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!
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.
Posted: November 3, 2021
| 1 comments
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?
Posted: September 28, 2021
| 3 comments
By Shauna Campbell, DO
In comparison with most medical specialties, radiation oncology offers a more family friendly schedule, for both a trainee and practicing physician. However, the board certification process is extensive, including four individual examinations spanning an average of three years. This prolonged process often leaves early career physicians trying to coordinate major life events, such as family planning, with the intensive study required to obtain board certification. From 2018 to 2020, there were several unfortunate events that left a divide between many young physicians and the ABR. This included an unprecedented failure rate in the basic science examinations, examinees who reported their request for accommodations were not fulfilled and cancellations due to the COVID-19 pandemic. In response, there has been a concerted effort by several stakeholder organizations, including the ABR, ARRO, ADROP, SCAROP and ASTRO, to improve the board certification process. As we emerge from the COVID-19 pandemic, I would like to highlight the recent changes that have been implemented.
- As of 2021, all ABR written and oral examinations are now virtual. The ABR should be commended for creating this platform on such a limited timeline, as well as their commitment to continuous improvement.
- Candidates taking the oral examination are no longer required to travel to Tucson, Arizona, limiting the time and financial burden of board certification.
- Candidates are now able to take the written and oral examinations in the environment of their choice, improving the ease of special accommodations.
- The ABR now has improved ability to schedule examination dates based on feedback from stakeholder organizations, as it is no longer dependent on a third-party company for examination administration.
- This change made the extra April 2021 basic science and clinical written examinations possible.
- ARRO has provided feedback requesting the clinical written examination be permanently moved from July/August following graduation to May of PGY-5. This feedback was received favorably by the ABR, and the 2022 examination dates will be released in early June.
- ABR personnel now have direct access to the examination platform and no longer depend on a third-party administrator to implement special accommodations, such as longer breaks or increased testing time.
- Residents are now eligible, with the permission of their program director, to sit for the medical physics and/or radiation and cancer biology examination at the beginning of PGY-4. This is one year earlier than previous requirements and provides residents with personal choice and flexibility to accommodate other life events with board certification.
Family & Medical Leave Policy:
- The ABR is expected to announce their official family and medical leave policy in early June 2021. All medical boards under the American Board of Medical Specialties were called to establish a maximum amount of time away permitted during residency before extension of training is required, as of July 1, 2021.
- The ABR has been responsive to feedback from stakeholder organizations informing this policy, and in the latest draft has introduced a leave policy inclusive of 28 weeks’ leave over four years for radiation oncology trainees. This policy accounts for time away, inclusive of vacation, family, medical and caregiver leave.
- There is also consideration for additional leave, without extension of training, for residents deemed competent by their program director and with special permission of the ABR.
- The ABR will be a leader among medical boards should it finalize this contemporary policy, which is consistent with the recent editorial published in Radiology, Family and Medical Leave for Diagnostic Radiology, Interventional Radiology, and Radiation Oncology Residents in the United States: A Policy Opportunity, which was endorsed by ARRO and ADROP. If this policy is finalized as proposed, it would be in agreement with Resolution 48, passed at the 2021 ACR meeting, recommending all residents receive 12 weeks of family and medical leave during residency, with additional time at the discretion of the program director and the ABR.
As we emerge from a difficult few years, the board certification process in radiation oncology has undergone substantial modernization. The changes implemented thus far represent a collaborative effort by several organizations and significant dedication by the ABR to support the growing workforce of radiation oncologists. Continued collaboration and improvement in board certification will help ensure radiation oncology continues to attract talented and diverse physicians that represent the future of our specialty.
Join us on the Gender Equity community on the ROhub to continue the conversation. What future changes do you think should be considered for the continuous improvement of board certification in radiation oncology?”
For additional information, read the ASTRO letter to the ABR on parental leave. This page also includes a link to SCAROP’s letter to the ABR.
Shauna Campbell, DO, is a PGY-5 resident at Cleveland Clinic and immediate past chair of the ARRO Executive Committee.
Posted: May 25, 2021
| 2 comments
By Crystal Seldon, MD; Awad Ahmed, MD; Anna M. Laucis, MD, MPhil; and Cristiane Takita, MD, MBA
Gender inequality is an ongoing problem among United States (U.S.) medical professionals.1-2 While there have been gains in diversifying the field of medicine, such as the number of women surpassing the number of men matriculating into U.S. medical schools,3 women continue to remain in the minority among faculty of academic institutions.4 Academic oncology is no exception.5 Women make up the minority of all faculty in the fields of medical oncology, radiation oncology (RO) and surgical oncology at U.S. academic institutions.6 This extends to leadership positions, specifically program director and department chair positions. In RO alone, women constitute 30.7% of the academic workforce and only 17.4% of the leadership roles.6 Women also make up the minority of positions on governing boards, such as the Board of Directors, as well as leadership positions for the national professional societies of the American Society of Clinical Oncology (ASCO) and the American Society for Radiation Oncology.7 There is some progress in this arena, as the current ASCO President is Lori J. Pierce, MD, FASCO, FASTRO, a female radiation oncologist and vice provost at the University of Michigan. And ASTRO currently has three women in Board leadership roles: ASTRO President Laura Dawson, MD, FASTRO, President-elect Geraldine Jacobson, MD, MPH, MBA, FASTRO, and Secretary/Treasurer Neha Vapiwala, MD.
Over the years, we have seen more women enter the field of medicine in the U.S., now representing a narrow majority of matriculating medical students, 50.5% as of 2019.8 However, as more women join the field of medicine, the number of female RO residents appears to have plateaued at 30.2% as of 2019.9 This plateau is also seen in leadership roles in RO residency programs. In 2012, the percentage of female program directors and department chairs was 24% and 9% respectively10 as compared to 23.8% and 11.7% in 2020.6 Studies have shown that female trainees are more likely to practice in programs with women in leadership positions.11-13 The lack of gender equity in leadership positions also likely contributes to the low number of female trainees who matriculate into the field each year, creating a self-perpetuating cycle with a limited supply in the workforce to become leaders.
To address the lack of gender equity in radiation oncology, barriers to equality must be addressed. These barriers include but are not limited to gender specific expectations, barriers to mentorship, disparities in research funding and biases in tenure and academic tracks.14 The lack of predefined finite time limits to leadership positions in academic radiation oncology may contribute to the lack of inclusion in the U.S. academic RO community. Policies introducing term limits for leadership positions in academic medicine have been proposed as a potential solution.15 Work by Odie et al. has showed that gender disparities among chairs exist and are widespread, even in fields where women make up the majority of the workforce, such as obstetrics and gynecology.16 This suggests that the pipeline may not be the heart of the matter. The current disparities seen in leadership, both gender and racial, represent a relic of the past and are unlikely to change without motivational policy; social and institutional guidelines will likely be needed to create gender parity in these leadership roles.
Within recent years, movements geared toward promoting gender equity, such as the #MeTooSTEM, #WomeninMedicine and #HeforShe online platforms, have identified the need for addressing this issue, especially in academia. With more women entering into the field of medicine, it is important to close the gap between men and women faculty members, especially those in leadership positions. Observing other women in leadership roles can inspire and motivate a bright message to students and the public that the field of RO is not only diverse but inclusive as well. An honest assessment of these barriers will be integral as the specialty seeks to attract future radiation oncologists and create a diverse workforce, such that the ideas and opinions representing those from diverse gender, racial and socioeconomic backgrounds can be better represented to ultimately help guide and inform the very best oncologic care for our patients.
Join us in the Gender Equity Community on the ROhub to continue the discussion. What are your suggestions to improve gender equity in radiation oncology?
Crystal Seldon, MD, is a PGY-3 radiation oncology resident at the University of Miami/Sylvester Comprehensive Cancer Center.
Awad Ahmed, MD, is a radiation oncologist practicing at Multicare Tacoma Washington and ASTRO CHEDI member.
Anna M. Laucis, MD, MPhil, is a chief resident physician in radiation oncology at the University of Michigan and an ASTRO CHEDI member.
Cristiane Takita, MD, MBA, is a professor and residency program director at the University of Miami/Sylvester Comprehensive Cancer Center and ASTRO CHEDI member.
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AAMC, 2019 Fall Applicant, Matriculant, and Enrollment Data Tables. Accessed April 22, 2021. https://www.aamc.org/system/files/2019-12/2019%20AAMC%20Fall%20Applicant%2C%20Matriculant%2C%20and%20Enrollment%20Data%20Tables_0.pdf
9. Boyle P. More women than men are enrolled in medical school. AAMC. Published online December 9, 2019. Accessed January 22, 2021. https://www.aamc.org/news-insights/more-women-men-are-enrolled-medical-school
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12. Sethi S, Edwards J, Webb A, Mendoza S, Kumar A, Chae S. Addressing Gender Disparity: Increase in Female Leadership Increases Gender Equality in Program Director and Fellow Ranks. Dig Dis Sci
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Posted: April 27, 2021
| 0 comments
By Christina Chapman, MD
In June 2019, I served as the discussant for an important abstract by Narjust Duma, MD, and colleagues presented at the ASCO Annual Meeting. In Dr. Duma’s study, a group of investigators watched videos of scientific presentations from two recent ASCO annual meetings and recorded whether speakers were introduced with a professional form of address (e.g., Dr. Last Name) or an informal address (e.g., speaker’s first name or Dr. First Name without last name). They found that women and Black individuals were less likely to be introduced with a professional form of address. They also found that men were more likely than women to introduce speakers informally. The abstract was subsequently published as a full length manuscript in the Journal of Clinical Oncology.1 Although the data on gender were published, the data on race were omitted from the final manuscript, which I discuss below. This research project was modeled after an earlier project that similarly demonstrated gender bias in speaker introductions at the Mayo Clinic’s Internal Medicine Grand Rounds. These studies add to the existing literature that demonstrates the pervasiveness of gender bias in medicine and biomedical research.
Christina Huang, MS, Fumiko Chino, MD, and colleagues performed a similar analysis focusing on recent ASTRO Annual Meetings. They did not find a statistically significant difference in speaker introductions on the basis of gender. However, their presentation prompted a series of conversations on Twitter during the 2020 ASTRO virtual Annual Meeting. Although they suggested that all speakers be introduced with a professional form of address, multiple male members conveyed opposing viewpoints. One was that formality in conference speaker introductions reinforces hierarchies that impair collegiality and free exchange of ideas. Another viewpoint was that calls for consistency are unnecessary in light of the study’s failure to demonstrate gender bias. One may wonder why such varied opinions exist on this topic. An examination of the existing evidence may shed light on why opinions differ strongly across gender and racial lines.
In general, people are less likely to support or see the need for formalized systems, rules or laws if they are treated justly without them. Those who are oppressed under current systems instead recognize that “honor systems” and informal structures often fail to produce justice in inequitable societies. In short, the marginalized clearly see the need for guardrails, while those who are centered may claim to be unaware that there is a dangerous cliff nearby. This cliff is well described in the literature, however, so it is incumbent upon everyone to recognize the bias, whether it directly affects them or not.
Although professional credentials are not the only factors that influence career success, they certainly help drive it. Furthermore, numerous studies have demonstrated racial, gender and other biases in the way that individuals with identical credentials are perceived. These facts demonstrate the dangers of informality in professional settings. Even if men and women are introduced informally at the same rates, the penalties are greater for women and the advantages are greater for men. When women’s credentials are not formally displayed, the audience is less likely to perceive them as a physicians or scientists. This does not hold true to the same extent for men, who are more likely to be perceived at the top of hierarchies or to possess advanced credentials regardless of their actual standing. When a male-presenting individual offers, “Just call me Jake,” it is somewhat disingenuous to think that this eliminates or substantially mitigates hierarchies, because he is still perceived to possess academic credentials and be perceived as a man, both of which elicit a certain level of respect in hierarchical and biased society.
To be clear, there are two types of hierarchies relevant here. They can be distinguished by whether they are publicly accepted as just or unjust. Most people will state publicly that racial or gender hierarchies are unjust while stating that hierarchies based on academic credentials or achievement are generally just if equitably implemented. For example, most departments would find it acceptable to deny an application for an academic radiation oncology faculty position from someone without training beyond a bachelor’s degree. Many conference attendees would also find it acceptable that scientific discussants are selected based on their training and content expertise. Without display of their formal credentials, however, women are perceived to be at lower levels of accepted hierarchies, leading to discrimination that is repackaged to make it appear justifiable (e.g., “Oh, I didn’t even realize she was a funded immunologist. I thought she was a student presenting her lab mentor’s research.”) Women then experience additional discrimination when the unjust hierarchy of gender inequity is applied, as in the context of two people perceived to be students with identical credentials: “I thought that male student was more competent than the female student.”2
Simply put, informality, even if applied evenly, leads to inequality in an unjust world. Formality serves to mitigate the impact of gender and other biases. If individuals or groups want to reduce the impact of hierarchies on scientific progress, one high yield place to start is eliminating hierarchies that have no basis in science: those based on gender. Furthermore, it could serve the field well to challenge the notions underlying just hierarchies by recognizing a broader array of scientific methods and topics as legitimate and important (e.g., qualitative research, health equity research) and recognizing that junior members of the field can make groundbreaking contributions. Converting to informal forms of address without challenging these underlying beliefs is unlikely to amplify the voices that we need to hear more clearly to advance our field.
Finally, it would also serve the field and broader community well to consider intersectionality and other forms of bias in their own right. When the Duma et al. paper was published, the significant finding of bias in introductions against Black speakers was removed because race was not self-reported. Study team-assigned race was not actually a major limitation of the study, given that it still measures an important endpoint (i.e., how individuals perceived to be Black are treated). Furthermore, there is little evidence that there would have been high discordance between the study team assignments and self-report, so it also would have likely given a reasonable approximation of the impact on self-reported Black individuals. Instead, important science was lost, despite the tremendous effort on the part of the study team to efficiently investigate multiple forms of bias. Problems like this can be mitigated by eliminating the scientific hierarchies that downplay the expertise of health equity researchers and instead appropriately elevating them to reviewer and leadership positions in journals.
Solutions to minimize the impact of hierarchies on medicine and science must be definitive and not performative. Informal introductions will lead to failure to recognize excellent science and scientists, which will be further compounded by biases that exist when equivalent credentials are made explicit. Calls for equity from the marginalized should not be minimized by those who are often centered, lest we run the risk of slowing progress in a field that sorely needs it.
Join the Gender Equity community on the ROhub to continue the discussion on this important topic by answering this question: In addition to speaker or clinic introductions, where else do you think greater consistency should be implemented to advance equity?
Christina Chapman, MD, is a health equity researcher and radiation oncologist specializing in head and neck and lung cancer. She obtained her BA in Biomedical Engineering from the Johns Hopkins University, her MD from the University of Pennsylvania Perelman School of Medicine, and her MS in Health and Healthcare Research from the University of Michigan, where she also completed her radiation oncology residency training.
1. Duma N, Durani U, Woods CB, et al: Evaluating Unconscious Bias: Speaker Introductions at an International Oncology Conference. J Clin Oncol. 2019;37:3538-3545.
2. Moss-Racusin CA, Dovidio JF, Brescoll VL, et al: Science faculty’s subtle gender biases favor male students. Proceedings of the National Academy of Sciences. 2012;109:16474-16479.
Posted: March 24, 2021
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