Formal Mentorship as an Opportunity to Expand the Urology Pipeline: Under Represented Trainees Entering Residency (UReTER) Program Evaluation 2020-2021

Support for the Struggling Learner in Urology

PURPOSE OF REVIEW

Supporting struggling urology residents is an important yet challenging task. We describe strategies to assess resident performance, challenges in the clinical learning environment that contribute to resident remediation, and support mechanisms. This review highlights existing resources for positive outcomes in remediation and promotes exploration of innovative strategies to support future urology residents.

RECENT FINDINGS

Burnout is associated with poor resident performance. Factors that promote burnout include unsatisfactory work-life balance, education or financial debt, access to mental health care, and identifying as a member of an underrepresented group. Competency-based assessment and tailored educational interventions can effectively address the needs of a struggling learner. Efforts to create standardized language, specialty-specific remediation programs, and robust mentorship infrastructure have been successful in other specialties. Study of interventions and outcomes for struggling urology residents is somewhat limited; deeper understanding of prevailing remediations practices and individual needs of struggling residents will be critical to develop more robust support for trainees.

Facilitating a More Diverse Workforce: The Value of Mentorship in Cardiothoracic Surgery

Background

Cardiothoracic surgery (CTS) is one of the least diverse surgical specialties in both gender and race. Aside from the inherent benefits of a diverse working environment, mitigating this diversity gap improves patient care. Mentorship is important for creating a diverse, nurturing environment for trainees. This review appraises the impact of formal mentorship for trainees and specifically assesses its significance for underrepresented groups in CTS.

Methods

A literature search was performed using keywords relating to CTS, mentorship, and underrepresented groups. Principal findings were extracted and synthesized; supporting literature discussing mentorship in other surgical specialties was also included.

Results

Mentorship is desired by CTS residents. Its benefits include aiding the matching process, decreasing stress, and increasing academic productivity. Mentorship programs can be used to increase the recruitment and retention of women and others underrepresented in medicine.

Conclusions

Mentorship is a valuable tool for which implementation must be prioritized in CTS; this requires more education on mentorship for trainees. Institutions should be using mentorship programs to diversify trainees in CTS with the objective being equality.

Increasing Diversity, Equity, and Inclusion in Urology Residency Recruitment: Recommendations From the Society of Women in Urology

OBJECTIVE

To provide a framework for diversifying the urologic workforce through residency recruitment by integrating principles of diversity, equity, and inclusion (DEI) into program mission and values, application review, and interview process.

MATERIALS AND METHODS

For this narrative review, the Society of Women in Urology Advancing DEI in Urology Residency Recruitment Task Force identified 4 areas for incorporating DEI into residency recruitment: defining a residency program's mission and values, holistic application review, an objective interview process, and implementing DEI principles into a program. Using PubMed and Google Scholar, we performed a non-systematic literature search of articles from January 2014 to January 2024. Search terms included combinations of "diversity", "equity", "inclusion", "residency", "holistic review", "applications", "interviews", and "initiatives". Additional resources were identified through citations of selected articles. Based on findings from these articles, Task Force members made recommendations for best practices.

RESULTS

The diversity of practicing urologists is disproportionate to that of the United States population. Emerging evidence demonstrates that DEI efforts in healthcare are associated with better outcomes and reduction in healthcare inequities. We offer strategies for residency programs to integrate DEI initiatives into their recruitment, application review, and interview process. Furthermore, we address extending DEI principles into a program's mission and culture to create an inclusive environment conducive to training and supporting individuals from unique backgrounds.

CONCLUSION

It is critical to recruit and retain diverse talent in urology to improve patient care. We urge residency programs and their supporting institutions to adopt DEI principles into their recruitment efforts.

Analyzing the Current State and Visibility of Diversity, Equity, and Inclusion Initiatives at Urology Residency Programs

OBJECTIVE

To analyze AUA urology residency program websites to determine visibility of diversity, equity, and inclusion (DEI) initiatives. There is growing interest in DEI initiatives by urology applicants, and in recent years, urology programs have invested in efforts to promote DEI.

METHODS

All ACGME-accredited urology residency program with a website were assessed. Military programs were excluded. A DEI Score Card was developed using published pillars of DEI, including five domains: departmental inclusion, pipeline growth, departmental education, community engagement, and faculty demographics. Program Doximity rank, address, and surrounding demographics were collected to determine predictors of investing in DEI.

RESULTS

One hundred forty-one urology residency websites were included for analysis. Only 40.7% of programs referenced DEI on their webpage, and 21.4% offered funded mentorship opportunities. Department education and community engagement were the least popular initiatives. The Western, Northeastern, and North Central sections had the highest DEI total score with wide variation across domains. Mention of DEI was not associated with program's county-level social vulnerability or percent minority but was associated with being a top 50 program (OR=4.0; 95% CI 1.8, 8.9; P = .0007).

CONCLUSION

Less than half of academic urology programs' websites referenced DEI initiatives. Using a DEI score card, our study shows that investment in DEI varies widely by AUA section, and greater investment is positively correlated with program rank. Our DEI score card serves as a tool that programs can use to assess their current DEI investment, identify areas for improvement, and ensure existing initiatives are visible to applicants.

Factors Influencing Underrepresented Medical Students' Career Choice in Surgical Subspecialties

OBJECTIVES

Surgical subspecialties rank among the least racially and gender diverse of the medical specialties. The purpose of this systematic review is to evaluate the current factors that influence female, gender and sexual minority (GSM), and underrepresented in medicine (URiM)-identifying medical students' decision to pursue a career in a surgical subspecialty.

DATA SOURCES

A structured literature search of PubMed, Scopus, Web of Science, and Medline was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Criteria for eligibility included surveys and interviews assessing factors and barriers influencing underrepresented medical students' career choices.

REVIEW METHODS

Two independent researchers screened the articles' titles and abstracts for relevance; three performed full-text reviews.

RESULTS

Of 343 studies identified, 17 met the inclusion criteria. Fourteen (82%) were survey-based studies; three (18%) were qualitative interviews. Represented minorities included females (14), URiM (13), and GSM (4). Female medical students were most influenced by (1) exposure to surgery, (2) mentorship, and (3) surgical lifestyle. URiM medical students were most influenced by (1) mentorship, (2) culture and diversity, (3) research opportunities, and (4) personality fit. GSM medical students were most influenced by identity acceptance and instances of discrimination and bias.

CONCLUSIONS

Our review provides granular data on positive and negative factors influencing career choice among underrepresented medical students to facilitate the development of a more diverse surgical workforce. Female medical students were more positively influenced by increased exposure to surgical subspecialties, whereas URiM medical students were more positively influenced by race-concordant mentorship. Laryngoscope, 134:1498-1506, 2024.

Impact of Mentoring for Underrepresented Groups in Undergraduate Medical Education: A Systematic Review

OBJECTIVES

Despite efforts to mitigate challenges to advance underrepresented groups (URG) groups' representation in medical education, diversity remains underwhelming. In response to this several mentoring programs to increase diversification within medical education have been implemented. However, the impact of these programs on URG representation across disciplines is unknown. The aim of this review is to evaluate the impact of structured mentoring programs on URGs in undergraduate medical education.

DESIGN

Systematic review.

METHODS

A comprehensive search strategy was performed of electronic databases including PubMed, Ovid Medline, and EMBASE between January and September 2022 in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Both qualitative and quantitative outcomes including characteristics of the mentoring structure explored within each study were collected, and differences in study outcomes analyzed.

RESULTS

In total 17 studies were included for analysis. Mentoring within URGs resulted in an increase in research opportunities, exam performance, medical specialty applications, and residency matching. Structured feedback yielded positive experiences by both mentors and mentees participating in programs, with both emotional and cultural competence issues explored across studies included for analysis.

CONCLUSIONS

Mentoring for medical students underrepresented in medicine across mentoring relationships including peer, senior, formal, and informal structures yield positive outcomes within research, academic modules, and career pathways. Future applications of mentoring programs should consider the use of tandem mentoring from both senior and peer mentors to optimize benefits URG students derive from each mentoring relationship.

Mentoring for Admission and Retention of Black Socio-Ethnic Minorities in Medicine: A Scoping Review

Purpose

Despite numerous mentoring strategies to promote academic success and eligibility in medicine, Black students remain disproportionately underrepresented in medicine. Therefore, we conducted a scoping review to identify the mentoring practices available to Black pre-medical students, medical students and medical residents, specifically the mentoring strategies used, their application, and their evaluation.

Method

Between May 2023 and October 2023, the authors conducted a literature review. Studies that described a mentoring strategy applied among Black learners were eligible for inclusion, and all years of publication were included. Two reviewers screened each article using the Covidence tool, and conflicts were resolved by a third author. All reviewers extracted the data to summarize the various mentoring practices.

Results

After screening 6292 articles, 42 articles met the criteria for full review. Of these, 14 studies were included in the study. Mentoring practices for Black students included peer mentoring, dyad mentoring, and group mentoring. Mentoring was typically offered through discussion groups, educational internships, and didactic activities. Evaluation of mentoring programs took into account (1) pass rates on medical exams (eg, MCAT, Casper), (2) receipt of an invitation to a medical school admissions interview, (3) successful match to a competitive residency program, and (4) a mentee's report of the overall experience and effectiveness of the program.

Conclusion

This review is the first, to our knowledge, to focus on mentoring strategies implemented among Black learners in medicine. The results will inform mentoring strategies adapted for Black learners and will therefore address the underrepresentation of Black students in medicine.

Identifying Barriers Faced by Applicants without a Home Residency Program when Matching into Plastic Surgery

Background  Applying into plastic surgery (PS) is competitive. Lacking a home residency program (HRP) is another barrier. Our goal is to characterize challenges faced by PS applicants without HRPs and identify solutions. Methods  Surveys were designed for current integrated PS residents and applicants in the 2022 Match without HRPs. Surveys were distributed electronically. Only U.S. allopathic graduate responses were included. Results  Of 182 individuals surveyed, 74 responded (39%, 33 residents, 41 applicants). Sixty-six percent reported feeling disadvantaged due to lack of an HRP. Seventy-six percent of applicants successfully matched. Of these, 48% felt they required academic time off (research year) versus 10% of unmatched applicants. Ninety-seven percent of matched applicants identified a mentor versus 40% of unmatched applicants ( p  < 0.05). Matched applicants identified mentors through research (29%) and cold calling/emailing (25%). Matched versus unmatched applicants utilized the following resources: senior students (74 vs. 10%, p  < 0.05) and social media (52 vs. 10%, p  < 0.05). Among residents, 16 had PS divisions (48%). Thirty-six percent with divisions felt they had opportunities to explore PS, compared with 12% without divisions. Residents without divisions felt disadvantaged in finding research (94 vs. 65%, p  < 0.05), delayed in deciding on PS (50 vs. 28%), and obtaining mentors (44 vs. 35%) and letters of recommendation (31 vs. 24%). Conclusion  PS residents and applicants without HRPs reported feeling disadvantaged when matching. The data suggest that access to departments or divisions assists in matching. We identified that external outreach and research were successful strategies to obtain mentorship. To increase awareness for unaffiliated applicants, we should increase networking opportunities during local, regional, and national meetings.

The Role of Alumni Networks and Career Advising in Early Career Stability of Urologists: Results of a Multi-institutional Study

OBJECTIVE

To characterize training program and early career factors that impact decision-making and job retention following graduation in a diverse population of urologists.

MATERIALS AND METHODS

We performed a computer-based survey distributed to residency graduates from 25 urology training programs. Five focus institutions were identified with a goal >30% response rate. The survey included questions about training program specifics and post-training employment characteristics.

RESULTS

We obtained 180 responses from urology residency graduates of 25 programs. Overall, 72% (N = 129) remain in their initial post-training position at a median of 6years postgraduation (Interquartile Range (IQR) 3-10). On Cox-regression analysis stronger trainee-rated formal career advising was associated with lower risk of changing jobs (HR 0.77, 0.60-0.99, P = .048). Location/proximity to family was the most consistently cited as the top reason for selecting a job (41%). Sixty-three respondents (35%) joined practices employing graduates of the same residency program. Cox regression analysis showed that joining a practice with alumni of the same program was associated with lower risk of changing jobs from one's initial post-training position (HR 0.39, 95% CI 0.17-0.91, P = .03).

CONCLUSION

In this multi-institutional study of urologists, we observed a high rate of job retention out to a median of 6years following completion of training, with formal career advising and joining alumni in practice being associated with job retention. Collectively, our data highlights that training programs should emphasize advising programs and alumni networking in guiding their graduates in the job search process.

Michigan Urology Academy-Our Role in Diversifying the Urology Workforce

OBJECTIVE

To evaluate the value/utility of developing an online mentorship program for underrepresented in medicine (URiM) students interested in urology. The Michigan Urology Academy (MUA) was launched in 2020 to increase exposure and provide mentorship to URiM students interested in urology, in an effort to address the continued low numbers of Black and LatinX urologists in the workforce.

METHODS

The 2-day virtual mentorship program was launched in June 2020 and held annually thereafter. Demographic information was collected, and surveys were distributed at 1week and 3months after the events. Surveys assessed participants' perception of the utility and effectiveness of the sessions. Thematic analysis was performed on qualitative data. Fourth-year med students were followed longitudinally to determine urology match results.

RESULTS

Over the last 3years, MUA hosted 208 students from 104 medical schools. Participants self-identified as 42.3% (n = 88) identified as African American/Black, 14.9% (n = 31) Hispanic/LatinX, 12.98% (n = 27) white, 18.75% (n = 39) as Asian/Indian 7.7% (n = 16) as Middle Eastern/North African, and 0.48% Native Hawaiian/Pacific Islander (n = 1). Overall, fourth-year MUA participants matched at a higher rate than the national average (80.2% vs 71.4%; P = .0486). Narrative feedback revealed five themes: (1) the importance of community support within urology, (2) the utility of vulnerability and storytelling, (3) the importance of representation of diverse backgrounds, (4) the desire for in-person mentorship opportunities, and (5) the need for transparency in application logistics.

CONCLUSION

Mentorship programs such as MUA allow URiM students to have greater exposure to the field of urology and to networking opportunities.

The Other Pandemic, Racism, in Urology

Racism is deeply ingrained in our society with lasting effects within medicine. The COVID-19 pandemic further highlighted racial disparities in the medical field, including in the field of Urology. This has led to investigation regarding the effects of racism on education, patient care, and research within Urology. This article aims to review current literature on the "other pandemic," structural racism, within medicine and specifically urology and provide ways to combat its impact.

A Systematic Review of the State of Preclinical Mentorship Programs in Plastic and Reconstructive Surgery

Background

Plastic and reconstructive surgery is consistently one of the most competitive medical specialties in the match. The recent United States Medical Licensing Examination score reporting switch to pass-fail led to a change in metrics by which applicants are evaluated by plastic surgery programs. Applicant research productivity and the demand for plastic surgery mentorship will continue to rise. Given the competitive nature of the residency match and shift in metrics emphasis after the change in STEP 1 scoring, early exposure to plastic surgery and mentoring relationships are paramount to applicant success. However, most medical students are not exposed to plastic surgery until they begin clinical rotations.

Methods

A literature review of plastic surgery mentorship programs available during preclinical years was conducted to identify preclinical mentorship opportunities in plastic surgery. Sixty-eight references were identified, but only two studies met the inclusion criteria of addressing mentorship programs in preclinical years.

Results

Examination of the included studies indicated that preclinical medical students achieve self-identified goals and generate longitudinal benefits in plastic surgery by participating in early and focused mentorship programs.

Conclusions

The limited number of studies in this review highlights a lack of available, studied preclinical mentorship programs in plastic surgery and reveals a knowledge gap concerning the creation of successful preclinical mentorship programs. Early exposure to plastic surgery, combined with the development of structured preclinical mentorship programs, can potentially replicate successful outcomes seen in other surgical subspecialties' mentorship programs while addressing the lack of formalized mentorship opportunities for preclinical students in plastic surgery.

Perceived Barriers Among Underrepresented and Historically Marginalized Medical Students Pursuing a Career in Urology

OBJECTIVE

To assess perceived barriers to pursuing urology among medical students and to determine if marginalized groups identified greater challenges to entry.

METHODS

The Deans of all New York medical schools were asked to disseminate a survey to their students. The survey collected demographic information to identify underrepresented minorities, students of low socioeconomic background, and lesbian, gay, bisexual, transgender, queer, intersex, and asexual individuals. Students were asked to rate various survey items on a five-point Likert scale to determine which factors were perceived as barriers to applying to urology residency. Student t tests and ANOVA were used to compare mean Likert ratings between groups.

RESULTS

A total of 256 students responded to the survey from 47% of medical institutions. Underrepresented minorities students cited lack of evident diversity within the field as a more significant barrier than counterparts (3.2 vs 2.7, P= .025). Lesbian, gay, bisexual, transgender, queer, intersex, and asexual students perceived the lack of evident diversity within urology (3.1 vs 2.65, P = .01), exclusivity of the field (3.73 vs 3.29, P = .04), and fear that residency programs would have negative perceptions of them as students (3.0 vs 2.1, P < .0001) as substantial obstacles compared to peers. Students with childhood household incomes less than $40,000 cited socioeconomic concerns as a higher barrier compared to students with household incomes greater than $40,000 (3.2 vs 2.3, P = .001).

CONCLUSION

Underrepresented and historically marginalized students perceive more significant barriers to pursuing urology than their peers. Urology training programs must continue to foster an inclusive environment to recruit prospective students from already marginalized groups.

Assessment of Demographic Changes of Workforce Diversity in Otolaryngology, 2013 to 2022

Importance

Given the growth of minoritized groups in the US and the widening racial and ethnic health disparities, improving diversity remains a proposed solution in the field of otolaryngology. Evaluating current trends in workforce diversity may highlight potential areas for improvement.

Objective

To understand the changes in gender, racial, and ethnic diversity in the otolaryngology workforce in comparison with changes in the general surgery and neurosurgery workforces from 2013 to 2022.

Design, Setting, and Participants

This cross-sectional study used publicly available data from the Accreditation Council for Graduate Medical Education and the Association of American Medical Colleges for 2013 to 2022, and included medical students and trainees in all US medical residency programs and allopathic medical schools.

Main Outcomes and Measures

Average percentages of women, Black, and Latino trainees during 2 intervals of 5 years (2013-2017 and 2018-2022). Pearson χ2 tests compared demographic information. Normalized ratios were calculated for each demographic group in medical school and residency. Piecewise linear regression assessed linear fit for representation across time periods and compared rates of change.

Results

The study population comprised 59 865 medical residents (43 931 [73.4%] women; 6203 [10.4%] Black and 9731 [16.2%] Latino individuals; age was not reported). The comparison between the 2 study intervals showed that the proportions of women, Black, and Latino trainees increased in otolaryngology (2.9%, 0.7%, and 1.6%, respectively), and decreased for Black trainees in both general surgery and neurosurgery (-0.4% and -1.0%, respectively). In comparison with their proportions in medical school, Latino trainees were well represented in general surgery, neurosurgery, and otolaryngology (normalized ratios [NRs]: 1.25, 1.06, and 0.96, respectively); however, women and Black trainees remained underrepresented in general surgery, neurosurgery, and otolaryngology (women NRs, 0.76, 0.33, and 0.68; Black NRs, 0.63, 0.61, and 0.29, respectively). The percentage of women, Black, and Latino trainees in otolaryngology all increased from 2020 to 2022 (2.5%, 1.1%, and 1.1%, respectively). Piecewise regression showed positive trends across all 3 specialties.

Conclusions and Relevance

The findings of this cross-sectional study indicate a positive direction but only a modest increase of diversity in otolaryngology, particularly in the context of national demographic data. Novel strategies should be pursued to supplement existing efforts to increase diversity in otolaryngology.

The Revolving Door of Residency: Predictors of Residency Attrition for Urology Matriculants Between 2001 and 2016

OBJECTIVE

To add to the literature which has reported higher attrition rates amongst General Surgery residents who identify as female or underrepresented in medicine (URM), we aimed to determine how these factors contribute to attrition within Urology. We hypothesized that women and URM Urology residents will similarly have higher attrition rates.

METHODS

The Association of American Medical Colleges surveyed residents to obtain matriculation and attrition status from 2001 to 2016. Data included demographics, medical school type, and specialty. A multivariable logistic regression model was performed to identify predictors of attrition amongst Urology residents.

RESULTS

In our sample of 4321 Urology residents, 22.5% were female, 9.9% were URM, 25.8% were older than 30 years, 2.5% were Doctor of Osteopathic Medicine graduates and 4.7% were International Medical Graduates. On multivariable analysis, being female (Odds ratio [OR] = 2.3, P < .001) was associated with increased residency attrition when compared to male residents. Additionally, residents who matriculated between 30 and 39 years old (OR = 1.9, P < .001) or ≥40 years old (OR = 10.7, P < .001) had an increased risk of residency attrition when compared to residents who matriculated between 26 and 29 years old. Attrition rates for URM trainees have recently increased.

CONCLUSION

Women, older, and URM Urology residents experience higher rates of attrition compared to their peers. It is essential to identify trainees with a higher likelihood of attrition to determine system-level changes to combat departures from training programs. Our study highlights the need to foster more inclusive training environments and change institutional cultures to diversify the surgical workforce.

A Review of Mentorship in Urology: Are We Satisfied?

PURPOSE OF REVIEW

To evaluate the state of mentorship in the field of urology.

RECENT FINDINGS

Mentorship has been shown to decrease burnout, increase recruitment of underrepresented minority groups, and have a positive influence on the career trajectory of mentees. Approximately half of surgical residency programs have mentorship programs. The current literature supports the idea that formal mentorship programs are successful based on level 1 satisfaction scores. However, studies are sparse and of low quality. Mentorship program success is rarely objectively measured. Structured mentorship programs appear to be beneficial, but require serious planning, evaluation, and ongoing support without which the programs can fail. Future research should be focused on objective and measurable metrics of success.