BackTable Urology
Ep. 192 Closing the Gender Gap in Urology with Dr. Yahir Santiago-Lastra
Fri, 04 Oct 2024
Inequality persists in pay and career advancement between male and female urologists. In this episode of the BackTable Urology Podcast, Dr. Suzette Sutherland hosts Dr. Yahir Santiago-Lastra from the University of California San Diego. They discuss the gender wage gap in medicine, particularly amongst urologists. --- This podcast is supported by: Photocure https://www.photocure.com/ --- SYNPOSIS Dr. Santiago, a Latina from Puerto Rico and a first-generation physician, highlights the latest data on pay, research funding, and professional advancement for women physicians. They debunk common myths, discuss the importance of transparency, and emphasize the need for inclusive work environments. The conversation also covers the economic phenomena underlying current discrepancies and the benefits of fostering diversity. This episode offers valuable insights for leaders on retaining and nurturing talent within their organizations. --- TIMESTAMPS 00:00 - Introduction 06:28 - Impact of Menopause and Women’s Health 10:33 - Gender Gaps in Urology 31:52 - The Meritocracy Myth 35:56 - The Abrasiveness Trap and Gender Schema 40:04 - Navigating Work Personalities 47:54 - Leadership and Inclusivity in Organizations 51:30 - Tokenism vs. True Inclusion 56:58 - The Benefits of a Diverse Workforce --- RESOURCES Photocure https://www.photocure.com/
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Further, with only 23% of patients coming back for re-resection, it's all the more important to do a complete TURBT right from the start.
Recently, there have been some conversations and some data about how the wage gap is shrinking. Now, the wage gap has gone up into the 80s, so 80% to the dollar. However, if you stratify wage gap, for lower earnings versus higher salaries. The wage gap for higher salaries is still pretty different, but there has been more pay equity for lower salaries, which I think is a silver lining.
If anyone deserves to get to pay equity faster, it's women who are working at lower income jobs and working just as much as men do definitely deserve that increase in salary. But it looks like in professional situations where the range in salaries is a lot more subjective and industry driven, there are still significant gaps.
Welcome once again to Backtable Urology Podcast, your educational source for all things urology, and then some. Backtable Urology offers many informative and entertaining episodes, which you can find on iTunes, Spotify, and of course, backtable.com.
I'm your host today, Dr. Suzette Sutherland, and I'm super excited to have Dr. Jair Santiago-Lastra with us today from the University of California, San Diego. She's here to discuss issues pertaining to the gender gap, the gender gap in medicine, and especially in surgery and urology. Why it exists, what are the common misconceptions or misconceptions
myths concerning why there is a gender gap and what perpetuates it and what can be done, what needs to be done in order to even the playing field in both medicine and surgery for compensation, promotion, and other aspects as well. So thanks, Dr. Santiago-Lestra for being here with us today. Happy to be back, Suzette. Thank you for having me. So a little bit about her.
She is Latina from Puerto Rico. She's a first-generation physician, surgeon, and urologist. She's an associate professor at the University of California, San Diego. She has been designated a rising star in our national organization, the American Urology Association, because she's very involved in a number of task force and committees. most prominently the AUA DEI Task Force.
She's also been involved in the DEI Task Force for our Society of Urodynamics and Female Pelvic Medicine. And she is the Society of Women and Urology Representative on Public Policy. So she's very involved in advocating for women and underrepresented minorities across the board in the area of urology. She's a member of Urology Unbound as well.
I forgot to mention that, which is also an organization that supports underrepresented minorities in urology. And of course, has a personal interest in health care equity for all patients. So this isn't just about the physicians and equity about the physicians and in the workforce, although that's a big issue, but also equity when it comes to patient care. So thank
It's really wonderful work that she's been able to do in our national organizations, and we sure appreciate all of your efforts. So thank you, Dr. Santiago Lastra, once again. Thank you so much. That was very generous. So let's dive in. I've had the great fortune of hearing you speak on this topic, the gender gap, before. So that's what we're going to be talking about here today.
I was very impressed with all of the data. You certainly know your stuff, and you had a great presence to be able to convey the issues in a very concrete way. So that's what we want to do today. So first of all, though, when we talk about gender gap, most often people assume we're talking about issues in compensation between men and women, maybe promotion.
And we'll dive into that, of course, in a minute. But I'd also like to talk about some other gender gaps that exist in the medical arena. between men and women that affect not only individuals, but populations of people too.
And that's things like the gender gap in funding for research in areas specifically that focus primarily on female-related issues, which leads to gaps in our knowledge about things that predominantly affect women. So can you speak to that, please?
Yeah, there's significant gaps not only in research funding, but there are also significant knowledge gaps when it comes to specific areas of women's health. So with regards to research, there are certain conditions that affect women predominantly.
For example, Alzheimer's and these sort of late-stage dementia diseases make up around 12% of the funding dedicated to research, although it disproportionately impacts women. About two-thirds of the patients are women. For example, in cardiovascular disease, funding is predominantly focused on trials that recruit a majority of male patients.
So the focus on women's health and women's cardiovascular disease is a huge disparity. There's actually some researchers looking at gender-based trials. differences in how we experience things like cardiovascular disease, which is one of the main mortality drivers for human beings at this time. So that is a really stark contrast.
And then there are other things like women's health, for example, where we know that recently the Biden administration has put a bigger lens on research funding towards those efforts. But historically, women's health has accounted for less than 10% of the NIH total budget, even though women make up around 50% of the population.
So it's a really stark gap and that feeds into a lot of downstream effects. One example that I'll give the members in our audience is we now have more women reaching the age of menopause and being active and working than ever before. yet we know very little about how menopause impacts women. And in fact, we know very little about how hormones impact women.
And we've had to not only spend time unraveling those impacts, hormonal impacts, and how to mitigate the effects of menopause, but we also have had to fight against all of the decades of misinformation regarding those hormones. So those things actually challenge the workforce.
Because if you're in menopause and you want to work and you feel like you still have a lot to give, but you're having symptoms that aren't appropriately treated or diagnosed, that can be a huge impact to your ability to remain in the workforce.
Yeah, a very common thing that we think about in urology, of course, because we deal with sexual health, is how many millions of dollars have been spent and how much research has been done on male sexual function, erectile dysfunction specifically, and other issues with the penis that can go wrong.
And yet the paucity of research that's done on female sexual health and hormones included, to your point, right? So that's sort of a glaring one that we see, you know, in our area of urology for sure. So thanks for bringing that up. So yes, this becomes, you know, of course, this affects individuals.
It becomes then a generational issue, passing on misinformation from one generation to another concerning as your example, hormones, right? Then it becomes a population-based issue.
We hear all the time women going into the emergency room and they're having classic chest pain like an MI, right, a heart attack, and it's not diagnosed in a timely fashion where a man would come in with those same symptoms and the first thing they do is give them aspirin and do the whole routine for an MI, whatever, right? And women don't think about it.
So it becomes then not only a population-based thing, but we can think of it as a global issue too, right? Because this just expands the entire globe, women across the globe and how it impacts their health. So...
There are different ways that women engage with society or different, shall we say, gender schema for women across the world. So the way that women navigate spaces in society. The Americas or in the United States will be very different than how women navigate spaces in Asia or in the Middle East or Africa.
There's different ways that women are perceived and different agencies that they might have in each of these arenas. So these impacts of knowing or not knowing about health can have more or less of an impact societally, but across the board, it is an impact because health is wealth. And so if we are not our healthiest best selves, that really impacts our ability to be income generators.
So that is extremely important. And The way I like to look at gender equity sometimes is looking at it as the ability to be productive and productivity to me doesn't mean making money necessarily. It means that we have limited time on this earth. And are we able to check all or very close to all of the boxes that we strive for in our life? You know, if we
If we seek to be partners, if we seek to have fun, travel, eat, drink, whatever, work, contribute to society, all of those things really depend on our wellness and our health. We have to be healthy in order to obtain those things. And so if there is already a gap in work,
health knowledge for women then you know it's a race that we're already starting from behind so that's why it becomes you know an incredibly important issue and then the other thing i wanted to mention when you made that point was you know how women are diagnosed with certain diseases or or maybe the persistence of symptoms without a diagnosis lasting longer for women
One very important one in urology is bladder cancer, where women present often at a later stage and having suffered from symptoms related to the disease for longer because it gets misdiagnosed and confused for other things like lower urinary tract symptoms or even urinary tract infections. So we don't have to go far into Alzheimer's research or the Women's Health Initiative necessarily.
You know, we look just at our own disease experiences within urology and we can already see those gaps. And there are plenty more. We would need to record several podcasts to go into each one in depth, but they are there.
Yeah, that's a great point and a great example. And I love what you said, health is wealth. And certainly, and we think about that across the globe, we know that, right? And it's so important. Yeah. And as you also said, I love the productivity issue is just being a contributor to society, right? However, whatever role that takes, right? So that's awesome.
Let's look now at what people traditionally think when they think about gender gap. People think about compensation, but what we do is put that into a bucket called professional, right? Gender gap and the different issues that are at play there. So there are a number of assumptions that often get spewed, I would say. Misconceptions are what you like to call myths, right?
about the things that contribute to this gender gap. So I'd love to go over these, our four main myths, and take them one by one. So the first one is a very common one. We hear this all the time, that the reason there's a big gap is because it's a lifestyle choice. The women are choosing to not work as much because they are striving towards this perfect work-personal life balance.
But can you poke holes in that myth, please?
Absolutely. So the first thing I want to say to the audience is give two very important plugs where credit is due. Firstly, with regards to the four common gender and equity myths, there is a really fantastic editorial written in 2022 by one of our own urologists, Dr. Raina Malik, I'll put the PMID. It's 35277290. And she wrote this editorial with a general surgeon.
And they looked at and debunked with data and facts. the four common gender equity myths. And so that I thought that that was a really brilliant way to bring forth these myths in a really, you know, just easy to understand way. You can't imagine how many times I have been asked to speak on gender equity and have people ask me Is there really an inequity? I just don't understand.
Or I don't see it because we pay all of our women doctors the same as we pay men. Or we have the same compensation model for everyone. So why would there be an inequity? Everyone has the same model. within which they can make their salary. And so the first piece of debunking is giving credit. This slide deck and these formats that I have often talked about actually have been published.
There's data surrounding it. They did an excellent job of that. And I think that that is an excellent article for any program director, chair, department head to read, especially if they are aiming to retain or recruit more women into their department. So just wanted to make that plug. And then secondly, when we talk about the knowledge gap that exists for women's health, women's
related to their reproductive organs, because there are gender gaps in many other areas of health, not just in reproductive medicine, is a book that's very fun to read called Vagina Obscura by Rachel Gross. She's a New York Times author, and it's an excellent read, very fun as an audiobook or just reading as a book. So I wanted to recommend those two things.
So when we get back to that myth that you mentioned that women have lower compensation because they choose to work less, it's very important to really look into that. Firstly, very easy, myth debunked, women urologists work the same number of hours as male urologists do. So if we're looking at it with regards to urology, that is a completely historically false assumption.
They do work very similar hours in comparison to men. There are some differences that we can go into a little bit more. For example, women tend to see more non-surgical patients. And there are a lot of different reasons why that is the case.
Women physicians, there was a recent article very excellently written that was published recently that says that women ask more questions and they spend more time listening to their patients. And that's certainly true. For our department, for example, and in the clinic that I have the privilege of administering, I noticed that our female doctors do spend more time with patients.
I don't make any assumptions about quality when I talk about that, but the reality is that they do spend more time. And sometimes there's a complications penalty. So if a woman experiences a severe complication with a patient, that can impact the trust that other women partners may have in resending patients, and it may disproportionately impact women and women of color. So those things are there.
So even if the hours worked are the same, there are those impacts. But I also, again, urology is a microcosm of the world. So a lot of the phenomena that happen worldwide, you see within urology. And I wanted to talk about the compensation gap and women choosing to work less.
So in a working society, there certainly are trends where women gravitate to certain professions at a higher rate than others. And there are a lot of reasons why that occurs and that also contributes to gaps. And I'll explain two reasons why.
So the first thing that happens is that as women are raised, and this has changed as we have grown perhaps more open in the bubble in which we live in the United States to women having different opportunities and and engaging more women in science, technology, engineering, math, or STEM professions.
But the reality is that there are some gender schema or gender stereotypes that women use or that women perceive even from when they are very little. that kind of steer them towards certain professions. So we can see certain really high-quality, valued professions, two of which are education teaching and nursing, for example, where we attract and retain professionals
vast, vast quantities of women in that workforce, far outnumbering the men in those professions. So that is something that's persistent. We have not seen women leaving those professions. They are just as likely to become teachers now as they were, you know, 30 years ago. And those tend to be professions that are frequently outnumbered. Overvalued and undercompensated.
Teaching is a really great example. So there is the reason number two that I wanted to go into. And it is that when a field attracts more and more women into its ranks, especially when it hits a tipping point where women are composing more than 30% of said workforce, wages start to go up at a lower rate.
And as the rate lowers and those wages stop increasing the way that they were when men were mostly in that field, There is a second tipping point where men start to leave the field and then the wages start to stagnate. And we saw that in teaching. Teachers are very undercompensated and as inflation rises, it's more and more of a stark contrast with other professions.
And we see that in medicine as well. One very stark example is obstetrics and gynecology. So obstetrics and gynecology experienced that tipping point a few decades ago and And gynecologists or gynecologic surgeons tend to be the most undercompensated of the surgical specialties. So it is an economic fact. This isn't one of these DEI talking points that
is a complaint without knowledge or without information. This is an economic phenomenon that happens in different professions and it is definitely something we need to keep an eye on because women continue to enter said workforce and there are men in those professions as well.
So we really want to make sure that these highly valuable professions are compensated fairly so that we have enough of those professionals going into the future.
When you spoke about the difference in the pay structure then and how that changes, whether men or women are in the field, there's a great example that we have how certain tasks or procedures are compensated for. In urology, it's the difference between putting in a mesh synthetic sling for stress incontinence in a man and
versus the amount of money you make for putting in a mesh synthetic mid-urethral sling in a woman, which, by the way, was done in women way before it was done in men. And so it was a technique that was refined to fit the male anatomy, I would say, right? So it was in the women's world way before it was in the men's. But the compensation difference between those two are pretty outrageous.
Go ahead and tell us about that.
Yeah, so as urologists, we have a really unique privilege because we kind of straddle, no pun intended, straddle for urologists, but we kind of straddle the domain between taking care of a very niche surgical specialty where we actually see and sometimes perform procedures that are homologous on men and women.
And so we can understand if there are such stark gaps, it has to be some kind of inherent bias behind it. And we're not going to be able to understand what those biases are, what led to those changes, but we know that they're there. We'll give an example. So if you revise or place a male sling, that can generate a work RVU of around 23%. 23 and change.
And then for a woman or a female sling, it would be 11. And so people will say, well, you know, they're completely different procedures. You're putting in more mesh when you're placing it in a man. The TOT type technique with respect to the male sling, you have to anchor it to the bull bar urethra. There's all these other things.
that you have to do, but is it really double the work or double the training that you need to perform those different procedures? And one would say, and I'm someone who, when I see something that I think is inherently incorrect, I try to find out why. And then I also try to see what can I do to change that? How can I shake the table and get this to change? But the reality is this, when a...
campaign is set up to lobby and change work RVUs, what ends up happening is that the RVUs go down across the board. And that is why we haven't really seen advocacy and change towards resetting and including some inherent fairness in how RVUs
work there aren't just gender based differences there's differences across specialties there are some specialties that are historically under compensated and some that are over there are procedures that are egregiously overcompensated but for me to say that and try to elevate other procedures that's not going to happen what's going to happen is that they're all going to be brought down and that makes people really reluctant to campaign for change because people don't want to lower
the relative value units of the work that they perform. So it gets into a tricky situation as far as advocating for change. And I hate presenting data without saying, okay, so what's the solution being a solutions driven person, but I see why it stops there and the advocacy doesn't continue because of that risk that compensation overall will be brought down.
Yeah. So the other thing that you touched on a little bit, but in the same category with respect to what women are able to get during in their working environment compared to the men. And so a big thing that also can affect compensation is number one, you mentioned that they spend more time with their patients, but oftentimes they have less resources provided to them.
I don't know if it's an assumption or thought or aggressiveness on the part of their male colleagues, but just as an example, having more rooms in clinic, right? Or having more support staff or even having administrative assistant that takes care of more of the sort of menial tasks. The assumption is that the women can take care of their own menial tasks or be the one to do
Uncompensated work is their contribution to things in the department, right? Like plan the holiday party, whereas somebody else might be asked to write a paper and that helps them for their promotion. Me planning a holiday party doesn't help for my promotion. So those kinds of things really increase that gender gap as well.
Oh, absolutely. And it starts really early too when people, not just when they're at work advocating or where work is being distributed and a lot of the unproductive or not promotion ready tasks are doled out. A lot of times those end up being doled out to people women, and particularly women of color.
There's also the text on top of that of the burden of mentoring all of the students of color, residents of color, all the DEI activities, etc., So all of those things can tend to happen, but there's even some things that are a little earlier in the process, even when people are out looking for jobs, where there are some myths there too.
For example, a common myth is that women aren't compensated as much because they don't negotiate their salaries. When there's recent, very compelling research that shows that women do actually ask and negotiate a lot for their salaries, but sometimes are denied in ways that men perhaps are not denied. So the idea that women are fearful or that women are not leaning in enough.
I hate that term, by the way, but they're not leaning in enough. to advocate for themselves isn't true. And anecdotally, I've seen that. I've had friends say, hey, I negotiated. And they were like, yeah, this is what you get. And salary is not negotiable. I think that these realities and what is said are very different things. And they continue to impact women across the board. I think
I've been particularly fortunate because I have not experienced that in my own career, but I have had the fortune of having really great mentors who have sort of paved the way for me. But at the same time, I hear, I have friends, I listen. And I can see that across the board, it's still pretty tricky for women to navigate
not having those unproductive tasks or tasks that don't really sponsor them in a way that they can get into leadership roles where the compensation might be better. One more point I would like to make about the pay gap in particular, because I know we have a lot of other things to talk about, but I think people will find incredibly interesting, is that recently,
there have been some conversations and some data about how the wage gap is shrinking. So now the wage gap from 63% has gone up into the 80s. So 80% to the dollar. However, if you stratify wage gap for lower earnings versus higher salaries, the wage gap for higher salaries is still pretty different.
But there has been more pay equity for lower salaries, which I think is a silver lining if anyone deserves to get to pay equity faster. It's women who are working at lower income jobs and working just as much as men do definitely deserve that increase in salary.
But it looks like in professional situations where the range in salaries is a lot more subjective and industry driven, there are still significant gaps.
Yeah. So that's encouraging that things are changing. And I think I wanted to touch on a big piece of this, especially with respect to the compensation issue is really transparency. Right. So if we give any advice, I think, to anybody about getting out there and negotiating for yourself is just ensuring that there's transparency.
You're dealing with an organization or you're dealing with someone who's going to be your boss who's really honestly being transparent because being told we don't do it like that here, everyone has the same compensation model, but then you find out there are lots of little cherries placed on the top that you're not privy to or you don't have that opportunity.
And so that's how the compensation increases, right? Or someone has more resources so they can be more productive. So they are getting bonuses and they look at... the woman and say, well, you're not working hard enough. You're not getting the bonus. Why don't you work harder? Well, I don't have the same resources. I don't have the same number of staff.
I don't have all the residents working with me. I don't have two rooms going at a time. All of those kinds of things. That's the lack of transparency, I think. And so it's super, super important to find yourself whole in a place where everything's really transparent. It should just be on the table.
Oh, for sure. Transparency is one of the, or if not the most important foundation for equity. When an organization is not transparent with its members, there are opportunities for all sorts of shenanigans to happen. So pay transparency is essential. I noticed in my department, for example, we had conversations about how to be transparent just to keep people safe and not disclose too much.
People get nervous about disclosing financials. So we figured out a way to be completely transparent without unraveling people's identity, shall we say. And it was really helpful. And I think one easy way that it's helpful so that it doesn't scare division chairs or leads. I don't think it leads to an uprising amongst your staff if you have a lot of pay variability.
What it led to was more cooperation. I want to talk to the person who is doing really well. What are they doing that I'm not doing? And can I advocate to do the same?
And I think a supportive institution who notices that stark contrast and actually puts resources towards leveling it, as opposed to putting in solutions later that don't really fix root causes, I think will be successful, even if they notice in the beginning that their women or their urologists or surgeons of color are undercompensated.
So figuring that out and using that transparency to implement solutions can be extremely helpful. Yeah.
So I'm going to switch gears here a little bit because we have three more myths to talk about. But this one is really, I think, the compensation one and all of the pieces that come into that are just such a big one. So one, the other myth is the competency issue, right? Right. So we call it the meritocracy myth, right?
So women and their merit, their sense of competency, and are they leadership worthy, right? Go ahead. Let's talk about that.
Wow. Yeah. There's a lot to say about this one too. I'll give you a little anecdote that has always stuck with me because it was such an egregious way for it to be communicated. I remember match day, we'll never forget it, when I matched into urology, told one of the first male medical school classmates that I'd matched. And he's like, of course I knew you were going to match. You're a woman.
Of course they were going to take you. And that really stuck with me because it sort of felt like it didn't matter if I deserved it or not. Just because of my identity, I was going to be rewarded. And I think that's a perception that is very prevalent today. It goes without saying. There's even a urologist amongst our ranks, a senator in North Carolina who I worked
whose name I will not deem to mention, but he has put forward what's called the Educate Act. And that act is aiming to restore fairness in the process of medical school admissions and medical school teaching, implying that the way in which we recruit a more diverse medical school workforce or medical school class is
will result in people being in those ranks who don't necessarily deserve to be there. And that is really harmful myth because it creates the perception that women who are very deserving are perhaps being promoted in ways where they are undeserving. And that is really false. Women take longer to be promoted oftentimes, even if their productivity and scholarly work is equivalent to that of men.
And men are more likely to receive promotion accelerations, which can often be
I was going to just pepper something in there is a lot of times people think, well, women are taking longer to get promoted because they're having babies. But we know there's data to show that is not the case. That's not getting in the way of their promotion. taking off time to have their babies. It's not that at all.
And when you look at very well-qualified women who are going, as you just said, early promotion and going up against some of their male colleagues for early promotion, and they don't get it, but the male does. But the qualifications are there.
Yeah. So there's two important things there that I think we need to say. Number one, is that how on earth are women going to be not promoted or not warranting the promotion because they're out there having babies when we are, as a society, having fewer children than ever before in our history, and women are having children at a later age than ever before,
Fertility preservation and fertility treatment in general has skyrocketed because women are trying to have more babies and are not successful. And particularly for women surgeons, infertility is pervasive. So I think women are delaying having families, which is it is a tragedy for some women who desire motherhood. Others are not interested and more power to them. I think that's excellent as well.
But I don't think that women are out there having children and that's what keeps them from being promoted. That is absolutely false and the data does not support that. And then there's a lot of studies, especially in the business and STEM literature, that that show that when you blind to race and gender, you see a lot more abilities for promotion for women and for employees of color.
And that is a fact. And there's something called the abrasiveness trap as well, where as women go higher in the ranks of leadership and promotion eligibility, their personality and their ability to fit in within that leadership structure becomes very important in their ability to receive or gain that promotion.
And those are things that disproportionately impact women still because of what I mentioned earlier, the gender schema. So gender schema, again, is how we perceive women in society. What do we expect of women and what do we expect of men and how do we think a woman should look and how do we think a man should look differently? And there are potentially some things that are jarring.
For example, if I see a man who is dressed in a skirt or a man that's wearing makeup like that, I will I will notice that, you know, that is not the gender schema that I like. immediately gravitate to. And I enjoy seeing that. I think that is really cool when it happens. But I would be lying if I said that it didn't strike my eye.
I mean, it's striking to see that because it goes against the gender schema that I was raised with. And there is no person in society who doesn't have those things told to them and ingrained in them. And abrasiveness is one of those things. There are expectations of how we expect women to act. And how we expect men to act.
And even though those things are subtly changing over time, there is still an abrasiveness trap for women. And that does also impact their promotion ability.
Gosh, that could be another podcast and probably should all by itself. I mean. So we see this very commonly, of course, we're in a very male-dominated field, urology, right? One of the most male-dominated still today of all of the surgical specialties, right? Has the lowest number of women. And, you know, women traditionally have tried to fit in to a man's world, right?
We certainly try to gravitate away from that to some degree and allow women to feel empowered to be themselves, even if it's extremely feminine and that is who you are and it makes you a great doctor. And the culture needs to embrace that, embrace those differences, as opposed to the women just need to fit in.
But even there are some business characteristics that are very advantageous if someone comes in and can be quite decisive about and can move the needle forward in a quick manner. That's great for business. But when men, women do that, they're oftentimes, you know, perceived as being bossy, or you're too pushy. You need to make sure that you have the consensus in the whole room and get
Kumbaya, have everybody put their arms around each other and feel good about what you're doing. But when a man comes in and is very decisive and says, this is what we're going to do, acknowledges you can't please everybody. I'm going to try to please most, but I'm not going to kumbaya and please everyone. And that's acceptable, right? It becomes really this catch-22.
You want to be effective in what you're doing, but you can't do it in too aggressive manner, right? or you're labeled, and then suddenly all these negative connotations are attached to you as a leader, right? And it becomes really difficult. So that's another hard one. And we just need people to wake up to that, right?
And to understand, and they can see that in the boardroom as an example, and recognize we have a very decisive woman here, giving great advice as opposed to being really pushy.
Yes, that's definitely true. And I think one way that I've seen this mitigated to a degree is that we are trying to understand people's work personalities and how we can coach them to be more effective leaders. So I will tell you full disclosure, when I was a resident, for sure, my work personality was perceived as jarring and sometimes a bit difficult to work with.
And through coaching, I was able to understand how my words and actions and demeanor were being perceived. And That helped me navigate the space. I'm really reluctant to tell people that they have to contort themselves to fit in within the workforce. To a degree, I did have to learn to navigate, but I've been able to find how to keep my work self and my
authentic self from being too misaligned because I think that makes people burn out. And there's data that shows that. So there's some really interesting testing that some leadership courses will have their trainees undergo. I was lucky enough to have one and read the data behind it.
And it was really interesting because when you perform this test, you look at your work personality, decisions, and behaviors that you exhibit at work. and then your authentic self out of work personality. And then it gives you a perception of yourself at work and outside of work. And if they're really discrepant, that is burning you out.
And in the parlance of being underrepresented for a lot of black women or a lot of urologists of color or surgeons of color, sometimes that's called code switching and that can be exhausting and it can be really difficult People of color, particularly black employees, need to code switch a lot because of those penalties that are thrust upon them if they are their authentic selves at work.
But I think those types of leadership testing and looking at everyone defining who their authentic self is and how they are creating their work personality matters. can help you find ways to align it in a degree to maybe mitigate some of the burnout. So I see that as a way forward because it allows everyone to participate and then maybe everyone adapt together.
Because we all have ways in which our authentic personality can affect our work performance, but just recognizing that it disproportionately impacts some groups over others, I think is a path forward.
Yeah, that's a great point. So let's move on to the third myth, the big one. We call it the pipeline issue. You hear this term often. And what's really meant by that, the pipeline issue?
Yeah, so the pipeline issue that's mentioned is that there aren't sufficient applicants or a very common question that I get after I give a lecture on improving workforce diversity and urology, for example, which is a topic that I commonly talk about. Very often someone in the audience gets up and says, you know, we'd love to have a
more women or more people of color in our program or in our department. It's just so difficult to recruit. It's like there aren't enough. There's not enough in the pipeline. And that's just not true. So women have entered medical school and neared parity for many decades. So That is one myth debunker. There are plenty of women that could be potentially recruited into urology.
I think we have seen a tipping point there. I see a lot of women applicants. So I don't know that we are seeing a pipeline issue there. That said, if you go along the pipeline, so follow that timeline between medical school, residency applicants,
finishing residency, board certification, promotion, leadership, chairmanship, presidency, that is where we start to still see people exiting the pipeline. And there have been a lot of studies looking at this. I think it's really important to say that this leaky pipeline affects women and urologists of color, particularly black women, most of all, and the disproportionate targeting of
of Black women trainees. The disproportionate exiting of academic medicine by Black physicians is another really unfortunate and important emergency that needs to be addressed. And there are a lot of factors that impact women there. Perhaps the environment isn't welcoming.
Maybe, for example, speaking back to the compensation structure, maybe the compensation structure that's there is just not built in for women to succeed. And one really important one that we haven't really touched on is the tax if you are pregnant. The tax if you're pregnant, if you go on leave, You know, what happens with your compensation for that time?
When you come back from leave and you choose to breastfeed, are you going to falter in your productivity because you need to take time to pump? And that takes away from the time that you need to see more patients. So a lot of employers are understanding that as being incredibly important and are trying to put some fixes in. Oh, let's give some RVUs, some breastfeeding RVUs, accommodations.
Let's figure out a comp plan for maternity leave, etc. The problem with those fixes is that they really only work at a departmental or institutional level. And there isn't like a widespread policy. So you may be in a really supportive environment. I have been in those supportive environments myself. Again, I consider myself a very fortunate person.
But I have seen that the wide and vast majority of locations don't have those accommodations and they don't take those things into consideration, especially if the woman is the only. So if there are no other women in that department, that can be incredibly and disproportionately impacting for that female physician.
And their partners may not want to change a comp plan to accommodate maternity leave or breastfeeding. So that is what affects the pipeline. It's not a numbers issue. There are plenty of deserving, really kick-ass women that we could recruit and retain into our field. that we do not because of that. And then the other promotions myth up top, two things that happen there.
One is that because people enter these leadership roles and then they don't leave them until they have to be like escorted out in a walker, there isn't opportunity for the women or the young women that are rising. Again, not my experience or even young voices at all.
Right. With that example, whether it's male or female, you know, in academia, yeah, there are people that seem to stay in these positions for so long. And if you're going to change a culture and bring it up to date, you have to do it from within.
So, and I want to bring up two things, again, not something that perhaps at its inception was intended to keep women or people of color out, but certainly does is for example, the way that leadership is selected within our own organization, within the American Urological Association.
Many times when I've talked about diversifying the leadership in the AUA, I've been told and I've learned across the years that leadership rises through the sections. We've all heard this. Section leadership is essential for rising towards leadership at the AUA national level. What happens is you have to accrue time. It's like getting a transplant, right?
If you haven't accrued time on committees, on the boards, on Western section presidency or North Central section presidency, et cetera, then you don't have the opportunity to rise to the upper echelons of leadership. And I want to recognize that there is one important reason why that exists, and it's to reward people who have put in the time and the effort.
Being in these societies takes a lot of work. And it's mostly uncompensated. And I totally recognize that. But at the same time, we are urologists because we love to evolve and innovate.
And if we notice that the leadership structure is disproportionately keeping people out of it because of how long you have to accrue time, then that can be an area of maybe changing a mindset and being a little more inclusive. You and I work together, for example, on the Sufu diversification. And the conversation was about that, right?
How do we reward people and diversify by rewarding and including younger individuals who may have a lot to offer? And we may not be seeing a lot of them in panels or in committees, etc. How can we make that more inclusive. And I think that those are potential solutions.
But when leadership rises because someone has to leave for you to be able to come in, when there are no term limits, for example, or when the leadership process itself involves accruing a lot of time, then obviously you're going to get older men, typically older white men, occupying those positions because they're the ones that have been in the space the longest.
And it will take some time for those men to exit and for a more diverse workforce to enter.
Yeah, that's really a great point, right? So we know that there's the stepping stones that have to happen, but who made those rules?
And it's so interesting. The old guard leadership. And they have the power to change them. So it's so incredible. Similarly, we go back to the RVU change, right? Why doesn't it change? It's an inconvenience to change it. Why doesn't this change? It's an inconvenience to change, but they do have the power.
They are not powerless in all situations, but it will require more conversations about that value. And hopefully conversations like this one will illustrate the immense value that it has in doing that for people that are very deserving and put in the work.
A big thing that you were talking about, you put it on the list of things, but I just want to go back and touch a little bit more about this because I think it really needs to be emphasized is the difference between changing a culture so that people feel that they are included, and they feel like they're part of that whole process, as opposed to the word we use is tokenism, right?
I have a very diverse department, says the head of the department. Look at my picture. It looks like a picture out of the colors of Pendleton, right? But do all those people feel like they truly belong and their voices are all heard? That's such an important thing. What can we do to really ensure
that you've hired these people, all of these different types of people, and how does everybody feel engaged?
Yeah, tokenism, I say, is something that is hidden in the umbrella of virtue signaling. So virtue signaling and tokenism are things that are done in a perfunctory or symbolic manner to show that you are championing diversity and
or that you were supportive of women or supportive of people of color without really doing the uncomfortable work of actually making the workplace inclusive and supportive of every single one of the people within it. So medicine, academic medicine, most corporate America, was built in an era when predominantly white men were in said workforce.
So it's going to be built on foundations that are promoting and supporting men. And that's smart. If it's all men in the workforce, by all means, make sure that those foundations support men as the workforce shifts. And by the way, in every single moment in time,
Since the history of time began, since we were hunters and gatherers, whenever women put their kids on their back and go work in the fields, that is great for society. Women have worked historically. Whenever that has happened across history, that has been positive for wages. It's been great for society. And it's led to a better distribution of work and family overall for everyone.
And a lot of men will tell me that they're like, when we've started championing for women in the workplace, I've noticed that I've felt more comfortable going on my paternity leave. You know, there are benefits to men as well when these... structures or foundations that favor men are questioned and sometimes toppled.
So that can sometimes be uncomfortable because, for example, sometimes compensation has to be discussed and changed. The way that we compensate has to be discussed and changed. Sometimes term limits have to be placed on how long people can occupy positions of leadership to give opportunity to other rising stars.
Sometimes a discussion about what is valuable, what is a valuable contribution at work also has to be discussed. For example, taking a little bit of compensation, a percentage of everyone's productivity and giving points to people who do tasks that are typically uncompensated and redistributing some of that to reward people for doing the work themselves. that typically goes unpaid.
And a lot of that is education, team building, wellness, a lot of things that are so essential for departments to thrive. Mentoring underrepresented students, for example. A lot of my colleagues, I receive a stipend for that. A lot of my colleagues do that work for free. One example in Urology Unbound, for example, Chanel Wilson, who's the CEO and founder of Urology Unbound,
has created such an excellent pipeline program and is doing that literally like bill gates from garage right from her own office it it should be the you know premier pipeline program of the aua but yet it's coming from her. And a lot of my colleagues do that.
They do a lot of this work within their departments and it's not compensated, but there's an easy way to say, hey, let's give people agency and decide amongst us that we value this and let's put that forward and compensate people for these things.
And by and large, I think departments are more and more open to that if that transparency and discussion takes place, but sometimes it just doesn't and things don't change. And then the other thing that I think is very powerful is involving people, especially your underrepresented or your tokens. Oh, I hate that word. Involve them in your compensation committee.
Involve them in the decision making that takes place. Make sure their voice is heard. And if there are very significant barriers to their being included or their being supported at work, make sure as their leader, this is more for leadership, make sure as their leader that those barriers are leveled in some way so that they can continue to be successful. Yeah, those are really great points.
So, and the last myth is that one we've already sort of touched on and talked about a bit, but just to say the last myth is the issue about diversity, having a diverse environment versus an excellent one. Are diverse candidates as qualified, right? Or are we just choosing diverse candidates because we need to feel we need to have a diverse environment?
And I think we've talked quite a bit about that already. I don't know if you have other things that To add, we talked about the inclusion. Workforces are much more productive, are happier workforces. So inclusion does matter. And it hits the bottom line, the bottom dollar line, too, in different businesses and organizations. And so we know that to be the case.
Oh, absolutely. Diverse teams publish more. They publish in higher impact journals. There's a lot of cross-pollination that takes place in a lot of perspectives. For example, my area of expertise is increasing and improving care delivery to marginalized groups. And for sure, recruiting person of color in my example, you know, I am a native Spanish speaker.
Of course, it's going to be easier for me to take care of a predominantly Spanish speaking population. And it's not even I didn't even I mean, I put in the work when I was 18. one year old to learn Spanish, but that was it, right? There's nothing more about it. My background brings this wealth of information, this lived experience, a language, and all of that adds inherent value.
And that is on top of the other things that we bring to the table. So no question about it. It's a great investment. Diversifying is an excellent investment and it does not lead to underperformance at all.
One area that people will say because I've been in these discussions is, oh, in the corporate literature, as they've started to give women and men more opportunities for parental leave, when these individuals come back to work, there's a real lag before they get to productivity again. And that's such a short-sighted way of looking at the benefits of leave.
You're not going to see the benefits of leave within the first six months of someone coming back from parental leave. The way that you'll see it is the downstream effect of who you get to recruit because that person was able to take that on, and also loyalty and performance across time. So someone who works in a supportive environment where they
had the opportunity to have their parental leave, had the opportunity to come back, set their schedule, have their relative work-life balance, because that also doesn't exist in all forms, but have their agency to come back and get back into the groove of work on their terms ultimately will be
a better employee, a more mindful employee, and perhaps an employee who not only gives you loyalty by staying in your institution, but even when they exit the institution for another opportunity, that will be a positive for your institution that that was supported.
And let's not talk about the fact that this person has added on, you know, one more, hopefully future productive member of society who will contribute to Medicare or who will contribute to a lot of other social programs, who will pay taxes. So there's a lot of ways of looking at the benefits of diversification.
And that's one argument that people are less productive in those first few months and that there's a ramp up period I think is very short-sighted. Yeah, absolutely.
We want to wrap this up here at this point, but I want to give an opportunity to just sort of look at it overall. We talked about a number of myths that contribute to what we call the gender gap, right, with this discrepancy between men and women in the workforce and certainly in medicine and urology. A couple of big ideas is that issue of transparency is really paramount. That's so important.
The issue of having a diverse workforce, but then making sure that diverse workforce feels included in all the processes that are going on, right? That it really is almost a big family. And that's how you keep people happy. And that's how people then remain productive.
And I think one of the other things that you had talked about too was, you know, if you're the leader in that organization and you're not very diverse in your organization or you're losing people, you talked about the leaky pipeline, which is so important. You recruit people, they're not successful. You let them go. You say, well, they weren't successful because they weren't really qualified.
We hired them because they were, you know, either a Latina or they were a woman or they were whatever it was, right? Turn the lens back on yourself and say, what's going on in my organization that's not allowing us to be having a successful, diverse workforce, right? Looking back at the biases with your own organization.
So maybe you can speak a little bit more to that, put that in more profound terms than I did.
I thought that was great. I thought that was a great summary. I agree with what you said. I think that, look, there are a lot of ways to recruit and retain people. talented individuals, talented women, talented people of color. And the best way to recruit and retain them is to ask them what they need to stay in a role. Check-in frequently, check-ins are so important.
when people get recruited, after they're recruited, and recognize, especially if someone is in the minority in the department, recognize that there are going to be some things that are inherently inequitable in that situation, and that you want to be the first to know from them what those things are and you want to spitball solutions together.
I think that the mentors that I've had have never made me think that these things don't exist. They've actively recognized that there are certain barriers and that they're going to be tricky. But we've had conversations about how to improve those things, and they've listened to me and have been transparent. And that has been a humongous benefit. And so if you want to recruit, you've got to listen
And you have to act based on what you're told. And you have to advocate for that change that the person is telling you is necessary. Or they're going to let you know, you know, they'll walk to another opportunity if that one is not supportive enough.
And I think that's a really important kind of call to action for any leaders, including women, who become leaders so they don't become agents of women's own demise.
I wanted to add to that really quickly as I know the firsthand experiences of so many women talking about the leaky pipeline who didn't get regular check-ins and they were so miserable or whatever the situation was that by the time somebody checked in with them, they'd already found another opportunity. They had one foot out the door. They get excited about that. moving on.
And it's really hard to pull somebody back once they have a foot out the door. And so that organization lost that opportunity to retain that very highly qualified person because they didn't check in enough and stop the train before it hit the station, so to speak.
And it's a big investment for companies, organizations to recruit somebody new. And I will tell you across academia, and that's kind of where I navigate. So that's my bias in this talk, you know, that I belong to an academic institution. There are a lot of other barriers that are experienced by people in other industries and in other types of work.
But I'll tell you that in academia, a lot of junior women faculty will leave after a few years. And if you think that it is a frustration to have someone come back from parental leave and need to have a bit of a ramp up period, if you have to consistently recruit for a role every few years because you cannot retain someone in said role to be able to perform work,
Patients will suffer, your institution will suffer, and you're going to lose a lot of productivity as far as patient care is concerned and healthcare delivery because you've not been able for whatever many years to recruit someone and retain them because there were specific issues that had you asked and acted and advocated, you would have been able to mitigate.
Yeah. And what is it? Two to three years is the average ramp up period before a junior faculty, somebody new gets to their productivity level where they're sort of on automatic pilot and they can do their thing. Right. So that's a huge cost right there. And I will say I've I've navigated both arenas, the academic arena as well as a private practice arena.
I have a lot of friends in private practice as well as I'm sure I know you do, too. But that idea of an all-male group wanting to have a woman come into their group because they know they need it to be competitive in that community and they hire a woman and then that woman's really not supported, right? And then that woman ends up leaving after a few years.
She has her two to three year guarantee on which then she has to go on a productivity model and she's like, I'm not happy. and then she leaves and you have to start all over again. So I think you said that, and it's really important.
Those regular check-ins, I mean, it should be for any new hire, no matter what your gender is or your race or ethnicity, but that's a part of really having an inclusive environment where people feel they're part of that process and they're being checked in on, right, and considered. So it's really important.
Leaders have check-ins built in. I mean, your admin coordinator is going to have you check in with every single one of your faculty. But that's the thing. The check-in has to be genuine and authentic to that specific person.
And again, because those structures are not built for that person, they were built for men, you have to listen to whatever problems are articulated, even if they are uncomfortable problems. that require you to be uncomfortable and change something. That's where the check-in really happens. Or is the person checking in with you every quarter and telling you things, but there is no change?
That's frustrating. So it's not just having the check-in. It's also listening and informing the person physically
through feedback that you have listened and you understand the problem so the validation is important but then the action has to happen as well so validation is great when you leave after meeting with your boss i've had this meeting many times and and i'm validated in my concerns that is so trust building in your leader but that the change has to happen as well so validation excellent change
even better, and then advocacy so that that continues to change across the institution. And some leaders do it, and I'm so proud of those of you that do. Some of my closest are just like that. And others don't. Others stop when it gets uncomfortable, and then they go on to their next faculty that may be easier to nurture because there are fewer barriers. And that's the big gap there.
And if leaders are attentive to that, they can have successful recruitment and retention.
Look, thank you. We need to wrap this up at this point. I could talk about this all day with you, but I think, you know, you brought home some great points and great advice, not only for the individual, the women, the men, underrepresented minorities, but also some really great points for those leaders out there, how they can develop a good diverse culture and foster it, right?
And nurture it is the word you use. That's really great. So Thank you so much, Dr. Javier. Santiago Lastra from the University of California, San Diego. You can see why we had her as a guest on here. She's an absolute expert in this area and very, very entertaining podcast here today. So thanks so much.
Thank you so much for having me.
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