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Diane Newman: Welcome to UroToday's Bladder Health Center of Excellence. I'm Diane Newman, a nurse practitioner and the center's editor. I'm really pleased today to introduce you to a colleague of mine who actually did her urology residency at the University of Pennsylvania, which is where I practice. It's Dr. Siobhán Hartigan. She's a urologist and director of the Reconstructive Urology and Pelvic Health at Hunterdon Urologic Associates in Flemington, New Jersey. As I said, she did a residency at Penn, but also she did a fellowship in female pelvic medicine and reconstructive surgery at Vanderbilt. So please welcome Dr. Hartigan.

Siobhán Hartigan: Thanks so much, Diane. It's so good to be here. It really is a pleasure to be here. Today I want to talk to you about women in urology. A little bit about how far we've come and where we need to go. So looking at the history of women in urology, in 1962, Elizabeth Pickett became the first female board certified urologist. And in 1978, there were still only 1.8% of female urology residents out of all residents. By 1985, there were still only 22 women practicing urology in the United States, and that was about 50% of the 50 total women urologists in the world. A study from 1985 citing reasons why women chose urology, they were most likely to report diagnostic techniques, combination of medicine and surgery within the field and favorable hours. And compared to studies for today, those reasons seem to be consistent. From 1978 to 2013, the proportion of female residents across all specialties rose from 15.4% to 46.1%, and women in urology training rose from 1.9% to 23.1%.

Urology actually had the highest growth compared to all other specialties, which was an 11-fold increase. However, you can see from the red line here, the proportion of urology residents that were women was still short and lower than the total in surgery subspecialties combined. Looking at the mean proportion of women in residency in medical school compared from 1978 to 1982 through 2009 to 2013, this five-year period, urology still had the lowest proportion of women in residency across all specialties except for orthopedic surgery and neurosurgery. So we're still very low. And more recent numbers from the 2022 AUA Census show that indeed there is an increasing number of women in urology from 2014 to 2022. Each year that number rises slightly. We're now up to 11.6%. However, that is still a very small percentage of women incorporated into the practicing field of urology. And it wasn't until 2020 that we actually tipped over that 10% mark.

So when we look at the age of women that are practicing urology in the workforce, AUA Census data from 2022, the vast majority are very young under 45, and there's a very small percentage of women that are more seasoned in practicing urology. So only 1.3% of urologists over the age of 65 are female, and only 5.6% of urologists over the age of 55 are female. That does not leave a ton of female mentors that are more senior in this field for younger urologists that are female to look up to. There are several challenges and disparities that might lead to this low number of women practicing urologists. We know that women in urology are more likely to pursue fellowships and are more likely to have jobs in an academic center. However, among academic urologists, men actually authored more publications and were more commonly principal investigators. On average, it takes women 1.2 years longer than men to advance from assistant professor to associate professor, and men had a three times higher rate of rapid advancement compared to women.

Why might this be? Well, is there underrepresentation of women in senior leadership positions advocating for younger females and their advancement? Women might be spending more time in administrative or teaching roles that don't contribute as much to academic advancement instead of research or disproportionate time spent on family responsibilities, even compared to male peers that also have families. We know that women are also very likely to face discrimination and harassment. There is implicit bias towards women in surgical specialties. Female medical students have been dissuaded from entering surgical fields due to concerns about their ability to start a family or work-life balance, which we know is a priority for younger physicians, including millennials like myself. And there's also a perception that is commonly perpetuated of surgery being an old boys club or concern for having a masculine enough personality to fit in this field.

It's important that we increase exposure for medical students in order to increase female representation in urology. So rotations in urology during their surgical rotations in medical school or modeling of women in urology to show these young female medical students that urology can be an enjoyable and prosperous career for them. Mentors are extremely influential even at the student level for specialty selection and also as a model for decreasing discrimination and persuasion of women interested in urology for our peers. Even if a home medical school does not have a large presence of urology, social media has really changed the game. So SWIUdents is a subsection of the Society of Women in Urology that is helping to increase exposure for female medical students across the world, honestly. And they have events that young medical students can get involved with virtually as well as at the annual meeting. There are other organizations like UroStream or Urology Unbound that have really been able to expand the exposure for students on a social media or virtual platform, including resources, support, peer connection, mentoring, modeling, and encouragement.

We know there's a huge pay gap. Adjusting for age, position, and specialty, women make on average about $20,000 less than their male counterparts. However, this is likely a gross underestimation. Pay gaps are much more pronounced in surgical fields. When we look at surgical specialties with an equal number... or surgical practices with an equal number of male and female physicians, men still earn 10 to 12% more than women. And when adjusting for male dominance within a field, the pay gap increased to 20 to 27% more for men. So that would be typical in a urology practice. This could translate to up to a $150,000 differential for women in male-dominated practices every year. And that's not even considering compounding over time. Pregnancy, maternity leave, and breastfeeding are also considerations for women. We know that biological facts of gestation and neonate nutrition lead to a disproportionate burden on women, which is inevitable just based on this.

So there's timing of these things, which is going to happen during training or in the early formative years in practice. And this is inevitable. This will likely become more significant with a greater number of younger women entering the urology workforce and overall one out of three female surgeons despite some increasing prevalence as more women enter this field would still discourage female medical students from a surgical career owing to the difficulties of balancing pregnancy and motherhood with training. So overall, we really need to improve support for all family planning needs in order to recruit and retain women in urology.

And as I alluded to before, mentoring for women in urology I think is really the crux of all of this. Mentorship is a key contributor to improving representation of minorities within urology in general, and it's critical to providing support needed to overcome gender bias. Women have been shown to be statistically less likely to have a mentor compared to male colleagues. This may be due to the overwhelming informal mentoring models that exist within training programs. Most training programs do have some sort of mentorship model in place. However, a lot of it is an informal setting, so not an outlined structure for timely meetings or a scheduled mentoring relationship. And women are less likely to seek out mentors than their male counterparts. Goals of mentoring would be professional and career development, academic success, networking, retention within the field and increasing diversity and inclusion. So it kind of lends itself to this vicious cycle for women in urology.

When you have a low number of women in urology, there are fewer women and fewer senior women to be present for gender-concordant mentoring. And it does not always have to be gender concordant. You can have allies and gender-discordant mentoring, which is also extremely valuable. But I think the modeling is also very important for women to actually see themselves in this field. And with such a few number of women that have successfully navigated this over the last several decades, it's hard for younger physicians to always be exposed to those models.

This tends to perpetuate barriers and disparities. And then women are dissuaded from pursuing urology, which again leads to fewer number of women in urology. But if we can break this cycle and increase the gender concordant mentoring or allyship for younger females interested in joining the field of urology, then we can model that work-life balance and other aspects of our field are actually achievable. We can break down these barriers and disparities, persuade women to pursue a career in urology that's quite fulfilling and therefore increase the number of women in urology and keep this cycle moving forward. Here are my references. Thanks so much.

Diane Newman: Thank you so much. I mean, I agree with you that urology tends to be a male kind of profession. I mean, I've always thought that, but it's nice to see we're increasing. Now you are fellowship trained, but you went into a community practice correct? So what was your decision making when you decided that?

Siobhán Hartigan: It's really interesting. I was at a crossroads honestly, when I was in fellowship of, "Did I want to pursue an academic career or go into community practice?" And all of my mentors, which were monumentally influential in my career path, had been academic so far. And I actually didn't have any models to really look up to or see what a community practice might be for someone that's sub-specialized like myself in FPMRS. But I had to write down a list of what my priorities were. And for me, one of my priorities was a really good work-life balance and a little bit more autonomy. And I wanted to provide excellent patient care, which we all know patients in the community need excellent patient care as well, not just in academic centers. And I was able to find somewhere that was grossly underserved in my opinion, from a urology FPMRS perspective and really able to fill a void there. That's been extremely fulfilling for me.

Diane Newman: Are you the first female urologist to come into the practice?

Siobhán Hartigan: I'm the only woman in my practice. We have previously, before I joined, had other females in this practice. None of them were FPMRS trained, but they had moved on before my time here. And currently, I'm the only female urologist in our county and the only FPMRS trained urologist or gynecologist in our county.

Diane Newman: Well, yeah, that's interesting too. When you look at the women going into urology, where are they going? Cancer, pelvic floor, like you're saying, as far as female pelvic floor reconstructive work? Where do you think they're going?

Siobhán Hartigan: So we know that there's a greater number of women in urology pursuing fields of FPMRS or pediatrics. So we know that there's a greater number of women there. However, women are represented in every subspecialty of urology. And like I said in the talk, women are more likely to pursue a fellowship than their male counterparts. Men are more likely to not pursue fellowship and practice in a community setting versus academics. And women are more likely to be fellowship-trained and practice in academics.

Diane Newman: So they're really highly skilled and highly trained, which I think is really positive. I wonder though, if women are going to fellowships because they feel they have to prove something though too. I mean, it's an interesting dichotomy. Why do women go where? But I think it's exciting that you're in primary practice as far as in the New Jersey area because you're right, we need experts who specialize in certain areas of urology in the community, and I think that that need is only going to grow. Thank you so much for this. I know it's going to be of great interest whenever we post this on UroToday. So thanks so much.

Siobhán Hartigan: My pleasure. Thanks, Diane.