Women in Radiology: Challenges and Opportunities

Abstract

Improving the status of women in radiology is crucial to better work environments. There is strong evidence in the business world that women leaders improve the workplace by making it more financially viable and by increasing collaboration, job satisfaction, and engagement. Diverse leadership fosters innovation, and women approach problem-solving with unique insights and collaborative styles. Gender diversity in leadership correlates with improved patient outcomes because women leaders prioritize patient-centered care and communication. Women create sustainable, productive work and improve radiology. Women serve as powerful role models, inspiring the next generation of women in radiology and addressing gender disparities. Increasing women leaders in radiology is essential to increase the number of women in radiology. This article summarizes many challenges women face when taking leadership roles: organizational biases prioritizing male viewpoints and marginalizing women’s voices and contributions, a lack of role models, a lack of time (“second shift”), a lack of confidence, a lack of interest or perceived benefit, a lack of support, burnout, and previous poor experiences. While systemic issues are difficult to overcome, this article assists in the training and development of women radiologists by offering strategies to enhance job satisfaction and bring new and valuable perspectives to leadership.

Introduction

Gender diversity is beneficial to radiology because it is in the self-interest of the organizations, hospitals, groups, clinics, and the people who work in them—it is good for the bottom line. Research has shown that more women in the upper echelons of a corporation’s senior executives and managers leads to greater financial benefits than organizations with less diversity and gender-biased leadership.¹ In their study of 22 000 firms worldwide, Noland et al found that 60% of corporations had no women board members, and only 5% had a female chief executive officer.¹ However, there was a positive benefit of having women board members; going from 0% to 30% women leadership positions was associated with a 15% increase in profitability.¹ Hunt et al studied organizations in many countries and found that those in the top quartile for gender diversity were 15% more likely to exceed average national financial returns.² Companies with gender and ethnic diversity were 35% more likely to outperform those without diversity.² Interestingly, no statistically significant correlation between gender diversity and performance occurred until women constituted at least 22% of a senior executive team.² From that point, the correlation observed for American companies was that, for every 10% increase in gender diversity, there was an increase of 0.3% in earnings before interest and tax.² Diversity makes good business sense.

Greater diversity has also been shown to increase employee satisfaction, leading to greater job satisfaction and collaboration.² It is critical to avoid token effort, defined as something done with very little effort and only to give the appearance that an effort is being made. A study found that, if an applicant pool included only 1 woman applying for a position, she had a 0 chance of being selected, whereas if 75% of applicants were women, there was a 67% chance of a woman being selected.³ It has been proposed that >15% representation was required to overcome a sense of token effort.⁴

Including different perspectives can lead to innovation that may overcome challenges that previously seemed unresolvable. Organizations require diverse thinkers to challenge the status quo and improve the quality of solutions. Having a diversity of informed views facilitates exploring alternatives more efficiently and adopting solutions more readily and with greater confidence.² Women in leadership attract more diverse talent and contribute to improved patient care and success of the organization.⁵

More women in leadership roles in radiology are expected to have similar improvement in the bottom line of their organizations, greater job satisfaction, employee retention, and innovative solutions to complex problems. But business author Sucheta Nadkarni put it simply: “The benefits women in top executive roles bring [sic] is the ethical (right thing to do) and the business case (smart thing to do),” and both are tightly interconnected.⁶

In The Seven Habits of Highly Effective People, Steven Covey advises us to “begin with the end in mind.”⁷ Gender diversity is defined as “a greater share of women and a more mixed ethnic/racial composition in the leadership of large companies.”² This article will illustrate the importance of achieving gender diversity in radiology while recognizing the challenges and the opportunities to get there. It requires that more women in radiology take leadership roles. Helpful strategies to encourage and engage women will be provided.

Where are we now?

Although women make up half of graduating medical students and interest in radiology among women and men is similar,⁸ radiology is still one of the least diverse medical subspecialties in North America.⁹ Only ~29% of the applicants to diagnostic radiology residency programs are women, which has not changed significantly in several years,¹⁰ with 24% of practicing radiologists being women in Canada and the United States.¹¹ In other countries, women are almost equally represented in radiology.¹² In leadership roles in radiology, the percentage of women is even lower; fewer than 10% of department chairs are women.¹¹ In a study of academic breast radiologists, although 69.7% of practicing radiologists were women, a smaller proportion (58.3%) of faculty leadership positions were held by women.¹³ This may relate in part to the fact that women radiologists are more likely to work part-time than their male counterparts (27% vs 9%).¹⁴

Women radiologists from a racial or ethnic group that is underrepresented in medicine (UIM) face additional hurdles. Underrepresented in medicine groups constitute 30% of the U.S. population but account for a much smaller percentage of physicians and only 13.8% of trainees.¹¹ Underrepresented in medicine medical students shoulder burdens of microaggressions or overt racism, which can precipitate stress responses that may interfere with their ability to function in a work environment.¹⁵ The intersectionality of being female and a UIM physician compounds the challenges. A “colorblind” approach to increasing women in radiology and leadership is not likely to succeed, and additional efforts for those UIM is needed.

The goals for gender equity and diversity in medicine are not well-established. The 2012 McKinsey report on gender equity established 4 metrics for gender diversity in business: 1) a starting position with women making up ≥53% of entry-level professionals, or at least equal to men; 2) women accounting for at least 22% of the executive committee; 3) better odds of promotions, at least 85% of the chances men enjoy for advancing to higher roles; and 4) women holding at least 55% of the vice president (VP) and senior VP positions.¹⁶ A systematic review of the aspects of women leadership in organizations provides a useful framework for increasing women in radiology (Table 1).^17,18

Challenges and opportunities

There are several challenges for women in radiology, especially in leadership roles. Recognizing the challenges allows us to identify opportunities to overcome them.

1. The lack of role models.There have never been women in this role before, so why would this appeal to me and why would they want me? Isn’t this just a token role? No one like me has filled this role before.

Radiology residency programs are more likely to attract women residents when they have a woman program director,¹⁹ and identifying successful women role models may correlate with women choosing radiology.²⁰ Medical students need to see the opportunity in radiology as a specialty that will benefit them. This can be accomplished with intentionality.

Radiology needs to be included in medical school curricula. This was highlighted over 20 years ago²¹ but remains a gap, with 72% of 471 surveyed medical students in the United States stating that they received too little radiology education.²² Breast imaging was previously taught at our medical school by a non–radiologist specialist. When we produced data demonstrating the inaccuracies that were being taught by other specialists, the education hours allotted to radiology at the University were doubled. This change not only taught future physicians the benefits of improved integration of radiology into medical practice,²³ but it also led many of the women to consider radiology as a career. When women radiologists are involved in teaching at medical school, this encourages more women students to see themselves in the field.

Mentorship has been shown to be one of the enablers of women’s leadership in organizations.¹⁷ Mentors are needed to support women entering radiology and to encourage them to apply for leadership roles and top academic positions. Both structured and informal mentorship are essential to improving diversity in health professions.^18,24 Mentoring has been shown to boost careers and increase workplace retention.¹⁷ Although it does not change organizational biases, it creates support and develops new skills.²⁵ A large survey of the American College of Radiology (ACR) found that women prefer same-gender mentors and UIM radiologists prefer a mentor of the same ethnicity and/or race.²⁶ This is a strong impetus for increasing diverse representation in radiology, building a positive amplification of change.

However, more than mentorship for women is needed; “sponsorship” is required.²⁷ A sponsor actively promotes the career of their protégé, introducing them to their network and providing career opportunities they may not have had access to without the sponsor. Connection with other women is a way to support and retain women in radiology and creates opportunities for mentorship and sponsorship. The World Health Organization has found that, to enable women to achieve leadership in global health, there is a need to develop formal and informal networks for women’s leadership development with access to information and opportunities.²⁸ This was the basis of founding the Canadian Society of Breast Imaging, the American Association for Women Radiologists,²⁹ Canadian Radiology Women, and Women in Radiology. These organizations create positive spaces for women in radiology to discuss common challenges, experience a community of support, and share best practices.

Women leaders should share successes and failures so that others can learn from them. Taking a leadership role in radiology may serve as a role model for more junior colleagues. Ruth Bader Ginsburg said, “When I’m sometimes asked when there will be enough [women on the Supreme Court]? and I say when there are nine, people are shocked. But there’d been nine men, and nobody’s ever raised a question about that.”³⁰

The number of women leaders in radiology must increase. Dr Virginia Roth, the first woman chief-of-staff physician in Canada, created a Woman’s Physician Leadership Committee in 2011, with the aim to overcome gender inequities by identifying and supporting women physician leaders. There was a marked increase in the number of women physicians from 30% (255/862) in 2011 to 42.5% (486/1144) in 2022 in the hospital, but the number of women division and department heads did not change significantly, maintained at 8% (1/12). Despite noting positive changes of increased formal mentorship and workforce coverage during maternity leave in the same period, persisting disparities in leadership among women leaders was recognized as a sign that additional initiatives were needed.³¹ Each department head was tasked with identifying their top woman leader candidate, who was then publicly recognized in the hospital. Additionally, the Medical Advisory Committee’s by-laws were amended such that both men and women had to be nominated for either president or VP, and in 2022, the first woman physician president was elected to the committee. Intentionality required cohesive action to achieve this goal. Specific initiatives geared to women by women may be more successful at accomplishing this goal.

2.The lack of time.Why would I take on the leadership role when I am barely holding on with my other responsibilities?

It is well recognized that women carry more than their fair share of the child care and household responsibilities, the so-called “double duty” or “second shift.” How can this be addressed within radiology?

The work-life balance has been recognized as a limitation to women’s leadership.¹⁷ Women strive to work hard in radiology while balancing the added responsibilities of family, but too often, women radiologists perceive that there is too much clinic work to allow taking on administrative or leadership tasks. There is also a significant issue with burnout among breast radiologists, particularly those early in their career.³² Innovations to address the workload and burnout in radiology are needed. A top management authority on leadership, Herminia Ibarra, advocates that, for improving job satisfaction, one should become efficient, allow time for strategizing, and consider redefining your current job.³³ In radiology, this may require optimization of the workflow, such as reducing constant interruptions.

Institutions or practices should ensure there is time set aside during the workday to allow minimal interruptions. Batch-reading screening mammograms without interruptions has been shown to reduce recall rates.³⁴ This improves performance and leads to a greater sense of “flow.” Applied to work, flow is defined as a “short-term peak experience that is characterized by absorption, work enjoyment, and intrinsic work motivation.”³⁵ This can lead to greater satisfaction with work and reduced multitasking.³⁵ It has been suggested to aim for flow for 90 minutes at least once or twice per week.³⁶ A recent study found that uninterrupted reading sessions had significantly higher accuracy and that readers reported feeling significantly less busy and having less cognitive demand, lower levels of physical fatigue, and higher levels of satisfaction.³⁷

Re-evaluating the work being done in the workday leads to more time for administration and leadership. It becomes a positive cycle; creating change in the workday leads to more positive change for others such that taking on leadership roles becomes more natural and facilitates needed changes. By creating more time and more satisfaction during the workday, a leadership role can become a positive instead of “just another task.” Furthermore, there can be tremendous positive energy gained from accomplishing tasks and successful results. Active striving to improve workflows while advocating for work-life balance helps to build a sustainable practice in an evolving health care climate.

There are many initiatives that are required to ensure protected time for women in radiology. This includes having clearly written policies that support parental and sick leave, in accordance with local laws.¹⁰ Having transparency about clearly communicated policies facilitates their implementation and a sense of equity among the group. Offering flexible work hours as well as the “hybrid model” of remote and on-site work has many benefits for women in radiology and is being increasingly adopted by many groups, particularly since COVID.³⁸ In the United States, a 2018 ACR survey of 23% of practice leaders (367) representing 10 179 radiologists (30% of all practicing radiologists in the United States) found that 18% of practices reported radiologists had switched from full-time to part-time employment in 2017. A positive trend for breast imaging was found, and practice leaders reported that they planned the greatest number of hires in breast imaging, neuroradiology, and interventional radiology.³⁹ A 2021 study of 1 academic center in Texas illustrated that that academic part-time work was feasible in their institution. They found that the COVID pandemic increased the demand for faculty to go part-time and that, after the pandemic, women were 3 times more likely to reduce their working hours to part-time.⁴⁰ The option of part-time work in radiology is one that can be highly useful to women in radiology, particularly if they want to protect time for other interests, including an academic career. Dedicated administrative or academic time should not come at the expense of personal or family time and should not be simply added to clinic responsibilities. That is a recipe for burnout.⁴¹

Paid administrative time should be considered an investment with downstream benefits. For example, in our large radiology group, the leaders were asked what had been accomplished with the nonclinical time provided. Administrative time dedicated to implementing a shortened breast MRI protocol from 25 to 13 minutes resulted in increased capacity for breast MRI, 33.5% increased capacity in 2019 and 40% in 2020 using the same number of hours, with a net increase in revenues. The administrative time paid by the group led to return on investment of >$100 000 a year. The group recognized the financial benefits.

3. Lack of perceived support for this role.The guys are going to walk all over me, they don’t want me…I did this before and was traumatized by it.

Women leaders face biases due to gender differences at the organizational level, and these organizational biases are a major barrier to women’s leadership.¹⁷ Many women in radiology bear the burden of microaggressions and major aggressions. This is compounded for women who are UIM. A survey of 461 American radiologists, 51% of whom were women, found that women were 18 times more likely than men to experience unfair or disrespectful treatment, and mistreatment was 10 times higher among radiologists UIM compared with White radiologists.²⁶ Acknowledging and identifying systematic issues is fundamental to change. This needed change requires institutional policies that are inclusive and a workplace environment that is supportive, which has been shown to be built on 1) respectful communication in the workplace, 2) a supportive and affirming environment, 3) a culturally competent environment, and 4) a workplace that values work-life balance.⁴²

Training is an intervention that strengthens women leaders and helps them to acquire new skills.¹⁷ It also builds relationships and forms networks with other leaders. With new perspectives, work colleagues may be educated about the impact of their actions and language. Gender equity should include gender-neutral words, such as chair instead of chairman.¹⁰ The best place to start is to assume good intentions and to be empathetic; colleagues are likely unaware of the impact their language and actions may have on others. When a non–gender-neutral term is used, it can be an opportunity to raise awareness. For example, asking to speak to a colleague away from the group and saying “Did you know that term manpower is not inclusive of women who make up 30% of our group? A better term to use might be workforce” is a proactive but respectful way to approach change. Another approach is to use data to illustrate the problem and its potential solutions. When faced with evidence, opinions can change. Ruth Bader Ginsburg wrote, “Fight for the things that you care about, but do it in a way that will lead others to join you” and “You can disagree without being disagreeable.”³⁰ It is noted that perseverance is a key strength of women leaders and is critical to achieving lasting change.¹⁷

4. Lack of belief in the ability to do this job and lack of confidence.I have never done this before and I don’t have the skills! There is a huge gap in what I know and what is needed for this role.

The McKinsey report identified the confidence gap and individual mindset as 1 of the 4 major barriers to women leadership.¹⁶ In their report, more than half of successful women held themselves back from accelerated growth.¹⁶ “The biggest barrier women face when contemplating leadership positions is the fact that women do not perceive themselves as leaders.”³¹ Dr Mamta Gautam notes that there are 3 themes that undermine women’s confidence: 1) perfectionism—“if I can’t do it right, I shouldn’t do it at all”; 2) the inner critic—“it will never be good enough, my colleagues are much smarter than me”; and 3) the imposter syndrome—“I’ve managed to fool everyone so far, but they are going to find me out soon.”⁴³ Be aware of unconscious biases that may play against taking on a new role based on the unconscious belief that a woman cannot perform this task or must behave a certain way. Just as our unconscious biases may influence us towards others, they can also play an important role in our individual mindset.¹⁶ Institutions should provide unconscious bias training to help teach about the stereotypes that are barriers to change.¹⁸ It is good to be aware of negative and positive stereotypes, which may include gender and different ethnicities.⁴⁴

There are helpful tips to overcome the confidence gap: 1) recognize it—“there is that voice again—and I don’t have to listen to it”; 2) be prepared; 3) visualize success; 4) focus on the “we,” not “me,” for a greater goal; 5) project confidence; and 6) do it! Learn by experience; it’s okay to fail. Acquiring skills is a useful strategy (Table 2).⁴² The use of virtual technologies to increase training and networking opportunities, mentorship, sponsorship, combatting imposter syndrome, and the importance of work-life balance were all cited in a recent publication on strategies to improve preparation for women’s leadership.⁴² Risk-taking has been recognized as 1 of the enablers that facilitates women leadership.¹⁷ Risk-taking is an important skill to acquire, and networking may help support its development. The McKinsey report noted that successful women leaders were no different from their successful male counterparts but that confidence, grit, and resilience were the 3 top abilities that women needed to thrive as leaders.¹⁶

Be at the table

Michael Enzi, an American politician, stated, “If you’re not at the table, you’re on the menu,” which goes hand-in-hand with a quote from Ruth Bader Ginsburg: “If you’re going to change things, you have to be with the people who hold the levers.”³⁰ This means you have to find a way to work with the people in leadership (Table 3).

When leaders make decisions about breast imaging without involving important stakeholders, it invariably leads to poor decision-making. Breast imaging radiologists, who are majority women, need be “at the table” for leadership to make the best and most informed decision. Just showing up and being present as a vested stakeholder can make all the difference in striving towards expected outcomes. When you are there, aim to say at least 1 thing; your voice matters.

Conclusion

This article began with the “why” of having women leaders in radiology. Starting with “why” is fundamental to achieving meaningful and lasting change. Women leaders improve the workplace by making it more financially viable and increasing collaboration, job satisfaction, and engagement. Women leaders are vital to improve radiology and create sustainable, meaningful work, which ultimately will increase the number of women in radiology. There are many challenges to increasing the number of women leaders in radiology. The confidence gap, lack of interest and perceived benefit, burnout, and previous poor experiences are some barriers women face when taking leadership roles, and this is accentuated in women who are UIM. However, women can look for the positives, such as leadership positions, that enhance job satisfaction. Mentorship, sponsorship, collaboration, courage, and a community of support can go a long way to tackling the obstacles and minimizing the gender gap in radiology.

Acknowledgments

The author would like to thank Dr Paula Gordon, Dr Raman Verma, Dr Susan Peddle, and Dr Jackie Lau for assistance in editing the manuscript.

Funding

None declared.

Conflict of interest statement

J.M.S. declares that she has received a speaker honorarium from BD, Inc.

References