Five years ago, as Rachel B. Issaka, MD, MAS, was beginning her second year as a gastroenterology fellow and feeling proud of the progress she was making in her training, she was suddenly confronted with an all-too-familiar slight that underrepresented minority providers may often experience. As Dr. Issaka was making rounds on the transplant hepatology service and awaiting her turn to introduce herself to a patient, the patient asked if Dr. Issaka was a student on her medical team. When Dr. Issaka responded with her name, title—gastroenterology fellow—and her role on the team, as the others had done, the patient looked at her curiously and said, “Well, good for you.”1 Compounding the insult was the fact that the rest of the members on the medical team, all White, remained silent.
These subtle—and often not so subtle—verbal indignities are known as “microaggressions,” a term coined by psychiatrist Chester Pierce, MD, in the 1970s to describe the “subtle…often automatic, nonverbal exchanges [that] infringe on a person’s space, energy, and mobility.”2 This definition was later expanded by psychologist Derald Wing Sue, PhD, Professor of Psychology and Education at Columbia University in New York, to include the “brief and commonplace verbal, behavioral, and environmental indignities, whether intentional or unintentional, that communicate hostile, derogatory, or negative slights and insults that potentially have harmful or unpleasant psychological impact on the target person or group.”3
“Microaggressions happen on a frequent and ongoing basis in medicine and are painful for those experiencing it,” said Dr. Issaka, Assistant Professor, Clinical Research Division at the Fred Hutchinson Cancer Research Center (Fred Hutch), and Division of Gastroenterology and Hepatology at the University of Washington in Seattle.
The encounter was a reminder to Dr. Issaka that, despite her accomplishments, there would always be an assumption, by some, that she didn’t belong. Although Dr. Issaka initially regretted not responding to the remark, she has come to realize that the constant need to justify her presence in a predominantly White, male-oriented profession is not her failing but rather the failure of the medical profession.
Rachel B. Issaka, MD, MAS
Damage Caused by Systemic Racism for Physicians and Patients
According to the most recent census figures, although 13% of the United States population is Black or African American and 18% is Hispanic, just 2.3% of practicing oncologists self-identify as Black or African American and 5.8% of practicing oncologists self-identify as Hispanic. In addition, only about 11% of medical students are Black/African American or Hispanic, and fewer still are represented in oncology fellowships or residency programs.4 This lack of diversity in the oncology workforce not only results in more difficult working conditions for gender and ethnic minority physicians, including lower pay for the same positions, fewer chances of recruitment or promotion, and lower success rates in research funding applications,5 it also contributes to inequality in oncology care for minority patients.6
Earlier this year, ASCO President Lori J. Pierce, MD, FASTRO, FASCO, reaffirmed ASCO’s commitment to cultivate a diverse oncology workforce and support people of color as they advance their careers and to ensure cancer health equity for patients, especially vulnerable minority populations.7
In a wide-ranging interview with The ASCO Post, Dr. Issaka discussed the impact systemic racism has had on her career, its effect on patients, and how ending racism in medicine is everyone’s responsibility.
Addressing Racism in Medicine and in Oncology
At the time of the previously mentioned encounter with your patient, your colleagues did not respond to the patient’s comment or come to your defense. What would you have liked them to say to the patient?
There is no perfect response, but the lack of acknowledgment was most hurtful. One response could have been, “We noticed that you responded to Dr. Issaka differently from the rest of the team, and it is actually good for all of us that Dr. Issaka is here.”
Now that I am an attending physician who leads teams, including trainees, I make it a point to speak up when a patient or another member of the team makes an insensitive or overtly racist or sexist remark, because oftentimes it is difficult for students or trainees to defend themselves.
Do you still experience microaggressions and racism from your patients and colleagues?
The field of medicine has historically been dominated by White men. For many patients, the image of a physician is still a White man, and when they see me, I’m not what they expected.
Patients will say to me, “I wasn’t expecting you to look the way you do,” or “I wasn’t expecting you to be the person providing care for me.” In those instances, I simply ask, “What did you expect your provider to look like?” Those conversations are often fruitful.
I and other underrepresented minorities in medicine have, unfortunately, become used to dealing with these episodes. Now, within our current racial justice movement, what we are asking is that our colleagues not idly stand by when they witness microaggressions occur and that they help address what is a systemic problem in medicine because of how the field has historically been structured.
Ensuring Health Equity for All Patients With Cancer
How has structural racism in medicine impacted your career?
As a gastroenterologist, I’ve focused my career on reducing colon cancer mortality. Colorectal cancer is the second leading cause of cancer death in the United States, and it disproportionately affects racial and ethnic minorities. Black people are more likely to be diagnosed with colon cancer and are more likely to die of the cancer than any other group. Due to the fact that screening can prevent colorectal cancer and that it isn’t used to its full potential within Black populations due to policies that limit access to care, I see the practice of gastroenterology and my clinical research as mechanisms to help address these issues.
Ending Structural Racism in Medicine
How does medical practice perpetuate structural racism in our society, and how can medicine, and the field of oncology in particular, dismantle the problem?
There are disturbing beliefs about Black people from the 19th century that continue to impact how Black patients are treated. One example is pain. In a survey of 222 White medical students and residents, half of the respondents agreed there were biologic differences between Black and White people, including that “Black people’s nerve endings are less sensitive than White people’s,” and that “Black people’s skin is thicker than White people’s.”8 Those who believed these myths also perceived that Black patients feel less pain than White patients and were thus less likely to treat Black patients’ pain appropriately.
We know this perception is factually inaccurate. The final analysis, in 2003, of the Human Genome Project confirmed that genetically, we are 99.9% identical.9 We need to dispel misinformation about race and health outcomes in medical education.
What can we do in the field of oncology to address these biases? We need to examine why there are inequitable cancer outcomes in minority patients. We need to ask what are the social determinants leading to poorer oncologic outcomes in Black and other minority patients. How is racism playing a role in poorer health outcomes? Are minority patients unable to access care at the same rate as White patients? Do they have the same access to cancer prevention, surveillance care, and clinical trials?
As leaders in medicine, beyond considering how our own biases impact our colleagues and patients, we also have to interrogate the policies and structures within medicine that make it more difficult for minority patients to thrive.
What is your institution doing to curtail structural racism and reduce microaggressions against staff and faculty?
The current mechanisms to report episodes of bias and racism are being reviewed and revised. Fred Hutch has allocated a substantial amount of funding over the next decade for the recruitment and retention of underrepresented minority faculty. In addition, our cancer center is developing antiracism training for all employees, which is an important first step to understanding the impact racism has on overall health and on patient outcomes.
Ending Historical Injustices Against Minority Patients
Cancer disproportionately affects racial and ethnic minorities, especially Black people, who have the highest death rate and shortest survival of any racial and ethnic group for most cancers.10 Please talk about how historical injustices against Black people and other racial and ethnic groups have led to distrust in the medical establishment and are contributing to worse cancer outcomes.
We are all aware of the Tuskegee Syphilis Study of untreated syphilis in Black men in the 1930s through the early 1970s and the atrocities against those patients. Now, more people are learning about J. Marion Sims, the “father of gynecology,” a White 19th century doctor who performed surgical experiments on enslaved Black women without anesthesia. So, historical evidence about the egregious treatment of Black people by the medical establishment is well documented.
I want to talk about the more recent impact of racism on the health outcomes of Black people. For example, Black women are more likely to die in childbirth than White women; Black children are more likely to have disabilities than White children; and Black people have worse cancer outcomes than White people. When you add ongoing racism in the medical system to the history of medical experimentation and mistreatment of Black people, it is not surprising that there is mistrust of the medical system by racial and ethnic minorities.
It is up to us as medical professionals to assure our patients that we are working hard to overcome these historical tragedies and the current inequities in our health-care system, including lack of access to high-quality oncology care, surveillance, and participation in clinical trials.
Engaging Minority Communities to Improve Clinical Trial Participation
What can the oncology community do to improve trust with minority patients and encourage participation in clinical trials, which could be potentially beneficial to their cancer treatment?
Clinicians and research investigators engaged in clinical trial enrollment should partner with local organizations that have trusted relationships within minority communities (for example, churches). For far too long, scientific inquiry and discovery have been based within academic cancer centers. Community engagement through trusted partners within minority patient populations can help increase minority participation in clinical trials. These community partners should be compensated for their time and contributions.
Additionally, cancer centers can commit resources to community partnerships by training investigators in culturally competent study designs and recruitment.
Combating the COVID-19 Pandemic and Colorectal Cancer
In addition to cancer, the COVID-19 pandemic is also disproportionately affecting Black and Hispanic individuals. What is the impact of the pandemic on colorectal cancer disparities in these patients, and what are the actionable steps clinicians and researchers can take to reduce colorectal cancer care disparities during this time?
The circumstances that put Blacks, Hispanics, and Native Americans at higher risk of contracting the coronavirus also contribute to a higher risk of developing colorectal cancer and having worse outcomes. Many of these individuals are essential workers, which puts them at greater risk of exposure to the virus. They also have inconsistent access to health insurance, which then affects access to colorectal cancer screenings.
So, all the health disparities in colorectal cancer that existed prior to the pandemic, in large part due to lack of screening, have been accentuated by the pandemic. Fortunately, we have multiple screening tests for colorectal cancer, including stool-based tests, that people can do at home and return to their doctor or mail to a lab.
For those in need of a colonoscopy, this is a safe time to do so, and we should encourage all our at-risk patients to maintain their colorectal cancer screenings, as well as their other cancer screenings. However, structural solutions in the health-care system are severely needed to ensure access to health insurance and high-quality oncology care.
DISCLOSURE: Dr. Issaka reported no conflicts of interest.
REFERENCES
1. Issaka RB: Good for us all. JAMA 324:556-557, 2020.
2. Pierce CM, Carew JV, Pierce-Gonzales D, et al: An experiment in racism: TV commercials. Educ Urban Soc 10:61-87, 1977.
3. Sue DW, Capodilupo CM, Torino GC, et al: Racial microaggressions in everyday life: Implications for clinical practice. Am Psychol 62:271-286, 2007.
4. ASCO: Facts & figures: Diversity in oncology. Available at www.asco.org/practice-policy/cancer-care-initiatives/diversity-oncology-initiative/facts-figures-diversity. Accessed September 21, 2020.
5. Williams JS, Walker RJ, Egede LE: Achieving equity in an evolving healthcare system: Opportunities and challenges. Am J Med Sci 351:33-43, 2016.
6. Winkfield KM, Flowers CR, Patel JD, et al: American Society of Clinical Oncology strategic plan for increasing racial and ethnic diversity in the oncology workforce. J Clin Oncol 35:2576-2579, 2017.
7. Pierce LJ: Responding to racism and health inequality as a cancer care community. ASCO in Action. Available at www.asco.org/practice-policy/policy-issues-statements/asco-in-action/responding-racism-and-health-inequality. Accessed September 21, 2020.
8. Hoffman KM, Trawalter S, Axt JR, et al: Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites. Proc Natl Acad Sci USA 113:4296-4301, 2016.
9. National Institutes of Health, National Human Genome Research Institute: Whole genome association studies. Available at www.genome.gov/17516714/2006-release-about-whole-genome-association-studies. Accessed September 21, 2020.
10. American Cancer Society: Cancer facts & figures for African Americans, 2019–2020. Available at www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/cancer-facts-and-figures-for-african-americans/cancer-facts-and-figures-for-african-americans-2019-2021.pdf. Accessed September 21, 2020.
