Unseen and Unheard: In the Cath Lab, Anti-racism Efforts Fall Short

Yolanda Carter, RN, MSN, JD, began her career in the 1980s working as a trauma nurse in a Texas emergency department, where she would often accompany STEMI patients to the cath lab, and fell in love with the work being done there. Born to Native American and Black parents, Carter’s own childhood history of rheumatic fever convinced her that cardiovascular medicine was her calling. But years of frustration followed. Several times she says she tried to obtain a permanent position in the cath lab but was passed over in favor of less-skilled, less-educated white colleagues.

“There was a mentality that came from leadership and management that I wasn't allowed to do it, quite frankly, because my skin was brown,” she said. Once, at a California hospital where she was seeking a management position, a coworker told her that the CEO had referred to her using the N-word.

“I have been treated badly not because of my skills, but because of the color of my skin, and that's sad,” Carter said. “But it exists, and it's real, and it's real across this country.” Her husband, who is Black and also works in a cath lab, has relayed similar experiences.

Over the past year, cardiology societies, journals, academic departments, and meetings have issued position statements and road maps aimed at stamping out racism and increasing diversity and inclusion in cardiovascular medicine. But much of that call to arms has been led by physicians on behalf of physicians; the voices of nurses, techs, and other support staff have too often gone unheard.

Earlier in the pandemic, nurses and techs, both in the cath lab and beyond, were in the spotlight for leaving full-time positions to become high-paid travelers taking short-term posts around the United States. But for some it has never been an option to quit a full-time job for the allure of the road, and money was never the driver. In Carter’s case, the only way she felt should could even get a cath lab position was to become a traveler. “The people who are hiring you can't see you. If they can't see you, they can't judge you; they just need the help and that's what they get,” she explained.

“There are too many talented people of color who are just not being appreciated and who could bring so much to the cath lab environment,” Carter added.

Falling Through the Cracks

Triston Smith, MD (Trinity Health System, Steubenville, OH), a Black interventional cardiologist, agreed that stories like those of Carter and her husband are indeed real and all too common, both for short-term travelers and full-time staff.

“If you look at the workforce composition of most cath labs, you'll see that there isn't a fair representation of minorities . . . either as interventionists, or techs, or nurses,” he said. “Does that happen by chance? I doubt it.” Smith said his experience suggests that excuses are often made that certain groups—which tend to be all-white—work better together, and that if few people of color have been in leadership positions at a given institution, it’s likely to stay that way.

“When you break through that barrier, it's just sheer willpower to get it done and not accept anything else [but] having your eye on the prize, so to speak,” he observed. “Many times, someone recognizes your talents and gives you a leg up, but in my opinion, it’s always more difficult for that to happen when it comes to people of color.”

Despite efforts to address diversity, equity, and inclusion, minority cath lab staff are clearly falling through the cracks with no support structures to amplify their voices and experiences, noted Bailey Ann Estes, BSN (Hendrick Medical Center, Abilene, TX).

“Stories like Yolanda’s are something we need to address, and you sometimes wonder if issues like this even cross anyone’s mind,” she added. “We get caught up in our own little worlds, our own little cath labs . . . and we don't have a great, strong society that connects us. The first step is that we have to create awareness that a problem exists.” Doing so increases the opportunity to garner support through a chorus of allied health voices, as well as physician leaders who are willing to step up. It also decreases the opportunity for excuses to not address what is going on, she added.

We have ‘he for she.’ Why not ‘doctors for nurses’ and ‘doctors for staff?’ Bailey Ann Estes

“One thing we know about cardiac cath lab people is they are there for the long haul. People fall in love with it and they become ‘cath lab-ers’ for life,” Estes noted. “That's something that we need to foster and build on. Physicians don't want baby nurses and baby techs coming in that don't know what they're doing. Turning away people who are highly experienced based on their race is a very, very big issue that we can’t ignore.”

For Smith, being judged on the color of his skin was far from his mind as a child growing up in multicultural Grenada, but he’s felt it firsthand in the United States. Having showed strong leadership ability and helped build a thriving structural heart program straight out of his fellowship, he was denied the director position and told he was too young despite seeing white colleagues with similar qualifications go into director positions out of fellowship.

“For me as a physician, it's been tough, so I understand how difficult it would be for nurses and techs who are trying to navigate around all of these issues and trying to gain acceptance in the community,” he said.

A Reckoning on Racism in Medicine

The critical juncture of race and medicine was thrust into the spotlight following the 2020 police killing of George Floyd on top of the already stark disparities laid bare by the disproportionate effects COVID-19 was having on racial and ethnic minorities. In response to the Black Lives Matter movement, the Association of Black Cardiologists (ABC), the American Heart Association (AHA), and the American College of Cardiology (ACC) issued a joint statement calling on medical organizations, particularly cardiovascular ones, to speak out against racial discrimination given the role it plays in limiting access to cardiovascular health and quality care. The board of trustees of the American Medical Association (AMA) also urged physicians to “stand in opposition to racism because it truly is a public health emergency.”

Less than a year later, however, JAMA found itself apologizing and promising to do better after airing a tone-deaf podcast that suggested physicians can’t be racist and that the term “racism” may be harmful and should be replaced with something else. STAT subsequently reported that researchers had for years been asked by the journal’s editors to scrub the word racism and similar terms from their submitted articles, and confirmed with their own search that they couldn’t find any articles in either JAMA or the New England Journal of Medicine that had racism in their title or abstract.

Many times, someone recognizes your talents and gives you a leg up, but in my opinion, it’s always more difficult for that to happen when it comes to people of color. Triston Smith

Some journals have since stepped up and published articles aimed at addressing the need for collaborative work to improve racial diversity in the workplace. In a recent paper in the Journal of the American College of Cardiology, for example, Nina Williams, MD (Saint Francis Hospital, Tulsa, OK), and colleagues offered steps for building an antiracist culture in cardiology.

Speaking to TCTMD from her own experience as a Black woman who recently completed a fellowship in interventional cardiology, Williams said it’s important to speak out about the fact that racially directed microaggressions at work, either said or unsaid, are often simply accepted for the sake of professionalism, “and then we just keep moving.” For trainees, she said, “there are barriers that are not discussed or identified, and individuals are suffering in silence or suffering together, and just accepting it as a norm when it doesn't need to be.”

Speaking, Listening, Changing

Manesh Patel, MD (Duke University Medical Center, Durham, NC), a former cath lab director and now chief of cardiology, said inequality in medicine is something everyone must work harder to address. One way to combat structural racism in the healthcare environment, he noted, is with diversity in the workforce at all levels, from physician and nursing leadership to administration.

“For every position, for every job that we're trying to fill, we need to ensure that we have an open and transparent process by which applicants know about the job, and have the opportunity to apply for the job,” he said. “Secondly, you have to have a culture where people feel comfortable wanting to do that and feel the value of having a diverse workforce, both at leadership levels and everywhere throughout the organization.”

There also have to be processes and supports for people reporting hostile behavior, microaggressions, or other harmful and racist conduct on the job.

“When white people say the same sort of things, they are called ‘passionate’ for speaking out,” Smith observed. “When you’re Black and you speak out, you’re ‘angry.’ Words like that are said to make you not speak out or speak up, which is unfortunate.”

Where some might choose to either ignore it or vent to spouses, family, or friends, Smith said those conversations won’t spark the changes needed for the people who care for patients while feeling mad, hurt, and unheard. As a voting member of the Society for Cardiovascular Angiography and Intervention’s recently formed Diversity, Equity, and Inclusion (DEI) Taskforce, he feels strongly that not addressing pervasive racism in medicine is not only demoralizing to healthcare workers, but also can cost some minority patients their lives and increase the chance that others will avoid getting the care they need. 

Patel agreed. “Our patients are more likely to feel comfortable with us and more likely to consider recommendations and changes to their healthcare behaviors when they're coming from people that they trust, and who look [like them], and feel and understand their cultural backgrounds,” he said.

As a nonphysician and a woman of color in nursing leadership, Elizabeth Perpetua, DNP, ACNP-BC (Empath Health, Seattle, WA), noted that giving voice to the pain caused by microaggressions and admitting to feeling powerless to change in the workplace are rarely encouraged in the healthcare arena. Yet she agreed that it is necessary, even if moving on—literally or figuratively—to avoid confrontation often seems, intuitively, to be the best option.

“Moving on from it hurts us more than it helps us,” she observed. “But giving voice to it and speaking up about it is really, really scary.” At different times in her career, Perpetua added, “I've told myself all kinds of different stories to not speak up, and then when I have spoken up, I have certainly been less effective than I had hoped or dreamed, or have suffered consequences from it, and it's painful.”

I’ll gladly speak out about this, because there has to be a voice at some point who does, and maybe this is that point. Yolanda Carter

The silver lining, she added, is that by voicing these personal stories, there’s a high likelihood of them resonating and maybe even helping others be a little braver about speaking up for themselves or colleagues.

“I think people are listening a little bit more and [by listening to others] it becomes more normalized instead of something so scary,” Perpetua said, adding that it’s really the moving on that is more likely to result in nothing changing, even if it feels like the only way to take back power in that situation. Speaking truth to the pain, she added, can actually create more options than one might think. What concerns her most, though, is that without champions for the cause and organizations that extend themselves to continuing and broadening the conversations, opportunities for change and support may be lost.

Estes said holding the organizations that collect professional dues from cath lab professionals to account is a good place to start. This then could become the hub where all cath lab team members can talk about racial issues that affect them and work on recommendations to leadership to make changes happen.

“I think having a big voice of allied health, in the form of cath lab staff, step up and say something is going to be a big thing,” she said. “Also, physician support, especially from cath lab directors, would go a long way. We have ‘he for she.’ Why not ‘doctors for nurses’ and ‘doctors for staff’?”

Carter said her love for cath lab work persists despite all she has experienced, although she said she will never again apply for a management job despite holding a master’s degree and a juris doctorate in addition to her RN education. So what makes her want to stay?

“Because that's my gift, and you don't let someone steal your joy. You just don't,” she said. “I’ll gladly speak out about this, because there has to be a voice at some point who does, and maybe this is that point.”