How do we attract and retain women in cardiology?

Abstract

The recruitment and advancement of women in cardiology is an important priority for the cardiology community. Despite improvements in sex disparities over the last 2 decades, women remain a small minority in cardiology. Recent studies have revealed key obstacles facing female cardiologists including radiation exposure, family responsibilities, unequal financial compensations, and lack of career advancement. To attract and retain more women into the field of cardiology, the cardiology community, including professional society leaders, division chiefs, and program directors, must all work to overcome these barriers.

1. INTRODUCTION: THE LANDSCAPE

Unprecedented progress has been made toward reducing gender disparities in medicine over the last 2 decades, but the under‐representation of women remains a consistent concern. In 2003, for the first time in history, women made up half of US medical school applicants.1 Today, nearly 50% of all US medical school students2 and 40% to 42% of US internal medicine residents are women.3 Despite this trend, only 20% of cardiology fellows4 and 12% of board‐certified cardiologists are women.5, 6 The gender gap is even more stark in procedural specialties such as interventional cardiology (7.2% women) and electrophysiology (6% women).7 Furthermore, disparities in salary and career advancement remain challenges for women cardiologists throughout the course of their careers.

Gender diversity in the workplace naturally improves access to education, health, and economic resources to disadvantaged populations, an important benefit to communities and society.8 It has also been shown repeatedly to improve innovation, productivity, and even profitability.9 At a time when gender equality is increasingly threatened, it is crucially important that steady progress toward the advancement of women in cardiology remains a priority. Here, we review the barriers that women in cardiology face in the present‐day workforce, and propose strategies to mitigate these obstacles.

2. WHO ARE THE WOMEN IN CARDIOLOGY TODAY?

In 1996, the American College of Cardiology (ACC) conducted its first professional life survey (PLS) to define the ACC's member workforce and identify areas of concern to guide the development of the ACC's initiatives.10 The PLS has subsequently been conducted 2 additional times, in 2006 and 2015, providing insight into the changing landscape and needs of the cardiology workforce. The most recent 2015 PLS of 964 women and 1349 men, conducted by the ACC Women in Cardiology leadership section, reveals persistent gender disparities. From a practice perspective, women were more likely to work part time (10% women vs 4% men, P ≤ 0.01), spend more time conducting research or teaching (14% women vs 10% men, P ≤ 0.05), and work in a medical school or university practice (43% women vs 34% men, P ≤ 0.001). Women were more likely than men to practice general cardiology (48% women vs 39% men, P ≤ 0.001) or echocardiography (10% women vs 3% men, P ≤ 0.001) rather than invasive subspecialties such as interventional cardiology (3% women vs 23% men, P ≤ 0.001) or electrophysiology (6% women vs 10% men, P ≤ 0.01). The percentage of cardiologists practicing echocardiography is likely under‐represented, as many cardiologists who practice echocardiography identify as general cardiologists, but overall, these data highlight the trend that women are more likely to practice noninvasive specialties. Despite the differences in practice patterns, both men and women were equally satisfied with their careers. From a personal perspective, women were less likely to be married (75% women vs 89% men, P ≤ 0.001), less likely to have children (72% vs 87%, P ≤ 0.001), and more likely to be older at the time of their first child. Overall, these trends highlight the continued challenge that women face while negotiating the demands of work and personal life.

3. BARRIERS FACING WOMEN IN CARDIOLOGY

For the first time, in 1996, the initial iteration of the PLS offered a glimpse into the motivations and personal lives of the ACC member workforce.5 Amongst the opportunities identified for improvement was the critical need to address gender disparities. The survey identified 5 key barriers: (1) occupational radiation exposure, (2) discrimination, (3) family concerns, (4) lack of advancement, and (5) disparity in compensation. We will review each perceived barrier and propose possible solutions and recommendations.

3.1. Occupational radiation exposure

Although radiation exposure is a concern among both men and women in cardiology, minimizing radiation exposure during pregnancy is a distinct challenge facing women. In a survey of 501 female physician members of the ACC evaluating the interplay between a career as a cardiologist and pregnancy, women were more likely to modify their training or career paths to avoid radiation exposure, an observation that has not changed over the last 20 years.6 Radiation concerns also impacted family planning, with 50% of women age 50 years or younger more likely to avoid pregnancy during periods of radiation exposure. Despite these observations, 57% of women still reported radiation exposure during pregnancy. In fact, compared to 10 and 20 years ago, fewer women are planning their pregnancies around radiation exposure (21% in 1996 vs 18% in 2006 vs 16% in 2015, P ≤ 0.05 for 1996 vs 2015). Furthermore, few women were aware of departmental radiation policies and safety precautions. Only 24% of surveyed women who experienced radiation exposure during pregnancy used additional lead, 42% increased their distance from radiation sources, and 20% used fetal radiation badges. Although there are no established national standards for minimizing radiation exposure in physician trainees, these rates fall far below that of radiation oncology residents; in a recent study, 89% of radiation oncology residents who became pregnant used fetal radiation badges.11 The reasons for this disparity are incompletely understood. Improving awareness of radiation reduction strategies remains a priority. Equally important is the need to promote a culture that empowers women to take necessary steps to reducing radiation exposure without fear of reproach.

3.2. Recommendations

• All cardiologists should receive education regarding pregnancy radiation upon entering fellowship, at time of employment, and each time they undergo fluoroscopy credentialing.

• All cardiologists who do not feel comfortable with radiation exposure during pregnancy should be afforded the opportunity to alter their practice activities during pregnancy without risk of retaliation. Increased research is needed to determine the safety of radiation exposure during pregnancy.

• Faculty and hospital leadership including division chiefs, catheterization lab directors, and fellowship directors should develop and implement initiatives for minimizing radiation exposure for pregnant women. Leadership should work to create an ethos where pregnant women feel supported in their efforts to minimize radiation exposure.

3.3. Discrimination

Sex discrimination remains disappointingly high for female cardiologists. In the 2015 PLS, 65% of women reported some degree of discrimination in the workplace as compared to 23% of men.10 The type of discrimination also varied by sex. Women were more likely to experience discrimination about sex and parenting, whereas men more commonly experienced racial and religious discrimination. Female cardiologists experience sex discrimination at every level, from patients to allied health professionals and other physicians. Female cardiologists are frequently mistaken for medical assistants or nurses by their patients, an observation that is pervasive throughout all fields of medicine.12 Colleagues too are guilty of unconscious sex bias. In a recent observational study of video‐archived speaker introductions at internal medicine grand rounds, women were less likely to be introduced by professional title than their male counterparts if the introductory speaker was a man (49.2% for women vs 72.4% for men). When the introducer was a female, both men and women were similarly introduced by professional title (97.8% female vs 95.0% male).13

In spite of these observations, rates of discrimination have declined for female cardiologists over the last 20 years (71% in 1996 vs 65% in 2015, P ≤ 0.05). In contrast, rates of reported discrimination have remained stable for men.10 Factors contributing to this decline are not well understood, but increased public awareness has been postulated. The authors of the 2015 PLS analysis have emphasized the importance of harnessing the visibility of medical societies to help lead initiatives to promote the culture change necessary to eliminate discrimination. They cite the Royal Australasian College of Surgeons and their initiative to promote extensive research and create an action plan to reduce discrimination, bullying, and sexual harassment.

3.3.1. Recommendations

• Professional societies should create initiatives that focus on identifying the sources of discrimination that face their female members and to create action plans aimed at reducing disparities including sex disparities.

• Existing leadership—both men and women—should make workplace diversity an important priority and encourage female cardiologists to assume positions of leadership in their local practices/hospitals and in professional societies.

• There should be a collective effort by all women in cardiology—physicians, scientists, and allied health professionals—to raise awareness and find solutions to challenges that face women in cardiology.

3.4. Sexual harassment and misconduct

There has been an important movement to expose and end sexual misconduct in the workplace. Although the entertainment and political industries have been the center of most media attention, sexual harassment is rampant in medicine and cardiology. Over 30% of female recipients of National Institutes of Health (NIH) K08 and K23 career development grants reported sexual harassment.14 Of those women, coercive advances (14%), unwanted sexual advances (41%), and sexist remarks or behavior (92%) were cited as examples of sexual misconduct. This is not a new phenomenon. In 2000, a survey of over 3000 academic medical faculty found that 52% of respondents reported sexual harassment.15 Despite these staggering statistics, victims of sexual misconduct have not been empowered to report harassment to their superiors for fear of retaliation, marginalization, and stigmatization.16 In fact, some women find that the culture of “the old boys' club” patriarchy that is pervasive in medicine and cardiology often sides with the perpetrator, further alienating victims of sexual harassment. It is therefore the obligation of our institutions and leadership to establish a culture where sexual misconduct is openly discussed and condemned.

3.4.1. Recommendations

• Institutions and professional societies must enforce a strict no‐tolerance policy for workplace sexual misconduct and harassment.

• Institutional leadership including department/division chairs and chiefs, hospital leadership, and fellowship program directors must create a top‐down culture to reduce locker‐room talk and promote a safe environment where victims of sexual misconduct feel empowered to report harassment.

• Increase research on nature of sexual harassment as well as evidence‐based prevention and intervention strategies to eliminate sexual harassment and misconduct.

3.5. Family concerns

Work–life balance has frequently been cited as a barrier toward women's professional advancement across all fields of work. Recently, there has been a movement toward reframing the issue as work‐life integration. Work‐life balance evokes opposition between work and life, whereas the goal is ultimately to create synergy between work, home, community, and the private self.17 Although restrictions on work‐life integration previously rendered the field of cardiology hostile to women, there has been improved flexibility and availability of lifestyle choices for both men and women. As such, we have seen an increase in the number of female cardiologists with children. In 2015, 72% of surveyed women cardiologists reported having children in 2015, compared to 63% in 1996.10 Despite this trend, the lack of consistent maternity leave policies remains a significant disincentive for young women considering a career in cardiology.6 Furthermore, household responsibilities, including childcare and domestic labor, disproportionately fall on women. Fifty‐seven percent of male cardiologists reported having a spouse who was a full‐time caregiver, whereas only 13% of women had a spouse who was a full‐time caregiver. Women with children were more likely to employ part‐time care, full‐time care, or a daycare center for childcare. In another recent study of NIH K08 and K23 grant awardees, the authors found that women grant awardees spent an average of 8.5 more hours per week on domestic work than men.18 Not surprisingly, women were more likely to report that family responsibilities had a negative effect on their professional advancement (37% women vs 20% men, P ≤ 0.001).10 Women were more likely to report that household responsibilities interfered with their ability to do work and prevented travel for professional opportunities. Interestingly, from 1996 to 2015, there was an increase in the number of men who identified family responsibilities as a barrier to work travel, committee work, or professional advancement (41% vs 29%, P ≤ 0.001).

How to address work‐life integration is extraordinarily challenging, as there are numerous cultural, systemic, and personal factors at play. The Stanford Department of Emergency Medicine has recently been showcased for their pilot time bank program. The program was a 2‐year pilot program funded by the Sloan Foundation, which gave credit to faculty for perks including laundry service, prepared meals, and grant‐writing help in exchange for work that is not traditionally compensated such as mentoring students and committee work.19 At Massachusetts General Hospital, the Women in Medicine Trainee Council introduced a travel grant that helps women with children travel to professional conferences by providing a stipend to cover the cost of childcare. Programs like the Stanford Time Bank pilot and the MGH Travel Grant may offer creative solutions to mitigate the burden of household work that increasingly encumber female cardiologists.

3.5.1. Recommendations

• Institutions should create consistent maternity leave policies. These policies should provide coverage during maternity leave that minimizes burden on colleagues, potentially employing the services of allied health professionals including nurse practitioners and physician assistants.

• Institutions should implement programs that provide nontraditional benefits such as household services, grant writing services, or childcare in exchange for professional work that are often important for career advancement but not financially compensated.

3.6. Lack of advancement

Even with a growing number of female cardiologists in the last 20 years, major sex differences in professional advancement persist. A study of 3810 cardiologists with faculty appointments in 2014 found that women were much less likely to be full professors than men (hazard ratio: 0.63, 95% confidence interval: 0.43‐0.94, P = 0.02), consistent with earlier findings across all specialties.20, 21 The study was a retrospective cross‐sectional study, so causation cannot be established. However, the authors identified independent predictors of cardiologists' academic rank including physician age and experience, total publications, NIH grant status, participation in clinical trials, and subspecialization in invasive subspecialties.

These predictors can only be hypothesis generating, but they highlight potential targets for intervention. For example, the strong association between physician age and experience with faculty rank suggests that increasing the pipeline of women entering cardiology may be able to help mitigate the sex differences in faculty rank. In the analysis by Blumenthal et al., female cardiologists were younger and had fewer years of experience. However, the association between total publications and NIH grant status to academic rank speaks to the importance of research productivity in achieving full professorship; interestingly, the number of first and last author articles was not associated with academic rank. Women consistently publish less and receive fewer NIH grants than men. The reasons are incompletely understood, but research suggests that lack of access to resources including mentorship, time, funding, and research networks may contribute to this disparity. Importantly, the early‐career time often coincides with a woman's childbearing years. Interrupted productivity during pregnancy and childbearing has been proposed as an important contributor to delayed promotion, although data have not been consistent.6 Finally, the observation that invasive subspecialty is associated with academic rank is an interesting one. The authors postulate that invasive specialists are potentially more desirable and are more likely to participate in a clinical trial, which was also independently associated with faculty rank. It is well known that the number of women in invasive subspecialties is exceedingly low. Radiation exposure, lack of opportunity, and preference were the most commonly cited reasons in a survey study of 1084 woman worldwide.22 Addressing radiation safety and increasing exposure to invasive subspecialties for women may help to reduce this disparity.

3.6.1. Recommendations

• Work to increase the pipeline of women entering cardiology. Increase efforts to target women interested in medicine during high school, college, and medical school.

• Early career is a vulnerable time for female cardiologists because of the conflicting demands of childbearing and family responsibilities. Flexible‐hour positions including part‐time positions, job sharing, or working from home can provide support to female cardiologists during this period of their careers.

• There continues to be a dearth of mentors for rising female cardiologists. Although it is important to increase the number of female mentors, male mentors must also be attuned to the needs of women for career growth as well.

• Increasing the number of women in invasive subspecialties must be a priority for cardiology fellowships and for professional societies.

• Engage and educate those in leadership positions including chiefs of cardiology, and medicine, residency, and fellowship program directors about gender disparities in career advancement. Encourage implementation of existing and future policies aimed at reducing these disparities.

3.7. Disparity in compensation

A major source of career dissatisfaction among women is financial compensation. In an analysis comparing work activities and salaries of 2679 cardiologists nationwide, Jagsi et al found that men and women had very different job activities, which contributed to differences in compensation.23 As discussed previously, women were much more likely to work in general or noninvasive cardiology (53.1% women vs 28.2% men) rather than in the more lucrative interventional subspecialties (11.4% women vs 39.3% men). Women are more likely to work in an academic practice rather than a private practice where compensation is generally higher. However, even after adjusting for these variables, a significant sex‐based disparity in salary of $33 749 for academic cardiologists and $37 717 for private cardiologists persisted.

The factors that underpin the salary gap are multifactorial and complex, but among the numerous factors, negotiation has frequently been cited as an important Achilles heel for women. A telephone survey study of 20 medical faculty identified that men were more likely to view negotiation as an important skill for their professional advancement.24 Research has also identified that overall women value harmony over confrontation. As a result, women are generally more cautious in negotiation, negotiate less when the outcome is win–lose, and falsely presume that salary is not negotiable.25 Jagsi et al. also identified that women are often pursuing nontraditional positions such as part‐time jobs or jobs with fewer on‐call responsibilities, which can make negotiation more challenging.23 Nevertheless, the persistence of salary gap after removing influences from clinical volume, on‐call responsibilities, and other work activities highlights the need for improvement to address this disparity.

3.7.1. Recommendations

• Negotiation workshops should be offered to female cardiology trainees and faculty as they prepare for job interviews.

• Institutions should perform analyses of faculty salaries to uncover any unconscious bias in salary negotiation.

• Compensation for nontraditional positions should be dictated by the same standards applied to traditional positions.

4. CONCLUSION

In 1992 and 1994, the American Heart Association and ACC established the first Women in Cardiology committees respectively, illustrating the cardiology community's commitment toward the professional development of women in cardiology. Since then, there has been steady growth of women pursuing clinical and research careers in cardiology. Although career satisfaction is high among female cardiologists, women remain a small minority of cardiologists nationwide. Factors such as radiation exposure, family responsibilities, and lack of advancement are key barriers that continue to plague women in cardiology today. Now, 15 years later, it is time for the cardiology community to address these barriers, assess the changing landscape of cardiology, and recommit to the advancement of women in cardiology.

Lau ES, Wood MJ. How do we attract and retain women in cardiology? Clin Cardiol. 2018;41:265–269. 10.1002/clc.22921