By Krisha J. Howell, MD, and Penny R. Anderson, MD
As health care providers pre-pandemic, we were all far too familiar with the 10-hour clinic days, parade of administrative documents, barrage of medical calls/emails/texts/pages inevitably delivered during “unplugged time” and the emergencies that pop up at 5:00 p.m. on a Friday. As parents, we each adapted as best we could with our own piecemeal childcare system to maintain the demands of burgeoning clinics and the needs of our family. Minor emergencies happened frequently: school lunches forgotten, pick-up times from sports practice missed. Then there was that one Christmas week when the family dog gulped down a box of chocolates ― that well-intended, beautifully gifted box of malt balls from Uncle Scott ― culminating into a 6:00 p.m. frenetic storm of family crisis and urgent childcare needs amid an on-going Tumor Board. But as unsatisfactory as it was, the system persisted. Conditioned from the moment of that first newborn cry, we gradually progressed into our own individual patchwork system of Dr. Mom/Dr. Dad.
In America, we profess a need for a robust infrastructure ― roads, utilities, communication systems are all worthy investments for the health of our economy. Yet it seems, as a culture, we remain married to the idea that the federal government only need to offer limited childcare assistance outside of the traditional kindergarten to high school model. Along with the nursing, therapy and administrative staff, women now constitute a large portion of our physicians and physicists. A more robust infrastructure would allow these women to make an even greater impact to our patients and our communities.
During the COVID-19 pandemic, we saw our health care workers report to work in the face of inadequate PPE, absent or under-resourced COVID testing and with the oncology cancer patient population quickly infiltrated by the disease. Not only were we consumed with our own safety but the probability of bringing the disease home to our families. One set of friends, both emergency physician parents, made matching living wills. Elsewhere, a physician mother quarantined at a hotel rather than go home to her family after an exposure.1
The pandemic exposed the lack of a countrywide childcare infrastructure. Old sources of support became unavailable, less accessible, or, for many, executed the removal of an elderly family member as caregiver out of concern for their vulnerability. Many health care workers now found themselves in the triple role of essential worker/babysitter/teacher. Each, in itself, would constitute a full-time position. In turn, the daily act of raising children now required a greater investment in time and effort. A 101F degree fever in a baby during the era of COVID translated into an automatic two-week home quarantine from daycare. Baby’s doctor visit meant one parent had to take time off from work to stay home with siblings, as only a single guardian and no siblings were allowed to accompany an underage patient.
In dual income families, the typical parental dynamics may have altered. Many women conceded that it was no longer possible to be all roles at once. In general, women are more likely to be in part-time employment, more likely to be the lower earner in straight couples and likely to already have the greater expectation of doing household chores and meeting child-rearing obligations. If both parents had the pressure of working, then it more often than not resulted in women leaving the workforce.2,3 Beyond this struggle, we do not even elaborate on those hurdles faced by single-parent households (9 out 10 headed by women) or those with separated households wherein child custody time may have been threatened by a parent’s role as a health care provider.
From a child’s perspective, understandably, the pandemic has caused a departure in their physical and social support. Their previous social outlets of friends, sports and school are not accessible or have been reimagined in a less intimate, virtual manner. Children of frontline health care workers have demonstrated increased anxiety and worrying. “The electronic media did come to their rescue during home confinement but not without its own drawback….”4 It is easy to imagine the paramount role a parent need play at this time as an accessible and reassuring figure to a child.5
A large-scale survey conducted by Athenahealth in 2017 found that the majority of physicians under age 44 were women.1 Given the onset of COVID in early 2020, it would make sense that this population would be especially vulnerable to the aforementioned stresses. And, indeed, a drop in publications by female authors was demonstrated during the pandemic period.5
At our department, we realized early on many of these consequences and how they could impact our physicians. And, beyond them, the dosimetrists, physicists, nurses and therapists would experience similar, if not worse, upheaval in their lives at home. We set out to increase communication and strive to optimize safety and support throughout the department. As with the majority of health care clinics, we quickly integrated virtual days. This reduced risk of transmission and gave many parents greater freedom when children needed at-home care. A “buddy” system was created to optimize coverage so as not to compromise patient care and protect against surprise physician absences due to emergencies. This facilitated collaborative efforts regarding consents, simulations and SBRTs. Fortunately, our center already had in place an on-site daycare, similar to what companies did during World War II.6 Holidays were matched to the clinic holiday schedule, and the hours mirrored that of the clinic hours to optimize effective care. Furthermore, we tried, and ultimately succeeded, to honor all requested vacations despite months of upheaval. To take advantage of time away, we strove to improve communication among long-standing professional silos so that an attending’s physical clinic closure could translate to staffing the exact number of required support staff. Thus, a nurse with children being home-schooled could make appropriate plans to be home. Male colleagues, who in the past would rarely if ever admit to needing help, now approached me with requests for cross-coverage due to family needs or consideration of a father’s help being needed at home. This has caused a visible stress in my colleagues, culminating in an evident need for an improved work-life integration. Hopefully, this will continue to manifest into the future in a way to facilitate consideration and willingness to collaborate with other colleagues.
I wonder, were there ― and are there ― other solutions employed elsewhere? Going forward, as the pandemic subsides, will this awareness abate? And, finally, are there opportunities here that we will want to carry forward beyond the pandemic? Join us in this discussion on the ROhub.
Dr. Krisha Howell is an assistant professor and clinical director of the radiation oncology department at Fox Chase Cancer Center in Philadelphia. She is actively involved in ASTRO as the Gender Equity Community Champion and in the American Association for Women Radiologists (AAWR) along with other virtual platforms promoting mentoring in the space of gender equity.
- Dawar R, Rodriguez E. Chronicles of a Physician Mom in a Pandemic: When Doing It All Is No Longer Possible! Accessed January 25, 2021. https://connection.asco.org/blogs/chronicles-physician-mom-pandemic-when-doing-it-all-no-longer-possible
- Lewis H. Don’t Build Roads, Open Schools. The Atlantic. Accessed January 25, 2021. https://www.theatlantic.com/international/archive/2020/06/child-care-infrastructure-britain-boris-johnson/613672/
- Edwards K. Women Are Leaving the Labor Force in Record Numbers. The Rand Blog. Accessed January 25, 2021. https://www.rand.org/blog/2020/11/women-are-leaving-the-labor-force-in-record-numbers.html
- Mahajan C, Kapoor I, Prabhakar H. Psychological Effects of COVID-19 on Children of Health Care Workers. Accessed January 25, 2021. Anesth Analg. 2020;131(3):e169-e170. doi:10.1213/ANE.0000000000005034
- Andersen JP, et al. eLife. 2020;9:e58807. doi: 10.7554/eLife.58807
- North A. Vox. Elizabeth Warren made a crucial point at the Democratic convention: Child care is “infrastructure for families”. Accessed January 25, 2021. https://www.vox.com/2020/8/20/21376792/elizabeth-warren-dnc-convention-child-care-biden
By Rehema Thomas, MD candidate, Class of 2022
Going into medical school, I knew that treating cancer was what I was called to do. With my eyes set on oncology, I was aware that there were still options when it came to choosing a specialty. There was surgical oncology, medical oncology and radiation oncology. What road would I choose in the end? As my first year of medical school went along, our preclinical curriculum covered aspects of medical oncology, chemotherapies and surgical techniques. However, I realized I was not getting much exposure to radiation oncology, and I wanted to know more. With that and a growing love for imaging, I knew I wanted more experience in “rad onc” and decided to find out how I could secure it. With a simple internet search for summer research opportunities in radiation oncology, the ASTRO Minority Summer Fellowship (MSF) was the first result I saw. It was perfect! I reached out to my mentor, Curtiland Deville, MD, via email, scheduled a meeting with him, completed the application and ― the rest is history.
Being a recipient of the ASTRO MSF Award provided me with one of the most rewarding experiences in my medical training that I have had to date. My summer experience truly cemented my choice to pursue radiation oncology as a specialty. Throughout my summer working at the Johns Hopkins Sidney Kimmel Comprehensive Cancer Center with Dr. Deville, I was exposed to many different facets of radiation oncology. I was able to witness firsthand what goes into a complete course of treatment ― from the consultation to treatment planning, to treatment delivery. I had the opportunity to spend time with nurses, dosimetrists, physicists, therapists and physicians and see just how much each member of the team contributes to patient care. I sat in on several consultations with Dr. Deville for his prostate and sarcoma patients. I really appreciated how much patient education goes into consultations and how there is a visible alleviation in the uncertainty patients feel after having a conversation with the physician and getting a better understanding of their options.
Not only did I get to observe prostate and sarcoma consultations, but I was able to sit in on breast, lung and gynecologic consultations with other radiation oncologists in clinic. In my observation of on-treatment visits, I was able to gain more insight into the radiation-associated side effects that patients experience throughout treatment and how they are managed. Patient simulations, treatment set-up and treatment delivery were also exciting elements of my clinical exposure. Although the majority of my experience was in Washington, D.C., I did get the chance to travel to Baltimore and participate in Johns Hopkins’ Prostate Cancer Multidisciplinary Clinic. I thoroughly enjoyed that experience, as I value the shift medicine is taking toward multidisciplinary individualized care. Outside of the clinical visits and research, I had the opportunity to contour volumes for patient organs at risk and through that, gain familiarity with treatment planning systems used by the team.
Most importantly, I was able to foster a meaningful mentorship and complete significant research throughout the eight weeks of the fellowship. Dr. Deville was and continues to be an excellent mentor. I am very proud of how much I was able to learn and what we produced in the eight weeks. My poster, “Comparative in Silico Analysis of Pre-operative Scanning Beam Proton Therapy, Intensity-Modulated Photon Radiation Therapy, and 3-D Conformal Photon Radiation Therapy in Adult Soft Tissue Sarcoma,” was presented at the 2020 ASTRO Annual Meeting.
I enjoyed all aspects of the fellowship, and it confirmed my choice to pursue radiation oncology as a specialty. I extend my sincerest thanks to the ASTRO Committee on Health Equity, Diversity and Inclusion for the invaluable opportunity.
Share this opportunity with medical students and colleagues. See the eligibility requirements and access the application for the ASTRO 2021 Minority Summer Fellowship.
Rehema Thomas is an MD candidate in the Class of 2022 at the George Washington University School of Medicine and Health Sciences. She is a METEOR Research Fellow and president of the GW SMHS Women in Radiology.
By Thomas Eichler, MD, FASTRO, ASTRO Chair
After more than a decade of enjoying the prestige of being one of the most highly sought-after specialties in the medical student match process, there have been troubling signs in the past few years that something was amiss. In 2019, the number of medical students who initially matched into radiation oncology declined with multiple slots unfilled. At the time, there was speculation about whether this was an anomaly or the beginning of a trend that had been forecast years before. In 2020, the field saw a larger decline in the number of medical students who matched, coupled with an increase in the number of people who then entered the field through the Supplemental Offer and Acceptance Program (SOAP) process. In fact, radiation oncology had the highest percentage of spots filled through the SOAP of any medical specialty.
From a treatment perspective, many factors, including the decreased use of radiation for some disease sites and an increased use of hypofractionation, bring into question the long-term viability of our specialty. Despite the many positive aspects of radiation oncology, there are growing concerns about the future of the workforce. There has been an increase in the number of available trainee positions despite the apparent decline in medical student interest and concern regarding patient volume projections. These issues contribute to forecasts of declining income streams and anxieties about the future given the recently proposed ― and now delayed ― radiation oncology alternative payment model. The worrisome trend in the SOAP percentages for radiation oncology underscores some of these negative perceptions about the field among students and residency applicants, which are in turn amplified on social media platforms. Not surprisingly, many students are confused about what career path to choose and may be discouraged to pursue radiation oncology before they even truly explore it.
ASTRO leaders have sought to be forthright with our members about challenges in the field (see previous blog posts below) and ASTRO’s role in addressing them. While there are strict anti-trust principles ASTRO must abide by, the Board of Directors felt compelled to issue a definitive statement so that there is no ambiguity about our position.
ASTRO Position Statement on the U.S. Radiation Oncology Workforce
- Radiation oncology has long been a critical component of multidisciplinary cancer management, driven by clinical and scientific innovation. Recent advances in technology and our understanding of cancer biology have allowed radiation oncologists to offer more accurate and effective therapies, often in fewer total treatments than before, resulting in improved patient care. ASTRO has observed growth in residency training positions over the past two decades. With more efficient treatment delivery, fewer radiation oncologists may be needed in the coming years. Residency training positions should be reserved for those who are enthusiastic about the field and should reflect the anticipated societal need for radiation therapy services. As we prepare the next generation of radiation oncologists for independent practice, we encourage stakeholders to carefully consider these aspects affecting our specialty as they review the size and scope of their training programs.
Additionally, ASTRO acknowledges the continued need to grow and nurture diversity within the next generation of our workforce. We serve diverse peoples, and our trainees and faculty should reflect that diversity. We are committed to addressing all aspects of bias as we seek to ensure equity and inclusion within our specialty and to improve health outcomes for all our patients.
While we acknowledge that this statement will not magically solve the issues impacting the field, we do want to be clear with our current and future members about ASTRO’s stance on this critical issue. We also strive to keep the lines of communication open with all members, including our residents. We listen to and appreciate the insights and perspectives from Association of Residents in Radiation Oncology (ARRO) to better understand their perceptions and experiences. Results from a survey of the class of 2020 found that residents had an average of five job interviews, received at least two job offers and, perhaps most significantly, 89% of residents were satisfied with the offers they received. While there are some vocal naysayers on social media, the direct response from residents gives us confidence and hope about the current realities in the field.
Radiation oncology has always sought the best and the brightest minds for our field because we know it is a truly rewarding area of cancer treatment. That will not change. We have deeply meaningful interactions with our patients, curing many of their cancers, alleviating suffering and extending life. Technology continues to play a large role in the field with novel and groundbreaking synergies between radiation and systemic agents, including immunotherapeutics, and many contemporary research questions are emerging, ripe for exploration and clinical trials. The field is also expanding due to innovations in radiopharmaceuticals and theranostics, offering radiation oncologists exciting new ways in which to help patients. While the future is unpredictable, we unequivocally believe in the continued impact and relevance of our specialty going forward, and perhaps more importantly, have unshakeable faith in the dedicated professionals who have made radiation oncology fundamental in the fight against cancer.
Read previous posts:
A Commitment to the Field - Dr. Theodore DeWeese, March 10, 2020
The Residency Training Landscape, Continued - Dr. Paul Harari, May 28, 2019
The Residency Training Landscape - Dr. Paul Harari, March 20, 2019