racial injustice – The Early Career Voice

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)

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Written by Isaiah A. Peoples MD, MS, Christy N. Taylor MD, MPH, and Nasrien E. Ibrahim MD

The current climate in America has taken the rose-colored lens off society and allowed the world to see the gross disparities faced by Black Americans and other marginalized groups. Initiated by the multiple murders of unarmed Black Americans by police officers to the unprecedented dissimilarities in the death rate of Black and brown people due to COVID-19. This has given pause to the medical community; forcing us to reflect on the ever-increasing health disparities facilitated by institutional racism, which has sadly been perpetuated in medicine including in heart transplants. This is partially reflected by the low number of hearts being transplanted to people of color even when medically indicated. Often the factors of financial and social “requirements” are what lead to many being turned down for transplantation. These are young patients, Black patients, brown patients, patients with young children, patients without financial means, patients without caregivers, patients neglected in the healthcare system; souls that will haunt us forever. Our healthcare system is broken.

Heart transplantation is one of the greatest innovations in medicine to date. Helping patients with end-stage heart failure (HF) and New York Heart Association IV symptoms have a second chance at life, hiking the Grand Canyon, or keeping up with their young children- nothing comes close. However, along the continuum of HF from the prescription of guideline-directed medical therapies (GDMT) including internal cardioverters defibrillators to advanced therapies including heart transplant, Black patients are undertreated.

Transplant selection is a complicated process where ethics, emotions, and implicit biases occasionally muddle the process further. A study by Dr. Khadijah A. Breathett and colleagues examining racial bias in the allocation of advanced HF therapies found Black women were judged more harshly by appearance and adequacy of social support.¹ In transplant selection there are non-modifiable factors as well as modifiable factors to consider, with modifiable factors carrying the greatest risk for bias and inequitable listing and organ allocation decisions. Patients too sick to survive, for example, a patient with multi-organ failure intubated and on extracorporeal membrane oxygenation or patients with active cancer have absolute contraindications- these are non-modifiable. Age cut-offs vary across transplant centers, but in all cases, the same standards must be held for all patients to ensure equity.

Modifiable risk factors are where decisions are more likely to be influenced by implicit biases and where the greyest zones exist. When patients are asked to identify social support systems do we consider a group of church members who agree to care for the patient in a rotating fashion adequate support or does a family member or partner need to be identified? What about patients with insurance but limited finances to the extent co-payments are unaffordable? Do we expect patients to fundraise or does the transplant institution assist in some costs for a prespecified number of patients each year? Do we expand insurance coverage? What about undocumented patients, patients without insurance, and patients in prison? What about patients with substance use disorders? Are we morally obligated to assist them to ensure future transplant candidacy? Modifiable is where things get murky.

We wanted to examine the percentage of Black patients who received heart transplants in the highest volume transplant centers in the United States relative to the demographics of the cities where these transplant centers reside; we looked at 2019 data for sake of completeness (Table 1). We recognize this is merely a snapshot in the history of transplant programs from a bird’s eye view, that cities may have multiple transplant centers, Black patients may prefer certain centers, and finally, the city demographics are from 7/1/2019 and may differ if we had year’s end demographics. HF is more prevalent and is associated with higher mortality and morbidity in Black individuals than in white individuals² and once it has developed, Black patients have more events and worse health status compared to white patients. As such, the proportion of Black patients transplanted at each center should in theory at the very least match demographics of the city where the transplant center is located, but without granular data, we cannot be certain.

What we are certain of is the need for improving the care Black patients with HF receive. The first and most important is earning trust amongst Black communities and reestablishing the doctor-patient relationship through community engagement. This will allow us to inform Black communities about the transplant process and when a transplant should be considered and what to expect. We must develop GDMT optimization programs in Black communities to reduce morbidity and mortality, identify patients who need device therapies, and identify those who do not improve and require evaluation for transplant earlier since Black patients are sicker when listed and more likely to die waiting with longer wait times.³ Additionally, transplant centers should be tasked to develop outreach programs to Black, Hispanic, minoritized, and marginalized communities and perform a prespecified number of transplants in patients who lack financial means based on transplant center volume. Implicit bias and antiracist training for all team members involved in transplant selection must be required and transplant selection teams must be diversified by concerted efforts in hiring diverse faculty but also improving the diversity of the pipeline. And for modifiable factors, rigorous efforts such as substance treatment programs and involvement of weight loss clinics must be attempted consistently with our moral obligation to assist patients in becoming eligible for transplant.

Heart transplant is one of the most incredible things in medicine, we must ensure it is accessible to all by dismantling the oppressive systems in place that have made access to organs inequitable. Black Lives Matter in Heart Transplant Too.

References

Breathett K, Yee E, Pool N, Hebdon M, Crist JD, Yee RH, Knapp SM, Solola S, Luy L, Herrera-Theut K, Zabala L, Stone J, McEwen MM, Calhoun E and Sweitzer NK. Association of Gender and Race With Allocation of Advanced Heart Failure Therapies. JAMA Network Open. 2020;3:e2011044-e2011044.
Sharma A, Colvin-Adams M and Yancy CW. Heart failure in African Americans: Disparities can be overcome. Cleveland Clinic Journal of Medicine. 2014;81:301-311.
Lala A, Ferket BS, Rowland J, Pagani FD, Gelijns AC, Moskowitz AJ, Horowitz CR, Pinney SP, Bagiella E and Mancini DM. Abstract 17340: Disparities in Wait Times for Heart Transplant by Racial and Ethnic Minorities. Circulation. 2018;138:A17340-A17340.
United States Census Bureau https://www.census.gov/quickfacts/fact/table/US/PST045219 accessed 12/20/2020.
United Network for Organ Sharing https://optn.transplant.hrsa.gov/data/view-data-reports/center-data/ accessed 12/20/2020.