Duke’s Douglas Highlights Need for Respect in Promoting Diversity, Health Equity

Promoting diversity in the cardiology workforce and improving health equity requires the field to demand respect among fellow doctors—because it’s the right thing to do, and it affects patient care, Duke University’s Pamela S. Douglas, MD, told cardiology professionals who gathered to open the 2022 Congress of the American Society for Preventive Cardiology (ASPC).

Douglas, who is the Ursula Geller Distinguished Professor for Research in Cardiovascular Disease, in the School of Medicine and a member of the Duke Clinical Research Institute, is so highly regarded for her work to promote diversity, equity, and inclusion in the field that the American College of Cardiology (ACC) named its award for this work in her honor.

“She’s really changing the landscape of who is entering the cardiology field,” said Martha Gulati, MD, MS, the incoming president of ASPC, who is a cardiologist at Cedars-Sinai Heart Institute, and director of Prevention and associate director of the Barbra Streisand Women's Heart Center.

Douglas told the group meeting in Louisville, Kentucky, that, “Without respect, we discourage participation and engagement, invite burnout, encourage uncivil behavior, [and] fail to create psychological safety. We damage our teams,” she said.

And, increasingly, medical institutions that fail to demand respect “risk regulatory and accreditation sanctions and even legal action.”

In her talk, “Strengthening Cardiovascular Prevention for the Future: Beyond the ABCs,” Douglas focused on the principles of respect, diversity, and health equity as pillars for the profession—both to attract the best young doctors to the specialty and to delivery better health outcomes.

Cardiology has work to do in diversity, she said, showing data that the specialty is well behind others in attracting women and minorities; a 2019 paper found women make up just 13% and minorities just 5%. These numbers are not just unacceptable in the abstract, Douglas said. That’s talent that isn’t being accessed, and a failure to fix structural sexism and racism “can threaten patient safety.”

In addition to achieving greater diversity, Douglas said, fellowship programs must take a more holistic view to the recruitment process, weighing both clinical expertise with values. Is the person honest? Does he or she display cultural competence, and perform community service? Does this person have experience with diverse populations?

All these things matter, she said, because “This is what the person brings to the bedside.”

Respect. Focusing on professional respect is important, Douglas said, because survey data show lack of respect is the second most-cited factor leading to burnout among cardiologists. And she showed how this spills over into patient care with a disturbing case of an attending physician who referred to a chief fellow as being “from Mexico,” along with comments about the border, even though the younger doctor was born in the United States. When the chief fellow noticed the attending had made an error in a patient’s physical exam, he was afraid to bring it up—and so was everyone else.

In May, Douglas was the lead author on a Health Policy Statement from the ACC on building respect, civility, and inclusion in the workplace. Douglas, a former ACC president, has long a leader in the organization’s work in promoting workforce diversity and better treatment and pay for women in cardiology. The statement cited surveys that found 44% of cardiologists had experienced a hostile work environment, with gender being the most frequent cause of discrimination.

When a large number of physicians feel that they are experiencing emotional harassment, sexual harassment, or discrimination, Douglas said, “There are adverse effects on their professional activity activities with colleagues and patients, not just, ‘I had a bad day.’”

Fixing a cultural that lacks respect and diversity starts at the top, she said. It’s a strategic priority at ACC, which just named a new chief diversity officer who reports to the CEO. Persons in these roles “can't be some adjunct in HR,” she said.

When asked how medical institutions can overcome powerful players and “fiefdoms,” Douglas said it’s going to be all about the research dollars. The days are over of saying “’That person has 3 grants, that person gets referrals; can’t we sweep it under the rug?’ No, you can’t.”

Accreditation groups such as the Joint Commission and funding sources such as the National Institutes of Health (NIH) are taking these things seriously, she said. When NIH set up a hotline for people to report harassment, the result was that 75 investigators lost funding, which Douglas attributed to clearing out “a backlog of people who had toxic behavior.”

Funding sources aren't waiting for medical institutions to respond to carrots. “The stick is happening out there in the world," she said.

Diversity. What can be done to improve diversity? Douglas pointed to efforts at Duke to overhaul the cardiology fellow recruitment and application process from top to bottom—the effort included overhauling the website to changing who participated in the selection process. Over a 3-year period from 2017 to 2019, Duke’s ability to enroll the women and minority candidates who interviewed soared. In the decade before the interventions, an average of 23.2% women and 9.7% underrepresented minority candidates matriculated as first-year fellows; afterward, 54.2% of the women and 33.3% of the minority candidates enrolled. The share of the entire fellowship program who were women rose form a 5-year average of 27% to 54.2% after 3 years; minority enrollment rose from 5.6% to 33.3%.

Health equity. While many specialties have turned their attention to increasing health equity, Douglas said it’s especially urgent for cardiologists, since up to 40% of patients’ outcomes are driven by social determinants of health (SDOH)—which include a patient’s education level, access and insurance coverage, economic stability, their social and community contexts, and their neighborhood and built environment. There are calls to make SDOH a “vital sign,” she said.

It’s known that long-term psychosocial and environmental stressors have adverse impacts on health, through increasing stress hormones, inflammatory markers, and cellular aging, Douglas said.

But she called out racism as especially harmful. “All of these factors are made worse by racism,” she said.

Following standards is one way to find solutions. Douglas pointed to resources from the American Medical Association and HHS; the latter provides a 15-point list of culturally and linguistically appropriate services—such as providing services in the right language, and improving other communications.

“It’s been unacceptable that we're not providing social justice and getting medicine in communities,” she said.