women in cardiology

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Women In Cardiology: A Mother’s Day Tribute to Women, Wives, Weekend Warriors, & Workaholics In Cardiology

Briana Costello, MD

*Buzz*. Most of us can relate to that alarm going off way earlier than we would like. Wake up, make coffee, throw the clothes in the washer or dryer, clean up the kitchen, put on your office attire or scrubs, and run out the door to start the day taking care of patients, reading nuclear studies, reviewing echocardiograms, or doing catheterizations. For many, this sort of routine is comforting. Enter motherhood or pregnancy to start. This topic in cardiology, a field dominated by men who make up 85% of the workforce, can be an exciting topic to navigate.

The Pregnant Cardiologist

Pregnancy is supposed to be one of the most joyous celebrations in life. I often reminded myself of this while recently pregnant with my second child as I squeezed in OB appointments between patients while simultaneously reassuring them that I would be back after eight weeks. Women in cardiology face obstacles that their male counterparts do not have to use mental bandwidth on. We finish training in our early 30s keenly aware that our “biological clock” is ticking. We try to decide when the right time is to have children whilst trying to grow our own practice and make our footprint. Many questions zoom through our brains. When is the “right” time to take off anywhere from six to twelve weeks with our employer and partners accepting it, covering call, and caring for our patients? How will pregnancy and motherhood affect my career? Is there a maternity leave policy? What if I have complications during pregnancy? Will my partners assume I am going to scale back after I have a child and give preferential treatment to the men? How will pregnancy impact my salary? We sacrifice some of our professional growth to achieve one of the most joyous life events. Or do we? Dr. Martha Gulati, et al recently surveyed women who were members of the American College of Cardiology Women in Cardiology section to assess real life experiences during pregnancy. 341 responded they had children as a practicing cardiologist. Of these, most notified their chair, chief, or practice that they were pregnant in the late first or early second trimester. The most common reason for waiting to report was due to concern of adverse treatment or perception (37.5%). Maternity leave varied dramatically among respondents. The most common leave time was three months (48.9%) followed by less than six weeks (22.6%). 41.2% of respondents had a salary decrease during pregnancy. 37.2% reported performing extra calls or service while pregnant “making up” for being on maternity leave. 21.5% of women thought that taking extra calls or service contributed to pregnancy complications. I must share that I am fortunate to work with some of the most wonderful, understanding, partners and bosses. This was reflected in my pregnancy and leave experience. Not all of us will have a positive experience, but we should. The lack of consistency in maternity leave and support for childbearing is not only a problem in cardiology. We hear this among colleagues of all specialties. Cardiology just so happens to pose a unique challenge given the historical lack of women in the specialty and the rigorous schedule for many. Efforts to create a more uniform maternity leave policy and welcoming pre and post-natal experience are more than past due.

Wonderwomen in Cardiology

Getting back to work after having a child can be overwhelming. The “routine” has changed to a less “routine” routine. That alarm clock buzz is most likely replaced by a crying baby and cold coffee left on the counter somewhere around the house. You are tired. When the sun comes up it is time to feed the baby, get them ready for whatever care you have arranged, and, if breastfeeding, pumping JUST before you leave so you can maximize work time when you arrive. Pumping while doing charts or on zoom calls has become a norm. The concerns about perception at work continue. You wonder, “will I be perceived as fragile or more interested in home life now?”. Struggling to “prove” that motherhood has not taken away your passion for work is almost inevitable. An inherent bias exists. While we juggle motherhood, being a wife (which for many includes cooking, laundry, nighttime routine), and work, we try to convince our colleagues that we are still the same. But are we? I would argue we return better. Finding a group to work with who thinks the same might be hard, but it is attainable. I can attest to that.  Raising children as a cardiologist is a busy new journey. Working together with your spouse is a must. Finally admitting that maybe you cannot do it all at home is okay. Asking for help is okay.  “Subcontracting” household tasks is sometimes necessary to get back to being you: a woman—no, a Wonder Woman both in cardiology and at home. Happy Mother’s Day to all the moms, soon-to-be moms, and those hoping to be moms one day.

Footnote: This was 50% written while pumping and 50% while the children were napping.

REFERENCE

  1. Gulati M, Korn R, Wood M, et al. Childbearing Among Women Cardiologists. J Am Coll Cardiol. 2022 Mar, 79 (11) 1076–1087. https://doi.org/10.1016/j.jacc.2021.12.034

“The views, opinions, and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness, and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions, or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your health matters. If you think you are having a heart attack, stroke, or another emergency, please call 911 immediately.”
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Women in Electrophysiology

Lina Ya'qoub, MD

While I was chatting with a few fellows in our hospital hallway, I met one of the fellows who was very interested in electrophysiology (EP). We had a very interesting chat about her application and future career forward. In this blog, I summarize my chat with Jasneet Devgun, an aspiring electrophysiologist.

Question: Hi Jasneet, great to have you here! Let’s start with this question: When and how did you know you love EP?

  • Answer: EP is something I never really thought of pursuing initially. In fact, I was interested in interventional cardiology since my second year of medical school. It was not until I met an electrophysiologist at the University of Chicago during my third year of medical school that I thought of EP as a possible future career. He was so excited to show me the world of EP and frequently took me to the lab to see EP in action. I still remember the day he said, “we need more women in EP…you should consider it.” From then on, my curiosity grew. I found myself drawn to the lab, scrubbing in on cases in residency and fellowship. The unique therapeutics, cutting-edge procedures and technology, intellectual and logical nature of EP, alongside very memorable and rewarding encounters with patients and wonderful attendings, made me realized that EP was the right field for me.

Question: This is great!! What are your thoughts about women in EP?

  • Answer: Last year, Dr. Kamala Tamirisa wrote a very thoughtful piece for EP Lab Digest on the EP fellow shortage.1 At the time, the National Resident Matching Program (NRMP) demonstrated that approximately 40% of 130 EP fellowship positions in the US were unfilled.2 In 2021, that number drastically declined to 4%. Despite clear rising interest in EP, there remains a paucity of women in the field. The American Board of Internal Medicine (ABIM) reported that women comprised only 10% of first year EP fellows, while remaining steady at this rate for the past 10 years.3

The paucity of women pursing EP is a multi-faceted issue. A recent survey of cardiology fellows-in-training published in the Journal of American College of Cardiology showed that the most significant reasons women did not choose EP were greater interest in another field, radiation concerns, lack of female role models, a perceived “old boys’ club” culture, and discrimination/harassment concerns.4 Another reason was length of training. Reasons why women did choose EP were positive mentorship, unique features about the specialty, expertise, and the presence of a female role model, the latter being the major influencer.

These results are not surprising, but there are ways we can tackle the question at hand.

Question: Absolutely!! And this brings up the importance of mentorship, can you share your experience with that?

  • Answer: I cannot stress enough the value of a good mentor. A good mentor inspires and cultivates the foundations of turning one’s future into reality. This was personally a huge factor for me; I did not know anything about, let alone consider, EP until I met electrophysiologists who had a genuine interest in my career development. Interestingly, none of them were female. Our male colleagues can be some of our biggest advocates. I certainly see how a female role model is uniquely relatable and valuable. However, the gap will remain until more females in EP exist. That said, networking with female electrophysiologists through existing organizations, as well as creating outreach/interest groups in-person and on social media to involve residents, medical students, and even undergraduate students, would be very effective.

Question: What advice do you have for fellows who do not know much about EP or are not sure if they would want to pursue it? What are some possible barriers to developing interest?

  • Answer: Exposure is key! Many trainees do not have much exposure to EP, and therefore may not know enough to develop an interest for it. Fellows should be aware of the distinctive benefits and exciting features unique to EP, which can only be achieved by increasing their time with electrophysiologists and the EP lab. This can also dispel concerns about radiation safety. For example, female cardiology fellows concerned about radiation in the survey may not know about the use of 3D mapping systems and multi-modality imaging, affording “low-fluoro” or “fluoro-less” cases and reduction in procedure times. Moreover, the development of robotically assisted procedures has provided an avenue to reduce occupational hazards.
  • I was fortunate that my residency program offered an EP elective, where I met electrophysiologists who were excited to show me their world. A structured elective early in residency and more electives for medical students, with some exposure to the lab, may help bridge the gap and channel early interest. The earlier it is, the better, since interests develop quickly (as did mine!).

Question: What are your thoughts on the length of training and how this may be impacting fellows’ wellness and career decisions?

  • Answer: Length of training is an important issue.1,4 This time overlaps with childbearing years and critical family development. Fellows, both male and female, should not have to feel like they must choose one over the other. There must be a genuine culture of promoting work-life balance during the long years of training. Fellows are also consequently faced with prolonged financial strains from student loan debt. These are things that fellows consider when deciding to pursue another fellowship. As medicine progresses towards a milieu of sub-specialties requiring ever-more training, the training structure must be modernized to optimize the workforce. Unfortunately, many people, including female fellows, may be missing out on great sub-specialties like EP because of these issues. Some have proposed modifying the last 6 months of cardiology fellowship as the beginning of CCEP, which is a great short-term goal.1 A “fast-track” program in fellowship that may even extend into residency may be a proposition for much later in the future. These changes can make a major difference in fellows’ career decisions, health, and well-being.  

Despite the paucity of women in EP, I am positive that the great strengths of this field will surpass any barriers to recruiting them. Building exposure early, having more visible role models and mentors, modification of the training structure, and many other solutions previously stated will allow for tremendous progress. Even simple interventions can make leaps and bounds in bringing more women into the wonderful world of electrophysiology.

I would like to thank Jasneet Devgun, DO, who is currently a general cardiology fellow at Henry Ford Hospital, and an aspiring electrophysiologist, for sharing her experience and thoughts with us. A special thank you goes to Dr. Judith Mackall and Dr. Cristina Tita who helped in writing this blog.

References:

  1. Tamarisa, K. The Importance of Choosing Cardiac Electrophysiology as a Career: Thoughts on the EP Fellow Shortage. EP Lab Digest. Available at https://www.hmpgloballearningnetwork.com/site/eplab/importance-choosing-cardiac-electrophysiology-career-thoughts-ep-fellow-shortage. Accessed October 9, 2021.
  1. Fellowship Match Data and Reports. National Resident Matching Program. Available at http://www.nrmp.org/fellowship-match-data/. Accessed October 9, 2021.
  2. Percentage of First-Year Fellows by Gender and Type of Medical School Attended. Available at https://www.abim.org/about/statistics-data/resident-fellow-workforce-data/first-year-fellows-by-gender-type-of-medical-school-attended.aspx. Accessed October 9, 2021.
  1. Abdulsalam N, Gillis AM, Rzeszut AK, Yong CM, Duvernoy CS, Langan MN, West K, Velagapudi P, Killic S, O’Leary EL. Gender Differences in the Pursuit of Cardiac Electrophysiology Training in North America. J Am Coll Cardiol. 2021 Aug 31;78(9):898-909. doi: 10.1016/j.jacc.2021.06.033. PMID: 34446162.

“The views, opinions, and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness, and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions, or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your health matters. If you think you are having a heart attack, stroke, or another emergency, please call 911 immediately.”
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AHA Women in Cardiology Blog Series: DEVELOPING YOUR NICHE

Sherry-Ann Brown, MD, PhD

Written by :Sherry-Ann Brown MD PhD and Renee P. Bullock-Palmer MD

As the subspecialty of cardiology continues to expand, opportunities abound for developing new niches. A few, among others, of great interest to Women In Cardiology, are Cardiovascular Disease in Women, Cardio-Obstetrics, and Cardio-Oncology (especially breast cancer), as well as Structural Heart Disease and Sports Cardiology, among others. How does one develop a new niche? Various strategies are summarized in this blog as outlined below. Review all of these tips and take away the ones most relevant to your career, needs, goals, and interests.

EX.C.E.L.
Gain as much exposure as you can to the area within your subspecialty to which you would like to devote most of your career (1). The more you learn, and the more experience you gain, the more you will become an expert.

Networking is incredibly important. This applies locally, Regionally, nationally, and globally. The more exposure you gain to your colleagues and other leaders at your institution and in your national societies (1), the more you will become known as an international expert.

As you introduce yourself and market your brand, you must be aware of your own capabilities, as well as the capabilities of your institution (1). Gauge your talents, strengths, passions, and personality. Assess your background, training, and preparation. Determine how to best apply your abilities. Evaluate the availability off the tools, resources, and personnel you will need to achieve your professional goal of building a niche.

Expectations are key. Early on, establish expectations that your institution may have of you as you develop a new program (1). Expectations for patient care, education, research, community engagement, and institutional citizenship should be made clear. Your own expectations of support for your vision, as well as administrative time as applicable, ought to be delineated.

Know your limitations (1), weaknesses, and opportunities for growth. Stretch and develop yourself, but not beyond where your intellect and training are willing to go. Know too the limitations of what you have available to you at your institution.

P.Q.R.S.T.
Cultivate partnerships (2) with colleagues at various stages of building similar programs at other institutions. Being able to share mutual insights on patients in your niche will be invaluable.

As you attempt different approaches in your program building, be willing to be flexible and take “quicksteps” (a lively combination of steps in ballroom dancing). Adaptability in medicine and leadership are key, just like in ballroom dancing.

Make your rounds among various departments and divisions. Offer to give and coordinate multidisciplinary grand rounds and short presentations at the division or department meetings. Provide didactics for the fellows, residents, and students.

Consider knowledge gaps or needs in complementary subspecialties locally, and devise solutions that can help other subspecialists and enhance collaboration (2).

Remember, patient care occurs best in the setting of teamwork (2). Build your team. Know your team. Lead your team.

3Ls
Look at the landscape to assess changes on the horizon within your area of expertise. Adapt to these changes. Cardiology as a field is always evolving in several areas and this will affect your practice. There are ever emerging fields, such as Adult Congenital Heart Disease, Cardio-Oncology, Interventional Echocardiography, and Cardio-Obstetrics. Therefore, it is important to never stop learning and acquiring new skills. Do not become stagnant, otherwise, there is a risk of becoming irrelevant. Lean in, be present both at your institution by participating actively at department meetings, volunteering for committees at your institution in your area of interest, and offering your expertise to lead and/or guide initiatives in your department.

3As
Find and align yourself with other experts locally, nationally, and even globally. This will help develop new leadership skills and promote your skills. Networking is crucial in one’s career and is one of the key benefits of professional societal involvement. Professional societal involvement is also a great way to learn and develop new research ideas.

Being accessible to your colleagues is important and will be helpful in developing your niche. Accessibility can be a great way to promote your practice, as well as increase your patient referral base.

Being accountable for your work is critical as you establish your niche. Accountability is a vital part of good patient care and being an effective leader in your practice.

2Ps
Find a platform to share your expertise either through outreach by giving educational talks to providers at local grand rounds, or dinner talks and participation in regional conferences and webinars. Participate in writing groups when the opportunity arises, and publish articles in your field. Opportunities for research may be either locally at your institution or nationally with multi-institutional national studies or registries.

Patient care is paramount, to demonstrate the effectiveness of your practice on clinical outcomes. After all, we entered this profession to take care of patients – do not practice in a vacuum. Excellent patient care will establish you as a meaningful contributor to the Cardiology service line at your institution.

Conclusion
Finding your niche is an important part of establishing your career. Never forget your career goals and focus and do not lose sight of these. We have outlined several strategies that may be customized to your practice environment and professional goals.

REFERENCES:

  1. Kilic A. How to develop a niche: Focus on adult cardiac surgery. J Thorac Cardiovasc Surg. 2016;151(3):636-9.
  2. https://www.acc.org/membership/sections-and-councils/early-career-section/section-updates/2016/08/16/08/53/developing-a-niche-in-structural-heart-disease

 

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”

 
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11 Women Cardiology Leaders – How to Overcome Adversity & Thrive

Renee Bullock-Palmer, MD

Summarized by Nidhi Madan MD Sarah Rosanel, MD; Cynthia Kos DO, Renee P. Bullock-Palmer MD, Kamala P. Tamirisa MD and Purvi Parwani MBBS MPH. Edited by Marissa Bergman.

Presented by the ACC Women in Cardiology (WIC) Section, AHA WIC Section and Women as One, this webinar highlighted a panel of female cardiologists with leadership roles in the field. The opportunity of gathering 11 female leaders of international Cardiology organizations comes rarely and the webinar was incredibly inspirational. It was co-moderated by ACC WIC Chair Dr. Toniya Singh, MD, Cardiologist at St. Louis Heart & Vascular and AHA WIC Chair, Dr. Annabelle Volgman, MD, Professor of Medicine, Rush College of Medicine;

The webinar focused on providing guidance, empowerment and optimism to women in cardiology through personal journeys and experiences. The presentations equipped attendees with the necessary skills and qualities to more than just survive, but, rather, thrive, during the ongoing pandemic and racial crisis.

Cindy Grines, MD, FACC, MSCAI

President of the Society of Cardiac Angiography & Interventions.

                                    “Accept the situation and have a game plan.”

Dr. Grines began the presentation with her personal journey. She had an extremely successful cardiology career in Michigan for over 25 years. Then, she decided to move, for family reasons, and began a new position as Academic Chair of Cardiology in New York. She was told during the interview process that her focus needed to be 90% on academics, research productivity, mentoring the faculty, and gaining the program a national presence. Over the next 1.5 years, she worked hard towards these goals and exceeded the expectations. Yet, despite going above and beyond in her professional duties, Dr. Grines was terminated from her position without a valid reason – with claims that it was a “business decision” and “trying to merge some roles.” She alluded to how she handled this unprecedented situation, and formulated a game plan. She negotiated a severance package and found her current position, with which she is very happy. Her presentation emphasized the importance of networking and  destigmatizing what might feel like a humiliating and isolating situation. Dr. Grines concluded with words of motivation:

“You need to pick yourself up, brush yourself off and get back in the saddle and ride that horse again. The bottom line is change is good and when these things happen to you it’s going to motivate you to do something different and to prove yourself.”

Roxana Mehran, MD, FACC, FACP, FCCP, FESC, FAHA, FSCAI  

 The Cofounder of “Woman As One.”

“Don’t give up on your goals.”

Dr. Mehran’s presentation started with a bang: “Celebrate Women!” She continued with powerful words, “When we focus on our goals, we can achieve everything and we should never give up on our goals. They are yours, cherish them, fight for it, you will achieve it.”

Dr. Mehran was born in Iran and she dreamt of being a doctor since she was quite young. Amidst the hostage crisis in Iran, her family immigrated to Queens, NY. Despite facing poverty and restarting her life as an outsider, she never lost sight of her aspirations and eventually became an interventional cardiologist. With her determination and strong will, Dr. Mehran was one of the first female fellows at Mount Sinai. She pursued her career and continued her mission to contribute to science and clinical outcomes. As a woman in a male dominated field, she felt the inequalities in interventional cardiology, and she made it her new goal to ensure women are heard. Ultimately, she co-founded “Women As One” to encourage women not to accept inequalities or harassment in any form. As she explained, “You just have to see it all, keep your eye on the ball just like they tell you in baseball and in tennis… and make sure you hit that bull’s eye. Work hard and it will come to you.”  She concluded with her favorite quote by Maya Angelou,

 “Do your best you can until you know better, then when you know better, do better.”

Athena Poppas, MD, FACC, FASE

President of the American College of Cardiology

 “Strategic Leadership & Change Management”

Strategic leadership has never been as important as it is during the challenging times of the pandemic. Dr. Poppas referred to the importance of influential leadership and emphasized that one does not need a title to lead. These times are an incredible opportunity for everyone to step up and contribute. She explained that strategic leadership is not linear, but mostly circular – anticipating, recognizing challenges, interpreting and making decisions, staying aligned but learning along the way. She then shared some of the key tools from her leadership toolbox:

  1. Authenticity is essential.
  2. Use influential skills rather than just telling someone what to do – utilize the tools of change management to bring people along.
  3. Manage conflict and work together.
  4. Realize one’s own strengths, be honest about those strengths and bounce ideas off friends and allies. Be cognizant about weaknesses with a goal to improve them.
  5. Put yourself out there and seize opportunities.

Dr. Poppas concluded by reiterating that change management and strategic leadership is a continuum and a continuous cycle of learning. At the same time, succession planning with mentoring and helping others is key, so that there is an entire group capable of replacing you.

Andrea Russo, MD, FHRS

Immediate past President of Heart Rhythm Society (HRS)

                                                               “Resilience”

 In Dr. Russo’s first week as President of HRS, a controversial topic of Maintenance od Certificate (MOC) surfaced. HRS was looking into ways to create a less disruptive and  more customizable educational program and certification. Therefore, HRS put together an MOC Task Force and conducted a member survey assessing the feasibility of other options. Throughout this battle, resilience helped her look into options that would be relevant to the HRS members. The COVID-19 pandemic put the annual HRS meeting in jeopardy. She led the team, which considered the safety of travel and alternate ways to deliver education. Arrhythmias related to the coronavirus needed attention with protocols; how to deliver EP care to patients in the COVID era while also protecting the EP team by reducing their exposure became a priority. To answer these questions, HRS put together a group called the COVID-19 Rapid Response Task Force to collate the major information and provide guidance. There was an outpouring of volunteers and these documents were prepared in record time. This experience emphasized  the resilience of a collective resolve from the volunteers who contributed to the HRS staff. Dr. Russo concluded by saying that COVID did jump start the utilization of online educational platforms and digital health to successfully deliver the HRS 2020 content online.   She explained that one of the most rewarding experiences of her presidency was the ability to share ideas, work together with leaders from around the globe and improve knowledge.

Christine Albert, MD, MPH, FHRS

President of Heart Rhythm Society

“Embrace Change, Be Creative”

 Dr. Albert’s advice is, when one cannot change the adversity, it is important to change gears and embrace the new opportunity. Listening to new suggestions, moving forward and ultimately bringing the group along as a leader are an integral part of being creative. Advances in digital forms of communication in COVID times are one such example of embracing the change.  She ended with these empowering words, “Don’t be afraid to forge ahead in adversity.”

                                                  Mariell Jessup, MD, FAHA

                Chief Science & Medical Officer of American Heart Association

                                               “Believe in your Capabilities”

 Dr. Jessup’s presentation focused on how it takes courage to overpower impostor syndrome and its nagging question, “Are you capable?” She pointed to Michelle Obama’s comments as a guiding example: “Am I good enough?” “Of course!” She argued that courage might not be easy to find every moment, and that friends and mentors play an important role against a doubtful mind.

She referred to Eleanor Roosevelt’s challenging life and quoted, “You gain strength, courage and confidence by every experience in which you really stop to look fear in the face. You are able to say to yourself, ‘I have lived through this horror. I can take the next thing that comes along.’ You must do the thing you think you cannot do.”

Dr. Jessup offered several more phrases and quotes to empower and remind women that it is vital to focus on courage to lift up mentees. She was reminded of Queen Elizabeth’s quote, “When life seems hard, the courageous do not lie down and accept defeat; instead, they are all the more determined to struggle for a better future.” Another voice of reason she found very relevant is Winston Churchill, regarding sharing courage “I never gave them courage; I was able to focus theirs.” She concluded her presentation on an uplifting note – “Have the courage!”

 Michelle Albert, MD, MPH, FAHA, FACC

President, Association of Black Cardiologists (ABC)

 “Remembering your purpose”

 Dr. Albert emphasized being innovative and creative while also being kind and compassionate in a society facing healthcare disparities. It is important to remember the purpose, when attempting to have an impact. She also emphasized harnessing one’s background to help focus on one’s individual passion and follow that purpose.

Raised by her grandparents, Dr. Albert witnessed hardship and segregation, and she perceived how the socioeconomic background of the patients influenced healthcare. As she explained, “The largest gap in healthcare is in cardiovascular medicine”.

Dr. Albert further highlighted the importance of appropriate support, including key mentorship and faith to overcome adversity. She stressed that being disciplined; bold, collaborative and always thinking outside of the box are key for achieving ultimate professional purpose.

She concluded by warning against transactional relationships or being predatory in the professional setting.

Chiara Bucciarelli-Ducci, MD, PhD, FESC, FRCP

CEO, Society of Cardiac Magnetic Resonance (SCMR)

“What opportunities can this adversity bring?”

 Dr. Bucciarelli-Ducci believes there are endless opportunities and each challenge simply leads to more opportunities. She is a transformational leader, someone who tries to identify the need for change, create a vision, guide change through inspiration and work collaboratively. She always aspired to be that woman in cardiology and her experience has taught that with change always comes resistance. She stressed the importance of listening to all parties while honing the power of negotiation. She quoted Socrates, in emphasizing the power of a collaborative team, “The secret of change is to focus all of your energy, not on fighting the old, but on building the new.”

Her Italian background, upbringing and world history inspire her tremendously. To Dr. Bucciarelli-Ducci, the COVID-19 pandemic parallels what happened during World War II (WWII). Just like WWII, she believes that this pandemic is creating new ways of thinking, working and connecting with people across the globe.

Sharmila Dorbala, MD, MPH, FASNC

President, American Society of Nuclear Cardiology (ASNAC)

“Be Optimistic”

In Dr. Dorbala’s experience, “Optimism is one of the keys to success.” She believes that whether one looks at the glass as half-full or half-empty is a matter of perspective and choice. One can choose to be an optimist and train oneself to focus on the positives, and that optimism gives one confidence to take risks and then becomes contagious.

She provided an example of contrasting optimists and pessimists and how they view the world differently. Optimists see challenges as being temporary, something that can be conquered and used as a stepping-stone to better solutions, whereas pessimists view challenges as insurmountable obstacles. She referenced her research interest in cardiac amyloidosis to illustrate how optimism has influenced her own career. Dr. Dorbala actively chose to be optimistic and stayed in this field despite the hurdles she encountered. She always remained passionate about her field and confident that her hard work would lead to opportunities. She believes that the advances in medicine seen today are because the medical community chose to focus on the potential of the future.

Her overall advice for professional life is to have the integrity to do what is right, irrespective of the consequences, focus on excellence and be passionate about the cause. She reminds us to never underestimate the importance of having an optimistic outlook to gain confidence and to look for opportunities by embracing risks.

Judy Hung, MD, FASE

Incoming President, American Society of Echocardiography (ASE)

“Forget the noise and forge ahead”

Dr. Hung emphasized that during one’s medical career there will be many instances of biases and inequality, intentional or unconscious. She advised that these injustices should not distract one from pursuing their goals.  To her, it is important to always stay in the lane. Dr. Hung explained that one could transform anger and sadness into positive energy, and make an impact professionally. Her strongest advice to women in cardiology is to stay focused and not let negative attributes of mental energy sway one away from their focus.

Biykem Bozkurt, MD, PhD, FHFSA, FACC, FAHA

President of Heart Failure Society of North America

“Create Change and acknowledge the ‘never-evers’ ”

 In a time that has left everyone grappling with unprecedented personal and professional challenges, how can do you thrive as leaders? Dr. Bozkurt argued, “most advancements come from acknowledgement of the ‘never-evers’”. “You have to face obstacles head on” or else face “stagnation and complacency.” She offered words of wisdom that adversity creates opportunity for resilience to get out of one’s comfort zone and create a meaningful change.

The COVID-19 pandemic has exacerbated a constant truth of the profession – doctors are witness to human suffering, but, at the same time, healing. “Do not sanitize suffering…learn from it… and teach the next generation,” said Dr. Bozkurt.  She cautioned against disinfecting the truth out of uncomfortable realities.  Amongst the suffering and sacrifice lies empathy, humility, and growth.

Dr. Bozkurt cited the story of Marguerite Matisse as a compelling example. Marguerite suffered from severe illness at a young age, requiring a tracheostomy. Despite poor health and a prominent scar, she became a lifelong muse for her father, the renowned artist Henri Matisse. As he once explained, “I don’t remember adversity, I remember resilience.” Dr. Bozkurt hopes that when the world looks back on the current healthcare, economic, racial, and political situations, Matisse’s quote will ring true.

Visit this website for access to this important webinar.

Summarized by Nidhi Madan MD Sarah Rosanel, MD; Cynthia Kos DO, Renee P. Bullock-Palmer MD, Kamala P. Tamirisa MD and Purvi Parwani MBBS MPH. Edited by Marissa Bergman.

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”
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Bifurcations: EPISODE 3 – TAP TECHNIQUE

Mirvat Alasnag, MD

As the summer holidays wind down to the final few days, many of us are heading back to the routine of work, school and home.  With the end of summer, my Bifurcation Series comes to a close as well. The final episode is the TAP technique.

Operators find this to be the least cumbersome of all the 2-stent strategies. Many resort to it during emergencies as the access to the main branch (MB) is maintained throughout the procedure. The steps are fewer which ensures expeditious coverage of both vessels followed by the conventional optimization steps including kissing and proximal optimization with a non-compliant balloon. Similar to culotte, this strategy allows operators to start with a provisional strategy and convert to TAP should the need arise. In addition, there is minimal stent overlap. This technique is considered a modification of what was formally known as T-stenting. The primary limitation of the original T-stenting was missing the ostium of the side branch (SB). This geographic miss is what prompted many operators to perform minimal protrusion to mitigate in-stent restenosis at that missed segment. Hence the name TAP, T and small protrusion, was coined. Although this technique has been adopted worldwide, there are no large randomized trials with long term outcome data to reference. There are some published data; however, that are worth reviewing.

 

Study TAP strategy Patients (n) Unprotected
left main stem		 Follow-up
duration		 TVR Definite stent
thrombosis
Burzotta et al’ Bail-out TAP in provisional 73 37.0% 9 months 6.8% 1.40%
Al Rashdan
et al7		 Systematic TAP 156 10.3  % 36 months
(range 24-48 months)		 5.3% 0.06%
Burzotta et a1 Bail-out TAP in
provisional procedures		 19 5.0% 12 months 5.3% none
Naganuma et al Bail-out TAP (type B dissection or
TlMI <3 or stenosis >50% in the SB)		 95 18.9% 36 months 9.7% none
ARTEMIS
study10		 Bail-out TAP (type B dissection or
TlMI <3 or stenosis >75% in the SB)		 71 26.8% 12 months 8.5% none
 SB:side branch;TVR: target vessel revascularisation

 

Burzotta et al, 2007

The modification of the T-stenting was first described in 2007 by Burzotta et al.1 It was evaluated in vitro and in two independent series of patients undergoing elective drug-eluting stent (DES) implantation on a bifurcation lesion. In vitro testing demonstrated perfect coverage of the bifurcation with minimal stent’s struts overlap at the proximal segment of SB ostium with a single layer stent struts. Sirolimus, paclitaxel, or zotarolimus DES were deployed in 73 patients (67% with Medina 1,1,1 lesions and 44% of unprotected distal left main disease) using the TAP technique. The procedural success was achieved in all cases. At 9 months the clinically-driven target vessel revascularization (TVR) was 6.8%. Since this was a pilot study, the investigators recommended larger outcome trials to further evaluate this technique. No comparison arm was available in this initial trial.

 

Al-Rashdan et al, 2009

In 2009 Al-Rashdan et al published their series of 156 consecutive patients who underwent TAP stenting.2 This was a single center study that resulted in a 99% procedural success rate and a major adverse cardiac events (MACE) free survival rate of 88% at 36 months average follow up. The TVR rate was 5.3%. Although to date this represents the largest cohort of TAP cases, the results are limited to a single center with no randomization which precludes further conclusions.

 

Burzotta et al, 2009

In 2009, Burzotta’s group prospectively enrolled 266 consecutive patients requiring treatment of a bifurcation lesion.3 The MB was treated with a DES and TAP was reserved as a bailout strategy. Only 19 of the total required a bailout 2-stent strategy. Nine percent of the total had unprotected left main disease. At one year, the MACE rate was 8.2%. A non-hierarchical analysis revealed a 0.4% cardiac death, 4.1% MI, 4.5% TVR and 2 of the total had probable stent thrombosis (ST).  Given the small number of bailout 2-stent strategy arm, this study only demonstrates safety.

 

Naganuma et al, 2013

Naganuma et al retrospectively analyzed data of all patients who underwent TAP technique with DES between July 2005 and January 2012.4 A total of 95 patients were enrolled. Angiographic procedural success was achieved in all cases. A true bifurcation was found in 78.9% of those enrolled. The 3-year MACE, cardiac death or myocardial infarction, TVR and target lesion revascularization (TLR) rates were 12.9%, 3.1%, 9.7%, and 5.1%, respectively. No ST was observed in this cohort. Once again, the investigators recommend larger trials to make solid recommendations.

Naganuma et al, JACC Cardiovasc Interv. 2013;6:554-61.

Naganuma et al, JACC Cardiovasc Interv. 2013;6:554-61.

 

ARTEMIS Study 2014

The ARTEMIS study was published in 2014.5 It evaluated the mid-term angiographic results of TAP as the bailout strategy in symptomatic patients who were treated with one-stent strategy (DES of the MB) and kissing balloon inflation of the SB who subsequently developed impingement of the branch. TAP was performed if residual diameter stenosis of SB was ≥75%, presence of ≥type B dissection or flow impairment of the SB occurred. A total of 71 patients were enrolled with a MEDINA classification 1,1,1 lesions occurring in 60% of the total. At 9 months, restenosis was occurred in 12.5% of the total. Late lumen loss in the MB and SB was 0.22 ± 0.19 and 0.34 ± 0.37 mm, respectively.

 

Dzavik et al, 2014

In 2014, there was much hype revolving around bioresorbable technology. Dzavik et al performed in vitro bifurcation stenting employing different modalities on synthetic arterial models.6 The everolimus-eluting bioresorbable vascular scaffold (Abbott Vascular, Santa Clara, California) (BVS) was used. A low-pressure final kissing balloon inflation was performed to complete the procedures. The results demonstrated that a single-stent technique optimally opened the SB without deforming the BVS in the MB. T or TAP-stenting covered the SB ostium completely. Culotte and crush with 2 BVS stents was successful; however, disruption was reported after the low pressure kissing inflation in one case. Investigators concluded that it was feasible to perform bifurcation stenting with BVS in large caliber vessels. They also recommended that a provisional strategy as the default. TAP or T-stenting with a metal DES is preferable. As the overall in vivo outcome data for BVS remains cautionary at best, the use of BVS outside clinical trials is not recommended whether for focal type A lesions or complex bifurcations.

The technique itself is illustrated below. As mentioned earlier, it is one of the simpler 2-stent strategies. Like other strategies, appropriate sizing, positioning and optimization ultimately dictate the final angiographic and clinical outcomes. Intracoronary imaging facilitates these crucial steps. Yet, as with all interventions, judgment is the cornerstone of any successful procedure. When appropriate, and based on both Syntax score and clinical scores, surgical revascularization should be considered. When one opts for percutaneous revascularization, the indication for the procedure, its potential risks and complexity should be shared with the patient. For operators, judging the significance of the SB, the angle of the bifurcation, the size of both vessels and the need for mechanical circulatory support is valuable. Finally, complex bifurcation stenting is not for everyone. When appropriate, such complex procedures should be referred to expert operators for the best outcomes.

Animations/illustrations courtesy of Graphic Designer Dania Al-Shaibi

Email: [email protected]

 

 

References:

  1. Burzotta F, Gwon HC, Hahn JY, Romagnoli E, Choi JH, Trani C, Colombo A. Modified T-stenting with intentional protrusion of the side-branch stent within the main vessel stent to ensure ostial coverage and facilitate final kissing balloon: the T-stenting and small protrusion technique (TAP-stenting). Report of bench testing and first clinical Italian-Korean two-centre experience. Catheter Cardiovasc Interv.2007;70:75-82.
  2. Al Rashdan I, Amin H. Carina modification T stenting, a new bifurcation stenting technique: clinical and angiographic data from the first 156 consecutive patients. Catheter Cardiovasc Interv.2009;74:683-90.
  3. Burzotta F, Sgueglia GA, Trani C, Talarico GP, Coroleu SF, Giubilato S, Niccoli G, Giammarinaro M, Porto I, Leone AM, Mongiardo R, Mazzari MA, Schiavoni G, Crea F. Provisional TAP-stenting strategy to treat bifurcated lesions with drug-eluting stents: one-year clinical results of a prospective registry. J Invasive Cardiol.2009;21:532-7.
  4. Naganuma T, Latib A, Basavarajaiah S, Chieffo A, Figini F, Carlino M, Montorfano M, Godino C, Ferrarello S, Hasegawa T, Kawaguchi M, Nakamura S, Colombo A. The long-term clinical outcome of T-stenting and small protrusion technique for coronary bifurcation lesions. JACC Cardiovasc Interv. 2013;6:554-61.
  5. Jim MH, Wu EB, Fung RC, Ng AK, Yiu KH, Siu CW, Ho HH. Angiographic result of T-stenting with small protrusion using drug-eluting stents in the management of ischemic side branch: the ARTEMIS study. Heart Vessels.2014 Mar 14.
  6. Dzavik V, Colombo A. The absorb bioresorbable vascular scaffold in coronary bifurcations: insights from bench testing. JACC Cardiovasc Interv.2014;7:81-8.

 
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Learning to Lead in New Ways

Nosheen Reza, MD

Last November, I attended Career Advancement and Leadership Skills for Women in Healthcare, an illuminating conference that changed my approaches to my personal and professional development.

Led by Drs. Julie Silver and Saurabha Bhatnagar, this Harvard Medical School women’s leadership course delivers evidence-based strategies, skills development, and education to help women across health professions assume and succeed in leadership positions. Executive leaders from my institution have written about the critical need for health systems to support emerging physician leaders and to nurture them at each stage of professional advancement. Considering these organizational priorities, I thought that this course would effectively combine education with skills development in a unique environment and would provide strategic and cultural alignment with my own interests in leadership.

The course itself spanned two and a half days with a mix of daily morning plenary sessions, afternoon small group breakout sessions, and evening networking opportunities. From the outset, the tone of the conference was unlike that of any I had previously attended. There was a sense of genuine camaraderie in the rooms, despite the huge number of attendees largely from different clinical, research, and administrative backgrounds. Interpersonal interactions were built on a mutual understanding of the obstacles of underrepresentation and inequity. I noticed how openly women discussed successes and failures, asked questions, and negotiated when surrounded by a supportive group with shared experiences. As one of the few trainees in attendance, I felt especially empowered through hearing about the career trajectories of these successful women leaders.

The first day of the conference focused on identifying your mission and vision, recognizing your leadership potential and style, and learning strategic planning. Here are five of my top takeaways from day 1:

5 takeaways from day 1

The second day focused on refining your oral and written communication skills. Here are five of my top takeaways from day 2:

key takeaways from day 2

In the last session of the conference, Dr. Silver delivered an impassioned call to action for us to take our newly developed skills back to our institutions to share with others and to advance our own careers. After I returned home, I created my own customized plan for career development using the course principles. I also led an abbreviated career advancement and leadership skills workshop for my institution’s Women in Cardiology group, sharing the highlights of what I had learned with my resident, fellow, and faculty colleagues.

For more content from the conference, check out the #SheLeadsHealthcare hashtag on Twitter and this year’s conference project, the #BeEthical campaign.

This year’s course is scheduled for November 14-16, 2019 in Boston, Massachusetts. If you work in health care and are interested in developing your leadership skills, I strongly recommend investing in your personal and professional development through a course like this or another similar experience.
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Balancing versus Integration of Motherhood and Your Career as a Female Cardiologist

Renee Bullock-Palmer, MD

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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Anxiety, Food Security, & Beyoncé: Addressing Young Women’s Cardiovascular Health

Elizabeth Knight, PhD, DNP

What can you do to address gender disparities in health and health care? In my last post, I suggested working to identify your own bias by increasing your awareness. I’m walking this path, too. A few years ago, I made a concerted effort to diversity my reading habits after I noticed that a huge percentage of the work I was consuming was produced by white men. I spent a year choosing to read only books by women and people of color instead. I learned that it was not hard to do this, but it required that I pay attention. I read a lot of wonderful work that I might have otherwise overlooked, and I was exposed to much more diverse viewpoints. I continue to seek out broad representation, and I suggest a similar approach to reading scientific literature.

Start by paying attention to 1) study populations, and 2) authorship. Are you reading articles about (and by) underrepresented populations? In cardiovascular health, this includes women, who remain underrepresented in clinical trials (estimates as low as 34% of participants in trials supporting drugs for some CV conditions1), clinical practice (just 20% of cardiology fellow are women2), and academia (check out the #nomanels hashtag on Twitter).

Clearly, we need more cardiovascular research by and about women. In this post, I want to highlight some exciting research by and about women.

Evidence of the pervasive male bias: we've programmed our machines to assume patients are male.

Evidence of the pervasive male bias: we’ve programmed our machines to assume patients are male.

At the recent American Heart Association EPI/Lifestyle conference, a woman-led team from Boston Children’s Hospital presented their work on perceptions of cardiovascular risk among adolescent and young adult (AYA) women. The team recognized that young women didn’t seem particularly informed about or interested in their heart health. Based on this clinical insight, they designed a study to identify barriers to awareness and preventive behaviors among AYA women. I spoke with Courtney Brown, an early-career professional herself and the first author of the abstract3, who explained the team’s findings. First, noted Brown, AYA women have a low baseline knowledge of their cardiovascular risk— lower than expected. They also face competing demands to focusing on their cardiovascular health, such as limited time and financial resources. One key finding was the role of mental health concerns like depression and anxiety: it’s hard to care about something that might happen to you in thirty years when you’re worried about getting through your next few days. Some participants also noted that eating healthy seems too expensive, and sometimes healthy food just isn’t available. These barriers to healthy behaviors are real! Yet behaviors established in young adulthood tend to persist as we age, so AYA women are at a crucial time in their lives for their heart health.

A key point for intervention development, says Brown, is that lifestyle behaviors (including exercise and high-quality nutrition) that are good for mood are also good for heart health. So while cardiovascular health may not be this group’s priority, they will likely benefit from risk-reducing behaviors in multiple ways.

Delivering the message in the setting of competing demands is tricky— and important.  When asked what might facilitate their adoption of heart-healthy behaviors, participants in the study indicated that family was their biggest influence, followed by their health care providers and celebrities (favorites were Drake, the Kardashians, and Beyoncé). They also talked about using Facebook, Snapchat, and Instagram to get information and communicate. This is rich data, and it suggests that a “meet them where they’re at” approach is likely to be successful. “We’d love for more people to take up this work— we have more steps to take,” Brown says. “We’d love to create and test materials.” It’s encouraging to see rigorous science targeting the needs of a group that’s often overlooked in cardiovascular research. As the body of evidence grows, perhaps some of the disparities in women’s cardiovascular health will fade.

There are also some great lessons here from a methodological standpoint. This study utilized mixed methods, including online focus groups. Courtney Brown, the researcher from the AYA study, stressed that the qualitative component of the work is highly valuable because it can help researchers develop interventions that will effectively reach the population of interest. “It lets us dig deeper into responses to find out what the unique barriers are and how to reach this population, not just what to tell them”, she says. When so much of existing clinical practice is based on research that excluded women, this approach is very relevant. In a climate where the RCT is king and the p-value determines whether or not a finding is considered significant, qualitative work is often undervalued, but these kinds of studies are crucial in understanding the needs, values, and preferences of patient populations— especially those, such as young women, that have been previously understudied and undertreated.

 

Have you read (or authored!) any great women’s health studies lately? Try to add some to your reading list!

 

References:

  1. Scott, P, Unger, E., Jenkins, M. Southworth, M., McDowell, T., Geller, R., Elahi, M. Temple, R., & Woodcock, J. (2018). Participation of women in clinical trials supporting FDA approval of cardiovascular drugs. Journal of the American College of Cardiology, 71(18), 1960-9.
  2. Lau, E. & Wood, M. (2018). How to we attract and retain women in cardiology? Clinical Cardiology, 41(2), 264-268.
  3. Brown, C., Revette, A., de Ferranti, S., Liu, J., Stamoulis, C., & Gooding, H. (2019). Heart Healthy Behaviors in Young Women: What Prevents Teens from Going Red? Abstract presented at American Heart Association Epidemiology, Prevention, Lifestyle & Cardiometabolic Health Scientific Sessions, Houston, TX.

 

 

Who is writing what you're reading? Look at the great mix of people on the AHA early career blogging team!

Who is writing what you’re reading? Look at the great mix of people on the AHA early career blogging team!

 
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Women’s History Month: Cardiology Edition

Christa Trexler, PhD

Somehow it’s already March, which means it’s Women’s History Month, so I wanted to take this opportunity to highlight some of the many amazing cardiologists and researchers (who also happen to be women) who have shaped our field.

Last month, I wrote about the importance of science outreach, especially with regard to promoting science and cardiology to young girls and women, because women still make up around only a third of scientific researchers and only around 13% of cardiologists are women. To learn more, Renee P. Bullock-Palmer’s most recent blog is a great resource.

This month I wanted to highlight some of the women who paved the way for the rest of us.


Now, unsurprisingly, simple Google searches for things like “scientists who shaped cardiology” or “most famous cardiologists” provide results that are pretty male and pale. There weren’t that many pieces that included women in their lists of cardiologists/researchers, and there were only a handful of sources I found that focused specifically on women. Lucky for you, I’ve collected what I found here! I’m also going to highlight several of the brilliant women who shaped our field – this is by no means an exhaustive list of amazing women in cardiology (or their accomplishments) because there are too many to fit on one list.

 

Maude Abbott, MD was a Canadian physician who invented an international classification system for congenital heart disease in the 1930’s. Her work the Atlas of Congenital Heart Disease became the definitive reference guide on the subject.

 

Helen B. Taussig, MD, FACC is widely regarded as the Founder of Pediatric Cardiology. In the 1940’s she developed the operation to correct the congenital heart defect that causes “blue baby” syndrome. She received the Medal of Freedom from President Lyndon B. Johnson and was the first female president of the American Heart Association.

 

Myra Adele Logan, MD was the first woman (and only the 9th person!) to operate on a human heart in 1943.

 

Marie Maynard Daly, PhD was first African American woman to obtain a PhD in chemistry in the United States, whose research in the 1950’s was invaluable in demonstrating the relationship between high cholesterol levels and heart attacks.

 

Celia Mary Oakley, MD was one of the first women cardiologists in the United Kingdom and was part of the team that coined the term hypertrophic cardiomyopathy in the late 1950’s.

 

Sharon A. Hunt, MD was just one of seven women in her 1967 medical school class and she went on to revolutionize the field of heart transplantation by working to improve survival rates by identifying and treating rejection and determining how to reduce the side effects of the drugs.

 

Nanette Kass Wenger, MD, was among the first cardiologists to focus on heart disease in women, and to evaluate the different risk factors and manifestations of the condition, specifically coronary artery disease, in women and men. I was lucky enough to talk with her about her work at AHA Sessions 2018, which I wrote about here. You can also follow her on twitter @NanetteWenger.

 

Christine Seidman, MD, is a researcher who transformed the field of cardiovascular genetics with her research that uncovered the genetic basis of many human cardiovascular disorders, including cardiomyopathy, heart failure and even congenital heart malformations.

 

Elizabeth O. Ofili, MD, MPH, FACC is a clinical scientist who led the effort to implement the landmark African American Heart Failure Trial (AHEFT), whose findings improved the practice guidelines for the treatment of heart failure in African Americans. She also became the first woman president of the Association of Black Cardiologists in 2000.

 

Ileana Piña, MD, MPH, FACC is a nationally renowned cardiologist known for her work in heart failure and improving patient rehabilitation outcomes. Her work has also upturned preconceived notions about women in the medical community and she works tirelessly to get more women into clinical trials.

 

Rong Tian, MD, PhD is a leader in the field of cardiac metabolism whose work has been translated to clinical trials. Among her many contributions, she was the first to demonstrate that AMP-activated protein kinase (AMPK) acted to remodel cardiac energy metabolism, which critically informed the heart failure field. You can also follow her on twitter @Rongtian2.

 

I want to note, that these cardiologists and researchers are not important just because they are women – they are talented scientists and cardiologists who happen to also be women. But pieces like this are important because representation matters. It’s important for everyone, especially young girls and women, to see that it’s possible not just to be successful in this field, but also to revolutionize it.

 

Helpful sources & suggested reading:

 

 
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The Invaluable Importance of Mentorship Throughout Your Career as a Female Cardiologist

Renee Bullock-Palmer, MD

Featuring an Interview with Dr. Stacey Rosen recipient of the American Heart Association (AHA) 2018 “Women in Cardiology Mentoring Award”

 

Lack of Females in the Cardiology Field

Over 36% percent of Internal Medicine residents are females. Despite this fact, females account for less than 20% of the Adult Cardiologist workforce in the United States and account of less than 10% of Interventional Cardiologists in the United States1. Recruitment and retention of many talented female cardiologists remain a constant challenge and is due to a variety of reasons. Some of these reasons include the thought that cardiology is a grueling field that does not allow for work life balance and is often inhospitable for females desiring to start a family. There is also difficulty in retaining females in the field due to increased gender discrimination in the field1. In fact the Professional Life Survey conducted by the American College of Cardiology had reported that many female cardiologists in the field report a high level of career satisfaction which has not changed over the last 20 years1. However, there are many challenges that have remained the same for female cardiologists over the last 2 decades, such as gender discrimination, the need to arrange for paid or unpaid childcare, being single and not having any children1. In addition, there has been aging of the workforce and there are increasingly more female cardiologists practicing in an academic and/or hospital employed setting rather than in private practice1 and therefore having less autonomy over their work schedule and environment.

 

Need for Effective Mentorship For Female Cardiologists and the American Heart Association Women in Cardiology Mentoring Award

 

There is an ever increasing need to not only recruit more females in the field of Cardiology, but to also retain many talented female cardiologists in the field. Finding a good mentor and fostering good mentorship is invaluable for many females throughout their career in Cardiology. The Women in Cardiology Committee of the American Heart Association (AHA) values the importance of good mentorship and as such bestows the Women in Cardiology Mentor Award that is sponsored by the AHA Council on Clinical Cardiology to Cardiologists who have been recognised as having an outstanding record of effectively mentoring and supporting female cardiologists. Dr. Stacey E. Rosen,  Endowed Chair and Vice President for the Katz Institute for Women’s Health at Northwell Health, Partners Council Professor of Women’s Health at Hofstra North Shore-LIJ School of Medicine at Hofstra University and Professor of Cardiology at the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell is the recipient of the 2018 AHA Women in Cardiology Mentoring Award. She has mentored and supported numerous female cardiologists, and in the following interview, I had the honor of discussing the following questions with Dr. Rosen.

Courtney could we add a hyperlink to the AHA WIC mentor award nomination site?

 

What attracted you to the field of Cardiology?

Dr. Rosen: “I am the first member of my family to become a doctor. I am the daughter of educators and while in high school , I volunteered at Memorial Sloan Kettering in the pediatric child-life center. I thought that the medical field would allow me to pursue various professional options including clinical care, education, advocacy and research. I felt one could never be bored in medicine! As a student in the 6-year medical program at Boston University, we dissected a bovine heart and I was so amazed by the “simplicity” of the structure. Nothing else seemed intriguing after that – my only important decision was between pediatric cardiology and adult cardiology.”

Who were the inspirational persons that influenced this decision?

Dr. Rosen: “The Division of Cardiology at Boston University School of Medicine in the 1980’s – and ever since – was extraordinary. The faculty at Boston City Hospital (BCH) demonstrated commitment and passion for those in the underserved neighborhoods near BCH and the faculty at University Hospital were national respected clinicians , investigators and educators.”

Who were your mentors in Cardiology and how did they contribute to the advancement of your career?

Dr. Rosen: “I completed Internal Medicine residency and a chief resident year at Montefiore Medical Center in the Bronx, and was privileged to work with an impressive Division of Cardiology. Hildrud S. Mueller, MD and James Scheuer , MD taught me the importance of rigor and attention to detail in both clinical work and research. I presented my first oral presentation with John Fisher, MD – the recently retired division chief – and learned to perform a complete and thorough cardiac exam with Mark Menegus, MD.

As a fellow at Cornell – New York Hospital, Mary Roman, MD, Peter Okin, MD, Paul Kligfiled, MD, and Richard Devereux, MD fostered my fascination with imaging and non-invasive cardiology. Doppler physics was replacing hemodynamic assessment in the cardiac catheterization lab and I was hooked!

Finally, my first faculty position was at Mount Sinai Medical Center. Working in the echo lab with Martin Goldman, MD was an extraordinary opportunity. He inspired me to view echocardiography as a critical tool to enhance optimal patient care and helped me to develop the skills to become a lab director in my next position.

You have mentored many colleagues in the Cardiology field and have been valued by many as a great mentor, which led to your selection for the 2018 AHA Women in Cardiology Mentorship Award. What are the factors that mentees should consider when selecting a mentor?

Dr. Rosen: “Mentees should consider several critical factors:

  • Compatibility – Choose someone with whom you are compatible but not someone who is a “mini me“ of yourself. You do want a mentor who will challenge you, be comfortable providing feedback, and teach you to internalize and utilize feedback to advance your goals.
  • Trust – You want a mentor whom you can trust – you will likely be sharing important and perhaps confidential conversations. It is also critical to know that you must earn a sense of trust from your mentor.
  • Expertise – Your mentor does not have to have the most senior titles or positions, but should have the requisite expertise to help you advance your career and help navigate challenges.
  • Willingness – A great mentor is one who is devoted to helping you develop a vision and is delighted to share knowledge and wisdom. It should be someone who is a good listener and has sufficient time to commit to the relationship.

 

Would you recommend having more than one mentor?

Dr. Rosen:  “Absolutely! But do remember that the mentee needs to commit sufficient time to each relationship in order to optimize the value of the partnership

 

How can mentees truly harness the power of strong mentorship?

Dr. Rosen: “First – choose your mentor wisely and respect the relationship. Meet with individuals who you think may be good mentors and ask questions that will help you make a decision and get advice from friends and colleagues. Networking is often the key to identifying good choices.

Second – do the work and always respect the relationship! Discuss the goals and expectations of the partnership, as well as the process for communication, meetings and feedback. Be respectful of your mentor’s time and build trust immediately.

 

What are the differences between mentorship and sponsorship?

Dr. Rosen: Simply put – mentors advise you, while sponsors advance your career. A mentor is someone who can offer support, guidance and feedback, and allow you to develop your personal vision. A sponsor is earned – not chosen. A sponsor connects us to opportunities and advocates for our career advancement. It has been said that women are over-mentored and under-sponsored.

 

 

How has the experience of being a great mentor for so many colleagues contributed to your own career and personal growth?

Dr. Rosen: My late father was a middle school principal and my mother is a retired school teacher who taught in an underserved community in Brooklyn, NY. I learned from them the deep satisfaction one gets from teaching and advancing someone’s skills and abilities. I am also so grateful to MY mentors and get great satisfaction from “paying it forward.”  I am certain that I have learned as much from my mentors as they have learned from me!

What have been the 3 most rewarding experiences you have had throughout your career?

Dr. Rosen: As the director of the fellowship program at Northwell, I have had the privilege to work with dozens of trainees. I have helped impact their professional success and hopefully, the joy they find from practicing cardiology.

As chief of cardiology at Long Island Jewish Medical Center, I was able to rebuild a division that had weathered a hospital merger. Together with my colleagues, we completely revamped the division.

As a lifelong advocate for women’s heart health, I get enormous pride seeing the impact we have had on women’s health through improved clinical care, advances in gender-specific investigation and through advocacy and changes in policy. I know that our work is not done and that we still need to continue to advance women’s heart health agenda.

How has the field of Cardiology evolved over the duration of your career with regards to gender diversity and inclusivity of women in Cardiology?

Dr. Rosen: Unfortunately, our field has not advanced sufficiently when it comes to gender diversity and inclusion in Cardiology. Currently, fewer than 25% of cardiology fellows are female and fewer than 15% of board-certified cardiologists are women. Now that women are 50% of medical school graduates, the importance of developing a strategic approach to this lack of diversity is critical, or we will see a true talent drain in the near future. The good news is that both the American Heart Association and the American College of Cardiology have focused on lessening this disparity by better understanding the barriers facing female cardiologists and by making changes that will encourage young women to choose Cardiology.

What advice would you give to females considering a career in Cardiology?

Dr. Rosen: I can honestly think of no better choice! As clinicians, we can develop long-term longitudinal relationships and have an enormous impact on health and longevity. I believe that cardiology combines the best features of primary care and subspecialty medicine. As investigators, we can have a lasting impact on individuals and communities. Cardiology is also a field that is perfect for those who enjoy advocacy and advancing health policy improvements. I urge women NOT to eliminate Cardiology as a possibility because of concern about the challenges. Find the area of the field that you love, without fear or compromise, and then make decisions that will allow you to fulfill your vision of work – life integration.

References:

  1. Lewis SJ, Mehta LS, Douglas PS, et al. Changes in the Professional Lives of
    Cardiologists Over 2 Decades on behalf of the American College of Cardiology Women in Cardiology Leadership Council. J Am Coll Cardiol 2017