty as their potential vocation or career, if they go on to find urology because they are exposed to it in their third year, that starts the beginning of, hey, I could look like a urologist. I could be a urologist. If they are ever so more lucky to encounter a mentor, particularly if they happen to be a woman mentor. But that is by far not necessary. Most importantly, as a mentor that potentially could sponsor them into a research project, into an opportunity to meet a network and create a network to be a successful applicant in the match, well then they're a little bit ahead of the game to be able to enter into our field.

Sam Chang: Oh, absolutely. Sure.

Simone Thavaseelan: So I think the reason why more women are choosing urology is because it was always a great subspecialty. We have the opportunity to be masters of our domain, to own our disease states, to impact patient care across so many subspecialties. And so we would be fortunate for more women to potentially enter into the field.

Now, once a student might have interest or exposure, the goal is then to have a successful match in a very competitive field. And how do you do that these days? It's apart from the away rotation experience, it's gaining a network and getting involved in research opportunities. Students demonstrate their grit and resiliency through research projects, but it's also very much a reflection of what networks they have open to them in order to be involved in these projects. And for those that are underrepresented in urology, those networks are not built in.

And so in particular, at the Society of Women in Urology level, we recognize the need to reach medical students early and to provide them an opportunity, not just to look like a role model, but deliver a built-in network so they can get those early opportunities to be a competitive applicant in our competitive subspecialty. So I think the reality is, the secret sauce is urology has always been a great field and women should want to be part of a field like this, and they do.

There are also subtle messages during medical school that procedure-based fields and surgical subspecialties in general have been on the back end of diversification, both as it relates to gender and certainly as it relates to race. This is a variety of historical reasons and built-in bias, and at some point discrimination that influences who might choose to join our field. I think the real goal is if we create an environment that's inclusive to women and underrepresented minorities, that we have an opportunity to make our workforce more reflective of the patient population we serve.

Sam Chang: That message I think, we've done a very poor job of disseminating. That idea of, hey, the patients we help deliver care to, it's a population that we as caregivers should also be similar to. Understanding that who and how that individual can provide care... I learned a lot as this course has been put together, but specifically to me the most, I don't want to use a curse word here, but the most damning numbers are the numbers when it comes to salary and opportunities. So tell us a little bit about the research that's been going on in that area.

Simone Thavaseelan: Yeah, I look at it from the lifecycle and the trajectory. How do we encourage women students to get into urology? But let's say we get there, what is the experience of training at the urology residency level? What autonomy is given to women? What fields are they exposed to? How many women are going into oncology? Are they being pigeonholed into female urology or pediatrics? So very early on, there's those issues to contend with. Do they want to see female patients and practice in FPMRS or pelvic medicine? Do they want to perhaps not see those patients? And be a BPH specialist or a men's health expert. After they get through that area, and the issue of gender impacting women's ability to practice urology, which the data shows through multiple studies, including looking at the ABU case logs, that gender does affect, particularly general urologists who are women, are more likely to see women patients.

They are less likely to have major caseloads. They're less likely to do run of the mill general urology, which they've probably been very well-trained into doing so. And this is again, for a variety of reasons. It could be the front desk of their practice who brings up the fact that they're a woman and a patient selects not to see a woman with discordant gender. It could be because they're competing for referrals with colleagues, or it could be that they're not necessarily recognized as the expert despite their training. But as we get to the issue of salary equity and you're out of your training where we really don't have an issue with salary equity. The system we have of compensating residents is independent of gender.

Sam Chang: Absolutely.

Simone Thavaseelan: But then we get to practice, and we see that the value of women's work in our systems, in our institutions is simply not valued the same, be it inherent sexism with a system of RVUs, or the value we assign to citizenship work or non-clinical work. We know from the census that women are meaningfully engaged in their workplaces, that they are working as significantly hard as their male colleagues are. There's a workforce shortage. There's no shortage of patients. Women are out there seeing patients. The census data shows that they're in the clinic in the same number of times. Census data shows also that they're spending more time with patients, approximately 19 minutes versus 16 versus their male counterparts. We also see data showing that there's a greater burden on women as it relates to the expectations of patients. They're spending more time in the EMR, they're answering more patient messaging, their staff and support and resources surrounding them being block time or office staff or scribes or nursing support is different, and it might not be as effective in making them work to the top scope of their license.

All of these issues then contribute to what is approximately an $80,000 salary gap over the lifetime of women physicians in medicine. That adds up to over a million dollars in career earnings. We don't do the job for money. You don't get to this level of sacrifice in education and training to do this for the paycheck that you take home. But when we fundamentally think about just an inclusive culture in our organizations and our systems, salary equity is a key marker of how we value women's work. I think this is a much bigger issue than just urology. This is every field of medicine. And if we really step out from medicine, this is almost every field in every occupation.

Sam Chang: Sports, business.

Simone Thavaseelan: Precisely. Urology is exceptional, but we are clearly not exceptional out here. But what I fundamentally think it also comes down to is the fact that women are engaging in non-paid labor across their workplace and the homeplace, the home life. Put differently, women and girls are engaged in the vast majority of caretaking across the globe. And that caretaking is fundamentally not paid. That doesn't necessarily have to be that way. That could be labor that is split or shared in any type of fashion, be it in the citizenship work we all engage in, and for example, academics, to the caretaking duties that we have at home.

And so I think there's an opportunity here because what I do think that is exceptional about urology is the men in urology. I'm not here today without Dr. Sam Chang inviting me. That sponsorship is powerful. And I think for the men in urology and the leaders, because the reality is the vast majority of leaders in urology are in fact men, the best way to grow your power is to share your power. So I think that the opportunity for the leadership of the men in urology is a great one, is an opportunity to make sure that this growing proportion of our workforce has an opportunity to be as successful as they possibly could in their job. And I think that act of sponsorship is very powerful, and will speak to our male leader's legacy at the conclusion of their career in terms of how they were able to advance those folks that have otherwise been minoritized or historically excluded. And I specifically speak about race right now within our subspecialty.

Sam Chang: So any action may not be enough. And no question that can be frustrating, but steps need to be made. Tell me some concrete things you think that we can do as a subspecialty to start... I'm not saying it's going to be changed overnight, but to really start and make this movement not forward, but to where it should be, tell me some solid things.

Simone Thavaseelan: I think of this as individuals and systems. So when we think of individuals, I'd say think about your network. Think about the last paper you wrote and who was the group of authors on it. Do you have an author group, for example, that reaches outside of your network? Does that author group potentially include someone who's not within your gender or your race or your institution? Because if you think actively, intentionally about increasing that network, then the folks who are historically marginalized have an opportunity to gain or at least overcome that issue of network selectivity that hinders our ability to really create inclusion.

Number two apart from that is who could you sponsor that's different than you? And sponsorship comes in little and big things. The first opportunity to be a first author on an article, the opportunity to present at a national conference, the chance to potentially scrub on a surgery you're never going to see, maybe even an invitation to someone who's within your network so that leads to the next opportunity.

If we think about professional societies and the roles in leadership and responsibilities associated with professional societies, be it journals, leadership opportunities, committees, all of these are who you know, and it's not just what you know. And so if you're intentional about diversifying those opportunities, I think that's an individual opportunity for change.

I would also say you have to be an ally, and everyone can be an ally in a different way. Sometimes allyship means you speak up when you see something that's not just. If you have an opportunity because you sit in a position of power leadership, well, are we compensating our faculty? Should we assess that on the lines of gender? And if we're not, can we develop an action plan to address that? We can't have our heads in the sand.
This also means you're going to screw up. Being an ally or speaking up to a microaggression means you might get it wrong. And I've been in the situation plenty of time and I focus my scholarship on DEI, and yet I still screw it up. And so then you have to have some level of humility to be like, well, I'm going to do better now than I know a little bit better, but I won't let the fact that I might fall on my face prevent me from speaking up. So I think that that idea of being an ally from an individual level, pretty critical.

At the institutional level, you can either approach this as evolution or revolution. And I'm on the spectrum. I think overall I tend to be evolution. I'm willing to work within systems to change them. But I very much see the need for outsider grassroots support to create revolution. When we look at urologists who are black and only 2% of the workforce in urology is black, that's an urgent problem. And as you said, there's many ways to tackle this, but I hope to use my privilege to address those issues. And so I can see that also the need for simultaneous revolution outside the systems that exist of our professional societies, our national organizations are methods for assessing candidates to successfully match in urology. You can't throw the baby out with the bathwater, but clearly some of the stuff we're doing is not working.

Sam Chang: I think that the way that you've described it of what individually you can do, and those individuals then can really be impactful for the systematic changes. And a system requires many individuals to actually initiate that change. And I love your description of evolution versus revolution and the appreciation of the importance of both and that there are times where you got to shake the tree, really push. And those are times you really need to do that. And you may risk falling on your face. You may risk that. So before I finish by thanking Simone, I want to just emphasize to everyone there, this is someone who really not only talks to talk, but walks the walk. So you all can't see behind the camera, but actually in this room is a high school or college student. I've got to find out who is here on a program that the AUA has started.

And Simone has dedicated her time to spend time with this individual for the whole day during this AUA meeting, showing her what this meeting is about, what urologists talk about, the disease processes, but more importantly the people that are involved in the specialty. So I want to thank you first for showing us that this is something that you are not only actively talking about and getting the message out, but actually doing. And that means the world to me. And so I want to thank you for all your efforts and thank you for spending some time with us. And I look forward to a lot more from you.

Simone Thavaseelan: Sam, this has been a thrill. I so thank you, especially on behalf of the Society of Women in Urology. You are a former mentor award winner, and so there is a legacy of women that have been sponsored by you, and we are so appreciative for those efforts.

Sam Chang: No, it's because... I am now at a loss for words because that was one of the most meaningful awards I've ever received. And I thank the Society of Women in Urology. They've really made some important steps forward, and truly are an incredible important organization for all of us. So thanks again.

Simone Thavaseelan: Thanks for having me.