By Filipa Lynce, MD, and Enrique Soto Pérez de Celis, MD, MSc

Diversity of the U.S. population and the physician workforce

The United States is an incredibly diverse country, where people from many cultural, racial, and ethnic backgrounds live together. Although most Americans are non-Hispanic white, 13% of the U.S. population is black/African American.¹ Hispanic or Latino Americans comprise 18% of the population; importantly, this group has been the principal driver of the U.S. demographic growth, accounting for half of the national population growth since 2000.^1,2 Currently, Asians are the nation’s fastest-growing racial or ethnic group, with a 3% growth rate between 2015 and 2016, now making up almost 6% of the U.S. population.¹

In contrast, the composition of the physician workforce is very different, and we continue to struggle with adequate representation of the racial and ethnic groups that make up the U.S. population. In 2013, out of the total active physicians in the United States, 49% were non-Hispanic white, followed by 12% Asian, 4% Hispanic or Latino, 4% black or African American, and 0.4% American Indian or Alaska Native.³ In oncology, the percentage of active international medical graduates (IMGs) represents 36% of total active physicians, compared with the 25% of active IMGs in all other specialties.⁴ However, only 2% of practicing oncologists self-identify as black or African American and 6% as Hispanic or Latino.⁵ In addition, when comparing medical oncology and internal medicine fellows, black individuals were significantly underrepresented, suggesting a greater disparity in training.⁶

Why does this matter? As stated by health equity expert Karen M. Winkfield, MD, PhD, “There is a sense of trust and a comfort level that patients may experience simply from having a provider who comes from a similar ethnic or racial background.”

In fact, the question of whether and why diversity matters is not new and has been addressed by different studies. In 2002, researchers from Johns Hopkins conducted telephone interviews with 2,720 patients (910 white, 745 black, 676 Hispanic, and 389 Asian Americans) who participated in the Minority Health Survey, and concluded that patients who had a choice in the selection of their physician were more likely to be race concordant.⁷ Moreover, among each racial/ethnic group, responders who were race concordant reported greater satisfaction with their physician compared with responders who were not race concordant. Similar findings were confirmed in a study of over 100,000 patients and 1,750 physicians from Kaiser Permanente.⁸

In addition, a racially and ethnically diverse oncology workforce that reflects the diversity of the U.S. population will improve attitudes toward the various ethnic and cultural groups, increase intercultural responsiveness, and contribute to better cancer care.

Cultural competence

An important component of a diverse health care system is cultural competence, which refers to the set of knowledge and practical skills needed to provide care for patients and families who belong to different cultures. Cultural competence is a fundamental tool to eliminate barriers for accessing care and reduce existing health care disparities. Developing patient-centered health care services that are respectful and responsive to the cultural and linguistic needs of the population they serve is necessary for providing high-quality cancer care.⁹

That being said, even defining what culture is represents a difficult task, and this is even harder when trying to understand the way in which an individual’s values, educational background, religion, and social interactions influence the perception of illness, as well as interactions with health care providers. Therefore, one of the most relevant actions for improving cultural competence may be increasing awareness among physicians and other health care workers regarding our own biases, and developing appropriate strategies aimed at addressing and minimizing them.¹⁰ This might lead not only to an improvement in communication with the patients and their families throughout the cancer care continuum, but also to increased inclusion of underrepresented populations in clinical trials.

One relevant resource is the ASCO University^® online case-based course on Cultural Competence for Oncology Practice, which is freely available for ASCO members. The course aims to enhance the cultural literacy and confidence of health care providers when interacting with patients from diverse backgrounds. An updated course will be released later this year.

ASCO’s role in increasing workforce diversity

Increasing the diversity of the oncology workforce and expanding the number of opportunities for underrepresented in medicine (URM) trainees has become a priority for many organizations, including ASCO. In 2017, ASCO released the Strategic Plan for Increasing Racial and Ethnic Diversity in the Oncology Workforce, a 3-year plan built on the premise that increasing workforce diversity will improve cancer care quality and access.¹¹ The plan’s goals include a focus on providing career development and leadership opportunities for members from backgrounds that are underrepresented in the medical workforce.

A good example of ongoing opportunities for the career development of URM trainees is ASCO’s Diversity Mentoring Program. Mentors who are interested in participating are encouraged to join this rewarding program, and the online application is continually open during the year. Other efforts, such as the Medical Student Rotation and the Resident Travel Award from ASCO’s Conquer Cancer Foundation, provide URM trainees with funding to undertake clinical or research rotations and to attend the ASCO Annual Meeting, and represent a great opportunity for networking and obtaining career guidance.

Ultimately, one of the main goals of these initiatives is enhancing ASCO leadership diversity, and encouraging ASCO members from URM backgrounds to volunteer for leadership positions within ASCO committees, apply for the ASCO Leadership Development Program (LDP), and submit proposals for funding opportunities, such as Conquer Cancer’s Young Investigator Award or Career Development Award. In order to achieve this, various ASCO committees are working to develop one-on-one mentoring opportunities with URM fellows and to create networking opportunities with leaders who are URM.

In an increasingly diverse and connected world, we all should embrace the urgent need to increase the diversity of the oncology workforce, be mindful of the different racial and ethnic backgrounds of the patients we serve, and be proactive to enhance our cultural competence.

References

1. U.S. Census Bureau. Quick Facts. Available at https://www.census.gov/quickfacts/table/PST045216/00. Accessed Jan 6, 2019.
2. Flores A. How the U.S. Hispanic population is changing. Pew Research Center. 18 Sep 2017. Available at http://www.pewresearch.org/fact-tank/2017/09/18/how-the-u-s-hispanic-population-is-changing. Accessed Jan 6, 2019.
3. Association of American Medical Colleges. Diversity in the Physician Workforce: Facts and Figures 2014. Available at https://www.aamc.org/data/workforce/reports/439214/workforcediversity.html. Accessed Jan 6, 2019.
4. Association of American Medical Colleges. 2018 Physician Specialty Data Report. Available at https://www.aamc.org/data/workforce/reports/492536/2018-physician-specialty-data-report.html. Accessed Jan 5, 2019.
5. American Society of Clinical Oncology. Facts & Figures: Diversity in Oncology. Available at https://www.asco.org/ practice-guidelines/cancer-care-initiatives/diversity-oncology-initiative/facts-figures-diversity. Assessed Jan 6, 2019.
6. Deville C, Chapman CH, Burgos R, et al. J Oncol Pract. 2014;10:e328-34.
7. Laveist TA, Nuru-Jeter A. J Health Soc Behav. 2002;43:296-306.
8. Traylor AH, Schmittdiel JA, Uratsu CS, et al. Health Serv Res. 2010;45:792-805.
9. Surbone A. Ann Oncol. 2010;21:3-5.
10. Cuevas AG, O’Brien K, Saha S. Psychol Health. 2017;32:493-507.
11. Winkfield KM, Flowers CR, Patel JD, et al. J Clin Oncol. 2017;35:2576-9.