A Diversity Scorecard to Teach, Not Shame, Cardiology to Do Better

; Michelle Albert, MD; Eldrin F. Lewis, MD, MPH


June 14, 2022

This transcript has been edited for clarity.

Robert A. Harrington, MD: Hi. This is Bob Harrington from Stanford University, for Medscape Cardiology and theheart.org. Thanks for joining us.

During the pandemic, we've talked about a lot of important issues facing cardiovascular medicine, including the science of COVID and cardiovascular risks among patients with COVID. We've talked about a variety of issues that affect us more broadly — I'll call it healthcare in society, including the fact that the pandemic has laid bare the issues of vulnerable populations being most adversely affected by COVID. That opens up the broader conversation about diversity, equity, and inclusion in medicine and specifically in cardiovascular medicine.

Cardiovascular medicine is not a diverse professional field, but a lot of work is underway by a variety of groups to try to address some of those issues. The group that is perhaps foremost in advocating for change in those issues around workforce equity is the Association of Black Cardiologists (ABC). They've recently released the results of a diversity scorecard, which grades institutions on how well they're doing with diversifying their training programs.

We thought this would be a great time to bring in two leaders of American cardiology and the ABC to have this conversation. It's a privilege to introduce two close friends and colleagues, coincidentally both here in the Bay Area. Dr Michelle Albert is the Walter A. Haas-Lucie Stern Endowed Chair in Cardiology. She is professor of medicine at the University of California, San Francisco (UCSF); director of the NURTURE (CeNter for the StUdy of AdveRsiTy and CardiovascUlaR DiseasE) Center, a research-oriented institute at UCSF; and the dean of admissions. Michelle is the recent past president of the ABC, and she is the president elect of the American Heart Association (AHA). Michelle, thanks for joining us here on theheart.org.

Michelle Albert, MD, MPH: Thank you. It is indeed an honor to be here to discuss this important topic and the scorecard.

Harrington: We look forward to hearing about it and your views on it.

Next, we have my good friend and colleague here at Stanford, Dr Eldrin Lewis. Eldrin is the Simon Stertzer Professor of Medicine and chief of the Cardiovascular Medicine Division at Stanford University. He is also the chair of the research committee of the ABC. Eldrin, thanks for joining us on theheart.org.

Eldrin F. Lewis, MD, MPH: Thank you so much, Bob. I'm excited to be a part of this conversation as well.

Harrington: Before we jump into the topic at hand and focus on the scorecard and what you found and what we can all do about it, Michelle, can you frame the importance of a diverse workforce as we think about clinical care, education, research, and all the things academic medical centers should be focused on? Why is it important?

Albert: Now more than ever, given the disproportionate impact of COVID-19 on communities of color — especially African American, Hispanic American, and Native American communities — as well as lower socioeconomic status communities, it's critically important that we have a diverse workforce that addresses the unmet needs. We've certainly seen improvements in technology, drug therapy, and clinical trials over the past three decades. But the facts of those improvements in cardiovascular medicine have not translated into improvements in life expectancy or disability for communities of color, specifically Black and Hispanic communities.

Why is this the case? In part, this is the case because we don't have the workforce that can communicate effectively with those communities and also design research and clinical trials that incorporate elements that are important for addressing the disparities. We also don't have a diversity in clinical trial participants or in investigators. This investigator aspect is particularly important as we think about the workforce. As dean of admissions at the UCSF School of Medicine, I know that over the past 30 years, there has been a 30% decrease the number of Native Americans applying to medical school. Applications from African Americans have only gone up by 1.2%. And this is despite an increase in applications to medical school in general.

And that's not about the pipeline that feeds into medical school, which is so critically important. All this reverberates into residencies, into cardiovascular fellowships, into not having the clinicians and researchers who can bond and gain trust from the communities that need to be in clinical trials that then relate to what we see in terms of disparities in healthcare.

The ABC has been in existence for 50 years and was founded on the principle of taking care of and focusing on the needs of a diverse America, especially African Americans. During my presidency over these past 2 years, it has been important from a strategic prep standpoint for me to usher in programs that focused on the workforce.

Harrington: That was a nice overview of the importance of this.

Eldrin, you're chief of cardiology. That means you're helping select trainees for fellowships and postdoctoral research spots. You're also hiring faculty at all levels, from assistant professors to professors. How do you think about the workforce? You have to assemble a team. How do you think philosophically about assembling that team? What are you thinking about in terms of the kind of fellows you want, the kind of postdoctoral research and postdoctoral graduates you want? Who are you looking for?

Lewis: First, I would echo what Michelle has said about the importance of the pipeline. I'm looking for excellence across the board — in clinical care delivery and advocacy for our patients, but also to help in the national landscape with policy development, research, and meeting patients where they are. Part of that is meeting the diverse needs of our patients.

Many patients want doctors who look like them. We want a better understanding of how we can use those similar cultural backgrounds and apply them to changing behavior for secondary prevention, primary prevention, and even primordial prevention. But we realize that one of the best ways to recruit a diverse science and cardiology workforce will be to actually develop the workforce ourselves. So, it's important to have not only a wide variety to choose from in regard to people who've already completed their internal medicine residencies and who are applying to fellowships, but also to have a diversity of interests. Just because someone comes from an underrepresented racial or ethnic group doesn't necessarily mean that they're interested in doing disparities research, which is it's so important. We want basic scientists, translational scientists, population scientists, addressing what they want.

My job as chief of cardiovascular medicine is to ensure that the interests, whatever they are, will be met and that there will be a fertile environment for residents and fellows to get the training. Part of that training involves recruiting a good cadre of mentors and a mentorship team who can not only mentor but also sponsor, so that we can shepherd people through the process. What better way of doing that than by working hard to have a diverse fellowship program and provide them with the tools necessary to not only understand what they want to accomplish in their academic and clinical careers, but also to enable them to become the future mentors across the spectrum of people who are in the training pipeline.

Harrington: Michelle, I want to highlight something that Eldrin said because it's so important. He said that patients sometimes, maybe even all the time, like to engage with clinicians who look like them. Some important work, such as the Barbershop Blood Pressure Study, shows that when you have a community of caregivers who reflect the community, the care and outcomes are better. Could you touch upon that? We're not just saying that this is a good thing to do. This is evidence-based.

Albert: I want to touch on several things around that issue. First, we know that, and on a personal note, many patients will reach out to the cardiovascular clinic at UCSF and say, I want to see Dr Albert. Then, when I meet with them, they say they specifically chose me because I am an African American woman. And they believe this is going to offer them the opportunity to express their lived experience in a way that they have not been able to with other clinicians. I know that from a personal perspective; that's my lived experience.

Now, moving to the evidence-based aspect of this, there was a study from Florida looking at the racial concordance between providers and babies born, and the and the perinatal outcomes were improved for those babies who had racial concordance with the provider. This was not the mother; this was the child. Similarly, the barbershop study that you mentioned is important in that regard because it brings another part of the healthcare team — pharmacists — into the social determinants of health, and it meets people where they are. All those elements put together engender more trust, more uptake, and more adherence to recommendations.

This competence or understanding of how discrimination is baked into our medical systems and structure is important to understand in our therapeutic relationships with patients. This doesn't mean that in the wide swath of our beautiful spectrum of race and ethnicity in the world, you can't take care of a person of color if you're not a person of color. It's really understanding that the issue of diversity is important. Eldrin mentioned diversity in thought as well as diversity as it relates to lived experience. Those are all important.

The other thing Eldrin touched on that I want to pivot back to is, when we're recruiting for fellowships or for the medical school, one of the things I say in the opening when I'm talking to the applicants is, you know, we're looking for doctors who are going to address the most pressing issues that face us over time. We can't anticipate what those are, we only know what some of those are right now. But what that means is that we need to recruit people who are going to be exceptional across the spectrum of medicine.

Harrington: You both brought up this issue of trust. There is a deep literature now that's very much in favor of the notion that trust is an important part of the clinician-patient relationship. People do better when they trust who is taking care of them. Now we have data that support that.

Eldrin, let's get to the ABC work in this area. Certainly, ABC is interested in diversifying the workforce. In the cardiology workforce, it starts with a very early pipeline. I always love the pictures of Quinn Capers doing white coat ceremonies for kindergartners in Columbus, Ohio. But that's not what you're doing out here. You're picking cardiology fellows. And the ABC has started to quantify how those institutions that have training programs are doing. Tell us about the project, and then maybe Michelle can give us an insight into some of the data, including the UCSF and the Stanford data.

Lewis: The project is meant to give us a snapshot and ask where we are, understanding that this is a snapshot year over year and it certainly can change, especially when you have relatively small numbers. The idea is that if you don't look at something, then you won't know when there needs to be a change.

The example I would use is disparities research again. For decades we've said, okay, there are disparities — racial disparities and gender or sex disparities. What we don't do enough is to emphasize what we can do to change. These are the things that work; these are the things that don't. If you don't characterize it, then you don't look for it.

The scorecard for institutions with a 20% or higher representation from a racial or ethnic group among the fellows — basically Black, African American, Hispanic or Latinx, et cetera — would be in the green category; those with 10%-19% would be in the yellow category; and less than 10% would be in the red. When this data came out, it hurt that we at Stanford were in the 10%-19% category. I know that if we were to look today, we would be in the green. But it was a snapshot at the time.

It means that we need to be purposeful. We can't just say we'll recruit agnostically. We have to look specifically at what the makeup of the fellowship program will be. An example that doesn't include race is if I were to look at the seven fellows coming into cardiology, and all seven wanted to become interventional cardiologists or basic scientists. I would say, okay, I need to make sure I find a place for all seven people coming in, so I want to look for diversity of interest. But also, it's important to be a vibrant fellowship training program. You want to make sure that you have diversity across all lenses, with racial and ethnic diversity as well as gender and sex-based diversity. So I'm excited about what we've done and the next iteration we will be integrating.

Harrington: Michelle, give us the snapshot of US medical schools when the ABC released these results.

Albert: First, I want to backtrack a little, because I want to make sure we include a couple of other factors. The scorecard is called the Association of Black Cardiologists' Diversity, Inclusion and Belonging Scorecard (ABC DIBS). A 10-member committee worked to pull this together, but it is a new spin on an older version that the ABC issued about 15 or 20 years ago. There was an institution that, since its inception, had never recruited any African Americans to their program. Because of that earlier version, that institution later became one of the most diverse institutions in the United States. So putting something out there so people can see it acts as a real motivator. We all know that there are problems in programs, but it doesn't mean necessarily that programs would make an effort to change.

The other point is that it was difficult to garner the information to put on this scorecard. We contacted 42 programs, including the top 20 US programs and other geographically diverse institutions. It took a lot of effort to get this information. The official sources from which you can get this information said they would give us the information, said they would give us the information, said they would give us the information, said they would give us the information. And often, we never got it. We ultimately received information from 29 programs, mostly from program directors. This is important, because this is how we perpetuate structural discrimination and racism, if we're not able to actually put our laundry out there. What was nice about what Eldrin just said is that he knows where Stanford is on this list and is using it as a growth opportunity, as a growth mindset. This is really important.

The scorecard was intended to capture the number of Black and Hispanic trainees across the programs, as well as the number of faculty, because the faculty is an important part of this. We have not published the faculty data yet. We'll do that in the next rendition.

It's also important to highlight which programs were in the green: Beth Israel Deaconess Hospital; Boston Medical Center; Brigham and Women's Hospital; Duke University Hospital; University of Pennsylvania; Mass General Hospital; Morehouse School of Medicine, which is a predominately and historically Black college and university; UCSF, my home institution; University of Florida, Jacksonville; University of Pittsburgh Medical Center; and Vanderbilt University Medical Center. Those programs need to be commended as well as the programs in transition.

This is not a shaming document. I want to congratulate all the programs that submitted data, because being vulnerable enough to submit data means that you care about this issue. In this document, maybe you're in the red, but you put yourself out there and made yourself vulnerable. The ABC appreciates that.

Harrington: Thank you for listing the sites that are in the green. Getting back to Eldrin's point, these are outstanding cardiovascular medicine training programs no matter how you look at it, so it's fantastic that they're committed to this aspect of excellence, along with other measures of excellence. I would also agree with both of you that, similar to quality improvement work, you first have to measure things, then you have to report on them, and then you have to come up with a plan of action. This is an opportunity for all of us who lead residency and fellowship programs to get better at what we do.

What else can we do to make cardiology a welcoming place for people of all backgrounds? One thing Michelle talks about a lot is the intersectionality of things, like being Black and a woman. Cardiology has been working hard at trying to increase the number of women in cardiology. We're working hard to increase the number of Black cardiologists, Hispanic cardiologists, and those from other underrepresented groups. Eldrin, what can we do in addition to measuring, reporting, and consciously thinking about this?

Lewis: We have to break down the misperceptions. I'm not going to just focus on racial and ethnic diversity, but also on gender diversity when we're looking at 15% of the workforce in cardiology being women. Many times when I talk to medical students and try to encourage them to go into cardiology, they say, I don't like the work-life balance. But there are so many things to do within the field of cardiology. The misperception that it's hard, that it's not an area where I can thrive, that must be broken down.

The reason it's so important to have a diverse workforce is that there is nothing better than to look at someone who has a similar background, a similar upbringing, who can say, I've done it. Let me tell you how life is and let me tell you how I got to where I am now. So, in addition to breaking down the misperceptions, we have to move upstream — that includes high school, undergrad, certainly medical school — to continue to say, this is how you can become a clinician, a clinician scientist, a clinician educator. Here are the many paths, the diverse fabric of how to be a cardiologist and how to succeed.

Harrington: I love that example. Talking about the personal narrative can make a difference. You and I have participated in some of the AHA high school programs where you meet these amazing young kids and you wonder, how can we pull them into cardiology with us? The personal story goes a long way. Michelle, what can we do? What tangible advice can you give to the audience?

Albert: Grounded in the principle that we all belong to the human race and that we all hope for the best for our neighbors and friends, if you think of a neighbor or a friend who is from a different background than you, I'm sure you wouldn't want anything bad to happen to them. You want a workforce that can take care of them. In that light, starting from that grounding, I think one thing we need to do is to transform our educational and training modules.

Right now, medicine is becoming more diverse; 50% of our medical students are women, for example. Certainly at some medical schools, the UIM (underrepresented in medicine) percentage is upward of 30%-50%. That means that the culture of medicine has to evolve to be in parallel with the needs for those students and trainees. That's something we have to do in terms of cleaning our house.

That also gets to the intersectionality issue you mentioned, Bob, because as you know, medicine traditionally has been White and male. And if medicine is traditionally White and male, many White men now are concerned that if all we're talking about is this diversity and inclusion, then, what about me? That speaks to those persons rolling up their sleeves and joining the transformational movement that's occurring in medicine. That's a really important thing.

Finally, leaders must be judged on their mentorship and sponsorships. We need more leaders who will commit to that.

Harrington: I believe you're both spot-on that mentorship, sponsorship, and allyship are critically important and about the call-out to all leaders to make that part of their own personal scorecard.

Thank you both, Dr Michelle Albert from UCSF and Dr Eldrin Lewis from Stanford. The work you're doing is incredibly important for all of us, as we aim to diversify and make even more excellent our cardiovascular workforce. This has been a terrific conversation. Kudos to the ABC for taking this on. It's hard work.

Thanks to our audience for listening to us. This is Bob Harrington on Medscape Cardiology and theHeart.org.

Robert A. Harrington, MD, is chair of medicine at Stanford University and former president of the American Heart Association. (The opinions expressed here are his and not those of the American Heart Association.) He cares deeply about the generation of evidence to guide clinical practice. He's also an over-the-top Boston Red Sox fan.

Follow Bob Harrington on Twitter

Follow theheart.org | Medscape Cardiology on Twitter

Follow Medscape on Facebook, Twitter, Instagram, and YouTube


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.