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Pathways and Barriers to Careers in Academic Clinical Cancer Prevention: a Qualitative Study

Pathways and Barriers to Careers in Academic Clinical Cancer Prevention: a Qualitative Study National surveys document steady declines over time in interest in academic medicine and cancer prevention careers (Am J Prev Med 54(3):444–8, 2018). Through interviews with 16 academic cancer prevention physicians at one comprehensive cancer center, this study identifies motivations and barriers to physician careers in academic cancer prevention and proposes recom- mendations to increase recruitment. Participants reported that cancer prevention was vague to them early in training, impairing career exploration. Further, without role models and opportunities to learn about cancer prevention, many were ignorant of career options. Many had incorrect views about cancer prevention practice being mainly within the scope of primary care physicians, and some reported colleagues viewing the rigor of cancer prevention skeptically. However, all described notable experiences—in classes, with mentors, on research projects, or from encounters with patients, motivating them to pursue academic clinical cancer prevention regardless of challenges. Clearly, a lack of both information and guidance towards careers in clinical cancer preven- tion has been critical barriers to robust recruitment of physicians to the field and must be addressed urgently. Helping physicians earlier during training to both understand the value of prevention and cultivate their interests in it, particularly for clinical cancer prevention, would have widespread benefits. . . . Keywords Occupational choices Training Professional development Medicine Introduction intended to focus on cancer prevention [2], suggesting that among physicians choosing careers in cancer, the number Advances against cancer, particularly in preventing cancers, who will feature cancer prevention in their careers will be can only result from translating research discoveries into prac- small. Further, current recruitment rates to oncology are lower tice in the clinic and community, often led by physicians. than retirement rates among cancer prevention physicians in Despite the critical role that physicians play in furthering can- the USA, indicating that the number of physicians in cancer cer prevention, interest in this field has declined [1]. A nation- prevention will continue to shrink unless deliberate efforts are al survey in 2014 found that < 10% of oncology fellows made [1]. Studies reporting low recruitment rates generally cite as contributing factors, a lack of clarity about pathways into ca- Melissa Y. Kok and Janelle C. Chavez are co-first authors. reers in clinical cancer prevention [2]. Lack of clarity could relate to the field of cancer prevention being broad, * Shine Chang encompassing many disciplines and topics and, critically for Shinechang@mdanderson.org this issue, being without universal definition. No widely rec- Baylor College of Medicine, Houston, TX, USA ognized structured training exists to prepare medical students 2 and residents for careers in this field, a problem compounded Stanford University School of Medicine, Stanford, CA, USA by difficulties finding knowledgeable mentors [3]. While bar- Otolaryngology-Head and Neck Surgery, The University of Kansas riers have been identified using quantitative surveys [2, 4], no Medical Center, Kansas City, KS, USA qualitative studies have focused on describing barriers affect- Department of Psychiatry and Behavioral Health, Virginia Tech ing physician careers in clinical cancer prevention. Carilion School of Medicine, Roanoke, VA, USA Conducting such studies can help surface and define unrecog- Department of Epidemiology, Division of Cancer Prevention and nized barriers for further quantitative evaluation with larger Population Sciences, The University of Texas MD Anderson Cancer representative samples. Center, Houston, TX, USA 1070 J Canc Educ (2022) 37:1069–1075 To provide such insight about career challenges and moti- This study was conducted using a constructivist grounded vations of physicians in academic clinical cancer prevention theory approach, described by Watling et al. [5]. Qualitative and to identify opportunities to improve recruitment of med- data were obtained during structured interviews with partici- ical students and early career physicians into the field, we pants. Recorded interviews were coded and analyzed using mapped career pathways of physicians involved in academic specialized software, and themes were grouped to provide cancer prevention at The University of Texas MD Anderson detailed insight into barriers and motivations for pathways to Cancer Center. Our goal was to identify barriers encountered careers in cancer prevention. Participant recommendations for and experiences that motivated them when considering and addressing challenges to cancer prevention career paths were pursuing careers in cancer prevention. We also gathered rec- also coded. ommendations to improve recruitment and define better path- Participant curriculum vitae were obtained before inter- ways into clinical cancer prevention. views, so interviewers could familiarize themselves with the participants’ career achievements and academic record. Interviewers used an interview guide developed by the research Methods team (SC, TT-D, OA) based on ideas drawn from studies of medical education and careers in cancer prevention (Table 1). This project was based at The University of Texas MD Interviews ranged from 15 to 40 min and were audio-recorded Anderson Cancer Center, a large NCI-designated comprehen- with handwritten notes taken. Interviews were conducted by sive cancer center within the Texas Medical Center, Houston, MK, JC, OA, and TT-D between July 2016 and October Texas, with over 1700 clinical and nonclinical faculty mem- 2017. Data collection ended after all eligible faculty at MD bers and a workforce of over 21,000 individuals. We identi- Anderson had been contacted and willing participants had been fied participants through snowball recruitment starting with interviewed by the study closing date, October 31, 2017. faculty within the five departments of the Division of Cancer Prevention and Population Sciences (DCPPS): behavioral sci- Data Analysis ence, clinical cancer prevention, epidemiology, health dispar- ities research, and health services research. We identified oth- Recorded interviews and notes were reviewed by MK, JC, and er faculty at MD Anderson conducting research in cancer PQ for themes via the qualitative data management software, prevention who had served as mentors to trainees in the Atlas.ti (v7, 2015, Berlin, Germany). The coding template Cancer Prevention Research Training Program (CPRTP). was developed by MK, JC, and PQ to address the study pur- After receiving approval from the Institutional Review pose: to map career pathways of physicians in cancer preven- Board of MD Anderson (IRB #2016-0397), we contacted pro- tion, to identify factors that motivated pursuit of cancer pre- spective participants by email and follow-up calls. Participants vention careers, barriers faced, and recommendations to ad- were included based on the following criteria: dress career challenges (Tables 2). Selected interviews were independently re-coded by different investigators to ensure & Has a medical degree (MD, MBBS, etc.) complete capture of themes and ideas from each participant & Holds a faculty position at MD Anderson and alignment of coding by investigators. & Is involved in cancer prevention research, defined as ap- pointment in DCPPS, joint appointment in DCPPS, or mentorship of CPRTP trainees (e.g., bench research, Results population-based research/interventions, clinical activities) Of 37 faculties eligible to participate, 21 declined participa- tion, 18 were interviewed, but two withdrew, leaving data Individuals were excluded according to the following from 16 participants for analysis. Of these 16 participants, criteria: eight were women; five were self-designated as research fac- ulty and the remaining 11 as clinical faculty although all par- & Not faculty at MD Anderson or retired ticipated in research activities. Two participants were assistant & Did not complete medical training professors, six were associate professors, and eight were full & Not currently involved in cancer prevention activities professors. (self-reported) Impact of a Vaguely Defined Field (i.e., Cancer The recruitment email contained a link to a RedCap data Prevention) collection form used to confirm eligibility, obtain electronic informed consent, and request times for scheduling in-person Given that the multidisciplinary, collaborative, and broadly interviews. diverse activities comprising cancer prevention make it J Canc Educ (2022) 37:1069–1075 1071 Table 1 Interview guide Table 2 Qualitative themes data codebook A. Career path decisions 1. Career path decisions—academic medicine/cancer prevention 1. At what stage of your training did you first think about going into Codes: cancer prevention as specialty? � By design or by accident (was a conscious decision actually made) 2. What made you consider this path? � When/at what stage 3. During your training, did you ever participate in any formal or � Strong influencing factor(s), event(s), or individual(s) that inspired the informal educational activity related to cancer prevention or academic choice medicine as a specialty choice? If any, what kind? � Draw/motivation to specialize in cancer prevention/academic medi- 4. Did you have a mentor during your training (medical school, graduate cine school, or residency)? 2. Pathway to academic medicine/cancer prevention 5. Do you attribute your interest in academic medicine and cancer Codes: prevention (wholly or in part) to your mentor? � How was your career direction determined? 6. Besides a mentor, were there other influential people (such as role � Gaps in information/resources encountered models) who informed your decision to go into academic medicine/cancer prevention? � Opportunity cost of choosing cancer prevention (what options did you choose to ignore) B. Pathway to academic medicine/cancer prevention 3. Perceived barriers to recruiting students and residents into academic 7. What other career choices were you considering? medicine/cancer prevention 8. What made you choose one over the other? Codes: 9. Looking back, would you have made different decisions knowing � Mentorship what you know now? � Concerns (financial, professional, family time, prestige) C. Perceived barriers � Misinformation 10. What were your major concerns when considering cancer prevention? � Hidden curriculum 11. Were there any difficulties understanding the responsibilities that a 4. Recommendations profession in cancer prevention research entitled? If any, how did you overcome those difficulties? 12. What were some of the barriers to pursuing a career in academic an impediment to applying cancer prevention to clinical care medicine? in their career paths. 13. Overall, would you say that you are satisfied with your choice to In addition to low awareness and knowledge of clinical pursue academic medicine/cancer prevention? Please tell us why or cancer prevention, participants also described the absence of why not visibly structured career paths and career resources as chal- D. Recommendations lenges to finding and successfully navigating careers in the 14. What could medical schools and/or residency programs do to in- field. They contrasted this deficiency with the general knowl- crease interest in cancer prevention as a clinical or academic career among oncologists? (Open Box) edge of clear paths that existed for other professionals into 15. Do you see merit in any of the initiatives below: cancer prevention (e.g., NCI-funded cancer prevention post- � Sponsorship of mentored postdoctoral fellowships in cancer doctoral research training programs) and into public health. prevention This deficit, they commented, was especially apparent at early � Development of a toolkit for training program directors career stages when many participants were exploring their � Provision of more educational sessions in cancer prevention (include interests in cancer prevention. One participant observed that natural products, behavioral interventions such as weight loss, even within oncology training, strategies for incorporating a tobacco cessation) focus on cancer prevention were absent. Related to insuffi- � Special informational sessions for fellows on what a career in cancer cient career resources, participants reported knowing few role prevention might look like models from the field and having difficulty finding knowl- 16. Other comments edgeable mentors in cancer prevention for career and research guidance. Participants described challenges in finding men- tors with particular expertise in population health, medical practice, and cancer prevention when they were beginning to challenging to clearly define the field, participants reported pursue their interests in the field. lack of clarity about cancer prevention as a barrier to knowing about careers in clinical cancer prevention (Table 3). In par- ticular, several participants noted that they could not remem- Impact of Misunderstandings about Cancer ber receiving education during medical school or residency Prevention about cancer prevention, whether due to lapses in memory or low emphasis placed upon cancer prevention. Many also Not only was there not enough information about cancer pre- cited lack of knowledge about cancer prevention practices as vention, but in some cases, the information was inaccurate. 1072 J Canc Educ (2022) 37:1069–1075 Table 3 Themes and representative quotations from interviews with physician faculty in clinical cancer prevention Themes and subthemes Representative quotes Vagueness of field impeded finding career path into cancer prevention for physicians Few role models for careers in clinical cancer prevention “It was hard, when I finished my fellowship and joined the faculty, finding mentorship in this area was hard for me because I was interested in working with big population databases to see sort of what was happening more at the national level. And there were not really many people at [institution] that were doing that.” Lack of widely known career resources and absence of structured “Particularly for a clinician, that’s what I would say. It was more established training opportunities to guide entry into clinical cancer prevention for a population scientist or a behavioral scientist, but for an applied clinical careers cancer prevention, [it] did not really exist at the beginning of this in any mature form.” “Maybe I’ve just forgotten it all. But I do not think we really ever had that much training in cancer prevention type interventions or counseling. It’s much more focused on disease and how to treat disease.” Uncertainty about how to connect cancer prevention “At that time, I really did not know anything about cancer prevention other to clinical career interests than the cervix part of it, but I never thought of that as a field or a specialty. You know as I said even training here it did not even seem to be part of what we did.” “We know about cancer prevention, but you do not know that it’sa career...Especially when you are so highly specialized, in such highly specialized training, that you could sort of take all of that back to kind of a public health perspective, a cancer prevention perspective.” Misinformation about cancer prevention Misattribution of responsibility of cancer prevention “The people who are most knowledgeable about cancer prevention are your to other types of physicians primary care doctors. I did not think I wanted to be a primary care doctor so that wasn’t anywhere on my radar.” “I think one of the problems as specialists is we think that’s all the primary care provider’s area and that it does not really need us or we are not part of it.” Discouraging negative comments about the field of “My chair of the department there was like ‘I trained you to treat cancer, and cancer prevention and about pursuing cancer prevention careers you are trying to prevent what I told you to treat…’ ‘Oh, you aretryingto put yourself out of business.’" “One of the barriers, is that the cancer prevention field has collectively seemed to have been too caught up and overlapped too much with the natural product research and that really trying to distance the cancer prevention field from the complementary alternative medicine field would probably help increase the external rigor that the field is perceived as.” Motivations and pathways to clinical cancer prevention Unintended but inspiring exposure to cancer prevention careers and "So probably it would be I was already on faculty and kind of expanding research research and had picked up a few projects that had some cancer prevention efforts. So it was probably ten years into my career on faculty." Motivated by patient experiences “It was just my clinical experience, and sort of like the frustration of seeing patients with cancer, with advanced stage disease that could not be cured that made me kind of want to look into how we can catch it early and how can we prevent it.” Educational experiences that motivated active steps “I then started attending some educational programs that [institution] was putting on Cancer Prevention and found that interesting. Tried to apply that in my practice when I was in private practice in the early years of my family medicine career. That was kind of the start of it all.” “Before I chose the PhD program at [institution] I have a long term goal to control cancer either by prevention or by blocking metastasis so both way, because in these two steps if we can do something good you can significantly decrease the mortality associated with cancer.” Some participants noted that they initially viewed cancer prevention as falling mainly within the purview of a primary J Canc Educ (2022) 37:1069–1075 1073 care physician’s responsibility and did not understand how clinical cancer prevention workforce. Unfortunately, recruitment cancer prevention could align with their own career interests has been affected by multiple barriers and only some facilitators. in oncology. Additionally, participants reported colleagues Here, in-depth interviews with physicians at a major academic having negative comments and perceptions about the field of health center dedicated to cancer care and research provided rich cancer prevention, which may have reinforced misunderstand- insights about careers in cancer prevention beyond what has been ings. Such views, some reported, may have perpetuated the obtained from quantitative surveys. Novel observations include misconception that cancer prevention as a field lacked scien- the multiple adverse impacts of misconceptions about cancer tific rigor. Indeed, one participant was told by a department prevention. Participants reported negative comments from influ- chair that prevention was in opposition to training in ential colleagues and mentors that may have damaged working oncology. relationships or hindered pursuit of cancer prevention career. However, participants also reported experiences that motivated Motivations and Pathways to Pursuing Cancer them to pursue such careers, including patient care experiences Prevention that deepened and made more personal the drive to provide better care through cancer prevention. In addition to barriers, participants described factors that facil- Some barriers that we report were previously reported but in itated their career pathways into cancer prevention. Many re- less detail. For example, a task force to review workforce issues ported becoming involved in cancer prevention unintentionally in cancer prevention research suggested that trainees do not real- while engaged in research projects related to cancer prevention, ize that cancer prevention encompasses many disciplines and which led them to actively pursue their interests in the field. For interests [6], supporting the idea that there is confusion about example, some joined research projects with a cancer preven- what is within the field of cancer prevention, as we found tion aspect that helped them discover how this field aligned (Table 1). In particular, we found that clinical cancer prevention with their interests. Others had the fortunate opportunity to was often initially viewed as somebody else’sjob,and some work with research mentors in cancer prevention, who provided participants reported negative comments and perspectives from feedback and guidance for career exploration in the field. colleagues intended to discourage pursuit of these careers. Other A recurring theme among participants was a desire to make themes our work echoed from earlier surveys of oncology fel- a bigger difference in the lives of their cancer patients. Many lows were that both the lack of clarity about careers in cancer physicians from multiple specialties expressed frustration prevention and the lack of clinical mentors in cancer prevention about “missed opportunities” for cancer prevention as they posed barriers to incorporating cancer prevention in their careers saw the burden of advanced stage, incurable cancer diagnoses [2]. Specifically, some of our participants initially had difficulty on their patients. This frustration, they reported to us, led them connecting personal interests in cancer prevention with their de- to turn towards cancer prevention activities, which gave them sired careers. Even after establishing interest in cancer preven- a greater sense of fulfillment and possibly more agency to tion, some still had difficulty finding suitable mentors and getting intervene with their patients. informed, knowledgeable, and supportive guidance about inte- After committing to career interests in cancer prevention, grating cancer prevention successfully into their careers. participants took active steps to become more involved in the In addition to barriers to careers in cancer prevention, par- field. Participants pursued educational opportunities, research ticipants also described opportunities that stimulated interest projects, and mentorship experiences to learn more about can- and facilitated exploration of such careers. Most participants cer prevention or to gain expertise in areas relevant to their had an event or perspective that motivated them to seek more interests. Learning through professional development courses opportunities in academic cancer prevention. Many cited feel- about cancer prevention helped some see how such activities ing frustrated by how little they could do for their cancer could be integrated in their work. Others pursued positions patients; but subsequently, through pursuit of a career in clin- specifically in cancer prevention that allowed more time to ical cancer prevention, several expressed having great fulfill- do cancer prevention research or be involved in patient care ment through cancer prevention than in cancer treatment. directly focused on cancer prevention. Whether participants Such sentiment, we speculate, reflected physicians’ deep em- changed positions or not, they all began to include cancer pathy for the suffering of cancer patients—unnecessary if prevention in their research and clinical practice after discov- greater advances in preventing cancer could be achieved. ering the value of the field and their interests in it. Appealing both to such strong emotions—frustration and empathy—and to provider dedication to minimizing patients’ suffering could be ways to encourage interest in and pursuit of Discussion careers in clinical cancer prevention. Ideally this appeal would happen earlier in training, before accumulated frustration from Advancing the current progress in cancer prevention contributed missed opportunities for prevention stimulates a late shift to a career in cancer prevention. by physicians requires greater physician recruitment to the 1074 J Canc Educ (2022) 37:1069–1075 Another participant suggestion to stimulate interest was recruitment into careers in clinical cancer prevention is past involvement in cancer prevention research, whether as stu- due. Steps can be taken in medical education, by funding agen- dents or as physicians, because such experiences foster incor- cies, and by national professional organizations to increase the poration of research into physician careers [7]. Thus, the value visibility of the field, to reduce uncertainty and misinformation of research experiences in cancer prevention for physicians- about physician careers in academic cancer prevention, and to in-training is critical for learning how to conduct research in address career barriers. For example, early and repeated career general, gaining direct experience conducting cancer preven- exposure in medical school and residency curricula by improv- tion research, and expanding their knowledge of research ing or emphasizing cancer prevention courses and curricular topics in the field. These experiences may provide a space content could increase the visibility and importance placed on for physicians to solidify how their interests in cancer preven- the field. This could simultaneously dispel misperceptions tion apply to both research and clinical settings while building about clinical cancer prevention practice and offer strategies self-efficacy in cancer prevention research careers. Moreover, for weaving cancer prevention into clinical practice. Exposure by working with scientists leading such projects, physicians- can also occur through cancer prevention research, ideally in-training have direct access to role models and mentors in funded for medical students and guided by seasoned cancer the field. prevention scientists, both physicians and non-physicians As with all studies, ours has limitations. First, participants working in multidisciplinary teams. These experiences, wheth- were selected from physicians holding faculty positions at a er short-term summer experiences or fellowships, can deepen single institution within a division dedicated to cancer preven- future physicians’ understanding of how to translate clinical tion, including a department of clinical cancer prevention, and practice needs in cancer prevention into systematic research who were required by inclusion criteria to be involved in can- that they can conduct and, someday, implement in the clinic cer prevention activities. Therefore, individuals who had in- and community for impact against cancer. For medical stu- terest in cancer prevention but either never pursued those in- dents entering clinical rotations, opportunities to rotate with terests were formerly engaged in cancer prevention or had left physicians combining cancer prevention with clinical practice the institution before our study began were not included. Also, may have indelible impact upon their career trajectories into physicians pursuing careers in clinical cancer prevention else- the field. Such early career exposure is critical for recruitment where may encounter different barriers and facilitators. Thus, because students and residents need to know about cancer we may not have captured in this initial effort all barriers to prevention first, before they can consider clinical cancer pre- careers in academic clinical cancer prevention. As well, the vention as a career option. To sustain emphasis on the impor- physicians at the study institution may have attributes that tance of cancer prevention during early career training, more make them resilient and persistent in their careers, producing questions about cancer prevention and control could be includ- ed by the Federation of State Medical Boards and National a “healthy worker” bias, in which more workers who are “healthy” remain in the workforce and available for study Board of Medical Examiners in licensing exams, as well as inclusion. Regardless of the potential for such an effect, phy- by the National Board of Osteopathic Medical Examiners in sicians we interviewed reported career barriers nonetheless exams for those for in osteopathic medicine, thus requiring and some were reported elsewhere [2, 6], suggesting that the greater continuous attention while preparing for licensing. experiences reported in our study were not uncommon and National professional organizations, such as the American still have yet to be addressed successfully. A strength of our Association for Cancer Education (AACE), the American study was the diversity of participants by faculty rank and Association for Cancer Research (AACR), the American gender, such that the analysis of their interviews provided a Society of Preventive Oncology (ASPO), and the American rich and broad scope of career experiences in academic clin- Society of Clinical Oncology (ASCO), are ideally positioned ical cancer prevention. However, the results from this qualita- to facilitate mentorship and increase visibility of role models tive study do not represent the experiences of all physicians in in cancer prevention. They could provide lists of members academic cancer prevention. Additional work needs to assess involved in cancer prevention research and available to men- how similar issues faced by those early in their careers today tor those exploring cancer prevention careers. Membership are to those experienced in early career by the senior faculty websites and meeting flyers about the different approaches participants in our study as our study included only two indi- and topics addressed in clinical cancer prevention could in- viduals at the Assistant Professor rank. Nonetheless, these form and attract individuals with interest in those areas. These findings can support and guide further investigation using organizations can also create position statements that chal- large groups of probability-sampled physicians from which lenge the hidden curriculum messages about clinical cancer conclusions can be generalized. prevention being a “lesser” pursuit than oncology and cancer Given that we reported deeper insight into themes related to treatment. Such messages will directly challenge misunder- pursuing clinical cancer prevention careers than reported pre- standings and misperceptions about cancer prevention while viously [2, 4, 6], the time to organize activities to improve making clear its valuable contribution to clinical and J Canc Educ (2022) 37:1069–1075 1075 Code Availability Atlas.ti, a software package designed for coding qual- community practice, including primary prevention and early itative text, interviews, etc., was used to code the data for this project. detection of cancer. These arguments must be made directly both to established colleagues and to those in training. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adap- In sum, by understanding the career paths of successful tation, distribution and reproduction in any medium or format, as long as physicians in the field, we have learned what events and ex- you give appropriate credit to the original author(s) and the source, pro- periences hindered and helped propel them into academic vide a link to the Creative Commons licence, and indicate if changes were cancer prevention careers. Going forward with other studies made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a that report the prevalence of career barriers and facilitators, credit line to the material. If material is not included in the article's this information can guide efforts to help others advance their Creative Commons licence and your intended use is not permitted by career paths more directly and efficiently into the field, ideally statutory regulation or exceeds the permitted use, you will need to obtain earlier in their careers and by purposeful choice, not by acci- permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. dent, in isolation, or only after many years of effort. Only with such measures in place to improve recruitment into clinical cancer prevention will the cancer prevention workforce be able to achieve its full potential to lower the burden of pre- ventable cancers on the public health. Indeed, prevention mes- References sages from physicians to encourage everyone to continue 1. Moore MA, Goodman RA (2018) Physician training in cancer pre- practicing behaviors that reduce cancer risk are important for vention and control: a population health imperative. Am J Prev Med the public health, including during times of difficulty, an im- 54(3):444–448 portant lesson from the recent COVID-19 pandemic. 2. Fabian CJ, Meyskens FL Jr, Bajorin DF, George TJ Jr, Jeter JM, Khan S, Tyne CA, William WN Jr (2016) Barriers to a career focus Acknowledgments The authors would like to thank Tania Torres- in cancer prevention: a report and initial recommendations from the Delgado who made instrumental contributions at the initiation of this American Society of Clinical Oncology Cancer Prevention project. We would also like to thank Lotis Ann Batan for the assistance Workforce Pipeline Work Group. J Clin Oncol Off J Am Soc Clin with formatting of this manuscript. Oncol 34(2):186–193 3. Jackson VA, Palepu A, Szalacha L, Caswell C, Carr PL, Inui T Funding The project and several authors (MYK, JCC, PQ, SC) were (2003) "Having the right chemistry": a qualitative study of mentoring supported in part by an award from the National Cancer Institute (R25 in academic medicine. Acad Med 78(3):328–334 CA056452, PI: Chang). 4. Ganz PA, Kwan L, Somerfield MR, Alberts D, Garber JE, Offit K, Lippman SM (2006) The role of prevention in oncology practice: results from a 2004 survey of American Society of Clinical Data Availability Data from coded interviews can be made available up- Oncology members. J Clin Oncol Off J Am Soc Clin Oncol on written request to and approval by the corresponding author and co- 24(18):2948–2957 authors. 5. Watling CJ, Lingard L (2012) Grounded theory in medical education research: AMEE guide no. 70. Med Teach 34(10):850–861 Compliance with Ethical Standards 6. Newhauser WD, Scheurer ME, Faupel-Badger JM, Clague J, Weitzel J, Woods KV (2012) The future workforce in cancer pre- Conflict of Interest The authors declare that they have no conflicts of vention: advancing discovery, research, and technology. J Cancer interest. Educ 27(2 Suppl):S128–S135 7. Jeffe DB, Andriole DA (2018) Prevalence and predictors of US Ethics Approval IRB #2016-0397. medical graduates' federal F32, mentored-K, and R01 awards: a na- tional cohort study. J Investig Med 66(2):340–350. https://doi.org/ 10.1136/jim-2017-000515 Consent to Participate Electronic informed consent. Consent for Publication All authors provide consent for this manuscript Publisher’sNote Springer Nature remains neutral with regard to jurisdic- tional claims in published maps and institutional affiliations. to be published in this journal. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of Cancer Education Springer Journals

Pathways and Barriers to Careers in Academic Clinical Cancer Prevention: a Qualitative Study

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Springer Journals
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Copyright © The Author(s) 2020
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0885-8195
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1543-0154
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10.1007/s13187-020-01921-z
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Abstract

National surveys document steady declines over time in interest in academic medicine and cancer prevention careers (Am J Prev Med 54(3):444–8, 2018). Through interviews with 16 academic cancer prevention physicians at one comprehensive cancer center, this study identifies motivations and barriers to physician careers in academic cancer prevention and proposes recom- mendations to increase recruitment. Participants reported that cancer prevention was vague to them early in training, impairing career exploration. Further, without role models and opportunities to learn about cancer prevention, many were ignorant of career options. Many had incorrect views about cancer prevention practice being mainly within the scope of primary care physicians, and some reported colleagues viewing the rigor of cancer prevention skeptically. However, all described notable experiences—in classes, with mentors, on research projects, or from encounters with patients, motivating them to pursue academic clinical cancer prevention regardless of challenges. Clearly, a lack of both information and guidance towards careers in clinical cancer preven- tion has been critical barriers to robust recruitment of physicians to the field and must be addressed urgently. Helping physicians earlier during training to both understand the value of prevention and cultivate their interests in it, particularly for clinical cancer prevention, would have widespread benefits. . . . Keywords Occupational choices Training Professional development Medicine Introduction intended to focus on cancer prevention [2], suggesting that among physicians choosing careers in cancer, the number Advances against cancer, particularly in preventing cancers, who will feature cancer prevention in their careers will be can only result from translating research discoveries into prac- small. Further, current recruitment rates to oncology are lower tice in the clinic and community, often led by physicians. than retirement rates among cancer prevention physicians in Despite the critical role that physicians play in furthering can- the USA, indicating that the number of physicians in cancer cer prevention, interest in this field has declined [1]. A nation- prevention will continue to shrink unless deliberate efforts are al survey in 2014 found that < 10% of oncology fellows made [1]. Studies reporting low recruitment rates generally cite as contributing factors, a lack of clarity about pathways into ca- Melissa Y. Kok and Janelle C. Chavez are co-first authors. reers in clinical cancer prevention [2]. Lack of clarity could relate to the field of cancer prevention being broad, * Shine Chang encompassing many disciplines and topics and, critically for Shinechang@mdanderson.org this issue, being without universal definition. No widely rec- Baylor College of Medicine, Houston, TX, USA ognized structured training exists to prepare medical students 2 and residents for careers in this field, a problem compounded Stanford University School of Medicine, Stanford, CA, USA by difficulties finding knowledgeable mentors [3]. While bar- Otolaryngology-Head and Neck Surgery, The University of Kansas riers have been identified using quantitative surveys [2, 4], no Medical Center, Kansas City, KS, USA qualitative studies have focused on describing barriers affect- Department of Psychiatry and Behavioral Health, Virginia Tech ing physician careers in clinical cancer prevention. Carilion School of Medicine, Roanoke, VA, USA Conducting such studies can help surface and define unrecog- Department of Epidemiology, Division of Cancer Prevention and nized barriers for further quantitative evaluation with larger Population Sciences, The University of Texas MD Anderson Cancer representative samples. Center, Houston, TX, USA 1070 J Canc Educ (2022) 37:1069–1075 To provide such insight about career challenges and moti- This study was conducted using a constructivist grounded vations of physicians in academic clinical cancer prevention theory approach, described by Watling et al. [5]. Qualitative and to identify opportunities to improve recruitment of med- data were obtained during structured interviews with partici- ical students and early career physicians into the field, we pants. Recorded interviews were coded and analyzed using mapped career pathways of physicians involved in academic specialized software, and themes were grouped to provide cancer prevention at The University of Texas MD Anderson detailed insight into barriers and motivations for pathways to Cancer Center. Our goal was to identify barriers encountered careers in cancer prevention. Participant recommendations for and experiences that motivated them when considering and addressing challenges to cancer prevention career paths were pursuing careers in cancer prevention. We also gathered rec- also coded. ommendations to improve recruitment and define better path- Participant curriculum vitae were obtained before inter- ways into clinical cancer prevention. views, so interviewers could familiarize themselves with the participants’ career achievements and academic record. Interviewers used an interview guide developed by the research Methods team (SC, TT-D, OA) based on ideas drawn from studies of medical education and careers in cancer prevention (Table 1). This project was based at The University of Texas MD Interviews ranged from 15 to 40 min and were audio-recorded Anderson Cancer Center, a large NCI-designated comprehen- with handwritten notes taken. Interviews were conducted by sive cancer center within the Texas Medical Center, Houston, MK, JC, OA, and TT-D between July 2016 and October Texas, with over 1700 clinical and nonclinical faculty mem- 2017. Data collection ended after all eligible faculty at MD bers and a workforce of over 21,000 individuals. We identi- Anderson had been contacted and willing participants had been fied participants through snowball recruitment starting with interviewed by the study closing date, October 31, 2017. faculty within the five departments of the Division of Cancer Prevention and Population Sciences (DCPPS): behavioral sci- Data Analysis ence, clinical cancer prevention, epidemiology, health dispar- ities research, and health services research. We identified oth- Recorded interviews and notes were reviewed by MK, JC, and er faculty at MD Anderson conducting research in cancer PQ for themes via the qualitative data management software, prevention who had served as mentors to trainees in the Atlas.ti (v7, 2015, Berlin, Germany). The coding template Cancer Prevention Research Training Program (CPRTP). was developed by MK, JC, and PQ to address the study pur- After receiving approval from the Institutional Review pose: to map career pathways of physicians in cancer preven- Board of MD Anderson (IRB #2016-0397), we contacted pro- tion, to identify factors that motivated pursuit of cancer pre- spective participants by email and follow-up calls. Participants vention careers, barriers faced, and recommendations to ad- were included based on the following criteria: dress career challenges (Tables 2). Selected interviews were independently re-coded by different investigators to ensure & Has a medical degree (MD, MBBS, etc.) complete capture of themes and ideas from each participant & Holds a faculty position at MD Anderson and alignment of coding by investigators. & Is involved in cancer prevention research, defined as ap- pointment in DCPPS, joint appointment in DCPPS, or mentorship of CPRTP trainees (e.g., bench research, Results population-based research/interventions, clinical activities) Of 37 faculties eligible to participate, 21 declined participa- tion, 18 were interviewed, but two withdrew, leaving data Individuals were excluded according to the following from 16 participants for analysis. Of these 16 participants, criteria: eight were women; five were self-designated as research fac- ulty and the remaining 11 as clinical faculty although all par- & Not faculty at MD Anderson or retired ticipated in research activities. Two participants were assistant & Did not complete medical training professors, six were associate professors, and eight were full & Not currently involved in cancer prevention activities professors. (self-reported) Impact of a Vaguely Defined Field (i.e., Cancer The recruitment email contained a link to a RedCap data Prevention) collection form used to confirm eligibility, obtain electronic informed consent, and request times for scheduling in-person Given that the multidisciplinary, collaborative, and broadly interviews. diverse activities comprising cancer prevention make it J Canc Educ (2022) 37:1069–1075 1071 Table 1 Interview guide Table 2 Qualitative themes data codebook A. Career path decisions 1. Career path decisions—academic medicine/cancer prevention 1. At what stage of your training did you first think about going into Codes: cancer prevention as specialty? � By design or by accident (was a conscious decision actually made) 2. What made you consider this path? � When/at what stage 3. During your training, did you ever participate in any formal or � Strong influencing factor(s), event(s), or individual(s) that inspired the informal educational activity related to cancer prevention or academic choice medicine as a specialty choice? If any, what kind? � Draw/motivation to specialize in cancer prevention/academic medi- 4. Did you have a mentor during your training (medical school, graduate cine school, or residency)? 2. Pathway to academic medicine/cancer prevention 5. Do you attribute your interest in academic medicine and cancer Codes: prevention (wholly or in part) to your mentor? � How was your career direction determined? 6. Besides a mentor, were there other influential people (such as role � Gaps in information/resources encountered models) who informed your decision to go into academic medicine/cancer prevention? � Opportunity cost of choosing cancer prevention (what options did you choose to ignore) B. Pathway to academic medicine/cancer prevention 3. Perceived barriers to recruiting students and residents into academic 7. What other career choices were you considering? medicine/cancer prevention 8. What made you choose one over the other? Codes: 9. Looking back, would you have made different decisions knowing � Mentorship what you know now? � Concerns (financial, professional, family time, prestige) C. Perceived barriers � Misinformation 10. What were your major concerns when considering cancer prevention? � Hidden curriculum 11. Were there any difficulties understanding the responsibilities that a 4. Recommendations profession in cancer prevention research entitled? If any, how did you overcome those difficulties? 12. What were some of the barriers to pursuing a career in academic an impediment to applying cancer prevention to clinical care medicine? in their career paths. 13. Overall, would you say that you are satisfied with your choice to In addition to low awareness and knowledge of clinical pursue academic medicine/cancer prevention? Please tell us why or cancer prevention, participants also described the absence of why not visibly structured career paths and career resources as chal- D. Recommendations lenges to finding and successfully navigating careers in the 14. What could medical schools and/or residency programs do to in- field. They contrasted this deficiency with the general knowl- crease interest in cancer prevention as a clinical or academic career among oncologists? (Open Box) edge of clear paths that existed for other professionals into 15. Do you see merit in any of the initiatives below: cancer prevention (e.g., NCI-funded cancer prevention post- � Sponsorship of mentored postdoctoral fellowships in cancer doctoral research training programs) and into public health. prevention This deficit, they commented, was especially apparent at early � Development of a toolkit for training program directors career stages when many participants were exploring their � Provision of more educational sessions in cancer prevention (include interests in cancer prevention. One participant observed that natural products, behavioral interventions such as weight loss, even within oncology training, strategies for incorporating a tobacco cessation) focus on cancer prevention were absent. Related to insuffi- � Special informational sessions for fellows on what a career in cancer cient career resources, participants reported knowing few role prevention might look like models from the field and having difficulty finding knowl- 16. Other comments edgeable mentors in cancer prevention for career and research guidance. Participants described challenges in finding men- tors with particular expertise in population health, medical practice, and cancer prevention when they were beginning to challenging to clearly define the field, participants reported pursue their interests in the field. lack of clarity about cancer prevention as a barrier to knowing about careers in clinical cancer prevention (Table 3). In par- ticular, several participants noted that they could not remem- Impact of Misunderstandings about Cancer ber receiving education during medical school or residency Prevention about cancer prevention, whether due to lapses in memory or low emphasis placed upon cancer prevention. Many also Not only was there not enough information about cancer pre- cited lack of knowledge about cancer prevention practices as vention, but in some cases, the information was inaccurate. 1072 J Canc Educ (2022) 37:1069–1075 Table 3 Themes and representative quotations from interviews with physician faculty in clinical cancer prevention Themes and subthemes Representative quotes Vagueness of field impeded finding career path into cancer prevention for physicians Few role models for careers in clinical cancer prevention “It was hard, when I finished my fellowship and joined the faculty, finding mentorship in this area was hard for me because I was interested in working with big population databases to see sort of what was happening more at the national level. And there were not really many people at [institution] that were doing that.” Lack of widely known career resources and absence of structured “Particularly for a clinician, that’s what I would say. It was more established training opportunities to guide entry into clinical cancer prevention for a population scientist or a behavioral scientist, but for an applied clinical careers cancer prevention, [it] did not really exist at the beginning of this in any mature form.” “Maybe I’ve just forgotten it all. But I do not think we really ever had that much training in cancer prevention type interventions or counseling. It’s much more focused on disease and how to treat disease.” Uncertainty about how to connect cancer prevention “At that time, I really did not know anything about cancer prevention other to clinical career interests than the cervix part of it, but I never thought of that as a field or a specialty. You know as I said even training here it did not even seem to be part of what we did.” “We know about cancer prevention, but you do not know that it’sa career...Especially when you are so highly specialized, in such highly specialized training, that you could sort of take all of that back to kind of a public health perspective, a cancer prevention perspective.” Misinformation about cancer prevention Misattribution of responsibility of cancer prevention “The people who are most knowledgeable about cancer prevention are your to other types of physicians primary care doctors. I did not think I wanted to be a primary care doctor so that wasn’t anywhere on my radar.” “I think one of the problems as specialists is we think that’s all the primary care provider’s area and that it does not really need us or we are not part of it.” Discouraging negative comments about the field of “My chair of the department there was like ‘I trained you to treat cancer, and cancer prevention and about pursuing cancer prevention careers you are trying to prevent what I told you to treat…’ ‘Oh, you aretryingto put yourself out of business.’" “One of the barriers, is that the cancer prevention field has collectively seemed to have been too caught up and overlapped too much with the natural product research and that really trying to distance the cancer prevention field from the complementary alternative medicine field would probably help increase the external rigor that the field is perceived as.” Motivations and pathways to clinical cancer prevention Unintended but inspiring exposure to cancer prevention careers and "So probably it would be I was already on faculty and kind of expanding research research and had picked up a few projects that had some cancer prevention efforts. So it was probably ten years into my career on faculty." Motivated by patient experiences “It was just my clinical experience, and sort of like the frustration of seeing patients with cancer, with advanced stage disease that could not be cured that made me kind of want to look into how we can catch it early and how can we prevent it.” Educational experiences that motivated active steps “I then started attending some educational programs that [institution] was putting on Cancer Prevention and found that interesting. Tried to apply that in my practice when I was in private practice in the early years of my family medicine career. That was kind of the start of it all.” “Before I chose the PhD program at [institution] I have a long term goal to control cancer either by prevention or by blocking metastasis so both way, because in these two steps if we can do something good you can significantly decrease the mortality associated with cancer.” Some participants noted that they initially viewed cancer prevention as falling mainly within the purview of a primary J Canc Educ (2022) 37:1069–1075 1073 care physician’s responsibility and did not understand how clinical cancer prevention workforce. Unfortunately, recruitment cancer prevention could align with their own career interests has been affected by multiple barriers and only some facilitators. in oncology. Additionally, participants reported colleagues Here, in-depth interviews with physicians at a major academic having negative comments and perceptions about the field of health center dedicated to cancer care and research provided rich cancer prevention, which may have reinforced misunderstand- insights about careers in cancer prevention beyond what has been ings. Such views, some reported, may have perpetuated the obtained from quantitative surveys. Novel observations include misconception that cancer prevention as a field lacked scien- the multiple adverse impacts of misconceptions about cancer tific rigor. Indeed, one participant was told by a department prevention. Participants reported negative comments from influ- chair that prevention was in opposition to training in ential colleagues and mentors that may have damaged working oncology. relationships or hindered pursuit of cancer prevention career. However, participants also reported experiences that motivated Motivations and Pathways to Pursuing Cancer them to pursue such careers, including patient care experiences Prevention that deepened and made more personal the drive to provide better care through cancer prevention. In addition to barriers, participants described factors that facil- Some barriers that we report were previously reported but in itated their career pathways into cancer prevention. Many re- less detail. For example, a task force to review workforce issues ported becoming involved in cancer prevention unintentionally in cancer prevention research suggested that trainees do not real- while engaged in research projects related to cancer prevention, ize that cancer prevention encompasses many disciplines and which led them to actively pursue their interests in the field. For interests [6], supporting the idea that there is confusion about example, some joined research projects with a cancer preven- what is within the field of cancer prevention, as we found tion aspect that helped them discover how this field aligned (Table 1). In particular, we found that clinical cancer prevention with their interests. Others had the fortunate opportunity to was often initially viewed as somebody else’sjob,and some work with research mentors in cancer prevention, who provided participants reported negative comments and perspectives from feedback and guidance for career exploration in the field. colleagues intended to discourage pursuit of these careers. Other A recurring theme among participants was a desire to make themes our work echoed from earlier surveys of oncology fel- a bigger difference in the lives of their cancer patients. Many lows were that both the lack of clarity about careers in cancer physicians from multiple specialties expressed frustration prevention and the lack of clinical mentors in cancer prevention about “missed opportunities” for cancer prevention as they posed barriers to incorporating cancer prevention in their careers saw the burden of advanced stage, incurable cancer diagnoses [2]. Specifically, some of our participants initially had difficulty on their patients. This frustration, they reported to us, led them connecting personal interests in cancer prevention with their de- to turn towards cancer prevention activities, which gave them sired careers. Even after establishing interest in cancer preven- a greater sense of fulfillment and possibly more agency to tion, some still had difficulty finding suitable mentors and getting intervene with their patients. informed, knowledgeable, and supportive guidance about inte- After committing to career interests in cancer prevention, grating cancer prevention successfully into their careers. participants took active steps to become more involved in the In addition to barriers to careers in cancer prevention, par- field. Participants pursued educational opportunities, research ticipants also described opportunities that stimulated interest projects, and mentorship experiences to learn more about can- and facilitated exploration of such careers. Most participants cer prevention or to gain expertise in areas relevant to their had an event or perspective that motivated them to seek more interests. Learning through professional development courses opportunities in academic cancer prevention. Many cited feel- about cancer prevention helped some see how such activities ing frustrated by how little they could do for their cancer could be integrated in their work. Others pursued positions patients; but subsequently, through pursuit of a career in clin- specifically in cancer prevention that allowed more time to ical cancer prevention, several expressed having great fulfill- do cancer prevention research or be involved in patient care ment through cancer prevention than in cancer treatment. directly focused on cancer prevention. Whether participants Such sentiment, we speculate, reflected physicians’ deep em- changed positions or not, they all began to include cancer pathy for the suffering of cancer patients—unnecessary if prevention in their research and clinical practice after discov- greater advances in preventing cancer could be achieved. ering the value of the field and their interests in it. Appealing both to such strong emotions—frustration and empathy—and to provider dedication to minimizing patients’ suffering could be ways to encourage interest in and pursuit of Discussion careers in clinical cancer prevention. Ideally this appeal would happen earlier in training, before accumulated frustration from Advancing the current progress in cancer prevention contributed missed opportunities for prevention stimulates a late shift to a career in cancer prevention. by physicians requires greater physician recruitment to the 1074 J Canc Educ (2022) 37:1069–1075 Another participant suggestion to stimulate interest was recruitment into careers in clinical cancer prevention is past involvement in cancer prevention research, whether as stu- due. Steps can be taken in medical education, by funding agen- dents or as physicians, because such experiences foster incor- cies, and by national professional organizations to increase the poration of research into physician careers [7]. Thus, the value visibility of the field, to reduce uncertainty and misinformation of research experiences in cancer prevention for physicians- about physician careers in academic cancer prevention, and to in-training is critical for learning how to conduct research in address career barriers. For example, early and repeated career general, gaining direct experience conducting cancer preven- exposure in medical school and residency curricula by improv- tion research, and expanding their knowledge of research ing or emphasizing cancer prevention courses and curricular topics in the field. These experiences may provide a space content could increase the visibility and importance placed on for physicians to solidify how their interests in cancer preven- the field. This could simultaneously dispel misperceptions tion apply to both research and clinical settings while building about clinical cancer prevention practice and offer strategies self-efficacy in cancer prevention research careers. Moreover, for weaving cancer prevention into clinical practice. Exposure by working with scientists leading such projects, physicians- can also occur through cancer prevention research, ideally in-training have direct access to role models and mentors in funded for medical students and guided by seasoned cancer the field. prevention scientists, both physicians and non-physicians As with all studies, ours has limitations. First, participants working in multidisciplinary teams. These experiences, wheth- were selected from physicians holding faculty positions at a er short-term summer experiences or fellowships, can deepen single institution within a division dedicated to cancer preven- future physicians’ understanding of how to translate clinical tion, including a department of clinical cancer prevention, and practice needs in cancer prevention into systematic research who were required by inclusion criteria to be involved in can- that they can conduct and, someday, implement in the clinic cer prevention activities. Therefore, individuals who had in- and community for impact against cancer. For medical stu- terest in cancer prevention but either never pursued those in- dents entering clinical rotations, opportunities to rotate with terests were formerly engaged in cancer prevention or had left physicians combining cancer prevention with clinical practice the institution before our study began were not included. Also, may have indelible impact upon their career trajectories into physicians pursuing careers in clinical cancer prevention else- the field. Such early career exposure is critical for recruitment where may encounter different barriers and facilitators. Thus, because students and residents need to know about cancer we may not have captured in this initial effort all barriers to prevention first, before they can consider clinical cancer pre- careers in academic clinical cancer prevention. As well, the vention as a career option. To sustain emphasis on the impor- physicians at the study institution may have attributes that tance of cancer prevention during early career training, more make them resilient and persistent in their careers, producing questions about cancer prevention and control could be includ- ed by the Federation of State Medical Boards and National a “healthy worker” bias, in which more workers who are “healthy” remain in the workforce and available for study Board of Medical Examiners in licensing exams, as well as inclusion. Regardless of the potential for such an effect, phy- by the National Board of Osteopathic Medical Examiners in sicians we interviewed reported career barriers nonetheless exams for those for in osteopathic medicine, thus requiring and some were reported elsewhere [2, 6], suggesting that the greater continuous attention while preparing for licensing. experiences reported in our study were not uncommon and National professional organizations, such as the American still have yet to be addressed successfully. A strength of our Association for Cancer Education (AACE), the American study was the diversity of participants by faculty rank and Association for Cancer Research (AACR), the American gender, such that the analysis of their interviews provided a Society of Preventive Oncology (ASPO), and the American rich and broad scope of career experiences in academic clin- Society of Clinical Oncology (ASCO), are ideally positioned ical cancer prevention. However, the results from this qualita- to facilitate mentorship and increase visibility of role models tive study do not represent the experiences of all physicians in in cancer prevention. They could provide lists of members academic cancer prevention. Additional work needs to assess involved in cancer prevention research and available to men- how similar issues faced by those early in their careers today tor those exploring cancer prevention careers. Membership are to those experienced in early career by the senior faculty websites and meeting flyers about the different approaches participants in our study as our study included only two indi- and topics addressed in clinical cancer prevention could in- viduals at the Assistant Professor rank. Nonetheless, these form and attract individuals with interest in those areas. These findings can support and guide further investigation using organizations can also create position statements that chal- large groups of probability-sampled physicians from which lenge the hidden curriculum messages about clinical cancer conclusions can be generalized. prevention being a “lesser” pursuit than oncology and cancer Given that we reported deeper insight into themes related to treatment. Such messages will directly challenge misunder- pursuing clinical cancer prevention careers than reported pre- standings and misperceptions about cancer prevention while viously [2, 4, 6], the time to organize activities to improve making clear its valuable contribution to clinical and J Canc Educ (2022) 37:1069–1075 1075 Code Availability Atlas.ti, a software package designed for coding qual- community practice, including primary prevention and early itative text, interviews, etc., was used to code the data for this project. detection of cancer. These arguments must be made directly both to established colleagues and to those in training. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adap- In sum, by understanding the career paths of successful tation, distribution and reproduction in any medium or format, as long as physicians in the field, we have learned what events and ex- you give appropriate credit to the original author(s) and the source, pro- periences hindered and helped propel them into academic vide a link to the Creative Commons licence, and indicate if changes were cancer prevention careers. Going forward with other studies made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a that report the prevalence of career barriers and facilitators, credit line to the material. If material is not included in the article's this information can guide efforts to help others advance their Creative Commons licence and your intended use is not permitted by career paths more directly and efficiently into the field, ideally statutory regulation or exceeds the permitted use, you will need to obtain earlier in their careers and by purposeful choice, not by acci- permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. dent, in isolation, or only after many years of effort. Only with such measures in place to improve recruitment into clinical cancer prevention will the cancer prevention workforce be able to achieve its full potential to lower the burden of pre- ventable cancers on the public health. Indeed, prevention mes- References sages from physicians to encourage everyone to continue 1. 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Jackson VA, Palepu A, Szalacha L, Caswell C, Carr PL, Inui T Funding The project and several authors (MYK, JCC, PQ, SC) were (2003) "Having the right chemistry": a qualitative study of mentoring supported in part by an award from the National Cancer Institute (R25 in academic medicine. Acad Med 78(3):328–334 CA056452, PI: Chang). 4. Ganz PA, Kwan L, Somerfield MR, Alberts D, Garber JE, Offit K, Lippman SM (2006) The role of prevention in oncology practice: results from a 2004 survey of American Society of Clinical Data Availability Data from coded interviews can be made available up- Oncology members. J Clin Oncol Off J Am Soc Clin Oncol on written request to and approval by the corresponding author and co- 24(18):2948–2957 authors. 5. Watling CJ, Lingard L (2012) Grounded theory in medical education research: AMEE guide no. 70. Med Teach 34(10):850–861 Compliance with Ethical Standards 6. Newhauser WD, Scheurer ME, Faupel-Badger JM, Clague J, Weitzel J, Woods KV (2012) The future workforce in cancer pre- Conflict of Interest The authors declare that they have no conflicts of vention: advancing discovery, research, and technology. J Cancer interest. Educ 27(2 Suppl):S128–S135 7. Jeffe DB, Andriole DA (2018) Prevalence and predictors of US Ethics Approval IRB #2016-0397. medical graduates' federal F32, mentored-K, and R01 awards: a na- tional cohort study. J Investig Med 66(2):340–350. https://doi.org/ 10.1136/jim-2017-000515 Consent to Participate Electronic informed consent. Consent for Publication All authors provide consent for this manuscript Publisher’sNote Springer Nature remains neutral with regard to jurisdic- tional claims in published maps and institutional affiliations. to be published in this journal.

Journal

Journal of Cancer EducationSpringer Journals

Published: Aug 1, 2022

Keywords: Occupational choices; Training; Professional development; Medicine

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