The Accreditation Council for Graduate Medical Education Mandates That You Attempt to Enhance Diversity in Your Cardiology Program

A second-year internal medicine resident at University Hospital, Shawn, had always been interested in cardiology. Shawn was the only African American in the University Hospital program. During his postgraduate year 2 Shawn learned that his coresidents interested in cardiology were all working on cardiology-related research projects with cardiology attendings with whom they had rotated. On the first day of his next cardiology rotation, he informed the attending of his interest in pursuing cardiology as a career. After 1 month of enthusiastically working very long hours, Shawn was disappointed when no mentorship offers or opportunities to work on a research project materialized.

When Shawn’s coresidents met with their research advisors, they were given advice on the optimal number of cardiology programs to apply to and were steered toward programs where their advisors had close colleagues. Shawn received no such advice as he did not have a defined mentor. He applied to 8 cardiology fellowship programs that ranked high and were located in cities where he might like to live. With letters of recommendation stating that he was “dependable,” “quietly competent,” and had performed “solidly” on his cardiology rotations and a United States Medical Licensing Examination Step 1 score of 220 (passing but not outstanding), he received no interview invitations. Over the next year and a half, Shawn eventually warmed to the idea of a career as a general internist.

The catheterization laboratory director looked at Julia with concern; his demeanor radiated empathy and sincerity. “Interventional cardiology is a tough job, especially for a young woman, given all of your added responsibilities. We work late and don’t get to see our kids much. There is a reason you don’t see many women interventionalists. Are you sure that this is what you want?” As she sat in his office, the only woman cardiology fellow, she struggled with the right response. Julia had always been able to translate hard work, perseverance, and a knack for doing well on standardized tests into success in achieving her goals. For the first time, she felt that her work ethic and intellect might not be enough. Feeling like she needed to debrief with a woman, she sought the counsel of Dr Smith—the echocardiography laboratory director (there are no women interventional cardiologists). Dr Smith was sympathetic, understanding, and was able to defuse the situation with humor. Julia had always considered Dr Smith a role model—she was a leader in the cardiology division, a productive researcher, and had a satisfying family life. Shortly after starting an advanced elective with Dr Smith, Julia made a decision: although she found cardiac catheterization and intervention more exciting than imaging, she would pursue the field of advanced echocardiography and follow in Dr Smith’s footsteps.

Recent reports show that only 13% of practicing cardiologists are women and that underrepresented minorities (URMs; including Hispanic, African American, American Indian, and Native Alaskan/Pacific Islander individuals) account for <6% of practicing cardiologists.¹ Given recent information that URM and women physicians may enhance the quality of care provided to a diverse patient population in the United States,^2–4 it is imperative that we enhance diversity in our workforce. This will include establishing strong pipelines from kindergarten onward that expose girls/women and URMs to medicine; mentoring programs in college and medical school; dismantling bias in application processes; active efforts to make the specialty more appealing and inclusive; and active (as opposed to passive) recruiting efforts. Ultimately, dismantling structural biases in the entire educational system and society will be required to enhance diversity in higher education and medicine. Such important efforts are beyond the scope of this essay; we will discuss the more immediate pipeline and its barriers to enhancing diversity in cardiology.

In a 2009 survey, men and women internal medicine resident physicians were asked about what factors influenced their career choices to pursue cardiology.⁵ Interest in cardiovascular pathophysiology, high earning potential, and positive role models were considered the most important positive factors in choosing cardiology and were more likely to be considered important by male trainees; adverse job conditions, interference with family life, and lack of diversity were some of the highest ranked negative factors. Women were significantly less likely to choose cardiology as a career; those who ultimately did so were less likely to consider cardiology a male-dominated field and less likely to report having been discouraged from considering cardiology. Similarly, in a 2017 survey of cardiology trainees, women were more likely than men to be influenced against interventional cardiology by negative factors such as the physically demanding nature of the job, concerns regarding radiation exposure, lack of female role models, sex discrimination or harassment, and perception of an old-boys-club culture.⁶

While women now comprise >50% of US medical students and nearly half of internal medicine residents, URMs are in short supply throughout. In fact, a recent publication by the Association of American Medical Colleges revealed that fewer Black men applied to medical school in 2014 than in 1978.⁷ Lack of resources in the early school years, lack of visible role models, and bias and racism throughout the educational journey are some of the underlying reasons. Women of color face similar hurdles.

How can our profession counter these negative factors and bring in more women and minorities? The Table outlines strategies to enhance diversity in cardiology training programs. One of the strongest factors in positively influencing career choice is the presence of mentors and role models; women in particular report a need for female role models—individuals who look like them and can demonstrate that combining a rewarding career in cardiology with having a family is possible.^5,8 Furthermore, a fundamental culture change is needed. Benevolent paternalism such as advice that directs young women away from cardiology because “it’s too hard for women” has no place in our field and must be explicitly discouraged by program directors. Parental leave policies, duty-hour restrictions, and flexible training schedules must be clearly articulated and adhered to.

With regard to URMs, programs can actively engage individuals from the immediate (internal medicine residents and medical students) and deep pipeline (college, high school, and earlier), by partnering with universities and schools. Cardiology training programs can host high school and college students in regular events to discuss cardiology as a career, provide hands-on experiences on simulators, and where possible, offer shadowing experiences. This could be done in collaboration with local American College of Cardiology chapters.

For both Shawn and Julia, appropriate mentoring could have made all the difference in their ultimate career trajectories. Some studies suggest that white males are more likely to be offered mentorship than women or minorities.⁹ The formation of mentoring pairs should not be left to chance. Training programs should have formal processes to ensure that every trainee has 1 or more faculty mentors who can provide career guidance and, if advice outside of the mentor’s specialty is required, introduce the mentee to appropriate colleagues.

Graduate medical education programs can adopt the holistic review practice utilized by most medical school admissions committees and evaluate candidates by placing equal emphasis on an applicant’s experiences, personal attributes, and standardized test scores.¹⁰ For programs that traditionally emphasize United States Medical Licensing Examination scores in the screening and ultimate ranking of fellowship candidates, this will be a sea change but consistent with the lack of evidence that test scores predict clinical competence.

And finally, teaching faculty and fellowship selection committee members should be encouraged to reexamine their individual implicit biases and participate in annual implicit bias mitigation training. A recent study showed that the majority of a medical school admissions committee had implicit white race preference¹¹ but that after undergoing annual bias mitigation training, the medical school began matriculating classes that mirror the diversity of the patient population in the United States. Training in holistic review and implicit bias mitigation works best if the selection committee is a fixed group of individuals—a captive audience for training and education. Intentional efforts to increase diversity in cardiology fellowship programs can be successful¹² but are unlikely to lead to long-term changes unless leaders truly believe that diversity enhances the quality of patient care and research.

In 2019, the Accreditation Council of Graduate Medical Education introduced a new accreditation standard requiring programs to “engage in practices that focus on mission-driven, ongoing, systematic recruitment and retention of a diverse and inclusive workforce of residents, fellows (if present)…and other relevant members of its academic community.”¹³ Beginning July 2020, programs that fail to do so risk being issued a citation.

Shawn and Julia never realized their true career goals. While they are composite characters, the authors have known many Shawns and Julias, and while most went on to promising careers in medicine, countless cardiac patients have been deprived of excellent, compassionate, and culturally appropriate care, and thousands of young women and URMs have been deprived of role models. Current national and world events like the novel coronavirus pandemic, which has disproportionately affected Black people, and frequent episodes of police brutality leading to fatal encounters between police and Black people have ignited a worldwide call for equity and justice.¹⁴ The cardiology community can answer this call by working to dismantle processes that have resulted in a persistent lack of diversity in our specialty.

The authors recommend that cardiology programs operationalize diversity enhancement efforts with urgency, as if lives are at stake. We are convinced that they are.

Footnotes