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Life is busy, and it’s hard to get it all done during business hours! Journal of Clinical Oncology recognizes that you do not always have time to review an article in depth, and yet you wish to understand how the results will influence your clinical practice or research. JCO After Hours is a podcast intended to enhance the readership experience by presenting key results of high-profile publications in a convenient audio format, placing selected articles into a clinically useful perspective that you can listen to in the office or on the road.

Dec 9, 2022

Dr. Shannon Westin and Dr. Stephanie Graff discuss a revision to the famous "Simone's Maxims" and the broader nature of intersectionality.


The guest on this podcast episode has no disclosures to declare.

Dr. Shannon Westin: Hello, everyone, and welcome to another episode of JCO After Hours, where we get in-depth on articles that have been published in the Journal of Clinical Oncology.

I am your host, Shannon Westin, a GYN Oncologist, and Professor at MD Anderson Cancer Center, and I'm honored to serve as the Social Media Editor of the Journal of Clinical Oncology.

Today, we're going to be discussing the very important work called “Understanding Modern Medical Centers: Beyond Simone—Intersectional Maxims for a New Era.” And this was published online in the JCO on September 27th, 2022. And joining me to discuss this important work is Dr. Stephanie Graff, who is the Director of Breast Oncology at the Lifespan Cancer Institute at the Warren Alpert Medical School, Brown University.

Welcome, Dr. Graff.

Dr. Stephanie Graff: Thanks so much for having me. It's going to be fun to talk about this piece with everyone.

Dr. Shannon Westin: Yeah. It's a great piece of work. And before we start, I will just note that all participants have noted no conflict of interest for this manuscript.

So, let's get down to it. I want to level set. What were Simone's Maxims, that you just revised, and why did they matter?

Dr. Stephanie Graff: Yeah. So, Dr. Joseph Simone, who is a legend in oncology, and our revision of his work is truly in respect of what he did, not in any way meant to be anything less than that. So, in 1999, Dr. Simone published, in Clinical Cancer Research, this piece that would famously come to be known as Simone's Maxims, and the official title was, “Understanding Academic Medical Centers.”

And that list of, you know, sayings and circulated truths have really sort of been this commonly quoted list of things that people talk about in medicine as just the truth of what it takes to sort of cut it, if you will, in the world, especially in academic medicine, but just medicine in general. Like, one of the famous ones is "Institutions don't love you back."

And I think that you've probably heard these and maybe not even realized that you were quoting or hearing Simone's Maxims, but they're pretty ubiquitous in the world of academic medicine and, in particular, oncology, because Joseph Simone was an oncologist. He actually went on to write a book. There's a text called Simone's Maxims as well that's much longer than the Clinical Cancer Research piece. We didn't have a book in us yet, so we just started with updating the original manuscript.

Dr. Shannon Westin: That's so great. And it's so funny when I was younger--I don't know if I'm still young or not, but there was things that we said, and I had no idea where they came from. So, I bet that a lot of our listeners are saying the same things, like, "Oh, that's a Simone's Maxim." So, I guess the question is now why did your group set out to update these?

Dr. Stephanie Graff: I think if you look at the list of authors, a bunch of the authors have had recent career changes. And so, it actually started as just sort of this casual conversation about how for many of us who have recently undergone career changes, that some of these maxims don't hold true for us. The list of authors is a group of very intersectional physicians in our identities--and I know you'll ask me a question in a moment here about what exactly intersectional means. But, you know, I think that Dr. Simone wrote Simone's Maxims at a time when Medicine was more homogeneous, and so, some of the Maxims that he wrote represent the more traditional values of medicine, what medicine looked like in 1980, in 1990.

And I think medicine in 2022, 2023, 2033 is just continuing to evolve and change shape. And so, it's important that we reframe the truths of what it takes to foster a successful career, create successful working environments for the modern workforce.

Dr. Shannon Westin: I think this is so critical, and we're seeing it across a number of different fields, not just medicine. We're seeing it in politics and policy and other places. So, why don't you just make sure that all our listeners do understand this concept of intersectionality and how it applies, you know, in medicine and feminism and other areas?

Dr. Stephanie Graff: Yeah. And that--shout out to our co-author Edith Mitchell. Dr. Mitchell very quickly said, "Well, we have to start the manuscript by defining intersectionality if we're going to include it in the title because a lot of the readers won't even be familiar with the concept of intersectionality."

So, it's included there in the maxims. Intersectionality was first introduced in 1989, and the definition is this nature of social categories, like race and class and sex and gender and the way that they overlap, so that I'm not just white or Christian or a farmer's daughter or a woman, but I'm all those different things, and that creates my intersectional identity. And obviously, there are millions of different intersectional identities, because we have all of these different facets of our personality, of our identity, that come together. And as medicine gets more diverse, which I believe makes us stronger, we'll see more and more complexity in the intersectional personalities, intersectional identities, of the people working in healthcare.

Dr. Shannon Westin: Thank you. I couldn't have said it better myself. You know, the other question that comes up as we start seeing more diversity in our workforce, and I mean, frankly, in our patient population, how do you think that that understanding about diversity and the accentuation of our diversity helps improve the success of medical organizations?

Dr. Stephanie Graff: Oh, gosh. There's like a million examples. I think that-- ah, Shannon, there's so many different examples I can quote. So, I think that you know, there's a study that looked at patients coming into the emergency department having heart attacks. And if they were female patients cared for by female doctors or female patients cared for by male doctors, that had an impact on their risk of death. Not surprisingly, it was the women patients cared for by male doctors that were the most likely to die and the female patients cared for by the female doctors that were the most likely to live, telling us that when there's this concordance, this understanding between patient and physician, that it improves outcome.

But that could be corrected if the male physicians had more female partners. So, just that understanding of relationships, that exposure to more people, more female physicians, increased male physicians’ ability to care for female patients or communicate with female patients, it just increased confidence, our collective confidence. And that's been proven in other settings too. But that's just one sort of great example.

The McKinsey group has shown how financial performance improves with gender diversity and ethnic diversity. And that's been shown, not just in healthcare, but in numerous different business environments. And if we think about, you know, as an oncologist, as a clinical researcher, if I imagine that innovation is improved by diversity, imagine that translating into better clinical trial outcomes with a more diverse workforce. And the outcomes that the McKinsey group show, ethnic diversity drove a 35% improvement in financial performance, which is huge.

And again, that's at a time when the oncology workforce is really struggling with everything from, you know, recruitment to trials, staffing, revenues. That would be enormous if we could derive that sort of performance. So, I think that there's a million different ways to illustrate what diversity could do, whether it's make us better or stronger or more confident or provide better care, and it's been shown in a million different ways, in a million different contexts.

Dr. Shannon Westin: Well, you're convincing everyone, I know. I think we'll get into some of the kind of more nitty-gritty details of the manuscript. I want to be very clear; I think all our listeners should absolutely 100% read the entire manuscript because it's so critical. But let's try to hit some of the major high points. And I say this all the time, and I'm going to take your line, but which one's your favorite? What do you think is the most important one? Just like you would totally tell me which of your children is your favorite, right?

Dr. Stephanie Graff: I can't possibly pick a favorite. That's completely impossible. I really like--one of the Maxims that we have is, "Everyone's time and voice is valuable. Institutional leaders must respect time and encourage diversity of thought." Originally, Dr. Simone had a maxim that said, "Members of most institutional committees consist of about 30% of people who work despite other pressures and 20% who are idiots, status seekers, and troublemakers." And we changed that to say, again, "Everyone's time and voice is valuable. Institutional leaders must respect time and encourage diversity of thought," as a way of saying that, you know, I think that in 2022 and beyond, we're getting to a place where it's important that we find better labels for people than idiot and troublemaker and that we reach beyond that to identify how we can help everyone find an environment to be successful and that we fill the working corners of our cancer centers, the working corners of our hospitals, healthcare systems, clinics, with the people that are excited about the work that needs to be done.

And, you know, not all of us are gonna want to run clinical trials. Not all of us are going to want to do quality improvement projects. Not all of us are going to want to do five straight days of clinic. Not all of us are going to want to do--insert the day-to-day grind of whatever it is that needs to get done to make a cancer center function. But somebody somewhere loves that little thing. And it's important that we work together to accomplish what needs to be done for best care of the patients that we're honored to take care of. And so, we have to respect that time, respect that voice, and work to connect people with the thing that drives them.

Dr. Shannon Westin: I think that one, how you just ended there, kind of touches on one of the ones that really grabbed my attention, which was the original maxim that was, "Leaders are often chosen primarily for characteristics that have little or no correlation with successful tenure as a leader." And instead, as an intersectional maxim, you all changed it to, "Leaders should be chosen for their ability to inspire." That really spoke to me because it's exactly what you said.  That leader has to work to inspire people to do what they love within each piece of that, you know, department or division or hospital or organization or whatever.

You can't expect everybody to do the same cookie-cutter thing, but help inspire people to be behind the mission and do what they love as part of moving that hospital organization forward. I thought that was really perfect.

Dr. Stephanie Graff: Yeah. And we've too often seen, you know, in academic medicine especially, that we equate a really high h-index or a really successful history of grant funding with leadership. And those aren't the same skills, right? Like, you could be a really fantastic researcher and not a really great person at organizing a team of people to run a cancer center. And you might have both skills, in which case, wow, congratulations. But I think that it's important that we look at the job in front of us and select for that, rather than assuming that all of the same skills fill every single job because that's just not true.

Dr. Shannon Westin: I think that, again, I know I said this already, listeners, but please, please run, don't walk, to read the whole paper and get more information.

On our last note, one of the things I really loved about this paper was you really provided some clear reforms really to help improve physician wellness. Can you maybe summarize some of those reforms that could improve intersectionality within healthcare organizations?

Dr. Stephanie Graff: Yeah. Those are all in Table 2. So, again, I hope you guys all grab the paper and give it a download and pin them up somewhere and think about them. I think that some examples are, you know, to really promote intersectionality, which means that you've got a lot of diversity in characteristics across your cancer center, which is going to be things like gender, race, introverts, extroverts, researchers, clinicians. You really have to have very clear metrics that are shared and discussed. And so, you might need to publish benchmarks for things like median RVUs or come up with a group incentive structure, so that whether you’re a person who is in clinic less and publishing more or in clinic all the time and publishing less, you can work together to be flexible collectively, and then everybody can be contributing to that greater team environment. I think it's really important that if you want to grow intersectionality, that your search committees and your leadership interview strategy undergoes unconscious bias training.

There's still not really great strategies to make sure that we're 100% pursuing a no-bias environment in our workplace, but there is evidence that unconscious bias training can be effective to help us recruit a more diverse workforce. And that's the simplest strategy - is if you're going to be putting a search committee together, have everybody do an implicit bias training and work together to select candidates that don't necessarily fit what feels like your traditional mold, and then find strategies, once you've hired into your organization, to partner your new employee, new physician, new hire, for maximum success in that workplace.

Another important thing is, as you're growing diversity in your organization, is to make sure that you're creating opportunities to give everybody a voice. You should be looking at who's being invited to speak and making sure that that's representative and diverse. You should be considering changing up strategies. One of the examples I often give is that, when we have a problem and we do brainstorming, where you bring everybody in a room and they shout out, "This is what I think we should do," what happens is you get the loudest extrovert or the most powerful person at the table who just gets their way.

And it's far more effective to do brain writing, where you have everybody write down the three or five or 10 things that they think might work, and then you read those out in a neutral way, because then, everybody's voice and everybody's idea gets equal play in a neutral way that allows you to elevate those ideas independent of the other bizarre, irrelevant hierarchies that may exist in your system and can really elevate some of those diverse voices and ideas in your organization. Those are just some of the examples that are listed.

Dr. Shannon Westin: Yeah. Listeners, there's a ton of very clear frameworks that you could potentially implement tomorrow in your organization if you want to strive to improve the intersectionality.

Well, the time always goes so fast. It has been so great to speak with you, Dr. Graff. Thank you so much for being here.

Dr. Stephanie Graff: It's such an honor. I hope everyone gives it a read and comes up with the next iteration and update together with us.

Dr. Shannon Westin: Perfect.

So, again, readers and listeners, this was, “Understanding Modern Medical Centers: Beyond Simone—Intersectional Maxims for a New Era,” published online in the Journal Clinical Oncology, on September 27th, 2022. And we are so thrilled that you came to listen to JCO After Hours.

Please go check us out on the website and see what other podcasts you've missed.


The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions.

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