Evaluation of Women and Underrepresented Racial and Ethnic Group Representation in a General Cardiology Fellowship After a Systematic Recruitment Initiative

Trends in female representation in cardiology and its subspecialties: The current state and the desired state

INTRODUCTION

Women have been historically underrepresented in Cardiology and its subspecialties. However, limited research has been done to examine the trends of representation of women in cardiology and its subspecialties over time. Our study aims to examine these trends and compare them to other internal medicine subspecialties.

METHODS

We used data from the Accreditation Council for Graduate Medical Education (ACGME) to conduct a retrospective analysis of the gender trends of cardiology and its subspecialties over a decade from 2013 to 2023. Chi-square statistical testing was used to compare representation percentages across groups. A p-value <0.05 was considered statistically significant.

RESULTS

Compared to all internal medicine subspecialties, cardiology and its subspecialties continues to remain the least represented by women. We found a statistically significant increase in women's representation in cardiovascular disease and interventional cardiology. However, there was no statistically significant changes in the representation of women in electrophysiology and advanced heart failure. We have found over the last decade that there was a positive trend in overall women fellows choosing cardiology and its subspecialties, especially since 2018.

CONCLUSION

While strides have been made in increasing the number of female fellows in cardiology, it still lags compared to other internal medicine subspecialties. As we celebrate this minor milestone, it is crucial to emphasize the importance of persistently overcoming obstacles and fostering a supportive environment throughout all training phases to attract, retain, and mentor female trainees.

Geographic Mapping of Gender Disparities in Authorship of Cardiovascular Literature

BACKGROUND

Women in cardiology experience considerable gender disparities in publications, which hinders their career advancements to higher faculty and senior leadership positions. However, the extent of these disparities across different types of cardiovascular literature is not well understood.

OBJECTIVES

We investigated gender differences in authorship across various cardiovascular publications over a decade and examined geographic variations in the representation of women authors.

METHODS

All papers published from January 1, 2010, to December 31, 2019, in 4 major cardiovascular journals (Journal of the American College of Cardiology, European Heart Journal, Journal of the American Medical Association Cardiology, and Nature Reviews Cardiology) were reviewed.

RESULTS

Of the 18,535 papers with 111,562 authors, 20.6% of the authors were women, and 47.7% of the papers had no women authors. Over 10 years, the proportion of women authors remained low (20.7% in 2010 to 21.4% in 2019), with the lowest proportion in editorial papers (14.8%) and the highest in research papers (21.8%). More women as first (34.6%) and last (47.6%) authors were affiliated with institutions in the United States compared with other countries. The proportion of women middle-order authors was higher on papers with women as first authors (29.4% vs 20.5%) or last authors (30.6% vs 21.3%), compared with papers with men as first or last authors, respectively.

CONCLUSIONS

Over the past decade, the proportion of women authors across all article types in major cardiovascular journals remained low. A call to action is needed to promote women in cardiology and provide them with equitable opportunities.

The Impact of Social Determinants of Health on Transition From Pediatric to Adult Cardiology Care

Social determinants of health (SDoH) are the economic, social, environmental, and psychosocial factors that influence health. Adolescents and young adults with congenital heart disease (CHD) require lifelong cardiology follow-up and therefore coordinated transition from pediatric to adult healthcare systems. However, gaps in care are common during transition, and they are driven in part by pervasive disparities in SDoH, including race, ethnicity, socioeconomic status, access to insurance, and remote location of residence. These disparities often coexist and compound the challenges faced by patients and families. For example, Black and Indigenous individuals are more likely to be subject to systemic racism and implicit bias within healthcare and other settings, to be unemployed and poor, to have limited access to insurance, and to have a lower likelihood of transfer of care to adult CHD specialists. SDoH also are associated with acquired cardiovascular disease, a comorbidity that adults with CHD face. This review summarizes existing evidence regarding the impact of SDoH on the transition to adult care and proposes strategies at the individual, institutional, and population and/or system levels. to reduce inequities faced by transition-age youth. These strategies include routinely screening for SDoH in clinical settings with referral to appropriate services, providing formal transition education for all transition-age youth, including training on navigating complex medical systems, creating satellite cardiology clinics to facilitate access to care for those who live remote from tertiary centres, advocating for lifelong insurance coverage where applicable, mandating cultural-sensitivity training for providers, and increasing the diversity of healthcare providers in pediatric and adult CHD care.

Descriptive Analysis of Vitreoretinal Surgery Fellowship Program Directors

Purpose: To evaluate the demographic, educational, and scholarly characteristics of Association of University Professors of Ophthalmology-accredited vitreoretinal surgery fellowship program directors in the United States and Canada. Methods: Demographic, educational, and scholarly profiles of identified program directors were collated from online public resources. Characteristics were compared by sex, program size, ranking, and affiliation. Results: Eighty-one program directors (mean age [±SD] 54.7 ± 11.0 years) from 78 fellowship programs were identified. The minority were women (14.8%), who were on average 6 years younger than their male counterparts (P = .07). The majority of program directors had an academic affiliation (90.1%), most commonly professor (54.8%). The mean h-index, 5-year h-index, and m-quotient were 20.9 ± 14.9, 5.9 ± 4.4, and 0.82 ± 0.42, respectively. Compared with their counterparts, program directors of both "top 10" and large programs published more manuscripts (P < .05), accrued more citations (P < .05), and had a higher h-index (P < .05). Fellowship programs with female program directors had a significantly larger proportion of female retina faculty (P = .002). Conclusions: The backgrounds of vitreoretinal surgery program directors are diverse. However, women remain underrepresented in this position, highlighting an area with the potential for greater equity in ophthalmology.

Recruiting a Diverse Cardiology Physician Workforce

Importance

Understanding trends in the representation of women and individuals from underrepresented racial and ethnic populations in cardiovascular disease and cardiovascular subspecialty fellowships is essential to improving the diversity of the cardiology workforce.

Objective

To examine changes in the representation of women and underrepresented individuals in cardiovascular disease and cardiovascular subspecialty fellowships over time.

Design, Setting, and Participants

This cross-sectional study of trainee sex and race and ethnicity in various training programs from 2008 to 2022 used data from the Accreditation Council for Graduate Medical Education's publicly available online source. Participants included all residents, internal medicine residents, general surgery residents, and fellows in cardiovascular disease and cardiovascular subspecialty fellowships.

Main Outcomes and Measures

Percentages of women and Black and Hispanic trainees in these programs were calculated for each year. Mann-Kendall tests were used to determine if changes over the years represented a significant trend.

Results

Among the 3320 cardiovascular disease trainees in 2022, 848 (25.5%) were women, and 459 (13.8%) were Black or Hispanic, less than the representation among internal medicine trainees at 43.8% and 15.6%, respectively. However, the percentage of women trainees in cardiovascular disease significantly increased from 17.6% in 2008 (P = .001 for time trend) and also increased for interventional cardiology fellowships (from 6.3% in 2008 to 20.1% in 2022; P = .002). Over the same period, the proportion of women in general surgery increased from 27.4% to 45.2% (P < .001). The percentage of Black and Hispanic trainees in internal medicine significantly increased from 8.6% in 2012 (P < .001) while increases in general surgery were not statistically significant (9.7% to 16.1%; P = .35). There were also important increases in the percentages of Black and Hispanic trainees in cardiovascular disease (from 8.3% in 2012; P = .09) and interventional cardiology (3.8% to 13.4%; P = .12).

Conclusions and Relevance

In this study, the representation of women in cardiovascular fellowships, including interventional cardiology, increased over recent years. While representation of Black and Hispanic individuals is low in all residencies, including cardiovascular fellowships, recent positive trends are important to recognize and provide hope to drive future efforts.

Updates on Diversity Among Cardiology-Related Fellowships

Within the United States (US) medical system, diversity in healthcare is a growing concern although studies have shown improved patient outcomes when healthcare teams are diverse. We were interested in cardiology-related fellowships from internal medicine and surgical specialties to understand how females, osteopaths (DOs), and non-US graduates were represented compared to males, allopathic medical doctors (MD), and US-graduated peers. We obtained data about accredited cardiology fellowship programs from the Fellowship and Residency Electronic Interactive Database Access System (FRIEDA™) for 2022-2023 and determined statistical significance for male/female, DO/MD, and US/non-US graduate status by reviewing program sites. Statistical analysis utilized SAS Studio 3.8, version 9.4 (SAS Institute, Inc., Cary, NC) and Wilson score for confidence intervals. Cardiology-related fellowships from internal medicine and surgery backgrounds showed generalized marked disparities (p<0.001) with only a couple of exceptions. For Interventional Cardiology, non-US graduates were well represented (p=0.3775), and for Heart Failure & Transplant Cardiology, females were represented equally (p=0.0863). For all other specialties and values, females, DOs, and non-US graduates were underrepresented. Despite conversations about diversity, underrepresentation persists. We encourage further steps to address barriers preventing underrepresented groups from advancing to their full potential in leadership and careers. Increasing diversity promotes competence, empathy, communication, and inclusive patient care.

Addressing diversity in the physician workforce through social determinants of medical education

Social determinants of medical education are the most impactful aspects of recruiting, retaining, and producing the next generation of a diverse physician workforce. We can use the same framework well known to describe social determinants of health to identify social determinants that impact medical education learners and their ability to enter the workforce and succeed to completion. Efforts aimed at recruitment and retention should not exist in isolation and must be matched with those that continuously assess and evaluate the learning environment. The development of a climate where all can bring their full selves to learn, study, work, and care for patients is critically important in the creation of a learning environment where every participant can grow and thrive. If we are to address the need to diversify the workforce, we must be intentional with strategic plans, which includes addressing the social determinants that are prohibitive for some of our learners.

Evidence-based Best Practices in Recruitment of Diverse Residents: A Perspective From a Diversity Officer

The recruitment of a diverse resident workforce is the immediate proximate step to growing a diverse physician workforce. This recruitment requires intentionality on the part of residency programs and institutional graduate medical education offices. This article describes evidence-based recruitment "best practices" and encourages programs to stay committed.

Interventions Associated With Racial and Ethnic Diversity in US Graduate Medical Education: A Scoping Review

IMPORTANCE

Racially and ethnically minoritized individuals remain underrepresented in graduate medical education relative to their proportion in the population. While many programs and initiatives have been developed to address this problem, there is little consensus regarding strategies that work to improve representation across specialties.

OBJECTIVE

To examine and synthesize evidence-based practices that have been used to increase the proportions of underrepresented in medicine (URiM) trainees at US residency and fellowship programs.

EVIDENCE REVIEW

The authors searched PubMed, Google Scholar, Embase, PsycInfo, ERIC, Cochrane Reviews, Cochrane Trials, CINAHL, Scopus, and PROSPERO electronic databases to identify relevant studies published through January 2022. They screened all titles and abstracts for relevance and read full-text articles to identify articles reporting reliable data describing the outcomes of interventions to improve racial and ethnic diversity among trainees.

FINDINGS

Twenty-seven articles were included in this review. Two studies reported on fellowship programs. The most common interventions included holistic review (48%), decreased emphasis on United States Medical Licensing Examination Step 1 scores (48%), and explicit institutional messaging regarding the importance of diversity (37%). A combination of interventions was associated with an increased number of URiM applicants, interviewees, and matriculants across various medical and surgical specialties.

CONCLUSIONS AND RELEVANCE

In this scoping review, approaches and interventions associated with increased diversity in residency and fellowship programs were identified. Continued efforts are necessary to sustain such efforts and assess long-term outcomes.

Nurturing Diverse Generations of the Medical Workforce for Success With Authenticity: An Association of Black Cardiologists' Roundtable

The COVID-19 pandemic exposed the consequences of systemic racism in the United States with Black, Hispanic, and other racial and ethnic diverse populations dying at disproportionately higher rates than White Americans. Addressing the social and health disparities amplified by COVID-19 requires in part restructuring of the healthcare system, particularly the diversity of the healthcare workforce to better reflect that of the US population. In January 2021, the Association of Black Cardiologists hosted a virtual roundtable designed to discuss key issues pertaining to medical workforce diversity and to identify strategies aimed at improving racial and ethnic diversity in medical school, graduate medical education, faculty, and leadership positions. The Nurturing Diverse Generations of the Medical Workforce for Success with Authenticity roundtable brought together diverse stakeholders and champions of diversity and inclusion to discuss innovative ideas, solutions, and opportunities to address workforce diversification.

Association of Women Leaders with Women Program Director and Trainee Representation Across US Academic Internal Medicine

BACKGROUND

Women are underrepresented within internal medicine (IM). Whether women leaders attract women trainees is not well explored.

OBJECTIVE

To characterize leader and trainee gender across US academic IM and to investigate the association of leader gender with trainee gender.

DESIGN

Cross-sectional study.

PARTICIPANTS

Leaders (chairs, chiefs, program directors (PDs)) in 2018 and trainees (residents, fellows) in 2012-2016 at medical school-affiliated IM and seven IM fellowship programs.

EXPOSURE

Leadership (chair/chief and program director; and, for resident analyses, fellow) gender.

MAIN MEASURES

Our primary outcome was percent women trainees (IM residents and, separately, subspecialty fellows). We used standard statistics to describe leadership and trainee gender. We created separate multivariable linear regressions to evaluate associations of leader gender and percent women fellows with percent women IM residents. We then created separate multivariable multilevel models (site as a random effect) to evaluate associations of leader gender with percent women subspecialty fellows.

KEY RESULTS

Our cohort consisted of 940 programs. Women were 13.4% of IM chairs and <25% of chiefs in each fellowship subspecialty (cardiology: 2.6%; gastroenterology: 6.6%; pulmonary and critical care: 10.7%; nephrology: 14.4%; endocrinology: 20.6%; hematology-oncology: 23.2%; infectious diseases: 24.3%). IM PDs were 39.7% women; fellowship PDs ranged from nearly 25% (cardiology and gastroenterology) to nearly 50% (endocrinology and infectious disease) women. Having more women fellows (but not chairs or PDs) was associated with having more women residents (0.3% (95% CI: 0.2-0.5%) increase per 1% fellow increase, p<0.001); this association remained after adjustment (0.3% (0.1%, 0.4%), p=0.001). In unadjusted analyses, having a woman PD (increase of 7.7% (4.7%, 10.6%), p<0.001) or chief (increase of 8.9% (4.6%, 13.1%), p<0.001) was associated with an increase in women fellows; after adjustment, these associations were lost.

CONCLUSIONS

Women held a minority of leadership positions in academic IM. Having women leaders was not independently associated with having more women trainees.

Match Outcomes for Cardiovascular Disease Fellowship Training: 2010 to 2021

Background This study elucidates recent trends in application and match rates in the Cardiovascular Disease Fellowship Match. We hypothesized that (1) match rates have increased with time; (2) match rates are highest for US allopathic graduates; and (3) most candidates match at 1 of their top 3 ranked fellowship choices. Methods and Results This was a retrospective cohort study of all applicants in the Cardiovascular Disease Fellowship Match from 2010 to 2021 (n=14 674). Chi-square tests were used to compare trends over time and match rates by applicant archetype (US allopathic graduates and non-US allopathic graduates). The annual number of applicants increased from 1184 to 1575 (33% increase) while training positions increased 718 to 1045 (46% increase) over the study period. The percentage of applicants that matched increased from 61% in 2010 to 66% in 2021 (P=0.090). The average match rate was 70% over the study period. During each year, US allopathic graduates had higher match rates than non-US allopathic graduates (P<0.001), but this disparity narrowed with time (83% versus 41% in 2010 and 83% versus 54% in 2021). Most applicants matched at 1 of their top 3 choices (first, 37%; second, 12%; third, 7%). Applicants matching at 1 of their top 3 choices decreased from 51% in 2010 to 48% in 2021 (P=0.704). Conclusions The Cardiovascular Disease Fellowship Match has remained equally competitive over the past decade. US allopathic graduates have an advantage over non-US allopathic graduates. Most applicants match at 1 of their top 3 ranked fellowship choices.

Inclusion and representation in the pediatric surgery workforce: Strategies to mitigate bias in the fellowship application process

Diverse perspectives are critical components of effective teams in every industry. Underrepresentation of minorities in medicine leads to worse outcomes for minority patients, and efforts to increase diversity in the health care workforce are critical. Presently, about 70% of the pediatric surgery workforce is white, and pediatric surgeons at large do not reflect the racial or ethnic diversity of the populations they serve. Pediatric surgery fellowship training programs are the gateway to the field, and fellow selection processes should be optimized to support diversity and inclusion. The Association of Pediatric Surgery Training Program Directors (APSTPD) Diversity Equity and Inclusion subcommittee compiled best practices for bias mitigation during fellow selection, drawing from published literature and personal experiences in our own programs. A list of concrete recommendations was compiled, which can be implemented in every phase from applicant screening to rank list creation. We present these as a position statement that has been endorsed by the executive committee of the APSTPD. Pediatric surgery fellowship programs can utilize this focused review of best practices to mitigate bias and support diverse applicants.

A roadmap of strategies to support cardiovascular researchers: from policy to practice

Cardiovascular disease remains the leading cause of death worldwide. Cardiovascular research has therefore never been more crucial. Cardiovascular researchers must be provided with a research environment that enables them to perform at their highest level, maximizing their opportunities to work effectively with key stakeholders to address this global issue. At present, cardiovascular researchers face a range of challenges and barriers, including a decline in funding, job insecurity and a lack of diversity at senior leadership levels. Indeed, many cardiovascular researchers, particularly women, have considered leaving the sector, highlighting a crucial need to develop strategies to support and retain researchers working in the cardiovascular field. In this Roadmap article, we present solutions to problems relevant to cardiovascular researchers worldwide that are broadly classified across three key areas: capacity building, research funding and fostering diversity and equity. This Roadmap provides opportunities for research institutions, as well as governments and funding bodies, to implement changes from policy to practice, to address the most important factors restricting the career progression of cardiovascular researchers.

Gender Differences in International Cardiology Guideline Authorship: A Comparison of the US, Canadian, and European Cardiology Guidelines From 2006 to 2020

Background Women continue to be underrepresented in cardiology and even more so in leadership positions. We evaluated the trends and gender differences in the guideline writing groups of the American College of Cardiology/American Heart Association (ACC/AHA), Canadian Cardiovascular Society (CCS), and European Society of Cardiology (ESC) guidelines from 2006 to 2020. Methods and Results We extracted all guidelines authors from 2006 to 2020, assessed their gender from publicly available profiles, and compared differences based on subspecialties and specific societies. Stratified and trend analyses were performed using χ² and average annual percentage change/average 5 year percentage change. A total of 80 ACC/AHA (1288 authors [28% women]), 64 CCS (988 authors [26% women]), and 59 ESC (1157 authors [16% women]) guidelines were analyzed. A significant increase in inclusion of women was seen in ACC/AHA (12.6% [2006] to 42.6% [2020]; average annual percentage change, 6.6% [2.3% to 11.1%]; P=0.005) and ESC (7.1% [2006] to 25.8% [2020]; average annual percentage change, 6.6% [0.2% to 13.5%]; P=0.04), but the trend remained similar in CCS (20.6% [2006] to 36.3% [2020]; average annual percentage change, -0.1% (-3.7% to 3.5%); P=0.94), guideline authors. More women were coauthors in the ACC/AHA and ESC guidelines when women were chairs of guidelines. There was a persistent disparity of women among guideline authors for general cardiology and all subspecialties, except for pediatric cardiology and heart failure guidelines. The appointment of women authors as a chair was significantly low in all societies (22.4% [ACC/AHA], 16.9% [CCS], and 7.2% [ESC]; P=0.008). Conclusions There is a significant disparity in the inclusion of women on all national guideline committees, in addition to serving as a chair of cardiology guidelines. Further advocacy is required to promote equity, diversity, and inclusion in our cardiology guidelines globally.

Faculty Recruitment, Retention, and Representation in Leadership: An Evidence-Based Guide to Best Practices for Diversity, Equity, and Inclusion from the Council of Residency Directors in Emergency Medicine

Improving the recruitment, retention, and leadership advancement of faculty who are under-represented in medicine is a priority at many academic institutions to ensure excellence in patient care, research, and health equity. Here we provide a critical review of the literature and offer evidence-based guidelines for faculty recruitment, retention, and representation in leadership. Recommendations for recruitment include targeted recruitment to expand the candidate pool with diverse candidates, holistic review of applications, and incentivizing stakeholders for success with diversity efforts. Retention efforts should establish a culture of inclusivity, promote faculty development, and evaluate for biases in the promotion and tenure process. We believe this guide will be valuable for all leaders and faculty members seeking to advance diversity, equity, and inclusion in their institutions.

Racial Diversity Among American Cardiologists: Implications for the Past, Present, and Future

In the United States, race-based disparities in cardiovascular disease care have proven to be pervasive, deadly, and expensive. African American/Black, Hispanic/Latinx, and Native/Indigenous American individuals are at an increased risk of cardiovascular disease and are less likely to receive high-quality, evidence-based medical care as compared with their White American counterparts. Although the United States population is diverse, the cardiovascular workforce that provides its much-needed care lacks diversity. The available data show that care provided by physicians from racially diverse backgrounds is associated with better quality, both for minoritized patients and for majority patients. Not only is cardiovascular workforce diversity associated with improvements in health care quality, but racial diversity among academic teams and research scientists is linked with research quality. We outline documented barriers to achieving workforce diversity and suggest evidence-based strategies to overcome these barriers. Key strategies to enhance racial diversity in cardiology include improving recruitment and retention of racially diverse members of the cardiology workforce and focusing on cardiovascular health equity for patients. This review draws attention to academic institutions, but the implications should be considered relevant for nonacademic and community settings as well.

National Trends of Gender Disparity in Canadian Cardiovascular Society Guideline Authors, 2001-2020

Background

The level of representation of women in cardiology remains low compared to that of men, particularly in leadership positions. We evaluated gender disparity in the authorship of Canadian Cardiovascular Society (CCS) guidelines.

Methods

All CCS guidelines from 2001-2020 were identified. Gender was assessed based on pronoun use in the biographies and social media of the authors. Only primary panel authors were included in our analysis. Stratified analyses were performed based on subspecialties.

Results

A total of 76 guidelines were identified, with 1172 authors (26% women, 74% men, P < 0.0001), with no significant change in percentage of women authors over 2 decades, (37.1% in 2001, 36.3% in 2020, P = 0.34). Inclusion of women as authors occurred less frequently than inclusion of men in general cardiology guidelines (20.1% vs 79.9%, P < 0.0001) and all subspecialties—heart failure (36.4% vs 63.6%, P < 0.0001), interventional cardiology (12.6% vs 87.4%, P < 0.0001), electrophysiology (20.2% vs 79.8%, P < 0.0001), and pediatric cardiology (41.7% vs 58.3%, P = 0.02). It was less likely for women to be a chair or cochair of a guideline writing committee, compared with men (20.1% vs 79.8%, P < 0.0001). There were 609 unique authors (25.6% women, 74.4% men, P < 0.0001), 542 unique medical doctorate (MD) authors (20.7% women, 79.3% men, P < 0.0001), and 67 unique non-MD authors (65.7% women, 34.3% men, P = 0.0003).

Conclusions

There is a persistent shortfall in the inclusion of women authors for CCS guidelines, which has not changed over time. Further efforts are required to promote women's inclusion in leadership roles, which may lead to authorship of the guidelines.