A Survey Study of Female Radiation Oncology Residents’ Experiences to Inform Change

International Journal of

Radiation Oncology biology

physics

www.redjournal.org

Women in Radiation Oncology

A Survey Study of Female Radiation Oncology Residents’ Experiences to Inform Change Virginia W. Osborn, MD,* Kaleigh Doke, MD,y Kent A. Griffith, MS, MPH,z Rochelle Jones, MS,x Anna Lee, MD, MPH,k Genevieve Maquilan, MD,{ Adrianna Henson Masters, MD, PhD,** Ashley A. Albert, MD,yy Laura L. Dover, MD, MSPH,zz Lindsay L. Puckett, MD,xx Courtney Hentz, MD,kk Jenna M. Kahn, MD,{{ Lauren E. Colbert, MD, MSCR,*** Parul N. Barry, MD,yyy and Reshma Jagsi, MD, DPhilzzz *Department of Radiation Oncology, Mount Sinai Faculty Practice at Elmhurst Hospital Center, Elmhurst, New York; yDepartment of Radiation Oncology, University of Kansas Cancer Center, Kansas City, Kansas; zDepartment of Biostatistics and xCenter for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor, Michigan; kDepartment of Radiation Oncology, SUNY Downstate Medical Center, Brooklyn, New York; {Department of Radiation Oncology, Massachusetts General Cancer Center at Cooley Dickinson Hospital, Northampton, Massachusetts; **Department of Radiation Oncology, Wake Forest Baptist Comprehensive Cancer Center, Winston-Salem, North Carolina; yyDepartment of Radiation Oncology, University of Mississippi Medical Center, Jackson, Mississippi; zzDepartment of Radiation Oncology, University of Alabama at Birmingham, Birmingham, Alabama; xxMedical College of Wisconsin, Milwaukee, Wisconsin; kkDepartment of Radiation Oncology, Loyola University Medical Center, Maywood, Illinois; {{Department of Radiation Oncology, Virginia Commonwealth University, Richmond, Virginia; ***Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas; yyyDepartment of Radiation Oncology, Rush University Medical Center, Chicago, Illinois; and zzzDepartment of Radiation Oncology, University of Michigan, Ann Arbor, Michigan Received Apr 8, 2019. Accepted for publication May 10, 2019.

Corresponding author: Dr. Reshma Jagsi, MD, DPhil, CBSSM, North Campus Research Complex, 2800 Plymouth Road, Bldg 14, G016, Ann Arbor, MI 48109-2800. Tel: (734) 615-8377; E-mail: [email protected]. edu Virginia W. Osborn and Kaleigh Doke are co-first authors, as they contributed equally to this research. No extramural funding was required; study costs were supported by the University of Michigan via discretionary departmental funds to R.J. Study data were collected and managed using REDCap electronic data capture tools hosted at the University of Michigan (Michigan Institute for Clinical & Health Research grant support, CTSA: UL1TR002240).

Int J Radiation Oncol Biol Phys, Vol. 104, No. 5, pp. 999e1008, 2019 0360-3016/$ - see front matter Ó 2019 Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.ijrobp.2019.05.013

Disclosures: R.J. reports stock options as compensation for her advisory board role in Equity Quotient, a company that evaluates culture in health care companies; she has received personal fees from Amgen and Vizient and grants for unrelated work from the National Institutes of Health (National Cancer Institute), the Doris Duke Charitable Foundation, the Greenwall Foundation, the Susan Komen Foundation, and Blue Cross Blue Shield of Michigan for the Michigan Radiation Oncology Quality Consortium, outside the submitted work. V.W.O., K.D., A.L., G.M., A.H.M., A.A.A., L.L.D., L.L.P., C.H., P.N.B., and R.J. are uncompensated founding members of the Society for Women in Radiation Oncology. Supplementary material for this article can be found at 10.1016/ j.ijrobp.2019.05.013.

International Journal of Radiation Oncology  Biology  Physics

1000 Osborn et al. Summary In a survey of all female US radiation oncology residents in 2017-2018, with 125 respondents (74% response rate), half agreed that gender-specific bias existed in their programs, and a quarter reported experiencing sexual harassment. Half reported that lack of mentorship affected career ambitions, and 90% expressed interest in joining a professional group for women in radiation oncology. These findings inform interventions to promote gender equity in a field where women remain underrepresented.

Purpose: Women remain underrepresented at all levels within the field of radiation oncology. We sought to study current female residents’ experiences and concerns to inform interventions to promote gender equity. Furthermore, we evaluated interest in a professional society specifically for women radiation oncologists. Methods and Materials: An anonymous 76-item survey was designed and distributed to current women residents in radiation oncology in 2017-2018. Analyses describe personal, program, and family characteristics and experiences before and after joining the field. Results: Of 170 female residents surveyed, 125 responded (74% response rate). Over one-quarter were in programs with 2 female residents (29%) and 2 female attendings (29%). One-third (34%) reported having children. Over half (51%) reported that lack of mentorship affected career ambitions. Over half (52%) agreed that genderspecific bias existed in their programs, and over a quarter (27%) reported they had experienced unwanted sexual comments, attention, or advances by a superior or colleague. Only 5% reported no symptoms of burnout. Almost all (95%) agreed that radiation oncology is perceived as family friendly; however, only 52% agreed that it actually is. An overwhelming majority (90%) expressed interest in joining a professional group for women in radiation oncology. Conclusions: In the first study to our knowledge to focus specifically on the experiences of women residents in radiation oncology, a number of areas for potential improvement were highlighted, including isolation and underrepresentation, mentorship needs, bias and harassment, and gender-based obstacles such as need for support during pregnancy and motherhood. These findings support the organization of groups such as the Society for Women in Radiation Oncology, which seeks to target these needs to promote gender equity. Ó 2019 Elsevier Inc. All rights reserved.

Introduction The percentage of women among all residents training in radiation oncology in the United States peaked at 34.8% in 2007 and declined to under 30% by 2014.1 By comparison, 48% of US medical school graduates were women in 2013-2014.2 Representation of women is also low in more senior positions; women comprised 27.7% of full-time faculty in 20151 and 13.9% of full professors and chairs in 2012.3 Women remain underrepresented in radiation oncology despite rating above the mean in satisfaction with work-life balance,4 a concern that some speculate to be particularly important to women, although research suggests that a specialty with a “controllable lifestyle” is in fact desired by both men and women in the current generation of trainees.5 Several explanations have been proposed to explain why radiation oncology remains an unpopular choice among women, with only 28.2% of all applicants being female in 2017, behind only orthopedics, neurosurgery, and urology. These explanations include unconscious bias, overt discrimination or harassment, conflict with family plans, and lack of exposure to the field.6 A perceived emphasis on basic sciences may also play a role. Board certification requires graduates to pass examinations in physics, a field in which only about 20% of undergraduate degrees are awarded to women.7 Lack of prominent female role models may also be a challenge.8

Investigators have conducted surveys to evaluate gender differences in experiences in radiation oncology. Holliday et al conducted a survey of radiation oncology residents and the prior year’s graduates, exploring experiences with parenthood and pregnancy during residency. Women reported significantly higher childcare responsibilities than men despite similar research productivity and career aspirations.9 Barry et al found that significantly more female than male radiation oncology residents perceived gender biases or obstacles (56% vs 22%, P < .001).10 Both of the aforementioned studies surveyed men and women alike to highlight differences by gender. Existing professional societies have recognized the need to support women in radiation oncology. For example, the American Association of Women Radiologists includes not only diagnostic radiologists but also radiation oncologists. It has developed programs such as popular sessions for women at the annual American Society for Radiation Oncology (ASTRO) meeting each year. ASTRO itself has a Committee of Health Equity, Diversity, and Inclusion that considers issues of gender equity and has convened educational sessions at ASTRO’s annual meeting. The American College of Radiation Oncology also hosts a popular event at its annual meeting, the Sucha Asbell Women’s Forum. However, not all members of the field can attend these sessions, and it remains unclear how aware or engaged resident physicians have been in these activities. Therefore, further research was necessary to assess interest

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in additional programming geared specifically toward women in radiation oncology and whether female residents would be interested in the formation of an independent group of women radiation oncologists. In this context, we sought to conduct a survey study focused on current female residents. Specifically, we sought to facilitate an in-depth evaluation of their experiences and concerns to inform interventions to promote gender equity. Furthermore, we evaluated interest in a professional society for women radiation oncologists.

Methods and Materials

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for participants’ consideration of completing the survey (and not conditional on completion of any portion of the survey).

Analysis We generated simple descriptive statistics. Missing data owing to item nonresponse was low, and all analyses reported exclude missing responses. Authors also categorized write-in responses for description.

Results

Questionnaire development Response rates Using input from content and methodological experts, a novel survey questionnaire was designed to collect crosssectional data on experiences and concerns of US female radiation oncology residents. The survey had 11 sections: Demographics, Introduction to Specialty, Residency, Mentorship, Research, Harassment, Career Planning, Obstacles, Family, Burnout, and Women’s Group in Radiation Oncology. It included 76 questions compiled after comprehensive literature review; available existing measures were used where possible, and where no measures existed or existing measures were inadequate, novel items were developed using standard techniques of questionnaire design.11 Before distribution, the survey underwent cognitive pretesting and was administered to 10 recent women graduates from radiation oncology training and was iteratively revised.12

Survey content Questions (see Supplementary Appendix E1, available online at https://doi.org/10.1016/j.ijrobp.2019.05.013) instructed respondents to “select 1 best response” for some items and “select all that apply” for others. For the latter, each item was coded as “checked” or “unchecked” and summarized such that percentages total more than 100%. Select open-ended questions were also included for subsequent coding after data collection. Some questions incorporated a 5-point Likert scale (ranging from “strongly disagree” to “strongly agree”) to rate agreement with statements.

Survey administration After approval by the institutional review board of the University of Michigan, we distributed an online survey via email to current female residents in radiation oncology in 2017-2018. The contact list was obtained from the Association of Residents in Radiation Oncology. Responses were collected anonymously via REDCap.13,14 A coffee gift card of $5 was offered in a separate communication to all those invited to participate as a gesture of appreciation

The survey was distributed to 170 female residents, of whom 125 responded, resulting in a 74% response rate.

Respondents’ demographic, program, and personal and family characteristics Table 1 presents the personal and program characteristics of the survey respondents. The median number of residents in the respondents’ programs was 10. Over one-quarter were in programs with 2 female residents (29%, 35 of 123), and the same number reported 2 female attendings (29%, 35 of 121). Most respondents (59%) were married (71 of 120). One-third (34%, 40 of 119) reported having children.

Training experiences and career plans Table 2 shows that most heard about the field of radiation oncology through word of mouth (55%, 69 of 125) and many via personal connection (28%, 35 of 125). A large majority (83%, 104 of 125) reported being able to develop a relationship with at least 1 radiation oncology mentor. When asked to select characteristics of any of these mentors, many had at least 1 male mentor (85%, 88 of 104), attending physician mentor (84%, 87 of 104), and mentor from their home program (78%, 88 of 104). About half of those with a mentor in medical school reported having at least 1 female mentor (57%, 59 of 104). Of the 41% (50 of 123) who stated that they did not feel they had adequate mentorship in residency, 46 explained why in their responses. The responses predominantly reflected difficulty in finding mentors and limitations in potential mentors’ time, interest, and training. Those expressing adequate mentorship selected all characteristics that applied to their mentors. Eighty percent (59 of 73) responded that they had a female mentor, and roughly the same number (60 of 73, 82%) reported having a male mentor. Most had a mentor at their own program (55 of 73, 75%), and about one-third had a mentor at a different residency program (25 of 73, 34%). When asked to check all the ways that they

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1002 Osborn et al. Table 1

Table 2

Characteristics of respondents

Respondents’ training experiences and career plans

Total respondents (N Z 125*) Demographic characteristics Birth year, median (IQR) Year of training, N Z 124 (%) PGY2 PGY3 PGY4 PGY5 Program characteristics Geographic region, n (%) Northeast Midwest South West Total no. of residents in program, median (IQR)y Total no. of female residents in program, N Z 123 (%) 1 2 3 4 5 or more Total no. of attending physicians in program, median (IQR)z Total no. of female attending physicians in program, N Z 121 (%) 0 1 2 3 4 5 or more Family characteristics Relationship status, N Z 120 (%) Married Committed relationship Single Number of children, N Z 119 (%) 0 1 2 3 4

1986 (1985-1988) 13 35 45 31

(10) (28) (36) (25)

44 29 30 22 10

(35) (23) (24) (18) (7-13)

12 23 27 11 50 14.5

10 15 10 21 17 48

(10) (19) (22) (9) (41) (9-20)

(8) (12) (8) (17) (14) (40)

71 (59) 36 (30) 13 (11) 79 20 15 2 3

(66) (17) (13) (2) (3)

Abbreviations: IQR Z interquartile range; PGY Z postgraduate year. * Total does not reach 125 for all items owing to item nonresponse. y N Z 123 z N Z 124

initially connected with their mentors, many indicated through their residency program (64 of 73, 88%) or medical school program (29 of 73, 40%); some indicated that they found their own mentor (23 of 73, 32%) or introduced themselves to their mentor (18 of 73, 25%). Six people out of 73 had found a mentor through a professional society (8%).

Total respondents (N Z 125*) Medical school How respondent first become aware of RO as a specialty, n (%)y Medical school curriculum Word of mouth Personal connection Other Respondents who had at least 1 RO mentor as a med student, n (%) Respondents who participated in RO research as a med student, n (%) Residency Respondents agreeing females underrepresented in own residency program, N Z 121 (%) Respondents indicating having adequate mentorship currently, N Z 123 (%) Career plans Projected career plans, n (%)y Academic Physician scientist Private practice Full time Part time Other Respondents considering fellowship, N Z 123 (%) Disease site among 78 respondents planning to subspecialize, n (%)y CNS Head and neck Lung and thorax GI GU Gynecologic Breast Sarcoma Pediatric Hematologic Other

15 69 35 20 104

(12) (55) (28) (16) (83)

109 (87)

70 (58)

73 (59)

85 15 58 85 15 5 10

(68) (12) (46) (68) (12) (4) (8)

23 17 21 14 13 23 28 7 11 9 9

(29) (22) (27) (18) (17) (29) (36) (9) (14) (12) (12)

Abbreviations: CNS Z central nervous system; GI Z gastronintestinal; GU Z genitourinary; RO Z radiation oncology. * Total does not reach 125 for all items due to item nonresponse. y Totals sum to more than 100% because respondents were asked to select all that applied.

When asked to select their top 3 limitations to academic productivity, respondents listed clinical responsibilities (106 of 125, 85%), studying (74 of 125, 59%), insufficient mentorship (54 of 125, 43%), childcare (32 of 125, 26%), housework or errands (30 of 125, 24%), and significant other (15 of 125, 12%). When asked to select all projected career plans, the majority expressed intention to pursue positions that were

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Female radiation oncology residents’ experiences 1003

% who agree there are gender-specific biases or obstacles for women in Radiation Oncology

% who have encountered unwanted sexual comments, attention or advances by a superior or colleague

% who have been left out of opportunities for professional advancement based on gender

% agreeing that there are gender specific biases or obstacles for residents in their program

% who have had increased opportunities for professional advancement based on gender 0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Fig. 1. Perceptions of gender equity, bias, and harassment. Women resident respondents were asked questions about perceptions and experiences regarding gender equity, bias, and harassment in their residency programs and within the field of radiation oncology as a whole. full-time (85 of 125, 68%); fewer expressed intention to pursue part-time positions (15 of 125, 12%); and a sizable minority did not select either. Two-thirds were considering academic positions (85 of 125, 68%), almost half were considering private practice positions (58 of 125, 46%), and 12% (15 of 125) specifically planned for positions as physicianescientists. Most were not considering fellowship (113 of 123, 92%); those who were not cited lack of necessity (92 of 113, 81%), additional time investment (52 of 113, 46%), and responsibilities to significant other or family (34 of 113, 30%) as the most common reasons. Sixty-two percent (78 of 125) planned to specialize. The most common projected subspecialties among these were breast (28 of 78, 36%), gynecologic (23 of 78, 29%), central nervous system (23 of 78, 29%), and lung and thorax (21 of 78, 27%). When instructed to select all factors that have affected their career ambitions, responders included lack of mentorship (64 of 125, 51%), personal or family obligations (59 of 125, 47%), and insufficient networking (49 of 125, 39%). Only 20% (25 of 125) indicated that these challenges were not applicable because their career ambitions had remained consistent.

Perceptions of gender equity, bias, and harassment When asked to rate agreement with the statement, “Females are underrepresented in my residency program,” over half agreed (38 of 121, 31%) or strongly agreed (32 of 121, 26%). As depicted in Figure 1, over half agreed (31 of 120, 26%) or strongly agreed (31 of 120, 26%) with the statement, “There are gender-specific biases or

obstacles for residents in my program.” The vast majority agreed (55 of 123, 35%) or strongly agreed (44 of 123, 44%) that “[t]here are gender-specific biases or obstacles for women in radiation oncology.” About a quarter (33 of 122, 27%) believed that they had been left out of opportunities for professional advancement based on gender; 11% (14 of 123) felt that their gender had led to increased opportunities. Over one-quarter of respondents (33 of 123, 27%) reported they had experienced unwanted sexual comments, attention, or advances by a superior or colleague. Among those, most reported sexist remarks or behavior (30 of 33, 91%), and nearly half reported unwanted sexual advances (14 of 33, 42%). Few (4 of 33, 12%) reported coercive advances.

Burnout Figure 2 depicts responses regarding burnout. Only 5% (6 of 119) answered, “I enjoy my work, I have no symptoms of burnout,” the most positive answer on the 5-point scale. Almost half (57 of 119, 48%) answered that they are “occasionally under stress,” over a third (42 of 119, 35%) answered “definitely burning out,” and 10% (12 of 119) answered that their “symptoms of burnout won’t go away.” Two respondents (2%) chose “I feel completely burned out and often wonder if I can go on.” Respondents were then asked, on a 5-point ordinal scale, how often over the past year they were able to achieve balance among work, family, relationships, play, and rest. Half (57 of 118, 48%) answered “occasionally,” one-quarter (30 of 118, 25%)

International Journal of Radiation Oncology  Biology  Physics

1004 Osborn et al. 2%

A

5%

10%

I enjoy my work. I have no symptoms of burnout

Occasionally I am under stress, and I don’t always have as much energy as I once did, but I don’t feel burned out. I am definitely burning out and have one or more symptoms of burnout, such as physical and emotional exhaustion. The symptoms of burnout that I’m experiencing won’t go away. I think about frustration at work a lot.

35% 48%

I feel completely burned out and often wonder if I can go on. I am at the point where I may need some changes or need to seek help.

3%

B

1%

25% Frequently 23% Occasionally

Rarely

Never

It never occurred to me 48%

Fig. 2. Burnout among women residents in radiation oncology. Women residents were asked questions about their wellbeing. (A) Respondents rated their level of burnout on a descriptive 5-point scale. (B) They were also asked how often they were able to achieve balance among work, family, relationships, play, and rest over the past academic year.

“frequently,” and another quarter “rarely” (27 of 118, 23%) or “never” (3 of 118, 3%).

Pregnancy and parenthood experiences Figure 3 shows respondents’ thoughts on family planning during residency: 95% either agreed (59 of 119, 50%) or strongly agreed (53 of 119, 45%) that radiation oncology as a field is perceived as family friendly; however, only 52% agreed (53 of 119, 45%) or strongly agreed (8 of 119, 7%) that it is actually family friendly. Over three-quarters either agreed (33 of 119, 28%) or strongly agreed (57 of 119,

48%) that their current or future children affect their potential career options; 3 respondents stated that they do not have or plan to have children. Over half agreed or strongly agreed that “[m]y reproductive plans have been limited during residency” (65 of 120, 54%), and 14 respondents indicated that they had not hoped to have children during residency. The most frequent reasons cited by the 65 who agreed that their reproductive plans had been limited in residency included desire to avoid extending training (49 of 65, 75%), desire not to burden their colleagues (38 of 65, 58%), and the constraint that parental leave time was limited during residency (35 of 65, 54%). Over a third

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Female radiation oncology residents’ experiences 1005 Thoughts on Family Planning during Residency 20

0 “Radiation Oncology as a field is PERCEIVED as family friendly”

“Radiation Oncology as a field is ACTUALLY family friendly”

“My reproductive plans have been limited during residency”

Neutral (%)

4

28

9

27

35

Disagree (%)

26

5

18

26

49

21

100

50

45

7

“My partner’s career has been limited by my medical training”

Agree (%)

80

45

“My current or future children affect my potential career options”

Strongly Agree (%)

60

40

8 3

12

26

20

17

15

4

Strongly Disagree (%)

Fig. 3. Women residents’ thoughts on family planning during residency. This figure depicts scores of questions regarding matters pertaining to family planning during residency. Questions were answered with an interval 5-point scale from strongly agree to strongly disagree. reported either stated (3 of 65, 5%) or unstated (21 of 65, 32%) pressure from leadership as a reason they delayed their reproductive plans. Of those who delayed parenthood during residency, 29% were dissatisfied (13 of 71, 18%) or very dissatisfied (8 of 71, 11%) with the decision. Of those residents who had at least 1 pregnancy during residency by the time of the survey (43 of 120, 36%), 72% were pregnant once (31 of 43), 26% were pregnant twice (11 of 43), and 1 respondent was pregnant 3 times during residency. Among the 43 individuals who had been pregnant during residency, most had a delivery during the PGY3 year (18 of 43, 42%) or PGY4 year (15 of 43, 35%), whereas only 16% (7 of 43) and 12% (5 of 43) delivered during their PGY1 or PGY2 year, and 16% (7 of 43) during their PGY5 year. Three people (3 of 43, 7%) who became pregnant in residency anticipated delivery after completion of their residency training. When asked to rate how supported they felt during their pregnancy on a 5-point scale (with “somewhat” or “well” supported considered “supported” here, versus “neutral,” “somewhat not supported,” or “not supported”), 72% (31 of 43) felt emotionally supported by coresidents, 51% (22 of 43) felt emotionally supported by attendings, and 47% (20 of 43) felt emotionally supported by their program director and administration. With respect to logistical support, 76% (32 of 42) reported that their coresidents were supportive, 50% (21 of 42) reported that their attendings were supportive, and 62% (26 of 42) reported that their program director and administration were supportive. Among those reporting pregnancy during residency, respondents took a mean of 1.2 weeks of leave before delivery (range 0-8), with a mean of 7.2 weeks after delivery (range 2-12); 71% (29 of 41) stated that this was less time than they would have liked. They reported that their partners took a

mean of 3.1 weeks (range 0-20) of parental leave after delivery. When asked to choose 3 determining factors for the length of parental leave taken, the most common was a desire to not have to extend their residency (31 of 43, 72%), program mandate (11 of 43, 26%), a desire to not have to delay boards (10 of 43, 23%), and newborn bonding (10 of 43, 23%). Several wrote in that they were told they were only allowed to use vacation and sick days for parental leave. Only 2 respondents (2 of 31, 6%) with pregnancy during residency indicated extending the residency training period owing to maternity leave and that they were allowed to take an average of 7.9 (range 0-20) weeks of leave time before requiring an extension to their residency training. Almost half (21 of 43, 49%) of respondents who had become pregnant reported a requirement to “pay back” on-call duties missed while on leave. The majority of residents (41 of 43, 95%) planned to breastfeed (provide breastmilk for more than 50% of infant feedings) and reported doing so for an average of 8 months (range 0-18). The most commonly reported barriers to breastfeeding upon returning to work (when asked to select all that applied) included insufficient time at work (32 of 43, 74%) and the lack of a place to pump at work (20 of 43, 47%). Half of the 40 respondents with children used a daycare for childcare (20 of 40, 50%), but just under a third of all respondents reported that their hospital had workplace daycare about which they were aware (36 of 120, 30%). Only 6 of 40 respondents (15%) with children reported that their spouse or significant other cared for their children while they were at work. When parents were asked if “required evening or early-morning meetings make it difficult to arrange child care,” 95% of those who responded either agreed (11 of 40, 28%) or strongly agreed (27 of 40, 68%).

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1006 Osborn et al. Mentorship Networking Work/life balance Job hunting Leadership Visibility Diversity Awards Female cancers Political 0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Fig. 4. Professional society for women in radiation oncology. This figure displays the topics that 125 female radiation oncology residents indicated they would be most interested in seeing a professional group specifically for women radiation oncologists prioritize. Totals sum to more than 100% because respondents were asked to select all that applied.

Women’s group in radiation oncology Respondents expressed overwhelming interest in a professional women’s group specifically in radiation oncology, with 90% of respondents reporting that they would join one if available. Support for in-person experiences was strong, the majority stating that they would be interested in attending an independent in-person meeting of a radiation oncology women physicians’ group (89 of 119, 75%). Even more responded that they would attend a day of sessions for such a group associated with another national meeting (112 of 119, 94%). Figure 4 displays the topics that all respondents would be most interested in seeing such a group prioritize; respondents selected all that applied. The most popular priority suggested was mentorship (103 of 125, 82%), followed by networking (99 of 125, 79%), workelife balance (93 of 125, 74%), job hunting (91 of 125, 73%), leadership (81 of 125, 65%), visibility (77 of 125, 62%), diversity (71 of 125, 57%), and awards (50 of 125, 40%).

Discussion In the first comprehensive survey specifically targeting female radiation oncology residents, results illustrate in detail the nature and frequency of myriad obstacles that women may encounter at various points in the pipeline toward careers in radiation oncology. They also identify potential targets for intervention to improve women’s representation in the field. We found that introductions to the field primarily occur outside of the medical school curriculum, and most connections to mentors or research supervisors occur at “home” programs. This suggests that potential applicants

who lack access to informal networks (as women and other historically underrepresented groups may lack), are not affiliated with strong academic radiation oncology departments, or do not find a way to participate in research (as over 80% of respondents reported doing) may never discover the field. Standardized approaches to medical student education in radiation oncology therefore merit further attention to ensure that our field has access to the full talent pool of students.15 Moreover, when women reach residency, they may find themselves in settings where women may be even less well represented than in the field as a whole: 29% of female residents have 2 female resident peers, and 29% have 2 female attendings in their programs. Twelve respondents (10%) were the only female resident in their program. Innovative approaches to combat the isolation women may feel are sorely needed.16 These findings build on and complement insights from prior research. One survey highlighted a preference of women to join radiation oncology residency programs based on gender representation (45% vs 1% for men, P < .001) and discovered that women reported more difficulty finding mentors than men (P Z .042).10 Our results confirm that women are dramatically underrepresented in a number of programs, which might limit interest in applying to the field. A substantial minority reported inadequate mentorship, and just over half indicated that lack of mentorship affected their career ambitions, suggesting a key need for improvement. Of note, studies demonstrate that men can be highly effective mentors to women17; therefore our field should continue to encourage crossgender mentorship to maintain access to the full talent pool, which contains more female students than our field contains senior women. Although few of the current respondents indicated finding mentors through professional

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societies, these organizations could represent a potentially powerful avenue through which to improve mentorship of students, including women, in the future. We also observed perceptions of gender-specific obstacles. These include limitations of reproductive plans during residency and perceived lack of support for pregnancy. Such findings have also been documented elsewhere, not only within the field of radiation oncology9 but also more generally within postgraduate medical training,18-21 adding further evidence to the case for concerted professional attention and intervention to ensure workelife integration within this field. This study also documents disappointingly substantial rates of gender bias and harassment perceived by the respondents. Recent research has focused on the challenge of sexual harassment in medicine more generally.22 Although the 27% rate of harassment observed in this study is similar to those in other studies using similar measures,23 we find it concerning that over a quarter of our respondents have encountered these unacceptable behaviors in their short careers to date. Clearly, the profession of radiation oncology must focus on fostering accountability and building a community of allies to transform a culture that may otherwise allow these unacceptable behaviors to impede the well-being and contributions of women to our field.24 Although women participate in a wide range of research fields, when reporting projected subspecialties, the most common responses include breast and gynecologic. To some extent, women’s interest in disciplines that care for female patients may relate to a desire to serve other women. However, given robust evidence that women excel at caring for men and women alike,25 further research is necessary to ensure that women’s interest is not itself a reflection of access to mentorship or subtle encouragement to pursue these areas rather than to consider all potential disease sites treated with radiation. Finally, respondents clearly desired a women’s group specifically in radiation oncology. The most commonly chosen priority for the group was mentorship, with 82% of all survey respondents citing interest in seeing this topic addressed within a professional group setting. It comes as no surprise that female residents would value a society that emphasizes mentorship, with only 59% of female residents in this study reporting adequate mentorship. Mentorship is clearly important to residents’ success, with 43% of respondents citing inadequate mentorship as one of their top 3 obstacles for academic productivity and 51% stating that a lack of mentorship has affected their career ambitions. With only 6 respondents reporting that they had found their mentor through a professional society, this is a void that could potentially be filled by the proposed organization. In fact, since the time of the survey, the Society for Women in Radiation Oncology (SWRO) has been established to advocate for, support, and connect women within the field. SWRO has held in-person meetings tied to several national conferences; advocated in Washington, DC;

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initiated webinars for leadership and career development; created a blog, website, and social media accounts to encourage communication among females in the field (including the #WomenWhoCurie campaign); and organized a nationwide mentorship and sponsorship program.26 SWRO also aspires to conduct further research. Part of the SWRO mission is to promote female physicians and expand awareness of the specialty among young women to address the gender disparities within radiation oncology. In collaboration with other new groups, such as the women radiation oncologists’ Facebook group, and experienced existing organizations like the American Association of Women Radiologists, ASTRO, and the American College of Radiation Oncology, these organizations must address the needs demonstrated by these survey results. Strengths of this study include its high response rate, which was considerably higher than those in prior surveys of radiation oncology residents or recent graduates.9,10,27 With the increased attention to women’s concerns in professional settings over the last couple of years, perhaps the timing was ripe to capture the respondents’ attention with a survey specifically focused on women. It may also be that women residents were simply eager to voice their concerns. In any case, this high response rate helps to ensure the representativeness of the analytical sample and to reduce concerns about bias due to selective nonresponse. The study also has certain limitations. As in any selfreported questionnaire study, the risk of biased measurement exists. Although the questions we used were either derived from prior instruments or pretested and had strong face validity, results may have been affected if respondents did not understand the questions as intended. Similarly, because of the observational nature of the data collected, correlations would not necessarily be causal; this is why we restricted our analyses to descriptive statistics. As Holliday et al highlighted recently, representation of women in radiation oncology is a concern at more than just the resident level, and proposed solutions have included a focus on addressing unconscious bias, mentorship, interventions targeting harassment, and adaptation of policies to facilitate integration of career and family, which is particularly challenging given the timing of peak fertility for women and societal expectations regarding a gendered division of domestic labor.6 Our findings suggest that a group for women in radiation oncology may also have benefits for more than just the female residents who initially desired such a group. Indeed, such an organization might help women at all levels from feeling isolated or vulnerable.

Conclusions This survey study is the first to focus specifically and indepth on the experiences of women residents in radiation oncology and highlight a number of potential areas for improvement. These areas include isolation and

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International Journal of Radiation Oncology  Biology  Physics

underrepresentation, harassment, and gender-based obstacles, including the need for support during pregnancy and motherhood. That 80% of female residents perceive gender-specific biases or obstacles for women in radiation oncology should be a call to action. Evidence-based responses are necessary to promote gender equity in our field.

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