Women in Cardiology: ‘Underrepresented, Underestimated, and Undervalued’

Numerous problems face the cardiology workforce, but women who work in the field face added pressures. Now, in a new series of papers published this week, leading cardiologists are taking a closer look at what barriers may keep women—and also men—from choosing to pursue the specialty and what challenges adversely affect the female physicians who opt to sign on.

“JAMA Cardiology is really trying hard to shine a light on the profession,” said Pamela Douglas, MD (Duke University School of Medicine, Durham, NC), who is the lead author of a study exploring the professional expectations of internal medicine trainees and their perceptions of cardiology. “I think it’s incredibly bold of them, but I also think it’s very much needed. There’s a lot of national conversation about things like the quadruple aim [from the Institute for Healthcare Improvement] and provider well-being as being an essential component of population health.”

The study by Douglas et al showed that the career preferences of trainees, who put a premium on work-life balance, did not align well with their perceptions of cardiology—for neither men nor women. Addressing that disconnect, the authors say, could go a long way toward making cardiology a more attractive and diverse specialty.

But three opinion pieces—an invited commentary on the study by Douglas et al and two viewpoints—put the spotlight on issues affecting women, who continue to be underrepresented in cardiology. Those include wage disparities, discrimination based on the perception that women will have to leave jobs to have children, and sexual harassment and bias.

All of the papers were published online May 30, 2018, ahead of print in JAMA Cardiology.

What the journal editors are trying to say by releasing these papers together, according to Douglas, is that “the state of our profession and the state of our providers is just as important to our mission of providing good healthcare as knowing the next new drug or the next new piece of clinical data. We’re not just automatons with data. We’re real people interacting with each other and with our patients and we need to make sure that we have a strong, healthy, vibrant profession to be able to deliver cutting-edge care.”

Work-Life Balance Trumps Other Concerns

In their paper, Douglas’ team, which encompassed members of the American College of Cardiology’s (ACC) Task Force on Diversity and Inclusion and its Women in Cardiology Council, reports the results of a survey of 4,850 internal medicine trainees from 198 residency programs. Of the 23% who responded, more than half (56%) were men. Women were more likely than men to have never considered going into cardiology (63% vs 37%) and less likely to have chosen cardiology already (34% vs 12%).

Eight major factors were identified as most important in terms of professional development preferences (in order of descending importance): stable hours, family friendliness, female friendliness, the availability of positive role models, financial benefits, professional challenges, patient focus, and the opportunity to have a stimulating career.

Overall, women and trainees who chose not to go into cardiology placed greater value on factors related to work-life balance, whereas men and future cardiologists emphasized the desire for professional challenges and a stimulating career.

Unless cardiology figures out a way to have more stable hours, more predictable hours, I think we will suffer. Pamela Douglas

When asked about their perceptions about cardiology, trainees offered a dim view, giving the highest ratings for adverse job conditions, interference with family life, and a lack of diversity. But there was a split similar to that seen for career expectations: women were more likely than men to see cardiology in a negative light.

“Given the slight majority of female medical-school matriculants and internal medicine resident physicians, identifying and addressing cultural and societal barriers in women’s perceptions of cardiology is crucial for the field to access the full range of talent in internal medicine,” Douglas and colleagues write.

Douglas stressed, however, that the sex differences observed in the survey were not very large, indicating that cardiology has problem with recruiting both men and women that needs to be addressed.

“Women are kind of, if you will, the warning sign here. I think men are right behind them,” she said. “I don’t think this is a gender issue at all. [It] just may be a matter of degree, but the problem is not a gender problem.”

Enticing Trainees to Join Cardiology

Douglas and colleagues point out that both men and women in cardiology reported high satisfaction with their career choice in the most recent ACC Professional Life Survey. Nevertheless, they write, “trainees’ negative perceptions are not wholly unfounded, indicating that targeted efforts to address work-life balance and enhance mentorship are important to influencing career choice as well as improving career satisfaction.”

Cardiology requires longer hours and more calls than most specialties, and said those issues need to be addressed to ensure a strong cardiology workforce moving forward, said Douglas.

“Unless cardiology figures out a way to have more stable hours, more predictable hours, I think we will suffer, and in fact continue to suffer, in not necessarily being able to attract the best talent into the profession and perhaps not retain them,” she added.

Dealing with those issues might mean rethinking what it means to be on call, thinking about moving to shift work, and limiting workloads, Douglas said. “We also need to create environments that are highly supportive, that value work-life balance, that value mentoring, that value family friendliness. You get an inkling of it in the commentaries that that is not always true in the cardiology profession. So I do think we have a need for a culture change as well as some structural change.”

In an invited commentary, Anne Curtis, MD (University at Buffalo, NY), and Fatima Rodriguez, MD (Stanford University, CA), highlight the need for early exposure to positive role models, particularly for women.

“Even if one is very interested in cardiology as a career choice, there may be some hesitation regarding the ability to train and work in the field and still raise a family,” they write. “This is the reason why positive role models are so important. If one sees women who have chosen to go into cardiology and yet still have achieved their personal goals, the chances that a resident will look favorably on a career in cardiology will increase.”

Like Douglas, Curtis and Rodriguez suggest structural changes could be necessary to attract more talented people to cardiology. “A major change in cardiology that may help in this area is the marked swing from a mainly private practice model, whether self-employed or (more commonly) as part of a large group, to a model of hospital or system employment,” they explain. “While there is some loss of autonomy with this model, it also creates opportunities for more structured and predictable work schedules.”

In addition, they write, concerted efforts from professional societies—which focus on providing role models and mentors to medical students and residents, advancing the careers of female cardiologists, and emphasizing the benefits of diversity in the workplace—are needed to boost the representation of women in cardiology.

“The career satisfaction of our female trainees and the interests of our patients deserve no less,” Curtis and Rodriguez write.

Ongoing Challenges for Women Cardiologists

There have been efforts in recent years to enable women cardiologists to have a greater voice in the specialty, underscored by the all-female live case at CRT 2018 and efforts at other meetings to increase the proportion of women who serve as moderators or panelists. But there’s still a long way to go.

In one JAMA Cardiology viewpoint, Roxana Mehran, MD (Icahn School of Medicine at Mount Sinai, New York, NY), calls attention to the continuing lack of female voices in cardiology, expressing disappointment that despite a concerted effort to increase the number of women and people from racial/ethnic minority groups on the faculty of last year’s TCT meeting, sessions dedicated to diversity were poorly attended.

The ongoing challenge women face in cardiology was highlighted, too, when a fellow stood up in a session to describe being asked about “her so-called biological clock and questioned whether she was serious about becoming a practicing interventional cardiologist” during her interview process for an interventional cardiology fellowship program.

“I realized that the rocky roads up the mountains we had climbed and tried to pave behind us were not paved at all; in fact, they are covered by mud in which others continue to sink,” Mehran writes.

She goes on to describe the insults to which women in cardiology have been subjected, with nearly half reporting that they have been asked during interviews about their intention to have children and the majority reporting sex-based discrimination. Sexual harassment is also pervasive.

“I do not know of a single woman who has trained in cardiology and chosen interventional cardiology as her career who has not faced some level of sexual harassment or misconduct,” Mehran writes. “This is not hyperbole. Women have been underrepresented, underestimated, and undervalued for many long years—and I have not started on the salary gap.”

Rather than make excuses or nod sympathetically, leaders must do something in response to these voices—even if it makes them uncomfortable. Roxana Mehran

That gap is described well in another viewpoint by Rashmee Shah, MD (University of Utah School of Medicine, Salt Lake City), who estimates that, on average, a woman in cardiology will earn $2.5 million less than a man over a 35-year career. When extrapolated to the entire cardiology workforce, women would lose a collective $11.2 billion in gross earnings over that time span.

And that estimate, Shah adds, might actually be on the low side because the wage gap in academic medicine increases over time, with men being more likely to rise through the academic ranks and earn higher salaries.

The onus is on employers to address this disparity, she says, pointing out that prior research has shown that “diverse groups, such as those that include women, have a higher collective intelligence and better performance rate.” Thus, she says, “Investing in women’s salaries is not only socially and legally just, but is also a financially smart investment.”

Shah concludes by stating that men and women need to work together to address this inequity.

“Rather than place the burden solely on women to change the status quo, the predominantly male leadership needs to assume responsibility by creating a system that measures the value provided to the organization in a uniform, transparent way,” she says. “In the words of Lindy West, ‘We did not install this glass ceiling, and it is not our responsibility to demolish it.’”

Mehran also issues a call to action: “I believe we must all do something. As women, if we speak up now and share our stories, we force change. Just as that brave fellow at TCT who shared her story, we must seize the moment to use our voices to speak out to the world about the injustices we have all faced throughout our trainings. Rather than make excuses or nod sympathetically, leaders must do something in response to these voices—even if it makes them uncomfortable. We all must act.”