Gender Disparities in Cardiology

Abstract

Gender disparities within the field of cardiology are often described in the literature. However, it is not always clear how they came about, why they persist, or practically, what to do about them. Furthermore, the individuals usually tasked to address these disparities within an organization are usually the same individuals who are disproportionately affected by these disparities—women. In this review, the authors discuss the complex historical and systemic roots for the observed gender disparities within cardiology. They also highlight how men can not only be educated regarding experiences they may not face but also work toward fostering an improved working environment and eliminating of these gender disparities.

Central Illustration

Highlights

• •Women cardiologists face persistent and pervasive disparities, creating barriers to career success and satisfaction.
• •Women’s unique roles in childbearing and caregiving, sexism, discrimination, and compensation inequities require urgent attention.
• •Overcoming structural and cultural barriers will improve women’s opportunities, morale, and financial and scholarly productivity.
• •Actionable, evidence-based cultural and structural interventions are recommended to eliminate gender disparities in cardiology.

Despite comprising 50.8% of the U.S. population,¹ women remain underrepresented in the field of cardiology,2, 3, 4 comprising only 15.5% of practicing cardiologists (Figure 1). Statistics are even more dire for women practicing procedural cardiology subspecialties, such as interventional cardiology (IC) (8.2%) and electrophysiology (10.1%) (Figure 2).^9,10 Due in part to both underlying bias and structural issues, becoming a cardiologist as a woman often involves unique hurdles. Figure 3 summarizes the important historical developments of women in medicine and cardiology. A groundswell of recent publications has also highlighted significant underrepresentation of women in leadership roles, and as both participants and principal investigators in cardiovascular clinical trials.13, 14, 15 This suggests further steps are necessary to address gender inequality and increase the retention of women in cardiology (WIC).

Figure 1.

The Trends From Different Stages of Medical Education and Cardiology Practice Above

With increasing levels of training, the proportion of women declines.^5,6

Figure 2.

The Percentage of Women in Subspecialties of Cardiology Depicted Above

(A and B) The data for successive years (2021 and 2022). The percentage of women in procedural cardiology subspecialties increased, while decreasing in advanced heart failure and transplant. Values were rounded to the nearest whole number (except when the sum would not add up to 100%).^7,8

Figure 3.

A Timeline of Events Pertaining to Women’s Presence in Medicine as Well as Research, Policies, and Legislation Addressing Gender Disparities

ACC = American College of Cardiology; AHA = American Heart Association; WIC = women in cardiology.^11,12

Problems and systemic solutions

Gender inequities should be reframed not as a “women’s issue,” but a “leadership issue.” In 1996, American College of Cardiology (ACC) leadership commissioned its first Professional Life Survey (PLS) to characterize the changing cardiology workforce. Notable findings included gender-specific professional concerns, including radiation exposure, family responsibilities, unequal compensation, and lack of career advancement opportunities.¹⁶ Many of the gender disparities persisted in the third iteration of the PLS in 2017.¹⁷ Below, we discuss each of these problems and propose potential systemic solutions that organizations and departments can work towards implementing, followed by actions to which each person can commit (Central Illustration).

Central Illustration.

Gender Disparities in Cardiology: Learning From History to Envision the Future

Abbreviation as in Figure 3.

Work-life integration

A 2010 survey of 1123 internal medicine residents found that negative work-life balance and work culture were strongly associated with the decision not to pursue a career in cardiology.¹⁸ A follow-up survey in 2020 showed that these negative perceptions persist, and in some respects, have worsened. The authors emphasized the importance of improving the culture of cardiology.¹⁹ Length of training has also been described as a barrier to field entry in IC, electrophysiology, and other cardiac subspecialties. Pilot programs are currently trialing various methods of streamlining cardiology training,^20,21 similar to how interventional radiology and vascular surgery programs have addressed this issue.²²

From 1996 to 2015, WIC with children increased (63% to 72%).¹⁷ Most pregnancies among women cardiologists occurred during fellowship (49%) or early career (63%), with 19% using assistive reproductive therapies, and 40% experiencing pregnancy-related complications. WICs were also found to have significantly lower rates of breastfeeding beyond 6 months (46%)⁵ compared to house staff from obstetrics and gynecology (59%).²³ Obstacles to breastfeeding included stigma, lack of support, lack of schedule flexibility, and concern for placing an increased work burden on their coworkers.²⁴ Increased maternal leave, collegial support, and availability of time/space at work to express milk/breastfeed significantly increased duration of exclusive breastfeeding.²⁵ In 2022, the Accreditation Council for Graduate Medical Education (ACGME) instituted an institutional leave policy requiring programs to offer at least 6 weeks of paid medical, parental, and caregiver leave. The potential effects of this change are yet to be determined.²⁶

Pregnant adult and pediatric cardiologists are often subject to an increased burden of work (eg, taking extra call (EC) prior to maternal leave).^27,28 This is associated with a higher risk of an extended period of prenatal bedrest (17.5% EC vs 7.4% no EC, P = 0.005).²⁸ Fellows and practicing cardiologists often feel pressure to take shorter maternity leaves, taking 4 weeks less than allotted.⁵ Once on maternity leave, the shadow of work responsibilities can loom large. Up to 60% of women check email while on maternity leave.²⁸ As household responsibilities fall disproportionately on women, they are more likely than men to report a negative effect of family responsibilities on their professional advancement (37% women vs 20% men, P ≤ 0.001).^27,29 These observations demonstrate that from childbearing throughout every stage of childrearing, current policies are inadequate to serve women in the cardiology workforce.

Leadership must prioritize changing the structure of clinical practice to allow for greater work-life integration. Some organizations have offered grants for childcare expenses during professional conferences or provided clinical coverage during maternity leave (via part-time physicians or advanced practice providers) to minimize the burden placed on colleagues.²⁸ Administrative, clinical (medical scribes), and research assistants in addition to physician coaching, have all been offered as potential solutions to alleviate the stress.^27,28 One study examined interventions including career-life planning, time-banking, support for household tasks (eg, laundry service, prepared meals), and time-consuming work tasks (grant-writing) in exchange for work that is not traditionally compensated (eg, mentoring students and committee work). In the short term, these interventions significantly increased perceptions of a work culture of wellness, understanding of professional development opportunities, and institutional satisfaction. Additionally, participants enjoyed an increase in research productivity and a funding difference of approximately $1.1 million per person compared to matched controls.³⁰

Systemic solutions

• •Educate and engage leadership to resolve challenges women face in the cardiovascular workplace.^3,5,28,31, 32, 33
• •Develop transparent and consistent policies for parental leave for both birth parent and partner.
• •Foster a culture normalizing paternal leave and address the stigma and penalties related to pregnancy and maternity leave.
• •Offer designated pumping breaks and clean, private lactation spaces for breastfeeding women.
• •Discourage and/or formally prohibit contacting WIC by email for work-related issues during parental leave, vacation, or leave due to disability. Refer to the 2022 ACC Health Policy Statement on Career Flexibility in Cardiology to guide incorporating flexibility over the career arc of cardiologists.
• •Improve coverage of the direct and indirect costs of childcare.
• •Provide nonfinancial compensation for noncompensated professional work, as a tool to prevent and reduce burnout while maximizing productivity.

Lack of mentorship and limited opportunities for advancement

Lack of identifiable mentorship, the paucity of women, and the culture of cardiology have been common themes of concern cited among aspiring women cardiologists. Similar concerns have been raised among practicing adult women cardiologists (PLS) and in a recent survey of 59 pediatric cardiologists, ranging from early to late career (mean years since training 12.3 ± 10.3), in which over half of the 59 respondents cited lack of mentorship as a career barrier.^17,27 While the number of IC positions increased from 169 in 2006 to 374 in 2023, the proportion of women in IC was stagnant between 4 and 10% from 2009 to 2014. Fortunately, numbers are improving, with women representing 20.1% of all IC fellows in 2022.34, 35, 36 Of all the IC program directors in the country in 2025, only 4% were women (down from 5% in 2016).^34,37 In fields with low workforce diversity, appointment bias of faculty can reinforce low applicant diversity.³⁸

Although the proportion of women cardiovascular specialists has increased in recent years, the proportion of women cardiovascular clinical trialists has not.¹⁵ Only one in 10 lead authors of cardiovascular trials published in high-impact journals are women.¹⁵ Systemic sexism, lack of access to mentorship and research networks, and limited time and funding are all possible contributors.^17,27,29 Women senior authors are notably more likely to lead diverse research teams. Blumer et al found a higher proportion of female coauthors with female vs male-led teams (29.8%, 18.68% [P < 0.001]).³⁹ Research equity also requires equitable subject recruitment. A recent review recommended designing clinical trials with representative enrollment of women (including those of childbearing potential) and the funding of trials focused on female-predominant and specific cardiovascular diseases.⁴⁰ Women cardiologists represent 100% of the Directors of Women’s Heart Health programs in the United States³⁷ and have a greater opportunity to be in a position to enact change. Furthermore, gender concordance has been associated with improved rates of guideline-directed medical therapy and risk factor control.⁴⁰ Encouraging female-led teams is therefore crucial in propagating more female authors and achieving greater research equity to guide clinical care of cardiovascular disease in women. Another proposed solution includes organizational-driven opportunities for mentorship and sponsorship, both within and from outside the organization.²⁷

One solution for the mentorship gap is to encourage and equip men to mentor WIC. Men may not mentor women due to feeling they cannot provide effective mentorship or citing fears of false accusations of harassment, potentially limiting women’s access to individuals who may most effectively advance their careers.^41,42 Behavioral health research shows organizations with established cross-gender mentoring perform better; men who either mentor women or are mentored by women benefit from increased access to information across the organization and improved interpersonal skills (eg, emotional intelligence and empathy).⁴¹

Systemic solutions

• •Increase the representation of women cardiologists in leadership roles to aid recruitment, retention, and mentorship of a diverse early career cardiology workforce.^29,34,43
• •Mentor women both before and during medical school by exposing them to cardiovascular clinical practice and research and activities in professional societies.
• •Encourage students and residents to join cardiovascular professional societies (eg, ACC, Heart Rhythm Society, and Society of Coronary Angiography and Intervention) to utilize the exponential power of networking within (sub)specialty organizations and identify role models and potential mentors, potentially outside of their home institution.
• •Invite residents, fellows, and early career faculty to join groups such as WIC of ACC or American Heart Association and similar groups in subspecialties (eg, the Women in Innovations Committee of Society of Coronary Angiography and Intervention, the Growth and Leadership Opportunity for Women in Electrophysiology program of Heart Rhythm Society, and similar groups in industry like Women in electrophysiology by Abbott).⁴⁴
• •Provide formal mentoring for women cardiology fellows, focusing on each fellow building a network of mentors that includes at least one woman, where possible.
• •Within fellowship programs, set goals for gender diversity, study local trends, and track whether the stated program goals are routinely met.
• •Sponsor women fellows and faculty for stretch opportunities commensurate with experience and interest. Department chairs and program directors can facilitate this.

Discrimination, sexism, and culture

Women generally perceive the climate of academic medicine more negatively than men in terms of diversity, sexism, and racism.⁴⁵ This in turn is likely to lower their sense of belonging and increase the likelihood of leaving their institution or even, the profession. A survey in 2023 found that 61% of women reported at least a slight likelihood of leaving their respective health care institutions within 2 years.⁴⁶ Therefore, cultivating an inclusive culture is not only of utmost importance from an equality standpoint but also from an economic standpoint.

Guideline and guideline-like documents (eg, decision pathways, health policy statements, appropriate use criteria) from national organizations play a critical role in guiding physicians, organizations, insurers, and governmental agencies regarding clinical care as well as health policy issues, including assessment of quality of care, medical liability, payment, etc.^3,4,47,48 ACC has emphasized the importance of creating actionable knowledge or “solution sets,” to readily address complex health care challenges.^3,4,48 The 2020 American Heart Association/ACC Consensus Conference on Professionalism and Ethics sought to update recommendations on issues including effects of diversity, equity, inclusion, and belonging for cardiovascular clinicians and scientists.⁴⁹ Foundational to these efforts is the need to achieve diversity within the cardiovascular workforce and its leadership to better reflect and represent the patients and populations served. There was an intentional effort to increase representation in the writing group, and in 2020, 41.2% of the 61 participants were women compared with 11.2% female representation in the prior 2 conferences.

The 2022 ACC Health Policy Statement on Building Respect, Civility, and Inclusion in the Cardiovascular Workplace built on this foundation by describing organizational structures and policies and individual skills necessary for minimizing bias, discrimination, bullying, and harassment. These include moving from a bystander (someone who passively observes detrimental behavior without taking action) to an upstander who intervenes; developing awareness of implicit bias; becoming an ally to marginalized groups, etc. These behaviors can be incentivized through performance reviews.⁴

Women are more likely to have experienced workplace gender-based discrimination or microaggressions (65% women vs 23% men) from patients, allied health professionals, and colleagues.¹⁷ Patients are more likely to assume women physicians are allied health professionals with less training (nurse or medical assistant), even after introducing themselves as the patient’s physician.^50,51 Men are less likely to introduce women speakers at grand rounds with formal titles (49.2%) than they do men (72.4%).⁵²

Sexist behavior/misconduct is a problem in academic medicine and cardiology is no exception. Cardiology-specific data from the American Academy of Medical Colleges in 2022 revealed that over the prior 12 months, 40% of women and 15% of men experienced sexual harassment, which was higher than the average across all medical specialties (34% of women and 22% of men).⁵³ Prior survey data from 2018 revealed that in over 50% of reported instances, there was either no action taken or it was trivialized.⁵⁴ Strong institutional hierarchies were associated with sexual harassment,⁵⁵ highlighting the importance of organizational culture. The downstream effect of a failure to address these issues in cardiology may impact a trainee’s choice of (sub)specialty.^15,35 A 2019 survey of 5,931 cardiologists worldwide (23% women) revealed that 44% experienced a hostile work environment (particularly early-career individuals), with gender cited as the most frequent target of discrimination.¹⁴ The risk of workplace retaliation may hinder some women from self-advocacy, underscoring the importance of men at all stages in their careers advocating for their women colleagues, aptly coined as #HeforShe.⁵⁶

Systemic solutions

• •Educate and train faculty, staff, and members of boards and committees about harassment, sexism, and gender discrimination.^29,41,57
• •Commit to the longitudinal evaluation of quality and diversity metrics. Examine the composition of organizational leadership and commit to hard targets for improving representation and sponsorship of women cardiologists.
• •Provide mechanisms for transparent reporting of harassment, reducing stigma, and prohibiting retaliation.
• •Empower all colleagues to collegially identify when a microaggression occurs and address the behavior in the appropriate setting. Department chairs and program directors can help establish this cultural norm.
• •Address overt sexism or discrimination—particularly in a public setting—in real time, as incongruent with the culture of your organization. Silence implies complicity. Speaking out affirms the desired culture and empowers the target of the inappropriate behavior.
• •Conduct and promote research evaluating bias, discrimination, and sexism in the workplace.
• •Periodically reassess the prevalence of workplace discrimination to help guide local interventions.
• •Establish departmental support for zero tolerance of sexual misconduct throughout the organization.

Unequal financial compensation

Douglas et al estimated that after adjusting for known differences in compensation such as practice setting (academic vs private), subspecialty (noninvasive vs interventional fields), and up to 100 total variables, men in cardiology are still paid more than their women colleagues (by $33,749 annually in academic settings and $37,717 in private settings).^29,48 Compounding this, 41.2% of WIC experienced a salary decrease while pregnant and postpartum,²⁸ amounting to a $2.5 million difference in earnings over the course of a 35-year career.⁵⁸ These compensation inequities stem from a lack of transparency in the hiring/compensation process, lack of routine compensation audits, gender biases, and the previously discussed burdens that women disproportionately bear (eg, “the motherhood penalty,” part-time work, family responsibilities).^27,59 Cited reasons for these gaps include a belief that women are less skilled at and less likely to negotiate or are aware of stiff penalties for violating gender norms.^60,61 Additionally, some find salary negotiation more challenging if they already hold or are also negotiating for part-time positions or jobs with fewer on-call duties.^29,62

In 2019, the ACC Health Policy Statement on Cardiologist Compensation and Opportunity Equity supported a (prospectively developed) modeled, systems approach based on consensus principles. Payment models should also explicitly reward nonbillable, but valuable work (eg, quality improvement, leadership, service, mentoring) and minimize unwarranted systemic differences based solely on subspecialty. ACC suggests that organizations examine their definition of productivity, examine fit with stated values, and review compensation plans, including strategies and formulas offering flexibility, to accommodate different job descriptions.^27,48

Systemic solutions

• •Regularly audit total compensation and address gender-based inequities. Commit to achieving both equity and transparency.^28,29,59,62
• •Refer to the ACC Health Policy Statement on updating payment models to achieve gender equity.
• •Offer support for negotiation training for women cardiologists. Engage women trainees early on this topic to normalize and adequately prepare them for future negotiations.

Radiation exposure

Women cardiologists are more likely to alter their career paths and structure family planning to avoid radiation exposure, with almost half of women cardiologists avoiding pregnancy during periods of exposure.^5,63 Fortunately, exposure to ionizing radiation during fluoroscopy has decreased by approximately 95% over the past decade.⁶⁴ Additionally, evidence suggests that cardiology fellows may not fully utilize available resources for protection against radiation.²⁹ While 57% of cardiology fellows surveyed experienced radiation exposure while pregnant, only 20 to 40% employed radiation reduction strategies (eg, increasing lead protection [24%], increasing distance from radiation [42%], or wearing a fetal radiation exposure badge [20%]), compared to interventional radiology residents, of whom 89% wore radiation exposure badges.^29,65

Systemic solutions

• •Leadership should ensure that all members of the department—including fellows, attendings, radiation officers, cath lab and electrophysiology nurses of all genders—are familiar with and regularly review the institutional radiation protection protocol. Reform the existing institutional culture to support pregnant people (and other employees) who desire to take additional steps to protect themselves from radiation.^5,66
• •Promote anonymous reporting to facilitate identification of programs struggling with implementation of the institutional radiation protocol.

Actionable individual solutions for men in cardiology

While systemic change is most sustainable, implementing changes at a grassroots level may quicken the groundswell of positive change. How can men act in supporting women and address historically driven, gender-based biases and inequities in the field of cardiology? We propose that all men cardiologists commit to the following actionable items:

• 1.Acknowledge that gender disparities exist. Recognize the role of gender and consider how it may or may not impact opportunities for WIC.
• 2.Educate yourself on gender differences and biases in medicine and cardiology. Ask questions and listen to women with empathy and without judgment, particularly regarding experiences you may not share. Believe them.
• 3.Intentionally seek either to directly sponsor a woman cardiologist/trainee or connect her with other sponsors.
• 4.
  If you are not mentoring women now, commit to doing so. Consider the setting and timing of mentor and sponsor meetings and ensure you are consistent with how and where you mentor both men and women trainees/colleagues.

  • a.
    Open doors/public settings for breakfast/lunch may be preferred to a closed office or dinner as a matter of individual judgment.
• 5.
  Provide specific, actional feedback on performance; encourage and provide opportunities.

  • a.
    You’re really quick at learning hemodynamics. Have you considered cardiology? Would you like to scrub into a cath lab case?”
  • b.
    You’ve been very effective leading fellows. Have you thought about joining or leading a committee/becoming program director?”

Conclusions

Gender disparities in cardiology are historically rooted. Only in the last 30 years have professional societies and organizations within cardiology seriously focused on eliminating them. While some progress has been made, disparities persist. Every #HeforShe act of sponsorship and allyship is (potentially) historic—another step toward building an equitable cardiology workforce. In order to achieve sustainable progress, systemic change must occur, and leadership must embrace the challenge of eliminating gender inequities. Additionally, men in cardiology must commit to taking (at least) one action. Together, we can work to eliminate gender disparities and continue to strive to provide the best care for our patients.

Funding support and author disclosures

The authors have reported that they have no relationships relevant to the contents of this paper to disclose.