As a female interventional radiologist, I am often asked why I chose a traditionally male-dominated field. After all, IR was not a field that piqued my interest early on. In fact, I was not even aware it existed until after I started working as an internal medicine hospitalist.

It wasn’t until a mid-career switch to radiology, during which time I was blessed with wonderful and encouraging IR male role models and a supportive physician spouse, when I developed a true interest and passion for the field. Now, as one of only 8 percent of female IRs, I find myself looking around at conferences, asking, “Why aren’t there any women in line to the ladies’ room?”

Fortunately, recent efforts such as the training paradigm shift to an integrated IR/DR residency, growth of social media, and new societal practice parameters and position statements will help transition IR into an increasingly diverse and equitable workforce. These developments are sure to further benefit the field and improve patient care.

Breaking the glass floor: Introducing medical students to IR

Lack of early medical student exposure to IR has served as a “glass floor,” hindering the entry of women into the field. Misconceptions about the field, including the fear of radiation exposure and exaggerated night and weekend call responsibilities, have been cited by female medical students as barriers preventing their cultivation of interest for the field (Perez et al. 2016).

Because IR has traditionally been a subspecialty of diagnostic radiology, available only as a fellowship after the completion of a residency, the field understandably may seem like a mystery to junior medical students, whose medical school curricula focus on the traditional core topics of surgery, internal medicine and obstetrics.

The impressionable nature of medical students, however, has proven to be a low hanging fruit, as demonstrated in several recently studied and easily implementable methods aimed at the early exposure of medical students to radiology.

• In Indiana, a “Women in Radiology Group” boosted women’s interest in the field by 90 percent (Ladd et al. 2017).
• In Pennsylvania, a series of joint IR/gross anatomy lectures boosted interest by 40 percent (Depietro et al. 2017).
• In Mississippi, an interactive student interest group doubled the number of radiology applicants in just a single year (Taylor et al. 2018).

While few of us would expect a third-year medical student to spend an entire rotation on the IR service, we can foster recruitment by pressing for the implementation of a short IR rotation during the DR elective and further providing opportunities for senior medical students to spend a dedicated month in the field. The opportunity for medical students to pursue the IR/DR residency will allow women to contemplate the specialty early on instead of waiting until after medical school, internship, and residency, when often family and social commitments serve as a barrier for women advancing into more rigorous fellowship training programs.

Breaking the glass ceiling: Increasing the number of women in leadership positions

The “glass ceiling” phenomenon, well known to women in multiple cultures and occupations, also exists in academic medicine and across medical specialty fields. Not only are women experiencing a pay gap due to segregation of women into lower-wage-earning careers relative to men, as seen in pediatrics vs. surgery (Heitkamp et al. 2017), but women are not advancing to leadership positions at the same rate. Although the distribution of men and women in medical school is nearly equal, a significant disparity remains between the genders in leadership positions with women representing a small fraction of full professors and medical school deans (Lautenberger et al. 2014)—contributing to the lack of relatable mentors for female medical students.

Glass ceiling issues generally relate to bias and institutional culture (Surawicz 2016). Although many may assume that conscious bias is no longer prevalent, it is curious to consider why women in radiology are more likely to be victims of sexual harassment and less likely to report it compared to other fields (Camargo et al. 2017).

Unconscious gender bias has been demonstrated in workforce recruitment and advancement. Consider as an example two job applicants who are identical except in gender; the male applicant is not only chosen more frequently (surprisingly, by both male and female reviewers) but also usually offered a higher starting salary (Moss-Racusin 2012).

Unconscious bias and gender segregation in medicine crosses political boundaries. In multiple countries, certain specialties (e.g., pediatrics and family medicine) are considered to align more closely to perceived feminine traits (nurturing and interpersonal communication), while surgical specialties favor the perceived male traits of stamina, strength and competition, with relative hiring of women and men in those specialties following suit (Heitkamp et al. 2017; Hill & Giles 2014; Charles & Bradley 2009).

Institutional culture, which also plays a role, may be judged on the basis of relative number of promotions, salaries, opportunities for mentoring, family-friendly policies and support for work (Surawicz 2016).

Gender inequality across leadership positions should be viewed as a tremendous opportunity for female interventional radiologists because of the tremendous value we bring to the health care team and the benefit we bring to our patients (Tsugawa et al. 2017; Wallis et al. 2017). However, increasing the number of women in leadership positions will not be easy.

Critics may blame the lack of female leaders on the fact that women more often manage their household and their children (often single-handedly). As such, women work part-time more often than their male colleagues (Bluth et al. 2015). However, allowing for this trend still does not explain the dearth of female leaders as detailed above.

Although flexible work schedules, on-site child care and a generous maternity/paternity leave policy will not reverse bias in promotions, these strategies may increase the number of female applicants for promotions and leadership positions. SIR practice parameters for radiation protection of pregnant workers (Dauer et al. 2015) and the recent addition of the SIR position statement on parental leave (Englander et al. 2017) are excellent tools for working IRs with additional resources for trainees on the horizon.

Breaking the glass cage: Facing internal barriers

Women in any field may find themselves facing a self-imposed “glass cage,” a barrier constructed from our misgivings and self-doubt about our abilities. Often referred to as the imposter syndrome, this phenomenon is much more common in women and may affect our representation in leadership positions.

For example, men typically apply for a new position when they meet only 60 percent of the hiring criteria, while women typically wait until they reach 100 percent. Women are less likely to sit at the main table during meetings, less likely to offer suggestions, less likely to take credit for their own ideas, and often feel their success is a sequela of external factors, such as “being lucky”; men are more likely than women to take credit for borrowed ideas and feel that they earned their position by skill and talent (Sandberg 2013).

Shattering the imposter syndrome and the glass cage is not an easy task, but through professional development and leadership workshops geared specifically toward preparing female physicians for leadership positions, we can continue to develop the necessary communication and negotiation skills to excel.

Mentorship programs coupled with social and online media forums provide women who are current and future physicians with opportunities to ask difficult questions and obtain honest feedback from other women. Since I started “Radiology Chicks” and “Future Radiology Chicks,” online Facebook support groups for female radiologists and medical students, respectively, I’ve been approached by countless individuals who highly value the ability to anonymously ask questions. These systems generate useful discussions around important issues, such as dealing with self-doubt and improving resilience. Often, a simple encouraging word is all that is required to boost an individual’s confidence to continue pursuing her dream.

I urge female and male IR leaders to reach out to female medical students, trainees and colleagues and offer encouragement, advice and perhaps an opportunity (bit.ly/2Mzy6Yp).

Women’s integral value to the IR team

Given the benefits of a diverse workforce and the effectiveness of female physicians compared to their male colleagues in respect to mortality rates and other outcomes (Tsugawa et al. 2017; Wallis et al. 2017), all specialties should be recruiting female physicians to join their teams. The benefits of a diverse workforce are well known: inclusive companies outperform the S&P 500 index, attract top talent rich in creativity and innovation, and can better anticipate a broad range of customer needs (Spalluto 2018). Since women make over 90 percent of their family’s health care decisions (Spalluto 2018), female IRs have an edge at understanding and meeting the needs and expectations of the female health care consumer. As the minimally invasive options for patients grow to include gynecologic, urologic, gastrointestinal and breast procedures, female patients are likely to more often request a female physician.

Conclusion

Despite the relative paucity of female physicians in IR, the integrated IR/DR residency program affords a new opportunity at breaking the glass floor by providing dedicated exposure earlier in women’s medical training to the field of interventional radiology. It is important to offer a wide variety of educational and mentorship opportunities to medical students ranging from local interest groups and online support groups to larger scale societal efforts.

Attempts at breaking the glass ceiling are more challenging, as unconscious bias and societal expectations can take generations to change. Family-friendly policies benefit both men and women and will encourage a more diverse spectrum of leaders, resulting in innovation, creativity, novel solutions and improved decision-making in the organization (Kruskal et al. 2018).

We can best break the glass cage through a social network of peers, excellent mentors/supervisors and other self-/professional development strategies including workshops, books and podcasts.

Today, no medical student should be actively discouraged from applying to IR on the sole basis of being female. No woman should be denied employment or promotion on the sole basis of being female. We women must work together and with our male colleagues to break the glass barriers that continue to surround us.

References

1. Bluth, E.I. et al., 2015. The 2015 ACR Commission on Human Resources Workforce Survey. Journal of the American College of Radiology: JACR, 12(11), 1137–1141.
2. Camargo, A., Liu, L. & Yousem, D.M., 2017. Sexual Harassment in Radiology. Journal of the American College of Radiology, 14(8), 1094–1099.
3. Charles, M. & Bradley, K., 2009. Indulging our gendered selves? Sex segregation by field of study in 44 countries. AJS; American journal of sociology, 114(4), 924–976.
4. Dauer, L.T. et al., 2015. Occupational Radiation Protection of Pregnant or Potentially Pregnant Workers in IR: A Joint Guideline of the Society of Interventional Radiology and the Cardiovascular and Interventional Radiological Society of Europe. Journal of Vascular and Interventional Radiology, 26(2), 171–181.
5. Depietro, D. et al., 2017. Increasing first-year medical student exposure to interventional radiology: a pilot-study of integrating IR into the gross anatomy lab. Journal of Vascular and Interventional Radiology, 28(2), S21.
6. Englander, M.J. et al., 2017. Society of Interventional Radiology Position Statement on Parental Leave. Journal of vascular and interventional radiology: JVIR, 28(7), 993–994.
7. Heitkamp, D.E., Norris, C.D. & Rissing, S.M., 2017. The Illusion of Choice: Gender Segregation and the Challenge of Recruiting Women to Radiology. Journal of the American College of Radiology, 14(7), 991–994.
8. Hill, E.J.R. & Giles, J.A., 2014. Career decisions and gender: the illusion of choice? Perspectives on medical education, 3(3), 151–154.
9. Kruskal, J.B. et al., 2018. Fostering Diversity and Inclusion: A Summary of the 2017 Intersociety Summer Conference. Journal of the American College of Radiology: JACR.
10. Ladd, L.M. et al., 2017. A Mentorship and Networking Group for Women in Radiology. Journal of the American College of Radiology: JACR, 14(7), 987–990.
11. Lautenberger, D.M. et al., 2014. The State of Women in Academic Medicine: The Pipeline and Pathways to Leadership, Washington, DC: American Association of Medical Colleges.
12. Perez, Y.V. et al., 2016. A Glance at Gender-Specific Preferences Influencing Interventional Radiology Selection. Journal of vascular and interventional radiology: JVIR, 27(1), 142–143.e1.
13. Sandberg, S., 2013. Lean In, Knopf.
14. Spalluto, L.B., 2018. The Purse Strings of Radiology. Journal of the American College of Radiology, 15(2), 362–363.
15. Surawicz, C.M., 2016. Women in Leadership: Why So Few and What to Do About It. Journal of the American College of Radiology: JACR, 13(12 Pt A), 1433–1437.
16. Taylor, C.S. et al., 2018. Generating Medical Student Interest in the Field of Radiology. Journal of the American College of Radiology: JACR, 15(2), 340–342.
17. Tsugawa, Y. et al., 2017. Comparison of Hospital Mortality and Readmission Rates for Medicare Patients Treated by Male vs Female Physicians. JAMA Internal Medicine, 177(2), 206.
18. Wallis, C.J. et al., 2017. Comparison of postoperative outcomes among patients treated by male and female surgeons: a population based matched cohort study. BMJ (Clinical research ed.), 359, j4366.