diversity – The Early Career Voice

Bias

April 12, 2021April 9, 2021 Aubrey J. Grant, MD

A middle-aged black woman presents to her local emergency department via emergency medical services (EMS) with chest and back pains, nausea, and vomiting. She has a history of IV drug abuse and is disheveled in appearance. Prior to her arrival, EMS notes that her chest pain appears non-cardiac and provides supportive care while en route to the hospital. She is triaged to the appropriate care and an emergency provider assesses the patient.

The patient continues to have chest discomfort and nausea. The emergency team agrees with the EMS assessment and deems her symptoms as atypical for a cardiac etiology. An EKG is performed which demonstrates subtle ST-segment elevations in her inferior leads as well as faint reciprocal changes. However, the catheterization lab was not activated at this point.

High sensitivity troponin ultimately revealed a modest enzyme leak and the cardiology team was consulted. The patient was urgently taken to the cath lab to reveal an acute lesion of her proximal right coronary artery. There were no complications during the procedure and she ultimately had an uneventful hospital course.

Implicit bias refers to the attitudes or stereotypes that affect our understanding, actions and decisions in an unconscious manner. These biases are activated involuntarily, without an individual’s awareness or intentional control. Unfortunately, we are all susceptible to bias and there is extensive evidence showing how bias can lead to differential treatment of patients by race, gender, age, weight, language, socioeconomic status, and insurance status. As such, it begs the question, if our patient had no history of drug abuse or was white, would their acute myocardial infarction been treated faster?

A seminal 2007 study of internal medicine and emergency medicine residents found that, while the participants reported no explicit racial bias, Implicit Association Tests (IATs) indicated an implicit preference towards White Americans. Further, the higher the preference, the more likely that physician was to treat Whites and not treat Blacks with early thrombolysis in the setting of acute myocardial infarction.

While it is clear the effects of implicit bias in medicine, it is also clear that implicit bias is malleable. There are a number of leading strategies for combating implicit bias including stereotype replacement, counter-stereotypic imaging, individuation, perspective-taking, and increasing opportunities for contact with individuals from different groups. Further, new research must be conducted to find more innovative techniques for managing implicit bias. As clinicians, it is our responsibility to be constantly aware of our bias and to actively work to address that bias in every patient encounter.

References

Green AR, Carney DR, Pallin DJ, et al. Implicit bias among physicians and its prediction of thrombolysis decisions for black and white patients. J Gen Intern Med. 2007;22(9):1231-1238. doi:10.1007/s11606-007-0258-5

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”

Reducing Disparities through Diversity and Inclusion in Stroke Science, Clinical Trial Enrollment, and Community Engagement

April 6, 2021April 5, 2021 Catherina Chang Martinez, PhD

As part of its mission to be a relentless force for a world of longer, healthier lives, the American Heart Association (AHA) has been working diligently to eliminate barriers to health equity in the U.S. diverse population through education and research, raising awareness through their many programs and initiatives. In the stroke arena, we continue to face significant inequities related to stroke incidence, prevalence, care, and outcomes in ethnic minorities.¹ Consequently, there has been a number of initiatives launched to address these disparities. The Health Equity and Actionable Disparities in Stroke Symposium, a collaborative initiative of the American Heart Association and National Institute of Neurological Disorders and Stroke, took place in 2020 with the goals of reducing inequities in stroke care and research. It also aimed to accelerate the translation of research findings to improve outcomes for racial and ethnic minorities.¹

This year the American Heart Association continues the efforts to promote awareness of the importance of diversity and inclusion in stroke science. A roundtable session took place on Friday, March 17, during the last day of the prestigious 2021 International Stroke Conference. A panel of experts shared their views and presented alternatives to improve diversity and Inclusion in the healthcare workforce, clinical trial enrollment, and community engagement. The expert roundtable included experts in the field such as Dr. Emelia Benjamin, MD ScM FAHA, Michele Evans, MD, Michelle Jones-London, Ph.D., Bernadette Boden-Albala, MD MPH, Fern Webb, Ph.D., Candace Whitfield, BS, Trudy Gaillard, RN Ph.D., Mellanie Springer, MD MSc. Mr. Olajide Williams, MS served as the moderator of the roundtable. The panelists presented a fresh and clear view of the diversity and inclusion barriers encountered in the research arena. They also offered alternatives to support inclusion and diversity in the development of research protocols, proposal procedures through institutional review boards, and through community engagement, with the use of community-based participatory research.

The experts highlighted the issue of representativeness in the conduct of research and presented diversity as a solution. Diversity in research means that people of different ages, different racial and ethnic groups and both men and women participate in research studies. The lack of diversity in participants of research impedes the ability to generalize study results and make medical advancements of effective therapies. It may further prevent some populations from experiencing the benefits of research innovations and receipt of high-quality care.²

In the context of clinical trial enrollment, the speakers emphasized the importance of having a diverse sample. They also discussed the need for inclusivity of minority groups during the enrollment period. They also highlighted the importance of informed consent forms available in other languages to facilitate the diversity of the sample during enrollment. They also suggested the approval of translated informed consent forms in an expedited fashion to avoid delays in the consenting process for ethnic minority groups. Another very important factor was the importance of having the infrastructure to support diversity and inclusion in the stroke science workforce. Factors such as the hiring of clinicians and research personnel that may resemble the target population of interest are vital to facilitate the recruitment of ethnic minority groups much needed in these studies.³

As academicians and researchers, we should advocate for diversity as it drives excellence and enhances innovation in the biomedical sciences, leading to novel findings and treatment of diverse populations.³ Diverse and inclusive scientific teams can generate new research questions, develop methodical and analytical approaches to better understand study populations, and offer approaches to problem-solving from multiple and different perspectives. Moreover, the promotion of diverse groups presents opportunities for the inclusion of individuals with different perspectives who can complement each other and inform of new approaches.³ This may further strengthen the approach of the research team through the various phases of the research process, especially when their diversity and inclusion match the racial and ethnic minority group under study.

One of the experts, Dr. Michelle Evans highlighted the importance of community-based participatory engagement in research, especially in ethnic minorities. Another speaker, Dr. Trudy Gaillard discussed the opportunity to engage members in the community, stakeholders, and utilize this as a venue to engage study participants through community-based participatory research (CBPR). Engaging in active reflection and adopting promising partnering practices are important for CBPR partnerships working to improve health equity.⁴

The roundtable presentation aligns with current National Institutes of Health (NIH) strategies to support diversity and inclusion in the science community. A program called UNITE was launched in 2020 to tackle the problem of racism and discrimination in science while developing methods to promote diversity and inclusion across the biomedical enterprise. Some of its functions include understanding stakeholder experiences through listening and learning, pursuing research on health disparities, minority health, and health equity, improving the NIH culture and structure for equity, inclusion and excellence, transparency, communication, and accountability with internal and external stakeholders, changing policy, culture, and structure to promote workforce diversity (NIH, 2021).⁵

In addition to NIH, the National Institute of Neurological Disorders and Stroke (NINDS) (2021) is committing to diversity, equity, and inclusion in the neuroscience community as both an employer and funding agency, addressing the stark differences in neurological health outcomes related to where one lives, has access to care, their race/ethnicity, and socioeconomic status.⁶ In the process of implementation of these initiatives, it will be important to note that implementation science can exacerbate health disparities if its use is biased toward entities that already have the highest capacities for delivering evidence-based interventions.

There is a call for making efficient use of existing data by applying epidemiologic and simulation modeling to understand what drives disparities and how these can be overcome. There is also a need for designing new research studies that include populations experiencing disparities in cardiovascular disease, neurological disease, and stroke.⁷ It will be interesting to observe in the next coming months, the implementation of some of these strategies to promote diversity and inclusion in stroke science. Much remains to be done to bridge the gap and reduce healthcare-related disparities in racial-ethnic minority groups, especially in the context of stroke science. In the meantime, it is up to us to continue the work of raising awareness, promoting diversity and inclusion in our academic circles, in the science field, and in our communities.

For additional information on the efforts American Heart Association to support diversity and inclusion in heart science, please be sure to check out https://www.heart.org/en/about-us/diversity-inclusion.

References:

Towfighi A, Benson RT, Tagge R, Moy CS, Wright CB, Ovbiagele B. Inaugural Health Equity and Actionable Disparities in Stroke: Understanding and Problem-Solving Symposium. Stroke. 2020;51(11):3382-3391. doi:10.1161/STROKEAHA.120.030423
University of Maryland. Health Equity Project. (2021). Top five reasons why diversity is important in research. Retrieved from https://buildingtrustumd.org/unit/importance-of-research/importance-of-diversity#:~:text=Diversity%20in%20research%20means%20that%20people%20of%20different,specific%20reasons%20why%20diversity%20in%20research%20is%20important.
Swartz TH, Palermo AS, Masur SK, Aberg JA. The Science and Value of Diversity: Closing the Gaps in Our Understanding of Inclusion and Diversity. J Infect Dis. 2019;220(220 Suppl 2):S33-S41. doi:10.1093/infdis/jiz174
Dickson E, Magarati M, Boursaw B, et al. Characteristics and Practices Within Research Partnerships for Health and Social Equity. Nurs Res. 2020;69(1):51-61. doi:10.1097/NNR.0000000000000399
National Institutes of Health. (NIH). (2021). Ending Structural Racism. Retrieved from https://www.nih.gov/ending-structural-racism/unite on 4/2/21.
National NINDS (2021). NINDS is committed to ending structural racism. Retrieved from https://www.ninds.nih.gov/News-Events/Directors-Messages/All-Directors-Messages/NINDS-committed-ending-structural-racism
McNulty M, Smith JD, Villamar J, et al. Implementation Research Methodologies for Achieving Scientific Equity and Health Equity. Ethn Dis. 2019;29(Suppl 1):83-92. Published 2019 Feb 21. doi:10.18865/ed.29.S1.83

Equity & Inclusion in Medicine – Part III: How to Create a Diverse Cardiology Workforce

March 30, 2021March 29, 2021 Mary Branch, MD, MS

In Part I, I discussed experiences of BIPOC in medicine as well as those underrepresented in cardiology as a framework to build understanding. In Part II, I made a good case for why diversity will help cultivate innovation and improve health disparities. In the final part of this blog series, I will review how cardiology programs can improve diversity.

We are in an era of great reflection and growth as we endure the extreme pressures of the COVID19 pandemic. This horrendous experience has fostered some positivity which is the strong motivation towards racial harmony and equity. This is a special time of modernity and we can capitalize on this momentum by amplifying initiatives towards increasing diversity in cardiology.

The Duke cardiology group published a data-driven manual on how cardiology fellowships can improve diversity, especially for those who are underrepresented. In this article, Rymer et al.¹ designed a quality improvement study from 2017-2019 with the aim of increasing the numbers of underrepresented cardiology fellows in their training program. This initiative included reorganizing the fellowship recruitment committee, changing the applicant process and interview day, as well as making changes to the applicant ranking process. Finally, there was a postmatch intervention. This involved developing a diversity and inclusion task force to spearhead these initiatives. Comparing applicants 10 years before and during the intervention period, there was a significant increase in women and underrepresented applicants. Women increased from a 5-year mean of 27% to 54.2% after the intervention and underrepresented fellows increased from 5.6% to 33.3%. After the intervention, the fellowship population was 2/3rds either women or members from an underrepresented ethnic group!

Williams et al. further pushed toward cultivating an antiracist cardiology culture in their article entitled: How to Build an Antiracist Cardiovascular Culture, Community, and Profession ². The authors took a deep dive into several ways to build a diverse team. They state that to purposely create a culture of diversity, especially for those that lack diversity; programs should aim to share their objectives in creating a less biased training program for applicants. This strategy also includes having a diversity and inclusion committee to evaluate promotional materials to ensure they do not include racially biased language. Once trainees are there, they recommend continuing this initiative by having structured teaching sessions that include implicit bias training. They further recommend allowing for space for underrepresented trainees to share microaggressions. One example of a microaggression expressed by underrepresented physicians is constant questioning regarding country of origin or ability to speak English with a condescending tone. These stories can be shared on a personal level to help each other understand and appreciate different experiences.

There are professional ways to support trainees and create an inclusive environment. The authors suggest encouraging respect by introducing fellows as “Dr.” and leaders of the team. They emphasize intentional mentorship for underrepresented trainees shared amongst faculty. They further warn against perpetuating the “minority tax”, which puts the entire onus of diversity and inclusion on faculty of color with often a lack of compensation. In addition, the authors encourage all faculty to help introduce trainees into a network and provide a platform for successful promotion by nominating under-represented minority members to appropriate positions. Certainly, this can extend beyond fellowship. It goes without saying, that nomination and promotion is suggested for those who earn it; however, not uncommonly underrepresented fellows meet this criterion and may be overlooked.

The future of this country is one in which there may not be a majority. It is important that we understand one another and work together to move forward. Diversifying cardiology will bring about innovation and growth in the field. The patient experience can improve as well with more physicians who share their personal experiences. This can build communication and preventative measures. I hope that we continue this momentum and cultivate a better experience for all.

References:

Rymer et al. Evaluation of Women and Underrepresented Racial and Ehnic Group Representation in a General Cardiology Fellowship After a Systematic Recruitment Initiative. JAMA Netw Open. 2021; 4(1)
Williams et al. How to Build an Antiracist Cardiovascular Culture, Community, and Profession. JACC 2021 77 (9)

Why Diversity Matters: from a fellow perspective

March 13, 2021March 12, 2021 Lina Ya'qoub, MD

In this blog, I want to share my thoughts on diversity, why it matters in medicine, especially in cardiology.

Why does diversity matter in medicine?

We all are seeing more and more diverse patients, especially in the United States, where “minorities” who come from various backgrounds and cultures constitute a significant proportion of our patients, yet there remain significant disparities across various levels of social life and health care.

Effective Communication

While the language is key in order to provide effective communication between patients and physicians, optimal care should be provided to all patients, irrespective of their origin or language proficiency. Interpreters can help in person or using online resources.

Understanding the Culture

In addition to the language, culture differs significantly between various populations, even those speaking the same language might have different cultures. This is an important part of the patient-physician relationship. One example of how to improve that would be that we try to talk briefly with our patients about their preferences and what is important to them, especially when it comes to goals of care.

Diversity in the Workplace

The importance of culture and diversity in the workplace is tremendous; not only does it add to the various perspective each physician has on the discussion table or their different approaches in taking care of patients, but also it familiarizes our patients with our diverse workforce. With that being said, seeing more women in cardiology, and cardiologists of various backgrounds is crucial to deliver that message.

What are our leading societies doing to promote diversity?

Thankfully, our leading societies, in medicine, cardiology, and other specialties, have recognized the impact of diversity on the workforce and its role in taking care of the growing diverse population we have been seeing. The American Heart Association (AHA) and American College of Cardiology (ACC) among other societies have continued to work relentlessly to advocate for our patients, fight structural racism and health inequity while promoting diversity and inclusion in the cardiology workforce [1,2]. With that being said, having mentors from similar backgrounds helps juniors find role models to look up to, including students, residents, and maybe fellows who have just started their journey and looking for guidance. Talking about my own experience, I have had mentors from various backgrounds, including my background, and this helped me in so many different ways. I do believe our cardiology community has amazing leaders and role models, and together we can make the future brighter for everyone!!

References

AHA website: Diversity and inclusion https://www.heart.org/en/about-us-shared/diversity-inclusion
ACC Diversity and inclusion https://www.acc.org/about-acc/diversity-and-inclusion

Equity & Inclusion in Medicine – Part II: Inclusion in Cardiology

February 17, 2021February 16, 2021 Mary Branch, MD, MS

In Part 1, I shared common experiences between myself and other BIPOC physicians in medicine and cardiology. In this piece, I will dive into the importance of why increasing diversity and inclusion in cardiology is so urgent. Cardiology is a coveted specialty and can incentivize a power dynamic that does not often include BIPOC. I would argue that for a progressive program, creating an inclusive workforce will help programs progress, be innovative, and positively impact patient care in the community. This change will be a win-win for all.

When reflecting on this topic, I am reminded of an African American woman who was crying on the cath table the other day, with a look of fear and helplessness. This was not long after a report of a physician of color, who was infected with COVID19, reported that her symptoms were dismissed, and later died. If a physician feels unheard, how can a woman of color who is not a physician feel safe? The cath team did a great job of comforting her, but it was hurtful to see her in such fear.

African Americans are significantly affected by heart disease risk factors; in fact, together these conditions contributed to >2.0 million years of life lost in the African American population between 1999 and 2010¹, with heart disease being the leading cause of mortality in African Americans. Unfortunately, there is a lack of African Americans in the physician workforce considering African Americans make up ~ 13% of the U.S population, but only 4% of U.S. doctors². According to the Harvard Business Review, increasing the numbers may improve health outcomes. They described a study in Oakland that assigned African American male patients recruited from barbershops to African American and Non-African American physicians. What they found was that African American patients were more inclined to agree to more invasive and preventative services than those with non-African American doctors. This is not an argument for a segregated system, but certainly increasing the numbers and learning from colleagues can help BIPOC patient outcomes.

One historical change in medicine that impacts care in the African American community is likely rooted in the Abraham Flexner Report³. An African American medical student applying to medical school in 1900 had 10 choices which declined to approximately a quarter of that by 1920. The Flexner Report, which was meant to trim the medical workforce to only those with the greatest quality of training, decided that only two medical schools that trained African Americans (Howard University and Meharry Medical College) were worthy of staying open. His devastating comments terminated the rest⁴. My cousin, Dr. Hubert Eaton, wrote about this dilemma in his book Every Man Should Try⁵. He graduated from the University of Michigan School Medical School in 1942 and his father went to Leonard Medical School (see Table 1⁴). He found his father’s exam scores and noted they matched his own. He was perplexed that Leonard was shut down and he wondered: Who validated the Flexner report? Why was one individual able to create this modernity in medicine without any scrutiny?

By building diversity and increasing contact between those who have shared experiences, the field of cardiology could improve BIPOC patient trust and compliance as well as reduce cardiovascular disease outcomes. This change could lead to lower hospital admissions and increase prevention efforts. Many BIPOC is inspired by giving back to the community and being involved in community engagement. This community service is via BIPOC oriented organizations (e.g., The Divine 9 fraternity and sororities, the Boule, The Links, Incorporated, etc.) as well as the Black Churches. As BIPOC cardiologists, we have the ability to teach important primary prevention to thousands of people and the message is stronger if that provider looks like the community they represent.

Cardiology is a prestigious field and as such should aim to set an example for leadership across the country. We know that inequities exist in all aspects of cardiovascular disease and one way to combat this issue is to build a diverse workforce. When we lost community physicians after the Flexner report, we lost the community itself; the field of cardiology has the resources to restore this relationship and improve heart disease outcomes.

References:

Carnethon et al. Cardiovascular Health in African Americans: A Scientific Statement From the American Heart Association. Circulation 2017: 136(21)
Research: Having a Black Doctor Led Black Men to Receive More-Effective Care by Nicole Torres. Harvard Business Review 2018
Flexner A. Medical Education in the United States and Canada. Washington, DC: Science and Health Publications, Inc.; 1910.
Savitt. Abraham Flexner and the Black Medical Schools. Journal of the National Medical Association. 2006: 98 (9)
Every Man Should Try by Dr. Hubert Eaton

The Power of Representation

January 27, 2021January 26, 2021 Kylia Williams

On January 20th, Vice President Kamala Harris was sworn into office, becoming the first woman, African American, and Asian American to hold the position. Just two weeks earlier, Reverend Raphael Warnock and Jon Ossof became the first African American and Jewish senators, respectively, to represent my home state of Georgia. In addition, President Joe Biden has committed to the most diverse Cabinet in history, with about half of his nominees being women. If you have always had a plethora of examples of people who look like you and share your story, you may not understand why this is such a big deal. For the first time, millions of Americans (including myself) are seeing themselves represented at the highest levels of government. This got me thinking more about how representation affects us because having diverse representation, particularly in government and media, is important for establishing how others see us and how we see ourselves.

While diversity is about who is allowed in certain spaces, representation is about who is given a voice and the opportunity to tell an authentic story. These voices and portrayals affect how groups of people are perceived by others and define what issues are deemed important. Lack of representation does not simply mean that there is a lack of diversity, but that diverse voices go unheard and contributions go unnoticed. When there is a gap in representation, those gaps are filled by our preexisting biases about what people are like and who can hold certain roles. If we have no exposure to other people’s stories, how can we empathize with them?

When you see portrayals that feel true to your life and that of those around you, it expands the horizon of what you feel is possible because you can only be what you can see. And as actor Riz Ahmed said, “we all want to feel seen and heard and valued.” Lack of representation can lead to imposter syndrome, which I wrote about in a blog post in November. If we don’t see people we identify with doing something, we may not feel that we can do it. And if no one values contributions from people who look like us, we feel like no one should value ours.

**There is an encore webinar on Imposter Syndrome at AHA International Stroke Conference 2021 on 3/17, you can register for the conference here**

There are a few traps to avoid when thinking about representation. Tokenism occurs when we expect one person to be the voice of an entire group of people, and stereotyping occurs when we oversimplify our representation of a group of people. Often, portrayals of minorities, especially Black people, are in the role of the victim. While these can be important, victimhood does not encompass the full lived experience of most minorities. All of these pop up when diversity is lacking, and when we don’t acknowledge that even within a group of people, there is an infinite number of individual experiences.

Aside from the recent progress in public politics, there are many examples of good representation in the media. That list is ever-growing, and these positive representations have noticeable effects. The character of Agent Scully on The X-Files, an FBI agent, and medical doctor, prompted an increase in the number of women studying and working in STEM fields, a phenomenon coined “The Scully Effect.” Doc McStuffins, the Disney Junior show about a Black girl who is a doctor for toys and stuffed animals, was a hit among children and adults, helping kids get over their fear of going to the doctor and leading to members of the Artemis Project starting the We Are Doc McStuffins campaign to inspire more future doctors. In current news, women of color have been widely sharing photos and videos of themselves being vaccinated against COVID-19 to help overcome the deep mistrust of medical institutions, which Dr. Aubrey Grant wrote about in a previous blog post. Also, be on the lookout for Dr. Mary Branch’s upcoming blog post with more on diversity and representation in medicine.

I’m assuming that most people reading this aren’t in the fields of politics or television, but you don’t need a public office or a prime time slot to promote representation. Everybody has a platform, whether that be in-person conversations with friends or a Twitter following. You can use your platform to promote other voices, especially those of people more marginalized than you or when addressing issues that you do not have personal experience with. Also, think about whether there is an issue that could use your voice or a story that you can authentically tell and be that representative for others.

Equity & Inclusion in Medicine – Part 1: my experience as a BIPOC in medical training

January 18, 2021January 15, 2021 Mary Branch, MD, MS

As someone who integrated her elementary school in Ohio (a Yeshiva), enrolled in an exclusive prep school in New England and became the first AA female in her cardiology program, I’ve spent my life analyzing how to adapt to environments in which I was different. When I enter an environment, I learn the lay of the land, identify key players, and observe interactions. I am a fourth-generation African American physician and was raised learning about my relatives’ experiences as minorities in medicine. If I, as early as age 9, could learn how to thrive in diverse environments others can too. I would like to share these experiences and make a case for diversity in cardiology. With this blog, I will help kick off the New Year with part 1 of a multiple part series that aims to define bias in medical training; openly make a case for and provide solutions towards inclusion in cardiology.

In this blog, I will review specific features that demonstrate bias, which can lead to less diversity in training programs. These are topics related to experiences in medicine that are shared by myself as well as my BIPOC and women colleagues.

Affirmative Action, The myth

There’s this assumption that BIPOC has a leg up unfairly given by Affirmative Action, and therefore are enrolled in academic programs without earning it and being unqualified. Truthfully, nepotism and ease of identifying mentors provide more opportunities than any small % quota which does not seem to translate to faculty positions. In research, at times I have had to become my own mentor to continue to propel myself forward. Without visible faculty mentors, it is difficult to envision a role in academic medicine which makes this career aspiration less likely for many BIPOC. The educational system’s balance as a whole has been skewed related to the American Caste system (consider reading Caste by Isabel Wilkerson). This affects testing metrics and exposure to certain educational experiences. However, with the right inclusion, training, and belief in someone; talented students will become great physicians and cardiologists. In fact, this idea that BIPOC is all unqualified is ironic; many of us feel we have to work twice as hard with a cool and steady temperament all the way through (think of President Obama) to get half as far. Despite strong backgrounds; I often hear colleagues make comments like: “ They are not as clinical.” I already know the race before hearing the full story. We can’t all be inept; not possible.

Double Standards/ Lack of Benefit of the Doubt

Double standards, a topic at this nation’s center as we watched different responses to the siege on Capitol Hill. In cardiology and medicine, it is not uncommon that the same errors in one person may receive a different response from leadership compared to another. One cardiologist stated that he, like many of his colleagues, inadvertently caused a coronary dissection. The response, however, was harsher than what his colleagues experienced for the same incident. One simple misunderstanding with a BIPOC resident or medical student led to unnecessary poor feedback to this resident that could have been remedied with a conversation. She was not given the benefit of the doubt like her peers would have; in fact, I don’t think the incident would have been reported at all considering how trivial it was. At times, we feel closely observed and overly scrutinized. At times by other women and BIPOC as well. Perhaps there is a “crabs in a barrel” mentality when there are so few represented in one place, this can actually create tension. What’s most difficult is, there’s less ability to be human; which is amplified when it seems as if there is not always a trustworthy authority to turn to. It may not be that one BIPOC placed in a leadership position; they may not want to rock the boat.

So we feel that we must work twice as hard; smile (wear the mask long before COVID19), with only marginal to no room for error (there is a great scene in the movie about the Tuskegee Airmen on HBO that highlights this point).

Abstract Feedback

Often we receive feedback that is very vague and abstract and seemingly more personal than constructive. It’s generally a vague comment that has one racking their brain over and over with no real tangible solution provided by the person giving the feedback; this was described in “Research: Vague Feedback Is Holding Women Back.” For example, I was once told, “You’re too confident.” How do I change my confidence? How can I be less confident, but at least somewhat self-assured? Do you see how this happens? Not too uncommonly we receive nonactionable feedback that has one racking their brain and can have an emotional impact. It’s distracting. Actionable feedback is more helpful especially if it is not something very personal and aimed more at patient care. One mentee of mine received an overall vague evaluation and marked her with critical deficiencies without good evidence. I did not want this practice to continue, and I wrote to the associate program director to describe the scenario and shared my concerns. It was determined that this evaluation was a mistake after a larger review. Imagine a situation had it stayed on her record; it could have had negative implications to her career, especially, when she is planning to pursue a selective fellowship.

Assumptions

During a medical school interview, I was asked if they should accept fewer women due to pregnancy. I was never comfortable sharing my pregnancy considering this was my first introduction. He assumed women couldn’t make these decisions, and that, affirmative action should be taken away (this was 2008; not long ago). I have also found that, before really knowing one’s interest, it is assumed a female cardiologist will pursue a career in imaging. I am often asked “ You’re doing imaging, right?” Or I’ve heard, “ she is an imager, typical.” This can impact cath scheduling if there are no fixed schedules for all fellows. In fact, scheduling is where bias can creep in ( I have heard of giving longer hours to BIPOC forcing one group of residents to threaten federal intervention.) This can be avoided with as much equal scheduling as possible (not always perfectly feasible) without assuming anything. Assumptions are not meant to be hurtful; it’s human nature. However, at times it may pigeonhole folks to roles that must end with women’s health, equity, or inclusion (exceptionally relevant roles). These folks can also have leadership roles related to other clinical interests as well.

Certainly, these may not all be unique to BIPOC and women; however, I hear similar stories over and over again, as if they are told by the same person. As we enter into a new era, I hope cardiology joins the future of progress. In parts II and III, I will answer why inclusion is important and some solutions on how to cultivate an inclusive specialty.

For this series, we will be discussing –

Part 1. My experience
Being hypnotized that I am lower in the caste system and limited. The emotion clouded my abilities and held me back from further progress. I have to prove my resume more than my colleagues every time and it’s exhausting. In research, I’ve felt like an outsider constantly having to build my own way and have been directly judged for lack of prolific publications.

Part 2. Why?
Embracing difference can help a program evolve (% diversity at Harvard ) it’s a win-win; a synergistic relationship in which we grow together. Representation matters, and to diversify the workforce will help the patients’ comfort and compliance.

Part 3. How?
Aim for a standard similar to Goldman Sachs’s 25%¹. Provide resources and assistance to BIPOC. Show up for each other. Engage ABC and uplift ; normalize discussing differences and being different. Check in with your BIPOC trainees’ wellbeings, if there are issues driven by bias speak up with your peers in a collegial way.

Reference

https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2774738?utm_source=twitter&utm_medium=social_jamajno&utm_term=4395647160&utm_campaign=article_alert&linkId=108893385

Diversity, Equity, & Inclusion Are Not Just Buzzwords— Practical Steps for People Who Teach

July 2, 2020July 2, 2020 Elizabeth Knight, PhD, DNP

Those of us who work in science, healthcare, and academia often find ourselves teaching others, whether or not we set out to be educators. Residents teach medical students. Nurses precept new nurses. Graduate students teach undergraduates. And faculty roles for researchers and clinicians also include teaching loads. Yet for many of us, our training did not include any grounding in how to teach. We might not have brought the same theoretical rigor and deep expertise to our teaching that we have to our other roles. Now, as we are teaching in a world of rapid change and increased awareness around structural racism, we must approach equity in our educational practices with intention, but some among us may not feel prepared and we are already overwhelmed. We are already adapting to enormous change related to COVID-19, and the intellectual energy required to reexamine another entire part of your professional life can feel paralyzing. It can feel like an impossible task that there will never be time for.

Despite these barriers, I strongly believe that you can start (or carry on) right now, no matter where you or your institution are in the struggle for antiracism. Here are some immediate suggestions to make your practice as an educator explicitly equity-focused and antiracist, for folks who teach in all kinds of contexts (these topics work for self-education, too):

No matter what format you teach in, there are some basic practices you can adopt to establish a “floor” for equity and inclusion.

Can you pronounce the name of everyone in your group? Do you know what they prefer to be called and what pronouns they use? Some teachers inadvertently avoid calling on students because they haven’t bothered to learn these things and don’t want to make a mistake. Don’t be that teacher.
How much time does every person (including you) speak? Is anyone taking up more space than they need? Now, the era of video calls, some platforms can actually show you how much time each individual speaks for, and this can be eye-opening. I encourage you to actually measure and observe this at least once. It can be surprising to see how some groups are consistently dominating conversation at the expense of others.
Have you adopted principles of Universal Design for Learning in your teaching? If not, now is a good time to start. UDL is a set of principles that improves the experience for all learners by focusing on accessibility and flexibility and assuming diversity.
Are you yourself familiar with concepts of antiracism? Have you examined your own privilege, bias, and ignorance? Are you learning?

For those who teach in a classroom or seminar format, Dr. Valerie Lewis has shared some more tips:

Include an equity-focused reading with every topic (e.g., if you are teaching about asthma, include an article about disparities related to race and social determinants of health).
Message that equity isn’t a specialty; every field should address it as part of ongoing professional practice.
Create a dedicated class session for equity, and if possible do two— one at the beginning to frame the ideas for learning, and one towards the end to integrate the content you’ve covered with broader ideas around equity. This can help to lay the groundwork for ongoing reflective professional practice.
Audit your syllabus: can you include AT LEAST one scholar of color every week? You might have go-to reading lists that you’ve inherited or developed, but if your list doesn’t measure up, you can change it. Go to PubMed or google scholar. Look at professional societies. Ask colleagues. Crowd-source on twitter. This is a key way to amplify voices— remember that citations are academic currency.
Don’t be afraid to make mistakes. Be open with students that you are doing this intentionally and why, and take feedback.

This is not a checklist or an exhaustive resource for inclusivity. But I hope that if you are floundering as you try to figure out how to teach with a focus on equity and inclusion, that you’ve got a good first foothold. Let’s keep the conversation going— I’d love to hear more ideas. Hit me up on twitter @TheKnightNurse and let me know what you are doing.

Why Advocacy is Critical for the Future of Cardiovascular Research & Medicine

January 10, 2019March 28, 2019 Christa Trexler, PhD

As researchers and physicians, many of us got in to our professions to push the scientific enterprise further to ultimately help others. We’ve all trained for an insane amount of years and collectively we work as a unit to uncover the intricacies of the cardiovascular system, develop therapeutics and treat patients. We traditionally think of ourselves as researchers or physicians first, but obviously we are all so much more than our jobs. We are also citizens within a really complex system that has been continually struggling to serve all of its citizens equally. It’s no secret that access to affordable health care is currently not equitable within our society. Similarly, there are also large diversity & inclusivity issues within our training institutions for both researchers and physicians.

However, something we don’t think about enough is that our intensive training and experience within these systems has also prepared us to be effective advocates for these issues. We have the opportunity to promote tangible change and some might argue it’s even our responsibility.

One of the things I really appreciate about being apart of the American Heart Association (AHA) is that this is something the organization doesn’t shy away from. During his presidential address at AHA Scientific Sessions 2018, Dr. Ivor Benjamin gave a heartfelt and determined talk about what the future of the AHA’s advocacy mission looks like. He discussed how supporting local and federal advocacy, early careers and mentoring is key to supporting the future of the AHA – but only 3% of cardiac professionals are African American men and this is something the AHA wants to help change. To help solve the diversity and inclusivity issues within the cardiac field, the AHA is expanding major undergraduate initiatives to fix the leaky pipeline. My favorite part of Dr. Benjamin’s talk was when he urged everyone at AHA18 to get involved in advocacy, not just for our field, but also for our communities. Because this is the key point: in order for our work to have meaning and to be effective, we need to ensure our communities are healthy. We also need to put value to advocacy efforts in our field – this is an essential part of our profession.

Well, this is all great, but how can you get involved? We are all insanely busy; I know adding advocacy efforts can seem daunting. Luckily for all of us, one of the focuses of the AHA for January is Advocacy. Since over 7 million Americans with cardiovascular disease are currently uninsured, advocating for the protection of the Affordable Care Act is something we can all do from our computers right now.

How can you help? (Provided by the AHA newsroom)

Tell Congress to protect Americans’ access to health care.
Add your voice: 21 million Americans could lose their health insurance coverage by 2020 if the Affordable Care Act is overturned. Tell Congress to protect Americans’ access to health care.

Looking for more ways to help on other issues?

The AHA has a great advocacy resource page for to get involved with efforts at the federal, state and community levels with issues regarding health care, tobacco prevention, and healthy lifestyles for kids.
Sign up here to become part of the AHA’s grassroots network, You’re the Cure, which is focused on advocating for heart-healthy and stroke-smart communities.
There are many great non-profits around the country focused on promoting science funding, literacy, inclusion, diversity & advocacy – finding the right one for you is key and many of them have already done the legwork by developing toolkits for you to get started in your community.
Interested in STEM outreach as a way to get involved in your community? The great Marian Wright Edelman said, “You can’t be what you can’t see.” Participating in local educational initiatives is one of the best ways to expose kids to what scientists and physicians actually look like (in addition to getting them excited about science). The STEM Ecosystem is a great way to get started; there are local chapters all over the country.

I recently watched the brilliant documentary (I highly recommend it!) about Mr. Rogers, “Won’t You Be My Neighbor”, where I was reminded of his advice many of us take comfort in during intense times.

“When I was a boy and I would see scary things in the news, my mother would say to me, “Look for the helpers. You will always find people who are helping.” – Mr. Rogers

We are the helpers. Its time we use our power to advocate for equity within our field and communities.

Representation Matters: How Can We Improve Equity and Diversity in Our Professional Lives?

January 4, 2019March 28, 2019 Jeffrey Hsu, MD, PHD

This past August, the phrase “Representation Matters” commonly graced entertainment and popular culture headlines. Why? In what was ultimately called “Asian August,” several major movies starring Asian-American actors were appearing in theaters, led by the first American film to feature an all-Asian cast in 25 years – “Crazy Rich Asians.” This fervor was inspired by over two decades of under-representation of Asian-American culture in the entertainment industry.

As I am an Asian-American, this particular movement did indeed resonate with me in my personal life. However, I regrettably was not mindful about it in my professional life. Throughout my training, I felt that I had worked with, learned from, and/or befriended men and women of a wide variety of colors, beliefs, and socio-economic backgrounds. Perhaps it was because I was fortunate to train in programs that were diverse, but I don’t necessarily recall reflecting on the diversity nor the benefits of diversity.

In early December 2018, Dr. Hannah Valantine visited our campus at UCLA to deliver our Medicine Grand Rounds lecture, and she was kind enough to meet with many of our faculty and trainees. A renowned physician-scientist and advanced heart failure/transplant specialist, Dr. Valantine is the NIH’s first Chief Officer for Scientific Workforce Diversity. She led an outstanding, eloquent, and (of course) evidence-based discussion on the importance of improving the diversity in academic medicine. She highlighted the emphasis that the NIH is placing on this mission, and the resources her office has developed to not only educate professionals on the issues at hand, but also a toolkit they have created to help promote diversity at our institutions, including how to create a diverse talent pool and perform unbiased talent searches.

Dr. Valantine presented data showing that while there has been improvement in diversity of trainees early in their training, there remains a significant “transition barrier” for diversity upon entering the junior faculty stage of an academic career (between “Postdoc” and “Independence” in the slide below).

Further, she also mentioned data supporting the improved performance of more diverse groups. In an article from Nature this past year, the subjective and objective benefits of diversity were featured. Interestingly, in an analysis of over 9 million scientific articles, one group found that research “papers written by ethnically diverse groups were cited 11.2% more than were papers written by non-diverse groups.”

With clear reasons for why we should work to focus on a culture of equity and diversity in our scientific workforce, I realized that I will soon be at a stage where I will be choosing the members of my research team. In the spirit of the New Year and with the help of tools provided Dr. Valantine, I have made the following “resolutions” to myself to help prepare myself as I embark on organizing a research team in the future:

Discover and explore my implicit biases: There are online resources/tutorials on implicit bias, including an excellent one from my home institution, UCLA, as well as tests you can take to discover your own implicit biases. Regrettably, after my first test, I already learned that my results suggested, stereotypically, “a moderate association for ‘Male’ with ‘Career’ and ‘Female’ with ‘Family.’”
Be mindful of the benefits of diversity when present: Whether in a research group or the team I am rounding with in the hospital, I plan to acknowledge these benefits when present, whether aloud or to myself.
Follow the NIH Scientific Workforce Diversity blog: It is an excellent reminder of reasons and ways to create an effective & diverse scientific team.

In one of her excellent blog posts from last year, Dr. Valantine wrote:

“Our nation is presented with the unique opportunity of connecting an increasingly diverse talent pool of scientists with the full range of biomedicine careers encompassing basic discovery to health applications, a critical part of the NIH mission to advance human health.”

I am grateful that the NIH has placed high priority on this mission, because indeed, Representation Matters, and in the field of academic medicine, representation can lead to better science and better treatments for our patients.