By Gita Suneja, MD, MS, and Robert C. Miller, MD, MBA, FASTRO
The Radiation Oncology Institute (ROI) is delighted to announce new research awards to four teams of investigators who seek to understand how biomarkers can be used to optimize outcomes for patients receiving radiation therapy. A record-breaking number of applications were submitted in response to this request for proposals, highlighting the promise that many in the radiation oncology community see for biomarkers to transform the field. The ROI always seeks to fund the highest quality research that will have an impact on practice and patient care, and these new grants are the result of the ROI’s comprehensive and diligent peer-review process. The awarded projects utilize a variety of scientific methodologies and focus on four different disease sites, many of which are new within the ROI research portfolio. The following four research teams are the recipients of this year’s Biomarkers for Radiation Oncology Awards.
David Miyamoto, MD, PhD, and his team at the Massachusetts General Hospital will develop a new blood test to detect and analyze circulating tumor cells in patients with muscle-invasive bladder cancer. This non-invasive liquid biopsy test will help identify patients who can be effectively treated with bladder-preserving trimodality therapy, a combination of radiation therapy, chemotherapy, and limited surgery that avoids removing the entire bladder. The test could also be used to monitor patients for recurrences after therapy.
Nina Sanford, MD, and Wen Jiang, MD, PhD, will be co-Principal Investigators on a project to develop a novel microscale biochip device to monitor disease progression and treatment response in anal cancer. Their innovative technology will be used to capture circulating exosomes and to detect a microRNA specific to anal cancer in patient blood samples before, during and after chemoradiation that would allow for greater personalization of treatment. Dr. Sanford specializes in the care of gastrointestinal cancers at the University of Texas Southwestern Medical Center and Dr. Jiang studies microfluidic and nanoengineering at MD Anderson Cancer Center.
Two ASTRO Members-in-Training are receiving special recognition as recipients of James D. Cox Research Awards. Their grants are supported by generous gifts made by Ritsuko Komaki-Cox, MD, FASTRO, in honor of her late husband and their shared commitment to training the next generation of radiation oncologists.
Hesham Elhalawani, MD, MSc, a clinical fellow at Brigham and Women’s Hospital, will use radiomics to develop a decision-making tool to help diagnose radiation necrosis (RN) earlier in patients being treated with immunotherapy and stereotactic radiosurgery (SRS) for brain metastases. Along with mentor Ayal Aizer, MD, MHS, Dr. Elhalawani will use artificial intelligence to conduct a longitudinal analysis of MRIs performed before and after SRS to identify imaging biomarkers to predict which patients are most likely to develop RN.
Sonal Noticewala, MD, MAS, a resident at MD Anderson Cancer Center, will explore the role of the microbiome in how patients with pancreatic cancer respond to neoadjuvant chemoradiation. Together with mentor Cullen Taniguchi, MD, PhD, Dr. Noticewala will examine bacterial profiles in paired tissue samples of pancreatic tumors and peri-tumoral regions to define a signature microbiome associated with patient response to chemoradiation. They aim to show that differences in the microbiome can account for variations in treatment response and lay the groundwork for future studies that target the microbiome to optimize treatment and improve outcomes.
Together with the support of donors, we are investing in these talented investigators who are exploring how biomarkers can advance radiation oncology, and we look forward to sharing their progress and outcomes with you in the future. Be sure to keep up with the ROI’s latest research news by visiting our website or following us on Twitter and Facebook.
Posted: May 5, 2021
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By Crystal Seldon, MD; Awad Ahmed, MD; Anna M. Laucis, MD, MPhil; and Cristiane Takita, MD, MBA
Gender inequality is an ongoing problem among United States (U.S.) medical professionals.1-2 While there have been gains in diversifying the field of medicine, such as the number of women surpassing the number of men matriculating into U.S. medical schools,3 women continue to remain in the minority among faculty of academic institutions.4 Academic oncology is no exception.5 Women make up the minority of all faculty in the fields of medical oncology, radiation oncology (RO) and surgical oncology at U.S. academic institutions.6 This extends to leadership positions, specifically program director and department chair positions. In RO alone, women constitute 30.7% of the academic workforce and only 17.4% of the leadership roles.6 Women also make up the minority of positions on governing boards, such as the Board of Directors, as well as leadership positions for the national professional societies of the American Society of Clinical Oncology (ASCO) and the American Society for Radiation Oncology.7 There is some progress in this arena, as the current ASCO President is Lori J. Pierce, MD, FASCO, FASTRO, a female radiation oncologist and vice provost at the University of Michigan. And ASTRO currently has three women in Board leadership roles: ASTRO President Laura Dawson, MD, FASTRO, President-elect Geraldine Jacobson, MD, MPH, MBA, FASTRO, and Secretary/Treasurer Neha Vapiwala, MD.
Over the years, we have seen more women enter the field of medicine in the U.S., now representing a narrow majority of matriculating medical students, 50.5% as of 2019.8 However, as more women join the field of medicine, the number of female RO residents appears to have plateaued at 30.2% as of 2019.9 This plateau is also seen in leadership roles in RO residency programs. In 2012, the percentage of female program directors and department chairs was 24% and 9% respectively10 as compared to 23.8% and 11.7% in 2020.6 Studies have shown that female trainees are more likely to practice in programs with women in leadership positions.11-13 The lack of gender equity in leadership positions also likely contributes to the low number of female trainees who matriculate into the field each year, creating a self-perpetuating cycle with a limited supply in the workforce to become leaders.
To address the lack of gender equity in radiation oncology, barriers to equality must be addressed. These barriers include but are not limited to gender specific expectations, barriers to mentorship, disparities in research funding and biases in tenure and academic tracks.14 The lack of predefined finite time limits to leadership positions in academic radiation oncology may contribute to the lack of inclusion in the U.S. academic RO community. Policies introducing term limits for leadership positions in academic medicine have been proposed as a potential solution.15 Work by Odie et al. has showed that gender disparities among chairs exist and are widespread, even in fields where women make up the majority of the workforce, such as obstetrics and gynecology.16 This suggests that the pipeline may not be the heart of the matter. The current disparities seen in leadership, both gender and racial, represent a relic of the past and are unlikely to change without motivational policy; social and institutional guidelines will likely be needed to create gender parity in these leadership roles.
Within recent years, movements geared toward promoting gender equity, such as the #MeTooSTEM, #WomeninMedicine and #HeforShe online platforms, have identified the need for addressing this issue, especially in academia. With more women entering into the field of medicine, it is important to close the gap between men and women faculty members, especially those in leadership positions. Observing other women in leadership roles can inspire and motivate a bright message to students and the public that the field of RO is not only diverse but inclusive as well. An honest assessment of these barriers will be integral as the specialty seeks to attract future radiation oncologists and create a diverse workforce, such that the ideas and opinions representing those from diverse gender, racial and socioeconomic backgrounds can be better represented to ultimately help guide and inform the very best oncologic care for our patients.
Join us in the Gender Equity Community on the ROhub to continue the discussion. What are your suggestions to improve gender equity in radiation oncology?
Crystal Seldon, MD, is a PGY-3 radiation oncology resident at the University of Miami/Sylvester Comprehensive Cancer Center.
Awad Ahmed, MD, is a radiation oncologist practicing at Multicare Tacoma Washington and ASTRO CHEDI member.
Anna M. Laucis, MD, MPhil, is a chief resident physician in radiation oncology at the University of Michigan and an ASTRO CHEDI member.
Cristiane Takita, MD, MBA, is a professor and residency program director at the University of Miami/Sylvester Comprehensive Cancer Center and ASTRO CHEDI member.
1. Bleich SN, Findling MG, Casey LS, et al. Discrimination in the United States: Experiences of Black Americans. Health Serv Res
. 2019;54(S2):1399-1408. doi:10.1111/1475-6773.13220
2. Mandel H. The role of occupational attributes in gender earnings inequality, 1970-2010. Soc Sci Res
. 2016;55:122-138. doi:10.1016/j.ssresearch.2015.09.007
3. More women than men enrolled in U.S. medical schools in 2017 [press release
].Washington, DC: Association of American Medical Colleges; December 18, 2017.
4. Jagsi R, Guancial EA, Worobey CC, et al. The “Gender Gap” in Authorship of Academic Medical Literature — A 35-Year Perspective. N Engl J Med
. 2006;355(3):281-287. doi:10.1056/nejmsa053910
5. Ahmed AA, Hwang WT, Holliday EB, et al. Female Representation in the Academic Oncology Physician Workforce: Radiation Oncology Losing Ground to Hematology Oncology. Int J Radiat Oncol Biol Phys
. 2017;98(1):31-33. doi:10.1016/j.ijrobp.2017.01.240
6. 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. doi:10.1001/jamanetworkopen.2020.0708
Jagsi R, Means O, Lautenberger D, Jones RD, Griffith KA, Flotte TR, Gordon LK, Rexrode KM, Wagner LW, Chatterjee A. Women's Representation Among Members and Leaders of National Medical Specialty Societies. Acad Med
. 2020;95(7):1043-1049. doi: 10.1097/ACM.0000000000003038
. PMID: 31625994.
AAMC, 2019 Fall Applicant, Matriculant, and Enrollment Data Tables. Accessed April 22, 2021. https://www.aamc.org/system/files/2019-12/2019%20AAMC%20Fall%20Applicant%2C%20Matriculant%2C%20and%20Enrollment%20Data%20Tables_0.pdf
9. Boyle P. More women than men are enrolled in medical school. AAMC. Published online December 9, 2019. Accessed January 22, 2021. https://www.aamc.org/news-insights/more-women-men-are-enrolled-medical-school
10. Wilson LD, Haffty BG, Smith BD. A Profile of Academic Training Program Directors and Chairs in Radiation Oncology. Int J Radiat Oncol
. 2013;85(5):1168-1171. doi:10.1016/j.ijrobp.2012.10.035
11. Vengaloor Thomas T, Perekattu Kuruvilla T, Holliday E, et al. Cross-Sectional Gender Analysis of US Radiation Oncology Residency Programs in 2019: More Than a Pipeline Issue? Adv Radiat Oncol
. 5(6):1099-1103. doi:10.1016/j.adro.2020.07.008
12. Sethi S, Edwards J, Webb A, Mendoza S, Kumar A, Chae S. Addressing Gender Disparity: Increase in Female Leadership Increases Gender Equality in Program Director and Fellow Ranks. Dig Dis Sci
. Published online January 6, 2021. doi:10.1007/s10620-020-06686-5
13. Hill E, Vaughan S. The only girl in the room: how paradigmatic trajectories deter female students from surgical careers. Med Educ
. 2013;47(6):547-556. doi:10.1111/medu.12134
14. Woitowich NC, Jain S, Arora VM, Joffe H. COVID-19 Threatens Progress Toward Gender Equity Within Academic Medicine. Acad Med
. Published online September 29, 2020. doi:10.1097/ACM.0000000000003782
15. Beeler WH, Mangurian C, Jagsi R. Unplugging the Pipeline — A Call for Term Limits in Academic Medicine. N Engl J Med
. 2019;381(16):1508-1511. doi:10.1056/NEJMp1906832
16. Odei BC, Gawu P, Bae S, Fabian D, Odei J, Lee C, Mitchell D. Evaluation of Progress Toward Gender Equity Among Departmental Chairs in Academic Medicine. 2021;181(4):548-550. doi:10.1001/jamainternmed.2020.6267
. PMID: 33369632; PMCID: PMC7770616.
Posted: April 27, 2021
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By Casey Chollet, MD, Government Relations Committee Chair
2020. By any standard, it was a year to remember...and forget. The COVID-19 pandemic took hold over almost everyone’s energy and focus, sidelining so many routine things we previously took for granted. While the public health emergency rightly became the primary focus of our medical community, the radiation oncology field continued to face direct challenges and looming burdens on the congressional horizon. Be it the threat of a flawed RO Model, payment cuts in the 2021 Medicare Physician Fee Schedule (MPFS) or the progressive burdens of prior authorization, the ASTRO Advocacy team continued to fight for relief throughout the year.
Ultimately, 2020 closed with many victories for our community. The RO Model was delayed until at least January 2022, saving participants approximately $45 million in 2021. Payment cuts in the 2021 MPFS were significantly reduced, protecting radiation oncology from another $100 million in losses in 2021. And prior authorization reform legislation received the support of more than 280 bipartisan co-sponsors in the House, as well as a companion bill introduced in the Senate. On top of these radiation oncology victories, COVID-19 support was secured in the form of continued funding for the Provider Relief Fund that helped offset revenue declines triggered by the reduction of in-person care visits and cancer screenings.
These victories were possible only because of close collaboration between ASTRO Advocacy and our members, and strengthening this collaboration is critical to making 2021 even more successful for radiation oncology. Whether it be through participating in Advocacy Day or email advocacy campaigns, increased engagement by our membership is critical to success.
For instance, ASTRO staff lobbyists and Najeeb Mohideen, MD, FASTRO, teamed up to keep Rep. Raja Krishnamoorthi (D-IL), Dr. Mohideen’s congressman, informed about RO Model concerns. In response, Rep. Krishnamoorthi joined his colleagues in writing the HHS Secretary at the time, Alex Azar, about the need for reforms.
In 2020, ASTRO members sent over 3,200 messages to their representatives and senators advocating for our specialty: that’s almost nine messages a day! Rising to the challenge of the COVID era, 69 members participated in a virtual Advocacy Day on the Hill, attending over 90 meetings. But despite these impressive efforts, our specialty must do more to achieve our long-term policy goals. If we were able to make such a big impact in 2020 with a relatively small level of member participation, just think of the positive changes we can bring about by making our unified voice that much louder. Meaningful prior authorization reform, a viable value-based payment opportunity and sustained investment into cancer research are all possible, but they rely on your action.
Engaging your representatives and senators on these issues is easier than ever, and I encourage you to take advantage of every opportunity to support our policy goals. Write letters, send emails and engage leaders on social media. And if COVID-19 trends continue to improve in your community, please consider inviting them to visit your treatment facilities.
So, keep an eye out for those action alerts and ASTROgram stories, and be sure to check astro.org/advocate regularly. Every effort you make is another step toward improvements for our patients and our community.
Posted: April 20, 2021
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By Doriann Geller, ASTRO Communications
ASTRO’s APEx – Accreditation Program for Excellence® counts nearly 200 radiation oncology practices among those having earned the distinguished APEx badge since the program's inception in 2016. APEx recently granted its first reaccreditation in December 2020 to Lutheran Medical Center, located at the foothills of the Rocky Mountains in Wheat Ridge, Colorado. Lutheran Medical earned the distinction of being the first facility to become reaccredited after their first four-year cycle. Tyler Kemmis, MD, medical director of radiation oncology at Lutheran Medical, took time out of his day to talk about “Why APEx.”
“I know we were first in Colorado, only maybe sixth in the country for initial accreditation,” he said glowingly on a recent afternoon. “So, I guess it’s pretty neat that we’re first for reaccreditation.”
Lutheran Medical’s mottos include “Excellence: setting and surpassing high standards.” APEx accreditation, which demonstrates safe, high-quality care, validated their commitment to this value, Dr. Kemmis said. The accreditation process, which focuses on the entire radiation oncology team, allowed them to review and modify policies and procedures and to improve documentation. “I think what accreditation does, specifically ASTRO’s APEx, is it forces you to do a self-audit. It helped us modify some of our policies and procedures, update them, define them ― easily identifiable areas we were able to benefit.”
Dr. Kemmis mentioned that the team identified some deficiencies during the Self-Assessment, which is designed for success. “We did not realize some deficiencies until we were sitting down and going through [the Self-Assessment],” he said. “We improved on them, even though they were potentially going to be disclosed at the site visit.” If they were called out, the Lutheran Medical team was prepared with a proactive response. “We could say, ‘Yes, we noticed that, and we've done this to improve it.’”
Lutheran Medical Center’s website describes their facility as a place where “Our patients and families are the center of every thought, communication and action that takes place in this healing space.” The APEx accreditation program evaluates the standard of care that addresses communication, not only among staff but specifically with patients. “Here at Lutheran, we really make sure that we, as radiation oncologists, are there for the entire spectrum of care, and communication is really central to that.”
The APEx accreditation process, while achievable, is known to be rigorous. Asked if that is a fair assessment, Dr. Kemmis concurred. “Yes, I think it’s fair. I won’t lie. It is no walk in the park by any means. Of course, when you go through that much work, there is a greater sense of accomplishment when you get there. Whether it’s an initial accreditation or specifically reaccreditation, the majority of the work is done on the front end and leading up to the site interview. It involves a lot of people putting a lot of work into it, [which] makes it more fulfilling when you do receive your accreditation or reaccreditation,” Dr. Kemmis observed.
“There were additional things that we never thought of, even during the review, [that] forced us to think critically. So, at that point in time you say, ‘Yes this maybe is something that we need to work on.’ Each part of the reaccreditation you can use as a learning experience,” he remarked.
Among the changes Lutheran Medical implemented as a result of the accreditation process was improvement in new staff onboarding. The radiation oncology department enjoys low staff turnover, a point of pride. However, the surveyor noticed that documentation of onboarding processes needed some attention. “We're fortunate that we really don't have a lot of staff turnover, and we didn't really have the opportunity to review some of our training processes and procedures for onboarding new staff,” Dr. Kemmis said. As a result, they have revamped some of those policies and procedures.
The four-year accreditation cycle provides generous time for facilities to continue to improve. During the first four-year cycle, Lutheran Medical used ASTRO accreditation as a framework for future improvements in developing new documentation for their system of radiation oncology departments, expanding the benefits of accreditation system-wide.
Dr. Kemmis stated that Lutheran Medical’s radiation oncology department considered other accrediting bodies, but they chose APEx. “I think it was the fact that, as a radiation oncologist, I felt more aligned with ASTRO. And when it was offered as a new accreditation, I think there was that allure that this was a new accreditation, that [it] would be exciting to be involved with.” The four-year reaccreditation, as opposed to three, was also a factor, he said. “It was all those factors put together.”
Would Dr. Kemmis recommend APEx accreditation to his radiation oncology colleagues? “Yes absolutely,” he responded. “I haven't gone through any accreditation other than ASTRO, but I've had a good experience with it so far, so I would.”
If you would like information on how your facility can become accredited by APEx, we invite you to contact an ASTRO team member at APExSupport@astro.org to schedule an online discussion. By this time next year, your facility could join Lutheran Medical in the family of APEx accredited facilities.
Posted: April 6, 2021
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By Christina Chapman, MD
In June 2019, I served as the discussant for an important abstract by Narjust Duma, MD, and colleagues presented at the ASCO Annual Meeting. In Dr. Duma’s study, a group of investigators watched videos of scientific presentations from two recent ASCO annual meetings and recorded whether speakers were introduced with a professional form of address (e.g., Dr. Last Name) or an informal address (e.g., speaker’s first name or Dr. First Name without last name). They found that women and Black individuals were less likely to be introduced with a professional form of address. They also found that men were more likely than women to introduce speakers informally. The abstract was subsequently published as a full length manuscript in the Journal of Clinical Oncology.1 Although the data on gender were published, the data on race were omitted from the final manuscript, which I discuss below. This research project was modeled after an earlier project that similarly demonstrated gender bias in speaker introductions at the Mayo Clinic’s Internal Medicine Grand Rounds. These studies add to the existing literature that demonstrates the pervasiveness of gender bias in medicine and biomedical research.
Christina Huang, MS, Fumiko Chino, MD, and colleagues performed a similar analysis focusing on recent ASTRO Annual Meetings. They did not find a statistically significant difference in speaker introductions on the basis of gender. However, their presentation prompted a series of conversations on Twitter during the 2020 ASTRO virtual Annual Meeting. Although they suggested that all speakers be introduced with a professional form of address, multiple male members conveyed opposing viewpoints. One was that formality in conference speaker introductions reinforces hierarchies that impair collegiality and free exchange of ideas. Another viewpoint was that calls for consistency are unnecessary in light of the study’s failure to demonstrate gender bias. One may wonder why such varied opinions exist on this topic. An examination of the existing evidence may shed light on why opinions differ strongly across gender and racial lines.
In general, people are less likely to support or see the need for formalized systems, rules or laws if they are treated justly without them. Those who are oppressed under current systems instead recognize that “honor systems” and informal structures often fail to produce justice in inequitable societies. In short, the marginalized clearly see the need for guardrails, while those who are centered may claim to be unaware that there is a dangerous cliff nearby. This cliff is well described in the literature, however, so it is incumbent upon everyone to recognize the bias, whether it directly affects them or not.
Although professional credentials are not the only factors that influence career success, they certainly help drive it. Furthermore, numerous studies have demonstrated racial, gender and other biases in the way that individuals with identical credentials are perceived. These facts demonstrate the dangers of informality in professional settings. Even if men and women are introduced informally at the same rates, the penalties are greater for women and the advantages are greater for men. When women’s credentials are not formally displayed, the audience is less likely to perceive them as a physicians or scientists. This does not hold true to the same extent for men, who are more likely to be perceived at the top of hierarchies or to possess advanced credentials regardless of their actual standing. When a male-presenting individual offers, “Just call me Jake,” it is somewhat disingenuous to think that this eliminates or substantially mitigates hierarchies, because he is still perceived to possess academic credentials and be perceived as a man, both of which elicit a certain level of respect in hierarchical and biased society.
To be clear, there are two types of hierarchies relevant here. They can be distinguished by whether they are publicly accepted as just or unjust. Most people will state publicly that racial or gender hierarchies are unjust while stating that hierarchies based on academic credentials or achievement are generally just if equitably implemented. For example, most departments would find it acceptable to deny an application for an academic radiation oncology faculty position from someone without training beyond a bachelor’s degree. Many conference attendees would also find it acceptable that scientific discussants are selected based on their training and content expertise. Without display of their formal credentials, however, women are perceived to be at lower levels of accepted hierarchies, leading to discrimination that is repackaged to make it appear justifiable (e.g., “Oh, I didn’t even realize she was a funded immunologist. I thought she was a student presenting her lab mentor’s research.”) Women then experience additional discrimination when the unjust hierarchy of gender inequity is applied, as in the context of two people perceived to be students with identical credentials: “I thought that male student was more competent than the female student.”2
Simply put, informality, even if applied evenly, leads to inequality in an unjust world. Formality serves to mitigate the impact of gender and other biases. If individuals or groups want to reduce the impact of hierarchies on scientific progress, one high yield place to start is eliminating hierarchies that have no basis in science: those based on gender. Furthermore, it could serve the field well to challenge the notions underlying just hierarchies by recognizing a broader array of scientific methods and topics as legitimate and important (e.g., qualitative research, health equity research) and recognizing that junior members of the field can make groundbreaking contributions. Converting to informal forms of address without challenging these underlying beliefs is unlikely to amplify the voices that we need to hear more clearly to advance our field.
Finally, it would also serve the field and broader community well to consider intersectionality and other forms of bias in their own right. When the Duma et al. paper was published, the significant finding of bias in introductions against Black speakers was removed because race was not self-reported. Study team-assigned race was not actually a major limitation of the study, given that it still measures an important endpoint (i.e., how individuals perceived to be Black are treated). Furthermore, there is little evidence that there would have been high discordance between the study team assignments and self-report, so it also would have likely given a reasonable approximation of the impact on self-reported Black individuals. Instead, important science was lost, despite the tremendous effort on the part of the study team to efficiently investigate multiple forms of bias. Problems like this can be mitigated by eliminating the scientific hierarchies that downplay the expertise of health equity researchers and instead appropriately elevating them to reviewer and leadership positions in journals.
Solutions to minimize the impact of hierarchies on medicine and science must be definitive and not performative. Informal introductions will lead to failure to recognize excellent science and scientists, which will be further compounded by biases that exist when equivalent credentials are made explicit. Calls for equity from the marginalized should not be minimized by those who are often centered, lest we run the risk of slowing progress in a field that sorely needs it.
Join the Gender Equity community on the ROhub to continue the discussion on this important topic by answering this question: In addition to speaker or clinic introductions, where else do you think greater consistency should be implemented to advance equity?
Christina Chapman, MD, is a health equity researcher and radiation oncologist specializing in head and neck and lung cancer. She obtained her BA in Biomedical Engineering from the Johns Hopkins University, her MD from the University of Pennsylvania Perelman School of Medicine, and her MS in Health and Healthcare Research from the University of Michigan, where she also completed her radiation oncology residency training.
1. Duma N, Durani U, Woods CB, et al: Evaluating Unconscious Bias: Speaker Introductions at an International Oncology Conference. J Clin Oncol. 2019;37:3538-3545.
2. Moss-Racusin CA, Dovidio JF, Brescoll VL, et al: Science faculty’s subtle gender biases favor male students. Proceedings of the National Academy of Sciences. 2012;109:16474-16479.
Posted: March 24, 2021
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