It was a bright summer morning on June 9, 2020 in San Francisco. Sipping my coffee, I stared at the glistening blue waters of the Bay from our veranda. The fog from the previous evening had rolled away onto the distant horizon, leaving the Golden Gate Bridge standing tall and proud against the majestic backdrop of the hills of the California Coast Range.

For a moment, I forgot that the world was in the midst of a raging pandemic and anti-racial protests. I closed my eyes and prayed for my patient, "Ms. Graham," and for myself. It was a big day for us. Ms. Graham was a feisty, 93-year-old woman with perfectly styled hair - bob cut with under curls. It's a classic 50s hairstyle that she proudly maintained all her life. She had symptomatic severe aortic stenosis and was scheduled for TAVR that day. I was performing a TAVR for the first time as an attending. My prayers were interrupted by my phone buzzing from a Twitter feed expressing solidarity with the anti-racial protests.

In an attempt to continue my interrupted prayers from the morning, I turned on the "Om chant" during my commute to the hospital. The chant reverberated through the enclosed space of my car – a soothing, repetitive, sound compactly packed with the entire positive energy of the universe. I felt the urge to absorb all that energy to fight against the negative skepticism associated with my index – one among the 4% of women in interventional cardiology,¹ and an even smaller percentage doing structural heart interventions such as TAVR. My additional layers of icing on the index include being brown, an international medical graduate, and an early career physician with a petite frame and soft voice. Needless to say, I am the first and only woman interventional cardiologist at my institution.

For the last four years, I, like water, adapted to the crevices and nooks of being a woman in interventional cardiology – assertive but not authoritative, confident but not conceited, appearing oblivious outwardly but being keenly aware inwardly of implicit bias against me. Many times, I had to navigate deftly the fallacious perception that asking for help is a sign of incompetence. I patiently eroded through layers of skepticism by focusing on good patient outcomes and building trusting relationships with patients and a few supportive colleagues. Entering into a new niche of the tightly controlled, male-dominated space of structural heart interventions, I knew I needed to do it all over again with even greater poise.

As I donned the lead, sterile gown and gloves, I looked around the room. The cardiothoracic surgeon, my co-interventional cardiologists, the proctor, the anesthesiologist – all men. Suddenly, the lack of diversity and the gender discrepancy in highly specialized procedural fields and leadership positions felt suffocating. Over the years, we were able to increase the enrollment of women into medical schools to over 50%,² but this has not translated into surgical and procedural fields. This is because an oppressive and stifling glass ceiling has been created by all the microaggressions, implicit and hierarchical biases that exist in non-diverse work environments.³

I forced myself to take a deep breath and refocused my mind by doing a mental check list of all procedural steps – access, temporary pacemaker, coplanar angle, valve alignment and deployment technique. Over the next hour, I steadily executed each step confidently without any glitches. I thanked everyone in the room and stepped out. First TAVR done. A huge sigh of relief.

I had several messages from family, mentors and colleagues asking for an update. With overwhelming gratitude for their support, I informed them of the day's success. "I am happy for you, your patient, family, and the world today," said one of my mentors. Happy for the world? Not at this time, I mused initially. Slowly, the implications of his words dawned on me. In my own small way, I had broken the heavy, oppressive, glass ceiling that day.

Many minorities working in non-diverse environments are subject to frequent micro/macro-aggressions and insults because of their race, ethnicity, gender, sex, and/or religion. Feelings of anger, frustration, sadness and helplessness are not uncommon. Personally, the pent-up emotion from never calling out the insults or addressing the implicit bias against me directly has left me overwhelmingly frustrated over the years. Maybe the subconscious pro-social milieu of the ongoing protests and national discussions around racism have provided me with the context and the courage to openly write about my experience for the first time. I broke through the glass ceiling that day and I hope my story allows others to break through the oppressive and stifling ceilings above them as well. As a society, we should not merely stop with simple expressions of solidarity, but rather amplify the existing momentum rallying for actionable, systemic changes to enhance workplace diversity, specifically in leadership positions.

Later, I went to update Ms. Graham. On seeing me, she smiled. "All went well, Ms. Graham, you have a new valve now," I said. "Thank you doctor, for what you did for me. But more than that, thank you for what you did to yourself," she said. "What do you mean," I asked, perplexed. Squeezing my hand lightly, she said: "I know how hard it is for you to do what you do, coming from a different country and being a woman." Marveling at her wisdom and with tears of gratitude, I said: "Thank you. You are kind to say that." I thought: Nobody should ever have the need to break through a stifling glass ceiling. It should not exist. Not for me, not for anyone.

References

1. 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.
2. Association of American Medical Colleges (AAMC). December 2019 Report. Available here.
3. Deville Jr C. The suffocating state of physician workforce diversity: why "I Can't Breathe." JAMA Intern Med 2020;Aug 31:[Epub ahead of print].