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Page 1: Considerations for Female Interventional …...Considerations for Female Interventional Cardiologists 2 Introduction Liliana Grinfeld, MD, PhD, FSCAI Hospital Italiano de Buenos Aires,

Considerations for Female Interventional Cardiologists

Considerations for Female Interventional Cardiologists

www.SCAI-WIN.orgThe Society for Cardiovascular Angiography and Interventions

SCAI Women In Innovations

Driving Change for Women with Heart Disease

Page 2: Considerations for Female Interventional …...Considerations for Female Interventional Cardiologists 2 Introduction Liliana Grinfeld, MD, PhD, FSCAI Hospital Italiano de Buenos Aires,

Driving Change for Women with Heart Disease

1

General Editors:

Sohah Iqbal, MDNew York University Medical Center, New York, NY, USA

Roxana Mehran, MD, FSCAIMount Sinai School of Medicine, New York, NY, USA

Rebecca OrtegaDirector, Women in Innovations

Additional Contributors:

Mirvat Alasnag, MD, FSCAIKing Fahd Armed Forces Hospital, Jeddah, Saudi Arabia

Gill Louise Buchanan, MDCastle Hill Hospital, Cottingham, United Kingdom

SCAI Women In Innovations:Considerations for Female Interventional Cardiologists

Introduction ......................................................................................... 2 Liliana Grinfeld, MD, PhD, FSCAIHospital Italiano de Buenos Aires, Argentina

Training Opportunities in Interventional Cardiology ............................... 3Vijay Kunadian, MBBS, MD, MRCPNewcastle University and Freeman Hospital Newcastle, United Kingdom

Maternity and Childbearing Years as an Interventional Cardiologist ....... 4Kimberly Skelding, MD, FSCAIGeisinger Medical Center, Danville, PA, USA

Occupational Radiation Exposure .......................................................... 5-6Patricia Best, MD, FSCAIMayo Clinic Rochester, MN, USA

Antonia Anna Lukito, MD, FSCAISiloam Hospital, Tangerang, Banten, Indonesia

Patrizia Presbitero, MDIstituto Clinca Humanitas, Rozzano, Italy

Wages: Equal Pay For Equal Responsibility ............................................. 7Florencia Rolandi, MDCENPEC Investigaciones, Buenos Aires, Argentina

Conclusion ............................................................................................ 8

Citations ............................................................................................ 9-10

Page 3: Considerations for Female Interventional …...Considerations for Female Interventional Cardiologists 2 Introduction Liliana Grinfeld, MD, PhD, FSCAI Hospital Italiano de Buenos Aires,

Considerations for Female Interventional Cardiologists

2

Introduction

Liliana Grinfeld, MD, PhD, FSCAI Hospital Italiano de Buenos Aires, Argentina

Though recent statistics show that women will outnumber men in many areas of medicine within

the next decade, within the field of cardiology there are only a small proportion of female physicians

(18%), and even fewer who choose the subspecialty of interventional cardiology 1. This trend has

been shown to be consistent in many countries. In the United States, only 5.9% of board certified

interventional cardiologists are women 2. In Italy, just 12.5% of those physicians performing interven-

tional procedures are women 3.

The reasons for this discrepancy are unclear, but are likely multifactorial. Becoming a subspecialist

extends training time into the childbearing and childrearing years. There are concerns regarding ra-

diation exposure in the catheterization laboratory, especially during pregnancy. Women may be less

likely to pursue invasive subspecialties due to the strenuous work schedules without much guidance

on how to balance family life. Additionally, women may face professional discouragement or rejec-

tion due to a lack of female mentors in the field. Finally, it has been shown that women receive less

funding than men for research endeavors and unequal pay for equal work.

Women in Innovations (“WIN”) is an international initiative established by the Society for Cardiovas-

cular Angiography and Interventions (SCAI) in part to foster the professional development of female

interventional cardiologists in training, in practice, and in the research arena. WIN aims to increase

the overall number of female interventional cardiologists worldwide; increase the overall number of

female faculty at major medical conferences; increase the overall number of female principal investi-

gators in clinical trials; and provide a global network of female interventional cardiologists who are

able to collaborate to these ends. The aim of this WIN booklet is therefore to address the challenges

surrounding the practice of interventional cardiology for women around the world in the hope of

encouraging an open dialogue on how to improve and welcome more women into the profession.

Page 4: Considerations for Female Interventional …...Considerations for Female Interventional Cardiologists 2 Introduction Liliana Grinfeld, MD, PhD, FSCAI Hospital Italiano de Buenos Aires,

Driving Change for Women with Heart Disease

Training Opportunities in Interventional Cardiology

Vijay Kunadian, MBBS, MD, MRCPNewcastle University and Freeman Hospital Newcastle, United Kingdom

If a procedural subspecialty is of interest, the decision to apply to an interventional cardiology training

fellowship program requires careful consideration of multiple factors, including the ones discussed

in this booklet. Once accepted into any interventional cardiology training program, the training cur-

riculum is the same for both genders. There are no known national regulations or training curricula

that specifically address women. The majority of guidelines for training in interventional cardiology

provide emphasis on the 3 basic areas of training for an interventional fellowship: 1) Inpatient/outpa-

tient consultations; 2) performing interventional procedures in the catheterization laboratory; and 3)

research. Each of these areas must be accomplished in order to progress as an independent interven-

tional cardiologist, and a motivated, competent woman is well suited to each of these components.

In fact, women often employ strong empathy, patience and a good bedside manner, perhaps making

them better suited to be successful physicians.

If women and men are provided equal training opportunities to become successful physicians, why

then is there a lack of women in interventional cardiology? Perhaps the answer is in the details.

In Europe, there are a number of grants available to both sexes which aim to facilitate further training

and research. For example, the European Society of Cardiology (ESC)/European Association for Percu-

taneous Coronary Intervention (EAPCI) offer a training grant for additional clinical training in another

ESC member country and another for further research in another ESC member country. Applicants for

these grants must be under 36 years of age at the day of application deadline and be a member of

the EAPCI. Age limits imposed by such training grants may place women who may have postponed

their training in order to start a family at a disadvantage, and they would not have the experience

necessary to apply for such opportunities.

The WIN group would therefore recommend that training and professional organizations responsible

for providing training and research grants in interventional cardiology take into account the specific

challenges faced by women and address these issues in their application process in order to support

the successful training and subsequent progression of women as interventional cardiologists.

3

Page 5: Considerations for Female Interventional …...Considerations for Female Interventional Cardiologists 2 Introduction Liliana Grinfeld, MD, PhD, FSCAI Hospital Italiano de Buenos Aires,

Considerations for Female Interventional Cardiologists

4

Maternity and Childbearing Years as an Interventional Cardiologist

Kimberly Skelding, MD, FSCAI Geisinger Medical Center, Danville, PA, USA

A US study surveying female physicians found that 43% thought childbearing would interfere with their career plans and 21% thought it would lead to the loss of a fellowship position 4. The same study found that women intentionally postponed their pregnancies due to perceived career threats. A Norwe-gian study showed that the number of births for a female physician is inversely proportional to her choice of subspe-cialty 5, but postponing the first child made it more likely that the woman would complete her subspecialty train-ing. This information is concerning, but still female physicians often choose to have children in their less fertile years when there is higher biological concern for congenital defects.

In the field of medicine there is no such thing as a perfect time to start a fam-ily. The decision is up to the individual. A survey of 142 medical school deans found that only 14% of institutions had policies designed to increase gender equity with regard to childbearing and parenting, potentially providing for no time in which women feel safe having a child mid-career (4). In addition to the financial and career considerations created by the increased training time,

female interventional cardiologists also have the added concern of occupa-tional radiation exposure.

When an interventional cardiologist de-cides to have a child, communication is paramount both at the trainee and at-tending levels. If a woman is concerned about radiation exposure, despite the paucity of data, the most vulnerable timeframe is immediately following conception and throughout the first trimester and so the decision should be communicated immediately. Once the first trimester has passed the like-lihood of miscarriage (from all causes) decreases substantially, and so this also may be a good time to communicate the decision. Some training programs and departments have policies regard-ing pregnancy which serve as a good starting point. For a pregnant attend-ing, it is important to plan the sched-ule for the catheterization laboratory and on-call straight away. Rearranging on-call and rotations so the strenuous times occur earlier in pregnancy can be wise, as there may be no warning about a pregnancy complication and the need for time off may be urgent. Deciding whether or not to work in the catheter-ization laboratory when pregnant can be a personal decision. There are means in place with regard to protection and monitoring discussed in the radiation exposure section of this booklet. In ad-dition, women may choose to work sit-ting down at the table if the increased load carried becomes a problem in later pregnancy.

Long working hours and sleep depri-vation are also factors to consider for both maternal and fetal health. There is little in the way of guidelines or stud-ies available to support these issues. There is, however, data that finds no

increase in risk to pregnant physicians compared to the general population of pregnant women 6. Although the overall outcomes of women physicians were similar, studies have associated women physicians with higher pre-term labor, preeclampsia and low birth weight babies 7, 8. Another study done on this subject assessed female urolo-gists compared to “the average Ameri-can woman” 9 and found urologists were older by 7-8 years, utilized fertil-ity therapies 10 times as often, and the complication rates were greater than the lowest income bracket in the con-trol group.

Indeed, childbearing decisions may be different depending on geographic loca-tion, and there may be more protection and financial support for physicians tak-ing maternity leave outside the US than within (Medical Economics, 2012). Eu-ropean countries give women 70-100% of their wages for up to 26 weeks, with the bill paid by the government in all countries but Switzerland. US national policies affect businesses with more than 50 employees. Small private prac-tice medical groups often do not fit these criteria and are left to make deci-sions independently (Family and Medical Leave Act of 1993). There are certainly instances in which policies are more le-nient and generous than the national policy but the variability is large. This is an important consideration for a woman in interventional cardiology.

There is currently no literature spe-cifically about pregnant female inter-ventional cardiologists, or in closely identified fields such as interventional radiology or vascular surgery. WIN aims to contribute to this area of study to potentially help women interventional cardiologists in planning their families.

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Driving Change for Women with Heart Disease

Occupational Radiation Exposure and Pregnancy Radiation exposure and its effects continue to be an important issue preventing women from pursuing a career in interven-tional cardiology. Evaluating the true risk of radiation expo-sure from performing cardiac catheterization procedures is challenging and clear guidelines are not yet available. Despite the improvement of radiological equipment, the number of procedures has increased exponentially, as well as procedure complexity requiring greater fluoroscopy time and subsequent radiation exposure 10. Specifically to women, this risk is of even greater concern during childbearing years and radiation expo-sure has been found to be the reason for altering their career plan in cardiology in 24% of cases 11.

It is clear how understanding the real magnitude of radiation risk during pregnancy and educating the personnel to limit ra-diation exposure are critical. The radiation effects on the fetus are strictly dependent on the age of the embryo/fetus and on the dose of radiation to which it is exposed. The biological ef-fects of high dose of radiation are at DNA level and may result in deterministic effects (intrauterine growth retardation, preg-nancy loss, mental retardation, congenital malformations) or stochastic effects (childhood risk of cancer, hereditary diseases in the descendants) 12, 13. The overall probability of a child to have a congenital malformation or developing cancer has been estimated of ~ 0.07% in the general population. (Table 1 from P. West et all), shows that the probability of a child to develop cancer is only very mildly increased (0.079%) if the mother radia-tion exposure is 0.5-1 mSv; if the exposure is above 10 mSv the risk of a child to develop cancer will exceed 0.16% 14.

Unfortunately, there are no data available on the actual radia-tion exposure to the fetus of a mother working in the cath-eterization laboratory. This lack is mainly due to different ap-proaches to the pregnancy healthcare in the various countries. In some European countries, there is a strict policy on pregnant workers and women are obliged to leave the cardiac catheter-ization laboratory by law as soon as their pregnancy is known. Other countries allow women to continue performing proce-dures if the radiation dose not exceeds 1-2 mSv throughout pregnancy. These policies are not in any way evidence-based but rather are the result of the employers/organization´s fear of litigation. A discussion and uniformity of evidence-driven policies that respect women´s choices would certainly help this issue. Nevertheless, the fact that a career could be inter-rupted during pregnancy can contribute to persuade a trainee not to undertake this kind of profession.

Data collections from countries in which women continue to work during pregnancy in the catheterization laboratory are essential in order to standardize the legislation on the basis of scientific background. However, being aware that there is a small increase in the risk for the fetus when the mother ex-posure is above 1 mSv, every pregnant worker should evalu-ate her own individual risk and if needed should reduce the amount of procedures during pregnancy, monthly monitor-ing the radiation exposure under the lead at the waist level. The mean effective dose that an expert operator takes during one working year is around 4 mSv. This means that during the pregnancy the amount of procedures performed should be halved.

5

Occupational Radiation Exposure

Patricia Best, MD, FSCAIMayo Clinic Rochester, MN, USA

Antonia Anna Lukito, MD, FSCAISiloam Hospital, Tangerang, Banten, Indonesia

Patrizia Presbitero, MDIstituto Clinca Humanitas, Rozzano, Italy

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Considerations for Female Interventional Cardiologists

6

Occupational Radiation Exposure:Equipment Selection for the Female OperatorThere are several different ways to limit radiation exposure: a formal education, continued training in radiation protection and close occupational surveillance. Lead shields and proper types of lead or non-lead aprons should be utilized carefully. The thickness of these garments is also important (it has been demonstrated that a 0.25 mm lead apron absorbs ~ 96% of scatter radiation, while a 0.5 mm lead apron absorbs ~ 98%) 15. Larger size aprons specifically for pregnant workers are also available. Another technique includes wearing an addi-tional lead apron for double lead protection of the abdomen. Overall radiation exposure could also be limited utilizing spe-cific working views (postero-anterior or right anterior oblique preferably) 16. Furthermore, increasing the distance of the op-erator from the x-ray source is important 17, 18.

The National Council on Radiation Protection and Measure-ments (NCRP) and the International Commission on Radio-logical Protection (ICRP) recommend limiting occupational radiation exposure of the fetus to a value as low as reasonably achievable, but not to exceed 5 mSv (NCRP) or 1 mSv (ICRP) during the entire pregnancy respectively 19, 20, 21 (Table 2). In order to reduce operator radiation exposure, implementation of X-ray protection equipment, maybe with automatic sensors to lower the flat screen detector as close as possible to the pa-tient body, should be requested to the hospital. Furthermore, a training course for interventional fellows in radiation protec-tion should be arranged in every training center in order to

learn how to reduce operator radiation exposure (attention to fluoroscopy time, avoiding extreme angulated views, reducing the number of frames per second and frames recording).

As a female operator it is important to customize X-ray protec-tion, taking into consideration anatomical differences such as breast size, bone density, weight and stature. These adjust-ments may include X-ray protective apron with more complete chest coverage to protect the left breast., left arm coverage, and double coverage at the ovary and uterus level. Decision on radial vs. femoral access should be made by the individual operator, as there is conflicting data regarding possible in-creased radiation exposure via the radial approach 22. Whole body shields, though cumbersome, is another mode of protec-tion. Robotic-assisted interventions are also being explored 23.

Conceptus dose above back-ground (mSv)

00.512.5510

Probability of a child with a congenital malformation (%)

44.0014.0024.0054.014.02

Probability that a child will develop cancer (%)

0.070.0740.0790.0920.110.16

Probability child will have a congenital malformation or that will develop cancer (%)

4.074.0724.0784.094.124.17

Table 1: Probability of a child born with a congenital malformation or developing childhood cancer.

0 4 0.07 4.07

1 4.002 0.079 4.078

5 4.01 0.11 4.12

NCRP effective dose limits for occupational exposure

ICRP planned occupational dose limits

Body area

• Whole body• Lens of the eye• Skin, hands, feet

and other organs• Foetus (during

entire pregnancy)

• Whole body• Lens of the eye• Skin, hands, feet

and other organs• Foetus (during

entire pregnancy)

Occupational dose limit/year

50 mSv150 mSv500 mSv<5 mSv

20 mSv150mSv500 mSv<1 mSv

Table 2: Recommended occupational dose limits by National Coun-cil on Radiation Protection and Measurements (NCRP) and Interna-tional Commission on Radiological Protection (ICRP).

NCRP effective dose limits for occupational exposure

• Whole body• Lens of the eye• Skin, hands, feet

and other organs• Foetus (during

entire pregnancy)

50 mSv150 mSv500 mSv<5 mSv

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Driving Change for Women with Heart Disease

Wages: Equal Pay for Equal Responsibility

Florencia Rolandi, MDCENPEC Investigaciones, Buenos Aires, Argentina

A large concern for women intending on a ca-reer in interventional cardiology is remunera-tion. In 1964, the British Journal of Medicine published a letter titled “Equal pay for Women Doctors”, denouncing that female physicians were paid 75% of the male rate for performing the same job 24. This inequality in wages persists more than 40 years later. The 2008 Employ-ment Outlook report found that women were paid 17% less than their male counterparts. Moreover, a study based on survey data from roughly 8,000 newly trained physicians in New York showed that starting salaries in 1999 were $173,400 for male physicians vs. $151,600 for female physicians. This gap was even larger in 2008, when starting salaries were $209,300 vs. $174,000, respectively 25. Consistent with these observations, a Latin-American report stated that even if women represented 61% of profes-sionals in public hospitals, only the 48% of the total wage was divided among them 26.

Wage disparities are often explained away as a result of women working part time or limited hours, or choosing lower paying specialties to

allow for more time off raising a family. How-ever, even after accounting for specialty, hours worked and other measures of productivity and achievement, women still earn less than their male colleagues 27.

Female physician researchers earn lower salaries than their male colleagues, even when statistics are adjusted for specialty, academic rank, lead-ership positions, publications and research time 28. The reasons for these discrepancies need fur-ther investigation.

WIN recommends that pay disparities in inter-ventional cardiology be addressed to help wom-en achieve equal pay for equal work. Women should be taught to negotiate employment contracts so that they not only include fair wag-es but flexible working arrangements, adequate maternity leave and good quality, affordable child-care. Salaries should also be transparent, based on a merit system, and clearly communi-cated (similar to the model employed by the le-gal world). Moreover, major efforts are needed to ensure that all individuals have access to the same job opportunities. Even though women now account for over half of the applicants to medical schools, women physicians are much less likely to reach senior positions than their male counterparts. Promoting equal opportuni-ties requires a long-term investment in educa-tion and training, as well as policy interventions to promote access to productive and rewarding jobs. WIN supports the analysis and discussion about wage disparities as one of its aims is to facilitate the professional advancement of fe-male interventional cardiologists worldwide.

7

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Considerations for Female Interventional Cardiologists

8

Conclusion

There continue to be unresolved issues for women in interventional cardiology. The issues addressed

in this booklet, such as pay discrepancies, radiation safety concerns and family planning, continue

to be barriers to success. There are also other professional areas such as mentorship, research, and

entrepreneurialism, that while not specifically touched on here, pose additional challenges. Women

in Innovations (“WIN”) hopes to push all of these issues to the forefront, creating a more open dia-

logue in order to usher in a wave of change for female interventionalists around the world. Change

is underway. Physicians are slowly taking charge over their schedules. Improvements are being made

in radiation safety and cath lab equipment options. There are more women in leadership roles in in-

terventional cardiology, creating a louder and more unified voice in support of the female physician.

Cardiovascular disease continues to be a global health burden, and women should be encouraged

to join the exciting field of interventional cardiology. Through publications, research, forums, and

mentoring, WIN plans to contribute to this effort by urging more thoughtful consideration of women

and their value in all planning, training, educational and employment practices.

To learn more about the Society for Cardiovascular Angiography and Interventions’ (SCAI) Women

in Innovations (“WIN”) initiative, and to read profiles of WIN members from around the world visit

www.scai-win.org.

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Driving Change for Women with Heart Disease

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3. As reported by Patrizia Presbitero, MD for the publication “Why So Few Women in Interventional Cardiology?” Carlo Di Mario, EAPCI President Royal Brompton Hospital & Imperial College, Lon-don, United Kingdom. EAPCI Column - EuroIntervention Journal - April 2010.

4. Willett L, Wellons M, Hartig J, et al. Do Women Residents Delay Childbearing Due to Perceived Career Threats? Assoc. of Am Med Colleges 2010; 85:4.

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7. Gabbe S, Morgan M, Power M, et al. Duty Hours and Pregnancy Outcome Among Residents in Obstetrics and Gynecology. Am Coll of Obstet and Gynecol 2003; 102:5.

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13. Brent RL. Saving lives and changing family histories: Appropriate counseling of pregnant women and men and women of reproductive age, concerning the risk of diagnostic radiation exposures during and before pregnancy. Am J Obstet Gynecol 2009;200:4-24.

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Considerations for Female Interventional Cardiologists

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14. Best PJ, Skelding KA, Mehran R, Chieffo A, Kunadian V, Madan M, Mikhail GW, Mauri F, Taka-hashi S, Honye J, Hernández-Antolín R, Weiner BH; Society for Cardiovascular Angiography & Interventions’ Women in Innovations (WIN) Group. SCAI onsensus document on occupational radiation exposure to the pregnant cardiologist and technical personnel. EuroIntervention. 2011 Feb;6(7):866-74.

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Driving Change for Women with Heart DiseaseDriving Change for Women with Heart DiseaseDriving Change for Women with Heart DiseaseDriving Change for W

www.SCAI-WIN.org

Professional DevelopmentEducation Research Innovation

The Society for Cardiovascular Angiography and Interventions Driving Change for Women with Heart Disease