_{Published March 31, 2022}

In 2000, the Association of American Medical Colleges created two standards related to cultural competence: 

1. “The faculty and students must demonstrate an understanding of the manner in which people of diverse cultures and belief systems perceive health and illness and respond to various symptoms, diseases, and treatments.”
2. “Medical students must learn to recognize and appropriately address gender and cultural biases in themselves and others, and in the process of health care delivery.”

This means any patient, whether they be from Appalachia, Seattle, WA, or overseas; whether they speak English, Cantonese, a form of Sign Language, or are nonverbal; whether they identify as a man, woman, or nonbinary; whether their skin is dark, light, or in between deserve the same quality care and patient experience. For us as radiologists, many of whom spend more time interacting with other staff than patients, to provide culturally competent care to our patients, we need to be able to model those values in our own workplace and strive for a workplace culture founded on Diversity, Equity, and Inclusion (DEI). Workspaces that have embraced and showcased the principles of DEI demonstrate reduced workforce burnout and turnover, alongside improvements in employee morale, culturally competent care, and overall patient outcomes.

With this in mind, how do we go about developing a culturally competent imaging workforce?

Initial Steps

First, we need to develop a culture of inclusion. This includes recognizing and minimizing the presence of microaggressions—comments or action that subtly and often unconsciously or unintentionally express a prejudiced attitude towards a marginalized group. Additionally, we must encourage team members to move from being passive bystanders to upstanders willing to name the microaggression, intervene, and act in support of the victim of the microagression. Although this may produce uncomfortable situations, there are many helpful techniques to combat microaggressions, such as “GRIT” (Gather, Restate, Inquire, Talk It Out) or the “5 Ds” (Distract, Delegate, Document, Delay, or Direct).

Second, we need to mitigate bias in recruiting and hiring. To this end, we must minimize unconscious bias in hiring practices, increase the number of underrepresented applicants in our hiring pool, use holistic approaches to application review, and develop more objective interview metrics, like structured interviewing. Job advertisements should include terms like equal opportunity and affirmative action and, whenever possible, illustrating how the hiring institution embraces and showcases these practices. Furthermore, when inviting applicants for interviews, it is important to incorporate a clear statement about how to request accommodations, including a specific contact person. Reiterating measures that have already been taken to ensure access for interviewees would be efficacious (e.g., all interview spaces are wheelchair-accessible).

Third, we need to encourage DEI in promotion, networking, mentorship, and sponsorship. It is imperative for progress in cultural competency. Matriculation cohorts from medical schools are increasingly diverse; however, this plurality has not translated into diversity among leadership positions or in academic ranks. Given the lack of affirmative action in faculty recruitment, promotions, and leadership, after matriculating, members of underrepresented minority groups can be discouraged from pursuing competitive academic disciplines and dissuaded from leadership roles.

The pervasive nature and extent of gender and racial disparities have been studied in all medical disciplines—explained sometimes as a “sticky floor,” or “broken ladder,” and, at times, the “glass ceiling”. Two additional populations, which have received less attention, are gender and sexual minorities, as well as individuals with disabilities.

Gender and Sexual Minorities

Living in a heteronormative society, gender and sexual minorities (GSM) face multiple challenges in the workplace. While it is true that explicit hate speech and overt bias have decreased in the last 50 years since the Stonewall Movement of 1969, implicit bias and varying degrees of homophobia and transphobia are still prevalent in the medical field. In fact, according to Nama et al., 14.6% of trainees witnessed LGBTQ+ discrimination, and 31.1% witnessed heterosexism. Almost half of the trainees (41.6%) reported anti-LGBTQ+ jokes, rumors, and/or bullying by their colleagues or other members of the medical team. Addressing these adverse working conditions has multiple benefits, including greater job commitment, improved job satisfaction, and less discrimination among others.

As a community, we need to acknowledge the impact of disparities on our LGBTQ+ members, while developing strategies and policies to address them. In a recent literature search, no demographic data could be found on GSM, neither within the imaging nor general medical literature, regarding the percentage of individuals reporting nonbinary gender identification and sexual orientation. Additionally, no peer-reviewed data is available to detail the specific challenges faced by the LGBTQ+ community within academic or private practice radiology departments. In the absence of radiology-specific literature, we can draw upon the experiences of the business world to develop a strategic plan and best practices for our institutions, including:

1. Enact concrete protocols to protect both employment and health care rights of our LGBTQ+ cohort
   • Nondiscrimination policies for sexual orientation and gender identity
   • Identical benefits for domestic partners and same-sex spouses, including parental and FMLA leave
   • Gender-neutral restrooms
2. Increase visibility of support for our LGBTQ+ colleagues
   • Rainbow flag lapel pins
   • Inclusivity signage in clinical spaces, like reading and conference rooms
   • Support messaging from imaging chairperson or CEO sent to all community members
   • Highlight inclusivity on organizational websites and social media
   • Cosponsor related events at home institutions or within the community
3. Implement educational sessions for cultural competency—safe-zone training, Fenway Institute—for entire radiological department
4. Adequately fund dedicated interest group or full-time advisor within department to support radiology trainees
5. Become familiar with concepts of gender (pronouns, identity, expression, presentation) and sexual orientation

People With Disabilities

Disability is an important dimension of diversity we need to recognize as radiologists. Our practice partners and employees, just like our patients, should not face unreasonable challenges because of disability. Physicians with disabilities have a unique voice, given their dual roles as doctor and patient.

Inclusion of radiologists with disabilities requires fostering a culture of safety, where people are free to disclose a disability, without fear of stigmatization. Use person-first language, such as “person with a disability,” and discard phrases like “handicapped,” “suffering disability,” “wheelchair-bound,” and “confined to a wheelchair.” Even better, we can ask individuals their preference: “person with a disability” (commonly used in the US) versus “disabled person” (more common across Europe and Asia).

More importantly, practices should consider integrating someone with knowledge of disability, disability rights law, and reasonable accommodations to serve as a point person for confidential disclosure of disability and as lead for accommodations.

There is an ancient proverb that says, “physician, heal thyself.” If we hope to understand the unique cultural challenges that our diverse patients face, we must have a workforce as diverse as the patients we hope to serve. We cannot be afraid to stumble along the way, for with each mistake, we have an opportunity to learn, do better, and best serve all our patients and colleagues alike. This conversation regarding the provision of culturally competent care must continue, so that we can protect each patient and support every provider.