COMMENTARY

Changing the Face of Cardiovascular Medicine: Increasing Gender and Ethnic Diversity

Robert A Harrington, MD; Fatima Rodriguez MD, MPH; Sheila Sahni, MD; Eric J Velazquez, MD

Disclosures

May 25, 2017

Robert A Harrington, MD: Hi, I am Bob Harrington here on theheart.org | Medscape Cardiology. I am from Stanford University, and we are here at the American College of Cardiology [ACC] meetings in Washington, DC. We are taking this opportunity to talk with a group of colleagues about a really important issue in cardiovascular medicine, and that is the changing face of the cardiology profession, or maybe we will just say that more broadly: the changing face of cardiovascular medicine.

I am joined today by three colleagues who are going to lend their insights and thoughts on the topic. Let me start next to me, with Dr Sheila Sahni from [the University of California, Los Angeles] UCLA, where she is an interventional cardiology fellow and very active in the Women in Cardiology[WIC] section here at the ACC and on social media.

Next to her is Dr Fatima Rodriguez. Fatima is the chief cardiovascular fellow at Stanford University. She is interested in disparities of care, particularly among Hispanics, and brings a great deal of expertise and insight in preventive cardiology. Thanks for joining us.

Fatima Rodriguez, MD, MPH: Thank you.

Dr Harrington: Finally, on the other side, in some ways, Eric, you and I bookend the old face of cardiology, my good friend and colleague for many years from Duke University and the Duke Clinical Research Institute, Dr Eric Velazquez, who is a professor of medicine at Duke and the director of cardiovascular imaging. Thank you to all of you for taking the time to join us.

Dr Rodriguez: Thank you.

Dr Harrington: Sheila, I am going to start with you. First we will talk about the issue of women in cardiology, the gender issues, and give an overview of how you are thinking of where we are at as a profession and maybe some of the things the American College of Cardiology is doing to try to address that.

 
all it takes is somebody saying you can do it.
 

Dr Sahni: Starting with general cardiology with the American College of Cardiology, the Women in Cardiology council, ACC WIC has done a lot. We have seen the growth from what used to be less than 10% of women to more [like] 13%, 14% of women, and most recently a paper came out about the pregnant cardiologist.[1] There are a lot of publications and documents from women who might be deterred by issues of work-life balance.

A big initiative has been to engage the younger women. You need to reach a girl in medical school as she is deciding between internal medicine or surgery, or even in residency. This year at the ACC, they have a session, "Engaging Internal Medicine Residents." We are also trying to promote awareness that you can be a woman who is a cardiologist, have work-life balance, and be happy. Through the use of the hashtag #ILookLikeACardiologist, we have been able to increase awareness about the profession and change the face on social media. The support of the community in ACC has been huge.

Dr Harrington: Yes, the same thing the surgeons have been doing with #ILookLikeASurgeon, and I do find it very helpful for people around the globe to be tweeting these out. For those of you out there, tweet out a picture of yourself. Is it "I look" or "look like"?

Dr Sahni: It is #ILookLikeACardiologist. Young women have approached me on both Instagram and Twitter saying that they are studying science and are very inspired, and this kind of inspiration drives that passion you might have. We are so impressionable when we are schooling and during residency, and all it takes is somebody saying you can do it.

Dr Harrington: Fatima, let us build on something Sheila talked about, which is the pipeline or the pool. We know that more than 50% of our medical students in the United States today are women. We know that somewhere around 44% to 45% of internal medicine residents are women, and yet less than 20% of cardiology fellows are women, less than 10% of some of the more invasive specialties are women.[2] Where are we losing, because certainly other invasive, high-demand, 24/7 professions like OB/GYN are not having this challenge?

Dr Rodriguez: Excellent question, and I completely agree with everything that Sheila has said about the importance of starting early in medical school. I think it all comes down to mentorship and having people encourage you. You want to have mentors who look like you and do it all, people who have children, have a family, are successful at research and are women. However, at the same time, most of the mentors as you know are actually men (you are among them). You want to have mentors who encourage you to pursue all your passions, but at the same time know that you may have certain demands, particularly as a young woman in medicine, that need to be addressed.

Dr Harrington: Eric, let us move to what men need to do, male leaders, and I think Fatima has described some of the issues about mentorship. When you and I went through training, within a few years of each other at Duke, our fellowship was mostly men, although we did have women over the years, but it was mostly men. In the cath lab where I worked at Duke, over the years, it was mostly men. What did you note along the way, and maybe, because we are also bringing in some other diversity issues, how did your experience entering cardiology, try to tilt the field a bit?

Eric J Velazquez, MD: It is wonderful to hear all this great activity, because it is certainly needed and has perhaps been delayed. My experience over the past 25 years has been one where I have seen incremental changes and improvements, but there are still fundamental challenges around how we organize our training paradigm, how we organize our clinical activities as an academic faculty member or in practice. I do not believe we have really looked deeply enough into the challenges that we have to address to position the field of cardiology to attract the best and the brightest women into the halls. Until we do that, I think it is going to be very hard to recruit.

My personal comment in response is that I actually would disagree slightly. I think we have to go earlier. To find individuals interested in medical careers in cardiology, cardiovascular science, we have to look for them in high school, in college, and develop research programs, bring mentorship opportunities to them. As leaders, we should be going out to our colleges and high schools locally and identifying people. My experience mentoring has been that people that have succeeded on this path have been individuals who have had continual mentorship with individuals who work to bring them along. I would just highlight that it has to start even earlier than residency.

Dr Rodriguez: I will add to that just as a personal anecdote, my mom had rheumatic heart disease, so from high school, I said I want to be a cardiologist. Fortunately, I did not know how long that path was and what it entailed, but I think that that early passion and finding mentors were important. Her cardiologist was one of my initial mentors, and then in academics, I was able to stick with the plan. Along the way, you can definitely get distracted, so you want to make sure you have continued, consistent mentorship and maybe a mentorship team, which Bob and I have discussed, is more important than having just one mentor.

 
women make up more than 50% of the patients. They need to have representation on this side of the table
 

Dr Harrington: Eric, I want to build on something that you said, and then I want to ask Sheila a couple of questions. You said 'the best and the brightest.' One of the reasons that I am very interested in the topic and have become increasingly engaged in the topic is my concern over the future of our specialty. If we have 50% medical students and only 15% women as cardiologists, there is a huge talent gap that we are leaving on the table and that bothers me. That means that we are not accepting, on probability alone, the most talented people into our specialty. That is what we have to work on. This is a specialty issue. Yes, there is an equity component, but it is really about we need the best and the brightest. That is what our patients deserve, the best people offering cardiovascular care.

Dr Velazquez: And, women make up more than 50% of the patients. They need to have representation on this side of the table.

Dr Harrington: That is an excellent point. I want to come back to that. Sheila, one of the things that Fatima said is that at an early age she was exposed to cardiovascular medicine through her mother, who was a patient. Just before we started this recording, we all had the opportunity to see your dad taking some pictures. He is a cardiologist.

Dr Sahni: He is.

Dr Harrington: That had to have been an influence.

Dr Sahni: My mom is also a physician, and we have three girls in the house (I am the middle child), and she would dress me up during the holidays and I would do rounds with her. Seeing patients in the clinic setting, where I would smile at them and take a history with my mom. I would just watch, but that was where I engaged in chronic illness. I had a passion and an inquisitiveness for science and that started in high school, and then I pursued that at the School of Health Studies at Georgetown University and then similarly, started very early with science and mentorship.

Concerning your point about losing talent and what can we do about that. Men in the field who are at the senior level of their careers should open doors for women, engage in mentorship of women who have this challenge—you sit on the WIC committee, that is huge. Also, Dr Sunil Rao in the interventional cardiology community has spoken up and said, it is a top-down effect, I want work-life balance too, as a man. I think the voices in the room that have always been there are the male voices, and for them to engage in this issue is huge for us.

 
I was very determined. If they can do it, I can do it. It was almost better that I did not know how long the path would be
 

Dr Harrington: I think the more we bring that balance into all of our lives, the better the specialty is. As Fatima knows in our clinic, my kids are dropping by to drop off my car keys, pick stuff up, and it does show people that there are other things that are going on in your life.

Let us talk a little bit about science, because Eric makes an important point. We have a problem in this country, Fatima, not just about women in science, but young people in science. An extraordinary figure I saw the other day is that more than 80% of finalists in the science fairs in the US now are children of immigrants.[3] To me that sends two important messages, the importance of attracting the best talent wherever they come from in the globe to the United States, but the second is what is going on with kids born in the United States who are not being exposed to science?

Dr Rodriguez: I could not agree more. I am a product of pipeline programs. I went to a very large public high school in Miami that had all these different after-school programs—one run by Lucent technology that engaged us with science products. We also had opportunities to shadow physicians in the community. All that attracted me to science at a very early age, and I was very determined. If they can do it, I can do it. It was almost better that I did not know how long the path would be, as I mentioned before.

Dr Harrington: You keep saying that. You are finished in July.

Dr Rodriguez: I am finished, yes.

Dr Velazquez: You are never finished.

Dr Rodriguez: You are never finished, and that is the beauty of cardiology and lifelong learning. Going out to the community, and I think maybe even before the high school level, the earlier the better. When I was in Boston as a resident I worked in a Martha Elliott mentoring program bringing science to elementary schools and middle schools, and again showing people—I look like you, I am from your community, and I am an internal-medicine resident, I am going to be a cardiology fellow. I think that really resonates with young people.

Dr Harrington: Eric, one of the things that you continue to amaze me with is the diversity of what you actually do, and one of your commitments for years has been to global health. You have spent a lot of time in Africa working to try to improve the work force there. Do you see some similarities to Sheila's point, opening doors, giving opportunities, to Fatima's point, networking, mentoring? Are there some similarities?

Dr Velazquez: Absolutely. I think we have more to learn from these global health opportunities than we have to give. I have always said that. I think the reason to go into global health environments should be a very selfish one, for us as American cardiologists. I have seen what the impact that even the limited amount of mentoring that I can provide someone who is thousands of miles away can be. That discussion, pushing people a little bit, saying you can do it, let us put together a program, let us go through steps, and let us get to the end. Some of these individuals do not have an opportunity to do that with a cardiologist. They may not even have cardiologists in their countries or in their communities. I have been very interested in the part of diversity that focuses on the road traveled. I think it is very critical to engage communities who are underrepresented, particularly social-economic status-wise, and have cardiologists in those communities meet with students and potential applicants to medical school and get them engaged. What I have learned is that there is a tendency to say we cannot do this, this is too hard. When you have a myocardial infarction in Eldoret, Kenya, that is a daunting experience. Here we can take care of that, we have a cath lab.

Even supply chains around morphine are an issue there. I can understand why they would say, we cannot do this. You just have to say no, you can, and you have to continue to provide that positive guidance. A lot of it comes down to just positive guidance.

Dr Harrington: In part, this is the Paul Farmer, MD, ethos of really just "get out there and do it."[4] Let us go back to something you brought up earlier and then you just referred to it again, Eric, and that is the patients that we see. Eric pointed out more than half of our patients in cardiovascular medicine are women. A large percentage of patients are Hispanic American, a large percentage African American, a large percentage from various countries in Asia who have come to the United States and now are patients. What are you learning through this process of thinking about women but applied more broadly to other diverse groups?

Dr Sahni: Every time I have a female patient, especially now in the cath lab I thank them, and I ask them if they would share their story on UCLA's media page, which is a great patient portal. The reason for that is I want another woman who has heart disease to hear their story, that they got an angiogram for chest pain. I extend that to my minority patients as well. I tell them that because of their ethnic race, whether it is Hispanic or African American, they are at risk for stroke, or they are at risk for high blood pressure if they do not watch what they eat. I think that that helps reinforce it, not just to them but then to their community and their friends. I engage them in the issues we are facing.

Dr Harrington: Fatima, you have done a lot of original research work on understanding some of the disparities of care among Hispanic subgroups.[5] What are you learning through these discussions, thinking about women, but more broadly? Certainly, the Bay area where you practice has a very diverse patient population.

Dr Rodriguez: I completely agree with Sheila that it is about patient engagement. A lot of the issues that I am interested in from a research perspective are around metabolic syndrome and cardiovascular prevention that are unique sometimes in the Hispanic population and in the South-Asian population. Just by having that discussion with the patient, engaging them after their treatment, asking them to speak to their community, get family members screened, saying you have these risk factors, but you also have a brother who is 40 years old and has the same constellation of risk factors, bring them in, have them come to the clinic. You know that we often see entire families in the clinic and it is one of the best parts of our job, using this as a platform to get engagement in the community.

Dr Harrington: Eric is smiling because he thinks of me as a cath-lab interventional cardiologist. Fatima has helped transform me to be a preventive cardiologist. Eric, from your perspective, and I like the notion of "the distance traveled"; my colleague, Abraham Verghese, MD, uses that phrase all the time. Talk to me about your clinical practice and how you think about these issues.

Dr Velazquez: Initially I went into community health centers. We started a program there. I am focused on heart failure. I am a heart-failure cardiologist predominantly and focused on increasing access. I realized that that was not enough. It has to be sustained. It is a very important component I would like to say. It just cannot be a one-and-done affair. It has to be a sustained contribution to the community to increase people's awareness of disease processes and recognize that there are people like them who are willing to help them take care of them. I think that last part is very important, and one of the reasons we have to strive to increase the diversity among our colleagues in cardiology is that for whatever reason it may be cultural. It may just be human nature, but, patients want to see physicians who look like them, who talk like them, who can relate to their life issues. That sometimes is an area where we particularly fail, particularly in African American communities and Latino communities, where people do not feel that someone understands them, even though we all try really hard to do so. I think that is another issue that we have to continue to build on.

In my practice, you mentioned about my experience as an administrative leader at Duke, I feel very proud that our section is the most diverse in cardiology. We have probably the largest group of women and largest African American representation and Latino representation, but it is not a lot. I really have strived for at least 50%. That is distinctly different from other sections, and that is not because they are not doing a good job, it is just harder perhaps because in cardiovascular imaging, historically, there has been more flexibility. You have mentioned several times it takes a long time to train. You have other life experiences, you want to have children, and you want to have family-life balance. Cardiovascular imaging provides, perhaps, an easier way to get there, but it has to be obtained in every subspecialty. I think that is something that we need to figure out how to do.

Dr Harrington: Go ahead. I will give you the final word.

Dr Sahni: I wanted to say that you mentioned imaging and you have mentioned the length of practice, so I started out wanting to do cardiovascular imaging, and you brought up my dad; he wanted to probably protect me from the perils of the cath lab and the long hours. He could not. I did a lot of imaging research, but I loved the cath lab. I think that, yes, it takes a long time to train in cardiology and it is hard work for all of us. We have to connect to the young generation's passion, because if you are passionate about something then it does not matter how long the hours are. That is where I think having the strong role model of my dad has helped; he has supported my passion for interventional cardiology. That is what you are getting at, is really engaging the community.

Dr Velazquez: Cardiovascular imaging is not a fallback; it should be a goal.

Dr Sahni: Exactly.

Dr Velazquez: That is one of the comments and points I bring up when I interview someone for a position, do you want to do this, or are you here because you do not want to do something else? If you want to do something else, let us make sure you do that.

Dr Rodriguez: I know we are running out of time, but I will just add that sometimes we have to step back and go back home and step away from academia to say what a privilege it is at our job—every day is to take care of patients and to improve our body of knowledge through research. We should not forget that nor take that for granted.

Dr Harrington: Yes, that was a great wrap-up. I want to thank the three of you. Incredibly important topic about the diversity and the changing face of cardiology, whether we are talking about our patients or we are talking about our colleagues. Progress is being made, but there is a lot of work left to do. Our patients warrant it, the research warrants it, and it is an exciting time for trying to make some progress.

I want to thank you, Sheila, Fatima, Eric.

I am Bob Harrington, and thank you for listening.

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