Women, Black oncologists poorly represented in academic leadership
The issue of disparities in medicine — and in cancer care specifically —has gained increasing attention as Americans confront racism and sexism in the culture.
Much of the focus on disparities in oncology has been at the patient level and has pertained to differences in diagnosis, treatment and outcomes of those in underserved communities.
Yet, racial and gender disparities also exist in the oncology workforce in terms of hiring practices, competing demands on time and promotion to leadership roles.
“Some progress has been made over the past few decades; for the first time, we seem to have more equitable representation in our medical schools,” Gavin P. Jones, MD, a radiation oncologist at University of Kentucky Markey Cancer Center, said in an interview with Healio. “However, particular groups — including women and minority groups, remain underrepresented in academic medicine.”
Jones and colleagues, led by principal investigator Mudit Chowdhary, MD, chief resident physician in radiation oncology at Rush University Medical Center, conducted a study to assess representation of different demographic groups in all hematology/oncology and radiation oncology training programs approved by the Accreditation Council for Graduate Medical Education.
Healio spoke with Jones about the findings, presented during the virtual ASCO Annual Meeting, as well as possible explanations for racial/ethnic and gender disparities in academic oncology and how they might be reduced in the future.
Healio: What inspired you to conduct this study?
Jones: This is an ongoing goal within the physician workforce, and it’s something I’ve been interested in for a while. My principal investigator, Dr. Chowdhary, published some of the seminal work regarding disparities in academic oncology a few years ago, and this project was in many ways an outgrowth of his initial research. For our study, we categorized individuals by ethnic groups and more specifically across different strata within the field of academic oncology. We categorized positions as trainee, general faculty program director and the highest level of leadership, which is ostensibly department chair. That paved the way for this project: collecting this information to serve as a benchmark, but also getting a better sense of stratification at the different levels within medical and radiation oncology training programs.
Healio: How did you conduct the study?
Jones: We used essentially the same racial categorizations as the U.S. Census Bureau. We grouped individuals by sex and then into six categories: white men, white women, Asian men, Asian women, male unrepresented minorities in medicine and female underrepresented minorities in medicine. We queried all radiation and medical oncology training program websites from 2019 to 2020, and we looked at all constituent members of their departments. This included all residents, fellows, general faculty, program directors and chairs for each of those programs. Based on the identifiable data, which included their names and photographs, we used certain validated tools to categorize them as one of those groups.
Healio: What did you find?
Jones: In a combined analysis of all members of the hematology/oncology and radiation oncology departments, we looked at representation in leadership positions, including program director or department chair. We found these positions were occupied by white men more than half (52.6%) of the time and were least often held by female underrepresented minorities in medicine, who comprise only 2.9% of those within academic oncology. We found that white men make up about a third of trainees but 60% of department chairs. Female underrepresented minorities comprise 4.3% of trainees, 0.8% of department chairs and 2.8% of total faculty.
Healio: What do you think is the cause of these disparities?
Jones: Racial/ethnic representation and gender representation are intertwined to a certain degree. We are at a point where we have near gender parity among medical students. So, the question becomes, what is happening further down the line, especially at the highest level of leadership?
There are several possibilities. Reshma Jagsi, MD, DPhil, [Newman family professor, deputy chair of the department of radiation oncology and director of the Center for Bioethics and Social Sciences in Medicine at University of Michigan, and Healio Women in Oncology Peer Perspective Board member,] has written and talked about this using the analogy of a pipeline — a conduit by which talented and valuable trainees enter the workforce. Some people believe the pipeline of academic oncology is simply “long” in the temporal dimension. That is to say, they believe the lack of representation by women at the department chair level is due to the sheer amount of time required to advance far enough within one’s career trajectory to finally reach those senior positions, and that equitable representation eventually will be achieved as more female oncologists percolate to the top. However, given the fact that most U.S. medical schools achieved gender parity within the 1990s — more than 20 years ago — this doesn’t appear to be a sufficient explanation; other factors need to be taken into account.
Prior studies have shown that certain women or groups of women are paid less than their male counterparts, perhaps because they spend time on domestic and parenting responsibilities for which they are unfairly penalized. They also have higher rates of career-related burnout. All of this suggests that women face a unique set of challenges that may be hindering their ability to reach the highest level of leadership. “Motherhood penalty” may be a contributor to these representational disparities.
Moreover, the oft-repeated aphorism “you can’t be what you can’t see” posits that the lack of female oncologists at the highest level of leadership is reinforcing the disparity. Having strong female department chairs and mentors may be valuable motivators to ultimately encourage more female oncologists to pursue leadership roles.
Healio: Does implicit bias in hiring also play a role?
Jones: Absolutely. There is most certainly implicit bias and, lamentably, likely explicit bias. Another factor worth noting in that regard is the external process involved in selecting individuals for leadership and department chair positions. Several people vet and then select these individuals in a way that program directors or general faculty do not experience.
Healio: What do you think needs to be done to improve the situation?
Jones: Bias training can help to reduce some of the inequitable treatment women face in academic oncology. Other steps might include addressing potential harassment through institution-wide policies and having equitable leave and parenthood policies in place.
If a lack of turnover at the highest echelon of leadership — department chair — is part of this, it would be important to find a way to distinctly limit the amount of time any one individual can occupy that position. In our current system, it’s not unusual for a department chair to hold that position for decades. The ensured longevity of the department chair position essentially leads to an ossified hierarchical structure from the top down, stymying further influx of the “oncology pipeline” I mentioned before, where we are not able to get people to that uppermost level, or further perpetuate the clout of individuals who impede more female representation in these leadership positions.
So, even if we can’t precisely pin down why we’re seeing these patterns, identifying them will give us a valuable benchmark to assess future progress and an impetus for actionable efforts toward more equitable representation within these leadership levels in academic oncology.
For more information:
Gavin P. Jones , MD, can be reached at University of Kentucky College of Medicine; gavin.jones@uky.edu.
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Jones G, et al. Abstract 11009. Presented at: ASCO Annual Meeting (virtual meeting); June 4-8, 2021.