Reaction to Paper on Affirmative Action in Cardiology May Help Spur Change

A paper published last year that argued against affirmative action in medicine, and was subsequently retracted, may have had the unintended effect of broadening discussions around inclusivity and underrepresentation of minorities in clinical and academic circles, a newly published viewpoint suggests.

According to Saima Karim, DO (Case Western Reserve University, Cleveland, OH), and colleagues, the “white paper” written by electrophysiologist Norman Wang, MD (University of Pittsburgh Medical Center, PA), which was widely condemned on social media after its publication in the Journal of the American Heart Association, essentially showed why concerted efforts are needed to address biases and institutional racism that harm healthcare workers and patients. Among other things, Wang suggested that mandatory affirmative action programs meant to promote diversity and inclusion can result in unqualified applicants entering medical school or CVD training programs, and that minorities may end up working in underserved areas because of the “inability to secure a job in other areas because of low professional qualifications.”

Karim, also an electrophysiologist, is the latest to address the issue in JAHA. The journal and its editor-in-chief, Barry London, MD, PhD (University of Iowa Carver College of Medicine, Iowa City), have published several responses on what next steps should be taken at clinical, academic, and journal levels to tackle structural racism.

To TCTMD, Karim said she felt it was important to respond to Wang with data and facts, noting that “if people have sentiments such as this [and are] willing to write something to that degree, obviously they hold strong convictions, and they're probably not the only one.” Their viewpoint article refutes critical points in his paper, including how a simplistic view of “academically qualified applicants,” Medical College Admission Test (MCAT) scores, and other metrics do not guarantee great physicians. It also adds what Karim and colleagues say is much-needed context regarding the struggle of underrepresented minorities as they navigate educational and professional challenges in their chosen specialty, including “discouragement from faculty, lack of mentorship, and overt and covert racism.”

If someone is expressing their opinion in such an open manner, they should be ready for the backlash that comes with it. Purvi Parwani

Karim noted that there is “a higher burden and a higher amount of microaggressions that [underrepresented minority] people have to put up with or hoops that they have to jump through to prove that they are worthy, and I think that is something that is not very well understood.”

Commenting for TCTMD, Purvi Parwani, MBBS (Loma Linda University, CA), said she was glad to see Karim and colleagues put forth evidence showing structural racism at every level of an individual medical career. She described Wang’s paper as “a narrow-minded viewpoint by one person based on a very limited metric, without looking deep into why these disparities exist.”

Parwani added that it’s important for anyone who really wants to be an ally to fully understand how structural racism adversely affects the crucial support structures that produce successful physicians.

“The opinions expressed in this viewpoint by Dr. Karim are very much needed, as are the discussions on social media,” she said. While some of her colleagues worry about “cancel culture,” Parwani said, letting papers or statements that fuel structural racism go unchecked isn’t an acceptable solution.

“If someone is expressing their opinion in such an open manner, they should be ready for the backlash that comes with it,” she noted.

Bringing Larger Issues to Light

Among the other assumptions and positions in the Wang paper that Karim and colleagues address is that underrepresented minorities in medicine are in underserved areas thanks to being poorly qualified. This, they say, dismisses the documented need for more diversity in providers to improve the care and outcomes of minority patients.

“There are many physicians providing care for large sections of society where medicine is otherwise failing to intervene,” they write. “In fact, access to care as well as quality and intensity of care contribute to lower quality as well as quantity of life for racial/ethnic minorities.”

Karim said the hope in bringing these larger issues to light is that “the venues start expanding and people are more aware of how to be inclusive.” She noted that following the #MedBikini blow-up last year on Twitter, which questioned—via another retracted paper, this time in the Journal of Vascular Surgery—what physicians should or shouldn’t post on social media, the journal diversified its editors, and others followed suit by announcing marked changes in their editorial processes. Early this year, as reported by TCTMD, the editors of Circulation: Cardiovascular Quality and Outcomes acknowledged structural racism as a public health crisis and changed their instructions for authors to include a Disparities Guidelines Checklist. Last week, Howard Bauchner, MD, editor-in-chief of JAMA and its 12 network journals, stepped down months after they aired podcast questioning structural racism’s existence in medicine. His departure was followed by an editorial noting that JAMA must “do better and advance toward inclusion and antiracism in all journal-related activities” and that it is working to diversify their editors and editorial board members.

“We need organizational leadership that pays attention to the spectrum of society, including race, gender, ethnicity, origin, immigrants, and nonimmigrants, etc,” Parwani said. “We have so much diversity, and the least we can ask for is inclusion, given the diverse background everyone brings to the table.”

Karim said another important area that still needs significant work is standardization of diversity, equity, and inclusion (DEI) in the healthcare sector.

“A lot of institutions have assigned somebody in the DEI role, but a lot of times the people they assign are not [underrepresented minorities]. Even if [they are], you’re creating a position that doesn’t have any power to change, and there’s no money behind it to do anything. How is that helpful?” she said. “There have to be metrics that are performed to look at what DEI efforts have done. Is there more African-American faculty? Is there more Hispanic faculty? That is something that needs to be studied on a national level.”

Taking it one step further, she added, leadership and staff need to reflect the changes made by DEI efforts. “It shouldn't be that you have a lot of residents and interns and patients that are minorities and not enough physicians who are as well. Unfortunately, it’s something that's happened with cardiology over decades.”