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• W2964973181 abstract "HomeCirculation: Heart FailureVol. 12, No. 7Perceived Generational, Geographic, and Sex-Based Differences in Choosing a Career in Advanced Heart Failure Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplementary MaterialsFree AccessResearch ArticlePDF/EPUBPerceived Generational, Geographic, and Sex-Based Differences in Choosing a Career in Advanced Heart FailureAn International Survey Yasbanoo Moayedi, MD, Steven G. Hershman, PhD, Heather J. Ross, MD, MHSc, Kiran K. Khush, MD, MAS and Jeffrey J. Teuteberg, MD Yasbanoo MoayediYasbanoo Moayedi Ted Rogers Centre of Excellence in Heart Function, University Health Network, Toronto, Canada (Y.M., H.J.R.). Division of Cardiovascular Medicine, Department of Medicine, Stanford University, CA (Y.M., K.K., J.J.T.) Search for more papers by this author , Steven G. HershmanSteven G. Hershman Division of Cardiovascular Medicine, Department of Medicine, Stanford University, CA (S.G.H.) Search for more papers by this author , Heather J. RossHeather J. Ross Ted Rogers Centre of Excellence in Heart Function, University Health Network, Toronto, Canada (Y.M., H.J.R.). Search for more papers by this author , Kiran K. KhushKiran K. Khush Division of Cardiovascular Medicine, Department of Medicine, Stanford University, CA (Y.M., K.K., J.J.T.) Search for more papers by this author and Jeffrey J. TeutebergJeffrey J. Teuteberg Jeffrey J. Teuteberg, MD, Stanford University, 300 Pasteur Dr, Falk Research Bldg, CA 94305. Email E-mail Address: [email protected] Division of Cardiovascular Medicine, Department of Medicine, Stanford University, CA (Y.M., K.K., J.J.T.) Search for more papers by this author Originally published12 Jul 2019https://doi.org/10.1161/CIRCHEARTFAILURE.118.005754Circulation: Heart Failure. 2019;12:e005754One’s decision to pursue a career in medicine is multifaceted. Subsequently, the choice of subspecialty can be guided by several factors, such as interest in specific diseases, research focus, income, and other professional opportunities. With the growing prevalence of heart failure and the maturation of mechanical circulatory support, there has been a 200% increase in the number of trainees pursuing advanced heart failure and transplant cardiology as a subspecialty from 2012 to 2018. Concurrent with this expansion, there has been a tripling in the number of Accreditation Council for Graduate Medical Education certified programs from 25 to 75 in the United States to accommodate the number of fellows pursuing advanced heart failure and transplant cardiology training.1,2 Although cardiology is a male-dominated specialty, the subspecialty of heart failure appeals to a higher proportion of women. In the 2018 Accreditation Council for Graduate Medical Education report, women represented 33% of advanced heart failure and transplant cardiology trainees, compared with 23% of trainees in cardiovascular disease, 10% in electrophysiology, and 9% in interventional cardiology.2The aim of this study was to explore factors that influence cardiologists to choose a career in heart failure, and to identify generational, geographic, and sex-based differences in this chosen career path.MethodsInternational Society for Heart and Lung Transplantation members under the professional category of adult cardiology were invited by email to participate in an online 18-question survey (Data Supplement) using the Qualtrics survey platform. Data were summarized descriptively, and comparisons were performed by χ2 (Exact Fisher test) or t test (Mann-Whitney U) where appropriate. Two independent raters coded free-text comments into relevant broader themes. Institutional review board was waived for this study by the Stanford Ethics Review Board.ResultsAmong 1000 international heart failure cardiologists, 236 (23.6%) completed the survey. Respondents were predominantly male (65.3%), 176 (74.6%) were between 30 and 49 years of age, 146 (61.9%) self-identified as white, 37 (15.7%) South Asian, 18 (7.6%) Asian, 15 (6.4%) Hispanic/Latino, 12 (5.1%) Middle Eastern/North African, and 4 (1.7%) black. Junior faculty (0–10 years of practice) represented 58.5% of respondents. The majority (60%) practice within the United States, 19% in Europe, 10% in Canada, 5% in Asia/Australia, and 5% in South America/Latin America.Eighty-five percent of clinicians aged 30 to 39 years were clinically active in heart failure, heart transplantation, and mechanical circulatory support, whereas 78% of those 40 to 59 years old and 75% of those >60 years old were active in all 3 areas (P=0.48). Men and women were equally active in MCS (P=0.84). The distribution of academic rank based on age and sex is shown in Figure 1. In terms of academic rank, there were more males than females at the professor level (25% versus 10% respectively, P=0.04) but no difference between men and women at the assistant (P=0.45) or associate (P=0.33) professor level.Download figureDownload PowerPointFigure 1. Academic rank by age and sex of survey respondents (N=148).When asked to rank a provided list of 10 factors in terms of importance for choosing heart failure as a career (Table 1; Q9 in the Data Supplement), the 3 most important were patient complexity and continuity of care, clinical diversity, and evolving technology; there were no differences in rank order based on sex. Compared with other regions, Europeans, and Asian/Australians were more likely to indicate clinical diversity as the primary reason for choosing heart failure.Table 1. Most to Least Important Factors Ranked in Pursuing a Career in Heart Failure by SexFactorOverall Mean Rank±SD (N=236)Male Mean Rank±SD (N=236)Female Mean Rank±SD (N=236)Patient complexity and continuity of care1.8±1.61.9±1.61.7±1.5Clinical diversity2.5±1.42.5±1.52.6±1.3Evolving technology4.0±1.63.9±1.64.1±1.7Collegiality in work environment4.5±1.74.5±1.64.7±1.9Mentorship5.4±2.05.5±2.05.2±1.9Research environment5.4±2.25.4±2.25.4±2.1Working with trainees6.6±1.96.6±1.96.6±1.8Lifestyle7.5±1.67.4±1.67.6±1.7Income7.6±1.67.5±1.77.7±1.5Other9.7±1.49.8±1.29.5±1.7When asked about differences between heart failure and other cardiology subspecialties, the majority of respondents perceived increased collegiality (male 70% versus female 65%, P=0.39) and greater leadership potential (male 64% versus female 56%, P=0.17) but worse financial remuneration (male 60% male versus 77% female, P=0.008) and less work-life balance (male 49% versus female 45%, P=0.63).A total of 79 (34%) physicians took parental leave (36 women and 43 men) for a mean of 1 to 3 months. A higher proportion of women compared with men (25% versus 7%, P<0.01) reported negative consequences for taking parental leave, such as loss in patient volume and loss of income and benefits, with comments provided in Table 2.Table 2. Representative Negative Consequences for Parental LeaveConsequences for Parental LeaveRepresentative ResponsesFinancialDrop in RVU and a discussion about itNo leave at [institution] for adoption. Loss of salary.Catching up to build up procedural volumes, academic efforts slowed downNo actual leave, had to use vacation and sick and make everything upLoss of benefits after 6 monthsStill had to workSkills developmentSignificant interruption of education and skills developmentNegative environmentHarassment from the interventional cardiologists upon my returnCompared with men, women were more likely to perceive an imbalance favoring men in annual salary (57% versus 33%, P<0.001), academic promotion (61% versus 29%, P<0.001), institutional leadership (77% versus 47%, P<0.001), and organizational leadership positions (66% versus 32%, P<0.001) in the field of heart failure.Respondents were asked to provide any additional free-text comments about their experience in heart failure as a career. Five themes emerged from the representative comments, including burnout and work-life balance, career satisfaction, mentorship and sponsorship, women in cardiology, and internationality as shown in Table 3. A number of comments stated that physicians in heart failure are not adequately compensated for the complexity and critical nature of patients. Several comments indicated a lack of sponsorship for female faculty members and the need to form women’s councils to encourage advancement of women professionally.Table 3. Representative Free-Text Comments From Respondents Coded as ThemesThemesRepresentative Responses*Burnout and work-life balanceI feel that we do not choose this career for lifestyle. In my experience, our patients are among the most sick and we are often involved in the hospital at night and weekends. This would actually be a deterrent from this specialty but the rest of it—the patient complexity, relationships, camaraderie, mentorship—makes it more sustainable.General cardiology colleagues consistently fail or refuse to recognize how much time it takes to provide good care for this population.Complexity is not compensated with time and work-life balance.Difficult subspecialty for work-life balance and practice in a nonacademic arena. I wonder what physician burnout rates are in advanced HF.Career satisfactionI trained as a very general cardiologist (many interventions, devices, etc) prior to working in HF. Initially I missed and resented the loss of those procedural activities. Over time I have come to enjoy HF for a variety of reasons that include care continuity, the fact that it remains the only really clinical part of cardiology ... and dealing with very sick patients makes many decisions easier and clear cut.I can’t imagine a more rewarding field. I learn and grow every day. I feel blessed to have my patient’s trust to take this journey with them.Mentorship and sponsorshipAs a woman in HF/HTx, it has been a struggle to find good mentorship and nearly impossible to find sponsorship within the field. The one time I found a potential sponsor, another female faculty member joked that the sponsor must have a romantic interest in me.I have been very fortunate to have strong female mentors, including one female sponsor who really encouraged and fostered my career development. In general, however, advanced heart failure cardiology remains a very male-dominated field, especially in leadership positions, professional societies, etc. I feel that the heart failure societies need to do more to encourage advancement of women professionally, which ultimately benefit our field as a whole.The majority of my mentors are male. I am at an institution now with a greater than average prevalence of female role models in heart failure and general cardiology leadership... it is refreshing—the trainees are also of diverse gender background, likely reflective of the leadership.Women in cardiologyAs a female physician in heart transplant, I experience things my male colleagues probably do not (patients assuming you are a nurse despite the white coat, badge and introducing myself as a Dr).There is clearly both a gender and race gap within academic medicine... There has been little done to change the culture of academic medicine.I am a woman in cardiology... I have been tremendously valued and supported by my male mentors. I have never felt that being a female was a disadvantage in my professional life. I fear the culture is swinging in a direction of supporting women over men, instead of supporting outstanding work regardless of gender.In my first faculty position my HF/Tx director related that one country’s health system struggles because there are too many female physicians…There is a real lack of women who can be real mentors in the field. I think a women’s council at HFSA or ISHLT would be helpful. If it already exists, it is being poorly advertised as I am unaware of it.InternationalityIn my country, a lack of gender diversity in academic institutions is related to the need to wait a long time in a temporary, underpaid position for an eventual faculty position. Rather than an overt gender bias, there is a major career planning problem…One of the aspects of HF cardiology not addressed in this survey is the great deal that advanced heart failure/transplant physicians interact with cardiac surgeons on a daily basis, arguably more than any other field in cardiology. Depending on the culture of the institution, this may be favorable or unfavorable and always brings some associated challenges even in the best of circumstances. This relationship also contributes to gender disparities in leadership positions in the professional societies. This will change in Europe 75% of the fellows are female.Cardiology in general seems to struggle with recruiting female trainees in Australia/Asia despite a relatively high representation in physician specialties in general.HFSA indicates Heart Failure Society of America; and ISHLT, International Society for Heart and Lung Transplantation.*Comments on the surveys may have been altered or paraphrased for readability in an abbreviated format.DiscussionThis is the first study to evaluate factors that influence cardiologists in choosing a career in heart failure. The findings suggest that patient complexity and clinical diversity attract both men and women across all age groups. Despite higher female representation in heart failure, this survey highlights a strong perception of sex-based imbalances with regards to salary, institutional/organizational leadership positions, and academic promotions. These sex imbalances are not unique to the field of heart failure and have been described in various medical specialties and more broadly in science, technology, engineering, and mathematics. To further attract and retain women in the field, respondents emphasized the need for improved female sponsorship (a term distinct from mentorship, defined as guidance for academic success and promotion), removal of the negative consequences associated with maternity leave, and the need to provide income transparency.3 A recent correspondence from the Lancet suggests even more crucial interventions such as adopting transparency in the selection of leadership positions along with departmental report cards listing all members and committees to achieve gender equity.4While this questionnaire did not directly explore physician burnout, respondents described a great vulnerability to burnout given the critical nature, time demands that compromise work-life balance because of high patient complexity, and the nonprocedural focus which may negatively impact pay in comparison to other cardiology subspecialties. The American Heart Association has reported growing evidence that burnout is pervasive, affecting up to half of all cardiologists. In this same report, a higher proportion of women were at risk of burnout than their male counterparts, in part, because of increased past discrimination related to sex and parental status.5The main limitation of this study was that it was a voluntary survey (ie, self-report) with a modest response rate of 26%. Email privacy regulations precluded comparison of responders and nonresponders and, as a result, the representativeness of practicing adult cardiologists could not be determined. Furthermore, sex-based differences were perceived and not objectively measured (eg, salary, availability of leadership positions) and should be interpreted with caution. On reflection, several questions used in this survey tended to have an academic focus with less relevance to community physicians (ie, academic rank, distribution of time spent teaching), as noted by several respondents. Last, it is unclear from this survey whether perceived barriers experienced by women are unique to heart failure or are also applicable to other cardiology subspecialties.This survey highlights that men and women have similar reasons for pursuing a career in heart failure. While it is now a commonplace to value diversity in medicine and implement programmes to advance women’s careers, respondents of this survey have identified widely perceived imbalances in salary, promotion, and leadership positions favoring men. Subsequent actions in promoting salary transparency, providing an open selection process of leadership positions, and better representation of grant funders, journal editors, and institutional leaders are small steps in the direction of improved gender inclusion and equity.6ConclusionsThe most important factors that drive both male and female cardiologists to pursue a career in heart failure include patient complexity, clinical diversity, and evolving technology. Despite improved female representation in heart failure, this survey has identified perceived sex imbalances, physician burnout, and poor financial compensation as barriers warranting future research, policy changes, and focused efforts to retain talent in this rapidly growing field (Figure 2).Download figureDownload PowerPointFigure 2. Respondents’ perceived differences in choosing a career in advanced heart failure. Top: Most frequent reasons for choosing heart failure as a career specialty. Middle: Perceived gender inequities stratified by sex. Bottom: Academic rank by age and sex.AcknowledgmentsAll authors had access to the data and contributed to the preparation of this article.DisclosuresNone.FootnotesThe Data Supplement is available at https://www.ahajournals.org/doi/suppl/10.1161/CIRCHEARTFAILURE.118.005754.Jeffrey J. Teuteberg, MD, Stanford University, 300 Pasteur Dr, Falk Research Bldg, CA 94305. Email jeffrey.[email protected]eduReferences1. Savarese G, Lund LH. Global public health burden of heart failure.Card Fail Rev. 2017; 3:7–11. doi: 10.15420/cfr.2016:25:2CrossrefMedlineGoogle Scholar2. Accreditation Council for Graduate Medical Education. https://www.acgme.org/About-Us/Publications-and-Resources/Graduate-Medical- Education-Data-Resource-Book ACGME. Accessed November 5, 2018.Google Scholar3. Lewis SJ, Mehta LS, Douglas PS, Gulati M, Limacher MC, Poppas A, Walsh MN, Rzeszut AK, Duvernoy CS; American College of Cardiology Women in Cardiology Leadership Council. Changes in the professional lives of cardiologists over 2 decades.J Am Coll Cardiol. 2017; 69:452–462. doi: 10.1016/j.jacc.2016.11.027CrossrefMedlineGoogle Scholar4. D’Armiento J, Witte SS, Dutt K, Wall M, McAllister G; Columbia University Senate Commission on the Status of Women. Achieving women’s equity in academic medicine: challenging the standards.Lancet. 2019; 393:e15–e16. doi: 10.1016/S0140-6736(19)30234-XCrossrefMedlineGoogle Scholar5. Kuehn BM. To fight burnout, cardiologists look to change health system.Circulation. 2018; 138:836–837. doi: 10.1161/CIRCULATIONAHA.118.036637LinkGoogle Scholar6. The lancet. Feminism is for everybody.Lancet. 2019; 393:493.Google Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By BHARDWAJ A, RAMU B, BLUMER V, COGSWELL R, DEMARCO T and HALL S (2022) Women Empowering Women in Heart Transplantation and Mechanical Circulatory Support, Journal of Cardiac Failure, 10.1016/j.cardfail.2022.03.351, 28:6, (1031-1034), Online publication date: 1-Jun-2022. Abdulsalam N, Gillis A, Rzeszut A, Yong C, Duvernoy C, Langan M, West K, Velagapudi P, Killic S and O’Leary E (2021) Gender Differences in the Pursuit of Cardiac Electrophysiology Training in North America, Journal of the American College of Cardiology, 10.1016/j.jacc.2021.06.033, 78:9, (898-909), Online publication date: 1-Aug-2021. Chuzi S and Reza N (2021) Cultivating Interest in Heart Failure Careers: Can We Reverse the Current Trend?, Journal of Cardiac Failure, 10.1016/j.cardfail.2021.04.009, 27:7, (819-821), Online publication date: 1-Jul-2021. Van Spall H, Lala A, Deering T, Casadei B, Zannad F, Kaul P, Mehran R, Pearson G, Shah M, Gulati M, Grines C, Volgman A, Revkin J, Piña I, Lam C, Hochman J, Simon T, Walsh M and Bozkurt B (2021) Ending Gender Inequality in Cardiovascular Clinical Trial Leadership, Journal of the American College of Cardiology, 10.1016/j.jacc.2021.04.038, 77:23, (2960-2972), Online publication date: 1-Jun-2021. DeFilippis E, Moayedi Y and Reza N (2021) Representation of Women Physicians in Heart Failure Clinical Practice, Cardiac Failure Review, 10.15420/cfr.2020.31, 7 Reza N, Tahhan A, Mahmud N, DeFilippis E, Alrohaibani A, Vaduganathan M, Greene S, Ho A, Fonarow G, Butler J, O’Connor C, Fiuzat M, Vardeny O, Piña I, Lindenfeld J and Jessup M (2020) Representation of Women Authors in International Heart Failure Guidelines and Contemporary Clinical Trials, Circulation: Heart Failure, 13:8, Online publication date: 1-Aug-2020.Sweitzer N (2019) Choosing a Career in Heart Failure, Circulation: Heart Failure, 12:7, Online publication date: 1-Jul-2019.Lam C (2019) Choosing a Career in Heart Failure, Circulation: Heart Failure, 12:7, Online publication date: 1-Jul-2019.Crespo-Leiro M (2019) Heart Failure Is Taking Center Stage, Circulation: Heart Failure, 12:7, Online publication date: 1-Jul-2019. July 2019Vol 12, Issue 7 Advertisement Article InformationMetrics © 2019 American Heart Association, Inc.https://doi.org/10.1161/CIRCHEARTFAILURE.118.005754PMID: 31296097 Originally publishedJuly 12, 2019 Keywordscardiovascular diseasescardiologistsmedicineheart failureprevalencePDF download Advertisement SubjectsHeart Failure" @default.
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