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Andrea Miyahira: Hi, everyone, I'm Andrea Miyahira at the Prostate Cancer Foundation. Thank you all for joining me today. With me is Dr. Catherine Nam, currently Chief Resident in Urology at the University of Michigan. Dr. Nam will discuss her paper, "The Future is Female: Urology Workforce Projection from 2020 to 2057," which was published in Urologic Clinics of North America. Dr. Nam, thank you for taking the time to share this with us.

Catherine Nam: Thank you so much for having me. Alright, well, thank you for the opportunity for us to share our work on "The Future is Female: Urology Workforce Projection from 2020 to 2057."

The current urologic workforce shortage is well recognized, and it's actually an advocacy priority of the American Urological Association. It's multifactorial from both the supply and the demand side. First, the supply is currently limited by the Balanced Budget Act of 1997, which limits the government-subsidized residency positions and their funding. Second, urology is one of the oldest subspecialties with an average age of 55 years old, and 30% of the workforce being 65 years or older.

Over the past few decades, the gender composition of the urology workforce has changed dramatically. It has experienced an 11-fold increase in female representation from 1978 to 2013, and now approximately 10% of practicing urologists are female. Shifting gears to the demand on urologic care, there is projected to be an increase in the demand for urology care due to the impending "silver tsunami," where it's expected that by 2030, one in five people will be 65 years or older. It has been found previously that the Medicare population utilizes urologic care at three times the rate of the general population. The combination of the supply and demand leads to a worsening urologic workforce shortage, which has downstream consequences of decreased access to care for our patients and heightened pressure on practicing urologists.

While there have been urologic workforce projections into 2035, there has not been an updated projection beyond that. Therefore, we've updated the urology workforce projection to 2060 in two recent publications, featured below. We were asked to revisit this as part of the DEI issue of Urologic Clinics of North America, spearheaded by Dr. Tracy Downs.

We mirrored the same methodology that we used in our prior work, where we used two stock and flow models. We started with the urology population estimates using the 2021 AUA Census. The stock model consisted of incoming urologists based on the ACGME data resource book in 2022, and the flow model consisted of planned retiring urologists in five-year increments from the 2021 AUA census. Then we utilized the US Census Bureau's 2017 national population projections based on their census data from 2010. We calculated the urologist per capita estimates.

To answer this question at hand, we had this table of assumptions and we had two models. The first was the growth stagnant model of 0% growth of incoming urologists, and the second was the continued growth model, where we assumed a growth rate of 37.6% every five years based on the ACGME growth rate from 2017 to 2022. I've highlighted the two main differences from our original projections: the growth rate of 37.6% is significantly higher than the 13.8% that we used as our prior assumption. The current percentage of new urologists annually who are female is 30%, but in our prior projection, it was 25%.

Here is the projection model, and it's per capita as indicated by the Y-axis. The X-axis corresponds to the years that we project to. Here we find that even with the strikingly higher growth rate of 37.6% compared to our original projection, the workforce actually does not return to its baseline per capita until 2042. Another point is that even in the context of decreasing urologist per capita in the continued growth model, the number of female urologists per capita continues to increase in this projection.

In our stagnant growth model of 0%, we see a continued decrease of urologists per capita across our projection to 2057. Even in this context, however, you can see that the female urologists per capita continue to increase compared to the baseline in this projection.

When we look at the projection specifically at the number of urologists for the Medicare population (65 years or older), we see that there will be a prolonged shortage of total urologists in both models compared to the overall population. The workforce does not recover to its baseline until 2047, compared to 2042 for the general population. The number of female urologists continues to grow for the Medicare population as well.

So, the major takeaways from our study are that despite the 37.6% growth rate compared to the original projections of 13.8%, the workforce shortage will not return to its 2022 baseline until 2042. That's two decades until we're able to go back to where we are today. The impending shortage will most likely be felt by the elderly population, 65 years or older, and the most vulnerable, as they are high utilizers of urologic care. Female urologists consistently grow in both projection models and will likely play a very important role in the context of the urologic workforce shortage.

We wanted to use this as an opportunity for a call to action for stronger recruitment and retention efforts to ensure a strong urology pipeline, particularly for female urologists.

Andrea Miyahira: So, thank you so much, Dr. Nam, for sharing this. It is promising to see that more women are entering urology. What can we do to increase and maintain this pipeline, and how can we encourage more women to enter this space and support them as they do?

Catherine Nam: Yeah, so that was the call for action that I had at the end of the presentation, where I think there are a lot of opportunities for growth both in terms of recruitment and retention of women urologists. In terms of recruitment, there have been some studies that look at the annual rate of change in the increase of female representation among surgical subspecialties. [inaudible 00:06:46] just recently published this, and they actually saw that urology ranked eighth out of ninth place.

And so, I think there are a lot of different ways that we can be more thoughtful about recruiting women because this is a male-dominated subspecialty, so we need to make a special effort to reach out to the female applicants.

Another interesting study found that female medical students who pursue urology were more likely to report discrimination, abuse, and harassment compared to their male counterparts. This is simply not acceptable for the future of our field, and we need to be very cognizant of how we can be supportive of the female medical students who are considering urology as a field, to let them know that they are welcome and that we really need them to join for a healthier workforce.

In terms of retention, we want to make sure that urology makes it feasible for urologists to achieve pregnancy and parenthood if he or she desires it. This is in the context of female surgeons utilizing assisted reproductive technology at a much higher rate than the general population, and female surgeons are found to have higher rates of major pregnancy-related complications. Although parenthood is thought to be a traditionally female issue, having young children has been associated with lower work-life family satisfaction among urologists. This actually becomes an early career issue if they were to pursue having a family.

What we found in the literature is that parental leave is in place in training to variable degrees, and the American Board of Urology is actually in the process of trying to change that. However, some practices don't have any protected parental leave for practicing urologists. I think this leaves a lot to be desired for urologists who want to prioritize having a family while also having a full-fledged urology career.

Another issue is the gender pay gap that has been studied in the literature. A recent Health Affairs study found that women physicians over a 40-year career span earn $2 million less compared to their male counterparts. When looking specifically at female surgeons, the gap was even worse at $2.5 million, and this is just not okay. Within the scope of urology, there's also been a study that looked at female gender as a predictor for lower compensation, showing an annual difference of $76,000. This was while controlling for work hours, call frequency, age, APP employment, and many other factors that you would consider when thinking about the pay gap.

The Society of Women in Urology has put together a workforce to look at the gender pay gap and some specific ideas on how to tackle it at its source, such as having a faculty salary equity review committee to ensure that salaries are indeed equitable, or revisiting the RVU system because many female urologists are found to be practicing or providing care associated with lower RVU value.

There is also the issue of the leaky pipeline that affects female urologists at a higher rate. The AUA Workforce Task Force looked at the rate of burnout for female urologists compared to male urologists over the last five years. Interestingly enough, the male burnout rate decreased over the last five years, whereas it worsened for female urologists. Some component of this may be due to the COVID pandemic, where a lot of domestic and childcare duties fell on women. Additionally, in the context of there already being a differential, female physician-scientists were found to spend 8.5 hours a week more on domestic activities compared to their male counterparts.

And so I think there are many ways to be more supportive, and once again, this isn't just specifically for women urologists, but I think it can be helpful for all practicing urologists, in terms of granting them greater autonomy over their time and schedule, more flexibility, and providing a more diverse and inclusive work environment for them. I think one idea that was proposed was Stanford actually had a time banking program where if you have to cover for someone else's call unexpectedly, then you can use that time towards the future where you can pull from that time bank for when you need it in the future, which I think is brilliant.

And then the last point is as we continue to have increasing representation of women in urology, which is amazing, we also need to have that be mirrored in terms of the increasing number of women in leadership roles. There have been some studies looking at the delay in promotion where women take 1.2 years longer than their male counterparts to be promoted to associate professor, and they have also found a higher attrition in academic practice for female urologists compared to men.

And so there have been some efforts into this with the Society of Women in Urology, with a lot of different efforts there, and there's also been a diversity and inclusion task force of AUA, but I think there's a lot of room to grow in terms of the female representation on a national level, as well as in chair positions.

Andrea Miyahira: Well, thank you. Those are a lot of things to think about and find ways to really support women in urology. So, what are your next steps in studies on gender disparities in the medical and urology workforce?

Catherine Nam: Yeah, so I've done a single-center study looking at patient and patient's family-perpetrated sexual harassment of urology providers. Once again, it affects women urologists more, but this is a specialty-wide issue. We have had the privilege of getting our questions included in the American Urological Association Annual Census, and so it'll be really interesting to look at the urologists' experiences with harassment and discrimination from patients and their family members on a national scale, to be able to identify how we can be more supportive of the current urologists. Because we already have a workforce shortage issue, we don't want the ones who are in practice to early retire or to cut down on their work hours. And so I think that's something that I'm very excited about.

I think another thing that I want to look at is understanding that there are gender disparities within urology. I also want to flip the coin a little bit and look from the patient perspective: do patients have preferences in terms of the gender of their provider, male or female? There have been some studies done in the past, but I think there's a lot of room to answer this question and explore some of the implications that it may have in the context of the urologic workforce shortage.

And going back to the differences in terms of the domestic and family responsibilities that tend to fall on female physicians, I've been collaborating with the intern health group at the University of Michigan to look at the number or who’s the primary person in charge of the domestic and family duties based on their partner's employment status, whether they are also physicians or have full-time employment outside of medicine, or if they are not currently working. We are also looking at some of the implications that it may have on the female physician's mental health.

Andrea Miyahira: Okay, thank you. Then what messages would you like to give to those in leadership and mentorship roles?

Catherine Nam: Yeah, so for mentorship roles, I think the reason why I went into urology was one encounter I had with a female urologist who really gave me the ability to believe in myself and see myself in the field of urology. So all of those individual actions matter so much, especially to medical students who are considering the field of urology.

And I also want to say, I've had incredible mentors who were men who have been there for me every step of the way, making sure that they acknowledge my experiences, but also give me the same professional treatment that they would to my male colleagues as well. And so I think there's a great role for he for she's in urology, and I think all of us really benefit from that and make our field overall better.

And I think in general, for the people in leadership, what I wanted to go back to was, a lot of the issues that are of interest to me in terms of supporting women urologists, I think overall affect both men and women and urologists as a whole. And so I think it's really important for us to broaden our horizon and instead of just labeling it as a women's or a female issue, just think more broadly, how can we make our field more sustainable for all urologists?

I think one example of this was using the prior AUA Census data. We looked at the work-life balance or work-family balance in terms of their parental status, and we found that for urologists with kids under the age of 18, men or women, if they have kids, their work-family balance was lower and their work satisfaction overall was lower. And so I think typically, a lot of the things that affect women, it affects them differently, but overall can help the field grow and be more sustainable by addressing these issues one at a time. And I think there's a great role for us to be able to push our field forward, and it's especially time-critical right now given that the workforce shortage is likely going to get worse within the next few decades.

Andrea Miyahira: Okay, well thank you so much for sharing all of this with us and coming on this today.

Catherine Nam: Thank you so much.