On May 4, 2007, I was invited to speak to the cardiologists in training from the Big Ten academic institutions (University of Illinois, Indiana University, University of Iowa, University of Michigan, Michigan State University, University of Minnesota, Northwestern University, Ohio State University, Pennsylvania State University, Purdue University, and University of Wisconsin) that was held at Ohio State University. I was shocked that among the 100 attendees, there was not one African American in attendance and the audience was probably just as surprised when I shared with them that Ohio State University, one of this country’s leading medical academic state institutions, has never trained an African-American cardiologist in more than 50 years of training cardiologists! This disturbing truth is not uncommon in Big Ten schools or most academic institutions throughout the country, resulting in significant disparities and inadequacies in our health care delivery system.
Big Ten schools have a long history of excelling in almost everything and have the most comprehensive degree programs. All their member institutions are affiliated with the Association of American Universities, a prestigious collection of 60 research institutions, and lead all conferences in the total amount of research expenditures. However, with all their prestige and notoriety, they fall short in recruitment and retention of underrepresented minorities in their academic programs. If these programs put as much care, commitment, and tenacity in their recruitment, training, and retention of underrepresented minorities in their academic divisions as they do in their sports programs, the cardiology workforce would adequately reflect the composition of their states and the country. I must add that the featured speaker for the dinner program was former star of the Buckeyes and a high school and college hall of famer, Mr Archie Griffin. What is the message?
The urgent need to increase the number of minority cardiologists is illustrated by data in a 2002 report by the American Medical Association indicating that of the 2223 total trainees in cardiology, 3.4% were black and 5.7% were Hispanic, and 30% were Asian. Blacks and Hispanics constitute 25% of the population of the United States but less than 10% of the cardiologists in training. In 2006, the Association of Black Cardiologists (ABC) conducted a study to determine the most inclusive and exclusive training programs historically for underrepresented minorities. Of the 185 institutions receiving federal funding for their cardiology training programs, 25% had yet to graduate the first African American. On the other hand, the institutions with the most impressive record of training underrepresented minority cardiologists are Howard University, Harlem Hospital, Duke University, Johns Hopkins, Harvard (Brigham and Women’s Hospital), Emory University, the Cleveland Clinic Foundation, and SUNY Health Science Center. Unfortunately, the Harlem Hospital program closed in 2001.
The demographics of cardiology residents in training programs vary greatly. For example, Duke University consistently recruits and trains a class that is 25% African American and diversity is embedded throughout their institution. Wake Forest University, an equally prestigious institution 75 miles away, has never graduated an African American (although 3 are currently in the program).
While everyone will readily agree that there is a pipeline problem, contrary to common belief, there is no shortage of African American and other underrepresented minorities who are ready, willing, and able to be accepted into cardiology training programs. In fact, the program sponsored by Vanderbilt University, Meharry Medical College, and the ABC annually receive 32 applications for one available position. Unfortunately, acceptance into cardiology training programs is subjective and left up to the judgment of program directors. There are no tests or scores to compare and no application exams. It is inconceivable to believe that most African Americans who graduate from medical school and successfully complete internship, residency, and an internal medicine fellowship are then unqualified to enter cardiology training programs.
The cost of training cardiologists and other subspecialists in the United States is subsidized by federal tax dollars through the Medicare program. In more than 50 years of training cardiologists in this country, these funds have been used primarily to train white men and foreign medical graduates. This has resulted in a cardiology pool consisting of only 2% African American, 5% Hispanic, and 15% women. At least 20 of these federally funded programs have exclusively trained white men. The consequences of this lack of diversity have detrimentally affected a significant portion of cardiology patients that these cardiologists were trained to serve.
Just as heart health remains an area of inequality for African Americans, the underrepresentation of African-American cardiologists continues to be a dangerous and shameful development and accepted discriminatory practice in our country. A large body of literature explores the issue of “cultural competence” (by which health professionals who are sensitive to their patients’ cultural backgrounds can provide more effective and efficient services). By dramatically increasing the enrollment of African Americans and other underrepresented minorities into federally funded cardiology training programs, rural and urban communities, particularly underserved communities, benefit from a more diverse workforce. This diverse workforce would better represent the changing racial and ethnic composition of this country that is expected to be 50% minority by 2048. While there is no shortage of studies and reports that support the critical need for more cardiologists in general and more minorities in the cardiology workforce, little has been done to actually execute and implement recommendations and initiatives that have been created in the past.
Just as cardiology students are expected to have registered for Selective Service, cardiology training programs should be held to predetermined government oversight to ensure accountability, outcome reporting, and benchmarks. The public is entitled to see an annual diversity credentialing report that details who are and who are not complying with the nondiscrimination declarations each institution is required to sign annually to receive federal funds. Only by shining a light into the dark corners of existing policies can we improve compliance, and, by extension, reduce disparities in health care. This glaring disparity begs for scrutiny and intervention.