Diversity and inclusion in radiology: a necessity for improving the field

Abstract

Women and minorities are systematically under-represented in medicine, and this effect is pronounced in the field of radiology, across education, workforce and leadership. The proportion of women and minorities represented in radiology diminishes as their rank or job title elevates. Much of this are likely due to implicit biases, generational attitudes, and workplace cultures that can be discriminatory towards women and minorities. Steps that can be taken include closing the gender pay-gap, providing more opportunities for mentorship, addressing biases, and supporting the upward career mobility of women and minorities. Ultimately, increasing diversity will benefit all stakeholders in medicine, as collaboration among diverse individuals fosters innovation, greater financial efficiency, and better patient outcomes.

Introduction

Diversity is the range of human differences, including but not limited to race, ethnicity, gender, gender identity, sexual orientation, age, social class, physical ability, religious or ethical values system, national origin, and political beliefs. Diversity of representation bolsters medical innovation by fostering collaboration between individuals with different lived experiences, perspectives, and skillsets. Such collaboration elevates the quality of research and promotes equitable and patient-centered healthcare by enabling health-care providers to address the needs of diverse patient populations. Patients who are cared for by a diverse team of health-care professionals tend to have better health outcomes due to enhanced communication, improved risk assessment, decreased implicit prejudice, and increased financial efficiency of care.¹ Diversity increases creativity via collaboration among physicians from different backgrounds who offer unique perspectives, and this informs more solutions and comprehensive patient care.

Diversity in medicine

Despite the benefits of diversity, there are still vast disparities in medical training, workforce, and leadership. We will focus on gender, racial and ethnic disparities given their more common representation compared to the larger range of human differences.

Females (compared to males) and racial and ethnic underrepresented minorities (URMs) (compared to Whites) are less likely to be promoted to higher academic ranks or to be appointed to department chairs.^2,3 Potential causes for the gender gap in the promotion include lack of gender parity in leadership and compensation, lack of retention of females, a disproportionate burden of family responsibilities, and difficulties in achieving work–life balance.³ Further, the existing racial gap might be explained by the diversity-innovation paradox, whereby URMs demonstrate more innovation, but their novel contributions are recognized at lower rates than the contributions of majority groups.⁴

These disparities have been exacerbated during the COVID-19 pandemic since females, and racial and ethnic URMs academic productivity is disproportionately more affected. Female scientists reported a 5% greater decrease in time dedicated to research during the pandemic, and this effect was magnified to a 17% greater decrease among female scientists with young children, who likely had to dedicate more time to childcare due to school closures.⁵ Racial and ethnic URM trainees were less likely to accept unpaid research positions, and with the shift of funding and supplies to clinical practice and COVID-19-related studies decreasing the number of paid research positions, many URM had to accept second jobs in lieu of unpaid research positions.⁶

Disparity in radiology

While the issue of under-representation is pervasive in all medical fields, it is especially so in radiology. Among the 20 largest residency training specialties, diagnostic radiology was 17th in female representation, making it the least diverse nonsurgical specialty and less diverse than general surgery. Further, radiology was 20th in URMs representation as of 2014.⁷ The gender gap is more pronounced among certain subspecialties, including neuroradiology and interventional radiology.⁸ However, there is a greater representation of females than males in academia, and subspecialties such as breast imaging.⁸

Disparity in education

Females and minorities are under-represented at all levels of medical training and practice. White applicants were more likely to be accepted to UK medical schools than racial and ethnic URM applicants with equal qualifications.⁹ In 2010, 15.3% of the U.S. medical school graduates were racial and ethnic URMs (compared to 35% of US population), and they were significantly under-represented in diagnostic radiology residency.⁷ These disparities in education may be attributed to different factors, including socioeconomic disparities, poor access to education, limited mentorship from individuals with shared racial/ethnic or gender identities, and unconscious bias among non-minority higher education mentors.

Disparity in the workforce

Many physicians in the UK National Health Service (NHS) come from overseas, and despite making up a large portion of the NHS workforce, racial and ethnic minorities were nearly 50% less likely to be considered for senior hours officer positions.⁹ Differential treatment of URM and white doctors likely contributes to this phenomenon, wherein URM doctors in the UK were nearly 12 times more likely to be brought before the Professional Conduct Committee (PCC) and 9 times more likely to be charged with ‘disregard for responsibility to patients’. Similar disparities persist among British-trained Asian doctors, who are less likely to receive awards that facilitate upward mobility of their careers and more likely to receive less remuneration.⁹ Racial and ethnic URMs constituted only 6.5% of U.S. practicing radiologists.⁷ Further, there was no significant increase in female representation among the U.S. practicing radiologists between 2003 and 2011.⁷ These disparities exist across all facets of the workforce, from private practice to academia.

Even among radiologists in the same subspecialty, there is horizontal occupational segregation; female radiologists devote less work effort (i.e. RVU) to advanced imaging modalities than their male counterparts.¹⁰ The reasons need further evaluation, but gender-based discrepancies in work allocation might be a factor.¹⁰ These data highlight an urgent need to increase the recruitment and retention of diverse medical trainees in radiology.

Disparity in research

Apart from clinical workforce, a gender disparity is seen in first- and last-authorship among radiology investigators, with 31.6% of the first and 19.3% of the last authors in medical imaging journals being female.¹¹ Research productivity is an indicator of career success in academia and if females’s productivity is hampered compared to their male counterparts, an effect exacerbated during the COVID-19 pandemic, the gender disparity gap in the workforce and, subsequently, leadership will widen.

Disparity in leadership

Collectively, less than 10% of U.S. radiology department chairs identified as black, Hispanic, or multiple-race.¹² A survey of female interventional radiologists in Europe and the U.S. found that 52% had no leadership role and 79% had a direct superior who was a male.¹³ Much of this may be attributed to societal stigmas and gender roles; when females adopt characteristics and behaviors associated with leadership, they are often looked down upon compared to their male counterparts who are encouraged to adopt these traits. Furthermore, male physicians have disproportionately more access to scholarships, grants, awards, and honors which help further their careers, especially in academia where research achievements facilitate professional advancement.¹⁴

Although there is still a long way to go, there have been some improvements in gender representation and diversity in recent years. Between 2010 and 2019, 50% of American Society of Neuroradiology presidents and an average of one-third of its executive committee were female, a significant improvement from previous decades.¹⁴ Just recently other radiology journals including the Journal of American College of Radiology, and Radiographics have appointed female editors-in-chief. However, these advances are tempered by the significant remaining gaps in both gender and racial diversity in radiology. For instance, as of 2019, the American Journal of Neuroradiology had never had a female editor-in-chief.¹⁴

Closing the gaps

Mentorship and directed opportunities can facilitate the career development of female and URM individuals in science. The under-representation of females and minorities in radiology (and other medical fields) creates a dearth of mentors, leading to a cyclical structure of under-representation and unequal opportunities for educational and career advancement. Increasing preclinical exposure to radiological subspecialties that have greater patient contact may facilitate recruiting more females to radiology residency programs. Programs that provides financial support, tutoring, research opportunities, and career counseling to URM students in science have demonstrated success in facilitating the entry of URM students into graduate and medical schools.¹⁵ Increasing mentorship, decreasing unconscious biases, decreasing the gender pay gap, and combating generational attitudes about the roles of females and URMs can promote greater diversity in radiology and medicine overall.

Concluding remarks

The significant and ongoing gaps in racial and ethnic representation in medicine suggest that more must be done to promote diversity in radiology and medicine. The British Medical Association’s (BMA) Equality, Inclusion, and Culture (EIC) policy team and the American College of Radiology Commission for Females and Diversity share similar goals with a mission to advance diversity and inclusion for the benefit of our patients and profession. The BMA EIC team has worked with medical schools to address racial harassment, advocated for equal opportunity for disabled physicians and trainees, and called for equal treatment of LGBTQ + members of the medical community. Females and URMs still face numerous barriers to upward academic and career mobility, suggesting that the root lies in deeper issues, such as stereotyping and unconscious bias, that must be promptly addressed. We can promote representation by increasing mentorship, awareness of biases, and concerted efforts to provide equitable opportunity. Diversity is not only beneficial for health-care providers, but also for patients because it creates a more representative pool of physicians who can advocate for patients from different backgrounds. It is a necessity.