Leadership and Speaker Diversity in the Endourological Society: A Retrospective Study 2017–2019 and 2023

Introduction

The foundation of any highly functioning organization is a commitment to diversity and inclusivity. There is a robust body of evidence that confirms that the greater the diversity present in a group, the more effective that group will be. ^1,2

The Endourological Society assessed its diversity and inclusivity by means of a task force convened by the executive committee of the board of directors. This Diversity and Inclusivity (D&I) Task Force, established 2021, was charged with performing an assessment of the Society’s present state with regard to diversity and inclusivity and with providing recommendations for future efforts in these domains. The goal of the task force was to provide a roadmap to achieve diversity and equity within the Endourological Society.

Given the global nature of the Endourological Society, the task force noted that the Society had some natural baseline diversity. ³ In particular, the Society has a robust track record of international diversity in its membership. ⁴ The task force understood that promoting inclusion will improve the status for those segments of our Society that have been historically underrepresented. Therefore, rather than a cursory exercise, it was imperative that this endeavor was explicit, honest, direct, and transparent when performing this critical self-examination. ⁵

In embarking on this mission, the task force used working definitions of the terms of diversity, equity, and inclusion (DEI). We defined diversity as a representation of distinct individuals within a community. It implies an array of differences, including, but not limited to, subspecialty interests within the society, gender, nationality, age, ethnicity, race, religion, disability, and socioeconomic status. Equity was defined as the ability to recognize and systematically address a set of circumstances and unique barriers that impede the full participation of any subset of our members. The goal of equity is to create a set of conditions that enable everyone to have a fair and just opportunity to participate. Equity requires consciously and actively mitigating conditions that deleteriously affect the participation of individual groups. Finally, inclusion involves adopting a set of cultures or values that engender a feeling in members that they belong. At its core, inclusion is the act of empowering and affording opportunity to those who are traditionally overlooked for key positions of authority and decision-making capacity. ²

If members feel unrepresented at key events, they may conclude that equity is not a priority among key stakeholders in the Society, and initiatives aimed at creating diverse and inclusive spaces may be imperiled. Without an honest self-examination, the Society risks being perceived as insular and irrelevant, and dooms the Society to obsolescence. ³ Herein, we aimed to determine ways to measure and define the DEI of the Society in recent years preceding the establishment of the D&I Task Force. We subsequently reevaluated the status several years after establishing the DEI committee.

Methods

The D&I Task Force initially reviewed speakers and faculty on annual Society programming, 2017–2019, as well as the Society’s leadership. The conference programs for three consecutive World Congress of Endourology and Technology (WCET) meetings Vancouver, Canada 2017, Paris, France 2018, and Abu Dhabi, UAE 2019 were downloaded from the meeting websites, and the names of all the faculty participating as plenary speakers or course faculty were recorded for each meeting. The names of faculty moderating poster sessions or presenting only in poster/podium research sessions were not recorded. For all faculty members country of employment/academic appointment and gender were assessed. For faculty members not personally known to the authors, gender was determined by searching the speaker’s departmental website, which in all cases had biographies of each faculty member in which male or female pronouns were used. We thus assumed that the pronouns used on a faculty member’s website reflect the speaker’s self-identity. Finally, for each course or plenary session faculty members participated in, a broad topic category was assigned: stones/endoscopy, laparoscopy/robotics, focal therapy, benign prostatic hyperplasia (BPH), or other/miscellaneous. Some faculty participated in more than one plenary session and/or course and each was counted individually.

Ethnicity and race could not be determined as these characteristics are self-identified and were not recorded in the sources available for review (i.e., the Endourological Society profiles, individual faculty departmental biographies, or WCET program websites). This process was then repeated by the DEI committee for WCET 2023 that was planned to be in Jerusalem, Israel.

In addition, the Endourological Society website was queried in February 2021 and 2023 for similar gender and geographic origin of past and present executive board members, working committee chairs and members, award recipients, as well as the WCET meeting site chairs for the 2017–2019 and 2023 meetings.

Results

The national origin of current academic appointment and gender pronouns could be determined for all Endourological Society board members, committee participants, and award recipients, as well as the WCET meeting faculty, except for the 2023 meeting where 17 people, no English language faculty website could be found, and cancelation of the conference resulted in the authors not meeting the speakers in person to learn their pronouns. It was noted that this information is not maintained by the Society in an easily accessible database and had to be obtained through extensive internet searches. There was in all areas a domination of males, predominantly North American males.

Discussion

There is a preponderance of evidence that diversity is beneficial to an organization’s success. The desire for and the opportunity to achieve diverse representation in the Endourological Society seem particularly appropriate, given its founding by a group of urologists from different countries, seeking to share ideas and in the words of Arthur Smith, “promote and maintain international participation at the grassroots and organizational level.” ⁶

While this has continued to be the identity of the Society over the years, there has been increasing acknowledgment that the leadership, committee participation, and annual meeting faculty involvement have been less representative of the membership than hoped. The D&I Task Force was initially developed in response to a growing understanding that proactive engagement of all stakeholders would be required to improve the diversity of representation at all levels of the Society while ensuring the actions of the Endourological Society advanced the tenets of equity and inclusion in our membership and our approach to patient care.

Diversity is not equal to inclusivity and the disconnection between diversity and inclusivity is not unique to the Endourological Society. Although the number of females in urology has risen over the last several decades (8), the percentage of female faculty has not risen commensurately at international urology meetings. ^{7 –9} The sole international urology meeting with a more balanced gender representation was the International Continence Society, ⁷ which also reflects the fact that female urologists tend to be more likely represented in the subspecialty of female urology than in other subspecialties. ¹⁰ The low number of females receiving awards from the Endourological Society is also in line with other urological associations. ¹¹ Women are significantly less published in high-impact factor journals than males. And again, women are more likely to be represented in journals publishing on female urology. ¹² There are also studies proving that women are more likely to be published when the review procedures are double-blinded. ^11,12 Fewer females are also represented on committees and boards. ¹³ This global underrepresentation is consistent with the task force’s findings for the Endourological Society leadership numbers and annual meeting faculty participation.

In the present study, we found that leadership and annual meeting faculty opportunities were often extended to the same individuals repeatedly and that these individuals represented only a small number of countries. The Endourological Society is truly international with members across the globe, providing a unique resource that could be tapped for both meetings and Society goals. The renewed aim of the leadership is to ensure that active and extensive participation will be facilitated for urologists from all countries represented in our membership.

One of the first challenges the D&I committee encountered was finding that data concerning its members’ gender, ethnicity, race, and country of urologic practice were not available. While we were able to gather data on pronoun use and practice location from public institutional websites, this was time-consuming and may lack accuracy. Furthermore, self-identified ethnicity and race are not captured in these sources. A parallel effort of the task force was being undertaken by the Society’s data committee to perform a membership census in order to better document the size of the association as well as demographics, including sex, age, race, ethnicity, location, and clinical focus of the members. The census is now occurring annually. There is precedence for collecting such information from physicians with the National Institutes of Health funding program capturing these data and making the results publicly available on its website. We recognize that identifying areas where the Society may have fallen short with respect to representation can only be accomplished if we have a real sense of the makeup of the membership. Similarly, without knowing the exact makeup it is hard to know what benchmark to aim for in terms of leadership and faculty representation.

In a brilliant article by Kang and Kaplan, ¹⁴ it was stated that without specific behavioral guidelines to inform practice, diversity and inclusion are often unable to advance beyond attitude and goals. To move from abstract plans to action, organizations must clearly lay out specific steps that will be taken to reach the goals and to set up methods for assessments of success. Accordingly, based on the findings in our present study, the working group developed a series of recommendations to the board who subsequently established a DEI committee charged with accomplishing the goals set by the working group. Key recommendations were to ensure inclusivity as a core value of the Endourological Society as programming is created, as leadership opportunities are offered, and as it manages its public-facing presence. Starting at the WCET in 2022, a plenary session on DEI was added to the meeting program. Also, the gender balance improved in the program for WCET 2023 as well as in committees when compared with previous years. The Society launched a speaker database where members can sign up if interested in participating in the meetings. In 2022, the DEI committee additionally initiated quarterly DEI live webinar series with recordings available on the website under education to both members and nonmembers. However, one must never believe that the work is completed. To keep DEI alive is an active process.

The DEI committee will work with other committees within the Society leadership to increase support of the intellectual contributions, collaborations, and educational efforts of our members globally so that the work of the Society incorporates the input of and is relevant to the practice of all its members. The committee has recommended active recruitment of members with a focus on increasing the number of women and persons of varied ethnic and regional backgrounds. In 2023, the DEI committee recommended increased transparency with the Society’s committee selection process, and, with the support of the board, transitioned to a formal application process with an open call to the public with available positions. Such demographic diversity will help to inform conversations and educational programs where a wider variety of effective practice patterns will now be given exposure. We intend also to support early- and midcareer endourologists and minimally invasive surgeons getting involved in leadership, committees, and the annual meeting, as a means of expanding the reach and relevance of the society. The Society also launched a new mentorship program that pairs junior and senior faculty. Furthermore, to tackle the pipeline challenge, the Society has been able to obtain multiple fellowship scholarship grants to support underrepresented minorities and/or women recruited as fellows at North and South American programs.

Finally, we recognize the importance of supporting collaborations between our Society and others as we work to champion equity and inclusion as well as diversity in all its aspects.

It is hoped that through the efforts of the task force and DEI committee, the Endourological Society will continue to be an attractive organization for potential members to become a part of and become an even more dynamic environment that continues to further the disciplines of minimally invasive urologic surgery. ¹⁵