Walking the tightrope: women cardiologists in an old boys’ club

by Carolyn Thomas     @HeartSisters   

You know there’s trouble when the Women In Cardiology Leadership Council reports this year that their group (part of the American College of Cardiology) is “very frustrated and concerned about the lack of growth in the numbers of women pursuing a career in cardiology.”(1) 

And no wonder! Fewer than 13 per cent of cardiologists are women, despite what’s been called “a robust pipeline of female med students and internal medicine residents” who could choose this field.(2)  And I’d bet my next squirt of nitro spray that a man implanted your stent  – because only about 5 per cent of all interventional cardiologists (the ones specifically trained for this procedure) are women.

Female cardiologists are not only the minority in their profession, but “discrimination against women is entrenched in the culture of cardiology”; in fact, female cardiologists are more likely than males (96% vs 8%) to experience discrimination related to gender.(3)       .         .            .         .   

Dr. Celina Yong, who is one of those rare female interventional cardiologists out there, teaches cardiovascular medicine at Stanford University. She believes that “a gender-lopsided field can affect patient care.”

In her research, she identified “an old boys’ club” culture along with “a lack of female mentors'” and “discrimination” as specific real-life obstacles that keep women from entering or remaining in her profession.(4)  Others include concerns about work-life balance, limited leadership opportunities and a significant pay gap between men and women.

Despite those issues, 88% of current female cardiologists say that they’re moderately-to-very satisfied with their career choice. Yet the obstacles are still bad news – because there are so many good reasons to recruit and retain more women, as Dr. Yong explained:

“Overcoming the culture is going to take a concerted effort, but it would be worth it and would benefit patients. Women approach patients’ problems differently, which can expand possibilities for effective treatment. Also, women can bring a different perspective when it comes to research. When both men and women design studies and analyze data together, we do a better job, especially when it comes to treatment of female patients.”

She also addressed the predictable consequence of missing out on talent:

“If we consistently fail to recruit the best female trainees, we are losing out on the opportunity to advance our field.”

This might be a good time to interject a reminder here about that interesting 2018  study from Florida that found female patients are 2-3 times more likely to survive a heart attack when the doctor overseeing their care is also a woman. The cases that seemed to be exceptions were those in which male doctors worked in Emergency Departments that had a higher percentage of female physician-colleagues or more experience treating female patients.(5)

Mayo Clinic cardiologist Dr. Sharonne Hayes is the Director of Diversity & Inclusion, professor of Cardiovascular Medicine, and founder of the Mayo Women’s Heart Clinic. Her compelling online webinar presentation last month (she was one of an all-female trio of cardiologists speaking to their colleagues) was called “Effecting Change: Professionalism, Bias & Burnout”.(6)

While watching her presentation, I couldn’t help wondering about this “old boys’ club” culture in cardiology. In the year 2020, how could this kind of bias – either implicit or explicit – still be tolerated by their intelligent, educated female colleagues?  But realistically, there are likely few if any professions that don’t harbour at least a few representatives of their own ‘old boys club’.

Dr. Hayes also described “micro-aggressions” – as damaging as telling women out loud that they don’t belong. The term, originally defined to describe racial biases, also applies to reactions based only on another person’s ethnicity, age, appearance or gender.

Micro-aggressions may seem at first blush to be harmlessly sanitized comments. Dr. Hayes rejects that depiction – for example, the male physicians who introduce their male peers as “Doctor”, but refer to her as “Sharonne”. 

Dr. Hayes has in fact co-authored a study on this issue, published in the Journal of Women’s Health.(7)  The study determined that this gender bias while addressing women is not only annoying, but it’s astonishingly common. For example, she and her research colleagues found that female doctors being introduced by male doctors at Internal Medicine Grand Rounds were far less likely to be addressed by their professional titles (e.g. “Doctor”) than were the male doctors introduced by other men. Dr. Hayes explained:

“It’s the inequity and the context. I don’t mind being called ‘Sharonne’ — it’s my name! — but if all the men are being called ‘Doctor Jones’ and all the women by only their first names, that’s offensive. While I have to assume it’s inadvertent, the effect is to put me in my place.”

Dr. Hayes also asked her cardiology colleagues attending the webinar presentation if they could remember a time when . . .

  • you spoke up, but nobody heard you
  • you shared an idea, but then HE repeated it and got credit
  • you weren’t even in the room for the conversation/when the decision was made
  • you didn’t know the rules of the game
  • you were patronized
  • you got stuck
  • you fell silent, and became “de-skilled”
  • you got put in your place

“I’ve experienced all of these,” Dr. Hayes assured her audience.

She also described female cardiologists as “walking a tightrope”, which she explained to mean“too feminine to be competent vs. too masculine to be likeable”. High status jobs, she noted (like being a cardiologist, for example) are often seen as requiring ‘masculine’ qualities (e.g. calm, decisive, confident) as opposed to ‘feminine’ qualities (e.g. modest, communal, self-effacing) – adding that racial and minority groups are especially affected by this expectation.

“We are dealing with others’ cultural expectations of what and how a woman should ‘be’ and ‘act’ while getting one’s work done.”

The deep roots of gender bias in medicine have been a challenge for a long time everywhere. In their Canadian Journal of Cardiology commentary called The Girls in the Boys’ Club, Drs. Michelle Graham and Catherine Kells (both interventional cardiologists, coincidentally) reflected on their own early career experiences.(8)

As Dr. Kells explained:

“In 1984, it was so rare to have a woman choose cardiology that no one really had any advice to give me. So, I blindly started my training with little to no idea how difficult it would be to balance a career in cardiology with a family life as a wife and mother. The obstacles came in strange places and sometimes from unexpected sources. Nurses, patients, friends, family and colleagues would occasionally make comments like, ‘Women should not be in the cath lab’ or ‘When you have children, you will give up all this nonsense’. My particular favourite was, ‘You marry a wife; you call a doctor’ .”

Dr. Graham, arriving in the profession 10 years later than Dr. Kell, added her own story: 

“By the 1990s, a decade later, we had made progress in cardiology,  but my experiences unfortunately highlight ongoing issues. When I was an internal medicine resident, most of the attending physicians told me, ‘Don’t do it, you won’t have a job’.  To make matters worse, many of my friends said, ‘Don’t do it, you’ll never meet anyone, get married, have a family, have a life …’  

“This specialty really was a ‘boys’ club’. By 1996, I was still the only female in my cardiology residency program in the three years I was there. One of the male interventionalists told me that ‘women don’t belong in the cath lab’. However, I think that things would have been much harder for me had I not had the unique mentorship of my program director, Dr. Catherine Kells, to show me that women can have both a successful career in cardiology and a family – but not without pain and effort.”

That’s the historical background from yesterday behind what Dr. Sharonne Hayes is describing about women in cardiology today.

Dr. Hayes acknowledged during her webinar presentation that, while there’s a lot of self-help advice out there to assist women in coping with pervasive discrimination, the system is broken, and we need to stop ‘fixing’ women”.

She also talked about what she calls the stereotype identity threat that most female cardiologists have personally experienced on some level.

When you’re aware of a negative stereotype about your group, she explained to her audience, your attention is split between the activity at hand and your concerns about being seen stereotypically – which can divert your cognitive resources  – the skills that would otherwise be used to help maximize your performance. 

By the way, I’ve observed that my own cognitive resources evaporate whenever I have tried to squeeze my car into a tight parking spot if a bunch of (male) construction workers happen to be standing nearby watching. Even an experienced parallel parker like me can be reduced to giving up in a sweaty heap before abandoning a perfectly good parking spot in order to avoid critical stares and mocking comments.

Dr. Hayes shared this example of how a stereotype identify threat can work to derail abilities:

“I’m getting up in front of the boardroom to do a presentation on women’s heart disease or diversity and inclusion in the workplace. I’m the expert in the room, but I walk into a room filled with white grey-haired male leaders, and I feelde-skilled”. I am ready, I practiced this – but suddenly I cannot find my words!” 

She adds that a similar reaction is common among other negative stereotype identity scenarios, an example being the short kid on the basketball team.

Watch her webinar for more fascinating facts about this dilemma, and also some useful tips for women already working as cardiologists on how to stop feeling like that short kid on the basketball team. . . 


1. Lundberg, Gina et al. “Addressing Gender Equity in Cardiology”, American Journal of Medicine, Commentary, 2020 Elsevier Inc. doi.org/10.1016/j.amjmed.2020.05.016

2. Mehta LS et al.  “Current Demographic Status of Cardiologists in the United States”. JAMA Cardiol. 2019 Oct 1;4(10):1029-1033. doi:10.1001/jamacardio.2019.3247.

3. Maxwell, Y. “Discrimination Still Runs Rampant for Women in Cardiology”. TCTMD, April 2, 2016.

4. Celina M. Yong et al.  “Sex Differences in the Pursuit of Interventional Cardiology as a Subspecialty Among Cardiovascular Fellows-in-Training”. J Am Coll Cardiol Cardiovasc Interv 12 (3) 219–228

5. Greenwood, Brad N et al. Patient–physician gender concordance and increased mortality among female heart attack patients.” Proceedings of the National Academy of Sciences 115.34 (2018): 8569-8574.

6. The free webinar,“Effecting Change: Professionalism, Bias & Burnout”, presented by the American College of Cardiology’s Women in Cardiology Section. Speakers included cardiologists Dr. Sharonne Hayes, Dr. Jennifer Mieres, and Dr. Laxmi Mehta on the topics of professionalism, biases, and preventing burnout. October 29, 2020

7. Julia A. Files et al. “Speaker Introductions at Internal Medicine Grand Rounds: Forms of Address Reveal Gender Bias”, Journal of Women’s Health. http://doi.org/10.1089/jwh.2016.6044 Volume: 26 Issue 5: May 1, 2017. 413-419

8. MM Graham, CM Kells. “The Girls in the Boys’ Club: Reflections from Canadian Women in Cardiology.” Can J Cardiol 2005;21(13):1163-1164.

Q:   Any ideas on how cardiology could be more welcoming to women in the profession? 

NOTE FROM CAROLYN:  I wrote about the cardiology gender gap (but from a patient’s perspective) in my book, A Woman’s Guide to Living with Heart Disease , published by Johns Hopkins University Press in 2017.  You can ask for it at your local library or favourite bookshop, or order it online (paperback, hardcover or e-book) at Amazon, or order it directly from my publisher (use their code HTWN to save 20% off the list price).

See also:

Women in Cardiology: “Underrepresented, Underestimated, and Undervalued“:  (Four papers in the journal JAMA Cardiology tackle the issues affecting women who are thinking about joining or who have already joined the male-dominated field); article published in TCTMD.

A list of several Heart Sisters articles about gender bias in medicine

 

10 thoughts on “Walking the tightrope: women cardiologists in an old boys’ club

  1. As other commenters have noted, this behavior is not limited to cardiology or even medicine.

    I certainly saw and experienced it and most professional women I know who work in male dominated professions have encountered that type of treatment. It is unfortunate but true.

    Liked by 1 person

    1. Hi Helen – absolutely 100% correct! Medicine – including cardiology – mirrors societal norms in male-dominated professions, where we know that women tend to earn less/are promoted less/are harrassed more than their male colleagues. Still a long way to go!

      I like to believe that my daughter’s generation will be less willing to sit back and politely tolerate what her mother did for decades… much like we’ve seen in the #MeToo movement that finally reared up against generations of bad behaviour. Small steps…

      Take care and stay safe… ♥

      Liked by 1 person

  2. Lord, the adult world is a competitive place, no matter the field of employment. Being a high achieving high school student was lonely. Yes. But it also taught firmness of mind and observation. I was a geek who loved to sail, ski, play tennis and bike with the guys. The mean girls club had a lot of haters and they taught me well.

    Being one of three women studying engineering in my university in the 1970’s felt like being a zoo animal, all three of us smart women were highly competitive in our abilities.

    We challenged and questioned with the best of them, ignoring the moronic statements from among the faculty and fellow students, and socially from our friends and family. One learns to choose your friends carefully, surround yourself with a quorum of protectors who have your back. Life became strategic and political. All those mean girls prepared me for it. It was here that you learned how to put a stick into the BS… if you needed to graduate. The mean girls helped me with the “how to” on that as well.

    We would have had difficulties finding employment if it hadn’t been for the equal rights movement. That movement, however, raised resentment amongst the workforce – the only reason you were hired is because you fulfilled a requirement. True.

    Now it was time to get into the cockfight and play to win. Our opponents knew our weak spot – our families – and there were no shortage of dirty tricks and political moves meant to derail our careers. Find a way or wither away. We had formed our allies and our quorums morphed as our career developed.

    And we mentored the new hires – male and female. That is what natural leaders do. Suffice it to say, I had a very interesting career until my heart gave out. Too many years of dealing with the assholes, even with the help of my quorum. And I am forever thankful that Dr. S. Hayes has my back. She saved my life.

    Do I regret my choices? No. Learned a lot for sure. And now I hope and pray my daughter continues to include me in HER quorum as she starts her professional career. I am not a doctor, but I have earned my ticket and know there is a game and how to it.

    Liked by 1 person

    1. Thanks Anne for sharing that unique perspective – engineering in the 70s?!? Oh my! Challenging, but definitely a step up from the ‘mean girls’ back in high school. I felt sad while reading “no shortage of dirty tricks and political moves meant to derail our careers” – that for so many women was just a fact of life back then. It’s like those men believed in a zero sum game: if you did well, it would be bad for THEM. For me, it was like working with a bunch of babies sometimes… but worse, babies with power so that we had to be “strategic and political” in a way that few men fresh out of the gate ever have to encounter.

      I’d like to believe that women today don’t have to fight just to be heard, but what I was learning while writing this post was that we still have intelligent, educated, competent women working in cardiology who actually have (male) cardiologists around them, as Dr. Hayes listed, trying to “put them in their place”. What the hell is that all about?

      Very discouraging…

      Take care, stay safe… ♥

      Like

      1. Carolyn,
        It is the assholes and their battles that make you either wise/experienced or dead. Adapt or die. That doesn’t mean give up or give in. You lean into it and learn – and teach/guide/mentor. Treat people with respect and kindness. That doesn’t mean rainbows and unicorns, but communicate clearly with a cool head.

        Of course, women – or anyone who is different – today are faced with the same moronic nonsense. Ignorant people must resort to stupid tactics as they cant carry the battle on intelligence. You can and should correct people, but it helps if it’s not done in public so that they lose face. Adding anger and embarrassment only prolongs the disappointment of conflicting opinions. Same as raising a child. Appreciate publicly and be critical in private and do it with kindness and respect.

        Putting anyone in their place sounds like a power struggle – and the struggle is within someone’s noggin. Drink up that mug of coffee and get into the game. Playing the victim role is never going to earn the yardage in the game of life.

        Liked by 1 person

        1. Hi again Anne – glad you mentioned ‘teach/guide/mentor’. So important… Dr. Hayes talks about this in her webinar (worth a watch – the first 23+ minutes of this 90-minute webinar).

          At one point, she warns women against following ‘gender modesty norms’ (most men sure don’t follow them!) and also urges her female colleagues to BOAST publicly (authentically of course!) about each other’s science, clinical practice, accomplishments, etc. (she uses hashtags like #AmplifyHer #PromoteHer #QuoteHer and #CiteHer to remind them).

          BTW, there isn’t a hint of “playing the victim role” in any of her observations or experiences (or those of the other cardiologists whom I quote here). Hence the stats: 88% of female cardiologists say they like being a cardiologist – DESPITE what they (and let’s face it, most women in every other profession) have to put up with simply being a woman in a male-dominated profession. Naming it doesn’t mean they’re not “in the game” – it means they’re no longer willing to suck it up when facing “moronic nonsense”.

          Like

  3. Just a question to go with your question:
    Is there ANY medical field that is not an old boys club?

    It seems the “glass ceiling” is pretty pervasive in most specialties … except maybe OB -GYN or neonatology? ( just guessing)

    I’m older but definitely remember “Boys become doctors and girls become nurses“.

    Liked by 1 person

    1. Hello Jill – in answer to your question: “Is there ANY medical field that is not an old boys’ club?” – I think NOT! You only have to read Maya Dusenbery’s book Doing Harm to get a small glimpse at how pervasive the problem is throughout all specialties.

      But medicine simply reflects what goes on in the rest of society, where women have had to fight for every inch of fairness they get. I’ve spent my entire 35+ year career in public relations (corporate, government and non-profit sectors) and certainly witnessed that the ‘old boys’ generally ran the show throughout each of those sectors, many otherwise nice guys who simply didn’t ‘get’ it. Back then, they’d argue to your face why it made sense that you were making half of what the young guy you were training was earning… One director argued for example that he couldn’t even add the word “senior” to a star female colleague’s job title “because that wouldn’t be fair to all the men on her team who don’t get that same title change, too”….

      It’s not just in medicine. It’s everywhere!

      Take care, stay safe… ♥

      Like

  4. Just have to say I’m really grateful for my cardiologist, who is the only female doctor in her office. I have met and talked with several of the male cardiologists because of the heart patient support group I used to lead and the cardiac issues in our family.

    I respect them too, they are highly competent, but I really prefer women doctors in general. My impression is that my doctor is respected and treated equally by her colleagues. However, you are right in that the interventionists in the practice are male, including the one who placed my two stents.

    I also am grateful for the three female nurse practitioners that have been in their office (one left). They have been very helpful in explaining things to me; the one who left was instrumental in encouraging me to do the first cath. NPs have more freedom and flexibility to connect with patients in ways that a busy doctor might not be able to, and routine follow-up appointments with them free up the doctors to do the more serious procedures, like stress tests.

    But I mean really, doesn’t every woman just appreciate another woman to talk to? I know I do!

    Liked by 1 person

    1. Hi Meghan – you make an excellent point about Nurse Practitioners, who have the gift of TIME on their side, compared to the MDs they work with who are often overbooked and running hard. NPs have time to listen, time to discuss, time to help in shared decision-making – as you experienced firsthand.

      I happen to have a terrific male cardiologist (and I’m SO happy to have him on my team!!) but I’ve also met MANY terrific women who are cardiologists. Often it’s a matter of finding a good personality fit, although emerging research continues to suggest a clear difference in communication styles between the two sexes – and as in the Florida study, even improved survival rates if the physician in charge of care is a woman!

      Take care, stay safe… ♥

      Like

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