Women in Interventional Cardiology: A Middle East Perspective

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Me: "Good morning, I'm Dr. Alasnag. I performed the coronary angiogram for your mother. She has critical left main disease. The angiograms were reviewed with our cardiac surgeons. Given her age, frailty and poor distal targets, we recommend high-risk intervention by placing a stent with a circulatory support device."

Eldest son: "When will the doctor come to speak to us?"

Me: "I am her doctor."

This conversation was one of my first encounters after completing interventional cardiology fellowship (and might I add, not the last). For better understanding of the scene described, I am a young and petite woman. My patient was an elderly, petite, frail woman. Her room was packed with family members, including seven sons – tall, middle-aged gentlemen. It was intimidating and frustrating. In my scrubs and flat shoes, I walked them to a viewing station and showed them the angiograms. I described what we mean by a ruptured plaque in the left main, pulmonary edema and her prognosis. The angiogram made a remarkable visual impact on them. As the conversation continued, I answered all their questions about the procedure and its complications. By the end of the discussion, they trusted that I knew what I was doing, and they signed the consent form. Consent was signed. The procedure was successful, and the woman went home with her big family days later. This scenario repeated itself many times, albeit with different details. Every time, it is equally frustrating but far less intimidating.

In the Middle East, there are just as many women as men in medical school, and their average GPA is higher than that of their male peers. Similar to North America and Europe, the number of women who choose to venture into cardiology and interventional cardiology are less than five percent. When I started practice, I was the only female interventional cardiologist in the Gulf region. Eight years later, this number is growing. Today, there is handful of us.

Why? I asked that question many times, and the answer is multifactorial. For starters, many women fear the demands of this job, and the hours are long and unpredictable. The radiation risk remains a myth that we, as a community, have failed to appropriately debunk. The nature of cardiovascular interventions carries a higher risk and stress level that exceeds many other fields. Therefore, many women are apprehensive about being able to maintain a comfortable work-life balance.

Aside from the demands, it is also a very competitive field. The competitive edge is tangible as early as the fellowship application, and women have far fewer interviews than men. The interview itself can be brutal. Women are often asked questions about family life and time management that our male counterparts are not required to answer. The expectations during training also exemplify this obvious double standard. When my male co-fellow went to a school function with his kids, everyone in the program patted him on the shoulder and showered him with compliments for being an involved father. When my female co-fellow excused herself to go to her kids' school, I immediately saw the eye rolls questioning her reliability and commitment.

In my experience, the double standards continued well into my practice as an attending. I found that I needed to continuously prove my competence and commitment. I worked during sick days, throughout my pregnancy until I delivered and while my father was in an intensive care unit. I went back to work one week after he passed away. These experiences taught me who I am as a person and a physician. I also learned self-confidence, strength and resilience.

In the Middle East, we live in a conservative, male-dominated society. Most patients and their families expect to see a male cardiologist. Their disappointment when I, a woman, walk through the door in a white coat stings. Colleagues and medical school friends also questioned my career choice, and that was discouraging. "Are you sure? How will you arrange childcare during emergencies? How will you manage being the only woman in that department?" Yes, maintaining professionalism with male colleagues and balancing family and work were challenges. However, I am grateful for the people in my life who help me navigate those challenges.

Many women in this part of the world take pride that there is equal pay for men and women. However, it is not just about the pay. It is about equal opportunities, privileges, promotions and bonuses. I had to ask for equal cath lab time, equal admission privileges, my choice of supplies and promotions. It was not automatic. Looking back at my career, I would do it all over again simply because I am passionate about interventions, and I had the family support. However, I would not want other women to go through the discrimination and misogyny. If they have the passion and potential, the road should be made easier. I have learned through sessions at the ACC, American Heart Association and Transcatheter Therapeutics that this is not unique to the Middle East – it is a global phenomenon.

Women have served as presidents of the ACC, British Cardiovascular Society, European Society of Cardiology and Danish Society of Cardiology. These women are role models for many across the globe. More importantly, they are in leadership positions that allow them to effect change in the work environment. In fact, Iceland just mandated equal pay. Other pending issues include paid maternity leaves, flexible hours for lactation, accessible daycares, and a fair application and interview process. Collectively, we need to discuss and prioritize these issues with the ACC Women in Cardiology Section. In addition, there are many strategies to recruit women into this field, including having women serve as mentors, role models and decision-makers. We have all identified areas that need our intervention and defined the necessary interventions. It is time to put down concrete plans and move forward.

This article was authored by Mirvat A. Alasnag, MB, BCH, director of the catheterization laboratory at King Fahd Armed Forces Hospital in Jeddah, Saudi Arabia.