The percentage of women and underrepresented groups in radiology has largely remained stagnant, despite an increase in medical students who have been traditionally marginalized. There is an undeniable need to increase this number and to encourage and provide appropriate mentorship, sponsorship and coaching opportunities to ensure that talented and dedicated radiologists reach higher ranks. Some mid-career radiologists, however, find themselves hitting a wall when their institutions fail to recognize untapped talent and waning job satisfaction — leaving them feeling undervalued and detracting from the goal of positive patient outcomes.

The ACR Bulletin recently spoke with Charlotte Jane Yong-Hing, MD, FRCPC, vice chair of equity, diversity and inclusion (EDI) and clinical associate professor at the University of British Columbia Department of Radiology. Yong-Hing was a moderator and presenter at RSNA 2023 during a session on “Mentorship, Sponsorship and Coaching: Not Just for Early Career,” and her talk focused on the “mid-career leaky pipeline or pathway.” 

In this article, Yong-Hing discusses the critical need to bolster the number of women and others who are underrepresented in medicine and entering radiology. Beyond this primary need, she says, there is a growing crisis among mid-career radiologists who need mentors and more senior radiologists to guide them on a path toward promotion and leadership roles.

What is the “leaky pathway” and why is it significant in radiology?

While the agenda for my presentation used the word “pipeline” in the title, the preferred term is really “pathway” because it better reflects the nonlinear nature of radiology careers. The concept of the leaky pathway addresses attrition among professionals from underrepresented groups as they progress in their careers. It signifies gaps in the intended route for talent to move upward, resulting in the loss of diverse medical professionals.

A radiologist’s early career focuses primarily on establishing oneself and building a reputation. In mid-career, however, attention shifts to refining clinical expertise and finding opportunities to open doors that extend beyond daily responsibilities.

This mid-career leak can lead to a loss of experienced radiologists poised to make substantial contributions to the field.

This mid-career phase typically refers to 10 to 15 years post-training — a juncture where underrepresented groups can experience significant attrition. This mid-career leak can lead to a loss of experienced radiologists poised to make substantial contributions to the field. It is imperative to retain these radiologists to further develop their skills so they may contribute to research and education and to assume leadership roles that keep the specialty on the forefront of healthcare. 

Unfortunately, this pathway is more difficult for women and minorities in radiology. When we talk about minorities, these count not only race-based cohorts but also people with cultural, gender identification, socioeconomic and other differences. My coauthors and I collaborated to explore this topic in an editorial piece published last year in the Canadian Association of Radiologists Journal (CAR Journal).

Before the leaky pathway impacts mid-career radiologists, how important is it to reach medical students early on?

One of my big motivations for working on EDI challenges is to let medical students know that radiology might give them all the things they want from a career in medicine. Radiology is unique in that there is often the flexibility to work from home, to have direct contact with patients, to work across other specialties and to educate providers about radiology procedures in general. 

Radiology is a great field, and I don’t think medical students really understand that, unless they have a family member in the specialty or some other random exposure to it. Many of them, before beginning medical school, thought radiologists were technologists. We also need to assure them that not all radiologists look, think or practice the same. Visibility is key.

How is the current makeup of the radiology workforce potentially undermining the value of the specialty?

Mid-career leaks diminish diverse perspectives and expertise, hindering innovation and creative problem-solving. Ignoring this reality also reinforces gender-based disparities in leadership roles and unfair financial compensation. 

The lack of role models from underrepresented groups perpetuates the cycle, which can negatively impact the overall welfare of radiologists — increasing susceptibility to burnout in underrepresented groups. 

To enhance diversity and inclusion in radiology, and improve patient care, a comprehensive approach involving individuals and institutions is a must. Raising awareness of unconscious biases and giving due attention to diversity and inclusion practices can promote and advance equity in medicine. 

Within the radiology community, proactive support of mid-career women and minorities means mentorship and sponsorship programs that encourage and guide underrepresented groups. Mentors in leadership positions should support work-life balance and opportunities for remote or part-time reporting if those facets of day-to-day work present obstacles to an inclusive environment. Such solutions demand ongoing commitment and collaboration from all stakeholders to establish and maintain a more favorable work culture.

Radiologists are the ultimate consultants. There is a huge role for radiologists to play by participating in multidisciplinary teams and working groups. For example, we need to work more closely with primary care providers who may not have had a ton of exposure to radiology, even though they are using it all the time. 

You don’t have time to do these types of things in training or when you are coming up through the ranks. Joining committees or boards or collaborating with other specialists might not occur to mid-career radiologists — or they may not know where to look for opportunities that could showcase their abilities.

Why do you think women and minorities are more susceptible to mid-career attrition?

They often lack institutional support and may face discrimination and unconscious biases that can create hostile work environments and limit opportunities. Finding career development support and advancement can be a struggle due to a scarcity of mentors and sponsors — and balancing domestic responsibilities and caregiving further compounds these challenges. 

Women in radiology are more likely to report work-life balance issues and lower career satisfaction compared to men. These obstacles can significantly hinder women’s pursuit of demanding roles, especially in academic medicine. We need to grow the number of women in radiology who are full professors, department chairs, deans and recognized senior research authors. I think mid-career paths can be especially difficult for women from multiple marginalized groups, including racial or religious minorities, LGBTQ individuals and people with disabilities.

Women faculty leaders often assume roles focused on diversity faculty development and student affairs, which highlights their active involvement in fostering inclusivity and supporting the academic community. However, women are less commonly represented in leadership positions associated with clinical affairs and research — which may be valued more by institutions. Departments with a higher proportion of full-time women faculty have more women in leadership roles.

How can mentors and sponsors mitigate the potential consequences of the leaky pathway?

Early on in a radiologist’s career — and even before that, in terms of getting medical students interested in the specialty — mentorship, sponsorship and having a champion is so important. We are now seeing that mid-career radiologists need this, too. 

At this point in their career, people will not necessarily leave medicine, but they may leave academic medicine or decrease full-time commitments. In mid-career, as you become more settled and have established confidence in your abilities, there may be frustration over not advancing as quickly as once hoped, or boredom may set in. That’s where mentors and sponsors play a huge role. If a radiologist is just coasting along in the job they have been doing for 10 years, that person may be looking for a new or extra element to the job — maybe more of a leadership role or extra teaching responsibilities. In the absence of new opportunities, the position may not be fulfilling enough to keep that person there.

Mentors and sponsors can encourage mid-career radiologists to apply for different positions within the same group or institution — garnering recognition for what they are already doing. Awards can be a big deal, too, and re-energize people and get them re-engaged. A mentor or sponsor in a more senior position may put in a nomination for a mentee or point the individual in a new direction toward roles once seen as unattainable. These things can really change a person’s career path — increasing satisfaction and job performance.

What might all parties involved stand to gain through mentorship and sponsorship efforts?

Formal mentoring programs are important because they send a message that an organization sees the value in the guidance a mentor or sponsor has to offer. Mentors may get tremendous satisfaction from the experience even if they are paired with someone who is not necessarily the best fit. The experience gives them the skills to potentially mentor other people in the future that they better connect with. 

The entire process promotes career satisfaction for the mentor — maybe for someone in a position where they feel unheard or overlooked. It opens a door to give back and make a difference in someone’s career that may have lost momentum.

Mid-career radiologists have been working for many years to figure things out and establish themselves so that people know who they are. That is often their primary goal. The problem is that these people have always been incredibly driven and motivated by incrementally achieving goals. 

When they finally arrive at a point in their career where things have settled down and they may have some time to enjoy their lives outside of work, they won’t necessarily take advantage of that time. A mentor can encourage them to do something outside of medicine — run a marathon or pursue other personal interests — that brings more fulfillment. They have worked so hard for so long that doing something non-clinical — something that brings them personal happiness — can translate into greater satisfaction with their everyday responsibilities. 

Without that, it is easy to get jaded or burned out or even leave. These consequences have repercussions on new research, outreach, education and the quality of patient care.

What differences or similarities do you see between Canada and the U.S. around these issues?

A report from the Association of American Colleges titled The State of Women in Academic Medicine, demonstrates that while an equal number or more women than men enroll in and graduate from medical school, the representation of full-time women faculty in medicine is only 41% to 42%. This underrepresentation is even more pronounced in higher leadership positions — where only 25% to 28% of full professors and just 18% of department chairs and deans are women. 

In both the U.S. and Canada, the majority of faculty at the lowest rank of instructor are women. I think, however, that American efforts to transform the current landscape are much more organized, such as through the work of organizations like the ACR and the American Association for Women in Radiology (AAWR). The ACR’s vice president, Dr. Don Yoo, MD, FACR, actually sits as a representative on the CAR’s board of directors.

What efforts have you made personally to attract more attention to the need for EDI advancement opportunities?

Social media has been surprisingly successful. I tried for years to bring some of these issues to a variety of Canadian radiology associations and organizations, only to be met with “this isn’t our responsibility” or “this isn’t on our radar” types of responses. I basically gave up and started the Canadian Radiology Women Facebook group.

From that, we have grown many sponsorships, put on events through this community of women radiologists and are now collaborating with a university and holding physician leadership workshops. We have had success from a grassroots level that is demonstrating significant interest. Still, none of our official organizations in Canada have been interested in getting on board. 

The ACR has had formal committees and commissions in place addressing the advancement of women and minorities for years. For whatever reason, Canadian radiology has shown less urgency in looking into these things.

There aren’t a lot of Canadian radiologists on X (formerly Twitter), and I’m not sure why. We chose Facebook because people seem to feel more comfortable there posting and sharing ideas. Everyone is on social media, and it doesn’t require much of an extra effort to get your message and your struggle out there.

Why are you determined to educate the radiology community about the mid-career leaky pathway?

Mid-career challenges in radiology must be addressed to enhance diversity and equity and to improve patient care. Opportunities for improvement should include fostering a workplace culture that embraces diversity, prioritizing professional growth and ensuring a healthy work-life balance. Additional and intentional support for women and minority groups in radiology throughout their careers is essential to retaining talent — leveraging their expertise and ultimately driving investments in patient care and overall health outcomes.

It is incumbent on leadership to support mentorship and sponsorship programs. It doesn’t necessarily cost an institution more money, but it does require a change in thinking. There tends to be a trend of women and minorities sponsoring each other and doing a lot of extra work — through diversity and equity committees and the like — that is not valued as much as discovering some new imaging technique, for example. Institutional leadership can show its support by valuing this work equally alongside traditional research and lectures. 

I am vice chair of EDI, and that role did not exist until fairly recently. We cannot wait for more women and minorities to enter medicine organically to change fair access to leadership positions. Starting and participating in EDI initiatives is a more effective way to achieve results.

The time has come for people to understand the phenomenon of the leaky pathway and why it is bad for radiology and our patients. Anything that can increase the visibility of mid-career struggles — things like this article and all the work the ACR has been doing for years — is a good thing. Canada can learn a lot from your efforts without reinventing the wheel. 

We are behind on these issues, and radiologists, their patients and our profession are going to suffer as a result. If we look to institutions that have excelled at advancing EDI programs, we can emulate what they have done and hopefully see similar results.

Charlotte Jane Yong-Hing, MD, FRCPC, is immediate past president of the British Columbia Radiological Society and medical director of breast imaging at BC Cancer Vancouver. She has given international talks on the gender gap in radiology and ways to improve equity, diversity and inclusion (EDI) through workforce and training programs. In 2022, she won the inaugural UBC Radiology EDI Award.