SNO 2020 diversity survey: defining demographics, racial biases, career success metrics and a path forward for the field of neuro-oncology

Abstract

Background

Neuro-oncology has grown tremendously since 2010, marked by increasing society membership, specialized clinical expertise, and new journals. Yet, modest improvement in racial/ethnic diversity amongst clinical trial participants, researchers, and clinicians led us to conduct a survey to identify opportunities to enhance diversity and inclusiveness amongst neuro-oncology professionals.

Methods

In summer 2020, the Women and Diversity Committee of the Society for Neuro-Oncology (SNO) distributed an anonymous online survey to members and affiliates including the European Association of Neuro-Oncology (EANO), Asian Society for Neuro-Oncology (ASNO), Society for Neuro-Oncology Latin America (SNOLA) and Society for Neuro-Oncology Sub-Saharan Africa (SNOSSA). The survey captured personal and professional characteristics, biases, effective mentorship qualities, career service metrics, and suggested field/society changes. Results were analyzed by geography, profession, age, racial/ethnic, and sexual identity. Standard descriptive statistics characterized the study population.

Results

The 386 respondents were predominantly female (58%) with a median age range of 40–49 years (31%), White (65%), and SNO members (97%). Most worked in North America (77%) in a research profession (67%). A majority of White respondents reported never experiencing biases (64%), while the majority of non-White respondents reported unconscious biases/microaggressions, followed by a lack of/limited mentorship. Qualitative assessments showcased that personal/professional success metrics were linked to needed improvements in diversity and inclusion efforts within the neuro-oncology field.

Conclusions

The prevalence of racial/ethnic biases and poor mentorship rates amongst underrepresented groups in neuro-oncology is high and potentially linked to the limited diverse representation amongst members and affiliates. These findings warrant a swift implementation of equity and inclusion practices within the neuro-oncology field.

Key Points.

• The neuro-oncology field lacks racial/ethnic diversity in trial participants, researchers, and clinicians.

• This SNO survey details biases and career success metrics amongst members/affiliates.

• More work towards equity and inclusion in the field is needed.

Importance of the Study.

While the field of neuro-oncology has grown over the last decade, it has failed to see a rise in racial/ethnic diversity amongst clinical trial participants, researchers, and clinicians. This survey reports on the prevalence of perceived and realized biases that impact underrepresented groups, specifically their access to mentorship and career growth opportunities within the field. There remains a need to increase equity and inclusion initiatives for patients, clinicians, and researchers throughout neuro-oncology.

Introduction

In the current global awakening related to systemic racial injustice and historical exclusion, various institutions have been forced to reckon with their commitment to equity, diversity, and inclusion. As it relates to medicine, workforce diversity in the United States (US) directly impacts health equity and disparities.^1,2 According to the census estimates published in 2019, the racial/ethnic breakdown of the US population is comprised predominantly of non- Hispanic/White (60.1%), followed by Hispanic/Latino (18.5%), Black (13.4%), Asian (5.9%), American Indian/Alaska Native (1.3%) and Native Hawaiian/Pacific Islander (0.2%).³ However, these numbers are not mirrored in the physician workforce during the same period with 56.2% of active physicians identifying as White, 17.1% Asian, 5.8% Hispanic/Latino, 5% Black/African American, 0.3% Native, and 13.7% unknown. Prior to 2004, the racial/ethnic groups underrepresented in medicine (URiM) and research have been historically defined as Blacks, Hispanic/Latino, Native Americans/American Indians, and Hawaiian/Pacific Islanders. More recently, this designation has been broadened to include any population underrepresented in medicine as compared to their numbers in the general population.⁴ Diverse representation among specialists, specifically in oncology, remains dismal with 5.8% of practicing oncologists identifying as Hispanic and 2.3% as Black/African American.

This lack of diversity in practicing clinicians has downstream effects on clinical care, namely for patients from racially and socioeconomically underserved communities. Indeed, when there is race and/or gender concordance between patients and physicians, improved communication, understanding, and quality of care can be translated to improved patient survival and decreased morbidity rates. For example, Black patients who are cared for by Black physicians were more likely to receive preventative services, adhere to their medications, and understand their treatment plans.^5–9 As we seek to deliver the highest quality of care to all, equitable representation of women and diverse populations in medicine will lead to a more comprehensive understanding of the spectrum and impact of the disease.

In 2018 the Women in Neuro-Oncology (WiN.) committee within the Society of Neuro-Oncology (SNO) was created with the mission of identifying the needs and advancing the careers of women in neuro-oncology. In 2019, WiN. issued a survey to SNO members seeking to understand biases experienced within the workplace, ultimately demonstrating that women experienced significant bias in their respective workplaces regularly, with missed academic opportunities, salary discrepancies, burnout, and a lack of mentorship being predominant themes.¹⁰ In early 2020, SNO expanded the society’s diversity efforts through the creation of the Women and Diversity Committee (WDC), which evolved from the combined efforts of WiN. and the SNO diversity task force of the clinical trials enrollment working group. Acknowledging the critical unmet needs within the neuro-oncology community, WDC was formed to address membership engagement, and to improve research opportunities and clinical care for women and URiM. Collectively, the WDC holds a critical role in enhancing the success of women, underrepresented clinicians, and investigators early in their careers within neuro-oncology. The initial charge for the WDC, as set forth by the SNO president and executive leadership, was to understand who SNO members and affiliates are, as well as to evaluate the unique needs, sense of career satisfaction, concern for bias, and burnout of the underrepresented populations within our field. The findings from this questionnaire would aspire to then improve upon existing tools and prioritize new offerings to support SNO members and the neuro-oncology community at large. To date, these results are the first to clearly define the racial/ethnic demographic within neuro-oncology as well as the prevalence of experienced biases amongst SNO members and its affiliates.

Methods

The WDC developed a 27-question survey which was distributed via an anonymous survey link on three separate occasions in 2020: July 1, July 20, and July 28. Survey recipients included all members of SNO and its international cooperative societies including the European Association of Neuro-Oncology (EANO), the Asian Society of Neuro-Oncology (ASNO), the Society for Neuro-Oncology in Latin America (SNOLA), and the Society for Neuro-Oncology Sub-Saharan Africa (SNOSSA). Additionally, participants of recently registered SNO or SNO affiliate conferences were invited to complete the survey for further distribution of individuals within the neuro-oncology field. These 5 societies are composed of members including physicians, clinical and basic researchers, advanced practice providers and allied health professionals. At the time of the survey, the largest society, SNO, had 2077 members, 63% identifying as male, and 35% identifying as female. The survey was composed of three parts: (1) Eighteen demographic-focused questions, (2) Seven questions focused on experiences associated with bias, mentorship, and burnout, and (3) Two open-ended questions to allow for detailed suggestions for changes needed within the field of neuro-oncology or SNO. The questions were developed by members of the WDC based on prior SNO-developed surveys (Supplementary Figure 1). Demographic questions included age, sex, race/ethnicity, disability, military service, and gender identification questions. Questions focused on current professional practice included degrees held, professional activity, country of professional activity, type of practice (academic, hospital, private, university-based), years in practice, age of the treated patient population (pediatric, adult, combination), membership and length of membership in their respective neuro-oncology societies. The second part of the survey explored aspects of career satisfaction and development. The rate of experienced bias was assessed utilizing a 7-point Likert scale ranging from “never experienced” to “experienced almost daily.” If respondents answered with any experience of racial/ethnic biases, the type of bias and period experienced were explored in subsequent questions. The next group of questions asked respondents to rank the categories felt to be most important for career success, allowing five answers in the level of importance. Participants were asked to rank up to the three most important attributes of mentorship. Respondents were then asked if they had an effective mentor (yes or no) or if they wanted or needed a mentor. Symptoms of burnout were assessed utilizing the 7-point Likert scale, also ranging from “never experienced” to “experienced almost daily”. In the last two questions of the questionnaire, participants were asked what would provide more personal and professional satisfaction and, specifically, what services, resources, and support they would like to see offered through SNO.

Statistical Analysis

A total of 8693 SNO and affiliate members received the survey with 386 completing the survey in full (4.4% response rate). Rates for prior SNO-initiated surveys, including the SNO-EANO Burnout and WiN surveys were 7% and 10%, respectively. A total of 494 participants began the SNO Diversity Metrics survey and answered through question 3. By question 16, 108 (22%) participants stopped and answered through question 3. By question 16, 108 (22%) participants stopped completing the survey, with an overall completion rate of 78% among those who started the survey. There were no major differences in racial/ethnic identity frequencies when using only the sample who answered the questionnaire in its entirety compared with the total participant sample. Each identity lost participants, except for American Indian or Alaskan Native. All further analyses included data from 386 respondents who completed questions 1–27. All included surveys were evaluated for completeness. Missing or incomplete surveys were excluded from the full detailed analysis. Survey respondents were analyzed as a total group and then sub-analyzed by location practice. Other analyzed items included sexual identity, racial/ethnic identification, military participation, disability status of members, degrees held, duration of time within the primary profession or at current institution, duration of SNO membership, and biologic age range. Evaluation of respondent answers to questions regarding bias, mentorship, and burnout addressed differences related to geographical location, racial/ethnic identity, URiM vs. non-URiM status, age, and sexual identity. Standard descriptive statistics were utilized to characterize the study population. Mean, standard deviation, range and quartiles were calculated for years in SNO, years in practice, and years in current position. Median age was calculated of participants due to categorical range selection options. For analysis of mentorship associations with the reported demographic variables, chi-square tests and one-way ANOVA testing was utilized with significance defined as P < .05. A thematic approach was used to code the free-text responses, each response was repeatedly reviewed within a computer-assisted software (MAXQDA) to identify recurring themes. One author who has had training in the methods and principles of qualitative research work reviewed text responses and any questions regarding the codes and themes of the analysis were reviewed with additional authors. The process followed in creating the themes included re-reading the text to understand participant responses, developing categories (parent codes) based on the topics identified, then coding open-ended text responses and adding coded text to categories while creating subcategories if needed. The coding process was initiated by highlighting sections of the text that described the answers to the question and each was labeled with a code to describe the content. Similar codes were grouped together, which led to generating themes (parent codes) that the codes could be placed under. After this process, direct sub-codes (subcategories of parent codes) and lower-level codes (codes under direct sub-codes) were created to provide more detailed explanations of the parent codes identified to understand participants' overall experience. The analysis includes a count of the number of participants in which each of the parent codes and sub-codes occurs.

To generate the word clouds, word frequencies were identified in the MAXQDA software. For each question, the most frequent words used by participants shaped the word cloud and a stop list was created to remove any small words or basic language (“and,” “the,” etc.) that weren’t meaningful to the analysis.

Results

Demographics and Participant Characteristics

Responses from 386 individuals represented 26 countries, with most participants from North America (82%) (Table 1). The median age range was 40–49 years old (31%) with a female predominance (58%). Sixty-five percent of respondents identified as White, 13% Asian, 12% Hispanic or Latino, 9% Asian Indian, 5% Black/African American, 1% American Indian or Alaskan Native, 1% Native Hawaiian or Islander, and 3% Other. Seven percent of participants identified with multiple racial/ethnic groups, with a predominance of these being White-Hispanic (2%) respondents. Eight percent of participants identified as lesbian, gay, bisexual, transgender, queer, intersex, or asexual. Additionally, a minority of respondents reported disabilities (3%) and active military, reserve, or natural guard status (1%).

Table 1.

Demographics

Primary country of work	Total N = 386	North America 316 (82%)	Other countries 70 (18%)
	N (%)	N (%)	N (%)
North America	317 (82%)
United States	298 (77%)
Canada	18 (5%)
Mexico	1 (<1%)
South America	6 (2%)
Argentina	2 (1%)
Brazil	4 (1%)
Europe	43 (11%)
Austria	3 (1%)
Demark	1 (<1%)
Germany	8 (2%)
Hungary	1 (<1%)
Israel	1 (<1%)
Italy	4 (1%)
Lebanon	1 (<1%)
Netherlands	7 (2%)
Poland	1 (<1%)
Spain	2 (1%)
Sweden	1 (<1%)
Switzerland	2 (1%)
United Kingdom	11 (3%)
Asia	12 (3%)
India	5 (1%)
Indonesia	1 (<1%)
Japan	1 (<1%)
Pakistan	1 (<1%)
Republic of Korea	3 (1%)
Thailand	1 (<1%)
Africa	0
Oceania	8 (2%)
Australia	7 (2%)
New Zealand	1 (<1%)
Professional society
SNO	373 (97%)	316 (100%)	57 (81%)
EANO, ASNO, SNOLA, SNOSSA	59 (16%)	13 (5%)	46 (66%)
Multiple	45 (12%)	13 (4%)	32 (46%)
Sex
Female	223 (58%)	178 (56%)	45 (64%)
Male	160 (41%)	135 (43%)	25 (36%)
Prefer not to say	3 (1%)	3 (1%)	0 (0)
Age
21–29	31 (8%)	29 (9%)	2 (3%)
30–39	108 (28%)	88 (28%)	20 (29%)
40–49	118 (31%)	96 (30%)	22 (31%)
50–59	69 (18%)	49 (16%)	20 (29%)
60 or order	60 (16%)	54 (17%)	6 (9%)
Identification
White	250 (65%)	198 (63%)	52 (74%)
Black or African American	18 (5%)	18 (6%)	0 (0)
Hispanic or Latino	47 (12%)	42 (13%)	5 (7%)
American Indian or Alaskan Native	49 (13%)	5 (1%)	0 (0)
Asian	63 (13%)	39 (12%)	10 (14%)
Asian Indian	34 (9%)	29 (9%)	5 (7%)
Native Hawaiian or Pacific Islander	4 (1%)	3 (1%)	1 (1%)
Other	10 (3%)	8 (3%)	2 (3%)
Multiple	26 (7%)	23 (7%)	3 (4%)
LGBTQIA
Yes	30 (8%)	27 (9%)	3 (4%)
No	354 (92%)	287 (91%)	67 (96%)
Disabilities
Yes	11 (3%)	8 (3%)	3 (4%)
No	374 (97%)	307 (97%)	67 (96%)
Military
Yes	2 (1%)	2 (1%)	0 (0)
No	383 (99%)	313 (99%)	70 (100%)
Highest degree
Doctorate	335 (87%)	270 (85%)	65 (93%)
Clinical	255 (66%)	208 (66%)	47 (67%)
Non-Clinical	132 (34%)	107 (34%)	25 (36%)
Masters/Advanced	24 (6%)	20 (6%)	4 (6%)
Nursing	7 (2%)	6 (2%)	1 (1%)
Bachelors	19 (5%)	19 (6%)	0 (0)
Other	1 (<1%)	1 (<1%)	0 (0)

Membership Characteristics

A total of 373 (97%) of participants held SNO memberships, while 11% held EANO membership; and 12% of respondents held dual membership amongst varied societies. For those who were SNO members, the mean duration was 7.6 years, with a range between 1–25 years. Participants who practiced in North America reported being SNO members for 2.3 years longer than participants who practiced in other countries.

Clinical/Research/Professional Focus

Eighty-two percent of respondents primarily practiced or conducted research and/or administrative work within North America. Participants primarily held clinical doctorates (66%), followed by non-clinical doctorates (34%) and/or master’s degrees (22%). The primary Professional focus leaned towards research (67%), followed by medical (53%) and education (20%); however, 46% of respondents reported multiple professional foci. Among the researchers, 70% were conducting translational research and for respondents providing clinical care, 70% were caring for adult patients (Table 2). Clinicians predominately reported practicing in an academic (62%) setting. On average, participants reported being in their primary professional focus for 14.3 years and in their current positions for 7.7 years.

Table 2.

Professional Characteristics

Professional focus	Total N = 386	North America N = 316 (82%)	Other countries N = 70 (18%)
	N (%)	N (%)	N (%)
Research	257 (67%)	212 (67%)	45 (64%)
	Basic: 101 (39%)	Basic: 85 (40%)	Basic: 16 (36%)
	Clinical: 148 (58%)	Clinical: 116 (55%)	Clinical: 32 (71%)
	Translational: 181 (70%)	Translational: 151 (71%)	Translational: 30 (67%)
Medical	205 (53%)	170 (54%)	35 (50%)
Education	78 (20%)	60 (19%)	18 (26%)
Surgical	62 (16%)	47 (15%)	15 (21%)
Administration	46 (12%)	37 (12%)	9 (13%)
Industry	12 (3%)	12 (4%)	0 (0%)
Other	7 (2%)	5 (2%)	2 (3%)
Treatment population
Adult	269 (70%)	217 (69%)	52 (74%)
Pediatrics	60 (16%)	52 (16%)	8 (11%)
Both	57 (15%)	47 (15%)	10 (14%)
Specialty focus
Neuro-oncology	295 (76%)	237 (75%)	58 (83%)
Laboratory research	79 (20%)	63 (20%)	16 (23%)
Neurosurgery	72 (19%)	54 (17%)	18 (26%)
Neurology	51 (13%)	38 (12%)	13 (39%)
Medical oncology	45 (12%)	32 (10%)	13 (19%)
Pediatrics	41 (11%)	35 (11%)	6 (9%)
Radiation oncology	39 (10%)	30 (9%)	9 (13%)
Pathology	24 (6%)	19 (6%)	5 (7%)
Epidemiology	20 (5%)	14 (4%)	6 (9%)
Radiology	17 (4%)	11 (3%)	6 (9%)
Statistics	16 (4%)	14 (4%)	2 (3%)
Psychology	11 (3%)	5 (2%)	6 (9%)
Pharmacology	10 (3%)	5 (2%)	5 (7%)
Industry	9 (2%)	9 (3%)	0 (0%)
Nursing	8 (2%)	5 (2%)	3 (4%)
Allied Health	7 (2%)	6 (2%)	1 (1%)
Foundation	4 (1%)	3 (1%)	1 (1%)
Other	10 (3%)	8 (3%)	2 (3%)
Primary setting for clinical positions
Academic	241 (62%)	202 (64%)	39 (56%)
Hospital based	113 (29%)	79 (25%)	34 (49%)
Private practice	25 (6%)	18 (6%)	7 (10%)
Nonprofit	23 (6%)	18 (6%)	5 (7%)
Government	14 (4%)	7 (2%)	7 (10%)
Industry	10 (3%)	10 (3%)	0 (0%)
Non-clinical position	16 (4%)	12 (4%)	4 (6%)
Other	3 (1%)	3 (1%)	0 (0%)
Number of years in primary focus
Mean (SD)	14.3 (11.0)	13.9 (11.3)	15.7 (9.7)
Number of years in current position
Mean (SD)	7.7 (8.2)	7.7 (8.5)	7.7 (6.8)

Reported Biases

Participants were asked a series of questions centered around frequency, incidence, and type of racial/ethnic biases experienced to date (Figure 1, Supplementary Table 1). White respondents were the largest proportion of participants who reported never experiencing biases (64%). Among the respondents reporting biases, Black/African Americans reported the highest frequency at once a month (22%) or every day (17%), while Hispanics reported 26% experiencing biases once a month, 9% once a week, and 9% every day. A chi-square test revealed a significant association between being URiM member and experiencing ethnic/racial bias in work (X²(1) = 17.9, P < .001, OR = 3.4). Overall, URiM respondents were 3.4 times more likely to experience ethnic/racial bias in work than non-URiM respondents. The highest frequency within other racial/ethnic groups was in the once a month category with 40% American Indians or Native Americans, 24% Asians, 21% Asian Indians, and 50% Native Hawaiian/Pacific Islanders (Figure 1). Collectively for all participants, the predominant bias type was “not being invited to participate and/or being considered for professional opportunities as others in comparable rank”. In detailing the type of biases experienced by ethnic/racial identification, an overwhelming majority of non-White respondents reported unconscious biases/microaggressions, followed by a limited/lack of mentorship. With respect to timing, on average, 41% of all respondents reported a remote history (>1 month prior), while 35% reported a trend of biases at their current institution. Interestingly, there was no significant difference in the timing of biases when evaluating by ethnic/racial groups.

Fig. 1.

(A, B) Frequency of biases. (C, D) Type of biases. (E, F) Timing of biases.

Career Success Metrics

In the evaluation of the metrics associated with career progress/success, all respondents were asked to rank the importance of various categories: work collegiality, equitable salary, funding and/or resource allocation, equitable work distribution, mentorship/mentee opportunities, promotion opportunities, opportunity to hold leadership role(s) and authorship (Figure 2). While evaluating total responses, White and Asian respondents overwhelmingly ranked the opportunity to hold leadership role(s) as the highest importance. In contrast, Black/African American respondents reported work collegiality as paramount (56%), and Hispanics ranked having an equitable salary as the highest importance (47%). Participants were then asked to select the three most effective mentorship attributes for success. Interestingly, in the breakdown of race/ethnicity, most of the groups also ranked critical feedback and serving as a good advocate to be crucial for effective mentorship. Among North American respondents, critical feedback and the ability to be a good advocate were identified as key qualities in a mentor, while respondents from other countries reported that the identification of opportunities was an essential quality for a great mentor. Additional free-text responses not included in selected categories included: sponsorship for opportunities and transparency in career goals.

Fig. 2.

(A, B) #1 Rank importance to career success. (C, D) Optimal mentorship.

Lastly, we asked which of the respondents had effective mentorship currently. Fifty-three percent of total participants had effective mentorship, with higher percentages within North America (55%) as compared to other countries (43%). A chi-square test revealed a significant association between effective mentorship and age group (X²(12) = 86.1, P < .001, Cramer’s V = 0.27). More participants in the younger age groups (21–29, 30–29) reported having an effective mentor than participants in other age groups (Supplementary Table 1). While more participants in the 50–59 age group reported not having a mentor than in other age groups, more participants in the 60 and older age group reported not needing/wanting a mentor than the other age groups. One-way ANOVA also revealed a significant difference in the years of SNO membership in relation to effective mentorship (F(3,369) = 23.0, P < .001). Participants who reported not needing or wanting a mentor were SNO members longer than participants in the three other categories (16.4 years vs 6.1–8.8 years) (P < .001). More participants having longer SNO memberships reported not having effective mentors as compared to shorter-term SNO members (8.8 years and 6.1 years, respectively) (P < .01). In the evaluation of other categories, respondents less than one year of primary professional focus, Asian identity, and the professional “research” focus groups were the largest group to report having effective mentorship at the time of the 288 surveys (81%, 68%, 89%, 67%, 58%, respectively).

Burnout Incidence

Professional burnout can be described as a constellation of symptoms, including but not limited to the following: state of emotional exhaustion, depersonalization, and loss of personal achievement. We surveyed participants about the frequency of symptoms of burnout experienced; with further exploration of any differences related to gender, racial/ethnicity, and professional focus (Supplementary Table 2).¹¹ The overall majority of our total respondents reported symptoms of burnout once every few months (27%). There were no observed differences among ethnic/racial groups in burnout symptom rate. A chi-square test revealed no significant association between experiences of burnout symptoms and sexual identity. Like the WiN survey, 90% of respondents reported having some frequency of symptoms of burnout (Figure 3).

Fig. 3.

(A) Word cloud of personal and professional satisfaction within neuro-oncology. (B) Word cloud of suggested profession services offered through SNO.

Neuro-Oncology Professional Outlook

Parent codes generated around personal and professional satisfaction included such categories as personal and professional improvements, more open community, and healthy work environments. Common themes within personal and professional satisfaction included mentorship, opportunity, and advancement (Figure 3, Supplementary Table 3). Common parent codes found amongst recommendations for change within SNO included categories such as personal and professional improvements, more opportunities for inclusion, support, and opportunities for involvement and engagement. Common themes within recommendations of SNO changes included networking, mentorship, and opportunity. We selected specific comments that helped to further illustrate common themes around personal and professional satisfaction. Overall qualitative evaluation of these answers points towards a better sense of community and inclusion needed to foster achievements and success within SNO and the neuro-oncology field.

“Feeling like I have place to sit at the table. I love collaboration but exclusion re: career opportunities, social activities etc. is hurtful and I resent spending my time focused on these things vs. moving our field forward.”

“Supportive leadership who compassionately guide my career.”

“Genuine collaboration towards a common goal that allows everyone to participate and be recognized, valued for what they can offer.”

“A more inclusive and diverse environment. We need to increase the number of people from underrepresented backgrounds (women, LGBTQIA, lower socioeconomic status, racial/ethnic minorities).”

“Not experiencing the gender discrimination rampant at my institution which actively limited resources for my research.”

“Increased female leadership roles and mentorship opportunities. Especially for female early career researchers trying to start a family.”

“More mentorship opportunities for trainees would be wonderful. Specifically, accessibility to physician-scientist mentors in the field of neurosurgery/neuro-oncology.”

Discussion

The SNO diversity survey is the first evaluation of the demographics, membership characteristics, and experiences of bias reported by the members of SNO and its international affiliates. This work follows the efforts of other medical organizations such as the American Society of Clinical Oncology (ASCO) and the American Association of Medical Colleges (AAMC); which assessed the demographics of their membership to create a workforce that reflects the larger, general US population. Of the 386 respondents who completed the SNO survey, 65% self-identified as non-Hispanic White, consistent with representation in medicine and the general US population. This survey aimed to capture a representation of groups historically referred to as URiM, defined by the AAMC as “racial/ethnic populations that are underrepresented in the medical profession relative to their numbers in the general population”. Asians, inclusive of respondents who identified as East and/or South Asian, represented 22% of the survey participants. Racial/ethnic groups which have been historically associated as populations within URiM include Latino/Hispanic, Black/African American, and American Indian/Alaskan Native, and represented 12%, 5%, and 1% of survey respondents, respectively.

In consideration of experiences of bias, all racial/ethnic categories reported experiencing some biases. Among White respondents, 64% reported never experiencing bias. Conversely, Black/African Americans and Latino/Hispanic respondents reported experiencing some form of bias daily, commonly noting microaggressions as well as a lack of effective mentorship. The impact of bias on URiM physician trainees was studied by Osseo-Asare et al.¹² In a survey of minority resident physicians, additional challenges beyond those experienced by non-minority counterparts were identified, including microaggressions, lack of formal reporting mechanisms for experiences of bias, and a lack of belonging. These findings demonstrate the compounding impact of experienced biases amongst clinicians, in an already high-pressure and stressful time period of training.¹² The downstream complications of this may be lower job satisfaction and higher turnover rates, which in turn has an impact on overall patient care.¹³ In a recently published SNO survey, which evaluated burnout and career satisfaction amongst practitioners caring for brain tumor patients, 63% of SNO and 61% of EANO participants were identified as having high scores consistent with symptoms of burnout according to the MBI-HSS (Maslach Burnout Inventory-Human Services Survey) questionnaire.¹¹ In comparison, the WiN. SNO survey (where the majority of respondents were female), found that 94% of respondents reported having some frequency of burnout¹⁰. In this diversity survey, while there were no differences in the frequency of burnout related to race/ethnicity, the experience, and frequency of bias are likely to contribute to a lack of engagement linked with low career and personal fulfillment.

Like the general physician workforce, notably in Oncology, there continues to be a trend of inadequate representation of racial and ethnic minorities in medical specialties. The recent ASCO Workforce Diversity survey demonstrated that 2% of practicing oncologists in the US identified as Black/African American, as compared to the general US population of 13%.

Furthermore, Hispanic oncologists represented 3% of US oncologists, though 18% of the US population is Hispanic (ASCO Workforce Diversity statement).⁴ These studies have shown that diversity and representation within the oncology workforce expand and improves healthcare access, clinical trial recruitment, and research databases to help in reducing health care disparities.^4,13,14 In comparison, while the ASCO membership is larger than SNO and SNO affiliates, this survey also demonstrates the low representation of racial/ethnic diversity within the clinical and research membership, linking these low numbers to significant influences to both personal and professional successes amongst SNO and affiliate members and specifically within URiM groups.

Limitations

Though instructive, this optional survey might be prone to biases inherent to all survey studies; since data generated is based on the experiences of those who chose to respond and might not be generalizable to the entire membership. Our response rate is hard to estimate given the various groups (members and nonmembers) we reached out to and their changing membership, but it likely was a small percentage of the total. Additionally, members of the neuro-oncology community are heterogeneous in their professional backgrounds and their experiences vary widely based on professional circumstance and geographic location. Taken as a whole, the results of this study are meant to raise awareness of the issues of women and URiM SNO members, with reach to associated stakeholders.

Conclusion

The results of this survey demonstrate that consistent with trends in oncology and other medical specialties, despite the gradual introduction of pipeline initiatives to increase representation, there remains a lack of diversity in the racial/ethnic make-up of clinicians and researchers. Biases and discrimination are consistent themes reported by diverse members, the impact of which contributes to a lack of engagement, career development, and/or success. Concentrated programming directed towards SNO and its affiliate society members can begin to mitigate these challenges by developing and expanding opportunities specifically for leadership and promotion of URiM members, thus leading to a more equitable workforce. Specifically, the ASCO Strategic Plan for Increasing Racial and Ethnic Diversity in the Oncology Workforce is utilizing a three-pronged approach to this charge by addressing inclusion at the (1) trainee, (2) leadership, and (3) policy level.⁴ Their strategic plan was built from learning the large impact diversity within the oncology field has on decreasing morbidity and mortality rates in underserved and vulnerable populations. Collectively, establishing an inclusive program to improve belongingness within organizations where its members and community feel heard and understood with respect to their personal and professional needs is essential. While initial steps have been taken to expand the SNO Women in Neuro-oncology to SNO Women and Diversity Committee, these efforts are just the start of long-needed efforts to have the neuro-oncology field reflect the patient population. Additional work is required to routinely assess how the current societal climate and workforce cultures can further shape needed changes within the field. Specifically, as the mission of SNO is to “promote advances in neuro-oncology through research and education,” it is evident from these survey findings that a representative membership is essential to ensuring this mission is achieved, with the intent that its members, affiliates, and patients mutually thrive.

Funding

This work was partly funded by the intramural program of the National Institute of Neurological Disorders and Stroke at the National Institutes of Health.

Conflict of interest statement. No conflicts.

Authorship statement. U.N.C., E.V., A.A., S.H.J., Y.O., L.K., E.D., A.S., E.F., A.T., T.E.W.O., S.C.P., N.N.G., M.I.D., T.S.A., A.P., and S.J. contributed to design and survey development, manuscript drafting and review.