publication date: Jun. 5, 2020
Fostering a culture of gender-based respect and inclusion in oncology
Narjust Duma, MD
Assistant professor of medicine,
University of Wisconsin Carbone Cancer Center
Christina Chapman, MD, MS
Department of Radiation Oncology,
University of Michigan School of Medicine,
Center for Clinical Management Research,
VA Ann Arbor Healthcare System
Stephanie L. Graff, MD
Sarah Cannon Cancer Institute HCA Midwest Health;
Breast Cancer Research Program,
Sarah Cannon Research Institute
Tatiana M. Prowell, MD
Associate professor of oncology, Breast Cancer
Program, The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins,
Under Armour Breast Health Innovation Center
Miriam A. Knoll, MD
American Cancer Society
“Please welcome Claudia to the stage; she will be discussing resistance mechanisms to immune checkpoint inhibitors.”
This type of introduction is frequently heard at national and international professional medical meetings. However, it embraces one of the oldest challenges faced by women in medicine—unconscious bias.
Gender bias in speaker introductions
This issue was first published by Dr. Files et al., who evaluated speaker introductions at The Mayo Clinic Internal Medicine Grand Rounds. The authors observed that female speakers were less likely to be introduced by their professional title (Dr. Last Name or Dr. Full Name) than their male colleagues, and more-so when women were introduced by men.1 When Dr. Files reported the results to the medical community, many identified with the challenge and noted similar experiences in their own professional lives.
How prevalent was this familiar anecdote within our oncology community?
Gender bias in speaker introductions also occurs in oncology
During the 2018 ASCO annual meeting, Dr. Duma created a Twitter poll asking meeting attendees if they noticed a difference in introductions for women and men during the meeting’s scientific and educational program.
The poll was small and limited to fewer than 100 responses, but launched a robust research effort to answer the question. Dr. Miriam Knoll saw the poll on Twitter and contacted Dr. Duma. Together, they assembled a diverse team of men and women to evaluate archived videos of speaker introductions at the 2017 and 2018 American Society of Clinical Oncology annual meetings.
Results from the study were presented at the 2019 ASCO annual meeting. Duma et al. observed that at the world’s largest oncology conference, i.e., ASCO’s annual meeting, female speakers were addressed less often by their professional title compared with male speakers (62% vs. 81%; p< .001) and were more likely to be introduced by their first name only compared to their male colleagues (17% vs. 3%; p<.001).2 These findings brought awareness to the issue of unconscious bias within the global oncology community, perpetuating gender inequality in medicine. This research was subsequently published by Duma et al. in the Journal of Clinical Oncology in 2019. 2
Why titles matter
Unequal introductions have repercussions beyond the lack of equal recognition for professional status. These inequalities also maintain an outdated hierarchy in which women are positioned lower than their male colleagues.
When a woman is introduced as “Claudia” instead of “Dr. Fuentes,” it diminishes her credibility in front of an audience that may be less likely to be familiar with her work.3,4,5 Previous linguistic studies have demonstrated that speakers’ introductions affect the probability of the audience paying attention to the presentation and subsequent trust in the findings presented.6,7 This is particularly important in the era of social media in which our attention is divided between what is happening in the meeting and the discussion taking place across diverse social media platforms.
The impact of cumulative unprofessional address on the careers or psyche of women in medicine has not been fully characterized, but data on gender-based discrimination more broadly suggest how damaging this might be. Resume studies have long shown that women with equivalent credentials are discriminated against.8 Enacting bias in gender introductions is analogous to erasing an entire degree or years of work experience from a resume.
Women, therefore, face a double hit—they are discriminated against, when equal to men, and are made to appear inferior when they are not. This systematic bias means that for each degree, accolade, or work experience that women possess, they only reap a fraction of the credit. In addition to unjustly delaying their career progression, this results in inefficient use of human capital for society. If a woman is the most impactful cancer researcher in the room, and we don’t choose her, that impact is lost. That unnecessary loss translates to worse patient quality of life and fewer cancers being cured.
Additionally, women who observe this public display of gender bias may decide to exist in spaces that better value their worth. Junior faculty may be particularly susceptible. If men expect appropriate compensation for their work, why should women accept anything less?
Compensation includes more than salary here—promotion, inclusion, and respect should all be given where deserved. If women leave, we all lose.9,10
Language of respect
The ASCO “Language of Respect” guideline was developed to address the inequalities observed and foster a more inclusive environment at ASCO meetings. The guidelines were created under the direction of Dr. Tatiana Prowell, chair of the 2020 ASCO annual meeting Education Committee, in collaboration with 2019-2020 ASCO President, Dr. Howard “Skip” Burris, other annual meeting leadership, and ASCO staff.6 The document serves as a call to action for the oncology community and addresses respectful communication in reference to both patients and colleagues. The document, which was made available to all ASCO members and the public via social media platforms, provides several examples of commonly used problematic language followed by alternative language that demonstrates appropriate respect for patients, families, advocates, and health care professionals.
The Language of Respect guideline calls for the use of patient-first language that emphasizes the person over his or her disease. For example, “Patients with lung cancer” not “lung cancer patients.” The guidelines also point out that language like “the patient was a screen failure” or “the patient failed treatment” places blame on patients. Instead, the authors propose the use of more patient-centered language such as “eligibility criteria excluded the patient” or “cancer did not respond to treatment.”
Cancer does not define our patients, and we should avoid language that implies the patient is first and foremost a disease. Finally, the guideline encourages the use of more precise terms such as “risk reduction” rather than “cancer prevention” in response to concerns expressed by advocates that many patients following best practices such as eating a healthy diet, engaging in regular exercise, and avoiding smoking nonetheless are diagnosed with cancer. To these patients, the phrase “cancer prevention” suggests that if only they had tried harder to follow these practices, they would not have developed cancer, which is seldom true. As a result, the phrase risk reduction is favored.
2020 ASCO annual meeting
As a team, we waited for the 2020 ASCO Annual Meeting to continue encouraging the use of the Language of Respect Guidelines. Due to the COVID-19 pandemic, the meeting was converted to a virtual format to promote social distancing and infection control practices.
Introductions by session chairs have been removed for 2020 as the presentations were pre-recorded everywhere from living rooms and laundry rooms to home offices, eliminating the need for a chair to moderate a question and answer period.
The setting may have changed, but our pledge to promote respectful language remains intact. Our unconscious biases may be more likely to emerge during stressful times; therefore, we need to be more vigilant, not less, of the language we use during this time when referring to our patients and colleagues even at a distance. Though the 2020 ASCO annual meeting is not occurring in person, unconscious bias can manifest via social media as well. Therefore, we created a list of practical actions for attendees to use to foster gender equity at virtual meetings.
The language we use when speaking to or about our patients and colleagues should reflect our respect for them and their contributions to our oncology community.
Files JA, Mayer AP, Ko MG, Friedrich P, Jenkins M, Bryan MJ, Vegunta S, Wittich CM, Lyle MA, Melikian R, Duston T. Speaker introductions at internal medicine grand rounds: forms of address reveal gender bias. Journal of Women’s Health. 2017 May 1;26(5):413-9.
Duma N, Durani U, Woods CB, Kankeu Fonkoua LA, Cook JM, Wee C, Fuentes HE, Gonzalez-Velez M, Murphy MC, Jain S, Marshall AL. Evaluating Unconscious Bias: Speaker Introductions at an International Oncology Conference. Journal of Clinical Oncology. 2019 Dec 20;37(36):3538-45.
Boiko J, Anderson A, Gordon R. Representation of Women Among Academic Grand Rounds Speakers. JAMA Internal Medicine. 2017 May 1;177(5):722-724. doi: 10.1001/jamainternmed.2016.9646.
Albert M. #Me_Who Anatomy of Scholastic, Leadership, and Social Isolation of Underrepresented Minority Women in Academic Medicine. Circulation. 2018;138:451–454. DOI: 0.1161/CIRCULATIONAHA.118.035057
Yu P, Parsa P, Hassanein O, Rogers S, Chang D. Minorities Struggle to Advance in Academic Medicine: A 12-y Review of Diversity at the Highest Levels of America’s Teaching Institutions. J Surg Res 2013 Jun 15;182(2):212-8. doi: 10.1016/j.jss.2012.06.049. Epub 2012 Jul 17.
Pololi LH, Civian JT, Brennan RT, Dottolo AL, Krupat E. Experiencing the culture of academic medicine: gender matters, a national study. Journal of General Internal Medicine. 2013 Feb 1;28(2):201-7.
Morand DA. What’s in a name? An exploration of the social dynamics of forms of address in organizations. Management Communication Quarterly. 1996 May;9(4):422-51.
Handley IM, Brown ER, Moss-Racusin CA, Smith JL. Quality of evidence revealing subtle gender biases in science is in the eye of the beholder. Proceedings of the National Academy of Sciences. 2015 Oct 27;112(43):13201-6.
Prowell T. What’s in a Name: An Introductory Guide [podcast]. J Clin Oncol, 2019. http://jcopodcast.jcopodcast.libsynpro.com/whats-in-a-name-an-introductory-guide-with-tatiana-m-prowell-md.
Blackstock U. Why Black doctors like me are leaving faculty positions in academic medical centers. Stat News, 2020. https://www.statnews.com/2020/01/16/black-doctors-leaving-faculty-positions-academic-medical-centers/