Increasing the pool of academically oriented African-American medical and surgical oncologists

Evaluating the Importance of Mentoring in Undergraduate Research Education Programs

The National Institute of Health R25 Research Education Program was evaluated in the second year of implementation. Twelve mentors and 20 underrepresented minority students (URMs) scholars from partnerships and collaborations among five colleges and universities were added to the program to provide a more diverse research experience. Findings reveal that 100% of research mentors agree that the approachableness and accessibility of the program coordinator were beneficial in achieving mentorship goals and objectives. In addition, 85% of the students strongly agreed that the presentation of their research findings and the weekly reflection on goals, identification of accomplishments, and obstacles through the individual development plan were very effective. Of the 23 successfully tracked students for 2 years, six URMs (26.09%) obtained a bachelor's degree and were admitted into a graduate program; two were directly admitted to a PhD program in biomedical sciences.

Problematic Integration: Racial Discordance in End-of-Life Decision Making

We describe racially discordant oncology encounters involving EOL decision-making. Fifty-eight provider interviews were content analyzed using the tenets of problematic integration theory. We found EOL discussions between non-Black providers and their Black patients were often complex and anxiety-inducing. That anxiety consisted of (1) ontological uncertainty in which providers characterized the nature of Black patients as distrustful, especially in the context of clinical trials; (2) ontological and epistemological uncertainty in which provider intercultural incompetency and perceived lack of patient health literacy were normalized and intertwined with provider assumptions about patients' religion and support systems; (3) epistemological uncertainty as ambivalence in which providers' feelings conflicted when deciding whether to speak with family members they perceived as lacking health literacy; (4) divergence in which the provider advised palliative care while the family desired surgery or cancer-directed medical treatment; and (5) impossibility when an ontological uncertainty stance of Black distrust was seen as natural by providers and therefore impossible to change. Some communication strategies used were indirect stereotyping, negotiating, asking a series of value questions, blame-guilt framing, and avoidance. We concluded that provider perceptions of Black distrust, religion, and social support influenced their ability to communicate effectively with patients.

Trends in Leadership Among Neurosurgical Oncology Fellowships

OBJECTIVE

To examine current neurosurgical oncology leadership trends and provide a guide for those interested in obtaining fellowship directorship, we investigated fellowship director (FD) demographic, educational, and leadership characteristics.

METHODS

The American Association of Neurological Surgeons Academic Fellowship Directory and Committee on Advanced Subspecialty Training websites were reviewed for current U.S. program FDs for which data were collected using online resources and surveys.

RESULTS

In total, 23 FDs (20 male and 3 female) were represented whose mean age was 52.4 years (standard deviation = 8.7). Our analysis found 65% of current neurosurgical oncology FDs to be singularly trained in neurosurgical oncology, with 8.7% possessing multiple fellowships and 34.8% possessing additional degrees. Fellowship programs producing the most FDs were University of Texas MD Anderson (4), Memorial Sloan Kettering (3), and University of Miami (2). FDs possessed an average of 148 publications, 6423 citations, and an h-index of 33.9. H-index had a high-positive correlation with age and time from residency graduation but not duration of FD appointment. Among survey respondents, 91.7% reported membership and 75% reported leadership positions among national academic societies, whereas 66.7% reported holding journal-editorial positions. The mean age of FD appointment was 46.8 years, with a mean time from fellowship completion to FD appointment of 10.0 years.

CONCLUSIONS

Through the characterization of current leaders in the field, we provide valuable information with regards to training location trends, research productivity goals, career timelines, and target journal/national academic society involvement worth consideration among young trainees when making career decisions and plans.

Assessing the Prevalence of Microaggressions in Plastic Surgery Training: A National Survey

There has been increased awareness of microaggressions occurring during medical training. However, the prevalence and characteristics of microaggressions specifically in plastic surgery residency remain unknown. We aimed to fill this literature gap by conducting a nationwide survey to better understand and characterize microaggressions in plastic surgery training.

METHODS

A survey was distributed between March and May 2021 via the American Society of Plastic Surgeons Resident Representatives to 1014 integrated and 214 independent track plastic surgery trainees in the United States. Multiple Pearson's chi-square of independence and Fisher exact tests evaluated comparisons of microaggressions by sex, race, Hispanic origin, sexual orientation, and year in training. A multivariate regression analysis assessed associations between variables.

RESULTS

One hundred twenty-five participants responded to the survey (response rate: 10.2%). Of those who responded, 68.8% had experienced microaggressions in the past year. Female trainees experienced microaggressions more frequently than male trainees (P < 0.05). Asian trainees had higher odds to be a target of microaggressions compared with White trainees (P = 0.013). Nonheterosexual trainees were more likely to have experienced microaggressions compared with heterosexual trainees (P < 0.05). Independent trainees were more likely to experience microaggressions than PGY 1-2 and 3-4 integrated residents (P < 0.05).

CONCLUSIONS

Approximately seven in every 10 trainees stated that they experienced microaggressions in the past year. Females, racial minorities, sexual minorities, and independent trainees had higher odds of reporting that they experienced microaggressions. Further studies are needed to assess the implementation of strategies that address this problem to resolve inequities.

Cultural Complications Curriculum: Applicability to Surgical Oncology Programs and Practices

Background

Recognizing the need to raise awareness of core diversity, equity, and inclusion (DEI) issues in the healthcare system, our previously developed Cultural Complications Curriculum aims to support institutions in reducing cultural error. As we continue program deployment, we discuss the opportunity to apply the Cultural Complications Curriculum to multidisciplinary audiences, such as in cancer programs.

Methods

We discuss applicability of the Cultural Complications Curriculum to cancer programs and practices, including how to tailor case discussions to oncology audiences. By emphasizing the unique characteristics of the multidisciplinary care environment and anticipating potential barriers to curriculum implementation, we demonstrate how the Cultural Complications Curriculum may support culture improvement across broad audiences.

Results

The successful application of the Cultural Complication Curriculum to multidisciplinary care programs will depend on appreciating differences in background knowledge, tailoring discussions to audience needs, and adapting material by incorporating new data and addressing emerging DEI issues. Multidisciplinary environments may require innovative approaches to education including virtual platforms, increased collaboration across centers and systems, and support from professional societies. In integrated care environments, like oncology, effective DEI discussions call for the engagement of a variety of medical specialties and departments.

Conclusions

To meet the needs of an increasingly diverse patient population and workforce, our approach to DEI education must embrace the interdependent nature of care delivery. In oncology and other multidisciplinary care environments, application of the Cultural Complications Curriculum may be the first step to combating cultural error by engaging a broader demographic within our healthcare system.

Affirmative action programmes in postgraduate medical and surgical training-A narrative review

OBJECTIVE

This review aims to identify and summarise the literature pertaining to the implementation of affirmative action programmes (AAP) for selection of ethnic minorities and Indigenous peoples into selective specialist medical and surgical training programmes.

METHODS

A systematic literature search was conducted to identify relevant studies reporting on the background, implementation and results of AAP for ethnic minorities and Indigenous peoples into medical and surgical training. MEDLINE, EMBASE, PubMed, Scopus and Google Scholar databases were queried from inception through to 1 February 2020. All included studies were subjected to inductive thematic analysis in order to systematically collate study findings. Articles were read through several times in an iterative manner to allow the identification of themes across the included studies. The themes were cross-compared among the authors to establish their interconnectedness.

RESULTS

Forty-five articles described AAP pertaining to ethnic minorities in the United States of America (African-Americans and Hispanic Americans), women and ethnic minorities, Indigenous peoples (New Zealand Māori) and people with low socio-economic status. Four themes were identified. These included the need for social responsiveness in clinical training organisations, justification and criticism of AAP, how clinical training agencies should participate in AAP and what constitutes an effective AAP for specialist medical and surgical training.

CONCLUSIONS

Affirmative action programmes have been effective at increasing numbers of ethnic minority medical school graduates but have not been used for specialist medical or surgical training selection. AAP achieve the best results when they are associated with a comprehensive programme of candidate preparation, support and mentorship beginning prior to application, and support and mentorship extending through training and subsequently into the post-training period as an independent professional. The overall aim of any AAP in medical or surgical training must be graduation of significant numbers of minority and Indigenous trainees into successful practice with appointment to faculty member and leadership positions.

The Health Equity Scholars Program: Innovation in the Leaky Pipeline

Despite attempts to increase enrollment of under-represented minorities (URMs: primarily Black/African American, Hispanic/Latino, and Native American students) in health professional programs, limited progress has been made. Compelling reasons to rectify this situation include equity for URMs, better prepared health professionals when programs are diverse, better quality and access to health care for UMR populations, and the need for diverse talent to tackle difficult questions in health science and health care delivery. However, many students who initiate traditional "pipeline" programs designed to link URMs to professional schools in health professions and the sciences, do not complete them. In addition, program requirements often restrict entry to highly qualified students while not expanding opportunities for promising, but potentially less well-prepared candidates. The current study describes innovations in an undergraduate pipeline program, the Health Equity Scholars Program (HESP) designed to address barriers URMs experience in more traditional programs, and provides evaluative outcomes and qualitative feedback from participants. A primary outcome was timely college graduation. Eighty percent (80%) of participants, both transfer students and first time students, so far achieved this outcome, with 91% on track, compared to the campus average of 42% for all first time students and 58-67% for transfers. Grade point averages also improved (p = 0.056) after program participation. Graduates (94%) were working in health care/human services positions and three were in health-related graduate programs. Creating a more flexible program that admits a broader range of URMs has potential to expand the numbers of URM students interested and prepared to make a contribution to health equity research and clinical care.

A disparity of words: racial differences in oncologist-patient communication about clinical trials

BACKGROUND

African Americans are consistently underrepresented in cancer clinical trials. Minority under-enrolment may be, in part, due to differences in the way clinical trials are discussed in oncology visits with African American vs. White patients.

OBJECTIVE

To investigate differences in oncologist-patient communication during offers to participate in clinical trials in oncology visits with African American and White patients.

METHODS

From an archive of video-recorded oncology visits, we selected all visits with African American patients that included a trial offer (n = 11) and a matched sample of visits with demographically/medically comparable White patients (n = 11). Using mixed qualitative-quantitative methods, we assessed differences by patient race in (i) word count of entire visits and (ii) frequency of mentions and word count of discussions of clinical trials and key elements of consent.

RESULTS

Visits with African American patients, compared to visits with White patients, were shorter overall and included fewer mentions of and less discussion of clinical trials. Also, visits with African Americans included less discussion of the purpose and risks of trials offered, but more discussion of voluntary participation.

DISCUSSION AND CONCLUSIONS

African American patients may make decisions about clinical trial participation based on less discussion with oncologists than do White patients. Possible explanations include a less active communication style of African Americans in medical visits, oncologists' concerns about patient mistrust, and/or oncologist racial bias. Findings suggest oncologists should pay more conscious attention to developing the topic of clinical trials with African American patients, particularly purpose and risks.

Diversity by race, Hispanic ethnicity, and sex of the United States medical oncology physician workforce over the past quarter century

PURPOSE

To assess the medical oncology (MO) physician workforce diversity by race, Hispanic ethnicity, and sex, with attention to trainees.

METHODS

Public registries were used to assess 2010 differences among MO practicing physicians, academic faculty, and fellows; internal medicine (IM) residents; and the US population, using binomial tests with P < .001 significance adjusting for multiple comparisons. Significant changes in fellow representation from 1986 to 2011 were assessed.

RESULTS

Female representation as MO fellows (45.0%) was significantly increased compared with faculty (22.4%) and practicing physicians (27.4%); was no different than IM residents (44.7%, P = .853); and increased significantly, by 1.0% per year. Women were significantly underrepresented as practicing physicians, faculty, and fellows compared with the US population (50.8%). Traditionally underrepresented minorities in medicine (URM) were significantly underrepresented as practicing physicians (7.8%), faculty (5.7%), and fellows (10.9%), versus US population (30.0%). Hispanic MO fellows (7.5%) were increased compared with faculty (3.9%) and practicing physicians (4.1%); Black fellows (3.1%) were no different than faculty (1.8%, P = .0283) or practicing physicians (3.5%, P = .443). When comparing MO fellows versus IM residents, there were no differences for American Indians/Alaska Natives/Native Hawaiians/Pacific Islanders (0.3%, 0.6%, respectively, P = .137) and Hispanics (7.5%, 8.7%, P = .139), unlike Blacks (3.1%, 5.6%, P < .001). There has been no significant change in URM representation, with negligible changes every 5 years for American Indians/Alaska Natives/Native Hawaiians/Pacific Islanders (-0.1%), Blacks (-0.3%), and Hispanics (0.3%).

CONCLUSIONS

Female fellow representation increased 1% per year over the quarter century indicating historical gains, whereas URM diversity remains unchanged. For Blacks alone, representation as MO fellows is decreased compared with IM residents, suggesting greater disparity in MO training.

Minority Underrepresentation in Academia: Factors Impacting Careers of Surgery Residents

BACKGROUND

Underrepresentation of minorities within academic surgery is an ever present problem with a profound impact on healthcare. The factors influencing surgery residents to pursue an academic career have yet to be formally investigated. We sought to elucidate these factors, with a focus on minority status.

METHODS

A web-based questionnaire was sent to all administered to all ACGME-accredited general surgery programs in the United States. The main outcome was the decision to pursue a fully academic versus non-academic career. Multivariable logistic regression was used to identify characteristics impacting career choice.

RESULTS

Of the 3,726 residents who received the survey, a total of 1,217 residents completed it - a response rate of 33%. Forty-seven percent planned to pursue non-academic careers, 35% academic careers, and 18% were undecided. There was no association between underrepresented minority status and academic career choice (Odds Ratio = 1.0, 95% Confidence Interval 0.6 - 1.6). Among all residents, research during training (OR=4.0, 95% CI 2.7-5.9), mentorship (OR=2.1, 95% CI 1.6-2.9), and attending a residency program requiring research (OR=2.3, 95% CI 1.5-3.4) were factors associated with choosing an academic career. When the analysis was performed among only senior residents (i.e., 4^th and 5^th year residents), a debt burden >$150,000 was associated with choosing a non-academic career (OR=0.4, 95% CI 0.1-0.9).

CONCLUSIONS

Underrepresented minority status is not associated with career choice. Intentional recruitment of minorities into research-oriented training programs, increased mentorship and research support among current minority residents, and improved financial options for minorities may increase the number choosing an academic surgical career.

Life-Threatening Disparities: The Treatment of Black and White Cancer Patients

Cancer mortality and survival rates are much poorer for Black patients than for White patients. We argue that Black-White treatment disparities are a major reason for these disparities. We examine three specific kinds of Black-White treatment disparities: disparities in information exchange in oncology interactions, disparities in the treatment of breast cancer, and disparities in the treatment of clinically localized prostate cancer. In the final section, we discuss possible causes of these disparities, with a primary focus on communication within medical interactions and the role that race-related attitudes and beliefs may play in the quality of communication in these interactions.

Strategies for diversifying the pool of graduate students in biomedical sciences

As part of our National Cancer Institute-sponsored partnership between New Mexico State University and the Fred Hutchinson Cancer Research Center, we implemented the cancer research internship for undergraduate students to expand the pipeline of underrepresented students who can conduct cancer-related research. A total of 21 students participated in the program from 2008 to 2011. Students were generally of senior standing (47%), female (90 %), and Hispanic (85 %). We present a logic model to describe the short-, medium-, and long-term outputs of the program. Comparisons of pre- and post-internship surveys showed significant improvements in short-term outputs including interest (p<0.001) and motivation (p<0.001) to attend graduate school, as well as preparedness to conduct research (p=0.01) and write a personal statement (p=0.04). Thirteen students were successfully tracked, and of the nine who had earned a bachelor's degree, six were admitted into a graduate program (67 %), and four of these programs were in the biomedical sciences.

Training residents to address cancer health disparities

INTRODUCTION

Cancer is the source of significant morbidity and mortality in the United States, and eliminating cancer-related racial and ethnic disparities has become an ever-increasing focus of public health efforts. Increasing workforce diversity plays a major role in the reduction of health disparities, and a well-trained professional workforce is essential for the prevention, control, and ultimate elimination of this disease.

METHODS

To help address this need, the Public Health/General Preventive Medicine residency program at Morehouse School of Medicine (MSM) developed an innovative Cancer Prevention and Control Track (CPCT). We describe the structure of the track, funding, examples of resident activities, and program successes.

RESULTS

Since the development of the track in 2007, there have been 3 graduates, and 2 residents are currently enrolled. Residents have conducted research projects and have engaged in longitudinal community-based activities, cancer-focused academic experiences, and practicum rotations. There have been 3 presentations at national meetings, 1 research grant submitted, and 1 research award.

CONCLUSION

The CPCT provides residents with comprehensive cancer prevention and control training with emphasis in community engagement, service, and research. It builds on the strengths of the diversity training already offered at MSM and combines resources from academia, the private sector, and the community at large.

Voices of Diversity in Midwifery: A Qualitative Research Study

The practice of midwifery reflects the spectrum of diversity among midwives and the women they serve, yet the composition of midwives in ACNM does not reflect the diversity of the women for whom they provide care. Providing culturally appropriate care for women requires our best understanding of their beliefs, needs, and desires; it also requires a wide range of diverse clinicians. This study proposed to learn more about the practice of midwifery from a diverse sample of midwives. A qualitative research design, which included small group interviews, videotape collection of data, and content analysis, was used. Four major themes were identified: 1) the worldview of midwifery through the lens of diversity, 2) the experience of diversity, 3) midwifery strategies rooted in diversity, and 4) the legacy for the profession of midwifery. There must be purposeful action by every individual in the profession, as well as the collective voice of midwifery, to identify barriers to inclusiveness and to foster a culture of diversity through respect, recruitment, and mentoring.

Racial, ethnic and socioeconomic disparities in the treatment of brain tumors

Disparities in American health care based on socially-defined patient characteristics such as race, ethnicity, and socioeconomic position are well-documented. We review differences and disparities in incidence, pathobiology, processes and outcomes of care, and survival based on social factors for brain tumors of all histologies. In the US, black patients have lower incidences of most brain tumor types and lower-income patients have lower incidences of low grade glioma, meningioma and acoustic neuroma; ascertainment bias may contribute to these findings. Pathogenetic differences between malignant gliomas in patients of different races have been demonstrated, but their clinical significance is unclear. Patients in disadvantaged groups are less often treated by high-volume providers. Mortality and morbidity of initial treatment are higher for brain tumor patients in disadvantaged groups, and they present with markers of more severe disease. Long term survival differences between malignant glioma patients of different races have not yet been shown. Clinical trial enrollment appears to be lower among brain tumor patients from disadvantaged groups. We propose future research both to better define disparities and to alleviate them.

Mentoring early-career scientists for HIV research careers

Mentoring is important for early-career HIV researchers; it is key for work satisfaction, productivity, workforce diversity, and retention of investigators in a variety of research settings. Establishment of multidisciplinary research projects often is accomplished through mentoring. The work of early-career HIV investigators frequently requires networks of collaborators, and networking is regularly facilitated by mentors. A structured mentoring program that avoids unnecessary conflicts or time burdens and connects early-career investigators with senior mentors from different disciplines may stimulate new networking possibilities and lead to effective collaborations among investigators with different skills and perspectives. Effective mentoring by focused mentors will likely contribute to the skills and networks of investigators necessary for the next generation of HIV investigators.

Development, implementation, and assessment of a lecture course on cancer for undergraduates

The war on cancer has been waged for nearly 40 years, yet the cancer burden remains high, especially among minority and underserved populations. One strategy to make strides in the war on cancer and its disparate impacts is to increase the diversity of the cancer research workforce. We describe an approach to recruit a diverse population of future cancer researchers from an undergraduate student population at a minority-serving land-grant institution. Specifically, we have addressed the following questions: Given the dearth of published reports of undergraduate cancer courses, is it possible for undergraduates at a land-grant institution (rather than a research or medical institution) to successfully learn cancer biology from a lecture-based course? Can we develop a template that has the potential to be used by others to develop and implement an undergraduate cancer course? Can such a course stimulate interest in careers in cancer research? Based on a learning gains analysis, students were able to learn cancer content and related skills, and based on student surveys, students' interest in cancer research was stimulated by course participation. We have identified aspects of our course development process that were critical for the successful development, implementation, and assessment of the course.

Mentoring surgeons for the 21st century

BACKGROUND

Effective mentoring is especially critical in the training of surgeons. The practice of surgery in the 21st century is changing rapidly at every level, requiring a more complex approach to mentoring young surgeons.

METHODS

This article draws on the author's own experiences in mentoring surgeons at a large tertiary care cancer treatment center and on published reports of successful mentoring strategies at other institutions.

RESULTS

Besides clinical and surgical skills, surgical trainees must acquire a broad range of technical, interpersonal, administrative, and research skills. The 21st century brings special demands, including changing treatment patterns, increased diversity in trainees and in patient populations, restrictions on how we train our students, increased concerns about patient privacy, and an aging population. Besides the classic mentor/mentee relationship, different models of mentoring, including mosaic mentoring and collaborative mentoring, are being used to address these issues. Successful mentoring programs occur in institutions that maintain a culture that actively supports mentoring.

CONCLUSIONS

New approaches to mentoring can successfully meet the diverse needs of surgical trainees in the 21st century.

Effect of two Howard Hughes Medical Institute research training programs for medical students on the likelihood of pursuing research careers

PURPOSE

To assess the effect of Howard Hughes Medical Institute's (HHMI) two one-year research training programs for medical students on the awardees' research careers.

METHOD

Awardees of the HHMI Cloister Program who graduated between 1987 and 1995 and awardees of the HHMI Medical Fellows Program who graduated between 1991 and 1995 were compared with unsuccessful applicants to the programs and MD-PhD students who graduated during the same periods. Logistic regression analyses were conducted to assess research career outcomes while controlling for academic and demographic variables that could affect selection to the programs.

RESULTS

Participation in both HHMI programs increased the likelihood of receiving National Institutes of Health postdoctoral support. Participation in the Cloister Program also increased the likelihood of receiving a faculty appointment with research responsibility at a medical school. In addition, awardees of the Medical Fellows Program were not significantly less likely than Medical Scientist Training Program (MSTP) and non-MSTP MD-PhD program participants to receive a National Institutes of Health postdoctoral award, and awardees of the Cloister Program were not significantly less likely than non-MSTP MD-PhD students to receive a faculty appointment with research responsibility. Women and underrepresented minority students were proportionally represented among awardees of the two HHMI programs whereas they were relatively underrepresented in MD-PhD programs.

CONCLUSIONS

The one-year intensive research training supported by the HHMI training programs appears to provide an effective imprinting experience on medical students' research careers and to be an attractive strategy for training physician-scientists.