By AMY E. KRAMBECK, MD
With the exceptions of pediatrics and obstetrics/gynecology, women make up fewer than half of all medical specialists. Representation is lowest in orthopedics (8%), followed by my own specialty, urology (12%). I can testify that the numbers are changing in urology – women are up from just 8% in 2015, and the breakdown in our residency program here at Indiana University is now about 20% of the 5-year program.
One reason for the increase is likely the growth of women in medicine – 60% of doctors under 35 are women, as are more than half of medical school enrollees. I also credit a generational shift in attitudes. The female residents I work with do not anticipate hostility from men in the profession and they expect male patients to give them a fair shake. They may be right – their male contemporaries are more egalitarian than mine – but challenges still exist in our field.
Urologists see both men and women, but the majority of patients are male. Urology focuses on many conditions that only affect men such as enlarged prostate, prostate cancer, and penile cancer. Furthermore, stone disease is more common in men, as are many urologic cancers such as bladder cancer and kidney cancer. So the greatest challenge for young women in urology is to gain acceptance among older men who require examination of their genital region and often need surgery. I’m hopeful that women entering urology today can meet that challenge, largely because we have already made significant progress. For the barriers we still face, leading urologists have blazed a clear path to follow with these three guideposts.
1. Nix the Checkboxes
Any patient might be biased against a certain group of people and not want its members involved in their medical care. Bias aside, some patients have other reasons for preferring certain doctors (prior sexual assault, religious beliefs, etc.). But the only bias or preference we actually solicit on our intake forms is gender, when we ask patients to check if they want a male doctor, female doctor, or have “no preference.”
It’s time to remove that question. The small percentage of patients who have a preference based on religion or past trauma can still make their desires known, but there is no reason to ask every single patient to select the gender of their doctor. The results are discriminatory for both women and men in medicine. In urology, while some men prefer male urologists, research shows female patients prefer female urologists. There’s no reason for our society to support that discrimination.
To be clear, checking a box arbitrarily can have negative consequences for patients, as well as physicians. If we asked patients whether they want the surgeon who gets the best outcomes or one whose outcomes are so-so, they would choose the best every time. But a doctor’s gender is not tied to qualifications. By checking a box to rule out one gender, patients also can blindly rule out the most qualified physician for their needs. That isn’t fair to our patients.
2. Become an Expert
Amy Guise, MD, an urologist at Froedtert Hospital and the Medical College of Wisconsin, has a busy referral practice with a 2 to 3 month waiting list. She treats patients with erectile dysfunction or prostate enlargement, most of whom are referred directly because she is a rare surgeon who offers the most advanced, least invasive procedures.
“I’m happy to see the drastic shift in women joining urology in the last decade,” Guise says. “Still, within medicine as well as among the public, obviously attitudes have not changed completely. Even patients who might prefer a male doctor come to me because of the level of care I deliver. It’s pretty common to hear, ‘I didn’t know what to think about this, but you know what you’re talking about, and you made me feel comfortable.’”
Asked how other women in the profession could attract patients as she has done, Guise offers this advice: “Do better than everyone else. Show your competence and confidence. Establish yourself as an expert and let the quality of care speak for itself.”
Like Dr. Guise, I’ve built a career on my enthusiasm for meeting surgical challenges, and that has set me apart. I spent my residency and seven years of practice at the Mayo Clinic, where I was able to do research, and I’ve published over 200 manuscripts or book chapters. I helped write the AUA guidelines for the surgical management of stone disease and revise the guidelines for the medical management of stone disease.
Now my high-volume, specialized practice is focused on two things: 1) advanced percutaneous removal of large and complex kidney stones and 2) holmium laser enucleation of the prostate (HoLEP) using Lumenis’ MOSES Technology. Few surgeons have performed thousands of these procedures as I have, facing virtually every possible situation and challenge. What’s more, my colleagues and I have done innovative work to turn HoLEP into a minimally invasive procedure where patients can go home the same day and in some cases even leave without a urinary catheter. This improvement in care helped to earn the Indiana University Health Physician Quality Award in 2019.
The result: The vast majority of my patients are referred by outside urologists or find me online because they’re searching for HoLEP. Patients who want my rare experience and results choose me, even if they have some reservations about seeing a female urologist.
3. Sing Your Own Praises
As you’ve read, I’m comfortable listing my accomplishments, but that was not always the case. I was raised to be very modest and humble, and I carried that outlook into my career in medicine. I wanted to talk to my patients about their problems, not about myself. But then reality set in. Patients made comments like, “I really don’t want to talk about this with a woman” or “You’re too young/pretty to do this.” Patients called me by my first name or assumed I was a nurse, despite the “MD” on my jacket.
I realized I needed to overcome not only their discomfort, but also their preconceived ideas of expertise and authority. And the only way to do that has been to comfortably boast. Research shows that although some men prefer a male urologist, they place higher importance on professional skills, clinical experience and medical knowledge – all things women offer as well. Many patients value good listening skills, at which female physicians outperform their male counterparts.
I listen to patients concerns, and then I explain to them that they are in good hands. For example, for a patient who needs surgical treatment of an enlarged prostate, I say, “I’ve done 3,000 HoLEP procedures, and I was the first surgeon in the world to perform HoLEP with MOSES Technology. I’m one of the best people in the world to perform this surgery for you, and you will be satisfied when we are done.” That conversation works very well, but it has taken a long time for me to perfect it and feel comfortable “boasting.” Now it just takes a few minutes, and then we can move past the gender barrier and focus on the patient.
My online profiles list all the same accomplishments, so patients who research me in advance are already comfortable when we meet. In my experience, younger patients are also less likely to object to a having a female urologist or question my abilities. All the same challenges still exist for women in male-dominated specialties, but we’re certainly benefiting from society’s evolution toward equality as well as the reputations we’ve been building for excellence in our fields. With every generation, the adversity women must overcome in the workplace is less, but I do not foresee it disappearing any time soon. Women must continue to build upon their inherent strengths of grace, dignity, kindness, and hard-earned talent to not only help themselves excel in their careers, but also to smooth out the path for those women who will follow behind them.
Amy E. Krambeck, MD, is the Michael O. Koch Professor of Urology at Indiana University School of Medicine in Indianapolis.
