By Sara Bondell - January 31, 2023
EDITOR’S NOTE: In honor of National Women Physician Day on Feb. 3, Moffitt Cancer Center’s Women in Oncology group is highlighting the ways women physicians and researchers are contributing to the prevention and cure of cancer.
Alice Yu, MD, always knew she wanted to be a surgeon. She spent her training years deciding what surgical specialty to pursue and found herself drawn to urology. There was a large diversity of cases, and surgeons had state-of-the-art technologies at their fingertips in the operating room.
While many women residents in this field tend to go into female urology or pediatric subspecialties, Yu applied for fellowships in urologic oncology, which is a male-dominated field — both in terms of doctors and patients. She quickly realized she was part of the minority.
“When I interviewed for fellowship, some programs commented on the fact they’ve never had a female fellow. Some never even had a female resident interview before,” Yu said. “And this was only four years ago.”
Yu had very few women mentors in her training, and the lack of women mentorship in urologic oncology made her second-guess her decision throughout the application process.
“You can’t be what you can’t see,” she said. “There are very few female urologic oncologists. It’s changing, but still very few.”
Only 10.9% of all practicing urologists in the U.S. are women, according to the 2021 American Urological Association Census. Although that number has increased from 7.7% in 2014, growth of women in the field compared to growth in the number of urologists overall is actually decreasing.
Moffitt Cancer Center’s doors were open for 25 years before the first woman oncologist, Shilpa Gupta, MD, joined the Genitourinary (GU) Oncology Department. She left in 2015, and the department was once again solely made up of male physicians until Monica Chatwal, MD, joined in 2018.
Despite the lack of women in the field, Yu pursued a career in urologic oncology, and she became the first woman surgeon in Moffitt’s GU Department in 2020.
Today, Yu and Chatwal are the only women physicians in Moffitt’s GU Department, among a group of 13 doctors. Together, they are opening new opportunities for patients and offering different perspectives when it comes to care.
A Predominately Male Patient Population
Genitourinary oncology focuses on treatment of the urinary system in all genders and malignancies that affect predominantly the male reproductive organs. Many cancers that GU oncologists treat affect only men, such as prostate, testicular and penile cancers. While bladder and kidney cancers can affect everyone, they are more common in men.
For Chatwal, treating a predominately male patient population is interesting and exciting. After working as a satellite oncologist with a focus on genitourinary oncology at Moffitt at International Plaza, she became a full member of the Genitourinary Oncology Department in 2020.
"At first, I was a little hesitant how I would fit into the picture as a medical oncologist and then as a female and on the lower end of the totem pole in terms of clinical and research experience. But it was probably the best decision I have ever made."- Monica Chatwal, MD, Genitourinary Oncology Department
“I enjoy working with men and male patients and have often gravitated toward male friends more than female friends,” Chatwal said. “At first, I was a little hesitant how I would fit into the picture as a medical oncologist and then as a female and on the lower end of the totem pole in terms of clinical and research experience. But it was probably the best decision I have ever made.”
Both Chatwal and Yu agree that the majority of the time, patients don’t view them differently from a male provider.
“I have had rare incidents where patients have asked to see a male provider, mostly for prostate cancer because that’s a sensitive area, and it’s understandable,” Yu said.
However, in the reverse situation both women offer extreme benefit.
“Before we brought on Alice, there was an email circulating about a VA patient who was female and was requesting to see a female urologist, and we didn’t have anybody,” Chatwal said. “It was so nice and refreshing to bring her on because it really did open up so many more opportunities to care for patients.”
There have even been cases where male patients have asked to transfer to a woman provider because they prefer a woman’s communication style and demeanor. However, that doesn’t mean there aren’t times when the women oncologists have faced gender discrimination from patients.
An analysis of patient-derived gender-based discrimination performed at Massachusetts General Hospital and published in The American Journal of Surgery found that 100% of women and 69% of men reported experiencing gender-based discrimination from patients during their residency. On a 0-10 scale, the average frequency of the discrimination for women was 6.4 compared with 1.6 for men. Women residents were significantly more likely than male residents to say gender-based discrimination affected their quality of care, personal safety, job satisfaction and risk of burnout.
“It’s no secret that as a female resident, you’re treated differently by the nurses and staff. Your judgment and authority are questioned a lot more than a male colleague,” Yu said. “These repeated episodes of microaggression can really damage a trainee’s confidence.”
Other forms of gender-based discrimination reported by women residents included being mistaken for a nurse, being referred to by a term of endearment such as “honey,” receiving hugs or unwanted physical contact, and being called by their first name.
“Getting called by your first name isn’t a big deal at the end of the day, but when you think of all the training we have gone through, it really hits a nerve in some ways. It’s just a question of respect, and I don’t think it happens as often to our male colleagues,” Chatwal said.
“When you have a strong male attending who is very definitive, clear-cut and straightforward who gives an order, no one questions it, but if you have the same type of female with a straightforward and determined personality, then that doctor is often labeled as ‘difficult’ to work with,” Chatwal added.
Challenges Even in a Positive Environment
Thanks to the strong leadership of chair Julio Pow-Sang, MD, and positive culture within the GU Department and the institution, both Chatwal and Yu have always felt included and supported by their male colleagues.
“When I joined the department, it was so inviting and no one made it seem like there was a major difference in my qualifications or abilities compared to my male colleagues,” Chatwal said. “What you hear about regarding gender disparities in the workplace, I have luckily never encountered that.”
“I’ve only had positive experiences with my male urology colleagues at Moffitt,” Yu added. “Everyone is very supportive, and I have never felt like I was treated differently. This highlights the importance of male allies in creating an equitable culture in the workplace.”
But there are still challenges.
“I think there are inherent differences that you can’t get past when it comes to being a female in medicine,” Chatwal said. “The superwoman and imposter syndromes — maybe some of it is what we put on ourselves, but there is this undercurrent that we have ‘other’ things we also have to take care of, like the home, family, etc., and that we have to do it all.”
Chatwal led the department into uncharted territory when she started planning her maternity leave. No faculty in the department had given birth in recent memory, so administrators had to learn how to help her move forward in the process. But all were supportive.
Women Mentors Needed
For things to change, genitourinary oncology needs more women in the field and more women leaders. While the number is growing, it could take decades for the number of women to equal the number of men. Yu and Chatwal say the entire medical field needs to work harder to end gender bias.
"Culture is the main problem, and culture is hard to change. Most people do not recognize their bias toward women physicians, and talking about these issues helps promote awareness and introspection."- Alice Yu, MD, Genitourinary Oncology Department
“Culture is the main problem, and culture is hard to change,” Yu said. “Most people do not recognize their bias toward women physicians, and talking about these issues helps promote awareness and introspection.”
Women urologists around the country are working to increase their presence in the field and develop mentorship programs. The Society of Women in Urology and the Women in Urologic Oncology groups continue to grow. The American Society of Clinical Oncology also has a Women in Oncology Division for all women oncologists.
“I don’t see more females going into genitourinary medical oncology unless there is more mentorship for other fellows to see and consider it a promising field without feeling ostracized or uncomfortable about the male-dominated environment,” Chatwal said. “It’s hard when you have so many other options in medical oncology.”
In 1965, only 9.3% of medical school students were women. After the passage of Title IX in 1972, that number slowly grew, and in 2019, women comprised more than 50% of all medical school students in the U.S. for the first time. There is now a large pipeline of women students, and Yu and Chatwal say it’s important to focus on exposing them early to a variety of specialties and showing them that there are strong women mentors within traditionally male-dominated specialties.
Although change has been slow and difficult, Yu and Chatwal have hope. They are prime examples of how successful women genitourinary oncologists can be and how women can thrive in a male-dominated field. They continue to help and encourage women trainees interested in GU oncology to pursue work in the field and maybe one day close the gender gap.
“We recognize how valuable mentorship has been in our careers, and we look for opportunities to pay it forward,” Yu said.