Voices: Chelsea C. Pinnix MD, PhD
A Call to Action
Recent cell phone video recordings documenting violence and murder of Black Americans at the hands of police officers and American citizens have stunned the country and prompted many to denounce racism. For Black people in the United States (U.S.) however, these videos were not shocking and instead validate our anxiety and fear regarding daily life and raising children in a racially biased country. The most devastating consequence of racism is death, however, in our neighborhoods, academic institutions and hospitals, racism has other grave deleterious effects. Racism has many faces and can assume many forms.
As a Black woman with childhood aspirations of becoming a physician, I was taught early that education could serve as a potent tool to combat racial inequality. My mother’s constant message to me as a child was to be the best student I could be and to always do more than what was required. She, like Horace Mann, one of the first advocates of public education, had faith in the power of education to overcome disparity. Mann recognized education as a remedy to socioeconomic imbalance, declaring in 1848 “education, then, beyond all other devices of human origin, is the great equalizer of the conditions of men, the balance wheel of the social machinery.” However, since its inception, the educational system was built on an uneven playing field, deliberately designed to stifle Black progress and assure dominance of White Americans.1 While we have certainly made considerable progress since the landmark Brown v. Board of Education of Topeka case that deemed school segregation to be unconstitutional, significant disparities persist. Many Americans believe that the civil rights movement eliminated the vestiges of racial discrimination, however the data indicates otherwise.
A devastating consequence of racist policing is the murder of an unarmed Black man after traumatic asphyxia lasting for 8 minutes and 46 seconds by a White police officer. Consequences of racist communities are the murders of a Black man jogging in his neighborhood (Ahmaud Arbery) or of an African-American boy walking home from a convenience store (Trayvon Martin). The consequences of a racially biased healthcare system are equally devastating: inferior cancer care and increased mortality for Black patients. While many may attribute these poorer outcomes to genetic differences in tumor aggressiveness or poor access to care, implicit bias and interpersonal racism in our medical system share responsibility for higher rates of death among Black cancer patients.
It does not surprise me that racial biases can harm Black patients, as I have personally observed the factors that contribute to the inferior cancer outcomes. Empirical beliefs and anecdotal evidence are validated by peer-reviewed studies. Non-black physicians spend less time with their Black patients.2 In a system where Black patients are inherently distrustful of the medical system given the history of exploitation, doctors should conversely spend more time with Black patients to assure that they feel supported and understand the goals of care.3-5 Blacks are largely excluded from clinical trials and novel drug therapies, even for diseases that disproportionately affect them (e.g. multiple myeloma)6,7. While sustained mistrust of the medical system due to a history of unconsented experimentation is a factor, efforts are lacking to regain the trust of the Black community and include Black patients in trials with potentially life extending therapies. Finally, Black patients often receive lower quality oncologic therapy, including RT, and they often receive less aggressive therapies than their White counterparts.8,9
Health disparity researchers have done a superb job laying out the data for us and highlighting the racial inequality that exists in our medical system. Numerous studies have documented poor diversity among medical students and the physician workforce compared to the US population.10 Specifically, in radiation oncology, while gains have been made regarding narrowing the gender gap, Blacks remain underrepresented at the resident trainee level compared to their proportion of representation at the medical school graduate level.11 These disparities widen at higher levels of academic medicine. The paucity of Black faculty has been shown to be a barrier to increasing Black representation at the resident level.12 Within the U.S. radiation oncology workforce in 2019, 3.3% of practicing radiation oncologists were Black.13 I can count on one hand the number of radiation oncology resident program director positions that have ever been held by a Black radiation oncologist in the history of our field. Representation of Black radiation oncologists at the departmental chair level is equally abysmal. If we are truly committed to racial equality in our field, representation must be addressed at every level.
Program directors have tremendous influence in shaping the racial landscape of radiation oncology. We must be transparent and deliberate regarding our intentions to diversify the resident population and critically examine the factors that we prioritize in residency applications and our rationale for doing so.14,15 For instance, when one residency program increased their Step 1 score requirement from 220 to 240 based on choosing a threshold that was closer to the median of accepted candidates, this modification disproportionately decreased representation of applicants that were female, older than age 30 and underrepresented minorities.16 Is there a considerable distinction in the ability of an applicant that has a step 1 score of 220-239 versus ≥ 240 to be a successful resident and eventually radiation oncologist? With this change in practice, my Step 1 board score of 225 would have been insufficient, and my professional path would have certainly been different. However, my record as an academic clinical researcher and recognition as a top 1% provider as assessed by widely utilized patient satisfaction surveys suggest that I do belong.17 This is not to say that board examinations are not a useful tool for candidate assessment, however, an overreliance on this component of resident applications undervalues the many other characteristics and competencies that are integral in becoming an exceptional physician.
We must commit to willingly and openly confront bias and racial insensitivity. For Black physicians, race is associated with added burden in the workplace. Microaggressions and bias are present for Black residents and attendings daily.18 This can manifest as misidentification as non-medical personnel despite targeted efforts to demonstrate otherwise (such as always a stethoscope and white coat with a prominently positioned identification badge).19 When I became a junior faculty member, it was not uncommon for my patients to address the White trainee (medical student or resident) as the attending. Now I make sure to immediately introduce myself as the attending and the resident or medical student as the trainee to avoid experiencing this bias. I have had several patients ask the non-Black resident physician for their medical opinion after an extensive conversation with me regarding my proposed treatment plan. I have never heard a patient refer to one our White trainees as “well-spoken or articulate” yet these terms have been used to describe me by hospital staff and my patients in a way that suggests they are surprised. It is commonplace for patients and co-workers to address me by my first name, despite them referring to other physicians as “Doctor” in direct conversations with me. I have been called “girl” by a patient from a town in East Texas that is notorious for their active Ku Klux Klan population. I have been mistaken for other Black female faculty members by colleagues that I have known for more than a year, which serves as a reminder that I am not viewed as an individual but instead as a woman with brown skin. These are experiences that I have had as a junior and mid-career attending and likely they pale in comparison to the microagressions that Black residents face from the medical staff, their colleagues and patients. Moreover, Black resident physicians are more vulnerable as they may fear consequences of being outspoken, especially in situations of limited professional support and scarcity of Black faculty.19 As program directors and faculty members, we can no longer remain silent when we witness these forms of racism in the workplace.
In the face of the recent murders of George Floyd and Ahmaud Arbery, parents are taking the opportunity to have “the talk” about racism with their children and families. As program directors we must do more. It is imperative that we use this opportunity to move past talking about diversity and inclusion and instead commit to a strategic plan that will result in substantive changes. Our field is capable of broad and swift implementation of data driven strategies to improve outcomes. In response to highly publicized errors in radiation oncology that unfavorably impacted patients, a working “Call to Action” meeting was held and 20 recommendations emerged to impart guidance to radiation oncology departments and practices to enhance patient safety.20 The time is now to apply the skills that exist in our field to address a crisis that has continued for far too long.
Chelsea C. Pinnix MD, PhD
MD Anderson Cancer Center
- Wormser R. The rise and fall of Jim Crow. 1st ed. New York: St. Martin's Press; 2003.
- Penner LA, Dovidio JF, Gonzalez R, et al. The Effects of Oncologist Implicit Racial Bias in Racially Discordant Oncology Interactions. J Clin Oncol. 2016;34(24):2874-2880.
- Corbie-Smith G. The continuing legacy of the Tuskegee Syphilis Study: considerations for clinical investigation. Am J Med Sci. 1999;317(1):5-8.
- Kemet S. Insight Medicine Lacks - The Continuing Relevance of Henrietta Lacks. N Engl J Med. 2019;381(9):800-801.
- Skloot R. The immortal life of Henrietta Lacks. 1st pbk. ed. New York: Broadway Paperbacks; 2011.
- Svensson CK. Representation of American blacks in clinical trials of new drugs. JAMA. 1989;261(2):263-265.
- Loree JM, Anand S, Dasari A, et al. Disparity of Race Reporting and Representation in Clinical Trials Leading to Cancer Drug Approvals From 2008 to 2018. JAMA Oncol. 2019:e191870.
- Lee DJ, Zhao Z, Huang LC, et al. Racial variation in receipt of quality radiation therapy for prostate cancer. Cancer Causes Control. 2018;29(10):895-899.
- Gross CP, Smith BD, Wolf E, Andersen M. Racial disparities in cancer therapy: did the gap narrow between 1992 and 2002? Cancer. 2008;112(4):900-908.
- Lett LA, Murdock HM, Orji WU, Aysola J, Sebro R. Trends in Racial/Ethnic Representation Among US Medical Students. JAMA Netw Open. 2019;2(9):e1910490.
- Chapman CH, Hwang WT, Deville C. Diversity based on race, ethnicity, and sex, of the US radiation oncology physician workforce. Int J Radiat Oncol Biol Phys. 2013;85(4):912-918.
- Agawu A, Fahl C, Alexis D, et al. The Influence of Gender and Underrepresented Minority Status on Medical Student Ranking of Residency Programs. J Natl Med Assoc. 2019;111(6):665-673.
- Colleges AoAM. Diversity in Medicine: Facts and Figures 2019. https://www.aamc.org/data-reports/workforce/report/diversity-medicine-facts-and-figures-2019. Accessed June 11, 2020.
- Winkfield KM, Gabeau D. Why workforce diversity in oncology matters. Int J Radiat Oncol Biol Phys. 2013;85(4):900-901.
- Nead KT, Linos E, Vapiwala N. Increasing Diversity in Radiation Oncology: A Call to Action. Adv Radiat Oncol. 2019;4(2):226-228.
- Fernandez C, Lopez BL, Kushner M, Leiby BE, Den RB. Overemphasis of Step 1 Scores May Affect Application Pool Diversity in Radiation Oncology. Pract Radiat Oncol. 2020;10(1):e3-e7.
- Mazurenko O, Collum T, Ferdinand A, Menachemi N. Predictors of Hospital Patient Satisfaction as Measured by HCAHPS: A Systematic Review. J Healthc Manag. 2017;62(4):272-283.
- Bullock SC, Houston E. Perceptions of racism by black medical students attending white medical schools. J Natl Med Assoc. 1987;79(6):601-608.
- Osseo-Asare A, Balasuriya L, Huot SJ, et al. Minority Resident Physicians' Views on the Role of Race/Ethnicity in Their Training Experiences in the Workplace. JAMA Netw Open. 2018;1(5):e182723.
- Hendee WR, Herman MG. Improving patient safety in radiation oncology. Pract Radiat Oncol. 2011;1(1):16-21.