German physician Rudolf Virchow famously said, “Medicine is a social science, and politics nothing but medicine at a larger scale.” Dr. Virchow advocated that social problems are a physician’s responsibility, stressing the ability for physicians to enact social change through both practice and advocacy.
Dr. Virchow’s words and message were emphasized by the speakers during the SIR 2022 session, “Physician-driven change.” The goal of the session, according to co-coordinators Paula M. Novelli, MD, FSIR, and Philip D. Orons, DO, FSIR, was to highlight health care delivery and outcome disparities, and demonstrate the power and opportunities that IRs have to influence policy in support of the patient community as a whole—rather than of one patient at a time.
Bridging the data gaps
Part of this movement begins with a diverse workforce, according to Hirschel McGinnis, MD. In his presentation, Dr. McGinnis charted the history of diversity, equity and inclusion (DEI) efforts in IR and SIR, such as the work done by the SIR Women in IR (WIR) Section to not only increase representation but provide support for IRs once they begin practice.
Dr. McGinnis cited as an example the SIR statement on parental leave, which was developed by WIR members. “I’ve seen peers come back to work just days after giving birth,” Dr. McGinnis said. “The statement advocating no less than 6 weeks leave is revolutionary."
He also pointed to the success of programs such as the Grants for Education of Medical Students (GEMS) Program. “All 2021 GEMS scholars matched into their chosen IR programs,” he said. “This is how DEI work goes from a hope to something with fully realized workforce implications.”
While there has been significant success in advancing opportunities for women in IR, Dr. McGinnis says these opportunities are less clear for URM and LGBTQ+ providers in IR. Large data gaps exist regarding the race, ethnicity, sexual orientation and gender identity of the IR workforce. Unless we have a better grasp of representation and work experience of IRs throughout the career pathway, advancing equity through strategic planning will be difficult, Dr. McGinnis says.
“The gaps are most notable regarding LGBTQ+ providers,” he said. “While we know graduating medical students identify as LGBTQ+ at rates greater than 10%, their presence in DR and IR is largely unknown.”
Though Dr. McGinnis estimates there are at least 100 LGBTQ+ IRs practicing in the United States, recent efforts at forming a professional support system or affinity group have gone unfulfilled. “Almost 50 years after homosexuality was removed from the DSM, something within the culture of IR still seems to be inhibiting LGBTQ+ physicians from feeling comfortable openly associating,” he said “This represents an enormous opportunity for inquiry, professional development and workforce expansion.”
“We need to do a better job understanding what is going on in the workforce,” he said. “And we need to build a movement where people can come into a professional space and bring themselves, without feeling they have to comport to anyone else’s standards of who they ought to be.”
“DEI work isn’t about creating a pleasing pallet of colors and faces for photos,” he added. “It’s about creating diversity in terms of temperament, approach, style and thinking.”
Physician leadership
This diverse team approach is sorely missing in physician leadership, according to Aneesa Majid, MD, MBA, FSIR. Citing demographics figures for the corporate boards of the top 41 health care organizations, she showed that the overwhelming majority are white—white males in particular.
“Corporate boards have found that when you have diverse teams, you have a greater knowledge base, more creativity, more innovation, increased discussion and enhanced problem-solving,” she said. “And when you have at least one woman on the board, studies have found increased return in revenue.”
Dr. Majid says she believes this holds true when applied to health care as well. “A disconnect happens when society is going one way, but leadership is stuck going the other way,” she said.
More diverse boards can have concrete impact on patient and physician wellbeing—but only when the diverse workforce is given appropriate support.
“If you put someone in a DEI position, do they have support? Do they have resources?” she asked. “Are you providing culturally competent leadership training and support, and is everyone agreed to support the mandate for change?” Without support, the person put into the DEI role cannot enact change and acts more as a “checkmark” she says. That individual can quickly become burnt out by having to bear the brunt of DEI work alone—a phenomenon referred to as the “minority tax.”
That lack of support translates down the ladder, such as with an institution’s problems both in trying to create a diverse workforce and in retaining its existing workforce. “Some data shows that 40% of women are leaving medicine within 6 years of completing residency due to family work conflict, gender bias, harassment and salary inequity,” she said. “These are issues that a nondiverse leadership can address. But a nondiverse leadership may not understand the problem or know that there is even a problem to address. Similarly, it is very difficult to create a diverse workforce with nondiverse leadership.”
The solution, Dr. Majid says, is to create and commit to organizational change, provide resources for initiatives and recruitment, and develop leadership programs and pathways that will allow all physicians—particularly women and underrepresented minorities (URMs)—to succeed.
The impact of a diverse workforce
Does a diverse workforce actually impact patient outcomes? The short answer, according to Philip Orons, DO, FSIR, is “Most likely.”
“We know that diversity has a positive effect on business, and that gender-inclusive teams outperform. When you bring more ideas to the table, you have better outcomes,” he said. “But does this transfer to medicine?”
Unfortunately, there haven’t been enough long-term studies to positively confirm a positive correlation, he says. This may be because the workforce still has not caught up to represent the patient population—the workforce is still overwhelmingly white and male, and there are very few medical students who come from families in the bottom percentiles of household income.
However, Dr. Orons said that specific studies have shown that implicit racial and ethnic bias does play a role in patient–provider interactions and decisions, and other studies show that only 22% of Black adults report being the same race as their provider. Only 23% of Hispanic adults reported racial, ethnic or language concordance with their provider.
The data are clear, according to Dr. Orons: outcome disparities exist. Black patients are 30% less likely to receive revascularization at a coronary angioplasty and 40% less likely to receive coronary bypass surgery. In her presentation, Dr. Novelli focused on portal hypertension outcomes in IR, reporting that Black and Hispanic patients are less likely than Caucasian patients to receive a TIPS procedure for variceal bleeding and patients were less likely to undergo a shunt procedure if they received Medicare, Medicaid or if uninsured. Black patients have a 2-fold higher inpatient mortality following the procedure possibly related to greater disease severity before the procedure.
Comparison of workforce data to outcomes data does seem to suggest that workforce diversity plays a role in the outcome equity. When there is racial concordance, Dr. Orons said, patients appear to be more satisfied with their health care.
“The encounters last longer, and Black men have been found to be more likely to follow up with their care and be more compliant with after care when seeing a Black physician,” Dr. Orons said.
It’s also important to look at the wider workforce, beyond just physicians, said the presenters. Patients are seen by a large number of team members, who may each have their own biases or misconceptions that can impact care.
These biases may also appear in curricula designed to prevent inequities, he said. “Well intentioned but unprepared educators, when teaching typical characteristics of minority groups, may promote stigmatization without promoting health care outcome improvements. And microaggressions can become embedded in educational content.”
The more impactful ways to address these inequities, according to Drs. Novelli and Orons, are workforce diversification and patient outreach.
“We know the social factors that contribute to health care disparities,” Dr. Novelli said, citing racism, financial hardship, lack of insurance, fear, education and access as factors leading to inequities. “We also recognize some of the reasons that lead to decreased referrals for TIPS procedures in minority populations: referring physicians worry that the patient won’t have adequate social support. And follow-up therapy is expensive, and the disease progression may be too advanced for good long term procedural outcomes.”
The solution, Dr. Novelli says, is to find better methods to support, treat and monitor. “They need better access to our therapies,” she said, “so let’s refer them earlier and recognize the upstream factors leading to it.”
When physicians understand the barriers to care, she said, they are better able to identify ways to overcome them.
Ethics in IR
The importance of effective patient engagement is also an ethical matter, according to Helena Rockwell, a medical student at UC San Diego and Director of Research for the Applied Ethics in IR initiative, which seeks to identify ethical issues in IR and create practical resources and guidelines to address those challenges.
“Futility and consent are two important issues according to the IRs we’ve surveyed. Regarding futility, the critical question is, “when do the risks of a procedure outweigh the benefit, such that a procedure actually shouldn’t be done?” which Rockwell continues to explain is, in reality, a very difficult assessment, as what constitutes a meaningful benefit or acceptable risk may vary greatly from individual to individual. Fortunately, she continues, advance care planning, including goals of care discussions with patients and their families, is effective in clarifying patients’ preferences and evaluating whether a particular intervention is likely to yield benefit that aligns with their goals and values.
The Applied Ethics in IR Initiative looks next to trial a workflow to better prospectively identify procedures that may be futile—or “potentially inappropriate”—to ensure that there has been opportunity to clarify patients’ and families’ preferences, values, and goals of care prior to undergoing such procedures.
Informed consent is another salient ethical issue according to IRs. “We consent patients every single day, but there’s a lot of variability in how it’s done and what information is shared,” Rockwell said. “Patients also have differing levels of health literacy and language preferences. And issues surrounding consent can be a common cause for error or malpractice allegations.”
An effective tool that supports informed consent being an informed choice for patients is patient decision aids, which convey information about risks and benefits of a healthcare decision at an average reading level and ideally in a patient’s preferred language. In collaboration with the Interventional Initiative, the Applied Ethics group has been actively developing IR-specific aids. Prior to their use, these aids undergo an extensive vetting process to ensure maximal quality and comprehensiveness, including a literature, ethics, and health literacy review, and approval both by radiology clinicians and patients.
“These have been shown to improve patient understanding and satisfaction,” Ms. Rockwell said, adding that patients who receive these aids report feeling better informed and aware of the risks and benefits, and they feel more satisfied with their healthcare decisions.
According to Ms. Rockwell, there are additional resources across varying modes of delivery planned to further enhance patient engagement and information sharing in consent conversations.
Global IR
Physicians can do more than just enact change at home, according to Robert Dixon, MD, FSIR—those with a passion for global health can take part in international IR outreach.
Dr. Dixon, a program director for IR in Kenya through the RAD-AID initiative, presented on the impact of global involvement. Through RAD-AID, Dr. Dixon and other volunteers have worked with local physicians to help institutions develop IR programs and increase access to IR services. This is crucial in countries like Kenya, where, according to Dr. Dixon and recent literature, postpartum hemorrhage may be responsible for up to 34% of maternal deaths—and there are only six hospitals with the IR availability that could save patient lives.
“Our goal was to increase access to IR services by creating a fellowship at the University of Nairobi,” Dr. Dixon said. “In 2020 we accepted our first two fellows and accepted two more in 2021.”
The pandemic provided a unique challenge to the program, which typically involves site visits and hands-on education. Instead, the curriculum shifted to weekly lectures, case presentations, journal clubs, remote simulations and oral exam case reviews.
Physicians who work in underdeveloped countries or nations without IR access are familiar with finding creative solutions to significant barriers—be it infrastructure or regulatory and legal challenges. There are multiple models on how to help, Dr. Dixon says, and though there are many people who are passionate about global IR, time and money always pose a problem.
One way to combat these hurdles is to have a global leadership pathway, Dr. Dixon said, with a curriculum that gives residents the opportunity to learn the best practices for sustainability in global health and culminates in an international elective.
The other is to explore all possible avenues of funding. Dr. Dixon shared a list of various support opportunities and stressed that RAD-AID is not the only organization doing this kind of work. Especially now that travel has resumed, there are many opportunities in which IRs can become involved.
“International work is so important because it gives us a different perspective on what we do every day,” he said. “I think it makes us better physicians.”
Missed this session? Watch it any time via SIR Now.
