Since 1992 most medical graduates have been female . Working practices and career choices are known to differ by gender with significantly more females working part-time and only a minority working in surgery . Consequently, concerns have been raised that this influx of females might unbalance the medical workforce and in 2004 Professor Carol Black, then President of the Royal College of Physicians, went as far as commenting that this gender shift might ‘harm medicine’ . The potential challenges for workforce planning in an increasingly female-dominated medical community have been a constant topic for debate and speculation in recent decades. Although females remain a minority in surgical specialities, the proportion of female surgeons is increasing. We explore the probable influence of changes in gender demographics on workforce planning for urology in the UK and the wider world.
Predicting the Gender Make-up of the Future UK Urology Workforce
In 2011, 7.0% of consultant urologists were female, compared with 2.8% in 1992 . Furthermore, the proportion of female urology trainees is higher still, suggesting that even more urologists will be female in the future. In 2011, 24.3% of urology registrars (residents) and 47.8% of senior house officers (interns) in the UK were female . If the proportion of female urology consultants continues to increase at the rate sustained since 1992 (0.26% annually), then 10.9% of UK urologists will be female in 15 years . However, if the proportion of female urology consultants increases at the rate that female urology registrars did during the last 20 years (0.98% annually), then 22.0% of UK urology consultants will be female in 15 years , and this seems more likely as about that number of registrars are currently female.
Will Gender Influence How Many Urologists We Need?
Between 1992 and 2009, 15.0% of female urologists worked part-time compared with 8.9% of males (P = 0.02) . However, as females are expected to remain a minority, overall workforce participation is unlikely to drop much below 96%. If as previously predicted by BAUS, annual consultant expansion remains at 4.5%, then 2.2 additional consultants will be required annually to compensate for this level of participation (Fig. 1). If consultant expansion drops to 2% and 1%, then just 0.84 and 0.39 consultants will be required annually. Furthermore, the number of additional consultant urologists likely to be required to compensate for the influx of female urologists is actually the difference between an entirely male and a mixed workforce, a negligibly small excess (Fig. 1).
Workforce requirements are notoriously difficult to predict; however, significant changes to national workforce planning to allow for the influx of females into the medical workforce seem unnecessary for now. The UK healthcare system is currently undergoing its biggest ever re-organisation whilst simultaneously attempting to save up to a fifth of its budget due to the global recession. In addition, the number of surgical procedures performed by urologists is likely to decline in coming years. Such profound financial pressures, health-service re-organisation and the changing remit of the urologist are likely to have far more influence on workforce planning than gender shifts.
Other challenges for females, e.g. managing childcare, are more likely to be an issue for local departments, than for national policy. Interestingly men in the UK may become entitled to up to 12 months paternity leave after 2015, which is likely to add to this challenge and, given the male majority, might make it a workforce issue in urology. In other specialities, e.g. general practice, where both the absolute number and proportion of females working part-time is higher , gender will probably be much more important for workforce planning.
Will Gender Influence Training of Urologists?
In the UK between 1992 and 2009 significantly more female urology registrars (10.1%) worked part-time than males (1.4%; P < 0.001) . However, between 1996 and 2006 the duration of training for urologists did not differ significantly by gender, with both males and females taking a mean of 6.3 years to complete training (P = 1.0). The proportion of each sex on an out of programme experience did not differ by gender, suggesting most females did not take time out to start a family during training. Training might be longer for a minority of individual part-time female trainees but this is unlikely to have a significant influence on the national urology training programme.
Worldwide Implications of Gender Changes in the Urological Workforce
Most Western nations have seen similar increases in the proportion of female doctors and the influence of gender on career choice is also similar across countries, with surgery and urology being universally dominated by males, especially in the USA [1, 4]. Yu et al.  recently reported that the proportion of females electing to train in surgery in the USA is actually in decline despite their increased numbers. Even in countries where females have comprised the majority of doctors for many years, e.g. the former Soviet Union, they are less likely to work in surgery .
Worldwide it is therefore likely that female urologists will remain a minority for the foreseeable future, despite the influx of females into medicine. Consequently, the challenge for urology might actually be how to recruit more females. It has been reported that females are discouraged from pursuing surgery by lifestyle factors, lack of interest and most disturbingly, a perception they would not be welcome . However, this may not be the whole story, as equally demanding surgical specialties are more popular among females (Table 1). Most female urologists report satisfaction with their career choice, so is this simply an image problem for urology? Exposure to urology is a key reason for choosing the specialty, yet urology remains a notoriously small component of most undergraduate curricula. Perhaps the real priority for urology is to promote the speciality as a rewarding career choice if we are to attract the brightest and best from a female-dominated medical world in the years to come.
Table 1. Number of male and female UK consultants across specialities in 2011