September 6, 2024 • 29 mins
This week’s episode reviews the notion of the underrepresented in medicine physician and the decision to pursue pediatric cardiology. How would improved representation amongst the congenital heart work force result in better outcomes for patients? How does a diverse workforce foster improved communication with patients? What are some practical steps that can be employed to improve representation in the field? We speak with third year cardiology fellow, Dr. Ogochuckwu M Ezeoke Cox, MD of C.S Mott Children’s Hospital at the University of Michigan about her recent essay on this vital topic.
https://doi.org/10.1007/s00246-023-03144-7
https://doi.org/10.1007/s00246-023-03144-7
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Episode Transcript
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Speaker 1 (00:16):
Welcome to Pdheart Pediatric Cardiology Today. My name is doctor
Robert Pass and I'm the host of this podcast. I
am professor of Pediatrics at the Icon School of Medicine
at Mount SINAI thank you very much for joining me
for this three hundred and tenth episode of the podcast.
Before we get into this week's episode, I wanted to
address something I learned this past week which involves the
so called pd Heart net list server. Some have had
(00:39):
the mistaken impression that this podcast, called Ptiheart, because of
its name, is affiliated in some manner with that Google list.
It is not, in fact, improve this point, this past week,
I learned that some who have received my biweekly messages
about the podcast episodes that are about to come out
have flagged my email announcements as spam. Result, Google has
(01:01):
blocked me from posting anything about the podcast on that forum.
For this reason, you won't any longer be seeing any
more announcements about the podcast there. Of course, most of
you know that I place announcements in multiple areas of
the Internet every week, and on social media such as Instagram, Facebook, Twitter, LinkedIn,
and threads. But if you happen to be in the
minority of people who were getting information regarding the podcasts
(01:24):
exclusively there, I would instead ask that you just follow
me on any of those other social media venues for
information regarding the upcoming episodes. And thank you so much
as always for listening. I hope everybody. Last week enjoined
our episode with surgical pioneer John Brown of Riley Hospital
for Children in Indianapolis, Indiana for those of you interested
(01:44):
in the history of pediatric cardiovascular science and specifically Cardiovassler's surgery,
and recommend you take a listen to doctor Brown in
last week's three hundred and ninth episode. As I say
most weeks, if you'd like to get in touch with me,
my email is easy to remember. It's Pediheart at gmail
dot com. This week we move into the world of
diversity in the workplace of pediatric cardiology. The title of
(02:08):
the work we'll be reviewing is the Heart of the Matter,
A Path to Building Diversity in Pediatric Cardiology. The first
author of this work is Ogi Cox and the senior
author Britney Hills, and the authors come from multiple centers.
Doctor Cox is a Pediatric Cardiology Fellow in the Division
of Pediatric Cardiology at cs MAX Children's Hospital at the
University of Michigan. When we're done reviewing the paper, doctor
(02:30):
Cox has graciously agreed to speak with us about it. Therefore,
let's learn a little bit about this essay and then
speak with one of its authors. This week's work is
not really a research paper, but it's instead an essay
on the impact of underrepresentation in medical training with a
focus on pediatric cardiology. The work begins with a number
of comments regarding the dearth of black or Hispanic pediatric
(02:52):
cardiology trainees, and they reference the December twenty twenty numbers
where there were four hundred and forty five total fellows
in pediatricals ardeology training, with only fourteen identifying as black
and thirty seven as Hispanic. In other words, the authors
explain that black fellows represented only slightly more than three percent, or,
to use their terminology, a sliver of the pie. They
(03:15):
start by reminding us of the definition of underrepresented in
medicine groups, which are defined as black, Native American or
Hispanic people, and also reminding how their numbers in medicine
do not reflect their numbers in the general population, though
they do mention that there are a rising numbers of
these candidates in medical school. The reason for these numbers
rising are increases in summer programs during undergraduate years, which
(03:38):
facilitate mentorship as well as preparation for pre med students.
They explain that these efforts to enhance Black, Native American
and Hispanic physician enrollment is based on healthcare disparity research
showing that putting underrepresented in medicine doctors in the community
will improve patient centered care. They explain how graduate medical
(03:58):
programs are now support varding more diverse candidates by building
inclusive residencies for these candidates to thrive, and they explain
how in pediatrics, our goals should be attaining a diversity
of the workforce that mirrors our patient groups. The authors
then point to some literature suggesting better outcomes for patients
in general pediatrics when there is racial concordance between physician
(04:19):
and their patient, and they posit that the same should
be true for pediatric cardiology. They explain that the most
likely explanation for these outcomes with racial concordance is related
to improvements in communication and explain how communication is a
key driver in patient family buy in regarding pre and
post operative management of congenital hard patients, underscoring why anything
(04:41):
that can improve communication could potentially result in better outcomes.
The authors then review the financial factors that negatively impact
people choosing to enter pediatrics, which are all aware of,
with the low pay being a major concern, where pediatrician
salaries in the United States can be literally one half
to one third of starting salaries in other the fields
of medicine. Given the two hundred thousand dollars average student
(05:04):
loan debt that med students in the United States take
on and lower income backgrounds of black, Hispanic and Native
American families, and this gap between debt and income becomes
even more daunting. They then delve into the notion of
social determinants of health on congenital heart disease outcomes and
reference doctor Katia Lopez's work on this demonstrating significant post
(05:24):
operative mortality disparities between non Hispanic White and non Hispanic
Black children from twenty twenty and which we reviewed with
doctor Lopez some years back. They emphasize how there are
higher mortality rates amongst black and indigenous populations, and how
these disparities do not appear related just to access to
care or socioeconomic status, and they reference other works on
(05:45):
health communication improvements having potential to reduce disparities, and the
authors suggest that this literature supports the improvements in communication
that may arise from race concordance between doctor and patient.
They reference how concordance between the race of the pro
and the patient may result in more culturally centered care
and will improve communication and help uncover social factors that
(06:07):
may be affecting health of a child with congenital heart
disease that would not otherwise be easily determined. And so
the authors then ask the question how can representation be
improved in pediatric cardiology? They break it into four categories,
and I'm going to ask doctor Cox to review these
in greater detail in our interview, but I'll very briefly
explain what they are. First as reflection, which they describe
(06:29):
as an examination of applicant pools and the matriculence of
given programs over the last say five years, and looking
for trends in backgrounds within the program culture. They make
special reference to the notion of not emphasizing board scoring
as much given the manner in which these scores may reflect,
at least partially socioeconomic and racial class differences rather than aptitude.
(06:51):
Second is that of fostering, which involves engaging residents and
minoritized populations in cardiology and providing reasons to help with
fellowship navigation. They offer the American Collegure of Cardiologies Initiative
in Cardiology amongst Black, Hispanic and Native American physicians to
foster an interest in cardiology early during internal medicine residency. Third,
(07:14):
they speak of prioritization, explaining that all of the decisions
should not be made just on good fit qualities, but
instead qualities like empathy, emotional intelligence, cultural situational awareness, and tactfulness,
which are similarly critical. And they speak also how underrepresented
in medicine physicians should be encouraged to perform disparity research
(07:34):
if they wish to, and how it ought not to
be undervalued scientifically. Finally, they speak of mentorship, in which
talents of the underrepresented fellows and residents are identified and
cultivated as their strengths are supported by faculty. The work
ends with some comments by the authors about the daunting
feeling of presenting to a group of colleagues where no
(07:54):
one's face in the audience looks like yours. They speak
of wondering if they would fit in because of the
lack of diversity in many programs, and speak of how
important it was for mentors to provide for them confidence
to proceed with the application process and then grueling fellowships.
And they conclude by saying, quote, the decision to pursue
any specialty is heavily influenced by an individual's exposure to
(08:17):
the field and the sense of belonging that they may experience.
We must create a community that attracts those who best
represent the faces of our patients.
Speaker 2 (08:26):
Well.
Speaker 1 (08:27):
This is certainly an interesting and insightful work addressing the
lack of diversity in pediatric cardiology, but some specialty training
in general. The many ways in which a more diverse
workforce will improve outcomes seems unassailable at this time, and
really it seems the only remaining important questions are how
we can achieve the goal of improving our cardiology provider diversity.
(08:48):
I think that the authors provide for us a very
nice framework to think about things, and it seems clear
that providing mentors and support along the way was very
important for these authors. I think it will be useful
to hear doctor Coxe explain to us better than four
pillars upon which they feel representation can be improved, and
also what sort of efforts they're making in their own
training programs right now. In the interest of time, therefore,
(09:10):
let's move on to speak with doctor Cox. Ogie Cox
is a graduate of Biinghamton University for College. After that,
she worked as a research assistant at Memorial Sloan Kettering,
where she received a great deal of mentorship. Fostering her
own interest in pursuing medicine. She studied medicine at Sunny
Upstate for Medical School. Following this, she went on to
perform her residency and pediatrics at LURI Children's Hospital in Chicago,
(09:33):
followed by University of Michigan, where she is now a
third year fellow in cardiology, with a great interest in
cardio oncology, cardiomopathy and heart failure and transplant and also
health equity. It is a delight to welcome an up
and coming superstar at PTI Heart. Welcome doctor Cox to Pdheart.
Speaker 2 (09:50):
I'm here now with doctor Ogie Cox. Doctor Cox, thank
you very much for joining us this week on the podcast.
Speaker 3 (09:56):
Hi, thank you so much for inviting me. I'm really
excited to be here.
Speaker 2 (10:01):
I'm excited to have you thank you, you know, before
we get going, doctor Cox. One of the things I
was wondering is what motivated you and your co authors
to pen this essay on this very important topic.
Speaker 3 (10:12):
Now, absolutely so from a personal perspective, the article The
heart of the Matter, A Path to Building Diversity and
theatric Cardiology, really stemmed from my experience going through the
application process for fellowship, and I felt very introspective in
my early first year after the match in just talking
(10:35):
with my co authors and my colleagues. Now, we just
felt that there was some responsibility associated with it being
part of that small percentage of black or African American fellows,
and wanted to provide some guidance for something that in
the medical community is largely understood to be a problem.
(10:55):
And there are a lot of articles that sort of
delineate all of the issues associated with some of the
topics we discussed in the article, including race importance in
between patients and positions, and so we wanted to provide
some steps to really try to manage this and manage
the situation. And that was the that was the impetus
(11:17):
for the article. I felt like we needed to provide
some kind of guidance instead of just kind of discussing
what the problem was.
Speaker 2 (11:24):
Well, you certainly did that and achieve your goal for sure.
You know, you mentioned the vital role that good communication
provides and outcomes and care in general, and it seems
like virtually every every podcast that I do, something about
communication proves to be very important. And you speak also
about the evidence that race concordance between the patient and
(11:47):
the caregiver can improve communication. I'm wondering if you might
be able to sort of flesh that out for us
a little bit what the evidence is for this. And
you know, although we are making efforts to improve representation
by underrepresented trainees and we're working on that, I think
we could both agree it's going to take a little
bit of time. And in the interim, I'm wondering if
(12:09):
you might be able to offer some suggestions for physicians
or providers who are not from underrepresented groups how they
could better communicate to try and bridge that gap with
their patients, and what resources we might be able to
use to help.
Speaker 3 (12:25):
Yes, absolutely, you can talk a little bit more about
that and a few of the things that have been
discussed in previous articles, whether by op ED or really
just investigating sort of mortality outcomes have shown that the
inclusion of a race concordance in a situation does help
to build alliances between the patient and the position and
(12:47):
it overall helps to realize these optimal health goals that
we like to have for our patients. But largely they
really helped to open the discussion, the door to discussion
about the barriers to health management at home and discussions
about support for cultural practices or improving care overall. From
(13:09):
a family's perspective, and the goal for communication, it really
should be always to you know, identify what barriers are
potentially impacting the family's care and really patient centered, provide
information that's well understood and that helps with that partnership
building and patient engagement that we really want. And it
(13:32):
often seems that the goals may not be aligned at
the time that there's you have these breakdowns and inherence
and it seems like the goals aren't aligned, but sometimes
it is because of you know, communication that did not
did not achieve that optimal goal of you know, everyone
being on the same page. And yes, there's there's a
(13:54):
lot of data to show that there is improvement and
patient satisfaction and this intention to adhare and trust with
the risk concordance. And while that's continued to be worked on,
as you mentioned, I think engaging other team members in
those discussions with families, from social workers, nurses, other members
(14:16):
of the staff who contribute to the care of the patient,
and oftentimes, as someone who is from an underrepresented community
in medicine, I do find other people who are not
necessarily physicians but share the same geographical ancestry or background
as I do that I communicate with in the hospital,
(14:37):
and I do feel that families may have weight may
benefit from having.
Speaker 4 (14:42):
That in those teams.
Speaker 3 (14:43):
And I think sometimes we forget how important some of
those interactions may be with families and it may be
that person who's not maybe providing direct clinical care, but
maybe offer a different perspective and reach the family. So
I think in the interim, working on improving the overall
(15:04):
demographics of the medical team, the direct clinical team, really
including the other members of the team and discussions. And
then also the next thing I would mention is maybe
over communicating. Yeah, yeah, as a trainee, you know this
is helpful for me when I as in going through
(15:24):
now as a third year. Over communication has been really
important to help my attendings. Trust me, they understand where
I've stand, like where I am, and and I kind
of can run ideas by them. And I think over
communicating with patients sometimes may help identify any barriers may
have been missed initial assessments, and and may really help
(15:46):
the family understand that guests, you know, the goal is
to their benefit.
Speaker 4 (15:52):
Yeah, I think those those of the the two recommendations
I have.
Speaker 2 (15:55):
Yeah, I mean, I think over communication is definitely a
central feature of quality improvement efforts, right, and so I
think that that rings really true. Thank you for that answer,
of course, Olgie. I think I'm wondering if maybe for
those in the audience, I summarized your paper as I
do every week, but I would rather hear it from
(16:16):
the author. Maybe you could briefly summarize for the audience
the four pillars that you and your co authors felt
represented areas for improvement, namely reflection, fostering, prioritization, and mentorship.
Speaker 4 (16:32):
Yes, absolutely so.
Speaker 3 (16:34):
Overall our essays discussing the impact of under representation in
medicine and medical training with this focus in petric cardiology,
and like I said, we wanted to have you wanted
to have some goals to work towards or some guidelines
for institutions to start practicing. Then the first step we
thought about was reflection. Really, in every program, there are
(16:57):
generally trends that can be identified, whether they're in gender
or geography, background interest that the previous candidates have had.
And sometimes it may be helpful to include someone who's
not part of the initial team that draws these applicants
in to run through these these reviews and understanding what
(17:20):
the trends are may help you know clarify whether or
non institution is meeting the goals of their their entire
recruitment campaign. And so if if in assessing these trends,
everyone feels comfortable that, yes, we are achieving our goals
in terms of diversity, in terms of equity, then that's
(17:41):
obviously perfect and optimal. But if it turns out that
there are some changes that could be made to help
you know better the team, uh, those are one that's
one of the ways that could be used to identify that.
The next The next and we talked about was fostering,
and really the goal is to engage residents who are
(18:03):
in these underrepresented in medicine populations and provide resources for
navigating fellowship. And this ties really into mentorship, which is
one of the last steps we talk about. And the
idea is that if you have a candidate who may
be interested in this process, really identifying them earlier and
(18:24):
providing supports to help engage them through the years of
residency and into fellowship, and then you know, if they
choose to go to fellowship, really supporting them and their
growth through navigating that process of fellowship. And that also
goes into identifying what we're prioritizing and the recruitment in
(18:45):
that I know you talk about this a little bit
more in the essay and really focusing on residents who
may be already engaging in this kind of work where
they're identifying psychosocial stressors towards patients, understanding the role of
social determinance of health in patient outcomes, and really prioritizing
this work knowing that these candidates, these residents trainees have
(19:10):
these skills and they have the medical knowledge to meet
the rigors or fellowship, but they also bring with them
this unique perspective of understanding the problems that patients may
even self be facing or really having show an interest
in both investigating problems patients are facing and also identifying
potential solutions to them. I think that's that's really helpful
(19:33):
when you have people who are aligned to those goals,
if you're including them with the team, and they could
be from they don't necessarily need to be from the
backgrounds that are impacted by a lot of these social
determinants of help. If they've shown consistent interest in really
addressing these problems, I think is important. And then finally,
I think mentorship is seeks for itself. We all understand
(19:53):
the role of mentorship and just career trajectories that really
cultivating talents and identifying any strength, supporting their leadership goals
and their aspirations, and really sponsorship as they as they
work through their careers is really is key. And this
(20:13):
kind of leads to what is going to be our
next steps for this project?
Speaker 2 (20:19):
Yes?
Speaker 4 (20:19):
Going forward?
Speaker 2 (20:20):
Yeah? Please go go ahead? Okay, why don't you share
that with the audience? What are your next steps in this? Uh?
And I just wondering, also, what are you doing in
your own program to foster the concepts that you espouse
in your essay?
Speaker 3 (20:35):
Absolutely, so one of our next steps is really to
identify whether or not a lot of these these items
that we're listing our priorities for fellows.
Speaker 4 (20:46):
And we're doing this by a survey.
Speaker 3 (20:48):
That we've developed that really is the goal of the
surveys to kind of describe the mentorship experiences of residents
who have gone into Fellowship and really that understanding how
key was mentorship towards their decision to go to Fellowship. Additionally,
we wanted to identify the sort of the perception of
(21:10):
the culture of pediatric subspecialties, including pediatric cardiology, how with
the role of the availability of those sub specialties at
their at their home program, was financial constraints at pursuing
further training post residency. So we've developed the survey and
it is about it's close to being launched across we'll
(21:34):
probably be finding it out in the fall to all
to trainees and to The goal is to really get
a better sense of from those people who have gone
through the process, what how these factors mentorship, financial constraints, sponsorship,
this sort of idea fit and the perception of a
culture within those programs and how those how did those
(21:57):
impact the decision to go into Fellowship and to try
depending on those results that might actually help change our practices.
In terms of recruitment we have at so currently University
of Michigan, and you know, we've had a lot of
discussions within our program about understanding, you know, what are
the trends in our recruitment and what are our goals
(22:21):
as an institution, as a program, what are we working towards.
I think we've you know, there have been changes over
the over the years in terms of trends of the
applicants that we're getting, the sort of review and how
holistic it is, and who is included in that review
of applicants and what who the applicants are meeting, you know,
(22:42):
what is being highlighted in the program. And I think
that that has had a positive impact. I'm sure if
my program directors are working on sort of the data
for this, but I think has had a positive impact
and who we've been able to help train in our program.
Speaker 2 (22:58):
And Oki, are you talking about all subspecialties within pediatrics
or explicitly pediatric cardiology.
Speaker 3 (23:05):
So the first survey is going to go out to
just pediatric cardiology, and then the subsequent survey is going
to be through all pediatric subspecialties and in that We
are actually hoping to invite respondents to be involved in
a more in depth interview where we discuss some of
(23:25):
these topics, things that may not have the nuance they've
been missing from the survey, and we will be planning
to compensate for this interview portion and we'll be offering
a raffle for the initial survey.
Speaker 2 (23:42):
You know, I was wondering ogi when you guys were
writing this paper, did you find that there was a
difference of opinion in regards to the experiences that you
had all had as underrepresented physicians or were they shockingly similar?
Speaker 3 (24:00):
I would say that overall, there has been there have
been a lot more similarities and differences. I think we
have all and we are all at different institutions, and
we've followed different paths in order to get to where
we are and have had different experiences, positive and negative,
and I think that's shaped, you know, our career trajectories.
But there are certain things that you know, we find
(24:22):
some commonality in and just in talking to other trainees,
you know, not just in pediatric cardiology, who are who
are underrepresented in medicine, there's been a lot of there's
been similarities in the experience, and and just in sharing
this essay with people who are not in pediatric cardiology,
(24:44):
there has been a lot of sort of understanding that, yes,
this is not a problem that is unique to pediatric cardiology.
It is certainly something that you know, is being addressed
to discussed in a lot of other fields. And I
know in the paper we focus on the numbers, the
total numbers of fellows and trainees over the course of
(25:06):
years and pediatric cardiology, but it's not significantly different when
you look at the other sub specialties and.
Speaker 2 (25:15):
Pediatric sure sure, of course. Well for those in the audience,
it's late on Monday night. Doctor Cox was nice enough
to speak with me tonight, and I'm going to finish
the interview at this point, and I want to thank
you Ogi very much for highlighting what is obviously a
very important, critical topic that is not adequately addressed in
(25:36):
our literature thus far. But this paper certainly goes a
long way to pushing us in that direction. Congratulations to
you and all of your co authors, and I look
forward to hearing about the results of the study that
you just described for us. Thank you and congratulations.
Speaker 4 (25:52):
Thank you so much. It was really great to be
in the.
Speaker 1 (25:54):
Podcast great pleasure, thank you well once again, as I'm
apt to say when the guest is good, not a
whole lot to add. Doctor Cox shared her rationale for
the essay that she wrote and also offered for us
many examples regarding some of the important reasons that racial
concordance that can come from improvements and diversity in our
workforce can drive improved communication and outcomes. I also thought
(26:18):
that she provided for us a very nice framework for
all of us to think about how to achieve the
goals for better representation in our field. I am most
appreciative to her for taking time out as a busy
third year fellow at an excellent program to speak with us,
and hope you enjoyed her comments as much as I did.
This past week, many of you may have heard the
sad news of the passing of doctor Connie Hayes at
(26:40):
the age of eighty seven. Doctor Hayes was a Meritis
Professor of Pediatrics at Columbia University and was a cardiologist
on staff for well over forty years. She had many
roles in the division, and some may recall our conversation
just a few years ago with doctor Peter Lang in
which she explained how doctor Hayes was an inspiration for
him in the arena of cardiac critical care. For most
(27:02):
cardiology fellows and cardiologists at New York Presbyterian in the
past twenty five years, she was perhaps more well known
in her role running the cardiology outpatient clinic and teaching
cardiology fellows. She was a wonderful person who was beloved
by all who were privileged to know her, and I
am certain that I speak for many in my region
and expressing our profound gratitude to her for her kindness
(27:24):
and collegiality, and our sincerest condolences to the family. To
conclude this three hundred and tenth episode, and to honor
doctor Hayes, we end with the lovely Negro spiritual Ain't
That Good News? Composed by William Dawson and sung winningly
by the American soprano Kathleen Battle in a live performance
from nearly forty years ago. Thank you very much for
(27:46):
joining the podcast this week. I hope you will have
a good maak ahead.
Speaker 5 (27:50):
Oh God, I'm gonna be gonna shoulder a back cross,
gonna take it home to my Jesus, even at the
home of che and I room of me, and I kicks.
Speaker 3 (28:20):
I'm gonna be.
Speaker 5 (28:22):
Gonna shoulder a back cross, gonna take it home to Jesus,
even my God, A home of me, and I kind.
Speaker 2 (28:44):
My home of me.
Speaker 5 (28:45):
And I kill'm gonnas too before to Jesus, to kill
to Jesus.
Speaker 3 (29:05):
Take you to Jesus,
Welcome to Pdheart Pediatric Cardiology Today. My name is doctor
Robert Pass and I'm the host of this podcast. I
am professor of Pediatrics at the Icon School of Medicine
at Mount SINAI thank you very much for joining me
for this three hundred and tenth episode of the podcast.
Before we get into this week's episode, I wanted to
address something I learned this past week which involves the
so called pd Heart net list server. Some have had
(00:39):
the mistaken impression that this podcast, called Ptiheart, because of
its name, is affiliated in some manner with that Google list.
It is not, in fact, improve this point, this past week,
I learned that some who have received my biweekly messages
about the podcast episodes that are about to come out
have flagged my email announcements as spam. Result, Google has
(01:01):
blocked me from posting anything about the podcast on that forum.
For this reason, you won't any longer be seeing any
more announcements about the podcast there. Of course, most of
you know that I place announcements in multiple areas of
the Internet every week, and on social media such as Instagram, Facebook, Twitter, LinkedIn,
and threads. But if you happen to be in the
minority of people who were getting information regarding the podcasts
(01:24):
exclusively there, I would instead ask that you just follow
me on any of those other social media venues for
information regarding the upcoming episodes. And thank you so much
as always for listening. I hope everybody. Last week enjoined
our episode with surgical pioneer John Brown of Riley Hospital
for Children in Indianapolis, Indiana for those of you interested
(01:44):
in the history of pediatric cardiovascular science and specifically Cardiovassler's surgery,
and recommend you take a listen to doctor Brown in
last week's three hundred and ninth episode. As I say
most weeks, if you'd like to get in touch with me,
my email is easy to remember. It's Pediheart at gmail
dot com. This week we move into the world of
diversity in the workplace of pediatric cardiology. The title of
(02:08):
the work we'll be reviewing is the Heart of the Matter,
A Path to Building Diversity in Pediatric Cardiology. The first
author of this work is Ogi Cox and the senior
author Britney Hills, and the authors come from multiple centers.
Doctor Cox is a Pediatric Cardiology Fellow in the Division
of Pediatric Cardiology at cs MAX Children's Hospital at the
University of Michigan. When we're done reviewing the paper, doctor
(02:30):
Cox has graciously agreed to speak with us about it. Therefore,
let's learn a little bit about this essay and then
speak with one of its authors. This week's work is
not really a research paper, but it's instead an essay
on the impact of underrepresentation in medical training with a
focus on pediatric cardiology. The work begins with a number
of comments regarding the dearth of black or Hispanic pediatric
(02:52):
cardiology trainees, and they reference the December twenty twenty numbers
where there were four hundred and forty five total fellows
in pediatricals ardeology training, with only fourteen identifying as black
and thirty seven as Hispanic. In other words, the authors
explain that black fellows represented only slightly more than three percent, or,
to use their terminology, a sliver of the pie. They
(03:15):
start by reminding us of the definition of underrepresented in
medicine groups, which are defined as black, Native American or
Hispanic people, and also reminding how their numbers in medicine
do not reflect their numbers in the general population, though
they do mention that there are a rising numbers of
these candidates in medical school. The reason for these numbers
rising are increases in summer programs during undergraduate years, which
(03:38):
facilitate mentorship as well as preparation for pre med students.
They explain that these efforts to enhance Black, Native American
and Hispanic physician enrollment is based on healthcare disparity research
showing that putting underrepresented in medicine doctors in the community
will improve patient centered care. They explain how graduate medical
(03:58):
programs are now support varding more diverse candidates by building
inclusive residencies for these candidates to thrive, and they explain
how in pediatrics, our goals should be attaining a diversity
of the workforce that mirrors our patient groups. The authors
then point to some literature suggesting better outcomes for patients
in general pediatrics when there is racial concordance between physician
(04:19):
and their patient, and they posit that the same should
be true for pediatric cardiology. They explain that the most
likely explanation for these outcomes with racial concordance is related
to improvements in communication and explain how communication is a
key driver in patient family buy in regarding pre and
post operative management of congenital hard patients, underscoring why anything
(04:41):
that can improve communication could potentially result in better outcomes.
The authors then review the financial factors that negatively impact
people choosing to enter pediatrics, which are all aware of,
with the low pay being a major concern, where pediatrician
salaries in the United States can be literally one half
to one third of starting salaries in other the fields
of medicine. Given the two hundred thousand dollars average student
(05:04):
loan debt that med students in the United States take
on and lower income backgrounds of black, Hispanic and Native
American families, and this gap between debt and income becomes
even more daunting. They then delve into the notion of
social determinants of health on congenital heart disease outcomes and
reference doctor Katia Lopez's work on this demonstrating significant post
(05:24):
operative mortality disparities between non Hispanic White and non Hispanic
Black children from twenty twenty and which we reviewed with
doctor Lopez some years back. They emphasize how there are
higher mortality rates amongst black and indigenous populations, and how
these disparities do not appear related just to access to
care or socioeconomic status, and they reference other works on
(05:45):
health communication improvements having potential to reduce disparities, and the
authors suggest that this literature supports the improvements in communication
that may arise from race concordance between doctor and patient.
They reference how concordance between the race of the pro
and the patient may result in more culturally centered care
and will improve communication and help uncover social factors that
(06:07):
may be affecting health of a child with congenital heart
disease that would not otherwise be easily determined. And so
the authors then ask the question how can representation be
improved in pediatric cardiology? They break it into four categories,
and I'm going to ask doctor Cox to review these
in greater detail in our interview, but I'll very briefly
explain what they are. First as reflection, which they describe
(06:29):
as an examination of applicant pools and the matriculence of
given programs over the last say five years, and looking
for trends in backgrounds within the program culture. They make
special reference to the notion of not emphasizing board scoring
as much given the manner in which these scores may reflect,
at least partially socioeconomic and racial class differences rather than aptitude.
(06:51):
Second is that of fostering, which involves engaging residents and
minoritized populations in cardiology and providing reasons to help with
fellowship navigation. They offer the American Collegure of Cardiologies Initiative
in Cardiology amongst Black, Hispanic and Native American physicians to
foster an interest in cardiology early during internal medicine residency. Third,
(07:14):
they speak of prioritization, explaining that all of the decisions
should not be made just on good fit qualities, but
instead qualities like empathy, emotional intelligence, cultural situational awareness, and tactfulness,
which are similarly critical. And they speak also how underrepresented
in medicine physicians should be encouraged to perform disparity research
(07:34):
if they wish to, and how it ought not to
be undervalued scientifically. Finally, they speak of mentorship, in which
talents of the underrepresented fellows and residents are identified and
cultivated as their strengths are supported by faculty. The work
ends with some comments by the authors about the daunting
feeling of presenting to a group of colleagues where no
(07:54):
one's face in the audience looks like yours. They speak
of wondering if they would fit in because of the
lack of diversity in many programs, and speak of how
important it was for mentors to provide for them confidence
to proceed with the application process and then grueling fellowships.
And they conclude by saying, quote, the decision to pursue
any specialty is heavily influenced by an individual's exposure to
(08:17):
the field and the sense of belonging that they may experience.
We must create a community that attracts those who best
represent the faces of our patients.
Speaker 2 (08:26):
Well.
Speaker 1 (08:27):
This is certainly an interesting and insightful work addressing the
lack of diversity in pediatric cardiology, but some specialty training
in general. The many ways in which a more diverse
workforce will improve outcomes seems unassailable at this time, and
really it seems the only remaining important questions are how
we can achieve the goal of improving our cardiology provider diversity.
(08:48):
I think that the authors provide for us a very
nice framework to think about things, and it seems clear
that providing mentors and support along the way was very
important for these authors. I think it will be useful
to hear doctor Coxe explain to us better than four
pillars upon which they feel representation can be improved, and
also what sort of efforts they're making in their own
training programs right now. In the interest of time, therefore,
(09:10):
let's move on to speak with doctor Cox. Ogie Cox
is a graduate of Biinghamton University for College. After that,
she worked as a research assistant at Memorial Sloan Kettering,
where she received a great deal of mentorship. Fostering her
own interest in pursuing medicine. She studied medicine at Sunny
Upstate for Medical School. Following this, she went on to
perform her residency and pediatrics at LURI Children's Hospital in Chicago,
(09:33):
followed by University of Michigan, where she is now a
third year fellow in cardiology, with a great interest in
cardio oncology, cardiomopathy and heart failure and transplant and also
health equity. It is a delight to welcome an up
and coming superstar at PTI Heart. Welcome doctor Cox to Pdheart.
Speaker 2 (09:50):
I'm here now with doctor Ogie Cox. Doctor Cox, thank
you very much for joining us this week on the podcast.
Speaker 3 (09:56):
Hi, thank you so much for inviting me. I'm really
excited to be here.
Speaker 2 (10:01):
I'm excited to have you thank you, you know, before
we get going, doctor Cox. One of the things I
was wondering is what motivated you and your co authors
to pen this essay on this very important topic.
Speaker 3 (10:12):
Now, absolutely so from a personal perspective, the article The
heart of the Matter, A Path to Building Diversity and
theatric Cardiology, really stemmed from my experience going through the
application process for fellowship, and I felt very introspective in
my early first year after the match in just talking
(10:35):
with my co authors and my colleagues. Now, we just
felt that there was some responsibility associated with it being
part of that small percentage of black or African American fellows,
and wanted to provide some guidance for something that in
the medical community is largely understood to be a problem.
(10:55):
And there are a lot of articles that sort of
delineate all of the issues associated with some of the
topics we discussed in the article, including race importance in
between patients and positions, and so we wanted to provide
some steps to really try to manage this and manage
the situation. And that was the that was the impetus
(11:17):
for the article. I felt like we needed to provide
some kind of guidance instead of just kind of discussing
what the problem was.
Speaker 2 (11:24):
Well, you certainly did that and achieve your goal for sure.
You know, you mentioned the vital role that good communication
provides and outcomes and care in general, and it seems
like virtually every every podcast that I do, something about
communication proves to be very important. And you speak also
about the evidence that race concordance between the patient and
(11:47):
the caregiver can improve communication. I'm wondering if you might
be able to sort of flesh that out for us
a little bit what the evidence is for this. And
you know, although we are making efforts to improve representation
by underrepresented trainees and we're working on that, I think
we could both agree it's going to take a little
bit of time. And in the interim, I'm wondering if
(12:09):
you might be able to offer some suggestions for physicians
or providers who are not from underrepresented groups how they
could better communicate to try and bridge that gap with
their patients, and what resources we might be able to
use to help.
Speaker 3 (12:25):
Yes, absolutely, you can talk a little bit more about
that and a few of the things that have been
discussed in previous articles, whether by op ED or really
just investigating sort of mortality outcomes have shown that the
inclusion of a race concordance in a situation does help
to build alliances between the patient and the position and
(12:47):
it overall helps to realize these optimal health goals that
we like to have for our patients. But largely they
really helped to open the discussion, the door to discussion
about the barriers to health management at home and discussions
about support for cultural practices or improving care overall. From
(13:09):
a family's perspective, and the goal for communication, it really
should be always to you know, identify what barriers are
potentially impacting the family's care and really patient centered, provide
information that's well understood and that helps with that partnership
building and patient engagement that we really want. And it
(13:32):
often seems that the goals may not be aligned at
the time that there's you have these breakdowns and inherence
and it seems like the goals aren't aligned, but sometimes
it is because of you know, communication that did not
did not achieve that optimal goal of you know, everyone
being on the same page. And yes, there's there's a
(13:54):
lot of data to show that there is improvement and
patient satisfaction and this intention to adhare and trust with
the risk concordance. And while that's continued to be worked on,
as you mentioned, I think engaging other team members in
those discussions with families, from social workers, nurses, other members
(14:16):
of the staff who contribute to the care of the patient,
and oftentimes, as someone who is from an underrepresented community
in medicine, I do find other people who are not
necessarily physicians but share the same geographical ancestry or background
as I do that I communicate with in the hospital,
(14:37):
and I do feel that families may have weight may
benefit from having.
Speaker 4 (14:42):
That in those teams.
Speaker 3 (14:43):
And I think sometimes we forget how important some of
those interactions may be with families and it may be
that person who's not maybe providing direct clinical care, but
maybe offer a different perspective and reach the family. So
I think in the interim, working on improving the overall
(15:04):
demographics of the medical team, the direct clinical team, really
including the other members of the team and discussions. And
then also the next thing I would mention is maybe
over communicating. Yeah, yeah, as a trainee, you know this
is helpful for me when I as in going through
(15:24):
now as a third year. Over communication has been really
important to help my attendings. Trust me, they understand where
I've stand, like where I am, and and I kind
of can run ideas by them. And I think over
communicating with patients sometimes may help identify any barriers may
have been missed initial assessments, and and may really help
(15:46):
the family understand that guests, you know, the goal is
to their benefit.
Speaker 4 (15:52):
Yeah, I think those those of the the two recommendations
I have.
Speaker 2 (15:55):
Yeah, I mean, I think over communication is definitely a
central feature of quality improvement efforts, right, and so I
think that that rings really true. Thank you for that answer,
of course, Olgie. I think I'm wondering if maybe for
those in the audience, I summarized your paper as I
do every week, but I would rather hear it from
(16:16):
the author. Maybe you could briefly summarize for the audience
the four pillars that you and your co authors felt
represented areas for improvement, namely reflection, fostering, prioritization, and mentorship.
Speaker 4 (16:32):
Yes, absolutely so.
Speaker 3 (16:34):
Overall our essays discussing the impact of under representation in
medicine and medical training with this focus in petric cardiology,
and like I said, we wanted to have you wanted
to have some goals to work towards or some guidelines
for institutions to start practicing. Then the first step we
thought about was reflection. Really, in every program, there are
(16:57):
generally trends that can be identified, whether they're in gender
or geography, background interest that the previous candidates have had.
And sometimes it may be helpful to include someone who's
not part of the initial team that draws these applicants
in to run through these these reviews and understanding what
(17:20):
the trends are may help you know clarify whether or
non institution is meeting the goals of their their entire
recruitment campaign. And so if if in assessing these trends,
everyone feels comfortable that, yes, we are achieving our goals
in terms of diversity, in terms of equity, then that's
(17:41):
obviously perfect and optimal. But if it turns out that
there are some changes that could be made to help
you know better the team, uh, those are one that's
one of the ways that could be used to identify that.
The next The next and we talked about was fostering,
and really the goal is to engage residents who are
(18:03):
in these underrepresented in medicine populations and provide resources for
navigating fellowship. And this ties really into mentorship, which is
one of the last steps we talk about. And the
idea is that if you have a candidate who may
be interested in this process, really identifying them earlier and
(18:24):
providing supports to help engage them through the years of
residency and into fellowship, and then you know, if they
choose to go to fellowship, really supporting them and their
growth through navigating that process of fellowship. And that also
goes into identifying what we're prioritizing and the recruitment in
(18:45):
that I know you talk about this a little bit
more in the essay and really focusing on residents who
may be already engaging in this kind of work where
they're identifying psychosocial stressors towards patients, understanding the role of
social determinance of health in patient outcomes, and really prioritizing
this work knowing that these candidates, these residents trainees have
(19:10):
these skills and they have the medical knowledge to meet
the rigors or fellowship, but they also bring with them
this unique perspective of understanding the problems that patients may
even self be facing or really having show an interest
in both investigating problems patients are facing and also identifying
potential solutions to them. I think that's that's really helpful
(19:33):
when you have people who are aligned to those goals,
if you're including them with the team, and they could
be from they don't necessarily need to be from the
backgrounds that are impacted by a lot of these social
determinants of help. If they've shown consistent interest in really
addressing these problems, I think is important. And then finally,
I think mentorship is seeks for itself. We all understand
(19:53):
the role of mentorship and just career trajectories that really
cultivating talents and identifying any strength, supporting their leadership goals
and their aspirations, and really sponsorship as they as they
work through their careers is really is key. And this
(20:13):
kind of leads to what is going to be our
next steps for this project?
Speaker 2 (20:19):
Yes?
Speaker 4 (20:19):
Going forward?
Speaker 2 (20:20):
Yeah? Please go go ahead? Okay, why don't you share
that with the audience? What are your next steps in this? Uh?
And I just wondering, also, what are you doing in
your own program to foster the concepts that you espouse
in your essay?
Speaker 3 (20:35):
Absolutely, so one of our next steps is really to
identify whether or not a lot of these these items
that we're listing our priorities for fellows.
Speaker 4 (20:46):
And we're doing this by a survey.
Speaker 3 (20:48):
That we've developed that really is the goal of the
surveys to kind of describe the mentorship experiences of residents
who have gone into Fellowship and really that understanding how
key was mentorship towards their decision to go to Fellowship. Additionally,
we wanted to identify the sort of the perception of
(21:10):
the culture of pediatric subspecialties, including pediatric cardiology, how with
the role of the availability of those sub specialties at
their at their home program, was financial constraints at pursuing
further training post residency. So we've developed the survey and
it is about it's close to being launched across we'll
(21:34):
probably be finding it out in the fall to all
to trainees and to The goal is to really get
a better sense of from those people who have gone
through the process, what how these factors mentorship, financial constraints, sponsorship,
this sort of idea fit and the perception of a
culture within those programs and how those how did those
(21:57):
impact the decision to go into Fellowship and to try
depending on those results that might actually help change our practices.
In terms of recruitment we have at so currently University
of Michigan, and you know, we've had a lot of
discussions within our program about understanding, you know, what are
the trends in our recruitment and what are our goals
(22:21):
as an institution, as a program, what are we working towards.
I think we've you know, there have been changes over
the over the years in terms of trends of the
applicants that we're getting, the sort of review and how
holistic it is, and who is included in that review
of applicants and what who the applicants are meeting, you know,
(22:42):
what is being highlighted in the program. And I think
that that has had a positive impact. I'm sure if
my program directors are working on sort of the data
for this, but I think has had a positive impact
and who we've been able to help train in our program.
Speaker 2 (22:58):
And Oki, are you talking about all subspecialties within pediatrics
or explicitly pediatric cardiology.
Speaker 3 (23:05):
So the first survey is going to go out to
just pediatric cardiology, and then the subsequent survey is going
to be through all pediatric subspecialties and in that We
are actually hoping to invite respondents to be involved in
a more in depth interview where we discuss some of
(23:25):
these topics, things that may not have the nuance they've
been missing from the survey, and we will be planning
to compensate for this interview portion and we'll be offering
a raffle for the initial survey.
Speaker 2 (23:42):
You know, I was wondering ogi when you guys were
writing this paper, did you find that there was a
difference of opinion in regards to the experiences that you
had all had as underrepresented physicians or were they shockingly similar?
Speaker 3 (24:00):
I would say that overall, there has been there have
been a lot more similarities and differences. I think we
have all and we are all at different institutions, and
we've followed different paths in order to get to where
we are and have had different experiences, positive and negative,
and I think that's shaped, you know, our career trajectories.
But there are certain things that you know, we find
(24:22):
some commonality in and just in talking to other trainees,
you know, not just in pediatric cardiology, who are who
are underrepresented in medicine, there's been a lot of there's
been similarities in the experience, and and just in sharing
this essay with people who are not in pediatric cardiology,
(24:44):
there has been a lot of sort of understanding that, yes,
this is not a problem that is unique to pediatric cardiology.
It is certainly something that you know, is being addressed
to discussed in a lot of other fields. And I
know in the paper we focus on the numbers, the
total numbers of fellows and trainees over the course of
(25:06):
years and pediatric cardiology, but it's not significantly different when
you look at the other sub specialties and.
Speaker 2 (25:15):
Pediatric sure sure, of course. Well for those in the audience,
it's late on Monday night. Doctor Cox was nice enough
to speak with me tonight, and I'm going to finish
the interview at this point, and I want to thank
you Ogi very much for highlighting what is obviously a
very important, critical topic that is not adequately addressed in
(25:36):
our literature thus far. But this paper certainly goes a
long way to pushing us in that direction. Congratulations to
you and all of your co authors, and I look
forward to hearing about the results of the study that
you just described for us. Thank you and congratulations.
Speaker 4 (25:52):
Thank you so much. It was really great to be
in the.
Speaker 1 (25:54):
Podcast great pleasure, thank you well once again, as I'm
apt to say when the guest is good, not a
whole lot to add. Doctor Cox shared her rationale for
the essay that she wrote and also offered for us
many examples regarding some of the important reasons that racial
concordance that can come from improvements and diversity in our
workforce can drive improved communication and outcomes. I also thought
(26:18):
that she provided for us a very nice framework for
all of us to think about how to achieve the
goals for better representation in our field. I am most
appreciative to her for taking time out as a busy
third year fellow at an excellent program to speak with us,
and hope you enjoyed her comments as much as I did.
This past week, many of you may have heard the
sad news of the passing of doctor Connie Hayes at
(26:40):
the age of eighty seven. Doctor Hayes was a Meritis
Professor of Pediatrics at Columbia University and was a cardiologist
on staff for well over forty years. She had many
roles in the division, and some may recall our conversation
just a few years ago with doctor Peter Lang in
which she explained how doctor Hayes was an inspiration for
him in the arena of cardiac critical care. For most
(27:02):
cardiology fellows and cardiologists at New York Presbyterian in the
past twenty five years, she was perhaps more well known
in her role running the cardiology outpatient clinic and teaching
cardiology fellows. She was a wonderful person who was beloved
by all who were privileged to know her, and I
am certain that I speak for many in my region
and expressing our profound gratitude to her for her kindness
(27:24):
and collegiality, and our sincerest condolences to the family. To
conclude this three hundred and tenth episode, and to honor
doctor Hayes, we end with the lovely Negro spiritual Ain't
That Good News? Composed by William Dawson and sung winningly
by the American soprano Kathleen Battle in a live performance
from nearly forty years ago. Thank you very much for
(27:46):
joining the podcast this week. I hope you will have
a good maak ahead.
Speaker 5 (27:50):
Oh God, I'm gonna be gonna shoulder a back cross,
gonna take it home to my Jesus, even at the
home of che and I room of me, and I kicks.
Speaker 3 (28:20):
I'm gonna be.
Speaker 5 (28:22):
Gonna shoulder a back cross, gonna take it home to Jesus,
even my God, A home of me, and I kind.
Speaker 2 (28:44):
My home of me.
Speaker 5 (28:45):
And I kill'm gonnas too before to Jesus, to kill
to Jesus.
Speaker 3 (29:05):
Take you to Jesus,
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