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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.
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.1
Earning this future will require a fundamental shift from passively observing disparities to actively promoting equity through behavioral change, social justice, and action.2 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 2020.3,4 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.5,6 If the hidden curriculum contradicts the formal curriculum, instruction can become counterproductive and even enhance trainee burnout.6,7
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:
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.9 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).
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.11-13
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.14
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.
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