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Carpe Diem: An opportunity for the ABR to support its trainees with family-friendly policies

  • Kirti Magudia
    Affiliations
    Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, CA, United States of America
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  • Elainea Smith
    Affiliations
    Department of Radiology, University of Alabama at Birmingham, Birmingham, AL, United States of America
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  • Samantha G. Harrington
    Affiliations
    Department of Radiology, Massachusetts General Hospital, Boston, MA, United States of America
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  • Kristin K. Porter
    Affiliations
    American Association for Women in Radiology (AAWR), United States of America

    Diversity and Inclusion Committee, Department of Radiology, University of Alabama at Birmingham, Birmingham, AL, United States of America
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  • Elizabeth Kagan Arleo
    Affiliations
    American Association for Women in Radiology (AAWR), United States of America

    Clinical Imaging, Department of Radiology, New York-Presbyterian Hospital/Weill Cornell Imaging, New York, NY, United States of America
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  • Reshma Jagsi
    Affiliations
    Department of Radiation Oncology, Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor, MI, United States of America
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  • Lucy B. Spalluto
    Correspondence
    Corresponding author at: Vanderbilt University Medical Center, Department of Radiology and Radiological Sciences, 1161 21st Avenue, South, Nashville, TN 37232, United States of America.
    Affiliations
    American Association for Women in Radiology (AAWR), United States of America

    Office of Diversity and Inclusion, Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, TN, United States of America

    Vanderbilt Ingram Cancer Center, Nashville, TN, United States of America

    Veterans Health Administration – Tennessee Valley Healthcare System Geriatric Research, Education and Clinical Center (GRECC), Nashville, TN, United States of America
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      The COVID-19 pandemic has presented the radiology and radiation oncology communities with previously unprecedented challenges. Many of these challenges have exacerbated long-standing issues, which disproportionately affect women in radiology and radiation oncology specialties. We applaud the American Board of Radiology (ABR) for adapting and effectively restructuring the ABR Core and Certifying examinations for diagnostic radiology [
      • American Board of Radiology
      Calendar for diagnostic radiology: exam dates and locations.
      ], the oral certifying examinations for radiation oncology [
      • American Board of Radiology
      Calendar for radiation oncology: exam dates and locations.
      ], and the initial certifying exams with oral component for medical physics [
      • American Board of Radiology
      Calendar for medical physics: exam dates and locations.
      ] to virtual environments in the 2020–2021 academic year. These changes lessen the negative impact that rescheduling in-person ABR examinations have on family planning and childcare arrangements. We are pleased that the announcement referred to all future examinations being virtual, as we believe this transition to a virtual examination environment will have benefits beyond the pandemic, not only with regard to trainees' work-life integration but also may enhance the fairness of the examination itself (by introducing opportunities for recording and group review of marginal candidates' responses). Additionally, we hope that this signals the ABR's openness to considering other potentially beneficial changes, such as improvements in the ABR's lactation accommodation policy during examinations.
      We respect the ABR's role in maintaining the public trust by ensuring that all board-certified specialists meet the high standards of competency expected of professionals in our field. We commend the ABR for maintaining its important role as a fiduciary to both the profession and society and overcoming challenges to identifying a remote testing solution to add much needed flexibility for radiology and radiation oncology trainees. We hope the ABR's openness to embrace virtual examination will further drive the development of a fair and equitable examination process, including the consideration of multiple testing dates throughout the year to accommodate family planning or other major life events.
      The ABR examination process for radiology and radiation oncology is specifically challenging for those initiating or caring for family members. While virtual examinations provide flexibility and prevent the significant financial burden incurred by travel, the current process continues to ostracize women who are 32 weeks or more pregnant and creates challenges for parents who need to arrange for childcare during their absence.
      Due to the high stakes of preparing for the ABR examinations and the (approximately) 3-month preparation time period, both women and men preparing for these examinations are often forced to plan pregnancies and other major life events, such as weddings and relocation, according to the examination schedule. While the lack of flexibility with the examination process is inconvenient for any resident planning a family, the negative impact is far greater on women because of the physical demands of parturition and lactation as well as the ongoing gendered societal expectations of mothers. Test dates may fall close enough to a woman's due date that she may be unable to take her examination on schedule with her peers, delaying licensing processes, and affecting future employment and salary start dates. Despite men's current increased contribution to childcare when compared to earlier generations, the majority of the childcare burden continues to land on women, leaving them less time to meet limited, firm, set examination dates [
      • Jolly S.
      • Griffith K.A.
      • DeCastro R.
      • Stewart A.
      • Ubel P.
      • Jagsi R.
      Gender differences in time spent on parenting and domestic responsibilities by high-achieving young physician-researchers.
      ]. Increasing the number of test dates available would offer family-friendly flexibility for those preparing for the examination and also benefit all residents.
      Over the past several weeks, accounts of negative lactation experiences during ABR examinations have been shared on social media by breastfeeding women in radiology and radiation oncology. From this, it has become apparent that the current ABR arrangement for lactating mothers demonstrates an opportunity for improvement. The ABR Core examination is 7.5 h with 30 min of break time for all examinees; lactating women are provided an additional 30 min. In comparison, the American Board of Surgery (ABS) General Surgery Qualifying Examination is 8 h, for which 70 min of break time is allotted for all examinees; lactating mothers are allowed an additional 60 min of break time [
      • The American Board of Surgery
      ]. The American Board of Internal Medicine (ABIM) certification examination is 10 h with 100 min of break time for all examinees; lactating mothers are allowed an additional 60 min of break time [
      • American Board of Internal Medicine
      ]. Taking into consideration the time it takes to prepare for breast pumping, physically pump, properly store milk, rinse pump parts and redress, the lactation accommodations from the ABR are notably insufficient when compared to the ABS and ABIM. On average, lactating women pump breast milk every 2–4 h for up to 30 min duration [
      • American Academy of Family Physicians
      Breastfeeding and lactation for medical trainees.
      ]. One pumping session during an 8-h examination is insufficient to meet this necessity, especially if the lactating mother is pumping for an infant under the age of 6 months (often entirely sustained by breast milk). We urge the ABR to extend its lactation break policy in parallel with the transition to a virtual testing environment, as part of its forward-thinking embrace of change. This policy change has the potential to mitigate unnecessary burdens on examinees while maintaining the high threshold to ensure clinical competency within our fields.
      Women are markedly underrepresented in radiology and radiation oncology [
      • Chapman C.H.
      • Hwang W.-T.
      • Both S.
      • Thomas C.R.
      • Deville C.
      Current status of diversity by race, Hispanic ethnicity, and sex in diagnostic radiology.
      ,
      • Brotherton S.E.
      • Etzel S.I.
      Graduate medical education, 2010-2011.
      ]. While current representation of women on the ABR Board of Governors remains low (12%) [
      • American Board of Radiology
      ], recent national efforts aimed at examining gender diversity within radiology and radiation oncology leadership is noteworthy. We are hopeful that this will drive positive developments that may generate more family-friendly policies [
      • Wallner P.E.
      • Frey G.D.
      • Roberts A.C.
      • Canon C.L.
      • Jackson V.P.
      • Wagner B.J.
      Gender diversity within the American Board of Radiology: history, current status, and future implications.
      ,
      • Lightfoote J.B.
      • Fielding J.R.
      • Deville C.
      • et al.
      Improving diversity, inclusion, and representation in radiology and radiation oncology part 1: why these matter.
      ,
      • Knoll M.A.
      • Jagsi R.
      • Wallner P.
      Gender diversity in radiation oncology board certification.
      ]. We thank the ABR for transitioning examinations to a virtual environment in response to the COVID-19 pandemic, a commitment that will benefit trainees of all genders. This support can be further extended by increasing the number of examination dates offered and increasing the amount of break time allocated to lactating examination takers in order to continue to offer a fair and equitable exam for all trainee members.

      Author participation

      All authors substantially contributed to the design of the work, the writing and revision of the letter, approved the final version of the letter and are accountable for the letter's contents.

      Sources of support

      None.

      Declaration of competing interest

      The authors acknowledge the below conflicts of interest (none related to the submitted work).
      Dr. Porter is on the Bracco Diagnostics Inc. COVID-19 Healthcare Professional Advisory Board.
      Dr. Arleo is the Editor-in-Chief of Clinical Imaging.
      Dr. Jagsi has stock options as compensation for her advisory board role in Equity Quotient, a company that evaluates culture in health care companies; she has received personal fees from Amgen and Vizient and grants for unrelated work from the National Institutes of Health, the Doris Duke Foundation, the Greenwall Foundation, the Komen Foundation, and Blue Cross Blue Shield of Michigan for the Michigan Radiation Oncology Quality Consortium. She has a contract to conduct an investigator initiated study with Genentech. She has served as an expert witness for Sherinian and Hasso and Dressman Benzinger LaVelle. She is an uncompensated founding member of TIME'S UP Healthcare and a member of the Board of Directors of ASCO.

      Acknowledgments

      This open letter is jointly submitted by the Executive Board of the American Association for Women in Radiology, Leadership of the Society for Women in Radiation Oncology, and with valued input from many additional members-in-training, including Shadi Abdar Esfahani, Elizabeth B. Jeans, Laura Dover, Jenna Kahn, and Gabrielle Welch Peters. Dr. Magudia received salary support from NIH (Grant No.: NIBIB T32EB001631) for unrelated work.

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