Bye Bye, Work-Life Balance—Welcome, Work-Life Integration!

Are you voluntarily working longer hours and sacrificing your personal life for it? If the answer is yes, then you have no work-life balance

The idea of work-life balance is to achieve a state where the demands of work and career and the demands of our personal lives are of equal priority. Work-life balance acknowledges that our careers influence our personal lives and vice versa — one cannot thrive without the other. Ultimately, by keeping work and life in balance we hope to be less fatigued, more focused, and more productive in all aspects of our lives.  

The shift to a culture of work-life balance has had a number of positive effects: 

  • Health is now recognized as essential for work-life balance. Many employers offer health initiatives, such a fitness or weight loss programs and healthier food choices for employees. 
  • Employees feel empowered to say “no” to projects they feel overwhelms their bandwidth. 
  • Employers conduct engagement surveys to keep tabs on factors that can raise employees’ levels of dissatisfaction.
  • Employees are becoming more mindful of needing to take regular breaks. 
  • Many employers now offer flexible work schedules, which may include flexible hours and/or remote working options.
  • Employees seek coaching to cope with managers, coworkers, and rising workloads.
  • There is an expectation that technology “gets the job done,” meaning that technology addresses daily work challenges and is effective in helping users to achieve goals and objectives, resolve and avoid problems, and make progress in their lives. 

Work-life balance means that work-related meetings are not scheduled outside of regular office hours, not during break times, and not in the afternoon on the last day of any work week. People nowadays also frown upon receiving work emails on weekends. 

The strict separation of work and life, however, can be difficult. Trying to maintain artificial barriers between work and the rest of our lives can cause tension and feelings of guilt when work does intrude on our personal lives and vice versa. Work-life integration refers to the idea of “blending” work and personal responsibilities, eliminating any tensions or feelings of guilt. 

The idea of work-life integration assumes that a person’s professional and personal goals can be aligned so that one is not taking away as much from the other. Work-life integration will particularly become important as more Millennials and Gen Zers control the workforce. 

Post-Covid technological advances in our workflows, enabling remote work at a much larger scale than before, is an initial step towards work-life integration, breaking down barriers between work and personal time. It is acceptable again to let work tasks bleed into free time or even during vacation, while attending to personal matters, such as family obligations or health issues, is allowed to bleed into work time. One can leave work for a few hours to pick up a sick child from school and catch up on work from home later in the day. 

Radiology more than other medical specialties could pioneer work-life integration. There are already existing work models where radiologists are assigned a certain volume of studies that they have to read during a shift, and there can be some flexibility as to when they need to issue final reports. Many radiologists already work entirely or partially from home.

In the current job seekers’ market, everyone will choose the work conditions that are best for them. If you find yourself having trouble hiring folks, it may be worthwhile pondering work-life balance or integration and how it could work for your hiring goals.

Nadja Kadom, MD
Nadja Kadom, MD

Director for Quality, Department of Radiology, Children’s Healthcare of Atlanta
Interim Director for Quality, Department of Radiology and Imaging Sciences, Emory Healthcare
Professor, Emory University School of Medicine

The opinions expressed on RadTeams are those of the author(s); they do not necessarily reflect the viewpoint or position of the editors, reviewers, or publisher.

Anything Goes—Is It True for Leadership Styles?

There is no doubt that, over the next few years, we will need more leaders in radiology that can fill the shoes of the mighty baby boomer generation. Many early career radiologists believe they do not have what it takes for leadership. But is that true? Is it a matter of “nature versus nurture?”

I have concluded that “(almost) anything goes” when it comes to leadership styles, and that while it helps to be genetically endowed with such skills, everything can be learned. Or is that even necessary? After all, most everything, from developing a vision and mission to executing our daily work, can be driven by teams, and it can be the total of team members that has the skill set, rather than a single leader who has it all. After all, this is reflected in many academic radiology departments, where the leadership cadre is made up of vice chairs, who bring very specific leadership and subject matter skills to the table.

When I first became curious about a leadership journey in my career, I asked my then section chief and department chair for leadership book recommendations. One recommended Edward Kennedy “Duke” Ellington’s biography. In reading the Duke’s biography through a leadership lens, it became clear to me that he valued the musicians in his orchestra very much. In fact, he wrote music that would showcase the skills of individual musicians. In addition, Ellington was a phenomenal businessman who was committed to delivering music of the highest quality.

The other recommendation was to read Endurance, a book about the explorer Sir Ernest Henry Shackleton and his expedition to Antarctica on the ship Endurance. The book details how the ship got trapped in packed ice and sank, and how Shackleton’s exceptional leadership resulted in the survival and rescue of all crew. In essence, Shackleton never wavered in his vision of survival for the entire crew, which informed all decisions he made along the way. On the other hand, in terms of planning this expedition for all eventualities, Shackleton miserably failed in his leadership.

In my career, I have both employed and lived through a large variety of leadership styles, and I have concluded that more often than not, circumstances inform which leadership style works best.

Authoritarian – Participative – Delegative

While there are undoubtedly negative connotations to being an authoritarian leader in the political world, this leadership style can be very effective when projects need to be completed quickly. A group may prefer this leadership style, when the leader is the most knowledgeable group member. This style does not, however, support the professional skills and advancement of others.

Participative or democratic leadership, on the other hand, is all about welcoming diverse opinions and collaboration. Research finds that this leadership style leads to higher-quality outcomes, but it can take longer to get buy-in from all team members.

Delegative leadership is a laissez-faire style. The leader is removed from the team’s process, but expects a certain outcome. This could be successful when all group members are qualified experts.

Visionary – Coaching – Affiliative – Commanding – Pacesetting

Visionary leadership is often authoritative and can inspire and motivate others. However, a vision only takes the team so far. Having a clear vision to hold on to can help teams that are undergoing dramatic changes within the organization, such as a new practice leader.

Coaching leaders are those who can help team members improve to support the organization’s goals. This requires the ability to give feedback, which can be an artform in itself…

The affiliative leader is relationship-focused and creates harmony among team members. However, if harmony is of the utmost priority, team performance could suffer from lack of constructive feedback.

The commanding leader coerces the team through policies and procedures. As a sole leadership style, this can lead to disengagement of team members. Undoubtedly, though, policies and governance are the necessary foundation for creating accountability and guiding performance assessments.

Pacesetting leaders serve as an example in productivity, performance, and quality. Leaders who create clear requirements for their teams and set deadlines may be very successful, but this style can also result in overworked teams.

Transformational – Transactional

The transformational leader uses coaching and other means to empower teams towards building skills and growing towards a common goal. Meanwhile, the transactional leader drives performance through rewards and punishment. Since external reward/punishment systems work better for achieving short-term goals, this leadership style may not be successful in the long run. I hope this brief overview piques the interest of radiologists who are interested in leadership, but who are unsure if they are cut out for it. A good starting point may be to ponder one’s strengths and find a leadership opportunity in a setting that would benefit from existing skill sets.  

Nadja Kadom, MD
Nadja Kadom, MD


Director for Quality, Department of Radiology, Children’s Healthcare of Atlanta
Interim Director for Quality, Department of Radiology and Imaging Sciences, Emory Healthcare

Professor, Emory University School of Medicine

The opinions expressed on RadTeams are those of the author(s); they do not necessarily reflect the viewpoint or position of the editors, reviewers, or publisher.

A Recipe for Resilience: 10 Key Ingredients to Add to Your Mix

This post was originally featured in ARRS InPractice.

“This pandemic is really getting me down… I’m not sleeping well… Small things worry me constantly… My concentration drifts while interpreting studies… Antacids are taking care of my epigastric symptoms… Alcohol has become a necessary crutch to help me sleep… Everybody seems so needy around me… The media is driving me insane… The sense of loss overwhelms me at times… I cannot bear the thought of more Zoom meetings…”

Resilience. It’s a concept that predates the pandemic and one that we’ve heard about in personal development books, TED Talks, and leadership courses many times before. The word conjures a sense of unshakeable inner strength that’s impermeable to outside forces, like a giant African baobab tree—also known as the continent’s “tree of life”—during a torrential storm. You might define resilience as the capacity to recover and bounce back from adverse circumstances, such as those many of us are currently experiencing, as illustrated by the sampling of comments above.

It often feels like the pandemic swiftly derailed the pre-2020 tools and strategies we had introduced to our organizations to identify and combat employee burnout and support the collective health and wellness of our teams. While stressors have expanded and amplified, the concepts that were leading us on a path to healthier workplaces are still valid and valuable, particularly when it comes to resilience. With intention, practice, patience, and persistence, resilience can be learned, sustained, and strengthened; with resilience, we can emerge from our proverbial emotional basements, even during the most turbulent of weather.

Opening the Cookbook

While it’s not quite as simple as following a step-by-step recipe for your favorite meal, several key ingredients can help you develop resilience. Let’s explore 10 of them here.

  1. Take care of yourself, first and foremost: If you’re a leader, remind yourself of the airline analogy to put on your own oxygen mask first. Learn to practice mindfulness to slow down and reduce anxiety. Learn to focus on being intensely aware of your senses and feelings in the moment, without interpretation or judgment. Be mindful, too, that you may be using unhelpful coping solutions. Try to eat healthily, sleep to rejuvenate, and exercise as best as you can, wisely. Doing so should boost your capacity for physical resilience. Consider strategies to boost your mental resilience, as well. How do you reignite your energy and creativity after challenging situations? Are you able to effectively disconnect? Build time into your schedule to recharge. Develop coping skills to help you manage stress, so that it doesn’t compound. One example of a valuable coping mechanism is laughter, which can reduce anxiety and increase our intake of fresh oxygen. Try to find ways to laugh each day, as part of your self-care practice. You can even find laughter yoga exercises on YouTube.
  2. When something is not quite right, recognize, acknowledge, and call it what it is: Stress. Anxiety. Overwhelm. Depression. PTSD. Whether it is a formal diagnosis from a care provider or a gut instinct that you have, it’s OK not to be OK. The pandemic is amplifying our national mental health crisis. Recognize and mourn your losses, no matter how big or small you think they are. Communicate openly and honestly about your current state of mind; don’t minimize or ignore your symptoms until they become intolerable. Share your concerns with your primary care provider, a licensed therapist, a trusted family member or friend, or a 24/7 hotline. If you are in a potentially life-threatening situation, call 911, or go to your nearest emergency room. Opening up and asking for help can be terrifying, but you are worth it. No one is alone here. Seek the support and care that you deserve and need.
  3. Find your sense of purpose: Develop your personal W-H-Y? Find intentional ways to connect to your larger life purpose and learn to savor them. What are your volunteer efforts? What does your charitable giving list look like? Altruism drives a sense of purpose and is a recognized trait of resilient individuals. Try to integrate your work and life effectively for you. Strive to be a realistic optimist and, rather than focusing on the negative, hone in on what you can contribute to your community, region, state, or country.
  4. Get connected: Establish and nurture a supportive social network. Who comprises your safety net? Whose safety net are you in? Help others to support and nourish you by building a social resilience community. Never be afraid to lean on your support systems, even if virtually. How did you build your support group? Do you have an online community? Develop positive and trusting relationships in which you can work together to endure and recover from stressors. By listening and hearing, we can be kind and compassionate to others when they need it most. Do a proverbial mitzvah!
  5. Find your resilience role models: On a personal level, I derive such joy and inspiration experiencing the resilience of my immediate family members. As a South African, it will also never cease to amaze me when I consider the remarkable resilience shown by Nelson Mandela. His endurance and persistence in the face of severe adversity were coupled with his ability to show emotional regulation, empathize, build connections, demonstrate self-efficacy, and stick to his guiding moral compass through authenticity. His favorite poem was “Invictus,” written by William Henley, which ends with the powerful line, “I am the master of my fate / I am the captain of my soul.”  
  6. Seek to constantly learn and improve: Be coachable and seek feedback that you learn from and act upon. Seek this feedback from those sources most likely to be helpful to you. Recognize that change can be good, however inconvenient or uncomfortable. View so-called “failures” as learning and improvement opportunities and embrace them; activate your action plan, rather than dwelling on what might have been.
  7. Know what emotional intelligence looks like: Practice self-awareness by knowing your stress levels and noticing your emotions. Train your brain—build emotional intelligence, moral integrity, and physical endurance. To boost your emotional resilience, work on understanding, appreciating, and regulating your emotions, while consciously choosing your feelings and responses to avoid being reactive. Learn to become self-aware. This includes recognizing what drives your stressors. What pushes your buttons? Finding and sticking to your moral center may aid this journey.   
  8. Find ways to relax and decompress that work for you: Some examples include spending time with friends, pursuing hobbies, cooking, meditating, and listening to music. Each of these can be enjoyed in groups or individually, depending on what you prefer. As one example, photography is an art that can be practiced in mindful ways, shared with colleagues, and even used as a communication and connection tool. It might even influence your choice of travel locations and online connections. Surround yourself with positive energy. Misery doesn’t love company—find new ways to manage or even avoid adversities and adversaries. Have an executable plan to eliminate your blockages.
  9. Practice gratitude and self-compassion: Hardwire this into your daily activities list; it will help you to feel content. This might simply include journaling things that you are grateful for. You already possess a series of resiliency tools and have likely overcome adverse situations that you learned from. Your journey has already begun, and you have endured 100% of your worst days. Congratulate yourself for this.
  10. Reflect: This can go hand-in-hand with journaling. Simply put, sit quietly with the events and feelings of the day and see what comes up. Committing to creating the time for reflection allows one to build and increase self-awareness (an important component of emotional intelligence), encourages learning, and opens doors to being more adaptable. For events that occur, consider what happened, how it made you feel, and what lessons or new approaches you learned from the experience.

Sharing the Recipe

As a leader, your resilience impacts your performance, as well as the performance and engagement of your teams. Stressed leaders engage in fewer positive leadership behaviors, such as enunciating optimistic visions, setting and overseeing goals, communicating confidence, clarifying roles, showing genuine appreciation, and recognizing performance. Stressed leaders can become passive—they step in only when needed, tend to avoid decision-making, and can be emotionally absent. These attributes get noticed and impact teams. Resilient leaders can keep calm under pressure and develop additional skills (a component of posttraumatic growth) in the face of adversity. Through self-reflection and feedback, resilient leaders have a keen sense of the main components of emotional intelligence.

Resilient leaders can also regularly assess their leadership effectiveness and styles, more readily responding to change and unexpected situations. Striving to learn and grow continuously, resilient leaders are often purpose-driven individuals—they can visualize their work effort as being meaningful. Resilient leaders cultivate relevant and helpful relationships in their internal and external work environments that support them through tough times.

Why Is Resilience at Work Important?

Resilience shapes the way employees respond to the stress of change. It also relates to work engagement, job satisfaction, and organizational commitment. Resilience is inversely related to the frequency and manifestations of burnout and can improve organizational and employee performance.

How Do We Recognize Resilient Behaviors in Others?

A spectrum of characteristic behaviors and skills is recognized under the resilience rubric. Many of these are also included under a larger umbrella of effective leadership behaviors. A person who manifests resilient behavior communicates clearly, thoughtfully, and consistently. Moreover, effective leaders may design a strategy for communicating and managing change that accounts for different stakeholders and their communication preferences. Resilient individuals are coachable, regardless of their position in a hierarchy, and many seek opportunities for learning and improvement. They are willing to embrace change, and, ideally, they’re skilled at managing it. Resilient individuals are comfortable saying, “I don’t know” (and “I would like to learn”). They know how and when to take bold risks or when to initiate new ideas. Similar to effective leaders, resilient individuals are willing to and do invest in the development and advancement of others.

Those with high levels of resilience are better equipped to cope with stressful situations. They tend to see change as an opportunity, are optimistic, adaptable, and realistic about realities, and engage colleagues for support. Resilient individuals possess emotional regulation skills and don’t allow stress to impede their functioning. They practice self-compassion to reduce harsh self-criticism, soothe difficult emotions, and find sources of motivation. Resilient individuals show cognitive agility, a difficult skill to develop, which entails shifting how one thinks about negative situations.

Let’s face it: It’s really difficult learning to become resilient. It takes time, persistence, effort, commitment, energy, and a drive to succeed. We do know that resilient teams are best served by resilient leaders. Now more than ever before, we need our imaging teams to function effectively. Our teams should be equipped with resilience to face ever-changing challenges and unanticipated adversities, and whether they are or not begins with us as leaders.

About the Author
Jonathan Kruskal

Melvin E. Clouse Professor of Radiology, Harvard Medical School
Chair, Department of Radiology, Beth Israel Deaconess Medical Center

The opinions expressed on RadTeams are those of the author(s); they do not necessarily reflect the viewpoint or position of the editors, reviewers, or publisher.

Reimagining and Reinventing Postpandemic Radiology

This post was originally featured in ARRS InPractice.

Some days, it’s hard to recall what prepandemic life was like. Things have forever changed in light of this historic global event, and it’s vital to reflect and process these last three years. We’ve endured some of the most trying times of our careers, but we also have a bright future as a medical community ahead. You’re wondering what that might look like and how we can collectively “skate to where the puck is going to be, not to where it has been,” as Wayne Gretzky famously said.

COVID-19 precipitated a fundamental change in clinical service delivery, teaching, research, staff retention, employee wellness initiatives, and communications strategies. We amended workplace safety standards and practices, stood up and resourced remote teams, recruited trainees virtually, and transformed in-person grand rounds programs into digital ones. These are just some of the many efforts that we as a specialty undertook to protect our people, uphold our missions, and keep our teams employed. And while not all changes were novel ones, the pandemic catalyzed their implementation. We now have tremendous momentum to continue innovating, especially as we begin to emerge from crisis mode together.

Accelerating Change

Here at Beth Israel Deaconess Medical Center, we simply couldn’t have managed this public health crisis without our highly effective, efficient, and resourceful operational surveillance systems and teams. Some of these teams were in place before the pandemic started; they rapidly responded to the initial phases of COVID-19, then swiftly transitioned into a multidisciplinary incident command structure to assess, rethink, reinvent, iterate, and communicate our health care systems and strategies on a daily, hourly, and minute-by-minute basis. This collaborative structure operated in real time and kept our trains running, on schedule and on the tracks, far more often than not. Light started to appear at the end of the tunnel, and then, the alphabet of variants arrived. It soon became clear that we would never return to prepandemic normalcy. A fundamental shift had taken place in the way we delivered our services, and some of this change represented the necessary digital transformation many had envisioned long before COVID-19 struck.

So, what are our next steps? How can we effectively shift from a reactionary mode to one that is deliberate and purposeful? What structure will best support the necessary regrowth phase that will support our medical practices and organizations? Now is our time to be accelerators rather than incubators, to reinvent and rebrand our skills and clinical contributions, and to be thoughtful and strategic in the process. This is where the most strategic, imaginative, and operationally agile teams will lead the way and define our recovery. Those who embrace change and progress will be the best positioned to thrive. Lead the change. Be the change.

Building COVID Recovery Hubs

Let’s be the disruptive thinkers our field will be proud of. Define, then communicate your future radiology vision. Do this in an inclusive manner that involves all role groups. For such plans to be adopted and successful, leaders will need to continue to create forums for staff to weigh in, ask the right questions of their teams, listen to feedback, barriers, needs, and ideas, and provide other ways to share input, such as through short pulse surveys in a departmental newsletter or real-time polls during meetings. Ensure everyone’s voice is heard and incorporate major common themes into your plans.

We suggest constructing and resourcing a formal COVID recovery hub, which can house your postpandemic mission, vision, and recovery playbook. Appoint and support a multidisciplinary team to lead and own these pioneering transformation efforts. Who have you appointed to lead your radiology recovery, reinvention, and reengineering transformation? What does your “r4” portfolio look like? By answering these questions, you will help your practice continue to keep its staff and patients safe, deliver exceptional care, manage ongoing people and supply chain shortages, support staff morale and wellness, nurture remote teams, and effectively communicate and engage with a multigenerational workforce.

Reimagining Administrative Functions

As part of your COVID recovery hub, consider the roles, responsibilities, and constituents of your leadership team. Are you best positioned for your recovery? Now might be a great time to reimagine these elements and challenge the traditional hierarchy, as we work to flatten authority gradients, build diverse, inclusive, and multigenerational teams, and ensure that form follows function. Additionally, these roles have likely transformed out of necessity during the pandemic and might need to evolve to meet your practice’s future needs.  

Let’s be a little provocative: how can we identify the best person to be our “knowing exactly where the puck will be in 2030” portfolio leader? Actually, this is not a task for one person—and this is precisely why building and sustaining high-performing diverse and inclusive teams will become paramount and essential. Proudly establish your recovery hub, appoint a vice chair of recovery and reinvention to lead this effort, then establish and resource new portfolios to signal just how serious you are about recovery, regrowth, and reinvention. For example, have you considered the future of your remote teams? Based on national employee preferences, it’s clear that some level of remote work is here to stay. Perhaps, as part of a practice’s new digital innovation and transformation lab, it could create a remote workplace and team-building portfolio. Will your organization continue producing short video messages, digital newsletters, social media content, and academic webinars? What will your postpandemic communications strategy look like? Perhaps it’s a question for a newly formed digital communications and connections team. While these structures might not be novel in a large, digital-first corporate setting,they would be a progressive leap forward for many of our major academic medical practices.

Additionally, we all know that health care delivery has progressed to incorporate population health, cost reduction improvement efforts, care coordination and integration, and customer experience, among other important factors. Simply put, our aim is to deliver the highest-quality, safest possible care and experience at the most sustainable costs. This boils down to value, and who better to drive it than an effective chief value officer?We’ve certainly been talking about this value proposition for quite some time already. On a different but equally important note, we must think about how we will continue to support the health and wellness of our staff postpandemic, especially during our nation’s mental health crisis. Is there an influential and compassionate leader on your team who could become your chief wellness leader and drive these vital efforts to aid your entire team?

The structure of a leadership team should primarily relate to its intended function and purpose. Once you have reconfirmed your foundational core purpose, reimagined your vision and mission, and defined your annual goals, then form the team (and define their precise roles) that will help you reach your ideal future state. Energize your teams by including them in strategic brainstorming and planning sessions, imagining an exciting and successful future together.Designing a newoperational landscape is not a task for one person, which is why building and sustaining high-performing, diverse, and inclusive teams will be paramount.

The interesting exercise that we are all engaged in now is to define that future state. Has anybody considered a leader of a recovery and reinvention portfolio? Your entire team wants to contribute! Be inclusive and build diverse teams.

Mapping New Pathways

This is an era of posttraumatic regrowth. Reimagining your pathway should be an inclusive, aspirational, and even inspirational process. Be thoughtful and strategic when redefining your path forward toward the new normal you and your team aspire to achieve. Reengage and revitalize your most precious resource, your workforce. Recommit to safe practices, wellness initiatives, and high-performing team building. Reconnect your teams, and work to sustain these connections. Reimagine and rethink your strategic plan and goals, and start your new journey today. Those who will flourish and thrive will do this effectively, thoughtfully, and strategically; consider the long-term goals, map out your route, and take action. As you shift from managing operations to imagining the future, try to shift your focus from keeping the trains running to considering where new rails could be built. Periodically, it’s important to pause and ponder—to consider not only how trains can be better engineered, but also to contemplate whether train travel will be a safe and efficient customer choice in the future. That’s strategic thinking.

Let’s try to simplify. You’re done with reacting, reflecting, and responding. You’re starting to see some light at the end of this tunnel. You’re hoping that omicron is the last symbol of this pandemic alphabet. Now, more than ever before, is the time to look forward, plan your recovery strategy, and focus on building and sustaining innovation. The practices that are most likely to thrive are already thinking outside the traditional administrative oversight box. And they are moving ahead right now.

And, finally, find ways to share your experiences of this journey. We’re all traveling new paths and learning as we go. We must learn from each other’s successes and missteps, and there will be plenty of both. As we build our departmental COVID recovery hubs, we also need to design and build collaborative teams to communicate and interact with institutional, regional, and national COVID recovery hubs, to the extent they exist. These new systems must be capable of redefining and reimagining the future, so that we can all travel along the path of progress together.

It’s now time to be intentionally inclusive, as we commence this new journey.

About the Authors
Jonathan Kruskal

Melvin E. Clouse Professor of Radiology, Harvard Medical School
Chair, Department of Radiology, Beth Israel Deaconess Medical Center

James V. Rawson

Senior Lecturer on Radiology
Beth Israel Deaconess Medical Center

The opinions expressed on RadTeams are those of the author(s); they do not necessarily reflect the viewpoint or position of the editors, reviewers, or publisher.

Thriving in a Multigenerational Workforce

Unlike any prior time period in our history, the contemporary workplace will soon encompass five different generations, distinguished variously, but typically defined and labeled by year of birth. Here, I’m referring to Baby Boomers (1946–1964), Generation X (1965–1980), Generation Y or Millennials (1981–1995), Generation Z (1996–2010), and the forthcoming Generation Alpha (2011–2025). Largely driven by the advertising world, hoping to better target their marketing campaigns, efforts have been made to easily distinguish these groups based on social influences, generational values, behaviors, and preferences.  

I suspect that these labels may have complicated matters even further. For example, the COVID-19 pandemic-induced shift to the virtual workplace may well have exacerbated intergenerational tensions in areas where groups are supposed to differ. Think social interactions, communication preferences, work-life integration and wellness strategies, perceptions of technology usage, and willingness to change. These differences must surely have led to breakdowns in communications, team function, and clinical performance, among many others.

On one hand, these age-based delineations can be a helpful reference point, particularly when leading multigenerational teams. There are some proposed defining factors, such as cultural movements, historical milestones, technological advancements, learning preferences, and lifestyle traits for each period that can be interesting to delve into and see whether they resonate with yourself and your teams. These features can be lively conversation starters and help you glean insight into how best to manage morale and burnout, as well as create more inquiry, respect, and open-mindedness among such a diverse population. However, surely additional factors beyond age should be equally impactful; consider background experience and training, levels of maturity, tenure within an organization, and lineage in a role.

Is it possible that the COVID pandemic has influenced societal perceptions of generations, and might the pandemic influence the formation of generational identities for those still in formative years?

It seems to me that this is a very opportune time to work to address and dispel age-associated or generational stereotypes.

Dispel the Myths

That said, it’s so important that we inquire, appropriately and respectfully, about the stories of others to expand upon—and maybe even rebut—marketing matrices.

Upon reflection, I don’t think that people neatly fit into their age-based silo. As I look across the multigenerational tables as a Baby Boomer by age, I certainly have “silo creep” and span several different buckets. You might think World War II, for example, was a defining life event for me, but that wouldn’t be true. Rather, I grew up as a relatively privileged individual during the segregated South African apartheid era, which left an indelible impact on my values, philosophies, and priorities.

I know I’m not alone here. When speaking with a millennial colleague, it became clear that these categories are not cut and dried:

“I think some of these characteristics are pretty broad generalizations. I am part of the millennial category, but it has never quite resonated with me. Millennials are often painted in an unfavorable light, such as when it comes to work ethic, world views, and materialism, just as Baby Boomers can be criticized for not being tech-savvy, and seniors can be stereotyped as dependent and frail.”

“My father, a Baby Boomer, studied computer science as an undergraduate, before it became an official degree program at Boston University. My grandfather, a member of the Silent Generation, ran his final Boston Marathon in 4 hours and 30 minutes at age 72 and continued to participate in road races into his 80s. To me, labels can be tough because they don’t allow for nuance and individuality; they don’t tell the whole story.”

It’s easy to jump on the bandwagon and affirm negative generalizations, but this can be damaging when it comes to building an inclusive team. We must ensure these categories, simply based on a number, don’t serve as a detrimental springboard for misunderstandings about behaviors and preferences.

Seek Data and Understanding

It’s our responsibility as leaders to build diverse teams and foster respectful environments for every member of our workplace and beyond. We can strive to enact change at the national level, such as by communicating the importance of accommodating different learning styles for different generations at major conferences and advocating for educational material that best suits the learner (e.g., didactic talks vs. handouts vs. podcasts, etc.).

Locally, we can commit to better understanding our colleagues on a one-on-one basis. If one generation prefers frequent, regular, unvarnished feedback, provide that. If possible, be willing to adapt traditional annual reviews to meet worker preferences. Support departmental social media initiatives but be respectful of those who might not wish to expand their digital presence at this time. You’ll find that some cohorts might thrive on multitasking, while others prefer to focus on tasks linearly. Take all of these factors into consideration. 

Ask, listen, collect data, and repeat. Run a short quarterly communication survey asking how employees prefer to receive information within the department, or whether digital Grand Rounds lectures are meeting their academic needs. Sometimes, simply listening and giving people a choice can make all the difference when it comes to feeling a true sense of appreciation and belonging at work.

Not fully understanding the complexities of our multigenerational workforce has been described as a contributor to workplace stress and burnout. Challenges managing, building, and leading multigenerational teams have been recognized, yet solutions have not. We must first hear from our colleagues directly. For example, you might ask a more seasoned colleague what it was like when they first started out in radiology. How have things changed over time? In their perspective, has it generally been for the better, or have there been obstacles along the way? How has patient care evolved? Older generations might consider asking younger generations about what their highly digital academic training experiences are like today. When an opportunity presents itself, respectfully inquire and listen to build connections and understanding.

Celebrate Our Diversity of Ages 

One good aspect of the multigenerational descriptors is that they remind us of the remarkable diversity of values, preferences, and skills that we are so fortunate to have in our workforce. Understanding, embracing, welcoming, including, and being respectfully inquisitive about these differences will serve us far better. Acknowledging that differences exist and committing to learning about them is a lifelong journey.

Starting today, instead of trying to transform one generation to adjust to another, let’s:

  • celebrate the diversity of ages in our workforce
  • embrace all skills, expertise, and experiences
  • focus on intentional inclusion activities
  • shift the focus away from this single cultural descriptor (age) and build teams that are as diverse as possible
  • avoid alienating labels and siloes and stereotypes

Never before have four different generations worked together in Beth Israel Deaconess Medical Center radiology, bringing different values, preferences, communication styles, strategies for work-life integration, and wellness approaches into the milieu. The list of differences is extensive and complex. What a terrific and timely opportunity to embrace! A field such as imaging is so dependent on the structure and function of high-performing teams. Therefore, it behooves us to better understand the different generations and explore how best to take advantage of these opportunities.

Finding Our Proverbial Sunrooms

This post was originally featured in ARRS InPractice.

Feeling stuck, joyless, or “meh?” You, like many others, might be languishing. In fact, it might be the dominant emotion of 2021.

Sociologist Corey Keyes describes mental health as a continuum: ranging from flourishing, that state of wellbeing we all seek to achieve, to languishing, the absence of wellbeing, and a lower state of mental health. Languishing is distinct from depression, yet individuals who are languishing are at a higher risk of future mental illness (such as depression and anxiety disorders), as shown by Keyes et al..

Simply put, languishing is a series of emotions, rather than a mental illness. Adam Grant, writing in the New York Times, refers to languishing as “the neglected middle child of mental health” and “the void between depression and flourishing.” Given the negative impacts on productivity, morale, innovation, team building, retention, and engagement, nonprofit organizations and corporations alike must take this widespread state seriously.

The pandemic has impacted almost every structural framework of our lives, such as socializing, working, vacationing, traveling, and exercising—and, in turn, compromised our sources of joy. With no clear path as to when and how our “future state” will present itself, we continue to exist in an ongoing and indefinite interim state. As uncertainties persist and routines remain in flux, many people are being shuffled into a state of languishing.

You Might Be Languishing if You Are:

  • overwhelmed or emotionally numb
  • distracted and unfocused
  • depleted, empty, and/or disinterested
  • unmotivated or procrastinating
  • not functioning at your full capacity
  • unable to feel excited about upcoming events
  • cynical about your colleagues and leaders

How Can We Shift From Languishing to Flourishing?

Below, I share a compilation of suggestions from the experiences of many. If the symptoms of languishing seem familiar to you, perhaps one or more of these strategies might help. If even one person finds solace in these ideas, it would bring me joy.

  • Prioritize your health: Do your best to eat healthily, drink plenty of water, sleep well, and incorporate movement into your life. Schedule and keep your annual health appointments. Consider alternative medicine modalities, such as acupuncture and chiropractic medicine. Find moments to sit in silence and simply breathe. Use your personal time and plan vacations, including memorable “staycations.” Disconnect from work and social media during your time off. Set boundaries and learn how to respectfully say “no,” when needed. Take your first small step toward doing something you’ve always wanted to do for your health today.
  • Protect your time: Manage your time intentionally and purposefully. Detach, disconnect, and learn how to engage your personal reset button. You might try scheduling uninterrupted time for yourself to recharge your batteries, even if this means “doing nothing.” Limit social media scrolling and email checking. Consider recapturing your prepandemic experiences; for example, create a virtual “commute” that includes a home spin class, podcast episodes, reading, music, or another element that helps you transition from the waking to working hours.
  • Make positive connections: Reengage or recreate your personal and professional network. Recall who once might have lifted you up. Walk and chat, gather and eat, find and embrace, and explore commonalities with positive people. When possible, spend less time with those who drain your energy and spirits. Seek a peer support buddy with whom you can share your experiences and feelings. Look for authentic and uplifting connections to replenish yourself emotionally.
  • Reflect on the current situation: Acknowledge the loss and anxiety and frustrations and grief. What have you lost? What have others lost? What has everybody lost? Recognize that you’re not alone here.
  • And then, practice gratitude: Recognize what you do have, rather than focusing on what you don’t. Appreciate what is working, rather than focusing on what isn’t. Try keeping a daily gratitude journal or using a meditation app, like Calm or Headspace, for guided gratitude practices.
  • Find flow and motivation: What’s on your music playlist, and when did you last update the content? Step out of your comfort zone by trying a new recipe, exercise, podcast, app, or online class. Get better at something, whether it’s dance, yoga, art, reading, writing, meditation, music, composting, or gardening. Explore mindful crafting, photography, collecting, and other hobbies. Reconnect with and walk barefoot in nature for additional grounding.
  • Celebrate small successes: Rethink what constitutes success, however small. It may be someone else’s success or happiness that you contributed to. When overwhelmed, rethink your goal-setting strategy. Set simpler goals that are achievable, and enjoy the successes that you are contributing to. It’s OK to start small. Perhaps also schedule achievable self-care activities each day.
  • Rethink your possessions: What would you like to keep or surround yourself with? These items might include things that bring you joy, inspiration, hope, confidence, or calm. Consider decluttering a room or maybe even your entire living space over a period of time. According to a recent Psychology Today article, decluttering can be very beneficial.
  • Change your scenery: Breaking from a stagnant routine is challenging. I encourage all of us to find ways to get out of our emotional basement and head up to our proverbial sunroom. Take a stroll through your memory banks to recall what may have once ignited your passions. Learn the art of introspection—what does your perfect day look like?—and consciously do something new or different to refresh your spirits. Check out your local museum, gallery, or library with a friend. Sign up for an online class or enjoy a virtual comedy show. You never know what you may discover.
  • Find joy in giving: When did you last wrap a small gift? Who can you help today? What causes would you like to reengage with? Have you discussed and explored different options with your friends and family? Try to get back to your talents and gifts. Learn to be a peer supporter. Research volunteer opportunities in your community. Contemplate your purpose and remember what truly drives you. Helping others can bring a tremendous sense of inner fulfillment.
  • Activate your personal coping strategies: For some, the average workday may seem filled with one stressful encounter after another. Meetings may not go as planned. Your workflow may be interrupted. The dominant sentiment might be that this is just another tough day. Is it possible that you are being too hard on yourself and in your judgments? For example, while you may feel that a meeting, interaction, or event didn’t quite go as planned, perhaps that is from your perspective. Maybe others had a different perspective and felt more positive about the encounter. Activate your personal coping strategies to decompress, relax, boost your energy, stay focused, gain perspective, and reflect on the bigger picture.
  • Explore therapy. It’s a strength to recognize when we need professional help. According to a recent Value Penguin survey of more than 1,300 US adults, “nearly 30% of Americans have seen a therapist during the coronavirus pandemic, and 86% say it’s helped them cope.” Psychiatrists, psychologists, social workers, therapists, and other licensed practitioners are trained to help patients construct a personal repertoire of coping strategies. There are many forms of therapy to consider, including psychodynamic, cognitive behavioral, dialectical behavioral, mindfulness-based, and art. One or more of these modalities could help you address and manage stressful life events.

The journey from languishing to flourishing is of indeterminate length, and some of the “travel aids” listed above may be more effective than others. What we need is a means of sharing best practices—what worked well and what didn’t—multigenerational preferences and impacts, as well as other solutions that have been identified along the path. I can only wish each of you who may be experiencing a state of languishing a very safe, healthy, memorable, and rewarding trip back!

About the Author
Jonathan Kruskal

Melvin E. Clouse Professor of Radiology, Harvard Medical School
Chair, Department of Radiology, Beth Israel Deaconess Medical Center

The opinions expressed on RadTeams are those of the author(s); they do not necessarily reflect the viewpoint or position of the editors, reviewers, or publisher.

Addressing the Concept of ‘Moral Injury’

This post was originally featured in ARRS InPractice.

The COVID-19 pandemic continues to exacerbate the pre-existing epidemic of stress, distress, dis-ease and burnout in our profession—and across the country. Contributors to workplace stress in radiology have been further compounded as we grapple to provide safe care to our patients, keep our teams healthy, uphold social distancing requirements, support, sustain, and engage remote teams, deploy effective communication strategies, and cultivate diverse and high-performing teams. People across the country are fighting silent battles against chronic anxiety, depression, and other mental health disorders during any given workday.

Prior to the pandemic, we heard frequent reference to the hamster wheel environment in which we work; expectations of ever increasing workloads and so-called quality metrics driving us to work faster and longer hours all while meeting ever increasing regulatory requirements. Not surprisingly, the consequences of just trying to keep up include burnout, and the field of radiology is still seeking solutions to mitigate our recognized high incidence.

However, in parallel with burnout is the growing focus on mitigating known stressors, those that establish a genuine conflict between our core values as care-providing physicians and our daily activities in the trenches. This is the reality of the so-called moral distress and injury, which is frequently associated with burnout. To me, this implies that we as individuals are unable to balance work expectations against personal resources—that, somehow, we are failing at what we “should” be doing and achieving. There is a growing school of thought that the symptoms of burnout simply reflect a healthcare delivery system in need of urgent repair. The moral insults and injury of healthcare is not being able to provide the high quality of care that we would want to, thus highlighting the opportunity to address what is contributing to this state. And the consequences are dire: physician suicide rates are now twice that of active-duty military members. Now more than ever, it is clear that we must reprioritize employee wellness efforts and implement additional strategies to protect and support our workforce.

Treating the Cause

To effect lasting change, we must reshift our focus and address the cause rather than the symptoms. While appreciated and beneficial in their own right, wellness programs, flexible schedules, extra time off, and other employee benefits oftentimes treat the short-term symptoms, not the long-term cause.

Relaxation practices, exercise, vacation, mindfulness activities and meditation might be extremely effective at resolving some symptoms on a temporary basis, at least until that time that we are back trying to balance on the hamster wheel. To address the causes, we need brave and effective leaders who are willing to question and confront the constellation of drivers, and who recognize and respect the fourth component of the quadruple aim of healthcare (care of the patient requires care of the provider). We must excavate the problem that is moral injury until its origins become clear.

Numerous factors detract from what we believe is our primary mission and contribute to such injury, including the profit-driven healthcare environment, electronic health records and productivity metrics, provider review sites, litigation concerns, turnaround time targets, and the ever-expanding regulatory mandates. Here I refer to practices mandated by regulatory agencies such as audits, documentation expectations, annual testing, and of course, the unpopular practice of peer review.

Let’s consider peer review as our low hanging fruit here. This is a process that in radiology is often known for being onerous, burdensome, distracting, divisive, resource-intensive, inefficient, and ineffective. In my experience, it can be difficult to use peer review as a driver for meaningful and impactful improvement.

However, the concept persists, in large part due to meeting accreditation and reimbursement requirements. As radiologists, we are expected to devote time to rank the diagnostic skills of our colleagues. During this process, targeting occurs, under-reporting is rampant, and job security might be impacted, yet challenging the status quo is difficult. Despite evidence that radiologists make errors almost 30% of the time, national peer review data reports fewer than 5% of these discrepancies. Is this practice truly an effective use of our time and skills?

Forging a New Path

Peer learning and improvement offers us an enormous opportunity to remove a mandated hurdle to our work-related distresses; it also allows us to embrace an emerging practice that will provide new learning and improvement opportunities. Today, I’d like to give a loud shout-out to the many peer learning trailblazers out there, including: David Larson, Richard Sharpe, Jennifer Broder, Nadja Kadom, Lane Donnelly, Mythreyi Chatfied, Andrew Moriarty, and Richard Heller. And this cohort is growing rapidly.

Now is an ideal time for the field of radiology to commit to taking the necessary steps to embrace peer learning in our practices. This will be a journey that many have commenced, along varied paths, influenced by practice patterns and cultures. In some practices, this will require cultural transformations, so that staff are willing to speak up safely in a Just Culture without fear of consequences. It will require hospital administrators to embrace all components of peer learning as meeting local OPPE requirements. It will require that the focus shift from scoring diagnostic discrepancies to identifying learning and improvement opportunities, and that participation is expected. In fact, willing participation could replace annual denominators altogether. Peer learning leaders could be identified and appropriately trained, and their work acknowledged as a vital part of our performance improvement processes. Most important, the American College of Radiology (ACR) has now approved a new pathway for ACR-accredited facilities to meet the Physician Quality Assurance program requirement, opening a path for practices to embrace this learning and improvement and non-punitive approach, thus no longer needing to use a score-based approach.

I started this column addressing the additive impacts of the pandemic on our preexisting stressors and burnout numbers. I highlighted the growing recognition that the so-called moral injury is an additional and major contributor to our current distress. Transitioning from retrospective peer review to prospective peer learning practices is one superb example of how we can mitigate a known contributor and provide what will, hopefully, be some major relief to our radiologists. This could allow our colleagues to participate in a process that is likely to positively impact our performance and the quality of care that we deliver. Because, ultimately, I believe that’s why we are all here.

About the Author
Jonathan Kruskal

Melvin E. Clouse Professor of Radiology, Harvard Medical School
Chair, Department of Radiology, Beth Israel Deaconess Medical Center

The opinions expressed on RadTeams are those of the author(s); they do not necessarily reflect the viewpoint or position of the editors, reviewers, or publisher.

Abundant Opportunities to Bridge Digital Disparities

This post was originally featured in ARRS InPractice.

During this year’s virtual and highly successful American Roentgen Ray Society meeting, it became apparent that we are living in a time of accelerated development and deployment of existing and emerging digital technologies. Individuals and teams are using innovative solutions to care for patients, teach trainees, collaborate with colleagues, and connect within an expanding digital universe.

I for one never imagined that my weekly mobile COVID-19 prediction report would include hourly population densities in nearby airports, supermarkets, restaurants, and bars. With geographically traceable devices, what data could possibly be next?

In the same way that NASA’s Apollo program sparked the development of new technologies (many of which were largely realized and appreciated years later) that landed the first humans on the moon, we are witnessing a fundamental transformation in health care operations that will be captured in future history books. Few could have predicted, for example, that CT scans would become an indispensable screening, diagnostic, staging, and management tool during a global pandemic. Providers have harnessed such a wide swath of tools—from laptops, mobile and wearable devices, and video conferencing to artificial intelligence, thermal sensors, and robots—to better serve patients and their loved ones, sustain remote reading and teaching environments, and uphold compliance and safety protocol. We now achieve efficiencies through rapid scanning, recruit new faculty through social media, teach our trainees in cloud-based classrooms, and attend national conferences with just a click—all without ever boarding a plane or even crossing clinical campuses.

The Future Is Now

The evidence shows that embracing digital technologies results in improved patient outcomes, cost savings and efficiency, increased productivity, heightened compliance and safety, transformed teaching methods, stakeholder satisfaction through digital connections, sustained remote teams, and accessible employee communications and wellness initiatives.

Previously, such innovation resided primarily within the hospital and physician domains, with the gradual integration of patients as they began accessing their personal electronic health records. Now, our digital stakeholders include not only patients, but referring providers, remote teams, educators and learners, researchers, public health authorities, policymakers, schedulers, transporters, the public, commuters, and travelers.

And as the digital stakeholder pool expands, so does its impact: Such technologies now routinely support telehealth, data analysis, access, scheduling, and follow-ups, management decision-making, bidirectional communication, safety compliance and practices, PACS enhancements, teaching and readouts, patient monitoring, diagnostics, consulting, screening, training, forecasting, reporting, and, of course, socializing.

Examining Digital Disparities

We must remember that our digital environment is far from globally universal. At-risk, vulnerable, underserved, and marginalized populations, such as those living more than 7,600 miles away in India today, are grappling to secure simple access and connect effectively with providers and health care delivery services through traditional means, let alone digital ones. They desperately need hospital beds, oxygen and plasma, life-saving vaccine doses, and medical workers. Resources that hospitals, such as ours, are so fortunate to have readily on hand. However challenging these issues are to address, such disparities in access, care, and connections must be studied and included in the many national efforts aimed at eliminating them. What a terrific opportunity for us to make a meaningful difference that matters.

To a large extent, this digital divide is driven by equality, equity, and justice, or the lack thereof. With equality, we assume that here in Massachusetts, for example, all of our patients benefit from the same supports. All are treated equally, irrespective of any differences. But this isn’t necessarily true yet. Having a laptop certainly doesn’t mean a patient can easily access and understand one’s medical records. Additionally, not all laptops have video cameras, and not all hardware supports the ability to participate in video conferencing or telehealth solutions. And then there are those patients who don’t have access to a laptop to begin with. Where does that leave them? It is our responsibility to find out.

From the perspective of equity, everybody receives the specific and different supports they need and, therefore, receive equitable treatment. This is closely tied to justice (some view this as liberation); our underserved patients receive access to appropriate care without requiring specific accommodations because the fundamental causes of inequities have been addressed. In other words, the preexisting systemic barriers have been effectively identified and removed. Consider the impacts and barriers that may exist due to language, poverty, mobility, cognition, geography, access to water, electricity, food, transport, comorbidities, and employment status. By working to eliminate or flatten these barriers, care becomes more equitable and just. There are innumerable opportunities for making a difference that matters here, starting locally.

Bridging Local Gaps

Consider your own imaging team: When you hold video meetings, do all members have equal access to the necessary hardware and software to participate effectively? Are all members afforded the same privacy and time to participate in these meetings? This lesson was brought home to us when we recently convened a video meeting of our wellness council and noticed that several of our technical and nursing staff did not have access to video equipment in their workplace.

Consider your patients, as well: While a health care system might deploy sophisticated software to support their telehealth endeavors, this does not mean that all patients have the necessary hardware or software to participate. Additionally, solutions to barriers such as vision, language, and hearing must be readily available. One additional effort I applaud is to make our digital reports more comprehensible; not every patient understands what is meant by the phrase “the hepatic parenchyma demonstrates a normal echotexture,” nor should they. We should support software solutions to simplify the communication and accuracy of our recommendations.

And in keeping with our educational mission, think about the brisk implementation of so many solutions to support ongoing academic efforts. Will we ever return to our traditional morning resident teaching conference? I’d imagine not; if anything, the pandemic will finally allow us to move away from the prolonged didactic and synchronous teaching methods to ones that are more appropriate, personalized, and contemporary.

Another essential pillar of academic radiology is teaching and developing the next generation of radiology leaders during readouts. We seem to be mired in surveys and comparisons about what processes work best for our traditional readouts. Let’s instead open our eyes to completely new and asynchronous approaches. What an opportunity! And last within this category is lifelong learning. The necessary transformation to virtual national academic meetings this past year has demonstrated the many advantages that our digital environment offers for such forums. Be it cost savings for participants and practices, wider availability of CME credits and on-demand content, less time away from the workplace, or and the ability to directly connect with speakers, the benefits are plentiful.  

Keeping Our Imaginative Focus

Where the opportunities lie here are in fostering participant connections and rethinking how we should transform the content, styles, and media of our traditional talks to take full advantage of individual learner needs and preferences. Again, what terrific opportunities exist in this domain!

So, where do we go from here?

While tremendous and necessary strides have and continue to take place in our abilities to communicate, manage, and connect remotely, I only ask that we continue to be mindful and considerate that not all stakeholders are currently able to participate equally and effectively. The phrase “you’re only as fast as the slowest member of your relay team” is so apt nowadays. In our digital environment, the concept of “precision medicine” should now expand to embrace the specific needs and preferences of our many stakeholders.

As we continue to build and expand our digital frontend, it is equally necessary to focus on supporting the backend, so that all of our team members and stakeholders can participate and benefit from the systems and solutions that are being deployed. The opportunities here are endless, and we need to develop, implement, and share solutions that will ultimately meet the needs and improve the outcomes for our patients. Let’s please keep our imaginative focus on why we entered this wonderful, exciting, and ever-expanding field of radiology in the first place.

About the Author
Jonathan Kruskal

Melvin E. Clouse Professor of Radiology, Harvard Medical School
Chair, Department of Radiology, Beth Israel Deaconess Medical Center

The opinions expressed on RadTeams are those of the author(s); they do not necessarily reflect the viewpoint or position of the editors, reviewers, or publisher.

Dismantling Systemic Injustices Through Intentional DEI Strategies and Inclusive Team-Building

This post was originally featured in ARRS InPractice.

Those of you I have connected with virtually over the past year may recall that, in addition to family photos, my office (and thus my zoom background) is adorned with my old cricket bat, indigenous South African art, Khoisan necklaces, hummingbird photographs, and Shona stone sculptures. These are just a few artefacts that represent my cultural identity, on which I’ve been reflecting a lot these days.

One of the reasons I emigrated from South Africa after completing my medical and basic science training was to escape the abhorrent system of apartheid that I witnessed up close from a young age. My wife and I touched down in the U.S. in 1987 filled with hope and much anticipation. The days of watching fellow human beings suffer at the hands of systemic racism, marginalization, violence, and oppression were behind us, or so we thought. Perhaps our departure was one way of social distancing from that awful pandemic, though much guilt persists knowing that “running away” would not contribute to a solution in any lasting or meaningful way.

Demolishing Normalcy

Fast forward to the year 2020, and we find ourselves grappling with the factors that contributed to George Floyd’s death. Along with the outbreak of COVID-19, more than 15 long months ago, and the ubiquitous opioid addiction crisis, the America that we chose to move to is experiencing more than a single pervasive pandemic and finds itself in desperate and urgent need of a reckoning with structural racism.

The last year has exposed centuries-long inequities, disparities, and ignorance, which impact our employees, peers, patients, loved ones, and communities in ways big and small, seen and unseen, told and untold. Absent diversity, equity, and inclusion (DEI) strategies, combined with social distancing protocols, full-time remote work, technology and commitment overload, and skyrocketing mental health concerns have rightfully demolished what we once believed were the tenets of effective teams; the trademarks of normalcy. To return to what we as radiologists do best—providing top-quality, safe, timely, and evidence-based care—we must work together to dismantle, then to rebuild the status quo. How can we do this?

We Must Row as One

Whether based in a hospital, private practice, or academia, we need to develop and implement DEI strategies that will build high-performing teams through intentional inclusion practices. It’s the only way we can ensure the highest-quality care for our patients, eliminate care and outcome injustices, and begin to narrow the health disparity gaps. We must acknowledge that, yes, we all have biases, many of which are unconscious.

Consider the myriad of players and moving parts in our ecosystems: our technologists acquiring and managing images; our IT colleagues facilitating image interpretation, data management, and report communication; and our nurses providing compassionate, patient-centered care during minimally invasive procedures. We also have the essential contributions of our translators, transporters, schedulers, nurse navigators, medical assistants, advanced practice providers, administrators, and image repository staff. To effectively serve our patients, we must understand, respect, trust, and listen to one another. Simply put, we must row as one.

Doing the Work

As a first step, I encourage you to take Harvard University’s Implicit Aptitude Test to better understand some of your own biases. Set aside uninterrupted time, and take the test with an open and honest mind. You can also ask your employees or colleagues to do the same. Take time to discuss what everyone learned, and listen to each participant. Sit with them, either in person or virtually, and truly hear their experiences and perspectives. Make sure to create an environment of safety, compassion, and open-mindedness for each gathering. You can also consider designing a DEI survey for your team to receive anonymous or attributed feedback. In the spring of 2019, Harvard University created a three-minute “pulse survey” for its community. The executive summary, final report, and data charts and tables are available here.    

In these discussions and surveys, you can also delve deeper into topics such as cultural humilitymicroaggressions, and the difference between bystanders and “upstanders.” The emerging practice of cultural humility, a commitment to lifelong learning about global cultural differences, encourages us to inquire and learn about the experiences and identities of others. Ignorance can lead to an intended or unintended microaggression, which Medical News Today defines as “a comment or action that negatively targets a marginalized group of people.” Another important term to learn and practice is upstanders, or people who speak or act in support of an individual or cause, particularly on behalf of a person being attacked or bullied.

The Concept of Ubuntu

The Zulu and Xhosa concept of Ubuntu emphasizes the importance of “being oneself through others,” a form of humanism best expressed by the phrase, “I am because of who we all are.” Imagine if we realized that our best personal function was dependent on the function of our entire team?

To sustain and elevate team functionality, we must adopt this philosophy in a way that resonates with you. Perhaps it’s by remembering the Golden Rule, which instructs us to treat others the way we would like to be treated ourselves. Maybe it’s by thinking about Aristotle’s historic quote: “The whole is greater than the sum of its parts.”

At the core of our impact as imagers is a broad swath of races, cultures, ideologies, genders, religions, age groups, and much more. Over the next year, we will continue to share DEI resources and invite members of our ARRS family to volunteer, as we develop educational materials that are the building blocks for individual members and practices to rebuild their teams. To submit ideas and feedback, please email me directly at

About the Author
Jonathan Kruskal

Melvin E. Clouse Professor of Radiology, Harvard Medical School
Chair, Department of Radiology, Beth Israel Deaconess Medical Center

The opinions expressed on RadTeams are those of the author(s); they do not necessarily reflect the viewpoint or position of the editors, reviewers, or publisher.

Practical Diversity, Equity, and Inclusion

Presented at the 2022 ARRS Annual Meeting, this course covers key diversity, equity, and inclusion topics and their importance in serving the needs of the workforce, profession, and patients.

This post was originally featured in ARRS InPractice.

Proper communication in a health care setting is vital to delivering quality care to patients. Without it, the quality of health care would be compromised, leading to greater overhead costs and, ultimately, negative patient outcomes. It is well-established that good communication requires basic health care literacy, intercultural competence, and language translation, when needed. But what about communication between providers? Towards nurses? Medical technicians? Medical students? It is easy to forget that patient care is a team effort, which entails cooperativity. While direct aggressive behavior is seldomly seen nowadays, subtle negative attitudes are often projected into biased mannerisms and come across as indignant, derogatory comments. Both these behaviors are unprofessional, but the latter is witnessed much more—to which it seems many prefer to turn a blind eye. Eventually, it becomes the status quo. Such comments sting for a moment but can be ignored; however, repetitive comments are damaging and lead to self-confidence issues and mental health conditions, such as anxiety and depression. These are microaggressions. It is imperative that microaggressions are addressed promptly and professionally to avoid escalating tension in the health care team.

A microaggression is a comment or action that subtly and often unconsciously or unintentionally expresses a prejudiced attitude toward a member of a marginalized group. These types of comments are usually due to underlying implicit bias. Microaggressions are not just harmless side comments; they have significant psychological and physical consequences to the recipient. Microaggressions can be both verbal or nonverbal. Examples of verbal microaggressions include one attending saying to another attending, who is Asian in appearance (but is actually Korean): “We have a Chinese patient and need an interpreter. You speak Chinese, right?” Or a male saying to a female radiologist: “You are too pretty to be a radiologist and sit in the dark. You should be in pediatrics.” Nonverbal microaggressions could be a store owner following a black customer around the store, or a manager ignoring an idea when a female employee presents it, then praising a male employee for saying the same thing. When such examples are experienced as isolated events, they can cause the recipient to become angry or frustrated. When someone is the recipient of microaggressions repeatedly, these events become dehumanizing and can lead to anxiety, lack of self-worth, depression, as well as physical distress.

Difficult conversations at work have additional complexities because of factors such as rank, seniority, perceptions of power within the organization, and perceived threats to work identity, which is often more deliberately crafted than the identity of our private lives. Difficult conversations can be unsuccessful because we bring assumptions and narratives about the intentions of others to the table, without being mindful of the fact that these assumptions are fabricated from our experiences in the world.

Mindfulness is the practice of bringing your attention to the present moment without judgment. Mindfulness is a skill that, when learned, will hopefully lead to equanimity and the ability to respond, rather than react1. Mindfulness is a key element in using the Most Respectful Interpretation (MRI) method of responding to others. Instead of automatic negative assumptions about someone else’s actions or intentions, you are deliberately mindful, assuming the most generous intentions for that person. Bringing mindfulness to a difficult conversation allows you to arrive with compassion and empathy, but without judgment. Doing this will make the other person less defensive and more open to deeper and richer conversation. The threats to identity and ego are diminished, and you allow space for someone else’s perspective to be true.

A difficult conversation involves anything that is uncomfortable to talk about. Examples include confronting a supervisor making suggestive comments, a colleague unaware of their microaggressions, or coworkers with a conflict. Three questions to ask when contemplating a difficult conversation are:

  1. What do I really want?
  2. What do I want for others?
  3. What do I want for the relationship?2

There is a tendency to avoid difficult conversations because they can make us feel uncomfortable, vulnerable, and anxious about challenging responses. However, unaddressed issues often simmer and can eventually erupt into an emotionally charged confrontation focused on blame and assumed intentions. Approaches to handling a difficult conversation well include shifting to a learning/curiosity stance, disentangling impact from intention, and moving from a blame frame to understanding contributions to the problem from both sides. Effective conversation skills include inquiry, active listening, paraphrasing, acknowledgement, reframing, and contrasting3. The goal is to move from a difficult conversation to a learning conversation with mutual understanding and purpose.

Microaggressions can often be addressed with curiosity. For example, one could say, “I’m sorry, could you repeat what you just said? I’m not sure I understood what you said.”

The timing of one’s intervention should be considered. We should consider “calling in” in private rather than “calling out” in public.

New or renewed attention on how workplace and institutional culture and behaviors impact marginalized communities can be challenging. Most people do not receive training throughout their careers on these topics, and the cultural or societal implications they may bring up can be challenging. As education is a central pillar to the ARRS, it was determined necessary to establish a Diversity, Equity, and Inclusion (DEI) committee to help provide teaching and resources to members and the public on relevant topics.

About the authors
Patrick Young

Student Admissions Ambassador, Midwestern University Arizona College of Osteopathic Medicine
President, Asian Pacific American Medical Student Association

Carolynn DeBenedectis

Associate Professor (Breast Imaging), Vice Chair for Education, Radiology Residency Program Director University of Massachusetts Medical School/UMass Memorial Medical Center

Ann Jay

Associate Professor (Clinical Radiology and Otolaryngology), Director of Head and Neck Imaging,
Vice Chair of Education, Radiology Residency Program Director MedStar Georgetown University Hospital

Lori Deitte

Professor of Radiology and Radiological Services, Radiology
Vice Chair of Education Vanderbilt University Medical Center

Daniel Chonde

Resident Physician, Radiology
Harvard Medical School/Massachusetts General Hospital
Chair, ARRS Diversity, Equity, and Inclusion Committee

Nolan Kagetsu

Associate Clinical Professor (Neuroradiology)
Icahn School of Medicine at Mount Sinai/Mount Sinai West Hospital
Advisor, ACGME Office of Diversity and Inclusion