American College of Cardiology Steps Up: Equal Pay, Opportunities for All

Cardiologists of all stripes must have fair and equal access not only to pay but also to opportunity, the American College of Cardiology (ACC) asserts in a newly released document that sets standards for compensation and professional growth.

Both “are critical to the health and future of the cardiovascular workforce,” the document stresses.

Published online September 16, 2019, in the Journal of the American College of Cardiology, it represents the ACC’s first-ever health policy statement devoted to workplace issues in cardiology. Three more are currently in progress. Next up is a report focused on how flexible workplace policies—or the lack thereof—impact cardiologists, writing committee chair Pamela Douglas, MD (Duke University School of Medicine, Durham, NC), told TCTMD.

Just last week, a demographic study released in JAMA Cardiology with Douglas as senior author showed that, despite some improvements, women and racial/ethnic minorities remain underrepresented in this field.

Both that study and the policy statement stem from the ACC’s Diversity and Inclusion Initiative, a 5-year strategic plan that launched in 2018, Douglas said.

We don’t have pink RVUs and blue RVUs, so how is this happening? And where is it coming from? Pamela Douglas

“The ACC is really understanding that our ability to achieve our mission depends critically on our people,” she explained. “If our people are the best and the brightest, and we create an environment in which they can do the best possible work, then we will have done our job—but not until we do those things.”

Martha Gulati, MD (University of Arizona, Phoenix), praising these efforts, described herself as “very proud” of the ACC for addressing inequity.

“To take a stand on how we think our cardiologists should be compensated is huge. And it’s no easy task,” Gulati said, given the range of settings—from private practice to academic medical centers—where cardiologists work. Currently, “it’s complicated, but it doesn’t need to be,” she stressed. “I think we use that as an excuse.”

Pay structures should be transparent and objective, Gulati urged.

The Origins

The initial catalyst for JAMA Cardiology study and the policy statement was a 2016 paper showing sex-based gaps among cardiologists, a pattern that Douglas pointed out doesn’t make much sense since so much of physicians’ take-home pay comes from relative value units (RVUs).

“We don’t have pink RVUs and blue RVUs,” Douglas said, “so how is this happening? And where is it coming from?”

Recognition that there isn’t a level playing field informed the ACC’s efforts, she continued. “We think a big reason why there is a pay gap is because there’s an opportunity gap, which is why those two are coupled very, very tightly—if you never have the opportunity to be head of the cath lab, for example, you’re never going to get the extra medical director stipend for doing that leadership role and so your salary will always be less.”

To TCTMD, Gulati described what it was like when she graduated. “I didn’t even know what to ask for, and I think I did a [bad] job at negotiating. You could say, ‘Well, okay, it’s only a little bit of salary that you didn’t get.’ But it all adds up.” A loss of $40,000 that might have been invested early on translates into a large discrepancy in savings 20 years down the road. Moreover, cardiologists who start at a lower salary will continue to have their raises based on that amount and never quite catch up to their higher-paid counterparts.

Cardiologists get paid well, Gulati added, but most leave their training with a large amount of debt and often don’t begin earning salaries until their mid-30s.

We don’t want to spend our whole lives fighting battles. It shouldn’t be that hard. Martha Gulati

Early on in the process of writing, Douglas said, it became clear that inequity doesn’t just affect women but also racial/ethnic minorities, hence the document’s broad scope.

With practical advice on compensation plans, leadership roles, and legal concerns, the ACC statement covers a lot of ground, she continued, noting that there are also numerous online resources that can aid in digesting and applying all of that information as well as real-life but anonymized compensation plans donated by cardiologists.

Inside the document itself are no fewer than 17 recommendations on “best practices in constructing and implementing compensation models for cardiovascular physicians.” Among them is the statement that the ACC believes “cardiologist compensation plans should value and explicitly reward nonbillable work, including quality improvement, leadership/administration, teaching/mentoring, research, community service, and outreach activities.”

Such work regularly falls to women, Gulati pointed out.

“Often women get put on committees, sometimes thankless committees, but they don’t get any [pay] for it,” she observed. “I always tell women who I’m mentoring: if you’re going to say yes, make sure you know how that’s going to affect you. Because if there’s no value on it, you’re going to be resentful at some point if they’re on your back about your RVUs, your billable work. Many of these roles you take on aren’t the powerful ones where there’s money behind them.”

Another of the statement’s recommendations urges a level playing field among subspecialties, such that “those performing invasive procedures should not have their time unjustifiably valued over those providing other clinical skills, such as imaging, disease prevention and management, and clinical patient care.”

Here, too, Gulati was pleased.

“When you are part of a cardiology division, the resources often go to the people that bring in the most money to the hospital,” typically those doing procedures, she said. “Without all the other people as partners in this, you don’t have the referrals. [Not only that but] there’s a weird incentive to do interventions on people. If it’s evidence-based I have no problem with it, but we do know there’s a lot of people out there not always following guidelines but following the dollar sign.

“As a patient, I would say that if you’re doing a good job at preventing me from getting a disease or [from] needing a second procedure, and you put me on all of the right medications and take care of me, that should be just as valuable as putting the stent into me,” Gulati commented.

Flexible workplace policies are also emphasized by the ACC, with the group calling for approaches that “support cardiologists in meeting their professional and personal obligations, while maintaining certainty and stability of employment. Flexibility, as a strategic business tool, can help all cardiologists manage work and personal-life demands, thereby decreasing the risk of compromising salary in exchange for flexibility.”

The Numbers

For their snapshot of cardiology’s demographics, Laxmi S. Mehta, MD (The Ohio State University, Columbus), and colleagues obtained data from the Association of American Medical Colleges, American Medical Association, and American Board of Internal Medicine.

In 2016, nearly half of internal medicine resident physicians (42.6%) were women, but the same was not the case for general cardiology fellowships (21.5%) or, even more starkly, for fellowships in interventional cardiology (9.8%) or electrophysiology (13.7%).

With pediatric residencies, female physicians accounted for 72.9% of positions. The proportions of women among pediatric cardiology fellows and pediatric cardiologists were 50.5% and 34.0%, respectively.

Members of underrepresented minority groups—individuals who self-identify as black or African American; Hispanic, Latino, or of Spanish origin; American Indian or Alaska Native; or Native Hawaiian or Pacific Islander, either alone or in combination—comprised 12.5% of adult cardiology fellows, 9.9% of pediatric cardiology fellows, and slightly less than 8% of practicing cardiologists. Notably, Asian individuals make up 5.2% of the US general population and as such weren’t included in this analysis of underrepresented groups; for example, 19.9% of adult cardiologists and 20.1% of pediatric cardiologists are Asian.

Between 2006 and 2016, the percentage of female cardiologists treating adults increased from 8.9% to 12.6% (P < 0.001) while that of minority cardiologists rose from 5.3% to 7.5%, a nonsignificant difference.

The Future

For Douglas, the goal is to be inclusive. “Diversity is just a measure of whether you’re inclusive or not,” she observed. “We’re not aiming for a percent of cardiologists to look exactly like the US population or anything like that. We want to get talent. We want to be the top profession and stay the top profession.”

A key message is that the responsibility to address inequity falls on leadership at an institutional level. “This is something that has to be done intentionally,” she said, adding, “This is something you need to create in your program and need to build in from the beginning, not after you’ve set salaries but before.”

Moreover, employers need to recognize how their policies might benefit the health system as a whole, realizing it’s not just about equal pay, Douglas asserted. “It’s also about using compensation strategically to drive quality and to drive business goals to improve care. We tend not to think about that because we tend to think of compensation as what happens after the work is done, but actually it should be set before. . . . This is best practices in running healthcare delivery.”

Gulati said it isn’t clear how these ideas will trickle down through various cardiology workplaces, or what the incentives will be to encourage their use. But she, too, suggested that openly following the ACC’s standards would enable hospitals and other centers to recruit the best employees.

One noteworthy element of the new statement, Gulati said, is that it takes on not only inequity but also outright discrimination.

Gulati gave the example of a young female colleague who was overlooked when a job was given directly to a male colleague with similar training and experience, without it being advertised as an open position. When her female colleague asked why she hadn’t been offered the chance to apply, her male boss told her it was because she was pregnant. Upset, the junior colleague ultimately left academic medicine.

Then there is the all-too-common problem that continues to vex many professions: sexual harassment. As recently as 2015, Gulati said, two-thirds of female cardiologists reported experiencing either harassment or discrimination, the same proportion as in 1996.

“We have to address that head-on, right now. Hopefully people are, but it is something that unfortunately is still leading to fewer women choosing cardiology as a field,” she said. “I think that they hear stories [from] cardiologists that have been discriminated upon—why would they choose that if there’s a better environment? We don’t want to spend our whole lives fighting battles. It shouldn’t be that hard.”