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Wednesday, 18 July 2018

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    Since women make up about half of all medical students, the glaring gender gap in cardiology deserves attention.

                Dr Robert Harrington of Stanford called the dearth of women in cardiology a talent issue for our field. In a tweet, he noted that women make up 45% to 47% of internal medicine residents but less than 20% of cardiology fellows. And it"s worse in the lab-based subspecialties, where <10% of interventional cardiology or electrophysiology fellows are women.

                My private-practice group is unusual; 42% of partners are women. I asked them about the gender gap.

                Dr Rebecca McFarland, a mother of many (n=6), was first to respond to my emailed questions.

                "I laugh as I read [your email] because I"m sitting in a neighborhood waiting to pick up my son after soccer practice. I haven"t picked up a journal in about a week and I"m thinking about how to disperse my crew of kids to the various and sundry engagements that they have in the next 3 days. Never mind that I start call tomorrow morning [and] probably won"t surface to see the sunlight until Sunday night. Hmm . . . why aren"t there more women doing this?"

    Lack of Female Mentors

                Another partner, Dr Jamie Kemp, raised the issue of mentors. As her medical school progressed, Kemp found herself drawn to numerous specialty fields—urology, ophthalmology, and general surgery, for instance—but there were no female mentors in those fields at her training program.

                During her internal medicine rotation, however, she found countless female mentors, and midway through her second year, Kemp met Dr Athena Poppas, whom she described as a "renowned echocardiographer" and "a towering Greek woman with a physician husband." With Poppas as her attending, Dr Kemp"s love of cardiology grew.

                Our female interventional cardiologist, Dr Sreedevi Gondi, wrote, "I had so few female mentors, and none of them were interventional. And although I did have male attendings that were supportive, encouraging even, it was with an underlying understanding that as a female I was making my life harder by choosing this path."

                Gondi also cited "the masculine culture, [which] can [be] intimidating and difficult to navigate," as a barrier to women entering interventional cardiology.

                This lack of encouragement can begin before training. "When I was in residency and was gung-ho about cardiology, I can"t tell you how many people told me not to do it, that I couldn"t have a family, that I"d be miserable, that it was a terrible field for a woman, etc," noted Dr Jennifer Lash, who was undeterred at the time because she was single "and absolutely convinced I"d NEVER EVER in a million years want children."

     What About Sexism?

                Dr McFarland faced sniping and grumbling from former colleagues when she was pregnant. During her fellowship, a male electrophysiology attending noticed her condition and commented that "it was really not a good time for this." Years later, when McFarland announced her second pregnancy to her first private-practice group, she recalls being surprised by less-than-congratulatory comments from her male partners. One such comment: "I heard about your situation."

                I recently had dinner with a young colleague from Germany who told me about a German law that allows new mothers to have 1-year (paid) maternity leave, while new fathers get 6 months off. From an American frame of mind, I wondered how hospital and residency programs make this work. My friend said it"s easy: they know the law, and they plan for it.

                McFarland experienced no such luck. She worked in the cath lab until the day of delivery and was back to work within 4 weeks—which was her allotted vacation time. The worst part: she and other female cardiologists do extra call while pregnant to make up for the call nights they miss during their measly 6-week leave.

                Kemp was also subject to sexism during her training. "If I expected too much out of the residents, I was a "bitch." If I expected too little, I was "mothering them." No correlates existed for my male counterparts."

                Lash, who describes herself as thick-skinned regarding sexist comments, cited the "machismo" factor as one of the reasons she chose cardiac imaging as a subspecialty rather than interventional cardiology. Describing the culture of the cath lab during her fellowship, she wrote: "The thought of spending another 1 to 2 years of interventional fellowship having to listen to remarks about myself or other women was not appealing."

                Did sexism deter any of these women from choosing my beloved field of electrophysiology (EP)? Here the verdict was unanimous. No. They simply found EP tedious and boring. One of them said she "hated EP." (That comment stung.)

     Family and Professional Responsibilities

                Family considerations were repeatedly mentioned as a limitation to choosing interventional cardiology. Kemp loved interventions, her male mentors encouraged her to do it, but she married a general surgeon and wrote that "adding another shitty schedule to that mix was damn near impossible."

                Lash, who changed her mind about never having kids, was also concerned about her "quality of life and increased call responsibility."

                Gondi emphasized the seriousness of interventional call: "Call is call, but few calls involve dropping everything to rush to the hospital within 30 minutes. That can make it difficult to have other responsibilities outside of work when you are on call." 

    I did not know the acronym SAHM—for stay-at-home mom—until Kemp wrote that in her fellowship most of the male interventional cardiologists had SAHM wives. This is an important point.

                When I started private practice, my wife Staci delayed her medical career for a decade to stay at home and care for our children. We had our first child during our training. I sort of appreciated Staci"s professional sacrifice at the time, but I really do now. I can"t cite formal statistics, but it seems many more men than women in cardiology enjoy the benefit of a stay-at-home spouse.

               

    Lack of Job-Sharing Opportunities

                In many professions, job sharing improves the situation for women professionals. But not so much in cardiology. As Gondi wrote, "There is no good way to be "part-time" if you want to remain productive and a competitive proceduralist."

    The key word in that sentence is productive. To this day, despite whispers about moving to value-based compensation, private-practice cardiology remains beholden to productivity. Perhaps this will change in the future. Perhaps more women in cardiology will nudge us away from the awful productivity model.

     Conclusions

                A provocative 2016 study published in JAMA Internal Medicine reported that elderly hospitalized patients treated by female doctors had lower mortality and readmissions compared with those treated by male doctors.[2]

                One way to explain these findings is to say it"s an observational study with unmeasured confounders. Another way is to cite evidence that female physicians have different, often more patient-centered practice patterns,[3–6] adhere better to guideline-directed care,[7] and score better on exams.[8]

                As a young learner, one of the factors that drew me to cardiology was leadership. Cardiologists led in producing evidence that guided practice; we led in innovation; and my mentors held leadership positions in the hospital and professional societies.

    In 2017, male dominance of cardiology is embarrassing. It"s time for leadership; it"s time we create a branch of medicine that works for both genders.

                We should do this not only because it is just, but also because the added talent will advance our field, and likely improve patient outcomes.

    John Mandrola, MD

    http://www.medscape.com/viewarticle/880656#vp_1





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