At Issue: Lancet initiative sparks discussion on diversity in cardiology
As part of an effort to promote gender equity, diversity and inclusion, The Lancet journals announced it will no longer sponsor all-male panels, colloquially known as “manels,” and will take steps to improve the inclusion of all genders, ethnicities, regions and other social categories in research and publishing.
“We recognize that publication is a chief currency within science, medicine and public health. It is key to the ability of women and people of color to contribute, receive recognition and accrue the experience, visibility and achievement to compete for advancement,” Richard Horton, FRCP, FMedSci, editor-in-chief of The Lancet, said in a press release. “As editors and journals, we are just one part of an ecosystem that includes academic institutions and funders where gender bias is well documented, and of a broader society that disadvantages certain groups to create an uneven playing field. But we are committed to be the change we want to see, and to playing our part in helping create diversity and inclusion in health research and publishing. We encourage other publishers, journals and members of the science community to contribute to these pledges.”
As a specialty with a smaller percentage of women than most, cardiology has faced these same issues. It has been well documented that women choose to specialize in cardiology at lower rates than other internal medicine specialties for a variety of reasons, including poor flexibility, lack of female role models, an “old boys club” culture and gender discrimination. The disparity is even more pronounced in interventional cardiology and electrophysiology. However, diversity issues have received more attention in cardiology in recent years, and several cardiology conferences have made efforts to increase the percentage of presenters and panelists who are women, minorities or from foreign countries.
Cardiology Today and Healio spoke with several prominent cardiologists active in diversity and inclusion issues about their reactions to the news from The Lancet and where the cardiology specialty currently stands on diversity and inclusion. Martha Gulati, MD, MS, FACC, FAHA, division chief of cardiology at the University of Arizona College of Medicine – Phoenix, physician executive director for Banner University Medicine Heart Institute and editor-in-chief of the American College of Cardiology’s CardioSmart; Robert A. Harrington, MD, interventional cardiologist, the Arthur L. Bloomfield Professor of Medicine and chairman of the department of medicine at Stanford University and president of the American Heart Association; Cardiology Today Editorial Board Member Erin D. Michos, MD, MHS, FACC, FAHA, director of women’s cardiovascular health, associate director of preventive cardiology and associate professor of medicine at Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease; Juan M. Aranda Jr., MD, FACC, FHFSA, professor of medicine, interim chief of the division of cardiovascular medicine, vice chair of clinical affairs in the department of medicine and director of heart failure/cardiac transplantation at University of Florida in Gainesville; Cardiology Today Next Gen Innovator Ki Park, MD, interventional cardiologist and VA associate program director at Malcom Randall VA Medical Center and the University of Florida; and Clyde W. Yancy, MD, MSc, MACC, FAHA, MACP, FHFSA, vice dean of diversity and inclusion, Magerstadt Professor of Medicine, professor of medical social sciences and chief of the division of cardiology at Northwestern University Feinberg School of Medicine, associate director of Bluhm Cardiovascular Institute, Northwestern Memorial Hospital and deputy editor of JAMA Cardiology, provided their opinion on this issue.
Martha Gulati, MD, MS, FACC, FAHA
I am really happy about The Lancet’s statement. It is about time, but I don’t want to diminish it by saying that because someone has to be first and change the status quo. I’m glad that a journal has taken such a public stance, particularly one of such international influence. It means it is bigger than just devoting one issue to the topic, but actually influencing change in the entire Lancet family of journals. I’m hopeful that this will translate to other journals and beyond to meetings, panels, press interviews and other forums. The Lancet did address all of those points in their statement.
This is important because these steps need to be taken in order to make meaningful change. NIH Director Francis S. Collins, MD, PhD, in June said he won’t speak on “manels” anymore. Some cardiologists, including Robert A. Harrington, MD, the new AHA president, have said they won’t speak on “manels” either.
From a journal perspective, when there is a long line of authors that are all men, it seems it would be the perfect opportunity to include women, but by mandating it, those opportunities will open up and be more inclusive.
The Lancet statement goes even beyond just women. The Lancet is an international journal, so having people from low-income countries represented and having minorities represented is part of this initiative and this is important for us to recognize for our entire medical community. Diversity of voice and opinion is needed. As a cardiologist, I want the same thing for our cardiology community.
Sometimes I see adequately diverse representation on the podium at cardiology meetings I attend in some sessions, but often I leave feeling there is not enough. But here’s the great thing: Our next ACC president is a woman, Athena Poppas, MD, who will assume the presidency in March 2020. The vice president is also a woman. The board of trustees now also has more women. This is what cardiology needs to make women feel welcome in the cardiology community and a part of its future. It makes our community more welcoming to a more diverse group and, therefore, we’re better equipped to take care of our patients, who are increasingly diverse. We need to look like our population. We need to know our community, understand the issues that affect their health and access to it, to adequately represent everyone. A diverse workforce will make this possible.
This should also be done to attract the next generation of cardiologists. We need people to want to join us or we will have a shortage of cardiologists. If people don’t see cardiology as a career because they never see anyone that looks like them, we will suffer as a community.
There has been a lot of research on women and their CV health, and this really was the result of women cardiologists addressing these issues. We have guidelines and advice for women cardiologists about reducing radiation risk during pregnancy. Again, this came from women cardiologists because there was a need. These things are less likely to be addressed if there were only men, but women in cardiology remains a minority; it is still only 13% of practicing cardiologists.
What is seen to the outside world matters.
When we have our conferences, you maybe see just one woman at the podium and maybe they’re just a moderator, and not to minimize that role, but we need women as speakers too to discuss their research, present the guidelines and be at the experts table.
I would also ask us to consider other ways to grow our community and be more inclusive. Include more diversity and include junior faculty as well. We need to see more faces; not always the same faces.
In 2019, the images we display matter. Even at the meeting planning stages, if you don’t include women, you won’t get their perspective. So, to meeting organizers: Plan with women in mind. Plan ahead so they can get time for arrangements for day care. Don’t replace the women asked who declined with men. Ask another woman.
We know already in interventional cardiology there are fewer women, but there are ways to get women there. Ask the women who decline or are overcommitted to suggest other women. Consider emerging women faculty. Ask “Women As One” for names because that is why this nonprofit was created: to be a source for anyone looking for speakers within the cardiology community.
If you make policies like The Lancet has, they’re committed to have at least 50% of women on their editorial board, then they’re going to hold themselves to that. Fifty percent is the minimum, and that’s fantastic. The Lancet is more than cardiology, but in medicine, 50% or more of the community are now women. Let’s welcome them and integrate them in all aspects of medicine. In cardiology, we still have work to do. We’re still a minority, but ask women, make them be seen, feature them, make sure that they know they’re part of the community and make policies like this, the commitment to have more women on the stage, on the panels, part of guidelines, part of papers, research and editorial boards. Look for them, find them because they’re out there and they’re waiting, but they’re not always in a leadership position to be able to ask and don’t always have networks to be able to be pointed out.
This isn’t just a female issue actually; this should be all of our issue if we really want to diversify our field and be able to serve our patient population, which is increasingly diverse, whether we’re talking about race, gender or any underrepresented groups. There are a lot of men who also want more diversity and are champions of women, and highlight that we need to change things. This is what we need.
We need to keep expanding, keep growing, letting us become something greater. That’s how our cardiology community and our patients will benefit.
Robert A. Harrington, MD
I am pleased to see The Lancet make this announcement. Only by intentionally and deliberatively making changes like this will equitable progress be made.
Cardiology, and especially interventional cardiology, is not a diverse specialty. It’s especially concerning that there are almost 50% women in internal medicine residencies, which is the entry point to cardiology training, but less than 20% women as cardiology fellows and less than 10% in interventional fellowships. This is wrong from an equity perspective, but it’s also potentially bad for the field, as we are leaving talent behind. We need more diversity in cardiology for our patients, for the best science and for training the next generation.
Kudos to The Lancet for taking this step. More journals and institutions need to do the same. At the American Heart Association, we have instituted a Women in Science working group to address these issues and to increase the gender balance in our committees, research grant review, writing groups, etc.
The AHA Scientific Sessions planning committee is committed to no “manels” at this year’s meeting in November.
Erin D. Michos, MD, MHS, FACC, FAHA
By The Lancet’s commitment to diversity, they mean increasing representation not only of women, but also of persons of color, colleagues from low- and middle-income countries and early career researchers.
There are many barriers that limit the advancement of women, and one major barrier is implicit bias that leads to the subconscious devaluation of women’s professional work and accomplishments. The problem is that each one of us, even women, carries these implicit biases that can impede academic advance of women. There have been multiple studies about this, including a wonderful recent paper by Arghavan Salles, MD, PhD, in JAMA Network Open in July 2019 (Salles A, et al. JAMA Netw Open. 2019;doi:10.1001/jamanetworkopen.2019.6545) that looked at implicit bias tests of health care professionals. Both men and women filled out this implicit bias test, and health care professionals were more likely to associate the concepts of “career” with men and “family” with women. In addition, among medical careers, they were more likely to associate surgery with men and family medicine with women.
That is why I am very happy to see The Lancet, a major journal-publishing group that also has 18 sub-journals, leading this change and this awareness by speaking openly about it. This is part of a positive movement that has been going on for a little while. Frankly, this movement is long overdue, but better late than never that some top leaders and organizations like The Lancet are shining light on inequities and advocating for change.
The Lancet, under the leadership of editor-in-chief Richard Horton, FRCP, FMedSci, and executive editor Jocalyn Clark, PhD, MSc, has been bold and visionary about this with their journal’s declaration that “Feminism is for everybody.” I absolutely loved their special The Lancet Women issue in February 2019, entirely dedicated to the advancement of women in medicine, science and global health, and they made that content free access.
When you are an editor or a reviewer, you could discourage when you see these papers come through and suggest a more diverse team. This is one of the things The Lancet said in this pledge. There was a paragraph near the bottom of the article that states, “Our preference for diversity among author teams.” I love that. This encourages that the work that’s being submitted should include women and ideally should include persons of color, authors from low- to middle-income countries and individuals from all stages of their career, including early career and senior career. We want diverse author teams to promote the best possible science coming forward in our field.
In this Lancet pledge, they’ve declared that they as an editorial team will not sponsor or attend any conferences or public panels that are manels.
There have also been individual male faculty that have stated pledges saying, “I’m not going to speak on a panel if there are not any women.” That’s great that they do that, but many times when people get invitations as an individual, they don’t really know what the conference schedule looks like and who else is on the panel. They may show up and find out it’s a manel that they didn’t know about. Thus, the onus needs to be on the meeting organizers. I don’t think anyone sets out to say, “I want an all-male panel.”
Thus, professional societies need to have a mandate that they’re not going to have manels because this forces organizations to think beyond their initial box and actually reach out beyond their comfort zone. It turns out when the panels are more diverse, they tend to be much more interesting. Diversity is not only including more women and persons of color, but I also really like panels that are mixed with a senior investigator and a junior person to bring in a fresh perspective. The voice of early-career investigators is valued too. I assure you that there’s no shortage of talent out there.
Ideally, we want to get 50/50 representation on panels, but at a minimum, they at least have to be representative of the field. For cardiology, it should be at least 25%, or one out of four panelists have to be a woman at a minimum. We can do better than minimum though and avoid the “token woman.” I would like for it to be half-and-half. If that’s a mandate on the organizers, we can do better.
There are people who come to these meetings that are often students, fellows and residents in their early career and they see what’s up there on the stage as indicative of leaders in the field. You cannot be what you cannot see. If all you see is white men and you’re not a white man, it’s hard for you to envision that, “Yes, I can be up there on that stage as a late-breaking trialist and I can be the next president of whatever organization.” Representation matters and it matters a lot. It matters everywhere. It matters in conference panels, in grand rounds speakers, in awards/honors, in leadership positions, and in portraits that are displayed in institutional halls. There has been a lot of discussion about that recently, and I’m glad that people are speaking out.
Going forward, this started with “manels.” That is just one step and that is important, but clearly just the tip of an iceberg. We need to get to the root of the problem to enact meaningful changes and the time is now. This is the role of professional societies, of institutions and of individuals to be better.
There has been a devaluation in women’s work in the health care sector with these gaps in grant funding, in publications and in leadership and this needs to end. The Lancet pledge has a great quote in this paper: “The costs associated with lack of equity and diversity are huge.” We have all this talent and we are not utilizing it to its full capacity. This is a loss to health care and to science. Until it is fully addressed, there will be stagnation in progress for the field of cardiology by not capitalizing on all available talent.
Juan M. Aranda Jr., MD, FACC, FHFSA
This is very encouraging, and I’m glad that they’re making a stand on this. The whole issue of diversity — we know that different patient populations are subtleties in terms of care and what the issues have. They need to be well represented in clinical trials, in committees and in organizing bodies so that the leadership and authors can point out those subtleties, which leads to better care. Whether it’s care, whether it’s publications —the whole umbrella of diversity — it’s about time that this is being addressed. I’m very excited about what The Lancet is doing.
In the past, meetings that I have attended did not have diverse representation on the podium, but over the last several years, there’s a conscious movement of — we have our speakers, let’s look into diversity, how many women speakers, how many women’s issues, how many men, how many African Americans, Hispanics. At the grassroots level, it started to be addressed in the American College of Cardiology and a lot of its regional and national meetings, but The Lancet movement is a big step to moving forward about the issue of diversity.
The next step is a firm commitment that not only in picking the speakers and the content, but in the organizing bodies, the people that organize these meetings, the people in the national cardiology associations, the governing boards, diversity needs to be included so there’s equal representation to organize all these meetings downstream and do a better job of raising awareness of diversity. We still have to go further up the totem pole in terms of the organizing bodies that diversity be addressed at that level.
It’s a great step forward to address the issues of diversity and getting people of different ethnicity and culture the opportunity to represent the views on the patient populations that they represent.
Ki Park, MD
The announcement from The Lancet is a true landmark event in our current era of medicine. It is truly remarkable that The Lancet has taken the lead in making such an announcement. Cardiology is, unfortunately, well known for its lack of diversity, which also translates into academia. Women in cardiology are so often underrecognized and passed over for speaking engagements, academic writing opportunities and leadership positions. Although there has been much “talk” in this area, The Lancet is truly “walking the walk” by releasing this statement, which not only details the issues in this area but lays out very specific goals regarding inclusion of women in speaking panels, editorial positions, etc.
I have attended a wide variety of general cardiology and interventional cardiology meetings. Over the last few years I have seen some increase in the number of women present on speaking panels, although the numbers are far below where they should be. One trend that I have noted is for major conferences to feature sessions specifically dedicated to women interventional cardiologists to give lectures on didactic topics or present interesting cases. Although I appreciate the intent behind these sessions, I do hope that conferences can look beyond just dedicating one session or a series of lectures to women in our field, and make the overall inclusion of women in the conference schedule as a whole a focus. This speaks to The Lancet’s specific comment against manels, and that ideally half of the panelists should be women.
One specific area within diversity that should be more of a focus is engagement of young cardiologists in our field, particularly young women in cardiology. This is not only to highlight these women who deserve recognition, but also to increase visibility to younger generations of trainees who are considering a career in cardiology. This is particularly important in our procedural fields where women represent less than 10% of those in interventional cardiology and electrophysiology.
I hope that other major cardiology journals and conferences will follow The Lancet’s lead in promoting more diversity in our field by announcing concrete measures such as those outlined in this initiative.
Clyde W. Yancy, MD, MSc, MACC, FAHA, MACP, FHFSA
The Lancet publishers and editors are to be commended for taking an intentional step to advance the representation of women as editors, reviewers and contributors to the family of Lancet journals. Moreover, the commitment that none of the Lancet editors will serve on any all-male panels is laudable and follows the course set by Francis Collins, MD, PhD, director of the NIH. These are necessary steps that ought to be taken, given the changing demographics in medicine and the important heterogeneity of the patients we serve. At least 50% of entering U.S. medical students are women, and in the U.S., there is no longer a majority population among persons under age 18 years. Succinctly stated, the world has changed.
This discussion instigated by the Lancet group merits further exploration. As an African American, I represent a culture that has known bias all too well. Persons in medicine with my heritage remain terribly underrepresented, and this trend is only exaggerated in clinical trials, medical leadership and especially in scientific journal editorship. The hindrance this represents in the application of science, promulgation of new discovery and best quality of care to all applicable cohorts has been well documented and has been of negative consequence in minority communities; change is needed.
I applaud the force of change exerted by forthright women and those men in medicine that have offered unwavering support. It is inexcusable for the voice of any stakeholder to be left out of pertinent scientific discussions not withstanding sex/gender or race/ethnicity. The efforts of The Lancet editors to include those from low- and middle-income countries and, I hope sincerely, to include editors of color should also be acknowledged. But the road ahead remains not well paved and obstacles await: What is the correct percent representation? What is the pathway for career progression to journal leadership? Does this diversity pledge extend to the publishers of The Lancet? How deep is this commitment? It will take courage and resolve to fully execute these pledges. Are the editors ready to also make a “no apology” pledge and be steadfast in the attainment of these very clear objectives?
Finally, there should be no discussion regarding content expertise. The mere suggestion that such might be a concern is overtly a biased point of view. Indeed, The Lancet journals and all journals will benefit and be refreshed from the diversity of thought that this new editorial composition will yield. I am supportive. – by Darlene Dobkowski and Erik Swain
Disclosures: Gulati, Harrington, Michos and Park report no relevant financial disclosures. Yancy reports he has no relevant financial disclosures but serves as deputy editor for JAMA Cardiology and holds editorial board membership on several other scientific journals.