Cardiology departments across the country have stated their commitment to improving diversity and inclusion within the field. This is an important mission, as there are many obstacles that need to be addressed to succeed. An overlooked barrier to increasing diversity, however, is the “stereotype threat,” which affects the number of underrepresented minorities who even attempt to go into cardiology.

The stereotype threat is the psychological state that people experience when they are at risk of confirming a negative stereotype associated with their identity. This can be related to race, gender, social class or sexual orientation.

Psychologists Claude Steele, Joshua Aronson and Steven Spencer are thought to have discovered the concept of the stereotype threat. In one study, a group of Black and white college students of similar SAT scores were given a 30-minute test of difficult questions from the verbal section of the Gradate Record Exam (GRE). One group of students were told that the test was to assess intellectual ability. The other group was told that it was simply a problem-solving task. In the “intellectual ability” group, Black students scored worse than the white students. In the “problem solving” group, the scores were the same between the two.

In another study, a group of men and women were given a math test. Half of the women were told before the test that the results had been known to show differences between the genders. The other half of the women were not told anything. The women who received the message before the test performed worse than the women were not told anything.

The way this phenomenon manifests itself in medicine can be subtle but can also have long-term consequences. Particularly, the stereotype threat can lead to underperformance on the MCAT, or so much self-doubt that the test is skipped altogether.

Mentoring in Medicine is a non-profit organization started by Lynne Holden, MD, with the mission to help Black and Hispanic students in New York City pursue health care careers. While working there before medical school, I spent a lot of time with the college and post-baccalaureate students who were interested in becoming physicians.

Based on work ethic alone, every single student enrolled in the program deserved to go to medical school and become a physician. Yet, some of them never even applied to medical school. This was almost always because of a crippling fear of the MCAT. The fear of doing poorly – which reinforces a negative stereotype about intelligence – was enough to stifle some careers before they had even started.

It would often take a lot of encouragement and support to give some students I met the confidence to feel they were prepared and would do well on the test. While working for this program, I realized that positive reinforcement and a commitment to uplifting each other was more important for success on the MCAT than memorizing the Krebs cycle.

But even for the students who make it past that hurdle, it can still be a factor on the day-to-day life of medical training. In one article, Joyce Njoroge, MD, et. al, discuss how cardiology fellowship programs can promote diversity and inclusion and describe common scenarios faced by minority trainees. One scenario involved a Black medical student named Joan, who is the only minority member among the students, residents and fellows on the cardiology consult team. Joan is quiet and only answered questions when directly called on. She answers them correctly but is otherwise overly passive and deferential.

This scenario resonated with me because it is how I approached medical school. Joan is probably extremely smart, but because she is worried about speaking too much or getting something wrong, she might not come off that way. This could lead to perpetuation of a stereotype about her intellect and affect how she is treated on this rotation. This approach won’t lead to any particularly bad evaluations, but it also won’t help her make strong connections that could help her in the future.

So, what can we do to fix this? First, we need to increase diversity in medical training. This is a difficult, macro-level task that many programs are working on and will not be fixed overnight. ACC has created a series of pipeline/pathway programs including Young Scholars, Medical Students, Internal Medicine Residents and the Clinical Trials Research program.

The stereotype threat is difficult to beat alone. “Never worry alone” is a saying that my fellowship director, Xavier Prida, MD, FACC, always tells our fellows. He means that we should cultivate an environment where everyone feels comfortable asking for help. Mentorship is a chance to show that success is possible, but it also allows students to think of themselves as individuals, instead of as a walking stereotype. Whether it’s leading an organization like Mentoring in Medicine, or simply getting to know a student like Joan, it is important to make sure the students coming after us aren’t worrying alone.

Learn more about what ACC's Diversity and Inclusion Committee is doing to help diversify the cardiovascular workforce.

This article was authored by Chinedu Madu, MD, a fellow at University of South Florida, Morsani College of Medicine.

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