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Invited Commentary
Medical Education
January 11, 2021

Dismantling Structural Discrimination in Cardiology Fellowship Recruitment

Author Affiliations
  • 1Center for the Study of Adversity and Cardiovascular Disease (NURTURE Center), Division of Cardiology, Department of Medicine, University of California, San Francisco
  • 2Division of Cardiology and the Cardiovascular Institute, Department of Medicine, Stanford University, Stanford, California
JAMA Netw Open. 2021;4(1):e2031473. doi:10.1001/jamanetworkopen.2020.31473

Academic medicine bears responsibility for addressing structural discrimination in its midst. For example, women account for 13.2% of cardiologists, and 5% of cardiologists are Black or Hispanic physicians, statistics dictated by long-standing structural obstacles that impede recruitment and retention into the discipline.1 Rymer and colleagues2 must be commended for their efforts to diversify the Duke University cardiology fellowship program by focusing on mitigating structural factors. They embarked on increasing the number of women physicians and physicians from underrepresented racial and ethnic groups (UREGs; ie Black, Hispanic or Latinx, and Native American individuals) through the institution of initiatives during a 3-year period; their efforts resulted in an increase in women matriculants from 23.2% to 54.2% and in matriculants from UREGs from 9.7% to 33.3%, with a reflective increase in fellows enrolled overall from these groups.

The wake-up call for this endeavor is supported by research showing that 31% of cardiology fellowship program directors did not believe that health care diversity was important, 63% believed that their program did not lack diversity, and only 6% considered diversity a top 3 priority when ranking applicants.3 While published information on initiatives aimed at improving fellow and faculty diversity in training program remains limited, the latter is not surprising—albeit disappointing, given that improving diversity must be intentional. Indeed, internal medicine and cardiology leadership lacks gender and racial/ethnic diversity, with 7 Hispanic men and only 3 Black men and 1 White woman serving as cardiology division chiefs in the top 40 ranked programs.4

An increasingly appreciated tactic to improve diversity focuses on internal pipeline harnessing. To this end, while Rymer et al2 discuss fostering a relationship with the Duke School of Medicine and their internal medicine residency program to promote the passage of more women and physicians from UREGs along the path to cardiology, no information regarding the pipeline structure or how recruits were identified and retained is provided. Additionally, considering that 47% of Duke fellows from UREGs during the 3-year timeline were either Duke medical school graduates or internal medicine residents, caution must be exercised about internal pipelines reinforcing implicit biases about external candidates. Notoriously, candidates from diverse cultural and geographic backgrounds and training programs risk being sacrificed in mechanisms that heavily prioritize an internal pipeline, no matter how valuable that pipeline is. Thus, applying the principles of holistic review in alignment with institutional values to ensure fairness is necessary. Although the percentage of women applicants increased compared with all US Accreditation Council for Graduate Medical Education fellowships, the same was not true for applicants from UREGs, suggesting that a blueprint to channel is needed. A key step might be garnering feedback from all applicants who belong to UREGs, regardless of their match competitiveness. Additionally, a nurturing institutional climate, especially within cardiology, will dictate whether women and individuals from UREGs who are already in the pipeline choose to continue their careers at a particular institution. The analysis by Rymer et al2 indicates that, compared with physicians from UREGs, a relatively lower percentage of women enrolled in the Duke cardiology program from the internal pipeline. Because we have no information about the specific strategies used to enhance the progression of women to fellowship, we wonder about the perception, support, and academic progress of women fellows and faculty relative to their male counterparts at Duke.

The promotion of diversity, inclusion, and belonging is a cornerstone of the success of the medical profession overall and especially of addressing the unmet needs of health care. In this vein, it is crucial that women and individuals from UREGs in all disciplines of cardiology are equally supported. Women account for 21.5% of trainees overall, 9.8% of interventional fellows, 13.7% of electrophysiology fellows, 27.0% of heart failure fellows, and 21.5% of general cardiology fellows.1 Physicians from UREGs account for 12.8% of general cardiology fellows, 9.2% of interventional fellows, 10.3% of electrophysiology fellows, and 15.7% of advanced heart failure fellows.1 Given that the numbers of women and women from UREGs in fellowship and faculty positions are dismal in interventional and electrophysiology subspecialties and because procedural domains have traditionally enjoyed celebrated status in medicine, it remains vital to equitably respect and support all areas of cardiology. Lack of support contributes to structural discrimination for those in nonprocedural specialties in a manner that likely affects the interest of women and women from UREGs in any area of cardiology. Moreover, the unmet needs of health care will only be addressed by a robust workforce that prioritizes all cardiovascular medicine disciplines.

Rymer and colleagues2 should also be congratulated for acknowledging and beginning to take action around the limitations of standardized testing. They removed United States Medical Licensing Examination score criteria and masked reviewers to applicant photos. A next step might be discontinuing in-training service examination score utilization as a criterion and instituting pass-fail scoring to assess fellow quality. Standardized testing arguably represents a form of structural discrimination because the results are tied to socioeconomic status and preparation as opposed to intelligence or success as a physician, as many falsely believe.5

Potential limitations of this analysis warrant mentioning. First, continued longitudinal action and follow-up will be necessary to compare similar time frames. Second, transparency regarding successful and unsuccessful strategy details and metrics would be useful. Third, retention, belonging, and happiness data about fellows and faculty are key because these indices capture cultural and academic climate and support for women and members of UREGs. Consequential information garnered from feedback from persons who depart institutions because they did not have the right fit can be laden with bias; individuals who seemingly thrive in a location might simply be able to function within that climate, but this acknowledges nothing about the supportiveness of the environment. Fourth, systematic feedback from women ranked to match who did not attend Duke as well as all applicants from UREGs, regardless of match list status, should be obtained. Principal reliance on internal fellow and faculty impressions and on feedback only from applicants from UREGs who were ranked results in the loss of potentially critical data that might assist in recruitment efforts. Fifth, no specific information is provided about recruitment outreach—possibly implying overprioritization of internal candidates or those with a similar fit and perhaps consistent with their data showing no change in the percentage of applicants from UREGs. Finally, implicit bias training and impact measurement must be mandatory for everyone, not only for leadership.

It also bears mentioning that institutions need not go this road alone. Engagement of institutional efforts with those of professional societies is important. For example, cardiovascular professional societies, such as the Association of Black Cardiologists (ABC), have a long-standing history of supporting the careers of physicians from diverse racial and ethnic minority groups, particularly Black physicians across the medical professional landscape. During an almost 50-year timeframe, ABC has bolstered the cardiovascular workforce pipeline through mentorship and provision of scholarships from the premedical to faculty level as well as driven diversity and inclusion efforts at national and international levels. Over the years, interventional and electrophysiology fellowships have been offered to trainees to support their training. The American Heart Association has focused on supporting science and research endeavors of trainees and faculty from UREGs through substantive fellowship and research grant support. In recent years, the American College of Cardiology developed a diversity and inclusion initiative targeting women and individuals from UREGs to help address the pipeline. History teaches us that the most worthwhile life ventures require a collaborative, action-oriented marathon mentality—diversity in medicine is no exception.

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Article Information

Published: January 11, 2021. doi:10.1001/jamanetworkopen.2020.31473

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Njoroge J et al. JAMA Network Open.

Corresponding Author: Michelle A. Albert, MD, MPH, Center for the Study of Adversity and Cardiovascular Disease (NURTURE Center), Division of Cardiology, Department of Medicine, University of California, 505 Parnassus Avenue, San Francisco, CA 94143 (michelle.albert@ucsf.edu).

Conflict of Interest Disclosures: Dr Albert reported being president of the Association of Black Cardiologists. No other disclosures were reported.

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