Women In Cardiology & The 2:00am Leadership

The Women In Cardiology (WIC) community has grown in recent years and has represented professional women in many ways. Tangible accomplishments include advocacy for more women on panels (#NoManels), curbing harassment (#MeToo), opening leadership opportunities and much more. Many have recruited men into the campaign for women (#HeForShe). Guidance into what men can do has also been emphasized, for example, speaking up when a committee lacks diversity and lending an early career woman a research opportunity. But, have we given women enough guidance? I fear not. Allow me to display examples where women have failed other women. It’s a collection that I’ve discussed over the course of the last several months in WIC workshops across the globe.


Time: 2:00 am

Place: Cathlab

Setting: STEMI & shock

Woman interventional cardiologist (IC) calls the on-call anesthetist (a fellow woman) to provide deep anesthesia because “I need to cardiovert this patient who had primary PCI and now in AF with RVR and is hemodynamically unstable”.

Anesthetist: Okay the patient is asleep, but does he really need cardioversion?

IC: Yes.

IC calls to technician: 200 Joules.

Anesthetist: No. It should be 100 Joules according to the AHA algorithm.

With an unstable patient on the table, is this the time to be questioning a colleague’s judgment in front of her staff? I fear using “patient advocacy” as an excuse to lecture a qualified cardiologist on the management of arrhythmias is inappropriate. Many electrophysiologists have reservations about the very conservative algorithm. 2:00 am in the cathlab is hardly the time or place for such a discourse. Perhaps at a more suitable time, a scientific discussion can educate everyone on the indications of cardioversion for AF. Why is this incident reckless and detrimental on many levels?

  1. It undermines a colleague in front of her staff to whom she has to prove herself every day.
  2. It doesn’t help a patient who is unstable. Every failed shock reduces the chance for the next shock to work.
  3. It portrays an image of two professional women “bickering” over a crashing patient.


Time: 2:00 am

Place: Email

Setting: Clinic Schedule

Cardiologist (a woman) fires off an email to the Chief of Staff expressing disillusion with the “disruptive” clinic schedule that was planned by her immediate section head (a woman). Why is this incident reckless and detrimental on many levels?

  1. It undermines the leadership of the section head, a woman nonetheless.
  2. It negatively impacts the relationship between colleagues (2 women).

Wouldn’t it have been more constructive if she spoke to her head first and made her recommendations? The worst part of this whole story is that the immediate section head did not design the clinic schedule. It was the Chief of Staff. The “backstabbing” backfired and the notion was that this cardiologist is not a team player. It would have been wiser and more respectable to go through the appropriate channels with suggestions for improvements. Why is this incident reckless and detrimental on so many levels?

  1. It doesn’t build team spirit or trust. It does the exact opposite.
  2. It damages future prospects for both women in the workplace. It leaves the impression that the head cannot inspire or lead and the other woman is not a trustworthy team player (late night backstabbing email).
  3. On a larger scale, it suggests men can be more professional even when competitive.


Time: 2:00 am

Place: International Teleconference

Setting: Planning of a Scientific Activity

A woman participant claims ownership of an idea that belongs to the chair of one of the subcommittees (a woman) and bypasses her. The worst part of this story is the director of this scientific activity (also a woman) allows her to do so. She does not empower the head of the subcommittee by channeling all projects/decisions through her. She does not acknowledge the other participants. Instead, this woman’s name is placed first in all communications. Why is this incident reckless and detrimental on so many levels?

  1. It proves that women can do other women more injustice by stripping them of credit and authority.
  2. It projects an image that women leaders lack fair leadership suggesting that it’s no better (perhaps worse) than men’s leadership.
  3. It casts doubt on the efficiency of the various WIC programs in providing leadership training and addressing such inconsistencies.


The purpose of this month’s blog is not to be critical of women. To the contrary, there have been many women exhibiting true leadership and effecting concrete changes. Now we find lactation areas at major meetings, opportunities for women to serve as proctors and live transmission operators, and emphasis on diversity in training programs and the workplace. I do believe we have to build on that momentum. The purpose of this blog is to allow for some self-reflection on our part as women in the field. Whether we like it or not we are held to higher standards. Any deviation by one woman is considered a setback for all and any success story of one woman is a stride forward for all. It is not a fair world and prejudice/inconsistencies are noted on all fronts. I am a catheterization laboratory director and have been for a couple of years now. Every single day I have to prove I’m capable and reliable. Every single day, and no matter how much time has passed, I still need to assert my authority and earn respect from men and women. I know that when men are given leadership opportunities, the respect and authority are automatic until proven otherwise. For a woman, it gets exhausting after a while…and that’s why we have more work to do & more self-reflection can only help.


Not references for this blog, but worthwhile data for WIC:

  1. O’Sullivan S. Women in medicine: deeds not words. Lancet. 2018;392(10152)1002-1003.
  2. Mehran R. Women’s Voices in Cardiology: An Uncomfortable Silence. JAMA Cardiol.2018;3(8):676–677. doi:10.1001/jamacardio.2018.1289
  3. Breaking the Catheterization Laboratory Ceiling. JACC 2017;69(21)2668-2271.
  4. Lautenberger DM, Dandar VM, Raezer CL, Sloane RA. 2013–2014 The State of Women in Academic Medicine: The Pipeline and Pathways to Leadership. Washington, DC: Association of American Medical Colleges, 2014.
  5. Prasad M. Gender in cardiology: work yet to be done. J Am Coll Cardiol 2016;67:3016–9.
  6. Wang TY, Grines C, Ortega R, et al. Women in interventional cardiology: update in percutaneous coronary intervention practice patterns and outcomes of female operators from the National Cardiovascular Data Registry. Catheter Cardiovasc Interv 2016;87:663–8.
  7. Carr PL, Gunn CM, Kaplan SA, Raj A, Freund KM. Inadequate progress for women in academic medicine: findings from the National Faculty Study. J Womens Health 2015;24:190–9.
  8. Lewis SJ, Mehta LS, Douglas PS, et al., for the American College of Cardiology Women in Cardiology Leadership Council. Changes in the professional lives of cardiologists over 2 decades. J Am Coll Cardiol 2017;69:452–62.
  9. Bates C, Gordon L, Travis E, et al. Striving for gender equity in academic medicine careers. Acad Med 2016;91:1050–2.
  10. Marchant A, Bhattacharya A, Carnes M. Can the language of tenure criteria influence women’s academic advancement? J Womens Health (Larchmt) 2007;16:998–1003.
  11. Hlatky MA, Shaw LJ. Women in cardiology: very few, different work, different pay. J Am Coll Cardiol 2016;67:542–4.



Participating in Science Outreach is a Win-Win For Everyone

Last month I wrote about the January is for Advocacy AHA initiative and discussed the importance of physicians and scientists getting involved in science advocacy. Since I mentioned I wanted this New Year’s resolution to stick, I am continuing this theme for February because there are so many different ways to get involved with our communities and advocate for change.

One way I personally enjoy engaging with my community is by participating in science outreach activities. Now, the best part about this type of extra-curricular community engagement is that it comes in a variety of different forms, whether it be judging a local science fair, visiting an elementary classroom to talk about your science and do an experiment (my favorite is isolating DNA from strawberries with them), or even Skyping with a classroom of students through the fantastic Skype A Scientist program (you don’t even have to leave work!).

Before I highlight a fantastic cardiology outreach program that just recently happened, I want to take a moment to discuss why science outreach programs are so critical for our both our local and scientific communities. We are all busy, so finding time to fit something like this into our schedules feels like a scary game of Tetris. However, science and particularly the cardiology field, has diversity/inclusivity issues that need attention. Even though this is an issue that some may feel like has “been addressed,” women still make up around only a third of scientific researchers across the world. While this varies across disciplines, only around 13% of cardiologists are women – even though roughly 50% of medical students are women. All of these numbers are even lower for people of color.

While I understand that these issues are insanely complex and speak to the need of a re-vamp of how our scientific and medical institutions are structured, we need to continue to flame the excitement for science in students of every background, gender and race. The easiest way to do this is by getting involved and not just in your neighborhood, but also underserved communities. I highlighted a variety of ways to get involved in science outreach in last month’s post. The STEM ecosystem is a particularly good resource for getting in contact with underserved communities you may have not been aware of before.

I mentioned before that I completely understand that getting involved or organizing a science outreach event feels overwhelming. However, working with other colleagues within your network who are also passionate about this issue is the key to really making an impact. Just like with everything else in science, you don’t have to do this alone!

This is exactly the approach Dr. Kathryn Berlacher and Diana Rodgers took to organize their recent She Looks Like A Cardiologist event last month in Pittsburgh. Both women took their passion for increasing the diversity in cardiology into creating a fantastic event where 28 female high school students interested in becoming cardiologists got to meet with local women in cardiology. The day was filled with a mix of lectures, group discussions and some simulation, as well as one-on-one lunch with paired mentors. The best part of this event is that it’s not over – the organizers didn’t want this to be a “one and done” day, so every girl got paired with one of the mentors who will help answer college application questions, advise on jobs and summer experiences, and just be a resource for them in the future. You can find a great breakdown of the day on Dr. Berlacher’s twitter page (@KBerlacher). Seeing this event on Twitter is actually what inspired me to write this blog post and I emailed Dr. Berlacher right away to talk about it. I asked her if she thinks outreach activities are valued within our field and I loved her response:

Definitely – many of my colleagues do it and love it. Almost all of my fellows do it. The fellows who came on Saturday raved about the event afterwards, saying they thought it was going to be a great event for the high school girls, but at the end of the day they felt inspired and invigorated too.  Things like this (and all our other volunteering), keeps us grounded and really provides perspective. I honestly think it’s a great way to bond – AND to combat burnout in the field, which is another hot topic. If you feel valued and feel that what you’re doing is making a difference, then you’re much less likely to get burnt out at your job.”

I hope this event inspires you to get involved in science outreach within your community as much as it inspired me. Here’s to seeing many more events like this in the future.





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.



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.