Interventional Career? Female Fellows Repelled by ‘Old Boys Club,’ Radiation Risks, and Physical Demands
To bring about a more equitable workforce, the subspecialty needs to better address the challenges that women face while training, experts argue.
Many cultural factors at the core of interventional cardiology are deterring women from entering the field compared with men, according to the findings of a new survey. Addressing these issues and potentially creating work-arounds could help make the workforce more equitable down the line, experts say.
It’s no secret that women make up a small proportion of practicing interventional cardiologists—2016 data showed that only 4.5% of interventional cardiologists are female and 2.8% of angioplasty procedures are performed by women. Many, however, are striving to change that.
“Our patient population is half women, and in order to deliver care to our patients in a way that understands and meets their needs, I think it's important to have a professional group that at least roughly matches our patient population,” lead study author Celina M. Yong, MD (Palo Alto Veterans Affairs Hospital, CA), told TCTMD. “There are many unique aspects to the cardiovascular care of women, and when the people delivering that care and additionally doing the research on that care are not women, it's hard to be able to grasp all those perspectives as well.”
To better understand how trainees make the choice for or against pursuing interventional cardiology, Yong and colleagues surveyed 547 general cardiology fellows in the fall of 2017. Their results, published online yesterday ahead of print in JACC: Cardiovascular Interventions, showed that men were significantly more interested than women in seeking a career in interventional cardiology (39% vs 17%; P < 0.001).
Of the 190 fellows who indicated an interest in the field, men said they were most likely to be driven into interventional cardiology because of the allure of innovation, wanting to be an expert, likelihood of employment, financial advantages, and prestige. Women, on the other hand, indicated they were more likely to choose interventional cardiology because of a female mentor or role model.
As for negative influences, women were more likely than men to be affected by:
- Greater interest in another field
- Little flexibility in job prospects/opportunities over a lifetime
- Physically demanding nature of the job
- Radiation exposure concerns
- “Old boys club” culture
- Lack of female role models
- Gender discrimination/harassment
Compared with fellows interested in other cardiology subspecialties, those interested in interventional careers were less likely to have a spouse who works more than 50 hours a week (36% vs 47%; P = 0.04) and more likely to have a spouse who does not work (31% vs 13%; P < 0.001). Interestingly, no female fellows interested in interventional cardiology reported having a spouse who did not work.
This begs the question, Yong said, “does that mean that lack of flexibility in terms of family is one of the major hurdles for women to go into the field? And is there anything we can do as a field to make that more tenable for women who are trying to pursue this subspecialty?”
Lastly, on logistic regression analysis, male sex was the most significant predictor of a career choice in interventional cardiology (OR 3.98; 95% CI 2.38-6.68).
Alternatives and Changes
Poonam Velagapudi, MD (Nebraska Medical Center, Omaha), who recently completed her interventional cardiology training, told TCTMD that she wasn’t surprised by any of the study findings. “These are things that I've seen over my training period in my interactions with fellows and colleagues,” she said, noting however that most of her co-fellows in general did have spouses who worked.
If they have the passion for it, then they should absolutely go for it. Celina M. Yong
In terms of some of the negative factors that deter women from pursuing interventional cardiology, Velagapudi said there are indeed ways around many of them.
“For example, if there is a concern about radiation, people could always take a year or two break, have the kids, and then go back into the field,” she observed. “If you really like what you do, there are jobs out there that you can tailor to your lifestyle. If you don't want to be on call, you can find a group that has less call, or if you didn't want to be in the lab so many days in a week, you can find a position like that. So I think there's ways to go around all of these problems that have been cited and nothing seems to be really impossible to break through.”
Yong agreed. Other options might be to move to a shift-based schedule similar to how OB-GYN physicians work. “They deal with urgent procedural cases all the time, and culturally it's known that people take on whatever is on their schedule and they swap out at a certain time,” she explained. “That hasn't really percolated to our field yet. There's a lot of ‘territorialness’ about our patients and doing cases. We have a lot of pride in caring for our own patients regardless of the day or time—which clearly has value, but at what cost? The question is whether we, as a field, are willing to make such a big cultural move.”
Alternative training tracks that include a year of research could also help make the field more attractive for women who might want to start families and avoid radiation exposure, Yong suggested.
Neal Kleiman, MD (Houston Methodist Hospital, Texas), who has served as the program director of his institution’s interventional cardiology fellowship since its inception, also said he was intrigued by a 2-year, research-heavy program option. “I would love to do [that] if the powers that be ever let me do it,” he said. “That would afford the flexibility.”
Yong added that especially for female trainees strong mentorship is necessary to help recruit more women into the field. “One of the things we saw in our study was that the women were much more likely than men to want facilitated mentorship,” she said. “To me, that suggests that women may not feel like they can find mentors as well as men can. Given that almost everyone in the field right now is still male, that means that as a community, we need to reach out to female trainees to help them find mentorship in a more concerted way.”
Passion as a Driver
In an accompanying editorial, Annapoorna S. Kini, MD (Mount Sinai Hospital, New York, NY), writes that “despite all the obstacles and negative factors that we read about pursuing interventional cardiology for women, we should remember that there is one thing that will not stop us from doing what we want to do and that is PASSION. If we are passionate about seeing patients feel better after a complex procedure, passionate about the new cutting-edge technology/procedures that we can offer to our patients, passionate about the idea that women can equally work with men and be as good if not better [than] them, then we should not be afraid to pursue a satisfying career in this subspecialty of cardiology.”
Velagapudi said she appreciated this sentiment. “If you have the passion, there's always ways to overcome any of the troubles that you may have—you like what you do and there's ways to get around the problems that you may face,” she said.
Regarding radiation exposure, “most women are smart enough to believe that fear of radiation can now be resolved by following radiation safety measures while performing procedures in the cath lab,” Kini says. “Women can now multitask being a mother, a doctor, and a wife in order to achieve a work-life balance and deal with the same challenges with our male counterparts. This aspect in our life will not be that burdensome if we seek family support to help us with our everyday lives.”
However, “one of the things that the study demonstrated was that young women are still concerned about radiation exposure,” Yong responded. “The fact that women report this over and over again despite the available evidence makes me think that simply stating it more is not enough. . . . Rather than just continuing to present that data, I think we also need to look at whether options may exist to enable childbearing age women a way to complete their training while minimizing radiation exposure during this time.”
Ultimately, “we've got to be creative and come up with ways to overcome these limitations,” Kleiman said, noting that the challenge specifically for program directors lies with “figuring out the manpower needs at the same time that you're making sure that everyone has an adequate case load.”
“I sleep better at night thinking that the part of the world that I help manage is more equitable,” he concluded. “The broader your pool of people who can fit in, the greater the contributions will be.”
Advice for All
To the interventional cardiology community at large, Yong said she hopes many will make “a concerted effort to try to change some of those factors that are negative influencers. [That] I think would go a long way to help women follow their passions for the field and overcome the barriers to entry. . . . Something as simple as when you realize you're in a room full of men and there are trainees present, encouraging all of the trainees to be a part of the conversation and inviting them to participate in professional societies and other professional activities. Promoting female interventionalists to leadership positions will also enable existing women in the field to become more visible to junior trainees, proving that it can be done.”
For female trainees considering interventional cardiology, Yong said she would like them to recognize that while certain barriers may have dissuaded their predecessors, these can be overcome.
“There certainly are women who have succeeded at doing this, and it's possible,” she concluded. “If they have the interest, they should not be dissuaded by these factors. Reaching out to both men and women mentors can be really helpful in navigating this process. If they have the passion for it, then they should absolutely go for it.”
Yong CM, Abnousi F, Rzeszut AK, et al. Sex differences in the pursuit of interventional cardiology as a subspecialty among cardiovascular fellows-in-training. J Am Coll Cardiol Intv. 2019;Epub ahead of print.
Kini A. Women in interventional cardiology: if you love it you will make it. _ J Am Coll Cardiol Intv._ 2019;Epub ahead of print.
- This study was funded by the American College of Cardiology and the Women in Cardiology Section of the ACC.
- Yong reports receiving support from an American Heart Association Mentored Clinical & Population Research Award.
- Kini, Velagapudi, and Kleiman report no relevant conflicts of interest.