Fostering a Representative Workforce

Fostering a Representative Workforce

Linda R. Duska, MD, MPH

Nov 10, 2022
Welcome to the final issue of ASCO Connection in 2022, in which we take a close look at the topic of workforce diversity. 
What are we talking about when say “diverse workforce”? Race and ethnicity are both critical factors, but they are not the only ones. We also mean gender and gender identity and sexual orientation, of course. We also need to consider characteristics and challenges that are not visible, but that profoundly shape a person’s experience and perspective on the world: people from rural and underserved areas, where educational opportunities and exposure to STEM careers may have been limited; people from low socioeconomic situations who face significant financial barriers to education; people who are the first in their family to attend college and may not have a support network for the challenges they face in higher education. These characteristics sometimes get lumped under the euphemistic umbrella term “nontraditional students,” but if we look at that honestly, what we really mean is people who don’t have the typical advantages that we expect of a student bound for medical school and a career as a doctor. Examining our own biases about who belongs in medicine is a good place for all of us to start as we think about how to foster the representative workforce that we need. 
Workforce diversity is critically important but difficult to accomplish, because we must start at the source—young people need to know that oncology is a rewarding career option, have the opportunities and resources to pursue it, and receive support to stay in the field long-term. We are starting to see improvements in representation in medical schools. At my own medical school at the University of Virginia (UVA), 25% of our students come from populations underrepresented in medicine. These include students who are Black, Hispanic, American Indian/Alaska Native, and disadvantaged and/or rural Virginians. These are the populations in which health care disparities are known to exist and are the focus of our pathway and recruitment programs.  
However, both at UVA and nationally, although underrepresented populations are defined somewhat differently in each setting, we are not doing as well in the graduate medical education or in the faculty/attending arenas. Nationally, 6.9% of radiation oncology residents and 10.8% of medical oncology fellows are from underrepresented populations.1 One step into the pipeline and we are already losing valuable members of our community. We need to figure out how to fix that. 
Why should we all care about a diverse and representative oncology workforce? First of all, eliminating the systematic and institutional barriers to a career in oncology will lead to better overall cancer care. A diverse workforce will benefit all of our patients by exposing us all to new and different ideas, allowing culturally competent care, and ultimately improving cancer care for all patients.  
And second, I find myself thinking increasingly about trust. Trust in us as care providers, and trust in the health care system in general. I know from my own work in increasing diverse accrual to clinical trials that patients identify trust in the health care team as a key component that compels them to enroll in clinical research. While I have not seen it measured, one gets a clear sense that the chaos of the pandemic further eroded public trust in our institutions, including health care advisory groups and the health care system. When our patients see a medical workforce that is not diverse, they rightfully question who is being excluded and why. If no one in this field seems to look like me, or come from a similar background as me, then how can I trust that I will receive appropriate care for my specific needs? How can I trust that my concerns and issues will be taken seriously, and not brushed off or disregarded? How can I trust that my goals of care will be honored when no one in the practice seems to understand my cultural context? How can I feel safe in this space if people in my own community don’t seem to be welcome among these ranks? 
The workforce as it currently exists wasn’t built in a day; breaking down barriers and further building a more representative workforce will be the labor of years, if not generations. Our cover story outlines how our professional Society is engaged on this issue, and includes several ideas for individual actions that all oncology professionals can take to help make our field an equitable, diverse, and inclusive place for anyone, from any background, who wants to improve the lives of patients with cancer. 
It is inspiring to see Dr. Monica M. Bertagnolli appointed to lead the U.S. National Cancer Institute. During her tenure as ASCO president, Dr. Bertagnolli (who is herself from rural Wyoming) conducted a major effort related to geographic health disparities and access to cancer care in rural and underserved communities. Read ASCO’s ringing endorsement of her well-deserved appointment
As the year draws to a close, as always, I wish you peace, joy, and hope. Thank you for reading, and for the work you do around the world on behalf of everyone affected by cancer.
  1. Beltrán Ponce SE, Thomas CR, Diaz DA. Social determinants of health, workforce diversity, and financial toxicity: A review of disparities in cancer care. Curr Probl Cancer. 2022:100893. Epub ahead of print. 


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