Duke’s Douglas emphasizes the need for respect in promoting diversity, equity in health care

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

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

“She’s really changing the landscape of who goes into cardiology,” said Dr. Marta Gulati, ASPC president-elect 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’s meeting in Louisville, Kentucky, that “Without respect, we discourage participation and engagement, invite burnout, encourage rude behavior, [and] fail to create psychological safety. We hurt our teams,” she said.

And increasingly, medical institutions that do not demand respect “risk regulatory and accreditation sanctions and even legal action.”

In his lecture, “Strengthening Cardiovascular Prevention for the Future: Beyond the Alphabet,” Douglas focused on the principles of respect, diversity, and equity in health care as pillars of the profession—both to attract the best young doctors to the specialty and to better delivering health outcomes.

Cardiology has work to do in diversity, she said, showing data that the specialty lags far behind others in attracting women and minorities; a 2019 paper found that women made up just 13% and minorities just 5%. Those numbers aren’t just unacceptable in the abstract, Douglas said. It’s talent that isn’t available, and failure to fix structural sexism and racism “could put patient safety at risk.”

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

All of these things matter, she said, because “It’s what a person brings to their bedside.”

respect. Focusing on professional respect is important, Douglas said, because survey data show that lack of respect is the second most cited factor leading to burnout among cardiologists. And she showed how that spilled over into patient care with the troubling case of an attending physician referring to a senior associate as “from Mexico,” along with comments about the border, even though the junior doctor was born in the United States. When the head assistant noticed that the operator had made a mistake in the physical examination of the patient, he was afraid to pick him up – and so was everyone else.

In May, Douglas was the lead author of a Health Policy Statement from the ACC to build respect, civility and inclusion in the workplace. Douglas, a past ACC president, has long been a leader in the organization’s work to promote workforce diversity and better treatment and pay for women in cardiology. The statement cited studies that found 44% of cardiologists had experienced a hostile work environment, with gender being the most common reason for discrimination.

When large numbers of doctors believe they experience emotional harassment, sexual harassment or discrimination, Douglas said, “There are adverse effects on their professional activities with colleagues and patients, not just ‘I had a bad day.'”

Fixing a culture that lacks respect and diversity starts at the top, she said. This is a strategic priority for ACC, which has just appointed a new Chief Diversity Officer who reports to the CEO. People in those roles “can’t be HR assistants,” she said.

When asked how medical institutions can overcome power players and “feudalities,” Douglas said it will all come down to research dollars. Gone are the days of saying “This person has 3 grants, this person gets referrals; can’t we just sweep it under the rug? No, you can’t.

Accreditation groups like The Joint Commission and funding sources like the National Institutes of Health (NIH) take these things seriously, she said. When the NIH created 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 with toxic behavior.”

Funding sources do not wait for medical institutions to respond to carrots. “The stick happens somewhere in the world,” she said.

Diversity. What can be done to improve diversity? Douglas pointed to Duke’s efforts to overhaul the recruitment and application process for cardiology fellows from the top down — efforts that include overhauling the website to changing the participants in the selection process. Over a 3-year period from 2017 to 2019, Duke’s ability to enroll the women and minority applicants they interviewed increased. In the decade before the interventions, an average of 23.2% female and 9.7% underrepresented minority applicants enrolled as first-year fellows; then 54.2% of women and 33.3% of minority applicants enroll. The proportion of the entire program of fellows who were women increased from a 5-year average of 27% to 54.2% after 3 years; minority enrollment increased from 5.6% to 33.3%.

Equity in health care. While many specialties have focused on increasing health equity, Douglas said it’s especially urgent for cardiologists because up to 40 percent of patient outcomes are determined by social determinants of health (SDOH) — which include the level of patient education, access and insurance coverage, economic stability, their social and community context, and their neighborhood and built environment. There are calls for SDOH to become a “vital sign”, she said.

Long-term psychosocial and environmental stressors are known to adversely affect health, by increasing stress hormones, inflammatory markers and cellular senescence, Douglas said.

But she singled out racism as particularly harmful. “All of these factors are exacerbated 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 correct language and improving other communications.

“It was unacceptable that we weren’t providing social justice and we weren’t getting medicine into communities,” she said.