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Balancing versus Integration of Motherhood and Your Career as a Female Cardiologist

Balancing versus Integration of Motherhood and Your Career as a Female Cardiologist

As we recently closed the academic year last month, I attended our graduating fellows’ dinner and I was reminded of the continued challenges of motherhood for many female cardiologists.  This reminder came in the form of a conversation I had with one of our Interventional Cardiology fellows who was completing her Interventional fellowship and we were discussing the challenges of being a mother and navigating a career in Cardiology. I gave her some pearls of wisdom from my own experiences that I have had so far in my career and am still learning myself.

These conversations took me back thirteen years ago when I started my fellowship as a general cardiology fellow and was entering into my ninth month of pregnancy. I still remember walking into the cardiology conference room on the first day of fellowship orientation and feeling all the doubts and fears of wondering if I would make it through those three years. Although I had completed my Internal Medicine residency and had garnered the recognition from my attendings and colleagues as a Chief Resident, my confidence was shaken as a young soon to be mother entering this challenging field. There are many pearls of wisdom I have learnt or have been taught along the way. In this month’s blog I will be discussing a few of these pearls of wisdom.

Before discussing these pearls I will delve into the statistics with regards to females and our experience in the Cardiology field.

 

Statistics on Gender gaps in Cardiology  and its Challenges for Mothers

Unfortunately there is still a scarcity of females in the Cardiology field.  Females represent only 13 % of Cardiologists in the United States (US)1. Female representation is even lower in the procedural fields of Cardiology such as Interventional Cardiology where only approximately 8% of interventional cardiologists are females and only 6% of electrophysiologists are females1. Among Cardiologists in the US, 72 percent of female cardiologists are mothers and 86 percent of male cardiologists are fathers. It is important to note that most of these fathers (57%) have a spouse who provides child care at home while only 13% of these mothers have similar support1. This poses a significant challenge for mothers in the field of Cardiology as most often there are long work hours in addition to overnight call particularly during fellowship training. There is also a significant lack of scheduling flexibility during these training years and also in practice. These challenges often result in reliance on extended family members, colleagues,  or hired help to assist with child care.

Another challenge in our field is the concern with regards to radiation exposure particularly during procedural rotations and for proderural specialties such as Interventional Cardiology, Electrophysiology as well as the emerging field of Structural Cardiac Imaging. This poses challenges for mothers who are considering pregnancy or who are pregnant.

Generally, the Cardiology field is perceived as a very difficult field with long and grueling work hours. This perception along with the very unfortunate fact that it is still a male predominant field with potential gender bias and discrimination has resulted in many very talented females avoiding this field altogether.

As mothers in Cardiology we are pulled in 2 different directions, one direction with regards to our patient care and professional duties and responsibilities and the other direction with regards to our duties and responsibilities as a mother. While this seems daunting, there are several actions that can be taken to mitigate these challenges so that we can feel fulfilled both as a mother and as a Cardiologist.

 

Pearls of Wisdom

Build Your Support System- Your “Village”

Regardless of whether you are in training or in practice as a Mother in Cardiology, one thing will remain true throughout your career, you will need to create and build your “village” of support. This village of support will be a necessity particularly with regards to child care during long days and long nights at work. This village of support involves your spouse, extended family members, your colleagues and/or hired help.  This is a must, you will not be able to do this all on your own as much as we may have that “superwoman” mentality. Once you have created and built this village of support you should show your appreciation for each member of this village. This appreciation will go a long way especially when they may have to be called upon in the middle of the night or on weekends to provide child care when you have patient care duties to attend to.

 

Focus on Quality rather than Quantity of time with our Children:

Time with our children is precious, therefore focusing on making that time quality time is what is most important and will be the most memorable. Therefore, on weekends or days when you are away from work spending time with your children doing activities that are engaging, meaningful and fun is important.

 

Time Management

Planning your time both at work and at home with your children is a key factor. A family calendar is very useful in planning and managing time with your kids to ensure that there are no work scheduling conflicts. The weekend is a good time to reset, recover and plan for the week ahead. This may mean that meal plans are created for the week and food may need to be prepped ahead on the weekends so that preparing dinner in the week can be less daunting. This also applies to lunches for the children in the week.Grocery shopping should also be planned to alleviate that additional stress of getting this done in the week. Grocery delivery services may also be useful in this regard. Time for household chores should also be planned and if you are able to outsource some of these tasks to your spouse, older aged children, extended family members or hired help this is recommended.

Time management is also important at work to minimize any unnecessary distractions or interruptions so that we can perform our patient care duties in a safe and time efficient manner. Taking work home should be minimized as this often robs us of precious time that should be spent with our children and has the potential to result in professional burnout.

Time management is also vital with regards to professional activities such as board exam preparation and research activities. My advice is to start planning for these early in your training to give yourself enough lead time to be well prepared for the exam and with regards to research, enough lead time to complete your research activity during your training. As a fellow and even as a practicing cardiologist, a study guide should be created early so that you spend some time each day studying for board exams if applicable and reading the medical literature to keep yourself up to date in the field. Audio files are very useful especially during your commute to and from work as this will readily facilitate board exam preparation and even keeping up with the medical literature.

 

Prioritization

Making a “to do” list and prioritizing this list is important. You cannot do it all at the same time. There are times that less valuable activities with regards to motherhood or with regards to your profession may have to be placed on the “back burner” and revisited at another time when you may be available. There are times when these less valuable activities may even have to be deferred.

 

Finding Your “Me Time” is Important.

It is important to find the time to recharge and take care of yourself. Self care involves small things from finding the time at work to eat healthfully and rehydrate throughout the day. Self care also involves making the time to participate in an activity that takes you away from the throws of the day. This activity may be a hobby such as arts and crafts, gardening, playing an instrument, playing a sport or exercising.  Making the time to exercise is also vital to maintain not only your health but to maintain your physical and mental endurance. Getting adequate sleep is another important part of self care as sleep deprivation results in increased risk of professional burnout and not being able to function at your best throughout  the day. The emphasis is on making this time as often times it is far easier to have an excuse of not having the time to do these activities and it may create guilt as a mother. However, it is important to remember that if you are not happy and energized then this may be reflected at work and at home and in the long run will likely lead to a lack of fulfillment as a mother and as a cardiologist.

If you are feeling overwhelmed, it is important to seek assistance with your responsibilities if possible. Sometimes this assistance may have to be hired help. There are many services in the market that assist not only in child care but also provides assistance with other responsibilities such as professional cleaning services and laundry service. There are also tutoring services available to assist  school  aged children to not only ensure that they are completing assignments but to also ensure that they are keeping up with the school syllabus throughout the school year.

 

Finding a Mentor

Finding a mentor is important as this person not only provides guidance with regards to your career but could also be an advocate for you during your fellowship training. Developing and maintaining this mentorship relationship is invaluable and may evolve as you progress in your career. Having more than one mentor is often recommended as no one mentor will be able to provide guidance on every aspect of your career. For more ideas on the value of mentorship in Cardiology see my earlier blog on this topic.2

 

Negotiate for A Flexible Work Schedule

If it is possible it can be useful if a flexible schedule could be negotiated with your fellowship program director. An example of this would be allowing for time off for maternity leave after delivery of your child with the understanding that your fellowship completion date would be delayed to ensure that the 36 months of fellowship training is completed. Another example is re-arranging the fellowship rotation schedule to avoid exposure to radiation during cardiac cath rotations in your pregnancy. Therefore, during the pregnancy period rotations could be limited to those outside of the cardiac catheterization lab.

As a practicing cardiologist there may be more flexibility for negotiating with your practice group if in private practice or the Cardiology Chair if you are working in a hospital based academic setting to allow for an extended maternity leave  or to have the ability to go part time during the pregnancy. There are unique challenges to these arrangements in a relative value unit (RVU) based productivity model. However, it is useful to try to negotiate for these arrangements to ensure that you have the time that you need to take care of your child after the delivery as those moments are precious and also to ensure that you are able to have the greatest chance for a healthy pregnancy with regards to a reasonable work schedule.

 

Change the things you can and accept the things you cannot change

As a working mother in a demanding job as a Cardiologist it is important to remember that you cannot do it all and you are not perfect. This is a struggle for most of us to remember as many of us are high achieving women. However, as mothers and as physicians we should strive to do our best for our children and the best for our patients with the understanding that there are times the outcome may not be what we hoped for. During these moments we have to realize that we are also human and we can only be expected to change the things we can and accept the things that we cannot change.

 

Work-Life Integration vs. Work Life Balance

Over the last 5 to 10 years the term “work life integration” has been seen as a more realistic goal for working mothers rather than “work life balance” as the latter is seen as more of a myth and a rather unrealistic goal for many. The boundaries between your professional life and your personal life is often blurred especially in a demanding field such as Cardiology. This is even more true in today’s practice environment with electronic medical records and constant connectivity between emails and texts. It is most desirable to unplug when we are away from work, however this is not always possible. We also have to embrace the fact we are working mothers in a demanding field that we can find fulfilling but is sometimes daunting. This means that achieving a balance between your professional life and your personal life is often impossible and many times we may have to incorporate the two roles in a more adaptive work-life integration model. This may mean that there are times you may have to take the kids along with you to a scientific medical meeting and this could be made possible particularly if your spouse or family member is able to attend with you to take care of the children while you are attending the sessions at the meeting. This integration of both of your roles allow for a happier situation both for yourself as a mother not having to spend a prolonged time away from your children  and a happy situation for the children who often see this as vacation time with you. In fact several cardiology professional meetings have made accommodations for nursing mothers with areas designated at the meeting for nursing. This has a far reaching and positive impact for female cardiologists as this encourages attendance to these meetings even if nursing.

 

Conclusion

Being a female cardiologist and a mother, I consider to be a blessing. Our children often look up to us as positive role models as we navigate through a challenging and demanding Cardiology field to take care of our patients while also being able to take care of our children and provide the best life possible for them. I also believe that being a mother teaches us many skills that we often even subconsciously apply to our  jobs as physicians to make us better listeners to our patients and better communicators with our patients. Being a mother also makes us more efficient with our time and more productive at work3. Our children also learn the values of hard work, dedication, compassion and empathy from our role as a Cardiologist. Embracing our roles of motherhood and a practicing female cardiologist can be fulfilling as we have the privilege of having a meaningful positive impact on the health of our patients while taking the best care of our children and “yes” we can have the best of both worlds.

 

References:

  1. 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 Jan 31;69(4):452-462. doi: 10.1016/j.jacc.2016.11.027. Epub 2016 Dec 21. Review.
  2. Bullock-Palmer RP. The Invaluable Importance of Mentorship Throughout Your Career as a Female Cardiologist. American Heart Association Early Career blog site. February 25, 2019. https://earlycareervoice.professional.heart.org/the-invaluable-importance-of-mentorship-throughout-your-career-as-a-female-cardiologist/
  3. Krapf M, Ursprung HW, and Zimmermann C. Parenthood and Productivity of Highly Skilled Labor: Evidence from the Groves of Academe January 11, 2014
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Women & TAVR: “I Don’t Want Any Procedure”

Round 1…

Patient’s son-in-law: “My mother has been turned down for surgery. They tell me her mortality rate at 2 years is high since she had fluids collecting in her lungs. They told me to ask you about catheterization.”

Me: “Yes, she does have a tight aortic valve and did develop heart failure. She is also very high risk for surgery. Percutaneous or catheter-based replacement may be an option. She will need a CT Scan first to determine if she is suitable for that treatment.”

The patient’s son-in-law asked me only one question, but a number of questions rushed through my head.

When is a good time to give the patient a contrast load after her recent admission with pulmonary edema? How safe is contrast given her borderline renal dysfunction and recent pulmonary edema? What is the outcome of trans-catheter aortic valve replacement (TAVR) in women?

I realized that there were no concrete answers. Irrespective of risk of contrast induced nephropathy, she needs the CT Angiogram. Irrespective of the timing, she remains high risk for recurrent pulmonary edema with or without the 50-60 cc of contrast given during the CT scan. Irrespective of her gender, TAVR maybe her only option. So, the CT scan was done with a small amount of contrast & her renal function remained unchanged and she did not develop pulmonary edema. She had borderline parameters with a short distance from the aortic valve annulus to left main, significant calcification into her LVOT, small tortuous and calcified common iliac arteries bilaterally. She was not an “ideal” candidate.

 

Round 2…

 

Me: “You are at a higher risk of coronary occlusion. We can place an undeployed stent preemptively in the coronary artery. Your risk of requiring a pacemaker is high and we’ve notified our electrophysiologist. Your risk of rupture is high, so we plan to use a self-expanding valve. We may need to use an alternative access like your armpit artery.”

Patient: “I don’t want any procedure.”

Patient’s son-in-law: “Is there anything else that we can do that is less risky?”

Me: “Palliative balloon valvuloplasty, but the gradient will increase again in 6-12 months.”

Patient: “I don’t want any procedure.”

Patient’s son (in-law): “Can we repeat this valvuloplasty every 6 months if need be?”

Patient: “I don’t want procedure.”

*Awkward silence.*

Me: “She does not want any procedure. It is time you and I listen to her.”

 

This patient was referred to me by a colleague from another hospital. She had no sons of her own but had her son-in-law to accompany her. She was a small, frail, soft spoken, elderly lady. She was also grateful for the care she received. We immediately had the surgeons evaluate her. While the surgeons were examining her, I did a quick literature review:

Data from Vancouver demonstrated that the mortality rate at 30 days after TAVR was 6.5% in women and 11.2% in men after accounting for other variables.1 This advantage for the female gender was maintained at 1 year as confirmed by the PARTNER Trial sub-analysis. Whether this was due to worse surgical outcomes in women or an advantage of TAVR in women was further explored by Humphries et al. Although vascular complications were higher in women, the overall survival rate at 2 years was 72.1% for women and 61.7% for men. Real world international registry and the first WIN TAVR registry further confirmed that high risk women had low 30-day and one-year mortality and stroke rates.2-4

Naturally, I picked up the conversation where the surgeons left off. In retrospect, even as a woman interventional cardiologist, was I dismissive of my patient’s own preference? Do we have a tendency to ignore female patients’ wishes more than men? Do we have a tendency to ignore elderly patients’ wishes more than younger ones? Or do we find it difficult to resolve to hospice care even before exhausting all options? It may be a combination of all of these. I don’t normally dismiss my patients’ wishes, but this time, I was clearly not listening. Maybe I listened to my colleague (a physician) and maybe I just grew attached to this soft spoken grateful woman…and I couldn’t resign myself to writing hospice care for her. Women..men..no matter, we make imperfect choices at times driven by our humanity. May that imperfection continue to drive us to care.

 

References:

1. Humphries KH, Toggweiler S, Rodés-Cabau J, et al. Sex differences in mortality after transcatheter aortic valve replacement for severe aortic stenosis. J Am Coll Cardiol 2012;60:882–6.

2. Williams M, et al. Sex-related differences in outcomes after transcatheter or surgical aortic valve replacement in patients with severe aortic stenosis: Insights from the PARTNER Trial (Placement of Aortic Transcatheter Valve). J Am Coll Cardiol. 2014 Apr 22;63(15):1522-8.

3. Chieffo A, et al. 1-Year Clinical Outcomes in Women After Transcatheter Aortic Valve Replacement: Results From the First WIN-TAVI Registry. JACC Cardiovasc Interv. 2018 Jan 8;11(1):1-12.

4. Chieffo A, et al. Acute and 30-Day Outcomes in Women After TAVR: Results From the WIN-TAVI (Women’s INternational Transcatheter Aortic Valve Implantation) Real-World Registry. JACC Cardiovasc Interv. 2016 Aug 8;9(15): 1589-600.

 

 

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Notes from November: Medical Training is a Journey

November has been a whirlwind of angst and excitement for me.  It began with cramming for my final USMLE board exam.  After sitting for the two-day test, I flew directly to Chicago, where I attended my first AHA Scientific Sessions and presented a poster on bystander AED use at the Resuscitation Science Symposium.  Upon returning home to Atlanta, I pored over the list of fellowship interviews I had attended in the last two months and agonized over last-minute adjustments to my rank list.  Such is the life of a third-year internal medicine resident.

This Wednesday, I stumbled home after a 24-hour hospital shift and opened my email account.  That’s when I found out I had not only passed my board exam but also matched at Emory, my home institution and top fellowship choice.  In spite of my exhaustion, I was so elated that it was hard to fall asleep.

Reflecting back on the month, I’m reminded of Dr. Ivor Benjamin’s address at the AHA Presidential Session.  He waxed poetic about his circuitous journey–growing up in Guyana, traveling to the U.S., and training at several premiere academic medical centers.  He spoke about fortuitous relationships with key mentors that propelled his career as a basic science researcher.

Listening to Dr. Benjamin’s narrative was a delight and an inspiration.  His account echoed the stories of many impressive residents and fellows I met at AHA.  It was also a reminder of my own humble roots—born in Shanghai, growing up in the rural Midwest, and studying at Vanderbilt and Emory.  For each of us, medical training is long, and it is transformative.  I look forward to the next stage, and I hope to return for Scientific Sessions in 2019.  By then I will be a cardiologist in the making.

 

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Letting Go

Recently, I was reminded of one of my unique roles as an advanced heart failure cardiologist. 

As a physician in such a highly specialized field, I often have the opportunity to offer patients life-saving measures that can only be performed at highly trained qualified quaternary medical centers. This may span the gamut from a wireless hemodynamic monitor placed in the pulmonary artery to a temporary or durable ventricular assist device to an organ transplant.

I often think of the times that I have been able to be the first person to share with my patient and their family that we have finally found a suitable donor organ for them. The initial joy and sheer euphoria followed by the nervous anticipation for the next step of the journey that began often several years prior. I remember the tight hug of the patient’s wife, the embrace from a usually stoic patient, the high five from the patient who loves sports analyses. Burned into my memory, each of these patient’s experiences have been a beautiful addition to my own formation as a physician, clinician, and truly, as a human being. 

Frequently, however, are times where I have to traverse a path of palliation with patient and families. In this role, I help to guide families through quite literally the worst times of their lives.

While we have the invaluable assistance of specially trained palliative care and hospice providers, I have also found in my experience that patients’ families truly value the input and guidance from our heart failure team whom they have often had continuity with spanning both inpatient and outpatient care. I have witnessed tears and raw emotion from the healthcare teams who have invested so much of themselves in the care of the patient and are connected like family.  

The depths of these emotions however, the unparalleled highs tempered by the valleys of sadness, have molded me; sometimes shaken me to my core. Along my own journey forward I carry with me the stories and teachings of those who we have helped survive and those who   we have helped to die with dignity. It is in these times, where the lines between medicine and humanity are blurred, that I am reminded of my sacred privilege of being a physician.

Megan Kamath Headshot

Megan Kamath is a Fellow in Advanced Heart Failure and Transplant Cardiology at the University of California, Los Angeles. Her research interests include outcomes in advanced heart failure, decision making and relational medicine, and utilizing technology in healthcare. She is now tweeting @MeganKamath, so follow her on there!

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The Potential Of Social Media For Cardiologists

Social media through its inherent quality of personal engagement has changed the way we follow current events, learn about new advances in cardiovascular advancements, and communicate within our personal and professional lives. Cardiologists are enthusiastic to embrace new advancements in medical devices, therapies and technologies, but as a whole they tend to be late adopters when it comes to progressive communication tools such as social media. While many cardiologists consider social media a distraction, others think it is a liability threat.

Every day, the social media networks put thousands of posts related to healthcare. In recent years, cardiologists started using social media to learn what is new in cardiology, educate others, discuss challenging cases, promote practice, and even interact with patients to answer questions. Leaders in the field of cardiology think of social media as extension of the doctor-patient relationship.

Why Cardiologist Should Be on Social Media?

Social media is the perfect vehicle for educators, clinicians, and researchers to communicate and stay connected with each other. Instead of waiting to discuss new research in-person with a handful of colleagues at a conference, social media permit virtual discussion with many professionals across the globe giving feedback instantly. When you look at the data, it shows that as a cardiologist, you can have a much broader impact on social media than you normally would by word of mouth. Several areas have been defined where online engagement proved to be a viable platform which includes;

  • Better interaction with colleagues
  • Better access to information, particularly specialized info
  • Wider access to medical and health information
  • Increased support for patients and from peers
  • Improved surveillance for public health issues
  • Increased possibility of influencing healthcare policies

It worth noticing that when social media is used correctly, there are many important ways that it can improve the medical field. Not only can you spread information faster and engage in a wider discussion with other cardiologist, but you may also be able to influence public opinion and help shape policies that affect the entire medical field. We have to always keep in mind that, elected officials are online just as much as anyone, meaning that they can be exposed to new studies and information that they would otherwise ignore.

Limitations of Social Media

Despite the advantage of being dynamic and accessible to public, social media has certain limitations in the medical field. In certain instances, it is hard to control the discussions with potential to deviate from the main objective of the post that was published. Different from peer-review process, users do not have to declare relevant conflicts of interest that could give wrong impression to public who are not expert in the field. Last and for most, the presence of researchers and clinicians on social media is low in comparison with other segments of the population. Thus, there is urgent need for experts available to review social media posts and give their expert unbiased opinion to help the general public make the right choice and get the right impression.

Whether we realize it or not, social media is going to change the way we learn new science, ask questions, advocate for practice or patients, discuss science and share medical onion. Social media is as powerful a tool as we make it. Using social media, we can engage in various interactions in a much easier way than ever before. This can not only help keep us up to date, but also has the potential to save lives.

Chadi Alraies Headshot
M Chadi Alraies, MD is an interventional fellow and vice chair of Council on Clinical Cardiology Fellow-In-Training & Early Career Committee of American Heart Association.