Racial diversity

hidden

Solutions to Cardiology D&I Connection

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.

“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.”
hidden

The Medical Program Inclusivity List

Mary Branch, MD, MS

In medicine, there is no widespread list of medical programs that are considered inclusive. During this time, the cardiology community has both publicized the need for addressing racial bias in medicine and advocating for inclusivity. Dr. Quinn Capers IV, who is an interventional cardiologist and appointed the Chair of the ACC’s Diversity and Inclusion Committee in 2020, has made great strides in this effort. Dr. Capers has traveled the country describing the experience of BIPOC (Black Indigenous People of Color) patients and physicians. He is presenting to different institutions to tackle racial bias in medicine. Drs. Laxmi Mehta, Sharonne Hayes, Toniya Singh, and additional exceptional colleagues have identified concerning data regarding discrimination, harassment, and a hostile work environment (HWE) in cardiology. They found higher rates of HWE in women (68%, over three-fold higher than men) and African Americans (53% with 46% increased odds compared to Whites). These issues require real solutions and likely have deep roots for BIPOC (‘Equity & Inclusion in Medicine Part II’). The importance of including more BIPOC in medicine is to increase community representation. The less community representation we have, the more progressive community chronic disease and inequity we will see.

As programs grow to understand how to boost the numbers of underrepresented minorities in general, it is also important for trainees to know which programs are considered supportive currently. Therefore, I decided to identify which specific programs were considered inclusive. Further, the goal of this inquiry was to share the names of these programs to the cardiology community interested in boosting diversity and inclusion (D&I).

In October of 2020, I sent out a Facebook posting to a group of African American physicians and dentists. I polled the group to ask which medicine programs were inclusive.  All members were included to answer with no one excluded. A tally was created each time a member mentioned a program with the addition of ‘likes’.

After a follow-up time of approximately a week, there were 97 mentions and 329 tallies with the addition of ‘likes’. A total of 15 (4.5%) was the highest tally. The top three programs and specialties on the list were Emory – Emergency Medicine, Johns Hopkins-Internal Medicine, University of Chicago- Emergency Medicine (15,14,13 tallies respectively). The programs with the most frequent mentions were Baylor, Emory, and Mayo Clinic (mostly Minnesota) (5 mentions each). The most frequent specialties mentioned were family medicine (15), emergency medicine (11), internal medicine (11), and OB-GYN (11). In terms of cardiology, the top-rated programs in this specialty were Duke, Mayo Clinic, and Marshall with one tally each. I did a separate poll from a group of BIPOC/African cardiology fellows and the top program mentioned as being diverse and inclusive more than once was Duke. Other programs mentioned were Yale, Vanderbilt, SUNY Downstate, Mayo Clinic Arizona and Florida, UPENN, Rush, and the University of Kentucky Lexington. What constituted inclusive for the cardiology group came down mostly to pure numbers.

*EM-emergency medicine, *IM-internal medicine, *Anesth-anesthesia, *Neurosx-neurosurgery, *Peds-pediatrics, *FM-family medicine

This list is a helpful initial guide based on physician feedback regarding program diversity and inclusivity. This is a relatively novel approach to receiving feedback regarding D&I with crowdsourcing from social media/WhatsApp. Certainly, not all programs were represented, so one cannot extrapolate negative inclusivity from the lack of mention. As well, there may be a selection bias towards a program or specialty related to the group composition. Further, for both groups, this poll was on social media/WhatsApp and they may not have been alerted to it with busy training schedules.

 

Cardiology is a specialty that is encouraging diverse recruitment and aiming to create an environment of appreciation for fostering inclusivity (see ‘Equity & Inclusion in Medicine Part III’). The top programs have clearly invested time and resources into recruitment and retention. Cardiology program directors may benefit from their strategies. The goal of improving the number of underrepresented trainees in cardiology could boost curriculum innovation, incorporate a broader reach to a diverse patient population, and improve mentorship for URIM medical students and residents.

 

“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.”
hidden

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

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:

  1. 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
  2. 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.
  3. 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
  4. 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
  5. National Institutes of Health. (NIH). (2021). Ending Structural Racism. Retrieved from https://www.nih.gov/ending-structural-racism/unite on 4/2/21.
  6. 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
  7. 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

 

“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.”