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Gender Equity in the EP Field: Time to Ignite the Spark
Gender Equity in Cardiology
Women now constitute more than half of medical school graduates and 42%-46% of internal medicine residents; however, there is a well-recognized stepwise attrition as women progress to specialty and subspecialty training, with females representing only 20%-25% of Cardiology trainees and approximately 10% of procedural subspecialties (Figure 1).1,2 This percentage has remained relatively stagnant for over a decade, despite increasing awareness and concerted efforts to identify barriers to achieving gender diversity. This recruitment inertia is juxtaposed with trends in surgical specialties, whose female trainee representation has more than doubled in the last 10 years.3
According to several contemporary publications, commonly cited barriers to achieving gender diversity within Cardiology include a smaller pool of female mentors and role models, paucity of women in leadership positions, perceived and reported barriers to career progression, difficulty achieving work-life balance including family planning and lack of flexible training provisions, and perceived sexual harassment and gender discrimination.1,4,5
Women comprise only 14.1% of the overall Cardiology workforce, which is in stark contrast to other medical specialties such as endocrinology, rheumatology, and obstetrics and gynecology, where women constitute the majority of the physician workforce.5,6 This is despite similar on-call and after-hours commitments and procedural requisites in some of these disciplines, suggesting the presence of unique differences influencing the decision to (or not to) pursue a career in Cardiology and procedural subspecialties. Moreover, women are increasingly inclined to pursue a career in pediatric cardiology, with steady rises in representation between 2006 to 2016 at fellowship6 (40.4% to 50.5%) and consultant (27.1% to 34.0%) levels,7 highlighting an opportunity to learn from the successes of our medical and surgical colleagues.
Sex Gap in the EP Workforce
Despite the growing demographic data characterizing the Cardiology workforce, there continues to be significant variability in reporting female representation within subspecialty fields across international regions. Interventional cardiology (IC) comprising coronary intervention and cardiac electrophysiology (EP) continues to experience the lowest proportion of female physicians. Numerous publications have emerged highlighting the significant gender gap in IC and proposing solutions to promote diversity and inclusion.3,8 However, lack of international EP-specific data regarding gender equity leaves us ill-equipped to understand the perceived sex-specific barriers to the pursuit of a career in this field.
Less is known about the barriers to female entry into EP, despite both IC and EP representing procedural subspecialties that have historically been considered “male-dominated” fields, with similar rates of female underrepresentation at the fellowship (6%-13% vs 7%-10% in IC) and consultant levels (8.6% vs 4.9% in IC).9 Moreover, many would attest that the rigorous on-call commitments of IC including ST-segment elevation myocardial infarction (STEMI) call-ins may be more likely to dissuade women from pursuing a career in this field, when in fact, the EP workforce constitutes slightly lower or similar to IC.
There has been exponential growth in the field of EP, including significant procedural advances and evolving technologies. Despite efforts to increase female representation in the field, the sex gap within EP remains stark, with women comprising less than 10% of clinical EP fellows and 6% of consultants.5
A recent study by Abdulsalam et al found that among U.S. fellows-in-training (FIT), females were far less likely to express an interest in EP (16% vs 84%) and women interested in IC identified a lack of female role models, discrimination, and a perceived “boys’ club” as barriers to choosing EP as a subspeciality.5 While males and females identified common positive factors fostering the decision to pursue a career in EP, including positive mentorship, engaging field, prestige, specialty features, and expertise, female FITs commonly described a lack of female role models, long work hours, fear of discrimination/harassment, and radiation concerns as important dissuading factors. In contrast to earlier studies,3 the authors also reported that female fellows were equally likely to be married (48% vs 64%; P=.09) and have children (24% vs 36%; P=.56) than their male counterparts.5
Beyond these external factors is the element of personal choice — it has been suggested that the lack of female visibility within EP may dissuade women from entering the field on the assumption that work-life balance is not achieveable and perpetuates the stigma of EP as a “boys’ club.” Indeed, previous papers have described institutions with only a single female interventional cardiologist and the same can be said for EP, where many departments have very few or no female EP specialists. This highlights the importance of amplifying the voices of emerging and established women within the field and ensuring women are represented at all levels. This should extend to research, leadership positions, and collaboration in scientific sessions in program development and as presenting faculty. This will help to foster entry and retention of female talent into the field.
Sex Disparities in Clinical EP
Prevalence of cardiovascular diseases among women are not insignificant, with women accounting for 55% of atrial fibrillation (AF), 42% of acute coronary syndrome, and 47% of heart failure presentations according to U.S. registries.10 This is attributed to relative greater life expectancy among women, with accompanying accumulation of traditional and nontraditional cardiovascular risk factors across the lifespan.
There is ample recognition of long-standing female underrepresentation in clinical trials across the spectrum of cardiovascular disease management (Tables 1 and 2).11 This presents a substantial disadvantage for women who may either (1) benefit from treatments predominantly studied in men; or (2) may have different disease pathogenesis and clinical presentations requiring modified treatment strategies.
This is particularly evident in clinical trials examining arrhythmia management in patients with cardiovascular disease, where women are far less likely to receive timely diagnosis or be referred for device implantation or ablation procedures.15,16 This is, in part, explained by differences in disease development, whereby women tend to manifest cardiovascular disease in later life (on average, 10 years later than men), which may influence their relative consideration for procedures and inclusion in clinical trials.17 Despite greater attention generated toward achieving for sex parity in clinical trial enrollment, cardiovascular disease trials have shown minimal improvement over time, with recruitment remaining lowest (27%) in procedural cardiology trials.18
Furthermore, evaluation and reporting of sex-specific differences in clinical outcomes of major trials remains limited, despite women experiencing greater AF-related symptom burden and heightened risk of adverse drug responses although fewer repeat ablation procedures or direct cardioversion following catheter ablation for AF (Table 3).10
Time to Reset the Dysrhythmia of Sex Disparity in EP
Diversity has become a priority in Cardiology and EP, thanks to the advocacy and collaborative efforts of women in the field and male allies under the leadership of the American College of Cardiology (ACC) and Heart Rhythm Society (HRS). Recently, ACC and HRS established Diversity, Equity, and Inclusion (DEI) Taskforces to enhance engagement and inclusion through education, recruitment, retention, and leadership.
At the institutional level, there is also increasing commitment to enhancing female visibility within the field through academic and leadership appointments.
However, the overlap between childbearing and training periods will continue to hamper efforts to attract more women into the field unless institutions facilitate flexibility. Reducing the overall training period to 3-2-2 or 2-2-2 (in years: Internal Medicine-Cardiology-EP) might be one potential solution along with allowing flexibility towards work-life integration. Providing women with the option of protected time during pregnancy to focus on research and ambulatory services in place of procedural time if necessary is important. Equally, adequate training and supervision after such time should be provided to ensure procedural competency.
Procedural disciplines have additional unique considerations that must be recognized and addressed. For example, radiation exposure has previously been considered a concern for females contemplating a career in clinical EP, but the espousal of zero fluoroscopy procedures due to advances in mapping technology and availability of intracardiac echocardiography has revolutionized the field. This technological aspect of EP training is not well known outside the field of EP, and calls for early education and networking events to attract more female talent.
The key findings from the study by Abdulsalam et al highlighted the need to promote greater interest in EP among women at distinct early-career stages to enhance perceived acceptance and reduce perceived gender bias.5 The accompanying editorial proposed a framework to address existing barriers, including cultivating male allies, integrating local, regional, and national networking programs, promoting flexible training provisions, providing radiation safety education and provision of radiation-free procedural competencies, and enhancing a female- and family-friendly culture within EP.19 To facilitate mentorship and guidance, amplifying the stories of women in leadership positions can be impactful to attract more women into the field of EP. Personal narratives of role models affect unconscious and conscious career-life decisions and act as a source of reassurance for others.20
In the academic arena, funding bodies are increasingly promoting sex-specific cardiovascular research by developing specific grant applications to enhance discovery of sex-specific differences in cardiovascular diseases and treatment outcomes. Sex-related disease prevalence varies among cardiovascular disease subtypes, and therefore, recruitment should be adapted to better reflect differences in disease prevalence, known as the participation-to-prevalence ratio (PPR),10 rather than aiming for 50% female inclusion rates across the spectrum. Moreover, an improved understanding of sex-based differences may enable the medical community to better understand sex differences that are important to future guideline development in the evolving era of precision medicine and provide a more robust basis for translational research.
The benefits to workforce diversity extend to patient care, with a recent systematic analysis of 8 studies finding that patient-physician gender concordance influences clinical cardiovascular outcomes.21 This is of paramount importance in light of persisting sex disparities in patient cardiovascular outcomes. Further research exploring the impact of gender and gender concordance on the patient-provider relationship may have important implications for future cardiovascular and EP care (Figure 2). Increasing gender diversity in EP will likely enhance patient outcomes.
EP is an exciting field where analytical and logical deduction is combined with procedural and technological advances. Moreover, a career in EP has a multitude of options in clinical/procedural areas, academic/basic research, or industry/innovation. Despite persisting female underrepresentation, women are increasingly showing an interest in this field. Now is the opportunity to make great strides towards gender diversity in EP and keep the momentum.
We remain hopeful that in the future of EP, women will no longer be seen as “unicorns.” Echoing the sentiments of inspirational women in Cardiology: it’s time to reset the dysrhythmia of gender imbalance in the field of EP.
Disclosures: The authors have no conflicts of interest to report regarding the content herein.
References
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