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Todd Pickard: Hello, and welcome to the ASCO Education Podcast series. My name is Todd Pickard, and I'm a Physician Assistant specializing in Oncology at the MD Anderson Cancer Center in Houston, Texas. As today's host, I will be moderating a discussion on increasing diversity in Oncology practices with three guest speakers: Dr. Stephanie Pinder-Amaker is a Clinical Psychologist and Harvard Medical School professor; Dr. Lauren Wadsworth is a Licensed Clinical Psychologist in New York and Massachusetts, specializing in OCD and anxiety disorders; and Dr. Timothy Gilligan is a Medical Oncologist and Associate Professor of Medicine at the Cleveland Clinic Taussig Cancer Institute. 

Welcome everybody to this interesting discussion today. I'm very much looking forward to hearing from all of you about this important issue. 

Let's start with Dr. Gilligan. How diverse is the US oncology workforce today in terms of race, ethnicity, gender, age, culture background, and any other identity factors? 

Dr. Timothy Gilligan: Not nearly as diverse as we'd like, particularly, with regard to race. We've made significant progress with gender diversity, and there are many more women in Oncology now than there were previously, and more and more in leadership roles as well. But if we look at underrepresented minorities in medicine, Latinos, Blacks, other groups, the numbers are still very low. 3% of practicing oncologists are black, and 4% of oncology fellows are black, for instance. Fewer than 5% are Latino. And we haven't seen a lot of progress over time with those numbers. 

Todd Pickard: That's really interesting to me, Dr. Gilligan, because our population has changed. So why are we not reflecting that? So, can you think a little bit about that? What have you noticed in the diversity in medicine - oncology specifically? Has there been any kind of change in the past couple of decades, or have you observed any cultural shifts during the span of your career? 

Dr. Timothy Gilligan: I don't know how to explain the racial disparities other than obviously, the broader issues of systemic racism and bias and gaps in educational opportunities. But even if we look at medicine, 6% of graduating medical students are black and we're still seeing a significantly lower percentage going into oncology. Specifically, if we look at even just Internal Medicine subspecialties, oncology is at or very near the bottom of subspecialties that black residents apply to, to train in. So, I think we haven't done a good job of recruiting black doctors into oncology, and we certainly need more black doctors. And similarly, we need more Latino doctors in oncology as well.  

And it's a complicated issue. I think honestly, those of us who are working on that now really see it as a pipeline issue that we need to start as early as high school, to make this career seem attractive. First of all, to get more students of color to go into Medicine in the first place, and then hopefully, once they're in Medicine, to see oncology as an attractive subspecialty to go into. 

Todd Pickard: That's really interesting, because we see the same thing in advanced practice for PAs and Nurse Practitioners that we still have a diversity issue in recruiting folks. So, this is something that is widespread in our medical teams. So, this is a really important conversation to be having. 

I'm going to start with a different series of questions, and I'd like to ask Dr. Pinder-Amaker if she could respond first. What are the benefits of having a more diverse workforce? What's the impact on our wellness as teams, but also the patient experience? And then we'll ask Dr. Wadsworth to also chime in. 

Dr. Stephanie Pinder-Amaker: Thank you for the question, and thank you for having me. The evidence is compelling, and it's overwhelming. We know that there are many, many benefits. Diverse teams are stronger, they're smarter, they're more innovative, more profitable even. We know that this is true across industries, and across organizations, including medicine, and therefore, in academic medical centers. The challenge is that many organizations and systems and academic medical centers struggle to create a true culture of inclusivity and belonging.  

So, while there is, and has been an increased focus on the recruitment of individuals who historically have been underrepresented in Medicine, we know that the increase in recruitment doesn't necessarily translate into retention. There's a gap there, and it's really incumbent upon us to close that gap so that we can not only recruit, but retain diverse talent and achieve some of those superior outcomes, including improved patient care, more innovative research, and so forth. And we're aiming to close that gap in a very specific way by creating systems and organizations that are much more culturally responsive. 

Dr. Lauren Wadsworth: Yeah. I will just add, this is Dr. Wadsworth speaking, that when we have more diverse clinicians, we know that patients that have minoritized identities like black patients or queer patients, feel more comfortable working with their teams. This might be due to experiencing less microaggressions from black doctors to black patients, for example, and could also be for a number of other reasons. But additionally, we know that even if a patient isn't being seen by a provider that identifies the same as them, teams that are more diverse have the opportunity to have more cross-pollination, more conversations about cultural practices, microaggressions, et cetera, that can then improve the ability for the whole team to provide culturally-responsive and humble care to the patient. 

Dr. Stephanie Pinder-Amaker: Incidentally, the whole practice of cultural humility was originally founded by two women physicians of color, specifically to address this gap within hospital systems. And now it's of course taken root across other industries and other relationships that where there's sort of a critical imbalance of power, but it originated to look at addressing the power imbalance between doctors and patients. 

Todd Pickard: I am really fascinated to hear Dr. Wadsworth and Dr. Pinder-Amaker's perspective because they are both authors of a recent book, Did That Just Happen?! And I want to talk a little bit about the book, but before that, Dr. Wadsworth, you used the term microaggressions. Could you let our listeners know a little bit about-- I think they may assume what that means, but I'd like to hear an official version of what it means. 

Dr. Lauren Wadsworth: Sure. You might be sorry you've asked, because I actually have a lot to say on this topic. So, microaggressions historically has been a term used to describe often common, subconscious slights or statements, or physical movements that enact stereotypes. So, for example, a white woman seeing a black man walk down the street from the other direction, might clutch her purse or change her purse to the other side, which would be a physical manifestation of a stereotype that black men are dangerous. And that would be a microaggression, whether or not she was conscious that she was doing it.  

Dr. Pinder-Amaker and I believe that the term microaggressions is really helpful in starting to bring white people and other folks with privilege into the conversation, to start to recognize these unconscious biases playing. And the micro part of that term, we think really prioritizes the person with privilege, in that, it focuses on the smallness of it, the unconsciousness of it, which makes it a bit more palatable for people with privilege to recognize that they might be doing these things if they're not intending to. In our book, we actually coined a new term, 'Identity Related Aggressions' or IRAs, which is a new way of describing the same concept, but prioritizing the impact or prioritizing the person that was hurt or harmed in the instance.  

So, by saying Identity Related Aggressions, we're taking out the 'micro' and acknowledging the exponential burden that these experiences can have much like IRAs in financial terms. 

Todd Pickard: Yeah. It's really interesting because, as a person who might be identified as a person of privilege, it's really difficult to remember…you may meet somebody that you don't know, and they may have a very interesting accent. And I've done this before, and I've said, "You have a really interesting accent, where are you from?" And I had some social workers with me at the time, and they said, "Todd, I can't believe you're having these microaggressions." And I said, “I am?”. And so, it really is so easy just to slip into these things without even realizing it. And it's great to have this conversation.  

So, Dr. Pinder-Amaker, what was the reason to write this book? Why now? What was that about? Tell us more. 

Dr. Stephanie Pinder-Amaker: We had many, many motivating factors for writing this book, as you can probably imagine. I'll start with a couple, and then Dr. Wadsworth, you can take it here. One thing is, really to focus on what we're talking about now, like, how do you address this disconnect between diversity and create real inclusivity? It's pretty accurate to say we're fascinated by, intrigued by the practice of inclusivity and cultural humility. How do we work with organizations and people within organizations to move beyond what we refer to as, diversity by the numbers, which also matters, but to actually create systems that are welcoming and inclusive so that when people of diverse backgrounds do enter our spaces, in this case, we're talking about oncology, which have been historically white, that that diverse talent feels welcome, and valued, and seen, and heard. So, we're just really intrigued; What does that look like? What does inclusivity in practice look like? How do you break it down? How do you teach it to people? How do you explain the skills so that people feel empowered to learn them?" 

You mentioned, Todd, having been maybe called in by a social worker-- I'm not sure if you were called in or called out in that instance, but even knowing the difference there, is a skill that we want to be able to teach people so that we can get better at creating inclusivity and belongings. And there's real significance in those kinds of details. 

A second motivating factor; we're both psychologists, we're both clinical psychologists, we're practitioners, but we're also researchers. So, we were highly motivated naturally to apply evidence-based practices from within our field to understanding and explaining, operationalizing inclusivity. We wanted to do it in a way that would be accessible so that people could really hear it. Like, keep the science, but lose the jargon. How do you make this information practical, accessible, so that people can hear it, not turn away from it, lean into it, and also feel empowered? Like, “I could actually do this.” So, there's effort to both do it, but also to make it plain. And those two things were significant motivating factors. And Dr. Wadsworth, why don't you talk about a broader one? 

Dr. Lauren Wadsworth: Sure. I'm guessing you mean our personal motivations? Am I right? 

Dr. Stephanie Pinder-Amaker: I think you're right. 

Dr. Lauren Wadsworth: Okay. So, as people who hold marginalized identities or rising identities, which we're also trying to use both of those terms interchangeably, me as a queer woman, and Stephanie, as a black woman, we often had the common experience of being the only, or the pioneer in each of the places that we worked. Coincidentally, those were often medical settings or academic medical centers. So, to Dr. Gilligan's point, we experienced the lack of diversity ourselves. As a result of being the only, or the pioneer, we frequently experienced not only Identity Related Aggressions, but simultaneously requests to train those of our colleagues on how to become more culturally aware and responsive.  

So, we were given the label 'diversity expert' just by entering the room, in Dr. Pinder-Amaker's case, or coming out, in my case, in the workplace. And so, there was a lot of ambivalence there. We didn't seek to become diversity experts in our careers yet we're continuously given that forum and felt that we did have things to share just from our personal experiences. So, over the years, we ended up working in the same institution, and experiencing the same pattern, and finally finding each other, and finding a lot of support and solace in our work, discussing that experience together. And our hope was that we could create a booklet of advice that could be both validating, to those who are also experiencing Identity Related Aggressions in the workplace, and informative, and welcoming, for those in leadership to change things at their institutions. 

Todd Pickard: I really enjoy your story. And if folks could see us, they'd say I'm nodding my head a lot when you guys were talking, because so much of what you say really resonates with my own experiences and the things that I've witnessed in my 24 years practicing. I appreciate the fact that you are trying to make this welcoming, because when people become defensive, they stop hearing, and they don't learn. So, when it is presented in a way that brings them in and gives them permission to engage and ask questions in a truly thoughtful way, I think that's where you have the most impact. I'm very, very much aware of and appreciate the fact that y'all are doing it. I want to pull Dr. Gilligan back into the conversation, and I do want to hear more about your book, so we'll come back to that. 

But Dr. Gilligan, from your experience as the Diversity, Equity and Inclusion Officer for the Cleveland Clinic's Graduate Medical Education Council, could you tell us about diversity and inclusivity in medical training programs? Are the trainees prepared to succeed in a diverse workforce, or do they experience any issues in this area? 

Dr. Timothy Gilligan: They certainly experience issues. And you raised one of the issues; microaggression and Identity Related Aggressions are commonplace. That's been studied and documented, that trainees experience these regularly, both women and people of color. I don't know as much about the LGBTQ space in terms of how much that's been documented, but I do know anecdotally from colleagues here, that that happens as well. So, it's a big issue. This takes place at some of the levels that we already discussed; you show up in the program, and you're the only person who looks like you. And you're trying to find a mentor, and you can't find a mentor who looks like you. And so, there's structural problems that the lack of diversity makes it harder for people of color and other oppressed identities, for people to feel welcome, at home, competent.  

There's an issue of stereotype threat, which describes the process where people underperform because they're worried about conforming to negative stereotypes that people hold about their identities. And so, there's been interesting research on this, that black students or other students of color may not perform to their potential if they're noticing they’re not set up to succeed intentionally. So, I think the learning environment issue is important. One of the things that we're trying to do is to train faculty to be more aware of these issues, issues of implicit bias. There's evidence that people performing at the same level are judged differently based on their identities, particularly around racial identities. Written documents; if you tell someone that is written by a white person it will get evaluated at a higher score than if you tell them it was written by a black person, there's been evidence in the legal world about that.  

So, students come in and they encounter the same bias in medicine that they're going to encounter everywhere else and that can feel like a hostile environment, or unwelcoming environment. So, I think a lot of the stuff that has been discussed here already in terms of making people aware of oppressive behaviors of microaggressions, of implicit bias, so that we can start to do those behaviors less, or at least be aware of them when they have been, and respond to them. And then put into place support so that people feel like they are supported. So, one of the things we're doing is put in mentorship programs so that people can find mentors who look like them, and talk about their experience. It doesn't mean that all your mentors are going to share your identities, but at least to have access to people who share your identities, and could share the difficulty attached to those identities, of succeeding in a world that is to some extent, still dominated by white men. 

But again, it's a multifaceted thing. I think we're trying to change the culture from the top-down. If we diversified the institution, then the students are training in a more diverse environment, and feel more welcome, feel more supported. As people have more tools for recognizing bias, and reducing it, and responding to it when it occurs, people feel, I think, more supported there. I think one of the things that I find is that there's a sort of crazy making psychology where someone experiences bias and no one believes them. And then they're left wondering, "Is it just me? Is it just in my head?" And so, I think validating people's experiences… 

The last thing I'll say, one of our Diversity Officers we asked him, "What are some things that we can do today?" The first thing he said was to begin validating other people's experiences of their own life. If we just do one thing, like just focus on microaggressions, that's not going to do too much, it requires a much broader strategy from recruitment to faculty training, to the educational environment. 

Todd Pickard: I think that what you've said is so important. I want to highlight; it is not just about microaggressions. Implicit biases that we all bring from our experiences are really important to acknowledge. It's very easy to say, "Oh, this person looks like me, so they must act like me, and share the same values as me." 

And I'd like to ask Pinder-Amaker, what we're discussing is something that is not just a white person issue. It's about all of us, all of us depending on where we come from, and our background, and our experiences may have biases. Can you expand on that a little bit? I have friends who are from Africa, they're from Ghana. They have black skin, but they have biases against American black people because they think American blacks are lazy. And so, what I'm talking about is how it's not just the color of the skin that makes you capable of having implicit biases or microaggressions. It's larger than that. 

Dr. Stephanie Pinder-Amaker: In the opening question, there was a nod to what we mean by diversity. We're talking about diversity across social-cultural identities. We use a specific framework to help remind us about how expansive social-cultural identities are. And that happens to be what we often refer to as probably the longest acronym in the world; it's The ADDRESSING Model, by Dr. Pamela Hays. And ADDRESSING each letter of the word reminds us, directs us to a very specific aspect of identity, so that we are focused on, "Oh yeah, there's diversity." Yes, we're talking today, a lot about race and ethnicity, but also, there's age, ageism and ableism. And people hold historically minoritized identities, and oppressed identities, and statuses across these social-economic status, and sexuality, national origin, as you may have referenced earlier, religion, and so forth. 

And so, when we're working with systems to think about just what Dr. Gilligan mentioned earlier - why it's so important to have multi-pronged, systemic and holistic approaches - we don't have time to do one thing at a time when it comes to really addressing some of these very structural and systemic barriers that occur across a broad range of social-cultural identities. 

Todd Pickard: Well, this concludes part one of our discussion on increasing diversity in Oncology, with Clinical Psychologists, Dr. Lauren Wadsworth, and Dr. Stephanie Pinder-Amaker and Medical Oncologist, Dr. Timothy Gilligan. 

In the second part of this episode, we will discuss the importance of using correct pronouns, and consider different approaches to learn or pronounce a person's name. 

We will also explore culturally-sensitive tips for individual healthcare providers. 

Thank you to all of our listeners for tuning into this ASCO Education Podcast. If you have an idea for a topic or a guest you'd like to see on the show, please email us at: education@asco.org. 

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