Working group 2: How to encourage more women to choose a career in cardiology

Impact of racial, ethnic and gender disparities in Cardiology

Literature shows evidence of racial and gender biases in many sub-specialties of medicine including cardiology. Racial, ethnic, and gender disparities exist along the path to cardiology residency, beginning as early as medical school admissions. Approximately 65.62% White, 4.71% Black, 18.06% Asian, and 8.86% Hispanic are cardiologists, while there are a total of 60.1% White, 12.2% Black, 5.6% Asian, and 18.5% Hispanic people in the US in 2019, showing evident underrepresentation. Gender disparities have an inevitable role in the lack of a diverse cardiovascular workforce. According to a recent study, only 13% of practicing cardiologists in the US are women, even though the female population in the US is 50.52% as compared to 49.48%- of men. These disparities led to underrepresented physicians earning less than their similarly qualified counterparts, decreased equity, increased workplace harassment, and also results in patients facing unconscious bias from their physicians leading to deteriorated clinical outcomes. Implications in the field of research include the underrepresentation of minorities and the female population despite the increased burden of cardiovascular disease they face. However, efforts are underway to eradicate the disparities that exist in cardiology. This paper aims to increase awareness regarding the issue and inform future policies with the goal of encouraging underrepresented communities to join the cardiology workforce.

Lack of Equity in the Cardiology Physician Workforce: A Narrative Review and Analysis of the Literature

The gender and racial diversity in the cardiology workforce in Canada does not reflect that of the population we serve. As social awareness of the principles of equity, diversity, and inclusion rises, our profession must rise to meet the challenges they present. We detail contemporary examples of publication bias in the cardiac sciences literature and describe the factors that led to oversight in the peer-review process. We performed a narrative review to summarize the published literature on equity and diversity among cardiac physicians. We also summarize the challenges faced by women and racial-minority physicians when pursuing and thriving in a career in cardiology, and the systemic barriers to their success. In the past decade, social justice movements have advanced. Professionalism standards are changing, and awareness and understanding of these advances in terminology is imperative for all physicians. In this review, we summarize key language and concepts, with cardiology-specific examples, and propose a new paradigm of professionalism.

The Pivotal Role of Women in Cardiology Sections in Medical Organizations: From Leadership Training to Personal Enrichment

Women in cardiology (WIC) sections have emerged as important leadership, career development, and advocacy forums for female cardiologists. Over the past 3 decades, they have grown from small groups to large sections within volunteer science organizations. In addition to providing a sense of community and promulgating the principles of diversity, equity, inclusion, and belonging, the WIC sections have contributed to improving workplace culture and dynamics by generating evidence-based and actionable data, fostering leadership by and scientific enrichment of women, developing task forces and health policy documents targeted toward reduction of burnout and bias in medicine, and providing a platform to voice the unique challenges and opportunities of female cardiologists. The future holds great promise, as the WIC sections continue to play a pivotal role by being intentional, transparent, iterative, and sustainable, and working with important stakeholders, including men, to share data, best practices, and strategies to create and maintain a culture of equity and achieve its core principles.

How do we attract and retain women in cardiology?

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.

Sex Differences in Faculty Rank Among Academic Cardiologists in the United States

BACKGROUND

Studies demonstrate that women physicians are less likely than men to be full professors. Comprehensive evidence examining whether sex differences in faculty rank exist in academic cardiology, adjusting for experience and research productivity, is lacking. Therefore, we evaluated for sex differences in faculty rank among a comprehensive, contemporary cohort of US cardiologists after adjustment for several factors that impact academic advancement, including measures of clinical experience and research productivity.

METHODS

We identified all US cardiologists with medical school faculty appointments in 2014 by using the American Association of Medical Colleges faculty roster and linked this list to a comprehensive physician database from Doximity, a professional networking website for doctors. Data on physician age, sex, years since residency, cardiology subspecialty, publications, National Institutes of Health grants, and registered clinical trials were available for all academic cardiologists. We estimated sex differences in full professorship, adjusting for these factors and medical school-specific fixed effects in a multivariable regression model.

RESULTS

Among 3810 cardiologists with faculty appointments in 2014 (13.3% of all US cardiologists), 630 (16.5%) were women. Women faculty were younger than men (mean age, 48.3 years versus 53.5 years, P<0.001), had fewer total publications (mean number: 16.5 publications versus 25.2 publications; P<0.001), were similarly likely to have National Institutes of Health funding (proportion with at least 1 National Institutes of Health award, 10.8% versus 10.4%; P=0.77), and were less likely to have a registered clinical trial (percentage with at least 1 clinical trial, 8.9% versus 11.1%; P=0.10). Among 3180 men, 973 (30.6%) were full professors in comparison with 100 (15.9%) of 630 women. In adjusted analyses, women were less likely to be full professors than men (adjusted odds ratio, 0.63; 95% confidence interval, 0.43-0.94; P=0.02; adjusted proportions, 22.7% versus 26.7%; absolute difference, -4.0%; 95% confidence interval, -7.5% to -0.7%).

CONCLUSIONS

Among cardiology faculty at US medical schools, women were less likely than men to be full professors after accounting for several factors known to influence faculty rank.

Changes in the Professional Lives of Cardiologists Over 2 Decades

The American College of Cardiology third decennial Professional Life Survey was completed by 2,313 cardiologists: 964 women (42%) and 1,349 men (58%). Compared with 10 and 20 years ago, current results reflect a substantially lower response rate (21% vs. 31% and 49%, respectively) and an aging workforce that is less likely to be in private practice. Women continue to be more likely to practice in academic centers, be pediatric cardiologists, and have a noninvasive subspecialty. Men were more likely to indicate that family responsibilities negatively influenced their careers than previously, whereas women remained less likely to marry or have children. Men and women reported similar, high levels of career satisfaction, with women reporting higher satisfaction currently. However, two-thirds of women continue to experience discrimination, nearly 3 times the rate in men. Personal life choices continue to differ substantially for men and women in cardiology, although differences have diminished.

Work Activities and Compensation of Male and Female Cardiologists

BACKGROUND

Much remains unknown about experiences, including working activities and pay, of women in cardiology, which is a predominantly male specialty.

OBJECTIVES

The goal of this study was to describe the working activities and pay of female cardiologists compared with their male colleagues and to determine whether sex differences in compensation exist after accounting for differences in work activities and other characteristics.

METHODS

The personal, job, and practice characteristics of a national sample of practicing cardiologists were described according to sex. We applied the Peters-Belson technique and multivariate regression analysis to evaluate whether gender differences in compensation existed after accounting for differences in other measured characteristics. The study used 2013 data reported by practice administrators to MedAxiom, a subscription-based service provider to cardiology practices. Data regarding cardiologists from 161 U.S. practices were included, and the study sample included 2,679 subjects (229 women and 2,450 men).

RESULTS

Women were more likely to be specialized in general/noninvasive cardiology (53.1% vs. 28.2%), and a lower proportion (11.4% vs. 39.3%) reported an interventional subspecialty compared with men. Job characteristics that differed according to sex included the proportion working full-time (79.9% vs. 90.9%; p < 0.001), the mean number of half-days worked (387 vs. 406 days; p = 0.001), and mean work relative value units generated (7,404 vs. 9,497; p < 0.001) for women and men, respectively. Peters-Belson analysis revealed that based on measured job and productivity characteristics, the women in this sample would have been expected to have a mean salary that was $31,749 (95% confidence interval: $16,303 to $48,028) higher than that actually observed. Multivariate analysis confirmed the direction and magnitude of the independent association between sex and salary.

CONCLUSIONS

Men and women practicing cardiology in this national sample had different job activities and salaries. Substantial sex-based salary differences existed even after adjusting for measures of personal, job, and practice characteristics.

Career choices for cardiology: cohort studies of UK medical graduates

BACKGROUND

Cardiology is one of the most popular of the hospital medical specialties in the UK. It is also a highly competitive specialty in respect of the availability of higher specialty training posts. Our aims are to describe doctors' early intentions about seeking careers in cardiology, to report on when decisions about seeking a career in cardiology are made, to compare differences between men and women doctors in the choice of cardiology, and to compare early career choices with later specialty destinations.

METHODS

Questionnaire surveys were sent to all UK medical graduates in selected qualification years from 1974-2009, at 1, 3, 5, 7 and 10 years after graduation.

RESULTS

One year after graduation, the percentage of doctors specifying cardiology as their first choice of long-term career rose from the mid-1990s from 2.4% (1993 cohort) to 4.2% (2005 cohort) but then fell back to 2.7% (2009 cohort). Men were more likely to give cardiology as their first choice than women (eg 4.1% of men and 1.9% of women in the 2009 cohort). The percentage of doctors who gave cardiology as their first choice of career declined between years one and five after qualification: the fall was more marked for women. 34% of respondents who specified cardiology as their sole first choice of career one year post-graduation were later working in cardiology. 24% of doctors practising as cardiologists several years after qualification had given cardiology as their sole first choice in year one. The doctors' 'domestic circumstances' were a relatively unimportant influence on specialty choice for aspiring cardiologists, while 'enthusiasm/commitment', 'financial prospects', 'experiences of the job so far' and 'a particular teacher/department' were important.

CONCLUSIONS

Cardiology grew as a first preference one year after graduation to 2005 but is now falling. It consistently attracts a higher percentage of men than women doctors. The correspondence between early choice and later destination was not particularly strong for cardiology, and was less strong than that for several other specialties.

Internal medicine resident perceptions of optimal training duration

PURPOSE

To describe internal medicine residents' opinions regarding the optimal duration of internal medicine residency training, and to assess whether these opinions are associated with specific career interests.

METHOD

A national cohort study was conducted during the 2005 Internal Medicine In-Training Examination (IM-ITE), which involved 382 of 388 (98.5%) U.S. internal medicine programs. A sample of 14,579 residents enrolled in three-year categorical or primary care training programs in the United States reported their opinions regarding optimal residency training duration on the IM-ITE 2005 Residents Questionnaire. Reported optimal training duration was assessed by postgraduate training year, sex, medical school location, program type, and reported career plan.

RESULTS

Among the residents surveyed, 78.1% reported a three-year optimal length of internal medicine residency training, 15.3% preferred a two-year training duration, and 6.7% preferred a four-year duration. Residents planning careers in general medicine, hospital medicine, and subspecialty fields all preferred a three-year training duration (83.8%, 82.6%, and 75.9%, respectively). Residents planning subspecialty careers were more likely than those planning general or hospital medicine careers to prefer a two-year program (18.7% versus 7.4% and 8.3%). Residents planning generalist or hospitalist careers were more likely to favor a four-year program (8.9% and 9.1%, respectively) compared with residents planning subspecialty careers (5.4%).

CONCLUSIONS

Most internal medicine residents endorse a three-year optimal duration of internal medicine residency training. This perspective should be considered in further national discussions regarding the optimal duration of internal medicine training.

Eliminating disparities in cardiovascular health: six strategic imperatives and a framework for action

Disparities in cardiovascular health are among the most serious public health problems in the United States today. Despite the remarkable declines in cardiovascular mortality observed nationally over the last 3 decades, many population subgroups defined by race, ethnicity, gender, socioeconomic status, educational level, or geography show striking, and often widening, disparities in cardiovascular health. The pervasive nature of these disparities and compelling evidence of the adverse impact they have on clinical outcomes and quality of life have been well documented. The elimination of these disparities is 1 of the 2 overarching goals of the Healthy People 2010 national public health agenda; however, few publications provide guidance on what actions to take. In this review, 6 strategic imperatives within a framework for action are presented. Other key elements of the framework include 10 focal areas and 6 major settings within which the framework calls for accelerated interventions to eliminate disparities in cardiovascular health. Success in this endeavor will require innovative and comprehensive interventions built on a foundation of sound clinical and public health science. Strategic partnerships with communities, community-based organizations, state and local governments, and public and private partners from both health and nonhealth sectors are essential. Additionally, investment in local-level disparities surveillance, community-based participatory research, and development of a diverse clinical and public health workforce will be invaluable.

Women in cardiology: the US experience

"You are not required to complete the work, but neither are you at liberty to abstain from it.."-Rabbi Tarfon, Pirke Avot 2:16.