If You Can’t See It, You Can’t Be It

The under-representation of women in cardiology is widely recognized. In 2017, women represented 42% of internal medicine residents and only 23% of cardiology fellows (1). These disproportionate numbers have been attributed to workplace barriers faced by women, including gender and parenting discrimination, challenges in balancing family responsibilities, radiation exposure during pregnancy, and lack of professional advancement (2). As of a 2018 survey of internal medicine residents, female residents were more likely to have a negative perception of cardiology due to concerns about adverse job conditions, interference with work–life balance, and lack of diversity within the specialty (3).

However, this survey also revealed that women highly valued the presence of a positive role model as a part of their professional development (3). The positive influence of a mentor in a trainee’s career decision-making process has been supported extensively in the surgical literature where women are also underrepresented. Female medical students were more likely to choose a surgical career at institutions with a higher proportion of female faculty surgeons (4); both men and women who identified a positive surgical role model were more likely to choose a surgical career (5); and female physicians and trainees in surgical specialties placed more importance on mentorship in their careers compared with men (6). This was recently echoed in a survey of cardiology fellows, which revealed that a lack of female role models had a negative effect on a female fellow’s decision to pursue a career in interventional cardiology (7).

These survey data are initially discouraging, but on closer look, offer an impactful conclusion: female residents are significantly influenced by the presence of positive female role models when making career decisions. How can this knowledge be used to bridge the gender gap in cardiology? Increasing mentorship for women trainees, especially at the level of residency, has the potential to promote the recruitment of women into cardiology. Mentorship allows for professional guidance and sponsorship but also provides visibility into the specialty. Although female cardiologists are more likely to have same-sex mentors (2), the responsibility of mentorship does not fall solely on women in cardiology. Women in cardiology have the unique ability to serve as role models for female trainees; however, diversity in mentorship is key. A mentor can be found in a man or woman, faculty or fellow.

As a female internal medicine resident, one of us (N.V.C.) can attest to the invaluable impact of mentorship during residency. The actions of a female faculty cardiologist (J.K.H.) put me on a path to pursue a career I had not previously imagined—a career in cardiology. I feared the same conditions cited by the recent survey data: work–life imbalance, adverse work conditions, and lack of diversity in a male-predominant specialty. But, through the guidance of my mentor, I had the opportunity to debunk these misconceptions. Mentorship additionally provided me with a role model who can relate to and guide me through challenges, access to a professional network that includes faculty members and fellows-in-training, exposure to clinical and academic opportunities, and, most importantly, sponsorship. Through mentorship from both faculty and fellows, I have had the opportunity to imagine a career in cardiology and engage in steps toward professional advancement.

In light of the 2018 survey data, it seems that the field of cardiology is susceptible to losing talent and diversity in the transition from residency to fellowship. Strengthening the presence of mentorship at this juncture is a potential area of intervention. Figure 1 describes a framework for mentorship interventions at the residency level, ranging from individual to systems-based approaches. Fellows and faculty can engage in mentorship by identifying residents interested in cardiology and providing them with introductions to faculty and program leadership, opportunities in academic projects, and exposure to cardiology as a career. One particularly well-received program-level intervention at our institution is the Women In Cardiology initiative pioneered by 2 fellows-in-training. This initiative involves quarterly discussion panels with female cardiology faculty to promote mentorship and sponsorship between faculty and trainees. The first 2 meetings sparked discussion about career advancement, family planning, and mentorship, and were attended by male and female residents, fellows, and cardiology program leadership. An example of an innovative program created by a specialty society is the Association of Women Surgeons and their recent development of the AWS Coaching Project (8). This program provides faculty members with training on how to coach residents in personal and professional development to improve trainees’ career fulfillment and minimize burnout. Social media can additionally be a powerful tool in establishing mentorship. Social media, such as Twitter, allows for communication and networking beyond barriers, including geography, specialty, or practice setting (9). This format is particularly useful in medical specialties with female underrepresentation. Women with limited access to mentors at their home institutions can harness the strength of social media to build mentorship networks that would otherwise be inaccessible (6,9).

Figure 1.

Framework for Targeted Mentorship Interventions in Residency to Promote Recruitment of Women Into Cardiology

The figure provides a framework for individual and systems-level initiatives that can be used to strengthen mentorship for female internal medicine residents. Interventions include direct guidance and counseling from fellows and faculty, creation of programs that allow residents to connect with faculty at the residency and fellowship levels, recruitment of residents to networking events by professional societies, and utilization of social media. Early introduction of these measures has the potential to change female residents’ negative impression of cardiology and promote recruitment of women into cardiology.

Early mentorship is essential to the successful recruitment of women trainees into cardiology. Mentorship paves the way for professional development, personal coaching, and, most importantly, visibility. It enables trainees to appreciate that women in cardiology have high rates of career satisfaction (2) despite balancing personal and professional responsibilities and addressing workplace barriers for their community. Faculty and fellows have the power to step forward as mentors and show trainees what it means to be a cardiologist.

After all, if you can’t see it, you can’t be it.