I Can't Breathe: The Continued Disproportionate Exclusion of Black Physicians in the United States Radiation Oncology Workforce

A systematic review of barriers to pursuing careers in medicine among Black premedical students

Among the various etiologies of the exclusion of Black male physicians from the healthcare workforce, it is critical to identify and examine the barriers in their trajectory. Given that most medical school matriculants graduate and pursue residency training, medical school admission has been identified as the primary impediment to a career in medicine. Thus, this work aims to identify barriers in the journey of primarily Black, and secondarily underrepresented minority, premedical students. A systematic review of the medical literature was conducted for articles pertaining to the undergraduate/premedical period, Black experiences, and the medical school application process. The search yielded 5336 results, and 13 articles were included. Most papers corroborated common barriers, such as financial/socioeconomic burdens, lack of access to preparatory materials and academic enrichment programs, lack of exposure to the medical field, poor mentorship/advising experiences, systemic and interpersonal racism, and limited support systems. Common facilitators of interest and interventions included increasing academic enrichment programs, improving mentorship and career guidance quality and availability, and improving access to and availability of resources as well as exposure opportunities. No article explicitly discussed addressing racism. There is a dearth of studies exploring the premedical stage-the penultimate point of entry into medicine. Though interest in becoming a physician may be present, multiple and disparate impediments restrict Black men's participation in medicine. Addressing the barriers Black and underrepresented minority premedical students face requires an awareness of how multiple systems work together to discriminate and restrict access to careers in medicine beyond the traditional pipeline understanding.

Assessment of Student Perceptions of Aspects of a Career in Radiation Oncology

PURPOSE

To determine medical students' views of various aspects of a career in radiation oncology (RO) to identify areas that may benefit from reform and to guide initiatives to stimulate broader and more diverse student interest in the specialty.

METHODS AND MATERIALS

An electronic survey was sent to student oncology interest group members at seven US medical schools. The survey asked students to rate 19 aspects of RO on a 5-point bipolar Likert-type scale. Descriptive statistics are reported, along with subgroup analyses based on participants' demographics.

RESULTS

The response rate was 51.1% (n = 275 of 538). The most favorably rated aspects of RO were outpatient working hours (mean ± SD Likert-type rating of 4.51 ± 0.82), routinely working with other physicians (4.45 ± 0.76), and use of advanced technology to treat patients. The most unfavorably rated aspects of RO were less geographic flexibility for residency or employment (1.98 ± 1.04), spending a lot of time on a computer doing treatment planning (2.80 ± 1.21), and having a job that is not well understood by most doctors and the general public (2.89 ± 1.02). Gender was associated with significant differences in 8 of 19 questions in how each aspect of RO was viewed. Few differences were observed based on race or ethnicity, though Asian participants had a significantly more favorable view of RO being a more science-oriented specialty compared with White or underrepresented students, respectively (3.50 versus 3.21 versus 2.84, P = .01).

CONCLUSIONS

These findings inform the RO community in the development of more effective initiatives to encourage students to fully explore the specialty.

The Concerning Disaggregation of Gender and Racial/Ethnicity Disparity Investigation at Recent ASCO Annual Meetings

OBJECTIVES

There has been a recent emphasis in the peer-reviewed oncology literature on examining disparities by gender. Such emphasis provides an excellent opportunity to simultaneously examine race/ethnicity disparities in the same cohort. The degree to which gender disparities research has been performed concomitantly with racial disparities research at prominent oncologic societies has yet to be investigated.

METHODS

ABSTRACTs presented at the American Society of Clinical Oncology (ASCO) annual meeting were reviewed. Abstracts selected for the oral abstract or clinical science symposium sessions at the 2020, 2021, and 2022 annual meetings were evaluated to determine the amount of gender disparities research presented. Such research was further assessed to determine whether racial/ethnicity disparities were examined simultaneously.

RESULTS

From 2020 to 2022, 1219 abstracts were presented at the ASCO annual meetings, oral abstract or clinical science symposium sessions. Of these, 7 involved gender disparities examination, of which only 2 (29%) concomitantly examined race/ethnicity. No study since 2020 concomitantly examined gender and racial disparities.

CONCLUSIONS

More than 70% of gender disparities work presented at ASCO has been disaggregated from concomitant racial disparities examination, with complete disaggregation since 2021. Gender disparities work remains a miniscule aspect of the overall research landscape. Future work in examining gender disparities may be best aggregated with racial/ethnicity disparities to optimize timely solutions in both areas; such work could potentially be incentivized from the inclusion criteria of future funding mechanisms.

The National Cancer Institute's Cancer Disparities Research Partnership Program: a unique funding model 20 years later

The burden of cancer and access to effective treatment are not experienced equally by all in the United States. For underserved populations that often access the health-care system when their cancers are in advanced disease stages, radiation oncology services are essential. In 2001, the National Cancer Institute's (NCI's) Radiation Research Program created and implemented the Cancer Disparities Research Partnership Program (CDRP). CDRP was a pioneering funding model whose goal was to increase participation of medically underserved populations in NCI clinical trials. CDRP's Cooperative Agreement funding supported for awardees the planning, development, and conduct of radiation oncology clinical research in institutions not traditionally involved in NCI-sponsored research and cared for a disproportionate number of medically underserved, health-disparities populations. The awardee secured and provided support for mentorship from 1 of 2 NCI comprehensive cancer centers named in its application. Six CDRP awards were made over two 5-year funding periods ending in 2013, with the end-of-program accomplishments previously reported. With the current focus on addressing equity, diversity, and inclusion, the 6 principal investigators were surveyed, 5 of whom responded about the impact of CDRP on their institutions, communities, and personal career paths. The survey that was emailed included 10 questions on a 5-point Likert scale. It was not possible to collect patient data this long after completion of the program. This article provides a 20-year retrospective of the experiences and observations from those principal investigators that can inform those now planning, building, and implementing equity, diversity, and inclusion programs.

The 2021 ACR/Radiology Business Management Association Workforce Survey: Diversity in Radiology

The landscape of the radiology workforce is changing, especially in the diversity of the demographics of practicing radiologists across subspecialties, practice types, and leadership positions in both academic and nonacademic settings. The 2021 ACR/Radiology Business Management Association Workforce Survey examines these facets in detail and contributes to our understanding of the current state of diversity in the radiology workforce and potential barriers to change. The results suggest opportunities and future directions for improving diversity, equity, and inclusion.

Oncology Physician Workforce Diversity: Rationale, Trends, Barriers, and Solutions

ABSTRACT

This chapter will discuss (1) the rationale for physician workforce diversity and inclusion in oncology; (2) current and historical physician workforce demographic trends in oncology, including workforce data at various training and career levels, such as graduate medical education and as academic faculty or practicing physicians; (3) reported barriers and challenges to diversity and inclusion in oncology, such as exposure, access, preparation, mentorship, socioeconomic burdens, and interpersonal, structural, systemic bias; and (4) potential interventions and evidence-based solutions to increase diversity, equity, and inclusion and mitigate bias in the oncology physician workforce.

URM: Underrepresented or Underrecognized? A Case Study of Black Pediatric Critical Care Physicians

PURPOSE

This study explored Black physicians' experience via an antideficit lens to gain new ideas for advancing minoritized physicians in academic medicine more broadly. Increasingly, systemic racism in academic medicine is intentionally acknowledged and named. However, many solutions to tackle racism and the overall paucity of Black physicians use a deficit framing, painting Black physicians and trainees as lacking preparation, interest, or experience and qualifications. Such solutions aim to help Black people assimilate into the "White Space" of academic medicine, rather than focusing on Black people's strengths.

METHOD

This qualitative study included 15 Black physicians and trainees in pediatric critical care medicine (PCCM) from across the country who participated in semistructured interviews. Through an antideficit lens, the researchers examined the social, cultural, and structural contexts influencing the participants' individual experiences. They analyzed the data combining thematic and narrative qualitative analysis approaches, including restorying.

RESULTS

The data help promote understanding of the landscape and context in which Black PCCM physicians become successful. Achievement took on different forms for the participants. Participants described enablers of achievement that supported them through their individual journeys spanning 3 general domains-intrinsic, interpersonal, and systemic. Three additional enablers were tied specifically to participants' Black identities-harnessing Blackness as a superpower, leaning in to lead, and successfully navigating the "unwritten rules."

CONCLUSIONS

By using an antideficit framework, this study delineates and centers participants' ingenuity in cultivating repertoires of practice that enabled them to succeed, despite challenges rooted in systemic racism. Going forward, rather than focus solely on what is missing, academic medicine should try to shift systems and regularly recognize and value the knowledge, expertise, and merit Black that physicians bring. Perhaps an appropriate framing is not that Black physicians are underrepresented in medicine; maybe instead, it is that they are underrecognized.

Equity, diversity, and inclusion topics at a medical physics residency journal club

A journal club program was initiated in a clinically focused, geographically distributed medical physics therapy residency program. This program currently supports two residents at different clinical sites, who regularly present at the new journal club. For one of the sessions, residents were assigned to present on topics related to the broad themes of equity, diversity, and inclusion (EDI) in the context of medical physics, radiation oncology, or medical oncology. As in other journal club sessions, residents were responsible for choosing their respective articles within required criteria and with approval from the program director. The session was executed in late 2022, with both residents leading and facilitating discussion for the residents, the residency program director, and all residency faculty members. This education case report will include the learning objectives for the journal club session, a description of the content covered in the session, discussion regarding the session's alignment with the original learning objectives, and ideas for program directors intending to include evidence-based EDI topics in journal clubs.

Qualitative Study on Diversity, Equity, and Inclusion Within Radiation Oncology in Europe

PURPOSE

Organizational culture plays a major role in prioritizing diversity, equity, and inclusion (DEI) objectives by aligning individual values of employees with organizational values. However, effective strategies to create an inclusive organizational culture, in which these values are aligned, remain unclear. The European Society for Radiotherapy and Oncology (ESTRO) launched a qualitative study, as a follow-up of the previous project on DEI that highlighted low levels of inclusion and work engagement among radiation oncology (RO) professionals in Europe. The aim of the present study was to gain an understanding of how DEI could be improved within RO departments by creating a more inclusive organizational culture.

METHODS AND MATERIALS

A qualitative research study was conducted by enrolling RO professionals from 4 selected European countries through an open call on the ESTRO platform. Respondents who completed an online survey and met the inclusion criteria, such as experiencing low DEI levels at work, were invited for an online semistructured interview. Interview transcripts were analyzed thematically with an abductive approach via concepts in relation to "DEI," "work engagement," "organizational culture," and "professional values."

RESULTS

Twenty-six eligible respondents from Great Britain, Italy, Poland, and Switzerland were interviewed. The thematic analysis identified cases in which limited engagement at work emerged when the personal values of RO professionals conflicted with dominant organizational values, hampering DEI. Three conflicts were found between the following personal versus organizational values: (1) self-development versus efficiency, (2) togetherness versus competition, and (3) people-oriented versus task-oriented cultures.

CONCLUSIONS

Awareness of how organizational values can conflict with professionals' values should be raised to improve inclusion and engagement in the workplace. Additionally, efforts should be focused on tackling existing power imbalances that hamper effective deliberation on organizational- versus personal-value conflicts.

The Current State of Departmental Diversity, Equity, and Inclusion Efforts Within US Academic Radiation Oncology Departments

PURPOSE

Promoting a diverse workforce of health care professionals that delivers equitable patient care is an important goal in oncology, as in all of medicine. Although most medical schools have a diversity office and associated initiatives, little is known about radiation oncology (RO) department-level efforts to promote diversity, equity, and inclusion (DEI). We describe the current state of DEI leadership and initiatives in RO departments in the US to guide future policies and programs.

METHODS AND MATERIALS

A total of 124 US RO departments affiliated with a medical school were contacted to identify departmental DEI leadership. Identified DEI leaders were asked to complete an anonymous survey assessing characteristics of their departmental DEI leadership, committee/organizational structure, activities, and perceived barriers to, and effect of, their work. Descriptive statistics are reported.

RESULTS

Among 85 RO departments that responded (68.5% response rate), 48 (56.5%) reported having a departmental DEI leader. Thirty-four DEI leaders completed the survey (70.8%). Of those who answered each survey question, most DEI leaders were assistant or associate professors (n = 24, 82.8%), women (n = 19, 73.1%), and identified with at least one non-White race or Hispanic ethnicity (n = 15, 53.6%). Nineteen (57.6%) had an associated departmental DEI committee; with 10 of these starting in 2020 or later. Few DEI leaders had administrative support (38.2%), funding (29.4%), protected time (23.5%), or increased compensation for added duties Fifteen (50.0%) believed their DEI-focused efforts were considered for promotion. The most reported initiatives included offering programming/education, supporting students from backgrounds underrepresented in medicine, improving recruitment practices/hiring, and implementing pipeline/pathway projects. The perceived impact of DEI initiatives included an increased culture of respect (89.7%), improved health care disparity awareness (75.9%), and improved systemic/structural racism awareness (79.3%).

CONCLUSIONS

Departmental DEI efforts are increasingly common within RO, however, the structure, resources, and recognition associated with DEI work are variable. Additional dedicated resources and recognition for these efforts will help ensure a culture of inclusive excellence for the RO workforce and patients.

Diversity of medical dosimetry applicants and graduates

Diversity is a critical component in the advancement of human endeavor in science. Students who complete their education and training at diverse schools can serve patients from a wide range of ethnic backgrounds and promote cross-cultural competence. However, developing a diverse environment of professionals is a long-term effort which often takes generations to complete. Increasing awareness of underrepresented genders and/or minorities helps to establish goals for building a future of improved diversity. Specific to radiation oncology, professions such as medical physicists and radiation oncology physicians have reported underrepresented females and minorities. The problem is that there is a paucity of literature regarding diversity of medical dosimetry professionals. The professional organization does not track diversity data for those members currently working in the profession. Therefore, the purpose of this research was to present aggregate data demonstrating the diversity of medical dosimetry applicants and graduates. The methodology involved quantitative data collection from medical dosimetry program directors which answered the research question, what is the diversity of medical dosimetry applicants and graduates? In comparison to the U.S. population, there were less applicant and accepted students of Hispanic/Latino and African American ethnicities whereas the Asian population was higher. While the U.S. population data reveals 3% more females, there were 35% more female than male applicant and accepted students in this study. However, the results differ significantly from medical physics and radiation oncology physicians with only 30% female clinicians.

Predictors of Interest in Radiation Oncology: The Effect of Race, Ethnicity, Gender, and Other Diversity Measures

Purpose

The presence of women and people underrepresented in medicine (URiM) continues to be lower in radiation oncology (RO) than within the United States population, medical school graduates, and oncology fellowship applicants. The objective of this study was to identify demographics of matriculating medical students who are inclined to consider pursuing a residency in RO and identify barriers to entry that students may perceive before medical school training.

Methods and Materials

A survey of incoming medical students at New York Medical College was distributed via e-mail and assessed demographic background information, interest in and awareness of oncologic subspecialties, and perceived barriers to RO.

Results

Students of the incoming class of 2026 had a complete response rate of 72% (155 complete responses and 8 incomplete responses of 214 class members). Two-thirds of participants had prior awareness of RO, and half have considered pursuing an oncologic subspecialty, but less than one-fourth have ever previously considered a career in RO. Students responded that they need more education, clinical exposure, and mentorship to increase their chance of choosing RO. Male participants had 3.4 times the odds of having an acquaintance in the community tell them about the specialty and also had significantly greater interest in using advanced technologies. There were no URiM participants who had personal relationships with an RO physician compared with 6 (4.5%) non-URiM participants. The average response to "What is the likelihood that you will pursue a career in RO?" showed no significant difference between genders.

Conclusions

All races and ethnicities scored a similar likelihood of pursuing a career in RO, which differs greatly from the current RO workforce. Responses emphasized the importance of education, mentorship, and exposure to RO. This study demonstrates the need for support of female and URiM students during medical school.

Impact of a Virtual Introduction to Radiation Oncology Presentation on Stimulating Interest in the Specialty Among Diverse Medical Students at Multiple Institutions

PURPOSE

Many US medical students lack access to radiation oncology (RO). The authors' hypothesis was that a virtual, cross-institutional presentation introducing students to a career in RO would be valuable in exposing students to RO who are less likely to access it otherwise and would increase students' interest in a career in RO regardless of their gender, race, or ethnicity.

METHODS

A 1-hour, live, virtual, extracurricular presentation was offered to deans of US medical schools lacking affiliated RO departments and/or having high enrollments of students underrepresented in medicine (UIM) and also student groups composed primarily of UIM students. Presentations were given individually to each school by a single radiation oncologist. An electronic survey captured data from participating students.

RESULTS

One hundred ninety-seven students from 13 institutions attended presentations; 114 students responded to the survey (response rate, 58%). Ninety-two students (81%) were aware of the specialty of RO before the presentation; however, UIM students were significantly less likely to be aware of RO than all others (69% versus 87%, P = .05). Only 19 students (17%) reported previously hearing presentations from radiation oncologist (29% among second- to fourth-year students versus 9% among first-year students, P = .01). Ninety-eight students (86%) expressed more interest in pursuing a career in RO after the presentation. There was no significant difference in interest in RO for any demographic subgroups.

CONCLUSIONS

Virtual RO exposure was feasible to deliver to students less likely to be exposed otherwise and successfully stimulated interest in the specialty regardless of students' gender, race, or ethnicity.

Pilot Study Exploring the Feasibility of Incorporating Radiation Oncology Into Pre-existing Early Pathway Programs for Diverse Premedical Students

PURPOSE

Many medical schools in the United States have affiliated pathway, preparatory, and/or prematriculation programs that enroll a high percentage of students historically underrepresented in medicine (URiM). The purpose of this pilot study was to better characterize exposures to radiation oncology (RO) among students in these programs and determine the feasibility of incorporating a radiation oncologist within their pre-existing format if nonexistent.

METHODS AND MATERIALS

During the summers of 2021 and 2022, a radiation oncologist gave a presentation about basic principles of cancer care to 18 unique student groups in 12 premedical programs affiliated with 8 medical schools. Participating students were asked to complete an anonymous postpresentation questionnaire. Descriptive statistics are reported.

RESULTS

A total of 467 students attended the presentations, and 241 completed the questionnaire (response rate 52.0%). The majority of participants reported being female (63.5%), URiM (66.4%), and low income (57.3%). Students were less likely to report previous teaching from a radiation oncologist (11.2%) than a surgical (17.0%) or medical oncologist (18.3%). Prior clinical shadowing with a radiation oncologist (2.9%) was also less likely than shadowing a surgical oncologist (5.0%), medical oncologist (6.6%), or any other physician (53.1%). Students were also less likely to previously believe that radiation could cure cancer (65.8%) compared with surgery (74.9%) or chemotherapy (89.3%). After the presentation, 168 students (69.7%) were more interested in a career in RO, and 211 students (87.6%) responded that the presentation was either quite or extremely valuable (median Likert-type score, 5; interquartile range, 4-5).

CONCLUSIONS

Many of the students in premedical programs lack prior exposure to RO or knowledge of multidisciplinary cancer care, which was ameliorated by a simple yet effective presentation across a variety of different types of programs in this study. Longitudinal assessment of different types of educational initiatives and students' ultimate career trajectory will help optimize future RO initiatives among premedical URiM students.

Underrepresented Minority Composition of Invited Panelists at the 2021 ASTRO Annual Meeting

Purpose

The American Society for Radiation Oncology (ASTRO) Annual Meeting is one of the primary venues for radiation oncologists to present new research, network, and share innovations. In this brief report, we describe the racial representation of invited physician speakers at the Annual Meeting relative to the specialty.

Methods and Materials

The program list of all invited educational sessions and panel speakers in the ASTRO annual meetings from 2021 was accessed via the ASTRO website. Race was determined by a combination of facial recognition and Internet investigation. Speakers and panels were divided by race and specialty. Underrepresented in medicine (URiM) was defined as Black race and/or Hispanic ethnicity.

Results

We identified 182 cumulative speaking panels at the 2021 ASTRO annual meeting and 960 individuals who filled these panels. The majority of speakers were of White race (57%), followed by Asian race (34.2%). URiM speakers made up approximately 8.6% of speakers and were mostly congregated in diversity, equity, and inclusion in health care (DEI) panels. A total of 15.6% of panels were White-only, and 14.8% of panels had at least 1 URiM member. URiM race speakers were mostly congregated in DEI panels, comprising 44.9% of DEI speaker positions and 4.1% of non-DEI speaker positions; this difference reached statistical significance (P < .0001).

Conclusions

The proportion of underrepresented minorities receiving panel invitations at ASTRO remains minimal and is virtually nonexistent outside of DEI-related panels. Targeted efforts to increase URiM representation will be needed to make tangible progress on this issue, just as they have yielded progress on increasing gender diversity in panel invitations.

Black Physicians' Experiences with Anti-Black Racism in Healthcare Systems Explored Through An Attraction-Selection-Attrition Lens

Anti-Black racism is a specific form of racism directed at Black people. In healthcare, there are poignant examples of anti-Black racism in the recruitment, selection, and retention stages of the job cycle. Research shows that anti-Black racism is associated with inequitable work outcomes and the under-representation of Black physicians. However, empirical findings are scattered with no organizing framework to consolidate these findings. To add to the literature, in this paper we present the attraction-selection-attrition (ASA) model (Schneider, 1987) as an organizing framework to discuss Black physicians' experiences with anti-Black racism and discrimination throughout their careers. We draw from previous literature to highlight specific experiences of Black physicians at each stage of the job cycle (i.e., attraction, selection, retention), and we offer considerations on how practitioners can mitigate anti-Black racism throughout the job cycle. In the wake of COVID-19 and highly publicized social justice movements, healthcare systems are seeking ways to increase the recruitment, selection, and retention of Black physicians to ensure health equity. We believe this guide will be valuable to practitioners, leaders, researchers, and program directions seeking to advance diversity, equity, and inclusion of Black physicians in their healthcare systems. We conclude by providing practical implications and directions for future research.

Association Between Racial and Ethnic Diversity in Medical Specialties and Residency Application Rates

IMPORTANCE

The lack of racial and ethnic diversity in the US medical profession is a well-recognized problem, and racial and ethnic representation is highly variable across the medical specialties. Residency selection is a crucial juncture at which diversity and representation in specialties can be increased.

OBJECTIVE

To identify factors associated with residency application rates for medical specialties by race and ethnicity.

DESIGN, SETTING, AND PARTICIPANTS

This national cross-sectional study of medical student residency applications used American Association of Medical Colleges data on 2019-2020 applicants and information about the racial and ethnic characteristics of practicing physicians (including medical school faculty) and department chairs. A total of 26 320 applicants to medical residency programs, 592 296 practicing physicians, and 2121 department chairs across the US were included. Residency application rates for 18 medical specialties were evaluated.

MAIN OUTCOMES AND MEASURES

The main outcome was the specialty representation quotient (SRQ), which estimated the extent to which students from a racial or ethnic group were overrepresented (an SRQ >1) or underrepresented (an SRQ <1) in a given specialty compared with the racial and ethnic demographic characteristics of the corresponding graduating class. Covariates included the racial and ethnic demographic characteristics of practicing physicians and department chairs by specialty based on American Association of Medical Colleges data and student academic factors (mean United States Medical Licensing Examination step 1 score, number of research experiences, and AΩA honor society membership among matched students from the previous application cycle). Multivariable logistic regression analysis was used to examine associations between these covariates and application rates by race and ethnicity.

RESULTS

Among 26 320 specialty-specific applications to medical residency programs in 18 specialties, 90 (0.3%) were from American Indian or Alaska Native students, 6718 (25.5%) were from Asian students, 2575 (9.8%) were from Black students, 1896 (7.2%) were from Hispanic students, and 15 041 (57.1%) were from White students. Among 592 296 practicing physicians, 2777 (0.5%) were American Indian or Alaska Native, 117 358 (19.8%) were Asian, 36 639 (6.2%) were Black, 41 071 (6.9%) were Hispanic, and 394 451 (66.6%) were White. Among 2121 department chairs, 5 (0.2%) were American Indian or Alaska Native, 212 (10.0%) were Asian, 86 (4.1%) were Black, 88 (4.1%) were Hispanic, and 1730 (81.6%) were White. The specialties with the greatest representation among applicants from racial and ethnic groups underrepresented in medicine (URM) were family medicine (SRQ, 1.70), physical medicine and rehabilitation (SRQ, 1.60), and obstetrics and gynecology (SRQ, 1.47). The specialties with the lowest URM representation among applicants were plastic surgery (SRQ, 0.47), otolaryngology (SRQ, 0.53), and orthopedic surgery (SRQ, 0.86). Membership in AΩA was negatively associated with SRQ among American Indian or Alaska Native students only (β = -0.11; 95% CI, -0.17 to -0.05; P = .002). Racial and ethnic representation among practicing physicians was positively associated with SRQ for American Indian or Alaska Native students (β = 6.05; 95% CI, 4.26-7.85; P < .001), Asian students (β = 0.07; 95% CI, 0.06-0.09; P < .001), Black students (β = 0.10; 95% CI, 0.06-0.15; P < .001), and URM students overall (β = 0.05; 95% CI, 0.01-0.08; P = .02).

CONCLUSIONS AND RELEVANCE

This study's findings suggest that the propensity of medical students, particularly those from racial and ethnic minority groups, to apply to a given specialty for residency was associated with the representation of their racial or ethnic group among the specialty's practicing physicians. Future work to characterize the mechanisms of occupational sorting may guide interventions to improve equity within the physician workforce.

Racial Discrimination against Minority Healthcare Workers in Women’s Health

The women’s sexual and reproductive healthcare sector, one of the largest employers delivering services globally, does not always commit to equality, diversity, and inclusion. There is objective, published evidence that not only care provision but also workforce treatment permits inequality and discrimination. The black and ethnic minority workforce in the women’s health specialty, compared to their white counterparts, is often treated unfavorably in appointments, is less often afforded academic development opportunities, is, at many sites, subjected to disproportionately greater disciplinary penalties, tends not have representation in positions of authority, and undertakes training in what is often perceived as a climate of fear due to racism. This problem deserves immediate action by professional bodies. They have the responsibility to remove feelings of exclusion and lack of belonging to all staff, the negative impact on wellbeing caused by unnecessary stress, and concerns over career progression among minority ethnic healthcare workforce and other workers who report discrimination. This duty is part of the societal responsibility to ensure fairness and eradicate discrimination under the equality, diversity and inclusion agenda.

Demographics of ASTRO Student Members and Potential Implications for Future U.S. Radiation Oncology Workforce Diversity

Purpose

The radiation oncology workforce in the United States is comparatively less diverse than the U.S. population and U.S. medical school graduates. Workforce diversity correlates with higher quality care and outcomes. The purpose of this study was to determine whether student members of the American Society for Radiation Oncology (ASTRO) are any more diverse than resident members-in-training using the recently established medical student membership category.

Methods and Materials

Self-reported sex, race and Hispanic ethnicity, medical school, and degree(s) earned for all medical students (n = 268) and members-in-training (n = 713) were collected from the ASTRO membership database. International members were excluded. The χ² test was used to assess for differences between subgroups.

Results

Compared with members-in-training, student members were more likely to be female (40.0% vs 31.5%, P = .032), black or African American (10.7% vs 4.8%, P = .009), candidates for or holders of a DO rather than MD degree (5.2% vs 1.5%, P = .002), and from a U.S. medical school that is not affiliated with a radiation oncology residency program (30.5% vs 20.9%, P = .001). There was no significant difference in self-reported Hispanic ethnicity (7.3% vs 5.4%, P = .356). There were no indigenous members in either category assessed.

Conclusions

Medical student members of ASTRO are more diverse in terms of black race, female sex, and osteopathic training, though not in terms of Hispanic ethnicity or nonmultiracial indigenous background, than the members-in-training. Longitudinal engagement with these students and assessment of the factors leading to specialty retention versus attrition may increase diversity, equity, and inclusion in radiation oncology.

Holistic Admissions Review in Nursing Education: A Concept Analysis Using Rodgers' Evolutionary Method

AIM

The aim of this study was to analyze holistic review within the context of collegiate nursing program admissions.

BACKGROUND

Holistic review is the evaluation of individual qualifications for college admission based on a pattern of individualized factors, including standardized scores, personal characteristics, experiences, abilities, and educational/professional "fit." Medical schools regularly use holistic review, and more nursing schools may adopt holistic review in the future.

METHOD

Rodgers' evolutionary method of concept analysis was used to examine usage in current praxis.

RESULTS

Findings support a desire to enhance diversity in collegiate, health-related programs while increasing numbers of culturally competent, qualified providers representative of the US population.

CONCLUSION

Holistic review promotes diversity of nursing students and future nurse providers. This concept analysis provides a unified definition of holistic review to promote educational and health-care-related equity through increased representativeness of nursing students and future nurses.

2021 AAPM Equity, Diversity, and Inclusion Climate Survey Executive Summary

PURPOSE

The American Association of Physicists in Medicine (AAPM) shares the results, conclusions, and recommendations from the initial Equity, Diversity, and Inclusion Climate Survey conducted in 2021.

METHODS AND MATERIALS

The climate survey targeted medical physicists who are full members of the AAPM and included demographic inquiries and questions intended to assess the working environmental climate in terms of a sense of belonging and inclusion, experiences of discrimination and harassment, and obstacles to participation within the AAPM. The survey invitation was sent to 5,500 members. Responses were collected from 1385 members (response rate of 25%) between January and February 2021.

RESULTS

Overall, the medical physics workplace climate was positive. However, some demographic and professional subgroups reported lower levels of agreement with positive characteristics of their workplace climates. Compared with men, women ranked lower 7 of 8 categories that characterized the workplace climate. Other subgroups that also ranked the workplace climate descriptors lower included individuals not originally from the United States and Canada (3/8). Most respondents strongly agreed/agreed that the climate within the AAPM was welcoming. However, 17% of respondents reported personally experiencing or witnessing microaggressions within the AAPM. Overall, medical physicists reported low levels of agreement that opportunities within the AAPM were available to them, from 34% to 60% among 8 categories, including opportunities to volunteer, join committees, and compete for leadership positions within the AAPM. Several subgroups reported even lower levels of agreement that these opportunities are available. Asian and Asian American respondents (3/8) and physicists with origins in countries outside the United States and Canada (7/8) reported fewer opportunities to participate in the AAPM. Medical physicists reported their experiences of discrimination and sexual harassment in their workplaces and within the AAPM. For those who reported personal experiences of sexual harassment, only 24% (15/63) felt comfortable reporting when it occurred within their workplaces, and 35% (9/26) felt comfortable reporting when it occurred within the AAPM.

CONCLUSIONS

The report concludes with several recommendations for action.

A Survey to Assess and Delineate Approaches to Medical Student Outreach to Promote Diversity at Academic Radiation Oncology Programs

PURPOSE/OBJECTIVE(S)

To assess how academic radiation oncology departments engage medical students who are either female and/or from racial and ethnic demographic groups that are underrepresented in medicine (URiM).

MATERIALS/METHODS

An electronic survey was sent to all 83 radiation oncology residency program directors (or if applicable medical student directors) whose department is affiliated with an on-site medical school. Questions assessed whether any faculty in the participants' department offer exposure in radiation oncology specifically to medical and premedical student groups whose members are typically female or URiM, or promote the American Society for Radiation Oncology (ASTRO) Minority Summer Fellowship (MSF) Award. Barriers to these types of involvement were also assessed.

RESULTS

A representative from 54/83 programs responded (response rate 65%). Faculty from 83% of departments had given a presentation to an oncology or radiation oncology medical student interest group. However, faculty from only 18% of departments had given a presentation to a Student National Medical Association chapter, 9% to a Latino Medical Student Association chapter, and 11% to an American Medical Women's Association chapter. Faculty from 15% of departments actively promote the MSF to the general student body, and 24% promote it to any minority students who express interest in radiation oncology. Faculty from 22% of departments had given a presentation to a premedical student group, 10% to an undergraduate student group focused on minority or female students, and 20% to a pipeline program for high school (or younger) female or URiM students. Lack of awareness of the existence of such programs, or not being invited, were the most common barriers to participation.

CONCLUSIONS

Most academic radiation oncology departments do not offer educational outreach specifically targeting women or minority students or promote the MSF. Further efforts are needed to break from the status quo and attract a more diverse workforce.

Faculty Recruitment, Retention, and Representation in Leadership: An Evidence-Based Guide to Best Practices for Diversity, Equity, and Inclusion from the Council of Residency Directors in Emergency Medicine

Improving the recruitment, retention, and leadership advancement of faculty who are under-represented in medicine is a priority at many academic institutions to ensure excellence in patient care, research, and health equity. Here we provide a critical review of the literature and offer evidence-based guidelines for faculty recruitment, retention, and representation in leadership. Recommendations for recruitment include targeted recruitment to expand the candidate pool with diverse candidates, holistic review of applications, and incentivizing stakeholders for success with diversity efforts. Retention efforts should establish a culture of inclusivity, promote faculty development, and evaluate for biases in the promotion and tenure process. We believe this guide will be valuable for all leaders and faculty members seeking to advance diversity, equity, and inclusion in their institutions.

Diversity Trends by Sex and Underrepresented in Medicine Status Among US Radiation and Medical Oncology Faculty Over 5 Decades

Importance

It remains unclear how the historical exclusion of women and racial and ethnic minority groups from medical training, and therefore the oncologic subspecialties, has contributed to rates of faculty diversity among oncology departments over time. Oncologic faculty diversity is an important initiative to help improve care and address health disparities for an increasingly diverse US population with cancer.

Objectives

To report trends in academic faculty representation by sex and by race and ethnicity for radiation oncology (RO) and medical oncology (MO) departments and to describe comparisons with the general US population, medical students, RO and MO trainees, clinical department chairs, and faculty in other departments.

Design, Setting, and Participants

This cross-sectional analysis used data from the Association of American Medical Colleges to analyze trends by sex and by race and ethnicity among full-time US faculty in RO and MO departments from 1970 through 2019. Data were analyzed between October 2020 and April 2021.

Main Outcomes and Measures

Proportions of women and individuals from underrepresented in medicine (URM) racial and ethnic groups (Black, Hispanic, and Indigenous individuals) were calculated among RO and MO academic departments; trends were analyzed over 5 decades. These proportions were compared with cohorts already described. In addition, proportions of women and URM individuals were calculated by faculty rank among RO and MO departments.

Results

In 1970, there were 119 total faculty in RO (10 women [8.4%] and 2 URM [1.7%]) and 87 total faculty in MO (11 women [12.6%] and 7 URM [8.0%]). In 2019, there were 2115 total faculty in RO (615 women [29.1%] and 108 URM [5.1%]) and 819 total faculty in MO (312 women [38.1%] and 47 URM [5.7%]). Total faculty numbers increased over time in both RO and MO. Faculty representation of URM women proportionally increased by 0.1% per decade in both RO (95% CI, 0.005%-0.110%; P <. 001 for trend) and MO (95% CI, -0.03% to 0.16%; P = .06 for trend) compared with non-URM women faculty, which increased by 0.4% (95% CI, 0.25%-0.80%) per decade in RO and 0.7% (95% CI, 0.47%-0.87%) per decade in MO (P < .001 for trend for both). Faculty representation of URM men did not significantly change for RO (0.03% per decade [95% CI, -0.008% to 0.065%]; P = .09 for trend) or MO (0.003% per decade [95% CI, -0.13% to 0.14%]; P = .94 for trend). Representation of both women and URM individuals among both specialties was lower than their representation in the US population in both 2009 and 2019. Across all cohorts studied, RO faculty had the lowest URM representation in 2019 at 5.1%. At every rank in 2019, the number of total URM faculty represented among both MO and RO remained low (MO: instructor, 2 of 44 [5%]; assistant professor, 18 of 274 [7%]; associate professor, 13 of 177 [7%]; full professor, 13 of 276 [5%]; and RO: instructor, 9 of 147 [6%]; assistant professor, 57 of 927 [6%]; associate professor, 20 of 510 [4%]; full professor, 18 of 452 [4%]).

Conclusions and Relevance

This cross-sectional study suggests that RO and MO academic faculty have increased the representation of women over time, while URM representation has lagged. The URM trends over time need further investigation to inform strategies to improve URM representation in RO and MO.

Mitigating Implicit Bias in Radiation Oncology

Implicit bias is one of the most insidious and least recognizable mechanisms that can cause inequity and disparities. There is increasing evidence that both implicit and explicit biases have a negative effect on patient outcomes and patient-physician relationships. Given the impact of Implicit bias, a joint session between ASTROs Committee on Health Equity, Diversity, and Inclusion and the National Cancer Institute (the ASTRO-National Cancer Institute Diversity Symposium) was held during the American Society of Radiation Oncology (ASTRO) 2020 Annual Meeting, to address the effect of implicit bias in radiation oncology through real life and synthesized hypothetical scenario discussions. Given the value of this session to the radiation oncology community, the scenarios and discussion are summarized in this manuscript. Our goal is to heighten awareness of the multiple settings in which implicit bias can occur as well as discuss resources to address bias.

The Holman Research Pathway in Radiation Oncology: 2010 to 2019

PURPOSE

There has not been an assessment of the Holman Research Pathway (HRP) in radiation oncology (RO) in nearly 10 years. In this study, we sought to review the demographic characteristics, research productivity during and after residency, job placements, and National Institutes of Health (NIH) grant funding of RO residents who completed the HRP in the modern era.

METHODS AND MATERIALS

We created a comprehensive database of RO residents who completed the HRP between 2010 and 2019. Using a variety of data sources, we obtained demographic information, first-author manuscripts published in residency, and first- and last-author manuscripts published in the first 30 months after residency for each resident. In addition, we identified the first and current job and NIH grant funding for each resident.

RESULTS

Ninety-seven RO residents who graduated from 50 medical schools and 25 residency programs were included. The majority were male (82.5%), had a PhD (92.8%), and identified as white (64.9%). Collectively, these residents published 212 first-author, PubMed-searchable manuscripts during residency (mean: 2.2) and 142 first- or last-author, PubMed-searchable manuscripts in the first 30 months after completion of residency (mean: 1.5). The number of first-author publications authored by HRP graduates during residency was highly correlated (r = 0.62; P < .01) with the number of first- and last-author publications they authored during the first 30 months after completing residency. Ninety-six of the 97 residents (99.0%) were employed in full-time clinical positions after completing residency. Seventy-six HRP residents (78.4%) obtained an academic position as their first job after residency, only 4 of whom have since left academia, and 20 (20.6%) obtained a nonacademic position. Of the 75 HRP graduates currently employed in an academic position, 39 (52.0%) have their own laboratories. Twenty-three of the 96 HRP residents (24.0%) who secured employment in full-time clinical positions after residency switched jobs over the study period. Lastly, 33 of the 97 HRP residents (34.0%) have thus far received 47 extramural NIH research grants, 15 of which were R-01 grants.

CONCLUSIONS

Over the past decade, the HRP has proven successful in training a new cohort of physician investigators in RO. Although productive, HRP residents have had relatively homogenous sex, educational, and racial backgrounds. Ensuring sufficient representation of residents from a variety of backgrounds in the HRP in the future will be crucial.

Increasing Diversity in Radiology and Molecular Imaging: Current Challenges

This paper summarizes the 2020 Diversity in Radiology and Molecular Imaging: What We Need to Know Conference, a three-day virtual conference held September 9–11, 2020. The World Molecular Imaging Society (WMIS) and Stanford University jointly organized this event to provide a forum for WMIS members and affiliates worldwide to openly discuss issues pertaining to diversity in science, technology, engineering, and mathematics (STEM). The participants discussed three main conference themes, “racial diversity in STEM,” “women in STEM,” and “global health,” which were discussed through seven plenary lectures, twelve scientific presentations, and nine roundtable discussions, respectively. Breakout sessions were designed to flip the classroom and seek input from attendees on important topics such as increasing the representation of underrepresented minority (URM) members and women in STEM, generating pipeline programs in the fields of molecular imaging, supporting existing URM and women members in their career pursuits, developing mechanisms to effectively address microaggressions, providing leadership opportunities for URM and women STEM members, improving global health research, and developing strategies to advance culturally competent healthcare.

Journey to Diversity in a University Radiation Oncology Residency Program: The Role of Leadership and Target Goals

OBJECTIVES

Increasing diversity in radiation oncology with respect to sex, under-represented minorities (URMs), and people of color is a major objective of our profession. The purpose of this project is to plot diversity percentages in our residency program over the past 52 years and explain major causes for change when identified.

MATERIALS AND METHODS

Plots of the percent of residents in our program each year between 1967 and 2020 in the following categories: White male, female, URM, and people of color.

RESULTS

Between 1967 and 1992 diversity percentage in our program changed little with ∼90% of residents representing White males. Between 1992 and 1995, overall diversity increased by 40 percentage points, a change maintained from 1995 to 2020. Approximate annual percentages over the past 25 years were: female, 35%; URM, 10%; and people of color, 25%.The main reason for increased diversity starting in 1992 was new leadership seeking to promote diversity. Tools that helped promote diversity were measuring our diversity profile and setting target goals.

CONCLUSIONS

Our experience provides a model to measure diversity and track performance over time in residency programs, departments, or practice groups. The priority to place on diversity, and specific performance goals, vary by group. For those seeking to increase diversity, our experience shows it is possible to achieve substantial diversity in all categories, but change requires leadership making diversity a priority.