Disclosures: Ferdinand reports no relevant financial disclosures. Johnson reports she serves as a consultant for Clue Medical and received speaker honoraria from the American Academy of Family Physicians and Delta Research and Education Foundation.
August 13, 2021
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As barriers to workplace diversity in cardiology persist, experts call for key changes

Disclosures: Ferdinand reports no relevant financial disclosures. Johnson reports she serves as a consultant for Clue Medical and received speaker honoraria from the American Academy of Family Physicians and Delta Research and Education Foundation.
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Despite data showing diversity among providers improves patient care and outcomes, barriers remain to increasing the Black, Hispanic/Latinx and Indigenous cardiologist workforce, according to a recent review paper.

The narrative review, published in Circulation and written by Amber E. Johnson, MD, MS, MBA, and colleagues, highlighted many of the hurdles that have perpetuated race-based disparities in the CV workforce.

Pull quote on the narrative review written by Amber E. Johnson, MD, MS, MBA, et al.
Amber E. Johnson, MD, MS, MBA, assistant professor of medicine at the University of Pittsburgh School of Medicine.

“We found that diversity has several challenges for implementation,” Johnson, assistant professor of medicine at the University of Pittsburgh School of Medicine, said in an interview. “There are disparities in educational opportunities, such as structural racism, historical injustice and exclusion, which make it difficult for candidates of diverse racial backgrounds to obtain the requisite level of education to even be considered for applying to cardiology.”

Johnson and colleagues wrote that there is even some financial disincentive for people who are from underrepresented or marginalized groups to stay in medicine. They cited a JAMA study that found that physicians from historically underrepresented groups are more likely to care for medically indigent and sicker patients.

“So it can be an unwelcoming environment for a lot of people from diverse backgrounds,” Johnson said.

Additionally, reliance on standardized testing scores, like those of the Medical College Admission Test (MCAT), represents another obstacle. Johnson and colleagues wrote that students from racially diverse backgrounds have lower MCAT scores on average, a finding that, according to research, is more indicative of racial bias and structural barriers than a lack of intellectual ability. Further, they wrote, applicants with lower test scores who enter supportive training environments perform similarly to their colleagues with higher scores.

Keith C. Ferdinand

Cardiology Today Editorial Board Member Keith C. Ferdinand, MD, professor of medicine, John W. Deming department of medicine, Tulane University School of Medicine, who was not involved in the writing of the Circulation review, told Healio there is cultural bias inherent in relying on standardized testing scores. “Simply using standardized test scores and grade point average greatly oversimplifies the potential for a person to be an excellent physician or cardiologist,” he said.

Diversity benefits patient care

In the review, Johnson and colleagues wrote that current medical education literature has underscored the psychosocial benefits of training in diverse learning environments.

“Students who train at diverse medical schools are better equipped to care for patients from diverse backgrounds,” Johnson said in an interview. “Even if they themselves are not a diverse student, just having other students around them who can share their perspectives and experiences helps for caring for patients in the long term.”

Johnson said physicians who are from diverse or underserved backgrounds have been shown to have more empathy and are able to relate with patients regardless of racial concordance. The review by Johnson and colleagues referenced a study in the Annals of Internal Medicine, in which patients who received care from race-concordant physicians had higher levels of positive effect and satisfaction, and rated their physicians as more participatory compared with patients who had race-discordant physicians. Moreover, a second study concluded that patient-provider race concordance improved adherence to cardiac medications for Black patients, whereas language concordance improved medication adherence for Spanish-speaking patients.

In addition, after completing training, physicians and specialists from diverse backgrounds tend to care for a more diverse population, Ferdinand told Healio. “That includes large amounts of disadvantaged people in working neighborhoods which are often underserved,” he said.

Overcoming the hurdles

Johnson said strategies for resolving race-based disparities can be broken into three levels: individual, institutional and policy-based. The individual level includes those who are in academia or who are cardiologists in training programs; she said these individuals need to view diversity as a way to better the learning and working environment.

“People who value diversity are more likely to actively mentor and sponsor diverse faculty for promotion and for consideration of different leadership opportunities,” she said. “And this goes for people who are and who are not of racial minority backgrounds.”

At the institutional level, Johnson and colleagues emphasized the role of holistic review in ensuring that training programs recruit highly qualified, diverse candidates.

Ferdinand agreed with the importance of holistic review.

“Medical centers have to recognize the value of having a diverse physician workforce and specifically seek out those candidates who will be excellent not only in terms of technical skills, but also in the ability to communicate, relate, increase adherence and stimulate positive health-seeking behavior on the part of their patients,” he told Healio. “Many of the major academic centers in the United States are located in areas with large, disadvantaged populations.”

Ferdinand added that metrics, including personal history, commitment to diversity and interests outside of traditional academic achievement, may predict a more culturally sensitive and potentially active and diverse physician population.

Regarding policy, Johnson said, “Anti-racist policies are needed, such as making education equitable and affordable, irrespective of race, segregation and neighborhood — things that we know are associated with worse educational attainment.”

Reversing national trends

Without a concerted effort to address these persistent disparities, certain alarming trends are prone to continue, Ferdinand said.

“It’s often said that the reason life expectancy in the United States is perhaps as low as 16th among industrialized societies is because we have an ineffective health care delivery system. I don’t think so,” he told Healio.

Ferdinand said if someone has the means, an identifiable source of primary care, appropriate referrals to specialists, and the ability to pay for deductibles and evidence-based medications, outcomes and survival in the United States are just as good, if not better than, what is observed in western Europe and Japan.

“The reason life expectancy in the United States appears so disadvantaged is because of the disparities and the short life expectancy, especially among African American adults and certain other disadvantaged minority populations, including Indigenous populations and some Hispanic/Latinx populations,” he said. “Therefore, until we correct these underlying disparities, the health of America will continue to suffer.”

References:

Keith C. Ferdinand, MD, can be reached at kferdina@tulane.edu; Twitter: @kcferdmd.

Amber E. Johnson, MD, MS, MBA, can be reached at johnsonae2@upmc.edu; Twitter: @amberjohnsonmd.