Author + information
- Carole A. Warnes, MD, FACC, Chair,
- Savitri E. Fedson, MA, MD,
- Elyse Foster, MD, FACC,
- Mariell Jessup, MD, FACC,
- Marian C. Limacher, MD, FACC,
- Jacqueline A. O'Donnell, MD, FACC and
- Mary N. Walsh, MD, FACC
In 2003, 50.8% of applicants and 49.7% of matriculants of U.S. medical schools were women (1). This was the first time in our nation's history that women made up more than half of medical school applicants (2). Currently, 22.2% of female medical graduates choose an internal medicine residency. Although this number is high, only 6.3% of women trainees chose to enter an internal medicine subspeciality (3). In 2003, approximately 14% of American College of Cardiology (ACC) fellows-in-training were women (431 women, 2483 men, 273 unknown) (ACC data), and 6% of the total number of fellows of the ACC are women (4). According to data from the American Board of Internal Medicine (ABIM), the percentage of first-year cardiology trainees who are females has increased from 13% in 1994 to 1995 to 18% in 2002 to 2003, the most recently reported data for cardiology training programs (5). However, considering that nearly one-half of U.S. medical students are now female, the fact that only 18% of first-year cardiology trainees are women is cause for concern.
Women bring a different skill-set to the workplace, and the lingering shortfall of females in cardiology is striking compared with other sciences where the number of women is increasing more rapidly (6). It is interesting to note that a higher proportion of female pediatric residents choose cardiology than do female internal medicine residents. Today, cardiology training programs are facing additional challenges because international medical graduates (IMGs), some of whom are women, are confronting new barriers when they attempt to continue their medical training in the U.S. Working Group 4 deals with the important topic of IMGs in cardiology.
A 1998 report of the ACC Committee on Women in Cardiology included data derived from a questionnaire that was mailed in March 1996 to all 964 female ACC members and an age-matched sample of 1,119 male members who had completed training (7). That report is rich in detail and includes important conclusions and valuable suggestions. Our working group report combines some of its findings with data and impressions from other sources. Moreover, several of our observations relate to medicine as a whole, not just cardiology. The 1996 ACC survey found that family responsibilities may represent an obstacle for women considering a career in cardiology because it is not perceived as being as “family friendly” as are some other specialties.
Although significant societal changes have occurred in parenting, these have yet to be integrated into the medical community. Women, more than men, perceive that family responsibilities hinder their ability to pursue a professional career in medicine. Women are also more likely than men to interrupt their training or their practice for more than a month, usually related to pregnancy or childcare. Even if a woman physician works full time, in most instances she is likely to provide more childcare than her husband. Moreover, the implications for childbearing of six to seven years of postgraduate medical training (internal medicine plus cardiology fellowship) cannot be ignored as we consider how to attract more women into cardiology. After her training is completed, family responsibilities often limit a female physician's ability to travel to attend continuing medical education or other professional advancement programs and to serve on regional or national committees of organizations such as the ACC or the American Heart Association (AHA).
The 1996 survey compared the female and male respondent's primary practice setting and type of cardiology practice. Female cardiologists were more likely than males to define their primary or secondary role as a clinical cardiologist, echocardiographer, transplant cardiologist, or researcher. This finding has important implications with respect to the chronic unmet demand for general clinical cardiologists. These choices with respect to what type of cardiology practice women seem to prefer relate, at least in part, to the perception that some cardiology subspecialties (e.g., interventional cardiology) allow less flexibility with respect to on-call duties that, in turn, have important implications for parenting and for what has been termed a “controllable lifestyle.” The emphasis placed on acute cardiac care and emergency interventional procedures that both medical students and internal medicine residents witness during training surely reinforces this impression (8).
It is imperative that female medical students and internal medical residents become better informed about the broad spectrum of career opportunities in cardiology, several of which are compatible with a desire to achieve better work–life balance. We, as a specialty, must assume the responsibility for educating potential cardiologists about these career options. Working Group 8 discusses several types of cardiology practice and proposes a model for training more general clinical cardiologists, for whom the demand is great and growing. This role might hold special appeal for women cardiologists because much of the care provided by general clinical cardiologists is in the outpatient setting.
In terms of job satisfaction, the 1996 ACC survey revealed that 88% of women (versus 92% of men) were moderately or very satisfied with their work. The levels of satisfaction among women were similar in academic and private practice settings. This finding should be reassuring to female medical students or internal medicine residents considering a career in cardiology. Importantly, a majority of both female (54%) and male (61%) respondents reported that they were likely to recommend cardiology as a career choice to those who asked their opinion. A minority of cardiologists (20% of the female and 15% of the male respondents) would discourage students or residents from pursuing a career in cardiology. It is likely that job satisfaction will increase for all cardiologists if their workload is reasonable and they have more control over their personal work–life balance.
One area where women cardiologists were significantly less satisfied than their male counterparts was with respect to career advancement, especially those in academic medicine. The 1996 survey revealed that 39% of women in academic medicine reported achieving lower or much lower levels of advancement compared with only 3% of men (7). In terms of discrimination in the workplace, 71% of women compared with 21% of men felt they had experienced some form of discrimination, and they believed that it affected their interactions with colleagues. The predominant type of discrimination was gender-related for women and race-related for men.
These concerns are not unique to cardiology—they reflect the experience of women in other professional fields. Nevertheless, our working group wants to emphasize that perceptions (negative or positive) can have a very significant effect on female medical students contemplating a career in cardiology. Importantly, we hope our efforts (and those of other working groups) will encourage positive changes in the cardiology training and work environments that will make our specialty more attractive to women medical students and internal medicine residents.
In addition to the valuable insights provided by the 1996 ACC survey our working group reviewed several other sources of information including perspectives gained from focus groups with female medical students, residents, and trainees (9). One recurring theme is the vital role that mentors play in recruiting and retaining women in cardiology training programs. Women should have effective mentors at all levels of training (i.e., as premedical students, medical students, internal medicine residents, cardiology trainees, and beyond). It is important to note that male cardiologists can also be effective mentors of female students, residents, and fellows. Indeed, they mustshare this responsibility with their female colleagues if we hope to attract more women to our specialty.
Because the number of female physicians in most academic institutions is still small, women are often asked to participate in committee and other administrative responsibilities. Mentors should encourage women to choose carefully with respect to which, if any, of these duties they accept because they have the potential to take time away from academic pursuits that may be more important in career advancement. These are personal choices, however, that will reflect the professional interests and ambitions of the individual cardiologist.
There are certain critical steps in the process of choosing a specific career path in medicine. Personal interviews are usually part of each successive step in selecting an institution and, ultimately, a career and a job. Ideally, female applicants to medical school, residency, and fellowship positions should have the opportunity to meet with women in the position they are considering. In terms of our focus, female medical students or internal medicine residents considering a career in cardiology should have the opportunity to meet with female trainees and faculty members.
It would be useful to have a standard set of questions women could ask when they apply to different cardiology programs. These could include questions about the number of women in the program, mentoring practices, and maternity policies. Correspondingly, each cardiology program should be encouraged to develop a set of answers for all applicants, both men and women, to emphasize that lifestyle issues are not gender-specific. This exercise might also point out opportunities for cardiology training programs to enhance the approaches they use to support their trainees (and faculty members), most of whom are trying to balance professional and personal responsibilities. It is important for the training program director or his or her representative to outline their institution's policies with respect to family leave and other matters that relate to work–life balance. Positive feedback from current female residents and trainees has a powerful impact on the recruitment process, because interviewees usually value resident and fellow satisfaction highly when considering a training program.
Although some useful evidence about factors that women consider as they choose careers in medicine is available, this working group believes that a more detailed survey should be conducted of female medical students, internal medicine residents, and cardiology trainees to determine more precisely the factors that influenced (or are influencing) their career choices. The perceived challenges and obstacles to following a cardiology path may then be addressed more effectively.
Recruitment and visibility
The option of cardiology as a career choice needs to be actively demonstrated to high school and college students, with an emphasis on increasing the visibility of female cardiologists. Similarly, female medical students and internal medicine trainees need to be exposed to the possibility of cardiology as a subspecialty choice early in their training. Because the majority of cardiology trainees choose to enter private practice rather than stay in academic medicine, the broad spectrum of private practice options needs to be underscored. Specific steps should be taken to enhance the visibility and impact of female cardiologists in private practice, in academic medicine, and in regional and national organizations.
Various approaches exist to encourage women to consider a career in cardiology that can take place at the local, regional, or institutional level. We must identify cardiology training programs that have been especially successful at recruiting and graduating female trainees and recruiting, retaining, and promoting female faculty members. The training program director and/or division director (as well as the female trainees) of these institutions should be encouraged to share their perspectives on what specific steps they have taken to increase the number of women in their cardiology programs. This subject would be worthy of a panel discussion at national meetings of the cardiology training program directors. The goal would be to share information on best practices and to learn from programs that have demonstrated success in attracting a diverse faculty. This approach could also be used to attract underrepresented minorities, as discussed by Working Group 3.
There is a need to increase the visibility of female cardiologists in order to attract more women to our specialty. All cardiology divisions and departments of medicine should make an effort to enhance the visibility of female cardiologists that are either full-time or part-time members of the staff or trainees. The state or regional chapters of the ACC can also play a role in increasing the visibility of female cardiologists as potential role models by coordinating presentations at local high schools or colleges during “career day” events.
With respect to medical students and internal medicine residents, it is especially important to inform them of the broad range of career options available withincardiology. Women cardiologists are active in each of the various “types” of cardiology practice described in detail by Working Group 8. This would demonstrate to medical students and residents that there are many viable career tracks available in cardiology today. Another opportunity to reach out to potential cardiologists would be to encourage women cardiologists to participate in regional and national meetings of the American College of Physicians (ACP). The ACC could provide opportunities for actual or “virtual” mentoring for female housestaff and trainees. This could be done by enhancing the Women in Cardiology portion of the ACC website (http://www.acc.org). We propose piloting a project that links electronically an experienced (and willing) female faculty member with one or more female medical students, residents, or trainees at institutions that do not have enough local mentors.
Female cardiologists interested in participating actively in cardiology organizations such as the ACC, the AHA, and/or one of cardiology's specialty societies should be encouraged to make their interest known to officers or other leaders of those organizations. Depending on her interests she might be invited to be a speaker or moderator at educational sessions, to participate in or chair committees and working groups, or to serve on governing bodies or other leadership groups. Obviously, each of these activities (at the local, regional, and national level) takes time, and the number of female cardiologists in the U.S. today is limited. Most female cardiologists are already busy both professionally and outside the workplace. This presents a challenge in terms of encouraging women cardiologists to take on additional work. Women willing and able to devote energy to mentoring or to educating others about careers in cardiology are making an investment in the future of cardiology that will benefit cardiovascular specialists and patients with cardiovascular disease.
We conclude our report with a list of other efforts the ACC (and/or its chapters) could launch or coordinate:
1. Through its chapters, the ACC could develop a high school scholarship program using female cardiologists as faculty. A series of 1-h lectures could be given on three or four consecutive weekends about various aspects of the heart in health and disease followed by an examination. Pupils with the best scores could receive scholarship money to help pay for their college education. This plan has some synergy with an approach used for underrepresented minorities and serves to highlight potential career opportunities that might not otherwise be considered by some high school students.
2. The ACC could develop and distribute a set of slides to be used by faculty members willing to participate in “mini-med school” or physiology courses in high schools, colleges, or medical schools to stimulate the consideration of cardiology as a career.
3. The ACC, with other organizations and local institutions, could use print and broadcast media to demonstrate that there are many women who have successful and rewarding careers as practitioner or academic cardiologists. Indeed, the nation's two largest organizations devoted to cardiovascular disease will have female presidents in 2005 (Pamela S. Douglas will be ACC president and Alice K. Jacobs will be AHA president during that year). Many other female cardiologists are in leadership positions in these and other cardiovascular organizations. A television documentary (accompanied by a booklet for public distribution) focusing on cardiology as a career for women would resonate with the current emphasis that is being placed on enhancing public awareness of the importance of cardiovascular disease as a cause of morbidity and mortality among women. Such a program would have the potential to reach a large audience, including high school students who might not otherwise have considered a career in cardiology. A similar impact might be felt by female medical students, particularly in those programs where there are few, if any, female faculty.
4. The ACC, either nationally or through its chapters, could identify a core group of female visiting professors willing to visit programs with no or few female faculty and encourage interaction with the female trainees.
5. The ACC should identify ways to increase the involvement by a larger number of female college members in the various activities of the organization. Some examples follow: a) the ACC Program Committee should encourage members to suggest qualified women as session moderators, chairs, and speakers at the annual scientific sessions, b) the ACC should increase the number of females serving on committees, task forces, and working groups, c) the ACC should promote visibility of female cardiologists in practice by sponsoring networking and workshops at the Scientific Sessions and at chapter meetings, d) the ACC chapters should facilitate interaction of female cardiologists in practice with internal medicine trainees and students. This might involve having a medical student or resident spend one or more days with the cardiologist. The chapter could also serve as a resource for women to participate in college or high school career fairs. Female trainees could be invited to attend chapter meetings when the format is appropriate, e) the ACC should publicize the need for more general clinical cardiologists to help deliver care to growing numbers of elderly cardiac patients, f) the ACC should invite physicians with a track record of successfully mentoring female cardiologists to present at the ACC training directors meeting, g) the ACC should collect and disseminate successful practice and academic models that have created family-friendly programs and call schedules. There are alternative models in place in some institutions and groups that encourage shared practice opportunities that allow greater flexibility in scheduling. Such models might also encourage older cardiologists to remain in practice rather than to retire early. It would also be useful if the ACC sponsored a forum at the annual scientific sessions that described experiences with successful alternative practice models. This could include both “shared” fellowship opportunities as well as part-time practice opportunities in the academic and private settings for junior faculty members and partners starting families, and h) the ACC Practice Opportunities Line (available at http://www.acc.org) should be modified to include specific data about flexible practices and possible job-sharing opportunities.
- American College of Cardiology Foundation
Working Group 2 References
- ↵Facts: applicants, matriculants and graduates. Association of American Medical Colleges. Available at: http://www.aamc.org/data/facts/2003/2003summary.htm. Accessed January 30, 2004
- ↵Applicants to U.S. Medical Schools Increase. Association of American Medical Colleges (Press Release. November 4, 2003). Available at: http://www.aamc.org/newsroom/pressroom/pressrel/2003/031104.htm. Accessed February 1, 2004
- ↵Table 3. Distribution of Women Residents, 2002. Association of American Medical Colleges. Available at: http://www.aamc.org/members/wim/statistics/stats03/table3.pdf. Accessed February 19, 2004
- Fye W.B.
- ↵Summary of Workforce Trends in Internal Medicine Training. American Board of Internal Medicine. Available at: http://www.abim.org/Workforce/Fellgen.htm. Accessed February 19, 2004
- ↵Women, Minorities and Persons with Disabilities in Science and Engineering, 2002. National Science Foundation. Available at: http://www.nsf.gov/sbe/srs/nsf03312/c0/intro.htm. Accessed April 19, 2004
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