Hostility Is Common in Cardiology: Can a New ACC/AHA Statement Help?

The contemporary cardiology workplace is fraught with hostility, including discrimination and harassment, according to new data from a global survey. A very low response rate, however, raises questions as to why clinicians refrained from participating in the project.

Also this week, the American College of Cardiology and American Heart Association (ACC/AHA), released a consensus report on professionalism and ethics that potentially could help rectify many of the issues hindering physician well-being in the workplace.

The survey, published in the May 18, 2021, issue of the Journal of the American College of Cardiology, is far from the first to document a challenging culture in medicine generally and in cardiology specifically. But lead author Garima Sharma, MD (Johns Hopkins University School of Medicine, Baltimore, MD), told TCTMD it is the first to consolidate international perspectives: from Africa, Asia, the Caribbean, Eastern Europe, the European Union, the Middle East, Oceana, and North, Central, and South America.

“This is the beginning of a wave of change, because data like these are very few. And they're important, because if we are looking at cardiology as a profession to continue to attract the best minds and continue to be a viable option for everybody, I think we really have to come up with sustainable solutions not just for a specific population but for the entire workforce at large,” Sharma said.

Sharma and colleagues sent survey invitations to 71,022 cardiologists. Overall, 43.7% of the 5,931 who responded to the ACC survey, conducted in the fall of 2019, reported experiencing a hostile work environment. Not surprisingly, women were more likely than men to have experienced any type of hostile work environment, including emotional harassment, discrimination, or sexual harassment (OR 3.58; 95% CI 3.14-4.07).

“[The study] reinforces everything I've ever read about in cardiology, and I think it's just a really strong call for change that we'll need to be part of,” said Sonya Burgess, MD (Nepean Public Hospital, University of Sydney, and University of New South Wales, Sydney, Australia), who commented on the findings for TCTMD. “Unfortunately, cardiology has had this problem for a long time, and there's a long trail of data that suggests that these are not underestimates. This is what our colleagues are going through globally. I wish it were surprising, but it isn't.”

Moreover, Burgess said this survey was needed “because it's so easy to not believe individual comments about workplace hostility.”

“No one wants to believe that pervasive structural discrimination, sexism, and racism exist. It's unpalatable. We're all proud of being cardiologists, and we don't like seeing data like this,” she commented. “But contemporary data consistently demonstrates that this is a problem. And this JACC paper tells us we will need to address it and not deny it or ignore it.

“This is the fork in the road where we're at: where we've established that we want change, we've established that we need change, but what we really have a need for is evidence based tools that do work, not platitudes or ideas,” Burgess stressed.

Survey Data

In all, 29.3% of the survey respondents reported emotional harassment—either in the “form of microaggressions, [such as] as microassaults, microinsults, microinvalidations, or more overt ‘macroaggressions’ representing institutional and structural biases,” the researchers note, although they did not define it as such in the survey itself—while 29.5% reported discrimination and 3.7% sexual harassment. Each was more prevalent among women than men (P < 0.001). Discrimination was most often related to gender (44%) followed by age (37%), race (24%), religion (15%), and sexual orientation (5%).

I wish it were surprising, but it isn't. Sonya Burgess

Single and divorced respondents were each more likely than their married counterparts to report a hostile work environment. Black cardiologists were significantly more likely than white cardiologists to report discrimination and numerically more likely to report hostile work environments. Also, being early versus late career and being at an academic or government hospital versus physician-owned practice also led to increased workplace hostility.

In multivariate analysis, being female (OR 3.39; 95% CI 2.97-3.86) and being early career (OR 1.27; 95% CI 1.14-1.43) were factors strongly associated with having experienced a hostile work environment.

The results were maintained across the globe, although seemed to be most reported in North America.

“Although there were significant variations by region, the prevalence and consistency of reporting hostile work environment by diverse countries and regions are disturbing,” the authors write. “Given that cardiologists’ demographics, expectations, and practice settings environments can vary by region, there may be a pervasive, unchecked negative culture in medicine that supersedes local customs and culture.”

Lastly, 78.6% of those surveyed said their hostile work environments have led to adverse effects on professional activities with colleagues and patients, including 14.9% who called these effects “significant.”

In an editorial accompanying the study, Javed Butler, MD (University of Mississippi Medical Center, Jackson), and Ileana L. Piña, MD (Central Michigan University, Midlands), point out that while the survey was sent to more than 71,000 cardiologists, the response rate was only 8%.

“How do we interpret and generalize these results?” they ask. “Is it that the other 92% of those who did not respond are perfectly satisfied with their workplace culture and hence this survey suffers from responder bias resulting in an overestimation of the problem? Or is it that a large proportion of the cardiologists who did not respond were concerned about confidentiality and being potentially identified if they reported concerns and retaliated against, and hence the survey underestimates the problem?”

Similarly, Purvi Parwani, MBBS (Loma Linda University, CA), who was not involved in the study, told TCTMD she was surprised at the low response rate. “Did they not respond because they thought that things are never going to change and the system will remain the same? Or they didn't respond because they were just too busy, which is still a problem if you can't take a survey that is designed in the best interest of creating a better workplace environment for the cardiologists,” she said.

Problem Likely More Pervasive

Parwani, who recently authored a blog post summarizing her experiences with sexual harassment, said she suspects the global rates of hostile work environment, especially sexual harassment, are substantially higher than what was reported in this survey.

“Because emotional harassment wasn't defined in the survey, [I wonder] if there is intersectionality that goes from emotional harassment to sexual harassment,” she said. “I just thought that 12% wasn't very reflective of the real world in my opinion, because the prevalence of sexual harassment in medicine is double that of science and engineering specialty, and STEM in general is only second to the military when it comes to sexual harassment.”

She also noted a disappointing lack of improvement since the ACC began collecting data. “They have been doing these surveys for a long time, and there is very little change since 1996,” Parwani said. “So that just tells you that although there are all these interventions put out by different organizations, hospitals, and workplaces, we need to assess where we are going. Because if the endpoint is not changing, we need to modify the interventions to address the entire problem.”

While the onus of change lies with hospital systems and societies, as well, “we have to really start with ourselves,” Sharma said. “What makes a culture? It's not behaviors that are punished. It's really behaviors that are tolerated, and that makes the culture hostile over time because you have a learned helplessness, as it were, where you know that the culture is hostile but there aren't any measures to report it.”

Overt hostility and harassment might be obvious to report, but how should individuals deal with microaggressions? Sharma called for “bystander allyship where if you see something you have to speak up.” Additionally, she said change has to “move out of the realm of a 4-hour workshop into actual implementation.”

For Burgess, too, the challenge lies in finding remedies to the problem. “The hardest part is the next step, which is coming up with solutions that are appropriate that don't stigmatize people who experience the toxicity but also that don't upset potential allies,” she said. “What we need to do is make time allowances and make resources available, because if we just write policies but we don't give those policies power by giving them resources and priority, we really are not coming up with solutions that are likely to address the problem.”

Parwani said she would like to see individuals, no matter their race, sex, or training status, empowered to speak up when they observe something inappropriate. “You just need to have courage and say to the person, ‘I'm sorry, but what you said is sexist or it's racist and I would appreciate if you don't say [things like that].’” Sometimes the offender might not realize the power of their words or actions, she continued. “They don't think about it, but that's where the culture needs to change. We need to openly call people out.”

Creating Change

Published in both Circulation and the Journal of the American College of Cardiology, the ACC/AHA societal statement follows a predecessor from 2004 and was written based on discussions had during a virtual conference of 40 cardiologists, internists, associated healthcare professionals, and lay people held last fall.

“It was perfect timing to convene this conference and to look at these areas,” conference co-chair C. Michael Valentine, MD (University of Virginia, Charlottesville), told TCTMD. “It was also a perfect time to discuss the dramatic changes in the delivery of care that had occurred to our cardiovascular workforce from 2010 to 2020. So, all of these convened really to create an ideal storm for bringing these groups together and not only meeting but struggling and asking tough questions.”

The comprehensive document is split into five sections each led by a different task force: conflicts of interest; diversity, equity, inclusion and belonging; clinician well-being; patient autonomy, privacy and social justice in healthcare; and modern healthcare delivery.

“This document doesn't really have all of the answers,” Valentine said. “In fact, we ask as many questions as we have answers. But we as an organization and as leaders were searching for ways to help our members and help our health systems see the areas that we think are critical not only to patient care, but to the wellbeing of our members also.”

As for why it took more than 15 years to come back to this topic in a codified format, Valentine said it was likely partially due to the fact that “clinicians are so busy that they think that things are being published separately, [but] it takes a lot of time and effort to come together and do these.” Regardless, he said, the current statement will be a “fluid, living document,” so that no large gaps in time go by again without relevant updates.

Burgess said she thinks this ACC/AHA document will help change the culture. “This is America-focused,” she acknowledged, “but I'm hoping that we can as a global community endorse this at a much broader level so that we have shared standards that we say: this is what we want, this is what we should aim for, how do we move forward together?”

Parwani agreed. “It puts a lot of emphasis on organizations and hospitals, but in my opinion, the responsibility lies on each one of us, men and women within cardiology, the cardiologists,” she said. “I think the responsibility to change culture is within cardiology, and it starts from me.”