Systematic recruitment initiative diversified cardiology fellowship applicants
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A systematic recruitment initiative in the Duke Cardiovascular Disease Fellowship Program improved the proportion of women and underrepresented racial and ethnic applicants, interviews and first-year fellow matriculations.
According to research published in JAMA Network Open, the fellowship recruitment initiative increased the percentage of applicants in the entire population who were women and individuals from an underrepresented group from 27.8% in 2006-2016 to 66.7% in 2017-2019.
“Cardiology is not a diverse profession, with underrepresentation of women and Black, Latinx and other groups,” Jennifer A. Rymer, MD, MBA, interventional cardiologist at Duke University Hospital, and colleagues wrote. “The American College of Cardiology, American Heart Association and other societies have recognized this as a problem for the profession that limits access to talent and impacts the care of an increasingly diverse patient population. The goal of a more diverse profession can be accomplished only by attracting a broader range of trainees. Structural and unconscious biases are prevalent and difficult to counteract.”
Researchers evaluated the effects of a systematic recruitment initiative for cardiology fellowship and divisional leadership and general cardiology fellow applicants to the Duke Cardiovascular Disease Fellowship Program that aimed to improve matriculation of women and underrepresented racial and ethnic groups. Changes included the creation of a fellowship diversity and inclusivity task force that drafted recommendations that included reorganization of the fellowship recruitment committee and changes to the applicant screening process, interview day, applicant ranking and post-match interventions.
The primary outcome was changes in percentage of matriculating and overall women and underrepresented groups in the fellowship program in the 10 years prior (2006-2016) and 3 years after (2017-2019) the interventions were implemented.
Improvements in underrepresentation
According to the study, the Duke Cardiovascular Disease Fellowship Program received on average 462 applications annually before the interventions, which increased to 611 applications annually after the interventions.
The average percent of women applicants increased from 22.4% before the intervention to 26.4% in the 3 years after (P < .001), and the percentage of applicants from an underrepresented group increased from 10.5% to 12.5% (P = .01).
Among applicants who were interviewed for the fellowship program, the proportion of women increased from 20% to 33.5% (P = .01), and interviewees from an underrepresented group increased from 14% to 20% (P = .01).
Researchers also found that the percentage of women matriculated as first-year fellows increased from 23.2% to 54.2%, and the percentage of matriculations from an underrepresented group increased from 9.7% to 33.3%.
“We attribute this success to multipronged, intensive interventions including institutional commitment, thoughtful planning, reorganization of our program leadership and recruitment committee, changes to our recruitment interview processes, and, during recruitment and selection, highlighting our commitment to diversity and reducing implicit bias,” the researchers wrote. “We are able to report a significant increase in both women and underrepresented racial and ethnic group representation in a cardiology fellowship training program over a short period of 3 years.”
Following the intervention, the proportion of the entire fellowship who were women increased from 27% to 54.2% after 3 years of interventions, and the proportion of applicants from underrepresented groups increased from 5.6% to 33.3%.
Moreover, the proportion of applicants in the entire population who were women or from underrepresented groups increased from 27.8% to 66.7%, according to the study.
“Future educational interventions and areas for study include expanding implicit bias training to more faculty, expanding core curricula to include lectures on racial and ethnic disparities, and comprehensively assessing the association between the initiation of individual interventions on recruiting more diverse fellowship classes,” the researchers wrote. “In addition, assessing the association between deepening pipeline and faculty-directed initiatives such as ADVANCE-UP (Academic DeVelopment, Advocacy, Networking, Coaching and Education for Underrepresented Populations; developed by co-author Kevin L. Thomas, MD) on improved recruitment and retainment of diverse faculty is an area of active focus at Duke.”
Support needed in all areas of cardiology
“Given that the numbers of women and women from underrepresented racial and ethnic groups 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,” Joyce Njoroge, MD, clinical fellow in medicine at the University of California, San Francisco, and colleagues wrote in a related editorial. “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 underrepresented racial and ethnic groups 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 colleagues should also be congratulated for acknowledging and beginning to take action around the limitations of standardized testing,” Njoroge and colleagues wrote. “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.”
Reference:
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Nosheen Reza, MD
The main takeaway from this study is that the thoughtful implementation of a systematic, evidence-based recruitment program can significantly impact the number of individuals from historically underrepresented and excluded groups who successfully matriculate into cardiology fellowship training programs.
A recent survey of cardiology fellowship program directors, performed by the American College of Cardiology, showed that 63% of fellowship program directors who responded to the survey did not think that diversity needed to be increased in their programs. In this survey, only 6% of program directors ranked diversity as a "top 3" priority when constructing their fellowship rank lists. The Duke program provides an excellent model for diversification of the medical workforce. Their efforts have been successful due in part to their faculty and fellows' enthusiasm for this mission, as the authors note in this study. To achieve further advances in equity in CV training, we will need to directly address the perceptions that diversity does not need to be increased and educate and equip program directors with strategies to make their programs more inclusive.
Diversifying the medical workforce is of critical importance to eliminating racial, ethnic and sex-based disparities in CV care.
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