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Shortage of Female Cardiologists: Exploring the Issues

2008; Elsevier BV; Volume: 83; Issue: 9 Linguagem: Inglês

10.4065/83.9.1022

1942-5546

Leslie A. Saxon, Anupama Rao, Kyle W. Klarich,

Medical Education and Admissions

Medicine is so broad a field, so closely interwoven with general interests, dealing as it does with all ages, sexes and classes, and yet of so personal a character in its individual appreciations, that it must be regarded as one of those great departments of work in which the cooperation of men and women is needed to fulfill all its requirements.Elizabeth Blackwell (1821-1910)1Elizabeth Blackwell: First Woman Physician. Women's History Web site.http://womenshistory.about.com/od/blackwellelizabeth/a/eliz_blackwell.htmGoogle Scholar This astute observation was made by Elizabeth Blackwell,1Elizabeth Blackwell: First Woman Physician. Women's History Web site.http://womenshistory.about.com/od/blackwellelizabeth/a/eliz_blackwell.htmGoogle Scholar the first female physician in the United States, and a leading figure in medical education for women. Rejected by all the medical schools to which she applied, Blackwell was eventually accepted at Geneva Medical College in New York as a practical joke. She graduated first in her class and went on to establish the New York Infirmary for Women and Children, the Women's Medical College at the Infirmary, and also the London School of Medicine for women. Since Blackwell's time, women have made enormous strides in medicine and are increasingly choosing specialties previously dominated by men. In 1975, less than 15% of students entering US medical schools were women.2Association of American Medical Colleges The changing representation of men and women in academic medicine.Anal Brief. 2005 Jul; 5: 1-2Google Scholar In contrast, in 2005, 51% of incoming medical students were women.3Association of American Medical Colleges FACTS—Applicants, Matriculants and Graduates: Applicants, Accepted Applicants, and Matriculants by Gender, 1992-2003. AAMC Web site.www.aamc.org/data/facts/2003/2003summary.htmGoogle Scholar In the past, women almost exclusively chose or were relegated to practice in the areas of pediatrics or family practice. Currently, women are successfully overcoming several barriers and are entering virtually every field, including surgical subspecialties, traditionally perceived as exclusively masculine disciplines. Recent data indicate an 88% increase in women in surgical residency training classes during the past 30 years.4Mills D Women in surgery: past, present, and future [powerpoint presentation].Maine Medical Center. 2003; (Accessed July 22, 2008.)www.womensurgeons.org/about/items/womeninsurgery2003c.pptGoogle Scholar An exception to these positive trends is in the field of cardiology. Less than 6% of fellows in the American College of Cardiology (ACC) and l4% of cardiology fellowship trainees are women. These numbers have shown only marginal increases during the past 10 years.5Fye WB President's page: women cardiologists: why so few [editorial]?.J Am Coll Cardiol. 2002; 40: 384-386Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar Reasons that the number of women entering this field is not increasing are not obvious, even to the Women in Cardiology Section of the ACC formed to study this issue. Exploration of the problem requires recognition of the unique familial and societal issues that come to bear on women at all levels of medical training. In parallel with these inequities, the past 5 years have witnessed several successful national efforts to increase awareness of the problem and scope of cardiovascular disease in women, notably the Go Red for Women campaign, which began in 2004 and is sponsored by the American Heart Association and endorsed by the ACC and First Lady Laura Bush.2Association of American Medical Colleges The changing representation of men and women in academic medicine.Anal Brief. 2005 Jul; 5: 1-2Google Scholar, 5Fye WB President's page: women cardiologists: why so few [editorial]?.J Am Coll Cardiol. 2002; 40: 384-386Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar, 6American Heart Association Go Red For Women Web site.www.goredforwomen.org/Google Scholar Unfortunately, if current trends in training for cardiovascular medicine continue, the half of US medical school graduates who are women will enter specialties other than cardiology and there will be too few female cardiologists to care for an aging population. These shortages will be felt most profoundly by female patients who prefer cardiovascular screening and treatment by female cardiologists. The Bethesda Conference article on cardiology's workforce crisis, published in 2004, found that the number of cardiologists (regardless of sex) needed during the next decade will not be adequately met by the current and future numbers of graduate trainees.7J Am Coll Cardiol. 2004; 44: 216-275Abstract Full Text PDF PubMed Google Scholar Two factors contribute to the shortage: reduced supply and increased demand. A common perception in the 1990s was that the United States was overproducing medical specialists.8Council on Graduate Medical Education Improving Access to Health Care Through Physician Workforce Reform: Directions for the 21st Century: Summary of Third Report. US Dept of Health and Human Services, Rockville, MD1992www.cogme.gov/rpt3.htmGoogle Scholar This belief and the promotion of primary care by the Clinton administration as part of a plan to reform the delivery of health care prompted a 1993 Bethesda Conference recommendation to decrease the number of trainees in adult cardiology.925th Bethesda Conference: future personnel needs for cardiovascular health care, November 15-16, 1993.J Am Coll Cardiol. 1994; 24: 275-328Abstract Full Text PDF PubMed Scopus (17) Google Scholar As a result, both the number of training programs and the total number of trainees have steadily decreased in the past 10 years. These decreases have occurred in parallel with increases in the prevalence and recognition of cardiovascular disease because of lifestyle trends and the changing demographics of elderly people. Consequently, the number of patients requiring cardiovascular care has increased, but there are fewer cardiologists to provide it.10Fye WB Introduction: the origins and implications of a growing shortage of cardiologists.J Am Coll Cardiol. 2004; 44: 221-232Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar The 2004 Bethesda report noted that the lack of women entering the field of cardiology was partly due to perceptions that a career in cardiology was not as family-friendly as careers in other specialties. The report highlighted the need for cardiology, as a specialty, to recognize and respect the overall societal trend toward improved balance between professional and personal life during training as well as throughout a career.7J Am Coll Cardiol. 2004; 44: 216-275Abstract Full Text PDF PubMed Google Scholar Despite considerable societal change, women are more likely to interrupt their training or practice for family duties (including raising children and caring for aging parents). Women also are more likely than men to identify these family responsibilities as hindering their career development. These perceived or real obstacles can be prohibitive for women considering cardiology careers.11Warnes CA Fedson SE Foster E et al.Working group 2: how to encourage more women to choose a career in cardiology.J Am Coll Cardiol. 2004; 44: 238-241Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar The shortage of women choosing to enter the field of cardiology, because of real or perceived barriers, undoubtedly affects the ability to increase the number of qualified cardiology specialists. A convincing argument can be made that the duration of cardiology training programs, now lasting 3 to 5 years after prerequisite training in internal medicine, and the typically long work hours are incompatible with women's desire to bear children. A graduating cardiology fellow will be at least 32 or 33 years old with an average medical school debt burden of $100,000, increasing the pressure to enter a full-time practice.12Association of American Medical Colleges, Division of Medical Education 2005 Medical School Graduation Questionnaire: Final: All Schools Report.www.aamc.org/data/gq/allschoolsreports/start.htmGoogle Scholar If a woman has not already married or had a child, these time and financial constraints pose substantial obstacles. Indeed, according to data from the ACC Professional Life Survey performed in 1998, 19% of female cardiologists are unmarried (vs 4% of men), and 37% do not have children (vs 12% of men).13Limacher MC Zaher CA Walsh MN et al.The ACC Professional Life Survey: career decisions of women and men in cardiology: a report of the Committee on Women in Cardiology.J Am Coll Cardiol. 1998; 32: 827-835Abstract Full Text Full Text PDF PubMed Scopus (75) Google Scholar These numbers do not differ substantially from those for women in other areas of medicine or other professions. In the field of pediatrics, in which women represent 55% of all pediatricians and 66% of residents, 17% of women are unmarried, and 23% have no children.14American Academy of Pediatrics, Division of Health Services Research Characteristics of male v female post-residency pediatricians [powerpoint presentation].www.aap.org/womenpeds/WIP%202005.pptGoogle Scholar, 15Association of American Medical Colleges Women in U.S. academic medicine: statistics and medical school benchmarking, 2004-2005. AAMC, Washington (DC)2005http://www.aamc.org/members/wim/statistics/stats05/start.htmGoogle Scholar, 16Sells JM Sells CJ Pediatrician and parent: a challenge for female physicians.Pediatrics. 1989; 84: 355-361PubMed Google Scholar, 17Noonan MC Corcoran ME Courant PN Pay differences among the highly trained: cohort differences in the male-female earnings gap in lawyers' salaries. National Poverty Center Working Paper Series [serial on the Internet]. May 2003.www.npc.umich.edu/publications/working_papers/paper1/03-1.pdfGoogle Scholar In the field of law, 30% of women are unmarried, and 36% have no children.17Noonan MC Corcoran ME Courant PN Pay differences among the highly trained: cohort differences in the male-female earnings gap in lawyers' salaries. National Poverty Center Working Paper Series [serial on the Internet]. May 2003.www.npc.umich.edu/publications/working_papers/paper1/03-1.pdfGoogle Scholar However, other than a decline in fertility as women enter their 30s and 40s, work-life balance issues are not unique to women. Both men and women are increasingly choosing specialties that are lifestyle friendly, and this trend is so pronounced that students often refer to “taking the E-ROAD” (emergency medicine, radiology, ophthalmology, anesthesiology, or dermatology).18Green L. Medical students opt for “Lifestyle” careers: specialty trend leaves a looming shortage in primary care. The Ledger.com. www.theledger.com/article/20080324/NEWS/803240345/1005/NEWS02 Accessed July 22, 2008.Google Scholar These specialties are recognized as being in highest demand among medical students today. Some attribute this trend to the differences between baby boomers and members of Generation X, who place a higher value on family life, autonomy, and flexibility than on material success, with medicine defining only part of their identity.19Resneck Jr, JS The influence of controllable lifestyle on medical student specialty choice. Virtual Mentor..http://virtualmentor.ama-assn.org/2006/08/msoc1-0608.html#2Google Scholar To attract the best and brightest in today's work force, the field of cardiology needs to be redesigned to be more lifestyle friendly. Mayo Clinic, a large academic multispecialty group practice, facilitates a part-time work model. In the cardiology department, 15 (11%) of 135 staff members work part-time during at least part of their career. Interestingly, 7 men (of 117; 6%) and 7 women (of 18; 39%) take advantage of this model. In the department of medicine as a whole, 15% of staff work part-time. Thus, highly trained women and men (although to a lesser degree) in medicine are considering lifestyle issues much more than their largely male predecessors. Perhaps a more fundamental issue underlying the descriptive statistics is the lack of an identifiable and realistic standard of what constitutes achievement for women. This lack of a standard has introduced confusion and unheralded diversity in the way professional women ultimately choose to live and work. Recent articles on this issue found that 42% of professionally trained women either choose part-time employment or quit their jobs entirely, at least for a time, to raise their children.20Goldin C Working it out The New York Times (late edition) March 15, 2006: A27.www.nytimes.com/2006/03/15/opinion/15goldin.htmlGoogle Scholar In the 1998 professional life survey by the ACC, 30% of female cardiologists reported interrupting training, and 46% interrupted practice for more than a month, largely for pregnancy or childbirth. However, only 20% of men interrupted training, and 13% interrupted their practice. Only 8% of women as opposed to 55% of men had all child care provided by a spouse.13Limacher MC Zaher CA Walsh MN et al.The ACC Professional Life Survey: career decisions of women and men in cardiology: a report of the Committee on Women in Cardiology.J Am Coll Cardiol. 1998; 32: 827-835Abstract Full Text Full Text PDF PubMed Scopus (75) Google Scholar Because of the lengthy training for cardiology, a woman contemplating the option of staying home for some years to raise her children can reasonably ask whether training is worth the time and effort. The absence of a substantial number of senior and contemporary female role models in cardiology serves as further disincentive. The choices and unique pressures that female trainees in medicine face at several junctures in their training could steer them away from cardiology training, even if it is a field for which they are otherwise suited. If a woman finishing internal medicine training is unmarried or does not have a permanent partner, she often experiences what we have termed the victim of achievement syndrome. This consists of a tacit and explicit reversal of support of the very traits that led her to a career in medicine. Societal pressures to marry or have children before “it's too late” can convince a female cardiology candidate to change her priorities and make major life decisions on the basis of the theory that she will be denied a fulfilling personal life. Coupled with the lack of role models, this can alienate and bring insecurity to a potential candidate considering another 3 to 5 years of training. In contrast, the female trainee's male counterpart is better positioned to benefit from his accomplishments and prepare for the next steps. Although he could face a similar debt burden, he can enter cardiology training with confidence in his continued appeal to the opposite sex as he becomes more successful and in the endorsement of family and society to accomplish more. The pool of women willing to stay home and raise children and organize the family's life is much larger than the pool of men willing to serve that role for the female trainee. At this juncture, the theoretical personal price of a career in cardiology certainly seems lower for male physicians. If a female trainee in internal medicine does indeed elect cardiology with an additional 3 to 5 years of training, she could be on the defensive from the very beginning. Another factor for female trainees in cardiology is exposure to radiation during procedures; although this has not been shown to be an adverse factor for conceiving or maintaining pregnancy, it does pose yet another perceptual hurdle for women.21Limacher MC Douglas PS Germano G et al.ACC expert consensus document: radiation safety in the practice of cardiology.J Am Coll Cardiol. 1998; 31: 892-913Abstract Full Text PDF PubMed Scopus (179) Google Scholar Although the risk of genetic defects or neoplasm from radiation exposure during procedures remains low, it nevertheless could be a concern for women considering a career in cardiology.13Limacher MC Zaher CA Walsh MN et al.The ACC Professional Life Survey: career decisions of women and men in cardiology: a report of the Committee on Women in Cardiology.J Am Coll Cardiol. 1998; 32: 827-835Abstract Full Text Full Text PDF PubMed Scopus (75) Google Scholar, 22Strzelczyk JJ Damilakis J Marx MV Macura KJ Facts and controversies about radiation exposure, part 2: low-level exposures and cancer risk.J Am Coll Radiol. 2007; 4: 32-39Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar In late pregnancy, it can also be uncomfortable for pregnant trainees to wear heavy lead protective covering and stand for extended periods during procedures. Because of the current structure of training programs and the shortage of coverage due to residency work-hour regulations, a pregnant trainee places coverage burden on others and taxes the organizational structure, effects that are unlikely to be met with enthusiasm. Any time taken off for maternity leave places the female trainee behind her peers in training rank. Although appropriate, this change in rank is psychologically difficult and can induce resentment in competitive training programs. Some fundamental and somewhat irresolvable issues of modern life are illustrated by the dilemma of women considering a career in cardiology. If the standard in Western society is to follow one's talents and ambitions to their ultimate capacity, is it also fair to set a yet even higher standard for women in cardiology, that is, to encourage women to do the former and yet somehow have children? In the past 3 years, 2 articles in The New York Times gave voice to highly educated women who feel disappointed in their workplaces. The women featured in these articles chose to leave the workplace to assume a traditional model of the woman at home supported by her husband (all the women in the profiles were married to successful men with high-earning jobs).23Belkin L The opt-out revolution.The New York Times (late edition). Oct 26, 2003; 6 (Accessed July 22, 2008.): 42http://query.nytimes.com/gst/fullpage.html?res=9807E0DE113EF935A15753C1A9659C8B63Google Scholar, 24Story L Many women at elite colleges set career path to motherhood. The New York Times (late edition) Sept 20, 2005: A1.http://www.nytimes.com/2005/09/20/national/20women.html?pagewanted=printGoogle Scholar Profiles of women who continue to train or work in demanding jobs and have alternative models for achieving and maintaining a family are difficult to find. If women had a sense that it is fundamentally acceptable to create an alternative pathway, they might not feel pressured to curtail their career dreams and might enter the field of cardiology in greater numbers. Mentorship is a well-validated method of attracting students to certain fields. Of women who responded to the 1998 Professional Life Survey of the ACC, 71% identified a mentor during their subspecialty training. Most of these women reported that their mentors were a positive influence for participation in research, for career encouragement, and as noncareer role models.11Warnes CA Fedson SE Foster E et al.Working group 2: how to encourage more women to choose a career in cardiology.J Am Coll Cardiol. 2004; 44: 238-241Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar With the paucity of women in cardiology, it is essential to leverage and optimally use the time of people willing to serve as mentors to women in medical school and graduate training programs. In-person lectureships and symposia are powerful tools, but full use of video, written, and other training tools is also influential. Biographical formats lend themselves to these types of communication. Specialized Internet-based sites identifying women in cardiology who are willing to serve as mentors are already in place but are underused, primarily because they are not reaching women in medical school and training programs. Key collaborations with medical schools and residency programs to increase awareness of and to create this type of content seem warranted. Innovative structures and training programs that encourage, and do not dissuade or stigmatize trainees from, pregnancy and childbirth are also critical. “Fast-tracking” internal medicine residents who express an early interest in cardiology into a fellowship could be an innovative way to reduce the length of training, which can be a factor for establishing a life outside the workplace. Some fields are already introducing such a pathway: vascular surgery has an accelerated 5-year general surgery/vascular surgery track approved by the Accreditation Council for Graduate Medical Education.25Goldstone J Wong V New training paradigms and program requirements.Semin Vasc Surg. 2006; 19: 168-171Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar A powerful way to attract women to the field of cardiology also includes using the collective voice of women currently in the field to champion health care and other meritorious issues that confront women worldwide today. This involves not only raising awareness of cardiovascular disease in women but also addressing other critical global health issues, such as abortion on the basis of the sex of the fetus and female genital mutilation. Organizing highly educated women around such crucial human rights issues can often be a more robust way of motivating women and attracting talent than mentorship alone. At a time when the size of the workforce in cardiology is inadequate, a large potential pool of well-trained, talented women are choosing not to enter the field. To address this serious issue, a shift in the way that women are recruited, trained, and retained in cardiovascular medicine is necessary. If we embrace the idea that women are a valuable asset to the practice of medicine and to cardiology in particular, we need to reassess the role, recognition, and expectations of women during training and after, including consideration of job sharing, shortened training tracks, and flexibility in promotion for academic appointments.