Making Cardiology Family-Friendly Helps Men and Women

; Claire S. Duvernoy, MD


February 02, 2017

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Robert A. Harrington, MD: Hi. This is Bob Harrington from Stanford University on Medscape Cardiology and

In 2016, we had a very well-received and well-discussed program on gender pay disparities in the cardiovascular profession with Pam Douglas from Duke University. This led me to do a series of discussions with colleagues, both men and women, from around the country on the broader issue of the relatively low number of women in cardiovascular fields.

Why it is that 50% of medical students are women, and 44% of internal medicine specialists are women, but less than 15% of women specialize in cardiovascular medicine? This is a serious issue for the future of the field. If we are leaving talent behind, we are not recruiting the most talented people into the field.

I am absolutely delighted today to be joined by my friend and colleague, Claire Duvernoy. Claire is an interventional cardiologist and staff physician at the Veterans Affairs (VA) Ann Arbor Healthcare System. She is a professor of medicine in the Division of Cardiology at the University of Michigan. Maybe most importantly for our topic, Claire is the leadership chair of the American College of Cardiology's (ACC's) Women in Cardiology Council. Thank you very much for joining me today on Medscape Cardiology.

Claire S. Duvernoy, MD: Thank you so much for inviting me to your show, Bob. I'm really excited to talk about this issue with you.

Dr Harrington: Claire, in having worked with you now over the course of the last year, I know that not only are you passionate about this topic, but you are actually proactive about this topic. You have been working to publish documents, and you have been leading a group to address some of these issues.

Let's start with your overarching view of some of the challenges that women face when entering cardiovascular medicine. We will dive down into the recent paper that was the output of a professional life survey that specifically looked at some of the issues around "the pregnant cardiologist." Then we will talk about issues of academic promotion, access to leadership roles, and access to mentorship. Why don't you kick if off?

Misperception: Cardiology Is Too Intense

Dr Duvernoy: As you mentioned, although 50% of medical students are women, only about 13% of practicing cardiologists are women. That number has been pretty stagnant over the last 5 or so years. There are many reasons why that might be the case, but as you said, we are leaving talent on the table, and we need to do better to recruit more women into cardiology.

We need to get rid of this... 'old boys' club' feeling that cardiology has.

There are many perceptual issues when women look at cardiology. Probably the biggest thing is that they do not see people who look like them, and that can be discouraging. If there is a lack of mentors who look like you and who are trying to do what you are trying to do in your field, then you are going to be less likely to choose that area, even if you find the content interesting.

It's unavoidable and needs to be discussed that cardiology is perceived as a very work-intensive, high-stress, long-hours kind of career. That may put off both men and women who are interested in having time for their families and who are interested in having a healthy work-life balance. But, as others have pointed out, there are plenty of fields with long and unpredictable hours that have many more women than we see in cardiology.

This is not the only question. Certainly, cardiology is not for everybody, and it's not for you if you want a cushy lifestyle. But I and many of the women I know think that cardiology can be a fantastic career for women. We need to show that to women coming in and considering the field.

This is what the ACC Women in Cardiology section is trying to do. This is what we are trying to do with our publications. It's also what we are trying to do when we work to make the field better and more equitable for women. Helping leadership in programs, training programs, and practices to achieve more parity and work-life balance perhaps will benefit everyone in the end.

Dr Harrington: It's interesting. I'm going to go into some of the specific topics you raised and try to get your reactions. The first one is the misperception that women are not choosing cardiology because of the intensity of the work. In specialties like obstetrics/gynecology, the majority of residents and fellows now are women. This is a procedural specialty where people are certainly working long hours and coming in at all hours of the day and night, 7 days a week, 365 days a year. I absolutely agree with you. It's a misperception that women are not seeking out cardiology because of the intensity of the work.

Dr Duvernoy: When we look at other very work-intensive areas like hematology/oncology, over 30% of those specialists are women. Even 18% of general surgeons are women. There are fields considered to be work-intensive with unpredictable hours that women are choosing in greater numbers than cardiology. We need to get rid of this "old boys' club" feeling that cardiology has. We are trying to do this with the Women in Cardiology section.

Mentoring Women

Dr Harrington: Well said. Let's talk about how the field "does not look like me." Men are going to have to work on this. At least in the short term, the overwhelming majority of cardiologists are going to be men—particularly in the senior ranks where many of the mentors are found.

I tell young people coming up not to be afraid to pay somebody to do [house] work that they do not need to be doing.

What is effective mentorship for women? Is it exactly the same as for men? Are there some differences we ought to be aware of? As an example of a senior male cardiologist who mentors a lot of young people, how can I be better at mentoring women in cardiology?

Dr Duvernoy: In my personal experience, I have had not just one mentor; I have had lots of mentors, and most of them have been men. They have been fantastic mentors, not from the perspective of, "I'm a woman, and therefore this is how you can do it," but by working with me in a gender-neutral way on papers and publications, offering opportunities to advance, and by simply being there and believing in me that I can do this work. I never felt like there were barriers or that someone was saying to me, "I do not think you should be doing this."

My greatest mentors have been men in the field and leaders in the field. Because of them, I chose to go into cardiology. I have also had great women mentors. Betsy Nabel was the division chief at the University of Michigan when I entered fellowship, started as a young attending, and when I became pregnant in my first year as an interventional cardiology attending. She could not have been more supportive, welcoming, and warm to me at every stage in my career.

When I was a fellow, she had a gathering for the Women in Cardiology section at her home. At that time, I think there were fewer than 10 of us, including the fellows and the attendings. She talked about how she had a staff of people to do the work that needs to be done so that she and her husband could pursue their careers, their kids could get taken care of, and everybody could get fed. I remember thinking, "She employs three or four people in her home. I will never be in a position to do that." And now I do the exact same thing. I tell young people coming up not to be afraid to pay somebody to do work that they do not need to be doing.

Betsy was an incredible example for me, but there was also Markus Schwaiger. He was my greatest mentor as a resident and fellow and supported me for a research year in Munich after he had gone there and left the University of Michigan.

There are so many people, mostly men, who have been mentors. It points to the fact that a mentor does not have to be a woman. It's important that there are some women you can look to and say, "She's doing it. I can do it too." But most of the mentors in cardiology right now are going to be men just because of the demographics, as you said. They should not be afraid to take on mentees of every stripe and work with them. It does not have to be just about gender. It can be about being supportive and encouraging.

Dr Harrington: As I listen to you reflecting, I think what you are really describing is: Let's treat our mentees the same. Give them opportunities. Be supportive. Listen to their hopes, their dreams, and also their challenges. Network and introduce them. These are all the common themes of successful mentorship, and it doesn't matter if you are a man or a woman. We are all looking for some of the same things to help build our career.

I love your example from Betsy, and I would agree with you. She is a great role model for many of us in academic cardiology. She has accomplished amazing things and is not afraid to give people practical advice as she gave you.

My wife, who is a full-time professional, and I had the same idea of employing people to help us, whether by doing yard work, things around the house, etc. It is a balance, particularly if you are trying to balance a family with two careers.

Dr Duvernoy: Exactly. My husband, who is an electrophysiologist here at the University of Michigan, always jokes that I support the US economy—not by going shopping, because I don't do much shopping, but because we employ people to do work for us. We try to spend the time that we have together with our family. We travel a lot together. When the kids were younger, we took them and our nanny or au pair with us to almost every meeting that we went to. It was kind of an entourage. But that way we got to be together a little bit more, and it worked out very well.

Making Professional Practice 'A More Human Place'

Dr Harrington: Divisions in departments also become better places when the atmosphere is family-oriented. When leaders really encourage people to bring along their kids, their families, their network, if you will, it makes a division, department, or practice a more human place.

Dr Duvernoy: I agree with you. The University of Michigan is a great place in that regard. People sometimes talk about how you need to separate your work and your personal lives. I have found that that is not what works for me. I do better when I realize that things are going to bleed into one another. It's the only way that I can make my life work. My personal life is going to bleed into my professional life, and it would be artificial to try to create a barrier. Of course, my professional life will intrude upon my personal life. There are things I'm going to have to do on the weekend, like writing a paper, doing some research, or being on call. And it works both ways. That is just the reality. You can make yourself a little bit crazy if you try to build an absolute wall between those things.

Your colleagues and patients like to hear about what is going on in your personal life. I have so many patients now for 15 or 20 years who want to know, "How old are your kids now? What are they doing?" And I want to hear about their families. That is human nature, and it makes us better doctors.

Dr Harrington: Yes, I agree with you. That is, in part, the essence of doctoring: to develop those kinds of relationships that you have rightly pointed out. I find the most pleasure in relationships with my longstanding patients when they are bidirectional like that.

ACC Professional Life Survey and What It Gleans

Dr Harrington: Let's jump into some of the work that ACC is doing; they have done a nice job by creating the section for the Women in Cardiology. Why don't you give the audience some background of what the professional life survey is, how long it's been going on, and what kinds of things it's trying to learn. Then let's discuss the most recent paper, which is, "The Pregnant Cardiologist."

Dr Duvernoy: Back in 1996, ACC commissioned the first professional life survey[1] to look at many issues for women and men in cardiology: gender disparities, experiences, professional lives, types of careers, and discrimination. They asked the same questions in 2006,[2] and we started the process again in 2015[3] with essentially the same questions. Now we have 20 years of data, and we can see that while some things have changed for cardiologists, there are many things that actually have not changed that much. It gives us a lot of perspective and information on how we can move forward most effectively.

ACC started this process—and then as an offshoot and result of the process created the Women in Cardiology section—because of concerns about shortages and lack of parity in the workforce. There were very practical concerns that led ACC to start this process. I think those same concerns continue to exist. ACC still is dealing with the potential of a workforce shortage.

We also have learned a lot through the years by conducting the survey. For example, everybody in cardiology knows that the majority of cardiologists have gone from private practice settings to hospital-employed/academic medicine or other employed physician models. This has been a huge change that has happened most likely in the last 10 years. Cardiologists have gotten older. Both men and women are aging, and that has implications for who is going to follow and who is going to do this job in the next 20 years. Those are the kinds of changes that are affecting both men and women, that affect our workforce as a whole, and that we need to pay attention to so that we have enough people in the pipeline.

The Pregnant Cardiologist

Dr Harrington: That was a really great description of how these sorts of longitudinal studies can be enormously valuable to shed insight into what is going on in the profession. With that as background, let's talk about the recent publication, "The Pregnant Cardiologist."[4] What was the stimulus to write about that specific question? What were some of the key findings; and how have you, as somebody who thinks a lot about these issues, interpreted some of those findings?

Dr Duvernoy: This idea came out of one of our leadership workshops a couple of years ago for women in cardiology. We have tried to have these workshops now I think going on 4 years. They have proved to be great venues for women cardiologists to get together to learn about strategies for success and negotiating tactics, and we have lots of great conversations about the field and how to advance the position of women in the field.

Some of us had a casual discussion about cardiologists' experiences of pregnancy and how that worked for them with their profession and their personal lives. Amy Sarma, who is a cardiology fellow at Harvard University, and her mentor, Melissa Wood, who is on the leadership council of the Women in Cardiology section, and colleagues developed a survey to ask about pregnancies, maternity leaves, and breastfeeding issues for women cardiologists. All of that was distilled into this paper, which showed us that there are quite a few concerning issues and things that we need to try to change. There are a lot of difficulties with pregnancy, and assisted reproductive technologies are used frequently. Women describe a lot of pressure to take shorter maternity leaves and pressures that may lead to premature discontinuation of breastfeeding.

I don't think that these issues are unique to cardiology, but we can really try to do something about them. That has led me to want to talk personally with program directors and administrative leadership in cardiology practices to see whether we can advocate for policies that would help women have more successful pregnancies and not feel the kinds of pressures that the survey indicated that they do.

Parental Leave: Don't Forget Dad

Dr Harrington: One thing that struck me as I read the paper and the commentaries is that these issues around pregnancy and parental leave are important for men in cardiology as well. Our men in cardiology are not taking the time they ought to take for parental leave. I think it was you who pointed out that society would be better as a whole if we could arrive at some place where perhaps parental leave was not just tolerated but really embraced and expected.

Obviously this [parental leave] is much bigger than cardiology. This is a societal issue.

Dr Duvernoy: This struck me so strongly as I was researching both "The Pregnant Cardiologist" and the professional life survey paper. Scandinavian countries have been leaders in this area. There were a lot of data showing that when men and women take parental leaves that are equal in length and are longer, quite frankly, than what we typically see in the United States even for women, they have more equal distribution of workload in parenting and family issues, women show higher levels of advancement and higher levels of parity in earning potential throughout the lengths of their careers, and society as a whole becomes more equal with more equal partnerships of men and women.[5,6]

The implications of a relatively short period in somebody's lifespan—less than a year in a long career—have ramifications for the rest of the professional lives of men and women who choose to take equal parental leaves. That was very clear from looking at the research and the models that the Scandinavian countries provided.

Obviously this is much bigger than cardiology. This is a societal issue. The United States needs to look at and work on this. I think there are some tech companies in California that have instituted much more deliberate parental leave policies—especially paternal leave, with the stipulation that (I think this is really key) men have leave for the same period of time as women. That way, there is a much more equal distribution of work. When you look at the long-term data of implications of this kind of leave, it's amazing how much better relationships are between fathers and kids. It's something that we should aspire to.

Taking the Initiative

Dr Duvernoy: I do not think that we can wait for society to make changes on a legal or national level. At some point in our careers, we need to take the initiative for changes that we can make. That is what I want to do in conjunction with the leadership council for the ACC Women in Cardiology section. I want to go to programs and say, "I realize it's not a law, but this is something that we would like you to consider. It will have workforce implications." Amy goes over this in the paper to some degree.

You have to think about who covers. Who does the work if a woman is gone for 2 months and then a guy is gone for 2 months after they have a baby? Do you have to have a system where there is a covering person or a float person? That exists in other areas in medicine. It's a factor in internal medicine residency, but we have not had this in cardiology fellowship, and maybe we need to start thinking about how to do this.

Dr Harrington: Yes. This has been a terrific example of how beginning the conversation around women in cardiology rightly morphs into a broader discussion about what is good for the specialty, all of us as cardiovascular professionals, and ultimately what is good for our patients—because healthy living arrangements also affect how we interact with our patients.

Claire, I want to thank you for joining me today. We could go on for another half hour, but hopefully you can come back so we can continue the conversation. I want to thank our listeners. Our guest today has been Dr Claire Duvernoy, who is a staff physician at the VA in Ann Arbor Healthcare System and a professor of medicine at the University of Michigan. For the purpose of this discussion, and maybe most importantly, she is the leadership chair of the ACC Women in Cardiology section. Claire, thank you for joining us today on Medscape Cardiology.


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