In the JournalsPerspective

Resolution of barriers to pursuit of interventional cardiology may improve representation of women

A new study identifies several factors that dissuade female CV fellows-in-training from pursuing interventional cardiology compared with men, including occupational concerns, gender discrimination, job flexibility and overall culture.

The proportion of women across medical specialties has increased in the past decade, with more women than men enrolling in medical school. The number of female trainees has more than doubled in traditionally male-dominated fields like cardiothoracic surgery, urology and neurosurgery, according to background information in the study published in JACC: Cardiovascular Interventions. However, the same rise has not been observed in interventional cardiology, with 2017 estimates showing that only 9% of U.S. interventional cardiology fellows were women.

“This study is the first to examine reasons for selection of [interventional cardiology] as a subspecialty at the exact stage of training during which the decision is made — during general cardiology fellowship,” Celina M. Yong, MD, MBA, MSc, assistant professor and interventional cardiologist at Stanford University Medical Center and Palo Alto VA Medical Center, and colleagues wrote.

Sex differences among CV fellows-in-training

Researchers analyzed survey responses from 574 current CV fellows-in-training who answered questions about their personal and professional decision elements regarding cardiology subspecialty choices. Questions in the survey focused on opportunity, mentorship, lifestyle, interest and occupational health. The survey also collected information such as age, sex, race/ethnicity, marital/child-rearing status, specialization and training status.

Of the fellows-in-training in the study, 33% anticipated that they would specialize in interventional cardiology, with more men showing greater interest than women (39% vs. 17%; OR = 3.98; 95% CI, 2.38-6.68).

Men were more likely to have children (P = .002) and be married (P = .005). Among fellows-in-training who were married, male interventional cardiology fellows-in-training were more likely to have spouses who did not work compared with women who were married (P = .003).

Negative influences

In this study, men were more likely to be influenced by positive traits to pursue interventional cardiology, whereas women were more likely to be negatively influenced against pursuing interventional cardiology.

Among women, some of the attributes leading to a negative influence of pursuing interventional cardiology included little job flexibility (P = .021), greater interest in another field (P = .007), radiation during childbearing (P = .001) and physically demanding nature of the job (P = .005). Other factors included lack of female role models (P = .001), “old boys club” culture (P = .001) and gender discrimination (P = .001).

“Positive drivers that motivate fellows to choose [interventional cardiology] more predominantly influence men, while barriers to entering the field impact women more significantly,” Yong and colleagues wrote. “If we hope to have a workforce that reflects the diversity of our patients and optimizes delivery of care, directly addressing the unique barriers that are cited by women will maximize the impact of our efforts.”

The researchers noted that “there may be changes that can be made to the field to make it more manageable for both sexes, as well as for older interventionalists who may find interventional cardiology schedules untenable.”

Examples cited by the researchers include a transition to shift-based schedules; alternative training tracks to increase options for fellows who do not want to postpone childbearing, those completing research or those who want to pay student loans before entering further subspecialty training; and increased awareness via more meetings and sessions at scientific conferences dedicated to career issues.

In a related editorial, Annapoorna Kini, MD, professor of cardiology at Mount Sinai School of Medicine, wrote: “Women have proven their worth in performing simple to complex procedures. There is a great career path waiting for women in interventional cardiology and the outcome is gratifying and fulfilling. In the future, I can see how women physicians will evolve in terms of their skills, talents, good decision-making and leadership in interventional cardiology. I believe that if you are passionate about [interventional cardiology] and love it, you will make it.” – by Darlene Dobkowski, with additional reporting by Katie Kalvaitis

Disclosures: The study was funded by the American College of Cardiology and the Women in Cardiology Section of the ACC. Yong reports she received support from an American Heart Association Mentored Clinical and Population Research Award. Kini and the other authors report no relevant financial disclosures.

A new study identifies several factors that dissuade female CV fellows-in-training from pursuing interventional cardiology compared with men, including occupational concerns, gender discrimination, job flexibility and overall culture.

The proportion of women across medical specialties has increased in the past decade, with more women than men enrolling in medical school. The number of female trainees has more than doubled in traditionally male-dominated fields like cardiothoracic surgery, urology and neurosurgery, according to background information in the study published in JACC: Cardiovascular Interventions. However, the same rise has not been observed in interventional cardiology, with 2017 estimates showing that only 9% of U.S. interventional cardiology fellows were women.

“This study is the first to examine reasons for selection of [interventional cardiology] as a subspecialty at the exact stage of training during which the decision is made — during general cardiology fellowship,” Celina M. Yong, MD, MBA, MSc, assistant professor and interventional cardiologist at Stanford University Medical Center and Palo Alto VA Medical Center, and colleagues wrote.

Sex differences among CV fellows-in-training

Researchers analyzed survey responses from 574 current CV fellows-in-training who answered questions about their personal and professional decision elements regarding cardiology subspecialty choices. Questions in the survey focused on opportunity, mentorship, lifestyle, interest and occupational health. The survey also collected information such as age, sex, race/ethnicity, marital/child-rearing status, specialization and training status.

Of the fellows-in-training in the study, 33% anticipated that they would specialize in interventional cardiology, with more men showing greater interest than women (39% vs. 17%; OR = 3.98; 95% CI, 2.38-6.68).

Men were more likely to have children (P = .002) and be married (P = .005). Among fellows-in-training who were married, male interventional cardiology fellows-in-training were more likely to have spouses who did not work compared with women who were married (P = .003).

Negative influences

In this study, men were more likely to be influenced by positive traits to pursue interventional cardiology, whereas women were more likely to be negatively influenced against pursuing interventional cardiology.

Among women, some of the attributes leading to a negative influence of pursuing interventional cardiology included little job flexibility (P = .021), greater interest in another field (P = .007), radiation during childbearing (P = .001) and physically demanding nature of the job (P = .005). Other factors included lack of female role models (P = .001), “old boys club” culture (P = .001) and gender discrimination (P = .001).

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“Positive drivers that motivate fellows to choose [interventional cardiology] more predominantly influence men, while barriers to entering the field impact women more significantly,” Yong and colleagues wrote. “If we hope to have a workforce that reflects the diversity of our patients and optimizes delivery of care, directly addressing the unique barriers that are cited by women will maximize the impact of our efforts.”

The researchers noted that “there may be changes that can be made to the field to make it more manageable for both sexes, as well as for older interventionalists who may find interventional cardiology schedules untenable.”

Examples cited by the researchers include a transition to shift-based schedules; alternative training tracks to increase options for fellows who do not want to postpone childbearing, those completing research or those who want to pay student loans before entering further subspecialty training; and increased awareness via more meetings and sessions at scientific conferences dedicated to career issues.

In a related editorial, Annapoorna Kini, MD, professor of cardiology at Mount Sinai School of Medicine, wrote: “Women have proven their worth in performing simple to complex procedures. There is a great career path waiting for women in interventional cardiology and the outcome is gratifying and fulfilling. In the future, I can see how women physicians will evolve in terms of their skills, talents, good decision-making and leadership in interventional cardiology. I believe that if you are passionate about [interventional cardiology] and love it, you will make it.” – by Darlene Dobkowski, with additional reporting by Katie Kalvaitis

Disclosures: The study was funded by the American College of Cardiology and the Women in Cardiology Section of the ACC. Yong reports she received support from an American Heart Association Mentored Clinical and Population Research Award. Kini and the other authors report no relevant financial disclosures.

    Perspective

    The sex differences in interventional cardiology are disappointing, but not surprising. Interventional cardiology is very demanding on one’s time and family life. The reason is because one of the roles that interventional cardiologists play is to participate in STEMI calls. They are timed in terms of their responsiveness. They have to be in the catheterization lab within 30 minutes of receiving the phone call. That is tough. That is like working as a firefighter and is very demanding on one’s life. It is probably on top of the pay scale for cardiology, and for that reason, there are a number of people that will put up with it even though it is demanding.

    In the article, the “good old boys club” was cited as a reason why women do not choose interventional cardiology. That is less and less of an issue, but there is a little bit of machoism still because it is so demanding. It is like being a trauma surgeon.

    The authors touched on most of the difficulties. Most programs are more than happy to have women participate, so it is not at that level that women are not being selected. It is the choice that women are making to not pursue it. It isn’t that the directors of these programs are not selecting women. Speaking for everyone who has been in the role of hiring cardiologists, we would love to have women cardiologists in all of these areas.

    Another problem is lack of role models. That is a self-perpetuating factor. Because there aren’t very many women in those roles, there aren’t very many role models, and because there aren’t any role models, not many women are interested in pursuing it. It is a circular issue.

    Mentorship is a valuable thing. When we are in our training, whether we are in internal medicine or cardiology, we become attracted to certain individuals as mentors. Our attitude is “I am really inspired by this person. I think what they do is interesting. Everything about this job fascinates me, and I want to be a part of it.” We somewhat idolize or want to mimic people that we have high regard for, whose job seems interesting and want to make a career out of it. To that extent, as these personal issues become more difficult to balance in interventional cardiology, it is nice to see a woman in that area who has done a nice job of balancing work life, family life and personal time as well as career. It is to say, “I see how this person has made it work. I can do that, and I want to do that.”

    Awareness of these sex differences makes us ask the question, “Why is it this way? Are there things that, in a way, we setup barriers that we did not think were barriers that we did not intend for them to be barriers?” It is important for us to constantly ask that question.

    I participated as one of the coauthors in a study that was referenced in this paper (Jagsi R, et al. J Am Coll Cardiol. 2016;doi:10.1016/j.jacc.2015.10.038.) on pay discrepancies between men and women in cardiology. Being someone who has hired cardiologists and discussed contracts, the contracts were the same for men and women. They were on the same pay scale and entrance salary, but what is it that is creating that discrepancy? We were able to glean some insights about having some awareness of all of this.

    This is a topic that all of us would love to see things change. They will gradually, but it is one of those things that takes some time. Unfortunately, the way in which we approach interventional cardiology is so demanding on people’s time that it is challenging.

    • George P. Rodgers, MD, FACC, FACP
    • Cardiologist
      Seton Heart Institute, Austin, Texas
      Associate Professor, Department of Internal Medicine
      The University of Texas at Austin Dell Medical School

    Disclosures: Rodgers reports no relevant financial disclosures.

    Perspective
    Ki Park

    Ki Park

    This is an interesting study. Researchers previously have conducted surveys on the proportion of women in general cardiology, but not the transition from general cardiology to interventional cardiology for fellows in training. This is a huge step toward improving the representation of women in interventional cardiology. There are now more women in medical school than men, but a low number of female interventional cardiologists. I find it fascinating that the proportion of women in other very demanding surgical fields is increasing. I am unsure why the representation of women in interventional cardiology is stagnant. These survey results provide some insights.

    The study identified several factors that may lead to a negative influence of pursuing interventional cardiology among women. It is important to note that many of the factors identified do not apply only to women. Work-life topics are important across both sexes.

    A lot of the issues are not specific to just interventional cardiology and, rather, relate to recruiting women in the field of cardiology in general. I’ve heard a common theme of female fellows-in-training who are interested in interventional cardiology but chose not to pursue it because they were told they might take a spot from another fellow who is less likely to drop out because of family obligations or because they did not have a strong mentor.

    The mentor element is crucial, in my opinion. I was lucky to have two female interventional cardiology attendings when I was in training. At the time, they were older; one woman did not have children and the other had grown children. They were not in the same stage of life, but having that influence from women in different stages of life was helpful. Awareness of mentorship and women in cardiology, and interventional cardiology, is increasing, thanks in part to female-oriented forums like the American College of Cardiology’s Women in Cardiology Member Section and Leadership Council and the Society for Cardiovascular Angiography and Interventions’ Women in Intervention. It is important to continue to have detailed, in-depth sessions and conversations about work-life balance. Junior female fellows often say that they hear a future in interventional cardiology can work, but remain curious about what can be done to actually make it work? Sometimes a mentor can provide specific advice like outsourcing for household tasks to gain more family time when home. It is important to share stories of our own experiences, as female interventional cardiologists. A challenge remains, however, that many women work in places where there are no female interventional cardiologists or general cardiologists in their region, or a lack of available mentors.

    I am interested in seeing further research in this area. This study just scratches the surface. It would be interesting to delve into the availability of mentors by geographic region or comparisons against other surgical specialties that have done a better job at increasing the representation of women.

    • Ki Park, MD
    • Interventional Cardiologist
      Clinical Assistant Professor of Medicine
      University of Florida, Gainesville
      Cardiology Today Next Gen Innovator

    Disclosures: Park reports she is co-chair of the Florida ACC Women in Cardiology Section.