Feature | ACC Fellows in Training Leadership Council Statement on Diversity in Cardiology Training

Diverse Classroom; Conceptual Image

We have all faced tremendous challenges this past year. Between COVID-19, social unrest regarding police brutality and a tumultuous political transition, all while continuing to address the cardiovascular needs of our patients, it may feel as if we have little space to accommodate more. However, these events and the broader societal implications they have on our diverse population have compelled us to consider and — sometimes contentiously — discuss the role of diversity in cardiovascular medicine training.

In the U.S., we are defined by a unique collective of diverse cultures, identities and perspectives, and our patients and communities are manifestations of this cooperative tapestry. Our patients come from distinct backgrounds, means and beliefs, and they all are at risk for developing cardiovascular disease. Collectively and individually, we need to be prepared to care for each of them in culturally conscious ways.

However, what is the role of diversity in our training? Is the shared distinctiveness we see in our patients and our society relevant to how we train, from whom we learn or who we are? Does a diverse fellowship class better address the cardiovascular needs of a similarly diverse community?

The ACC Fellows-in-Training (FIT) Leadership Council is committed to promoting and celebrating diversity in our training programs. Hence, we sought input from fellows across the country on how diversity impacts their development as cardiologists.

A theme emerging from these statements relates to the costs incurred by trainees who navigate a homogeneous, inflexible and often unwelcoming training environment:

Zainab Mahmoud, MD

I have found myself imagining what it must be like to be a white male in the field of cardiology.
I imagine coming to work and not having anyone comment on my headscarf, my English or wondering if I was in fact a doctor. I imagine people just thinking I am good enough by virtue of my color and gender.  

Zainab Mahmoud, MD, Cardiology FIT at Washington University in St. Louis, St. Louis, MO

From this perspective also comes the feeling of needing to stifle oneself to belong:

Brittney Hills, MD

As a Black woman in medicine I'm very used to being the 'token,' the 'only' in a sea of people my opposite, and with that experience,
you learn to quiet parts of yourself… This continued in medical school and in training where I felt as though I had to constantly prove I belonged, while those around me just did.  

Brittney Hills, MD, Pediatric Cardiology FIT at Nationwide Children's Hospital, Columbus, OH

These obstacles can come from all directions, and this sentiment of exclusion leaves few, if any, safe spaces for trainees from underrepresented backgrounds.

Lina Ya'qoub, MD

Being a physician and cardiology fellow who looks 'different' and talks 'with an accent' has its own challenges at every level –
institutional, departmental, or even with coworkers and patients.  

Lina Ya'qoub, MD, Cardiology FIT at Ochsner-Louisiana State University, Shreveport, LA

These sentiments are reflections of an environment perceived to be uniform and without room for broader representation. These perceptions and realities force minoritized trainees to feel that their identities are obstacles to their education rather than assets enriching their growth. Though it is impossible to quantify, this relentless erosion of acceptance and belonging weakens trainees in a way completely disconnected from their clinical ability, academic aptitude or empathy towards their patients.

The personal costs of conformity and rigidity in our field is contrasted by the benefits a diverse fellowship training experience confers upon patients. A training culture that values diversity cultivates relationships between trainees and the populations they serve. Bridging cultural and language barriers demonstrates how these fellows facilitate and improve care for diverse populations.

Eddie Hackler, MD

Imagine being lost in a foreign country, where no one speaks your language and doesn't even attempt to. However, to find your way back to familiarity, you have
to trust unfamiliar individuals to lead you in the right direction. A patient who I once cared for gave me this analogy for her experience while admitted to the hospital. We planned for coronary angiography, which the patient was apprehensive to undergo. She spoke with the interventional fellow and the attending and was still uneasy. The morning of the procedure, I went to speak with her and she told me with a nervous smile, 'the only reason I am going through with this is because you are here, so take care of me.'  

Eddie Hackler, MD, Cardiology FIT at Case Western Reserve University/University Hospitals Cleveland Medical Center, Cleveland, OH

Fellows from representative backgrounds effectively advocate for marginalized populations who disproportionately suffer at the hands of a medical establishment which at best is naïve to their plight and is, at worst, the cause of it.

Karen Flores Rosario, MD

Throughout my training, I have noticed many of the challenges underserved populations face, particularly the Hispanic population.
Working with these patients reminded me of my family members, as they have had similar barriers to care and similar expectations from their physicians. Helping family members with cancer and cardiovascular disease navigate the health care world as patients has been eye opening. I have been outraged when seeing patients who look just like my mother being dismissed when they are having a heart attack because they were just another Hispanic lady with 'dolor.'  

Karen Flores Rosario, MD, Cardiology FIT at Duke University Medical Center, Durham, NC

The diversity of our training classes highlights the experiences of our patients. It brings focus to problems that have too often and too easily been overlooked. To have FITs who both understand and, more importantly, feel this injustice galvanizes us all to seek change and holistically improve medical care.

Tony Pastor, MD

The media tends to portray members of the LGBTQIA community 'coming out of the closet' as this pinnacle event in our lifetimes that leads to self-
acceptance and a happy ending. The truth is we never stop coming out. I come out every day when an attending asks me what my wife does or suddenly gets quiet when I speak about my husband. I come out when I have to correct a faculty member multiple times when he refers to a transgender patient with incorrect pronouns and complains about how confusing and inconvenient it is for him...I don't want my patients to have to come out to their doctor only to wonder if they are going to receive the same care as cis-hetero patients.  

Tony Pastor, MD, Adult Congenital Heart Disease FIT at the Harvard Adult Congenital Heart Disease Program, Boston, MA

We have a societal responsibility to enrich our physician workforce with people from a broad array of backgrounds, and our patients take notice when our institutions make a visible commitment to do so.

Norrisa Haynes, MD, MPH

Diversity and inclusion matter to our patients. I have lost count of the number of times that I have been greeted with a warm smile and a heartfelt 'I am so
proud of you, don't give up' from my African American patients for whom having a Black physician is still a rarity and a source of pride. It matters. Institutions' commitment to diversity and inclusion shapes not only our cardiology training but also society, as we are currently training future clinical cardiologists, physician-scientists, clinical trialists, policy makers and leaders.  

Norrisa Haynes, MD, MPH, Cardiology FIT at the University of Pennsylvania, Philadelphia, PA

We must be mindful of the social barriers that patients from disadvantaged backgrounds face. Trainees and physicians who have experienced their patients' struggles can only enhance our workforce and better serve our communities.

Heval Kelli, MD

As a person from low socioeconomic status, I was constantly aware that my background was scarcely represented in the medical community. Growing up,
I watched my parents and their friends and neighbors struggle with access to quality health care, education, employment and housing – all the basic necessities. We all shared a common struggle: poverty. I had to delay my medical school application and testing because I could not afford it after college graduation. Shadowing was a struggle for me because the hospital parking fee equaled two hours of my work as a dishwasher. The MCAT fees alone equaled two months of electrical bills. I didn't know any doctors, so finding a mentor was nearly impossible. Now I am privileged that I do not have to decide between a test and the monthly water bill, but the experience has allowed me to understand the socioeconomic challenges of my patients.  

Heval Kelli, MD, cardiologist at Northside Hospital Cardiovascular Institute and recent graduate of the Emory University cardiology fellowship, Atlanta, GA

Diversity in our fellowships also enriches the relationships within our institutions. When we learn with and from members of a diverse community, we are able to expand our perspective and cultivate empathy. Without opportunities to understand our contrasting starting points, obstacles and trajectories, we would not be able to acknowledge the uneven social structures underlying our opportunities or appreciate the triumphs of those who were able to overcome them.

J.D. Serfas, MD

Growing up, I was taught that I should strive to be 'color blind' – that the truly virtuous among us 'didn't see race.' While those who taught me this were well-
intentioned, I have since learned just how harmful this line of thinking was and continues to be. Importantly, I've only been able to learn this because I have had the great fortune to work alongside colleagues with diverse backgrounds, and the privilege of listening to their stories, hearing of their struggles and their triumphs. These experiences have made me more sensitive to the unique perspectives of my patients, coworkers and neighbors – they have made me a better doctor, a better colleague, a better person.  

J.D. Serfas, MD, Adult Congenital Heart Disease FIT at Duke University, Durham, NC

Diversity in mentorship is just as important – it enhances all of our learning by providing unique perspectives on important clinical concepts, and it encourages and cultivates trainees from underrepresented backgrounds.

Kemar Brown, MD

I still remember the first time I met a Black cardiologist. Unbeknownst to him, our meeting initiated a visceral cascade of reactions that helped to peel away my
own personal misapprehensions. Since medical school, I have had to learn how to thrive in a system where when I look around, I fail to see people who look like me rising amongst the medical hierarchy. Having mentors with mutual experiences has been an integral component of my journey to becoming a Black cardiologist.  

Kemar Brown, MD, Cardiology FIT at Massachusetts General Hospital, Boston, MA

These vignettes all highlight the importance of diversity in our training. Its significance is manifest in our interactions with colleagues, patients and communities. It drives us to be more compassionate as trainees, more perceptive as clinicians, and more understanding as people.

Despite the viewpoints offered here, the emphasis on creating diversity in fellowship classes is considered, by some, not a prescient pursuit. Some believe time will solve the issue of diversity in our training programs, and these gains will subsequently disseminate to our profession. They contend that gradual demographic shifting and passive recruitment will eventually lead to a specialty which is as representative as the population it serves, if, they question, such a goal is beneficial at all.

Such an indifferent approach, however, is clearly insufficient. Rather, diversity in our fellowship programs must be placed at the forefront of our duties as cardiologists. The advances made toward a representative fellowship class have been the result of active and intentional recruitment and retention and advocacy initiatives recognizing this important mission. These efforts must continue and expand so we can effectively cultivate a specialty that truly serves our patients.

However, diversity must not be the end in and of itself. Adding fellows of contrasting backgrounds without the will or resources to integrate their perspectives would be merely a symbolic effort. A fellowship that strives for diversity without inclusion and belonging provides an invitation for those fellows to languish; it is a solicitation for benevolent and vibrant clinicians to be thrust into an institution that perpetuates marginalization and aims to assimilate rather than integrate. Promoting diversity is not merely collecting diverse people, but cultivating a diverse environment.

We must understand that development of a workforce that integrates the multitude of perspectives from our diverse population is good for ourselves and the communities we serve. Diversity provides the foundation that fortifies our training and allows us to be more creative, more empathetic and more effective in our treatment of cardiovascular disease.

The ACC FIT Section Leadership Council pledges to represent fellows from all backgrounds and will continue to advocate for the promotion of diverse fellowship classes. To us, this undertaking is imperative for the continued progress of our profession and the treatment of our communities. Kelli says it best:

Heval Kelli, MD

Fundamental to the problem is the fact that the medical community is not present in our marginalized communities. We can treat their members in our clinics
and hospitals, but to fully address the issue we need to inspire their children and students to join us and guide us in addressing the health issues of their communities. Diversity not only drives excellence but creates the forum to create effective and sustainable health solutions.  

Heval Kelli, MD, cardiologist at Northside Hospital Cardiovascular Institute and recent graduate of the Emory University cardiology fellowship, Atlanta, GA

Aaron Vigdor, MD

This article was compiled by Aaron Vigdor, MD, on behalf of the ACC Fellows-in-Training Leadership Council, which endorses this article.

Clinical Topics: Acute Coronary Syndromes, Anticoagulation Management, Arrhythmias and Clinical EP, Cardiac Surgery, Cardiovascular Care Team, Congenital Heart Disease and Pediatric Cardiology, Diabetes and Cardiometabolic Disease, Dyslipidemia, Geriatric Cardiology, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Pericardial Disease, Prevention, Pulmonary Hypertension and Venous Thromboembolism, Sports and Exercise Cardiology, Stable Ischemic Heart Disease, Valvular Heart Disease, Vascular Medicine, Anticoagulation Management and ACS, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Cardiac Surgery and Arrhythmias, Cardiac Surgery and CHD and Pediatrics, Cardiac Surgery and Heart Failure, Cardiac Surgery and SIHD, Cardiac Surgery and VHD, Congenital Heart Disease, CHD and Pediatrics and Arrhythmias, CHD and Pediatrics and Imaging, CHD and Pediatrics and Interventions, CHD and Pediatrics and Prevention, Acute Heart Failure, Pulmonary Hypertension, Interventions and ACS, Interventions and Imaging, Interventions and Structural Heart Disease, Interventions and Vascular Medicine, Angiography, Nuclear Imaging, Hypertension, Sleep Apnea, Sports and Exercise and Congenital Heart Disease and Pediatric Cardiology, Sports and Exercise and ECG and Stress Testing, Sports and Exercise and Imaging, Chronic Angina

Keywords: ACC Publications, Cardiology Magazine, Cultural Diversity, Racism, Acute Coronary Syndrome, Anticoagulants, Arrhythmias, Cardiac, Cardiac Surgical Procedures, Metabolic Syndrome, Angina, Stable, Heart Defects, Congenital, Dyslipidemias, Geriatrics, Heart Failure, Angiography, Diagnostic Imaging, Pericarditis, Secondary Prevention, Hypertension, Pulmonary, Sleep Apnea Syndromes, Sports, Exercise Test, Heart Valve Diseases, Aneurysm

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