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 feel“de-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. 2019 Jan. 12 (3) 219–228
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. Journal of Women’s Health. http://doi.org/10.1089/jwh.2016.6044 Volume: 26 Issue 5: May 1, 2017. 413-419Speaker Introductions at Internal Medicine Grand Rounds: Forms of Address Reveal Gender Bias”,
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).
–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.