Author + information
- Received August 12, 2018
- Accepted August 21, 2018
- Published online November 19, 2018.
- Sonya Burgess, MBChBa,b,
- Elizabeth Shaw, MBBSc,d,e,
- Katherine Ellenberger, MBBSb,
- Liza Thomas, MBBS, PhDc,f,
- Cindy Grines, MDg and
- Sarah Zaman, MBBS, PhDh,i,∗ ()
- aThe University of New South Wales, Sydney, New South Wales, Australia
- bDepartment of Cardiology, Nepean Hospital, Sydney, New South Wales, Australia
- cThe University of Sydney, Sydney, New South Wales, Australia
- dMacquarie University Hospital, Sydney, New South Wales, Australia
- eDepartment of Cardiology, Hornsby Ku-ring-gai Hospital, Sydney, New South Wales, Australia
- fDepartment of Cardiology, Westmead Hospital, Sydney, New South Wales, Australia
- gNorthwell Health, North Shore University Hospital, Manhasset, New York
- hMonash Cardiovascular Research Centre, Monash University, Melbourne, Victoria, Australia
- iMonash Heart, Monash Medical Centre, Melbourne, Victoria, Australia
- ↵∗Address for correspondence:
Dr. Sarah Zaman, Monash Heart, Monash Medical Centre, 246 Clayton Road, Clayton, Melbourne, Victoria, Australia 3168.
In the United States and Europe, women comprise at least 50% of medical graduates. Despite gender balance within medical trainees, only one-third of practicing physicians, and <20% of cardiology trainees are women (1,2). Within the subspecialty of interventional cardiology, the gender disparity is even greater. A study performed in the United States by the Women in Innovations (WIN) group found that women account for only 4.5% of interventional cardiologists and perform <3% of angioplasty procedures (2). No studies have defined the proportion of female interventional cardiologists in Australia and New Zealand, and internationally, interventional cardiology gender diversity data are extremely limited.
The gender gap in interventional cardiology impacts on female students, trainees, physicians, cardiologists, and our patients. Cardiovascular disease is the leading cause of death in women. Many studies indicate suboptimal treatment and outcomes of female patients with heart disease in comparison to men. In cardiovascular and interventional research, a low proportion of women are recruited to clinical trials, leading to underpowered gender-based analysis. Female cardiologists may be more aware of the differences in coronary disease between men and women and advocate for recruitment of female patients in clinical trials and gender-focused research. Improving gender equality within cardiology has been identified as a powerful means to improve cardiovascular disease outcomes in women (3). Douglas et al. (4) recently found that, after subject matter itself, the 2 most commonly identified factors guiding trainees subspecialty selection are a supportive role model and positive encouragement (4). Cardiology literature is increasingly identifying the need for change, the value of diversity, and the uncomfortable silence that has historically existed regarding workplace disparity (5,6).
We obtained the total number and gender-specific number of practicing medical practitioners, vocational trainee doctors, specialists, and cardiologists for Australia and New Zealand from the Australian Health Practitioner Regulation Agency, Medical Council of New Zealand, and the Royal College of Physicians for the period between 2015 and 2017. Gender-specific numbers of practicing interventional cardiologists and interventional fellows were obtained from state and national cardiac outcome registries and by the Women in interventional Cardiology Australia/New Zealand group for the period between 2017 and 2018. Gender-specific numbers of total medical practitioners, specialists, and surgeons within a limited number of alternate specialties were obtained for comparison. Average annual taxable incomes according to specialty and gender were obtained from the Australian Taxation Office for 2015–2016. Data were categorical, summarized as frequencies and percentages, and compared using the chi-square test or the Fisher exact test, as appropriate. A 2-tailed p value <0.05 was considered statistically significant. Statistical analysis was performed using SPSS Statistics, version 21.0 (IBM Corporation, Armonk, New York).
From a total of 121,211 practicing medical practitioners in Australia and New Zealand, 42% were female (Central Illustration). Women comprised significantly lower proportions of overall specialists (36% vs. 64%; p < 0.001), obstetric/gynecologists (45% vs. 55%; p < 0.001), general surgeons (15% vs. 85%; p < 0.001), and orthopedic surgeons (4% vs. 96%; p < 0.001). From 1,529 cardiologists, the proportion of females was significantly lower than males (15% vs. 85%; p < 0.001). A total of 4.8% (n = 19 of 398) of interventional cardiologists in Australia and New Zealand were female, 95.2% were male (p < 0.001) (Figure 1). In Australia, 3 of 8 states/territories had no female interventional cardiologists and 17 of 19 (89%) operated at a site with no other female interventional cardiologist. The proportion of female catheterization laboratory directors in public hospitals was significantly lower than male directors (3.4% vs. 96.6%; p < 0.001). The average annual taxable income for the period 2015–2016 for female cardiologists was AUD$266,805, 55% of the income of male cardiologists at AUD$484,086.
From a total of 3,139 doctors in the physician training program (internal medicine), 50% were female. Significantly lower female representation was seen within the training specialties of cardiology (23% vs. 77%; p < 0.001), general surgery (36% vs. 64%; p < 0.001), and orthopedic surgery (11% vs. 89%; p < 0.001) whereas women had higher representation in obstetrics/gynecology (81% vs. 19%; p < 0.001). From a total of 46 interventional cardiology fellows in Australia and New Zealand, female representation (n = 4) was significantly lower than men (9% vs. 91%; p = 0.01).
Gender Gap and Strategies for Promoting Change
Women comprise only 15% of cardiologists and 4.8% of interventional cardiologists in Australia and New Zealand. The under-representation of women within the interventional cardiology community is comparable to that seen in the United States at 4.5% (2) and mirrors the gender disparity seen in orthopedic surgery (4%). The vast majority of female interventional cardiologists (89%) operate at a site with no other female operators, higher than the 41% described in the United States (2). The low numbers of female interventional cardiologists overall and their relative isolation has the potential to impact on recruitment, collegial support, mentoring, and research. The gender gap appears unlikely to narrow in the near future given the low female representation in cardiology training (23%) and interventional fellowships (9%). Cardiology societies in Australia, New Zealand, and across the world should lead change and promote the presence of women within their specialty.
The reasons for the gender disparity in interventional cardiology are myriad. Although unsociable working hours and on-call requirements along with concerns regarding radiation exposure were assumed to limit inclusion (7), this has proven incorrect. A worldwide survey found that female cardiologists identified lack of opportunity, radiation, and the prejudices of their male colleagues as the three main barriers (8). The other reported significant barrier to women pursuing an interventional career was a male-dominated culture with a lack of female role models and mentorship (8).
The hypothesis that women self-exclude from interventional cardiology due to on-call hours or the physical demands of the role are not well supported by our comparative data. Heavy on-call hours in obstetrics and gynecology, where the physical demands of surgery are also present, have not resulted in gender disparity in this specialty; females comprise 45% of registered obstetricians and 81% of trainees. Cardiology (15%) and interventional cardiology (4.8%) gender disparity rates in our data most closely match general surgery (15%) and orthopedic surgery (4%); specialties’ documented to have significant problems with their workplace culture. However, female representation at the trainee level in general surgery and orthopedics is higher than that seen in cardiology and interventional cardiology.
Our data highlights that female interventional cardiologists in Australia and New Zealand are rare and practicing in isolation. In addition, only 3.4% of public hospital catheterization laboratory directors are female. The absence of visible female role models discourages junior female doctors from entering interventional cardiology training programs. Female interventional cardiologists are rarely seen on conference panels, in leadership positions or on committees. A U.S. study of female medical students who chose to pursue a career in surgery has shown that these students were significantly more likely to have attended a medical school that employed a greater number of female surgical consultants. As female trainees come through cardiology training, the importance of seeing women actively participating in the interventional community cannot be underestimated.
Concerns regarding radiation exposure during pregnancy and child-bearing years are often cited as a barrier to women undertaking interventional training (8). Variation in pregnancy policy internationally and limited data contributes to these concerns. Australia and New Zealand support close monitoring rather than exclusion, and pregnant female interventional cardiologists continue to work in the laboratory throughout pregnancy, much like their American colleagues. With appropriate lead protection and radiation dosimeter monitoring, the actual radiation exposure to the fetus is almost nonexistent (9). The weight of lead coupled with the physical demands of pregnancy, and significant periods standing provide further challenges. Guidance from colleagues who have overcome such challenges is essential but not always possible due to the gender disparity and practice isolation our data identified.
Identifying the issue and its magnitude is the first step in addressing the significant gender disparity within the cardiology and interventional cardiology community. We are likely to have lost potential leaders and innovators who could have improved outcomes for our patients and provided role models for trainee doctors to become interventional cardiologists as a result of gender inequality in interventional cardiology. We must encourage a dialogue to identify barriers and provide potential solutions to empower more women to join this highly rewarding specialty.
No funding was received for the current study. Dr. Zaman has been supported by a fellowship  from the National Heart Foundation of Australia, a Monash University Early Career Practitioner fellowship, and a Robertson Research Cardiologist fellowship. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received August 12, 2018.
- Accepted August 21, 2018.
- 2018 American College of Cardiology Foundation
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