The benefits of diversity in medicine are clear: Having different perspectives can improve problem-solving, encourage demographically representative research and make underrepresented minorities (URMs) feel welcome and included—whether they are patients, trainees or physicians themselves.
But diversity in IR is an ongoing challenge, according to panelists in the “Improving diversity in the IR suite: A multi-dimensional perspective” session from SIR 2023. Presenters discussed areas of improvement in IR, what it’s like being a URM in the field and the importance of understanding patients from different backgrounds.
Diversity in IR: What does it mean?
Hirschel D. McGinnis, MD, FSIR, began by defining the purpose of diversity, equity and inclusion (DEI) initiatives. Diversity, he said, is the concept of variety; equity is fairness, justice, and opportunity; and inclusion is equal access for all. Engaging in DEI is creating a state of being valued, respected and supported.
“I believe DEI isn’t just an option, it’s an IR imperative,” Dr. McGinnis said.
According to the Association of American Medical Colleges’ (AAMC’s) data on physician demographics, only about 10% of active physicians in IR are female, which is behind most other medical specialties. Being one of the least diverse medical specialties, Dr. McGinnis said, limits IR’s talent pool and problem-solving abilities.
However, AAMC data also shows that since 2016, the number of sexual and gender minorities in medical students has increased 131%. “Is the culture of medicine ready for this demographic change that’s rapidly happening beneath our feet? I don’t know,” Dr. McGinnis said. “Unfortunately, once people leave medical school, we have zero insights into the presence and experience of sexual and gender minorities.”
Dr. McGinnis cited a 2022 article in the Journal of Vascular and Interventional Radiology (JVIR) “Healthcare disparities in interventional radiology,” which illustrated significant disparities in key IR services. Authors reported that 68% of hysterectomies performed each year in the United States are for benign bleeding, such as fibroids and adenomyosis, and elective hysterectomies for fibroids are disproportionately performed on Black women and people in rural areas.
“Of all hysterectomies performed in the rural South, 92% are performed on Black women,” Dr. McGinnis said. “That’s not choice, that’s not equity. This represents a huge opportunity for us to expand the reach of what we do.”
Therefore, he said, DEI is, “at most, a modest response to a public health crisis and a human rights crisis.”
IR is currently in its great fourth wave, Dr. McGinnis said. “I posit this fourth wave is going to be the era of equity. But this wave demands a deeper commitment to DEI in the IR workforce, a radical reimagining of optimal IR healthcare delivery and expansion of IR services to mitigate healthcare disparities.”
In closing, Dr. McGinnis reminded everyone that these problems are not one person’s fault.
“No one here created these problems,” he said. “These are structural things that have been in existence for hundreds of years. IR didn’t cause these disparities, and IR alone is not going to be able to solve them. But any of us can play a role in mitigating their effects.”
Understanding your patient’s culture: A case-based narrative
Next, Kirema Garcia-Reyes, MD, shared her experiences treating patients of different cultural backgrounds.
While every physician should be able to practice cultural competency and meet the social, cultural and linguistic needs of their patients, she said, certain barriers make this more difficult: a lack of diversity in healthcare, systems of care poorly designed to meet diverse patients’ needs and poor communication between providers and patients.
However, there are ways to overcome these barriers, Dr. Garcia-Reyes said. On an individual level, physicians should recognize their own biases and try to understand their patients’ viewpoints. “At a minimum we need to recognize that patients from various ethnic backgrounds view the world through a different lens,” she said. “But I would encourage you to try to use those lenses and view the world through their lens.”
Institutions can also work against these barriers by valuing diversity, developing institutionalized cultural knowledge and adapting to patients with varying needs.
Dr. Garcia-Reyes also touched on generalizations and stereotypes. The difference between them, she said, lies not in the content but rather the usage of the information.
“There’s a common concern that if we’re using cultural information, we are stereotyping,” she said. “Generalizations can help us understand and anticipate behavior, but you must talk to the patient to get further information and see if it applies to them. While generalizations are beginning points and can be helpful, stereotypes are ending points and will always be harmful.”
Dr. Garcia-Reyes shared examples of using cultural knowledge to understand and work with patients. In one case, a patient had hepatocellular carcinoma, but the family did not want the patient to know her prognosis. Because cancer is highly stigmatized and feared, she said, it's a custom in many cultures that a patient’s family is the first to hear about a poor prognosis and can decide how much to tell the patient. Rather than saying “cancer” and “chemotherapy,” Dr. Garcia-Reyes adjusted her language to say “growth” or “lesion” and “medication.”
In cases like these, she also recommends using an interpreter to ensure clear communication, being aware of nonverbal cues without jumping to conclusions, using normalizing statements and understanding one’s own biases.
More than just the doctor: Importance of having a diverse staff in your practice
In her presentation, Gloria M. Martinez-Salazar, MD, FSIR, touched on her experiences with Latino patients during the COVID-19 pandemic, illustrating the impact of racially concordant patient–physician interactions.
“This issue of diversity and equity came very clear for me when I was dealing with Hispanic patients in Boston during COVID,” she said. “In April 2020, half of the patients we had at Mass General did not speak any English—they were all Spanish speakers.”
The pandemic revealed shocking healthcare disparities, Dr. Salazar said, especially for Latino and Black patients. “There was a crisis going on,” she said. “The communities that are historically underserved in Boston were showing high numbers and severe cases of COVID.”
To address this need, she helped create the MGH Equity and Community Health COVID Response Team, a group of Hispanic physicians who communicated with Spanish-speaking patients. “I’m very proud to be part of it, but it was really tough for me because I started seeing the vulnerabilities of the system in a way that I had never seen before.”
During that time, her hospital participated in a study on racially concordant COVID messaging from providers, and she delivered messages specifically for Hispanic and Brazilian patients. The study found that racially concordant messages increased patients’ knowledge of COVID-19 symptoms and prevention methods.
Dr. Salazar cited a 2019 study comparing racially concordant and discordant patient–physician interactions about cardiovascular disease prevention measures. Results indicated that patients were “much more likely to select every preventative service, particularly invasive services, once meeting with a racially concordant doctor,” concluding that “Black doctors could reduce the Black–white male gap in cardiovascular mortality by 19%.”
Therefore, Dr. Salazar said, there is a need for more diverse physicians in healthcare.
“It is my personal belief that the lack of workforce diversity contributes to poor cultural match between minority patients and their providers,” she said. While 100% concordance is impossible, having “some concordance, or at least having the cultural competency to understand where your patient is coming from, is extremely important.”
Diversity, equity and inclusion: Becoming an ally
Osman Ahmed, MD, discussed three aspects of being an ally: education, advocacy and self-reflection.
Allies should educate themselves about URMs’ experiences in healthcare by learning their stories, attending training sessions and seeking mentorship from people with experience in promoting DEI, he said. Advocating for URMs requires speaking out against discrimination and bias, as well as mentoring them and creating an inclusive environment.
But most importantly, he said, “becoming an ally requires ongoing self-reflection and a willingness to learn and grow. Unconscious biases can affect the way we perceive and interact with others.”
At the University of Chicago Medicine, Dr. Ahmed is the director of health equity and mentorship/sponsorship. There, they do diversity grand rounds, and he serves as a mentor.
“I’m a big believer in paying it forward,” he said. “I’ve had a lot of people in my life who have helped me, and I think it’s important that we continue to do that for others as well.”
Dr. Ahmed is also an associate editor for JVIR. “I try to select a diverse group of reviewers, not only to get more people involved but also to get differing viewpoints and give opportunities to people who otherwise may not have the mentorship.”
He closed by emphasizing the importance of allyship.
“Becoming an ally is crucial for providing equitable and effective care for all patients,” he said. “Education and active support of underrepresented individuals are important mechanisms to achieve this.”
How to “stand up” for your minority patients: Are they really at a disadvantage?
Janice M. Newsome, MD, FSIR, presented about advocating for URMs, whether they be patients, physicians or hospital staff members.
“I am sharing from my experience and mine alone as one woman, an immigrant, living in the south, cisgender and someone who is here to break the silence of the ‘isms in our IR practice,” she said. “I don’t have all the answers, and I’m not qualified to speak on some things, but I am qualified because I work in the system, use the system and belong to a racialized minority group. And it is because of my firsthand knowledge of the system that I may be an expert here.”
It’s been almost two decades since a surgeon general report documented racial disparities in healthcare, she said. “Despite us recognizing this and documenting this, these disparities have persisted and, in some cases, even widened.”
A lack of diversity in clinical research, Dr. Newsome said, has contributed to these disparities.
“These disparities continue to be widened because there is lack of diversity in clinical research, so we don’t even know what we’re doing when we’re treating patients based on the research that we have,” she said. “I am so happy that our research organizations are beginning to understand that.”
Though limited access to care plays a role, Dr. Newsome said, addressing that problem alone is not enough. “It is easy for us to just talk about access to care,” she said. “But when you look even within where care is accessible, it turns out that it is still a problem. Anti-bias training is needed—it is necessary.”
Unconscious biases can lead physicians to use a condescending tone with patients, make assumptions about why they don’t adhere to treatment, keep patients waiting longer and fail to utilize interpreters, she said.
She emphasized the importance of asking for a patient’s preferred language and adopting a “language of caring” for all patients. “If we could try to develop this language of caring, regardless of what other language you speak, our patients will know that,” she said.
Disabilities also need to be considered in healthcare settings, Dr. Newsome said. This means checking for physical barriers, like steps or chairs, heavy doors and nonadjustable exam tables or chairs; accommodating vision-impaired patients through large text or audio versions of exams and paperwork; and accommodating hearing-impaired patients by having a pen and paper and interpreter.
My experience in IR as a minority trainee
Shenise Gilyard, MD, a PGY-6 at UCLA, shared the closing presentation about her experiences as a URM trainee. While training in IR has brought her to some great places and great people, she said, she’s also endured a number of racially biased comments.
"Every time these statements were said, there was no bystander saying, ‘Hey, that’s crazy. Back off,’” she said. “As a trainee, I’m not necessarily empowered to check an attending or someone else because that will cause me to be labeled as problem-maker or something else.”
Dr. Gilyard reiterated that addressing barriers to access is not enough to combat healthcare disparities.
“As Dr. Newsome referenced, a lot of times when we’re learning about biases and problems in medicine, the expectation is that it’s just because people don’t have access,” she said. “In fact, I know several African-American physicians who experienced incredibly biased healthcare even though they were in the highest quartile of earners. They had excellent health insurance and excellent health knowledge.”
She also pointed out that DEI requires more than just bringing in diverse people.
“DEI doesn’t equal anti-racism,” she said. “Bringing diverse people into a space that’s actively hostile toward them isn’t going to make them feel welcome, warm or included, even though inclusion is written in the DEI statement.”
Improving DEI, Dr. Gilyard said, requires self-education, self-reflection, mentorship of URMs and a willingness to be an intervening bystander.
“I pledge that when I become an attending, if I see something, I am going to speak up because I'm finally in the position where I can speak up for the little guys,” she said. “If I see a resident being treated poorly, if I see a patient, a nurse, a tech or the cleaning staff being treated inappropriately, I will say something. Even if that is harmful to my career, my integrity is worth more than my reputation.”
