Internal Medicine Trainees, Especially Women, Put Off by Cardiology

Patrice Wendling

June 08, 2018

In perhaps the most upfront, in-your-face look thus far, a series of papers published this week examine the obstacles facing women as well as men when pursuing a career in cardiology.

Prior studies, including a recent American College of Cardiology (ACC) Women in Cardiology Council survey, suggest that efforts over the past two decades to improve inequities in the male-dominated field have fallen short and that women continue to face discrimination and greater professional constraints from personal life choices than their male peers.

But the present survey, from the ACC's Women in Cardiology Council and its Task Force on Diversity and Inclusion, finds the latest generation of physicians not choosing cardiology, citing adverse job conditions, interference with family life, and a lack of diversity as the top reasons.

Women were more likely than men to have never considered a career in cardiology (62.6% vs 37%) and also less likely to have already chosen the specialty (11.5% vs 33.6%). Of the 1123 trainees who responded to the national survey, 55.7% were men.

"Our surprise in this study was to find out that men are also put off by cardiology," lead author Pamela S. Douglas, MD, Duke University School of Medicine, Durham, North Carolina, said. "At least in the millennial generation of people making choices now for cardiology fellowships, for both men and women what they want for professional development and what they perceive they will get from cardiology is diametrically opposed.

"To me that's the most interesting and important finding because it's really a call to say we are losing talent among men and women," she told | Medscape Cardiology.

Men and women graduate medical school in nearly equal numbers, but women comprise about 15% of cardiologists and only about 4% to 7% of interventional cardiologists.

While work-life balance is a central concern in the four papers, published May 30 in JAMA Cardiology, they also take a hard, blunt look the long-standing issues of sexual harassment, bias, and compensation in cardiology.

Roxana Mehran, MD, Icahn School of Medicine at Mount Sinai, New York City, recounts in a related viewpoint how a young fellow described at a meeting only last year that she was asked during her fellowship interview about her biological clock and whether she was serious about becoming an interventional cardiologist by five of six program directors.

"I do not know of a single woman who has trained in cardiology and chosen interventional cardiology as her career who has not faced some level of sexual harassment or misconduct," writes Mehran, a long-time equity champion. "This is not hyperbole. Women have been underrepresented, underestimated, and undervalued for many long years — and I have not started on the salary gap."

In a second viewpoint, Rashmee U. Shah, MD, University of Utah School of Medicine, Salt Lake City, estimates that women cardiologists will earn $21,900 less than men in the first year of employment but that this early career wage gap "snowballs over time" into $2.5 million less over a 35-year career.

Taking that a step further, "if there are 30,271 cardiologists in the United States and 15% are women, we are collectively leaving $11.2 billion in gross earnings on the table over 35 years," Shah writes.

She suggests the loss in lifetime earnings may be even greater in academia, where the wage gap increases rather than stays constant at 7.3%, as modelled, and salary increases are often tied to promotion between ranks.

Rather than taking a simplistic view that women are "stuck to the floor" and their salaries stagnate because they have fewer publications, fewer grants, and less time in the work force, Shah argues that "we need to understand why these patterns exist in the first place and identify the less obvious factors that prevent advancement."

For example, women receive less money for research start-up, while other factors, such as lack of sponsorship, fewer networking options, and less effective negotiations, are rarely examined in pay inequity studies.

"The fundamental back problem here is that the system has made it difficult for men to assume the caregiver role," she told | Medscape Cardiology. Fathers often get only 1 week of parental leave vs 6 weeks or more for mothers.

Shah also advocates creating transparent systems to report wages and uniformly measure productivity, such as relative value units but also teaching value units, as some institutions are starting to do. Notably, research in other fields shows that organizations with women in leadership positions have better financial performance rates and return on investments.

"For me as a healthcare provider, it's more than making money for the healthcare system, but are the patients doing better?" she said. "If we have a diverse work force that includes women, especially in leadership roles, maybe it's better for the patients. There's different types of doctors that patients can relate to; there's different styles of management that some patients may prefer."

In an invited editorial, Anne Curtis, MD, University at Buffalo, New York, and Fatima Rodriguez, MD, Stanford University, California, suggest that one of the potential solutions to the "staggering problem of underrepresentation of women in cardiology" is structured programs that provide positive role models and mentors to medical students and residents.

"We have no doubt that learning from other women who balance work and family responsibilities will have a positive influence on trainee specialty decisions," they write. "We must retain and advance the careers of female cardiologists who will serve as the best champions for recruiting other talented women to our field."

In the survey, female internal medicine trainees had more negative perceptions about cardiology associated with family and work/life balance, while male trainees were more likely to emphasize the intellectually stimulating aspects of cardiology as a career.

A major change in cardiology that may help address work/life balance is the marked swing from mainly private practitioners to a model of hospital or system employment, Curtis and Rodriguez suggest.

"While there is some loss of autonomy with this model, it also creates opportunities for more structured and predictable work schedules," they write.

Cultural changes are also needed to accommodate the millennials, who are more concerned with family friendliness than the workaholic Baby Boomers, Curtis told | Medscape Cardiology.

"There's nothing more unpredictable than when a baby will be born but ob/gyn is an overwhelmingly female profession now because they have changed the culture to be inclusive," she said. "They work shift work and when you're in the hospital all night doing something, you go home. And in cardiology, if you've been up all night doing STEMI [ST-elevation myocardial infarction]  call, it's time to scrub in again the next day into the cath lab and do some more procedures."

"This is purely conjectural but I'd personally rather have my cardiac intervention by somebody who slept last night," she added.

Past chair of the ACC's Women in Cardiology Council, Sandra Lewis, MD, Northwest Cardiovascular Institute, Portland, Oregon, said the publication of the four papers is "an incredibly bold move" that is shining a much-needed light on these issues.

"These are issues that reflect back on what we are as physicians, as cardiologists, somewhat to the Quadruple Aim that the Institute for Healthcare Improvement really brought out in the last year that the well-being of our providers really has to become a focus," she told | Medscape Cardiology.

Curtis agreed that the shift from the private practice model to larger groups should help attract more candidates but suggested cardiologists also need to do a better job exposing residents and trainees to the diversity of options in cardiology, including those with typically more stable hours, such as heart failure clinics, nuclear cardiology, and echocardiography.

Still, while the papers point out significant challenges facing cardiology, there is also a very palpable love for the specialty.

"We would be hard pressed to think of a cardiologist who would choose to go into a different field if the option were open again," write Curtis and Rodriguez. "To choose another field solely because of a perception that the hours will be better seems a poor bargain on balance."

Douglas and her colleagues point out that the most recent ACC Professional Life Survey found that once in the field, 88% of female cardiologists and 90% of their male peers report high satisfaction with their career choice and would recommend cardiology to others.

Taking a page from the #TimesUp movement, Mehran writes, "Rather than make excuses or nod sympathetically, leaders must do something in response to these voices — even if it makes them uncomfortable. We all must act. Interventional cardiology is such a beautiful subspecialty."

 The study was funded by the American College of Cardiology and  the Women in Cardiology section of the ACC. Douglas, Curtis, Rodriguez, and Shah report no relevant financial disclosures. Mehran reports receiving grants to her institution from AstraZeneca, Bayer, Beth Israel Deaconess, Bristol-Myers Squibb, CSL Behring, Eli Lilly/DSI, Medtronic, Novartis Pharmaceuticals, and OrbusNeich; consultant fees paid to her institution from Abbott, CardioKinetix, and Spectranetics; personal fees from Medscape and Boston Scientific; fees to her spouse from The Medicines Company and Abiomed; and equity from Claret Medical and Elixir Medical. She also reports serving on the executive committees of Janssen Pharmaceuticals and Osprey Medical; an advisory board for Bristol-Myers Squibb; and the data safety monitoring board for Watermark Research Partners.

JAMA Cardiol. Published May 30, 2018. Full text, EditorialShah viewpoint, Mehran viewpoint

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