Women are underrepresented in cardiology and there is a focus on increasing entry to the specialty and understanding how to overcome challenges. At the British Cardiovascular Society (BCS) annual conference 2019, there was a session dedicated to discussing barriers faced by women in cardiology and progress made in this area, making a ‘call to action’ for change. Representing and supporting women in cardiology is a priority of the BCS and the British Junior Cardiologists’ Association (BJCA). The BJCA has undertaken commendable work exploring challenges and proposing potential solutions: much of the data discussed in this article are from their annual survey or was reported at BCS 2019.
Current status of women in cardiology
In the UK, women make up 28% of higher specialty trainees and 13% of consultants in cardiology.1 This is a stark underrepresentation, particularly as women make up over half of doctors in Core Medical Training. One might expect that we were on our way to catching up with other medical specialties in terms of representation, but change has been slow, with no big increase in the percentage of women applying for cardiology for the last few years.
The most recent BJCA annual survey demonstrated that gender differences persist in subspecialty interests in cardiology.2 This year, the most popular choice for women became cardiovascular imaging (24% of women) edging ahead of coronary intervention (22%). Whereas the most popular choices for men remained coronary intervention (41% of men) and electrophysiology (16%). Notably, female trainees were more likely to change their preferred subspecialty during ST3–ST5 away from intervention and electrophysiology in favour of imaging, heart failure, and adult congenital heart disease (ACHD) (although the absolute number of male trainees is still greater in all subspecialties except for ACHD); whereas male trainees were more likely to stick with their initial career intentions.3 Reasons for this are not clear and likely multi-factorial. The perceived availability and support for less than full-time (LTFT) training in cardiology might be a contributory factor. In the combined medical specialties, 15% of trainees are LTFT and, of these, 91% are female.1 However, in cardiology, only 4% of trainees are LTFT and, of these, 69% are female.4
Why are more women not choosing cardiology and what challenges remain for inclusivity?
In a BJCA survey published in the European Heart Journal, trainees were asked if they had been subjected to or witnessed sexism during training.3 Results revealed women experienced sexism more often than men and, in particular, in the latter years of training (15% of women at ST5 level reported experiencing sexism). Sexism was also more prevalent in tertiary centres (17.8% of women) – the traditional homes of coronary intervention and electrophysiology. Additionally, sexism was higher in research – an increasingly important aspect of career progression. Interestingly, while female authorship of research articles (as first and second author) is increasing internationally, cardiology still lags behind general medicine in this regard.5 It is possible that the prevalence of sexism could discourage women from pursuing cardiology, and influence subspecialty selection or academic pursuits. In future surveys, the BJCA aim to further investigate trainees’ experiences of sexism and to monitor trends.
At BCS 2019, Professor Barbara Casadei, President of the European Society of Cardiology, acknowledged the importance of tackling sexism and offered a related concept for discussion: paternalism. Professor Casaedi spoke of witnessing paternalism in UK cardiology, describing it as the “slow, polite erosion of confidence”. She illustrated her description with an example of trainees who, upon revealing their ambitions, were repeatedly cautioned against the difficult path ahead, particularly if planning for a family.
Flexible/controllable working lifestyle
Compared with other specialties, a smaller proportion of trainees work LTFT in cardiology. The BJCA conducted a survey to explore the experiences of LTFT trainees in cardiology,4 which was discussed at BCS 2019 by Dr Rebecca Dobson, cardiology specialty trainee at Liverpool Heart and Chest Hospital NHS Trust. Results revealed that many working LTFT felt they had a good work-life balance. Importantly, it was noted that many received good support from supervisors and training programme directors. However, Dr Dobson explained that trainees also felt there was a perception that training LTFT meant they were not as dedicated as their full-time colleagues, they noted missing training opportunities, and described feeling guilty when gaps were created in the rota, which colleagues had to cover. It is not clear whether rota gaps are indeed created, or rather filled, by LTFT trainees, many of whom job-share or are occasionally supernumerary in rotas; nevertheless, unfavourable perceptions persist. The BJCA are currently in the process of creating a LTFT guideline to promote equitable rotas and to share best practice. Furthermore, the LTFT cohort is predominantly, but not exclusively, female, and it is important that men training in cardiology are equally supported and feel able to pursue LTFT training.
Supported return to work after a period of absence is an important issue for staff welfare and patient safety. Trainees may have time out of programme for a variety of reasons including maternity, shared parental leave, research, or ill health. Dr Dobson highlighted the loss of confidence that can follow even a short absence from clinical practice. She explained that ‘keep in touch’ days, shadowing, and rota adjustments (i.e. phased re-introduction into the catheter lab) can be immensely valuable. Return to Practice Guidance was published by the Academy of Medical Royal Colleges and promotes a structured and supported return to work focused on individual needs.6 At BCS 2019, Dr Cara Hendry, advised that a course supporting return to work in cardiology is planned.
While access to LTFT and supported return to work are not challenges exclusive to cardiology, they are relevant to discussions on improving the experience of trainees and boosting the fairly static application rate to cardiology for women. Particularly as a recent systematic review documented ‘flexible/controllable working’ as a key factor influencing career choices for medical students.7
Engaging medical students and junior doctors
Increasing the number of women in cardiology relies on engaging students and junior doctors. The interest is there: a national BJCA taster day in cardiology in 2018 for pre-registrar level trainees and students attracted an audience that was 65% female. At these events, we have the opportunity to promote the profession and allay any concerns or stereotyped beliefs. However, we should not forget about the difference we can make locally. At BCS 2019, Dr Hannah Sinclair, Cardiac Imaging Fellow and Women in Cardiology representative for BJCA, emphasised that students and juniors should be able to experience the breadth of subspecialties, in order to appreciate what cardiology has to offer. Improving the experience of students and juniors in cardiology is vital to engaging them as fledgling future cardiologists. A good clinical experience with excellent teachers can be all it takes to spark a career interest. The presence of mentors is acknowledged as another key factor influencing the career aspirations of medical students.7 There are many excellent mentors in cardiology – male and female – and mentorship for students, juniors, and trainees should be used to its full potential. The value of formal leadership training is increasingly recognised, and is an excellent way to help women achieve their career potential. This year, the inaugural cohort of the BCS Emerging Leaders programme, developed by Dr Sarah Clarke, immediate Past President of the BCS, was made up of almost 50% women.
Additionally, social media has provided a unique and equitable platform for networking. One report suggests that those who tweet about cardiovascular disease are more likely to be female.8 This engagement and interest should be harnessed into equal opportunities for men and women to hold positions on committees, chair panel discussions, and to deliver presentations at local, national, and international conferences.
Call to action: moving forwards together
It is not all doom and gloom. There is increasing recognition and rejection of sexism, better support for flexible training and returning to work, and renewed motivation for mentorship of students and juniors. We also have an increasing number of female role models in cardiology. BCS has demonstrated a commitment to stamping out sexism and have dedicated a specific session to Women in Cardiology at their annual conference for a second year running. A dedicated session was also held at the British Cardiovascular Intervention Society (BCIS) conference this year. However, there is still work to be done and the following action points illustrate how we can move forwards together:
- Call out sexism.
- Promote representation of women on committees and conference programmes/panels.
- Encourage and offer leadership training.
- Support trainees who wish to train LTFT and ensure all trainees have access to this pathway.
- Support return to work through a structured local programme. Additional guidance and support from national bodies (i.e. BCS) would also be highly valuable.
- Advocate for trainees and provide good mentorship and support for students and juniors.
- Inspire the next generation.
Conversations regarding women in cardiology must focus on the promotion of positive working environments. Furthermore, these conversations should promote wider discussion on how we support each other as a community. As working pressures increase, support from colleagues and mentors is paramount. Let us work together to ensure cardiology is an inclusive and supportive specialty in which to train and work.
Conflicts of interest
1. Royal College of Physicians. Focus on physicians: census of consultant and higher specialty trainees 2017–2018. London: RCP, 2018. Available from: https://www.rcplondon.ac.uk/projects/outputs/focus-physicians-2017-18-census-uk-consultants-and-higher-specialty-trainees [accessed 24 June 2019].
2. British Junior Cardiologists’ Association (BJCA). Trainee Survey 2019. London: British Cardiovascular Society, 2019. Available from: http://bcs.com/documents/23B_BJCA_Survey_BCS_Presentation_2019_Final19791.pdf [accessed 24 June 2019].
3. Sinclair HC, Joshi A, Allen C et al. Women in cardiology: the British Junior Cardiologists’ Association identifies challenges. Eur Heart J 2019;40:227–31. https://doi.org/10.1093/eurheartj/ehy828
4. Dobson R, Joshi A, Allen C et al. Less than full-time training in cardiology. Heart 2019;105:1445–6. https://doi.org/10.1136/heartjnl-2019-315226
5. Asghar M, Usman MS, Aibani R et al. Sex differences in authorship of academic cardiology literature over the last 2 decades. J Am Coll Cardiol 2018;72:681–5. https://doi.org/10.1016/j.jacc.2018.05.047
6. Academy of Medical Royal Colleges. Return to Practice Guidance 2017 Revision. London: Academy of Medical Royal Colleges, 2017. Available from: http://aomrc.org.uk/wp-content/uploads/2017/06/Return_to_Practice_guidance_2017_Revison_0617-2.pdf [accessed 24 June 2019]
7. Yang Y, Li J, Wu X et al. Factors influencing subspecialty choice among medical students: a systematic review and meta-analysis. BMJ Open 2019;9:e022097. https://doi.org/10.1136/bmjopen-2018-022097
8. Sinnenberg L, DiSilvestro CL, Mancheno C et al. Twitter as a potential data source for cardiovascular disease research. JAMA Cardiol 2016;1:1032–6. https://doi.org/10.1001/jamacardio.2016.3029