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Mol Imaging Biol (2021)
DOI: 10.1007/s11307-021-01610-3
*World Molecular Imaging Society, 2021
REVIEW ARTICLE
Increasing Diversity in Radiology and Molecular
Imaging: Current Challenges
Brett Z. Fite,
1
Virginia Hinostroza,
1
Lisa States,
2
Alexandria Hicks-Nelson,
3
Lucia Baratto,
1
Kimberly Kallianos,
4
Marina Codari,
1
Brenda Yu,
5
Priyanka Jha,
6
Mana Shams,
7
Tanya Stoyanova,
1
Fanny F. Chapelin,
8
Anna Liu,
9
Ali Rashidi,
1
Fernando Soto,
1
Yuri Quintana,
10
Guido Alejandro Davidzon,
1
Krzysztof Marycz,
11
Iris C. Gibbs,
12
Daniel B. Chonde,
13
Chirag B. Patel,
1,14
Heike Elisabeth Daldrup-Link
1,15
1
Department of Radiology, Stanford University, Palo Alto, CA, 94305, USA
2
Department of Molecular Imaging, Children’s Hospital of Philadelphia, Philadelphia, PA, 19104, USA
3
Department of Comparative Medicine, Stanford University, Palo Alto, CA, 94305, USA
4
Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, 94143, USA
5
Department of Biophysics, Stanford University, Palo Alto, CA, 94305, USA
6
Department of Radiology, University of California San Francisco, San Francisco, CA, 94143, USA
7
Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
8
Department of Biomedical Engineering, University of Kentucky, Lexington, KY, 40506, USA
9
Department of Biomedical Engineering, Georgia Institute of Technology, Atlanta, GA, 30332, USA
10
Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, 02215, USA
11
Department of Experimental Biology, Wroclaw University of Environmental and Life Sciences, Wrocław, Poland
12
Department of Radiation Oncology, Stanford University, Palo Alto, CA, 94305, USA
13
Athinoula A Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical
School, Charlestown, MA, 02129, USA
14
Department of Neurology & Neurological Sciences, Stanford University, Palo Alto, CA, 94305, USA
15
Department of Pediatrics, Stanford University, Palo Alto, CA, 94305, USA
Abstract
This paper summarizes the 2020 Diversity in Radiology and Molecular Imaging: What We Need
to Know Conference, a three-day virtual conference held September 9–11, 2020. The World
Molecular Imaging Society (WMIS) and Stanford University jointly organized this event to
provide a forum for WMIS members and affiliates worldwide to openly discuss issues pertaining
to diversity in science, technology, engineering, and mathematics (STEM). The participants
discussed three main conference themes, “racial diversity in STEM,”“women in STEM,”and
“global health,”which were discussed through seven plenary lectures, twelve scientific
presentations, and nine roundtable discussions, respectively. Breakout sessions were designed
to flip the classroom and seek input from attendees on important topics such as increasing the
representation of underrepresented minority (URM) members and women in STEM, generating
pipeline programs in the fields of molecular imaging, supporting existing URM and women
Summary Report of the September 9–11, 2020 Vi rtual Diversity in
Radiology and Molecular Imaging Conference
Correspondence to: Heike Daldrup-Link; e-mail: heiked@stanford.edu
members in their career pursuits, developing mechanisms to effectively address
microaggressions, providing leadership opportunities for URM and women STEM members,
improving global health research, and developing strategies to advance culturally competent
healthcare.
Key words: Diversity, Radiology, Molecular imaging, STEM
Introduction
The goal of the 2020 Diversity in Radiology and Molecular
Imaging Conference was to facilitate meaningful discussions
related to diversity in science, technology, engineering, and
mathematics (STEM) that would lead to lasting change for
individuals who are underrepresented in STEM fields and
molecular imaging in particular, including women and
underrepresented minorities (URMs; i.e., those who have
self-identified as American Indian/Alaska Native, Black/
African American, Hispanic/Latino, Native Hawaiian/Other
Pacific Islander). We strongly believe that every member of
our community, regardless of ability/disability, race, gender,
background, religion, sexual orientation, or mental health
status, should have the opportunity to thrive in a supportive,
inclusive, and diverse professional setting.
One central theme that emerged throughout all presenta-
tions and roundtable discussions was the need for role
models, mentors, and sponsors for underrepresented mem-
bers in STEM fields. While overlap may arise between role
models and mentors, each is considered a distinct role in
drawing and retaining underrepresented members into
STEM fields. Panelists defined role models as those who
can be drawn upon for inspiration and reassurance that they,
as underrepresented individuals in STEM, are not alone in
the field and, further, that they too can succeed. Panelists
concluded that greater visibility of women and URMs within
the field might inspire future molecular imaging scientists
and clinicians. Diverse role models increase motivation and
confidence in trainees and allow them to “see themselves”
following a similar career path [1–4]. This perspective was
following reports by Dennehy and Dasgupta, who enrolled
women in pipeline programs during their first 2 years of
college—a critical time of recruitment to STEM
majors—and concluded that “the benefits of peer mentoring
endured long after the intervention had ended”[1]. Panelists
considered a mentor as someone senior within a field who
actively works with a more junior member to develop the
skills needed to succeed within that field. Panelists agreed
that efforts should be made to make mentorship programs
and opportunities available not just to trainees but also to
early- and mid-career women and URM members, with the
goal of closing the “leaky pipe”(Fig. 1), a phenomenon in
which group members progressively leave a field over time.
While the “leaky pipe”phenomenon has been observed in
multiple situations (e.g., early science education), we noted a
“leaky pipe”of women who successively drop out of
radiology careers with increasing academic rank. During
the conference, a significant point of discussion during the
conference was the importance of introducing STEM as a
viable and attractive career path to URM members early on,
ideally starting in grade school, to partially remedy the
“leaky pipe.”Finally, panelists discussed the need for
sponsors to actively support a higher representation of
women and URM members in senior and leadership
positions. In this context, we defined sponsors as organiza-
tions or individuals that provide financial, service, or
material support to help underrepresented members in
STEM succeed.
A second major theme that arose from the discussions
was the need for STEM clinicians and scientists to better
serve an increasingly diverse community. This aim entails
striving for culturally competent or proficient healthcare in
the clinical setting and increasing the diversity of the
populations studied by scientists, as the current lack of
diversity in studied populations [10–14] results in worse
outcomes for Black and Hispanic community members. A
major hurdle lies in recruiting and retaining these individuals
in clinical studies [15–17]. The cause of this hurdle is
multifaceted and includes “mistrust of researchers and the
government, lack of transportation, fear of exploitation, and
low levels of familiarity with medical research”[15]. These
fears are not without merit and, in fact, are predicated on
numerous egregious historical violations and exploitations
[18,19] of these communities. Thus, the burden lies firmly
with researchers to ease these rightful concerns and make a
concerted effort for inclusion. Furthermore, participation in a
research study disproportionately burdens members of low-
income communities [20] through a multitude of factors
including physical accessibility (e.g., lack of resources to
travel to a research site) and time constraints (e.g., less job-
related flexibility), hindering their ability to participate in
medical research studies.
The virtual conference received 908 views as of the end
of September 2020, with 514 attendees who actively
participated in the live event and 394 people who viewed
the conference content through the online portal (https://
www.wmislive.org/). Conference attendees comprised a
wide range of demographic/ethnic backgrounds and included
clinical and community radiologists, basic scientists, and
researchers in the field of molecular imaging. The main
topics of the event were racial diversity in STEM, challenges
faced by women in STEM fields, and global health.
Participants discussed these primary topics via seven plenary
Fite B.Z. et al.: Increasing Diversity in Radiology and Molecular Imaging
lectures, twelve scientific presentations, and nine roundtable
discussions. The following summaries of the key conference
themes provide an excerpt of “take-home points”from the
scientific sessions (abstracts of the scientific sessions are
presented in the Supplementary Materials) and roundtable
discussions.
Increasing Racial Diversity in STEM
Dr. Kassa Darge reflected on the low rate of URM members
in the field of molecular imaging and clinical medical
imaging. Black trainees and faculty typically comprise
approximately 4–7 % of all trainees and faculty within
STEM fields, with only ~2 % within radiology [5].
Numerous extrinsic and intrinsic factors contribute to this
underrepresentation. One factor is a lack of academic
mentorship. Mentoring is a critical element for faculty career
advancement in academic medicine, including radiology. Dr.
Darge discussed the critical importance and impact of
mentoring on enhancing diversity and inclusion in an
academic radiology department.
Dr. Daniel Chonde presented challenges faced by
hospital-based diversity, equity, and inclusion (DEI) com-
mittees. These committees [1] are charged with ensuring
equitable access to care regardless of race, gender, age, etc.,
while also promoting diversity within the workforce [21]; [2]
have historically been devalued financially and in their
ability to affect policy [22]; and [3]relylargelyon
volunteerism, which limits access to technical expertise
[23]. While the business literature has described increased
innovation [24], institutional experience has demonstrated
that the majority of DEI volunteers have similar skillsets.
Unlike DEI initiatives, a significant increase has arisen
for hospital-based innovation centers and their funding [25].
A major benefit of these hospital innovation centers is their
ability to engage frontline workers (e.g., nurses, physicians)
in the innovation process [26]. Working with a clinical staff,
these incubators assist in bringing products to market that
can potentially create revenue. Separately, previous work
has shown that continuous improvements in health technol-
ogy have benefited marginalized populations [27,28].
How to increase URM representation and inclusion in
STEM A central discussion point in this session was the
importance of introducing STEM as a viable and attractive
career path to URMs early on, ideally starting in grade
school. Similarly, dedicated career development programs
should provide high school students with shadowing
Fig. 1. Although women make up nearly 50 % of medical school graduates, as seniority increases, women are less
represented with less than 10 % of radiology chairs being women. We need to develop solutions to fix this “leaky pipe”of
career progression (Figure from [5]). The study was performed on 2010 data with 541 radiology residents included. Data
sources had US population data from the US Census Bureau, practicing physician data from the American Medical
Association, medical school graduate data from the American Association of Medical Colleges, and residency data from [6–9].
The authors state that “for race and ethnicity measures, unduplicated totals were provided for U.S. census, medical school
graduates, and residents and fellows for race and ethnicity separately. For other data sources, Hispanic individuals were
included in the “other”racial category because no breakdown by race was provided.”[5]
Fite B.Z. et al.: Increasing Diversity in Radiology and Molecular Imaging
opportunities at universities, giving them firsthand exposure
to the scientific problems currently being worked on and
informing them on the necessary skills they may need for a
career in STEM. The notion of “seeing is believing”
supports the idea that it is important for young URM
students to see scientists, physicians, and engineers who
look like them, thereby fostering a belief that they too could
pursue such a career. In addition, seeing URM members in
STEM positions promotes the perception of belonging to
individual STEM groups (e.g., a lab) and to STEM as a
whole. To this end, school outreach programs, particularly in
disadvantaged schools, could provide URMs with important
exposure to STEM fields at an early age. STEM trainees and
faculty at universities should receive recognition for
connecting with the broader community. For students from
financially disadvantaged backgrounds, financial support for
internships and shadowing opportunities is critically impor-
tant in order to make these programs attainable.
Among training programs for 20 subdisciplines in
medicine, diagnostic radiology ranks 17th in women and
20th in URM representation [5]. Thus, there is an urgent
need for radiology to address its dire underrepresentation of
URM trainees. A significant factor in this disparity may arise
from URM students not feeling “seen”by faculty mentors. A
greater effort should be made to assist mentors in under-
standing the unique challenges faced by URM students,
including pressures from home, financial burdens, and
family challenges. Often, URM students deal with these
pressures in silence while attempting to balance research and
educational responsibilities. One solution would be enhanc-
ing efforts to create or expand URM-directed mentorship.
This approach would significantly enhance the experiences
and future directions of the URM student population. In
principle, the interdisciplinary nature of the radiology and
medical imaging fields offers the opportunity to draw students
from a wide variety of scientific disciplines including math,
engineering, and computer science. Therefore, it may be
helpful to reach out to undergraduates majoring in such areas,
in addition to the more traditional life science departments,
introducing the field of radiology at an early time, when they
are starting to consider applying to medical schools or graduate
programs. Although an increasing number of research and
internship opportunities are available at this stage, being ableto
provide funding for URMs would increase the likelihood of
these students being able to participate in such programs. Such
programs could also help URMs foster connections with other
peers or colleagues that may be slightly ahead of them—such
as graduate students and postdocs—who can often offer insight
and support, encouraging them to stay in STEM fields.
Furthermore, it is imperative that efforts are made to ensure
that mentors continue their relationship with mentees, even if at
a reduced level, after the completion of their formal program to
provide continued encouragement and support to retain these
members in the field.
The digital divide—the large disparity between indi-
viduals who have easy access to computers and the
internet and those who do not—is an obstacle for
recruiting URMs to STEM fields. Without ready access
to computers or the internet, it is substantially more
difficult to acquire or develop technical skills, which
would otherwise come naturally from the repeated use of
technology. As there is an increasing need for more
technical skills throughout all levels of medical imaging
and STEM fields, it is important for these skills to be
developed early on. Yet, exposure to technical skills can
vary regionally (e.g., Silicon Valley versus rural areas).
More recently, the dramatic shift toward virtual learning
has also highlighted the importance of ensuring that
students have access to computer resources and reliable
internet connections. Thus, while an enhanced social
media presence of STEM institutions presents opportuni-
ties for an increased reach to a subset of URM students,
institutions must recognize that a significant portion of
the URM students they wish to reach may not have easy
(or any) access to social media due to socioeconomic
challenges.
Lastly, this discussion emphasized the importance of both
structured and unstructured mentorships as essential factors
in recruiting URMs to STEM programs, a notion further
supported by research [29]. A structured mentorship typi-
cally involves actionable items to achieve measurable goals,
often with requirements and milestones set at the beginning
of the relationship. Unstructured mentoring is more infor-
mal; goals and interim requirements are still usually defined
but are not always measurable or rigidly incorporated.
Advice provided for finding good mentors included meeting
and getting to know a variety of people at one’s institution,
preferably on a one-on-one basis, accepting as many
invitations as possible for professional events, and being
persistent in seeking connections. An interesting point that
arose during this discussion was the importance of helping
URMs develop what are commonly known as “soft skills”to
facilitate networking, make the most of mentoring opportu-
nities, and build strong collegial relationships with peers. As
such, it would be beneficial to provide workshops or
activities that help URMs to build these nontechnical skills,
which can include effective communication, listening,
leadership, and motivational skills [30] as well as creativity,
adaptability, empathy, and other habits that determine how
one works, particularly with others [31]. Conversely,
university faculty should be educated in the successful
management of diverse communication styles to enable them
to communicate with trainees from a wide variety of
backgrounds.
The success of diversity programs will undoubtedly
require significant time and effort, particularly when
there is a need to find funding. As such, it will be
crucial for institutions to recognize the efforts of faculty
Fite B.Z. et al.: Increasing Diversity in Radiology and Molecular Imaging
who become actively involved in diversity initiatives, in
terms of promotion criteria, monetary compensation, and
leadership opportunities.
How to Support Current URM STEM Members This
breakout session focused on how to seek feasible solutions
to issues URMs may encounter in their daily lives. The first
point of discussion focused on prejudices and approaches for
ensuring that formal evaluations of URMs are less biased.
People are frequently measured against previously held
biased opinions. An example is the harmful stereotype of a
non-smiling black woman as angry, unapproachable, and
intimidating [32]. Strong and confident women can be
incorrectly viewed as unreachable and domineering, leading
to their wrongful exclusion from career development
opportunities. A possible solution proposed by the panel
was to replace subjective evaluations by objective and
measurable evaluation criteria, such as the number of
publications, impact factors, and grants, rather than “popu-
larity scores,”which favor office politics and cliques of
majority members over productivity.
The second point of discussion focused on approaches for
helping URMs feel supported in the work environment and
features that URM members should seek when pursuing a
job. Networking with peers and leaders at other institutions
is an important tool to find allies and prepare for the next
move. Examples of networking include meeting with others
virtually in a one-on-one setting, visiting an institution in-
person before starting a new position, identifying diversity
programs, asking about onsite URM support groups, and
talking with URMs already in the department to learn about
the work environment.
The third point focused on how one can be an ally to
URMs and women and limit microaggressions (discussed in
more detail in sect. “How to Address Microaggressions in
STEM”). In this context, an ally is an individual who is not a
URM or a woman but acts to support them. Daily
microaggressions can significantly impact the experience
and motivation of URM or women STEM members.
Examples include men receiving credit for women's ideas,
inappropriate comments at work, and URM team members
being relegated to mundane tasks. The emotional costs of
these experiences are significant, and “emotional energy”
unrelated to job responsibilities is required to face these
problems. Participants suggested peer mentoring as a
valuable way to provide inspiration and endorsement, either
as a one-on-one experience or within a group, which often
provides support as well as knowledge and skills transfer.
Faculty mentors should listen and be approachable, acting as
a connector and sponsor. It is crucial that underrepresented
members and their allies call out inappropriate behaviors and
not be afraid of uncomfortable situations. In most cases, the
marginalized member feels uncomfortable. If the minority
becomes the majority, then an inappropriate comment or
action will make the perpetrator uncomfortable.
How to Generate Pipeline Programs for URM Diversity in
STEM Increasing diversity in STEM requires an increased
representation of URMs. Barriers to entry into this pipeline
and program dropout are both challenges to supporting the
careers of those who are underrepresented in STEM. The
panel recognized that early intervention at the precollege
(K-12) and college levels is critical for engaging URM
students into STEM. Strategies to successfully manage
early-stage pipeline programs can be applied at an individual
level, such as mentorship, career advice, and research
opportunities, or in the form of career development
programs, such as the American College of Radiology
Pipeline Initiative for the Enrichment of Radiology [33].
Obstacles to individual interventions include limited
network reachability. Current networking strategies are
primarily based on in-person or local interactions, which
may not be efficient for talented URM students in
economically disadvantaged or remote settings. Another
issue is the limited bandwidth of university faculty to serve
as career mentors for URM students outside their institution.
Most faculty are already overcommitted in mentoring
students at their institution. URM faculty in STEM some-
times take on disproportionate mentoring responsibilities
relative to their peers, an activity that requires great effort
but receives little recognition in terms of academic promo-
tion and success metrics. Many session participants had
experience either as contributors to or designers of larger-
scale pipeline programs at their department or university.
Barriers to the success of such programs included the
significant effort required to design and successfully
implement tailored activities for students at different levels
of training. The time needed to design an intervention,
engage or mentor students, and supervise research activities,
as well as a lack of funding to support program faculty and
administrative staff, emerged as the most relevant issue to be
addressed in the future. One session participant noted that
retired professionals may be interested in helping to close
this gap and that their breadth of experience could be
particularly helpful for trainees. Thus, active measures
should be taken to recruit this potentially untapped resource.
However, formal mentoring programs between retired
university professors and trainees will likely require some
form of compensation.
Finally, the panel discussed approaches for efficiently
quantifying the success of ongoing diversity programs. It is
difficult to quantitatively evaluate the short- and long-term
effects of these programs, as the ultimate goal of increased
URM representation and success in STEM and related fields
takes many years to realize. Short-term feedback from
participants must be combined with longer-term follow-up
to assess the full impact of these interventions to continu-
ously improve ongoing activities. However, while awaiting
longer-term data, other interim metrics can indicate the
success of various initiatives. Some possible metrics include
the number of URM students recruited to radiology
programs, comparisons of graduation rates for URM
Fite B.Z. et al.: Increasing Diversity in Radiology and Molecular Imaging
students in relation to their non-URM peers, comparisons
with other institutional programs in which increased repre-
sentation has been achieved, correlations between increases
in URM faculty and URM trainee retention, and measure-
ments of increased recruitment of junior and senior URM
faculty. Furthermore, recent data-driven efforts to develop
models for URM recruitment and retention, such as the
Louis Stokes Center for Promotion of Academic Careers
MODELS led by Dr. Isiah Warner [34], are integral to
developing the quantitative framework needed to improve
the success of diversity programs.
The Challenges Faced by Women in STEM Fields
This session focused specifically on women in STEM and
was led by Dr. Iris Gibbs, Professor of Radiation Oncology
at the Stanford University Medical Center and Associate
Dean of MD Admissions. Dr. Gibbs has been a strong
advocate for increasing diversity within STEM, and espe-
cially within the field of radiation oncology, and has
published reports on this important topic [35,36]. Dr. Gibbs
explained that the overall representation of women in STEM
has increased over the past two decades. However, despite
these gains, women remain underrepresented in many areas
of medicine and science, including radiology, especially at
the more senior career levels (Fig. 2). The proportion of
practicing women radiologists increased from 14 % in 1995
to 27 % in 2010 [38], and the percentage of women first
authors and senior authors of publications in the field has
risen from 12 to 34 % and 11 to 20 %, respectively [39];
however, the field of radiology lags behind other disciplines
in female representation: as of 2015, women constituted
approximately 75 % of pediatrics residents, 57 % of
psychiatry residents, 85 % of obstetrics/gynecology resi-
dents, 46 % of internal medicine residents, 41 % of surgical
residents, and 38 % of emergency medicine residents, but
only 27 % of radiology residents [40]. Gender discrimina-
tion, sexual harassment, gender derogation, and incivility are
persistent barriers for equity and career advancement and
impact wellness. Dr. Gibbs discussed unique challenges
faced by women, particularly women of color, in academic
medicine by sharing her personal journey. Epidemiological
research on the intersectionality of race and gender often
employs intersectionality theory [41] or multidimensional
theory [42] to interpret health outcomes across multiple
social variables. However, the emerging use of a holistic
identity approach to addressing health disparities appears to
be a superior method [43]. Women of color are severely
underrepresented in medicine (only ~4 %) and have little
visibility [44]. While it is difficult to ascertain whether
women of color experience greater disadvantage than either
non-minority women or minority men, this is partially due to
a dearth of data on this under represented group. Further-
more, minority women face the same obstacles that are
common for women and also those faced by minorities [44].
This in itself makes the experiences of women of color
unique. In a recent membership study of the American
College of Radiology, women and minorities disproportion-
ately reported disrespectful or unfair treatment though there
were some differences in the attributions of these behaviors.
For women, unfair or disrespectful treatment was reported to
be due to their gender and age, by patients and families, and
in terms of opportunities for career advancement; underrep-
resented minorities reported disrespectful and unfair treat-
ment attributed to their race/ethnicity and in terms of
opportunities for career advancement [45].
Dr. Miriam Bredella, Professor of Radiology at Harvard
Medical School, Vice Chair of Radiology, and Director of
the Center for Faculty Development, shared important
insights regarding the impact of COVID-19 on the careers
of women in STEM. Despite extensive work to improve
gender equity in academic medicine, women continue to lag
behind men in promotions and leadership positions. This
inequity has intensified during the COVID-19 pandemic,
which has disproportionately affected women who are taking
on increased childcare and household responsibilities and/or
the care of ailing relatives. Dr. Bredella described ap-
proaches to support women during this crisis, including
capitalizing on the shift of scholarly conferences to a digital
format to encourage more women to present their work and
providing opportunities for women to be visiting professors
at national and international institutions, such as the
innovative Visiting Scholars Program at Harvard University,
where they receive mentorship and engage in career
development.
Pipeline Programs for Women in STEM Despite a heavy
investment in gender equality programs, there has been a
subpar return with low overall attrition rates of women in
STEM throughout their careers [46]. Notwithstanding
ongoing efforts, women account for less than 13 % of
engineers, 25 % of the STEM workforce, and 23 % of
STEM professors [47–50].
Researchers have proposed multiple factors that may
affect the attrition of women in STEM, such as a lack of
women role models [51]. However, a more insidious and
deep-rooted problem seems to be gender-based stereotypes.
Among primary school children, the differences in perceived
competencies in STEM are negligible [52]. Yet, as girls
mature, the perceived gender differences in science acuity
increase such that most girls have self-selected out of STEM
careers by the time they leave high school [48,51]. Reshma
Saujani, who founded a charitable organization called “Girls
Who Code,”believes that “women have been socialized to
aspire to perfection and as a result are overly cautious,”
resulting in a fear of failure, which dampens their
questioning nature and prevents a sense of fulfillment in
STEM careers [53].
Studies have shown that educators and mentors can have
a profound impact on the development of girls toward
Fite B.Z. et al.: Increasing Diversity in Radiology and Molecular Imaging
STEM careers [52,54]. These mentors can guide talented
girls, particularly those in low-income areas or underrepre-
sented groups, toward STEM fields [54]. Addressing
gender-related stereotypes and expectations is important
[47]. In addition, introducing young women to a wide
variety of STEM options early on in their career may
improve long-term career outcomes for women in STEM.
How to Increase Female Representation and Inclusion in
STEM This breakout session focused on efforts to better
support women students and trainees within STEM. The
session aimed to bring awareness to the challenges faced by
women trainees, particularly women of color, and ap-
proaches for actively addressing issues of representation
and inclusion. Moderators opened the session and encour-
aged participants to share their experiences and perspectives
of women representation within their own fields. A summary
of effective and successful strategies (e.g., resources, support
groups, initiatives) that can be implemented into pipeline
programs was shared with the participants and the organiz-
ing committee.
Panelists felt that women were more likely to enter STEM
from non-traditional trajectories; for example, some partic-
ipants reported being an artist or teachers before committing
to STEM fields. Many came to medicine and biology after
having previously pursued unrelated career paths. Panelists
felt that this trend was at least partially related to the fact that
young women are intimidated by STEM. Many misbeliefs
may exist, such as the myths that STEM is very difficult,
lifestyle choices are harder for women in STEM, or women
brains are not fit for STEM.
Women may also have perfectionist personality traits, and
as science and experimentation are imperfect, there may be a
hesitation to experiment. Expectations of being a “super-
mentor”and being able to help with all issues are unrealistic.
Being the only woman (or woman of color) in the room can
be daunting. Bias toward women professors persists in
academic medicine and has the potential to adversely affect
patient care.
Participants noted that, although STEM is supposed to be
difficult, the lesson is to not back down and to learn along
the way. Early exposure to STEM, including volunteering
experience at hospitals, laboratories, and other STEM
avenues, was helpful for some participants. Mentoring
relationships formed during these experiences is pivotal for
making positive career decisions. Establishing a mentoring
and support network of a variety of mentors including
professors, peers, and other advisors takes effort but is
fruitful in the long run and is more beneficial than relying on
a single mentor. Mentoring can be structured or non-
structured, and a calendar appointment is not essential for a
Fig. 2. The “elephant in the room”: while women make up ~50 % of medical school applicants and graduates, they are
increasingly underrepresented in senior and leadership positions. Reprinted from [37] with permission from the Association of
American Medical Colleges.
Fite B.Z. et al.: Increasing Diversity in Radiology and Molecular Imaging
meaningful conversation. Women must seek to make both
women and men allies. Moreover, challenges can be
particularly overwhelming for women of color. Discussion
participants suggested that attending historically black
colleges and universities (HBCUs) may enable some Black
women to flourish and discover satisfying careers. However,
HBCUs represent only ~3 % of US colleges and universities,
which makes this an unviable proposition. Furthermore,
while such a suggestion may, on its face, seem benign, it
shifts the responsibility of fostering the success of Black
women onto these institutions. Instead, we must carefully
examine the reasons behind why “traditional”colleges and
universities do not foster the same degree of success for
people of color.
When part of a larger group, promoting younger women
in the conversation helps boost inclusivity. Unconscious bias
training should be mandatory in institutions to allow
scientists to understand their biases, especially those against
women and people of color.
In addition, steps must be taken at departmental and
institutional levels to increase female representation. Many
STEM departments recognize this need, especially at more
senior and leadership levels, and have actively sought to
recruit women employees. However, especially in fields
such as radiology where women are drastically underrepre-
sented, more efforts are needed. One strategy that depart-
ments can employ is to increase the visibility of current
women radiologists to provide role models for those who are
considering the specialty but are unsure whether they would
fit in. Another way in which organizations can work toward
this goal is to make concerted efforts to place women in
leadership roles within the department. This approach serves
the dual role of making women more visible while also
giving them the opportunity to affect policy changes.
How to Address Microaggressions in STEM
Microaggressions are defined as indirect, subtle, or uninten-
tional statements or actions of discrimination against
members of a marginalized group. Although
microaggressions can result from unconscious beliefs linked
to systemic racism, they sometimes arise from a lack of
knowledge on the topic or a lack of awareness. Concerted
efforts are needed to correct microaggressions when they
happen. One possible way of responding to
microaggressions is by asking for clarification and further
information regarding the statement and providing feedback
about why a specific comment or action is hurtful (Fig. 3).
However, this is often easier said than done. A URM
individual may feel uncomfortable with directly addressing a
microaggression for a myriad of reasons, not least of which
is the worry that their colleagues may view them as being
“hypersensitive”or “not likeable.”Furthermore, a URM
individual is often the only one in a situation who recognizes
a microaggression; thus, by calling out the microaggression,
the URM individual risks being labeled as an “other,”which
is the opposite outcome that initiatives aimed at reducing
microaggressions attempt to achieve. Because they are not
targeted, allies can be in a better position to address
microaggressions. Allies must educate themselves on the
various forms of microaggressions, so they can immediately
challenge them. When allies address microaggressions, they
directly validate the target and provide feedback to the
perpetrator.
A majority of participants of this discussion group agreed
that microaggressions should be addressed immediately,
although not all participants felt that they would have the
courage to do so. Participants shared that microaggressions
made them feel different from others, upset, and angry.
Some participants felt that they had become numb to
microaggressions and thus did not try to respond to
microaggressions even when they recognized and were
negatively affected by them. In addition, participants
reported that they had been previously labeled as overly
sensitive when responding to microaggressions and had been
attacked when questioning microaggressions. Direct feed-
back to intentional microaggressions would likely not
change the future behavior of an individual, which may
require more formal disciplinary actions, while unintentional
microaggressions can be addressed more directly.
All participants agreed that group discussions on
microaggressions are helpful, that the issue should be
discussed more often, and that it is essential to increase
awareness about microaggressions and learn more about
strategies for dealing with them. Participants, consisting of
women only, also noted that it is important to increase the
gender distribution of those involved in such group
discussions.
Global Health
To start the discussion, Dr. Justin Tse provided an overview
of his experience as a visiting Radiology resident at the
Muhimbili National Hospital (MNH) in Dar es Salaam,
Tanzania. The MNH serves as a tertiary referral center for a
country of over 55 million people. Eight staff radiologists
provide medical-imaging-related services for this 1600-bed
hospital. Radiology as an independent department is rela-
tively new at MNH, and the residency program is only 10
years old. The hospital has modern radiology equipment,
highly motivated residents and staff, a wide referral base,
and a large patient population with complex pathologies,
including neurology, cardiology, oncology, and surgery. In
this lecture, Dr. Tze shared lessons learned, including [1] the
role of radiologists in promoting healthcare access in
developing countries, [2] common misconceptions about
global health radiology, [3] ways to contribute and maximize
impact, and [4] strategies to maintain sustained growth.
Dr. Yuri Quintana described approaches to increasing the
impact of medical research and treatments for global
populations. Curricula must integrate global health,
Fite B.Z. et al.: Increasing Diversity in Radiology and Molecular Imaging
specifically by linking cultural competence with global
health in medical education [56,57]. Furthermore, there is
a lack of diversity in the populations studied in clinical trials
[10–12], which limits their applicability to underrepresented
groups. Thus, we need more global collaborations that focus
on capacity building in clinical care and research [58]. One
example is the Men of African Descent and Carcinoma of
the Prostate Consortium, which is collaborating on epidemi-
ologic studies to address the high burden of prostate cancer
among this historically underserved population. These
investigators aim to understand the complex multifactorial
causes of prostate cancer etiology and outcomes among men
of African ancestry worldwide [58].
Dr. Michele Barry discussed women leadership in the
context of global health. Attention in global health is often
focused on financing, the distribution of commodities, and
the development of innovative tools, with little focus on the
people responsible for ensuring that these resources reach
everyone who needs them. Despite accounting for over 70 %
of the global health workforce, fewer than 20 % of
individuals in leadership positions identify as female. Hence,
we need to improve gender diversity in our teams [59,60].
The lowest percentage of female representation within the
American Association of Physicists in Medicine is among
council chairs, with only one woman having held a chair
position out of 42 positions (2.4 %) from 1970 to July 2019
[60]. In a report [61] that sampled 200 global health
organizations, more than 70 % of the leaders were men,
more than 80 % were nationals of high-income countries
(HICs), and more than 90 % were educated in HICs. Norway
increased the percentage of women on boards through
concerted efforts [62], by introducing quotas in 2003
mandating that publicly listed corporations reserve a
minimum of 40 % of board seats for women. Companies
were given until 2008 to achieve compliance. In 2003, the
year the quota was adopted, ~20 % of individuals on
Norwegian company boards were women; by 2005, this
proportion was 35 % (compared with 19 % in the USA and
3 % in Japan), and in 2009, this value exceeded 40 % [63].
Research has shown that a greater proportion of women in
leadership correlates with increased public health spending
[64] and greater public confidence in the government [65].
Fig. 3. Addressing microaggressions and interrupting bias, used with permission from [55].
Fite B.Z. et al.: Increasing Diversity in Radiology and Molecular Imaging
Multidisciplinary approaches to global problems, rather
than siloed solutions that are not inclusive or sustainable,
must be fostered. Some recommendations for the future
include [1] placing global health research on an equal
footing with domestic health research (funding, career
advancement); [2] achieving diversity in research teams, in
target population studies, and in funders (board members);
[3] improving the diversity of funding priorities focused on
the needs of low- and middle-income countries (LMICs); [4]
investing in sustainable training of people and infrastructure
in LMICs and modifying solutions for LMICs; and [5]
creating long-term partnerships between institutions and
creating Global Communities of Research and Practice to
sustain projects and relationships.
How “Global”Is Global Health? In a world that is
continuously becoming more connected, increased general
awareness and feelings of responsibility toward health
disparities worldwide have driven a global health movement.
Koplan et al. were the first to delineate the span of global
health as “an area for study, research, and practice that
places a priority on improving health and achieving equity in
health for all people worldwide”[66]. Of note, the ongoing
COVID-19 pandemic has unquestionably reminded us that
developed countries are not immune to deadly infections and
that global health coordination is essential to reduce
worldwide mortality and economic impacts.
Global health is usually characterized by health out-
comes, such as life expectancy, child mortality, and
infectious diseases. The panel discussed a few World Health
Organization charts depicting global health disparities in
these areas and concluded that numerous challenges remain,
falling into three main categories: data, research, and policy.
Panelists emphasized the importance of data gathering
and transparency (especially for sensitive topics such as
suicide and mental health) and the need for quantitative tools
to measure the impact of specific policies on the data.
Participants also suggested enhancing the diversity of
research subjects (age, gender, ethnicity, etc.) in clinical
studies. Moreover, panelists discussed the need to level the
field for disease funding to solve global health problems, for
example, by directing more funds toward preventable or
curable diseases in developing countries. The group
discussed whether the idea of a centralized global agency
that would coordinate and distribute medical research
funding equitably corresponds to a utopia and whether
global health disparity is simply a money issue. The
panelists emphasized that, beyond monetary help, policy
implementation and global cooperation are necessary to
maximize impact. Governments should promote access to
public services and support particularly vulnerable groups.
Policymakers, researchers, and healthcare professionals must
work together but remain independent from each other to
best guide decisions regarding public and global health.
The panel also discussed strategies that could be
implemented at the individual, university, and national level
to reduce global health disparities. At the personal level,
researchers have the responsibility to report reliable data to
the scientific community. At the institutional level, univer-
sities can implement visiting scholar programs, specifically
those with the goal of knowledge transfer, to yield a broad
impact in developing nations. The panel also discussed
encouraging universities to diversify their portfolio beyond
cancer, heart disease, and dementia research, to focus on
additional areas that affect global health. For example,
neglected tropical diseases primarily affect low-income and
developing countries [67]; however, research for these
diseases receives little funding compared with other infec-
tious diseases such as tuberculosis and malaria, despite a
similar health impact within developing countries [68,69].
The current pandemic has reinforced the rationale for such
pursuits. Rebalancing disease research disparities is a critical
step toward equity in health.
The panel concluded that effectively addressing global
health issues relies on promoting access to data, increasing
research means, and implementing policy changes at the
national level and as a global partnership.
How to Advance Global Health Research Global health
research focuses on the health of people living in LMICs and
on understanding systematic factors that shape health are
inherently global. Established researchers in developed
countries can support researchers in developing countries
through training and mentoring. However, research methods
in developed countries may require adaptation depending on
the infrastructure and resources of a low-income country.
For example, diseases that may be interrogated with cross-
sectional imaging studies in HICs may be approached with
different imaging modalities, or often not at all, in low-
income countries. The panel identified the need to expand
medical centers and universities in developing countries to
provide meaningful medical care for patients and career
opportunities for early-career researchers to mitigate the
“brain drain.”
The panel discussed the use of technology to address
limited resources and the need for skills transfer to
implement and adapt technologies for local healthcare
systems. Telemedicine and artificial intelligence (AI) are
good examples of technologies that can be employed to
reduce the burden on limited resource systems. AI may be
helpful, with the potential to make a difference in several
narrow applications (e.g., aiding radiograph interpretation).
To facilitate this approach, adaptation to local circumstances
is needed. Dr. Quintana described Alicanto (Fig. 4), a
platform and online community that could enable online
skills transfer for both clinical care and research in
developing countries [70].
While there is much excitement about AI applications for
clinical care in developing countries, there is no successful
Fite B.Z. et al.: Increasing Diversity in Radiology and Molecular Imaging
example related to medical imaging to date. The panel
discussed problems with AI bias in algorithms and the need
for further research prior to the use of algorithms developed
in high-income populations for other populations with
different clinical, genetic, and socioeconomic backgrounds.
Cultural Competence in Global Health Cultural compe-
tence describes the ability to understand, communicate with,
and effectively interact with people across cultures [71]. The
panel emphasized that cultural competence is a matter of
intellectual flexibility. Cultural competence is not only the
recognition that different cultures exist but also a funda-
mental acceptance of different styles and viewpoints [72–
74]. Cultural competency has become increasingly important
to meet the needs of diverse patient populations.
The panel discussed the benefits of cultural competence
in the clinical setting. A review of culturally competent
healthcare practices and outcomes [75,76] illustrated the
positive impact of language competence [77–80] and the
inclusion of culture-specific concepts [81–83]. Culturally
competent healthcare reduces health disparities, medical
errors, medical visits, and enhances preventative care.
Moreover, the added social benefits include increased trust
and community member inclusion. All of these factors lead
to improved outcomes for patients and increased provider
satisfaction and morale.
To improve cultural competency, the panel felt that more
substantive cultural competence education and integration as
a standardized part of the medical curriculum would provide
a good start. Other suggestions included using an interdis-
ciplinary approach to address the synergy between cultural
competence and global health and embedding the topic
throughout the curriculum. Furthermore, given the dynamics
of culture, more concerted efforts should be made to provide
continuing education in cultural competence [84].
Summary
It is widely accepted that gender and racial diversity benefit
both organizations (improved morale [85] and motivation
[86]) and fields/specialties (improved decision-making [87,
88] and results [89,90]). However, many current efforts
aimed at eliminating discrimination and increasing diversity
focus primarily on training. While training initiatives yield
success [91], there is a risk that these efforts will lead to
“box ticking”as opposed to real change. If not reinforced,
the initial success of DEI training can be lost. Conversely,
repeated training sessions (e.g., annual training) can be less
productive if the training becomes a repetitive course (i.e.,
same content presented every year) that people feel they
need to “get through.”When designing ongoing diversity
training/initiatives, organizers should seek new and innova-
tive ways to present material and ideas to their audience.
Diversity events and activities, such as the one summarized
in this review, are an integral component to shaping attitudes
and enhancing gender, racial, and cultural diversity [92].
Continuing education in diversity through themed programs
Fig. 4. Alicanto is a platform and online community that could enable online skills transfer for both clinical care and research in
developing countries.
Fite B.Z. et al.: Increasing Diversity in Radiology and Molecular Imaging
and activities, as opposed to annual “trainings,”offers the
opportunity to positively engage participants and find
solutions for emerging issues related to diversity.
Acknowledgements. The authors wish to thank Lisa Baird, CEO of the
WMIS, Lauren Whitman, and Sylvia Anderson from the WMIS, Mekemeke
Faooso and Tricia Hatcliff from Stanford Radiology, and Emily Manche
from the Stanford CME office, who organized all administrative aspects of
the event. We would also like to thank members of the WMIS and Stanford
Radiology leadership team, who provided opening remarks on each of the
conference days, including Dr. Martin Pomper, immediate past president of
the WMIS, Dr. Garry Gold, Interim Chair of the Radiology Department at
Stanford, Dr. Carolyn Anderson, President Elect of the upcoming WMIS,
Dr. Jason Lewis, Editor in Chief of Molecular Imaging & Biology, and Dr.
Payam Massaband, Program Director of the Stanford Radiology Residency
Program. Many thanks also to the 32 moderators from 15 different
institutions, who facilitated the presentations and breakout sessions! We
are grateful to our invited speakers, including Dr. Kassa Darge, MD, PhD,
DTM&P, FSAR, FESUR, Chair of the Department of Radiology at
Children's Hospital of Philadelphia, Dr. Iris Gibbs, MD, FACR, FASTRO,
Associate Dean of MD Admissions, Stanford Medicine, Dr. Miriam
Bredella, MD, Vice Chair, Department of Radiology and Director of the
Center of Faculty Development, Massachusetts General Hospital, Harvard,
Dr. Michele Barry, MD, FACP, Senior Associate Dean of Global Health at
Stanford, Dr. Yuri Qintana, PhD, Director of Global Health Informatics at
BIDC, Harvard, Dr. Brielle Ferguson, PhD, NRSA Postdoctoral Fellow at
Stanford, Dr. Jayne Seekins, DO, faculty leader of the Radiology outreach
program, and Dr. Justin Tse, MD, Stanford Radiology resident. We thank
Dr. Julie Gosse for editing this manuscript. A big thanks to all contributors
and attendees for investing the time and effort to share their experiences
with us!
Funding. The authors have no sources of funding to disclose. Dr. Iris C.
Gibbs, MD, declares receiving honoraria for lectures unrelated to the current
subject matter (Accuray, Inc.).
Declarations
Conflict of Interest
The authors declare that they have no conflict of interest.
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