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Breaking the Stereotype: Interventions Aimed at Changing Medical Student Misperceptions of Radiology and Increasing the Female Match Rate
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Medical Student Education
Breaking the Stereotype: Interventions Aimed at Changing Medical Student Misperceptions of Radiology and Increasing the Female Match Rate Victoria Podsiadlo, Carolynn M. DeBenedectis, MD
Background: Although nearly half of medical students are female there is still a significant discrepancy in the number of women specializing in radiology. In 2013, 26.9% of US diagnostic radiology residents were female, a 1% increase in 20 years from 25.5% in 1990. Purpose: The purpose of this project is to determine the effectiveness of the interventions implemented at a single medical school at decreasing negative attitudes about radiology held by medical students of all genders and whether those same interventions will increase the number of female medical students matching into radiology. Methods: The interventions were implemented between 2012 and 2016 and included incorporation of radiology into preclinical curriculum, electives in radiology for 3rd year students, a “Women in Radiology Panel,” and increase in female radiology faculty visibility. First year medical student participants of all genders used a free text box to write their attitudes about radiology, which were categorized into the “six most common attitudes about radiology.” Fourth year medical student participants used a free text box to write the reasons why they did not choose radiology as a specialty, and those answers were then placed into the same six categories. We then analyzed the data using Fisher’s Exact Test to determine whether there was a decrease in the negative misperceptions after exposure to the interventions. We also then determined whether there was an increase in the number of women matching into radiology using Chi-Square analysis. Results: There was a decrease in the negative misperceptions between 1st and 4th years, with the most notable decrease from 51% of 1st years to 0% of 4th years listing radiologists as being antisocial (p < 0.01). There was also a significant increase in the number of female medical students matching into radiology in the years in which students were exposed to 4 years of intervention when compared to three and fewer (0.76% 4.2%, p = 0.01). Conclusion: Exposure to 4 years of the interventions demonstrated a significant increase in the female match rate into the specialty when compared to female medical students who experienced three or fewer years of intervention. Additionally, it appears that these same interventions decreased the number of students of all genders having some of the common negative misperceptions about the field of radiology. © 2020 The Association of University Radiologists. Published by Elsevier Inc. All rights reserved.
INTRODUCTION
D
espite the fact that nearly half of medical students are female (47% in 2015) [1,2] there is still a significant discrepancy in the number of women choosing to specialize in radiology. In 2013, 26.9% of US diagnostic
Acad Radiol 2020; &:1–7 From the Department of Radiology, UMass Memorial Medical Center, Worcester, MA 01605. Received November 3, 2019; revised January 15, 2020; accepted January 15, 2020. The authors declare that they had full access to all of the data in this study and the authors take complete responsibility for the integrity of the data and the accuracy of the data analysis. Address correspondence to: C.M.D.B. e-mail: [email protected] © 2020 The Association of University Radiologists. Published by Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.acra.2020.01.021
radiology residents were female, a 1% increase in 20 years from 25.5% in 1990 [3]. Recently, there has been an increase in the number of studies performed to determine what can be done to foster medical student interest in the field at large, and more specifically to address the gender gap which has gone unchanged for many years [4 7]. A previous study performed at the University of Massachusetts Medical School (UMMS) proposed that the three interventions implemented between 2012 and 2016 (earlier exposure to radiology in the preclinical curriculum [4 6], changing the misperceptions about patient contact in radiology with “patient-centered” radiology electives [6], and mentorship by radiology faculty [7,8]) may increase overall student interest in radiology, but not female student interest in particular [9].
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ARTICLE IN PRESS PODSIADLO AND DEBENEDECTIS
It is thought that having increased visibility of female faculty and increased opportunities for mentorship between female radiologists and medical students is essential for recruiting female medical students to the field of radiology [6,10]. There is also a powerful motivating impact of interactions between female radiologists and female medical students, where the students are able to see what life would be like as a radiologist and subsequently be more likely to choose the specialty [6 8, 10 12]. Prior to 2016 when the previous study was performed, the visibility of female radiologists was limited resulting in few opportunities for female radiologist mentorship. First, most of the female radiologists at the institution were in the mammography department, which was not a rotation offered to medical students during the general radiology elective. Second, the radiology faculty that had the most exposure to medical students was male, including the preclinical anatomy cocourse director, radiology interest group advisor, and residency program director. Since the start of the current study in 2016, many of these roles were transitioned to female leadership, there is increased overall female faculty within the radiology department, and breast imaging became integrated into radiology electives. The first aim of this study is to determine what attitudes medical students of all genders hold about radiology and whether the implemented interventions were able to change any negative misperceptions. In particular, absence of patient contact in radiology has been cited by medical students as a main reason for not considering radiology. In one study 95% of female students, who had chosen a specialty other than radiology, stated lack of direct patient contact as a reason they did not choose radiology [7]. By identifying medical student attitudes toward radiology at the start of their first year (with a focus on female medical student attitudes), we are attempting to determine whether the interventions implemented at UMMS would correct the common negative misperceptions held by medical students. The second aim of this study is to determine whether the increased female radiologist visibility and mentorship since 2016 has made an impact on the most pervasive misperception that there is limited patient contact in the field of radiology, thereby increasing the number of women choosing radiology as a career specialty.
MATERIALS AND METHODS Radiology Interventions
Curricular interventions from the previous study at UMMS took place between 2012 and 2016. These included (1) A faculty radiologist joining preclinical anatomy course codirector, where 15 20 imaging lectures were added to the second year curriculum and delivered by a radiologist; (2) CT scans were performed of gross anatomy cadavers to provide radiology-pathology correlations during dissections as part of preclinical anatomy course; (3) Radiology residents were involved in gross anatomy dissection labs, reviewing cadaver CT scans with medical students; (4) “Patient-centered” 2
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Flexible Clinical Experiences (FCEs) in radiology (including pediatric, breast, and interventional radiology) during the third year of medical school, which are weeklong electives that allow career exploration outside of the core curriculum; and (5) Annual Women in Radiology panel (started in fall of 2016) open to all medical students to promote visibility of female radiologists and enable student-radiologist mentoring relationships. The panel is comprised of about five female radiology attending physicians and female radiology residents who first share their paths into radiology and why they chose their specific subspecialty. Students are then given an open forum for an hour and encouraged to ask questions. The bulk of the discussion is about what it is like to be a woman in the field of radiology, what the job entails, work-life balance, and details about levels of patient contact. Additional noncurricular interventions beginning in 2016 included several changes to the staffing of the medical student facing faculty. This included a new female radiology residency program director and the addition of a female codirector to the radiology interest group. There was also an increase in the amount of female radiologist mentorship which included roles such as Capstone project advisor and specialty advisor. Female radiologists also took a more active role in medical school events, including those hosted by the institution’s chapter of the American Medical Women’s Association. Additionally, there were adjustments made to the FCEs, including expansion of the breast imaging FCE and the addition of a new “Women in Radiology” FCE, where medical students are assigned to work with various female radiology attendings within several subspecialties. Data Collection and Analysis
First year (N = 188) and fourth year (N = 66) medical students of all genders over the course of 4 years voluntarily participated in an online survey for a cross-sectional study to assess whether the interventions implemented at the institution starting in 2012 had an impact on correcting some of the misperceptions and stereotypes attributed to radiology/radiologists. The Institutional Review Board determined the study to be exempt by Category 2 (educational survey). First year participants were given a free text box to write in their opinions and attitudes about radiology. The survey was distributed in late August of their first year, 2 3 weeks after starting school and prior to exposure to the interventions. Their responses were subsequently manually categorized into the “six most common attitudes” which included (1) There is no patient contact, (2) Radiologists are antisocial, (3) Radiology is a dying field/is being outsourced, (4) Radiologists spend all day in a dark room, (5) The “Positives” good pay, lifestyle, and work-life balance, and (6) Other. The titles of the previously mentioned categories were selected based on the number of responses that contained that particular phrase, but also encompasses responses that were variations of that phrase. For example, although many responses included the word “antisocial,” responses such as “radiologists are socially awkward” and
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“radiologists don’t know how/want to talk to people” were also included in the “antisocial” category. The “Other” category was created to house additional responses that did fit into the previous five categories. Fourth year participants were asked in a free text box the reasons why they did or did not choose radiology as a specialty, and those answers were then placed into the same six categories. This survey was distributed in April of each graduating year between 2016 and 2019. The data was then analyzed using Fisher’s Exact Test to determine whether the rate of any negative perceptions decreased when comparing the responses from year 1 students to year 4 students after they were exposed to the interventions. A p value <0.05 was considered significant. We then analyzed how many students of each gender participated in the implemented high-patient-contact radiology FCEs to determine whether the early exposure to radiology in the preclinical curriculum sparked enough interest to explore radiology as a career option during the third year of medical school. A database was created containing the number of students who took part in radiology FCEs (breast, pediatric, and interventional radiology). Participants were then stratified by both class year during which they were enrolled in the elective and gender. The data was analyzed by linear regression analysis and F-test with a p <0.05 considered a significant result. We additionally determined the intensity of impact the Women in Radiology Panel had on its attendee’s (N = 18) perception of patient contact and work-life balance in radiology and whether they were more strongly considering radiology as a specialty after attending. After the panel, students voluntarily participated in an anonymous survey about their perceptions of radiology before and after the panel as well as
BREAKING THE STEREOTYPE
whether they are more seriously considering a career in radiology after attending. Data on student perspectives before and after were analyzed by paired T-test, with p <0.05 considered a significant difference. Finally, the institution’s Match data between 2009 and 2019 was analyzed to determine the number of medical students matching into radiology as well as the female to male ratio of those students. There was a particular emphasis on the difference between match rates from 2009 and 2011 where there was no intervention versus 2012 2015 where there was 1 3 years of intervention versus 2016 2019 where there was 4 years of intervention. The data was analyzed using Chi-Square analysis with p <0.05 considered a significant result. RESULTS Among the first year medical students, who responded to the survey (188 participants, »400 students invited to participate), 51% of responses fell into the “radiologists are antisocial” category, 45% of responses fell into the “there is no patient contact in radiology” category, 32% of responses fell into the “radiologists as sitting in a dark room all day” category, 9% responses fell into the “radiology as a dying field or that radiology is being outsourced” category, and 35% of responses listed some positive perceptions about the specialty (lifestyle, work-life balance, salary, etc.) (Fig 1). However, there was no significant difference in the perceptions held by female medical students when compared to male medical students. Among fourth year medical students, the rates of the responses containing negative misperceptions as reasons for not choosing radiology as a specialty were mostly decreased when compared to first year
Figure 1. Percent of students in each class year (MS1 vs MS4) who listed each of the “preconceived notions” in their survey responses. Star symbol (*) represents statistically significant difference between the class years, analyzed using Fisher’s Exact Test (p < 0.05).
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medical students with 14% listing radiologists sit in a dark room all day (p = 0.004), 4.6% listing radiology as a dying field/is being outsourced (p = 0.30), and 0% listing radiologists as antisocial (p =< 0.0001). However, the rate of fourth year students listing no patient contact actually increased compared to first year medical students (from 45% to 70%; Fig 1). There have been 101 male and 84 female medical students who have participated in the radiology FCEs since their creation in 2012, with growth from the 2012 2013 Academic Year where 19 students took radiology FCEs (12 male, 7 female) to the 2019 2020 Academic Year where 33 students (14 male, 19 female) took radiology FCEs. Linear regression analysis was performed on the number of students by academic year for males and females. There was a linear association among females with an increase of 2 women per year participating in FCEs (p value for F-test is 0.03; Fig 2). Additionally, there appears to be a decrease in the gender gap between male and female medical students participating in radiology electives since their implementation in 2012. Following the Women in Radiology panel, the 18 female students who participated in the survey (survey distributed to 36 students) rated their perception of patient contact in radiology 16% higher after the panel compared to before the panel (48% vs 64%, respectively), which was statistically significant (p = 0.001). Similarly, female attendees rated how likely they are to consider radiology as a career 10% higher after the panel compared to before the panel (62% 72%, respectively), which was also statistically significant (p = 0.003). Although not statistically significant, female
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student perception of work-life balance in radiology improved by 4% after the panel compared to before the panel (88% 92%, respectively, p = 0.33; Fig 3). During the years where there was no intervention (2009 2011), 2.6% of female medical students and 5.4% of male medical students matched into radiology. Since the interventions began in 2012, there has been a significant increase in the number of female medical students matching into radiology during the years in which students were exposed to 4 years of intervention when compared to 3 and fewer with the rate increasing from 0.76% from 2012 2015 to 4.2% from 2016 2019 (p = 0.01; Fig 4). The number of male medical students matching into radiology was mostly unchanged over the same time periods with 4.7% matching between 2012 and 2015 and 4.5% matching between 2016 and 2019. DISCUSSION A previous study at UMMS suggested that early exposure to radiology during preclinical education and offering patientcentered radiology electives increases overall medical student interest in radiology, but active publicity and visibility of female radiologists from early in medical school would have the biggest impact on increasing female medical student interest [9]. The present study has longitudinally expanded on the previous findings to (1) identify the attitudes held by medical students of all genders about the field of radiology, (2) determine whether the interventions have corrected any negative
Figure 2. Number of students in each gender taking radiology Flexible Clinical Experiences (FCEs) per class year. Linear regression analysis for female students demonstrated a slope of 2, indicating the number of women taking radiology FCEs is increasing by two people per year and closing the gender gap among students taking radiology electives.
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BREAKING THE STEREOTYPE
Figure 3. Perceptions of radiology held by Women in Radiology Panel attendees pre- and postevent. Star symbol (*) indicates statistically significant difference in average rating between the two groups using paired T-test (p < 0.05).
misperceptions, and (3) determine whether the same interventions in addition to increased female radiologist visibility and mentorship would increase female medical student interest in the field. We have concluded that although there is no
significant difference in negative misperceptions held by male versus female medical students, the most pervasive misconception is that there is no patient contact in the field. We have demonstrated that by getting female radiologists out of
Figure 4. Percent of students matching into radiology within each sex grouped by academic year, with 2009 2011 being no intervention, 2012 2015 being 1 3 years of intervention, and 2016 2019 being 4 years of intervention. Data was analyzed using Chi-square analysis, with the 2016 2019 group showing statistical significance when compared to 2012 2015 group (p < 0.05).
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the reading rooms and actively publicized to female medical students (such as through the Women in Radiology Panel), we were able to significantly alter female student perceptions of how much patient contact there is in the field and increase the number of women choosing radiology as a career specialty over the same time course. Medical students of all genders were noted to have several negative attitudes toward the field of radiology, which most notably include the belief that radiologists are “antisocial” (51% of responses fell into this category) and that there is “no patient contact in radiology” (45% of responses fell into this category). The most dramatic attitude change occurred in regard to the belief that “radiologists are antisocial,” which dropped to 0% when analyzing fourth year student responses. We hypothesize that the most likely reason for this dramatic decrease is the imaging driven lectures delivered by a radiologist during the preclinical years. Because these lectures are part of the required curriculum, all medical students are exposed to radiology faculty and have the opportunity to see radiologists as interactive physicians. Additionally, students who participated in radiology FCEs and electives get personal interaction with radiologists to help dispel this misconception. Unfortunately, the rate of students who listed radiology as having no patient contact actually increased from first year students to fourth year students (45% 70%). This likely multifactorial in nature given (1) not all students participate in radiology electives, during which they would have the opportunity to discover the range of patient interaction available in certain radiology subspecialties, (2) individual student thresholds for what they consider a “clinical” specialty, for example, if they do not consider the brief patient contact during a biopsy “true” patient contact, (3) students experience more patient contact than they expect on other core clerkships (such as medicine or surgery), making the amount of patient contact in radiology appear even smaller, (4) the way that the field of radiology is described by nonradiologist colleagues, where medical students are primed from early on to believe that there is very little opportunity for patient contact. However, having just the one event highlighting and sharing female radiologists’ experiences improved female medical student perspective on this most pervasive misperception (that there is no patient contact in radiology) with statistical significance (p = 0.001). Moreover, following the panel the female attendees were also more seriously considering radiology as a career by a statistically significant margin (p = 0.01). In order to reach a broader population, the visibility of female radiologists needs to be expanded to all female medical students. This could be accomplished in several ways, ranging from guest lectures from female radiologists incorporated into the established preclinical imaging curriculum, increased participation in collaborative events with other student groups such as American Medical Women’s Association, or developing a database of ongoing female radiologist research endeavors in the department where medical students can get involved (especially as previous studies have demonstrated 6
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that women felt favorably about the opportunities for research in radiology [12]). It is important to note the misperception that “there is no patient in contact in radiology” could also be addressed more broadly to all genders during different stages of medical school. Preclinically, the faculty radiologist who is responsible for delivering the imaging lectures can utilize some of that time to discuss the different subspecialties and opportunities for patient interaction. During the clinical years, radiologists can be more proactive with students who are either rotating on their service or coming down to ask questions to promote radiology as a career option and highlight the unique opportunities for patient contact. One of the goals of these interactions should be getting medical students to compare how much quality patient interaction they would be getting after they have completed their training in “high patient contact fields” such as Internal Medicine to what they would get as a radiologist. Encouraging students to understand that it becomes difficult as an attending physician to have the indepth interactions they are currently having as a student (due to administrative tasks such as charting, shorter patient appointment windows, and a higher patient census) may help them be able to see that there may not be that much difference in quality patient contact between an attending internist and attending radiologist in certain subspecialties. Limitations to this study include a small survey sample size (188 first year medical student participants, 66 fourth year medical student participants) and manual categorization of survey responses into the “six most common attitudes.” There is some component of subjectivity given that the responses did not need to include the exact phrasing contained in the category title, however, the categories are discrete entities and the responses falling into any single category did not have much overlap with another category. One additional limitation is the possible sampling bias for participants in the Women in Radiology Panel, given that they may have already had some interest in a career in radiology prior to attending. Further studies are needed to fully determine the most effective ways in which to combat the negative attitudes about radiology held by medical students and expose more female medical students to female radiologist role models early in order to encourage women to explore radiology as a career option. However, these initial findings may be helpful to institutions looking to increase female medical student interest in radiology. CONCLUSION The interventions implemented at one institution aimed at increasing the number of women choosing to specialize in radiology appear to be an effective means of starting to address the gender gap. Events such as the Women in Radiology panel, in which students are able to see what life would be like as a radiologist and address the common misperception about limited patient contact in the field, are crucial to fostering interest. However, further studies are needed to determine the
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effects of female radiologist involvement on the female medical student match rate into the specialty.
AUTHOR CONTRIBUTIONS Victoria Podsiadlo Conception and design, writing of the manuscript, approved the final version of the manuscript, accountable for the manuscript’s contents Carolynn DeBenedectis, MD Conception and design, revision of the manuscript, approved the final version of the manuscript, accountable for the manuscript’s contents REFERENCES 1. 2.
3.
Young A, Chaudhry HJ, Pei X, et al. A census of actively licensed physicians in the United States, 2014”. J Med Regul 2014; 101:8–23. Lautenberger DM, Dandar VM, Raezer CL, et al. “The state of women in academic medicine: the pipeline and pathways to leadership”. Assoc Am Med Coll 2014. Frank E, Vydareny K. “Characteristics of women radiologists in the United States”. Am J Roentgenol 1999; 173:531–536.
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4. Grimm LJ, Ngo J, Pisano ED, et al. “Men (and women) in academic radiology: how can we reduce the gender discrepancy?”. Am J Roentgenol 2015; 206:678–680. 5. Potterton VK, Ruan S, Sunshine JH, et al. “Why don’t female medical students choose diagnostic radiology? A review of the current literature”. J Am Coll Radiol 2004; 1:583–590. 6. Branstetter BF, Faix LE, Humphrey AL, et al. “Preclinical medical student training in radiology: the effect of early exposure”. Am J Roentgenol 2007; 188:W9–W14. 7. Fielding JR, Major NM, Mullan BF, et al. “Choosing a specialty in medicine: female medical students and radiology”. Am J Roentgenol 2007; 188:897–900. 8. Hoffmann JC, Flug JA. “A call to action for medical student mentoring by young radiologists”. Curr Probl Diag Radiol 2016; 45:153–154. 9. Yuan ED, Makris J, DeBenedectis CM. Do interventions intended to increase female medical student interest in radiology work? Preliminary findings. Curr Probl Diagn Radiol 2018; 47:382–386. doi:10.1067/j.cpradiol.2017.09.003. Epub 2017 Sep 12. 10. Ram R, Jumper H, Lensing SY, et al. Understanding gender differences among medical students when choosing radiology as a medical specialty. Acad Radiol 2018; 25:1353–1358. 11. Jagsi R, Griffith KA, DeCastro RA, et al. “Sex, role models, and specialty choices among graduates of US medical schools in 2006-2008”. J Am Coll Surg 2014; 218:345–352. 12. Grimm LJ, Lowell DA, Cater SW, et al. “Differential motivations for pursuing diagnostic radiology by gender”. Acad Radiol 2017; 24:1312–1317.
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Medical Student Education
Breaking the Stereotype: Interventions Aimed at Changing Medical Student Misperceptions of Radiology and Increasing the Female Match Rate Victoria Podsiadlo, Carolynn M. DeBenedectis, MD
Background: Although nearly half of medical students are female there is still a significant discrepancy in the number of women specializing in radiology. In 2013, 26.9% of US diagnostic radiology residents were female, a 1% increase in 20 years from 25.5% in 1990. Purpose: The purpose of this project is to determine the effectiveness of the interventions implemented at a single medical school at decreasing negative attitudes about radiology held by medical students of all genders and whether those same interventions will increase the number of female medical students matching into radiology. Methods: The interventions were implemented between 2012 and 2016 and included incorporation of radiology into preclinical curriculum, electives in radiology for 3rd year students, a “Women in Radiology Panel,” and increase in female radiology faculty visibility. First year medical student participants of all genders used a free text box to write their attitudes about radiology, which were categorized into the “six most common attitudes about radiology.” Fourth year medical student participants used a free text box to write the reasons why they did not choose radiology as a specialty, and those answers were then placed into the same six categories. We then analyzed the data using Fisher’s Exact Test to determine whether there was a decrease in the negative misperceptions after exposure to the interventions. We also then determined whether there was an increase in the number of women matching into radiology using Chi-Square analysis. Results: There was a decrease in the negative misperceptions between 1st and 4th years, with the most notable decrease from 51% of 1st years to 0% of 4th years listing radiologists as being antisocial (p < 0.01). There was also a significant increase in the number of female medical students matching into radiology in the years in which students were exposed to 4 years of intervention when compared to three and fewer (0.76% 4.2%, p = 0.01). Conclusion: Exposure to 4 years of the interventions demonstrated a significant increase in the female match rate into the specialty when compared to female medical students who experienced three or fewer years of intervention. Additionally, it appears that these same interventions decreased the number of students of all genders having some of the common negative misperceptions about the field of radiology. © 2020 The Association of University Radiologists. Published by Elsevier Inc. All rights reserved.
INTRODUCTION
D
espite the fact that nearly half of medical students are female (47% in 2015) [1,2] there is still a significant discrepancy in the number of women choosing to specialize in radiology. In 2013, 26.9% of US diagnostic
Acad Radiol 2020; &:1–7 From the Department of Radiology, UMass Memorial Medical Center, Worcester, MA 01605. Received November 3, 2019; revised January 15, 2020; accepted January 15, 2020. The authors declare that they had full access to all of the data in this study and the authors take complete responsibility for the integrity of the data and the accuracy of the data analysis. Address correspondence to: C.M.D.B. e-mail: [email protected] © 2020 The Association of University Radiologists. Published by Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.acra.2020.01.021
radiology residents were female, a 1% increase in 20 years from 25.5% in 1990 [3]. Recently, there has been an increase in the number of studies performed to determine what can be done to foster medical student interest in the field at large, and more specifically to address the gender gap which has gone unchanged for many years [4 7]. A previous study performed at the University of Massachusetts Medical School (UMMS) proposed that the three interventions implemented between 2012 and 2016 (earlier exposure to radiology in the preclinical curriculum [4 6], changing the misperceptions about patient contact in radiology with “patient-centered” radiology electives [6], and mentorship by radiology faculty [7,8]) may increase overall student interest in radiology, but not female student interest in particular [9].
1
ARTICLE IN PRESS PODSIADLO AND DEBENEDECTIS
It is thought that having increased visibility of female faculty and increased opportunities for mentorship between female radiologists and medical students is essential for recruiting female medical students to the field of radiology [6,10]. There is also a powerful motivating impact of interactions between female radiologists and female medical students, where the students are able to see what life would be like as a radiologist and subsequently be more likely to choose the specialty [6 8, 10 12]. Prior to 2016 when the previous study was performed, the visibility of female radiologists was limited resulting in few opportunities for female radiologist mentorship. First, most of the female radiologists at the institution were in the mammography department, which was not a rotation offered to medical students during the general radiology elective. Second, the radiology faculty that had the most exposure to medical students was male, including the preclinical anatomy cocourse director, radiology interest group advisor, and residency program director. Since the start of the current study in 2016, many of these roles were transitioned to female leadership, there is increased overall female faculty within the radiology department, and breast imaging became integrated into radiology electives. The first aim of this study is to determine what attitudes medical students of all genders hold about radiology and whether the implemented interventions were able to change any negative misperceptions. In particular, absence of patient contact in radiology has been cited by medical students as a main reason for not considering radiology. In one study 95% of female students, who had chosen a specialty other than radiology, stated lack of direct patient contact as a reason they did not choose radiology [7]. By identifying medical student attitudes toward radiology at the start of their first year (with a focus on female medical student attitudes), we are attempting to determine whether the interventions implemented at UMMS would correct the common negative misperceptions held by medical students. The second aim of this study is to determine whether the increased female radiologist visibility and mentorship since 2016 has made an impact on the most pervasive misperception that there is limited patient contact in the field of radiology, thereby increasing the number of women choosing radiology as a career specialty.
MATERIALS AND METHODS Radiology Interventions
Curricular interventions from the previous study at UMMS took place between 2012 and 2016. These included (1) A faculty radiologist joining preclinical anatomy course codirector, where 15 20 imaging lectures were added to the second year curriculum and delivered by a radiologist; (2) CT scans were performed of gross anatomy cadavers to provide radiology-pathology correlations during dissections as part of preclinical anatomy course; (3) Radiology residents were involved in gross anatomy dissection labs, reviewing cadaver CT scans with medical students; (4) “Patient-centered” 2
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Flexible Clinical Experiences (FCEs) in radiology (including pediatric, breast, and interventional radiology) during the third year of medical school, which are weeklong electives that allow career exploration outside of the core curriculum; and (5) Annual Women in Radiology panel (started in fall of 2016) open to all medical students to promote visibility of female radiologists and enable student-radiologist mentoring relationships. The panel is comprised of about five female radiology attending physicians and female radiology residents who first share their paths into radiology and why they chose their specific subspecialty. Students are then given an open forum for an hour and encouraged to ask questions. The bulk of the discussion is about what it is like to be a woman in the field of radiology, what the job entails, work-life balance, and details about levels of patient contact. Additional noncurricular interventions beginning in 2016 included several changes to the staffing of the medical student facing faculty. This included a new female radiology residency program director and the addition of a female codirector to the radiology interest group. There was also an increase in the amount of female radiologist mentorship which included roles such as Capstone project advisor and specialty advisor. Female radiologists also took a more active role in medical school events, including those hosted by the institution’s chapter of the American Medical Women’s Association. Additionally, there were adjustments made to the FCEs, including expansion of the breast imaging FCE and the addition of a new “Women in Radiology” FCE, where medical students are assigned to work with various female radiology attendings within several subspecialties. Data Collection and Analysis
First year (N = 188) and fourth year (N = 66) medical students of all genders over the course of 4 years voluntarily participated in an online survey for a cross-sectional study to assess whether the interventions implemented at the institution starting in 2012 had an impact on correcting some of the misperceptions and stereotypes attributed to radiology/radiologists. The Institutional Review Board determined the study to be exempt by Category 2 (educational survey). First year participants were given a free text box to write in their opinions and attitudes about radiology. The survey was distributed in late August of their first year, 2 3 weeks after starting school and prior to exposure to the interventions. Their responses were subsequently manually categorized into the “six most common attitudes” which included (1) There is no patient contact, (2) Radiologists are antisocial, (3) Radiology is a dying field/is being outsourced, (4) Radiologists spend all day in a dark room, (5) The “Positives” good pay, lifestyle, and work-life balance, and (6) Other. The titles of the previously mentioned categories were selected based on the number of responses that contained that particular phrase, but also encompasses responses that were variations of that phrase. For example, although many responses included the word “antisocial,” responses such as “radiologists are socially awkward” and
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“radiologists don’t know how/want to talk to people” were also included in the “antisocial” category. The “Other” category was created to house additional responses that did fit into the previous five categories. Fourth year participants were asked in a free text box the reasons why they did or did not choose radiology as a specialty, and those answers were then placed into the same six categories. This survey was distributed in April of each graduating year between 2016 and 2019. The data was then analyzed using Fisher’s Exact Test to determine whether the rate of any negative perceptions decreased when comparing the responses from year 1 students to year 4 students after they were exposed to the interventions. A p value <0.05 was considered significant. We then analyzed how many students of each gender participated in the implemented high-patient-contact radiology FCEs to determine whether the early exposure to radiology in the preclinical curriculum sparked enough interest to explore radiology as a career option during the third year of medical school. A database was created containing the number of students who took part in radiology FCEs (breast, pediatric, and interventional radiology). Participants were then stratified by both class year during which they were enrolled in the elective and gender. The data was analyzed by linear regression analysis and F-test with a p <0.05 considered a significant result. We additionally determined the intensity of impact the Women in Radiology Panel had on its attendee’s (N = 18) perception of patient contact and work-life balance in radiology and whether they were more strongly considering radiology as a specialty after attending. After the panel, students voluntarily participated in an anonymous survey about their perceptions of radiology before and after the panel as well as
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whether they are more seriously considering a career in radiology after attending. Data on student perspectives before and after were analyzed by paired T-test, with p <0.05 considered a significant difference. Finally, the institution’s Match data between 2009 and 2019 was analyzed to determine the number of medical students matching into radiology as well as the female to male ratio of those students. There was a particular emphasis on the difference between match rates from 2009 and 2011 where there was no intervention versus 2012 2015 where there was 1 3 years of intervention versus 2016 2019 where there was 4 years of intervention. The data was analyzed using Chi-Square analysis with p <0.05 considered a significant result. RESULTS Among the first year medical students, who responded to the survey (188 participants, »400 students invited to participate), 51% of responses fell into the “radiologists are antisocial” category, 45% of responses fell into the “there is no patient contact in radiology” category, 32% of responses fell into the “radiologists as sitting in a dark room all day” category, 9% responses fell into the “radiology as a dying field or that radiology is being outsourced” category, and 35% of responses listed some positive perceptions about the specialty (lifestyle, work-life balance, salary, etc.) (Fig 1). However, there was no significant difference in the perceptions held by female medical students when compared to male medical students. Among fourth year medical students, the rates of the responses containing negative misperceptions as reasons for not choosing radiology as a specialty were mostly decreased when compared to first year
Figure 1. Percent of students in each class year (MS1 vs MS4) who listed each of the “preconceived notions” in their survey responses. Star symbol (*) represents statistically significant difference between the class years, analyzed using Fisher’s Exact Test (p < 0.05).
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medical students with 14% listing radiologists sit in a dark room all day (p = 0.004), 4.6% listing radiology as a dying field/is being outsourced (p = 0.30), and 0% listing radiologists as antisocial (p =< 0.0001). However, the rate of fourth year students listing no patient contact actually increased compared to first year medical students (from 45% to 70%; Fig 1). There have been 101 male and 84 female medical students who have participated in the radiology FCEs since their creation in 2012, with growth from the 2012 2013 Academic Year where 19 students took radiology FCEs (12 male, 7 female) to the 2019 2020 Academic Year where 33 students (14 male, 19 female) took radiology FCEs. Linear regression analysis was performed on the number of students by academic year for males and females. There was a linear association among females with an increase of 2 women per year participating in FCEs (p value for F-test is 0.03; Fig 2). Additionally, there appears to be a decrease in the gender gap between male and female medical students participating in radiology electives since their implementation in 2012. Following the Women in Radiology panel, the 18 female students who participated in the survey (survey distributed to 36 students) rated their perception of patient contact in radiology 16% higher after the panel compared to before the panel (48% vs 64%, respectively), which was statistically significant (p = 0.001). Similarly, female attendees rated how likely they are to consider radiology as a career 10% higher after the panel compared to before the panel (62% 72%, respectively), which was also statistically significant (p = 0.003). Although not statistically significant, female
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student perception of work-life balance in radiology improved by 4% after the panel compared to before the panel (88% 92%, respectively, p = 0.33; Fig 3). During the years where there was no intervention (2009 2011), 2.6% of female medical students and 5.4% of male medical students matched into radiology. Since the interventions began in 2012, there has been a significant increase in the number of female medical students matching into radiology during the years in which students were exposed to 4 years of intervention when compared to 3 and fewer with the rate increasing from 0.76% from 2012 2015 to 4.2% from 2016 2019 (p = 0.01; Fig 4). The number of male medical students matching into radiology was mostly unchanged over the same time periods with 4.7% matching between 2012 and 2015 and 4.5% matching between 2016 and 2019. DISCUSSION A previous study at UMMS suggested that early exposure to radiology during preclinical education and offering patientcentered radiology electives increases overall medical student interest in radiology, but active publicity and visibility of female radiologists from early in medical school would have the biggest impact on increasing female medical student interest [9]. The present study has longitudinally expanded on the previous findings to (1) identify the attitudes held by medical students of all genders about the field of radiology, (2) determine whether the interventions have corrected any negative
Figure 2. Number of students in each gender taking radiology Flexible Clinical Experiences (FCEs) per class year. Linear regression analysis for female students demonstrated a slope of 2, indicating the number of women taking radiology FCEs is increasing by two people per year and closing the gender gap among students taking radiology electives.
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Figure 3. Perceptions of radiology held by Women in Radiology Panel attendees pre- and postevent. Star symbol (*) indicates statistically significant difference in average rating between the two groups using paired T-test (p < 0.05).
misperceptions, and (3) determine whether the same interventions in addition to increased female radiologist visibility and mentorship would increase female medical student interest in the field. We have concluded that although there is no
significant difference in negative misperceptions held by male versus female medical students, the most pervasive misconception is that there is no patient contact in the field. We have demonstrated that by getting female radiologists out of
Figure 4. Percent of students matching into radiology within each sex grouped by academic year, with 2009 2011 being no intervention, 2012 2015 being 1 3 years of intervention, and 2016 2019 being 4 years of intervention. Data was analyzed using Chi-square analysis, with the 2016 2019 group showing statistical significance when compared to 2012 2015 group (p < 0.05).
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the reading rooms and actively publicized to female medical students (such as through the Women in Radiology Panel), we were able to significantly alter female student perceptions of how much patient contact there is in the field and increase the number of women choosing radiology as a career specialty over the same time course. Medical students of all genders were noted to have several negative attitudes toward the field of radiology, which most notably include the belief that radiologists are “antisocial” (51% of responses fell into this category) and that there is “no patient contact in radiology” (45% of responses fell into this category). The most dramatic attitude change occurred in regard to the belief that “radiologists are antisocial,” which dropped to 0% when analyzing fourth year student responses. We hypothesize that the most likely reason for this dramatic decrease is the imaging driven lectures delivered by a radiologist during the preclinical years. Because these lectures are part of the required curriculum, all medical students are exposed to radiology faculty and have the opportunity to see radiologists as interactive physicians. Additionally, students who participated in radiology FCEs and electives get personal interaction with radiologists to help dispel this misconception. Unfortunately, the rate of students who listed radiology as having no patient contact actually increased from first year students to fourth year students (45% 70%). This likely multifactorial in nature given (1) not all students participate in radiology electives, during which they would have the opportunity to discover the range of patient interaction available in certain radiology subspecialties, (2) individual student thresholds for what they consider a “clinical” specialty, for example, if they do not consider the brief patient contact during a biopsy “true” patient contact, (3) students experience more patient contact than they expect on other core clerkships (such as medicine or surgery), making the amount of patient contact in radiology appear even smaller, (4) the way that the field of radiology is described by nonradiologist colleagues, where medical students are primed from early on to believe that there is very little opportunity for patient contact. However, having just the one event highlighting and sharing female radiologists’ experiences improved female medical student perspective on this most pervasive misperception (that there is no patient contact in radiology) with statistical significance (p = 0.001). Moreover, following the panel the female attendees were also more seriously considering radiology as a career by a statistically significant margin (p = 0.01). In order to reach a broader population, the visibility of female radiologists needs to be expanded to all female medical students. This could be accomplished in several ways, ranging from guest lectures from female radiologists incorporated into the established preclinical imaging curriculum, increased participation in collaborative events with other student groups such as American Medical Women’s Association, or developing a database of ongoing female radiologist research endeavors in the department where medical students can get involved (especially as previous studies have demonstrated 6
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that women felt favorably about the opportunities for research in radiology [12]). It is important to note the misperception that “there is no patient in contact in radiology” could also be addressed more broadly to all genders during different stages of medical school. Preclinically, the faculty radiologist who is responsible for delivering the imaging lectures can utilize some of that time to discuss the different subspecialties and opportunities for patient interaction. During the clinical years, radiologists can be more proactive with students who are either rotating on their service or coming down to ask questions to promote radiology as a career option and highlight the unique opportunities for patient contact. One of the goals of these interactions should be getting medical students to compare how much quality patient interaction they would be getting after they have completed their training in “high patient contact fields” such as Internal Medicine to what they would get as a radiologist. Encouraging students to understand that it becomes difficult as an attending physician to have the indepth interactions they are currently having as a student (due to administrative tasks such as charting, shorter patient appointment windows, and a higher patient census) may help them be able to see that there may not be that much difference in quality patient contact between an attending internist and attending radiologist in certain subspecialties. Limitations to this study include a small survey sample size (188 first year medical student participants, 66 fourth year medical student participants) and manual categorization of survey responses into the “six most common attitudes.” There is some component of subjectivity given that the responses did not need to include the exact phrasing contained in the category title, however, the categories are discrete entities and the responses falling into any single category did not have much overlap with another category. One additional limitation is the possible sampling bias for participants in the Women in Radiology Panel, given that they may have already had some interest in a career in radiology prior to attending. Further studies are needed to fully determine the most effective ways in which to combat the negative attitudes about radiology held by medical students and expose more female medical students to female radiologist role models early in order to encourage women to explore radiology as a career option. However, these initial findings may be helpful to institutions looking to increase female medical student interest in radiology. CONCLUSION The interventions implemented at one institution aimed at increasing the number of women choosing to specialize in radiology appear to be an effective means of starting to address the gender gap. Events such as the Women in Radiology panel, in which students are able to see what life would be like as a radiologist and address the common misperception about limited patient contact in the field, are crucial to fostering interest. However, further studies are needed to determine the
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effects of female radiologist involvement on the female medical student match rate into the specialty.
AUTHOR CONTRIBUTIONS Victoria Podsiadlo Conception and design, writing of the manuscript, approved the final version of the manuscript, accountable for the manuscript’s contents Carolynn DeBenedectis, MD Conception and design, revision of the manuscript, approved the final version of the manuscript, accountable for the manuscript’s contents REFERENCES 1. 2.
3.
Young A, Chaudhry HJ, Pei X, et al. A census of actively licensed physicians in the United States, 2014”. J Med Regul 2014; 101:8–23. Lautenberger DM, Dandar VM, Raezer CL, et al. “The state of women in academic medicine: the pipeline and pathways to leadership”. Assoc Am Med Coll 2014. Frank E, Vydareny K. “Characteristics of women radiologists in the United States”. Am J Roentgenol 1999; 173:531–536.
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4. Grimm LJ, Ngo J, Pisano ED, et al. “Men (and women) in academic radiology: how can we reduce the gender discrepancy?”. Am J Roentgenol 2015; 206:678–680. 5. Potterton VK, Ruan S, Sunshine JH, et al. “Why don’t female medical students choose diagnostic radiology? A review of the current literature”. J Am Coll Radiol 2004; 1:583–590. 6. Branstetter BF, Faix LE, Humphrey AL, et al. “Preclinical medical student training in radiology: the effect of early exposure”. Am J Roentgenol 2007; 188:W9–W14. 7. Fielding JR, Major NM, Mullan BF, et al. “Choosing a specialty in medicine: female medical students and radiology”. Am J Roentgenol 2007; 188:897–900. 8. Hoffmann JC, Flug JA. “A call to action for medical student mentoring by young radiologists”. Curr Probl Diag Radiol 2016; 45:153–154. 9. Yuan ED, Makris J, DeBenedectis CM. Do interventions intended to increase female medical student interest in radiology work? Preliminary findings. Curr Probl Diagn Radiol 2018; 47:382–386. doi:10.1067/j.cpradiol.2017.09.003. Epub 2017 Sep 12. 10. Ram R, Jumper H, Lensing SY, et al. Understanding gender differences among medical students when choosing radiology as a medical specialty. Acad Radiol 2018; 25:1353–1358. 11. Jagsi R, Griffith KA, DeCastro RA, et al. “Sex, role models, and specialty choices among graduates of US medical schools in 2006-2008”. J Am Coll Surg 2014; 218:345–352. 12. Grimm LJ, Lowell DA, Cater SW, et al. “Differential motivations for pursuing diagnostic radiology by gender”. Acad Radiol 2017; 24:1312–1317.
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