ACC SURVEY REPORT
Survey Results: A Decade of Change in Professional Life in CardiologyA 2008 Report of the ACC Women in Cardiology Council*
Athena Poppas, MD, FACC, Chair, Writing Committee Member,
Jennifer Cummings, MD, FACC, Writing Committee Member,
Sharmila Dorbala, MD, FACC, Writing Committee Member,
Pamela S. Douglas, MD, MACC, Writing Committee Member,
Elyse Foster, MD, FACC, Writing Committee Member and
Marian C. Limacher, MD, FACC, Writing Committee Member
Key Words: ACC Survey Report • workforce • women in cardiology • job satisfaction • physicians, women • mentor • professional practice
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ACCF Women in Cardiology Council Members
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Athena Poppas, MD, FACC, Chair
Rasha N. Bazari, MD
Linda Calhoun, MD, FACC
Anne H. Dougherty, MD, FACC
Patricia V. Grodecki, MD, FACC
Catherine M. Kells, MD, FACC
Sandra J. Lewis, MD, FACC
Audrey C. Marshall, MD, FACC
Lynne V. Perry-Bottinger, MD, FACC
Leslie A. Saxon, MD, FACC
Nanette Kass Wenger, MD, FACC
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Table of Contents
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- Abstract......2216
- Objectives......2216
- Methods......2216
- Results......2216
- Conclusions......2216
- Introduction......2216
- Methods......2217
- Statistical Analysis......2217
- Results......2217
- Practice Setting......2217
- Mentoring......2218
- Personal and Family Issues......2218
- Radiation Concerns......2220
- Negotiating......2220
- Career Satisfaction......2221
- Discrimination......2222
- ACC Participation......2222
- Discussion......2222
- Practice Setting and Work Hours......2223
- Personal and Family Issues......2223
- Career Satisfaction and Advancement......2224
- Radiation Risks......2224
- Discrimination......2225
- Mentoring......2225
- Conclusions......2225
- Appendix......2225
- References......2226
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Abstract
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Objectives.
To meet the workforce needs in cardiology today, a thorough understanding of the factors affecting subspecialty choices of men and women is needed. This study was designed to examine the association between career decisions of women and men in cardiology and their satisfaction with personal and professional life and to determine how such associations may have changed in the past 10 years since the last American College of Cardiology (ACC) survey.
Methods.
The Women in Cardiology Section of the ACC refined their 1996 questionnaire to host it online. In 2006, requests were e-mailed to all 1,901 female ACC members and an age-matched sample of 2,360 male members.
Results.
A higher percentage of women than men are practicing in an academic setting. Also, women are more likely to describe their primary or secondary roles as noninvasive cardiologists (33% vs. 21%) and more men as interventional cardiologists (29% vs. 11%). These proportions have not changed in the past 10 years. Today, a similar proportion of women and men are working less than full-time (80% vs. 82%). More women than men have interrupted their training or practice (35% to 44% vs. 23% to 24%, p < 0.01), and while most interruptions for women were for pregnancy or delivery, approximately one third of the 66% of women with children did not take more than 1 month additional leave. Women continue to feel that family responsibilities have a negative effect on their ability to work (40% vs. 22%) and advance professionally (36% vs. 17%). Female cardiologists were less likely to be married (73% vs. 91%, p < 0.001), and this has not changed. Today, an increasing number of both men and women have additional caregiver duties, predominately for elderly parents (16% to 18%). Both women and men were equally highly satisfied with their careers in general but unequally satisfied with their financial compensation (63% vs. 72%, p = 0.007), which was more pronounced in the academic setting. Mentors had an increasingly positive role on careers for both sexes (86% vs. 92%). Unfortunately, discrimination still affects the majority of women in cardiology (69% vs. 22% of men, p < 0.0001) and has not changed in 10 years.
Conclusions.
The number of female cardiologists and fellows has nearly doubled in the past decade since our last survey. Coincident with this, we have seen an increased emphasis upon and fulfillment from mentors, increased flexibility in work hours, and a universally high level of satisfaction with career and family. Discrimination based on gender and parenting is still prevalent. Female cardiologists remain less likely to be married or to have children. Tracking and elucidating the effects of the societal shifts in attitudes towards career, family, and work-life balance on the cardiology workforce can guide the field of cardiology to make the changes necessary to fill its workforce needs with the best possible candidates.
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Introduction
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Concerns about a growing shortage of cardiologists in the United States led the ACC to convene a Bethesda Conference in 2003 to address the underlying issues. One of the chief areas of concern was the continued under-representation of women in cardiology; despite statistics that show nearly equal numbers of men and women graduate from medical schools, sharply lower numbers of women select cardiovascular training. One of the resolutions emerging from the Bethesda Conference was to encourage more women to enter the field of cardiology (1).
According to the Accreditation Council for Graduate Medical Education database, as of August 2004, the total number of graduate medical and surgical trainees was 101,291, of whom 42% were women. There were 21,332 residents in internal medicine and 2,119 fellows in cardiology of which women comprise 42% and 18%, respectively. Women trainees are even less well represented in the subspecialties of electrophysiology (11.3%) and interventional cardiology (8.7%). The only other internal medicine subspecialty training programs that have comparably low participation by women are pulmonary medicine (21.4%), critical care (21.5%), and gastroenterology (25.3%); these levels are similar to those found in general surgery (26.7%) (2). To devise and implement effective strategies to positively impact the career decisions of both men and women, current and detailed information on professional issues confronting practicing cardiologists is needed.
In 1996, the Committee on Women in Cardiology (WIC) of the ACC sponsored a survey designed to assess the professional experience of cardiologists. The survey focused on how career decisions affected the personal and professional lives of male and female cardiologists and recommended developing new paradigms for the future training, education, and support of cardiologists (3). The current research, which was conducted between September 2005 and January 2006, was designed as a follow-up study with 3 specific goals: 1) to describe the relationship between personal and professional life and the career decisions of U.S. cardiologists in academic and private practice; 2) to examine what differences may exist between men and women in cardiology; and 3) to determine how these parameters may have changed for cardiologists over the past 10 years.
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Methods
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The 1996 survey questionnaire was replicated verbatim so as to accurately compare the results of the 1996 study with responses from a contemporary sample of cardiologists. In addition, more detailed data were sought within a few specific questions. The 2006 questionnaire was hosted on a web server and accessed online via a link supplied in e-mail invitations. Invitations to participate were e-mailed to a total of 4,261 ACC members, including all 1,901 women members, and an age-matched sample of 2,360 male ACC members. Seven hundred thirteen e-mails were returned as undeliverable; consequently, the base of the actual sample became 3,545 (1,595 women and 1,950 men).
Between September and October 2005, each member of the sample was sent an e-mail invitation, and up to 4 follow-up "reminder" invitations were sent to those who had yet to complete a questionnaire. Wishing to increase response rates, the Committee reopened data collection between December 2005 and January 2006.
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Statistical Analysis
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Replicating the methods used in the 1996 predecessor study, chi-square tests were used to compare differences in responses by women and men, and p < 0.01 was established as the threshold for statistical significance. Because only the percentages and not the absolute numbers from the original 1996 dataset were available, formal statistical comparisons with the earlier results were not possible. The 1996 percentage responses are presented in table form with the current responses for completeness and visual comparison.
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Results
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At the close of data collection, 1,118 individuals had completed the survey questionnaire. Eight records were subsequently observed to be irregular and were eliminated prior to analysis. In all, 1,110 records were used for analysis: 667 (60%) female and 443 (40%) male, with an overall response rate of 31% (42% for females, 23% for males). This compares with a response rate of 49% in 1996 (54% female, 46% male). The age distribution between respondents and nonrespondents was similar; the age distribution between the sexes was similar except that there were fewer women over age 60 compared with men (8% vs. 15%) (Table 1).
Practice Setting.
Greater percentages of women compared to men were pediatric cardiologists (15% vs. 6%), and smaller percentages were adult cardiologists (78% vs. 89%) or cardiovascular surgeons (1% vs. 2%) (all ps < 0.0001). More women than men considered medical school or university faculty as the best description of their practice (49% vs. 30%), and accordingly, fewer women considered private practice their primary practice setting (35% vs. 56%, p < 0.0001). The most common type of private practice setting described for both sexes was a single-specialty group practice (67% vs. 71%, p = NS) (Table 2).
Fewer women than men defined their primary or secondary role as an interventional cardiologist (11% vs. 29%) or an administrator (5% vs. 9%). Conversely, more women defined themselves as an echocardiographer (33% vs. 21%) or a transplant cardiologist (5% vs. 2%, p < 0.01) (Table 2).
In 2006, a similar proportion of women and men defined their work hours as full-time (80% vs. 82%) or as part-time (9% vs. 6%) (Table 2). Women were more likely than men to have interrupted both their training or practice for longer than 1 month during training (35% vs. 24%, p < 0.01) or during practice (46% vs. 23%, p < 0.01) (Table 3). There was a trend toward more prolonged interruptions of training for men than women (for 12 to 24 months: 12% of men and 8% of women; for greater than 24 months: 5% of men and 2% of women). In practice, a few men and women had prolonged (12 to 24 months) interruptions (3% and 4%, respectively). For women, the most common reasons given were pregnancy (14% training, 9% practice) and childbirth (44% training, 52% practice). For men "other" conditions were the most common reported reasons for interrupting training (73%) or practice (48%), followed by vacation (16% training, 11% practice), illness (2% training, 16% practice), and to make long-term career decisions (8% training, 14% practice).
Mentoring.
Women and men were equally likely to identify a mentor during subspecialty training (70% vs. 73%) (Table 4). Women were more likely to have female mentors (18% vs. 2%, p < 0.0001). Women and men both reported that their mentor had a positive or highly positive influence through introductions in the field (78% vs. 75%), participating in research (73% for both), career encouragement (82% vs. 83%) and planning (64% vs. 63%), as well as connections for job placements (51% vs. 47%). Although the majority of both women and men thought their mentors served as positive role models for career activities (86% vs. 92%), dramatically fewer women (41%) or men (38%) thought their mentors served as positive role models or advisors for noncareer issues such as family and lifestyle. Furthermore, women more commonly noted that their mentor was actually a negative influence as a personal role model (14% vs. 8%, p = 0.007).
Personal and Family Issues.
In the current survey, the majority of respondents were married, but women were much less likely than men to be married (73% vs. 91%, p < 0.001) (Table 3). Three percent of women and less than 1% of men were living with a partner (p = 0.002). Fifteen percent of women and 5% of men were single (p < 0.0001), and a similar number were divorced (6% vs. 5%, p = 0.03). The racial or ethnic group distribution was similar for men and women, with 76% of all respondents designating themselves white, 2% black, 4% Hispanic, 14% Asian, and 3% other.
The majority of male respondents had children (92%), which was significantly greater than the number of women with children (66%, p < 0.001). Men tended to have more children than women, with 76% of women having 1 to 2 children (24% having 3 or more children), and 45% of men having 3 or more children. The average age for women at the time of their first child was 32 years (range 15 to 47 years) and 31 years for men (range 19 to 49 years), and at the last child 36 years for women (range 22 to 55 years) and 35 years for men (range 21 to 50 years).
With regard to childcare, the expected large difference between men and female cardiologists who had spouses providing all of the childcare was identified (9% vs. 66%, p < 0.001) (Table 3). Accordingly, more women compared with men utilized a variety of childcare options and combinations: paid live-in full-time (29% vs. 10%), paid full-time caregiver coming to the home (38% vs. 8%), paid part-time caregiver coming to the home (25% vs. 17%), out-of-home private care (12% vs. 5%), institutional (daycare) (33% vs. 16%), which included onsite childcare facilities (7% vs. 2%), and nonpaid relative (16% vs. 3%) (all ps < 0.001). Similarly, substantially more women than men had additional childcare arrangements for nights/on-call duties (51% vs. 18%, p < 0.001).
As reflects changing family demands in the aging workforce, 18% of men and 16% of women reported having primary caregiver responsibility for a person other than their children. More female cardiologists felt that their family duties hindered their ability to do professional work "a lot or some" (40% vs. 22%), and fewer women than men thought the effect was "a little or not at all" (48% vs. 70%, p < 0.001). Similarly, more women noted that family responsibilities hindered their ability to travel for professional advancement "a lot or some" (45% vs. 30%) and fewer women described the effect as "a little or not at all" (43% vs. 63%, p < 0.001). In addition, more women noted that parenting and family responsibilities had a negative impact on their overall career advancement "a lot or some" (36% vs. 17%), and considerably fewer women than men described the impact as "not at all" (28% vs. 60%, p < 0.001). On the other hand, the majority of both women and men were "very satisfied" or "moderately satisfied" with their family life (81% vs. 88%).
With regards to family leave policy, more men than women reported that there was no official policy (21% vs. 12%, p < 0.001), and more women than men (15% vs. 3%) were moderately or very dissatisfied with the policy, but similar raw numbers (29% of women and 31% of men) were either moderately or very satisfied. Alternatively stated, of those who had a policy with which they were familiar (400 women, 206 men), 50% of women and 68% of men were satisfied and 25% of women and 7% of men were dissatisfied with its content.
Radiation Concerns.
Over 30% of all survey respondents (334 of 1,110) altered their training or practice focus to reduce the risk of occupational radiation exposure (Table 5). The majority (84%, 280 of 334) of these individuals were women. Of those 280 women, 58% (162 women) chose a career/training tract, and 43% (122 women) planned conception and/or pregnancy to reduce radiation exposure. Seventy-six percent of women obtained information on radiation risks during pregnancy, which is more than the 66% of women who had children. Women consulted medical texts (35%) more often than hospital policy (29%). Other sources that were consulted included other cardiologists (16%), radiologists (10%), and their obstetricians (13%).
Negotiating.
Respondents were asked to rate a series of job features that they regarded as important at the time of their first job, and then again as if a job were being renegotiated at the time of the survey. For one's first job after training, the highest priority item was job description, being rated as "very important or important" by 93% of both women and men (Table 6). Women and men also rated the next priority items similarly, including benefits (65% vs. 64%), salary (62% vs. 63%), and time to promotion or advancement (57% vs. 58%). Women and men differed in their rating of work hours and vacation time, with more women rating these as "important or very important" (68% vs. 52%, p < 0.001, and 61% vs. 51%, p < 0.01, respectively).
However, the relative importance of negotiated items for "today's" jobs shifted significantly for both men and women. Salary, work hours, support staff, administrative responsibilities, space, seniority, and benefits increased in importance. Although both men and women exhibited this shift in priorities, when negotiating for jobs "today," women placed more importance than men on work hours (92% vs. 86%, p < 0.001), time to promotion (75% vs. 66%, p = 0.001), academic rank (57% vs. 45%, p < 0.001), and roles with community or institutional recognition (56% vs. 50%, p < 0.01) and national recognition (47% vs. 39%, p < 0.01).
Career Satisfaction.
Overall, both women and men were highly satisfied with their professional work, with 90% of women and 92% men reporting being moderately or very satisfied and few respondents reporting great dissatisfaction (<1%) (Table 7). Satisfaction rates were similar for women in academic and other practice settings and for both pediatric and adult cardiologists. Both women and men were generally satisfied with their financial compensation, although women were less so than men (63% vs. 72%, p < 0.01).
Both women and men in academic practice reported lower satisfaction with earnings than those in other practice settings, with 29% of women reporting dissatisfaction with academic salaries compared with 18% of men (p < 0.01) (Table 7). Only 55% of academic women reported being moderately or very satisfied with their financial compensation compared with 74% of women in private practice, 61% of men in academics, or 78% of men in private practice.
Women were much more likely than men to feel that their level of advancement since completing training was lower or much lower than their contemporaries (29% vs. 10%, p < 0.001) and less likely to feel that their advancement was higher or much higher (22% vs. 45%, p < 0.0001). In addition, women expressed less satisfaction (75% vs. 84%, p < 0.01) and more dissatisfaction than men with their opportunity to achieve their professional goals (14% vs. 6%, p < 0.001). Nonetheless, both women and men were highly likely to recommend cardiology as a career choice (79% and 80%, p = NS), with only 8% of women and 6% of men stating they would discourage an advisee from entering cardiology as a career.
Discrimination.
The survey asked whether each respondent had "experienced any effects of discrimination during your career." If the answer was "yes," the respondent was asked to select the type of discrimination or to describe it in a space for free-form comments. Most women (69%) reported having experienced discrimination during their career compared with 22% of men (p < 0.0001). Women reported that the discrimination was because of gender (65% vs. 1% of men, p < 0.0001) or parenting responsibilities (27% vs. 1% of men, p < 0.0001). Men and women reported similar levels of discrimination from racial (10% of men vs. 9% of women) and religious reasons (8% of men vs. 4% of women). Yet, of the 96 men reporting discrimination, 71% (68 of 96) stated this was due to race or religion. Discrimination on the basis of sexual orientation was rare for both men and women (1% and 0%, respectively). Among those 458 respondents experiencing discrimination, women and men were equally likely to report that discrimination affected their ability to conduct professional activities with colleagues (45% vs. 39%), patients (14% vs. 17%), and within the ACC (9% vs. 9%). There were no questions that specifically addressed sexual harassment.
ACC Participation.
Women and men were equally likely to have participated in the ACC Annual Scientific Session in the past 5 years (2000 to 2006) as an attendee (76% vs. 80%), abstract grader (12% vs. 13%), session moderator (13% vs. 12%), and invited speaker (11% vs. 12%) or panelist (10%). Also, compared with men, women respondents were equally likely to be a committee or task force member (14% vs. 14%) and a member of ACC leadership, defined as an officer or member of the Board of Trustees or Board of Governors (3% vs. 5%). When looked at from the perspective of the total ACC membership of 32,125, including international members and fellows in training, women appear to be well represented across all levels of leadership within the College (Table 8).
When asked what type of additional ACC programs would interest them, women were more interested in the topics of negotiating (77% vs. 66%, p < 0.0001), professional development (84% vs. 65%, p < 0.0001), grant writing (57% vs. 43%, p < 0.0001), and mentoring (73% vs. 54%, p < 0.0001), whereas men expressed more interest in additional programs in leadership training (49% vs. 63%) and, to a lesser extent, practice management (67% vs. 70%, p = 0.02). Respondents were more interested in online programming compared with an ACC annual meeting program or local program (for example, 33%, 28%, and 15% for professional development, respectively).
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Discussion
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As the burden of cardiovascular disease continues to grow, maintaining a workforce to meet these needs is important to both providers and consumers of U.S. health care. The representation of women in subspecialty training in cardiology has increased significantly over the past 10 years from 10% in 1996 to 18% in 2004 (2,3). The number of practicing female cardiologists in the United States has similarly increased from 5% in 1996 to 8% in 2006 (ACC membership file). The current survey of career and lifestyle issues of male and female cardiologists documents a number of similarities as well as notable differences.
Over the past decade, there have been some areas of progress and other areas of concern in medicine in general and cardiology in particular. The current survey highlights a continued high level of personal and career satisfaction among both male and female cardiologists. Furthermore, the important influence of mentors holds true for both sexes.
A number of inequalities were still identified. Fewer women than men in cardiology are married or have children, representing a common trend across a broad spectrum of professional women (4). One possible reason for this trend is our concerning finding that the majority of women in cardiology continue to experience discrimination, largely because of gender in general, and particularly because of parenting responsibilities. In further defining the issues, we can better outline a plan and goals for reaching gender parity, embracing all members of the community, and meeting our workforce needs.
Practice Setting and Work Hours.
Over the past decade, there has been a trend for more men and women to work in an academic setting and work less than full-time. Almost one half of the women respondents and one third of the men describe their practice as academic, suggesting a shift towards university or medical school practices and away from private practice. At present, 80% of women and 82% of men describe themselves as working full-time; this represents an absolute decrease of 6% for women and 13% for men compared with 1996. The number of women who are working less than full-time is unchanged, but the number of men in part-time practice appears to have doubled. An even more dramatic increase appears to be the number of men who are not practicing medicine or have "other" arrangements, increasing from 1% in 1996 to 12% currently. Men may be retiring early or working in administrative roles or may be striving for a better work-life balance. Also, more men than women are taking longer breaks in their careers. The number of men who interrupt their practice for more than a month has increased from 13% to 24%, but most of their reasons were not enumerated. At the same time, fewer women interrupted their training or their practice for pregnancy. Whether this reflects more liberal recommendations for continuing to work during pregnancy or, as other investigators have suggested (5), a greater degree of guilt or overt or subtle pressure not to burden one's colleagues is unknown. The trend for more men and women to choose to work less than full-time may have significant implications across the profession, including workforce supply, volunteerism, continuing medical education, and membership in professional societies, and requires further investigation and planning.
Personal and Family Issues.
Traditional family roles are more common among male cardiologists; over 90% of men are married with children. Conversely, only 73% of female cardiologists are married, and a smaller fraction have children, with the discrepancies in marital status and choices in childrearing unchanged over the last decade. Choices in childcare arrangements also remain quite different between male and female cardiologists, as an increasing majority of men have their spouses providing all of the childcare. Other trends in childcare arrangements include a two-fold increase in the use of daycare and onsite childcare facilities for both sexes. The reasons fewer female cardiologists decided not to marry or to have a family were not explicitly asked in our surveys, but other studies of physicians suggest the burden of the family responsibilities disproportionately falls to the woman professional and impedes her advancement by both personal volition and external discrimination.
Other studies have sought to elaborate on the inherent conflict between demanding careers and parenting. A Yale survey of female medical school graduates from 1922 to 1999 found that those without children were more likely to be in surgical specialties and to work full-time and less likely to be in primary care. Furthermore, one third of those without children felt they had to choose between having a career and having a family, and 46% felt they could not be both good mothers and good doctors (6). The choice of marriage and parenthood has been shown to differ between men and women in other medical fields such as general surgery, otolaryngology, and cardiothoracic surgery (7,8). In these other studies of professional women, they were less likely to be married and more likely to marry later in life and to have fewer children than they would wish. Similarly to the female cardiologists in our survey, female surgeons appear to have primary responsibility for childcare in their families. Furthermore, female surgeons also had primary responsibility for household tasks (6). Also, in a study of medical students, residents, and faculty members at a Canadian medical school, women at all levels of training were more likely to be single, childless, and to express a lack of time for family (9). The recently released National Institutes of Health study of gender disparities in retaining scientists among its own staff revealed that the heavier burden of family responsibility was one of the primary factors for women to not pursue advanced research careers. The majority of married female scientists had spouses who worked full-time compared with one half of their married male counterparts. Furthermore, of the dual-career couples, women were more likely to make career concessions than men. Spending time with family, affordable childcare, and plans to have children were ranked as more important to women, whereas salary was considered to be more important to the men (10).
One of the inherently unique impediments for working women is the burden of pregnancy and maternity leave. The Family Medical Leave Act was passed in 1993, and subsequent institutional policies have been made compliant. Between 1996 and 2006, there appears to be an increase in medical institutions with family leave policies in place; yet still, nearly one half of respondents reported that either their institution had no official policy or they were not aware of its details. Today, a minority of female cardiologists was both familiar and satisfied with their administrative family leave policy, and this has not changed substantially in the past 10 years. Restrictive and financially burdensome policies as well as colleagues' attitudes may be why the majority of female cardiologists have never taken a leave of absence for more than 1 month (65% of those in training and 56% in practice). Furthermore, more men and women are taking on other caregiver duties, predominately of a parent or an in-law. This will place further demands on work hours and family leave. More liberal and flexible leave and creative work hours in cardiology in particular and medicine in general may entice more women to enter the field, allow more women to have children and families, and allow both sexes to achieve a healthy work-life balance.
Career Satisfaction and Advancements.
Overall satisfaction with cardiology as a career has remained remarkably high for both men and women. Women's career satisfaction appears to have increased from 80% in 1996 to 90% currently, now equaling the level reported by men. Overall enthusiasm for cardiology has increased dramatically in the past 10 years; the number of both men and women who would strongly encourage cardiology as a career has nearly doubled, and dramatically fewer would discourage those seeking guidance. Since the overall satisfaction level has only modestly increased in the past decade, other factors must be influencing cardiologists' markedly stronger recommendations for prospective careers in cardiology. It may be that the future of cardiology or medicine in general has greater potential and expected growth than it did in the mid 1990s. These findings are similar to other recent surveys indicating a high level of career satisfaction among physicians (7,11–15). In most surveys, including ours, career satisfaction was not separated by marital or childrearing status. However, in a Canadian study, both men and women without children reported lower levels of satisfaction with their careers, and married female physicians reported lower job satisfaction than their married male counterparts (9).
In a question asking whether the respondent's level of advancement was higher or lower than his or her contemporaries, the gender differences may reflect less confidence or lower self esteem among female cardiologists as well as true gender differences in career trajectories. More women report that family duties slowed their career advancement. Furthermore, these differences are essentially unchanged from our survey of a decade ago. Similarly disproportionate family demands and self confidence have been shown to pull women away from the workforce in general (16) and advanced science careers in particular (10). Greater personal and family responsibilities are cited as reasons for slower advancement among women compared with men in otolaryngology and ophthalmology (17). Female cardiothoracic surgeons perceived a lower level of career advancement compared with their male counterparts and also report lower income (7). Although our survey asked about satisfaction with compensation, actual salaries were not obtained. There appears to be a significant difference between sexes in the academic setting but not in private practice, as more women than men in academics remain dissatisfied with their financial rewards; this has not changed over the past 10 years. If retaining women in faculty positions in medical schools is indeed a priority, then financial compensation packages need to be examined along with the other issues of flexibility and control as above.
Radiation Risks.
Occupational exposure to radiation is of concern to both men and women. Female cardiologists made more changes in their training and careers to reduce exposure, likely because of concerns related to risks to a developing fetus. The majority of women did not perform fluoroscopic procedures while pregnant. Furthermore, one fourth of women specifically selected career tracks to reduce their radiation risk, a finding which may partially explain the under-representation of women in interventional cardiology. When compared with the previous survey, more women are now consulting hospital radiation safety policies. Although these data are consistent with an improvement in awareness of and/or development of hospital policy on occupation radiation risks and pregnancy, women still report using a wide range of resources. Since the last survey in 1996, the ACC has published a consensus document on radiation safety in cardiology, but both men and women are either unaware of this document or chose other sources to educate themselves (18).
Discrimination.
Unfortunately, nearly one half of all cardiologists have experienced discrimination during their career. Compared with 1996, women in 2006 experienced the effects of discrimination with a similarly high frequency but with less of a negative impact on professional activities, patient care, and ACC activities. Men also experienced the effects of discrimination with a similar frequency of 21% to 22%, but with far greater negative impact today, whether on professional activities, patient care, or ACC activities. Furthermore, the type of discrimination has shifted over the past 10 years. Women experienced less gender discrimination in 2006 but greater discrimination on the basis of parenting responsibilities, despite the fact that the number of women with children has not changed. In our current survey, both men and women noted racial and religious discrimination. This may be linked to the increased percentage of international medical graduates in U.S. medical residencies (42%) and cardiology fellowships (32%) (2). In a recent statewide survey of practicing physicians of various specialties, a similarly high level of discrimination was noted; 63% of respondents had experienced some type of discrimination, with 27% of men aware of a significant gender bias against women and 44% of U.S. medical graduates reporting a significant negative bias against international medical graduates (19). Similarly, more female cardiovascular surgeons reported discrimination on the basis of sex throughout all aspects of preparation for and practice of their careers and also believed that this negatively influenced their career trajectory (7). In our current study of female cardiologists, the number of women who have experienced discrimination remains inexcusably high at 69%. Future work is needed in cardiology in particular and medicine in general to create a less hostile work environment in order to encourage and support more women in the profession.
Mentoring.
The majority of cardiologists surveyed have had a mentor during their subspecialty training, and most of these mentors were men. Similar to the prior survey, both men and women continue to have a very high level of confidence in their mentors; mentors exerted positive influences in most aspects of career development for both sexes. One encouraging trend is that today, more women feel that their mentors were a constructive help with planning their career. Unfortunately, the majority of mentors were not positive personal role models and actually had a negative influence on family and lifestyle issues for both sexes, but more so for women.
A number of previous studies have stressed the importance of mentors in the choice of career paths and for success within a given specialty. The recent survey of the British Cardiac Society emphasized the importance of mentoring for recruiting and retaining trainees as well as junior faculty (or consultants) (20). Also, the recent survey of National Institutes of Health scientists emphasized mentoring as being crucial to retaining talented women in research tracks (10). There has been an active effort to institutionalize and promote mentoring at many levels in a physician's training and career. For example, the ACC WIC section initiated a Web-based mentoring site for women that has been more broadly adopted by other groups within the ACC.
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Conclusions
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In summary, the current survey reveals some areas of progress, including an overwhelmingly high level of career satisfaction and an increased positive effect of mentors. We identified several areas that will require further attention: reducing discrimination, equality in the academic setting, reducing the barriers to childrearing, and increasing ACC leadership. For the culture of medicine to change, institutions must first acknowledge the pervasive impediments for women and improve their support for women throughout their careers such that leaders of hospitals, practices, departments, sections, and subspecialty laboratories can set an example of not tolerating any type of discrimination. With regard to childrearing, it will take changes in both the workplace and in society in general. The ACC has a fair family leave policy for its employees, but its membership is more diffuse. Finally, women must be both actively recruited and encouraged by mentors to pursue leadership roles.
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Staff
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American College of Cardiology Foundation
John C. Lewin, MD, Chief Executive Officer
Charlene L. May, Senior Director, Science and Clinical Policy
Stephanie C. Bailes, Director, Member Strategy
Moira D. Davenport, Director, Special Publications
Dawn R. Phoubandith, MSW, Associate Director, Science and Clinical Policy
Kelly E. Ventura, MHA, Associate Director, Member Strategy
Erin A. Barrett, Senior Specialist, Science and Clinical Policy
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Appendix
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The authors and reviewers of this document reported no relationships with industry or other entities that were relevant to this topic.
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Acknowledgments
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The authors wish to thank Craig A. Honick of Precision Reports, LLC who prepared the survey and conducted the statistical analysis.
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Footnotes
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The findings and conclusions in this report are those of the Writing Committee and do not necessarily reflect the official position of the American College of Cardiology Foundation.
The American College of Cardiology Foundation requests that this document be cited as follows: Poppas A, Cummings J, Dorbala S, Douglas PS, Foster E, Limacher MC. Survey results: a decade of change in professional life in cardiology: a 2008 report of the ACC Women in Cardiology Council. J Am Coll Cardiol 2008;52:2215–26.
Copies: This document is available on the World Wide Web site of the American College of Cardiology (www.acc.org). For copies of this document, please contact Elsevier Inc. Reprint Department, fax (212) 633-3820, e-mail reprints{at}elsevier.com.
Permissions: Multiple copies, modification, alteration, enhancement, and/or distribution of this document are not permitted without the express permission of the American College of Cardiology Foundation. Please contact Elsevier's permission department at healthpermissions{at}elsevier.com.
* The Women in Cardiology Committee became the Women in Cardiology Council in March 2008. The Women in Cardiology Council serves as the governing body of the Women in Cardiology Section. 
 Fellow-in-training.
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References
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ACC 2009 Survey Results and Recommendations: Addressing the Cardiology Workforce Crisis: A Report of the ACC Board of Trustees Workforce Task Force
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[Full Text]
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