By Reshma Jagsi, MD, PhD, FASTRO, Krisha Howell, MD, and Kirsta Suggs, ASTRO DEI

Women’s participation in the medical profession increased steadily after the enactment in 1972 of Title IX, which proscribed discrimination by educational institutions, including medical schools’ decisions for admissions, hiring and promotions. Before either physician author of this post entered medical school themselves, women constituted over 40% of the medical student body. However, even today, women comprise under a third of all radiation oncologists. They remain in an even smaller minority in positions of influence and authority in the field, ranging from professional society board members and honorees to institutional deans and department chairs.

At the national level, organizations such as the Association of American Medical Colleges have long been engaged in generating and disseminating evidence regarding the status of women in medicine. The National Academies explicitly included medicine in its Committee for Women in Science and Medicine in 2007, soon after publishing a landmark report on gender bias. This allowed subsequent efforts, including reports on the sexual harassment of women, promising practices to promote equity, and the impact of COVID-19 on the scientific workforce to specifically include recommendations relevant to women in medicine. These efforts generated observations that those who challenge the status quo, such as those entering a field from which they had historically been excluded, are often targets of hostility and harassment. Gender bias can be so pervasive that a name change at the top of a CV is enough to have a meaningful impact on whether a candidate receives a job interview or is hired. Moreover, gendered expectations of society lead to differences in family care responsibilities that can challenge women’s full participation in the professions, something that has been both highlighted and amplified by the COVID-19 pandemic. These types of challenges ultimately act to the detriment of all, given the demonstrated value that diverse perspectives bring to any endeavor, especially one as important as the improvement of human health.

Although efforts at the level of the profession as a whole have had great impact, needs still exist for work at the level of individual specialties. In radiation oncology, women’s participation among physicians reached approximately 30% over three decades ago and then essentially flattened. This pattern, which differs from what is observed in medical oncology and many other fields, requires focused attention. For as long as we can remember, the American Association for Women Radiologists (AAWR) has generated tremendous interest in its annual luncheon bringing women together at the ASTRO Annual Meeting. The AAWR celebrated its 40th anniversary during the pandemic and its impact in facilitating both the understanding and mitigation of challenges disproportionately encountered by women in both diagnostic radiology and radiation oncology cannot be overstated.

In more recent years, led primarily by newer members of the profession, a stronger desire for groups specifically focused on women in radiation oncology has emerged. This led to the founding of the Society for Women in Radiation Oncology and the Radiation Oncology Women Physicians Facebook group. At the same time, broader efforts within ASTRO to develop a robust committee focused on equity, diversity and inclusion led to the Committee on Health Equity, Diversity and Inclusion (CHEDI) and ultimately the more recent establishment of the Council for Health Equity, Diversity and Inclusion (HEDI Council). An ad hoc ASTRO task force that was first formed in 2020 and focused on gender equity was recently retired. In its place, a new Women in Radiation Oncology Affinity Group was formally created in the summer of 2022 as a component of the HEDI Council.

As the chair, co-chair and ASTRO staff liaison of this Affinity Group, we write this post to share its structure and goals with the broader community of radiation oncologists. We are excited that this task force is particularly well situated to advance equity with an intersectional lens, as one of six standing units within the HEDI Council. The membership currently includes a diverse group of 24 members, including physicians and physicists, ASTRO Gold Medalists and trainees.  We have created three working groups that will focus on 1) gender bias and harassment, 2) family caregiving, and 3) mentorship, sponsorship and leadership development. These groups will focus on developing education, research, policy and other initiatives in their areas of focus.

In this way, we seek to collaborate with, and build on, the tremendous foundation of existing groups, including those mentioned above, to create a unified forum within the primary professional society of our field to pursue research and initiatives that will promote equity for women in radiation oncology. We invite all interested members of the field to bring their ideas to our working groups and engage with us to pursue our mission. Please feel free to email us and join the Gender Equity community on the ROhub to start a conversation.

By Kelly Paradis, PhD

Our first child was born in the summer of 2018. It had been an arduous road to get to that point, but we were ecstatic at the arrival of this tiny little girl who came screaming into the world. My husband Eric, a professor of physics, was amidst his summer semester and covertly disappeared into our rainy bubble of chaos, laughter, tears and precious few hours of sleep. I soon became convinced that parenthood was a conspiracy — how had I not realized how difficult this would be? I googled a thousand iterations of, “is it normal if baby poop looks like…” and crumbled into tears if I dropped clean laundry on the ground (this would later be diagnosed as postpartum anxiety). I took the equivalent of 12 paid weeks of leave from my job as a clinical medical physicist: Six weeks at 0% effort, and then another six staggered over several months. It was classified as “extended sick” time. Though six weeks of parental leave for the birth of a child was included in Eric’s contract, the implications were clear that taking it would impact his chances of achieving tenure. He returned to work full time in the fall. Meanwhile, I considered never leaving the couch again.

Our second child was born in late summer of 2020, a time characterized by a haze of masks and nasal swabs and rooms drenched in bleach. It was 3:00 a.m. when I nudged Eric to tell him I thought we might need to go to the hospital. The next two hours were a rush of drowsy toddler, quiet city streets lit by dim lamplight, frantic phone calls to colleagues and Eric arriving moments before the birth of our second daughter. I was desperate to leave the hospital, where every interaction seemed dangerous and every surface menacing. At one point, while clutching my day-old child to my chest and standing barefoot in a half-tied hospital gown, I declared, “I think we are going to go home now,” to which our very patient nurse replied, “Ma’am, that’s not how this works.”

During this second rodeo, I took 12 consecutive weeks of what was then newly classified as maternity/parental leave by my institution. Eric, tenure in hand, negotiated a modified fall schedule that was the equivalent of six weeks of leave. We were largely alone, my family too far away to travel safely, and Eric’s family forcibly separated from us by border closings. Months earlier I’d had a phone conversation with a U.S. Customs and Border Patrol officer about whether Eric’s mother crossing the Canadian border a few weeks before my due date to ensure Eric could be there for the birth of our child constituted as “essential travel” (it did not). Together, we did the best we could with the resources we had. And, I have to acknowledge how incredibly privileged we were to have access to paid parental leave at all, as many in the United States still do not.

While sufficient paid leave for the birthing partner is critical, the fact that leave for non-birthing partners is frequently ignored is a clever assault on gender equity. It defaults mothers to caregiving-focused roles, where their careers are deemed less important compared to their partners’, and exacerbates biases in hiring, the gender pay gap, the dearth of women in leadership roles and attrition. If we must make a “business” argument, academic medical institutions know how extraordinarily expensive it is to replace faculty. Equal and adequate paid leave for both partners when a child is added to the family, beyond simply being humane, is also the economically sound path.

The stigma against men who take parental leave remains a significant barrier. U.S. Secretary of Transportation Pete Buttigieg recently had to defend attacks against him for taking parental leave after he and his partner adopted twins. Palantir co-founder Joe Lonsdale articulately responded that any man taking six months of leave was a “loser.” Relatedly, a 2019 study published in JAMA Network Open found that in a survey of 844 physician mothers, less than 10% of partners took leave from work, and only 3% took more than two weeks. For non-birthing partners with access to paid leave who returned to work early, 44.9% of first-time parents cited a personal preference to return to work earlier, and 33.3% had intrinsic feelings to not take leave because others did not take paternity/domestic partner leave.¹ Clearly, there is work to do.

I am grateful to the American Board of Medical Specialties for their new policy stating, “Member Boards must allow all new parents, including birthing and non-birthing parents, adoptive/foster parents, and surrogates to take parental leave.” In the 21st century, it should be embarrassing for an institution to have varying leave policies dependent on a parent’s gender or specific path to parenthood.

Four years ago, when I was pregnant for the first time, my mother gently said to me that I didn’t realize how lucky I was that Eric would be home with me for the first few months after our baby was born. She was right, not only in that I didn’t realize this (how hard could it be?), but also about the impact that it would have on our family for years to come. What’s more, without him at home, I’m not sure I would have returned to work at all. Eric, you’re my hero. Thank you for changing all the diapers while I cried about the laundry.

Kelly C. Paradis, PhD, is an associate professor of Medical Physics and associate chair of Equity and Wellness in the Department of Radiation Oncology at Michigan Medicine.

References

1. Juengst SB, Royston R, Huang I, and Wright, B. Family Leave and Return-to-Work Experiences of Physician Mothers. JAMA Netw Open. 2019;2(10):e1913054.

By Yun Rose Li, MD, PhD, Parul Barry, MD, and Adrianna Masters, MD, PhD

While many women scientists and physicians made critical contributions that paved the path to modern day advances in radiation oncology, few were recognized for their work. Perhaps one of the most well-known pioneers in the field of radiation oncology is a woman: Marie Curie, recipient of two Nobel Prizes for her extensive work on radioactivity and the discovery of radium.

But aside from Marie Curie, most of her contemporaries received little acknowledgment. For example, Lise Meitner, an Austrian-Swedish physicist, helped discover the element protactinium-231 and described the process of nuclear fission (Sime, 1996). Her work demonstrating that uranium atoms split when bombarded with neutrons allowed for the later development of nuclear energy and nuclear bombs. For her contributions, she was nominated for the Nobel Prize in chemistry and physics 48 times, though she never received the award.

Another example is Margaret Cleaves, who in the early 1900s was one of an estimated 20 physicians (the only female) to have access to radium for clinical purposes and ultimately became the first to use radium in gynecology to treat cervical cancer (Aronowitz, Aronowitz, & Robison, 2007). She was heavily criticized and was largely dismissed by other physician colleagues. At that time, not only were educational opportunities and access to postgraduate training for women extremely limited, but society placed strict limitations on the role of women as physicians and leaders in medicine.

It was not until the demands created by WWI and WWII that broader access to medical/graduate education and career opportunities, aside from those that were traditionally seen as “feminine” roles, were made available to women. Often considered to be a founder of nuclear medicine, Edith Quimby studied the medical effects of radiation and dose limiting side effects with the application of radioactive isotopes in the treatment of thyroid disease, brain tumors and other cancers during her time at Memorial Hospital for Cancer and Allied Disease in New York (Linton, 2012). In 1954, she became the first female president of the American Radium Society and was the recipient of the Janeway Medal of the American Radium Society, the Gold Medal of the Radiological Society of North America and the Gold Medal from the American College of Radiology.

Other important women who made contributions to radiation oncology include Chien-Shiung Wu, also known as the First Lady of Physics. Wu, a Chinese American particle and experimental physicist, worked on the Manhattan Project and played an important role in the advancement of nuclear and particle physics. Despite their successes, very few women obtained faculty positions and even fewer chaired departments during the mid-1900s. One example was Ruth Guttman, who became the director of the Department of Radiotherapy at Columbia University from 1955 to 1976. Other notable examples include Florence Chu, who was the chair of Radiotherapy at Memorial hospital 1976-1984, and Anna Hamann, who at the end of a long career, became the director of radiation therapy at Evanston Hospital, although she never attained a full professorship. These women and many other women physicians and scientists overcame tremendous challenges and faced persecution and hostility in order to pursue their dreams to advance the field of radiation oncology and radiation physics.

Though many would like to believe that efforts made to address challenges faced by women in science and medicine have allowed women to break the glass ceiling in radiation oncology, there is still a lot left to do. In fact, the lack of gender diversity among radiation oncologists begins with medical school applicants and continues to widen throughout career development. Currently, women represent at least half of all medical school students but make up only 30% of applicants to radiation oncology training programs. The gender disparity widens as women progress in their careers, with leadership positions and chair positions further widening the gap: academic positions 17.4% and female chairs 11.7% (Gharzai and Jagsi 2020).

Leadership roles on editorial boards of oncology journals are another area of noticeable disparities in representation of underrepresented minorities and women. A recent abstract presented by Patel et al. reviewed 54 oncology journals and 793 board members, and there was not a single editor-in-chief position held by a minority female. At a time when COVID-19 has disproportionately affected the career development of women, who often serve as primary caretakers at home, how do we create an even ground for achieving career success? This is a pivotal time to reevaluate our measures of productivity and the metrics we use to decide on tenure or promotion. Recognizing that women in STEM in general have shown much larger interruptions in submissions to journals during this time than their male counterparts, even those with young children, the charge is with institutions and national organizations within our field to make a change to do better for women in radiation oncology.

We would argue that we need to promote diversity of not just representation and service on committees, but chairing committees, successfully applying for FASTRO status and even the Gold medalists. We reviewed the listed ASTRO Gold medalists on the website and found that since 1977 only 12% of honorees were female. The majority of the current ASTRO executive committee is female. In reviewing the chair and vice-chair positions of the councils, two of five council vice-chairs are women. Because portions of the application process for FASTRO focus on recommendations of existing recipients, leadership roles and other metrics of academic success, is this placing an undue burden on persons from underrepresented groups? We are curious to know what the success rates are for applications and if there is a way to blind applications to reduce bias.

It is important to recognize that, even though much remains to be done to level the playing ground for women in radiation oncology, our field has seen enormous contributions made by women, and more and more women are being recognized for their work. The 2021 ASTRO Gold medalists were notably both women (Colleen Lawton, MD, FASTRO, and Lori Pierce, MD, FASTRO). Moreover, Sue Yom, MD, PhD, FASTRO, who has made tremendous contributions to major societies in our field including ASTRO and American Radium Society where she is the immediate past chair, is the incoming editor-in-chief of the Red Journal.

What are some of our thoughts on increasing representation of diverse groups of people in leadership?

• Recognize the accomplishments of others and go out of your way to highlight those who may not be in a position to do it for themselves.  
• Do not assume that someone doesn’t want to serve in a leadership role, is too busy or wouldn’t want to take time away from a specific activity (raising young children, for example). Why not simply ask? 
• Offer support in a positive way that sponsors the success of others and specifically think about multiple candidates for a task or role in leadership. 
• Be thoughtful with your word choices and their impact on those around you. 
• Acknowledge the additional burden of unpaid domestic work, specifically during global pandemics, and think about ways to provide resources: Adapt to a changing environment to allow diversity of experience to enrich our culture as radiation oncologists!
• Be aware of biases, speak up when you recognize them and acknowledge when you recognize your own. Positive change cannot happen unless we do. 

Join us on the ROhub to share your thoughts and discuss: What other ways can we support diversity of leadership and diversity of thought?

And be sure to acknowledge Marie Curie on Sunday, November 7 with #WeWhoCurie day!

References: 

Aronowitz JN, Aronowitz SV, Robison RF. Classics in brachytherapy; 2007.

Gharzai LA, Jagsi R. Ongoing Gender Inequity in Leadership Positions of Academic Oncology Programs: The Broken Pipeline. JAMA Network Open 3 (3): e200691–e200691. 2020. doi:10.1001/jamanetworkopen.2020.0691

Linton O. Edith H. Quimby. Journal of the American College of Radiology, 9(6), 449. 2012. https://doi.org/10.1016/j.jacr.2011.11.020

Sime RL. Lise Meitner: A Life in Physics. University of California Press. 1996.

By Jessica Schuster, MD

“The lows may feel lower, but the highs will be higher than you can imagine.” ―  Madison Area Down Syndrome Society board member

This was our first piece of advice given after my husband and I learned our middle son, Jacob, would have Down syndrome or trisomy 21. These words started a completely unexpected, but wonderful, journey filled with a little something extra we had not realized we were missing. It has been a hard journey with some struggles, but through it I have learned to see people ― patients, colleagues and other people’s children ― in the way I want the world to see my son. I have been taught by my experiences that it is the length of one’s journey and perseverance, not solely the final accomplishment, that are worth celebrating.

The start of this journey collided with a career scenario all radiation oncologists can relate to: Oral Boards prep. After a seemingly lifetime of preparation, I fully expected I would be encountering the “scariest” event of my life to date in May 2016 ― Oral Boards. However, in December 2015, my husband and I sat watching our second son on prenatal anatomy ultrasound. During the ultrasound, the technician spent extra time on the baby’s heart. She explained, “I am going to have the doctor come talk to you.”

Anxiously, we braced for “bad news.” The obstetrician revealed a complete atrioventricular (AV) canal heart defect. As if answering a step 1 board question, AV canal defect triggered in my mind an association with Down syndrome. Despite a desperate desire to capture and understand every word from the obstetrician and genetic counselor, I found myself sitting in silence. Swirls of words danced around me. In 30 minutes, they covered an array of different trisomies, statistics about death in utero, life expectancies, specialist visits and the need to decide about abortion. After hearing the word “abortion,” nothing more was heard as my mind started racing with a million other thoughts and hypotheticals.

Amid relentless specialist visits and further testing, my husband and I questioned our career choices. As we received confirmation of Jacob’s Down syndrome diagnosis and need for heart surgery at three months of age, I began to struggle with picturing a future as mom of a child with special needs and as a radiation oncologist. Despite knowing we needed support and help, it was challenging to share with our families, friends and colleagues. Each retelling of our baby’s diagnosis and heart defect forced us to admit our fear, vulnerability and unpreparedness to be special needs parents.

My original plans included intensifying Oral Boards prep while on maternity leave. Most parents reading that comment, including myself, will probably laugh! Caring for a newborn is wonderful, but it leaves little room for anything else. In mid-April 2016, we celebrated Jacob’s birth. But minutes later, Jacob's NICU journey would start. Within the NICU, learning respiratory and feeding supports, Down syndrome and AV canal defects, I realized I had replaced radiation oncology board preparation with “real life board preparation” by learning how to be Jacob’s parent.,/p>

Jacob made slow progress, but his oral intake was not increasing. It became clear he would not be discharged home prior to Oral Boards. The morning after my final study session, my husband and I were informed Jacob could be discharged home with a gastrostomy tube. This was our first emotional high! We were overjoyed by the possibility of our baby boy coming home. However, gastrostomy tube placement would require transfer to another facility. Outside of a few nurses, my commitments as a radiation oncologist seemed irrelevant to Jacob’s care team. We informed the NICU team that we consented to the procedure if the transfer did not happen while I was out of town for Oral Boards. Being present with Jacob on his first night in the new NICU was extremely important to me.

The day before my planned 36-hour trip to Louisville, Kentucky, a NICU team member popped in to alert me that after “some extra work,” the transfer NICU had accepted Jacob for the next day. Stunned, I stared as she left the room completely unaware of what devastating news she had delivered. This was a low moment. I was overwhelmed with feelings of being unheard and unseen. I was confronted with the fact that my two worlds seemed destined to be incompatible.

The Oral Boards paled in importance to my desire to care for my child. After wrestling with the decision, I arrived at the testing location largely due to a supportive husband gently pushing me and a gracious mother who drove me. Contrasting the devastating low of missing Jacob’s first night in the new NICU, we were able to celebrate Jacob’s homecoming and my Oral Boards results on the same day.

My husband and I learned that happiness from accomplishment is fleeting as special needs parents. We felt a pressure to push the next milestone to help Jacob be closer to a typically developing child and prove we were “good” special needs parents. Initially, we ran ourselves and him ragged, attending every possible therapy (feeding, speech, occupational therapy, physical therapy) and specialist appointments. We read about and tried alternative therapies ― diets, supplements, etc. The fatigue and guilt from constantly apologizing either to my patients or clinic staff or Jacob’s providers was (and sometimes still is) intense. The balance between work and special needs parenting proved to be difficult.

Thankfully, during this time, my husband and I met other parents through several local support organizations who related their journeys as special needs parents while balancing career decisions. They shared an openness about success, failure and regrets. Although no one used the term “sponsor” or “mentor,” this is the role these families served for us. They modeled and shared their life as a special needs parent while staying at home, part-time, or full-time work.

I decided ultimately to remain in my career full-time. I share my story not to say one choice is better ― remaining in versus leaving the workforce, but to validate how intense and complex work-life balance decisions can be for individuals. I also share, because I was helped immensely through the openness and willingness of other parents in the Down syndrome community to share experiences.

Prior to exposure to the Down syndrome community, as a physician and parent I found self-worth in accomplishments and saw failure until the next task was completed. However, the other special needs parents I met seemed to have “a little something extra.” They had the ability to celebrate progress and accomplishment. This represents one of the true highs. Some of my highs go completely unnoticed to most in society as they are not “big” accomplishments. I celebrated with uncontrollable happy tears upon Jacob’s hospital discharge after heart surgery, when Jacob learned to walk with confidence (age 3) and when he said “Mama, love you” (age 4 ½). Jacob’s accomplishments were celebrated, but Jacob himself and his journey are potentially even more positively impactful. For example, my oldest son, James, read a book called “47 Strings'' to educate his second grade class about how people with Down syndrome have a little extra in their DNA causing some milestones achievements a little slower than others. Through loving Jacob, our oldest son is often able to recognize differences in others and respond to those differences with kindness and depth of understanding well beyond his age. By opting to remain in our careers, my husband and I have been able to provide seemingly small insights to our colleagues, such as having the family present for inpatient team rounds and improved understanding of need for work hours flexibility.

From Jacob's medical experiences, I became a better radiation oncologist. My experiences remind me that, as an oncologist, I often meet people at one of their most vulnerable life moments. I remember that this uncertainty and fear makes information harder to process. I strive to emulate medical professionals that cared for Jacob, and also served as navigators through the complexities of his care. Establishing intersectionality between the patients, their families and myself starts with learning about the patient as a person first. Patients should not be reduced to only a “cancer patient.”

The Down syndrome community highlights the importance of person-first language, meaning a person is a person first, i.e., Jacob has Down syndrome versus Down syndrome kid. So, I often start visits with social history asking, “What is your career and what do you do for fun?” Rapidly over a few minutes, “cancer patient” transforms into John, avid biker and primary caregiver for his elderly mother who now has the additional stressor of prostate cancer. Without acknowledgement of a patient’s life before cancer and guidance from medical professionals like us, patients are often unsure how to rank pre-cancer life obligations and cancer care. Through my experiences as Jacob’s mom, I have learned to appreciate the “true highs” of helping patients navigate their balance ― cancer versus life.

Although I cannot travel back in time and remove the anxiety, fear and uncertainty from my 2015 self, I can share the message that from the lows there are also highs higher than I could have imagined. These highs are not because I have accomplished more; in fact, some might argue I have achieved less. These highs stem from a blessing that has allowed for unexpected personal and professional growth. Jacob has given us the opportunity to see all people in the way I desire the world to see Jacob. He is more than just a “kid with Down syndrome,” as each of us are more than just a label.

While an individual’s accomplishments deserve celebration, I find myself often admiring and celebrating people more for their journey and perseverance than the actual accomplishment. We have so much more to celebrate over a lifetime. I have such excitement for the future where my patients and children continue to help me grow as a radiation oncologist, colleague, mom, wife and advocate for parents and individuals with Down syndrome. I share our story to empower others to recognize that their own story and journey has value and is worthy of celebration and to highlight that the seemingly simple act of sharing has the power to help others.

Join the Gender Equity Community discussion on the ROhub to share: How has your journey shaped you?