COMMENTARY

#MeToo Era Presents Complex Questions for Oncology

Kathy D. Miller, MD; Reshma Jagsi, MD, DPhil

Disclosures

January 29, 2019

Kathy D. Miller, MD: Hi. I'm Dr Kathy Miller, professor and associate director of clinical research at the Indiana University Simon Cancer Center. Welcome to Medscape Oncology Insights.

Joining me today is Reshma Jagsi. Reshma is professor and deputy chair of radiation oncology at the University of Michigan, where she also directs the Center for Bioethics and Social Sciences in Medicine. Welcome, Reshma.

Reshma Jagsi, MD, DPhil: Thank you. Thanks for having me.

Miller: I wanted to talk to you today about gender equity in medicine in general, but specifically in oncology. That's been an interest you've had for quite a long time. What first got you looking at those issues?

Jagsi: In the way that most research begins, it began with a good mentor. My mentor when I was a resident in training was Nancy Tarbell, who at the time was the head of the Office of Women's Careers at Mass General. I was a young resident beginning my radiation oncology training and really hadn't encountered a whole lot of gender inequity, but Nancy asked me to be part of her committee, and of course I said yes.

I found it fascinating to see the results of a qualitative study that had been commissioned of the culture of the Mass General, and how women were facing unconscious biases and gendered expectations for the division of domestic labor where they were still expected to be the primary caregiver at home and to also be these extraordinary professionals. I became interested in investigating why women were not succeeding or reaching the higher echelons of leadership in our field at the rate that might be expected.

Miller: Tell me about some of the most important things you learned from that early work.

Jagsi: We found that even though women are now 50% of the medical school matriculants—this year was the first year, actually, that the number of women exceeded the number of men matriculating medical school and [women] have represented more than 40% for a quarter of a century now—women are only 16% of medical school department chairs and 16% of medical school deans.[1]

There's a treatment effect, except the treatment is a Y chromosome.

There are complex drivers of that. We have seen in studies of cohorts of women who graduate from medical school that women are less likely to achieve promotions than their male peers. This finding has been criticized by saying that we are comparing apples to oranges because women don't enter academic medicine for the same reasons as men. Maybe men are more likely to enter to pursue scientific discovery and women are more likely to enter to teach the next generation or to practice high-quality care in a collaborative environment. When we see differences in promotions, that's reflecting what medical schools value instead of disparate treatment of similar individuals.

Much of my research is actually focused on K awardees, recipients of prestigious National Institutes of Health Career Development Awards, who absolutely have the desire, potential, and aptitude to be independent scholars. We have still seen differences in that population.

Miller: There's an important population because, having written a K award very early in my career, you have to be dedicated to research to even think about submitting a K award. So it was a way of looking at apples and apples, just different gender.

Jagsi: Right—a group that Larry Summers himself couldn't argue was any less bright or any less motivated. It's a highly competitive process, as you know.

Miller: And still a different trajectory.

Jagsi: Very different trajectory. We actually plotted these out like we do actuarial survival curves in oncology. The curves separate like there's a treatment effect, except the treatment is a Y chromosome. Unfortunately, women are less likely, when they've had these K awards, to go on to achieve independent grants. They're compensated less well even after you control for their productivity and many other factors. They're less likely to go on to achieve promotions, be retained in academia, and so forth. We needed to understand the drivers of these differences.

Miller: While you were focusing on these inequities and the drivers within the profession, the work shifted about a year ago. You define a world shift these days by whether it gets a hashtag that everybody knows, and we are now firmly in the #MeToo era. Have you seen evidence of that sort of treatment in your work?

Jagsi: Yes. Actually, we asked about this on the very last page of a 12-page survey about sexual harassment.[2] I will admit that it sounds naive now, but this was several years ago, before #MeToo, that I actually thought that this battery of questions was going to allow me to show some good news. I replicated questions that were asked in a 1995 survey, where they had shown in a cross-sectional sample of medical faculty that over half of the women had experienced sexual harassment from a superior colleague during their careers.[3]

I replicated these questions and thought we would show that there are so many other really thorny challenges, and that can be depressing to see, so let's also show that there has been progress. [I thought] this was going to be my good news. Well, it was better—it wasn't 50%, it was 30%—but it was still 30% of the women. This was a Generation X cohort of K awardees.

Miller: These were recent events. These were not women nearing retirement and recalling their days as an intern.

Jagsi: And these were among women who attended medical school when the medical school class was over 40% female. The social scientists tell us that sexual harassment is more common when women are underrepresented in a profession. These are events that happened since women became a substantial share of the medical student body.

Miller: So much for good news. What drivers have you identified because, particularly with the focus on #MeToo, it feels like we had barriers—unconscious or conscious—before. Now, getting mentorship, getting into the best labs, and being able to advance has an even bigger barrier in that men are reluctant to enter into those relationships lest they be misperceived.

Jagsi: The good news is that the #MeToo movement has begun a very important conversation that is long overdue, and policy windows have opened up to address the drivers of this behavior. The other good news is that occupational psychologists have been studying this for decades, and there are good lessons from social science on what predisposes organizations and environments to sexual harassment. We can learn from that, and one of the most important things is a perception of organizational tolerance.

Thank you for making it clear that I'm not aberrational and it's not my fault; this happens to other people.

By becoming engaged and institutions saying, "We will not tolerate this behavior, these are the sanctions that we apply to transgressors, and these are the mechanisms for reporting," there is an opportunity to decrease the incidence of harassment. It's also critically important for women to share equally in power and authority for a profession to overcome sexual harassment. We have those wonderful lessons, but you're absolutely right that there is a very real danger of men pulling back. We know that sponsorship is so important for women's success and for everyone's success.

Miller: You mentioned being here because of an early mentor who happened to be a woman. My two earliest mentors were both men. I do wonder whether if I was that medical student/resident/junior faculty member now, would they have felt able to give me the same time, which was often very personal, one on one, and did not raise to any level of harassment or being uncomfortable, but might have given people that impression just by the time that we spent together.

Jagsi: We have to be very careful that we are not robbing women of the opportunity to learn from the men who are in the senior positions. Again, 16% of department chairs and 16% of deans are women. That means that the vast majority of individuals who are in positions of power who can be mentors, and particularly, who can be sponsors—this idea of giving a protégé an opportunity by putting a little bit of your own reputation on the line.

There are fewer women who are in positions of power and authority who are able to serve as sponsors. Women critically need those sponsors. We can't enter an era where men are afraid of informal interactions with women so they allocate those sponsorship opportunities to other men.

Miller: Where is the middle ground here for the fellow in radiation oncology, the new junior faculty member in your area, who happens to have two X chromosomes? What's your best advice to them? How do they navigate this tricky relationship?

Jagsi: Some of the great advice comes out of the recent National Academies' report on sexual harassment.[4] One of the things that is very important is building a network of mentors. One of the things that predisposes to the risk for harassment is if you're very highly dependent on a single mentor who has considerable power over you in a hierarchical relationship.

In recent years, we have come to learn how important peer mentorship is, how different individuals can serve different needs for mentorship, and how junior faculty in medicine actually have so many diverse needs that they probably aren't ideally served by a single individual anyway. This idea of building a network of mentors is something that junior faculty can proactively engage in, and it actually helps to reduce the risk for harassment and promote their careers.

Miller: Particularly given the breadth of their needs. That's advice equally suitable to junior members of our profession who happen to have Y chromosomes. They need diverse mentors as well. What about for the senior men? I imagine that many of them have done a bit of soul-searching and may have wondered if had they ever crossed lines, not realizing that someone was uncomfortable or felt in a difficult situation. Where do they go? How do they answer those questions for themselves?

Jagsi: I think this moment of introspection is a really important one for our society. After I wrote the research paper about sexual harassment in JAMA a couple of years ago,[1] I got a lot of emails from women telling me their stories and saying, "Thank you for making it clear that I'm not aberrational and it's not my fault; this happens to other people." Those stories ended up being collected into an essay I wrote in the New England Journal more recently.[5]

After that, I got a lot of emails from men. The men often were introspecting on their own behaviors. For example, one said to me, "I'm a hugger. I hug people when I haven't seen them in a really long time. All I can think, as the father of a high-achieving young woman and someone who's really been a champion of gender equity, is, 'Oh my goodness, I wonder if I've made other people feel uncomfortable. I feel so bad.'" And he concluded with, "I'll never hug anyone again."

Miller: Probably not the right response.

Jagsi: Not the right response, right. I emailed him back and I said, "I better get a hug at the next meeting or I'll be offended." His hugs have never made me feel uncomfortable. I think that men need to recognize that the behaviors we're talking about as sexual harassment are not the friendly, collegial behaviors that a true avuncular leader in the field might exhibit. The behaviors that make women feel uncomfortable are ones that truly come from ill intent.

There is some room for misinterpretation, and I think people have to be careful. I also think that we have to be very careful that the pendulum doesn't shift so far that we distance ourselves from one another, particularly if we are not of the same sex, because that's going to have negative consequences for women.

Miller: Well, unfortunately we have a model of that. We have the vice president of our country who says, "To avoid misperceptions, to avoid putting myself and others in that position, I will not share a meal alone with a woman who is not my wife." I think this means that if you're a woman on his staff, you are at a disadvantage because he didn't say, "I won't share a meal with any junior people in my staff alone." It was only women, so they had to have been at a disadvantage.

Jagsi: Absolutely, because when one has a sponsorship opportunity to allocate, for example, in academic medicine, it might be that I'm invited to go speak at a prominent meeting and I can't make it because I have a competing and conflicting commitment. I say, "You should invite so-and-so and they'll do just as good a job or even better. I know you usually invite someone senior, but invite so-and-so, my protégé. I promise they'll do a great job."

I put a little bit of my reputation on the line by doing that. I make that opportunity available. Who comes to mind as that protégé—probably the person I had a beer with last night rather than the person I only see in the workplace.

Miller: [These are] going to continue to be important discussions. Honestly, it is a bit sad that it took a hashtag to get us to have these discussions, but thank you for your role in this over the years and for helping us navigate this minefield.

Jagsi: Thank you. Thank you for the excellent discussion.

Miller: Thank you for joining us. This is Dr Kathy Miller for Medscape.

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