In her 2020 American Society of Clinical Oncology presidential address, “Equity: Every patient. Every day. Everywhere,” Lori J. Pierce, MD, challenges medical oncology to imagine a future when equity is considered a humanistic standard of oncology practice.

Earning this future will require a fundamental shift from passively observing disparities to actively promoting equity through behavioral change, social justice, and action.

 One area to begin this transformation is ensuring the next generation of medical oncologists comprehensively value and promote equity in practice.

The Accreditation Council for Graduate Medical Education (ACGME) made cultural competency (CC) a requirement in medical education in 2003, with specifics and standardizations emerging from 2010 to 2020.

 An important step forward, ACGME CC primarily focuses on securing therapeutic relationships with patients from diverse backgrounds by avoiding personal aggrievances and offenses. Programs also provide didactics on social determinants of health and cancer disparities. However, many of these discussions fall short of addressing ways to overcome barriers and provide equitable care.

More importantly, how training programs prioritize educational objectives and experiences communicates which are vital and which are not. The resulting sense of medical values, the “hidden curriculum,” is particularly influential in establishing professional identity.

 If the hidden curriculum contradicts the formal curriculum, instruction can become counterproductive and even enhance trainee burnout.

From my own teaching and learning experiences at 5 training institutions and 8 hospital systems, many programs struggle with equity in their hidden curricula, which inevitably detracts from efforts in CC, social determinants of health, and other parts of the formal curricula. Hidden curricula cannot be fixed by simply adding or removing components, but most programs could significantly improve their commitment to equity in education by:

recruiting and promoting career growth for historically underrepresented trainees and faculty beyond assignment to leadership roles in diversity, equity, and inclusion; 

promoting trainee engagement with diverse mentors and educators;

promoting learning collaborations between academic, hybrid, and community programs;

developing interprofessional education with case managers and social workers.

providing educational opportunities that showcase talents among underrepresented trainees;

discussing how historically ineligible or excluded patients can receive best standards of care;

developing longitudinal equity competencies with corresponding curricula.

Black and Latin peoples account for 13.4% and 18.1% of the US population, respectively, yet each group makes up only 4% of oncology drug trial participants.

 Demographically proportional enrollment—equality—would be an enormous achievement. To meet the definition of equity, trial enrollment must be sufficient to power hypotheses relevant to these populations. Increased funding opportunities for equity-focused oncology research is promising and helpful, but if equity is to become an integral part of oncology research, trainees must learn how to build equity into any research project.

To ensure premier research institutions are not simply acquiring grant funding to conduct outside research on underserved communities, research plans must include a commitment to community oversight and building capacity in partnering underserved institutions. Certain questions have been helpful in shaping my own commitment to equity in community engagement research, quality improvement, educational research, and clinical trials research in both academic and community settings (

Table. Reflections on Important Questions for Ensuring Equity in Clinical Research

Perhaps the most sensitive issue to confront is inequity in daily practice. Whether intentional or not, we must acknowledge that our current medical oncology system creates and continues to perpetuate existing disparities in cancer care. Recognizing this truth is not about assigning blame, but about understanding that equity in medical oncology will not occur without a change in practice.

Trainees can start by comparing their clinic and institutional demographics to the community and reflect on how their daily practice patterns contribute to or alleviate health disparities. If certain demographics are rarely encountered, programs should provide trainees with rotations at other institutions so trainees can appreciate what happens to groups their institution does not routinely see. Programs should also promote a culture of active accountability and stewardship over issues of financial toxicity and the unsustainable growth in cancer care costs.

Trainee groups should meet with their institutional medical director and chief medical officer to learn about the reasoning behind organizational policies that result in current practice patterns.

Although not every trainee will become an expert in advocacy or health policy, our training should ensure that all trainees appreciate how organizational, local, state, and federal policies affect a patient’s ability to access safe, affordable, and effective oncology care. Trainees can identify an issue pertinent to their anticipated career focus and present this issue at their state or national “Day on the Hill.” Trainees can also meet with cancer survivors from communities of historically disenfranchised peoples to understand the vastly different care experiences these groups receive and learn how to become an ally and advocate for these patients.

The final step to realizing true equity in practice is to ensure equity is not compartmentalized to work but becomes an instrumental life value. For individuals in historic positions of power, this means giving agency to minority voices in your daily life, actively listening, letting others lead, and leading primarily through supportive roles where success is defined by advancing the cause instead of personal ambitions or accolades. It also means being committed to improving as a person in addition to learning rules on how to interact with people of different cultures, accepting feedback, becoming aware of explicit and implicit biases, blind spots, and recognizing that good intentions do not equate with good deeds.

Establishing equity as an inherent value in medical oncology will require a comprehensive commitment to change. Training is a natural period when values and behaviors are shaped and influence long-term practice. Continued conversations on advancing the cause of equity are essential if we are to meet the challenge of providing quality oncology care to every patient, every day, everywhere.

Pierce, LJ. 2021 presidential address: equity: every patient. every day. every-where. ASCO Connections. June 7, 2021. Accessed August 12, 2021. https://connection.asco.org/magazine/features/2021-presidential-address-equity-every-patient-every-day-everywhere

Braveman P. What are health disparities and health equity? We need to be clear. 

. 2014;129(suppl 2):5-8. doi:10.1177/00333549141291S203 

Ambrose AJ, Lin SY, Chun MB. Cultural competency training requirements in graduate medical education. 

. 2013;5(2):227-231. doi:10.4300/JGME-D-12-00085.1

Smith WR, Betancourt JR, Wynia MK, et al. Recommendations for teaching about racial and ethnic disparities in health and health care. 

. 2007;147(9):654-665. doi:10.7326/0003-4819-147-9-200711060-00010

Lawrence C, Mhlaba T, Stewart KA, Moletsane R, Gaede B, Moshabela M. The hidden curricula of medical education: a scoping review. 

. 2018;93(4):648-656. doi:10.1097/ACM.0000000000002004

Mulder H, Ter Braak E, Chen HC, Ten Cate O. Addressing the hidden curriculum in the clinical workplace: a practical tool for trainees and faculty. 

. 2019;41(1):36-43. doi:10.1080/0142159X.2018.1436760

Webster F, Rice K, Dainty KN, Zwarenstein M, Durant S, Kuper A. Failure to cope: the hidden curriculum of emergency department wait times and the implications for clinical training. 

. 2015;90(1):56-62. doi:10.1097/ACM.0000000000000499

Massachusetts Medical Society. Racial disparities in clinical medicine: conversations, perspectives, and research on advancing medical equity. NEJM Group. https://www.nanosweb.org/fi les/Committees/DEI%20Resources/NEJM_Group_Racial_Disparities_in_Clinical_Medicine.pdf

Nazha B, Mishra M, Pentz R, Owonikoko TK. Enrollment of racial minorities in clinical trials: old problem assumes new urgency in the age of immunotherapy. 

McDavitt B, Bogart LM, Mutchler MG, et al. Dissemination as dialogue: building trust and sharing research findings through community engagement. 

de Souza JA, Yap BJ, Wroblewski K, et al. Measuring financial toxicity as a clinically relevant patient-reported outcome: the validation of the COmprehensive Score for financial Toxicity (COST). 

. 2017;123(3):476-484. doi:10.1002/cncr.30369

Desai A, Gyawali B. Financial toxicity of cancer treatment: moving the discussion from acknowledgement of the problem to identifying solutions. 

. 2020;20:100269. doi:10.1016/j.eclinm.2020.100269 

Mariotto AB, Enewold L, Zhao J, Zeruto CA, Yabroff KR. Medical care costs associated with cancer survivorship in the United States. 

. 2020;29(7):1304-1312. doi: 10.1158/1055-9965.EPI-19-1534

Greene-Moton E, Minkler M. Cultural competence or cultural humility? Moving beyond the debate. 

 2020;21(1):142-145. doi:10.1177/1524839919884912

Richard L. Martin III, MD, MPH

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A Challenge to Medical Oncology Training Programs: Promote Equity in Training