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By Matt Skoufalos

In any institutional space, conversations about diversity, equity and inclusion are inherently necessary and implicitly thorny – especially in medical and technical fields such as diagnostic imaging and intervention. When they crop up in scientific and technical settings, however it can be easy to overlook their relationship to the quantitative space occupied by that work.

“It’s often been thought that something as technical or specialized as imaging is merely a science, or a profession that exists in the absence of sociology or politics or history,” said Dr. Johnson B. Lightfoote. “And in fact, nothing could be further from the truth.”

Lightfoote, who is medical director of the department of radiology at Pomona Valley Hospital Medical Center in Pomona, California, believes the medical imaging space exists to serve two complementary communities: that of the American people – its patients and service populations – and that of its internal constituents, including radiologists, technologists and administrators, to manufacturers, service providers and paraprofessionals.

Axiomatically, Lightfoote believes that the key to serving the diverse communities of stakeholders in the world of medical imaging is to ensure that their perspectives are represented within it. Whether those perspectives are measured in terms of culture, ethnicity, gender, ability or access, each​ is meaningful to the operation and advancement of the field on the whole.

When the professional labor force in imaging resembles the general population for which it provides care and other services, those issues and concerns that are distinct to its unique segments may more easily be addressed in practice. When they are not, however, health outcomes can be less than optimal; patients may mistrust the guidance of their practitioners; or worse, care may not be delivered in places or for populations most sorely needing it.

“We exist to serve the community,” he said. “We don’t exist for our own benefit, and any measure of our success as community servants must be measured against how we serve the community. One way that communities can assure and ensure that they’re getting their equitable treatment, distribution and benefit from technology is by having their own representatives at the table.”

Lightfoote has done a considerable bit of analysis around these questions. In a two-part 2014 paper, “Improving Diversity, Inclusion, and Representation in Radiology and Radiation Oncology,” Lightfoote and his co-authors note that, “Cultural competence is not something into which a physician is born, but rather is a skill set developed through education, travel and work experience.”

By diversifying its workforce, the medical imaging field may address its shortfalls among communities who are underrepresented in medicine (URM), specifically because “physician race and ethnicity are the strongest predictors that a physician will care for more-vulnerable and underserved communities,” they wrote.

“The most reliable and predictable way to provide expanded access for traditionally disadvantaged segments of the U.S. population would be to expand representation of URMs in medicine,” the paper continued.

“There are interventional radiology (IR) deserts – places that are relatively under-served by angiography suites, or by radiologists who are capable of doing limb salvage IR procedures for vascular disease,” Lightfoote said. “We think Black people tend to go to amputation quicker and earlier because there are IR deserts, so we think we should train more Black interventional radiologists.”

“We know that women living in a lower socioeconomic area, women who are of lower educational attainment and women of color, are less likely to get breast tomosynthesis imaging even if the facility they visit offers it,” he said. “By having X-ray techs, mammography techs and radiologists who are of their community, they will make sure that doesn’t happen.”

“The main thing we seek of diversity is ​improved and equitable service to the population, and to mitigate health disparities,” Lightfoote said.

According to their analysis, Lightfoote, et al., conclude that non-white racial and ethnic groups are underrepresented among radiologists by about half. For example, although Black, Hispanic and indigenous Americans represent about 30 percent of the U.S. general population, they accounted for only 15 percent of graduating medical school classes in 2014, Lightfoote said. residencies in radiology – along with radiation oncology, ophthalmology, otolaryngology and orthopedics – suffer from a “specialty gap,” he said; that is, “they have less diversity than a graduating medical school class does.”

“What we feel that means is there’s a whole lot of talent that’s been missed,” Lightfoote said. “In micro and macro ways, people need to be represented, and the communities look to us for guidance on what’s important.”

He attributes part of that disparity to a lack of prior exposure to the field – without a robust radiology residency planning program, medical students are less likely to approach the specialty – coupled with stereotypes about radiology being an overly “technical” specialty.

“For some unknown reasons, many people, including career advisors, think that it’s so technical that it’s inappropriate for women or Hispanics or Blacks,” Lightfoote said. “They’re getting bad advice. Further back in the pipeline, it’s well known that African-American women are steered away from STEM fields in the first place. If you’re steered away from chemistry and or physics in high school, you won’t end up in radiology.”

To correct for this shortfall, Lightfoote, who chairs the American College of Radiology (ACR) Commission on Women and Diversity, said the ACR created the Pipeline Initiative for the Enrichment of Radiology (PIER), an internship program that partners rising second-year medical students from underrepresented demographics with established radiologists to improve their chances of earning a radiology residency in the future.

“We’re teaching them the trials and tricks three years early,” Lightfoote said. “We match them with a preceptor who is a world-class radiologist. We house these ambitious students and transport them to ACR headquarters for a one-day boot camp, and then we fly them to their institution where they spend six weeks with the preceptor, and, under the preceptor’s arm, write and publish a research paper.”

“In the PIER program, they’re getting world-class lectures as second-year medical student​s,” he said. “The general faculty preceptors read like a who’s-who of academic radiology; we have radiology luminaries and role models of this level of expertise passing knowledge onto their rising junior partners. These ACR PIER scholars’ names will be recognized in the journals of academic ​radiology literature.”

Dr. Yoshimi Anzai, the director of quality and safety of enterprise imaging at the University of Utah Department of Radiology & Imaging Sciences, and chair of the committee on diversity, equity and inclusion at the Radiological Society of North America (RSNA), said that mentorships may be especially important for underrepresented communities simply so that their members can find someone to whom they relate on an aspirational level. Even at their highest levels, professional organizations seeking to address these issues are best served to follow their guidance, she noted.

“In the past, the leadership of large institutions like RSNA or ACR were all white males,” Anzai said. “We didn’t really have a role model for minority radiologists or minority students. You want to have a role model so that students say, ‘One day, I can be like them.’ You want to imagine what your career trajectory looks like.”

“Organizations have to intentionally put diverse people into their leadership because diversity in thought perspectives comes from people of diverse background. That is the beauty of diversity and inclusion,” she said.

In addition to ethnic and cultural diversity, gender inclusivity is equally important to address in leadership, which Anzai said must move away from “check-the-box diversity, such as ‘Now we hire a minority woman; diversity is done.’ ” Inclusivity, she argued, is more than simple representation or a head count; it is a culture of organization.

“It is our own behavior,” she said. “It requires the leadership commitment to cultivating diverse perspectives and building inclusive culture.”

Anzai also said she believes in a “multi-dimensional” approach to diversity and inclusivity. Organizational leadership, including C-suites, dean’s offices, departments, individual faculty and staff, must commit the necessary resources and proactive, conscious effort.

“Diversity efforts should not be left to minorities and women,” she said. “Inclusive culture requires strong allies and recognizing the value of allyship. That’s mission-critical for any organization to thrive.”

“[America has] a long history of sexism, of racism, but we have to continue to remind ourselves of it,” Anzai said. “Are we prejudiced against marginalized populations? Are we kind to people who have disabilities? Are we providing care and imaging needs for transgender patients?”

“We are now very aware that the health disparities exist, so stop denying it,” she said. “We knew the problems have existed for decades, but we swept them under the rug. We now must find how to mitigate the negative impact of disparities. A multi-dimensional approach is required from patients, providers, payers and communities. All academic communities, large and small, have to work together to address the fundamental societal program of health disparities.”

“For as much as diversity in health care is a hot-button issue among health care institutions – particularly as globalization and demographic population growth trends have created a more diverse workforce and a more diverse patient set – the institutional commitment to addressing these shortfalls is often lacking,” said Northern Arizona Healthcare Systems Director Nicole Dhanraj. She believes that the best way to handle it is to provide “a pathway to health care,” from education to scholarships and career opportunities, that doesn’t stop at the front door of any given facility.

“We have to go to the root of it,” she said. “It can’t just be, ‘Nicole shows up at an organization and somebody takes her under their wing to groom her into a position.’ We’re expecting people to come to us, and then we will grow them and provide opportunities. However, organizations need to go back to ensure that we are creating the opportunities; helping create and chart the pathway into health care.”

“Organizations try to support diversity; however, other challenges can exist even among institutions that commit to diversifying their workforces,” Dhanraj said. “Entrenched, unconscious biases about gender roles can yield focused judgments about women of any ethnic or racial background whose choices about their careers, the preconceived notions of their cultural strength as a leader, or their families’ needs are hyper-scrutinized,” she said. Those judgments are particularly pronounced in radiology, she said, because “work-life balance is not there.”

“As a leader, it’s hard,” she said. “People say, ‘You’re a woman with young kids and a family; you must have sacrificed a lot to get where you are.’ Who said I have to sacrifice? I have a sound support system and a family. Why can’t I have it all? Do I have to juggle and have something suffer? No. However, the assumption, especially with women, is that we have to choose one or the other.”

“And then you have the unconscious bias of not wanting to put a woman into management because she may take leave to have children,” Dhanraj said. “As much as I promote women in the industry, it’s still a faint thought there because of how unforgiving organizations are about when somebody goes on FMLA or maternity leave. Most of the time, they don’t put a temp there, and the operation falls on whoever is left.” But how many people would advocate that it’s OK to be ill, on FLMA, or take time for family? Leaders cannot see any person’s additional responsibilities outside the job as potential barriers to their success in their role.”

Even when seeking mentorship, Dhanraj said competitiveness could emerge among some colleagues who believe that diversity forces choices among underrepresented groups. She described an experience at a previous workplace where, in seeking guidance from a female leader, she was regarded as a potential threat to usurp that woman’s position. Similarly, Dhanraj spoke about contending with “a lack of confidence and trust from male counterparts” that can undermine a woman’s ability to simply fulfill the obligations of her role.

“It’s a lack of confidence in skills; a lack of belief in the strength of women leadership,” Dhanraj said. “I had a colleague tell me, ‘Consider cutting your hair and wearing glasses so people will take you more seriously.’ In his mind, he’s thinking he’s trying to support me so that people recognize that I have the skill and talent, but it boils down to appearance.”

To eliminate behaviors like this from the workplace, Dhanraj argues that what’s needed more than anything are opportunities to have clear conversations about moments like these and the weight they carry with the people who comprise an organization.

“We need to go back to the basic building blocks to get it right,” she said. “I think the first thing is helping people understand their bias and having these open conversations. I’ve been talking about my experiences in little pockets, but it takes courage to be in a group together and allow that aspect of the population to say, ‘This is how I feel; this is how my seniors or colleagues treat me.’ ”

Dhanraj reported that people often come to her saying, “I’m afraid if I say anything about it, I’m going to lose my job.”

“We need to create that open space for anyone in any organization to say, ‘This is my experience in this organization, and this is how I would like it to improve,’ without them having a grudge,” Dhanraj said. “Before we go into diverse perspectives, we need to address toxic perspectives. We do not need to wait for HR to help us with this. Encourage team members to discuss these issues, not with the intent of getting anyone in trouble, but to educate; to help people know what they do not know; and to understand where we could start with ensuring that we are really embracing diversity.”

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