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- Megha Prasad, MD∗ ()
- ↵∗Reprint requests and correspondence:
Dr. Megha Prasad, Division of Cardiovascular Diseases, Mayo Clinic, 200 1st St SW, Rochester, Minnesota, 55901.
Women make up the minority of cardiologists. Work/life balance, family planning, radiation exposure, and the traditional male demographic among cardiologists have all been cited as barriers preventing women from choosing the cardiovascular field. Perhaps I was fortunate to be sheltered from these facts, as I had set my heart on cardiology when I was quite young—whether that was influenced by observing rounds with my father in the coronary care unit, my mother’s unwavering confidence in my goals, or my grandfather’s multiple cardiovascular hospitalizations. Regardless, at that point, the true obstacles that women must address when pursuing cardiology were beyond my comprehension. As I have progressed through my training, I remain grateful that I made this choice, but I now appreciate the hurdles women face during training. As these issues are addressed and traditional gender bias continues to fade with each generation, we hope to see more women choosing cardiology.
The Issue: Few Women in Cardiology
There have been many studies and surveys conducted that reveal the under-representation of women in cardiology over the years. A 2015 survey, presented at ACC.16 by Lewis et al. (1), wherein approximately 800 female cardiologists and 1,200 male cardiologists responded, indicated that women continue to feel that their advancement is slower than that of their male peers, and they remain significantly more likely to experience discrimination. Of women choosing cardiology, only about 9% choose an interventional subspecialty, compared with 25% of their male counterparts (1–4). This has been thought to be due to the length of training, the exposure to radiation during peak childbearing years, the masculine image that cardiology has carried, and the paucity of female mentors within the field (4). Moreover, women may experience less academic career advancement.
Although gender biases undeniably continue to exist, whether conscious or unconscious, they are diminishing with each generation. The question then is, should the degree of gender bias that exists in the current era of medicine be sufficient to deter women from pursuing and advancing within cardiology? Lewis et al. (1) found that although 63% of women report experiencing discrimination, only 22% of men report discrimination. There has been minimal improvement in the prevalence of discrimination among women, suggesting that even in this advancing era the majority of women still perceive bias. Additionally, women reported increased satisfaction, but noted their advancement was slower than that of their peers (1).
We must work together as a profession to eradicate the gender bias that continues to exist, yet this has proved to be difficult. Increased awareness of gender bias has been encouraged with programs addressing the issues that female cardiologists face. Identifying female mentors for female trainees is important early on, as these mentors may be especially helpful when sex-specific issues arise. For example, the Women in Cardiology section of the American College of Cardiology encourages leadership skills through networking events, professional development, and mentoring programs. Such initiatives will not only help women navigate their careers, but also help men understand the obstacles faced by women and address these in their respective practices and institutions. Ultimately, both genders must work together to address this issue. The sooner we embrace the issues that do exist and work together to find a solution, the sooner we will see a decreasing gender gap in our field.
Family and child-rearing are yet another common set of reasons cited for few women entering cardiology (5). Undeniably, a female fellow’s personal life is often inherently different from a male fellow’s with different challenges—timing a pregnancy, radiation concerns, increased responsibility at home, and working in a traditional male environment. With each successive generation, many of these issues may have become more gender neutral. Although cardiology training and practice can be demanding, this is also true of other specialties, such as obstetrics and gynecology, which is primarily female dominated. With each generation, the division of household labor increases in equality, with men sharing more responsibilities. As household responsibilities continue to be divided more equally at home, women may have the time and flexibility to pursue not only cardiology, but also invasive specialties and academic positions within cardiology. However, recent survey data suggest that 15% of female cardiologists are single as opposed to 5% of male cardiologists, and these numbers are dishearteningly similar to 1996 (1). Moreover, 57% of men reported having a spouse who provided childcare as opposed to 13% of women, leading to the conclusion that women require childcare when working nights or oncall more often than men (1). Given this, training programs could (and some have begun to) work to incorporate these considerations into the structure of training, allowing work/life balance to be more achievable by both men and women.
Increasing Female Mentorship
The lack of female mentors within cardiology plays a role in deterring women from pursuing cardiology. Although ideally, there would be more female mentors in cardiology, this will take time—as it will involve not only training more women, but also retaining them in academic positions, both of which continue to be a challenge. In the meantime, finding mentors who are dedicated to furthering a trainee and his or her overarching goals is more important than the gender of the mentor. In addition to career and research mentors, trainees may identify female mentors in other specialties who can help women navigate through gender-specific issues. In the meantime, trainees should avail themselves of opportunities to pursue mentorship through national organizations such as the women in cardiology sections of the American Heart Association and American College of Cardiology, which facilitate networking and mentorship for female trainees. This allows trainees to identify women in their subspecialty interest to help them in their careers with a focus on gender-specific issues. In turn, women trainees should provide mentorship for medical students, residents, and even high school students who may be interested in considering a career in cardiology. With increasing numbers of women in leadership roles and an increasing number of women entering cardiology, bias will naturally continue to diminish.
Many women avoid both cardiology and invasive specialties within cardiology due to concerns about radiation exposure, especially during childbearing years (6). Historically, little was concretely known about the effects of radiation in the catheterization laboratory, which are not specific to women. Radiation and its effects have been actively studied in recent years, and although it is true that both men and women are exposed to radiation as a part of training and/or their careers, there are no data suggesting any increased risk to the fetus of pregnant women in the catheterization laboratory (7). Such data have reassured many women, which may encourage them to pursue invasive subspecialties, such as electrophysiology and interventional cardiology. Also, new innovations such as robotic systems for coronary interventions could reduce the overall radiation exposure of interventional cardiology. The issue of radiation does, however, continue to pose a concern to trainees who may be in the early stages of pregnancy, as they must disclose this to their workplace for safety reasons. Although many institutions maintain strict confidentiality, it is important to allow the trainee to have privacy when family planning.
Addressing the Issue: Next Steps
In reality, few women exist in leadership academic positions and few women choose invasive specialties. Most agree that the reason for this is multifactorial, but increased awareness coupled with policies to address gender-specific issues may play a role in combating the issue at hand. Survey data show that both female and male cardiologists are satisfied with their careers, which is encouraging. This appears to be an improvement from previous years in the percentage of women who report satisfaction with their career. However, survey data suggest that women do not feel that their career advances significantly (1), and to address this, women must make an active effort early in their careers to identify a team of mentors, maintain research productivity, and develop a niche to aid in academic promotion.
As trainees and the next generation of cardiologists, the onus is on us too to overcome the barriers that exist for women in cardiology and help eliminate these in the coming generations. With each generation, we are making progress with more women pursuing cardiology, invasive specialties within cardiology, and academia. Although there is still a disparity, this may continue to diminish in the coming years as our culture shifts. Through increased awareness, sensitivity to the needs of our female trainees, and openly addressing issues like pregnancy, we may continue to see more women choose cardiology as we slowly do away with traditional stereotypes. Many of the current challenges in cardiology are faced by both male and female trainees, and as societal pressures change, more women enter cardiology, and traditional stereotypes of cardiology are debunked, we may continue to see more young women choose a career in cardiology. In the meantime, we should continue to support women cardiologists through networking, mentoring, and professional development programs and by encouraging young medical students and residents to pursue cardiology with preceptorships, visiting professorships, and mentorship. As trainees, both men and women, we must support one another and encourage one another to achieve our academic goals, despite the challenges that are often faced by both genders. Although much work needs to be done, with sequential steps, hopefully, we will see a higher percentage of women in the field of cardiology.
- Pamela S. Douglas, MD ()
RESPONSE: Justified Optimism or Magical Thinking?
The American College of Cardiology’s (ACC’s) then President and President-Elect, Drs. Williams and Chazal, recently noted that the scarcity of women cardiologists means that “American cardiology is failing to capitalize on recruiting enough talented female residents into cardiology. This can hurt our ability to best care for our patients” (1). Echoing this concern, Dr. Prasad writes eloquently and optimistically that gender bias is diminishing, work/life balance is improving, women are having an easier time finding mentors, and radiation exposure is a fading concern. Such changes would be cause for celebration, but we need to examine the situation realistically and dispel any misperceptions that might be preventing us from truly achieving our goal of gender equality.
Myth 1: The Under-Representation of Women in Cardiology is Just a Pipeline Issue
Although it will take time for the women currently in training to become full-fledged cardiologists, many women still opt out of cardiology. In 1984, the first year the ACC began keeping track, 3% of Fellows of the ACC practicing adult cardiology were women. In 2015 it was 9.1%. At this pace, it will take our profession 170 years to include women at the same level as internal medicine residencies do now.
Myth 2: It is Getting Better
Although longitudinal data are hard to come by, the 2008 ACC Professional Life Survey identified 11% of women and 29% of men as interventionalists (2). In 2013, a similar percentage of 11% of women identified as interventionalists, whereas the percentage of men rose to 39% (3). Women are standing still, and losing ground.
Myth 3: Women Just Need to “Man Up”
Long hours and unpredictable demands are oft-cited reasons why women are not attracted to cardiology, but as Dr. Prasad notes, this is hard to reconcile with women’s choices in obstetrics and gynecology. Instead, recent data demonstrate an adjusted lifetime pay discrepancy between men and women cardiologists of >$1 million (3). Further, a recent European Society of Cardiology survey reported that the most common reason women did not choose an interventional cardiology career was lack of opportunity (29%), whereas on-call duties (14%) and family reasons (8%) were less often important (4). In contrast, just 7% of men felt that lack of opportunity was a deterrent for women and 53% judged on-call duties and family reasons to be most important in women’s choices.
Myth 4: Cardiology is Among the Strongest of the Specialties—This does not Hurt Us
We are indeed strong, but we also know that diversity makes for stronger, more resilient organizations and businesses. Cardiology is no different. Our workforce needs access to the largest possible talent pool. Our patients need physicians who can relate to their rich—and growing—diversity. And we need all cardiologists to not only be but also feel like a valued part of our professional family.
Myth 5: Sufficient Change can be Created by Women Alone
The ACC, American Heart Association, European Society of Cardiology, and many specialty organizations provide leadership and professional development training for women. Although these “lean-in” efforts are both welcome and essential, change must come from the house of cardiology—women, like Dr. Prasad and the respondents to the European Society of Cardiology poll, are eager to step up, but lack the opportunities to contribute. Change will only come if we all decide to take this on, to “own this and fix it” (1).
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