Abstract
Background
Discrimination and harassment are common in cardiology but data on its impact are limited.
Objectives
This study sought to identify the prevalence and impact of workplace mistreatment among U.S. cardiologists overall and when engaged in clinical and academic work.
Methods
The American College of Cardiology conducted an online survey of 1,583 U.S. cardiologists in 2022. Demographics, types of mistreatment, professional experiences, and impact were self-reported. Multivariable logistic regression analyses were used to determine the predictors of “negative professional impact” defined as a composite of any of the following outcomes: being less productive, taking sick time, leaving a position, leaving cardiology, or leaving medicine.
Results
Three-quarters of cardiologists experienced workplace mistreatment, including incivility (34%), discrimination (62%), emotional or physical harassment (32%), and sexual harassment (13%). Unfair treatment was reported by 54% working in any clinical setting, including issues related to professional advancement (31%), clinical work expectations (27%), and compensation (23%). Unfair treatment was reported by 58% during academic work. Consequently, 20% avoided training, employment, or promotion opportunities, 20% felt silenced, and 16% reported social avoidance; 11% considered leaving medicine. Predictors of negative professional impact included type of mistreatment (harassment [OR: 10.01; 95% CI: 5.25-19.10], discrimination [OR: 3.03; 95% CI: 1.56-5.80]), identification as homosexual (OR: 5.60; 95% CI: 1.87-16.78), and woman gender (OR: 1.57; 95% CI: 1.19-2.07).
Conclusions
Three of four U.S. cardiologists report workplace mistreatment, including two-thirds reporting discrimination and/or harassment. Mistreatment negatively impacts professional lives, career trajectory, well-being, productivity, workforce retention, and ultimately impacts the delivery of patient care. These data highlight the need to improve the climate within cardiology.
Key words: cardiology, discrimination, emotional harassment, incivility, mistreatment, sexual harassment, workplace
Central Illustration
Workplace mistreatment is pervasive in scientific fields,1 including medicine. Prior American College of Cardiology (ACC) surveys show harassment and discrimination in U.S. cardiology persisting at high levels over 3 decades,2,3 with prevalence varying by gender, race, and ethnicity. Prepandemic data show a high prevalence of a hostile work environment to include discrimination and harassment among cardiologists globally, with adverse effects on professional and patient interactions, and mental health.4,5 These findings have driven concerted efforts to address mistreatment.6
Despite this repeated documentation, there are few data regarding details of the sources and types of mistreatment and their impact on professional behaviors and attitudes. Only by quantifying these daily occurrences can a fuller picture of the lived experience of being a cardiologist be obtained; an essential first step in understanding the prevalent climate. Similarly, there is a need to explore greatly expanded demographic groups among cardiologists, including such groups as sexual orientation and gender identity (SOGI), people with disabilities or underrepresented race and ethnicity, age, and immigrants to the United States. Finally, mistreatment can include incivility, in addition to harassment and discrimination, but this has not been previously quantified. Incivility is frequently centered on an individual’s personal characteristics or professional status, and can manifest in subtle but repeated verbal, nonverbal, and environmental slights, snubs, or insults—whether intentional or unintentional—that communicate hostile, derogatory, or negative messages, and can have a profound impact personally and professionally.6,7
Accordingly, this study analyzed the current state of professional mistreatment within cardiology in the United States, including shedding light on the breadth of lived clinical and academic work-related experiences with a goal of informing ongoing efforts to improve the work environment for cardiologists.
Methods
The ACC conducted a 31-item online multiple-choice survey of U.S. cardiologists to assess how the workplace environment is perceived by and impacts cardiologists in the United States. The full survey is available in the Supplemental Appendix). Demographic information collected included age, race and ethnicity, gender identity, sexual orientation, career stage, disability, and immigration. Survey questions covered topics including practice environment, career experiences, mental health, discrimination, and harassment. The survey included questions adapted from prior ACC surveys,2,4,8 Workplace Incivility Scale,9 National Institutes of Health Culture Climate Survey,10 and American Economy Association’s Professional Climate Survey.11 Burnout was assessed with the single-item burnout measurement question from the mini-Z survey.12 Depression and anxiety were assessed using the Patient Health Questionnaire-2 and Generalized Anxiety Disorder 2-item screening tests.13,14 Advarra Institutional Review Board Services reviewed the study protocol and using the Department of Health and Human Services regulations found at 45 Code of Federal Regulations 46.104(d) (2), the institutional review board determined that the research project is exempt from institutional review board oversight.
Survey deployment
The survey link was emailed to 16,083 U.S. cardiologists from the ACC database of 29,277 U.S. cardiologists utilizing a random sampling stratified by race and ethnicity. The survey was open from March 4 to May 16, 2022. A random drawing for four $250 Apple gift cards was used to incentivize participation, although names collected to facilitate the incentive award process were not used in data analysis and were unavailable to coauthors. 1,583 cardiologists completed the anonymous survey (9.8% response rate) and were included in the final analysis. Key demographics between respondents and nonrespondents are provided in Supplemental Table 1.
Mistreatment definition and subtypes
Based on self-reported responses to survey questions, cardiologists were categorized as experiencing mistreatment if they reported “yes” to any of the questions related to workplace incivility, discrimination, or harassment in the past 10 years. No mistreatment was defined as those who did not self-report any workplace incivility, discrimination, emotional or physical harassment, or sexual harassment. Workplace incivility was defined as perceived feeling of being excluded from work activities, judgment doubted, put down in a condescending way, opinion ignored, addressed in unprofessional manner, socially excluded in professional settings, or feeling disrespected, and/or disinterest in one’s work compared to that of colleagues. Discrimination was defined as experiencing unfair treatment due to personal factors, or in ways specific to their work environment. Emotional or physical harassment was defined as demeaning or derogatory remarks, physical threats, intimidating behaviors (finger pointing, invasion of personal space, shoving, or blocking way), or bullying. Sexual harassment was defined as having experienced workplace-related offensive or unwanted remarks or gestures, unwanted attempts to establish a relationship, subtle bribery attempts to engage in sexual behavior, receiving threats for not being romantically or sexually cooperative, approached for or engaged in nonconsensual sexual behavior or touching. To account for participants who experienced more than one subtype of mistreatment, respondents were categorized into 3 groups (incivility without discrimination or harassment, discrimination without harassment, any harassment) for ease of statistical analysis and clarity of presentation. Workplace incivility was ranked at the lowest end of the spectrum, discrimination was ranked higher along the continuum, and any type of harassment was the most severe form of mistreatment. Data tables and analyses are based on these categories, while the Central Figure shows any mistreatment.
Data analysis
Data analysis was performed using statistical software IBM SPSS Statistics for Windows, Version 25.0. Comparisons between groups were determined using chi-square or Kruskal-Wallis H tests as appropriate.
Multivariable logistic regression models were run to identify predictors of 2 outcomes: negative impact on profession and burnout. Criteria for variable model entry were P < 0.05 and for staying in the model P < 0.10. The outcome “negative impact on profession or organization” included any “yes” response to the survey question “Did your experience lead you to” be less productive, leave a position, take sick time, leave cardiology, or leave medicine. The outcome “burnout” was based on self-reported feeling of burnout (survey question: Using your own definition of “burnout”). Independent variables in the models included gender identity, career stage, living full time in the United States, sexual orientation, disability, race, workplace incivility, discrimination, emotional or physical harassment, sexual harassment, having a mentor, advisor, sponsor, and coach. Correlations between variables were examined using Spearman’s correlation coefficient and variables with a coefficient >±0.45 were excluded from the model. A value of P ≤ 0.001 was considered significant to account for multiple comparisons in the multivariable analysis.
Results
Demographics
Of the 1,583 cardiologists, 75% were men and 22% were women, while 3% did not wish to disclose their gender and 1 self-identified as nonbinary. Cardiologists largely self-identified as heterosexual (94%). The majority of cardiologists self-identified as White race (58%) or Asian race (20%, including South Asians 14% and East Asians 6%), with 7% of Hispanic ethnicity, 5% of Black race, 4% of Middle East heritage, and 6% declined to provide this information. Most cardiologists were born and raised in the United States (67%) whereas 19% reported that they began living full-time in the United States around the time of residency or fellowship. Most cardiologists did not report having a disability that interfered with their work (95%). Almost half of the cardiologists were 22+ years into practice (49%) (Table 1). The demographic profile of respondents closely matched that of those invited to participate in the survey.
Table 1.
Personal Characteristics and Type of Mistreatment
| Total (N = 1,583, 100%) | Type of Mistreatment |
Type of Harassmenta |
||||||
|---|---|---|---|---|---|---|---|---|
| No Negative Treatment (n = 395, 25%) | Incivility (n = 123, 8%) | Discrimination (n = 483, 30%) | Harassment (n = 582, 37%) | P Value | Emotional or Physical Harassment (n = 510, 32%) | Sexual Harassment (n = 202, 13%) | ||
| Sex | ||||||||
| Men | 1,182 (75%) | 30% | 9% | 31% | 30% | Ref | 27% | 7% |
| Women | 354 (22%) | 7% | 4% | 30% | 59% | <0.001 | 49% | 31% |
| Nonbinary/Agender/Something else | 1 | 100% | N/A | |||||
| Do not wish to disclose | 46 (3%) | 28% | 4% | 28% | 39% | 0.49 | 33% | 13% |
| Race and ethnicity | ||||||||
| Declined to provide | 88 (6%) | 27% | 6% | 30% | 38% | 0.58 | 31% | 20% |
| White | 920 (58%) | 28% | 10% | 27% | 34% | Ref | 30% | 10% |
| East Asian | 88 (6%) | 18% | 2% | 34% | 46% | 0.006 | 42% | 15% |
| South Asian | 228 (14%) | 20% | 6% | 34% | 40% | 0.003 | 35% | 13% |
| Middle East | 59 (4%) | 27% | 2% | 39% | 32% | 0.08 | 27% | 15% |
| Hispanic | 119 (7%) | 21% | 5% | 36% | 38% | 0.044 | 31% | 16% |
| Black | 81 (5%) | 10% | 5% | 39% | 46% | <0.001 | 38% | 20% |
| White or non-White by sex | ||||||||
| White men | 712 (45%) | 34% | 12% | 26% | 28% | Ref | 26% | 5% |
| Non-White men | 423 (27%) | 23% | 4% | 39% | 34% | <0.001 | 31% | 1% |
| Unknown race men | 47 (3%) | 34% | 4% | 30% | 32% | 0.411 | 23% | 17% |
| White women | 191 (12%) | 5% | 3% | 33% | 59% | <0.001 | 49% | 30% |
| Non-White women | 150 (9%) | 9% | 5% | 29% | 57% | <0.001 | 47% | 29% |
| Unknown race women | 13 (1%) | 15% | 8% | 8% | 69% | N/A | 62% | 46% |
| Live full-time in the United States | ||||||||
| At birth: born and raised in the United States | 1,053 (67%) | 27% | 9% | 28% | 36% | Ref | 32% | 12% |
| Before or during college | 131 (8%) | 21% | 5% | 32% | 42% | 0.17 | 39% | 11% |
| Before or during medical school | 10 (1%) | 40% | 0% | 20% | 40% | N/A | 40% | 20% |
| Before or during residency or fellowship | 293 (19%) | 22% | 5% | 37% | 36% | 0.005 | 30% | 13% |
| After completing training | 56 (3%) | 25% | 4% | 30% | 41% | 0.51 | 39% | 14% |
| Other, please specify | 21 (1%) | 10% | 19% | 38% | 33% | N/A | 29% | 9% |
| Do not wish to disclose | 13 (1%) | 27% | 8% | 23% | 36% | N/A | 8% | 31% |
| Career stage | ||||||||
| 1-7 y | 245 (15%) | 16% | 4% | 32% | 47% | <0.001 | 40% | 22% |
| 8-14 y | 212 (13%) | 19% | 7% | 25% | 49% | <0.001 | 46% | 19% |
| 15-21 y | 200 (13%) | 22% | 9% | 30% | 39% | 0.08 | 32% | 12% |
| 22+ y | 771 (49%) | 30% | 9% | 30% | 31% | Ref | 28% | 8% |
| No training data | 101 (10%) | 38% | 7% | 27% | 29% | 0.46 | 27% | 10% |
| Disability | ||||||||
| Yes | 43 (3%) | 19% | 5% | 30% | 47% | 0.47 | 44% | 9% |
| No | 1,497 (95%) | 25% | 8% | 31% | 36% | Ref | 32% | 13% |
| Do not wish to disclose | 40 (2%) | 25% | 5% | 27% | 43% | 0.81 | 37% | 17% |
Values are n (%) or %.
N/A = not applicable; Ref = reference group.
These columns are based on percentages of the total population and may include overlapping data since 22% of the harassment group experienced both emotional or physical harassment and sexual harassment.
Type of mistreatment
Only 25% of cardiologists reported not experiencing any mistreatment, whereas 75% of cardiologists experienced one or more subtype of mistreatment: 34% workplace incivility, 62% discrimination, 32% emotional or physical harassment, and 13% sexual harassment (Central Illustration, Tables 1 and 2).
Central Illustration.
Prevalence of Any Mistreatment Among 1,583 U.S. Cardiologists
Graphs show any mistreatment and relationships of any mistreatment in clinical and research/education environments, and impact of mistreatment. Note that data in tables and text represent worst mistreatment, while these plots show any mistreatment.
Table 2.
Mistreatment Spectrum: Overlapping Types of Mistreatment Experienced (N = 1,583)
| Total | Type of Mistreatment |
Type of Harassmenta |
|||||
|---|---|---|---|---|---|---|---|
| No Negative Treatment (25%) | Incivility (8%) | Discrimination (30%) | Harassment (37%) | Emotional or Physical Harassment (32%) | Sexual Harassment (13%) | ||
| No negative treatment | 395 (25%) | 395 | |||||
| Workplace incivility | 545 (34%) | 123 | 317 | 545 | 486 | 187 | |
| Discrimination | 987 (62%) | 483 | 504 | 447 | 183 | ||
| Emotional or physical harassment | 510 (32%) | 510 | 510 | 130 | |||
| Sexual harassment | 202 (13%) | 202 | 130 | 202 | |||
Values are n (%) or n.
These columns are based on percentages of the total population and may include overlapping data since 22% of the harassment group experienced both emotional or physical harassment and sexual harassment.
When classifying experiences by type of mistreatment (see Methods), 8% reported only workplace incivility, 30% reported discrimination (but not harassment), and 37% reported experiencing some form of harassment with or without other forms of mistreatment. There was no significant change in prevalence of mistreatment after weighting of data based on gender, age, race, and ethnicity (Supplemental Table 2).
Women relative to men were more likely to report experiencing any mistreatment (93% vs 70%; OR: 5.97; 95% CI: 3.88-9.21) and harassment (59% vs 30% OR: 3.3; 95% CI: 2.59-4.23), including emotional or physical harassment (49% vs 27%) and sexual harassment (31% vs 7%) (all P < 0.001). Black, South Asian, East Asian, and Hispanic cardiologists were more likely to report experiencing discrimination and harassment compared with White cardiologists. Analysis by gender, race, and ethnicity showed non-White men experienced more discrimination than White men, but harassment was similar in men of all races. Women of all races experienced more discrimination and harassment compared to White men. Those emigrating to the United States around the time of residency or fellowship were more likely to report discrimination compared with other U.S. cardiologists. Career stage was associated with negative treatment, including higher reported rates of harassment in those with <15 years of practice compared with those 22+ years into practice, and higher rates of discrimination among those with <8 years of cardiology practice compared with those with 22+ years of practice (Table 1), all P < 0.001. There were no statistically significant differences in mistreatment for cardiologists based on sexual orientation or disability status; however, the analysis was limited by the small number of respondents in these subgroups (Table 1, Supplemental Table 3).
Perceived reasons for mistreatment
Among the respondents experiencing discrimination (but not harassment), race and ethnic identity was the most frequently (30%) reported perceived cause of mistreatment, followed by (in descending order) age, sex, political views, religion, citizenship or visa status, and care giving responsibilities. Similarly, among those who reported experiencing harassment, race and ethnic identity was the most frequent perceived cause of mistreatment (31%), followed by sex, age, political views, and care giving responsibilities (Supplemental Table 4).
Experiences in clinical and academic work settings
Among the 1,494 cardiologists engaged in clinical work (Table 3, Supplemental Table 5), 54% reported experiencing discrimination or unfair treatment in the clinical setting related to professional advancement (31%), clinical work expectations (27%), compensation (23%), and hiring processes (16%).
Table 3.
Experiences of Mistreatment in Clinical and Academic Settings
| Total (100%) | Type of Mistreatment |
P Value | ||||
|---|---|---|---|---|---|---|
| No Negative Treatment (25%) | Incivility (8%) |
Discrimination (30%) | Harassment (37%) | |||
| Clinical type of work | ||||||
| Size | 1,494 | 371 | 115 | 447 | 561 | |
| No discrimination or unfair treatment | 46% | 91% | 90% | 30% | 19% | Ref |
| Professional advancement | 31% | 0% | 0% | 34% | 57% | <0.001 |
| Clinical work expectations | 27% | 0% | 0% | 30% | 48% | <0.001 |
| Hiring | 16% | 0% | 0% | 16% | 31% | <0.001 |
| Compensation for clinical work | 23% | 0% | 0% | 29% | 39% | <0.001 |
| Academic type of work | ||||||
| Size | 807 | 176 | 59 | 253 | 319 | |
| No discrimination or unfair treatment | 42% | 81% | 83% | 29% | 23% | Ref |
| Professional advancement | 24% | 0% | 0% | 30% | 37% | <0.001 |
| Compensation | 24% | 0% | 0% | 26% | 33% | <0.001 |
| Access to research opportunities | 23% | 0% | 0% | 27% | 36% | <0.001 |
| Publishing role | 18% | 0% | 0% | 18% | 30% | <0.001 |
Values are n or %. Total percentage could exceed 100%.
Ref = reference group
Among the 807 cardiologists engaged in academic work, 58% reported experiencing discrimination or unfair treatment in the academic setting (Table 3), related to professional advancement (24%), compensation (24%), access to research opportunities (23%), and publishing role (18%). Detailed examples are provided in Supplemental Table 5.
Negative impact
Nearly half of all respondents (49%) avoided disclosing personal characteristics or views due to fear of negative consequences, including political views (31%), religion (16%), parenting or caregiving responsibilities (12%), and age (10%) (Supplemental Table 6). The frequency of avoidance was higher among those who experienced harassment.
To avoid mistreatment, 20% of all respondents avoided training, employment, or promotion opportunities, 20% reported being silenced, and 16% reported social avoidance (Central Illustration). These compensating behaviors were less frequent among those without mistreatment and highest among those who experienced any form of harassment, all P < 0.001 (Table 4). Detailed examples are provided in Supplemental Table 7.
Table 4.
Career Impact of Mistreatment
| Total (100%) | Type of Mistreatment |
P Value | ||||
|---|---|---|---|---|---|---|
| No Negative Treatment (25%) | Workplace Incivility (8%) |
Discrimination (30%) |
Harassment (37%) |
|||
| Size | 1,583 | 395 | 123 | 483 | 582 | |
| Actions taken to avoid harassment/discrimination | ||||||
| None | 61% | 93% | 77% | 62% | 34% | Ref |
| Total: avoided training, employment, or promotion | 20% | 1% | 8% | 17% | 37% | <0.001 |
| Not applied or not accepted admission to training program or employment | 4% | 1% | 3% | 3% | 8% | <0.001 |
| Not applied or not taken a promotion or more visible role at place of employment | 7% | 0% | 3% | 7% | 12% | <0.001 |
| Left a particular employment position | 14% | 1% | 3% | 11% | 27% | <0.001 |
| Total: silenced | 20% | 0% | 9% | 18% | 37% | <0.001 |
| Not presented question, idea, or view at your organization | 18% | 0% | 8% | 15% | 34% | <0.001 |
| Changed the content, method, or conclusions of a research paper | 1% | 0% | 0% | 1% | 2% | <0.001 |
| Not started or continued research in a particular area of cardiology | 4% | 0% | 1% | 3% | 9% | <0.001 |
| Total: social avoidance | 16% | 0% | 6% | 12% | 32% | <0.001 |
| Not attended in a regional or national conference | 4% | 0% | 2% | 2% | 10% | <0.001 |
| Not spoken at a regional or national conference or during a presentation | 4% | 0% | 0% | 1% | 9% | <0.001 |
| Not attended social events at work, after hours or at a conference | 13% | 0% | 4% | 10% | 28% | <0.001 |
| Outcome (size) | 753 | 2 | 66 | 217 | 468 | |
| Nothing | 35% | 0% | 67% | 36% | 31% | Ref |
| Be less productive or effective in your work | 20% | 0% | 3% | 16% | 25% | <0.001 |
| Total: file charges or consider legal action | 11% | 0% | 1% | 6% | 14% | <0.001 |
| File official charge of complaint with your employer | 6% | 0% | 1% | 2% | 9% | <0.001 |
| Consider taking legal action | 7% | 0% | 1% | 5% | 8% | 0.004 |
| Total: consider avoiding work, position, or meetings | 44% | 0% | 18% | 44% | 48% | <0.001 |
| Consider leaving a project, committee, program, or other similar work endeavor | 15% | 0% | 6% | 10% | 19% | <0.001 |
| Consider leaving your position | 35% | 0% | 9% | 33% | 39% | <0.001 |
| Take leave, sick time, miss work unexpectedly, or other similar time away from work | 2% | 0% | 0% | 1% | 3% | 0.096 |
| Consider not attending future cardiology meetings or conferences | 10% | 0% | 6% | 8% | 12% | 0.006 |
| Total: consider leaving the profession | 11% | 0% | 1% | 6% | 14% | <0.001 |
| Consider leaving the field of cardiology | 8% | 0% | 1% | 5% | 10% | <0.001 |
| Consider leaving medicine entirely | 8% | 0% | 1% | 4% | 10% | <0.001 |
Values are n or %. Data presented as column with multiple response questions. Total percentage could exceed 100%.
Ref = reference group for significance testing.
Respondents who experienced harassment or discrimination were significantly more likely to perceive their level of advancement and compensation to be lower than their peers (37% and 23%, respectively, vs 10% no negative treatment, P < 0.001). Moreover, those who experienced harassment or discrimination were significantly more likely to feel dissatisfied with achieving their professional goals (28% and 16%) compared with those who experienced no negative treatment (5%, P < 0.001).
Among the 1,188 cardiologists reporting mistreatment, 753 (63%) reported an adverse impact on career decisions; however, only 11% filed charges or considered legal action. Eighty-three (11%) of those reporting an adverse impact considered leaving cardiology or medicine (5% of all respondents), with no significant differences by sex, race and ethnicity, or career stage (Table 4, Supplemental Table 7).
Cardiologists who were burned out were more likely to have reported experiencing harassment or discrimination compared to those who experienced no mistreatment (54% or 28% vs 12%, P < 0.001). Cardiologists who screened positive for anxiety on GAD2 or depression on PHQ2 scales were more likely to have reported experiencing harassment or discrimination compared to those who experienced no mistreatment (59% or 27% vs 10%; 61% and 25% vs 11%, respectively) (all P < 0.001) (Table 5).
Table 5.
Prevalence of Burnout and Mental Health Conditions
| Totala | Type of Mistreatment |
P Value | ||||
|---|---|---|---|---|---|---|
| No Negative Treatment (25%) |
Workplace Incivility (8%) |
Discrimination (30%) | Harassment (37%) | |||
| Burnout | ||||||
| No burnout | 454 (29%) | 40% | 6% | 31% | 24% | <0.001 |
| Stressed | 665 (42%) | 23% | 11% | 32% | 35% | <0.001 |
| Burned out | 446 (28%) | 12% | 5% | 28% | 54% | <0.001 |
| Anxiety Disorder Score | ||||||
| No anxiety (score = 0-2) | 1,364 (88%) | 27% | 8% | 31% | 34% | <0.001 |
| Anxiety disorder (score = 3-6) | 178 (12%) | 10% | 4% | 27% | 59% | <0.001 |
| Patient Health/Depression Score | ||||||
| No disorder (score = 0-2) | 1,376 (91%) | 26% | 9% | 31% | 34% | <0.001 |
| Depressive disorder (score = 3-6) | 139 (9%) | 11% | 2% | 25% | 61% | <0.001 |
NS = not significant.
Values are n (%) or %. No negative treatment is the reference group for significance testing.
Predictors of negative impact and burnout
A multivariable analysis was performed to determine which factors independently correlated with the composite endpoint “negative impact on profession or organization.” Negative impact was predicted with high discriminatory power (C-statistic 0.80; 95% CI: 0.78-0.83) overall. Specific factors independently associated with a higher rate of “negative impact on profession or organization” included harassment (OR: 10.01; 95% CI: 5.25-19.10; P ≤ 0.001), discrimination (OR: 3.03; 95% CI: 1.56 to 5.80; P = 0.001), identify as homosexual (OR: 5.60; 95% CI: 1.87-16.78; P = 0.002), and female gender (OR: 1.57; 95% CI: 1.19-2.07; P = 0.001). No negative mistreatment was protective against any negative impact on profession or organization (OR: 0.75; 95% CI: 0.02-0.28; P ≤ 0.001) (Supplemental Table 8). Of note, race and ethnicity, age, disability, and career stage were not predictive of a negative impact.
In the multivariable logistic regression model, burnout was predicted with moderate discrimination, C-statistic = 0.70 (95% CI: 0.67-0.73). Specific factors independently associated with burnout included harassment (OR: 3.68; 95% CI: 2.69-5.01; P ≤ 0.001), female gender (OR: 1.93; 95% CI: 1.47-2.50; P ≤ 0.001), and discrimination (OR: 1.92; 95% CI: 1.38-2.66; P ≤ 0.001). Factors protective against burnout included coming to the United States after training (OR: 0.36; 95% CI: 0.17-0.77; P = 0.008), coming to the United States during residency or fellowship (OR: 0.42; 95% CI: 0.30-0.59; P ≤ 0.001), and having had a coach (OR: 0.58; 95% CI: 0.37-0.93; P = 0.023), or a mentor (OR: 0.68; 95% CI: 0.54-0.88; P = 0.002) (Supplemental Table 9).
Organizational support
Those who experienced harassment were least likely to rank their organizations’ policies, practices, and attitudes as supportive or extremely supportive related to work schedule flexibility, total workload, timing and location of meetings, adequate support staff, parental leave policies, compensation, on-call policies, and the attitudes of leadership, colleagues, and staff (Supplemental Table 10).
Those who experienced harassment were more likely to report lack of or ineffective organizational policies and programs addressing microaggressions and emotional harassment, uncivil behaviors, racism, sexism, parental, or medical leave (Supplemental Table 11). When asked about comfort addressing a range of types of mistreatment directed at themselves or as a bystander, there was no significant difference across the spectrum of workplace treatment (Supplemental Table 12).
Discussion
There is an emerging body of evidence demonstrating an increasing prevalence of uncivil and harassment behaviors in medicine.15, 16, 17 Our data indicate workplace mistreatment is experienced by 3-quarters of cardiologists in the United States, including two-thirds reporting discrimination and/or harassment. While there is some variation in the prevalence of mistreatments by age, gender, and race and ethnicity, it is also important to recognize that mistreatment is experienced by cardiologists from all demographic groups and those engaged in clinical and/or academic work. Our data document the significant negative impact of mistreatment on individuals’ career choices, work experiences, well-being, and engagement, resulting in diminished effort and loss of talent available to organizations and the cardiology profession.
To our knowledge, this is the largest, most detailed survey exploring workplace mistreatment specific to U.S. cardiologists. Prior surveys were either smaller, did not evaluate the experiences of underrepresented groups, including race and ethnicity, SOGI and disability, or limited mistreatment questions to yes or no responses.2, 3, 4 The latter is especially important: by cataloguing experiences in multiple, specific circumstances and assessing a range of potential impacts, we were able to elicit a much richer and more comprehensive picture of the lived experiences of cardiologists. As a result, our findings represent a sum of interactions as harassment or discrimination and provide tremendous nuances rather than a single categorization as yes or no response, which is a critical concern in dealing with behavioral data. Furthermore, the consistency of responses across multiple-related questions greatly strengthens the validity of our findings. Finally, the demographic profile of respondents closely matches that of those invited to participate in the survey and the ACC member database indicating that the results are reflective U.S. cardiologists.
Prevalence of mistreatment
The present study notes a higher prevalence of mistreatment, at 75%, than has been previously reported. The 2015 ACC Professional Life Survey noted that 40% of cardiologists experienced discrimination (and did not ask about harassment) while the 2020 ACC Global Workplace study reported a 44% prevalence of harassment and/or discrimination.2,4 There are several potential reasons for this, including the more robust methodologic approach noted above. In addition, our survey was deployed in 2022 after the pandemic, an event with a profound effect on medicine and interpersonal relationships. Finally, the present study uniquely included all types and degrees of disrespectful behavior, including incivility. Although incivility was common, only 8% experienced this milder degree of mistreatment in isolation; most also reported more severe mistreatment. This suggests that the negative workplace experienced by most cardiologists is not simply due to targets’ hypersensitivity or minor misunderstandings.
Variability in mistreatment
In the current study, 93% of women report experiencing some form of mistreatment compared with 70% of men. Although other previously published cardiology studies also report higher mistreatment in women,2,4 it is highly concerning that nearly every woman cardiologist experienced some form of mistreatment. These gender differences in mistreatment are not unique to the field of cardiology and highlight the need for change in the entire house of medicine.18 In a recent study, mid- to senior-career women scientists with NIH K awards described experiencing 4 principal gender-related barriers across their careers, including: 1) the mental burden of gendered expectations at work and home; 2) inequitable treatment of women in bureaucratic processes; 3) subtle and less subtle professional exclusion of women; and 4) value of communities built on shared identities, experiences, and solidarity.19
According to the 2018 National Academy of Science, Engineering, and Medicine Report, sexual harassment is pervasive in all fields, however the prevalence in medicine is almost double that in other science and engineering fields.10 It is ironic that much energy and resources are devoted to attracting women into science and medical fields to close the gender gap, yet once recruited, women still encounter work environments rife with discriminatory and harassing behaviors. These workplace mistreatments negatively impact the well-being of women and their work, leading to professional dissatisfaction, organizational withdrawal, reduced productivity, poor mental health, and burnout, which hinders further recruitment and retention of women into cardiology, and jeopardizes closing the gender gap.10,20
Racial and ethnic differences exist in mistreatment experiences. While Black cardiologists only represent 5% of the survey respondents, in keeping with their low proportion in the profession, the prevalence’s of discrimination and harassment are significantly higher than that of White cardiologists. Furthermore, these negative experiences are also higher among East Asian, South Asian, and Hispanic cardiologists compared with White cardiologists. Prior cardiology global data also show higher rates of discrimination experienced by Black and Asian cardiologists.4 Furthermore, examining results by both race and gender show that women of color are at particular high risk.
Sexual and gender minority (SGM) cardiologists represented a minority (2%) of survey respondents, fewer than reported in the general population. Compared to cisgender heterosexual peers, SGM physicians are more likely to experience burnout mediated by mistreatment, bullying, and discrimination.21,22 At this time, the paucity of SGM respondents may be attributed to underrepresentation among cardiologists, mistrust regarding how and where SOGI data might be shared, or both.
The correlation of career stage and reported mistreatment is intriguing. Cardiologists of later career stage report lower rates of mistreatment in our study, consistent with prior ACC data.4 This may in part be due to the demographics of late career cardiologists (mostly male gender and/or White race), or they may have developed increased tolerance and coping mechanisms over time. Furthermore, the higher rates of mistreatment among early- and mid-career cardiologists may reflect the increasing diversity of workforce with more representation of respondents from various demographics23 who historically are more likely to experience mistreatment. Also, early career physicians may be more likely to speak up about mistreatment, perhaps due to generational shifts toward increased transparency, advocacy for equity, and a culture fostering open communication and speaking up about injustices.
Approximately 1 in 3 cardiology trainees in the United States is an international medical graduate (IMG).24 Interestingly, in our study, the prevalence of discrimination, but not harassment, is higher among those emigrating to the United States around the time of residency or fellowship compared with those who were born or raised in the United States, while burnout rates were lower. Research on mistreatment experienced by non-U.S. physicians is limited and largely focused on postgraduate training experiences. For example, in a sub study of the general surgical residents’ survey, foreign IMGs were less likely to report bullying, sexual harassment, or burnout compared with U.S. medical graduates.25 IMGs face unique challenges even after residency and fellowship, such as biases and limited career options; however, most studies address issues of career challenges and attitudes, and not specifically on mistreatment. Other studies have also shown higher rates of burnout among U.S. medical graduates compared to IMG during residency, and certain factors, such as more control over life’s events, less perceived stress, and higher quality of life have been shown to correlate with less burnout.26
Personal and professional impact of workforce mistreatment
Our study documents several important effects of adverse workforce experiences, ranging from minor to severe. Half of cardiologists reported not disclosing personal information due to fear of negative consequences. In an era in which teamwork and personal authenticity are increasingly valued, this raises concerns about the ability to fully engage all cardiologists.27
The prevalence of burnout, anxiety, and depression each increased along the spectrum of mistreatment in cardiology. The only other data on mental health conditions within cardiology showed emotional harassment and discrimination to be independent predictors of mental health conditions among 5,931 cardiologists globally.5 Among clinician-researchers, sexual harassment, cyber incivility, and climate were all independently associated with poor mental health.28 Workplace mistreatment has also been shown to be problematic in surgical settings and associated with physician burnout and suicidal thoughts.29,30
Negative impact on the organization and field of medicine
More than half the cardiologists in our study reported mistreatment related to specific clinical or academic professional experiences. Allowing for obvious differences in the 2 domains, the concerns were remarkably similar and therefore reinforcing. It also provides important direction to leaders and others seeking to improve the cardiology climate, outlining the need for systems changes that ensure equity in advancement, opportunity and compensation, and which may be a more accessible and easily actionable leadership intervention than changing entrenched patterns of day-to-day interpersonal interactions.31
Research has shown that women and individuals from racial, ethnic, and SGM groups face barriers in obtaining faculty positions, securing research funding, research productivity, advancing in academic rank, and leadership roles.32, 33, 34, 35 Our data show that discrimination and harassment contribute to these disparities by creating an environment in which cardiologists themselves create barriers to advancement and limit their own access to new positions, networking and mentorship opportunities out of fear of mistreatment, thereby perpetuating a culture that favors certain groups. Akin to “quiet quitting,” this self-censure causes harm not only to the individual but also to the organization, which is unable to benefit from withheld talent. Approximately 11% reported thinking about leaving cardiology or medicine, a proportion likely underestimated as we were unable to survey those who had already left. It goes without saying that continued excellence requires the active contributions of our entire workforce, particularly now when we are facing cardiologist shortages.36
Among those experiencing mistreatment, organizational support is perceived as limited, with perceptions that their organizations’ policies, practices, and attitudes are not supportive of personal work-life balance efforts. And when programs exist, harassed cardiologists are more likely to perceive them as ineffective and failing to reduce uncivil behaviors, reduce racism and sexism, or address leave policies. These findings indicate gaps in communication regarding organizational efforts and their credibility, if not effectiveness, among those most in need of their support.
Future directions
Establishing a positive work environment, and comprehensively and effectively addressing mistreatment are critical. In modern health care, teamwork is integral to fostering a psychologically safe and supportive working environment, high-quality person-centered cultures of cardiovascular care.37 Leadership sets the tone for the entire cardiology team.38 This includes fostering a supportive climate through leadership, providing the necessary tools to tackle mistreatment, and enhancing individual resilience. Leadership development programs, including training on unconscious biases, implicit bias mitigation strategies, situational humility and sponsorship, and performance evaluations which include effectiveness in creating a positive culture may be beneficial. Organizations can enhance the culture of faculty mentorship by providing effective tools and resources and tracking improvement. As the field of cardiology becomes more diverse, it is essential that each generation of cardiologists gain cultural competencies not only for patient care but also for interpersonal communications with other faculty. In addition, organizations need to measure current workplace experiences, conduct regular educational sessions, and have clear, comprehensive policies that provide standards on behaviors and also specify expedient institutional corrective responses to uncivil or abusive behaviors.6 Several ACC documents provide guidance on organizational support of well-being, equity, and inclusivity, and also address mistreatment, promote bystander and upstander responses, and embrace flexible careers.6,39,40 These documents can provide individuals, organizations, practices, and leaders with the necessary tools to improve the climate in cardiology.
Study Limitations
There are inherent limitations to this survey study. Although the survey was sent to a wide range of U.S. cardiologists, and respondent demographics match those surveyed, there is the potential for response bias. Moreover the proportions of underrepresented gender identities, race and ethnicity of respondents are similar to prior published cross-sectional demographic data in cardiology.23 Even among respondents, some cardiologists may be reluctant to disclose their negative experiences. There is the potential of recall bias when completing the survey, as the questions asked the respondents to reflect on experiences from the prior 10 years. Rates of mistreatment were higher in this survey than prior surveys, although more varied and granular experiences of mistreatment were collected in the current survey. The number of respondents in some subgroups of interest was small, impacting statistical power to detect differences between groups. Therefore, any lack of statistical differences or presence of statistical differences among the small subgroups should be interpreted with caution.
Conclusions
Mistreatment manifested as incivility, discrimination, and harassment is highly prevalent in the field of cardiology, with no gender, race, ethnicity, sexual orientation, or career stage group being immune from mistreatment. Mistreatment has profound negative personal, career, workforce, and patient impacts. A culture of respect and civil behavior is essential for the overall health and future of the cardiovascular team and critical for advancing the mission of improving cardiovascular health outcomes. These data are highly concerning and support a call for action to change the climate and culture within cardiology to one of support, trust, teamwork, and collaboration.
Perspectives.
COMPETENCY IN SYSTEMS-BASED PRACTICE: Cardiologists in the United States experience mistreatment in both the clinical and academic settings. Little is known about the personal and career impact of these negative experiences upon the individual and profession.
TRANSLATIONAL OUTLOOK: Efforts are necessary to improve the culture and climate within cardiology to one that improves the well-being of the entire cardiology workforce.
Funding support and author disclosures
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
Acknowledgments
The authors thank the Association of Black Cardiologists for their contributions and support.
Footnotes
The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the Author Center.
Appendix
For supplemental tables and and the 2022 ACC Workforce Survey Questions, please see the online version of this paper.
Supplementary data
References
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