Fighting the 'other pandemic' - systemic racism in urology.

“I wear scrubs hoping that they’ll serve as a reminder, just enough to give pause, forcing those who would judge or harm me because of my skin color to reconsider”.

These are the words of current fourth-year Urology resident Dr Arturo Holmes II at SUNY Downstate, published in a Perspective article in the Washington Post[1]. These words demonstrate the pervasive nature of racism, highlighting that even when you strive for excellence and willingly make sacrifices to care for patients, especially during the current COVID-19 pandemic, many individuals will view you as ‘less than’ simply because of your skin colour. Although this form of interpersonal racism is alarming, systemic racism is also a pandemic, and one that often gets overlooked.

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We are in the midst of an enormous public health crisis. This crisis, systemic racism, existed well before any mask-wearing mandates. It permeates all sectors of our society, and it results in current Black urology residents like Dr Holmes feeling the need to wear scrubs outside the hospital to reduce their risk of becoming a victim of violence owing to the colour of their skin. The recent killings of unarmed Black citizens, combined with the disproportionate number of COVID-related deaths in the Black community[2], have brought national and international attention to systemic racism, and medicine has not been immune to this other pandemic.

Systemic racism affects our patients’ treatments and outcomes, both overtly and subtly. In medicine, the effect of systemic racism is perhaps most blatantly exemplified by the Tuskegee experiments, in which syphilis treatment was intentionally withheld from Black men for over 40 years[3]. Studies have shown the more insidious effects of racial discrimination, such as chronically high cortisol levels in individuals experiencing weekly discrimination and, conversely, reductions in diabetes and major depression rates when Black individuals move to more affluent and safer neighborhoods[4]. If these examples are not alarming enough, Greenwood and colleagues[5] showed that Black infants have threefold higher mortality when cared for by a white physician than those cared for by a Black physician.

These are just a few examples of the ways systemic racism affects our profession, and they emphasize the importance of diversity in medicine and in urology. According to the 2019 AUA Census, only 246 of >12,000 practising urologists in the USA are Black, representing just 2% of our current workforce[6]. Furthermore, AUA Match statistics report rates of males versus females matching into urology but do not include information about under-represented minorities. Considered together, these data — and lack of data — demonstrate that this pandemic has gone overlooked for too long. Perhaps equally striking, these data show that we have not begun to acknowledge the spillover of systemic racism in the field of urology. We must recognize and accept both the historical and current impact of systemic racism in urology while attracting and promoting diversity among our workforce[7].

Improving diversity within urology for the benefit of our specialty and, more importantly, for our patients, is within our power and is our responsibility. This responsibility starts with the individual urologist but extends to our sub-specialty societies and governing bodies such as the AUA. When students reach out to us for mentorship, we need to be mindful of unconscious biases. These biases exist and, without acknowledgement, will continue to permeate our actions. Research shows that discrimination can start when we read an individual’s name. One such example is shown in a study that submitted identical resumes to job openings with white-sounding and black-sounding names. Resumes with white-sounding names were 50% more likely to receive callbacks than those resumes with Black-sounding names[8].

they are mistakenly identified as janitors or spoken down to by their own patients

Furthermore, we must recognize that our minority students and residents experience incidents of racial bias every day, whether they are mistakenly identified as janitors or spoken down to by their own patients. Often subtle, these racial discriminations can accelerate burnout, and every one of us should work to intervene[9]. Recognition that this problem exists is simply not enough.

In this regard, strategies to fight this other pandemic should be implemented by all of us within the field of urology. Medical student outreach remains crucial and should include the coordination of teaching and networking events with groups such as the Student National Medical Association, an organization committed to supporting current and future under-represented minority medical students. We must encourage and support diversity scholarships to attract minority students to visiting sub-internships and pay special attention to recruitment efforts at Historically Black Colleges and Universities (HBCUs) as none of the six HBCU Medical Schools has accredited urology training programmes. Additionally, residency programme leadership must engage in careful application reviews and avoid using single thresholds like USMLE STEP 1 scores to triage applicants. This screening process may unintentionally perpetuate the problem, as research shows that multiple historical inequities have led to substantial gaps in standardized testing scores between races[10]. Moreover, programmes must purposefully educate faculty and trainees on racial and ethnic disparities through frequent activities such as grand-rounds and journal clubs and must work to fight against racism in people’s everyday behaviours. Finally, the major organizations and associations within urology should aim to improve diversity and inclusion within their governing officer positions and the honours bestowed upon its members.

how much change are we willing to make to fight this other pandemic

With COVID-19, we have drastically altered how we live and practise medicine to limit the spread of infection to our patients, colleagues and families. But how much change are we willing to make to fight this other pandemic and combat the spread of systemic racism in urology? Collectively, let us pledge to value and improve diversity in urology as we strive to better our profession and society at large.