Author + information
- Received August 11, 2016
- Revision received September 22, 2016
- Accepted September 27, 2016
- Published online January 2, 2017.
- Amy A. Sarma, MD, MHSa,∗ (, )
- Chileshe Nkonde-Price, MD, MSb,
- Martha Gulati, MD, MSc,
- Claire S. Duvernoy, MDd,
- Sandra J. Lewis, MDe,
- Malissa J. Wood, MDa,
- American College of Cardiology Women in Cardiology Leadership Council
- aDepartment of Cardiology, Massachusetts General Hospital, Boston, Massachusetts
- bDepartment of Cardiology, Southern California Permanente Medical Group, Pasadena, California
- cDepartment of Cardiology, University of Arizona-Phoenix, Phoenix, Arizona
- dDepartment of Cardiology, VA Ann Arbor Healthcare System/University of Michigan Health System, Ann Arbor, Michigan
- eDepartment of Cardiology, Northwest Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon
- ↵∗Reprint requests and correspondence:
Dr. Amy A. Sarma, Department of Cardiology, Massachusetts General Hospital, 55 Fruit Street, Boston, Massachusetts 02114.
Women are a consistent minority in the field of cardiology, with concerns regarding balancing career and parenting responsibilities often cited as a contributing factor to this under-representation. To investigate the impact that a career in cardiology may have on the family planning decisions of female cardiologists, the Women in Cardiology section of the American College of Cardiology conducted a voluntary anonymous survey. The following perspective highlights lessons learned from the survey, and potential solutions to the issues surrounding maternity leave, radiation exposure during pregnancy, and breastfeeding accommodations raised by these data. Given that most female cardiologists are pregnant at some point during their careers, particularly during the vulnerable periods of training and early career, improving the experience of pregnancy and early parenthood for all cardiologists may secure the best possible candidates to the field of cardiology.
Women remain under-represented in the field of cardiology as compared with men, comprising 10% of board-certified cardiologists (American College of Cardiology [ACC], unpublished data, 2016). In 2015, 21% of general cardiology fellows and 8% of interventional cardiology fellows were women (1). Although the Association of American Medical Colleges found that women comprised 33% of the physician workforce in 2013, of the 41 specialties investigated, cardiology (with 12% women) was in the bottom 9 with respect to the proportion of women, and interventional cardiology (with 7% women) was in the bottom 4, illustrating that women are particularly under-represented in cardiology as compared with other fields (2).
A work-life survey conducted by the Women in Cardiology (WIC) section of the ACC in 2015 revealed that female cardiologists were less likely than their male counterparts to be married (74% vs. 89%; p < 0.05) or have children (72% vs. 86%; p < 0.05) (3). Women were also less likely than men to have a spouse providing daycare (13% vs. 57%; p < 0.05), more likely to require additional childcare overnight (48% vs. 24%; p < 0.05), and more likely to have interrupted training or practice for more than 1 month (28% vs. 13% for training, 44% vs. 15% for practice; p < 0.05 for both comparisons), suggesting that the experience of women differs significantly from men with respect to family planning and childcare. A recent survey comprised predominantly of participants from European Society of Cardiology countries (85%) explored barriers to women entering interventional cardiology, and similarly revealed that women were significantly less likely to be married (57% vs. 80%; p < 0.001) or have children (53% vs. 80%; p < 0.002) when compared with male cardiologists (4). When asked why cardiologists did not pursue interventional cardiology, women more commonly cited concerns regarding radiation exposure as compared with men (20% vs. 12%; p < 0.001). When compared with women older than 40 years of age, women <40 years of age were twice as likely to report radiation exposure as a barrier to choosing interventional cardiology (12% vs. 27%) (4).
Together, these data reveal that female cardiologists are less likely than their male colleagues to be married or have children, and have differential childcare roles. However, the experience of pregnancy among cardiologists has never been investigated, although it is speculated that concerns surrounding pregnancy may deter women from choosing a career in cardiology (5,6). Thus, the WIC Pregnancy Workforce Work Group sought to determine the impact of a career in cardiology on issues of family planning to understand better the current experience and inform strategies for reform. To this end, a voluntary anonymous online survey was sent to female physician members of the ACC through a listserv containing 5,005 e-mail addresses. Delivery was unsuccessful to 340 addresses. Between July 23, 2015, and August 21, 2015, a total of 501 women completed the survey, which asked about a range of topics regarding family planning considerations; infertility and use of assisted reproductive technology (ART); career stage of pregnancies; pregnancy complications; maternity leave and breastfeeding durations; and work-related considerations, including questions regarding family planning during interviews, and maternity leave and breastfeeding experiences. Given that specialties involving radiation exposure, including cardiology, may incur particular concerns during pregnancy, we also sought to determine whether concerns regarding radiation exposure affected family planning, the proportion of cardiologists who experienced radiation exposure during pregnancy, and the frequency of use of radiation reduction and monitoring strategies.
The response rate to our survey (11%) is higher than that previously reported for ACC listserv survey studies (3% to 8%) (7). A primary limitation of our survey was its voluntary nature, with the potential that the responding population skewed toward those particularly interested in pregnancy issues. In addition, on the basis of respondent comments, an updated version was sent to women within 24 h of the initial survey release that enabled them to provide responses for multiple pregnancies for certain questions regarding breastfeeding and maternity leave, whereas the initial version only allowed for a single response. A total of 294 women responded to this second version, and when women identified themselves as repeat takers, their responses to the first version were omitted from the final dataset. Data reported are merged from both versions. For certain analyses of questions that differed between version 1 and version 2 (specifically the questions that enabled respondents to provide unique responses for multiple pregnancies) only data reported for the first pregnancy in version 2 were considered. When applicable, it is specified in the discussion of the results that these data reflect a single pregnancy.
Forty-one percent of survey respondents were between 30 and 40 years of age, although they spanned a variety of career stages: 14% in training (with 2% in medical residency), 30% early career professionals <7 years out of training, 30% midcareer professionals (7 to 20 years out of training), 24% later-career professionals (>20 years out of training), and 1% retired (Figure 1A). Sixty-four percent self-identified as white, 6% as black/African American, 21% as Asian/Pacific Islander, 7% as Hispanic/Latino, <1% as American Indian/Alaskan Native, and 2% preferred not to specify (Figure 1B).
The points that emerged are discussed next.
Most Female Cardiologists Become Pregnant During Their Careers
Most women (76%) experienced at least 1 pregnancy, and among the 24% who had never been pregnant, 45% reported that they hoped to become pregnant in the future. These rates are comparable with data from the 2015 work-life survey in which 72% of women reported having children, despite an older average respondent age to the work-life survey as compared with the family planning survey (3). When cardiologists 50 years of age or older were compared with those younger than 50 years of age, there was no difference in the proportion of women who had been pregnant (80% vs. 75%) versus those who had not (20% vs. 25%; p = 0.19) (Figure 1C). However, data from the work-life survey did suggest an increase in the proportion of women with children over time, with 63% of women in 1996 having children as compared with 72% in 2015 (p < 0.05) (8).
Pregnancies Occur Early in Women’s Careers
Most pregnancies among female cardiologists occur during cardiology fellowship (49%) or early career (63%), with few pregnancies in midcareer (8%) or later-career (1%) professionals. An additional 22% reported pregnancy during medical residency and 4% before residency. Thus, women are concurrently trying to establish their careers while growing their families, leading to a rational interplay between family planning and career factors. In addition, almost one-half (43%) reported being asked in interviews whether they intended to have children. This question was asked more commonly of women in practice (45%) as compared with trainees (33%), a difference that nearly reached statistical significance (p = 0.051). However, it did not differ between respondents older or younger than 50 years of age (43% vs. 45%; p = 0.67), suggesting that the incidence of this question has not changed over time. The prevalence of this question raises important questions as to why interviewers so commonly inquire about family planning and whether it influences women’s choices regarding positions.
A High Proportion of Children Born to Cardiologists Are Conceived Using Art
Among female cardiologists who had at least 1 prior pregnancy, 19% used ART. This number is significantly higher than that reported for the general U.S. population, for whom ART accounts for fewer than 2% of births (9). It is also higher than that reported for other physician groups, including a survey of surgeons, in which 13% of successful pregnancies required ART (with 32% of women reporting infertility), and of female urologists, of whom 11% successfully became pregnant through ART (10,11). However, a recent survey of female physicians reported high rates of infertility (24%), diagnosed at an average age of 34 years (12). Our data additionally reveal that women younger than 50 years of age are increasingly using ART (24%) as compared with those older than the age of 50 (9%; p = 0.001). Possible explanations for these rates of ART use are a higher prevalence of infertility among female cardiologists (either from delayed childbearing or other career characteristics) or higher rates of use (with similar rates of infertility), because of a higher level of health literacy and access to treatments as compared with the general population.
Pregnancy-Related Complications Are Common
Among women with at least 1 pregnancy, 12% experienced at least 1 miscarriage, 14% had pre-term delivery or labor, 7% had pre-eclampsia, <1% had eclampsia, 4% had gestational diabetes, and 2% had multiple gestations. In total, 40% of women experienced a pregnancy-related complication at some point. Given that prior studies of pregnancy among physicians investigated slightly different variables, it is difficult to directly compare these data with other physician groups. In a national survey of resident physicians and the wives of male residents conducted in 1990 (13), the rate of miscarriage was 14% among female residents (as compared with 12% of wives of male residents). Among female residents versus wives of male residents, the respective rates were 7% and 6% for preterm delivery, and 9% and 4% for preeclampsia or eclampsia (13). Although no differences between overall complication rates of female residents compared with the nonphysician wives of male residents emerged, another study of Canadian surgical residents found a trend toward higher rates of pregnancy-related complications, including preterm labor, pre-eclampsia, placental abruption, hypertension, and small for gestational age babies among female residents (35%) compared with the partners of male residents (19%), although this difference also did not reach statistical significance (p = 0.31) (14). Similar complication rates were also found in a Canadian study of obstetrical complications among surgical and medical residents, where a miscarriage rate of 12%, preterm labor rate of 6%, gestational diabetes rate of 5%, and twin pregnancy rate of 2% were reported (15). Thus, the proportion of complications among female cardiologists in our survey was similar to those reported in these prior studies, although direct comparisons are challenging. Nonetheless, the proportion is high: almost one-half of female cardiologists who have been pregnant have experienced a pregnancy complication.
Cardiologists Are Increasingly Concerned About Radiation Exposure During Pregnancy, But Are Underusing Radiation Reduction and Monitoring Strategies
Radiation exposure during pregnancy is a frequently cited concern among women in cardiology. Forty-seven percent of women in our survey reported trying to avoid pregnancy during periods when they would be exposed to radiation. Nonetheless, 57% reported pregnancy exposure, and there was no difference in the incidence of radiation exposure among trainees (49%) versus attending physicians (58%; p = 0.28). Notably, respondents younger than 50 years of age were more likely to have avoided pregnancy during periods of radiation exposure than those older than the age of 50 years (50% vs. 39%; p = 0.03) (Figure 2), suggesting that younger cardiologists are more concerned about radiation. Despite these concerns, women were relatively uninformed about whether their department had an official policy regarding radiation exposure during pregnancy, with 34% reporting that they did not know if their department had such a policy, 32% reporting that their department did not, and 34% reporting that their department did. There was no difference between those older than 50 years of age versus younger than 50 years of age with respect to knowledge regarding such policies (p = 0.96), potentially limiting senior cardiologists from providing mentorship on this issue to younger colleagues.
On the basis of data from observational and animal studies, the Society for Cardiovascular Angiography and Interventions published a statement with recommendations for acceptable radiation doses per month and cumulatively for the entire pregnancy, and suggestions for radiation monitoring and reduction strategies (16). Outside of pregnancy, prior studies suggested that health care workers exposed to occupational radiation lack important knowledge with respect to radiation safety and inconsistently use protective measures (17–19). Among women who experienced pregnancy radiation exposure in our survey, only 20% used fetal radiation badges, 24% used additional lead, and 42% increased their distance from radiation sources, suggesting that pregnant women are not uniformly using means of monitoring or reducing fetal radiation exposure (8,16). These rates fall substantially short of those reported in a recent study of radiation oncology residents, among whom 89% who became pregnant wore fetal radiation badges (20). Barriers to these monitoring and radiation reduction strategies remain unknown: it is not clear whether women or their workplaces are unaware of such strategies, or whether women do not feel empowered to implement them.
Together, these data highlight that many women are concerned about radiation exposure during pregnancy, and more than one-half are exposed to radiation. However, women are often not implementing suggested strategies to limit radiation exposure. Although the reasons behind the underutilization of radiation reduction and monitoring strategies are unclear, better education of women with respect to available strategies and workplace encouragement of their implementation may improve their use, especially because this same group of women reports concerns regarding exposure. To this end, the WIC pregnancy workforce group suggests that all cardiologists receive education regarding pregnancy radiation exposure on entering fellowship, at the time of employment, and each time they undergo fluoroscopy credentialing, and that those who do not feel comfortable with pregnancy exposure be afforded the opportunity to alter their practice activities during pregnancy.
Women Feel Pressure to Take Shorter Maternity Leaves Than Available to Them
Of the 607 pregnancies for which women reported maternity leave durations, 15% resulted in a maternity leave of <1 month, 33% of 4 to 8 weeks, 33% of 8 to 12 weeks, 15% of 3 to 6 months, and 3% of more than 6 months (Figure 3A). Although maternity leave has not been well studied among physicians, a recent survey of radiation oncology residents revealed that 57% took between 1 and 2 months of leave, and 21% took between 2 and 6 months (20). Our data reveal that compared with women older than 50 years of age, cardiologists younger than 50 years of age have taken longer leaves for a single pregnancy (p < 0.0001), suggesting a cultural change with respect to this issue. Nonetheless, 51% of women reported feeling pressure to take shorter leaves than available to them, and those older versus younger than 50 years of age did not differ with respect this pressure (p = 0.22) (Figure 3B). In addition, more women in training than in practice felt pressure to truncate their leave (60% vs. 50%; p = 0.04) (Figure 3C).
Although the factors that result in pressure to return early from leave are likely multifaceted and require further investigation, the WIC pregnancy workforce group recommends that all workplaces develop leave policies and clearly include them in employment contracts. Ideally, at least 2 months of paid parental leave for both mothers and fathers should be promoted. These types of policies have been shown to lead to higher long-term earnings for women, higher numbers of women in leadership positions in the workforce, and greater gender equality with respect to domestic responsibilities (21,22). Practice and training environments should also have the flexibility to extend leaves, if needed, for unforeseen medical complications, given that pregnancy-related complications are common. However, further investigation is required into the specific reasons that women feel pressure to truncate their maternity leave to develop optimal strategies to address this issue.
Female Cardiologists Do Not Meet Their Breastfeeding Goals and Experience Significant Barriers to Breastfeeding
Although most cardiologists initiated breastfeeding (92%), the rate of breastfeeding beyond 6 months was 46%. These data are consistent with prior studies of physician breastfeeding, which reveal high rates of initiation (80% to 94%), but significantly lower rates past 6 months (58%), even in the post-80-h workweek era (23). When rates of breastfeeding for a single pregnancy among cardiologists older than 50 years of age were compared with rates of those younger than 50 years of age, younger cardiologists breastfed for significantly longer durations (p = 0.008). Nevertheless, actual breastfeeding durations were consistently lower than intended durations (Figure 4), and when compared for a single pregnancy, the intended versus actual rates of breastfeeding significantly differed (p < 0.0001), indicating that women are consistently falling short of their breastfeeding goals.
In light of these findings, it is not surprising that only 32% of women reported that they did not experience barriers to breastfeeding, with the remainder identifying time constraints, lack of pumping space, lack of adequate breaks, and inability to maintain supply. Data from several other studies of physician breastfeeding similarly identified work-related barriers, including concerns regarding cultural support in the workplace for breastfeeding (14,23–25). Given the importance of breastfeeding to the health of mothers and children, it is disappointing that women are struggling with this beneficial practice, despite working in health care. Beyond providing all women with suitable space and adequate time to express and store breast milk, workplaces should strive to create supportive environments for breastfeeding women, and enough flexibility to sustain this practice. This may take the form of scheduled breaks in clinic and procedure schedules so that women have adequate, unscheduled periods between obligations to express milk.
The Experience of Cardiology Fellows Does Not Significantly Differ From Those of Attending Physicians, Except When it Comes to Maternity Leave
The experience of cardiology fellows did not differ from that of attending physicians in our survey with respect to ART use, pregnancy complications, or radiation exposure. However, more fellows felt pressure to take shorter maternity leaves than available to them (60% vs. 50%; p = 0.04). Although the factors responsible for this pressure remain unknown, it is possible that given the small size of many fellowships, with women in the minority, women may experience pressure to return to work to offload the burden on cofellows. Given that the third year of general cardiology training is one in which there is often flexibility, one solution is to enable those who require parental leave during the first 2 years of fellowship to complete required rotations missed during the third year, thus ensuring that the 24 months of clinical training required by the Accreditation Council for Graduate Medical Education with the requisite rotations are met by fellows taking parental leave (26). Potential strategies for covering the clinical responsibilities of fellows while on leave (parental or otherwise) could include coverage from third-year fellows seeking additional experience in specific rotations or advanced fellows, when appropriate, and distribution of responsibilities among fellows, attending physicians, and (when appropriate) advanced practice nurses and physician assistants. Of note, the American Board of Internal Medicine (ABIM) currently permits 1 month away from training per year, which can include time required for vacation, illness, parental or family leave, or pregnancy-related leave (27). With the ABIM Deficits in Required Training provision, a trainee can take up to 1 additional month away from training without a requirement to extend the length of training if his or her program director provides attestation to the ABIM that the trainee has achieved clinical competence. By the ABIM definition, 1 month equates to 31 days or 5 weeks. Thus, all trainees, permitting that they attain appropriate clinical competence, are permitted to take a total of 15 weeks away from training within a 2-year period, without needing to extend training time with respect to board eligibility. The trainee and his or her program director can determine the distribution of these weeks within the 2-year period. Knowledge of this provision should be widely publicized to program directors and trainees, especially for its potential application to parental leave.
A Career in Cardiology Influences the Family Planning Decisions of Most Female Cardiologists
Overall, only 10% of women identified with the statement “my career did not influence my family planning,” regardless of whether they had experienced pregnancy or not. This sentiment was higher in our survey than in a recent survey of female physicians, in which 65% reported that their careers had influenced childbearing decisions (12). The remaining women identified with concerns regarding time constraints (60%), work/life balance (74%), pregnancy outcomes with respect to work hours (29%), and pregnancy outcomes with respect to occupational exposure (46%). Of women who chose not to become pregnant, 58% stated that their careers influenced this decision. Thus, our data reveal that the interplay between career and family planning affects most women. Consequently, strategies to improve the experience of pregnancy among female cardiologists are likely to improve the experience of most women in cardiology and, in doing so, will hopefully attract more women to the field. Thus, further research into optimal strategies to improve the experience of pregnancy among cardiologists is warranted.
The WIC Pregnancy Workforce Group Believes Cardiologists Deserve Recognition of the Importance of Issues Surrounding Pregnancy, Parental Leave, and Breastfeeding
The WIC Pregnancy workplace group found that most (76%) female cardiologists have been pregnant, most commonly in training or early career. A total of 43% are asked about family planning in interview settings, 19% use ART, 40% experience pregnancy-related complications, and 51% feel pressure to truncate maternity leave. In addition, 47% try to avoid pregnancy at times when they may be exposed to radiation, a trend that was more common among cardiologists younger (as compared with older) than 50 years of age. Despite this high rate of concern, pregnant cardiologists underuse radiation reduction and monitoring strategies. Finally, actual breastfeeding rates were consistently lower than intended rates, with many women identifying with work-related barriers. Together, these data highlight a need for workplace improvements for childbearing cardiologists (Central Illustration).
Parental leave should be seen as a minor adjustment to clinical duties in the scope of an expected long clinical practice, and should be taken as a learning event for how to manage health and life issues throughout one’s career. The American College of Surgeons recently approved a statement on the importance of parental leave, supporting standardization of leave (and importantly, extending it to fathers, in addition to mothers) and breastfeeding provisions for all surgeons (28). To improve the health of female cardiologists (and their potential offspring), the WIC pregnancy workforce group believes that such recognition is needed for cardiologists, with the following proposals. Paid leave of at least 2 months should be afforded to all cardiologists (both men and women), with flexibility to adequately address unforeseen medical needs. Parental leave policies should be transparent to position candidates and included in employment contracts. Upfront creation of policies enables divisions to think of solutions that afford parents flexibility, while minimizing potential adverse impact on practices, and allows cardiologists contemplating parenthood to accept positions with policies acceptable to them. Equal leave for both men and women will not only enable families to spend more time together with their newborns (because fathers often return to work soon after the birth of children), but also equalizes, and has a greater potential to normalize, parental leave in a field where women are still the minority, and thereby reduce women’s pressure to truncate maternity leave.
In addition, all employees should be provided information on the available data regarding fetal radiation exposure, radiation reduction and monitoring strategies, and information on their hospital’s radiation safety officer at the time of fluoroscopy credentialing. This is especially important in light of our data revealing that most women are not using currently available means of radiation reduction and fetal monitoring strategies. Departments should provide pregnant women who may be exposed to radiation with maternity lead and fetal dosimeters with prompt feedback. Women contemplating pregnancy may consider wearing a dosimeter under lead before conception to understand better the potential amount of fetal radiation their practice activities may result in, and then use this information to discuss optimal radiation-reduction strategies with a radiation safety officer. Finally, given that most cardiologists initiate breastfeeding, but are unable to continue for as long as they intend, workplaces should strive to optimize spaces, time, and promote cultural acceptance for women to express milk. Enabling adequate time for women during busy clinical days may include scheduling protected periods during clinic and procedure schedules. Policies that normalize parental leave and promote the health of pregnant women and the developing fetus may improve the ability of all cardiologists to better balance growing their families with their developing careers, and, in particular, may attract more women to the field.
The authors thank Dr. Marcy Bolster and the American Board of Internal Medicine for reviewing the description of the leave and Deficits in Required Training Time policy, Dr. Douglas Drachman for reviewing the section on fellows-in-training, Dr. Patricia Best and Dr. Kimberly Skelding for reviewing the manuscript, and gratefully acknowledge the advice and comments of Dr. Mary Norine Walsh and Dr. Richard Chazal.
The views expressed in this paper by the American College of Cardiology’s (ACC’s) Women in Cardiology Leadership Council does not necessarily reflect the views of the Journal of the American College of Cardiology or the ACC.
This work was conducted through the Women in Cardiology Council of the American College of Cardiology. All authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Abbreviations and Acronyms
- American Board of Internal Medicine
- American College of Cardiology
- assisted reproductive technology
- Women in Cardiology
- Received August 11, 2016.
- Revision received September 22, 2016.
- Accepted September 27, 2016.
- American College of Cardiology Foundation
- ↵(2016) ACGME Data Resource Book Academic Year 2015-2016 (Accreditation Council for Graduate Medical Education, Chicago, IL), p 72.
- Center for Workforce Studies
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- Central Illustration
- Most Female Cardiologists Become Pregnant During Their Careers
- Pregnancies Occur Early in Women’s Careers
- A High Proportion of Children Born to Cardiologists Are Conceived Using Art
- Pregnancy-Related Complications Are Common
- Cardiologists Are Increasingly Concerned About Radiation Exposure During Pregnancy, But Are Underusing Radiation Reduction and Monitoring Strategies
- Women Feel Pressure to Take Shorter Maternity Leaves Than Available to Them
- Female Cardiologists Do Not Meet Their Breastfeeding Goals and Experience Significant Barriers to Breastfeeding
- The Experience of Cardiology Fellows Does Not Significantly Differ From Those of Attending Physicians, Except When it Comes to Maternity Leave
- A Career in Cardiology Influences the Family Planning Decisions of Most Female Cardiologists
- The WIC Pregnancy Workforce Group Believes Cardiologists Deserve Recognition of the Importance of Issues Surrounding Pregnancy, Parental Leave, and Breastfeeding