Author + information
- Tabitha G. Moe, MD∗ ()
- ↵∗Address correspondence to:
Dr. Tabitha G. Moe, Cardiology Fellow, Adult Congenital Cardiology, Banner Good Samaritan Medical Center, 1111 East McDowell, Phoenix, Arizona 85006.
Women remain underrepresented among U.S. cardiologists. The past 40 years have seen a growth in the percentage of female physicians from 10% in 1970 to 32% in 2010 (1). However, cardiology is notable for its continued imbalance in the male-to-female ratio. The American Board of Internal Medicine statistics show that the percentage of female cardiologists remains at approximately 15.5%, a figure far lower than other internal medicine subspecialties (1). This remains true even though coronary heart disease is easily the leading cause of mortality among females across all ages in the United States (2). Women in cardiology allow patients an opportunity to relate to their care provider in positive ways, including a personal understanding of pregnancy, motherhood, and menopause.
A survey presented at ACC.14 hints at this persistent gender gap. A total of 39 female cardiologists in Arizona were e-mailed the survey (3), and there were 20 respondents, 55% of whom were clinical. Survey recipients were given 6 questions aimed at elucidating the work/family/life balance generally faced by cardiologists, as well as questions designed to solicit information from females concerning pregnancy and maternity leave. The majority of respondents (70%) said that they perceived barriers to pregnancy during their cardiology fellowships.
Conception and pregnancy is typically considered a private issue. The advent of social media is beginning to change that. Notification of pregnancy is a necessity for certain medical professionals with potential radiation exposure. However, timing of notification is challenging. First trimester spontaneous miscarriage rates are high; some estimates project loss rates of recognized pregnancies as high as 50% to 75% prior to 13 weeks (4). The high rate of miscarriages gives pause in early notification of pregnancy, with the added emotional burden of potential pregnancy loss. However, interventional cardiologists have long understood the radiation exposure risks. The consensus document from the Society for Cardiovascular Angiography and Interventions–Women in Innovations Group states that current data do not demonstrate an increased risk to the fetus of pregnant women in the cardiac catheterization laboratory. Thus, pregnant physicians are not justified in being precluded from performing procedures in the cardiac catheterization laboratory (5).
Fellows are in a particularly difficult position in that the rotation schedule for fellowship training requires negotiation, acrobatics, and a sense of humor even when no special requests have to be met, much less 9 months of them. The window of opportunity for learning invasive procedures is brief, and exposure to interventional faculty in the cardiac catheterization laboratory early in the training career creates further opportunities for an interventional cardiology career path. There also are no guidelines from the American College of Graduate Medical Education (ACGME) for pregnant physicians-in-training in the cardiac catheterization laboratory. Unfortunately, delaying notification of pregnancy until the second trimester allows for above-background radiation exposure during critical organogenesis, and the potential damage may already have been done.
The American College of Obstetricians and Gynecologists defines advanced maternal age as age >35 years at the time of delivery, which is in part due to the increased risk of genetic defects, most notably a 1:200 chance of a fetus with trisomy 21. The average U.S. medical student completes medical school at 28 years of age and completes a general internal medicine residency at 31 years of age. In the pursuit of a competitive subspecialty fellowship, many also complete a year as a chief resident, as I did. This places the age of entering general cardiology fellowship at 32 years and completion of fellowship training without additional subspecialty training at age 35 years. Should additional training in interventional cardiology, electrophysiology, heart failure/transplant, or adult congenital cardiology be considered, this further advances age. Higher-risk pregnancy after the age of 35 is not taken lightly. This places optimal reproductive time during the training years.
Other less well-understood challenges include both the external and internal stressors of being unable to share the good news without fear of repercussions: whether they are social, clinical, or educational. For example, the guilt associated with burdening your small group of cofellows with additional call or other onerous jobs. Maternity leave presents another complication. Although 12 weeks of leave are permitted by the federal Family Medical Leave Act, returning to work after 12 weeks also delays the completion of training by 12 weeks. Also, being employed by the institution for at least 1 year prior to eligibility for paid federal Family Medical Leave Act time adds a layer of financial burden. If additional subspecialty fellowship training is pursued, then the timing of training completion and obtaining a position outside the fellowship match are also confounding issues.
Breast-feeding is ideal for infants; it is recommended by the American Academy of Pediatrics exclusively until the age of 6 months and with supplementation until the age of 1 year and beyond (6). The World Health Organization, who in all fairness advocates for global health, recommends breast-feeding until the age of 2 and beyond (7). Expressing milk while away from your infant is a process that requires a private, quiet room and a time to relax for the let-down process to start. There are no data available regarding female physicians and expressing milk. Although we instruct our patients to follow guidelines, and our certification is based on our ability to memorize and apply guidelines, I suspect we are weak at adhering to these guidelines. Even with understanding faculty, the demands of a fellow’s schedule can be prohibitive in attempting to maintain adequate supply. Then, there is the concern of this additional duty taking away from the training experience that has already been truncated by work-hour guidelines and, now, maternity leave. To that end, it is helpful that several institutions have started to recognize this concern; they are now providing space and equipment for lactation.
Motherhood is difficult. The road to building a successful career as a cardiologist is also hard. One option to improve the shift of women into cardiology would be to shorten the training. For example: there are several U.S. medical schools that graduate students 6 years after completion of high school with bachelor’s degree, doctor of medicine degree combinations. Additionally, pursuing a more direct training pathway may be an option. This may warrant consideration of a combined internal medicine and cardiology certification. Another route may be flexible training opportunities, as imaging and teaching increasingly lend themselves to remote access and the possibility of “tele-teaching.” Remote-access options also may allow for distance learning in association with a center of excellence.
Women are social beings, and their perspective on patient presentation, symptoms, and management is vital to a healthy cardiology workforce. The gender gap in cardiology is striking, and some slow trends toward improvement are not meeting expectations. Standardizing physician training exposure with regard to radiation risks, encouraging open discussions with fellowship program directors, and offering opportunities for remote conference attendance while expressing milk or on maternity leave are all enticing targets for education modification. The idea of remote training, particularly in imaging-related months, also may allow for flexibility in the training schedule, and even maternity leave. Cardiology has always been on the forefront of research and technology. The onus is upon us to utilize cutting-edge advances to entice more women into our field.
- American College of Cardiology Foundation
- ↵Duvernoy CS. Challenges faced by women in cardiology. Available at: http://www.accmi.org/WomenInCardiology/ChallengesWIC.pdf. Accessed July 2, 2014.
- ↵Desai SD. Exploring barriers to gender gaps in cardiology. CardioSource. Spring 2014. Available at: http://www.cardiosource.org/News-Media/Publications/Cardiology-Magazine-Web-Edition/2014/Spring/Exploring-Barriers-to-Gender-Gaps-in-Cardiology.aspx. Accessed June 14, 2014.
- ↵MedlinePlus. Miscarriage. Available from: http://www.nlm.nih.gov/medlineplus/pregnancyloss.html. Accessed June 20, 2014.
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- ↵Feig C. Breastfeeding. World Health Organization International. Available at: http://www.who.int/topics/breastfeeding/en/. Accessed June 12, 2014.