10. WOMEN IN UROLOGY: UNIQUE CHALLENGES

5. Ash AS, Carr PL, Goldstein R et al: Compensation and advancement of women in academic medicine: is there equity? Ann Intern Med 2004; 141: 205. 6. Espaillat A, Panna DK, Goede DL et al: An exploratory study on microaggressions in medical school: what are they and why should we care? Perspect Med Educ 2019; 8: 143. 7. Nunez-Smith M, Pilgrim N, Wynia M et al. Health care workplace discrimination and physician turnover. J Natl

Med Assoc 2009; 101: 1274. 8. Clark R, Anderson NB, Clark VR et al: Racism as a stressor for African Americans: a biopsychosocial model. Am

Psychol 1999; 54: 805. 9. Sue DW, Alsaidi S, Awad MN et al: Disarming racial microaggressions: microintervention strategies for targets, white allies, and bystanders. Am Psychol 2019; 74: 128.

10. WOMEN IN UROLOGY: UNIQUE CHALLENGES TO WOMEN IN THEIR EARLY CAREERS

This section was authored by Julie Riley, MD, Assistant Professor and the Director of Endourology, and Director of Urologic Research at the University of New Mexico. While gender equality is steadily improving in the U.S., it is important to remember that women in urology are still relatively new, with the first becoming board certified in 1962. Currently, 10.3% (1,375) of practicing urologists are women – but with women accounting for a quarter of urology residents (and 21.3% of female practicing urologists under the age of 451), the number is steadily increasing. Furthermore, in the 2021 Urology Match, there was a record high match rate for women at 85%.2 And, as of 2019, women now represent a majority of medical school students.3

10.1 Practice Patterns

When entering a practice, women can oftentimes be pigeon-holed into seeing the female patients – even if this isn’t necessarily the desire of the physician. While this may be a much-needed role to fill within the practice, it is important to consider that these cases can often result in non-operative conditions that could potentially lead to decreased earnings. Suggestions to help with practice patterns: • Prior to joining a practice, discuss your targeted patient population with partners and consider adding clauses to contracts to note this. • Market to your target population. • If your target population is female patients, ensure your compensation reflects the work you do given that the RVUs and operative case potential may not compare to other subspecialties. • Ensure that those who schedule for you understand your desired patient population. The front staff can have significant influence on the patients scheduled into clinic. Some schedulers, for example, may ask patients if they mind seeing a woman. While non-malicious in intent, this question can be a very subtle way in which your practice can be dramatically affected. You may need to be involved in scripting the language used by schedulers, front staff and even Advanced Practice Providers within your practice who may refer patients.

10.2 Work/Life Balance

The term “work-Life balance” is a bit of a misnomer. There is no magical, harmonious balance between work and life. There are moments when life outside your profession will become priority and others when work will. Feeling guilt for prioritizing one over the other can distract from both productivity and satisfaction. Be present in what is happening in the moment and realize it is a give and take: no one is perfect; stop feeling guilty about it. Evaluate and prioritize your time and stick to it. Suggestions include the following: • Keep a unified calendar for your work and personal life. • Determine which events are important well in advance like family commitments or work events and put them on the calendar. Calendared events could include school schedules, spouse/partner/ family schedules, celebrations/milestones such as birthdays, anniversaries, etc. • Set time limits on activities and do not do anything else (such as check email, take phone calls, etc.). When the time is up, move on to the next activity. • Ask for help when you need it. If you don’t have the support staff you need, ask for it (particularly if your male counterparts have this help). • Streamline or simplify household duties like using a house cleaning and/or laundry service if it will help. • Schedule 20 minutes periodically for yourself (really, schedule it). A happier doctor is a more productive doctor. Remember, you would never miss a day in the operating room because there

“just wasn’t enough time in the day.” Another issue more prevalent for women can be the inability to say no and/or the strong desire to please those around them. It is important when you say yes to something that it is meaningful and you do what you say you will do. It is important to say yes to

some things (particularly things you are passionate about), otherwise the opportunities will begin to dwindle. On the other hand, taking on too much can be counterproductive and lead to decreased satisfaction and quality overall. Consider having two or three close friends to vet out a new offer. If the offer is not desirable, practice a professional way to say no. Make sure that whenever you do say yes to something, you do it and take credit for it.

LISTEN: Audrey Rhee, MD, discusses family and work-life balance for an episode of the AUA Inside Tract Podcast.

10.3 Burnout

Women are disproportionately affected by burnout. In 2017, Medscape reported that 70% of women urologists suffer from burnout compared to 49% of men.4 These numbers have been increasing over several years. Women usually experience burnout differently than their male counterparts. The first stage for women is emotional exhaustion. The belief is that women tend to support others in their lives and there is only so much emotional support to go around. The second stage for women is depersonalization and cynicism. This is a way to detach from the stress and overwhelming nature of medicine. It is usually short lived for women and often leads to the third stage of reduced accomplishment or a sense that one’s work doesn’t matter. Men more often start with depersonalization followed by emotional exhaustion. Rarely do men reach the third stage of feeling like they are a bad doctor. Because genders typically experience burnout differently, the presentation is also different. Women tend to first feel a lack of energy and inability to recover even with time off, followed by cynicism and blaming patients, which can lead to subsequent feelings of inadequacy. Men, on the other hand, tend to present first with blaming patients and cynicism, followed by exhaustion. It should be noted that younger physicians are more likely to suffer from burnout. This makes early-career women urologists particularly susceptible. Unfortunately, burnout can lead to depression and even worse, suicide. Male physicians have about a 1.41 relative risk of suicide to the general population. Compare this to female physicians who have about a 2.5 relative risk to the general population. In addition, women physicians have a suicide completion rate comparable to their male counterparts, which is in contrast to the general population where completion rates are lower for women.5 This has not been specifically studied in urologists. One of the best treatments for burnout is social support. This has been shown to be more effective than even counseling or therapy. Reach out when feeling even the first signs of burnout and reach out to others when it is recognized in colleagues and friends. Other suggestions to decrease burnout include exercise, meditation, mindfulness, setting boundaries, getting more sleep and even just simply pausing and taking a deep breath. See Section 11 for further resources on wellness.

10.4 Gender Pay Gap

There is a gender pay gap in the United States. As of 2015, women are paid 20% less than men for equivalent work. While the gap has significantly improved since the passage of the Equal Pay Act in 1963 (when women earned 31% less than men), at this rate, it will take until the year 2152 to totally erase the gap.6 Urology has not been spared from this. In fact, in 2017, urology had the third largest gender pay gap among all medical specialties and the widest gap among surgical specialties. Women urologists on average were found to make 20% less than male counterparts. This equated to $84,799 less per year.7 Maintained over the course of a career, this represents a nearly $3 million loss to women. While other factors such as less hours worked, more part-time work, maternity leave and others have been attributed to the pay gap, women urologists were still found to make approximately $76,000 less than men when variables that would affect take home pay were controlled.8 See Section 10.6 for information on negotiating.

10.5 Maternity Leave

There is no standard parental leave for men or women in the United States, so it’s important to research a potential employer’s policy for maternity leave as well as the Family and Medical Leave Act (FMLA), paid sick leave, unpaid sick leave and vacation (all of which may be required for time with a new child). When planning for maternity leave: • Consider when you’d like to tell your institution; letting your institution (not just clinic or OR schedulers) know early can help ensure all necessary paperwork is completed prior to leave. Being upfront about your needs and plans can also translate to more being offered when your group/institution/partners have time to accommodate.

• Learn what paternity leave consists of to understand what your male counterparts are receiving. • Discuss call coverage prior to starting leave. • If you are in private practice, you will likely need to continue to pay overhead so consider saving money for this. In addition, understand how maternity leave affects partnership, equipment buy in, etc. • For academia or employed practice models, know what effect this leave could have on promotion and incentives and have everything in writing. There are options of prorating RVU requirements if you ask for this. Consider this in negotiating with a potential employer if this may be a concern in the future. • Ask for the maximum allowed time off; you can always choose to return early or have the occasional urgent patient visit if necessary/ desired. Coming back from maternity leave can also be stressful. Hospitals are legally required to have lactation rooms, so do your research to ensure there is adequate space for this and block off time to pump (if applicable) several times throughout the day. After a break of up to three months or more, many surgeons will be rusty on surgical skills. This is a good time to consider scheduling less complicated, shorter cases while readjusting. If doing longer/larger cases, consider having a senior partner backup in case a break is needed for pumping or simply to take a little stress off. Unfortunately, there may be unavoidable discrimination related to maternity leave, even if unintended. The good news is that maternity leave has been taken by many successful female surgeons throughout their careers; reach out to those who have done this before and take advice. If your particular practice hasn’t had experience with maternity leave, checking out groups on social media and online for advice may be helpful.

10.6 Negotiating

There is a body of evidence to suggest that women do not negotiate as often as men. A recent study showed that 68% of women accepted the salary they were offered and did not negotiate as compared with 52% of men.9 Though a sensitive subject, more and more, physicians are willing to share about salaries. Research potential partners and compensation in a desired location. The first step is to know what fair compensation within the market is. Negotiating is more than just salary; everything is negotiable. Consider support staff, office space, time off, professional funds, titles, administrative time, equipment, etc. Consider that negotiating for ease of practice can sometimes be more meaningful at the end of the day than simply a base salary, particularly if you aren’t able to directly reinvest the money into your practice (academia, hospital-based practice).

10.7 Imposter Syndrome

Imposter Syndrome is the phenomenon of feeling like you do not belong and/or are not qualified. While these feelings can serve to motivate, they can also lead to anxiety and stress and prevent career advancement. Imposter Syndrome is more commonly seen in minorities within professional fields, particularly women. There are many reasons female physicians can be susceptible to this: staff and patients referring to a woman by first name but male counterparts as “Doctor;” patients asking a woman physician who the doctor is that will be operating on them after a consultation has been completed – or worse, when the doctor will be seeing them. So many subtle factors can predispose women physicians to feel inadequate. Imposter Syndrome causes doctors to feel that their success is from an external force or luck rather than internal forces like hard work, diligence and intelligence. Long-term effects can be burnout, depression, decreased productivity, career sabotage and being less likely to ask for promotion or leadership roles. Suggestions to overcome Imposter Syndrome include: • Writing down accomplishments and referring to them often until they are internalized • Using support systems to remind yourself how qualified you are to be in your role • Naming the Imposter Syndrome and recognizing when you are suffering from anxiety related to it • Taking credit for the work you do and trying hard to not self-depreciate those accomplishments • Getting rid of the word “just” in your vocabulary (e.g., “I am just a general urologist;” “I just do slings and manage incontinence,” etc.)

10.8 Mentors

Finding a mentor can be difficult. In fact, a third of female urologists were dissatisfied with the limited opportunities for mentorship and 25% of women who have left academia stated it was due to lack of mentorship.10 There is little formal training for mentors and few advanced career women within urology.

That said, mentorship can be invaluable to women (and men) when starting in practice (and throughout one’s career). While it is often encouraged to seek multiple mentors, there is utility for women to have female mentors. Many of the challenges that can be unique or approached differently as a woman can be navigated more easily with a female mentor. However, it is certainly not a necessity to have a female mentor, and it may be challenging to find one. The important thing is to have someone supportive who listens to your individual needs and is honest and approachable. Seek people who are knowledgeable in the area in which guidance is needed such as research, leadership, practice management, etc. Mentorship relationships can be short lived or over a career; don’t be afraid to move on if the advice is no longer relevant.

10.9 Leadership/Promotion

On the academic side, women have been shown to have decreased publications and decreased rates of promotion.10 As of 2017, only 11% of women in academia advance to full professor compared to 33% of men. In addition, there are three female Department Chairs (1.3% of female urologists) in contrast to 441 male chairs (26% of male urologists).11 14.6% of Program Directors are women and while better than the overall percentage of women in urology, this falls short of the representation of current female residents in urology. This is certainly multifactorial, but there remains a difference between genders. Within leadership of the AUA, there has been increasing numbers of women. However, while 75% of committees included at least one woman in 2017, only 75% were urologists (relative to 95% of men on AUA committees).12 In 2021, there is one woman on the AUA Board of Directors and four women trustees on the American Board of Urology. The AUA is making a conscious effort to increase women in leadership positions. • Society of Women in Urology https://swiu.org • The Secret Thoughts of Successful Women: Why Capable

People Suffer from the Imposter Syndrome and How to

Thrive in Spite of It by Valerie Young • Women in Surgery Committee of American

College of Surgeons www.facs.org • Association of Women Surgeons www.womensurgeons.org • Being a Woman Surgeon: Sixty Women Share Their

Stories by Preeti R. John • Ask For It: How Women Can Use the Power of

Negotiation to Get What They Really Want by Linda

Babcock and Sara Laschever Acknowledgments Thank you to all of the women urologists who gave advice and input to this section and special thanks to Drs. Jessica Ming and Frances Alba. References 1. American Urological Association. The State of the Urology Workforce and Practice in the

United States. 2021. 2. American Urological Association. 2021 Urology

Residency Match Results. 2021. 3. https://www.aamc.org/news-insights/morewomen-men-are-enrolled-medical-school 4. Peckham C. Medscape Urologist Lifestyle

Report: 2017: Race and Ethnicity, Bias and

Burnout. Jan 2017. 5. Schernhammer ES, Colditz GA. Suicide rates among physicians: a quantitative and gender assessment (meta-analysis). Am J Psychiatry. 2004 Dec; 161(12):2295-302. 6. Sanfey H, Crandall M, Shaughnessy E, et al.

Strategies for Identifying and Closing the Gender

Salary Gap in Surgery. J Amer Coll Surg. 2017

Aug; 225(2): 333-8. 7. https://blog.doximity.com/articles/doximity2018physician-compensation-report 8. Deal A, Pruthi NR, Gonzalez CM, et al. Gender

Differences in Compensation, Job Satisfaction and Other Practice Patterns in Urology. J Urol. 2016 Feb; 195(2):450-5. 9. Glassdoor Survey. 3 in 5 Employees Did Not

Negotiate Salary. 2017.