COMMENTARY

'Moving the Needle' in Oncology Workforce Diversity

Jyoti D. Patel, MD; Gladys I. Rodriguez, MD; Karen M. Winkfield, MD, PhD

Disclosures

February 22, 2018

Jyoti D. Patel, MD: Hello. I'm Jyoti Patel, professor of medicine and the director of [the Department of] Thoracic Oncology at the University of Chicago, here in Chicago, Illinois. Welcome to Medscape Oncology Insights, coming to you from the 2017 annual meeting of the American Society of Clinical Oncology (ASCO).

As oncologists, we develop personalized therapies for our patients. We use diverse treatment plans to treat a diverse disease. We recognize that patients come from diverse backgrounds and are in unique circumstances, and we adapt our health system to effectively treat their cancer and improve outcomes. We at ASCO contend that ethnic and racial diversity among oncologists improves the health of our profession and the care of our patients. In a statement[1] issued last May, ASCO reported that African Americans and Hispanics are underrepresented in our profession, and this significantly impacts the health of our nation.

Here to talk with me are two oncologists who helped develop ASCO's statement about workforce diversity. All three of us worked over the past several years on this. We wanted to address why this effort is needed and why our profession needs real tools and a concerted effort to move this forward.

Dr Karen Winkfield is associate professor of radiation oncology at the Wake Forest Baptist Health Comprehensive Cancer Center, in Winston-Salem, North Carolina, and Gladys Rodriguez is a medical oncologist and hematologist with the START Center for Cancer Care in San Antonio, Texas. Welcome.

Gladys I. Rodriguez, MD: Thank you.

Karen M. Winkfield, MD, PhD: Thank you.

Dr Patel: This effort has been the culmination of work over several years. We need to change the landscape for practicing oncologists and develop a pathway for people who want to enter the profession so we can truly move this profession forward, and adequately treat a diverse patient population.

It's likely that lack of diversity contributes to health disparities. We think that healthcare providers who are culturally competent probably deliver better care to diverse populations. But this takes plenty of work, and it's not as easy as, "Yes, we want more oncologists. Everyone sign up." This statement serves as a blueprint to move people into the field.

Diversifying Oncology Practitioners

Dr Patel: Karen, what are your thoughts about why it's been so difficult to draw underrepresented minorities into this particular field—one that is rapidly changing and in which only 2% of practicing oncologists identify as African American or Hispanic?

Dr Winkfield: Thank you so much for having this discussion; it is so important. As you mentioned, the ASCO statement is really a first step. There is still a lot of work to do.

Frankly, we find that oftentimes medical students are exposed to oncology as a subspecialty late in their training. Sometimes individuals, particularly those from backgrounds traditionally underrepresented in medicine, may be at institutions where they have no exposure to oncology. How then do we enrich a pool of applicants into a field that they may not get exposure to? That is one of the challenges.

We understand that there certainly is a decreased interest in some subspecialties because of fear of complexity, fear of what it means to be an oncologist, and fear of death. Frankly, I find oncology to be one of the most rewarding things ever. We get to interact with patients at such a vulnerable time. Unfortunately, I think the way that oncology curricula are, oftentimes medical students are exposed to oncology when patients are in the hospital and very sick. They do not get to see the relationships that we get to build with our amazing patients.

There may be some need for curriculum redesign, but also in finding students from these populations that are traditionally underrepresented in medicine by maybe going to institutions that do not have oncology training programs and exposing these young students to oncology early in their careers.

Dr Patel: Absolutely. Exposure is huge, but how do we go from exposure to really drawing people in and to showing them a path forward?

Dr Rodriguez: Thank you for the opportunity to be here. That is a complex problem, and it's not going to be solved with just one approach. Exposure is very important, because if you do not see anybody doing something, you cannot see yourself doing it. Also, there are economic barriers. People might look for careers they could do sooner so they could start earning sooner instead of going to another subspecialty within medicine.

You also have role models—people you see enjoying or taking care of patients—and you see yourself in them. For myself, I watched how one professor in particular treated patients and the way patients treated him back. It made me think, "Okay, not everybody is dying, and not everybody is suffering. It's something that people find rewarding."

It's a complex problem, and it's not going to be solved easily. Recognizing that there is a problem is the first step.

Developing an Inclusive Workforce

Dr Patel: Certainly, we can increase exposure and mentorship to show that oncologists are very human too. We can fill those roles. From my personal experience on many levels, sometimes you may be the only person in a room that sort of looks like you do, or maybe has a reaction to some sort of cultural prompt. What about that piece? How do we make a workforce that is inclusive and such that every person who goes into this field may not be the first one in this field? How do you develop the larger sisterhood and brotherhood of people who are like-minded?

Dr Winkfield: Coming from someone who was the first black radiation oncologist hired at my previous institution, there is a lot in what you are saying. Being the first has many challenges, including folks perhaps underestimating your abilities and not really creating an inclusive environment. It's not just about diversity. You cannot diversify the workforce without creating the inclusive environment.

Folks need to feel welcome; they need to feel a part of a community. That is a broader conversation as well. An important thing is making sure we have diversity at the faculty level, in academia. Yes, private practice is important, and we need to make sure that we have practitioners there. Frankly, as a resident coming through, not having someone who looks like you or someone you feel like you can talk with can be a challenge. It's the same thing with women, right? This is not just about racial and ethnic backgrounds, but also about [gender].

From a patient perspective, this makes a difference as well. I treat breast cancer, and having woman [physicians] that women can talk to really helps. Similarly, not only does having racial concordance between a provider and a patient improve their well-being and how comfortable they feel in that setting, but we know that it improves outcomes. It's important to start thinking about how we best meet the needs of that patient population.

Dr Rodriguez: Sometimes it just takes somebody like you to be the first one. After that, they will look for other people. There may be undisclosed bias that you do not know as much, or maybe you are not as good. When they see you do something, see you talk, or watch how you treat your patient, they realize, "Oh, [you're competent]." When I came to the program in San Antonio, I was the first Puerto Rican. Since then, they have had 10 other fellows from the same program I came from. They realized that they were well-trained and could work out here. It took one person, and then they opened their doors. People who start something are very important, and we all have to be the first to do something.

Imposter Syndrome

Dr Patel: Imposter syndrome certainly has been talked about a lot in the profession. It's where you walk in and feel that perhaps you are the only one who does not still remember every part of the Krebs cycle or the molecular structure of a particular chemotherapy compound. Then you realize that almost everyone is in the same boat. When you look or sound different, or have a different cultural experience, that may even be heightened. Feeling that you have to prepare twice as much, or be twice as good, in anything that you say—it's a pressure cooker. It's a lot. The ASCO statement saying that we understand that your circumstances are special may be impactful. Do you have thoughts about that?

Dr Rodriguez: That is very important. As new generations come, I think it's going to be easier. I see that my kids have very diverse friends—not only from the States, but from other countries. They see everyone all the same. Growing up, I think we had more divisions or more people with preconceived ideas. I think the new generation does not have the same ideas. It's going to be easier for them.

We still have people in leadership positions who need to recognize that, because the people that are in leadership in ASCO are older people already. We need to let [younger people] come up, and I think when they do, it will to be easier for them.

Dr Winkfield: I hope that is the case. We see though, with what is going on in our country, how there is still so much division. For a long time, I think that the older generation in some ways suppressed what they felt, and you can still feel it.

I want to get back to this imposter syndrome, because it's real. I do sometimes feel like I have to work twice as hard—even at my stage. One important thing that I've really come to value and try to instill in any of my mentees is the question of: What do I bring to the table that is special? When I walk into a room as a black woman and see a black patient sitting there and they ask, "Are you the doctor?" they get so excited. Right? It changes the dynamic instantly. I actually can pick up on some of the social cues that maybe other folks won't. That is a special talent. It's a special privilege that we have. We come from backgrounds that are similar to some patients that, frankly, my white counterparts won't have in the same way. That, in and of itself, is one of the things that allows you to build rapport and allows patients to be more comfortable with the treatments that they are being offered, and then be more willing to engage in the treatment process.

Career Hurdles

Dr Patel: Absolutely. What is perceived as maybe a weakness ends up being a significant strength. It's really a tool to work with.

When you look back on your career, did you ever feel that there were particular hurdles or systematic issues that you had to overcome? Are there things that maybe should have played out differently, or that have changed how you approach the people whom you are mentoring or the advice that you are giving? We all hope for sort of a postracial society, but I don't think we are going to be there unless we keep working really hard.

Dr Winkfield: I was the first person in my family to go to college, like a couple of my mentees who are much younger than me. One gentleman in particular was the first male in his family to graduate from high school. We need to understand the social context, and understand that we are not postracial. There is a huge wealth gap based on race and ethnicity, and we need to figure out how to get it under control. That impacts education. So many talented individuals are in situations where they are not getting the basics.

I was fortunate enough to be in a school system that was very proactive, but then there may be family pressures. My family was not happy when I went to college. You feel these pressures, or they think you are "too good." But that was not it. I really just wanted to help people. There are constraints.

Being someone who's been through that, when people find out that I'm the first person to go to college, [I can tell them that] I did not know what I was doing. It took me 9 years for me to get finished with college. It took me a long time because I loved everything and it was all new. Once you get [to college], how do you focus and find the right mentors along the way? Those are things that I kind of stumbled through, but now I can use that experience to help mentor others.

Dr Patel: The acculturation of how to do it and how to navigate the system is a huge piece. If you do not have anyone to bounce ideas off of—for example, what should I be applying for, and what experience should I strive for?—then you are at a disadvantage. Way too much talent is not coming to our patients and is not changing what we need here.

Physician Shortage Amidst the Need for More Diversity

Dr Rodriguez: Yes. We need more practitioners. We need more oncologists. We know there is a woeful shortage. The population is changing. It's a diverse population, so we need to really focus on trying to bring in some additional people to the program.

Sometimes I have a patient and I ask their kids, "What are you doing?" They say they are in college, and I ask, "What are you looking for?" Sometimes they say, "Maybe nursing." When I ask, "Is that what you want to really do?" they reply, "I would like to be doctor, but I don't know if I can." Usually I say, "Yes, you can. If you want to do it, you can. We're here. If you need help, let me know." They do not see themselves being able to go because nobody else in their family has gone to college. A lot of time, they shortchange themselves. It's important to say, "You can do it."

Dr Winkfield: You brought up a good point, though, about the fact that there is a global shortage of oncologists, and ASCO has stated that. We know that because there is a pipeline issue, if you will, in terms of underrepresented folks who are from backgrounds that are traditionally underrepresented in medicine, it's not going to be fixed.

This problem of having a diverse workforce is not going to be fixed overnight, but it reminds me of that paper by Saha and colleagues[2,3] that came out in JAMA many years ago. It talked about the importance of having diversity in medical school classrooms because it helped to acculturate others next to you. Diversity in medical school classes, oncology training programs, and faculty can actually help. Then others may [come to me and] say, "I had a patient who came in and said they were not interested in getting care." I may say, "Did you ask X,Y, Z?" If they are not from an impoverished background like myself, and if they do not understand the social context that people come from, they might not be asking the right questions. We can help them simply by being present and being a colleague.

What Can Providers Do Now?

Dr Patel: Absolutely. What else can we do to move that needle now? We can get out there and tell our stories, talk to our colleagues about lending a hand up, reach out to medical students, and do some community outreach. Yes?

Dr Winkfield: Yes. Just yes.

Dr Rodriguez: Also, you can volunteer to work on committees for ASCO.

Dr Patel: Owning up to leadership is a huge piece.

Dr Rodriguez: If you see somebody who is volunteering and being a leader, then other people will look up at them and do the same thing.

Dr Winkfield: In the past, some ASCO members tried to volunteer, but there were limited spaces. Now there is a volunteer corps, which we will hear a lot more about, that really broadens the exposure and capacity to volunteer. Community engagement is vital. Even at the state society level, [you can] look around and [ask], where can I have the best and the most impact? Maybe you can find colleges to go to and give talks. It does not have to be anything formal; it can just be a job talk or something about what you do as an oncologist.

Those early exposures are critical because ASCO, as an institution and as an organization, is not going to be able to reach back to kindergarten. We can have an impact at local levels, and then that impact can go even further beyond that. Part of it is using this snowball approach in terms of community engagement.

Dr Rodriguez: At the local level, there are STEM (science, technology, engineering, and mathematics) programs now for minorities, for kids in general, and women. [You could] volunteer at those and talk about oncology which may let them see themselves as doing something different and exciting that could help a lot of people.

Dr Patel: Karen and Gladys, thank you both so much. This has been a great conversation. Hopefully, it will spark a lot of excitement and ideas about next steps we can take. Thank you for joining us today. This is Jyoti Patel, reporting from ASCO 2017.

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