Recommendations for Improving Canadian Radiology Equity,Diversity and Inclusion

Abstract

Improving equity, diversity, and inclusion (EDI) within Canadian radiology is critical for optimal patient care and to reduce health disparities. Although there are increasing national EDI initiatives, there is a paucity of resources available to assist radiology departments as the culture of EDI evolves and faculty and institutions are expected to incorporate EDI in their practice. We present practical recommendations for radiology departments, radiology training programs, and individual radiologists wishing or mandated to improve EDI in the workplace. Actionable strategies for creating an environment that promotes EDI, attracting and supporting diverse trainees, and for how individual radiologists can be allies are presented. These EDI strategies are imperative to provide the best patient care and to strengthen the future of Canadian radiology.

Introduction

The radiology community recognizes that improving equity, diversity, and inclusion (EDI) within radiology is critical to enhance patient care and to reduce health disparities. ¹ Appropriate EDI training and assessment is necessary for radiology team members to ensure an understanding of cultural humility and trauma-informed care, the social determinants of health and health disparities, the historical roots of inequities and structural supports that continue to propagate them, and the impact of race-based medicine on clinical care and research ¹ .

In Canadian radiology, the first national efforts to raise awareness of EDI were in 2018 with the creation of Canadian Radiology Women (CRW), a community of Canadian women radiologists, fellows, residents and medical students interested in improving diversity in Canadian radiology. ² Six members of CRW proposed an EDI working group to the Canadian Association of Radiologists (CAR) board in late 2020 and in early 2021, the CAR EDI Working Group was formed to oversee multiple EDI committees addressing important EDI topics: encouraging application to radiology, addressing bias in recruitment, hiring, promotion and awards, the gender pay gap, and creation of an EDI Tool Kit.

Following creation of the CAR EDI Working Group, many Canadian academic radiology departments have begun to create their own EDI committees and have found that resources to improve departmental EDI and recommendations for individual radiologists to support EDI principles often do not exist. ³ This lack of resources leaves many institutions and individuals uncertain of what steps they can take to promote and increase EDI in their workplace. This fundamental gap in resources and knowledge must be addressed, as EDI is a concept that most faculty and institutions are now expected to incorporate in their practice. ⁴

As Canadian radiology leadership recognizes EDI as a priority there is great opportunity to provide guidance to optimize EDI efforts. ⁵ In this article, we recommend practical strategies to guide radiology departments, training programs, and individuals, wishing (or mandated) to increase EDI in their workplace. To our knowledge, no such Canadian radiology EDI resource exists.

Radiology Departments: Creating an Environment that promotes EDI

1. Establishing EDI committees: Radiology departments should have their own EDI committee whose mandate is to define the department’s EDI priorities, establish EDI goals, and help put into place steps to achieve these goals. ⁶ This committee should play a key role in creating and fostering a welcoming EDI culture within the department. Funding for EDI initiatives should be a departmental priority. Institutions should recognize those working to improve EDI in terms of monetary compensation, promotion criteria, and leadership opportunities. ⁷ The EDI committee can set targets and timelines for EDI goals and hold departmental leadership accountable should goals not be met. For example, status of diversity and inclusion within the department could be assessed every five years, which would facilitate targeted measures. ⁸

2. Fostering a culture of EDI: Radiology institutions should actively promote EDI. This can be done by formally acknowledging and rewarding work towards improving EDI in the workplace. Often and usually initially, the bulk of EDI work is done by women and underrepresented minorities (URM). This is an additional burden that women and URM must bear in addition to the systemic biases working against them. When EDI work is not fairly recognized, there is less incentive to continue the work and it makes it harder to recruit like-minded people. EDI work should be valued as much as conventional research and publication. ⁹ Most importantly, to retain diverse employees, it is crucial to create an inclusive culture that encourages employees to respect, listen and understand each other’s differences. Companies devoted to EDI and employee well-being report less employee burnout, fewer employees consider leaving, and more employees promote their workplace. ⁹ Departments need to send the message that EDI is important. Departmental awards and leadership positions recognizing EDI and mentorship work are recommended. Intentional changes to create and maintain an inclusive workplace may be required. Choosing gender inclusive terminology, for example using “Breast, Gynecological and Obstetrical Imaging” instead of “Women’s Imaging,” and encouraging pronouns be indicated in virtual meetings and correspondence can have a significant positive effect on staff and patients. ¹⁰ Departments should also ensure that adjustable workstation equipment is available and that the workplace is accessible to all.

3. Instituting clear policies on harassment and bullying: Radiology departments should have zero tolerance for all forms of violence (discrimination, bullying, harassment etc.) in the workplace, whether it is physical, verbal, or virtual. Departments should also have a clear and accessible written protocol explaining the steps for reporting discrimination, bullying, and harassment.^11-13 This process should be effective, safe, and anonymous. It is also recommended to keep a record of reports of such actions, their management and their impact to prevent future events.^8,14 Finally, radiology departments should offer resources in the workplace, such as a go-to person, to support individuals affected by such events.

4. Offering EDI training and awareness: Radiology departments should make EDI workshops and presentations available to all administrative staff, faculty and trainees. In addition to informing department members about EDI principles, such events will increase awareness of EDI and will affirm the department’s commitment to EDI. At a minimum, all members of leadership and selection committees should be required to undergo EDI training and some institutions have made it mandatory for all their members to take part in unconscious bias training. ⁷ For example, the RSNA provides such training for all of its board members, trustees, editorial boards and other leaders. ³

The leaky pipeline is a phenomenon used to describe the loss of women from the career advancement trajectory. ¹⁵ Departments should provide leadership training opportunities for women and URM so they can increase their representation in leadership positions.

5. Incorporating EDI into selection, recruitment, hiring and promotion: Intentional incorporation of EDI principles at all stages of the selection, recruitment, and promotion process is required to change radiology demographics. ¹⁶ The radiology community should reflect the population it serves. To do so, faculties could consider terminology used to attract applicants and try to avoid using stereotypes or “masculine words. ¹⁷ ”Institutions should also consider removing mandatory requirements for positions from position advertisements, as women have a tendency to only apply when they feel they meet or exceed 100% of the criteria.^15-18 All attempts should be made to recruit applicants with a wide range of experience. Finally, selection committees should also be as diverse as the candidates sought. ³ This may require deliberate restructuring of the selection committee.

6. Improving data collection: Finally, radiology departments must collect and review their own data. In order to properly address gaps in EDI, data must be obtained to identify underrepresented groups and the barriers they face to direct efforts where they will be most effective.^19,20 Radiology departments must create a safe space to encourage participation, which must be voluntary and in line with local institution and privacy policies. Data collection can be made via an inhouse survey if there is no appropriate survey available at the institution. All members of the department should be asked to participate-administration staff, faculty, and trainees. Results should only be shared in aggregate to eliminate identifying data and a minimum number of responses in a group could be considered for it to be reported back to the staff/team.

Radiology Training Programs: Attracting and Supporting Diverse Trainees

1. Increasing earlier exposure to radiology: Radiology is a specialty associated with common myths and stereotypes about its practice such as limited patient-contact, harmful radiation exposure to radiologists and prolonged time spent in dark and secluded rooms. ²¹ These myths can only be deconstructed by increasing earlier exposure to radiology. Hence, radiology faculties should develop shadowing opportunities tailored for women and URM medical students to provide early exposure to the field. Some programs even propose to expose women and URMS as early as kindergarten to radiology. ³ Early exposure to radiology and diverse radiologists with in person or online shadowing opportunities is a good way of increasing interest in radiology as a career choice. ²² Practical strategies include ensuring that all undergraduate radiology teaching opportunities include women and URM and that women and URM are part of the medical school shadowing database.

2. Offering more mentorship programs: Structured mentorship programs have the potential to create a snowball effect, as increasing the visibility of women and URMs in the radiology program has the power to increase the number of women and URM applying to radiology. For example, C.Yoon et al. showed that residency programs with the largest number of women are often run by women directors. ²³ Radiology programs should develop structured mentorship programs for all levels of trainees. Radiology departments should also consider incorporating “mini-mentorship” programs within their larger mentorship program to specifically target EDI issues. These “mini-mentorship” programs should reach out to medical students of underrepresented groups in radiology, such as women, and provide tailored mentorship opportunities, including research and shadowing experiences. The “mini-mentorship” programs would vary according to the needs of the target group.

3. Incorporating EDI in the CaRMS process: Radiology programs should focus on showing women, URMs and applicants from marginalized groups that EDI is an important part of the program’s culture. One North American radiology department has demonstrated how multiple changes together can have a significant impact on increasing diversity in applicants. By taking multiple steps to promote EDI throughout their application process such as using a website with a departmental diversity web page, reaching out to predominantly minority institutions and creating a welcoming and inclusive environment for visiting, they managed to obtain a significant increase in URM representation in their residency program. ²⁴ URMs are much more inclined to join programs that promote inclusivity and diversity, with 67% of medical students reporting that the climate of diversity and inclusion led to a higher radiology program ranking. ²⁵ If possible, the selection committee member diversity should reflect the community diversity. ²⁶ A more diverse committee will mitigate individual implicit biases and provide multiple perspectives in the selection process. ²⁷ Intentional restructuring of the selection committee may be required to meet these goals.

4. Increasing EDI training: In addition to departmental EDI training offered to faculty and the selection committee, EDI training should be incorporated into the Diagnostic Radiology Residency curriculum. Radiology trainees should be provided with the education and skills to provide the highest quality care for patients from all backgrounds and to understand patients’ health in the context of systems of structural racism and health disparities. Residency training programs must include dedicated time for EDI training. Examples include organizing a formal EDI academic half day for their residents in consultation with both the Department of Radiology’s and Faculty of Medicine’s EDI committees. To facilitate this, it is recommended that Program Directors connect with EDI committees outside of radiology, such as those within the university or Faculty of Medicine, for additional resources and support. Another approach would be to combine this academic half day topic with the teaching in subspecialty radiology residency programs (e.g. nuclear medicine, pediatrics, interventional) or even another similar residency program (e.g. radiation oncology).

5. Considering a holistic approach to application review: Radiology programs should consider setting a more holistic approach to review of applications rather than a strict metric based review. Strict review limitations and cutoff points may in fact limit diversity. Broadened scoring system parameters for review might include objective evaluation with standardized review metrics of application criteria such as letters of reference, research productivity, extracurricular activities, and life experiences.^28,29 This could minimize potential personal biases of members of the committee. Ongoing review of the evolving literature that evaluates selection tools is required to avoid using a tool that may limit diversity.

6. Standardizing Interviews: Unstructured interviews can result in bias by the members of the committee. The ability of a committee to objectively evaluate an applicant over the course of a few minutes is limited under the best of circumstances. We recommend rating scales to evaluate an applicant’s responses. More detailed information on how to create rating scales for the interview can be found in Best Practices for Conducting Residency Program Interviews, published by the Association of American Medical Colleges.^30,31

Individual Radiologists: How to be an ally

1. Increasing self-education and awareness: Radiologists committed to fostering EDI must educate themselves on the reasons EDI is important in radiology, existing EDI practices, and acknowledge the many long-standing existing systemic biases against women and URM.^4,32 Radiologists should be self-aware and understand how their actions can impact others around them. ³³ By acknowledging the role of EDI in radiology and the impact of biases in the workplace, individuals can hold themselves and others accountable and challenge problematic assumptions and actions. This can lead to change in language and behavior, which can create a more inclusive workplace. EDI resources are increasingly available. Whether or not mandated, we strongly recommend all radiologists seek out resources such as lectures, workshops, and articles. Radiologists can also reach out to organizations with existing EDI initiatives such as the CAR EDI Working Group, CRW, the American Association for Women in Radiology, and the American College of Radiology for up to date resources and to become more involved in EDI activities.

2. Recognizing unconscious bias: Unconscious biases are defined as “social stereotypes about certain groups of people that individuals form outside their conscious awareness.” ³⁴ Every individual has biases, which can vary according to background and experience. Recognizing unconscious biases is important in order to find strategies to counteract them.

Multiple resources exist about unconscious bias, but no standardized curriculum exists. ³⁵ One of the most common tools used to assess unconscious bias is the Harvard Implicit Association Test (IAT). ³⁶ The IAT is a free online test that guides participants to identify unrecognized gender and racial stereotypes.^37-39 These tests are useful to help individuals recognize their unconscious bias, but follow-up efforts are required for meaningful change.

Formal well-designed anti-bias training can also be useful to guide individuals. However, it is unrealistic to expect complete transformation from anti-bias training alone. ³³ Identifying and accepting one’s biases is the first step to avoid making biased decisions. ³ One must actively mitigate bias to create a culture of inclusion, which in turn will lead to improved workplace diversity and health equity.^35,40

3. Addressing microaggressions: Microaggressions are a wide spectrum of comments or behaviors, often subtle and sometimes unintentional, that discriminate against marginalized groups and usually originate from unconscious biases. ⁴¹ Examples of verbal microaggressions might include an individual saying to a female radiologist “You are too pretty to be a radiologist and sit in the dark. You should be a pediatrician.” or saying to an Asian resident “This patient is Chinese and we need an interpreter. You speak Chinese, right?” when the resident is Korean.^41,42 Microaggressions can also be directed at patients and allied health staff.

As individuals, we should be aware of microaggressions and the impact they have on others. Microaggressions can cause the recipients to be frustrated, and in the long term, repeated microaggressions can negatively affect self-confidence and self-image. ⁴² It is important to make a conscious effort to learn about microaggressions, as most microaggressors offend subconsciously. ⁴² When witnessed, microaggressions should be called out so that they can be acknowledged and addressed.

4. Mentoring and sponsoring: Mentorship and sponsorship are some of the most effective ways to provide support to women and URMs in their careers.^43,44 Mentors serve as advisers and provide support and knowledge. Sponsors advocate and actively seek out opportunities for their protégé. ⁴⁵ These two complementary concepts have a major impact at different moments in someone’s career. Mentorship often plays a more significant role at the beginning of a career, ⁴⁶ while sponsorship often plays a more important role mid career or late career. ⁴⁷ Currently, women are under-sponsored compared to men. ⁴⁸

At the medical student level, a positive mentorship experience was one of the leading reasons to pursue radiology. ⁴⁹ In addition, residents, fellows, and junior radiologists with a mentor and/or a sponsor have more self-confidence, publish more, and have more career advancement.^45,47-52

Currently, there is a paucity of women and URM radiologists available to serve as role models, making it more difficult to inspire the next generation of radiologists. ⁵³ One solution to this problem is to train male mentors to mentor women and URMs. ⁵⁴ This has proven to be effective in increasing mentor confidence and mentee satisfaction (up to 61% in 2019) at the University of California with the Faculty Mentor Training Program. ⁵⁵ We strongly encourage all radiologists to mentor or sponsor women and URMs, since this could have a significant impact on their career.

Conclusion

Canadian radiology EDI efforts must continue to increase both locally and nationally. Canadian Radiology departments, training programs and individual radiologists are responsible for improving EDI in the workplace. Inclusive work environments are imperative to prevent radiologist burnout and human health resource shortages. Increasing the diversity of the radiologist workforce will foster innovation and improve patient care. A radiologist population that more adequately reflects the population served can better meet the needs of our increasingly diverse patient population and improve health equity. Radiology leadership, institutions and individual radiologists can leverage the proposed actionable strategies to improve EDI in Canadian radiology. These EDI strategies are imperative to provide the best patient care and to strengthen the future of Canadian radiology.