Assessing the Female and Underrepresented Minority Medical Student Experience in the Urology Match: Where Do We Fall Short?

Characterizing Asian American medical students' experiences with microaggression and the impact on their well-being

PURPOSE

This mixed-methods study quantified and characterized incidents of microaggressions experienced by Asian American medical students. The authors report on their impact and suggest improvements to create a more equitable and supportive learning environment.

METHOD

Quantitative and qualitative data were collected from 305 participants who self-identified as Asian American or Pacific Islander. An online, anonymous survey was sent to US medical students through the Asian Pacific American Medical Student Association (APAMSA). Questions explored incidence, characteristics of, and response to microaggressions. We conducted four focus groups to further characterize students' experiences. Data were organized and coded, and thematic analysis was used to identify core themes.

RESULTS

Racial microaggressions were prevalent among Asian American medical students. Nearly 70% (n = 213) of survey respondents reported experiencing at least one incident during their medical training to date. The most common perpetrators were patients (n = 151, 70.9%) and fellow medical students (n = 126, 59.2%), followed by professors (n = 90, 42.3%). The most prevalent themes included being perceived as a perpetual foreigner, the assumption of timidness, and ascription of the model minority myth. Students rarely reported the incident and usually did not respond immediately due to fear of retaliation, uncertainties about the experience or how to respond appropriately, and perception that they would bear the burden of advocacy alone. Experiences with microaggressions led to feelings of frustration and burnout and had a negative impact on mental health. Recommendations were made to improve the anonymous reporting systems in medical schools, and to increase diversity and inclusion in medical education and leadership.

CONCLUSIONS

Asian American medical students face high exposure to racial microaggressions during their medical education that adversely impact their mental health. Changes are needed in medical training to create a more equitable and inclusive learning environment.

Exploring the intersectionality of race and gender on the incidence of and response to microaggression experienced by Asian American women medical students

BACKGROUND

Discrimination faced by Asian American trainees in medical school include those reported by female trainees. This study aims to characterize the microaggressions faced by Asian American woman medical students.

METHODS

We use a mixed methods approach to characterize the experiences of Asian Americans in United States (US) medical schools through an anonymous online survey and participation in focus groups.

RESULTS

Among our 305 participants, 65.9 ​% were women. More women experienced microaggressions than men (p ​< ​0.001). Compared to men, women reported significantly higher rates of supervisors having higher expectations of them, implying they were submissive, and describing them as too quiet. Women felt that their experiences with microaggressions were entangled with being Asian and a woman, but could not distinguish which identity was being targeted.

CONCLUSION

The intersectionality of being Asian American and a woman in medical training has not been explored. We found that this duality intensified experiences of microaggressions.

Current state of inclusion and diversity in pediatric urology fellowship programs

BACKGROUND

Increased racial/ethnic diversity of the physician workforce can improve health outcomes for marginalized populations. Currently, the pediatric urology workforce is less racially/ethnically diverse than the pediatric population it serves.

OBJECTIVE

We aimed to assess current recruitment efforts and barriers to recruitment of underrepresented in medicine (URM) fellows in pediatric urology fellowship programs.

METHODS

A 20-question REDCap survey was created and distributed to 27 pediatric urology fellowship program directors (PDs). The survey consisted of 4 sections of questions focused on PD demographics, program characteristics, recruitment efforts, and perceptions of barriers to recruitment.

RESULTS

A total of 20 PDs responded to the survey (74 %), including 3 incomplete responses. A majority of participants identified as Caucasian/white (79 %), male (68 %), over 40 years of age (89 %), and had served as PD for 5 years or more (68 %). Most PDs (70 %) identified their program having 5-10 full-time pediatric urologists. Many PDs (75 %, 15/20) identified their program as less diverse than the patient population served, and 53 % (9/17) reported having no methods in place for diversity recruitment. Of those who reported a recruitment method, mentorship was the most common (35 %, 6/17). When asked about recruitment barriers, 59 % (10/17) reported that no barriers existed, while those who identified a barrier most commonly cited an overall limited applicant pool (18 %, 3/17).

DISCUSSION

Pediatric urology fellowship programs are less diverse than the patient populations served; while PDs value program diversity, most PDs report that there are no mechanisms in place to recruit racially/ethnically diverse trainees. To address this, we recommend active and intentional efforts to increase URM recruitment in pediatric urology. By taking an active role in existing recruitment efforts, pediatric urologists can increase their visibility, broadcast their commitment to diversity, form relationships with trainees earlier in training and increase opportunities for mentorship and early exposure to the field.

CONCLUSION

Intentional recruitment efforts are needed to recruit URM trainees to pediatric urology fellowship programs and ensure the diversity of the pediatric urology workforce can better reflect patients served.

Urology Residency Applicant Selection: Program Directors' New Criteria

OBJECTIVE

To evaluate the impact of the recent changes to the urology residency application process on the criteria utilized by residency program directors (PDs) for interview invitations and their perspectives concerning these changes.

METHODS

One hundred thirty-seven urology residency PDs were invited to participate in an anonymous survey to explore interview selection criteria and the impact of the increase in preference signals (PS) per applicant.

RESULTS

Fifty-eight PDs (42.8%) completed the survey. The highest-ranked criteria were letters of recommendation (LoR) and successful sub-internship (sub-I) at the PD's institution, without statistically significant differences between these 2. Gender, ethnicity, and medical school prestige were the lowest rated criteria, without significant differences between these 3. Compared to before the increase in the number of PS per applicant, 80.7% of PDs reported that not receiving a PS from an applicant this cycle would more negatively impact the chances of offering an interview to that applicant. Moreover, 12.2% stated they would not interview any applicants who did not send a PS. Finally, 62.1% of PDs believed recent changes worsened the process.

CONCLUSION

Recent changes impacted PDs applicant evaluation, with the highest ranked criteria being LoRs and sub-I. Paradoxically, the increase in the number of PS per applicant has increased their importance as applicants are much less likely to receive interview offers from programs they have not signaled. Lastly, most PDs believe changes have worsened the evaluation process.

Gender Bias in Letters of Recommendation: Relevance to Urology Match Outcomes and Pursuit of Fellowship Training/Academic Career

OBJECTIVE

To review applications to a single urology residency program to determine application characteristics predictive of (1) successful match into urology residency and (2) pursuit of fellowship training and/or academic practice after completion of residency. Our principal variables of interest were gender bias as assessed in letters of recommendation (LOR), personal statements, Medical Student Performance Evaluation (MSPE), race, and gender.

MATERIALS AND METHODS

Applications submitted to our urology residency program in the 2014 cycle were reviewed. Twenty-three variables were analyzed, including applicant demographics, application materials, and gender bias. Deidentified text from LOR, personal statements, and MSPE was evaluated for gender bias using an open-source gender bias calculator. A subanalysis of applicants who matched at a top 25 urology program was performed. Logistic regression analysis was performed to identify applicant variables associated with (1) match success and (2) fellowship training or academic employment as of September 2021.

RESULTS

Two hundred and twenty-two completed applications were analyzed. First authorship of a published manuscript was significantly associated with greater odds of matching. Female gender and top 25 medical school attendance were both significant predictors of matching at a top 25 urology program. The number of first-author publications was associated with completion of fellowship training or current employment in an academic position.

CONCLUSION

First-author publications are the most important preinterview determinant of match success and subsequent pursuit of academic practice/fellowship training. Certain applicant characteristics are associated with matching at highly ranked programs. Gender bias in application materials (including LOR) does not appear to exert a significant influence on match and early career outcomes.

The Future is Female: Urology Workforce Projection from 2020 to 2057

Multiple estimates have approximated a urologist shortage per capita of around 30% by 2030. In the context of the impending urologic workforce shortage, it is critical to have a nuanced understanding of the degree of workforce shortage in comparison with the US population to mitigate the negative downstream effects in the future. In continued growth and stagnant growth projection models, we found that female urologists make up a significant proportion of the workforce growth over the next four decades. This projection highlights the need for purposeful recruitment, structural changes, and advocacy among urology leadership to support and retain female urologists.

Diversity Attracts Diversity: 2023 AUA Match Results

OBJECTIVE

To assess the rationale behind the choice of programs for preference signaling (PS) and subinternships by urology applicants in the 2023 cycle.

METHODS

We emailed an anonymous, multiple-choice survey to the 403 prospective candidates who applied to our institution for the 2023 Urology Residency Match.

RESULTS

121 applicants (30.0%) responded to the survey. 81.8% were in favor of the continuation of PS, with 4.1% against it. When choosing where to PS or subinternship, geographic location and perceived quality of clinical training were the highest-ranked criteria. Racial/ethnic diversity of the residents influenced PS or subinternship choice for 77.8% of Black, 72.7% of Asian, 57.1% of Latinos, and 46.5% of White respondents (P < .05 for Black and Asian vs White). Institutional statements on diversity influenced PS or subinternship choice for 88.9% of Black, 55% of Asian, 64.3% of Latino, and 25.4% of White respondents (P < .05 for Black, Asian and Latino vs White). Females had an increased likelihood of PS or choosing subinternship programs with gender diversity of residents (81.6% vs 33.8, P = .002). A program with PS was associated with a 2.74 increase in likelihood of obtaining an interview compared to programs that were not PS. Of 107 matched applicants, 47.5% matched at a program where they completed a subinternship, and 25.7% matched at a signaled program.

CONCLUSION

PS plays a major role in the match process. When choosing where to PS, applicants prioritize geographic location and perceived quality of training. Diversity of residents plays a major role in recruiting diverse applicants.

Factors Related to Differential Treatment and Practice Limitations Amongst Urologists: A Report of American Urological Association 2021 Census Data

OBJECTIVE

To assess rates of urologist-reported differential treatment in practice and practice limitations based on characteristics of urologists... identity.

MATERIALS AND METHODS

The 2021 AUA Census samples were linked with the United States (US) practicing urologist population file and assigned proper sample weighting to adjust for non-response bias. Responses to 2 questions of the Census related to (1) (negative) differential treatment experienced in practice and (2) limitations in patients/diagnoses seen in practice due to different aspects of respondent...s identity were evaluated. Responses were stratified based on self-reported gender (female vs male) and race (White vs non-White); results were compared using a chi-squared test.

RESULTS

A total of 1742 urologists, representing 13,790 practicing US urologists through post-stratified weighting, responded to the Census. Overall, amongst those who answered the relevant questions, 16.3% reported having experienced differential treatment in practice due to their identity and 6.1% reported being limited in patients/diagnoses seen in practice due to their identity. Women were more likely than men to have experienced differential treatment (75.0% vs.ß10.2%, P.ß<.ß.001) and to be limited in patients/diagnoses seen in practice (27.0% vs.ß3.7%, P.ß<.ß.001). Similarly, non-White respondents were more likely than White urologists to both have experienced differential treatment (30.4% vs.ß14.1%, P.ß<.ß.001) and to be limited in patients/diagnoses seen in practice (12.8% vs.ß5.0%, P.ß<.ß.001).

CONCLUSION

Female and non-White urologists are more likely to experience differential treatment in their practice and limitations in the scope of their practice. Further studies are needed to characterize these experiences and explore the etiologies of these differences.

Evaluating Diversity and Inclusion Content on Graduate Medical Education Websites

Websites are important tools for programs to provide future residency applicants with freely accessible information regarding their program, including diversity, equity, and inclusion (DEI) initiatives.

OBJECTIVE

To describe the variability of DEI content in residency programs and compare DEI website content by specialty.

METHODS

Using the 2021 Accreditation Council for Graduate Medical Education (ACGME) list of residency programs, residency training websites were identified and evaluated. Information was extracted from program websites as indicators of DEI content. Chi-square analysis and one-way ANOVA were chosen to assess for statistical differences.

RESULTS

In total, 4644 program websites representing 26 specialties were assessed. Among all the programs, the average DEI completeness of a program website was 6.1±14.6% (range 0-100%). While 6.2% of all programs had a diversity webpage, only 13.3% included a commitment to DEI, and few programs (2.7%) provided information about underrepresented in medicine (URiM) faculty.

CONCLUSIONS

Graduate medical education programs can enhance information for current and prospective applicants about DEI initiatives on their websites. Including DEI initiatives on residency websites may improve diversity recruitment efforts.

Applying Representation Quotient Methodology to Racial, Ethnic, and Gender Trends of Applicants and Matriculants to Urology Residency Programs From 2010-2018

OBJECTIVE

To accurately examine the trends in the racial and gender composition of medical students applying and matriculating to urology residency programs.

METHODS

Reports on race/ethnicity and gender for medical school graduates, and urology residency applicants and matriculants were obtained for years 2010-2018. The proportions of individuals representing different racial and gender identities among urology applicants and matriculants were divided by a denominator of their proportion in medical school graduating classes to produce representation quotients (RQ_app and RQ_mat, respectively). Linear regression models were performed on yearly RQs to estimate the RQ changes over time. Nonparametric testing was used to evaluate for differences in applicant to matriculant representation within each identity. ANOVA was performed separately on RQ_app and RQ_mat values to assess differences in representation between identities in the applicant and matriculant populations.

RESULTS

Asian men experienced increases in representation among urology applicants (RQ_app: slope 2.04 × 10^-2; P = .03) and matriculants (RQ_mat slope: 7.46 × 10^-2; P = .0076) during the study period. Black men trended towards under-representation among applicants (RQ_app slope -1.51 × 10^-1; P = .03) and matriculants (RQ_mat slope: -1.71 × 10^-1; P = .02). When examining genders, both men (RQ_app=1.43 vs RQ_mat=1.44; P = .80) and women (RQ_app=0.52 vs RQ_mat = 0.51; P = .67) had unchanged representation in the applicant and matriculant cohorts, but women severely underrepresented on average.

CONCLUSIONS

Women and Black men are underrepresented in the urology workforce. These concerning findings demonstrate the dire need for initiatives regarding recruitment into urology to support and to ensure successful entry into the field for minority groups.

Someone Like Me: An Examination of the Importance of Race-Concordant Mentorship in Urology

OBJECTIVE

To describe differences in urology mentorship exposure for medical students across race/ethnicity and to explore how much potential mentees valued the importance of race-concordant mentorship.

METHODS

All medical students at UCLA received a cross-sectional survey. Dependent variables were perceived quality of mentorship in urology and association between race-concordant mentorship and perceived importance of race-concordant mentorship. Mentors were self-selected by medical students. Variables were compared across race/ethnicity using descriptive statistics and multivariate analyses. Subset analyses looking at race-concordance between mentor and student was performed using stratified Cochran-Mantel-Haenszel tests. This was performed to determine if there were differences, across race/ethnicity, in rating of importance of having a race-concordant mentor.

RESULTS

The likelihood of having a urologist as a mentor was similar across race/ethnicity. Under-Represented in Medicine (URiM) students were more likely to report that having a mentor of the same race/ethnicity was extremely important (Asian 9%, Black 58%, Latinx 55% and White 3%, P < .001) compared to their non-URiM peers who were more likely to rate having a race-concordant mentor as not at all important (Asian 34%, Black 5%, Latinx 8%, White 79%, P < .001). URiM students with race-concordant mentors were still more likely to rate having a mentor of the same race/ethnicity as extremely/very important (73%) compared to their non-URiM peers (9%, P = .001). URiM students with race-discordant mentors also rated importance of mentors of the same race/ethnicity as extremely/very important (67%) compared to their non-URiM peers (11%, P = .006).

CONCLUSION

URiM medical students regard race-concordant mentorship as extremely important. Interventions addressing mentor racial/ethnic concordance and those promoting culturally responsive mentorship may optimize recruitment of URiM students into urology.

The Fate of the Unmatched Urology Applicant

OBJECTIVE

To determine the outcomes and eventual career paths for unmatched applicants by evaluating a historical cohort of unmatched applicants in the Urology Match.

METHODS

The 2008-2014 AUA Match lists were obtained from the Society of Academic Urologists and 730 unique applicants were identified with at least one unmatched result. Additional information such as preliminary training and eventual specialty choice were obtained from publicly available sources. Comparative analysis with univariable and multivariable analysis was performed between eventual urologists and those who chose alternative career paths.

RESULTS

Overall, 43.5% (318/730) of unmatched urology applicants subsequently continued their interest in Urology and 77.4% (246/317) of initially unsuccessful applicants eventually became urologists. Males (80.9%, P = .01), Doctor of Osteopathy (DO) degree (62.5%, P = <.001), and those undergoing a research year compared to a preliminary surgery year (85.2% vs 72.0% respectively, P = .047) had an increased likelihood of successfully becoming a urologist. The most common alternative specialty choices were Internal Medicine (13.8%), General Surgery (12.9%) and Anesthesiology (11.9%).

CONCLUSION

Urology is a competitive surgical sub-specialty. Surprisingly, approximately 3 in 4 unmatched urology applicants who continue their interest in urology will eventually obtain a residency position. However, only 33.7% of initially unmatched students ultimately became urologists. Unmatched applicants have several viable pathways to obtain a urological residency position. Male gender, a DO degree, and a research year are associated with successfully obtaining a urology residency position.

Representation Matters: One Urology Residency Program's Approach to Increasing Workforce Diversity

OBJECTIVE

To address the challenge in urology in recruiting physicians from backgrounds racially and ethnically underrepresented in medicine (URiM), we sought to design, implement, and evaluate methods for recruiting URiM candidates to our urology residency program.

METHODS

We developed a 3-pronged approach aimed at increasing the number of interviewed applicants, and subsequently number of URiM residents recruited to our program. The 3 facets included: (1) funded visiting student rotation, (2) holistic evaluation of applications, (3) implemented targeted outreach. Statistical analysis of the applicants interviewed and matched into our residency program, as well as traditional metrics used for residency recruitment, were performed from 2015 to 2022.

RESULTS

The number of URiM interviewees significantly increased from 6.1% in 2015 to its peak, 40%, in 2020. In 2015, there were no URiM residents in our urology residency program. By 2022, the total URiM complement increased to 35%. In evaluating traditional metrics of residency recruitment, there was no significant difference in mean USMLE Step 1 score before compared with after the implementation of our recruitment approach. The maximum rank number reached to fill the urology residency positions also remained relatively stable throughout the study period, with a range from 5 to 38.

CONCLUSION

We demonstrate that the implementation of our innovative and intentional 3-pronged recruitment approach effectively increased the number of URiM interviewees and residents in our residency program. The diversification of our urology workforce depends on the implementation of such efforts, and we encourage urologists to lead the way on such initiatives.

Trends in the Racial and Ethnic Diversity in the US Urology Workforce

OBJECTIVE

To examine the historical trends and factors underlying the current state of racial/ethnic representation within the urology workforce at each stage of the educational pipeline.

METHODS

Using data from the US Census Bureau and the Association of American Medical Colleges, trends in racial/ethnic distribution for 2007-2008 to 2019-2020 were tracked in the educational pipeline for academic urologists. This pipeline was defined as progressively diminishing cohorts, starting with the US population, leading to medical school application, acceptance, and graduation, through to urology residency application, matching, and graduation, and ending with urology faculty appointment. A comparative cohort analysis was performed for academic year 2018-2019 for differences in racial/ethnic distribution across cohorts by binomial tests.

RESULTS

From 2007-2008 to 2019-2020, while the proportion of Latinx/Hispanic urology applicants increased by 0.38% per year (95% CI 0.24, 0.52), their proportion in the urology resident population remained unchanged (0.07% per year, 95% CI -0.20, 0.06) from 2011-2012 to 2019-2020. There was a decrease in the proportion of Black urology applicants (-0.13% per year, 95% CI -0.24, -0.02) and no change in the resident population (-0.03% per year, 95% CI -0.11, 0.05), despite an increase in total number of residents (n = 1043 to n = 1734) from 2009-2010 to 2019-2020. In 2018-2019, there were step-wise decreases in proportion of Black and Latinx/Hispanic members represented at critical stages of the educational pipeline (P <0.0001).

CONCLUSION

Attrition in URM urologists occur at key educational stages. This paper offers opportunities for the design of interventions to diversify the urology workforce.

Defining the Variance: The Current State of Female and URM Concordance of Urology Resident Workforce to the General U.S. Population

OBJECTIVE

To compare the current representation of women and underrepresented minorities in medicine (URM) of the urologic resident workforce to the general U.S.

POPULATION

MATERIALS AND METHODS

Data on current gender and racial distribution of U.S. urology residents was obtained from the 2019-2020 ACGME Data Resource Book and compared to the projected 2019 U.S. population as reported in the U.S. Census data. In this study, URM status included Black/African American, Hispanic/Latino, Native American/Alaskan, Native Hawaiian or Pacific Islander and Other. For each gender and race/ethnicity, the percent differences in representation were calculated by subtracting the frequency in the general U.S. population from that of the urology resident workforce and two sample z-tests were performed.

RESULTS

1734 urology residents were identified in 2019-2020, of which 471 (27.2%) were female and 258 (14.9%) were URM. Two sample z-tests revealed a significantly lower representation in urologic residency programs for women (-23.6%, P-value < .05) and URMs (-19.1%, P-value < .05). Race/ethnicity subgroup analyses revealed underrepresentation of Black/African American (-9.7%, P-value < .05), Hispanic/Latino (-14.2%, P-value < .05), Native American/Alaskan (-1.1%, P-value < .05).

CONCLUSION

Women and URMs continue to be significantly underrepresented in urology residency relative to the general U.S.

POPULATION

Further study should better understand barriers to entering the urologic workforce and identify strategies to encourage interest in urology among female and URM prospective trainees.

Diversifying Graduate Medical Education & the Urology Workforce: Re-imagining our Structures, Policies, Practices, Norms, & Values

This article offers a framework for critically examining the structures, policies, norms, practices, and values that shape the Urology Match as a foundation for interventions to improve diversity, equity, inclusion, and justice in the workforce. Points of leverage for transformational change in the urology workforce diversification include modifying the structure of the urology application process, optimizing reviewer factors, addressing Under-Represented in Medicine applicant experience, providing resources to applicants, and evaluating selection criteria. To achieve an inclusive diverse urology workforce, we must change policy and practice, expand what we include in the norm, which will translate into increased value ascribed to a more varied cohort of applicants, leading to the establishment of structures that accommodate true diversity.

Solutions: Bridging the Diversity Gap in Urology Trainees

OBJECTIVES

To address healthcare inequities, diversifying the physician workforce is an important step and improved efforts to recruit Underrepresented in Medicine (URiM) students is vital. We aim to examine the current state of minority recruitment and provide solutions to increase diversity in urology residency training.

METHODS

We conducted a retrospective analysis of self-reported race and ethnicity data for active urology trainees using the Data Resource Book by the Accreditation Council of Graduate Medical Education from 2011-2020. We also performed a longitudinal analysis comparing the number of urology applicants to urology trainees from 2016 to 2020 using the Electronic Residency Application Service statistics database. URiMs were designated in alignment with ACGME definitions. Categorical variables were summarized as frequencies and percentages and compared using chi-squared test between race and ethnicity.

RESULTS

We identified 11,458 active urology trainees for analysis. Of these, 6638 (57.9%) identified as White, 1690 (14.7%) as Asian/Pacific Islander, 442 (3.9%) as Hispanic, 380 (3.3%) as Black, 11 (0.1%) as Native American, 608 (5.3%) as other race/ethnicity and 1689 (14.7%) as unknown race or ethnicity. In 2011, 8.1% of trainees identified as URiM which remains the same at 8.2% in 2020.

CONCLUSIONS

As we strive to improve patient care and support our URiM colleagues, diversity, equity, and inclusion must be prioritized. Despite increases in students entering medical school and the expansion of urology training spots, the numbers of URiM in urologic training remains stubbornly unchanged. This work highlights an area of residency training that requires critical transformation.

Linguistic Differences in Personal Statements of Urology Residency Applicants by Self-Reported Race and Ethnicity

OBJECTIVES

To assess a potential source of bias that could contribute to underrepresentation of minorities in urology, we analyzed differences in linguistic characteristics in personal statements between urology residency applicants of various racial and ethnic groups.

METHODS

Personal statements submitted by urology residency applicants to a urology program were evaluated with Linguistic Inquiry and Word Count, a validated text analysis program. Analyzed statements and application characteristics were compared according to self-identified race/ethnicity of the applicant using multivariable analysis and independent sample T-tests.

RESULTS

Of 342 submitted personal statements, 181 applicants self-identified as White non-Hispanic, 86 as Asian, and 75 as "underrepresented in medicine" (URM) including Black and Hispanic/Latino applicants. Asian and URM applicants listed more research projects (11.7 and 12.9 vs 8.8, P = .01) and URM applicants had slightly lower USMLE Step 1 scores (238.5 vs 244.6, P = .01) compared to White applicants. When evaluating personal statements, all applicants wrote with the same degree of analytical thinking. Asian applicants scored lower in authenticity (P = .03) and emotional tone (P = .04) while URM applicants scored higher in clout (P = .04) compared to White applicants. In use of pronouns, Asian applicants used 'we/us/our' more often (P < .01), URM applicants used 'you' more often (P = .02), and White applicants used 'I' more often (P = .01).

CONCLUSION

Significant linguistic differences exist among urology personal statements by racial/ethnic groups that may perpetuate stereotypes and bias in the application process. Appreciating these differences may help applicants avoid possibly detrimental linguistics and help residency programs recruit and support urology applicants from underrepresented backgrounds.

Rising Black voices in urology - the next generation

Diversity in medical fields is beneficial to both clinicians and patients, and Nature Reviews Urology is committed to improving the diversity of our specialty and supporting Black and under-represented minority urologists. In this Viewpoint, 12 medical students who are embarking on a career in urology describe their reasons for choosing the specialty, explain what they think can be done to increase the number of Black urologists, and describe what has led them to apply to specific programmes.

Very long-term follow-up of the anterior vaginal wall suspension procedure for incontinence and/or prolapse repair

OBJECTIVE

To report outcomes of the anterior vaginal wall suspension (AVWS) procedure for stress urinary incontinence (SUI) and/or anterior compartment prolapse (POP), with minimum 10-year follow-up.

METHODS

Following institutional review board approval, a database of patients with > 10-year follow-up after AVWS for bothersome SUI with early stage anterior compartment prolapse (stage ≤ 2) or symptomatic anterior compartment prolapse (stage > 2) was reviewed. Preoperative evaluation included validated questionnaires [Urogenital Distress Inventory-Short Form (UDI-6), Incontinence Impact Questionnaire-Short Form (IIQ-7), quality of life (QoL)], Pelvic Organ Prolapse Quantification (POP-Q), and voiding cystourethrography. Follow-up data was based on clinic visits or telephone interviews for patients not seen in the past 2 years. Telephone interviews used validated questionnaires and were conducted by a third party not involved in patient care. Failure was defined as reoperation for SUI or POP. The influence of lost to follow-up (LTF) was also analyzed.

RESULTS

Between 1996 and 2008, 161 of 328 patients met study criteria, with follow-up from phone interviews (103) or clinic visits (58). The LTF patients were deceased (52), mentally disabled (5), or unreachable by telephone (110). Median follow-up was 13.5 years (IQR 11.5-17). Type of follow-up (clinic vs. phone) and uterine status (concomitant/prior/no hysterectomy) did not impact reoperation rates. Reoperation occurred in 23/161 (14%) and consisted of sacrocolpopexy (8), anterior colporrhaphy (5), injectable agents (8), fascial sling (2).

CONCLUSIONS

The AVWS procedure to restore anterior vaginal support to the bladder neck and bladder base to correct SUI/POP can provide satisfactory and durable results.