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How Patient Advocacy Is Integral to High-Quality Oncology Care

A Conversation With Karen M. Winkfield, MD, PhD


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Karen M. Winkfield, MD, PhD

Karen M. Winkfield, MD, PhD

Karen M. Winkfield, MD, PhD, has made patient advocacy—with a specific emphasis on health equity and access to high-quality care—front and center of her oncology practice since she completed her residency at the Harvard Radiation Oncology Program in Boston, where she noticed that most of the patients at the top-tier cancer centers in the city were white. “Boston is a diverse city with a large minority population, but the patients I saw did not reflect that diversity,” said Dr. Winkfield. “It wasn’t until my second year of residency, when I rotated through Boston City Hospital and saw large numbers of African American and Hispanic patients, that I started questioning why they weren’t accessing the wonderful care at Harvard. That’s when the issue of patient advocacy and access to high-quality cancer care became a priority for me.”

Patient advocacy requires a multilevel approach to meet each patient’s needs, and it can be difficult and labor intensive.
— Karen M. Winkfield, MD, PhD

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Since then, Dr. Winkfield, Associate Professor of Radiation Oncology at Wake Forest University School of Medicine and Director of the Office of Health Equity at Wake Forest Baptist Health Comprehensive Cancer Center in Winston-Salem, North Carolina, has become a dedicated ASCO volunteer to address disparities in oncology care and help find solutions on both the local and national levels. She is Past Chair of ASCO’s Health Equity Committee and is currently Chair of ASCO’s Workforce Diversity Task Force, whose goal is to increase racial/ethnic diversity in the field of oncology as a means of reducing disparities in access to cancer care and improve patient outcomes.

In January 2019, Dr. Winkfield was recognized for her patient advocacy with the WebMD Health Heroes Award. (See “WebMD Recognizes Seven Cancer Innovators With Its Health Heroes Award” in the March 25, 2019, issue of The ASCO Post.)

Recently, The ASCO Post talked with Dr. Winkfield about her efforts to end health disparities in oncology care and how that work has impacted her career.

Meeting the Needs of Every Patient

You have made patient advocacy the central focus of your career. What did receiving the WebMD Health Heroes Award for your advocacy work in cancer care mean to you?

I was surprised that my advocacy work had reached recognition on a national level. Frequently, we think that no one is paying attention to our work. What this award showed me is that people are paying attention, and it not only makes me happy, it also stokes the fires to continue this work.

Patient advocacy requires a multilevel approach to meet each patient’s needs, and it can be difficult and labor intensive. The effort largely goes unrewarded, which is okay, because we don’t do advocacy work to benefit personally. We do it because it is critically important to patient care, and we know that patients may have difficulty self-advocating or don’t have friends or family to advocate for them.

On a micro level, when patients come to me for treatment, it is my job as their physician to make sure that they understand their cancer diagnosis, the treatments available to them, and my recommendations for treatment. And then I help coordinate their care with their medical oncologist and other members of their medical team, including their primary care physician. Usually, primary care physicians get left out of the equation, but patients with cancer often have comorbidities that need attention, so we can’t exclude them from the conversation.

About 60% of the patients coming to Wake Forest Baptist Comprehensive Cancer Center are from rural communities, which means they may have transportation concerns, so I ask all patients walking through my door how far they live from our center, and I evaluate them to see if they can receive high-quality radiation therapy and supportive care closer to their home. I feel this is an important part of good cancer care because patients are going to do better if they can remain in their local environment.

If their cancer is complex, requiring more state-of-the-art care, I’ll recommend they receive their treatment at our center. I’ll offer potential housing opportunities and introduce them to our social workers and navigators to help them with housing, transportation, and other ancillary expenditures.

As Director of the Office of Health Equity, my team and I also advocate for our patients on a more macro level, including community outreach and education. For example, we have a “Lunch and Learn” series that takes place in churches and other community settings, to talk about the importance of cancer screenings and answer questions. We also participate in health fairs in black, Hispanic, and rural communities.

A lot of our community outreach is focused on cancer prevention and the importance of exercising, smoking cessation, and maintaining a healthy weight. We also work with state legislators to educate them about the high cost of cancer care and the financial difficulties patients have when they are diagnosed with cancer.

My work on ASCO’s Strategic Plan for Increasing Racial and Ethnic Diversity in the Oncology Workforce and as 2016–2017 Chair of ASCO’s Health Equity Committee has allowed me to advocate for patient care on a national level, as well, to ensure that everyone, no matter what his or her race or financial situation, has the same opportunity to be treated and cured of cancer and to live a high-quality life throughout survivorship.

Providing Optimal Care for Underserved Populations

Please talk about the importance of an ethnically diverse oncology workforce in the care of underserved patients.

According to the U.S. Census Bureau, by 2044 the United States will become a “majority-minority country”1—where one or more racial and/or ethnic “minorities” make up a majority of the population. It’s important that we have an oncology workforce that reflects that diversity.

Unfortunately, only 2.3% of the oncology workforce currently self-identifies as black or African American and only 5.8% as Hispanic or Latino.2 And since the proportion of black/African American and Hispanic/Latino oncology fellows is persistently lower than many other fellowships in subspecialties of internal medicine,3 increasing the percentage of oncologists from these underrepresented backgrounds will not occur overnight.

In my field, there are only a handful of black radiation oncologists working in academia. You can imagine the benefit of having at least one black physician on staff at an institution to confer with colleagues when cultural differences impact patient care, as well as to help oncologists and trainees recognize their own implicit biases when treating patients from traditionally underserved -communities.

Data show that minority patients are more comfortable when they are cared for by providers who look like them or have similar cultural backgrounds. It’s important to understand that workforce diversity is connected to health equity and quality of care and should be used as a metric to measure quality of care in practices and training programs.

Improving Workforce Diversity

You were instrumental in developing ASCO’s Strategic Plan for Increasing Racial and Ethnic Diversity in the Oncology Workforce.4 Have there been results from this effort so far, for example, in expanded mentoring opportunities for early medical trainees, residents, and fellows?

This strategic plan has three primary goals: first, to establish a longitudinal pathway for increasing workforce diversity; second, to enhance ASCO leadership diversity; and third, to integrate a focus on diversity across ASCO programs and policies. ASCO understood that in order to improve quality cancer care in the United States, we would have to have an oncology workforce from diverse backgrounds. With this strategic plan, ASCO put forward a detailed plan to get us to that goal.

Usually, primary care physicians get left out of the equation, but patients with cancer often have comorbidities that need attention, so we can’t exclude them from the conversation.
— Karen M. Winkfield, MD, PhD

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To develop the plan, we brought together stakeholders and leaders from around the country to have a conversation about what ASCO could do to improve workforce diversity. One of the issues that was brought up was that ASCO’s leadership needed to be more diverse. With that in mind, I was pleased that in December 2018, ASCO members elected a black woman, Lori J. Pierce, MD, FASTRO, -FASCO [Professor and Vice Provost for Academic and Faculty Affairs at the University of Michigan], as its President for the term beginning in June 2020. We are also strategically implementing other task force recommendations to ensure greater diversity among ASCO’s different working groups and -committees.

The strategic plan also acts as a guide to ASCO’s overall workforce diversity efforts and builds on existing programs, including ASCO’s Diversity in Oncology Initiative, which offers award opportunities for medical students and residents who are from backgrounds that are underrepresented in oncology. They include the Medical Student Rotation for Underrepresented Populations, which supports an oncology rotation and pairs medical students with clinical oncologists who provide academic and career guidance, and the Resident Travel Award for Underrepresented Populations, which provides financial support to medical students traveling to the ASCO Annual Meeting.

ASCO has also developed a Diversity Mentoring Program (www.asco.org/practice-guidelines/cancer-care-initiatives/diversity-oncology-initiative/diversity-mentoring-program) for underrepresented medical students and residents who wish to pursue a career in oncology. The challenge is that not enough minorities are enrolling and graduating from medical school, and fewer still are pursuing careers in oncology. Also, many students of color are going to medical schools that specialize in primary care and internal medicine and may not have oncology programs as part of their curriculum, so they are not being exposed early on to the field of oncology and may not even know it is a career option.

We need to do a better job of finding ways to expose these individuals to oncology as a potential career and then ensure they get the experience they need to be competitive. ASCO’s Diversity in Oncology Initiative will definitely help encourage more underrepresented medical students to pursue a career in oncology.

The Diversity in Oncology Initiative was launched in 2008, so we are gathering data to see how effective these programs have been and how they might be improved. But there is no question: we have to do a better job of getting the word out about these programs and even go to the medical schools with a high proportion of underrepresented students to attract more of them to the field of oncology.

Making Career Sacrifices

In your acceptance speech at the WebMD Health Heroes Award ceremony, you said that you were warned early in your career that your focus on health disparities and patient advocacy would impact your career and restrict your academic promotion and that it has. How has your career been impeded by your patient advocacy, and what advice do you have for young oncologists entering the field?

There has been much more emphasis on patient satisfaction over the past few years, and physicians and cancer centers are paying greater attention to how well they score on patient satisfaction surveys. My patients tend to love me, and they appreciate the energy I put into making sure they have as good an experience as possible. But no one is going to pay me more money because my patients love me. No one is going to make me a professor because my patients love me.

The reality of being in an academic setting is that the currency of promotion is your ability to write research papers and get grant funding. Patient advocacy is labor intensive and often leaves little time to pursue academic activities, but it is critical to ensure equitable care and worth the sacrifice.

Patient advocacy is labor intensive and often leaves little time to pursue academic activities, but it is critical to ensure equitable care and worth the sacrifice.
— Karen M. Winkfield, MD, PhD

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In terms of advice to early-career oncologists, residents, and medical students, whenever I’m asked to give a talk at grand rounds or as a visiting professor, I use that opportunity to talk about health disparities in cancer care and the need to support young people interested in pursuing a career in cancer health equity research to advance the field. Things are improving. There are more opportunities, but we need to move away from describing cancer disparities and instead focus on best practices and implementation of solutions.

I would also advise medical students and residents interested in oncology as a career to find a good mentor who can offer guidance and serve as a professional resource. Finding a suitable mentor is not only critical to the success of a mentee’s career—it can also provide greater professional fulfillment and less burnout for the mentor. I am grateful for the opportunity to give back and support the next generation of diverse oncologists. 

DISCLOSURE: Dr. Winkfield has served in a consulting or advisory role for Novartis.

REFERENCES

1. U.S. Census Bureau: New census bureau report analyzes U.S. population projections. Available at www.census.gov/newsroom/press-releases/2015/cb15-tps16.html. Accessed August 20, 2019.

2. American Society of Clinical Oncology: Facts & figures: Diversity in oncology. Available at www.asco.org/practice-guidelines/cancer-care-initiatives/diversity-oncology-initiative/facts-figures-diversity. Accessed August 20, 2019.

3. Brotherton SE, Etzel SI: Graduate medical education, 2015-2016. JAMA 316:2291-2310, 2016.

4. Winkfield KM, Flowers CR, Patel JD: American Society of Clinical Oncology strategic plan for increasing racial and ethnic diversity in the oncology workforce. J Clin Oncol 35:2576-2579, 2017.


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