Applied Radiation Oncology’s latest blog covering today’s issues in oncology

Nadia Saeed, BA, is a fourth-year MD candidate at Yale School of Medicine, Class of 2022. She serves as the Medical Student Representative for Applied Radiation Oncology.

Applications of Virtual Learning to Diversify the Radiation Oncology Workforce

June 2021

Significant deficits in gender and racial/ethnic representation are well documented in the radiation oncology (RO) workforce. Females comprise less than one-third of faculty positions in RO, lagging behind other oncologic subspecialities.1 Only 3.2% of the RO trainee pool in 2016 was comprised of Black residents.2 Hispanic trainees too are significantly underrepresented in RO compared with other specialties.3 Medical students who are underrepresented in medicine (UIM) and/or female face a number of barriers to entering the field, including but not limited to insufficient or late exposure to RO, deficits in mentorship, low numbers of female and UIM role models owing to inadequate representation in the field, and interpersonal bias at many levels.4 Moreover, the substantial financial investment required for the residency application process hinders students who are economically disadvantaged from pursuing the specialty.

While a growing number of initiatives has been undertaken in recent years to advance diversity in RO, there remains a critical need for innovative solutions to address barriers to representation in the field—particularly when considering the overall decline in RO applicants in recent years.5 The COVID-19 pandemic accelerated the development of new virtual educational and professional resources in RO in response to disruptions in medical education. Looking ahead to the post-pandemic era, an essential question becomes how these resources can be used to promote female and UIM recruitment into RO to diversify the future workforce.

Virtual RO rotations are among these new resources. RO electives let students not only gain hands-on experience in the field but also obtain letters of recommendation and meet potential future mentors. UIM students are significantly less likely to attend medical schools with an affiliated RO program, hindering access to this crucial component of residency application.6 This also places even greater importance on away rotations, which may pose significant financial barriers in terms of travel and housing, creating structural inequalities in the application process. Virtual electives created during the pandemic in response to canceled away rotations may serve to reduce some of these inequities by increasing access to RO experiences. Moreover, many virtual electives are two weeks rather than the usual four weeks for in-person rotations, allowing for the possibility to rotate at more programs which may be especially valuable for those without a home RO department. These virtual electives should continue to be offered post-pandemic, in addition to providing greater financial assistance for in-person away rotations.

Virtual rotations should also be used as a springboard for formal RO clinical experiences specifically targeted toward female and UIM students to support recruitment into the field. In response to the cancelation of away rotations, an intensive virtual shadowing experience (RISE) was recently developed at two academic medical centers for fourth year UIM students, complete with a 1-week disease-specific curriculum, mentorship, and capstone experience.7 Compact two-week virtual electives can be adapted to create similar institution-specific initiatives aimed at providing comprehensive RO experiences for students underrepresented in the field; moreover, these should be offered earlier in medical school, such as the summer between first and second year, to facilitate longitudinal mentorship and research experiences.

While targeted experiences for UIM and female students are needed to diversify the applicant pool, increasing general exposure to RO in the medical school curriculum may also be beneficial.8 Currently, most medical schools do not cover radiation oncology in either the standard pre-clinical or clinical years. The condensed materials used in virtual electives—including interactive didactics, treatment planning seminars, and multidisciplinary tumor boards—may be integrated at different stages to ensure all students are aware of RO as a career option. For example, a mandatory one- or two-week oncology rotation that includes time in the RO clinic may be integrated into the clerkship year; similarly, didactics and workshops adapted from virtual RO electives could be included in the pre-clinical oncology unit to introduce the specialty early in medical school. In addition, online educational resources, which were expanded during the pandemic, improve access to foundational RO knowledge. For example, the Radiation Oncology Virtual Education Rotation (ROVER) held a series of case-based site-specific seminars for medical students in the summer of 2020.9 Such initiatives shift learning to an open-access platform, reducing some of the barriers that limit diversity in the field.

Female and UIM students also face hurdles when it comes to mentorship opportunities. Lack of access to a home RO department—as has been shown to be more common among UIM students—creates challenges in finding mentors and securing research projects. In addition, a lack of representation in the field creates a gap in female and UIM faculty available to mentor students. Since it has been shown that the gender and racial/ethnic composition of faculty affects recruitment,10 current deficits in representation in the RO workforce act to perpetuate further disparities in the field. Moreover, studies have shown that interpersonal bias by gender and race can also influence selection for mentorship opportunities in science and medicine.11-13 Amid the pandemic, new opportunities in online networking and mentorship emerged, which can be leveraged to address some of these disparities. For example, the Radiation Oncology Education Collaborative Study Group (ROECSG) organized a virtual networking session to connect third- and fourth-year medical students with residents and attendings across the country; many programs also held institution-specific meet-and-greets for prospective applicants. The Society for Women in Radiation Oncology (SWRO) began a remote mentorship program in 2018 to pair members with a mentor who is one level higher in training. More recently, ASTRO established the online program Mentor Match. These virtual initiatives should be continued post-pandemic and used to provide networking and mentorship for students from groups underrepresented in RO. These would be particularly effective during the early part of medical school to facilitate longitudinal professional relationships.

Lastly, it should be emphasized that continuing to expand the RO pipeline, such as through modified virtual resources, alone is insufficient to reduce the lack of diversity in the workforce. Further efforts are needed to support female and UIM faculty retention, identify and eliminate interpersonal bias, and promote diversity within RO leadership.14 It is critical to tackle these barriers head-on to create a future RO workforce that reflects the diverse patient population it aims to serves.

REFERENCES

  1. Chowdhary M, Chowdhary A, Royce TJ, et al. Women's representation in leadership positions in academic medical oncology, radiation oncology, and surgical oncology programs. JAMA Netw Open. 2020;3(3):e200708. Published 2020 Mar 2. doi:10.1001/jamanetworkopen.2020.0708
  2. Deville C Jr, Cruickshank I Jr, Chapman CH, et al. I Can't Breathe: The continued disproportionate exclusion of Black physicians in the United States radiation oncology workforce. Int J Radiat Oncol Biol Phys. 2020;108(4):856-863. doi:10.1016/j.ijrobp.2020.07.015
  3. Deville C, Hwang WT, Burgos R, Chapman CH, Both S, Thomas CR Jr. Diversity in graduate medical education in the United States by race, ethnicity, and sex, 2012 [published correction appears in JAMA Intern Med. 2015 Oct;175(10):1729]. JAMA Intern Med. 2015;175(10):1706-1708. doi:10.1001/jamainternmed.2015.4324
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  8. Suneja G, Mattes MD, Mailhot Vega RB, et al. Pathways for recruiting and retaining women and underrepresented minority clinicians and physician scientists into the radiation oncology workforce: a summary of the 2019 ASTRO/NCI Diversity Symposium Session at the ASTRO Annual Meeting. Adv Radiat Oncol. 2020;5(5):798-803. Published 2020 May 21. doi:10.1016/j.adro.2020.05.003
  9. Kahn JM, Sandhu N, von Eyben R, et al. Radiation Oncology Virtual Education Rotation (ROVER) for medical students [published online ahead of print, 2021 Apr 9]. Int J Radiat Oncol Biol Phys. 2021;S0360-3016(21)00359-X. doi:10.1016/j.ijrobp.2021.03.057
  10. Mattes MD, Bugarski LA, Wen S, Deville C Jr. Assessment of the Medical Schools From Which Radiation Oncology Residents Graduate and Implications for Diversifying the Workforce. Int J Radiat Oncol Biol Phys. 2020;108(4):879-885. doi:10.1016/j.ijrobp.2020.06.018
  11. Moss-Racusin CA, Dovidio JF, Brescoll VL, Graham MJ, Handelsman J. Science faculty’s subtle gender biases favor male students. Proc Natl Acad Sci USA. 2012;109(41):16474-16479. doi:10.1073/pnas.1211286109
  12. Milkman KL, Akinola M, Chugh D. What happens before? A field experiment exploring how pay and representation differentially shape bias on the pathway into organizations. J Appl Psychol. 2015;100(6):1678-1712. doi:10.1037/apl0000022
  13. Barry PN, Miller KH, Ziegler C, Hertz R, Hanna N, Dragun AE. Factors affecting gender-based experiences for residents in radiation oncology. Int J Radiat Oncol Biol Phys. 2016;95(3):1009-1016. doi:10.1016/j.ijrobp.2016.02.007
  14. Jones RD, Chapman CH, Holliday EB, et al. Qualitative assessment of academic radiation oncology department chairs' insights on diversity, equity, and inclusion: progress, challenges, and future aspirations. Int J Radiat Oncol Biol Phys. 2018;101(1):30-45. doi:10.1016/j.ijrobp.2018.01.012

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