key: cord-0978387-o35g5r5x authors: Deville, Curtiland; Cruickshank, Ian; Chapman, Christina H.; Hwang, Wei-Ting; Wyse, Rhea; Ahmed, Awad A.; Winkfield, Karen; Thomas, Charles R.; Gibbs, Iris C. title: I Can’t Breathe: The Continued Disproportionate Underrepresentation and Effective Exclusion of Black Physicians in the United States Radiation Oncology Workforce date: 2020-07-12 journal: Int J Radiat Oncol Biol Phys DOI: 10.1016/j.ijrobp.2020.07.015 sha: 06def637fb6fce31a8717be60bc5d5a2c341e9f9 doc_id: 978387 cord_uid: o35g5r5x Abstract Purpose Black physicians remain disproportionately underrepresented in certain medical specialties, yet comprehensive assessments in Radiation Oncology (RO) are lacking. Our purpose was to report current and historical representation trends for Black physicians in the US RO workforce. Methods Public registries were used to assess significant differences in 2016 representation for US vs RO Black academic full-time faculty, residents, and applicants. Historical changes from 1970-2016 were reported descriptively. Linear regression was used to assess significant changes for Black residents and faculty from 1995-2016. Results In 2016, Blacks represented 3.2% vs 1.5% (P<0.001), 5.6% vs 3.2% (P=0.005), and 6.5% vs 5.4% (P=0.352), of US vs RO faculty, residents, and applicants, respectively. While RO residents nearly doubled from 374 (1974) to 720 (2016), Black residents peaked at 31 in 1984 (5.9%; 31/522) and fell to 23 (3.2%; 23/720) in 2016 across 91 accredited programs; Black US GME trainees nearly doubled over the same time period: 3,506 (1984) to 6,905 (2016). Between 1995-2016, Black US resident representation significantly increased 0.03%/yr, but decreased significantly in RO -0.20%/yr before 2006 and did not change significantly thereafter. Over the same time period, Black US faculty representation significantly increased 0.02%/yr, while Black RO faculty significantly increased 0.07%/yr before 2006, then decreased significantly -0.16%/yr thereafter. The number of Black RO faculty peaked at 37 in 2006 (3.1%; 37/1203) and was 27 (1.5%; 27/1769) in 2016, despite the nearly 1.5-fold increase in the number of both RO faculty and Black US faculty overall (4,169 in 2006 and 6,047 in 2016) during that time period. Conclusions Black physicians remain disproportionately underrepresented in RO despite an increasing available pipeline in the US physician workforce. Deliberate efforts to understand barriers to specialty training and inclusion, along with evidence-based targeted interventions to overcome them, are needed to ensure diversification of the RO physician workforce. National attention has shifted to how health disparities based on race and ethnicity impact population health due to the COVID-19 pandemic and calls for racial justice surrounding the fatal asphyxiation of George Floyd. While Black/African American and American Indian/Alaskan Native populations have the poorest overall health status among population groups in the United States, Blacks experience the worst cancer outcomes of all races and ethnicities 1 . The lack diversity within the physician workforce is a potential contributor to disparities, particularly those related to cancer outcomes 2 , and thus, increasing physician workforce diversity has been identified as a means to address health disparities and improve health equity 3 . For example, Black academic faculty are more likely to conduct health disparities research than their White counterparts 4 , and minority physicians are more likely to practice in underserved communities and treat uninsured patients than their White counterparts 5 . In fact, a physician's race and ethnicity are more predictive of their likelihood to care for the underserved than growing up with a socioeconomically disadvantaged background 6, 7 . Underrepresentation of specific minority groups may be driven by structural barriers, including inadvertent and/or overt exclusion of these populations (i.e. structural racism) throughout society and the academic pipeline 8 . While there have been efforts to address physician workforce diversity and increase the representation of individuals from racial and ethnic demographic groups that are historically underrepresented in medicine (URM) 9,10 , Black physicians remain disproportionately underrepresented in certain medical specialties such as Radiation Oncology despite the current available pipeline. An analysis of 2012 data found that Radiation Oncology ranked near the bottom of the largest 20 training specialties with respect to racial, ethnic, and gender diversity, with significantly less women, Blacks, Hispanics, and combined URMs compared to the total graduate medical education (GME) pool of trainees 11 . Between 2003-2010, there was a significant declining trend in Black representation amongst Radiation Oncology trainees 12 . Yet more recent and comprehensive historical analyses are lacking. The purpose of our study was to assess current and historical representation trends for Black physicians in the US Radiation Oncology workforce. Variables evaluated included race, ethnicity, and sex, defined as consistent with US Census Bureau. 13 Racial groups included: White; Black; Asian or Asian American (referred to as Asian); American Indians, Alaska Natives, Native Hawaiians, and Pacific Islanders (AI/AN/NH/PI), grouped as one category; and Other, defined in this study, as any person with unknown racial information or not classifiable into one of the listed racial categories. Ethnic groups included Hispanic, and non-Hispanic. Sex included males and females, which was self-reported in the primary data sources. Primary data on race, ethnicity and sex were obtained from publicly available sources. For race and ethnicity variable measures, unduplicated totals were obtained of the US medical school graduates, residency applicants, residents, faculty, and practicing physicians for race and ethnicity groups separately. US medical school graduate numbers 14 and Electronic Residency Applicant Service (ERAS) residency applicant data 15 for 2016 were obtained from the Association of American Medical Colleges (AAMC). Historical data from 1970-2016 for Accreditation Council for Graduate Medical Education (ACGME) US and Radiation Oncology residents were obtained from annual Journal of the American Medical Association supplements of actual trainee numbers as previously described 16 ; the specific years available were: 1970-1972, 1974, 1977-1990, and 1995-2016 . Historical data on academic, full-time faculty from 1970-2016 were obtained from the AAMC 17 , 18 with all years available; racial distribution by sex was only available for faculty data. Practicing physician data was obtained from the 2015 American Medical Association Masterfile, which represented 2013 data -the most recent year available for this group 19 . All data sources and selected years represent the entire population in question, providing an estimate of the race, ethnicity, and sex of all applicants, trainees, faculty, and practicing physicians within the US and Radiation Oncology physician workforce. To assess current representation for the most recent year (2016) with publicly available data at the time of the analysis, binomial tests were used to investigate differences in the proportion of Blacks amongst US vs Radiation Oncology faculty, residents, and applicants, separately; US vs Radiation Oncology The fitted lines under the piecewise models were more consistent with the observed RO data based on Rsquared statistics rather than a simple linear trend line . In 2016, Blacks represented 5.6%, 6.5%, 5.6%, and 3.2% of US medical graduates, ERAS applicants, GME trainees, and faculty, respectively (Supplemental Table 1 ). Within Radiation Oncology, Blacks represented 5.4%, 3.2%, and 1.5% of ERAS applicants, GME residents, and faculty, respectively. Blacks Table 2 ), representation was found to be significantly increasing at the following percentages per year for Asians (Table 2) , representation was found to be significantly increasing at 0.021%/yr (P<0.001) for US Black faculty overall. Black faculty in Radiation Oncology were significantly increasing in representation before 2006 at 0.067%/yr (P<0.001), then significantly decreasing in representation thereafter at -0.155%/yr (P<0.001). In this analysis of Black representation in the US Radiation Oncology physician workforce, we found that Similar declines were noted for Black faculty in Radiation Oncology, which will inevitably remain underrepresented due to the lack of increasing representation of Black residents in Radiation Oncology. While there remain challenges in the Black medical student pipeline 20 , the percentage of Black medical student applicants approximates that of Black matriculants 21 . This is distinctly, not the case for the yield of Black applicants to Radiation Oncology residency training programs. 26 . Black students, through structural societal barriers and systemic racism and discrimination, may not have the opportunity to obtain research opportunities 27 . For example, Black medical students are less likely to attend schools that have affiliated Radiation Oncology residency programs 12 and may face financial barriers to performing research within or outside of their school curriculum 28 . Furthermore Blacks, as well as other URMs and women, are not sufficiently represented as MD/PhD students, which may be driven by the leakage and aforementioned exclusion that occurs throughout the educational pipeline and STEM sciences 29 . While basic science PhD research training may be important for those who go on to pursue academic careers, it has not been demonstrated to predict for success among those who choose to advance the field via other avenues, including leadership and delivery of high-quality patient care. By using selection criteria that presume to be merit-based, yet are "blind" to privilege and societal inequities, the end results include perpetuation of unjust societal structures and reduction in diverse, intellectual capital for our field and patients. Interventions that may facilitate greater diversity and inclusion in Radiation Oncology resident selection include investigating whether the heavy weighting of pre-residency research experiences and /or a basic science PhD as selection criteria is unbiased, and implementing more widespread use of holistic review and selection practices. According to the AAMC, holistic review refers to mission-aligned selection processes that consider a broad range of factors -experiences, attributes, and academic metrics -when reviewing applications, allowing consideration of the "whole" applicant, rather than disproportionately focusing on any one factor 30 . The increased compositional diversity of medical school matriculants, for example, has been correlated with the widespread implementation of holistic review by medical school admissions committees since 2009 31 . Although the lack of a significant difference between Black US and Radiation Oncology ERAS applicants may also suggest that disparate exposure may not be a barrier to training, this comparison is likely an inadequate measure to fully assess demographic differences in exposure. Given the small overall number of Black Radiation Oncology applicants, it may not be possible to detect small but still meaningful differences in relative to US applicants overall, and thus disparities in exposure should still be explored. Prior analyses have shown that Blacks (and Hispanics) are less likely to attend medical schools with affiliated programs 12 , which may be detrimental to specialty selection and matching since the majority of residents (82%) in Radiation Oncology generally emanate from medical schools with affiliated Radiation Oncology programs with 30% staying at their home institution as evidenced in an analysis of 2013 residents 32 . Providing funded exposure opportunities for students at medical schools with unaffiliated residency programs may therefore foster increased diversity. It is also vital to address how the financial costs of the entire residency exposure, interview, and selection process may impose structural barriers to inclusive recruitment and retention 34 ; greater implementation of remote learning and use of electronic interview processes, as is currently being discussed as part of managing ACGME activities during the COVID-19 pandemic, may help reduce these costs and provide improved access for URMs as well as geographically and socioeconomically disadvantaged groups. Black representation as Radiation Oncology faculty showed the greatest relative disparity compared to other physician categories. The proportion of Black female faculty compared to Black males was notably less in Radiation Oncology compared to the US workforce (Figure 4) , likely representing an intersectional issue related to gender diversity 33 . The male predominance of the field further acts to decrease Black representation when considering that Black female medical students now outnumber Black males nearly 2:1 26 . Additionally, rank distribution of Black faculty demonstrated significant attrition. Since the relative proportions were similar to the US faculty, this suggests more pervasive structural issues with the retention of Black faculty in academia which may not be unique to Radiation Oncology. Previous explanations for attrition and barriers to career advancement for URM and Black physicians at the midcareer levels include: absent institutional and executive commitment to diversity and inclusion; the minority tax/majority subsidy (terms used to describe the additional and usually unrewarded work of promoting diversity and inclusion that fall disproportionately to URM physicians); social isolation and exclusion; burnout; overt discrimination, harassment, and bias; and undervaluing of activities that do not meet traditional metrics of academic promotion, such as community outreach and engagement and exercises in social justice 34 . The lack of recruited and/or retained Black faculty to provide visibility and mentorship in our relatively obscure specialty often omitted from the medical school core curriculum, inevitably contributes to the lack of Black trainees and further exacerbates the perpetual circle of underrepresentation. The aforementioned implicit bias against minorities when seeking mentorship may therefore further inhibit Blacks and other URMs from being able to successfully match into the field. The strategies and points of intervention discussed in this section are summarized in Table 2 . Limitations of this study include the small number of Black physicians in Radiation Oncology overall, which limits the power to detect small yet potentially relevant differences, and the single year assessed for the comparative analysis, which represented the most recent year of publicly available data given the 2 year lag in reporting. Historical trends over time were assessed to mitigate this potential limitation. Moreover, we acknowledge that the racial categories utilized -as defined by the US census and consistent with the AAMC and ACGME -fail to discern the geographic and cultural heterogeneity (e.g. country of origin) within these groups, which may influence representation trends over time. Black physicians remain disproportionately underrepresented in Radiation Oncology with minimal historical improvements and decreased representation despite an increasing available pipeline in the US physician workforce. Deliberate efforts to understand the barriers and structural determinants to specialty training and inclusion relative to other successful specialties, along with evidence-based targeted interventions to overcome them, are needed to ensure diversification of the Radiation Oncology physician workforce. 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