Thank you all, so I'm going to talk a little bit about workforce diversity and vascular specialties. This is a topic near and dear to my heart. I'm an interventional cardiologist and also do peripheral vascular interventions at Duke. Objectives today. So I first want to set the landscape for where we are right now, and then I want to describe the importance of diversity within the vascular workforce, and then explore approaches that we've been working on at Duke and at other places to improve workforce diversity in these specialties. So just a key assumption here, I am going to mainly present data with regard to interventional cardiology and vascular surgery. I recognize that this is a very heterogeneous population of providers, but this is where the primary data is coming at this point. So I want to highlight workforce diversity in vascular surgery to begin with. So this was a publication out in 2021, looking at women, Hispanic, and black trainees in vascular surgery, fellowships, residencies, compared to other surgical subspecialties. And you can see in general, from 2013 to 2017, there's an increase compared to the 90s and early 2000s across the board. However, what I want you to draw your attention to is the bottom part of this graphic. So with regard to women, you can see that the relative ratio is less than one, so 0.56 for vascular surgery fellowship, meaning we're losing women coming out of medical school going into either other surgical subspecialties or other specialties in general. Hispanic trainees, actually, there's a greater proportion of trainees who are Hispanic in vascular surgery fellowships and residencies compared to medical school. And then with black trainees, this is actually a little bit misrepresenting here. So look, it looks like it's near a one-to-one ratio. However, the representation of black trainees in medical school is so low that they're going into vascular surgery at almost a one-to-one ratio. However, it's off parity, it's not near parity to what we're seeing with the general population. So there's a lot of work, in particular, with women and black trainees in vascular surgery. So what about underrepresentation of women? So I love looking at this figure, it depresses me at the same time. So this was published by Sonia Burgess in circulation back in 2019, and you can see that this is some Australian data, but the proportions of women cardiologists in Australia is about the same and is growing about the same as here in the U.S. We won't have parity with regard to female cardiologists in my lifetime within the next 50 years. We won't have parity with regard to interventional cardiology within my daughter's lifetime. Women in interventional cardiology make up about 21% of fellows in training, only about 9%. This is unfortunately still the case as well for UREX for both general cardiology and interventional cardiology. This unfortunately extends to research leadership. So this was a study back in GMA IM back in 2020, looking at 200 major cardiovascular and vascular trials. Only 11% of leadership committee members were women. Among the 200 trials, and these were trials published in New England Journal, GMA, and only 41.5% had no female investigators, and over half had no female physicians on their leadership committees. So what are the etiologies of this lack of diversity? So Pam Douglas did a survey of thousands of internal medicine health staff, published back in GMA Cardiology in 2018, to say, what's the reason? Why don't you want to go into cardiology, and why don't you want to go into interventional cardiology? And they cited that there's a lack of visible role models, lack of diversity begets lack of diversity, perceptions of cardiovascular and vascular surgical subspecialties as having a bias towards men, potential concerns about family friendliness. The vascular surgery integrated fellowships have actually increased representation of women because of thoughts for greater sort of lifestyle flexibility, and then concern for work-life balance, as well as for pay discrepancies. So why is diversity important? So everything I've said to you thus far is based on a premise that this matters, it matters for our patients, and it matters for our research and our trainees. So we know that diversity is important for mentorship and the experience for students. I just cited that internal medicine health staff and trainees state that they don't go into cardiovascular and vascular subspecialties because there's a lack of people who look like them and who could be mentors to them, potentially. What about better patient care and health outcomes? So I've cited a couple of key studies here. So racially concordant visits in the office were cited to have significantly longer duration, and then patients also cited that they were more pleased and they felt like their provider took them seriously. We know that UREC physicians are also significantly more likely to work after graduating training in areas of underrepresented and underserved patients. And so as we've seen in the prior studies and the prior presentations today, this is really key. And then we know that it potentially contributes to higher quality research. We know that gender heterogeneous working groups are associated with significantly more citations and produce oftentimes higher impact science. So this is really an issue of the recruitment pipeline. You cannot start your efforts at the time of medical school, at the time of fellowship, because it's too late at that point. We've lost too many people that are potential vascular surgeons, interventional cardiologists, vascular specialists. So at Duke, we had a major issue with this about five years ago. I was in a training class at Duke at that point. I was the only female out of eight cardiovascular fellows, and we had no other diversity at that point as well. And so some of us said that this is a real issue, and we got institutional buy-in from our chief, from a fellowship program director to change this. So we formed a diversity and inclusion task force. We actually surveyed highly ranked applicants who decided not to match at Duke and said, why didn't you match at Duke? Help us understand this better. We appointed a more diverse fellowship leadership group, and we changed key areas of the application review. So we removed the USMLE score criteria. We also blinded reviewers to applicant pictures. Purposely increased our applicants' interview pool diversity. So we aimed for about 25% of women in UREGs to be interviewed, and UREG candidates had to be reviewed by UREG members of the fellowship recruitment committee. You can remember hosting multiple interview events for women in UREGs on the day of the interview as well as the night before, and we focused importantly on having them meet with diverse faculty members during their interview day. And so what did this intentionality contribute to? So we published this back in 2021, and I want to draw your attention to the bottom right-hand figure, and you can see that prior to undergoing this intervention, over our whole fellowship, so that's at Duke that's four years because we do an extra research year, we had about 25% that were either women or UREG trainees. As of 2020, we had increased that to 67%, and it continues to increase over this time. One of the people I look up to the most is Quinn Capers, and he's taught us a lot about implicit bias over the years. We undergo implicit bias training. If you're on the fellowship recruitment committee, you have to undergo this training, and we've had journal clubs to have our fellows undergo this training. And so he's given us a few key tips on how to think about implicit bias. So how do you improve recruitment, and then how do you improve your vascular specialty workforce? It has to come during the training years, so you have to focus on mentorship. Can't just recruit them into your fellowship or into your residency. You have to help them with mentors afterwards. You have to recruit at all stages of the pipeline, and there's a need for institutional desire to change. You have to have buy-in. It has to be an intentional process. So in the conclusions, a lack of diversity still remains in the vascular workforce. There's issues with the pipeline at all levels, and increased workforce diversity improves all areas of the academic mission, from clinical outcomes to training to research, and initiatives aimed at increasing the diversity of the pipeline do work.

workforce diversity

vascular specialties

underrepresentation

gender diversity

diversity initiatives