The 2016–2017 report of the Association of American Medical Colleges showed that only 21% of general cardiology trainees in Accreditation Council for Graduate Medical Education (ACGME) programs were women, with even lower numbers in interventional cardiology and electrophysiology.1 To understand 10-year trends, we examined representation of women among cardiology trainees during the most recent available period (2017–2018) and compared it with the past decade and with other internal medicine (IM) and non-IM specialties.
We extracted Association of American Medical Colleges data to examine representation of women and men among training programs for general cardiovascular disease medicine and the 4 adult cardiology subspecialties recognized by the American Board of Internal Medicine, as well as pediatric cardiology.1 The proportion of women trainees within each cardiology specialty/subspecialty during 2017 to 2018 was compared with the last decade (2007–2008)1 and with other main ACGME IM and non-IM subspecialties. Pearson χ2 tests were used to compare data, and values of P<0.05 were considered significant. This analysis was exempt from institutional review board approval because of the use of publicly available data.
From 2017 to 2018, among all adult cardiology trainees, 21.4% (n=710) were women and 78.6% (n=2,606) were men. Among trainees in adult cardiology subspecialties, interventional cardiology (10.2% women [n=31]) and electrophysiology (11.6% [n=22]) had the most skewed sex distribution compared with advanced heart failure/transplantation (31.2% [n=24]) and adult congenital heart disease (46.7% [n=7]). Over the past decade, the increase in proportion of women trainees in adult cardiology was modest (21.4% women [n=710] in 2017–2018 versus 15.9% [n=445] in 2007–2008) but statistically significant (P<0.01; Figure [A]).
Figure. Depiction of women trainees across the United States.
A, Percentage of women trainees in the Accreditation Council for Graduate Medical Education (ACGME)–accredited adult cardiology specialties and subspecialties (internal medicine shown for comparison) and pediatric cardiology (pediatrics shown for comparison) by decade. °Since the start in 2014. ×Since the start in 2012. B, Percentage of active trainees by sex with other internal medicine subspecialties for the year 2017 to 2018. C, Percentage of active trainees by sex with other ACGME-accredited specialties for the year 2017 to 2018. HF indicates heart failure.
In contrast, among pediatric cardiology trainees, approximately half were women, a substantial increase from the past decade (51.9% women [n=232] in 2017–2018 versus 39% [n=119] in 2007–2008). The increased percentage of women in pediatric cardiology training reflects the overall field of pediatrics (72.3% pediatrics versus 42.3% in IM).
Figure (B) displays the proportion of men and women trainees for each of the adult IM subspecialties. Cardiology, critical care medicine, and pulmonary disease were the 3 most male-dominated fields. Compared with trainees in non-IM specialties, all other specialties except orthopedic surgery (84.7% men [n=3242]) had higher proportions of women trainees compared with cardiology (Figure [C]). Obstetrics/gynecology had the highest number of women trainees (83% [n=4334]).
In summary, this review of ACGME-accredited training program data found that cardiology ranked second for the greatest underrepresentation of women, preceded only by orthopedic surgery. This prevalent disparity within cardiology, particularly for the procedural cardiovascular subspecialties, mirrors that of surgical specialties in many ways.2 Underrepresentation of women in surgery has been attributed to several factors such as implicit biases that lead to associations of men with surgery, microaggressions that affect the climate of women in surgical specialties, concerns about lifestyle/family factors, and lack of women role models in the field. In contrast, obstetrics/gynecology, another demanding surgical specialty, has more women than men choosing it compared with cardiology or other surgical specialties.
Because the 2 most commonly identified factors guiding trainees’ subspecialty selection are supportive role models and positive encouragement,3 efforts for change will effectively be initiated around these 2 factors. Establishing focused mentoring and volunteer programs for women medical students may serve to ignite interest in cardiology and to reduce misconceptions.4 Providing travel grants to attend cardiology conferences for networking opportunities and sponsoring visiting rotations would increase exposure of early trainees to the cardiology field and to women role models.4
The professional development of women cardiologists will need to be addressed at all stages. Fellow-ship program directors should work with ACGME to provide transparent family medical leave policies and flexible training pathways. Research funding agencies should advertise non–sex-biased funding opportunities and ensure sex equity in review committees.5 Scientific journals should ensure sex balance in editorial boards and unbiased review process for women authors.5 Scientific conferences should ensure sex representation among their invited speakers to improve visibility of women in cardiology. Professional societies should continue to publish data on sex disparities in funding, publications, leadership roles, and salary compensation and be advocates for favorable change.5 Fellows-in-training and early- and mid-career cardiologists can contribute toward sex equity by nurturing a supportive culture in their workplaces and diversifying their professional collaborations.5
There are a few limitations to this present study. We evaluated data from US-based training programs, which may not represent worldwide trends. Data were limited to materials published by the Association of American Medical Colleges and ACGME, so further exploration by variables such as age, year of residency, and US region could not be carried out. We did not have institution-level data; thus, a generalized liner mixed model could not be used.
In sum, a marked sex disparity still prevails for training within the cardiology field and its subspecialties, with little change over the past decade. This finding highlights the pressing importance of implementing appropriate measures toward sex equity and of conducting focused follow-up evaluations of their effectiveness.
Footnotes
Data sharing: The data, study materials, and analytical methods for this study are all publicly available on the ACGME website’s Data Resource Book page (https://www.acgme.org/About-Us/Publications-and-Resources/Graduate-Medical-Education-Data-ResourceBook).
This article is part of the Science Goes Red™ collection. Science Goes Red™ is an initiative of Go Red for Women®, the American Heart Association’s global movement to end heart disease and stroke in women.
Disclosures
None.
REFERENCES
- 1.Accreditation Council for Graduate Medical Education. Data resource book. 2018. https://www.acgme.org/About-Us/Publications-and-Resources/Graduate-Medical-Education-Data-Resource-Book. Accessed August 6, 2019. [Google Scholar]
- 2.Lewis SJ, Mehta LS, Douglas PS, Gulati M, Limacher MC, Poppas A, Walsh MN, Rzeszut AK, Duvernoy CS; American College of Cardiology Women in Cardiology Leadership Council. Changes in the professional lives of cardiologists over 2 decades. J Am Coll Cardiol. 2017;69:452–462. doi: 10.1016/j.jacc.2016.11.027 [DOI] [PubMed] [Google Scholar]
- 3.Burgess S, Shaw E, Ellenberger K, Thomas L, Grines C, Zaman S. Women in medicine: addressing the gender gap in interventional cardiology. J Am Coll Cardiol. 2018;72:2663–2667. doi: 10.1016/j.jacc.2018.08.2198 [DOI] [PubMed] [Google Scholar]
- 4.Shahid M. Addressing the underrepresentation of women in cardiology through tangible opportunities for mentorship and leadership. Methodist Debakey Cardiovasc J. 2019;15:e1–e2. doi: 10.14797/mdcj-15-1-e1 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Sharma G, Sarma AA, Walsh MN, Hayes SN, Sahni S, Brown SA, Singh T, Harrington RA, Douglas PS, Duvernoy CS; American College of Cardiology Women in Cardiology Leadership Council and Diversity and Inclusion Task Force. 10 Recommendations to enhance recruitment, retention, and career advancement of women cardiologists. J Am Coll Cardiol. 2019;74:1839–1842. doi: 10.1016/j.jacc.2019.08.016 [DOI] [PubMed] [Google Scholar]