Feature

Support, policy changes may lead to more women in cardiology

Erin D. Michos

Women continue to be the minority in training within the cardiology field and its subspecialties with minimal change during the past 10 years, according to a research letter published in Circulation.

Researchers examined data from the Association of American Medical Colleges from 2007-2008 and 2017-2018. There was a particular focus in training programs for general CVD medicine and four subspecialties: interventional cardiology, electrophysiology, advanced HF/transplantation and adult congenital heart disease.

The data show that among all adult cardiology trainees in 2017-2018, 21.4% were women, which was a modest increase from 15.9% in 2007-2008. The most skewed sex distribution was present in interventional cardiology (10.2% women) and electrophysiology (11.6% women) compared with advanced HF/transplantation (31.2% women) and adult congenital heart disease (46.7%).

Healio spoke with Cardiology Today Editorial Board Member Erin D. Michos, MD, MHS, FAHA, director of women’s cardiovascular health at Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, to learn more about the findings and what cardiologists can do to make their field more representative of everyday patients.

#
Cardiology Today Editorial Board Member Erin D. Michos, MD, MHS, FAHA, director of women’s cardiovascular health at Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease

Question: What are some of the major takeaways from this research letter?

Answer: Unfortunately, although there was a modest increase over the past decade, these findings largely reflect a stagnation of growth of the number of women entering cardiology fellowship, with only 21% of cardiology fellows being women.

When you compare this to other specialties within internal medicine, cardiology has the lowest percentage of women. When you compare it to other specialties outside of medicine, only orthopedic surgery does worse. More women are choosing to train in general surgery than they are in cardiology.

This is certainly concerning because heart disease is a woman’s disease too.

Fifty percent of our patients are women. At the end of the day, we’re delivering a service, and if our profession in cardiology is not made up of the wider population, we’re not going to be able to effectively deliver our service. It’s not going to resonate with end users.

That’s not to say that male physicians cannot provide excellent care; they certainly do, but we know that sometimes men and women have different communication styles, which can translate into differences in how we communicate with patients and listen to their needs. Furthermore, everybody has implicit biases, both men and women — that’s part of being human. Thus, medicine and cardiology are better as a whole when we have a diverse health care team so we can all learn from each other and be representative of the patients we serve.

We’re not going to have success until we can look into the incoming classes of cardiology fellows and see that they’re representative of our patients. We have half of medical students being women and almost half of internal medicine residents being women, but only 21% of cardiology fellows being women. Thus, we’re losing over half of the potential talent pool in cardiology to other specialties and we’re not making much progress in this over the past decade.

We need to have a culture change, a climate change and think about strategies of examining why is our cardiology specialty not as attractive to women and what can we do to change it for the better of the profession and for the better of patients in general.

Q: Why was there a more skewed sex distribution in interventional cardiology and electrophysiology compared with advanced HF/transplantation and adult congenital heart disease?

A: It’s a lot of things. One is what the field currently looks like. You can’t be what you can’t see. If you are early in your training and you don’t see any women interventional cardiologists and you don’t see any women in electrophysiology because there are just so few of them, it’s hard to imagine becoming one of them. Women in cardiology, particularly in interventional fields, need to be visible to early learners. Otherwise, we’re lacking the mentorship and sponsorship for those coming up in the pipeline, and it’s hard for them to visualize themselves in this role.

Plus, there is some concern about radiation safety around pregnancy and child care, and concerns about work-life integration. Interventional cardiology and electrophysiology are more like surgical specialties because they’re more procedural.

That being said, look at OB-GYNs. That’s a demanding surgical specialty. They do cesarean sections and high-risk procedures. Just like cardiology with STEMIs that can come all hours of the night, babies can be delivered all hours of the night, yet OB-GYN is a specialty that’s more than 80% women.

Thus, I don’t think it’s that women are afraid of doing technical or surgical fields. I don’t buy that. Women are not afraid of working hard. We lack women in cardiology, particularly interventional cardiology, because women are systematically discouraged along the way. When people tell you, “You don’t want to be an interventional cardiologist. What if you get pregnant? How can you work those hours if you want to have kids?” Women in early training are constantly getting these messages and are being talked out of these fields, saying, “That’s a terrible work-life balance. Why would you want to do that?” I know a number of women that are current cardiology trainees and they want to do interventional or electrophysiology training. Even in 2020, they are being talked out of it: “Why do you want to do that? That’s not a good field for women.”

In sum, a lot of it has to do with visibility, bias and people discouraging women from pursuing it. You need a strong mentor and encouragement along the lines like, “Yes, this is a good field for women. This is how you can make work-life integration work. You belong here. This is an exciting field. There’s a lot we can do to help patients in cardiology, and the patients want you here.” We need to do more to support and encourage women.

Q: What do you think needs to be done to make cardiology a more balanced specialty?

A: We need to change the climate and the impressions we are sending out about our specialty throughout the whole career spectrum and make cardiology accessible to women all the way up to senior leadership positions. But let’s start with the very early learners. People start getting impressions about what they might want to do for their careers early in medical school and during residency.

We need to have more visibility to these early learners. In the paper, we discussed things like having more travel grants and opportunities to bring medical students and early learners to cardiology meetings where they can interact with cardiologists and, in particular, women in cardiology for exposure.

Another example of visibility is getting students exposed to women in cardiology as early as their classroom days. This is one thing that we’re trying to do at Hopkins.

For example, I teach in a cardiology course for the second-year medical students at our medical school. We try to make sure that speakers and lecturers in this course are both male and female faculty. Additionally, we have a social event that is a “meet and greet” for the medical students with women in cardiology. It’s open to all students. Mostly female medical students come, but we’ve had a few male medical students come each year too, which is great. At this event, the medical students come meet women in cardiology, both fellows and faculty, and ask us questions about our careers. We tell them what life is like as a cardiologist, what kinds of things we do in our daily jobs. We bring in faculty who represent various cardiology subspecialties — we all do something a little different. And we enjoy being cardiologists, so we share that joy and passion with the students. It’s fascinating; these are second-year medical students and they already have these preconceived notions of what they think being a cardiologist is like. For example, a few have thought that every cardiologist does percutaneous interventions in the middle of the night. They don’t realize that there’s a lot of heterogeneity in cardiology of what you can do. You can do research, noninvasive imaging, prevention, HF and more. And we certainly need people to do interventional and electrophysiology too.

How else can we improve culture? We need to have better support and policies in place related to pregnancy, lactation and child care. The whole system cannot collapse because some cardiology fellows are out on parental leave. Fellowship training overlaps with childbearing years. We need to plan for it, expect to have fellows out for parental leave during this time of their lives. I must emphasize again that maternity leave is not a vacation, and women in training sometimes are pressured into feeling guilty about maternity leave and “imposing” on colleagues. More flexibility in the system is needed to allow for this rather than have everything collapse when people are out on parental leave. We need better support, encouragement and help for transitioning back. I do want to note that women are not pregnant their entire professional lives. So we need to support them earlier in their careers because if we can help people through this pivotal times in their life, then we have built a sustained workforce that can be working for decades and decades.

When I was in cardiology fellowship training, I was the only female in my year. Both during fellowship and my early career as faculty, it was this boys club, I didn’t feel included. The whole climate was very fraternity-like and I didn’t feel part of the club. Things fortunately are improving.

There’s been tremendous work lately in this regard on a national level. The American College of Cardiology and American Heart Association have very active women in cardiology committees with social and networking events. This is what has helped me personally in my career. I had already chosen to be a cardiologist, but the reason why I stayed and haven’t left yet is the support that I found through this network of women in cardiology throughout the field. I found all these other women who were experiencing similar things as me in terms of negotiating for salary equity and other issues. While it was somewhat discouraging to realize that so many of us were encountering the same barriers, it was comforting to not feel alone.

Representation matters everywhere. There has been a strong push lately to make sure that meetings and conferences don’t have “manels,” or all-male panels, and making sure of that everywhere, from small sessions to the big late-breaking clinical trials sessions, that they have women who are discussants up there on the big stages being visible to the world. Cardiology is a field that has women excelling, and women experts should be recognized and included in the conversation.

I’m a very big advocate that more women need to be on more editorial boards of journals, editors-in-chief and on grant review committees because there are also studies that have demonstrated bias in publication and grant awards by gender. For women to advance in their careers and be promoted, they need to get grant funding and publish. It needs to be an even playing field.

Science should be collaborative. I also strongly discourage what I call “MANuscripts,” which are papers with a long list of all-male authors and no female authors. I can’t tell you how many papers I’ve seen where there were 10 or 15 authors and they’re all men. There’s not a single woman on the author list. People tend to invite and collaborate with people that come to their mind. This is affinity bias. People tend to first think of people that are most like them but need to think more broadly outside the box. There are women experts out there; we just need to look for them and think about them.

We need to consciously make an effort to be more inclusive. We need to include women in this project, on this panel or in this program. It does take concerted effort to change the climate because this is all implicit bias. I don’t think people aren’t intentionally discriminating against women, but they also don’t think about including them. Diversifying a field is not enough unless you have true inclusion. The lack of inclusion can have negative downstream effects where women don’t want to go into this field because they don’t feel welcomed or part of the culture.

Q: What advice would you give women who may be in the minority in their year to help them become successful cardiologists?

A: We need to end the boys club and make it an inclusive culture for all. What helped me was being active on social media and meeting this wonderful network of women in cardiology across the world who encountered similar professional challenges in their environment. I have also met “HeForShe” male supporters who want to help drive this culture change too.

Together, they make up my professional network that I call my “raft of otters.” Otters hold hands so they don’t float out to sea, so we need to find our network or otters to hold onto each other during turbulent tides. I’m trying to amplify the voices of women so that they’re seen and heard. We should make sure that women don’t feel alone. Our patients want us here. They want their doctors to be representative of them.

Cardiology is a great field for women. We do surveys of the professional life of cardiologists. Most cardiologists including women have a lot of career satisfaction, so people like their careers when they choose cardiology. We just need to have more women entering our field in the first place.

But it’s not just the job of women in cardiology to recruit more women. There are not enough of us. We need to put this burden back on men. Men play a big role in this, and they can try to support and amplify women. Right now, there’s not enough women at the top to be the mentors and sponsors of all other women. I hope that will change. I hope that leadership at the top will eventually be 50/50, but right now, few leaders are women, so we need men to engage. We need male faculty who are in the position to be able to mentor and sponsor women to help bring them along and advance their careers because we will all do better as a profession if we are diverse. Medicine is better when we’re more inclusive and representative of the patients we care for every day.

Q: Does this seem to continue once women enter cardiology or is this somewhat a career-long situation?

A: This paper was about entering cardiology via fellowship training, which is important, but I also feel passionately about how we can’t lose women via attrition at any stage of their career. There are these broken rungs in academia, particularly in cardiology, where women might get into the door but then they can’t climb the ladder upward in professional advancement. Studies have shown that women are not promoted at the same rate as men despite having similar accomplishments. Studies have demonstrated over and over that there are gender gaps in salary that persist even after accounting for potentially confounding factors like productivity. Finally, there are very few women in leadership roles, particularly in cardiology. Entry is very important, but there’s a leaky pipeline, so we need to have more women in leadership so that we can bring up the people that are coming up from behind us. – by Darlene Dobkowski

Reference:

Khan MS, et al. Circulation. 2020;doi:10.1161/CIRCULATIONAHA.119.044693.

For more information:

Erin D. Michos, MD, MHS, FAHA, can be reached at edonnell@jhmi.edu; Twitter: @erinmichos.

Disclosures: The authors report no relevant financial disclosures.

Erin D. Michos

Women continue to be the minority in training within the cardiology field and its subspecialties with minimal change during the past 10 years, according to a research letter published in Circulation.

Researchers examined data from the Association of American Medical Colleges from 2007-2008 and 2017-2018. There was a particular focus in training programs for general CVD medicine and four subspecialties: interventional cardiology, electrophysiology, advanced HF/transplantation and adult congenital heart disease.

The data show that among all adult cardiology trainees in 2017-2018, 21.4% were women, which was a modest increase from 15.9% in 2007-2008. The most skewed sex distribution was present in interventional cardiology (10.2% women) and electrophysiology (11.6% women) compared with advanced HF/transplantation (31.2% women) and adult congenital heart disease (46.7%).

Healio spoke with Cardiology Today Editorial Board Member Erin D. Michos, MD, MHS, FAHA, director of women’s cardiovascular health at Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, to learn more about the findings and what cardiologists can do to make their field more representative of everyday patients.

#
Cardiology Today Editorial Board Member Erin D. Michos, MD, MHS, FAHA, director of women’s cardiovascular health at Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease

Question: What are some of the major takeaways from this research letter?

Answer: Unfortunately, although there was a modest increase over the past decade, these findings largely reflect a stagnation of growth of the number of women entering cardiology fellowship, with only 21% of cardiology fellows being women.

When you compare this to other specialties within internal medicine, cardiology has the lowest percentage of women. When you compare it to other specialties outside of medicine, only orthopedic surgery does worse. More women are choosing to train in general surgery than they are in cardiology.

This is certainly concerning because heart disease is a woman’s disease too.

Fifty percent of our patients are women. At the end of the day, we’re delivering a service, and if our profession in cardiology is not made up of the wider population, we’re not going to be able to effectively deliver our service. It’s not going to resonate with end users.

That’s not to say that male physicians cannot provide excellent care; they certainly do, but we know that sometimes men and women have different communication styles, which can translate into differences in how we communicate with patients and listen to their needs. Furthermore, everybody has implicit biases, both men and women — that’s part of being human. Thus, medicine and cardiology are better as a whole when we have a diverse health care team so we can all learn from each other and be representative of the patients we serve.

PAGE BREAK

We’re not going to have success until we can look into the incoming classes of cardiology fellows and see that they’re representative of our patients. We have half of medical students being women and almost half of internal medicine residents being women, but only 21% of cardiology fellows being women. Thus, we’re losing over half of the potential talent pool in cardiology to other specialties and we’re not making much progress in this over the past decade.

We need to have a culture change, a climate change and think about strategies of examining why is our cardiology specialty not as attractive to women and what can we do to change it for the better of the profession and for the better of patients in general.

Q: Why was there a more skewed sex distribution in interventional cardiology and electrophysiology compared with advanced HF/transplantation and adult congenital heart disease?

A: It’s a lot of things. One is what the field currently looks like. You can’t be what you can’t see. If you are early in your training and you don’t see any women interventional cardiologists and you don’t see any women in electrophysiology because there are just so few of them, it’s hard to imagine becoming one of them. Women in cardiology, particularly in interventional fields, need to be visible to early learners. Otherwise, we’re lacking the mentorship and sponsorship for those coming up in the pipeline, and it’s hard for them to visualize themselves in this role.

Plus, there is some concern about radiation safety around pregnancy and child care, and concerns about work-life integration. Interventional cardiology and electrophysiology are more like surgical specialties because they’re more procedural.

That being said, look at OB-GYNs. That’s a demanding surgical specialty. They do cesarean sections and high-risk procedures. Just like cardiology with STEMIs that can come all hours of the night, babies can be delivered all hours of the night, yet OB-GYN is a specialty that’s more than 80% women.

Thus, I don’t think it’s that women are afraid of doing technical or surgical fields. I don’t buy that. Women are not afraid of working hard. We lack women in cardiology, particularly interventional cardiology, because women are systematically discouraged along the way. When people tell you, “You don’t want to be an interventional cardiologist. What if you get pregnant? How can you work those hours if you want to have kids?” Women in early training are constantly getting these messages and are being talked out of these fields, saying, “That’s a terrible work-life balance. Why would you want to do that?” I know a number of women that are current cardiology trainees and they want to do interventional or electrophysiology training. Even in 2020, they are being talked out of it: “Why do you want to do that? That’s not a good field for women.”

PAGE BREAK

In sum, a lot of it has to do with visibility, bias and people discouraging women from pursuing it. You need a strong mentor and encouragement along the lines like, “Yes, this is a good field for women. This is how you can make work-life integration work. You belong here. This is an exciting field. There’s a lot we can do to help patients in cardiology, and the patients want you here.” We need to do more to support and encourage women.

Q: What do you think needs to be done to make cardiology a more balanced specialty?

A: We need to change the climate and the impressions we are sending out about our specialty throughout the whole career spectrum and make cardiology accessible to women all the way up to senior leadership positions. But let’s start with the very early learners. People start getting impressions about what they might want to do for their careers early in medical school and during residency.

We need to have more visibility to these early learners. In the paper, we discussed things like having more travel grants and opportunities to bring medical students and early learners to cardiology meetings where they can interact with cardiologists and, in particular, women in cardiology for exposure.

Another example of visibility is getting students exposed to women in cardiology as early as their classroom days. This is one thing that we’re trying to do at Hopkins.

For example, I teach in a cardiology course for the second-year medical students at our medical school. We try to make sure that speakers and lecturers in this course are both male and female faculty. Additionally, we have a social event that is a “meet and greet” for the medical students with women in cardiology. It’s open to all students. Mostly female medical students come, but we’ve had a few male medical students come each year too, which is great. At this event, the medical students come meet women in cardiology, both fellows and faculty, and ask us questions about our careers. We tell them what life is like as a cardiologist, what kinds of things we do in our daily jobs. We bring in faculty who represent various cardiology subspecialties — we all do something a little different. And we enjoy being cardiologists, so we share that joy and passion with the students. It’s fascinating; these are second-year medical students and they already have these preconceived notions of what they think being a cardiologist is like. For example, a few have thought that every cardiologist does percutaneous interventions in the middle of the night. They don’t realize that there’s a lot of heterogeneity in cardiology of what you can do. You can do research, noninvasive imaging, prevention, HF and more. And we certainly need people to do interventional and electrophysiology too.

PAGE BREAK

How else can we improve culture? We need to have better support and policies in place related to pregnancy, lactation and child care. The whole system cannot collapse because some cardiology fellows are out on parental leave. Fellowship training overlaps with childbearing years. We need to plan for it, expect to have fellows out for parental leave during this time of their lives. I must emphasize again that maternity leave is not a vacation, and women in training sometimes are pressured into feeling guilty about maternity leave and “imposing” on colleagues. More flexibility in the system is needed to allow for this rather than have everything collapse when people are out on parental leave. We need better support, encouragement and help for transitioning back. I do want to note that women are not pregnant their entire professional lives. So we need to support them earlier in their careers because if we can help people through this pivotal times in their life, then we have built a sustained workforce that can be working for decades and decades.

When I was in cardiology fellowship training, I was the only female in my year. Both during fellowship and my early career as faculty, it was this boys club, I didn’t feel included. The whole climate was very fraternity-like and I didn’t feel part of the club. Things fortunately are improving.

There’s been tremendous work lately in this regard on a national level. The American College of Cardiology and American Heart Association have very active women in cardiology committees with social and networking events. This is what has helped me personally in my career. I had already chosen to be a cardiologist, but the reason why I stayed and haven’t left yet is the support that I found through this network of women in cardiology throughout the field. I found all these other women who were experiencing similar things as me in terms of negotiating for salary equity and other issues. While it was somewhat discouraging to realize that so many of us were encountering the same barriers, it was comforting to not feel alone.

Representation matters everywhere. There has been a strong push lately to make sure that meetings and conferences don’t have “manels,” or all-male panels, and making sure of that everywhere, from small sessions to the big late-breaking clinical trials sessions, that they have women who are discussants up there on the big stages being visible to the world. Cardiology is a field that has women excelling, and women experts should be recognized and included in the conversation.

PAGE BREAK

I’m a very big advocate that more women need to be on more editorial boards of journals, editors-in-chief and on grant review committees because there are also studies that have demonstrated bias in publication and grant awards by gender. For women to advance in their careers and be promoted, they need to get grant funding and publish. It needs to be an even playing field.

Science should be collaborative. I also strongly discourage what I call “MANuscripts,” which are papers with a long list of all-male authors and no female authors. I can’t tell you how many papers I’ve seen where there were 10 or 15 authors and they’re all men. There’s not a single woman on the author list. People tend to invite and collaborate with people that come to their mind. This is affinity bias. People tend to first think of people that are most like them but need to think more broadly outside the box. There are women experts out there; we just need to look for them and think about them.

We need to consciously make an effort to be more inclusive. We need to include women in this project, on this panel or in this program. It does take concerted effort to change the climate because this is all implicit bias. I don’t think people aren’t intentionally discriminating against women, but they also don’t think about including them. Diversifying a field is not enough unless you have true inclusion. The lack of inclusion can have negative downstream effects where women don’t want to go into this field because they don’t feel welcomed or part of the culture.

Q: What advice would you give women who may be in the minority in their year to help them become successful cardiologists?

A: We need to end the boys club and make it an inclusive culture for all. What helped me was being active on social media and meeting this wonderful network of women in cardiology across the world who encountered similar professional challenges in their environment. I have also met “HeForShe” male supporters who want to help drive this culture change too.

Together, they make up my professional network that I call my “raft of otters.” Otters hold hands so they don’t float out to sea, so we need to find our network or otters to hold onto each other during turbulent tides. I’m trying to amplify the voices of women so that they’re seen and heard. We should make sure that women don’t feel alone. Our patients want us here. They want their doctors to be representative of them.

PAGE BREAK

Cardiology is a great field for women. We do surveys of the professional life of cardiologists. Most cardiologists including women have a lot of career satisfaction, so people like their careers when they choose cardiology. We just need to have more women entering our field in the first place.

But it’s not just the job of women in cardiology to recruit more women. There are not enough of us. We need to put this burden back on men. Men play a big role in this, and they can try to support and amplify women. Right now, there’s not enough women at the top to be the mentors and sponsors of all other women. I hope that will change. I hope that leadership at the top will eventually be 50/50, but right now, few leaders are women, so we need men to engage. We need male faculty who are in the position to be able to mentor and sponsor women to help bring them along and advance their careers because we will all do better as a profession if we are diverse. Medicine is better when we’re more inclusive and representative of the patients we care for every day.

Q: Does this seem to continue once women enter cardiology or is this somewhat a career-long situation?

A: This paper was about entering cardiology via fellowship training, which is important, but I also feel passionately about how we can’t lose women via attrition at any stage of their career. There are these broken rungs in academia, particularly in cardiology, where women might get into the door but then they can’t climb the ladder upward in professional advancement. Studies have shown that women are not promoted at the same rate as men despite having similar accomplishments. Studies have demonstrated over and over that there are gender gaps in salary that persist even after accounting for potentially confounding factors like productivity. Finally, there are very few women in leadership roles, particularly in cardiology. Entry is very important, but there’s a leaky pipeline, so we need to have more women in leadership so that we can bring up the people that are coming up from behind us. – by Darlene Dobkowski

Reference:

Khan MS, et al. Circulation. 2020;doi:10.1161/CIRCULATIONAHA.119.044693.

For more information:

Erin D. Michos, MD, MHS, FAHA, can be reached at edonnell@jhmi.edu; Twitter: @erinmichos.

Disclosures: The authors report no relevant financial disclosures.