Women doctors in female urology: current status and implications for future workforce

Abstract

Objective

To objectively determine the percentage of female trainees and consultants who are interested in their career being focussed on female urology (FU) in order to facilitate the improved planning for the future of this sub-specialty.

Subjects and methods

This was an international cross-sectional study spanning 1 year, from December 2018 to December 2019. An anonymous, voluntary survey was generated using the online survey generator Survey monkey^®. The survey was sent to urology consultants and trainees who were female from Australia, New Zealand, and Canada.

Results

The total response rate to the survey was 61%. Up to 50% of female consultants and trainees selected a career in FU due to their gender, but up to 75% of respondents were also interested in FU of their own accord. Common concerns held by a majority of respondents included both the medical community’s and the public’s lack of awareness of FU as a component of urological expertise. Despite these concerns, most of the trainees were not concerned regarding their future work opportunities in FU, and many had intentions to pursue a fellowship in FU.

Conclusion

Female urology is an increasingly popular sub-specialisation of urology, given the steady increase in the intake of female trainees. Similar trends were identified internationally. Urology training in this area will need to continue to increase the community’s and the primary health care referrer’s awareness in order to ensure the continued success and growth of the sub-specialty.

Introduction

Over recent years the involvement of women in surgery has significantly increased. This is also evident in urology [1]. Both the USANZ and the Canadian Resident Matching Service (CaRMS) have accepted a greater number of women onto the urology training programme. This is a reflection of the increased interest and number of applications received from female doctors. For example, in 2015, 9% of the USANZ applicants were female and of the successful candidates, 14% were female [2]. In 2018, 40% of the USANZ applicants were female with 30% of successful applicants being female [3]. The USANZ had its first female trainee in 1991, illustrating how much change has occurred.

Once urology training has been completed, anecdotally, there has been a perceived tendency for women to pursue further specialisation in female urology (FU) over other areas of urology [4, 5]. FU is a sub-specialty discipline within urology that deals with female patients with LUTS, urinary incontinence, pelvic organ prolapse, recurrent UTIs and voiding dysfunction. This is an area overlapping with the expertise of urogynaecologists (a sub-specialty of gynaecology), although there are significantly fewer urologists practicing FU and the perspectives are different [6]. For example, Urogynaecologists are trained in Obstetrics, whereas Urologists have trained in Surgery operating on both males and females. The present study aimed to objectively determine the percentage of female trainees and consultants who are interested in FU. We aimed to provide data to facilitate the improved planning for the future of this sub-specialty.

Subjects and Methods

This is an international cross-sectional study that spanned 1 year from December 2018 to December 2019. A survey (Appendix) was generated using the online survey generator Survey monkey^® (San Mateo, CA, USA). As this is the first study of its kind, the questions were chosen to gain an understanding into the reasons why female trainees and consultants choose a FU pathway and to determine the amount of exposure trainees have to clinics, theatre and urodynamics through their training. The survey was targeted to female consultants and trainees in Australia and New Zealand. In Canada, only the female trainees were e-mailed as the number of female consultants involved in FU is so low. The Australian and New Zealand urology trainees have a common training programme under the auspices of the USANZ. Survey respondents were asked about their clinical practice structure, preference in urology sub-specialty and their exposure to FU throughout training. Urodynamics is an essential part of the training in FU and consultant led urodynamics invariably result in more training and direct exposure to this field for the trainee attending the sessions. A question on urodynamics is therefore also included in the survey. All the female consultants and trainees were e-mailed anonymously via an e-mail distribution list and participation was voluntary. A reminder e-mail was sent at the 1 month mark to encourage completion of the survey. The platform, Survey Monkey, is user friendly and only required boxes to be electronically ticked. This program was also able to tabulate the results and provide the results in an anonymous and confidential manner. The authors were blinded to the person completing the surveys.

Results

From the USANZ, a total of 52 consultants and 24 trainees had surveys e-mailed to them. There were a total of 48 replies, i.e. a 63% completion rate. Of these, 60% (n = 29) were consultants and 40% (n = 19) were trainees. From Canada, there were a total of 14 responses from 25 surveys, i.e. a 56% completion rate. When any of the questions were not answered, the participant was not excluded from the calculations.

In terms of the consultants, 23% were junior consultants within 5 years of fellowship completion, 39% were between 5 and 10 years post-fellowship, and 39% were senior with >10 years of experience. Only about half (50%) considered themselves sub-specialised in FU, and the remainder considered themselves general urologists practicing other fields of urology. These other fields included endourology, uro-oncology, paediatric urology, reconstructive urology, andro-urology, transplant urology, and neuro-urology.

A breakdown of the trainee’s seniority is included, as senior trainees are less likely to change their sub-specialty interest compared to junior ones. Of the USANZ trainee respondents, 76% were senior trainees, being in their final 3 years of training. Of the Canadian trainees, 43% were senior trainees.

Public vs Private Workload

Most (76%) of the female USANZ consultants worked in both the public and private sectors. Of the 32% who did predominantly private work, FU represented 27% of their caseload. In terms of public operating, 46% had <1 public operating list a month for FU and 19% had a weekly public urology list for FU. The majority (65%) attended a public outpatient clinic for the review of FU patients. Only 24% did not attend any public outpatient clinics. In Canada, there is no significant private urology sector.

Urodynamics as an Index of FU Workload

About half (56%) of female consultants were performing their own urodynamics, 8% had nurse led urodynamics and 36% did not offer urodynamics (a high proportion of this group most likely do not specialise in FU). Similarly, only 59% of the USANZ trainees reported having exposure to consultant-led urodynamics. This was in stark contrast to the Canadian urological training, where 93% had exposure to consultant-led urodynamics throughout their training.

Training

Exposure to FU as part of urology training has been an issue that has been repeatedly discussed, even though this has been in the USANZ curriculum for over two decades.

About 47% of the USANZ trainees felt that they had adequate exposure to understand some of the scope of the sub-speciality but none of the trainees reported feeling competent at the end of their urology training. These data were consistent with the consultants’ perception of FU training within urology training; only 19% of consultants reported that their trainees had adequate exposure to FU, whereas 61% did not think that the exposure was adequate. These numbers are consistent with the Canadian experience, where 57% of trainees felt they had adequate exposure to FU. Despite these figures, of the USANZ trainees, 65% were interested in sub-specialising in FU and 41% were planning to pursue a fellowship in FU. Interestingly, this 41% comprised of trainees who both had exposure to FU but also trainees who reported very little exposure to FU throughout their training. Of those USANZ trainees with an interest in FU, a majority (53%) intended to work full-time in FU and 18% planned to work in a part-time capacity in FU. Six USANZ trainees did not respond to this question. All the Canadian trainees with FU interest planned to work full-time (Table 1).

Table 1. Plan for future work within FU in those with FU interest.

	USANZ trainees, %	Canadian trainees, %
Part-time	18	0
Full-time	53	100

Reasons for Interest in FU

In Canada, only 29% (four trainees) were interested in sub-specialising in FU compared with over half of their USANZ counterparts. The four Canadian trainees were all at least in their fourth year of training. Of these, three trainees reported that they were interested because it would help them obtain a hospital appointment. Two trainees also expressed that it was expected of them based on gender; however, these same trainees were also interested of their own accord in pursuing the sub-specialisation. These data are similar to historic data, where 26% of female graduates pursued a fellowship in this area [4].

Recognition of FU as a Sub-Specialty

There have been ongoing discussions regarding the recognition and awareness of FU. All international respondents held wide-spread concerns that FU is under-recognised by fellow urologists, primary care practitioners as well as the general public (Table 2). Promisingly, despite the above concerns, prospects in FU seem plentiful, as the overwhelming majority are not concerned regarding the availability of future work in FU (Table 3).

Table 2. Concerns regarding the recognition of FU.

	USANZ consultants, %	USANZ trainees, %	Canadian trainees, %
Under-recognised by urology	75	71	79
Under-recognised by primary care physicians	67	88	86
Under-recognised by the general public	83	82	79

Table 3. Concerns regarding future work in FU.

	USANZ consultants, %	USANZ trainees, %	Canadian trainees, %
Concerns about future work	8	6	20
No concerns about future work	92	94	80

Female Trainee Intake

The distribution of both the trainees’ and consultants’ opinions on the annual trainee intake of female trainees was fairly similar. Approximately 60% thought that the USANZ is accepting enough female trainees, and only 29% thought that the intake could be higher. A minority (12%) thought too many female trainees were being accepted.

Discussion

Urology has been traditionally viewed by the public as well as the medical community, as a specialty focussing on men’s health, but it truly encompasses female health as well.

It is interesting to consider the impact of increasing numbers of women in urology on the patient referral. A study was conducted in the USA, where log-books were reviewed of women in urology. Female surgeons operated on a significantly higher percentage of female patients compared to their male counterparts (54% vs 33%, P < 0.01) [7]. Female surgeons also performed more female-specific procedures including sling procedures compared to their male peers, 18 vs 10 per year (P < 0.001) [7]. Additionally, from the patient’s perspective, women tend to prefer being treated by female surgeons. When female patients were individually questioned as to whether they preferred a particular gendered surgeon, 62% preferred female urologists, 36% had no preference, and 1% preferred a male urologist [8, 9]. The male patients seemed more indifferent and minded less about genders, except when the discussion involved erectile dysfunction [8, 9].

Women in urology have often been stereotyped as choosing FU because of their gender. Indeed, a previous American study of academic urologists found FU as one of the most common fellowships among women [5]. The present survey reflects that sentiment, as a significant proportion (35–50%) of respondents felt that they were expected to pursue this field, despite the abundance of choices of other urology sub-specialties (Table 4). However, this survey has also demonstrated that a majority (42–75%) of these women choose to pursue FU out of their own interest.

Table 4. Reason for selecting FU as sub-specialty.

	USANZ consultants, %	USANZ trainees, %	Canadian trainees, %
Percentage of total who sub-specialise or are interested in FU	50	65	29
Expected to do it because of gender	42	35	50
Need of future job appointment (private or public)	22	51	75
Over-supply of other sub-specialties	12	35	25
Own interest	42	52	75

Of those USANZ trainees with an interest in FU, a majority (53%) intended to work full-time in FU and 18% planned to work in a part-time capacity in FU, with 29% unknown (six trainees did not answer this question). All the Canadian trainees with FU interest planned to work full-time (Table 1). This discrepancy may relate to the private/public appointments and health system differences between countries. This may also reflect that in the USANZ, FU is not quite recognised as a sub-specialty in its own right amongst trainees and some of them still plan to partially do general urology, as compared to Canada.

Even though 71–79% of respondents felt FU is under-recognised by urology itself, the role and recognition of FU has had rapid growth in recent years. This has been attributed to a greater number of urologists, and especially a greater proportion of women in urology since the early 1990s. Urologists have increasingly promoted FU as a domain of urology. The USANZ has strongly supported this movement in the form of the Female Urology Special Advisory Group (FUSAG). This group is responsible for developing national guidelines, policies and recommendations pertaining to issues of FU, as well as facilitating an increasing number of meetings and courses focussing on FU [10]. Additionally, social media and electronic communication have facilitated this communication, for example via Twitter^® and Facebook^®. On a local level, regular multi-disciplinary team (MDT) meetings and an increasing number of mentors in FU have helped to promote functional urology and support female trainees’ interest in pursuing a sub-specialisation in FU. In North America, both the Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction (SUFU) and the Society of Women in Urology (SWIU) offer mentorship, research support, and support for public education in FU. These organisations have worked to increase FU representation within urology and many women have senior leadership roles. There have also been an increasing number of meetings and courses focussing on FU.

The concern regarding the lack of awareness by urology, as well as primary healthcare physicians and the general public seems to be an international issue [11, 12]. The FUSAG alongside the USANZ have instituted more teaching sessions on FU throughout training. FU is an important part of the core curriculum and therefore examinable. There are now many international conferences and continuing education programmes that are dedicated to FU, e.g. the Functional Urology Symposium. Collaborations have been established with international societies including the Pan-Pacific Continence Society (PPCS), SUFU, and the ICS. Urology conferences routinely have sessions on FU research, e.g. the Canadian Urological Association (CUA), European Association of Urology (EAU) and USANZ Annual Scientific Meeting. Two out of seven research awards given out at the USANZ Annual Scientific Meeting are specifically for presentations in FU.

These measures will hopefully address many of the concerns that trainees currently have about the need for adequate exposure and to acquire necessary skills. Our present study noted a surprising percentage of trainees had either little to no exposure or did not feel competent with aspects of FU during their general urology training, necessitating further fellowship training in this field for those who are interested. Consultant-driven urodynamics teaching to USANZ trainees has been identified by our present study as an area that can still be improved. Most training occurs in the public sector, but surgical caseloads in the public system in Australia and New Zealand prioritise patients according to how probable the condition is to become an emergency, and although FU conditions can be debilitating, they do not tend to be ‘life threatening’. As such, FU tends to be delivered more often in the private system, with the majority of sling operations being carried out in this sector, therefore leading to this mismatch in education and exposure. Inclusion of partial training in the private system should be considered in the future.

These concerns not only impact the training scheme but may also influence the willingness of trainees to pursue a career involving FU and the future advancement of this evolving specialty. Part of this self-reflection of trainees could be attributed to imposter syndrome; however, given that the consultant reflections were similar, it is likely to be a true deficit in exposure [13].

Despite the clear concern regarding the awareness of potential referral sources, almost all of the urologists and the trainees are optimistic about their referral basis and believe that there will be sufficient work in FU in the future. It is our impression that this high response rate, despite the previous concerns regarding awareness, is secondary to the increased USANZ and FUSAG involvement in FU, as well as individual consultant effort to promote their sub-specialty. A large proportion of women in urology work in both the private and public sectors, who are involved in the teaching of the trainees. Almost all (94%) of women in urology would encourage other women to enter this field [14, 15].

The USANZ has engaged with the broader community via community groups, e.g. the Continence Foundation of Australia (CFA) and state-based continence resource centres, e.g. the Victorian Continence Resource Centre. The USANZ has supported them through fundraising, supporting research and being involved in their conference/meetings. The USANZ supports the nursing sub-specialty group, the Australian and New Zealand Urological Nurses Society (ANZUNS). Furthermore, there has been a greater collaboration with the UroGynaecological Society of Australia (UGSA).

In this era of workforce gender equality, more female applicants are entering the surgical training programme. Women now account for 55% of medical graduates but in 2018, they made up only 33% of applicants into surgical training. This number will only increase in the future. In our present survey, it is still surprising that almost half (Table 4) of women in urology are expected to sub-specialise in FU based on their gender. There was already a sizeable discrepancy seen in a 2018 study in the USA, where women reported sub-specialising in FU (24.2%) at higher frequencies than their male colleagues (4.6%, P < 0.001) [16]. It is important that fairness of choice must be upheld in this situation, and the urology community does not ‘pressure’ a woman into FU. Surveys such as this and more open discussion will help to increase awareness in this issue and combat the perception that female trainees are expected to specialise in FU. Vice versa, both male and female trainees should also have exposure to FU throughout their training, and male trainees allowed equal opportunities to pursue this field. At the same time, it is reassuring that a high proportion of FU sub-specialists chose this field due to their own interest (Table 4), although this number can be further improved upon; 48% of the USANZ trainees pursuing FU do not rate their own interest as the main reason. Mentoring, adequate training and exposure during general urology training should help to improve this.

Our present study showed a high interest in FU amongst the USANZ female trainees. Combined with male doctors who may also want to sub-specialise in FU, an increase in the total number of urologists working in FU must be anticipated, with future implications in the workforce, which already has some overlap with the type of work done by urogynaecologists. Almost all respondents were optimistic about the availability of work in this field in the next 10 years, and this is reflected in a Deloitte Access Economics report that estimated that the number of Australians with urinary incontinence is projected to increase from 4.16 million in 2010 to 5.59 million in 2030 [17].

The limitations of the present study include the small sample size. It is challenging to extrapolate from the results of the Canadian trainees based on 14 responses. However, the pool of female trainees in Canada is quite small. The survey was only made in English and therefore a portion of those e-mailed who reside in Quebec (French speaking) may not have responded. Response bias may also be an unknown factor, as those who responded are more likely to be interested in the field of FU. Therefore, respondents may demonstrate a greater interest in FU, compared to those who have not responded to the survey. The questions were also limited to tick box answers, in order to improve the responses and minimise the time taken to complete the survey. As such, in depth analysis of the results (e.g. why female surgeons feel ‘pressured’ into pursuing FU) could not be performed. Male trainees and consultants were not invited to the survey, as we wanted to focus more on the responses of women in urology. Their inclusion in future surveys would allow improved planning for the workforce. The varied mix of responders can be considered a weakness of the study, but it also gives us a wider insight into the views of established consultants and upcoming trainees. The mix of private and public practice reflects the real-world practice of urologists especially in Australia and New Zealand, which is why we decided to include both in the survey. The amount of support within FU circles to allow trainees to feel comfortable practicing the sub-specialty such as regular MDT meetings, accessibility of mentors, local or national meetings dedicated to FU, training courses, was not assessed in our original survey, and we recommend the inclusion of these in future surveys.

It is important that urologists and urological training organisations take a lead role in maintaining FU and nurturing interest in this field [18]. Trainees also need to have increased access to FU. Training units without urodynamics or ultrasound access, may need to utilise their private hospital colleagues to further their trainee’s experience in the field. Given the lack of exposure that trainees have to FU throughout their training, they will need to continue undertaking fellowships in order to be competent in all aspects of FU. This need should be balanced with the consideration regarding the workforce and the demand for FU work without over-supplying urologists working in FU, as this may lead to insufficient public or private work or opportunities for employment. Regular surveys every 5 or 10 years such as this, may provide feedback on how the workforce is evolving in the future.

Conclusions

Female urology is an increasingly popular sub-specialisation of urology, associated with a steady increase in the intake of female trainees. This possibly relates to gender bias, although genuine interest plays a significant role. The present study documents the perception that there is poor awareness in the general public and medical community of the role of female urologists, which could be addressed in the future. The present survey demonstrates a need for greater training opportunities in FU for trainees in general and advanced training.

Conflict of Interests

None.

Appendix

Survey

Female Urology Survey

Thank-you for taking the time to complete this survey. This should take <5 min to complete. You have been chosen to complete this survey because you are a woman in Urology practice/training. This survey aims to assess the current and future needs as well as concerns in the field of Female Urology.

Level of practice

□ Consultant □ Trainee

IF Consultant

1. How many years post fellowship are you?	……………………………………….
2. Do you subspecialise in female urology?	□ Yes □ No – what do you subspecialise in then? …………………………………………
3. Nature of practice	□ Private □ Public □ Both
4. What % of private work is female urology?	□ <25% □ 25% □ 50% □ >50% □ N/A
5. How do you perform your own urodynamics in private practice?	□ Self-run □ Nurse-run □ Don’t do it
6. How many female urology operating lists do you perform in public per month?	□ <1 □ 1–2 □ 3–4 □ >4 □ N/A
7. Do you attend a public clinic where you can see female urology patients?	□ Yes □ No □ N/A
8. Do you think your current trainee has enough exposure to female urology cases?	□ Yes □ No □ N/A
9. Do you think USANZ is accepting enough female (gender) trainees?	□ Not enough □ Just right □ Too many
10. Why did you choose to do female urology? (Can pick more than one)	□ Expected to do it due to my gender □ Need of public appointment □ Need of private practice group □ Over supply of other subspecialties □ Own interest □ Other ………………………………………………………… ……………………………………………………………………… □ N/A
11. Do you have any concerns about future work? (Can pick more than one)	□ Not enough referrals □ Urogynaecology dominance □ Poor GP awareness of urologists in female urology □ Increased number of future trainees □ I have no concerns □ N/A
12. Do you think that female urology is under-recognised by: general urology? general public? GP?	□ Yes □ No □ Yes □ No □ Yes □ No Why?.................................................................... ………………………………………………………………………….
13. Do you anticipate there will be enough work in female urology in the next 10 years?	□ Yes □ No □ N/A

IF Trainee

USANZ = Urological Society of Australia and New Zealand.

CaRMS = Canadian Resident Matching Service.

1. What level of training are you now?	□ SET 1/PGY1 Urology □ SET 2/nSET 1/PGY2 Urology □ SET 3/nSET 2/PGY3 Urology □ SET 4/nSET 3/PGY4 Urology □ SET 5/nSET 4/PGY5 Urology □ SET 6/nSET 5 and above/Fellow
2. Do you plan to subspecialise in female urology?	□ Yes □ No – what do you want to subspecialise in then? …………………………………………………………………………
3. Why do you want to subspecialise in female urology? (Can pick more than one)	□ Expected to do it due to my gender □ Need of future public appointment □ Need of future private practice group □ Over supply of other subspecialties □ Own interest □ Other ………………………………………………………… ……………………………………………………………………… □ N/A
4. How much exposure have you had to female urology during training (excluding fellowship)?	□ Nil □ Very little □ Adequate enough to understand some of the scope of the specialty □ Good enough to feel competent in most of the scope of the specialty
5. Do you have exposure to consultant-led urodynamics training in your current post?	□ Yes □ No
6. Do you have fellowship plans in female urology?	□ Yes □ No
7. Do you think USANZ/CaRMS is accepting enough female (gender) trainees?	□ Not enough □ Just right □ Too many
8. Do you have any concerns about future work in female urology? (Can pick more than one)	□ Not enough referrals □ Urogynaecology dominance □ Poor GP awareness of urologists in female urology □ Increased number of future trainees □ I have no concerns □ N/A
9. Do you plan to work full or part-time as a consultant in female urology?	□ Full-time □ Part-time □ Occasionally □ N/A
10. Do you think that female urology is under-recognised by: general urology? general public? GP?	□ Yes □ No □ Yes □ No □ Yes □ No Why?.................................................................... ………………………………………………………………………….
11. Do you anticipate there will be enough work in female urology in the next 10 years?	□ Yes □ No □ N/A

Abbreviations

FU

female urology

FUSAG

Female Urology Special Advisory Group

MDT

multi-disciplinary team

SUFU

Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction