equity – The Early Career Voice

Equity, Diversity, and Inclusion: The Pillars of #AHA21

December 23, 2021December 17, 2021 Devesh Rai, MD

I was delighted to be selected as one of the American Heart Association (AHA) early career fellows in training bloggers for the year 2021-2022 during my first-year cardiology fellow. During 2019, the AHA conference was in Philadelphia and in-person. However, with the COVID-19 pandemic surge, we have learned how to attend virtual to hybrid conferences. Slowly, we have adapted to the new way of the virtual conference to be our harsh reality amidst an ongoing pandemic. The COVID-19 pandemic shed light on an essential aspect of healthcare. It brought forward the disparities in health care from enrollment of underrepresented patient populations in trials to the care of these patients.

The AHA has always emphasized equity, diversity, and inclusion (EDI) in the conferences and attempted to promote enrollment of the underrepresented population. The #AHA21 was a testament to these continued efforts visible in all sessions and specially planned sessions based on EDI. During the 3-day #AHA21, there were multiple exciting sessions.

Along with incredible live sessions regarding the ongoing groundbreaking research in the field of cardiology. There were multiple exciting on-demand sessions on EDI. Financial Toxicity and Cardiovascular Health Management and Outcomes by Dr. Krumholz from Yale School of Medicine was an incredible session raising important questions regarding the impact of the costly intervention on patients’ financial freedom, an aspect that is often ignored by the providers. Similarly, another session by Dr. Sharm from Johns Hopkins University discussed important concepts about monitoring of women with pregnancy complications or preterm deliveries discussed the important aspect of Cardio-Obstetrics, which has not been discussed much in the past.

With the pandemic, cardiac rehabilitation became challenging in the first place. However, with the evolution of the reach of virtual technology, Dr. Beaty from the University of California, San Franciso, discussed the innovative ways to encourage and involve patients in remote cardiac rehabilitation in older adults, women, and people of color as well. This kind of remote approach can potentially help in reaching all patient populations, thereby breaking the barriers of social determinants of health.

Not only #AHA21 provided a platform to practice with keeping social determinants of health. It also provided a platform for the fellows in training regarding how to navigate being a new parent in a special seminar. This was a heavily attended session with more than 100 participants where fellows shared their experiences of navigating through the challenges of being a parent during the fellowship. Everyone shared the nuances, tips, and tricks of being a parent during the fellowship, which was very powerful. These kinds of sessions can encourage more women to join cardiology and thereby close the leaking pipeline and bridge the gap.

The #AHA21 commitment towards motivating women in cardiology is also evident by the complete absence of MANELS in this 3-day conference and a testament to immediate past president Dr. Bob Harrington’s commitment towards #HeforShe campaign encouraging more women towards cardiology.

It’s heartwarming to see the success of #AHA21 and the fruition of EDI efforts of AHA extending from patient care, fellows in training to physicians.

“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.”

Solutions to Cardiology D&I Connection

December 9, 2021December 8, 2021 Mary Branch, MD, MS

Now that we know the harmful myths, importance & benefits of inclusion, as well as steps towards inclusion of BIPOC in cardiology. I hope we are aware too that this is not a zero sum game and we all can benefit by practicing together in this field.

So, what is the answer? Well, from someone who has integrated many spaces growing up, I know. You find connection, you learn from one another, and you grow.

The same principles can apply for all. Here are some final thoughts about how we can achieve cardiology workplace equity.

Communication

We all have one thing in common. We’re human. Finding commonality with trainees can help bridge any gaps and change biases. Socializing in the beginning to get to know people can be one way to start. This fosters good relationships and we all start on equal ground and build trust. It can be helpful also to check-in. These conversations can be open and honest in a safe space to share experiences (without judgement and non punitive).

Benefit of the Doubt

This is an important principle. With bias and hierarchy this can manifest into lack of benefit of the doubt. Many trainees who graduate medical school are smart. After a certain IQ, there is a marginal difference (discussed in Outliers by Malcolm Gladwell). If a mistake is made, assume the person is smart and discuss better strategies moving forward. It helps to give each other grace. Being clear about your own biases may address this issue. Negative actions stemming from bias and hierarchy can play out during frustration or stress. This can make an uncomfortable environment for the trainees. Consider addressing issues in your own life and this may be a remedy to this issue. We all have bias and personal issues, building awareness is a starting point.

Sponsorship

Once a trainee makes it through medical school and residency, they are smart and have endurance. Those who have drive and passion can likely be molded into successful researchers, teachers, and bedside clinicians. One way to help build community and help it grow in training is sponsorship. This can include recommendations for research projects or offering to bring them along to a talk or presentations (hopefully will be in-person soon). It can be fun to be a part of someone’s journey.

For BIPOC medical students and trainees

The above principles apply to us too. In any situation, it helps to look at the man/woman in the mirror and take accountability. We can recognize our own bias and ego. We also can work strategically towards excellence. Remember that at the end of the day; game recognize game. Further, we can determine how we may be holding ourselves back with imposter syndrome. You belong on that wall too! Some of us carry generational weight and feel the need to represent an entire community. You don’t have to hold that weight and can let go. Consistently remember to keep your eye on the prize and rise above the mellow drama. Just hold on. This too shall pass. There is a reckoning in this country; and this is the time to step out into the light. You are worthy.

This essay does not include every principle. Recommendations for how to connect can also be program specific. Many may grumble about these efforts and worry there will be a reversal of inequity. It’s important we swing the pendulum back to the center first. This takes intentionality. We all will benefit from this work to make a more peaceful environment. This can translate to improved patient outcomes and address health disparities, if we start from within.

Health Equity, the Forgotten Pillar

November 15, 2021November 15, 2021 Ayana April Sanders, PhD

This year’s AHA21 Scientific Session placed an intense spotlight on understanding and achieving health equity in cardiovascular health (CVH). AHA has a broad vision for being transformative in all of the ways that structural inequities influence health outcomes. Specifically, AHA’s 2024 Impact Goal states that: Every person deserves the opportunity for a full, healthy life. As champions for health equity, by 2024, the American Heart Association will advance cardiovascular health for all, including identifying and removing barriers to health care access and quality.

On Day 1 of AHA21, during the ‘Cardiovascular Health After 10 Years: What Have We Learned and What is the Future?’ session, we engaged with experts about the genesis of CVH, how it has been studied throughout the life span over the past decade, and methods for influencing CVH at critical life stages. Darwin Labarthe, MD, MPH, PhD, provided a historical review of the conceptual origins and definition of CVH, and the meaning of CVH in translation. CVH is defined by key features of AHA’s Life’s Simple 7, including assessments of diet, smoking status, physical activity, weight management, blood pressure, cholesterol, and blood glucose.

Ideal CVH is determined by the absence of clinically diagnosed CVD together with the presence of the 7 metrics. Longitudinal evidence has shown that maintaining ideal CVH is more cardioprotective than improving and achieving CVH from a lower CVH level. But US NHANES data shows that about 13% of adults meet 5 of the 7 criteria, 5% have 6 of 7, and virtually 0% have ideal CVH or meet 7 of 7 metrics. This begs the question of how do we attain and maintain a high level of CVH? Ideally, maintaining CVH by Life Simple 7 standards should be SIMPLE…just ensure that all 7 metrics are met, and you will have ideal CVH! But realistically, it is near impossible for individuals to achieve ideal CVH. It is more likely that both individual and population-level efforts are needed to achieve and maintain CVH.

From a life course perspective, high CVH in adulthood is more likely when high CVH is present in early life. But as the panelist continued to describe the state of CVH in America, we quickly learned that while high CVH is consistently associated with lower risk of cardiovascular disease (CVD), disparities in CVD rates vary by sociodemographic factors like age, sex, race/ethnicity, and educational attainment. A recent study by panelist Amanda Marma Perak, MD, MS, FAHA, FACC, and colleagues (2020) using data from the CARDIA study found that less than a third of young adult participants had high CVH, and this was lower for Blacks than Whites and those with lower than higher educational attainment. These results demonstrate that CVH is far from ideal even among younger cohorts. Over the last few decades, we have witnessed increasing rates of cardiovascular abnormalities and subclinical and overt CVD in adolescents and emerging or young adults. The low prevalence of ideal CVH in young adults suggests that factors contributing to CVD risk may be embedded at earlier life stages. The experiences that happen or do not happen in early life settings (i.e., family, households, schools, communities, etc.) are important opportunities to achieve or maintain high CVH. The drivers of health disparities, like social determinants of health (SDOH), structural racism, and rural health inequalities, are necessary to achieve sustainable health equity and well-being for all. One method is effectively developing culturally-tailored community-engaged partnerships to promote CVH. LaPrincess Brewer, MD, MPH, shared the phenomenal community-based interventions being conducted to intervene on low CVH in Black neighborhoods by addressing SDOH at the community-level. These included the Fostering African-American Improvement in Total Health CVH (FAITH!) CVH wellness program, Community Health Advocacy and Training (CHAT) program, and The Black Impact Program.

The conversation on CVH and health equity continued strong on Day 2 of AHA21 at the ‘Achieving Health Equity: Advancing to Solutions’ session. With a panel of leading experts in health equity research, calls for action rang out at each presentation. David Williams, PhD, argued that racial inequalities in health are fortified from centuries of established institutional/structural racism, individual discrimination, and cultural racism, which result in a significant cost to mental health and millions of African-American lives lost each year. Sonia Angell, MD, MPH built on the discussion with a call to action in investing in understudied and marginalized communities that experience poorer CVH. Importantly, as clinicians, research scholars, and policymakers, we need to consider the significant impact of spending more time addressing intervention areas with the largest impact on health, like the structural causes of health inequities. When we work to eliminate structural causes of health inequities, we can begin to spend less time and energy working on small impact areas like counseling, education, and referrals for emergency foods and housing. Ultimately, we can reduce the time and costs of mitigating health inequities when we focus on eliminating the structural causes of health inequities.

Finally, in a powerful video, Health Equity: Patients’ Perspectives, we were invited to hear the stories and experiences of those from Black and Hispanic/Latino communities who were significantly affected by health inequities and failed by their healthcare systems. The tales were jarring and left the audience and panel with a strong sense of remorse. The impact of inequalities in health has been a regular staple in marginalized communities across America for centuries. Collectively, from these voices, we recognize that patients and participants need to be treated as humans. In seeking to meet AHA’s 2024 Impact Goal, I want to echo the sentiments of Kirsten Bibbins-Domingo, PhD, MD, MAS, that equity was always an important pillar in health quality and safety, but it is the forgotten pillar. We must make health equity front and center. As such, we need to 1) actively make health equity a priority and place it front and center in our professional and personal work; 2) have respect for all of humanity from all social groups; and 3) we need better science to understand how risk and disease are being experienced.

References

Lloyd-Jones, Donald M., et al. “Defining and setting national goals for cardiovascular health promotion and disease reduction: the American Heart Association’s strategic Impact Goal through 2020 and beyond.”Circulation 4 (2010): 586-613.
Enserro, Danielle M., Ramachandran S. Vasan, and Vanessa Xanthakis. “Twenty‐year trends in the American Heart Association cardiovascular health score and impact on subclinical and clinical cardiovascular disease: the Framingham Offspring Study.”Journal of the American Heart Association 11 (2018): e008741.
Benjamin, Emelia J., et al. “Heart disease and stroke statistics—2017 update: a report from the American Heart Association.”circulation 10 (2017): e146-e603.
Perak, Amanda M., et al. “Associations of late adolescent or young adult cardiovascular health with premature cardiovascular disease and mortality.”Journal of the American College of Cardiology 23 (2020): 2695-2707.
He, Jiang, et al. “Trends in Cardiovascular Risk Factors in US Adults by Race and Ethnicity and Socioeconomic Status, 1999-2018.”JAMA 13 (2021): 1286-1298.

Housing and Health Equity in Cardiovascular Disease

July 24, 2020July 27, 2020 William Aitken, MD

So far, 2020 has been a year of public health crises. By early spring, it was apparent that people living in socio-economically disadvantaged areas were being hit hardest by Covid-19 [1]. In these same areas, people across the United States took to the streets protesting the murder of George Floyd, an unarmed Black man – in police custody [2]. In the words of James Baldwin, “It demands great spiritual resilience not to hate the hater whose foot is on your neck, and an even greater miracle of perception and charity not to teach your child to hate.”, and we as a country are still looking for this resilience [3]. Among the many consequences of this year’s events, these tragedies have really prompted a long, hard look at our healthcare system. One recently published article that was particularly heartening to read was the American Heart Association’s Council on Epidemiology and Prevention and Council on Quality of Care and Outcomes Research Scientific Statement on “Importance of Housing and Cardiovascular Health and Well-Being”. It outlines how housing stability, quality, affordability, and neighborhood environment are linked to cardiovascular disease. The statement doesn’t shy away from evidence of how increased psychosocial stress in the Black community and other social determinants of health are associated with cardiovascular health disparities.

The world has changed profoundly over the past year and while we continue to strive to show charity to others in our everyday encounters, I look forward to reading more research that will help inform how we as a community can better address health inequity.

References:

Chowkwanyun M, Reed AL Jr. Racial Health Disparities and Covid-19 – Caution and Context. N Engl J Med. 2020;383(3):201-203. doi:10.1056/NEJMp2012910 (https://www.nejm.org/doi/full/10.1056/NEJMp2012910)
Taylor, Derrick Bryson. “George Floyd Protests: A Timeline.” The New York Times, The New York Times, 30 May 2020, www.nytimes.com/article/george-floyd-protests-timeline.html. (https://www.nytimes.com/article/george-floyd-protests-timeline.html)

Baldwin, James, 1924-1987. The Fire next Time. New York: Dial Press, 1963. (https://www.newyorker.com/magazine/1962/11/17/letter-from-a-region-in-my-mind)
Sims M, Kershaw KN, Breathett K, Jackson EA, Lewis LM, Mujahid MS, Suglia SF; on behalf of the American Heart Association Council on Epidemiology and Prevention and Council on Quality of Care and Outcomes Research. Importance of housing and cardiovascular health and well-being: a scientific statement from the American Heart Association. Circ Cardiovasc Qual Outcomes. 2020;13:e000089. doi: 10.1161/HCQ.0000000000000089 (https://www.ahajournals.org/doi/10.1161/HCQ.0000000000000089)

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.