January 26, 2017 | Sanah Christopher, MD
Career Development

Committing to sub-specialty training after cardiology fellowship can be one of the most challenging decisions faced by FITs. Current estimates for female FITs in cardiology training programs are at 15 – 18 percent, however, the percentage of female FITs in sub-specialty training tends to be much lower. These estimates for sub-specialties and the stagnation in numbers over the past few years likely reflect the inherent complexity of all the factors that eventually lead to under-representation of women in these fields.

Factors such as additional training time, mounting student debt and concerns for work-life balance can deter both male and female fellows from considering sub-specialty careers. Female FITs often self-exclude themselves from considering sub-specialty training due to the above factors and concerns about relative paucity of mentorship and female representation in sub-specialty professions. Nevertheless, the landscape of cardiology as a profession is changing for the better, and the present generation of female cardiologists now has access to more mentors and organizations for networking, such as the ACC Women in Cardiology (WIC) council can help expand options. 

In my experience as a female FIT, although my program had previously trained many female fellows, I started fellowship as the only female fellow at the time. I was fortunate to find widespread acceptance among my colleagues and patients alike, and this acceptance paradoxically brought to the forefront discussions on the specific considerations that influence female FITs for sub-specialty training. I found an abundance of inspirational perspectives from my attendings, sonographers, catheterization lab and electrophysiology (EP) lab staff that helped me develop the base of my own personal and professional decision points for consideration of further training. It is appropriate to highlight how work-life balance, gender based wage discrepancies in practice and an overall paucity of female representation may affect your decision-making. These issues can be raised during your discourse with others who have traversed the same subspecialty training pathway to define goals, identify unknown resources and develop clarity of thought. Knowledge truly is power.

Perhaps one major concern that influences procedural subspecialty consideration by female FITs is the issue of radiation exposure. In a recent JACC article on the experience of female cardiologists with pregnancy and early parenthood, Sarma et al. noted that 46 percent of respondents to a survey, identified occupational exposure as having affected their decisions for family planning and pregnancy¹.  Nearly half of the respondents indicated that they avoided pregnancy during periods of radiation exposure. Currently, the true radiation exposure risk remains unknown. Overall, there is lack of sufficient literature or guidance on what to do in procedural fields where fluoroscopy is utilized. Hence, the ACC WIC council highly recommends that all female cardiologists receive education regarding pregnancy radiation exposure on entering fellowship and in succeeding stages. A vast majority of centers with fluoroscopy and procedural capabilities have radiation safety departments that organize formal education and courses regarding various methods to reduce fluoroscopy time, angulation of views and tips for reducing the number of frames per second, among other things. Discussion with procedural administrative personnel to ensure personal protective equipment fits appropriately and to ensure the availability for additional coverage for double lead, or larger aprons in pregnancy, is encouraged. Frequent surveillance of dosimeters can also ensure radiation exposure remains low for both personal protection and before, or during pregnancy. Although many centers have policies regarding pregnant employees in procedural areas, it is a strongly personal decision. Empowering yourself with the correct resources and equipment can make the decision-making easier.

All things considered, we do not function in isolation. Training proves to be a long and arduous time, and establishing support networks that can broaden a limited introspective view, can sometimes make all the difference in decision-making. During residency and fellowship, we tend to focus on the development of a strong sense of self-sufficiency to enable us to function in stressful situations. Through this process, we often develop a sense of skills sets that we can grasp and excel in easily and others that require more effort. Identification of the skills that you excel in and enjoy is important to prevent self-exclusion from a particular sub-specialty training decision. It is beneficial to seek feedback from senior FIT colleagues to ensure that you are not holding yourself back with perceived shortcomings that can be easily rectified. Furthermore, getting an outside perspective from family and friends is a tremendous way of exploring motivating factors and aspects that define you as an individual that would fit more with one field versus another.

We are fortunate to train in cardiology, which offers the opportunity to find our niche in such a wide spectrum of practice areas and models. A significant dynamic shift is already underway with more and more women considering cardiology as a preferred profession. The momentum from this positive change is likely to open pathways and innovate measures to ensure that the decision to pursue subspecialty training, or not, for female FITs becomes a truly fulfilling one.

Reference

1. Sarma AA, Nkonde-Price C, Gulati M, Duvernoy CS et al Cardiovascular Medicine and Society: The Pregnant Cardiologist. J Am Coll Cardiol. 2017 Jan 3;69(1):92-101. doi: 10.1016/j.jacc.2016.09.978.

This article was authored by Sanah Christopher, MD, a Fellow in Training (FIT) at Virginia Commonwealth University Health System.