By Matt Skoufalos
Across America, the past few years have seen the social and cultural issues related to diversity, equity and inclusion (DEI) elevated to a prominence comparable to the Civil Rights era of the 1960s. Institutions from law and government to business, athletics, the arts – and, of course, health care – have all striven to address long-held assumptions and implicit biases within their work.
In a June 22, 2022 article from the Harvard T.H. Chan School of Public Health, Katherine J. Igoe noted “an explosion of organizations creating DEI offices, equity officers and other commitments to formal improvement.” What’s more meaningful than their establishment itself, Igoe wrote, is laying the groundwork for their sustainability.
“But beyond this important moment, where organizations see this as a hot-button issue worth paying attention to, how are these groups or individuals set up — or not, as the case may be — for actual success?” Igoe wrote. “How have they been integrated into an organization? Is their work sustainable in the long term and, if so, what are effective predictors of success? Are adequate resources being allocated?”
In many instances, the health of such initiatives – much like the health of the vulnerable populations at the fringes of broader health care access itself – hinges on commitment to meaningful change in its various forms, and providing the resources, both financial and otherwise, to achieve it.
As the DEI chair for the Association for Medical Imaging Managament (AHRA), Karen L. Stewart, senior clinical applications analyst in the IT department at Penn Medicine/Princeton Health, said her committee is working to help communicate the importance of diversity, equity and inclusion in the medical imaging space by relating experiences from their distinct, individual backgrounds.
“We’re trying to come up with ways to put personal spins on these issues,” Stewart said. “We want to have everybody treat everybody with respect and dignity. We’re trying to promote kindness, and to take everyone as an individual and not as a class.”
“I like being able to make things show up on X-rays that you wouldn’t know are there by just looking at a person,” she said. “You should be curious about other people. You should want to know traditions, or something about them, because it will help you understand them better. That’s really what we’re trying to do right now: understand how somebody’s feeling who isn’t treated the same way. You’re there providing a service for them; you need to let them know how you are doing the things to make them better.”
To Stewart, the opportunity to engage on the basis of cultural differences represents a departure from the kinds of interactions that professionals were coached to have in the workplace even a few years ago. Expressions like, “I don’t see color,” which at one time may have been a sanitized attempt to express an absence of bias, have become viewed as examples of cultural erasure rather than inclusion.
“What it would mean is ‘I won’t treat you any differently,’ ” Stewart said; “what I’m finding is. I probably did, and didn’t realize it.”
“We need to go to the uncomfortable spot,” she said. “What we’re trying to do is get people to understand that DEI is not a race thing, it’s not a sex thing, it’s not a kid and an adult thing. It’s about being nice to people and respecting them. And if you show the respect, you get the respect.”
Adopting a culture of inclusivity is particularly critical for a segment of health care that not only needs to diversify, but also has been losing professionals at an unsustainable clip, like so many other pieces of the global economy during the Great Resignation. A February 2022 message in the American College of Radiologists Bulletin described a radiology labor shortage owing to professionals aging out of practice, enduring high rates of burnout, and only half of radiology, radiation therapy, and nuclear medicine training programs at full enrollment.
“RTs are becoming a rate-limiting factor for many of our practices,” ACR Board of Chancellors Chair Howard B. Fleishon wrote. “In discussions with our allied health partner societies, some contributing factors include wages, concerns about safety during the pandemic, limited advancement opportunities, and a lack of respect and support compared with nurses and other health care workers. Clearly, we can and should do more to help support our valued allied health colleagues.”
Stewart believes that one key to bringing more young people into careers in medical imaging and its paraprofessional fields is finding ways to connect with them by telling authentic and personal stories about how medical imaging offers a career that matches their individual needs.
“When it came time for me to go to school, my parents said to me, ‘We’re sending your brother to school because he’s the man, and he’s going to take care of the family,’ ” Stewart said. “I chose to go to X-ray school and got my associates and bachelor’s degrees at night. This was a career that allowed me to be a mother as well as a professional. What people don’t understand is when they’re needed, how they’re needed and how you can accommodate a work-life balance.”
Gail C. Christopher, D.N., executive director of the National Collaborative for Health Equity, said that the way to end health inequity involves understanding its connections to environmental and social conditions in America – which, given the distinct history of the country, “have a long legacy in racial hierarchy.” The Collaborative works to build coalitions to address that legacy of inequity, as well as leveraging research, data and information systems to reframe discussions of health inequities, from documentation to developing quantifiable goals for closing those gaps.
The hallmark project whereby the Collaborative works to achieve those goals is called the Health Opportunity and Equity (HOPE) Initiative, which uses interactive data tools to track social determinants of health and health outcomes by race, ethnicity and socioeconomic status.
“What’s unique about HOPE is that it has a framework of what you need to do to make things better,” Christopher said. “We wanted to see if local communities can take a data-driven approach and recognize what it takes to achieve goals. They were able to make changes in areas of environmental justice and access to housing.”
By designing the framework of the HOPE Initiative to be broad, it has been able to be adopted in a variety of environments, from college campuses to various professional organizations to neighborhoods and municipalities, Christopher said.
The greatest aim of the Collaborative, however, and the one that requires the most inertia to implement, is what Christopher called “a Truth Process for America,” which would parallel reconciliation work done in 45 other countries across the globe “to grapple with our centuries of enslavement of people.”
“Some people say slavery has existed since antiquity, but we were the first nation to both racialize enslavement and maintain it for consecutive centuries,” Christopher said. “We really need to come to grips with that as a society, and not view its legacy today as if it has nothing to do with the past.”
Taking on such a transformative process relies on a handful of principles, including narrative change, racial healing and relationship building. Christopher believes that “by making a deep connection to our common humanity,” it is possible to explore how hierarchies of human value are institutionalized in segregation that exists in legal, economic and criminal justice systems.
“The question is, how do we mitigate these structural realities?” she said. “I think we have to be honest about these realities, and then decide what do we do to reduce the risk of mistrust or stereotypes. We have to be willing to analyze our patterns in institutions. Physicians have to go through some training and awareness, and you have to put systems in place within the organization for checks and balances. At the top level of the organization, there has to be this collective commitment to say, ‘We want to change these outcomes and patterns because they’re grounded in the legacy of racism.’ ”
To get there requires diversifying institutional leadership, building systems of accountability within individual organizations and the field of medicine more broadly, and maintaining a commitment to continuous improvement on these very deeply rooted issues.
“In the moment right now, there’s a tremendous investment in inequity and every federal agency has been mandated to look at their work, and come up with a plan to do something about it, but it could all disappear in two years,” Christopher said. “We have to reach the broader community. We have to change the way of thinking and feeling about one another, and we have to see that it’s all in our mutual interests to do this work.”
Most critically, she said, the work of repair begins with an inward-looking eye towards healing the self.
“We can’t relate to others in ways that exceed the way we relate to ourselves and our self-worth,” Christopher said. “That’s why the strategy is grounded in lifting people up rather than tearing them down. If you don’t have a grounded self-concept, you’re not going to see others as having value either. You build relationships, you build trust, you lift up everyone in the process, and you’re able to see the collective benefit. If America’s going to work as the beautiful experiment that it is in self-rule, we’ve got to do this work.”
Carla Brathwaite, DEI program manager at ACR, and team lead of the Radiology Health Equity Coalition, said organizations like hers are working to address issues of injustice and racism in health care that are microcosmic of comparable disparities in the world at large. During the novel coronavirus (COVID-19) pandemic, when the health care system was overwhelmed and under-staffed, the social protests that erupted with the death of George Floyd at the hands of Minneapolis police also provided a backdrop for the disparity among Black and Latin Americans – groups that sustained a disproportionately higher rate of death from COVID than other Americans did.
In response to these conditions within the field of health care and society at large, the Coalition was convened by members of various entities within the imaging world.
“We honed in on patient care and increasing access to medical imaging, radiological care and radiation oncology therapies in underserved populations,” Brathwaite said. “In asking what can we do to support underserved communities, we created a roadmap and resource guide on how to partner with community health organizations. We’re fairly new, but there’s more work to do. We will continue to raise awareness, build partnerships and network to support community health organizations that want to build access to screening and support their patients.”
Among health professionals, DEI concerns overlap with those related to the delivery of care and health equity at large. Beyond improving access to care, DEI involves addressing broader community issues – things like cultural competency, socioeconomic barriers, food deserts, imaging resources in safety net hospitals. Approaching issues such as these, even as well-understood as they are, can be daunting to contemplate. To Brathwaite, the solutions lie in forming critical community partnerships involving experts in nonprofits and other industries.
“We don’t have to fill every role,” she said. “Partnerships are really the only way. If you get into the web of school districts being under-resourced, we can’t solve that problem, and we definitely can’t solve it on our own, but how about we partner with organizations that are more adept at working with vulnerable populations?”
“We can handle making sure our standards are up to par, making sure the quality of imaging is consistent, and holding ourselves accountable for the delivery of care, wherever that care is delivered,” she said. “The approach that we should take is a collaborative approach instead of working in silos. Small wins lead up to big wins.”
Wins, to Brathwaite, can be seeing improvement in health outcomes for specific patient populations, getting more patients to follow up on appointments, or increasing screening rates among high-risk groups. Making connections with community health organizations so that radiology practices can get their hands on those populations that have been medically underserved? That’s a win, too. She argues for the business case behind implementing community health outreach workers in hospitals and departments as being the same for that of partnering with outside organizations: it strengthens the relationships that drive the delivery of care to those who most need it.
“We’re looking for ways of engagement,” Brathwaite said. “Individual professionals can make sure that we’re up to par with our training cultural competency – how you deal with different populations, language barriers, accessing a diverse set of patients. A more diverse health care workforce population improves the quality of care for all.”
