The X factor: An Indian perspective on women in academic oncology

Although women worldwide, and certainly in India, are traditionally described as the weaker sex, I am unsure if this is true in today's world, or indeed if it has ever been true. History is rife with the success stories of strong women in practically every walk of life: from the time of Cleopatra in 69 BC, who ably led Egypt as queen from the age of 17, to Joan of Arc in the fifteenth century, who led the French army to victory in the Hundred Years War, to Marie Curie, the first woman Nobel Laureate, who discovered radioactivity, down through the ages to the strong twentieth century women leaders like Indira Gandhi (India's first woman prime minister) and Indra Nooyi, the powerful chief executive officer (CEO) of PepsiCo. However, when it comes to medicine, historically, women have taken a backseat to men, and have preferentially assumed roles in the paramedical field, as nurses, physiotherapists, midwives, and so on. The American Medical Association admitted only men until 1915.[1] This ‘medical male chauvinism’, for lack of a more accurate term, has very gradually changed and the modern world does see more women in medicine: in 1965, 7% of the applicants to medical schools in the USA were women, while in 2007, this figure had skyrocketed to 49%.[2] India has similarly followed suit, although the exact figures are not available.[3] Unfortunately, even the terminology for medical studies and for that matter academia and societies in general, is typically chauvinistic, reinforcing the fact that women were late entrants to a traditionally male-dominated field. When I decided to become a doctor, I joined the medical ‘fraternity’, or the medical ‘brotherhood’, I attained the ‘Bachelor of Medicine and Bachelor of Surgery’ degrees. I was not satisfied being a ‘Bachelor’, hence decided to become a ‘Master’ of Internal Medicine. I then went on to become a ‘Fellow’ in Medical Oncology and Hematology. I could go on, but suffice it is to say that I am finally an Associate Professor, and have been rid of the recurrently masculine titles. I would probably have not been able to join the medical ‘fraternity’, had it not been for a few brave women who paved the way. The pioneer in India was Anandibai Joshi, the first Indian woman doctor. Those were the days of child marriages, and Anandi was no exception. She got married when she was only nine years old and delivered her first baby when she was fourteen. Sadly, her son died soon after birth, due to lack of medical care. This tragedy prompted her decision to become a doctor, which was unheard of in those days for a woman in India. Fortunately, her husband was extremely supportive and forward-thinking. In spite of condemnation from society, financial constraints, and ill-health, Anandi went to America, studied medicine at the Women's Medical College of Pennsylvania, and attained an MD degree in 1886. She subsequently died of complications of tuberculosis less than a year later, but by then, she had already established the precedent for other Indian women, like me, to become physicians. In spite of the increased representation of women in the medical field, there still remain striking gender differences. A study on the career trajectories of male and female recipients of a career development award, found that women were significantly less likely to attain success, which for the purpose of the study was defined as being the principal investigator of a large well-funded project, publishing over 35 articles since the award was granted or being in a leadership position, like a Department Head or Dean.[4] Women are significantly less likely to receive research funding.[56] In fact, the women medical faculty in academic institutions get lower salaries than their male counterparts, on an average $30,000 less in annual salary.[78] This difference in salary holds true even after adjustment for other possible confounding factors like specialty, academic position, research time, work time, leadership position, and publications. Women are less productive than their male counterparts, which has been measured as less hours of work per week, less patients seen per hour, less likely to go into active practice after attaining a medical degree, more likely to be in part-time practice, and more likely to have a break in their careers.[910111213141516] There is a lack of women authorship for leading publications. A study by Jagsi et al. has revealed that between 1970 and 2004, the number of women who had been the first authors of original articles in six leading American journals increased from 6 to 29% for first authors and from 4 to 19% for the senior authors. The bulk of the increase in women authorship has been in the fields of Obstetrics/Gynecology and Pediatrics.[17] Similarly, only 11.5% of the Editorial Board members of leading American medical journals are women.[18] Perhaps the most striking gender disparity occurs in leadership positions. The Association of American Medical Colleges (AAMC) has reported that in spite of the fact that approximately 50% of the medical school graduates are now women; only 19% of the tenured full professors, 13% of the department chairs, and 11% of the deans are women.[19] However, in terms of women leadership, the field of oncology appears to have evolved faster than the other branches of medicine and a number of the major oncology groups are actually led by women. Dr. Jane Wright was a cancer surgeon, the discoverer of methotrexate, and an early pioneer of chemotherapy and oncology research. She went on to become one of the original founders of the American Society of Clinical Oncology (ASCO). In recent times as well, women have held leadership posts in most of the prominent oncology groups, including Dr. Sandra Swain, the immediate past president of ASCO, Dr. Colleen Lawton, president of the American Society for Radiation Oncology (ASTRO), Dr. Francoise Meunier, the Director General of the European Organization for Research and Treatment of Cancer (EORTC), Dr. Anne Schott, the deputy chair of the Southwest Oncology Group (SWOG), Dr. Monica Bertagnolli, the former group chair of the Cancer and Leukemia Group B (CALGB), which has now merged with the North Central Cancer Treatment Group (NCCTG) and the American College of Surgeons Oncology Group (ACOSOG) to form the Alliance, Dr. Margaret Foti, the secretary-treasurer and CEO of the American Association for Cancer Research (AACR), and Dr. Martine Piccart, the President of the European Society for Medical Oncology (ESMO). Unfortunately, India lags behind the rest of the world in terms of women in oncology leadership positions. All of the major Indian Oncology Societies are led by men, including the Indian Cooperative Oncology Network (ICON), the Indian Society for Medical and Pediatric Oncology (ISMPO), the Indian Society of Oncology (ISO), the Association of Radiation Oncologists of India (AROI), and the Indian Association of Surgical Oncology (IASO). To be fair, it would not be entirely accurate to state that there have been no women oncology leaders in India. In the recent past, a few prominent institutions, like the All India Institute of Medical Sciences (AIIMS) Rotary Cancer Center in Delhi, Adyar Cancer Institute in Chennai, and the Tata Memorial Hospital in Mumbai, have been led by women. The possible reasons for a paucity of women leaders in medicine and oncology are myriad, and include hierarchy in academia,[20] sexism in the medical environment,[21] lack of mentorship,[2223] and various other factors like the requirement to attend meetings, which are most often held after hours, and the need to put in long hours of work, which usually conflict with their child-rearing needs.[24] Male and female physicians are inevitably different. A recent article in the Times of India reported that a study by the University of Montreal has found that women are better doctors than men.[25] However, a meta-analysis revealed that patients are generally more satisfied with a male physician.[26] Women have a more patient-oriented communication style.[27] Women physicians tend to spend more time with patients, and are more likely to discuss emotional issues.[28] Male physicians are more likely to prescribe medications. Examinations like vaginal and prostate examinations are less likely be performed by the opposite gender physician.[29] There are several issues unique to women who practice oncology. Women oncology pharmacists, nurses, and physicians, who mix and administer chemotherapy medications face the risk of infertility and poor birth outcomes, including miscarriages and malformations, if they are exposed to chemotherapeutics during pregnancy.[3031] Oncologists inevitably need to break the bad news to patients. Women oncologists have the advantage in this area of breaking bad news and counseling.[27] On a personal note, what does it mean to me to be a woman oncologist in India? Gender bias and stereotyping are still very prevalent. Many patients walk into my Outpatient Department (OPD) and address me as ‘sister’. Yesterday, a patient's relative, who was a woman, walked into the head and neck OPD, where I was sitting in the consultant's chair. She looked puzzled and asked me, “When will the doctor come?” Unfortunately, she was not the one to blame; our society as a whole is to blame. Many of my female colleagues have had similar experiences. Managing a career as an academic woman oncologist and managing a family with two small children is like walking a tightrope, the so-called ‘work-life balance’. A typical day involves completing my clinical, research, and academic responsibilities, in tandem with getting the kids ready for school, picking them up from the bus stop, facilitating or often doing homework, ferrying kids for birthday parties, and after-school activities. These routine activities are sometimes compounded by the occasional parent-teacher association (PTA) meeting, the requirement to stay up nights to care for sick kids, taking calls at night from patients and residents, then going to work the next day. Academic pursuits, writing articles, doing research, going for conferences, working from home, all come at the cost of family time. This is especially true in India, where protected research time is practically non-existent and clinical responsibilities are all-consuming. Unfortunately, I have come to realize that you cannot do it all. The career, children or the marriage will inevitably have to be compromised, and often all are compromised, leading to an actual situation of a perpetual ‘work-life imbalance’. To function as a woman in oncology or medicine in general, one needs a good support system, in the form of a family that stays with you or reliable maids. However, not everybody is fortunate enough to have this. System changes are necessary in the form of creation of part-time career options, onsite childcare facilities, elimination of after-hour meetings, and other methods, to encourage and support the women faculty.[3233] Changes have already begun. Arundhati Bhattacharya, the chairperson of the State Bank of India recently introduced a system, wherein women employees can take a total of six-year sabbaticals, two years at a time, to be with their children and family. Starting about two years ago, the Tata Memorial Hospital, in Mumbai, allowed women employees to take up to two years of childcare leave, in blocks of up to 90 days at a time. The importance of women in oncology has been acknowledged by several of the major oncology groups. Last year at the annual ASCO meeting, which is arguably one of the most important oncology meetings worldwide, there was a special education session entitled, ‘Women in oncology - Challenges and Keys to Success’. AACR has a ‘Women in Cancer Research’ group, which is focused on women involved in cancer research, mentoring, career development, and recognition of scientific achievements of women researchers. The European Society for Medical Oncology (ESMO) held a ‘Women for Oncology’ forum in September 2013, as a means to bring women oncologists together, to discuss common problems and solutions, and to encourage the emergence of women leaders. Similar programs do not exist in India, and are sorely needed. In essence, the issue of women in oncology is complicated, with numerous problems as well as some triumphs. Much is being done, as illustrated by the increased representation, increasing leadership, and increasing research work being done by women in oncology. However, much more can and must be done. Hopefully, soon gender will not be an issue at all, and the idea of writing a piece on ‘women in oncology’ or for that matter ‘men in oncology’ will be a laughable one. Until then, change must originate from us, at the individual level, and we must get organized so as to effect system-level changes. Source of Support: Nil Conflict of Interest: None declared.

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