Women in UK cardiology: report of a Working Group of the British Cardiac Society

Reasons and resolutions for gender inequality among cardiologists and cardiology trainees

Women represented 29% of cardiology trainees and 16% of consultants in the UK in 2021. While the numbers of women in cardiology have increased over the last 20 years, these proportions remain among the lowest in comparison with other medical specialties. This essay aims to explore the contributing factors behind, and plans to reduce, gender disparity in cardiology. PubMed was searched using keywords such as 'gender', 'inequality', 'women', 'training' and 'cardiology'. Retrieved studies were screened for themes contributing towards, and strategies to overcome, gender inequality within cardiology. Reasons for gender inequality included poor perceptions of cardiology as a female-friendly specialty, experiences of gender-based discrimination, inflexible working hours, poor work- life balance, and lack of female role models. Recommended resolutions should target these themes; increase opportunities for flexible working hours, enforce a discrimination-free workplace culture, and encourage mentoring relationships between female senior and junior doctors. Improving the experience of the existing female workforce in cardiology will have a knock-on effect on the perceptions of trainees rotating through departments, in addition to initiatives promoting cardiology as a female-friendly specialty. In conclusion, promoting gender equality within cardiology remains an ongoing challenge. Nationwide efforts to increase retention and improve perceptions should target issues highlighted by the voices of women.

Women physicians in cardiovascular magnetic resonance: Past, present, and future

Women's engagement in medicine, and more specifically cardiovascular imaging and cardiovascular MRI (CMR), has undergone a slow evolution over the past several decades. As a result, an increasing number of women have joined the cardiovascular imaging community to contribute their expertise. This collaborative work summarizes the barriers that women in cardiovascular imaging have overcome over the past several years, the positive interventions that have been implemented to better support women in the field of CMR, and the challenges that still remain, with a special emphasis on women physicians.

The sex and gender dimensions of COVID-19: A narrative review of the potential underlying factors

Multiple lines of evidence indicate that the male sex is a significant risk factor for severe disease and mortality due to coronavirus disease 2019 (COVID-19). However, the precise explanation for the discrepancy is currently unclear. Immunologically, the female-biased protection against COVID-19 could presumably be due to a more rapid and robust immune response to viruses exhibited by males. The female hormones, e.g., estrogens and progesterone, may have protective roles against viral infections. In contrast, male hormones, e.g., testosterone, can act oppositely. Besides, the expression of the ACE-2 receptor in the lung and airway lining, which the SARS-CoV-2 uses to enter cells, is more pronounced in males. Estrogen potentially plays a role in downregulating the expression of ACE-2, which could be a plausible biological explanation for the reduced severity of COVID-19 in females. Comorbidities, e.g., cardiovascular diseases, diabetes, and kidney disorders, are considered significant risk factors for severe outcomes in COVID-19. Age-adjusted data shows that males are statistically more predisposed to these morbidities-amplifying risks for males with COVID-19. In addition, many sociocultural factors and gender-constructed behavior of men and women impact exposure to infections and outcomes. In many parts of the world, women are more likely to abide by health regulations, e.g., mask-wearing and handwashing, than men. In contrast, men, in general, are more involved with high-risk behaviors, e.g., smoking and alcohol consumption, and high-risk jobs that require admixing with people, which increases their risk of exposure to the infection. Overall, males and females suffer differently from COVID-19 due to a complex interplay between many biological and sociocultural factors.

History of the British Cardiovascular Society

In 2022, the British Cardiovascular Society celebrates the centenary of its foundation. Starting out as a small group of government-appointed physicians interested in heart disease, the Cardiac Club has grown and adapted to represent all those working in cardiovascular care and research. The historical stages of the organisation's development are outlined, alongside major innovations in science and technology providing context for a rapidly changing medical world. Only a small part of the history of cardiology in Britain is told, with greater emphasis on describing the broader need for services, skilled workforce, healthcare policy and continuing education. Above all, the history of the British Cardiovascular Society is a story of people and places. The people are those with vision, attitude and leadership to improve the care of communities across the world. The places are those that enabled conversation, innovation and freedom to bring about change. It is hard to believe the remarkable progress in diagnosis, prevention and treatment of heart disease over 100 years, but a thriving modern Society must be the greatest legacy of its founders.

European Society of Cardiology: cardiovascular disease statistics 2021

AIMS

This report from the European Society of Cardiology (ESC) Atlas Project updates and expands upon the widely cited 2019 report in presenting cardiovascular disease (CVD) statistics for the 57 ESC member countries.

METHODS AND RESULTS

Statistics pertaining to 2019, or the latest available year, are presented. Data sources include the World Health Organization, the Institute for Health Metrics and Evaluation, the World Bank, and novel ESC sponsored data on human and capital infrastructure and cardiovascular healthcare delivery. New material in this report includes sociodemographic and environmental determinants of CVD, rheumatic heart disease, out-of-hospital cardiac arrest, left-sided valvular heart disease, the advocacy potential of these CVD statistics, and progress towards World Health Organization (WHO) 2025 targets for non-communicable diseases. Salient observations in this report: (i) Females born in ESC member countries in 2018 are expected to live 80.8 years and males 74.8 years. Life expectancy is longer in high income (81.6 years) compared with middle-income (74.2 years) countries. (ii) In 2018, high-income countries spent, on average, four times more on healthcare than middle-income countries. (iii) The median PM2.5 concentrations in 2019 were over twice as high in middle-income ESC member countries compared with high-income countries and exceeded the EU air quality standard in 14 countries, all middle-income. (iv) In 2016, more than one in five adults across the ESC member countries were obese with similar prevalence in high and low-income countries. The prevalence of obesity has more than doubled over the past 35 years. (v) The burden of CVD falls hardest on middle-income ESC member countries where estimated incidence rates are ∼30% higher compared with high-income countries. This is reflected in disability-adjusted life years due to CVD which are nearly four times as high in middle-income compared with high-income countries. (vi) The incidence of calcific aortic valve disease has increased seven-fold during the last 30 years, with age-standardized rates four times as high in high-income compared with middle-income countries. (vii) Although the total number of CVD deaths across all countries far exceeds the number of cancer deaths for both sexes, there are 15 ESC member countries in which cancer accounts for more deaths than CVD in males and five-member countries in which cancer accounts for more deaths than CVD in females. (viii) The under-resourced status of middle-income countries is associated with a severe procedural deficit compared with high-income countries in terms of coronary intervention, ablation procedures, device implantation, and cardiac surgical procedures.

CONCLUSION

Risk factors and unhealthy behaviours are potentially reversible, and this provides a huge opportunity to address the health inequalities across ESC member countries that are highlighted in this report. It seems clear, however, that efforts to seize this opportunity are falling short and present evidence suggests that most of the WHO NCD targets for 2025 are unlikely to be met across ESC member countries.

Gender differences in cardiology professionals: A Latin American Survey

BACKGROUND

Gender-based differences among cardiology professionals have been reported in North America and Europe. However, the perspective of Latin American cardiologists remains unexplored.

OBJECTIVES

The objectives of the study were to analyze the gender gap perspective among cardiologists from Latin America.

METHODS

A cross-sectional study using an online survey directed to Latin American cardiologists from five different cardiology societies. The survey included questions on demographic data, professional development in the field of cardiology, and perceived barriers in clinical practice.

RESULTS

A total of 240 professionals were surveyed, of which 41.7% were women (100) and 58.3% were men (140). The majority of women tend to work in the subfields of clinical cardiology and cardiovascular imaging. Women were underrepresented as heads of departments, earn less, and report less work satisfaction than men. The barriers that female cardiologists face at their workplace include labor discrimination, sexual harassment, family-related concerns, and lack of career development.

CONCLUSIONS

The survey points toward the prevalence of a gender gap among cardiologists in Latin America, which is primarily driven by labor discrimination, sexual harassment, family-related concerns, and lack of career development among female cardiologists. Actions aimed at addressing this issue should be considered by different parties.

Sealing the leaky pipeline: attracting and retaining women in cardiology

Multiple publications have addressed the under-representation of women in the cardiology workforce, and indeed in leadership positions and procedural subspecialities, despite gender parity among medical school graduates. The work-life balance does not appear to be the only determining factor since other specialties such as obstetrics have a adequate representation of women. Vlachadis Castles et al report the results from their online survey of 452 female doctors (both trainees and specialists) from Australia and New Zealand, 13% of whom were women in cardiology. Female cardiologists reported working longer hours and more on-call commitments; significantly fewer women in cardiology reported a balanced life, or that cardiology was family friendly or female friendly, despite a greater earning capacity and an overwhelming majority agreeing that they were professionally challenged whilst intellectually stimulated in their jobs. Our editorial addresses the deterrents to women in cardiology seeking leadership opportunities in all areas including academic, administrative and research positions.

National Trends of Gender Disparity in Canadian Cardiovascular Society Guideline Authors, 2001-2020

Background

The level of representation of women in cardiology remains low compared to that of men, particularly in leadership positions. We evaluated gender disparity in the authorship of Canadian Cardiovascular Society (CCS) guidelines.

Methods

All CCS guidelines from 2001-2020 were identified. Gender was assessed based on pronoun use in the biographies and social media of the authors. Only primary panel authors were included in our analysis. Stratified analyses were performed based on subspecialties.

Results

A total of 76 guidelines were identified, with 1172 authors (26% women, 74% men, P < 0.0001), with no significant change in percentage of women authors over 2 decades, (37.1% in 2001, 36.3% in 2020, P = 0.34). Inclusion of women as authors occurred less frequently than inclusion of men in general cardiology guidelines (20.1% vs 79.9%, P < 0.0001) and all subspecialties—heart failure (36.4% vs 63.6%, P < 0.0001), interventional cardiology (12.6% vs 87.4%, P < 0.0001), electrophysiology (20.2% vs 79.8%, P < 0.0001), and pediatric cardiology (41.7% vs 58.3%, P = 0.02). It was less likely for women to be a chair or cochair of a guideline writing committee, compared with men (20.1% vs 79.8%, P < 0.0001). There were 609 unique authors (25.6% women, 74.4% men, P < 0.0001), 542 unique medical doctorate (MD) authors (20.7% women, 79.3% men, P < 0.0001), and 67 unique non-MD authors (65.7% women, 34.3% men, P = 0.0003).

Conclusions

There is a persistent shortfall in the inclusion of women authors for CCS guidelines, which has not changed over time. Further efforts are required to promote women's inclusion in leadership roles, which may lead to authorship of the guidelines.

Sexism experienced by consultant cardiologists in the United Kingdom

OBJECTIVES

The aims were to compare the frequency with which male and female cardiologists experience sexism and to explore the types of sexism experienced in cardiology.

METHODS

A validated questionnaire measuring experiences of sexism and sexual harassment was distributed online to 890 UK consultant cardiologists between March and May 2018. χ² tests and pairwise comparisons with a Bonferroni correction for multiple analyses compared the experiences of male and female cardiologists.

RESULTS

174 cardiologists completed the survey (24% female; 76% male). The survey showed that 61.9% of female cardiologists have experienced discrimination of any kind, mostly related to gender and parenting, compared with 19.7% of male cardiologists. 35.7% of female cardiologists experienced unwanted sexual comments, attention or advances from a superior or colleague, compared with 6.1% of male cardiologists. Sexual harassment affected the professional confidence of female cardiologists more than it affected the confidence of male cardiologists (42.9% vs 3.0%), including confidence with colleagues (38% vs 10.6%) and patients (23.9% vs 4.6%). 33.3% of female cardiologists felt that sexism hampered opportunities for professional advancement, compared with 2.3% of male cardiologists.

CONCLUSION

Female cardiologists in the UK experience more sexism and sexual harassment than male cardiologists. Sexism impacts the career progression and professional confidence of female cardiologists more, including their confidence when working with patients and colleagues. Future research is urgently needed to test interventions against sexism in cardiology and to protect the welfare of female cardiologists at work.

Representation of Women Authors in International Heart Failure Guidelines and Contemporary Clinical Trials

BACKGROUND

Gender disparities in authorship of heart failure (HF) guideline citations and clinical trials have not been examined.

METHODS

We identified authors of publications referenced in Class I Recommendations in United States (n=173) and European (n=100) HF guidelines and of publications of all HF trials with >400 participants (n=118) published between 2001 and 2016. Authors' genders were determined, and changes in authorship patterns over time were evaluated with linear regression and nonparametric testing.

RESULTS

The median proportion of women authors per publication was 20% (interquartile range [IQR], 8%-33%) in United States guidelines, 14% (IQR, 2%-20%) in European guidelines, and 11% (IQR, 4%-20%) in HF trials. The proportion of women authors increased modestly over time in United States and European guidelines' references (β=0.005 and 0.003, respectively, from 1986 to 2016; P<0.001) but not in HF trials (12.5% [IQR, 0%-20%] in 2001-2004 to 8.9% [IQR, 0%-20%] in 2013-2016; P>0.50). Overall proportions of women as first or last authors in HF trials (16%) did not change significantly over time (P=0.60). North American HF trials had the highest likelihood of having a woman as first or senior author (24%). HF trials with a woman first or senior author were associated with a higher proportion of enrolled female participants (39% versus 26%, P=0.01).

CONCLUSIONS

In HF practice guidelines and trials, few women are authors of pivotal publications. Higher number of women authors is associated with higher enrollment of women in HF trials. Barriers to authorship and representation of women in HF guidelines and HF trial leadership need to be addressed.

Using medical specialty and selection criteria clusters to study specialty selection by Israeli medical students

BACKGROUND

During their final year of medical school, Israeli students must consider which specialty to choose for residency. Based on the vocational counseling literature we presumed that choices are made by selecting from a cluster of related specialties while considering professional and socio-economic issues.

METHODS

Questionnaires distributed to final-year medical students at two Israeli medical schools ascertained inclinations toward various medical specialties and the importance of various selection criteria. Analysis focused on seven specialties where >20% of students reported they had positive inclinations. For each such specialty, the specialty and selection criteria query were compared using unpaired two-tailed Student's t-tests to determine differences between students with positive inclinations toward the specialty with those not so inclined. These data were placed in tables, with the significant differences highlighted to facilitate visual recognition of cluster patterns.

RESULTS

Completed questionnaires were obtained from 317 of 455 students. Students often had positive inclinations toward more than one specialty (specialty clusters) associated with a group of selection criteria (selection criteria clusters). For example, interest in internal medicine was clustered with interest in internal medicine subspecialties, cardiology and research. Furthermore, there was a "reciprocal" aspect to some specialty cluster patterns. For example, those interested in internal medicine had little interest in surgical specialties. Selection criteria clusters revealed occupational interests and socio-environmental factors associated with the specialty clusters. For example, family medicine, which clustered with pediatrics and psychiatry, had a sub-cluster of: Bedside specialty with family orientation affording long-term patient care. Another sub-cluster was time for childrearing and family, only daytime work and outpatient care. Clusters also revealed students' perceptions that differed from expected: Cardiology is changing from a cognitive to a procedure-oriented subspecialty, clustering not only with internal medicine and its subspecialties but also with emergency medicine, surgical subspecialties and anesthesiology.

CONCLUSIONS

The concept that career choice involves selecting from a cluster of related specialties provides information about the specialties students might be considering. Moreover, students are not only looking for individual aspects of a specialty, but for a package including clusters of socio-economic and occupational features. Practically, examining clusters can help in career counseling of medical students and assist residency program directors in marketing their specialties.

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.

Solutions for retention of female cardiologists: from the survey of gender differences in the work and life of cardiologists

BACKGROUND

To prevent a future shortage of cardiologists, it is important for female cardiologists to continue working. Gender differences in the professional and private lives of cardiologists, as well as the barriers to work for female cardiologists, were surveyed.

METHODS AND RESULTS

In August 2007, a questionnaire was mailed to all 195 faculty members/fellows and 155 alumni of the Department of Cardiovascular Medicine at Nippon Medical School. More female cardiologists were dissatisfied with their job than male cardiologists (34% vs 17%, P<0.005). Women reported greater career limitation by family responsibilities and housework. Men and women both reported that long working hours was the most problematic issue, but significantly more women reported this than men (76% vs 94%, P<0.05). Female cardiologists were more concerned about occupational radiation exposure (88% vs 59%, P<0.01) and wanted opportunities for retraining after childcare leave (100% vs 76%, P<0.01).

CONCLUSIONS

The following measures should be taken: (1)establishment of more family-friendly working conditions in hospitals, (2)provision of various work positions that allow more flexibility and predictability for women, (3)establishment of a retraining system, and (4)development of work and research opportunities that are attractive to women. The Japanese Circulation Society is expected to establish a retraining system at certified institutions.

Women in cardiology: a UK perspective

Women are particularly under-represented in cardiology in the UK, even though women outnumber men in admissions to medical school. Could this disparity be detrimental to the specialty in this country?

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.

Women in cardiology: a European perspective

Women may be under-represented in cardiology in the UK, but what about the rest of Europe?