Feature Story | Diversity and Inclusion in Medicine: Defining the Scope of the Problem

Awareness is the crucial first step in creating change. Recent studies provide us insights regarding the representation of women and of under-represented minorities in the cardiology workforce, as well as more detail about the lack of women in clinical trials. Here we share an overview to fuel your awareness. Then, take the next step and get involved. Learn more about what you can do at ACC.org/Diversity.

Survey Highlights Need For Culture Change in Cardiology Workforce: Viewpoints Detail Sex-Based Discrimination and Wage Inequality

There is a need for a culture change in the cardiology workforce that aligns with preferences and perceptions of internal medicine trainees, according to a study published in JAMA Cardiology.

Members of the ACC Task Force on Diversity and Inclusion and the ACC Women in Cardiology Section Council surveyed 1,123 internal medicine trainees enrolled in 198 residency programs in the U.S. to determine professional development preferences and perceptions of cardiology as a career choice. Read More >>>

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Results showed that professional development preferences included stable hours, family friendliness, female friendliness, the availability of positive role models, financial benefits, professional challenges, patient focus and the opportunity to have a stimulating career. When asked about perceptions of cardiology, the top responses were adverse job conditions, interference with family life and a lack of diversity.

Women and residents not choosing cardiology valued work-life balance more highly and had more negative perceptions of cardiology than men or future cardiologists, who emphasized the professional advantages available in cardiology. Professional development factors and cardiology perceptions were strongly associated with a decision to pursue or avoid a career in cardiology in both men and women.

“Unfortunately, we found that trainees perceive that the things they want most from their professional lives are often characteristics that they see as foreign to cardiology. This is sobering,” says Pamela S. Douglas, MD, MACC, lead author of the paper and chair of ACC’s Diversity and Inclusion Task Force. “To continue to attract top talent, the cardiology profession needs to address the negative perceptions of the field, including the reality underneath those perceptions. This is especially needed to attract women into our overwhelming male profession — a key consideration since about half of all residents are female.”

Cardiology Magazine Image"Unfortunately, we found that trainees perceive that the things they want most from their professional lives are often characteristics that they see as foreign to cardiology. This is sobering." Pamela S. Douglas, MD, MACC
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In a related editorial comment, Anne B. Curtis, MD, FACC, and Fatima Rodriguez, MD, FACC, explain that an organized and sustained effort by professional societies in cardiology “is necessary to draw attention to this problem.” They add that “structured programs that provide role models and mentors to medical students and residents are needed … [and] efforts to increase diversity in cardiology should focus on the excellence it creates in the workplace. Finally, both conscious and unconscious barriers to women in cardiology must be recognized and addressed.”

Regarding sex-based discrimination women face in cardiology, Roxana Mehran, MD, FACC, chair of ACC’s Interventional Section, notes in a viewpoint also published in JAMA Cardiology, that she does not “know of a single woman who has trained in cardiology and chosen interventional cardiology as her career who has not faced some level of sexual harassment or misconduct.” She explains that “Never again should anyone feel uncomfortable in the work place and intimidated into feeling inferior by the powers that be. We must find the tools to encourage talented women to become interventional cardiologists. If we do not, then nothing will change.”

In another viewpoint, Rashmee U. Shah, MD, MS, member of ACC’s Cardiovascular Disease in Women Committee, acknowledges the wage inequality that exists in cardiology and explains “over a 35-year career, the woman will earn $2.5 million less than the man.” She concludes that “We have arrived at a moment when change is within arm’s reach; women and men must rally together to make the workplace fair, more productive, and better for everyone.”

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#MeWho: Under-Represented Minorities, Women Missing From Academic Medicine

Cardiology Magazine ImageMichelle A. Albert, MD, MPH

“Under-represented minorities, especially under-represented minority women physician-scientists, are faced with walking a tight rope in academic medicine that requires excellence in both clinical and scholarly domains, typically with insufficient academic support, social capital and attainment of senior leadership roles that would turn their zeal and commitment into progress,” writes Michelle A. Albert, MD, MPH, in a perspective published in Circulation.

Albert highlights data from the American Association of Medical Colleges showing a limited number of under-represented minorities serving as internal medicine chairs compared with whites (29 vs. 137) — and only 24 overall are women. Additionally, among the top 40 ranked cardiology programs, none are chaired by women. While there are more under-represented minority women than under-represented minorities in total, these women are less likely to be professors and occupy leadership positions in academia. Read More >>>

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According to Albert, lack of racial/ethnic diversity, racial/ethnic discrimination from parents and families, bias from superiors and colleagues, hypervigilance from stereotype threat, and reactions to tokenism are among the drivers of isolation felt by under-represented minorities, especially women. She also notes that women are “more frequently faced with insufficient family resources/wealth to help manage family-work conflicts,” as well as limited mentorship and leadership opportunities.

An authentic approach to diversity and inclusion is paramount to not only ensuring the success and professional well-being of under-represented minorities and women today, but in also building an equitable pipeline of future leaders, Albert writes. She recommends that institutional and organizational leaders be required to champion diversity and inclusion and evaluated on their results. She also suggests the creation of hybrid career opportunities that “interdigitate academics with private practice.” Other recommendations include bias training and identification, creation and nurturing of peer networks, and diversity funding targeted at under-represented minority well-being.

“Albert’s #MeWho article serves as a great reminder of why a comprehensive approach to diversity and inclusion is so critical for not only cardiology, but medicine as a whole,” says Pamela S. Douglas, MD, MACC, chair of ACC’s Diversity and Inclusion Task Force. “The ACC has developed a Diversity and Inclusion Strategic Plan that gets at the core of many of Albert’s recommendations. Our goal: to harness the power of the diversity of ACC members to advance patient care, spur innovation, and improve health equity among individual patients and populations. In doing so, ACC will ensure opportunity for all cardiovascular providers by working towards a fully inclusive organization and profession.”

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Addressing the Gender Gap in Physician Compensation

At its June meeting, the House of Delegates for the American Medical Association (AMA) passed a resolution proposed by the ACC aimed at addressing the substantial gender gap in physician compensation.

The resolution resulted from the work of the College’s Task Force on Diversity and Inclusion Initiative, which recently released a five-year strategic plan to improve diversity and inclusion in cardiology. Specifically, the resolution called for the AMA to take the following steps: Read More >>>

  • Advocate for institutional and departmental policies to make more transparent the criteria for physician compensation.
  • Advocate “for equal base pay based on objective criteria.”
  • Work to promote bias and compensation determination training for people in positions to decide physician compensation.
  • Promote “a specified approach, sufficient to identify gender disparity, to oversight of compensation models, metrics and actual total compensation for all employed physicians.”
  • Begin educational programs to help all physicians negotiate equitable compensation.

Read more about the ACC’s Diversity and Inclusion Initiative in the June issue of Cardiology (ACC.org/Cardiology). Additional information is also available at ACC.org/Diversity.

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Study Explores Representation of Women in Clinical Trials

Women are underrepresented in clinical trials for heart failure, coronary artery disease and acute coronary syndrome, but proportionately or overrepresented in trials for hypertension, atrial fibrillation and pulmonary arterial hypertension, when compared with the incidence or prevalence of women within each disease population, according to a study published in the Journal of the American College of Cardiology. Read More >>>

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Researchers examined the numbers of women and men who participated in cardiovascular trials submitted to the U.S. Food and Drug Administration (FDA) supporting new drug application approvals. Between Jan. 1, 2005 and Sept. 15, 2015, 36 approvals of 35 drugs for acute coronary syndrome/myocardial infarction, atrial fibrillation, coronary artery disease including angina, heart failure, hypertension and pulmonary arterial hypertension were reviewed.

Estimates for the participation of women were calculated by dividing the percentage of women among trial participants by the percentage of women in the disease population, with a range between 0.8 and 1.2 reflecting proportional representation. In total, the proportion of women enrolled ranged from 22 to 81 percent, with a mean of 46 percent.

The ratio for atrial fibrillation was 0.8-1.1, 0.9 for hypertension and 1.4 for pulmonary arterial hypertension – all within or above the desirable range. Heart failure, coronary artery disease and acute coronary syndrome/myocardial infarction were all under the desired ratio level, at 0.5-0.6, 0.6 and 0.6, respectively. Researchers also looked at sex differences in efficacy or safety, but found little indication of clinically meaningful differences.

According to the researchers, previous studies have suggested that clinical trial inclusion and exclusion criteria disproportionately exclude women from cardiovascular studies. However, data in this latest study show that the lower enrollment of women reflects the lower number of women referred for pretrial participation screening. Factors prior to screening, such as the identification of potential trial participants and the ability of a candidate to participate, may be more likely reasons for low enrollment of women.

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“Based on this work, future research is needed to identify factors leading to under participation of women in cardiovascular clinical trials, particularly those occurring before screening,” writes Pamela Scott, PhD, first author and director of research in the FDA Office of Women’s Health. “Research is needed to better define barriers that limit participation of diverse populations, not only of women but of minority and older populations.”

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Clinical Topics: Acute Coronary Syndromes, Arrhythmias and Clinical EP, Heart Failure and Cardiomyopathies, Prevention, Pulmonary Hypertension and Venous Thromboembolism, Atherosclerotic Disease (CAD/PAD), Atrial Fibrillation/Supraventricular Arrhythmias, Acute Heart Failure, Pulmonary Hypertension, Hypertension

Keywords: ACC Publications, Cardiology Magazine, Acute Coronary Syndrome, American Medical Association, Angina Pectoris, Anxiety, Atrial Fibrillation, Cardiovascular Diseases, Career Choice, Coronary Artery Disease, Goals, Heart Failure, Hypertension, Hypertension, Pulmonary, Incidence, Internal Medicine, Internship and Residency, Leadership, Mentors, Minority Groups, Myocardial Infarction, Parents, Patient Care, Pharmaceutical Preparations, Physicians, Women, Prevalence, Private Practice, Salaries and Fringe Benefits, Sex Characteristics, Sexual Harassment, Students, Medical, Training Support, United States Food and Drug Administration, Work-Life Balance, Workplace, Cultural Diversity

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