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Ruchika Talwar: Hi everyone. Welcome back to Uro Today's Health Policy Center of Excellence. My name is Ruchika Talwar. And today, I'm so excited to be joined by Dr. Katie Marchetti, who is a urologic oncology fellow at the University of Pittsburgh. She will be sharing some work that she recently published in the Gold Journal that has to do with gender disparities in the surgical experience of male and female urology residents. Dr. Marchetti, thank you for taking the time to be here with us today. We really appreciate it.

Kathryn Marchetti: Of course. I'm so happy to discuss the work that we've just published. I'll jump into my presentation then about our project.

So yes, today I'll be discussing a recent publication on the gender disparities that exist within the surgical experience of male and female urology residents. So we are all aware that gender disparity unfortunately exists within medicine. It's very well published on, despite the fact that women, the representation of women in medicine has increased over the years. In urology training in particular, this gender disparity manifests as a lack of mentorship, stunted academic development through first-author publications. And the AUA census data actually shows us that there's a higher percentage of women who pursue further mentored education with a fellowship following residency.

So what about the surgical training? Is there a disparity in that? That question had previously not been answered, but the quality of residency training and training preparedness for practice are two... The important measures of those two points are the surgical case log data that residents submit at the time of graduation. Data from other surgical specialties actually has identified a disparity in the numbers of case logs that male and female residents log. And three specialties in particular, general surgery, otolaryngology, and ophthalmology, show that female residents log fewer cases than their male counterparts.

One of these studies actually showed that female residents logged a number of cases that equated to about three months of training after the standard five-year surgical residency, which personally I feel is not an insignificant amount of time. So that got us interested in looking into these potential disparities within urology, having us ask, what about urology training?

So we were fortunate enough to work with a total of 13 ACGME accredited urology programs, and we obtained case log data from these 13 programs from 2007 to 2020, so 13 years. The programs that we included were located in geographically diverse areas throughout the United States and they varied in size to hopefully be a representative sample of the national cohort.

We were able to collect logs by year and by role. And so, the case logs by year gave us information on case number per PGY year. And then the role data gave us information on the resident self-described role in cases, so assistant surgeon and teaching assistant. And just as a reminder, the assistant in the case does less than 50% of the case and not a substantial amount of the critical portions. The surgeon does 50% of the case with a substantial number of the critical portions. Then teaching assistant is a resident who takes another resident or another trainee through a case. And we just included in our analysis the four years of urology specific training. So, for most programs, this is the last four years of urology training, urology residency.

So ultimately, in our cohort, we included about 500 residents total. A hundred of these were women, so about 20% of our cohort. And across the years from 2007 to 2020, the percentage of female residents matched with the ACGME published data about the total number of female residents across all urology residencies, again, showing that our cohort hopefully represents the national dataset. There was no statistically significant difference in male or female resident distribution by residency volume or by residency size, which is good to see if those were confounders.

But ultimately, we did find that over the four years of urology training, male residents did significantly more cases than female residents. In total, it equaled to 99 cases, or about a hundred case difference between the two cohorts. So, this is our main figure in the paper.

On the bottom axis is case type, so general urology, stones, reconstructive surgery, oncology, etc. But I'm going to direct your attention to bars on the far right side of the graph, the Y-axis is the cumulative median number of cases. The green bar is women and the blue bar is men. And as you can see in these bars, men, as I mentioned before, did about a hundred more cases than female residents, so 2200 versus 2100.

And then looking at case log by type, we saw that most of this significant difference in the case log numbers was driven by differences in the oncology case subtype and the general urology case subtype. So, men did around 20 more cases, oncology-specific cases than women, and about 50 more general urology cases than women.

And so, a couple of things to highlight from this graph alone. The findings that we came across in our urology case series are similar to other surgical specialties that were studied, that the difference between male and female residents accumulated over all four years, so it wasn't just one specific year that led to a significant difference in the case log numbers between male and female residents.
The other thing to help put these numbers into context is thinking about what does... So, 30 more oncology cases than female residents, male residents complete. What does 30 cases provide a resident? Well, previously studied learning curves in urology tell us that around 15 to 30 cases is the learning curve for robotic radical cystectomy. Now, I doubt that all the cases that male residents logged more than female residents were robotic radical cystectomies. But it puts it into context that that number can make a significant difference in a trainee's education. And then, as I mentioned before, the disparity accrued over the four years that we included in the study, it wasn't just one specific year that led to the difference. So, about a 25-case difference between men and women over the four PGY years included.

Looking at the proportion of cases by role, we had a slightly smaller cohort in this subsection of our study. Around 250 residents were included in the analysis. Again, about 27% were women. Female residents logged significantly more cases in the assistant role than male residents, about 5.8% compared to 3.5%. Two things I'll highlight from this graph in particular. Number one is that the distribution of cases across roles—assistant, surgeon, teaching assistant—really aligns with other published literature. So the vast majority of cases that residents log are in the surgeon and the teaching assistant roles, most in the surgeon role, with the minority in the assistant and the teaching assistant roles.

But I think this highlights that even in the surgical experiences that female residents do have, their perceived role or the part that they take in those cases, they see it as being different than what their male counterparts see themselves as the role that they have in the cases. And so that compounds. A potentially reduced experience during the fewer cases that female residents are completing means maybe even further diminished growth over the cases that women are actually completing.

And so why does this matter right now? I mean, besides the just general reason for wanting equity in a field, this is the table of our match statistics from this year, which shows that almost 50% of our newly matched residents are women. And so our hope in publishing this data is that we are getting programs prepared to create a training environment for all these budding female urologists that's equivalent to their male counterparts. And I think it's even more important now than ever considering the fact that women are only becoming a larger proportion of our field.

I'm so thankful to all of the collaborators on this project, all of the programs that were willing to contribute data to our study. It's really exciting to be a part of this and, as I say, get the conversation started about gender equity within our field.

Ruchika Talwar: Great. Thanks, Dr. Marchetti. I mean, this is just such an important conversation. And I commend you and your co-authors for publishing this sort of work because we know anecdotally that there's a lot of work to be done in this space, but it really helps when we have the literature and the evidence to back up the fact that this needs to be a focus of improvement for our field, particularly considering the point that you brought up. We're seeing the proportion of women entering the workforce rise over time. And so, this disparity will only exacerbate the issue of making sure that we have well-trained urologists ready to serve our patients. I mean, we talk a lot about this workforce shortage and all of that, and these kinds of issues are central to making sure that we're not aggravating an already existing problem.

Now, I'm going to ask you the million-dollar question, and I know that you're not going to have the answer, but I'm curious just your thoughts on what is driving this. We can have a discussion with lots of potential issues, but in your opinion, what do you think is contributing to this disparity that we're seeing?

Kathryn Marchetti: I think it's easy to say that parental leave is contributing, but anecdotally, my male co-residents took paternal leave and I also took maternal leave. And one can, to do a hundred cases over a six-week parental leave just seems unrealistic. So I don't think it has anything to do, or only in small part to do with parental leave.

I think probably some of this is due to potentially women, maybe female residents gravitating towards work in roles that maybe are outside of the operating room. Or this could have to do with just mentorship, on-call cases that are performed or add-on cases performed by male surgeons. Are they as likely to involve female residents in the discussion of, "Hey, do you want to come join me for this unplanned case?".

So I think it's certainly multifactorial, but I'm sure some of it is driven by attendings or the scheduling side of things, but I think some of it's probably also driven by trainees in the way that they approach the work that they're given in a certain day.

Ruchika Talwar: Yeah, I couldn't agree more. Obviously, I asked you that question almost facetiously, acknowledging the fact that you're not going to have the answer. And like you said, 100% this is a multifactorial issue. There's no way we're going to be able to pinpoint one specific area that's going to be the magic bullet here.

However, I think your second table that you presented brings up some really important insight. The fact that women are more likely to log themselves as an assistant during training definitely reflects at least... Because it's a self-reported role, so it's at least your perceived role in the case. And is that somehow compounding the fact that perhaps women are not getting those extra 20, 30 cases, perhaps?

I think these are all just important things to be aware of when we consider the type of environment that we provide to our female trainees. I think making sure that it's an environment that is inclusive, that is encouraging. These are all important points.

But what are your thoughts on the reason why women are logging themselves as assistants more often?

Kathryn Marchetti: Yeah, that's a really good question. There is some data in general surgery that suggests that the interoperative autonomy between male and female residents can differ by gender. So that may have something to do with it. It may have something to do with, as you had mentioned, we're showing that women are involved in significantly fewer cases. That could have something to do with it. I know personally I'm very critical of myself, so maybe that has something to do with it. Yeah, certainly multifactorial.

Thankfully, the number of cases that residents overall log in the assistant role is the minority of the cases that they log, but still, it highlights what you're saying, a significant difference in residents' perception of how involved they are and how many steps they perform in cases. And as I said, that compounded with the fact that female residents are performing or logging fewer cases may lead to an additional stunt in their growth into independent practicing urologists.

Ruchika Talwar: Yeah. Yeah, because let's remember, that's the goal here. And so although sometimes these conversations can be a little uncomfortable when we both examine the systems in which women train as well as the behaviors that we experience and exhibit, and all of that, I think these are just important things to assess when you're analyzing this particular problem. But again, these are important conversations that are needed to move the field forward.

As we start to wrap up here, I was just curious, what do you think the big takeaways are here for the urologic community, particularly those involved in resident education?

Kathryn Marchetti: Definitely. Definitely. The whole point of why we published this is to really get the conversation started on an individual program level about analyzing individual program data about the environment that's provided to male and female residents, and also residents of different other underrepresented minorities within urology.

So yeah, our hope is that this gets specific programs talking about whether this is something that's going on in our program, and if so, what are the factors that are influencing it. Does it have to do with scheduling, the way cases are scheduled? Does it have to do with the way that residents are participating in work? So yeah, just really getting the conversation started is our hope at the program level to make sure that we have an equitable training environment for all residents.

Ruchika Talwar: Thank you. Thanks, Dr. Marchetti again. I commend you and your co-authors for publishing this work. I think it's important that we see more of these kinds of analyses as time goes on because our workforce is changing. It's changing in terms of gender, as you also just referenced, and it's changing in terms of racial and ethnic makeup. And so, I think these sorts of analyses to give ourselves these sorts of quality improvement checks are going to be critical to make sure we're heading in the right direction.

And thank you for spending time chatting with us today.

Kathryn Marchetti: Yeah, thank you for having us. We're really excited to talk about our work.

Ruchika Talwar: Awesome. Well, thanks to our UroToday audience for joining, and we'll see you next time.