COMMENTARY

'I Was That Kid': Dr Quinn Capers Inspires #BlackMenInMedicine and Beyond

Interviewer: Robert A. Harrington, MD; Interviewee: Quinn Capers IV, MD

Disclosures

July 15, 2019

Robert A. Harrington, MD: Hi. This is Bob Harrington from Stanford University on theheart.org | Medscape Cardiology. As always, we're thinking about issues that are pertinent to the cardiovascular community. There are few topics in medicine today more important than diversity—diversity of thought, of background, and of people who are working in our field. I think the issue for cardiovascular medicine has reached a point where we need all hands on deck to pay attention to this.

We have an increasingly diverse population of patients that we're serving in our country, and we need our workforce of cardiovascular clinicians and scientists to reflect that, but we don't at the current time. Both the American Heart Association (AHA) and the American College of Cardiology (ACC) have renewed efforts in their commitments to diversity in our profession, and so I thought it would be a good time to engage in some discussion on this topic on Medscape Cardiology with a friend and colleague who has been one of the leaders in this area.

I'm pleased to welcome Dr Quinn Capers, from the Ohio State University. Dr Capers is a professor of medicine, an interventional cardiologist, and also dean of admissions at the medical school, so he offers us a perspective from medical students up through training programs in interventional cardiology. He is also playing a national role in helping us address some of these issues. He is a major force on social media. His Twitter hashtag, #BlackMenInMedicine, has resonated with a lot of people in the field, myself included, as an important way to call attention to outstanding young people and their accomplishments.

Quinn, thanks for joining me here on Medscape Cardiology.

Quinn Capers IV, MD: Thanks so much for having me, Bob. It's a real pleasure and honor to talk to you.

Why Do Diversity and Inclusivity Matter?

Harrington: The honor is mine. Let's dive right in. Could you set the stage for the audience on why this matters? Why should we be having this conversation? What are we trying to achieve when we talk about diversity and inclusivity in cardiovascular medicine?

Capers: At a high level, we know from fields outside of medicine, such as business and law, that when you have a group of people making decisions, the decisions are actually better. Those decisions are more profitable and more money is made if that group of people is not the same. When they have different backgrounds, different perspectives, and they think differently, they come up with better decisions that help the organization be more successful.

Now imagine in medicine, where we're literally making life and death decisions. For instance, who gets the heart transplant? What will be the next drug that we study and lobby for the US Food and Drug Administration to approve? What is the best treatment protocol? We want to make the best decisions so we can save the most lives. We need diverse people in the room who think a little bit differently because creative tension helps make better decisions.

Another very important aspect of this is that we all feel a little more comfortable around people who share a common background with us. Our patients are getting more and more diverse, and there are good data[1,2] that not only might many of them be more comfortable with people who share their background, but this might translate into things like compliance, adherence, and following the doctor's recommendation, etc.

On what I refer to as a dark side of this topic, practitioners may be contributors to healthcare disparities because they may tend to make different treatment decisions in different groups of people.[3] A physician might look at someone with diagnosis A from their background and recommend a certain treatment, but they might recommend a different treatment for somebody with diagnosis A who has a different background. They might recommend a different treatment because of implicit bias and maybe even explicit bias.

The way to minimize that is to have us all interacting with each other; but if we're all interacting with each other, it needs to be a diverse pool of physicians, students, nurses, pharmacists, etc. We'll make better decisions, minimize bias, and make our patients more comfortable and more willing to come to the table, speak freely, and tell us what they need.

Harrington: I like the way you have given us at a very high level why this matters and also pulled in some evidence from other fields. As you have rightly noted, we do make better decisions when we have a more diverse group of people contributing to the discussion.

Diversity (or Lack Thereof) in Cardiovascular Medicine

Harrington: Let me go to the level of cardiovascular medicine. You have been very involved on the national scene of trying to understand some of the diversity issues within our workforce. Let's specifically talk about the physician workforce for now.

We're not very diverse in cardiology, are we?

Cardiology, as a community of physicians, is not even close to being representative of the diversity in this great nation.

Capers: No, we're not. All fields of medicine are important. We're doctors first. But cardiovascular disease is the leading cause of death, as we know, and it kills more people every year than anything. But as a field, we're not very diverse. I don't think 20% of cardiologists are women, and when you go into the more procedural-based subspecialties of cardiology, the numbers are even lower. There are barely double digits of women in interventional cardiology.[4,5]

When you talk about the underrepresented racial and ethnic groups, they are the same underrepresented racial and ethnic groups in colleges, medical schools, and in residencies. Hispanics, African Americans, American Indians, Native Alaskans, and Native Pacific Islanders make up a very small portion of the pie. Not even 4% of cardiologists are African American, and not even 6% self-identify as Hispanic. When you try to look at the numbers of American Indians and Alaskan Natives, it's usually less than 1%. It is very hard to get a hold of that. So we're not even close.

Cardiology, as a community of physicians, is not even close to being representative of the diversity in this great nation. If you were to think, Maybe help is coming from people who are currently in the pipeline with our cardiology fellows, it isn't. We're not getting help from the immediate pipeline anytime soon because those same dismal numbers that I quoted for current cardiologists are about the same in our cardiology fellowship training programs.

Harrington: When you began to talk about cardiovascular disease as the globe's leading cause of death and disability, what struck me was that there are also some real health inequities in who gets cardiovascular disease. We need to be thinking about how we can have a diverse workforce that can help us address some of these issues.

There seems to be a difference in the diversity by gender versus the diversity of underrepresented racial and ethnic groups. We have plenty of women in our internal medicine pool and we're ending up with a small number of them in our cardiovascular training programs. In our racial and ethnic underrepresented groups, we're doing poorly at the resident level and at the cardiovascular level.

Do you want to talk about the gender issues and the racial and ethnic group issues?

Gender Imbalance in Cardiovascular Medicine

Capers: You and I both sit on the ACC Task Force on Diversity. This [phenomenon] right after residency was coined "the cliff." I think you were the first one I heard use that term.

Almost 50% of internal medicine residents, the specialty immediately preceding a cardiology fellowship, are women. But then we get this cliff, where we're down to 20% [who choose cardiology]. What happened to all of those women? It's not that they all want to be general internists. Are we doing things that are making our specialty less attractive to women?

There have been some very well-done studies, mostly with survey-based data, to show that women internal medicine residents feel like this may not be the specialty for them, whether it's because of how they perceive long work hours, because they don't see enough women cardiologist role models, or because somehow there is a notion that it's impossible to have a truly meaningful family life and be a cardiologist.[6,7]

As a specialty, are we doing things that are making our specialty less attractive to women?

It's been a bit of an embarrassment to cardiology that the American College of Surgeons and surgery as a group are being quite progressive in terms of making their specialty more attractive to women. If there is one specialty in medicine that was thought of as a true boy's club, it was surgery. There are some good lessons there for the ACC. We've got to figure out what we're doing that is turning women off, and we have a good start with two recently published papers.[6,7] Half of internal medicine residents are women, so let's act on this and get them interested in going into cardiology.

Underrepresentation of Minorities in Cardiovascular Medicine

Capers: For the underrepresented minorities, it's more complex. Not only are they underrepresented in internal medicine residencies but also in medical schools and in colleges. The Task Force on Diversity has coined this the "deep pipeline." To really move the needle, not only do we need to work on the immediate pipeline for underrepresented minorities to go into cardiology programs, but we also need to work on the deep pipeline. We've got to go back to college, we've got to go back to high school, and we probably ought to go back earlier than high school.

Harrington: I recall a meeting where you gave a presentation showing little kids having a white coat ceremony at the elementary school level. That is like the deepest pipeline.

Capers: A study really impacted me a few years ago. Fourth graders across the nation were interviewed and asked the same question that we always like to ask little kids: "What do you want to be when you grow up?" The proportion of little black kids who said, "I want to be a doctor" was not very different from that of little white children who said, “I'd like to be a doctor when I grow up."

They checked back in with them 2 years later, in the sixth grade, and there was a significant drop-off in the black children who were still saying that they wanted to be a doctor. Something is happening between the fourth and sixth grade that is leaving minority students feeling like medicine is not for them. That is why we all have to take this deep pipeline so seriously. We've got to encourage young people. We've got to let them see us and we have to demystify medicine.

https://twitter.com/DrQuinnCapers4/status/1124695980463591428

What you just mentioned is something I'm particularly proud of. The Ohio State University Wexner Medical Center, in a partnership with the Columbus, Ohio, public schools (kindergarten through 12th grade), created a Health Sciences Academy consisting of four middle schools, four elementary schools, and four high schools that feed into each other. From kindergarten through the 12th grade, they have a curriculum that is spiced with the health sciences. Medical students, pharmacy students, and nursing students have contact with these students. From kindergarten on up, they are being made to feel like medicine is not only something that they can do but it's something that they can be good at, and that they are wanted in this field. I would love to see this replicated in not only large cities but our medium-sized cities.

Harrington: I'm hoping that with this conversation we can let our listeners know that these are things that can be done at the grassroots level, at the local level, and they can really make a difference. We're in this for the long game. The AHA is funding opportunities for high school students to spend summers in science and college students to spend time on other campuses so that they can get exposed to high-level science and the excitement of the problems we're trying to solve in cardiovascular medicine. But we have to have a 10-, 15-, 20-year view on this so we can grab these 10-year-olds and get them excited, and provide them some mentoring and resources to stay engaged.

I love the piece of data that says something happens between the fourth and sixth grade, because that would suggest that we can intervene and do something.

Capers: Yes, absolutely. It's probably human nature that when we work hard on an intervention, we would like to see an outcome a year or two later. Trying to convince people to work in the deep pipeline [can be difficult] when they know that by the time this fourth-grade kid they are working with becomes a doctor, they won't be around to see it because they will be retired. We have to rethink that and grab some satisfaction and say, "I may be retired by the time this eighth grader is a doctor, but I'm helping humanity."

Harrington: I once heard a lecture from somebody talking about medieval times and this notion of building cathedrals. It was not likely that the workers who set out to build a cathedral would ever see a cathedral built because these things were built over 50, 75, 100 years, and yet there was a commitment to doing it. In many ways, what we have to do is have that mindset of building a cathedral that is going to take a generation or more to make a difference. We have to be able to view it from the long view if we're going to look back 20, 25 years from now. You and I will be sitting on the porch watching what is going on. We will want to know that that has made a difference.

Using Social Media to Raise Awareness

Harrington: You have raised awareness—certainly for me. I love following you on Twitter because the interactions that you have, particularly when you call students and you tell them that they have been accepted to medical school, gives me chills. It's so exciting and fun. As dean of admissions, you see yourself as having a social responsibility to help change things. Why have you chosen to publicize this on social media?

https://twitter.com/DrQuinnCapers4/status/1051811508181762048

Capers: It's quite simple. I was that kid, Bob, who was on my knees praying that God would allow me to become a doctor. It was in my heart and soul and I felt like I was called to this. So the day I got accepted to medical school was one of the happiest days of my life; it was the day I knew that medical school was not just something I had been dreaming about, but it was actually going to happen. As the dean of admissions at one of the nation's largest medical schools, I am now in the position to help others have that moment, and it's just such a happy and joyful moment. We live in times where it's not hard to find bad news on the Internet, television, and in newspapers, so I thought, "Let's put some of these joyous moments out there."

Harrington: When we see that and hear the shrieks of happiness, it makes a lot of us feel good about what you're doing and, by extension, makes us think about what we're doing in our own lives.

You've become known for the hashtag #BlackMenInMedicine. I love the stories when you are on call for the cath lab and you happen to wander through the student or resident lounge and find somebody hard at work.

What made you start calling attention to that hashtag, and what kind of feedback are you getting?

Capers: Thanks for the kind words. The Association of American Medical Colleges published a landmark report, Altering the Course: Black Males in Medicine, a few years ago[8] and it was calling attention to the lack of black males applying to medical school. In fact, those data showed that from 1978 to 2014, the number of black males applying to medical school had steadily gone down. There were more applying to medical school in 1978 than in 2014, and the line continues to go down.

They interviewed thought leaders and experts and came up with what they thought were probably some reasons why. Some of it was lack of role models. Some of it was just not seeing themselves. If you're a black young man, you think about becoming in life what you see a lot of. So they are not seeing us and they don't feel encouraged. Often, the nation can have a negative bias against black males.

[T]o use #BlackMenInMedicine, you don't have to be black, you don't have to be a man, and you don't have to be in medicine.

In November of 2017 I was interacting with several other black male physicians on Twitter, and we were talking about the report. We were kicking around some ideas, trying to figure out what we could do about that, and we came up with an idea.

What if we absolutely flooded social media with positive images of black male physicians, not only at work or with a scalpel or stethoscope in their hand, but at home with their family? Or riding a bike? We wanted to show everybody that we are here to encourage young people to perhaps go part way in helping to change the nation's implicit bias about black men—ie, that they are not all dangerous, and many of us are doctors. We thought it was a great idea. The group of us planned a launch date, and in the first couple of days there were several million impressions on Twitter. Twitter is the only social media platform that I am on, but #BlackMenInMedicine is meant to promote black males in medicine, those who are in medicine and doing exciting things, those who are in the pipeline, and to speak out against injustice.

https://twitter.com/DrQuinnCapers4/status/1123028626486767617

I always like to say—and I hope the listeners hear this and take this to heart—that to use #BlackMenInMedicine, you don't have to be black, you don't have to be a man, and you don't have to be in medicine. You just have to support that idea that diversity in medicine is a positive thing and you want to show some images that will inspire. It's all about inspiring people.

Harrington: I can't think of a better way to close this conversation. This has been a terrific reflection on the importance of diversity in medicine and, maybe more important, on things that we can all do to improve our field of cardiovascular medicine.

My guest today has been Dr Quinn Capers from the Ohio State University, where he is a professor of medicine and dean of admissions at the medical school. Quinn, thank you so much for joining me today on Medscape Cardiology.

Capers: Thank you so much, Bob. Take care.

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