Gender Representation Among Academic US Radiation Oncology Department Chairs: Who are They?

Abstract

Purpose

Women are underrepresented in academic radiation oncology (RO), particularly in leadership positions. In this study, we sought to better understand the characteristics of individuals who currently serve as academic RO chairpersons at institutions with an associated Accreditation Council for Graduate Medical Education–accredited RO residency training program.

Methods and Materials

We created a database of academic RO chairpersons in the United States by using publicly available sources, including residency training program websites, hospital/institutional websites, Doximity, LinkedIn, the American Society for Radiation Oncology (ASTRO) website, the American College of Radiation Oncology website, and the National Plan and Provider Enumeration System National Provider Identifier Registry. We used the χ² Goodness of Fit test, Mann-Whitney U test, and Fisher exact test via R version 4.1.1 to evaluate for statistical significance among categorical variables, medians, and proportions, respectively.

Results

We identified 85 of the 90 chairpersons (94.4%) currently serving at institutions with an Accreditation Council for Graduate Medical Education–accredited RO residency training program, 5 of whom hold interim positions and were thus excluded from further analyses. Of the remaining 80 chairpersons, 9 (11.3%) are women, and 71 (88.8%) are men (P < .01). Seventy-six chairpersons (95.0%) are full professors, and 19 (23.8%) hold dual MD PhD degrees. Thirty-two chairpersons (40.0%) hold an official leadership role in a cancer center affiliated with their current institution (43.7% of men vs 11.1% of women; P = .08). Seventy-three chairpersons (91.3%) secured their current positions a median of 16 years (range, 6-33 years) after completing RO residency. Thirty-five chairpersons (43.8%) were promoted to chair from positions within their current institutions (40.8% of men vs 66.7% of women; P = .17). The majority of chairpersons are ASTRO Fellows (62.5%); notably fewer are ASTRO (5.0%) or American College of Radiation Oncology (2.5%) Gold Medalists. Eight RO residency programs trained more than half of current chairpersons.

Conclusion

Significantly more men than women currently serve as RO chairpersons. Future interventions that promote the recruitment, retention, and promotion of talented women in academic RO should be considered.

Introduction

A diverse physician workforce that adequately reflects the patients it treats has been shown to improve health care utilization among underresourced communities, patients’ perceptions of the care they receive, clinical outcomes, and survival.1, 2, 3 Within radiation oncology (RO), however, women have been underrepresented for years. Although women represent more than half (55.6%) of medical school matriculates, they constitute a minority of new RO graduates (31%) and academic RO faculty (29%).4, 5, 6 This disparity is particularly stark at the level of RO leadership, where in 2013 women made up just 24% of residency program directors and 9% of chairs, suggesting significant attrition in the leadership pipeline of women in RO.⁷ Within this context, the goal of this study was to provide a contemporary understanding of the makeup of current academic RO chairpersonships.

Methods and Materials

We obtained a list of Accreditation Council for Graduate Medical Education (ACGME)-accredited RO residency training programs in the United States (US) from the ACGME. From September 2022 to January 2023, we identified the associated academic RO chairperson at each program from residency training program websites. With the assistance of multiple publicly available sources, including residency training program websites, hospital/institutional websites, Doximity, LinkedIn, the American Society for Radiation Oncology (ASTRO) website, the American College of Radiation Oncology (ACRO) website, and the National Plan and Provider Enumeration System (NPPES) National Provider Identifier Registry, we created a comprehensive database of academic RO chairpersons in the US. This database includes the gender, medical school and RO residency training program attended, employment history, and disease site focus of each academic RO chairperson we identified.

Discordances between data sources were discussed among members of the research team. While the principal investigator made the final determination on how to proceed in such cases, priority was given to information available on NPPES, hospital/institutional websites, and residency training program websites. We subsequently used the χ² goodness-of-fit test, Mann-Whitney U test, and Fisher exact test via R version 4.1.1 to evaluate for statistical significance among categorical variables, medians, and proportions, respectively. When calculating the interval between the start of a current chairpersonship and the receipt of a designation or award, we excluded chairpersons for whom the year in which he or she obtained his or her current chairpersonship was not publicly available.

Results

We identified 85/90 chairpersons (94.4%) whose departments are affiliated with an ACGME-accredited RO residency training program, 5 of whom hold interim positions and were excluded from further analyses. Of the remaining 80 chairpersons in permanent positions, 9 (11.3%) are women, and 71 (88.8%) are men (P < .01). Seventy-six chairpersons (95.0%) are full professors, and 19 (23.8%) hold dual MD PhD degrees. Other advanced degrees include MS (8, 10.0%), MPH (4, 5.0%), MPH/MSPH (1, 1.3%), MA (1, 1.3%), MBA (1, 1.3%), MSCl (1, 1.3%), and DPhil (1, 1.3%). Thirty-two chairpersons (40.0%) hold official leadership roles, such as “director” or “chair,” in the cancer centers affiliated with their institutions; while such titles are more common among men than women, the difference is not statistically significant (43.7% vs 11.1%, P = .08). Table 1 shows the characteristics of academic chairpersons in the US.

Table 1.

Characteristics of chairpersons

	Men (n = 71)		Women (n = 9)
Characteristics	Number	Percentage*	Number	Percentage*	P value
Attributes
No. of chairpersons	71	88.8†	9	11.3†	<.01
Full professors	67	94.4	9	100.0	1.00
Dual MD-PhD degrees	17	23.9	2	22.2	1.00
Official leadership roles in affiliated cancer center	31	43.7	1	11.1	.08
Pathway to chairpersonship
Median # of years between residency graduation and chairmanship	16 y‡ (IQR 11-19 y)		17 y (IQR 15-18 y)		.63
First attending position was in the same institution as their residency program	24	33.8	3	33.3	1.00
Promoted to chair from another position at their respective institutions	29	40.8	6	66.7	.17
Worked at ≥3 institutions after completing residency	17	23.9	2	22.2	1.00
Worked in private practice	3	4.2	0	0.0	1.00
Awards
ASTRO Fellow	43	60.6	7	77.8	.47
ASTRO Gold Medalist	4	5.6	0	0.0	1.00
ACRO Gold Medalist	2	2.8	0	0.0	1.00

Abbreviations: ACRO = American College of Radiation Oncology; ASTRO = American Society for Radiation Oncology; IQR = interquartile range.

^⁎Percentage calculated with the denominator as 71 for the male cohort or denominator as 9 for the female cohort unless otherwise noted.

^†Row percentage was reported in this table.

^‡The year in which 7 chairpersons obtained their current positions could not be identified.

Bold signifies statistical significance.

The year in which 7 chairpersons obtained their current positions could not be identified. The remaining 73 chairpersons secured their current positions at a median of 16 years (range, 6-33 years) after the completion of RO residency, with no statistically significant difference between the intervals for men and women (median, 16 vs 17 years, respectively; P = .63). The examined chairpersons had been in their current positions for a median of 11 years (interquartile range, 3-15 years) as of 2022. Table 2 shows the period when they become chair.

Table 2.

Period in which current academic radiation oncology chairpersons obtained their current positions

Period	Men (n = 64*)	Women (n = 9)
Pre-2000	4	0
2000-2004	7	0
2005-2009	21	0
2010-2014	10	2
2015-2019	9	3
2020-present	13	4

^⁎The year in which 7 chairpersons obtained their current positions could not be identified.

Eight RO residency programs trained more than half of the chairpersons identified (41 chairs, 51.3%; Table 3). After completing RO residency training, 27 chairpersons stayed in the same hospital system for their first attending physician position (men 33.8% vs women 33.3%; P = 1.00), 9 of whom ultimately became the chair at the residency program they each respectively trained at.

Table 3.

The top 8 chairperson-producing radiation oncology residency programs

Residency program	Number (percentage*) of chairpersons
Brigham and Women's Hospital/Massachusetts General Hospital/Harvard Medical School Program†	17 (21.3)
Memorial Sloan Kettering Cancer Center Program	4 (5.0)
University of Michigan Health System Program	4 (5.0)
University of Pennsylvania Health System Program	4 (5.0)
McGaw Medical Center of Northwestern University Program	3 (3.8)
University of Chicago/University of Illinois College of Medicine at Chicago Program	3 (3.8)
University of Texas MD Anderson Cancer Center Program	3 (3.8)
Sidney Kimmel Medical College at Thomas Jefferson University Hospital Program	3 (3.8)

^⁎Column percentage was calculated with the denominator as 80 and is reported in this table.

^†Formerly 2 residency programs at Harvard Medical School: the Massachusetts General Hospital and the Joint Center for Radiation Therapy.

The majority of chairpersons are ASTRO Fellows (62.5%); notably fewer are ASTRO (5.0%) or ACRO (2.5%) Gold Medalists. There are no statistically significant differences in the proportions of men and women who have been designated ASTRO Fellows (60.6% vs 77.8%, respectively; P = .47) or have received ASTRO Gold Medals (5.6% vs 0.0%, respectively; P = 1.00) or ACRO (2.8% vs 0.0%, respectively; P = 1.00).

Disease sites of interest were identified for 77 of the 80 chairpersons (96.3%) examined (number of disease sites of interest: median, 1; range, 0-6). Table 4 shows the grouping of disease sites. Four individuals (5.0%) listed brachytherapy as a clinical focus. Of the 80 chairpersons examined, 40 chairpersons’ (50.0%) professional websites only list English as the preferred language, and 15 (18.8%) list English and at least one other language; 25 (31.3%) do not list a preferred language.

Table 4.

The chairpersons’ disease sites of interest

Disease site category	Number (percentage*) of chairpersons
Genitourinary	23 (28.8)
Central nervous system	22 (27.5)
Head and neck	19 (23.8)
Gastrointestinal	17 (21.3)
Thoracic	17 (21.3)
Breast	15 (18.8)
Leukemia/lymphoma	9 (11.3)
Gynecologic	6 (7.5)
Pediatric	4 (5.0)
Sarcoma	3 (3.8)
Skin	3 (3.8)
Benign condition	1 (1.3)

^⁎Row percentage was calculated with the denominator as 80 and was reported in this table.

Discussion

Historically, there has been a gender imbalance in the composition of the academic RO workforce.⁸ Given the increasing diversity of patients treated by academic radiation oncologists across the US, sufficient representation of women in the leadership of academic RO is crucial. In this cross-sectional study, we aimed to identify the characteristics of individuals currently serving as academic RO chairpersons whose departments are affiliated with an ACGME-accredited RO residency training program in the US.

Previous studies on representation at the senior level in academia have focused on gender imbalances in academic research productivity and faculty-held positions.^7,9, 10, 11, 12 However, other work has identified gender differences in the research productivity of RO trainees, suggesting that these disparities in academic achievement occur early in a physician's career and may contribute to the lower rates of women in academic and leadership positions.^13,14 While the rates of membership of women in the ASTRO rose from <10% in 1980 to 27% in 2005, it has since plateaued, standing at just 28% as of 2023.^11,15 A 2006 study by Jagsi et al reported that despite the increasing composition of women among the American RO community, representation of women among national board members, gold medals awardees, and chairpersons remained low.¹¹ Similarly, subsequent studies found that 9% to 12% of RO chairpersonships were held by women, compared with 21.7% of such positions in medical oncology and 3.8% in surgical oncology.^7,12,16 These figures demonstrated that despite increases in gender representation among the RO community, gender disparities persist at the senior leadership level, perhaps due to the slow turnover rate. Our study has demonstrated the persistence of this gender imbalance at the academic RO chairpersonship level in the modern era. While we additionally found that a higher proportion of men, compared with women, hold an official leadership role in the cancer institutions affiliated with their institutions, have received an ASTRO Fellow designation or Gold Medal and have received an ACRO Gold Medal, the differences were not statistically significant.

When assessing their pathways to their chairpersonships, we found that men and women work for a comparable number of years before obtaining their current positions. In addition, comparable proportions of men and women are publicly known to have worked in the same institutions for both their residency training and early career attending physician positions and to have worked at 3 or more institutions after completing residency. Interestingly, although not statistically significant, a higher proportion of chairs who are women, compared with men, are promoted to chair from another position within their respective institutions. In other words, a higher proportion of men, compared with women, transferred institutions and relocated to obtain their chairpersonships. This is consistent with the results of a prior survey of academic RO chairpersons, which found that women often find relocation for their positions to be more difficult than men.¹⁷

There are opportunities for the attrition of women at every stage of an academic career, spanning the periods that they spend as junior attendings, midcareer attendings, senior attendings, and finally, chairpersons. Barriers to the advancement of women in academia may include the imbalance between work and home life, insufficient mentorship and sponsorship, and bias and sexual harassment.¹¹ To better retain women at each step in the academic pipeline, institutions may consider adopting policies and a work culture that promotes work-life balance and offers sufficient parental leave, developing dedicated formal and informal mentor and sponsorship networks, demonstrating their commitment to gender equity via the establishment of dedicated institutional committees aimed at retaining women in academia, and requiring continuing medical education aimed at reducing unconscious bias and boosting bystander interventions. Properly addressing the gender disparities inherent in our field, however, will prove to be a complex endeavor that will require a collective, national effort.

In 2013, Wilson and colleagues reported that 38% of RO chairpersons had graduated from 5 residency programs.⁷ Likewise, in this study, we found that 50% of chairpersons today graduated from just 8 residency programs, with much overlap with the programs reported by Wilson et al. Given that department chairs determine the missions of their departments and help mentor the future generation of radiation oncologists, this finding is especially notable because it suggests that a few residency training programs are having an outsized impact on both the leadership of the field and the trajectory of the specialty. As the number of RO graduates has grown significantly in recent years, there are now more candidates from a wider variety of residency training programs, who would make promising candidates for promotion to an RO chairpersonship. While this would represent a break from the past, such a change might usher in a wider variety of perspectives in the field of RO in the future.

To our knowledge, this is the first study that has assessed the disease site and brachytherapy practices of academic RO chairpersons in the US. Popular disease sites treated by chairpersons include central nervous system, head and neck, breast, thoracic, gastrointestinal, and gynecologic cancers, which happen to reflect the most common disease sites treated by the general RO population.¹⁸ For example, of the approximately 5300 practicing radiation oncologists in the US, approximately 300 (6%) are brachytherapists.^19,20 Thus, the proportion of chairpersons (5%) who listed brachytherapy as their clinical focus appear to reflect the general radiation oncologist population in the US. Our findings show that treating a specific disease site is not associated with becoming a RO chairperson, suggesting that there is not one common clinical pathway to becoming an RO chairperson in the US.

This study has several limitations. The comprehensive chairperson database we created is based on multiple publicly available data sources. Any information that has been omitted from public sources of data would not be reflected in our database. Furthermore, gender is classified as male or female by NPPES, and thus does not accommodate individuals who identify as transgender or nonbinary.

Conclusion

Significantly more men than women currently serve as academic RO chairpersons in the US. Future interventions that promote the recruitment, retention, and promotion of talented women in academic RO should be considered.

Disclosures

Kristin Hsieh is the 2023 American Society for Radiation Oncology AstraZeneca Radiation Oncology Research Training Fellow. Karyn A. Goodman participates in Viewray Data Safety Monitoring Board, RenovoRx Advisory Board, and Philips Advisory Board; and she is a cochair of National Cancer Institute Gastrointestinal Steering Committee. The remaining authors declare that they have no conflict of interest.