Urology is the fourth largest surgical specialty in the UK with just under 1000 practicing consultants [1]. Following the 2-year Foundation Programme, doctors wishing to pursue urology training will typically go through two competitive national recruitment processes to enter Core Surgical Training (CST) followed by Higher Surgical Training (HST), starting as a Specialty Trainee Year 3 (ST3). In 2022, 2302 doctors applied for 622 CST posts across the UK, giving an overall competition ratio of 3.70, and 235 doctors applied for 59 ST3 urology posts, with a competition ratio of 3.98 [2]. There is growing interest in evaluating and improving diversity in the surgical workforce. While >50% of medical students and foundation trainees are women, this number drops as doctors progress through their career, with women making up 41% of core trainees, 31% of urology registrars, and only 12% of urology consultants [1, 3]. Literature on ethnicity and socioeconomic factors in the context of HST is scarce. Within urology, it is estimated that almost 25% of the consultant workforce identify as 'Ethnic Minority' (EM) [4]. EM doctors across specialties have lower pass rates in postgraduate examinations, a higher chance of obtaining an unsatisfactory Annual Review of Competency Progression (ARCP) outcome and are underrepresented in surgical leadership [5]. Examination pass rates are also lower for doctors from the lowest socioeconomic background, with compound adverse effects seen in EM doctors. For example, Black trainees from areas with high index of deprivation have a lower examination pass rate compared to White trainees with comparable socioeconomic background. [5]. This study aimed to explore whether demographic, socioeconomic and educational factors are associated with applying for and successfully receiving an offer for an ST3 post in urology. We conducted a retrospective cohort study employing data from the UK Medical Education Database (UKMED) with permission from the General Medical Council (GMC). Our data come from the UKMEDP134 extract generated on 16 June 2021, approved for publication by UKMED on 1 December 2023. Our population included doctors who completed CST and were eligible to submit a first-time application for HST in the UK between 1 January 2014 and 31 December 2019. The predictors of interest for this study were applicants' demographic factors including: age, gender and ethnicity, and items relating to their socioeconomic status, and academic performance. The ST3 application itself was analysed by looking at the following binary variables: whether the trainee applied for urology HST, whether they had sent parallel applications to other specialties, and whether they were offered a post. Further details on the utilised variables can be found in the UKMED data dictionary and in the study protocol. In line with UKMED and Higher Education Statistics Agency (HESA) statistical disclosure controls, all numbers are reported to the nearest multiple of five, with suppression of some percentages and averages. The statistical analysis was based on raw numbers; however, certain figures and percentages may seem inaccurate due to such constraints. The primary outcomes were whether trainees applied for a Urology ST3 post, and if they were subsequently offered a post. Data were provided from 2014 to 2019 and we combined applications from these years for the analysis. All applicants who had not succeeded at first attempt and were submitting a re-application were excluded. The cohort characteristics were described in a descriptive manner. Univariate logistic regression models were first carried out to calculate the odds ratios (ORs) for the association between each predictor and the outcomes of interest. A directed acyclic graph (DAG) was then used to explore causal inferences and identify relevant confounders (Fig. S1). Logistic regression was run again for all predictors to calculate adjusted ORs accounting for confounders as directed by the DAG. All analysis was carried out on Stata Statistical Software, release 15.1 (Stata Corp., College Station, TX, USA). A 95% CI was chosen to indicate significance. To uphold rigorous standards of security, governance and confidentiality, data access was limited to two authors. The Medical Schools Council confirmed that projects utilising solely UKMED-held data would be exempt from ethics approval requirements. Among 1960 trainees who applied for HST, 88% (n = 1720) achieved Outcome 6 at ARCP (i.e., having gained all required CST competences), enabling them to progress to the next stage of training. In all, 61% (n = 1195) of applicants were offered an HST post in any specialty. Most trainees were born between 1980 and 1989 (69%). The majority were male (63%), UK residents prior to medical school (81%), and identified as 'White' (57%). Socioeconomic status was assessed by examining parents' occupations, with 32% of trainees having parents in higher managerial and professional occupations. Looking at geographical factors, 32% of trainees came from the least deprived Index of Multiple Deprivation quintile area, and 39% belonged to the highest participation of local areas (POLAR) quintile area, indicating an 'extreme likelihood' of entering higher education for younger individuals. Table 1 reports our key findings. In all, 64% of urology applicants were male and 56% were White; none of the variables of interest (age, gender, ethnicity, socioeconomic or educational factors) were associated with increased likelihood of applying for urology training. Of the 275 first-time urology applicants, 145 (53%) were offered an ST3 post. There was an association between gender and being offered a post, favouring women—60/95 (63%) of female applicants were offered a post, compared to 85/175 (48%) of males (OR 1.80, 85% CI 1.09–3.00; P = 0.023). Age, ethnicity, socioeconomic or educational factors were not associated with increased odds of obtaining an offer. In all, 30 (11%) applicants applied to more than one speciality in the same recruitment round; however, applying to multiple specialties was not associated with increased odds of being offered a post. Strengths of this study include its large sample size and detail, utilising long-term granular longitudinal data on 1960 trainees. As the UKMED database was utilised, this study did not rely on voluntary completion of surveys. Quantitative data were processed via logistic regression analysis while accounting for confounders. Limitations include the fact that our population only comprised applications submitted by doctors who obtained their degree in the UK and had completed CST. International medical graduates or applicants to HST via alternative routes were not included. Ethnicity was analysed in a binary fashion (White vs EM), without further granularity in the EM group. Repeat applicants were excluded from the analysis. Lastly, all data included predates the COVID-19 pandemic, which had a significant impact on surgical recruitment and training in the UK. The BAUS has been leading the workforce in widening participation by formalising a 10-point Equality, Diversity and Inclusion (EDI) plan [6]. Additionally, the society established an EDI working group to evaluate the workforce and develop an inclusive and diverse leadership. Our findings are in line with the BAUS workforce reports, which found that the proportion of women in urology is rising—now making up ~30% of trainees and 23% of consultants under the age of 45 years [7, 8]. Ethnicity has also been a recent focus of research, with ethnicity figures to be included in future censuses. To our knowledge, this is the first study to investigate whether demographic, socioeconomic and educational factors play a role in applying to and being offered a HST post in urology. Overall, we found that and there was an association between gender and receiving an offer for ST3 urology favouring women. Age, ethnicity, socioeconomic or educational factors were not associated with increased odds of obtaining an offer. Compounded with initiatives implemented by organisations, societies and the NHS, we hope that these encouraging findings will result in the formation of an increasingly diverse senior workforce. Sarika Grover and Siddarth Raj conceptualised the idea with the guidance and expertise of Simon Fleming and Stella Vig. Beth Russell and Martina Spazzapan directly accessed and verified the underlying data reported in the manuscript as well as performed the statistical analysis and Martina Spazzapan wrote the manuscript with support from Sarika Grover and Siddarth Raj. Sachin Malde reviewed the data and the manuscript, providing comments and edits. The project was supervised by Simon Fleming and Stella Vig. All authors read and approved the final manuscript for submission. Martina Spazzapan, the corresponding author, attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted. All authors accept responsibility to submit for publication. None of the authors have any conflicts of interest to declare. No specific funding was obtained for this study. Martina Spazzapan receives funding from the UK National Institute of Health Research. To uphold rigorous standards of security, governance, and confidentiality, data access was limited to a select group of team members within a secure environment. Ethics approval was deemed unnecessary for this study as it involved the analysis of anonymised data and had already established research agreements and access arrangements authorised by the GMC, the data controller for UKMED. The Medical Schools Council (MSC) stated that research projects utilising solely UKMED-held data would be exempt from the ethics approval requirement. The authors are grateful to UKMED for the use of these data. Data files used in the study are securely held by the UKMED Database and cannot be shared by the authors; however, these data are available via application (see www.ukmed.ac.uk). UKMED bears no responsibility for data analysis or interpretation. Further details for the names of variables can be found in the UKMED data dictionary which is available to the public. The study protocol for this study will be made available with publication. The data includes information derived from that collected by the Higher Education Statistics Agency Limited ('HESA') and provided to the GMC ('HESA Data'). Source: HESA Student Record 2002/2003 and 2015/2016 Copyright Higher Education Statistics Agency Limited. The HESA makes no warranty as to the accuracy of the HESA Data, cannot accept responsibility for any inferences or conclusions derived by third parties from data or other information supplied by it. Fig. S1. Directed acyclic graph (DAG) and adjustments. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.
