This article is the fifth in a five-part ACR Bulletin health equity series and examines the need for more education, research and a diversified healthcare workforce to address disparities. Read the previous articles:

Part 1: Exploring Radiology's Role in Advancing Health Equity

Part 2: A Health Equity Hurdle: Access to Affordable CT Colonography

Part 3: Screening at the Source: Mobile Health Units Deliver 

Part 4: The Local Landscape: Lung Cancer Screening Proponents Unite 

Efforts to eradicate disparities in delivering critical imaging services continue to gain momentum — removing systemic barriers for vulnerable populations. Current healthcare inequities in radiology can result in lower quality of care, poor patient outcomes and higher costs to patients and providers. A more diversified radiology workforce would be better equipped to address and overcome challenges faced by marginalized populations and the medical community — including education and outreach, fair access and greater consideration of societal factors impacting underinsured and underserved populations. Initiatives that establish health equity partnerships and build from innovative institutional efforts to ensure equitable care on a united, national front are advancing the cause.

The ACR is part of the Radiology Health Equity Coalition (RHEC), a group of organizations that joined forces in 2021 to positively impact health equity for vulnerable outlier populations. To paint a picture of how radiologists and physicians from other specialties are moving the needle, the ACR Bulletin is talking to changemakers striving to meet Coalition goals around more equitable care.

Understanding Drivers of Healthcare Disparities

Peter F. Abraham, MD/MAS

Some radiologists believe they do not play an integral role in the advancement of health equity. A better understanding of the drivers of disparities in fair and equal care can be a real revelation. More research, education and the open exchange of information on a national level help bring into focus a physician responsibility to improve outcomes and a pressing need to build a more diverse radiology workforce to ensure representation for patients who are too often overlooked.

“A lot of radiologists are more focused on the diagnosis in front of them than the reality that drivers of inequity are baked into every patient encounter and case — and everything a patient may experience when she or he comes in for care,” says, resident physician in the department of diagnostic radiology at the University of California San Diego (UCSD) and ACR representative of the RHEC.

Medical imaging touches most patients at some point in their lives, and radiologists should be taking the lead to further education around why disparities continue to limit access to care, Abraham believes. He has been undeterred since the COVID-19 pandemic painfully revealed the facts around inequitable care for certain cohorts of patients — and how greater diversity within radiology and other areas of medicine can positively shape future thinking and initiatives.

“I think we can do a lot of good working with the RHEC through both didactic, instructive programming and through opportunities to meet and commune (virtually or in person) to network and form true on-the-ground movement toward equity in radiology,” Abraham says. “One of the things I enjoy the most through my work is reaching out to join or form coalitions — to interact with different people and groups and learn from their lived experiences.”

Educating to Hone Strategies

Abraham has been working with the RSNA’s Health Equity Committee, which collaborates with other major radiology societies in the RHEC to spur positive change in the radiology community and beyond. “One of the things we have been thinking about with the committee is how to highlight equity projects that are presented each year at large gatherings, such as the RSNA’s annual meeting,” Abraham says. “We want to organize like-minded people who are interested in similar topics so they get to know one another and build bonds.”

For example, the group has been working on a mechanism to identify abstracts addressing equity issues, review the research findings and then provide a type of resource guide. “Whether that’s a summarization of topics or a guide to physical locations and speakers, we need something to help anyone working toward the same goals to find their home,” he says.

At UCSD, there are ongoing projects that can be applied locally or at a national level — and similar efforts are growing in other academic settings across the country, Abraham says. “Something we have stuck with since the onset of COVID-19 is a curriculum for our residents that includes health disparities and health equity considerations in radiology,” he says. “We have built in required didactic education lectures so that at least once per quarter there is a focused lecture on disparities or diversity and inclusion.”

Advocating for payment reform and strategies targeting health-related social needs is becoming common in other specialties. We should be helping dictate how radiology will play a role in health equity.

Education should be tailored for individuals at their level of understanding and career stage, so some of the early lectures were more foundational, Abraham says. “Then we dove into some research projects at our institution, and additional lectures were devoted to talking about that research and what it meant for our patients in San Diego — and also how it can be generalized for the entire patient population.”

Literature on practical tools for advancing radiology health equity efforts that are applicable to a wide variety of patient populations and care settings is lacking. The overarching goal moving forward is to equip radiologists with a practical knowledge toolkit of evidence-based strategies, Abraham says. Whatever a group’s specific approach to garnering more attention to and action on barriers to equitable care may be, it should be intertwined with research, education, clinical care and innovation. Forming multidisciplinary relationships with other groups in medicine can steer a national discussion on disparities and bolster physician interest.

“I have been thinking about the mission of the RHEC and the value-add that would be necessary for buy-in from institutions and individuals,” Abraham says. “I tend to think about our call to equity work as pertaining to several domains.” 

Start by identifying and researching disparities in radiology and suggesting targeted solutions, he says. “Then focus on educating ourselves, our patients and our trainees (through didactic lectures and workshops) on health equity — including anti-racism and bias recognition and their underlying structural causes.” 

Creating intentional identity-conscious programming to diversify the radiology workforce is essential, and advocating for patient access while considering fair expectations and compensation for radiologists also allows for greater buy-in. 

“Advocating for payment reform and strategies targeting health-related social needs is becoming common in other specialties,” Abraham says. “We should be helping dictate how radiology will play a role in health equity.”

Considering Social Determinants of Health

Equity within radiology and healthcare in general cannot be achieved without cooperative, large-scale efforts to broaden awareness of SDOH in medicine. During the pandemic, the disproportionate toll on racial minorities, patients of lower socioeconomic status and uninsured or underinsured patients demonstrated the need for targeted institutional and national interventions in radiology. Radiologists can contribute by addressing factors that impact differential screening and patient interventions.

“We are conducting and accumulating more research on SDOH to foster more discussion around its impact on health outcomes,” Abraham says. To successfully intervene in the care of their patients, physicians must examine situational factors that affect people’s daily lives — their socioeconomic status, living environment, level of education, access to proper nutrition and even the quality of the air they breathe, he says.

“Poor health outcomes are often due to factors that affect daily living as opposed to the care people get in clinics or hospitals,” Abraham says. “We recently published a piece on SDOH that is sort of a primer for practicing radiologists, focused on providing case examples from clinical practice and then looking at the outcomes of those patients,” he says. It provides data to support cost-effective measures that can improve patients’ health. “This is something other physicians are talking about — in family and internal medicine — while the discussion in radiology has not spread sufficiently or significantly.”

One great resource he has found is the Center for Health Disparities Research at the University of Wisconsin School of Medicine and Public Health. Abraham describes it as a search engine of sorts, set up in response to hearing that data on equity in radiology is hard to find. It has a search function that allows users to look at all available data on a particular topic and categorize it based on inpatient and outpatient interventions.

“While some of the work I am doing is more theoretical, I always try to include in papers any central and actionable areas of improvement that we can focus our attention on,” Abraham says. “If people do not see improvements, they can start to lose faith in the process and become less energized in their efforts.” 

Diversifying the Radiology Workforce

An especially overdue area of improvement in radiology to propel more equitable care is diversity within the specialty. Despite some attention to downstream strategies to improve diversity in radiology — through increased recruitment efforts and holistic application review — workforce diversity has not tangibly improved in recent decades. It is vital to define obstacles that might complicate or prevent people or groups who have been traditionally marginalized and minoritized from a career in radiology. A focus on upstream barriers to medical education is key to sustainable workforce diversity efforts.

“If we want to improve diversity in radiology, we have to go to the future radiologists when they are younger,” Abraham says. “We want and need to look at the actual interventions being proposed and those proven to be beneficial. There are potential early educational interventions at middle schools and high schools to introduce younger people to science and radiology.” 

The ACR Pipeline Initiative for the Enrichment of Radiology (PIER) program is one example of growing efforts to reach potential radiologists early on. It is a medical student program offering mentorship through an assigned preceptor, weekly educational webinars and an independent student project. PIER began through the ACR’s Commission for Women and Diversity with the goal of giving underrepresented minorities and women an opportunity to explore radiology and engage in research.

“We need to attract more women and minorities to radiology,” Abraham says. The ACR has made gains in this arena, he adds, but there still needs to be a greater base to work from so that health equity issues stay visible and top of mind. “A paper we published in the JACR goes hand in hand with the work of the ACR’s Commission for Women and Diversity and explores how healthcare workforce diversity is vital in combating disparities. We also have a couple of working groups that generate papers — trying to push the discussion out on a national level so that people who may have never thought about this as an avenue to explore in radiology can find their way.”

Dismantling structural racism in medicine is also integral to diversifying and requires widespread buy-in and transdisciplinary collaborations across institutions to establish systematic, rigorous approaches that enable sustainable change. Radiology is at the center of medical care, and a renewed focus on diversity, equity and inclusion provides an open forum for physicians to discuss racialized medicine to catalyze change.

“More education is also needed to uncover and identify subconscious bias — in our day-to-day life, but also with our patients, trainees and staff,” Abraham says. “We have proposed an education curriculum around antiracism for our department and talked about why some people might be hesitant about such change. I can see this becoming a part of a series of lectures like those produced by the ACR’s Radiology Leadership Institute^®.

“We are very focused on what radiologists need to do, both in terms of their trainees and their institutions,” Abraham says. “While it’s great to have a formal curriculum, not every one of my medical student mentees is going to become a radiologist. So how do we bridge the divide between specialties and institutions and larger health equity groups like the RHEC?”

Engaging Yourself Through Others

When choosing radiology, Abraham says one of his initial reservations sprung from his perception that not many radiologists seemed interested in health equity work. “I soon realized that we do see the value in it, but not being the first physician to see a patient face-to-face might make it more difficult to engage in the work,” he says. “This got me interested in joining and convening health equity groups.”

When looking at health equity issues from afar, it can be difficult to see tangible opportunities to make a difference. “Like me, you may even question your career path as a result,” Abraham says. While there may be only a handful of people at an institution who are keen to get involved, clinicians across the country are working to tackle healthcare disparities, he says. “The great thing about participating in a health equity group is that you can learn from each other’s experiences by tapping into networks of support and new ideas.”

Abraham says he has been pleasantly surprised by non-radiology organizations — groups like the AMA and the Accreditation Council for Graduate Medical Education (ACGME) — who are doing interventions and providing resources. “Things can often be siloed in academia, and in private practice if you are on your own in an isolated area. It can be easy to lose track of what’s going on elsewhere and of the resources available to you.”

Successful movements have found a way to mend divides, Abraham says. “They have been multi-generational efforts bridging gender, class, race and so on. Forming a coalition like the RHEC is a lot like these social movements — we need everyone on board to provide whatever insight and expertise they can so that all segments of the population are served equally.”

Members of the RHEC are committed to finding ways to bridge different divides, Abraham says. “While partners and participants may have different specific interests, everyone is coming together to advance the cause. This work is not limited to a particular specialty, generation or practice setting — anyone who wants to put in the work will be welcomed and appreciated.”