JCO After Hours: A Discussion With Abby Rosenberg and Reshma Jagsi

Journal of Clinical Oncology (JCO) Podcast

Dr. Shannon Westin, Dr. Abby Rosenberg, and Dr. Reshma Jagsi discuss the timely issue of diversity, equity, and inclusion in the field of oncology.

TRANSCRIPT

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SHANNON WESTIN: Hey, everyone and welcome to JCO After Hours, the podcast that gets a little bit more in-depth about some of the articles and amazing research that have been published in the Journal of Clinical Oncology. I'm so excited to be with you today. And more importantly, I'm very excited to talk about this amazing manuscript, which is called "Picture a Professional-- Rethinking Expectations of Medical Professionalism Through the Lens of Diversity, Equity, and Inclusion."

And this was a Comments and Controversies article that was just published in October of 2021. And I am beyond thrilled to be joined by Dr. Abby Rosenberg, who was the lead author on this manuscript. And she is currently an associate professor in the Division of Hematology-Oncology, as well as in the Division of Bioethics and Palliative Care at the University of Washington School of Medicine.

She has a number of different amazing accomplishments, including being the director of Palliative Care and Resilience Lab at the Seattle Children's Research Institute, the director of Pediatrics at the UW Cambia Palliative Care Center of Excellence, and the director of Survivorship and Outcomes Research in Pediatric Oncology at the University of Washington. In addition, she is our ASCO chair of our Ethics Committee. Welcome, Dr. Rosenberg. So excited to have you.

ABBY ROSENBERG: Thanks for having me. Happy to be here.

SHANNON WESTIN: And in addition to Dr. Rosenberg, we're also joined by one of her co-authors, Dr. Reshma Jagsi, who is the deputy chair of radiation oncology, the Newman Family Professor of Radiation Oncology, and the residency program director and the director of the Center for Bioethics and Social Sciences at the University of Michigan. You guys, we're going to spend this whole podcast just talking about how amazing the two of you are. Thank you so much for being here.

RESHMA JAGSI: Thanks for having me.

SHANNON WESTIN: So let's get into it. I'm really excited about this paper. I think it's super timely and certainly something that we've all been, I think, dealing with on a day-to-day basis and also reading about and really trying to get better at. So can you tell us a little bit-- and we'll start with you, Dr. Rosenberg-- about what first drew you to this work, how you got involved and, really, how you became passionate about it?

ABBY ROSENBERG: Yeah, happy to. I think just, as you said, Dr. Westin, there is this ubiquity in the experiences, in particular of women and folks of color in medicine, where we feel discriminated against, and we feel like we don't belong. And we know from some really great data from the National Academies of Sciences that 50% of women in med school, for example, experience discrimination before they graduate. And when we educate them about what microaggressive and sexist behaviors can actually look like, that number goes way up.

And most women, in particular, say that they're willing to, quote, "pay this price" for being in medicine because they believe in the work, and they believe in the mission. And for me, this was really personal. Because I was one of those people, too, until I got to the point in my career where I noticed how my mentees and people who reported to me were being held back. And that, to me, made me feel like there was something I really needed to do now as an advocate and mentor to try to change the system so that more women and people of color could be successful in our field.

SHANNON WESTIN: That's great. And then how did you get involved Dr. Jagsi? I'd love to know how the collaboration came about and also about your passion for this work.

RESHMA JAGSI: Thank you. Yes, so both Dr. Rosenberg and I have had the privilege of chairing ASCO's Ethics Committee. And I think, to both of us, this is a fundamental matter of professional ethics. And there's really two reasons that this is so centrally and fundamentally an ethical issue.

And so one of them is that human beings have a duty to resect the dignity of other human beings. And this is a situation in which we are not treating one another with due dignity. And then, of course, there's also really important consequences when we do fail in that duty.

And so it's important because we share a professional mission here to promote the highest quality of patient care, to educate those who are following in our field, and to do the scholarly research to discover advances that will ultimately benefit patients and society in the future. And all of those missions are enriched when we have a diverse workforce. So this is really squarely in the lane of ethics. And so when Dr. Rosenberg proposed this article, I was just more than delighted to be included in this work.

SHANNON WESTIN: And it's so important for us, as women. And I am not a woman of color, but especially as we cross all of these different groups to really elevate each other and to move the message and put it out there and make sure that people feel OK bringing these things up and understand that they're not alone, I think that's, to me, that resonated so much, with both of you saying this.

Like, we've all experienced this and some of us don't even know we're experiencing it, right? Because it's just, oh, this is the way it's always been. This is the price you pay. It's the price of doing business. And I'm so grateful for people like you all that are kind of not afraid to step up and step out so that our trainees, and even pre-trainees-- people that are considering coming into the practice of medicine-- will know that this is a safe space. Because I think that's the issue, right?

So I'm so grateful to you. I think, for me, it's been very interesting across these last few years, especially in the idea around #MeToo, which I know was not a new idea but certainly became very much a focus over the last three or four years. This focus on diversity, equity, and inclusion has really become, I think, a welcome change amongst a number of professions.

Can you speak a little bit-- and I'd be interested on both your takes, and feel free to interact-- but can you guys speak on why we've been slow to take this on in medicine? Is it just that kind of-- gosh, I'm going to offend some people-- old, white male kind of leading the way and keeping us from doing this? Or what's been the hold-up here? Nobody wants to-- they're like, whoa, Shannon. Whoa, Shannon.

RESHMA JAGSI: I have some thoughts if you want me to go. I'm yielding to you because this is really your thing.

ABBY ROSENBERG: No, you go.

RESHMA JAGSI: This might be a landmine, so let me go first.

[LAUGHTER]

No, it's totally fine. Because I think that there are very good reasons that medicine has been a conservative profession, that we've had strict hierarchies. It makes sense. You're in the operating room, you really want one person to be in charge. You need a captain of the ship. There's a lot of reasons that many of our traditions sprang up the way that they did.

But they have made us a field within which individuals rise to positions of leadership. There's relatively little turnover. We've not embraced, for example, term limits in the way that many other academic fields have.

And so there has been this tendency for people who have certain shared lived experiences to be able to react to the things that they've experienced but perhaps not to have as much familiarity with those things that they haven't experienced. And so I think that's one of the challenges that we have.

SHANNON WESTIN: Dr. Rosenberg, do you have anything to touch on or add there?

ABBY ROSENBERG: I totally agree. And thanks for launching that grenade for us. [INAUDIBLE].

[LAUGHTER]

I think that change is hard, and change takes a lot of time. I'll share sort of a minor anecdote, but bear with me. When I started to really try to speak about this publicly and move the needle, my father was very ill. And he actually died during the year that I started this own crusade at my workplace. And my father had been this big civil rights activist back in his day.

And I was talking to a colleague who said, oh, your dad would be so proud of you. And he said, what do you think your dad would say? And I said, you know what my dad would say is how silly it is that I thought I could make this dramatic change within a matter of months. Because it takes years and years and years to really do that.

And I think where we are in academic medicine is years behind everybody else. And we're watching this change happen and this culture change happen in other industries, and we're trying to catch up. But within our own culture, it just takes a lot of time. Because there is this real institutionalized history, as Dr. Jagsi was describing, of the way we've always done it.

I will also name, to just be even more provocative, that the people who have the power of influence, the people who have the power to really make those changes, are the very people who I think wrongly perceive it as a loss of their power to diversify and change the way we do it. And that's really threatening to people who can make those changes with us. And so the additional barriers we have as a grassroots community that's trying to make change becomes really hard when it's not ubiquitous from the bottom up and the top down that people are trying to be change makers themselves.

SHANNON WESTIN: I think that's a great point. And I guess that kind of leads to my next question. How do we overcome this? How do we help those people in power understand what the benefits are to focusing on diversity, equity, and inclusion?

And also, how do we overcome that existing bias in medicine that is affecting not only our professionalism standards but also, frankly, the care of our patients? We know that this is a clear indicator of poor outcomes for our patients, not only in oncology, which, obviously, is where we all sit, but across a number of different fields. I'm just asking you to solve all the world's problems in this podcast.

ABBY ROSENBERG: Yeah. Well, Dr. Jagsi mentioned some of this. I think if you go back to it needs to be top-down and bottom-up. The top-down piece is we need leaders who look like the workforce. People cannot aspire to belong if they don't see that they belong. And so things like term limits, our abilities to promote and ensure that the tippy-top levels, and every level in addition, is really representative of the diversity of the workforce we want. That's really important.

But then, from the bottom up, we need to be bringing people in. We need to be working extra hard to make sure that folks who have been historically marginalized with fewer opportunities are given the additional opportunity and resources they need to succeed in medicine.

And so the system, to go back to our previous question, why it's so hard, it's not easy. I mean, all of us know going through our medical training and getting to where we are is really, really difficult. And every step along the way, there are so many obstacles. And what we need to be doing is supporting those who are bringing diversity in to ensure that they continue to succeed.

RESHMA JAGSI: Yeah, I love the way that you've approached this with the top-down and the ground-up for culture change. And just to add to some of the things that we can do from the top down, in addition, we can provide sponsorship. We can be intentional about that, not exhibit homophily and simply think of the person that reminds of us of ourselves when we were younger when we have the opportunity to give someone a chance to shine.

We can be absolutely intentional about developing mentor networks for individuals, recognizing that simple hierarchical dyads tend both not to be effective and not to be safe. We should be thoughtful about implementing unconscious bias training.

Certainly, there are some that don't work. But Molly Carnes at the University of Wisconsin has actually developed some within medicine that can be very effective. And again, I'm saying this all from the top down because this is not about fixing the individuals.

The top-down bit is that we have to change the structures, right? We're not fixing individual human beings. We're fixing systems. We need to develop transparent, consistent, criterion-based hiring, promotion, compensation processes.

And then, from the ground up, we need to develop our allyship behaviors. I had a very smart trainer come to our department about a year ago who talked about how we should approach allyship development in the same way we approach behavior changes in other areas.

There's people that are pre-contemplation. They're not really sure they want to be an ally yet or don't even know that allyship is a thing or necessary. There's people who are in contemplation who'd like to be allies. They're not sure exactly how to do it.

There's people who are actively trying to be allies and even become advocates for change but need more support. And we need to meet people where they are in that behavior change wheel so that we get that ground-up cultural transformation at the same time that we're changing the system.

ABBY ROSENBERG: As we're talking, I'm sitting here, realizing that we're talking about the larger problem of diversity in medicine. And I did want to get back to this idea of what professionalism in medicine is and how the two are related. Because that's sort of what we endeavor to do with this project.

And it gets more granular and more opaque at the same time. So the granularity is part of that progression of success is this thing that we call professionalism, which is hard to measure. Sometimes it's like are you accountable, are you honest, do you communicate well? But they're these super-nebulous things-- are you a good person, essentially? And I think we all want to be those people.

The folks who are judging professionalism, the folks who are grading it, so to speak, especially as we're trainees, are not necessarily consistent with how they assign good or bad professionalism merit. And what we want to do with this project, we wanted to focus on this particular aspect of how to improve the diversity of our workforce and the success of a diverse workforce by sort of naming this problem.

And what Dr. Jagsi is saying is, I think, the accountability of how we record professionalism, the accountability of how we say, no, no, no, that wasn't actually professional behavior and therefore, you are not necessarily representing what we want as the best of our field, those kinds of behaviors and those kinds of metrics have not really been established in medicine. And I think that's the particular needle we were trying to move with this paper.

RESHMA JAGSI: And that's where the brilliance is in the title that Dr. Rosenberg developed for this piece-- "Picture a Professional." Because when we're trying to assess, are you a good person, really, what we end up doing is deciding, do you look like a good person? I mean, we literally look at appearances rather than behaviors. And I think that she just so hit upon such an important point there.

SHANNON WESTIN: Yeah. And you all mentioned that those biases are, again, the way medicine was originally-- what was the face of medicine-- the white male. And now that the face has changed, how can we also adjust what we picture?

Also, I've heard this before, but when I was reading the paper about the children that were asked to draw a professional or draw a physician or a scientist and what that was back in the '60s and what might it be now? I know in the 2010s, it was still overwhelmingly male. And I think that speaks to a bigger problem. That speaks to a larger issue.

So now the question is, how do we change that picture in the minds of people that are hiring and promoting physicians and medical professionals? I think that's what I took away. And I felt this table was so-- I was like, wow, how did they even figure this out? Because it's so granular and so specific.

And I feel like that is really the marching orders that I got from this paper is how do you take these types of descriptions and apply them when you're looking at candidates and when you're looking at promoting within your institution. And I'd just be interested to hear your thoughts. I know that really wasn't a question. I'm just so inspired by kind of what you were able to do in this short piece.

ABBY ROSENBERG: Oh, yeah. No, thanks, Dr. Westin. I'll start because when we were developing this, we were actually looking up, how does professionalism get defined in different places? And it is super vague. It's super different in different places.

There are some really outrageous, frankly confined, if not racist and sexist, things out there that say, you should dress like this. And it's very white patriarchal standards. But most places have these nebulous things, like the American Medical Association, which is what we pulled down. And I actually have the paper in front of me. Because it's sort of like, "Refrain from supporting or committing crimes against humanity." I mean, really? Is our benchmark that you didn't commit a crime against humanity?

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SHANNON WESTIN: It's a pretty low bar.

ABBY ROSENBERG: That is so bizarre to me. But OK, fine. So let's say we all endorse that we are not going to commit a crime against humanity. How do you actually measure that? And so what we wanted to say is, actually, what we should be doing is holding ourselves accountable, being responsible for what we think represents our field in medicine.

And in this new era, as we are becoming more and more aware of the importance and the value of diversity, equity, and inclusion within any workplace, we need to really come up with ways to translate "refrain from this badness" to "do good." And so we thought, what if we instead said, we're going to demonstrate an intolerance of bias. You have to actually show that you are willing to speak up, that you're willing to interrupt it when it happens, that you are investing in the skills development to be that kind of inclusive leader or workforce member.

And those are actually measurable things that we can say, as far as folks are going along in their training and their career development, are you meeting these particular benchmarks? Do we see that you are demonstrating these particular values that we all hold so dear?

RESHMA JAGSI: It's that type of specification that makes it so useful. And I'm just so grateful, Dr. Rosenberg, for you taking this on. Because I really do think that this document is, as you said, Dr. Westin, something that is concrete and can be useful to people who are in the position of assessing professionalism as a competency, for example, as I do, as a residency program director.

SHANNON WESTIN: I think that's what we're lacking, right? Because it has been this idea that's so nebulous. And I think we've all had experiences where your hair is too big or your skirt is too short or you're whatever-- you're too quiet, or you're too loud, or you're too pushy. I mean this is what we get judged based on.

And I think I just was so pleased with how clear and how measurable each one of those things were. And some of them weren't even related to diversity or equity, like applying evidence-based best clinical practices, acknowledging medical errors, that type of thing-- conducting rigorous research and disseminating your results.

This spans well beyond DEI. But it's rooted in overcoming those issues of bias. So I really just was so impressed with this paper. And I think that it really does bear getting this out here. Obviously, everyone listening right now loves the Journal of Clinical Oncology and is thrilled to hear the novel research that's presented there on a weekly basis.

But I really do think we should be thoughtful about how else we can get this information out here. And I'm just interested to see, are the invitations just flooding in now? Are you preparing a dog and pony show to go out to disseminate these practices and these ideas to the world?

ABBY ROSENBERG: So Dr. Jagsi has been so kind and effusive, I'll just put that back on her. She is really a hero to so many of us as an advocate for women in medicine and has been such a role model for how do you do this work, how do you do this advocacy, how do you get this message out there, and how do you persevere, to be totally honest.

Because I think what happens is folks will have a story. They'll have an experience. They might share it. They might not. And then we get kind of smushed back under the rest of the burdens of our work and the hardness of change-making so that folks just stop trying and they stop talking about it. And then the cycle repeats itself.

And so what I have learned from working with Dr. Jagsi is that you can't stop talking about it. You do have to continue to get back up on that soapbox, share this message. And every single time that I do, the number of people who reaches out to me to say thank you is overwhelming.

And that tells me two things. Number one, we still have a lot of work to do. And number two, we are doing real good by continuing to distribute this message and remind people that, no, they're not crazy. This is actually real and that together, we can make a really meaningful change.

RESHMA JAGSI: Thank you. I really can't say more than that, other than blush. But I am so grateful that I've seen, over the years that I've been studying these issues and speaking about these issues, the number of people who are doing thoughtful, rigorous research into these issues and taking the platform and having the courage to speak up about experiences they've had, to provide that vivid detail, that personal stories can provide that dry data simply cannot.

That's the power of the #MeToo movement. It's showing people that they're not alone. It's encouraging people who haven't had these experiences to understand what it is like. And it really does, then, motivate us to change. And I think it's a great time right now for us to be doing this kind of work. I really do see change.

And so we may have been a little slow in coming to it. And we may be the field that, in the National Academies Report on the Sexual Harassment of Women in science, technology, engineering, mathematics and medicine, we may have been the worst field of everyone they studied. But I have faith that we can actually have the fastest trajectory towards positive change, as well, and we can become exemplars.

SHANNON WESTIN: That's great. Super inspiring. And I hope that our ASCO leadership are listening to set this up as a educational session at the next ASCO and really also figure out how we can get these very granular and very specific ways to improve our inclusivity in medicine over the next few years. So I am so grateful to both of you, Dr. Rosenberg and Dr. Jagsi, for spending the time with me.

And I hope that we can have a podcast, maybe, in a year or two, talking about all that we've accomplished and a celebratory podcast, perhaps. So with that, thank you all so much for listening to JCO After Hours. And see you next time.

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