Perspective | Health Equity: An Academic Approach For Research and Change
The deadly use of force by police and the raging COVID-19 pandemic continue to disproportionately impact people of color, uprooting any denial that racism and inequities in our society are exaggerated. This year starkly illustrates that inequities can result in death. The names of the victims shouted out at Black Lives Matter rallies and whispered at the memorials of lives lost to COVID-19 are heard at disproportionally higher rates within the same communities. These tragedies have incited a long overdue urgency for change in the way racism, diversity, equity and inclusion are thought about in cardiovascular medicine.
As a Black woman, I feel the pain and concern of our community, and as a cardiologist and a researcher studying inequities, I see the urgency to act as an opportunity that cannot be wasted. We must harness this yearning for progress to reduce racial inequities and eradicate racism in cardiology. To accomplish this, we must employ the same methodologies we have used to make other important advancements in academic cardiology. We must be academic. In this perspective, I outline how we can apply our academic standards to equity and anti-racism work across four key areas of focus.
Make equity a quality measure. Most major academic medical centers have one service through which traditional fee-for-service care is delivered, mostly to patients with insurance, and another teaching service, most often covered by residents and fellows under supervision of an attending physician, that delivers care to patients with no or minimal insurance or no designated primary care physician outside the clinic system. Often, this tiered delivery of care falls along racial lines, with the majority of the Black, Indigenous and People of Color (BIPOC) population being seen in the clinic catering to patients with no or minimal insurance. This is essentially apartheid in cardiovascular medicine. We have developed and accepted two separate but unequal health care systems for too long. This is unjust and completely undermines our efforts to reduce health care inequities.
More importantly, it leads to poor quality and inequitable outcomes. Chief of Diversity and Inclusion for the Accreditation Council for Graduate Medical Education (ACGME) William A. McDade, MD, PhD, recently explained to me: "Equity is a quality measure." Cardiovascular divisions should embrace this as a core value, track racial equity in treatment and outcomes as a quality measure and insist on reducing inequity using best available evidence and rigorous methodology.
Use evidence-based methods to increase diversity in training. It is not a matter of political correctness, it is a matter of life or death. A diverse group of trainees is the prerequisite for creating a more diverse field of cardiologists. And we know that diversity among physicians saves lives. Here we need to focus on implicit bias embedded in the trainee selection process because this is a major limitation to having a more diverse group of trainees.
All programs should require implicit bias training for all persons participating in any aspect of the selection process. Here there couldn't be a better blueprint than what Quinn Capers IV, MD, FACC, has developed: a studied, evidence-based method that has made Ohio State University College of Medicine one of the most diverse cardiovascular training programs and faculty in the country. Finally, study our trainees experiences. Ask our trainees about their experiences and involve them in designing systematic changes that will improve their experiences.
Acknowledge the methodologic error and limitation of using race to define groups in research. Because we can measure race, it is often used to categorize groups of individuals. Just because race is easily measured doesn't mean it's an accurate measurement. Most agree there is very little evidence to support the notion that race is a biologic construct. Racism, however, has indisputable negative impacts on health. We need to conduct the research necessary to disentangle race from racism, and create reliable reproducible measurements for racism.
In the interim, we must challenge ourselves to be meticulously critical of our race-based analyses and acknowledge this as a limitation in the research we conduct. Without careful consideration of this limitation we leave the research conclusions open for interpretation that may unknowingly perpetuate race-based bias and racists views. Institutions need to value and promote research and studies that advance our understanding and accurate use of these widely used terms.
Compensate Diversity, Equity, Inclusion and Anti-Racism Work With Academic Currency. For institutions and programs, accreditation, funding and reputation are the currency that drive behavior. The ACGME, other accrediting bodies and funding agencies play a critical role here. The appropriate incentive structure from these bodies can influence institutions to move beyond supportive solidarity web pages to producing real change. Until anti-racism work is tied to tangible outcomes that have value in academia, it's unlikely that institutions will have the incentive to do the work effectively.
Similarly, for faculty, trainees and staff, salary, protected time and promotion drive priorities and behavior. If department chairs and division chiefs are not willing to compensate those who are willing and able to do the equity and anti-racism work needed, they will have a difficult time arguing that it is an institutional value and an even more difficult time producing or sustaining results. In other words, show me an institution's budget and I will tell you what they value.
In addition to compensation for those who do the work, all trainees and faculty should be required to demonstrate competency in diversity, equity, inclusion and anti-racism principles. These competencies should be required for advancement in training and promotion. We need to provide the training and education our workforce needs to gain competence in these areas and then hold them accountable for its demonstration.
The current crises that we face are a wake-up call for change. If we do what we know how to do – be academic – we can harness our collective outrage, sadness and desire for meaningful change to drive progress.
This article was authored by Gmerice Hammond, MD, MPH, cardiovascular health policy research fellow at Washington University in St. Louis School of Medicine in Missouri.
Keywords: ACC Publications, Cardiology Magazine, COVID-19, Racism, Universities, Motivation, Medically Uninsured, Police, Quality Indicators, Health Care, severe acute respiratory syndrome coronavirus 2
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