105. Narratives in Cardiology: Racial Di...

CardioNerds (Amit Goyal and Daniel Ambinder) join Dr. Bryan Smith (Advanced Heart Failure and Transplant Cardiologist at the University of Chicago) and Dr. Shirlene Obuobi (rising cardiology fellow, CardioNerds ambassador for the University of Chicago, and creator of ShirlyWhirl, M.D.) They discuss the story of a patient with end stage heart failure due to peripartum cardiomyopathy that highlights racial disparities in healthcare and advanced heart failure. They emphasize the importance of providing mentorship for Black and Indigenous People of Color (BIPOC) and share personal stories of their journey to Cardiology. Dr. Andi Shahu joins us to read his AHA blog titled “Let’s Ban the Phrase “Social Issues”: Social Justice and Advanced Heart Failure Therapies”. Audio editing by CardioNerds Academy intern, Pace Wetstein.

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Quotables:

“One of the reasons why I went into Heart Failure is because I connected a lot with these young patients, a lot of these young black men and black women who were terrified of the hospital. As a resident and a fellow I would go talk to them and really understand their fears and where they are coming from. I think a lot of times these patients can be labeled as ‘noncompliant,’ or ‘withdrawn,’ or ‘aggressive,’ but a lot of times you just have to understand where they’re coming from. And I really found that just sitting down to talk to them, and to get to know them, I was able to help get them better, or a lot of them went on to get VADs or transplant. And, to be perfectly honest, I’m in touch with a lot of these patients who I met as a fellow who…I feel are part of my life….You have to meet patients where they are. Meaning you need to text them, interact with them on social media, and really connect with them in a way they understand.” Dr. Bryan Smith (12:10)

“Being black in America means not getting the benefit of doubt. …I can’t help but wonder if unconscious bias among providers is imposing…unreasonable scrutiny on patients of color.” Shirlene (21:15)

“There are many different ways to combat [racial] disparities. As a Heart Failure physician we have these multidisciplinary meetings where we discuss patients for transplant. And I think it’s…important to highlight to our providers that how we discuss patients really matters. Language definitely matters. Heart failure is art in addition to science. …Sometimes when discussing these patients…charged words are used, like ‘withdrawn,’ or ‘aggressive,’ or ‘ghetto’ even. And it’s all coded, racist language. …Part of our responsibility is to educate everyone with implicit bias training….and to make sure we’re able to advocate for patients in the right way.” Dr. Bryan Smith (22:30)

“I’ve felt like I’ve been paying the minority tax…which is doing the necessary but unpaid and frequently seldom recognized labor of mentorship, community engagement, etc, and also of being hyper visible and acting as a symbol…” – Shirlene (24:52)

“It’s really easy when patients are in the hospital to think of them only as patients and forget that they’re people too, and that people are complex, they have complex emotions, they have reactions to things, sometimes those reactions aren’t necessarily what we would think are appropriate for their medical situation, but they’re what make us human.” – Shirlene (9:50)

Notes:

1. What are some of the racial disparities in diagnosis and outcomes of peri-partum cardiomyopathy, and what are some factors that might be contributing to those disparities?

• CVD disease is the leading cause of pregnancy-associated mortality in the US. Black and American Indian/ Alaskan Native women are 3-4x more likely to die from a pregnancy-related cause than white women. (1,2)
• The incidence of peripartum cardiomyopathy (PPCM) is 4x higher in black women than in white women. Black women may make up to 40% of the cases. (3,4)
• Black women with PPCM have lower LVEF at the time of diagnosis, lower rates of recovery of LVEF, higher incidence of mortality and need for LVAD/ transplant. (1,2)
• Studies looking for genetic reasons for this disparity have come up short.
• Black women are more likely to have comorbid conditions (i.e., gestational HTN, preeclampsia).

2. What is it like taking care of younger patients with LVEF, especially young black patients?

• Working in Advanced Heart Failure gives cardiologists the opportunity to work with younger patients due to the prevalence of CMs that present at younger ages.
• Younger patients tend to feel more invincible, and to have more distrust of the medical system.
• It is important to get to know these patients, meet them where they are, and communicate with them in ways they understand (text, social media).  

3. How can we help to break the black patients’ distrust in the medical system?

• Understand the history: medicine has historically excluded and abused black patients. (ie. the Tuskegee study withheld treatment from black sharecroppers, gynecological surgery experimentations on black slave women, a legacy of segregation, etc.)
• Listen to our patients and try to meet them where they are.
• Understand the social determinants of health (SDOH) that may influence their ability to “adhere” to therapy/ appointments (i.e., difficulty finding childcare, employment restrictions)
• Partner with community initiatives (i.e., Urban Health Initiative at University of Chicago)
• Hire and train members of the community to work in the hospital!
• Invest in Pipeline programs and mentorship.

4. Why is diversity in the medicine important?

• Concordance of race between providers and patients improves trust, quality of care, and improves patient outcomes! (5)
• Black patients are less likely to be referred for catheterization, AICDs, etc., despite our best efforts to provide equitable care.
• Language is important! Consider the use of coded language and racially disparate expectations for patients when discussing issues such as transplant candidacy.
• Recruit physicians who are interested in disparities research, and make research into disparities a basis for promotion.

5. How do we engage the rest of the cardiology community to be invested in the recruitment and mentorship of underrepresented minorities in medicine (URiMs)?

• URiMs frequently pay the “minority tax,” or the necessary but unpaid and seldom recognized labor of mentorship, community engagement, etc. That can be a heavy load to carry, especially considering only 5% of cardiology fellows identify as being Black.
• “You can’t really be what you can’t see” – there’s a responsibility that URMs have in cardiology to be visible to inspire future generations.
• However, mentorship of URiMs should not be limited to only URiM faculty. Centers should try to recruit and establish a culture that values diversity.
• Diversity shouldn’t be limited to just attributes like race/ gender, but also in interest. Without diversity of thought, you may not have adequate mentorship and community engagement.

Show notes updated as of 3.2.2021

The CardioNerds Narratives in Cardiology series features cardiovascular faculty representing diverse backgrounds, subspecialties, career stages, and career paths. Discussing why these faculty chose careers in cardiology and their passion for their work are essential components to inspiring interest in the field.

Each talk will feature a cardiology faculty from an underrepresented group, within at least one of several domains: gender, race, ethnicity, religion, national origin, international graduate status, disadvantaged backgrounds, etc.

Featured faculty will also represent a variety of practice settings, academic ranks, subspecialties (e.g. clinical cardiology, interventional cardiology, electrophysiology, etc), and career paths (e.g. division chief, journal editor, society leadership, industry consultant, etc).

Faculty will be interviewed by fellows-in-training for a two-part discussion that will focus on:

1) Faculty’s content area of expertise
2) Faculty’s personal and professional narrative

As part of their narrative, faculty  will discuss their unique path to cardiology and their current professional role with particular attention to challenges, successes, and advice for junior trainees. Specific topics will be guided by values relevant to trainees, including issues related to mentorship, work-life integration, and family planning.

To help guide this important initiative, the CardioNerds Narratives Council was founded to provide mentorship and guidance in producing the Narratives series with regards to guests and content. The CardioNerds Narratives Council members include: Dr. Pamela Douglas, Dr. Nosheen Reza, Dr. Martha Gulati, Dr. Quinn Capers, IV, Dr. Ann Marie Navar, Dr. Ki Park, Dr. Bob Harrington, Dr. Sharonne Hayes, and Dr. Michelle Albert.

The Narratives Council includes three FIT advisors who will lead the CardioNerds’ diversity and inclusion efforts, including the current project: Dr. Zarina Sharalaya, Dr. Norrisa Haynes, and Dr. Pablo Sanchez.

Guest Profiles

References

1. Irizarry OC, Levine LD, Lewey J, et al. Comparison of Clinical Characteristics and Outcomes of Peripartum Cardiomyopathy Between African American and Non-African American Women. JAMA Cardiol. 2017;2(11):1256-1260. doi:10.1001/jamacardio.2017.3574  (https://jamanetwork.com/journals/jamacardiology/fullarticle/2657313)
2. DeFilippis EM, Truby LK, Garan AR, et al. Sex-Related Differences in Use and Outcomes of Left Ventricular Assist Devices as Bridge to Transplantation. JACC Heart Fail. 2019;7(3):250-257. doi:10.1016/j.jchf.2019.01.008  https://pubmed.ncbi.nlm.nih.gov/30819381/
3. Arany Z, Elkayam U. Peripartum Cardiomyopathy. Circulation. 2016;133(14):1397-1409. doi:10.1161/CIRCULATIONAHA.115.020491 (https://pubmed.ncbi.nlm.nih.gov/27045128/)
4. Lewey J, Levine LD, Elovitz MA, Irizarry OC, Arany Z. Importance of Early Diagnosis in Peripartum Cardiomyopathy. Hypertension. 2020;75(1):91-97. doi:10.1161/HYPERTENSIONAHA.119.13291 (https://pubmed.ncbi.nlm.nih.gov/31707840/0)
5. Jetty A, Jabbarpour Y, Pollack J, Huerto R, Woo S, Petterson S. Patient-Physician Racial Concordance Associated with Improved Healthcare Use and Lower Healthcare Expenditures in Minority Populations [published online ahead of print, 2021 Jan 5]. J Racial Ethn Health Disparities. 2021;10.1007/s40615-020-00930-4. doi:10.1007/s40615-020-00930-4 (https://pubmed.ncbi.nlm.nih.gov/33403653/)
6. Takeshita J, Wang S, Loren AW, et al. Association of Racial/Ethnic and Gender Concordance Between Patients and Physicians With Patient Experience Ratings. JAMA Netw Open. 2020;3(11):e2024583. Published 2020 Nov 2. doi:10.1001/jamanetworkopen.2020.24583 (https://pubmed.ncbi.nlm.nih.gov/33165609/)