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Blinding reviewers to applicant photos, discarding standardized testing, and other strategies to improve equity increased the proportion of women and underrepresented racial and ethnic groups in a cardiology fellowship program, researchers reported.

The multipronged intervention boosted the proportion of the entire fellowship who were women from the previous 5-year mean of 27.0% to 54.2% after 3 years of the changes (2017-2019), reported Jennifer A. Rymer, MD, MBA, of Duke Clinical Research Institute in Durham, North Carolina, and colleagues in .

By the same comparison Black, Hispanic, Latinx, and Native American matriculants in the program rose from 5.6% to 33.3%.

"Importantly, we did not alter (ie, lower) our standard requirements for recruiting applicants," Rymer's group noted. "Aside from eliminating US Medical Licensing Examination score criteria, we continued to select applicants to interview who met previously published criteria. Furthermore, we did not stipulate percentages of ranked or matched applicants."

Together these changes made these traditionally underrepresented groups into a majority -- 66.7% -- whereas their proportion among all Accreditation Council for Graduate Medical Education internal medicine residencies and cardiovascular disease fellowships did not increase significantly from 2015 to 2019.

"Academic medicine bears responsibility for addressing structural discrimination in its midst," wrote Michelle A. Albert, MD, MPH, of the University of California San Francisco, and colleagues in an accompanying .

"The wake-up call for this endeavor is supported by research showing that 31% of cardiology fellowship program directors did not believe that health care diversity was important, 63% believed that their program did not lack diversity, and only 6% considered diversity a top 3 priority when ranking applicants," they stated.

One cardiology program fellowship director was recently removed after arguing against affirmative action.

At Duke, the "wake-up call" was in 2017 when its cardiovascular medicine fellowship program matched no women applicants and only one underrepresented racial and ethnic fellow.

At that time, the division started down a road to create equity of opportunity. "This included the creation of a fellowship diversity and inclusivity task force that drafted recommendations, which included reorganization of the fellowship recruitment committee, and changes to the applicant screening process, the interview day, applicant ranking process, and postmatch interventions," Rymer's group noted.

Compared with the 10 years prior (2006-2016), the proportion of applicants who were women and minorities increased during the interventions (2017-2019), from 22.4% to 26.4(P<0.001) and from 10.5% to 12.5% (P=0.01), respectively.

Their representation among applicants interviewed increased from 20.0% to 33.5% for women and from 14.0% to 20.0% for minorities (both P=0.01).

Pointing to the high quality of fellows, first-time in-training examination scores were numerically higher for women than men after the interventions during 2018 and 2019. Only two minority fellows took the exam, precluding comparison. "However, neither score was a statistical outlier," Rymer's group noted. Time to achieve milestone competency levels was similar across sex and racial groups.

The interventions didn't add significant expense or have unintended consequences, the researchers added.

The increases came in large part through the internal "pipeline" of candidates, with about half of the minority cardiology fellows and roughly 30% of women fellows having graduated from Duke's School of Medicine or coming in through its internal medicine residency.

Albert's group cautioned that "caution must be exercised about internal pipelines reinforcing implicit biases about external candidates. Notoriously, candidates from diverse cultural and geographic backgrounds and training programs risk being sacrificed in mechanisms that heavily prioritize an internal pipeline, no matter how valuable that pipeline is."

They suggested that programs more broadly should also stop in-training service examination score utilization in favor of pass-fail scoring to assess fellow quality. "Standardized testing arguably represents a form of structural discrimination because the results are tied to socioeconomic status and preparation as opposed to intelligence or success as a physician, as many falsely believe," they wrote.

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