Underrepresentation of African American Women in Urology: Improving Patient Outcomes Demands Action

Echoes of Dr. Carter G. Woodson’s 1915 Association for the Study of Negro Life and History resonate through today’s celebration of the African American women who were pioneers in urology. Dr. Woodson’s “Negro History Week” eventually lead to what we now call Black History Month. In 1976, President Gerald R. Ford officially recognized Black History Month in the United States and urged, “[his] fellow citizens to join [him] in tribute […] and [to recognize] the message of courage and perseverance it brings to all of us.”  

Through reflection and analysis, I realize and hope to convince you that honoring the pioneers of African American women in urology is necessary, but not sufficient, to empower the next generation of groundbreakers and changemakers. No matter what you look like, no matter your background, it is in all our interest to significantly increase the representation of African American women in our field because patient outcomes depend on it. The pioneering African American women should certainly be celebrated, but celebrated by looking at the past for clues to how our actions in the present will improve care in the future.

This article is my call to action for everyone in the field of urology. If you’re reading this, that likely means you.

Angela Y. Davis said, “In a racist society, it is not enough to be non-racist, we must be anti-racist.” There are likely few reading this who are racist. However, in our field that is not enough. We must be anti-racist because the status quo is not capable of changing the status quo.

I call you to action not for my sake, not for the sake of the budding students and physicians who may enjoy a career in urology, and not for the sake of equity in the workplace or with political motivations. I do so for our patients. We, as physicians, are the guardians of our patients’ health. To that end, we collectively questioned whether cultural competency training was enough to allow us to connect with those who both look differently and were raised differently than ourselves and have concluded that to significantly change outcomes for our patients, racial concordance (having a shared racial identity between physician and patient) provides a far more effective means.

To be fair, this was known long before we showed it through modern meta-analysis. Healthy slaves meant increased plantation productivity, so slave owners brought healers from West Africa who not only brought their knowledge of roots and healing with them but brought seeds for many of the roots and healing plants commonly incorporated into medicinal practice. Yet, from the 17^th century to the 21^st, we still suffer from an unacceptable lack of racial concordance with our urology patients and an even greater gap in gender concordance. The barriers were explicit then and originated from the very location where I am typing this article as the colony of Virginia “forbade ‘any negroe, or other slave’ to administer ‘any medicine whatsoever’ under pain of death ‘without benefit of clergy.’” The only exception was to treat other slaves with the full permission of the slave owner. “No matter how much white slave owners relied on and trusted slave healers, they also feared them.” With only 2.4% of urologists being African American and only a small percentage of those being women, the barriers may not be explicit, but they are nearly as effective. There is some improvement in the pipeline, as the 2023 MATCH reported that 5.7% of matched applicants identified as Black or African American.

Black men in the U.S. suffer a prostate cancer mortality rate 2.1-2.5 times that of White men. UTIs, while common in studies of racially and ethnically diverse children, are much more likely to be undiagnosed in black children. In 2014, African Americans represented only 2.5% of practicing urologists in the workforce, significantly lagging the black percentage of the population at 13.31% in 2016. Knowing these facts and knowing that racial concordance leads to better outcomes for patients, one would think that we would have closed the gap in representation. In 2015, Tracy M. Downs, MD, FACS, an African American urologist who has worked tirelessly to improve diversity in the field, recognized the need and explained in an interview with Urology Times that, “More work needs to be done to expand the role of minorities and women in urology leadership positions and to stay competitive with other specialties.”

Since then, we have failed to adequately address the representation of African Americans in the field of urology. The graph below is taken from the 2014-2021 AUA Annual Census and shows that African American representation has remained constant from 2014 to the present and is, in fact, slightly lower now than it was then. MATCH data suggests an uptrend in the pipeline, but there is more work to do.

With women representing only a small fraction of that 2.4%, African American women are one of the least represented groups in urology. One common explanation is that black women are underrepresented in medicine in general, and the limited pool of qualified individuals who can enter the field of urology has a trickle-down effect. Another plausible explanation is racial and gender bias. Black women have faced discrimination and bias in the workplace, including the medical field, which limits opportunities for advancement and make it difficult to climb the ladder to leadership positions or to enter competitive fields like urology. Still another explanation focuses on financial barriers and the high cost of education as a roadblock for many black women. Finally, another realistic explanation is that there is a lack of mentorship and support for Black women in the field of urology, which makes it difficult for young, Black, women medical students to enter the field. Despite these challenges, there are accomplished women who are pioneering Black urologists practicing in the U.S.; it is incumbent upon us to recognize their contributions and, because we care about patient outcomes, to increase their numbers. Addressing the four barriers I mentioned above is a monumental task, and I do not expect that battle to be the rallying cry for each and every one of you. My battle doesn’t need to be yours. However, I said this is a call to action for all of us. So, after I celebrate and honor some pioneering African American urologists, I am going to give you one task that you can do to improve our representation and our resultant patient outcomes. But first, let’s give credit where credit is due.

In 1976, the same year in which President Ford officially established Black History Month in the United States, Dr. Jack Lapides, MD, a native of Rochester, New York, and Chief of Section of Urology at University of Michigan published his influential textbook Fundamentals of Medicine. His influence in the field was both deep and wide, and while his contributions to the field (such as the development of clean intermittent self-catheterization in the management of neurogenic bladder) cannot be understated, his legacy as a changemaker includes opening his program to another pioneer in the field. Under his guidance, Carol Bennett, MD, an African American woman completed her urology residency at U-M. She was the first African American woman in urology in the United States and went on to make miracles happen by establishing University of Michigan’s spinal cord injury fertility program and enabled the first pregnancy in the United States from semen obtained through electroejaculation. Her remarkable history should be read at the link below her picture.

Other African American women soon followed. Cheryl Lee, MD, followed Dr. Bennett in residency at Michigan Medicine and is now both a Professor and Chair of Urology at The Ohio State University Wexner Medical Center. She has authored over 160 publications and has been part of over 60 clinical trials. Her research is on the cutting edge: using artificial intelligence to improve bladder cancer staging.

Dr. Shenelle Wilson showed us that a non-traditional African American woman can make the career change from nursing to medicine and be successful in the field of urology.

Dr. Bobbilynn Hawkins was the U.S. Army’s first female urologist and was also the first African American female full professor of urology. One of her many accomplishments came in the study of Ochoa Syndrome, a rare condition that causes patients’ smiles to turn to grimaces and also disrupts bladder and bowel control. She completed the arduous task of screening genes in patients from Colombia, the United States, and France, allowing her team to discover the gene that was mutated in every patient.

Dr. Gail Reed Jones, a Queens native, has spent decades educating people about prostate cancer and raising money to increase awareness. 

Dr. Jacqueline Hamilton is a “Triple H” urologist, having attending Undergraduate, Medical School, and Residency at Howard University. She is a past present of the RFJ Urologic Society and was the first fellow in Female Pelvic Medicine and Reconstructive Surgery at the University of Alabama and was the second female to matriculate through urology residency at Howard. 

Another Howard alumna, Dr. Pamela Coleman, works tirelessly throughout the Washington, DC, area to improve the health of some of the least served members of our community. She does this while serving as Interim Division Chief of Urology at Howard University and teaching at Howard University College of Medicine. Her advocacy for improving patient-physician concordance is making headway through all of her work.

There are countless other firsts made by African American women and heroes who have paved the trail. We honor you, celebrate you, and can never be nor replace you. Yet what we need now are not firsts, seconds, or individual heroes. It is up to us to recruit a next-generation army of urologists to whom we may pass the torch so they can magnify that light through their numbers and through their own efforts to improve patient care and concordance. Stuck between 2 and 2.5% African American representation in urology for nearly a decade, our first task is to acknowledge the problem indicated by the census data. Our next task is to maximize economies of scale.

In the corporate world, economies of scale provide cost advantages through becoming more efficient, increasing production, and lowering costs. In urology, we should look to efficiently increase representation of women of color in a way that maximizes the number of quality physicians, optimizes racial and gender concordance, and lowers the cost per acquisition of each new resident entering the field.

Overall representation in medicine, racial and gender bias, and financial barriers are three complex issues. And while they are worthy causes, if those are your fights, you’re already engaged. If they aren’t your battle, you’re unlikely to engage now. However, with regard to mentorship and support, this next ask is on you. Take the lead!

We have been working hard to create mentorship and support programs for students in groups underrepresented in medicine/urology, but those programs have left urology without a single percentage increase in African American representation since the 2014 census. As you recall, our last census in 2021 showed a net 0.1% decline since 2014.

Here’s how you can help. Stop being a “non-racist” and be an “anti-racist.” Being non-racists has led to the status quo. So for us, “anti-racist” means taking the lead. Don’t wait for students to approach you. They may never have a urology rotation. Like all of us, students don’t know what they don’t know. Dr. Cheryl Lee was in her intern year pursuing a career in hand surgery before she was even introduced to urology by way of observing a radical cystectomy. Commit yourself to some of the following means of outreach to women of color who could potentially enter urology. You’ll be surprised how many trees can grow when you plant seeds at every opportunity.

• Ask students of color for their time. Invite them personally to the OR with you. Don’t take no for an answer, at least not the first time. Don’t exclude others, but keep in mind that there may be apprehension in women of color that you don’t see in other groups as a result of generational barriers. A successful car salesperson asks for the sale 3, 4, 5, 6 times without ever batting an eye. Each time they ask, it is a soft close. It doesn’t matter how many times they ask because that number becomes irrelevant once the customer says, “Yes,” just once. Each time you ask, you are planting a seed in that student’s heart and mind. You are making them feel wanted in a field that may seem walled off from her reach. This plants the seed that they are wanted in the field and not just tolerated.
• Realize that students can help you. Take time to learn how students can help you to make your life as an attending easier and their time feel valued and appreciated. Relationships work best when each member feels wanted, needed, and appreciated. This again plants the seed of feeling wanted but adds in seeing the fruits of their labor helping someone already in the field.
• Offer to help with QBank sessions. Schedule off the clock Amboss or UWorld urology sessions with your students in small groups of 3-4 that make each student feel important. Allow them to discuss their questions and answers in your presence and be the voice of the expert when they get something wrong. This plants the seed that you will be there for them when they need you.
• Bring students to your clinic and educate them on the significance of racial concordance. Show them patients who look like them and have shared identities and backgrounds. Show them the AUA census data and let them know you are actively trying to improve patients’ access to providers whose identity they share.

These simple techniques cost you nothing but a little effort. They will yield not only increased exposure to urology for underrepresented women in urology but will earn you and your department a reputation of proactively serving the people most in need. Word of your welcoming environment will spread, and just like any business, your repeat and referral business will be your best and most loyal customers. Your students will appreciate it. They will appreciate it even more when they MATCH and are residents.

And the outcome? Patients will be better served, outcomes will improve, and you will be part of writing the next chapter in American Urological History. So, like the West African root healers who brought seeds that grew plants to heal their people, start planting seeds today in the hearts of our students so that they may grow into healers of us all. 

References

Carter G. Woodson: A Life in Black History. (n.d.). LSU Press.

“Slave Medicine.” Www.monticello.org, www.monticello.org/sites/library/exhibits/lucymarks/medical/slavemedicine.html.

‌Guillaume G, Robles J, Rodríguez JE. Racial Concordance, Rather Than Cultural Competency Training, Can Change Outcomes. Fam Med. 2022 Oct;54(9):745-746. doi: 10.22454/FamMed.2022.633693. PMID: 36219435.

Chen L, Baker MD. Racial and ethnic differences in the rates of urinary tract infections in febrile infants in the emergency department. Pediatr Emerg Care. 2006 Jul;22(7):485-7. doi: 10.1097/01.pec.0000226872.31501.d0. PMID: 16871107.

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