In 1923, the American College of Radiology (ACR) was founded, and in 1927, the first ACR Gold Medal, "awarded by the Board of Chancellors to an individual for distinguished and extraordinary service to the American College of Radiology or to the discipline of radiology" 1. American College of Radiology Gold Medal Award. https://www.acr.org/Member-Resources/Fellowship-Honors/Gold-Medal Google Scholar was bestowed. In 1931, the first ACR gold medal was awarded to a female, a female none other than the world-famous Mme. Marie Curie, who to this day is still the only female to receive two Nobel prizes. The second female ACR gold medal winner was not until 1963, when it was awarded to Edith H. Quimby, Sc.D., "a pioneering female physicist with pivotal contributions in diagnostic radiology and radiotherapy" 2. Karakatsanis N.A. Arleo E.K. Dr. Edith H. Quimby: a pioneering medical physicist and educator with outstanding contributions in radiation dosimetry. Clin Imaging. 2022 Jan; 81 (Epub 2021 Oct 8. PMID: 34700174): 118-121https://doi.org/10.1016/j.clinimag.2021.09.017 Google Scholar ; and then the third was not until 1984, when it was awarded to Alice Ettinger, MD, who introduced spot fluoroscopy to the United States from Europe. 3. Magudia K.Dr. Alice Ettinger: pioneer of fluoroscopy and exceptional teacher. Clin Imaging. 2019 Nov-Dec; 58 ([Epub 2019 Nov 6. PMID: 31759802]): A1-A2https://doi.org/10.1016/j.clinimag.2019.09.004 Google Scholar

In this survey of academic radiology department chairs, pathways to first chair appointment were similar between men and women in terms of prior professional accomplishments and chair position preparedness. However, women more commonly perceived that their gender negatively affected their career trajectory, and they more frequently reported experiencing overt discrimination and unconscious bias.

The article by Brandser and Kothari was interesting, describing a way of getting the work done by the same number of radiologists through increasing their number of working hours for extra pay [1Brandser E. Kothari T. Bunker shifts alleviate long list anxiety syndrome.J Am Coll Radiol. 2022; 19: 9Abstract Full Text Full Text PDF Scopus (2) Google Scholar]. I object to calling it “bunker shift.” The authors should know that the original description of “bunker” in 1758 meant a bench for sleeping, hardly what you want your radiology colleagues to do. The term then was used for underground shelters or dugouts in English and “bunker” in German. Reinforced concrete shelters supposedly bomb-proof were called “bunkers,” where some of our family members tried to survive in places like Budapest, Prague, Warsaw, and so on. Why call radiologists working after hours to help out a “bunker shift”? The term would depress me, so I would not want to do it. Call it what it is: “extra” shift or some other uplifting term. Response to Letter to the Editor Re: Bunker Shifts Alleviate Long List Anxiety SyndromeJournal of the American College of RadiologyVol. 20Issue 6PreviewThank you for the interesting history of the word “bunker.” Full-Text PDF Bunker Shifts Alleviate Long List Anxiety SyndromeJournal of the American College of RadiologyVol. 19Issue 9PreviewAs a general radiology practice with partial subspecialization with more than 30 radiologists, we have fast readers and slow readers making a typical bell curve but with prominent tails at both ends of the curve. Like others, we have radiologists who are speedy at some types of studies and less speedy at others [1]. Full-Text PDF

Background: The American College of Radiology (ACR) passed a historic paid family/medical leave (PFML) resolution at its April 2022 meeting, resolving that "diagnostic radiology, interventional radiology, radiation oncology, medical physics, and nuclear medicine practices, departments and training programs strive to provide 12 weeks of paid family/medical leave in a 12-month period for its attending physicians, medical physicists, and members in training as needed." The purpose of this article is to share this policy beyond radiology so that it may serve as a call to action for other medical specialties.Principal Findings: Such a PFML policy (1) supports physician well-being, which in turn supports patient care; (2) is widely needed across American medical specialties; and (3) should not take nearly a decade to achieve, as it did in radiology, especially given increasing physician burnout and the ongoing COVID-19 pandemic.Contribution: Supported by information on the step-by-step approach used to achieve radiology-specific leave policies and considering current and normative policies at the national level, this article concludes by reviewing specific strategies that could be applied toward achieving a 12-week PFML policy for all medical specialties.

The 1993 Family and Medical Leave Act (FMLA), a US federal labor law, requires covered employers to provide eligible employees with up to 12 work weeks (in a 12-month period) of job-protected, unpaid leave for specific family and medical reasons. These reasons can be experienced by all genders and include caring for a new child, for oneself, or for an immediate family member experiencing a serious medical condition. Physicians, including radiologists, are not immune to these and thus also make use of leave for FMLA reasons, and yet little is known about trends in the use of FMLA.

I am writing to update previous letters to the editor about the increasing number of female editors-in-chief of US radiology journals [1Arleo E.K. Not only do female editors-in-chief of radiology journals exist, they are increasing in number.J Am Coll Radiol. 2021; 18: 343Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar,2Arleo E.K. Do not let your field of view be too narrow.J Am Coll Radiol. 2022; 19: 500-501Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar]. In the first, I quoted former Supreme Court justice Ruth Bader Ginsburg as saying that there will be enough women (on the Supreme Court) when there are nine [1Arleo E.K. Not only do female editors-in-chief of radiology journals exist, they are increasing in number.J Am Coll Radiol. 2021; 18: 343Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar]. In this third letter, I am pleased to provide the update that there are now in fact nine female editors-in-chief of major US radiology journals. Specifically, in addition to the six female editors-in-chief of radiology journals previously reported en bloc [1Arleo E.K. Not only do female editors-in-chief of radiology journals exist, they are increasing in number.J Am Coll Radiol. 2021; 18: 343Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar], not only does Dr Linda Moy ascend to editor-in-chief of Radiology in January 2023 [2Arleo E.K. Do not let your field of view be too narrow.J Am Coll Radiol. 2022; 19: 500-501Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar], but also, Dr Geetikah Khanna becomes editor-in-chief of Pediatric Radiology at same time (meeting communication, November 5, 2022), and before that, effective December 1, 2022, Elizabeth Krupinksi, PhD, becomes editor-in-chief of the Journal of Digital Imaging, the official journal of the Society for Imaging Informatics in Medicine. Why is this important? Because, to quote the trailblazing Justice Ginsburg once again, “Women belong in all places where decisions are being made. It shouldn’t be that women are the exception” [3Ruth Bader Ginsburg in pictures and her own words. BBC News. September 19, 2020.https://www.bbc.com/news/world-us-canada-54218139Date accessed: November 5, 2022Google Scholar]. Now that there are nine, female editors-in-chief of radiology journals are no longer the exception, and this is noteworthy.

In recent years, the number of RSNA female gold medal recipients has increased. Also recently, the importance of diversity, equity, and inclusion (DEI) in radiology beyond gender has received greater attention. The ACR Pipeline Initiative for the Enrichment of Radiology (PIER) program "began through the Commission for Women and Diversity in hopes of giving underrepresented minorities (URMs) and women an opportunity to explore the radiology specialty and engage in research."1 Consistent with this mission and the mission of Clinical Imaging to "advance knowledge and positively impact patient care and the profession of radiology,"2 the journal is pleased to announce a forthcoming initiative in which PIER program medical students will be paired with senior faculty members and given the opportunity to write a first-authorship publication about the legacies of RSNA Female Gold Medal Recipients. With this form of intergenerational mentorship, scholars will gain a new perspective and guidance as they navigate their early career.

I am writing to update my 2021 letter to the editor [1], in response to the December 23, 2021, announcement by the RSNA that Linda Moy, MD, will become editor of the journal Radiology in January 2023 [2]. In the former letter [1], I detailed the six women named editors-in-chief of radiology journals, and given the latter, there will now be seven, as illustrated in Figure 1.

I have a confession to make. While in high school, I think I could have broken my CD player (now I'm dating myself) pressing the back button to repeat and repeat and repeat the 1993 hit song by the Swedish group Ace of Base, "The Sign"1– it was one of my absolute favorites. At the time, it was purely avocational, purely listening pleasure when I wasn't (or sometimes was) dutifully doing my homework. And yet now I wonder: was there a reason for this repeat listening after all?

Paid family/medical leave in radiology: now is the time. At the 2020 American College of Radiology (ACR) annual meeting, a paid family/medical leave resolution was deferred due to uncertainty surrounding the emerging COVID-19 pandemic. At the 2021 ACR annual meeting, ACR councilors passed the American Association for Women in Radiology (AAWR) amendment to resolution 48 in strong support of 12 weeks of family/medical leave for diagnostic radiology, interventional radiology, radiation oncology and nuclear medicine residents; the vote was 89.13% in the affirmative. The resolution itself was based on a 2021 Radiology editorial sponsored by 12 national organizations/societies1.Magudia K. Ng T.S.C. Campbell S.R. et al.Family and medical leave for diagnostic radiology, interventional radiology, and radiation oncology residents in the United States: a policy opportunity.Radiology. Jul 2021; 300: 31-35https://doi.org/10.1148/radiol.2021210798Google Scholar; however, it did not specify whether the leave was paid or unpaid. Thus, the next step is a normative paid family/medical leave resolution. Unpaid family/medical leave is an exclusive benefit that may only be taken by those whose circumstances permit. Paid family/medical leave is an inclusive policy that would benefit the wellness as well as the diversity, equity and inclusion of our specialty. Moreover, in contrast to the uncertainty of two years ago, it is certainly now clear that the last two years of COVID-19 have been ones in which more than ever, members of our specialty and beyond needed paid family/medical leave. So while we cannot turn back the clock, the time is really now to get a paid family/medical leave resolution enacted. The Family and Medical Leave Act (FMLA) of 1993 provides eligible employees with up to 12-weeks of unpaid, job-protected leave per year for the care of a newborn or adopted child.2.Family Medical Leave Act of 1993. Pub L 103-3, 29 USC.1993Google Scholar While FMLA mandates leave, it does not mandate that the leave be paid. The Federal Employee Paid Leave Act (FEPLA) of 2019 gives federal workers access to up to 12 weeks of paid time off for the birth, adoption or placement of a new child.3.Women's and Fair Practices Departments. Federal Employee Paid Leave Act (FEPLA).https://www.afge.org/globalassets/documents/wfp/pfl-booklet_march10-2021.pdfDate accessed: March 10, 2022Google Scholar However, while FEPLA mandates paid parental leave, it is only applies to federal employees and does not include paid leave for medical reasons. In fact, paid family/medical leave has been featured prominently in recent proposed federal legislation.4.Donovan S.A. Huston B.F. Build Back Better Act: universal comprehensive paid leave. Congressional Research Service.https://crsreports.congress.gov/product/pdf/IF/IF11994Date accessed: March 10, 2022Google Scholar Paid family/medical leave is associated with numerous societal benefits (Table 1). These benefits include decreased infant mortality, mother and infant hospitalizations, societal expenditures related to health- and childcare costs, as well as work force absences.5.Van Niel M.S. Bhatia R. Riano N.S. et al.The impact of paid maternity leave on the mental and physical health of mothers and children: a review of the literature and policy implications.Harv Rev Psychiatry. Mar/Apr 2020; 28: 113-126https://doi.org/10.1097/hrp.0000000000000246Google Scholar These benefits also include increased employee morale, job satisfaction, and productivity; notably, these differences are for both female and male workers.6.Huang G. The business case for paid leave at your company. Forbes.https://www.forbes.com/sites/georgenehuang/2017/02/28/the-business-case-for-paid-family-leave-at-your-company/?sh=586c44474eaeDate accessed: March 10, 2022Google Scholar, 7.Hedlin S. How paid parental leave benefits men, too. Harvard Journal of Law & Gender.https://harvardjlg.com/2018/11/how-paid-parental-leave-benefits-men-too/Date accessed: March 10, 2022Google Scholar States and other countries that have implemented paid-leave policies have found significant reduction in the number of women leaving their jobs in the first year after giving birth—and an even greater reduction in those who leave after five years, suggesting that this early support has lasting effect.5.Van Niel M.S. Bhatia R. Riano N.S. et al.The impact of paid maternity leave on the mental and physical health of mothers and children: a review of the literature and policy implications.Harv Rev Psychiatry. Mar/Apr 2020; 28: 113-126https://doi.org/10.1097/hrp.0000000000000246Google Scholar, 8.Jones K.M. Paid family leave increases mothers' labor market attachment. Institute for Women's Policy Research.https://iwpr.org/wp-content/uploads/2020/01/B383-Paid-Leave-Fact-Sheet.pdfDate accessed: March 10, 2022Google ScholarTable 1Overall societal paid family/medical leave benefits.DecreasedIncreasedInfant mortalityBreastfeeding initiation & durationInfant & mother hospitalizationsTimely immunizations & pediatrician visitsPost-partum depressionProductivity, loyalty, and moraleIntimate partner violenceJob satisfactionExpenditures related to health- and childcare costs and work force absences Open table in a new tab There are multiple business advantages to a formal paid family/medical leave policy for practices and departments (Table 2).9.Arleo E.K. Paid parental leave in radiology: the time is now-challenges, strategies, and the business case for implementation.J Am Coll Radiol. Mar 2019; 16: 389-392https://doi.org/10.1016/j.jacr.2018.10.031Google Scholar First, a formal policy promotes consistency and fairness by avoiding subjective decisions on employees' personal situations. A formal policy also facilitates budgeting and preparing for absences by allowing practices to project and cover costs. Furthermore, a formal policy minimizes concerns over discussing and taking leave, leading to employees providing more advanced notice, permitting earlier and more optimal planning. The benefits of paid leave also include improved employee retention, morale and productivity. A paid family/medical leave policy may also serve as a strong recruitment tool leading to a potential competitive hiring advantage. Finally yet importantly, a formal inclusive family/medical leave policy supports same sex and adoptive parents as well as diversity, equity and inclusion goals.Table 2Top benefits of paid family/medical leave: Practices & departments and individuals.Practices and departmentsIndividualsConsistency and fairness: a formal policy avoids subjective decisions on employees' personal situations.Physical recovery from childbirth or a serious medical illnessFacilitates budgeting and preparing for absencesBonding with a new childDiversity, equity & inclusion (including support for same sex and adoptive parents)Provision of parental or familial support to an immediate family member with a serious medical illnessRecruitment & retentionEnhanced economic security Open table in a new tab Providing new parents with paid time off to care for a newborn or recently adopted child improves maternal health by allowing physical recovery, promotes bonding, and enhances families' economic security.5.Van Niel M.S. Bhatia R. Riano N.S. et al.The impact of paid maternity leave on the mental and physical health of mothers and children: a review of the literature and policy implications.Harv Rev Psychiatry. Mar/Apr 2020; 28: 113-126https://doi.org/10.1097/hrp.0000000000000246Google Scholar As of 2019, 41% of working mothers were sole breadwinners, earning at least half of their total household income and nearly a fourth of mothers were co-breadwinners, earning about 25–49% of the household income; therefore, for many families, unpaid leave is untenable.10.Glynn S.J. Breadwinning mothers continue to be the U.S. norm - Center for American Progress.https://www.americanprogress.org/article/breadwinning-mothers-continue-u-s-norm/Date accessed: March 8, 2022Google Scholar Specific benefits of paid family leave for men (Table 3) include that fathers on paid leave tend to build closer relationships with their children; paternity leave improves male health and reduces household conflicts; and, paid paternity leave is linked to increased life satisfaction for men.6.Huang G. The business case for paid leave at your company. Forbes.https://www.forbes.com/sites/georgenehuang/2017/02/28/the-business-case-for-paid-family-leave-at-your-company/?sh=586c44474eaeDate accessed: March 10, 2022Google Scholar, 7.Hedlin S. How paid parental leave benefits men, too. Harvard Journal of Law & Gender.https://harvardjlg.com/2018/11/how-paid-parental-leave-benefits-men-too/Date accessed: March 10, 2022Google Scholar Paid medical and caregiving leave allows workers care for themselves and loved ones when ill or injured, and reduces financial insecurity and stress during those times.Table 3Top benefits of paid paternity leave for men.Fathers on paid leave tend to build closer relationships with their childrenPaternity leave improves male health and reduces household conflictsPaid paternity leave is linked to increased life satisfaction for men Open table in a new tab With the numerous benefits of paid family/medical leave established, the “risks” of coverage and cost must next be considered. Undoubtedly, both issues are more of a challenge for a small group of three radiologists compared to larger group of 30 or more radiologists. In the 2016 ACR Commission on Human Resources Workforce Survey, it was revealed that most practices (80%) made no workforce changes to cover absences due to FMLA leave.11.Arleo E.K. Parikh J.R. Wolfman D. Gridley D. Bender C. Bluth E. Utilization of the Family and Medical Leave Act in Radiology Practices According to the 2016 ACR Commission on Human Resources Workforce Survey.J Am Coll Radiol. Dec 2016; 13: 1440-1446https://doi.org/10.1016/j.jacr.2016.08.023Google Scholar However, this approach – or lack thereof – fails to take into consideration the prevention of burnout in radiologists who remain on the job. While there may not be advanced notice in the case of a serious medical condition both for oneself or for an immediate family member, pregnancy and adoption generally provide several months' notice for impending leave during which coverage can be organized. Regardless of the scenario requiring leave, practices and departments can cover leave by bringing radiologists on site or providing coverage with remote work. Remote work has never been more ubiquitous or seamless in radiology. While teleradiology used to be limited to specific groups, it is now the rare practice or department that is not equipped for some remote work due to operational changes made due to the COVID-19 pandemic. In short, with the recent renaissance of remote radiology work, coverage for family/medical leave is arguably easier to implement than ever before. Furthermore, the potential savings of providing paid family/medical leave balance perceived costs (Table 4). As previously delineated in a 2020 Clinical Imaging article on paid family/medical leave, direct costs include continued pay, continued benefits and other employee-related costs, temporary staff and overtime.12.Arleo E.K. Paid family/medical leave: that's great - what's next?.Clin Imaging. May 2020; 61: A1-a3https://doi.org/10.1016/j.clinimag.2020.02.004Google Scholar Indirect costs may include program administration. Conversely, direct savings include reduced wages if a practice has group short-term disability insurance or operates in a state with a paid leave program. Indirect savings include reduced hiring costs by retaining employees and increased productivity of employees who take sufficient leave and return ready to work. Additionally, an important cost not often considered is presenteeism, defined as “the problem of employees who are not fully functioning in the workplace because of an illness, injury or other condition.”12.Arleo E.K. Paid family/medical leave: that's great - what's next?.Clin Imaging. May 2020; 61: A1-a3https://doi.org/10.1016/j.clinimag.2020.02.004Google Scholar, 13.Kenton W. Presenteeism. Investopedia.https://www.investopedia.com/terms/p/presenteeism.asp#:~:text=Presenteeism%20refers%20to%20the%20lost,make%20mistakes%20on%20the%20jobDate accessed: March 10, 2022Google Scholar Presenteeism is associated with on-the-job productivity losses and mistakes, and represents a major component of total employer costs; on the job mistakes are particularly costly not only monetarily but also at the human level of pain and suffering when the job involves patient care, as it does in radiology.14.Schultz A.B. Chen C.-Y. Edington D.W. The cost and impact of health conditions on presenteeism to employers.Pharmacoeconomics. 2009; 27 (2009/05/01): 365-378https://doi.org/10.2165/00019053-200927050-00002Google Scholar Thus, it is incumbent upon us in radiology to mitigate presenteeism.Table 4Paid family/medical leave: Potential savings outweigh costs.SavingsCostsShort term disability or state paid leave programContinued pay & benefits↓ Hiring costs by retaining employeesAdministrative↓ PresenteeismaDefined as “the problem of employees who are not fully functioning in the workplace because of an illness, injury or other condition.”13a Defined as “the problem of employees who are not fully functioning in the workplace because of an illness, injury or other condition.”13.Kenton W. Presenteeism. Investopedia.https://www.investopedia.com/terms/p/presenteeism.asp#:~:text=Presenteeism%20refers%20to%20the%20lost,make%20mistakes%20on%20the%20jobDate accessed: March 10, 2022Google Scholar Open table in a new tab The 2020 decision by the American Board of Radiology (ABR) to transition examinations to a virtual environment in response to the COVID-19 pandemic15.June 22: ABR moving to remote exams. American Board of Radiology.https://www.theabr.org/announcements/coronavirus-updates#remoteDate accessed: March 10, 2022Google Scholar was a family-friendly policy change and inspired many to advocate for additional family and workforce friendly policies. At the May 2021 ACR annual meeting, the ACR voted to adopt amended Resolution 48, which supports 12 weeks of (unspecified paid or unpaid) family/medical leave during residency without extension of training.16.Wang S.S. Patel A. Everett C.J. Guerrero-Calderon J. Ali K. New Heights for family and medical leave policy for radiology and radiation oncology trainees.Radiology. Feb 2022; 302: E9https://doi.org/10.1148/radiol.2021211296Google Scholar Subsequently, by July 1, 2021, the ABR released its updated residency leave policy, such that “Beginning with the 2021-2022 academic year, residents will be considered eligible for Initial Certification without an extension of training with ‘Time Off’ that does not exceed an average of eight weeks (40 workdays) per academic year over the duration of the residency.”17.American Board of Radiology Residency Leave Policy.https://www.theabr.org/exam-details/residency-leave-policyDate accessed: August 29, 2021Google Scholar The ABR's leave policy means residents can take up to 16 weeks family/medical leave if needed in addition to four weeks of vacation per year during residency without extension of training. The ABR residency leave policy is focused on training requirements (i.e., eligibility for board certification and possible extension of training) and thus appropriately does not comment about whether the leave itself is paid versus unpaid. However, the updated Accreditation Council for Graduate Medical Education (ACGME) institutional requirements effective July 1, 2022 requires 6 weeks paid family/medical leave for all trainees in accredited programs regardless of program length, starting on the first day of the program, and with a separate week of paid vacation in the same year.18.Accreditation Council for Graduate Medical Education. Institutional Requirements: ACGME-approved focused revision: September 26, 2021; effective July 1, 2022.https://www.acgme.org/globalassets/pfassets/programrequirements/800_institutionalrequirements_2022_tcc.pdfDate accessed: March 10, 2022Google Scholar Additionally, in October 2018, the Society of Chairs of Academic Radiology Departments (SCARD) voiced support for 12 weeks of paid parental leave for faculty in academic radiology departments. This support was articulated in a letter to the editor stating that, “SCARD members support the AAWR and pledge to strive for departmental, institutional, and organizational change that provides 12 weeks of paid parental leave for eligible (as defined by the FMLA) faculty members of all genders.”19.Canon C.L. Enzmann D.R. Grist T.M. et al.Society of Chairs of Academic Radiology Departments statement of support for paid parental leave.J Am Coll Radiol. Mar 2019; 16: 271-272https://doi.org/10.1016/j.jacr.2018.12.029Google Scholar The next logical step would be support by our specialty and its major organizations, including the ACR, for academic departments, private practices and training programs to strive to provide paid family/medical leave. An ACR resolution on paid family/medical leave would be consistent with the ACR's stated commitment to, “the radiologist's well-being as an integral part of high quality and safe patient care and the health of our members,”20.Statement of support: National Academy of Medicine Collaborative on Clinician Well-Being and Resilience. American College of Radiology.https://nam.edu/wp-content/uploads/2018/01/American-College-of-Radiology-Commitment-Statement-.pdfDate accessed: March 10, 2022Google Scholar and “to actively promote inclusion at all levels of training, practice, and leadership.”21.Excellence Through Diversity and Inclusion. American College of Radiology.https://www.acr.org/Member-Resources/Diversity-at-ACRDate accessed: March 10, 2022Google Scholar The operative word “strive” is important to reflect the complexity of implementing a leave policy across different practice types and settings. In medicine, we talk about risks, benefits and alternatives; with respect to paid family/medical leave, the benefits outweigh the risks and the alternative (the status quo) is discordant with the ACR's commitment to the well-being of radiologists throughout their professional career. Paid family/medical leave supports those who experience a serious medical condition themselves (or have family members who do) and those who experience pregnancy and childbirth or adoption. These conditions apply to essentially all radiologists at some point in their career. While there is a cost to paid family/medical leave, these costs can be mitigated with short-term disability, state programs, as well as careful organizational planning. The business case for paid family/medical leave is compelling, with research showing improved retention, recruitment, productivity and morale. These outcomes are important to all practices and are critical to the future of radiology as a whole. Support for paid leave at the ACR level would help normalize family/medical leave and establish radiology as a leader among medical specialties.

Breastfeeding has medical and economic benefits and providing an environment supportive of breastfeeding should be a priority in radiology to promote diversity, equity and inclusion. Most breastfeeding radiologists do not meet their breastfeeding goals and inadequate time for pumping is the most commonly cited barrier. The UCSF lactation credit model sets the standard for breastfeeding support in medicine by providing protected time without productivity penalties and it should be adapted and implemented across radiology practices to more fully support breastfeeding radiologists and radiation oncologists.

Each year, the American College of Radiology (ACR) has awarded its highest honor, the ACR Gold Medal, to an individual for distinguished, extraordinary service to the ACR or to the discipline of radiology. While this prestigious award was established almost a century ago, only ten women have received the honor throughout its history. This article seeks to highlight the life and achievements of one of these women, Dr. Kay Vydareny. Despite encountering barriers facing women in the medical field during medical school and residency in the 1960-70s, Dr. Vydareny went on to embark on a remarkable, enduring career. Early in her career, she began to build a professional network of fellow women colleagues through the American Association of Women Radiologists (AAWR), eventually serving as AAWR President in 1984. In addition to the AAWR, she served in leadership roles in many professional radiological organizations including the ACR. She was elected the first female speaker of the ACR Council Steering Committee in 1993, served on the Board of Chancellors from 1995 to 2002, and was President in 2001. At the same time, she maintained a passion for medical education. In honor of her distinguished and extraordinary service to radiology full of many groundbreaking firsts, she was awarded the ACR Gold Medal in 2005. She was only the fifth woman ever to receive this award. Throughout her outstanding career, Dr. Vydareny has continually been a dedicated and thoughtful educator, mentor, and leader who has made a lasting impact on the field of radiology.

What is Imposter Syndrome, whom does it affect, and when, and why is it important to recognize? In this multidisciplinary article, the phenomenon is defined and discussed by a psychiatrist, followed by strategic advice by a radiologist, interventional radiologist and radiation oncologist.

HomeRadiologyVol. 300, No. 1 PreviousNext Reviews and CommentaryFree AccessEditorialFamily and Medical Leave for Diagnostic Radiology, Interventional Radiology, and Radiation Oncology Residents in the United States: A Policy OpportunityKirti Magudia , Thomas S. C. Ng, Shauna R. Campbell, Patricia Balthazar, Elizabeth H. Dibble, Comron J. Hassanzadeh, Neil Lall, Emily C. Merfeld, Shadi A. Esfahani, Rachel B. Jimenez, Emma C. Fields, Johnson B. Lightfoote, Susan J. Ackerman, Elizabeth B. Jeans, Meridith J. Englander, Carolynn M. DeBenedectis, Kristin K. Porter, Lucy B. Spalluto, Lori A. Deitte, Reshma Jagsi, Elizabeth Kagan ArleoKirti Magudia , Thomas S. C. Ng, Shauna R. Campbell, Patricia Balthazar, Elizabeth H. Dibble, Comron J. Hassanzadeh, Neil Lall, Emily C. Merfeld, Shadi A. Esfahani, Rachel B. Jimenez, Emma C. Fields, Johnson B. Lightfoote, Susan J. Ackerman, Elizabeth B. Jeans, Meridith J. Englander, Carolynn M. DeBenedectis, Kristin K. Porter, Lucy B. Spalluto, Lori A. Deitte, Reshma Jagsi, Elizabeth Kagan ArleoAuthor AffiliationsFrom the Department of Radiology and Biomedical Imaging, University of California, 1700 4th St, Byers Hall, Suite 102, San Francisco, CA 94158 (K.M.); Departments of Radiology (T.S.C.N., P.B., S.A.E.) and Radiation Oncology (R.B.J.), Massachusetts General Hospital/Harvard Medical School, Boston, Mass; Department of Radiation Oncology, Cleveland Clinic, Cleveland, Ohio (S.R.C.); Department of Diagnostic Imaging, Alpert Medical School of Brown University and Rhode Island Hospital, Providence, RI (E.H.D.); Department of Radiation Oncology, Washington University School of Medicine, St Louis, Mo (C.J.H.); Department of Radiology, Children's Healthcare of Atlanta, Atlanta, Ga (N.L.); Department of Radiology, Emory University, Atlanta, Ga (N.L.); Department of Human Oncology, University of Wisconsin School of Medicine, Madison, Wis (E.C.M.); Department of Radiation Oncology, Virginia Commonwealth University, Richmond, Va (E.C.F.); Department of Radiology, Pomona Valley Hospital Medical Center, Pomona, Calif (J.B.L.); Department of Radiology and Radiological Science, Medical University of South Carolina, Charlestown, SC (S.J.A.); Department of Radiation Oncology, Mayo Clinic, Rochester, Minn (E.B.J.); Department of Radiology, Albany Medical College, Albany, NY (M.J.E.); Department of Radiology, University of Massachusetts Medical School, Worcester, Mass (C.M.D.); Department of Radiology, University of Alabama at Birmingham, Birmingham, Ala (K.K.P.); Department of Radiology and Radiological Sciences, Vanderbilt University School of Medicine, Nashville, Tenn (L.B.S., L.A.D.); Department of Radiation Oncology, University of Michigan, Ann Arbor, Mich (R.J.); and Department of Radiology, New York-Presbyterian Hospital/Weill Cornell Imaging, New York, NY (E.K.A.).Address correspondence to K.M. (e-mail: [email protected]).Kirti Magudia Thomas S. C. NgShauna R. CampbellPatricia BalthazarElizabeth H. DibbleComron J. HassanzadehNeil LallEmily C. MerfeldShadi A. EsfahaniRachel B. JimenezEmma C. FieldsJohnson B. LightfooteSusan J. AckermanElizabeth B. JeansMeridith J. EnglanderCarolynn M. DeBenedectisKristin K. PorterLucy B. SpallutoLori A. DeitteReshma JagsiElizabeth Kagan ArleoPublished Online:Apr 13 2021https://doi.org/10.1148/radiol.2021210798MoreSectionsPDF ToolsAdd to favoritesCiteTrack CitationsPermissionsReprints ShareShare onFacebookXLinked In IntroductionThe American Board of Medical Specialties recently announced that effective July 1, 2021, member boards with training programs of 2 years or more must "establish requirements for candidates to become eligible for Initial Certification, including standards for training" and have "policies that accommodate reasonable leaves of absence from residency and fellowship training for personal or familial needs" (1). In preparation for this mandate, the American Board of Radiology (ABR) solicited comments from diverse stakeholders in March 2021—including the Association of Program Directors in Radiology, the Association of Program Directors in Interventional Radiology, and the ABR Initial Certification Advisory Committee for Radiation Oncology—with regards to Residency Service-Time Requirement (2), including considerations of family and medical leave. These communications included an initial proposed policy suggesting that "Programs may grant up to six weeks Parental, Caregiver and Medical Leave during the residency" (2) (ABR, written communication, March 12, 2021; March 16, 2021; and March 17, 2021).We appreciate the ABR's efforts to seek feedback as it develops an updated policy. The purpose of this piece is to promote transparent discourse and to examine the nuanced issues pertaining to family and medical leave considerations within the broader context of Residency Service-Time Requirement (2) policies for diagnostic radiology (DR), interventional radiology (IR), and radiation oncology (RO) residents, with the shared goal of optimizing both the training of competent clinicians worthy of public trust as well as professional well-being and diversity, equity, and inclusion. Given the rationale provided below, we recommend that the ABR leave policy allow a resident who is in good standing to take 12 weeks of family and medical leave during residency (in addition to 4 weeks of vacation per year), to sit for the Core/Qualifying Examinations on time, and to graduate without extension of training, with additional leave to be considered by the program director on a case-by-case basis.Recent Family-friendly ABR PoliciesThe ABR has recently instituted multiple family-friendly policies for DR/IR/RO residents. These include:1. The 2019 Core Exam policy allowing "residents who are in or beyond their 32nd month of DR training to take the [Core] examination if (1) the program director attests that the resident is believed to have sufficient knowledge and experience, and (2) the candidate attests that he or she understands the potential consequences of taking the examination early. This policy change [allows for] up to a 4-month leave of absence, in addition to standard vacation and meeting time, during the first 3 years of radiology residency" [emphasis ours] (3,4).2. The 2020 Clinical Qualifying Exam policy for RO residents broadening eligibility from "until after completion of PGY-5/R4 year," representing completion of 48 months of residency, to now include "with approval of the program director, this option may be exercised after completion of 44 months of residency" (5).3. The 2020 Medical Physics and Cancer Biology Exam policy for RO residents broadening eligibility from "after completion of their PGY-4/R3 year," representing completion of 36 months of residency, to now include "with approval of the program director, this option may be exercised after completion of 24 months of residency" (5).4. The 2020 transition to a virtual examination format for the DR, IR/DR, and RO Core/Qualifying and Certifying Exams, in response to the COVID-19 global pandemic (6).5. Improved lactation accommodation in 2020 from 30 minutes for the Core/Qualifying Exam to an unspecified amount of additional break time that can be requested by a nursing mother (7).We commend the ABR for these policy changes that have benefitted all residents, particularly women and residents with families.Family and Medical Leave: Federal Law and within Medical OrganizationsThe 1993 Family and Medical Leave Act (FMLA) allows eligible employees to take 12 weeks unpaid, job-protected leave for the birth and care of a newborn, adopted child, or foster child, as well as for care of oneself or an immediate family member with a serious health condition (8). The U.S. Department of Labor considers medical residents to be employees under the FMLA (9). More recently, the Pediatric Policy Council and the American Academy of Pediatrics asked the federal government to pass the Family and Medical Insurance Leave Act to create a social insurance system enabling workers to take up to 12 weeks of paid leave to care for themselves or their families (10). The need for these policies, especially with respect to parental leave, are manifold. Paid parental leave is associated with numerous benefits including decreased infant mortality, decreased mother and infant rehospitalizations, decreased post-partum maternal depression, improved infant attachment and child development, decreased intimate partner violence, more timely pediatrician visits and immunizations, and increased breastfeeding initiation and duration (11,12). These concerns are no different for those still in medical training, and in fact, compared with women of a similar age, residents experience higher rates of obstetric complications (13). Availability of leave for all parents can also encourage more equitable parental involvement in childrearing (14–16).In March 2019, the Society of Chairs of Academic Radiology Departments "[pledged] to strive for departmental, institutional, and organizational change that provides 12 weeks of paid parental leave for eligible (as defined by the FMLA) faculty members of all genders" (17). The following month, in April 2019, the Association of Program Directors in Radiology published a statement of support for family leave as well, affirming that "under FMLA, eligible radiology residents of all genders have the right to take up to 12 weeks of unpaid family leave" and the Association of Program Directors in Radiology "encourages program directors to make this right known to their trainees, as indicated by federal law, and to provide notice of any additional rights under relevant state family leave laws" (18). Multiple additional publications have recognized the necessity and importance of family and medical leave for medical trainees in general (19–22) and specifically for DR/IR/RO trainees and faculty (23–26).Shift toward Competency-based Training for ResidentsGiven the wide range in institutional and specialty board policies for family and medical leave (19,20), the American Board of Medical Specialties convened a joint workshop with the Accreditation Council for Graduate Medical Education in February 2020 that brought together more than 80 stakeholders, including the ABR, to discuss issues pertaining to offering appropriate family and medical leave for graduate medical education trainees (27). The discussion focused on moving from time-based training requirements to competency-based training, which has been an ongoing focus of the Accreditation Council for Graduate Medical Education since 1999 with the Milestones Project (28). Competency-based training affords flexibility to accommodate family and medical leave for trainees while balancing the duty of specialty medical boards to the public to ensure the clinical competence of graduating residents. The resultant American Board of Medical Specialties policy for all training programs with 2 years or more duration requires "a minimum of 6 weeks of time away from training for purposes of parental, caregiver and medical leave at least once during training, without exhausting all other allowed time away from training and without extending training" effective July 1, 2021 (1).Considerations Regarding Leave Policy Duration in DR/IR/ROThe ABR's initial proposed leave policy was written as follows with a request for collateral comments:"Programs may grant up to four weeks' vacation per training year. This allowance may be averaged over the training period and is not associated with a requirement to extend training in order to allow the individual to be considered eligible for Initial Certification. Programs may grant up to six weeks Parental, Caregiver and Medical Leave during the residency. This is defined as leaves of absence for personal or familial needs, including the birth and care of a newborn, adopted, or foster child ("parental leave"); care of an immediate family member (child, spouse or parent) with a serious health condition ("caregiver leave"); or the trainee's own serious health condition ("medical leave"). This allowance is not associated with a requirement to extend training to allow the individual to be considered eligible for Initial Certification and is in addition to the vacation allowance as defined" (ABR, written communication, March 12, 2021; March 16, 2021; and March 17, 2021).The above would limit DR/IR/RO residents to a single instance of no more than 6 weeks of family and medical leave for the entirety of residency training if candidates took the allotted 4 weeks of vacation per year, strived to obtain timely Initial Certification (Core and Certifying Examinations for DR/IR residents; Medical Physics Examination, Cancer Biology Examination, Clinical Radiation Oncology Examination, and Oral Certifying Examination for RO residents) (29–31), and aimed to graduate on time. This would be less family and medical leave than many DR/IR/RO residencies currently offer to their residents, and also less than what is allotted by some other medical specialty boards (25,32,33).The duration of allowable parental leave may have a profound impact on the future composition of the DR/IR/RO workforce, a workforce already known to be lagging in gender diversity. For instance, DR, IR, and RO had 28%, 18% and 37% female residents in 2020, respectively, compared with 46% across all graduate medical education specialties (34). Beyond training, compared with other specialties in medicine, DR has one of the lowest proportions of full-time faculty and chairs who are women, at 30% and 17%, respectively (35). For RO, the proportions of full-time faculty and chairs who are women are even slightly lower at 28% and 14%, respectively (36). Lastly, only 10% of IR faculty (40) and chiefs are women (M. J. Englander, written communication, March 2021).Constraining parental leave to less than the American Academy of Pediatrics recommended 12 weeks (10) has the potential to impact the recruitment of women to DR/IR/RO given that specialty training occurs during prime childbearing years (6-year training pathway for DR/IR, including a 1-year fellowship for DR, or 5-year training pathway for RO). While trainees can take the FMLA of up to 12 weeks, this may require an extension of training, possibly having reverberating personal and professional consequences. Delay in residency graduation would delay the start date of fellowship, which may cause a subsequent delay to fellowship graduation or possibly the loss of the fellowship spot itself. Such a delay may also put a trainee at a disadvantage when applying for jobs, with potential financial repercussions in their career for years to come. This could incentivize residents to take less family and medical leave than they are entitled to under FMLA, potentially at the cost of their own wellness and the wellness of their family (38–40). Others may choose to delay pregnancy, even with the knowledge that age-related fertility decline may present significant fertility challenges, especially for female physicians (41–43).Currently, the ABR certification requirements dictate that DR trainees need to complete at least 32 months of clinical training and RO trainees need to complete 36 months of clinical training (27 months for both if on the Holman Research Pathway), within the Accreditation Council for Graduate Medical Education–defined 48-month residency training period (44,45). This framework has allowed many programs to offer a variety of rich experiences within the 12–16 months of available elective time, including mini-fellowships, extended research blocks, and nonclinical pursuits in Leadership and Global Health (46–50). Co-optation of this time for a 4-year Nuclear Radiology Pathway (51) and a 5-year integrated DR/IR program (52) has also been established. Accommodating 12 weeks of family and medical leave within this period would allow trainees to satisfy ABR certification requirements without graduation delay. We do acknowledge that the combined IR/DR training or the 4-year Nuclear Radiology pathway in their current forms may present less flexibility than DR and RO for elective time, potentially requiring more careful planning to accommodate family and medical leave.As previously described (53,54), any family and medical leave policy development should also be mindful of the following federal laws. Title VII of the Civil Rights Act of 1964 (42 U.S.C. 2000e and following) "prohibits practices that seem neutral but have a disproportionate impact on a protected group of people" (55,56). Moreover, according to the Pregnancy Discrimination Act (an amendment to Title VII), "Title VII is violated if a facially neutral policy has a disproportionate adverse effect on women affected by pregnancy, childbirth, or a medical condition related to pregnancy or childbirth" (57). Furthermore, the Americans with Disabilities Act of 1990 prohibits discrimination against a person with a disability, such as a postpartum woman with complications requiring additional time off (58). Lastly, Title IX prohibits sex discrimination in federally funded education programs, including residency programs (59).Recommended Revisions to the ABR's Initial Proposed Leave PolicyWe recognize that the American Board of Medical Specialties policy mandates "a minimum of 6 weeks of time away from training for purposes of parental, caregiver and medical leave" (1). However, in the spirit of the FMLA and compatible with the American Academy of Pediatrics, Society of Chairs of Academic Radiology Departments, and Association of Program Directors in Radiology statements in support of 12 weeks of parental leave (8,10,17,18), as well as with the ongoing shift toward competency-based training, we propose that the ABR policy allows a resident who is in compliance with clinical competency and Initial Certification requirements as well as is in good standing within their program to:1. Take 12 weeks of family and medical leave during the course of residency (in addition to 4 weeks of vacation per year), while still remaining eligible to both sit for the Core/Qualifying Examinations and to graduate without extension of training.2. Take additional family and medical leave if approved by the program director without extension of training (to be considered on a case-by-case basis), in keeping with the ABR Initial Certification requirements and Leaves of Absence policy currently in place (4,5,60–63).The normalization of parental, caregiver, and medical leave is long overdue in medicine. The above recommended policy would represent an opportunity for the ABR to be a trailblazer among medical specialties with an approach that maintains high standards of clinical training and truly promotes diversity, equity, and inclusion as well as physician well-being, all of which will ultimately positively impact patient care.Disclosures of Conflicts of Interest: K.M. Activities related to the present article: RFS representative to the Committee for Women of the ACR Commission for Women and Diversity; received money for travel/accommodations/meeting expenses from American Board of Medical Specialties (ABMS) and Accreditation Council on Graduate Medical Education (ACGME) for February 2020 parental leave workshop. Activities not related to the present article: has grants/grants pending with Society of Abdominal Radiology, and Radiological Society of North America R&E Foundation. Other relationships: disclosed no relevant relationships. T.S.C.N. Activities related to the present article: disclosed no relevant relationships. Activities not related to the present article: is employed by Massachusetts General Hospital Physicians Organization; has grants/grants pending with MGH Imaging. Other relationships: disclosed no relevant relationships. S.R.C. Activities related to the present article: served as 2020-2021 Chair of the Association of Residents in Radiation Oncology (ARRO). Activities not related to the present article: disclosed no relevant relationships. Other relationships: disclosed no relevant relationships. P.B. Activities related to the present article: served as 2019-2020 President of the American Alliance of Academic Chief Residents in Radiology (ACR). Activities not related to the present article: disclosed no relevant relationships. Other relationships: disclosed no relevant relationships. E.H.D. disclosed no relevant relationships. C.J.H. disclosed no relevant relationships. N.L. disclosed no relevant relationships. E.C.M. disclosed no relevant relationships. S.A.E. Activities related to the present article: is a board member of American Association for Women in Radiology. Activities not related to the present article: disclosed no relevant relationships. Other relationships: disclosed no relevant relationships. R.B.J. disclosed no relevant relationships. E.C.F. disclosed no relevant relationships. J.B.L. disclosed no relevant relationships. S.J.A. disclosed no relevant relationships. E.B.J. disclosed no relevant relationships. M.J.E. disclosed no relevant relationships. C.M.D. Activities related to the present article: disclosed no relevant relationships. Activities not related to the present article: has grants/grants pending with Association of Program Directors in Radiology (Jerome Ardnt grant); received payment for lectures including service on speakers bureaus from MRIonline. Other relationships: disclosed no relevant relationships. K.K.P. Activities related to the present article: serves as 2021 President of the American Association for Women in Radiology (AAWR) and is a member of American College of Radiology's Commission for Women and Diversity. Activities not related to the present article: received honorarium for lectures including service on speakers bureaus from Bracco Diagnostics (COVID advisory panel); holds stock/stock options in Pfizer. Other relationships: disclosed no relevant relationships. L.B.S. Activities related to the present article: served as the 2020 President of the American Association for Women in Radiology (AAWR) and is a member of the American College of Radiology's Commission for Women and Diversity. Activities not related to the present article: has grants/grants pending with NIH, CDC, DHHS, VA Office of Research and Development, VA Office of Rural Health, and Association of VA Hematology and Oncology (AVAHO); received honorarium for lectures including Brown University Department of Radiology and University of Iowa Department of Radiology. Other relationships: disclosed no relevant relationships. L.A.D. disclosed no relevant relationships. R.J. Activities related to the present article: received money for travel/accommodations/meeting expenses from American Board of Medical Specialties (ABMS) and Accreditation Council on Graduate Medical Education (ACGME) for February 2020 parental leave workshop. Activities not related to the present article: is a consultant for Greenwall Foundation; has received payment for expert testimony; has grants/grants pending with NIH, Doris Duke Foundation, Komen Foundation, Greenwall Foundation, and Blue Cross Blue Shield of Michigan; has received payment for lectures for many professional societies and academic institutions; holds stock/stock options in Equity Quotient. Other relationships: disclosed contract for an investigator initiated study with Genentech. E.K.A. Activities related to the present article: served as 2019 President of the American Association for Women in Radiology (AAWR) and is a member of American College of Radiology's Commission for Women and Diversity. Activities not related to the present article: is employed by Elsevier as Editor-in-Chief of Clinical Imaging; received honorarium for lectures including University of Alabama, Department of Radiology. Other relationships: disclosed no relevant relationships.AcknowledgmentsThe authors gratefully acknowledge legal review of the manuscript by Anne Yuengert, JD, Partner, Bradley Arant Boult Cummings LLP, Labor & Employment practice group, Birmingham, Alabama; review of the manuscript by Austin J Sim, MD, JD; and the support of Kaleigh Doke, MD, Laura Dover, MD, Virginia W. Osborn, MD, Amy Patel, MD, Yi Yang, MD, and Olga R Brook, MD.EndorsementsAmerican Association for Women in Radiology (AAWR) Board of Directors, Executive Board; Association of Program Directors in Radiology (APDR); Association for Directors of Radiation Oncology Programs (ADROP);Association of Program Directors in Interventional Radiology (APDIR); American College of Radiology (ACR),

Objective: To examine the effects of COVID-19 pandemic on our department's Radiology Consultation Service (RCS) related to breast imaging, and how utilization of the provided services may have differed as compared to prior to the pandemic. Materials and methods: A retrospective cohort study of patients and health care providers who consulted the RCS, as well as those patients who had a screening mammogram and/or ultrasound between January 1, 2019 and September 1, 2020. Consultations were performed by an RRA, RN and one of 17 breast imaging radiologists assigned to consults on daily. Descriptive statistics were performed to describe the study subject population. Results: Between January 1, 2020 and July 31, 2020, a total of 1623 consultations were performed, in comparison to the control period from the year prior (January 1, 2019 to July 31, 2019), when a total of 1398 consultations were performed, representing a 16% increase in one year. Between March 1, 2020 and June 30, 2020, a total of 679 consultations were performed, in comparison to the control period from the year prior (March 1, 2019 to June 30, 2019), when 583 consultations were performed, representing a 16.5% increase in a four-month period. 350 out of 679 (36.8%) consultations addressed COVID concerns. Conclusions: While much of radiology experienced an unprecedented decrease in imaging studies during the initial peak of COVID-19 crisis, the RCS at our institution showed a significant increase in services provided, evolving to address pressing concerns related to COVID-19.