Women Appear to Quit Interventional Cardiology More Often Than Men Do

Women practicing interventional cardiology are far more likely than men to leave the subspecialty, an analysis of Medicare data suggests.

For the study, recently published online as a research letter in JAMA Cardiology, the investigators also compared cardiology to the procedure-heavy field of gastroenterology, finding no such sex disparity in dropout rates for either general or interventional gastroenterologists.

“Obviously, as a female interventional cardiologist, gender equity is kind of woven into the thread of my existence,” lead author Sarah K. Gualano, MD (University of Michigan, Ann Arbor and Lieutenant Colonel Charles S. Kettles VA Medical Center, Ann Arbor, MI), told TCTMD. “There's been some outstanding work on why trainees choose interventional cardiology or another specialty, [but] the question kept coming up: what happens to physicians once they choose interventional cardiology? There really hadn't been much describing the experience after you're committed to the specialty.”

Gualano said that she and her colleagues wanted to explore some anecdotal evidence they’d encountered about women leaving interventional cardiology at a higher rate than men.

Women continue to account for less than 5% of all interventional cardiologists, the researchers found. Surveys by the American College of Cardiology over the years, too, have revealed a broader problem that extends across the field.

What happens to physicians once they choose interventional cardiology? Sarah K. Gualano

“We always knew there was low representation of women in interventional cardiology compared to other specialties, including difficult surgical fields,” said J. Dawn Abbott, MD (Brown University, Providence, RI), vice president of the Society for Cardiovascular Angiography and Interventions (SCAI). The subspecialty is known for its challenges—exposure to radiation, long hours, middle-of-the-night emergencies, orthopedic injuries, and more—all of which are suspected deterrents to women choosing that career path.

This study, however, captures something unique, Abbott commented to TCTMD. “What is novel about this is that it’s looking at dropout from the field. These are women who went through training, successfully I’m assuming, because they went into practice and were doing percutaneous interventions. But then it appears they aren’t doing the procedures anymore,” at least as captured by the Medicare data, she specified.

The extent to which female interventional cardiologists seem to be moving on—one in five on an annual basis—“is really eye-opening to me,” said Abbott.

Gender Gap in Interventional Cardiology

Gualano and colleagues examined Medicare Part B fee-for-service data from 2013 to 2020 to identify physicians providing specialty-specific services to 10 or more beneficiaries within a year. The clinicians who did not meet that threshold were considered inactive.

They compared the trajectories of 8,488 interventional cardiologists (4.1% women) and 22,880 general cardiologists (17.6% women), as well as those of 3,416 interventional gastroenterologists (6.4% women) and 12,725 general gastroenterologists (19.8% women).

The annual probability that interventional cardiologists would become inactive was 21.1% for women and 14.9% for men. The same pattern was seen in general cardiology, though the gender gap was considerably narrower, at 13.3% versus 12.1%.

By comparison, female and male gastroenterologists became inactive at similar rates no matter whether they were interventionalists (21.0% vs 21.5%) or generalists (10.6% vs 10.1%).

Gastroenterology was chosen as a comparator for several reasons, including the fact that as a subspeciality of internal medicine, its training follows a path similar to cardiology’s, Gualano said. “They also perform long, arduous procedures, often with radiation [while] wearing lead. . . . So we thought it was a pretty close match in terms of some of those obvious characteristics of their jobs.”

She cautioned that, due to the limitations of the data, it’s possible that inactivity in Medicare billing doesn’t precisely reflect how many people were leaving the field. What’s more critical, added Gualano, is that the relative difference between women and men existed in interventional cardiology but not the other three groups they examined.

‘Structural and Cultural’ Factors

Abbott, too, stressed that it’s unclear what happens once interventional cardiologists appear to quit. Many may be switching to general cardiology. Another unknown is whether some are temporarily inactive and then return to performing procedures.

One contributor to women’s departure may be the isolation that comes with being the “only female interventionalist in her practice or the local region,” she suggested. “So they don’t necessarily have the same potential membership, the same support. They may not feel ‘backed up.’” It also may be harder for women to build a referral base as they’re starting out, Abbott added, and overt discrimination could be another factor.

What’s unknown in this study is how the dropout rate differed between private practice and academic medical centers, where early-career interventionalists are typically less isolated, Abbott noted. Other details like the size of the cath lab are important clues to the work environment as well.

She pointed out that SCAI’s Mentor Connect program is a way for young members to build connections. Only recently has the proportion of women in interventional training surpassed 10%, she added. “I do feel like we need to get to a certain level of women, so that there are women around women.”

Next steps, said Gualano, would be to do some qualitative research through surveys or interviews that dig into why people walk away from cardiology—whether they’re retiring, moving into another medical specialty, or simply shifting to a region or institution with fewer Medicare beneficiaries.

Looking at what a successful practice that promotes gender equity actually looks like could offer insight into the “structural and cultural aspects of what it’s like to be an interventional cardiologist,” she said. Lengthy, unpredictable hours don’t just affect women, Gualano stressed, adding that well-defined job characteristics and roles stand to benefit both female and male interventionalists.