CardioNerds (Amit Goyal and Daniel Ambinder), Dr. Victoria Thomas (Cardionerds Ambassador, Vanderbilt University Medical Center), and Dr. Quentin Youmans, cardiology fellow at Northwestern Medicine Bluhm Cardiovascular Institute, join Dr. Clyde Yancy, Vice Dean for Diversity and Inclusion and Chief of Cardiology in the Department of Medicine at Northwestern for an important discussion about underrepresentation in clinical trials and guidelines. This episode was recorded during a live event hosted by the ACC Illinois Chapter. Listen in to hear why diversity matters in clinical trials, how we can recruit more minorities in representation in CV trials and so much more! Stay tuned for a message by chapter Governor, Dr. Annabelle Volgman.
The PA-ACC & CardioNerds Narratives in Cardiology is a multimedia educational series jointly developed by the Pennsylvania Chapter ACC, the ACC Fellows in Training Section, and the CardioNerds Platform with the goal to promote diversity, equity, and inclusion in cardiology. In this series, we host inspiring faculty and fellows from various ACC chapters to discuss their areas of expertise and their individual narratives. Join us for these captivating conversations as we celebrate our differences and share our joy for practicing cardiovascular medicine. We thank our project mentors Dr. Katie Berlacher and Dr. Nosheen Reza.
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1. Why does diversity matter in clinical trials?
- Having clinical trial enrollment being representative of the general population in which we practice is essential for the generalizability of the trial results.
- Representative populations matter so we can say to patients, “yes, there were patients that think like you and look like you in the trial.” We can confidently tell them how patients within the trial have done. This is important when we are trying to narrow health disparities to provide confidence and comfort to our patients.
- Advocacy for health equity is important but not enough. We need data or evidence to support why a change in our behaviors and clinical practice is needed. An evidence base that reflects and includes all our patients is key to bridging health disparities.
- In medicine, the case for diversity also includes to better serve diverse patients, to promote health equity, to provide diverse mentors at all levels, to bring different points of view to debates and problem solving, to better engage our communities, and to include investigators with a broad range of perspectives in their scholarly activities. (1)
2. How do we recruit more minorities in representation in cardiovascular trials?
- We need more advocates for diversity in trials in the room when the conversations about trial designs are being made. This is why diversity of leadership is important.
- There needs to be an intentional approach for every clinical trial to recruit people that are likely to be candidates for enrollment.
- Stop asking patients to come “downtown” but instead go to their town or their communities. Meet them where they are.
- Always make sure you are providing some additional advantage or opportunity for the patients you have recruited into your trials. Don’t make it a one-way street. Allow patients to feel that they are getting the best care and generate trust with them.
- To gain trust, try to get a sense of what is happening in your patient’s life. Find 2-3 minutes to ask them to give a mini biography of their lives. This goes for routine clinical care as well as conducting trials!
3. What advice do you share with people who are underrepresented in medicine, and who may potentially face racism or sexism?
- You have two choices when people promote division and hatred. You can choose to be angry, or you can choose to not let others’ poor decisions or thoughts define you.
- Your best tool as UIM is to control yourself and to be successful.
- Remember that your uniqueness can make a difference in the lives of so many others. It can help you execute making a large impact for so many more people.
4. How do we recruit more diversity in medicine or cardiology in general?
- One strategy is to establish new medical school(s) at Historically Black Colleges or Universities (HBCUs). HBCUs recognize broad talent, refine that talent, and propel that talent to success.
- The current 4 medical schools in part aligned with HBCUs and serving Black medical students represent 2.6% of total medical schools yet account for 15% of all Black medical students. (2)
- We must stop looking at diversity as a “representativeness” cause. We should all be striving for excellence. To achieve this, we need diversity of thought, diversity of ideas, and diversity of execution. This will not be accomplished if we continue all have the same “skin”.
- There must be intentionality for diverse leadership. There needs to be diversity in the C-suite of hospitals and the Dean’s executive committee of medical schools. Diversity in medicine will follow suit when there is a diverse thought process in those rooms that affect the future.
5. How has structural racism affected studies and guidelines?
- There has been a system in medicine early on in our country that intentionally separated people as a function of race such as the “Jim Crow experience”. This disabled many opportunities for certain groups of people.
- Physicians must recognize there are still residual consequences of the Jim Crow experience that have allowed for a “cultural set point” that continues to be operative today. (3)
- The “cultural set point” has allowed many generations to become acculturated subconsciously to believe there are distinct differences between people and then behave accordingly that leads to effect of how one may practice medicine.
6. How do we combat structural racism within cardiology or medicine?
- If you are trying to incite culture change, something abrupt likely will need to happen. You must embrace and enjoy the need for change.
- CardioNerds and the new generation of physicians have the license to be architects of the future in medicine. We have the power to change the culture as we practice and develop new studies and guidelines.
- Consider a positive disruptive change when making new ideas for the future in medicine to battle social injustices within medicine.
- We must fundamentally change the way we do things to change our already known processes.
7. Should there be race or gender-based guidelines or socioeconomic status guidelines?
- The first step is recognizing this is a complex issue and when one is developing a trial there needs to be a thoughtful conversation.
- We do need more data in the study of racial and gender differences.
- We still need race and gender-based research – not race/gender-based research looking for a different biology, but research trying to unravel where do we see these differences that are otherwise inexplicable, with the exception of bias. (4)
8. How to get your peers and patients to trust you to advocate and promote diversity, equity, and inclusion?
- Per Dr. Yancy you need 3 traits to become a strong and effective advocate:
- Competency: to strive to be best physician you can be and to give the best care you can. You need your voice to be respected.
- Civility: be able to stand in a room where there is a difference of opinions and hold yourself appropriate. Manage to have eye contact, manage your emotions, because remember if you allow people to make you angry and show it then they have won.
- Compassion: show people that you genuinely care. Remember you may have had opportunities that your patients or colleagues may never have had.
- Also remember to go back to evidence! The evidence is there to promote for more diversity within the physician workforce. This in turn leads to diversity of thought, ideation, and execution which help improve clinical trial subject representation.
- Remind people that in the 2019-2020 academic year, 21,863 first-year medical students were enrolled in the US, of whom 1,626 were Black—a number that has been stagnant since 1978.
- Douglas, P. S., Williams, K. A., & Walsh, M. N. (2017). Diversity matters.
- Association of American Medical Colleges. Facts: Applicants, Matriculants, Enrollment, Graduates, MD-PhD, and Residency Applicants Data. Published 2020. Accessed December 3, 2020. https://www.aamc.org/data-reports/students-residents/report/facts
- Yancy, C. W. (2020). COVID-19 and African Americans. Jama, 323(19), 1891-1892.
- Ioannidis, J. P., Powe, N. R., & Yancy, C. (2021). Recalibrating the use of race in medical research. JAMA, 325(7), 623-624.
- Steinecke A, Terrell C. Progress for whose future? the impact of the Flexner Report on medical education for racial and ethnic minority physicians in the United States. Acad Med. 2010;85(2):236-245.