AbstractPurpose

We aimed to evaluate the growth of women within the general radiation oncology (RO) workforce in comparison to the growth among other medical specialties. We also sought to create a predictive model for gender diversity to guide future recruitment efforts.

Methods and materials

We identified 16 medical specialties, including RO, for analyses. We utilized data from the Association of American Colleges (AAMC) and assessed female representation at four time points (2006, 2011, 2016, and 2020).

Additionally, we determined characteristics of medical specialties that were predictive of increased gender diversity. We performed univariate statistical analysis with linear regression to evaluate factors predictive of greater gender diversity among the medical specialties in our cohort.

Results

The proportion of women within the represented specialties increased over time. Obstetrics/Gynecology [14,750 (2006), 23921 (2020); 18.7% absolute growth] and dermatology [3,568(2006), 6329 (2020); 15.1% absolute growth] experienced the highest absolute growth in female representation between 2006 and 2020.

When assessing changes between various time points in RO, the absolute change in female physicians increased by 1.5% between 2006 and 2011, by 2.2% between 2011 and 2016, and by only 0.4% between 2016 and 2020, which was the lowest growth pattern relative to the other 15 specialties.

Factors predictive of gender diversity among specialties were lower average step 1 scores (p=0.0056), fewer years of training (p=0.0078), fewer work hours (p=0.046), the availability of a standard 3rd year clerkship for a given specialty (p=0.0061), and a high baseline number of female physicians within a specialty (p=0.0078). Research activities (p=0.099) and interest among matriculating medical students (p=0.28) were not statistically significant.

Conclusion

The percentage of women in RO lags behind other medical specialties, and has been notably low in the last few years. Interventions that incorporate novel initiatives proposed within this study may accelerate current recruitment milestones.

IntroductionAt the conclusion of the 1981 academic year, only 25% of graduating medical students in the U.S were women. However, in 2019, the matriculating class of medical students was comprised of more women than men (50.5%)2The majority of U.S
medical students are women, new data show.. Despite closure of the gender gap among medical school matriculants, asymmetric distribution of female residents and attending physicians across medical specialties persists3Jagsi R Griffith KA DeCastro RA Ubel P. Sex, role models, and specialty choices among graduates of US medical schools in 2006-2008.. Several factors have likely influenced this trend including personal preference, prior exposure to a specialty, and mentorship, among other considerations.In radiation oncology (RO) and among other historically male-dominated specialties, there have been growing efforts to increase the presence of women in the physician workforce, and to eliminate barriers to mentorship and leadership4Lightfoote JB Fielding JR Deville C et al.Improving diversity, inclusion, and representation in radiology and radiation oncology part 2: challenges and recommendations., 5Dageforde LA Kibbe M Jackson GP. Recruiting women to vascular surgery and other surgical specialties., 6Moak TN Cress PE Tenenbaum M Casas LA. The leaky pipeline of women in plastic surgery: Embracing diversity to close the gender disparity gap., 7Odei BC Gawu P Bae S et al.Evaluation of progress toward gender equity among departmental chairs in academic medicine., 8Knoll MA Glucksman E Tarbell N Jagsi R. Putting women on the escalator: How to address the ongoing leadership disparity in radiation oncology.. With the exception of a few studies9Ahmed AA Hwang W-T Holliday EB et al.Female representation in the academic oncology physician workforce: Radiation oncology losing ground to hematology oncology.,10Deville C Hwang W-T Burgos R Chapman CH Both S Thomas Jr., CR Diversity in graduate medical education in the United States by race, ethnicity, and sex, 2012. highlighting variance in gender distribution between RO and other specialties, the majority of studies addressing gender concerns and reparative interventions in RO have often focused solely on female underrepresentation in RO11Chapman CH Hwang W-T Deville C. Diversity based on race, ethnicity, and sex, of the US radiation oncology physician workforce., and have thus lacked the benefit of objective comparison with other medical specialties.

In this study, we seek to provide a contemporary evaluation of the growth of women within the RO workforce compared with other specialties between 2006 and 2020 and assess if promising gains in gender diversity have been achieved within RO.

ResultsThe total number of women in our cohort of 16 specialties (Table 1) stratified by the 4 time points were as follows: 2006 (146,344; 29.8%), 2011 (176,517; 33.5%), 2016 (203,169; 37.0%), and 2020 (224,859; 39.2%). Collectively, primary care specialties constituted the highest absolute number of women in our cohort over time.

Table 1Distribution of women among medical specialties in 2006 and 2020.

Female representation among RO physicians was 23.4% in 2006 and 27.5% in 2020 (4.1% increase), which was tied for the second lowest absolute growth over time among the represented specialties. Obstetrics/gynecology [14,750 (2006), 23921 (2020); 18.7% absolute growth] and dermatology [3,568(2006), 6329 (2020); 15.1% absolute growth] experienced the highest absolute growth in female representation over the study period.

When assessing changes between various time points in RO, the absolute change in female physicians increased by 1.5% between 2006 and 2011, by 2.2% between 2011 and 2016, and by only 0.4% between 2016 and 2020. The 0.4% increase between 2016 and 2020 was the lowest in comparison to the other 15 specialties (Figure 1).

Figure 1Growth of women physicians within several medical specialties at various time points.

Statistical analysis was undertaken on specialty characteristics (Table 2) and its association to gender diversity rank. Factors associated with a higher gender diversity rank were lower average step 1 scores (p=0.0056), fewer years of training (p=0.0078), fewer work hours (p=0.046), the availability of a standard 3rd year clerkship for a given specialty (p=0.0061), and a high baseline number of female physicians within a specialty (p=0.0078).

Table 2Characteristics of medical specialties.

A low number of research activities (p=0.099), and greater interest among matriculating medical students (p=0.28) were also associated with higher gender diversity rank, but were not statistically significant.

Discussion

This study reports on the representation of women in RO in comparison to 15 other medical specialties between 2006 and 2020 and notes minimal increase in female representation in RO over time, with the most recent years showing an unprecedented low growth pattern relative to other specialties. Significant factors predictive of increased gender representation within a specialty were a lower step 1 average, fewer years of training, fewer work hours, availability of a standard 3rd year clerkship, and a high baseline number of female physicians within a specialty.

While our study evaluated predictive factors of gender diversity among all physicians (academic and non-academic physicians), a previous study15Chapman CH Hwang W-T Wang X Deville C. Factors that predict for representation of women in physician graduate medical education. by Chapman et al reported predictive factors of gender diversity among specialties within academic medicine alone, and also noted that a lower step 1 average, availability of a 3rd year clerkship, and a high percentage of female faculty were predictive factors. Chapman et al, however, did not evaluate years of training and work hours as was done in the present study, but their study provides important preliminary findings that corroborates our results.Our predictive model for intra-specialty diversity showed that high step 1 scores and research activities were not barriers to recruiting and matching women as evidenced by the high proportion of women in dermatology. However, our results also suggest that specialties with an overemphasis on Step 1 scores are generally less gender diverse. Consequently, efforts aimed at providing a more holistic approach to residency selection16Odei B Das P Pinnix C Raval R Holliday EB. Potential implications of the new USMLE step 1 pass/fail format for diversity within radiation oncology. will augur well for gender diversity within RO.We found that the inclusion of a specialty as part of the mandatory third year clerkships in medical school was predictive of increased gender diversity. The compounding realities that RO has low pre-matriculation interest (1%; Table 2) among medical students, limited inclusion in medical school curricula17Agarwal A DeNunzio NJ Ahuja D Hirsch AE. Beyond the standard curriculum: a review of available opportunities for medical students to prepare for a career in radiation oncology., and no standard third year clerkship, may provide context for why achieving higher visibility among female medical students has likely been challenging. Moreover, the little exposure to RO during the early phase of medical school is further taxed by expectations of high research productivity among residency applicants14

NRMP Match 2020. NRMP. Accessed April 9, 2021. https://mk0nrmp3oyqui6wqfm.kinstacdn.com/wp- content/uploads/2020/07/Charting-Outcomes-in-the-Match-2020_MD-Senior_final.pdf

, which may dissuade some female applicants who develop a late interest in RO from pursing the specialty. Thus, efforts targeting women during the pre-medical and pre-clerkship phases will be intrinsically important to effect change. National initiatives, under the auspices of the American Society for Radiation Oncology (ASTRO) and advanced by departmental leadership, which encourage engagement of undergraduate women as they obtain shadowing/clinical experience will be a valuable area of investment, and will place the recruitment pipeline “more upstream.” Furthermore, a summer research fellowship that focuses exclusively on women early in their medical education may also be an important consideration.

Fewer years of training and fewer work hours were significant predictors of increased female representation within a specialty. The 5 years of post-graduate training in RO is longer than other specialties with a high female representation [obstetrics/gynecology (4 years), pediatrics (3 years), and dermatology (4 years)], suggesting that RO may be less attractive when considering training duration. However, the generally lower average weekly work hours in RO provides a favorable counterpoint, which may be underappreciated given the poor exposure of medical students to RO.

Our data also showed that a high baseline number of female physicians within a specialty is an important driver of female representation within a specialty and may reflect mentorship opportunities. Given the relatively small number of the female RO in the workforce, and the likely geographical maldistribution of mentorship opportunities, a broader coalition of willing mentors will be needed to meet the current need for early female mentorship. It will be crucial for male radiation oncologists to enthusiastically seek opportunities to mentor women in the formative years of their medical training, especially in light of recent data showing the effectiveness of cross-gender mentorships18Lee A Albert A Griffith K et al.Mentorship in Radiation Oncology: Role of gender diversity in abstract presenting and senior author dyads on subsequent high-impact publications.. In this vein, current mentorship programs including those sponsored by The Society for Women in Radiation Oncology (SWRO)19Seldon C Wong W Jagsi R Croke J Lee A Puckett L. Remote mentorship in radiation oncology: Lessons to share., American College of Radiation Oncology (ACRO), and The Gender Equity Community, require ongoing support and resources to achieve their important aims. Social media can also broaden the outreach of mentorship initiatives, particularly for female students at institutions without an affiliated RO department, or in a scenario where only a few women mentors may be present. Ongoing efforts such as the innovative #ILookLikeARadOnc and #WomenWhoCurie campaigns22Albert AA Knoll MA Doke K et al.#WomenWhoCurie: Leveraging social media to promote Women in Radiation Oncology. will continue to be important in fostering inclusion and celebration of gender diversity within RO, and will also be paramount in breaking down stereotypical gender barriers and perceptions.While female representation in the RO workforce has been historically modest, the factors specifically influencing the recent pattern of deceleration in female growth in RO are likely complex and multifactorial and may include concerns about the trajectory of the field. In spite of this recent trend, more efforts are present than ever before aimed at tackling the issue of improving gender diversity in RO23Suneja 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.. In June, 2017 the Board of Directors of ASTRO approved a new strategic plan for RO24ASTRO Strategic plan
American society for radiation oncology (ASTRO) - American society for radiation oncology (ASTRO).; and among the five core values identified were diversity and inclusion. ASTRO's Committee of Health Equity, Diversity, and Inclusion (CHEDI) also continues to work to raise awareness and improve the representation of women in RO. These efforts are laudable and the full impact of these initiatives may take time to be fully realized.

A limitation of our study is our utilization of 4 time points over time rather than reporting annual changes over time. We believe the time points functioned as strong surrogates of trends over time. Another limitation involves the use of limited specialty characteristics for our predictive model, which was likely not exhaustive of all possible factors to consider.

Article InfoPublication History

Accepted: May 21, 2021

Received in revised form: May 16, 2021

Received: April 9, 2021

Publication stageIn Press Journal Pre-ProofFootnotes

Summary: This study reports on the representation of women in RO in comparison to 15 other medical specialties between 2006 and 2020 and notes minimal increase in female representation over time, with the most recent years showing the slowest growth pattern among all represented specialties. Additionally, factors predictive of gender diversity among medical specialties were lower average step 1 scores fewer years of training, fewer work hours, the availability of a standard 3rd year clerkship for a given specialty, and a high baseline number of female physicians within a specialty.

Identification

DOI: https://doi.org/10.1016/j.adro.2021.100735

Copyright

© 2021 The Author(s). Published by Elsevier Inc. on behalf of American Society for Radiation Oncology.

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