The presence of underrepresented minorities (URMs) in cardiothoracic anesthesiology is underwhelming, and progress toward diversity has been slow at best. Despite decades of efforts, change seems hard to achieve. For example, it took more than 30 years for women to make up 50% of medical school matriculants. However, women continue to be underrepresented in our professional subspecialty and notably. This slow movement is not idiosyncratic to women but also applies to equity related to race and ethnicity. Given this current state, this article seeks to bring attention to the lack of diversity in cardiac anesthesiology and is a call to action to accelerate efforts and the pace of change toward greater equity both in our field and in medicine in general. This piece is the final part of a 4-part series exploring opportunities for improving diversity in cardiac anesthesiology. The authors focus specifically on the professional experience of URMs in medicine in our subspecialty and the opportunities for improving diversity. While many barriers for URM physicians reflect those of women, the experience of URM practicing physicians is unique and solutions need to incorporate.

This paper is the first of a four-part series that details the current barriers to diversity in the field of adult cardiothoracic anesthesiology and outlines actionable programs that can be implemented to create change. Part I and Part II address the training experience of women and underrepresented minorities (URMs) in adult cardiothoracic anesthesiology (ACTA), respectively, and explore concrete opportunities to promote positive change. Part III and Part IV examine the professional experience of URMs and women in ACTA, respectively, and discuss interventions that can facilitate a more equitable and inclusive environment for both groups. Although these problems are complex, the authors here offer a detailed analysis of the challenges faced by each group both in the training phase and the professional practice phase of their careers. The authors also present meaningful and concrete actions that can be implemented to create a more diverse, equitable, and inclusive professional environment in cardiovascular and thoracic anesthesiology.

CHRONIC THROMBOEMBOLIC pulmonary hypertension (CTEPH) is a condition characterized by persistent obstructive thrombi that will lead to vascular scarring and, subsequently, progressively elevated pulmonary arterial pressure. These thromboemboli generally originate from deep venous thrombosis (DVT), typically from the lower extremities. 1 Kearon C. Natural history of venous thromboembolism. Circulation. 2003; 107: I22-I30 Crossref PubMed Scopus (931) Google Scholar The authors present an unusual case of CTEPH due to a rare anterior mediastinal venous malformation (VM) that was misdiagnosed previously in infancy as a cystic hygroma. Mediastinal vascular malformations are uncommon, and embolization to the pulmonary arteries from a VM is a rare event. 2 Nakano TA Zeinati C. Venous thromboembolism in pediatric vascular anomalies. Front Pediatr. 2017; 5: 158 Crossref PubMed Scopus (20) Google Scholar Early diagnosis and a multidisciplinary approach can enable prompt follow-up and treatment of this condition to mitigate adverse consequences of pulmonary hypertension.

DESPITE THE ACHIEVEMENT of parity in medical school matriculation decades ago, 1 Association of American Medical Colleges. AAMC chart 5: Graduates of US medical schools by sex, academic years 1980-1981 through 2018-2019. Available at: https://www.aamc.org/media/9631/download?attachment. Accessed December 10, 2020. Google Scholar female physicians across specialties continue to face barriers in their professional development. Women in cardiothoracic anesthesiology (CTA) are a growing and increasingly vocal minority in a medical subspecialty that has been dominated by men throughout history. Approximately 36% of United States medical school faculty anesthesiologists are women, 2 Association of American Medical Colleges. AAMC table 13: US medical school faculty by gender, rank, and department, 2019. Available at: https://www.aamc.org/media/8441/download?attachment. Accessed September 27, 2022. Google Scholar and women account for 29% of cardiothoracic anesthesiologists. 3 Capdeville M. If all the world's a stage, then where's our microphone?. J Cardiothor Vasc Anes. 2020; 34: 1810-1814 Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar These latter women face unique challenges in the often-stressful and dynamic environment of the cardiothoracic operating room. These challenges have led to the formation of organizations whose mission is to provide support and guidance in the professional lives of female cardiac anesthesiologists. Women in Anesthesiology Leadership: The Time is NowJournal of Cardiothoracic and Vascular AnesthesiaVol. 37Issue 6PreviewTHE LACK of gender equity in medicine has been discussed and published in academia for more than 3 decades. Although there is no lack of published research showing significant inequity in compensation, promotion, and advancement into leadership among women physicians compared to male physicians, barriers to gender equity for women in medicine, specifically for women in anesthesiology, remain.1,2 Routinely, reasons, and perhaps excuses, are cited as the reason for the disparity. Often cited is the limited pipeline and too few women represented over time when, in reality, the reasons that limit an equal number of women rising to full academic promotion and leadership advancement are a lack of equal opportunities for professional development, incomplete networking support, and inadequate sponsorship. Full-Text PDF

ENTER THE term “TAVR” into the Pub Med search box and more than 4,000 titles appear. For 2020 alone, there are 1,079 citations listed. At the rate that information is being generated, it has become increasingly difficult to keep pace with this rapidly evolving technology. When Alain Cribier first published the original report of percutaneous transcatheter aortic valve replacement (TAVR) in a human in 2002, most never would have imagined that this concept would become a standard of care, and in record time to boot.

MOST medical school graduates can remember the excitement they experienced after having decided on a medical specialty, and finally submitting the rank list that would determine the trajectory of their nascent careers. They also can hearken back to the trepidation felt while awaiting the final outcome of the match. Would they get their first choice and be jubilant, or would they feel a pang of anxiety knowing that “Plan B” would have to be put into effect? The influence of geography on rank lists and acceptance rates into residency and fellowship programs is a theme that seldom has been addressed in relation to a region on a US map, despite the role it plays in the lives of many prospective residents and fellows. The relationship of program location and rank lists to applicant gender is an altogether different question that seeks to address diversity on a regional scale, whereby a link between gender-driven acceptance rates and program location is considered. As will be discussed, there are a myriad of factors that come into play when pondering this question. There is a dearth of information on the relevance of a residency or fellowship program's location on a map to acceptance rates for female applicants. Most studies have been survey-based, with all the attendant limitations of this form of analysis, and generally have included geography as part of a larger question, particularly when it comes down to how individual applicants and program directors rank one another. An applicant must decide how important a program location is, a factor over which program directors have no control. In the current issue of the Journal of Cardiothoracic and Vascular Anesthesia, Drs Patel and Ngai have examined the influence of geographic location across the United States on the acceptance rates of women versus men into adult cardiothoracic anesthesia (ACTA) fellowship programs.1Patel S Ngai J. Gender diversity in cardiothoracic anesthesiology fellowship: The influence of geographical region.J Cardiothorac Vasc Anesth. 2021; 35: 1725-1731Abstract Full Text Full Text PDF Scopus (2) Google Scholar This study specifically addressed the finite question of acceptance rates based on gender, and their relationship to a sector on the map, from 2013 to 2018. In other words, are women more likely to be accepted into an ACTA program in a major city on the West Coast than say, a program in a small town in the Midwest? And then, of course, there is the question of geographic region versus regional customs, program culture, and attitudes within the program itself. One would naturally expect that in 2021, all programs, irrespective of locale, would be unbiased toward female applicants. Well, from this study's findings, we can comfortably rule out regional bias as a source of gender disparities in the acceptance rates of women into ACTA fellowships—this is an important observation, as this may not be the case in many of the male-dominated specialties. The real problem that lies herein is that fewer women apply to our subspecialty, a persistent trend with no immediate end in sight. What the study did not take into account, however, was the actual influence of geographic region on the likelihood of a program being ranked highly by applicants of either gender, which is an entirely different question, with no simple answers. The generation of rank lists is a painstaking matter, in which on the one hand, program directors must be able to attract the best applicants from the best residency programs, while on the other, applicants have to decide what program elements are most important to them, including the possibility of having to relocate to another state or across the country. Applicants, regardless of gender, need to consider their level of competitiveness, which program will offer the best mutual fit, and personal factors such as a spouse/significant other, and proximity to loved ones. Importantly, the role partners play in the selection of a residency or fellowship is intimately tied to geography. A study of fourth-year medical students (65% men) and their partners found that a partner had the greatest influence on choice of residency.2Arnold RM Landau C Nissen JC et al.The role of partners in selecting a residency.Acad Med. 1990; 65: 211-215Crossref PubMed Scopus (9) Google Scholar Female medical students were less influential and more likely to forego their desires for their partner's, and were less satisfied than men with the process of decision-making. These women may be self-selecting themselves out from programs they might otherwise prefer to attend. The concept of the “trailing spouse” is not unique to medicine, and often the assumption is that men are less likely to relocate than women for a partner's job transfer or promotion. One can only wonder if this applies to residency and fellowship candidates, and whether a program's leadership makes assumptions about spouse and partner mobility based on gendered roles when generating a final rank list. Do partners consider one another's needs when deciding on relocation? Is there a gender split on this question? Because many partners also work outside the home, relocating to a different region has a significant impact on their ability to continue working/finding a suitable job and financial well-being.3Ullrich J Pluut H Büttgen M. Gender differences in the family-relatedness of relocation decisions.J Vocat Behav. 2015; 90: 1-12Crossref Scopus (8) Google Scholar Outdated traditional roles, social norms, cultural influences, childbearing, and childcare needs also factor into the equation. In a perfect match, each party gets what it wants, and geography does not matter as long as everyone is happy with the outcome—whether the chicken came before the egg is irrelevant. Even if a program director has the last word on how applicants are ranked, desirable applicants can choose to go elsewhere. For program directors, ranking applicants can be a high-stakes gamble when trying to attract an individual from a region of the country with its own competitive programs, but perhaps greater proximity to family and friends. All things being equal, an internal candidate who is a known entity may be a safer bet than a comparable applicant who interviews well. With geographic location being a fixed variable, highly-sought-after applicants will tend to have the upper hand compared with program directors, which obviates the need for them to apply to many and more remote programs.4Simmonds AC Robbins JM Brinker MR et al.Factors important to students in selecting a residency program.Acad Med. 1990; 65: 640-643Crossref PubMed Scopus (55) Google Scholar Befoe the pandemic, there was also the cost of traveling for interviews to consider. For certain individuals, even climate is a consideration, and some would just as soon forego the need to purchase a winter coat, and only apply to programs in warmer parts of the country. An electronic survey study of very highly ranked applicants to 15 graduate medical education programs (including anesthesiology) at Duke University, who chose to match elsewhere, sought to identify factors that were very important to applicants in ranking programs.5Nagler A Andolsek K Schlueter J et al.To match or not: Factors influencing resident choice of graduate medical education program.J Grad Med Ed. 2012; 4: 159-164Crossref PubMed Google Scholar Of the 30 factors under study, qualitative analysis identified geographic location, program relationships, and the interview experience as being important. Geographic location was rated as very important by 61% and somewhat important by 32% of respondents. The importance of a program's geographic location to applicants has been described in several survey studies from multiple specialties including otolaryngology,6Sharp S Puscas L Schwab B et al.Comparison of applicant criteria and program expectations for choosing residency programs in the otolaryngology match.Otolaryngol Head Neck Surg. 2011; 144: 174-179Crossref PubMed Scopus (10) Google Scholar, 7Gebhard GM Hauser LJ Dally MJ et al.Do otolaryngology residency applicants relocate for training?.Laryngoscope. 2016; 126: 829-833Crossref PubMed Scopus (6) Google Scholar, 8Johnson AP Svider PF Folbe AJ et al.An evaluation of geographic trends in the otolaryngology residency match—Home is where the heart is.JAMA Otolaryngol Head Neck Surg. 2015; 141: 424-428Crossref PubMed Scopus (19) Google Scholar neuroradiology,9Beheshtian E Jalilianhasanpour R Sahraian S et al.Fellowship candidate factors considered by program directors.J Am Coll Radiol. 2020; 17: 284-288Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar emergency medicine,10Laskey S Cydulka RK. Applicant considerations associated with selection of an emergency medicine residency program.Acad Emerg Med. 2019; 16: 355-359Crossref Scopus (10) Google Scholar,11Love JN Howell JM Hegarty CB et al.Factors that influence medical student selection of an emergency medicine residency program: Implications for training programs.Acad Emerg Med. 2012; 19: 455-460Crossref PubMed Scopus (41) Google Scholar family medicine,12Wright KM Ryan ER Gatta JL et al.Finding the perfect match: Factors that influence family medicine residency selection.Fam Med. 2016; 48: 279-285PubMed Google Scholar plastic surgery,13Silvestre J Lin IC Serletti JM et al.Geographic trends in the plastic surgery match.J Surg Ed. 2015; 73: 270-274Crossref Scopus (20) Google Scholar and general surgery.14Falcone J. Home-field advantage: The role of selection bias in the general surgery national residency matching program.J Surg Ed. 2013; 70: 461-465Crossref PubMed Scopus (10) Google Scholar,15Dhar VK Hanseman DJ Young G et al.Does geographical bias impact the match for general surgery residents?.J Surg Ed. 2019; 77: 260-266Crossref PubMed Scopus (5) Google Scholar There was no suggestion from any of these studies that programs in certain regions were specifically biased against any particular group of individuals. For example, an investigation into the role of geography in the integrated plastic surgery match found that 15.1% of residents matched at their home institution, and 48.9% matched in the same region as their medical school.13Silvestre J Lin IC Serletti JM et al.Geographic trends in the plastic surgery match.J Surg Ed. 2015; 73: 270-274Crossref Scopus (20) Google Scholar Interestingly, most women matched at programs located in the West (43.1%) compared with the East (30.6%). Most female applicants attended medical schools in the South (38.2%), Northeast (26.7%), and Midwest (25.9%), compared with only 9.2% in the West. There was no obvious explanation for this trend beyond the possibility that West Coast programs might better meet women's needs than programs in other parts of the country, and, consequently, were ranked higher. Another consideration with regard to geography is that of internal candidates. In a study of categorical general surgery programs participating in the electronic residency application service that were matched to their associated allopathic medical school, it was found that approximately 25% of positions were filled by graduates from the home program, particularly in states with fewer medical schools.14Falcone J. Home-field advantage: The role of selection bias in the general surgery national residency matching program.J Surg Ed. 2013; 70: 461-465Crossref PubMed Scopus (10) Google Scholar Along similar lines, a study of the relationship of birthplace, college, medical school, and final matching into a general surgery residency found that among 198 applicants, 25% matched at a program located in the state of their medical school. The authors went so far as to suggest that, with increasing competitiveness and numbers of applications, programs should consider regional bias when selecting candidates to interview and rank.15Dhar VK Hanseman DJ Young G et al.Does geographical bias impact the match for general surgery residents?.J Surg Ed. 2019; 77: 260-266Crossref PubMed Scopus (5) Google Scholar Unfortunately, this philosophy can deprive superb candidates who are willing to relocate from being given any consideration. In contrast, a study of otolaryngology residents found that most applicants left their previous geographic region for residency, and recommended against placing a high value on an applicant's geographic origin when offering interviews.7Gebhard GM Hauser LJ Dally MJ et al.Do otolaryngology residency applicants relocate for training?.Laryngoscope. 2016; 126: 829-833Crossref PubMed Scopus (6) Google Scholar It would certainly be interesting to know how frequently anesthesiology residents remain at their home institution for fellowship training, and if they were granted an exception agreement by the program (an exception to the standard match includes active military duty during the application period, internal candidate status, and >one year institutional commitment, as in the case of combined fellowships, foreign graduate status, and couples match).16Society of Cardiovascular Anesthesiologists. Adult Cardiothoracic Anesthesiology (ACTA) Fellowship Executive Committee recruitment guidelines and exceptions. Available at: https://www.scahq.org/wp-content/uploads/2020/07/2013-ACTA-PDS-Agreement-for-SCA-website.pdf. Accessed February 28, 2021.Google Scholar From published data, it appears that geographic location of a program is relevant to many applicants, influences their decision of where to apply and train, and can surpass many program elements, including prestige and reputation, when generating a rank list. Whether ACTA program directors from different regions give more weight to a candidate's internal status, gender, or current home state is impossible to determine without more specific information about how both parties ranked each other. An email survey by Mackersey and Leff sought to identify factors that ACTA program directors consider most important. Among the free comments, an applicant's desire to reside within the program's geographic area was considered important unless program interest was based solely on relocating to the region.17Mackersey K Leff J. Preparing for a fellowship in adult cardiothoracic anesthesiology: Resources and approaches for the anesthesiology trainee.J Cardiothorac Vasc Anesth. 2019; 33: 621-638Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar Drs Patel and Ngai found that for men, there was not much variability in acceptance rates by region or time period, and more inconsistency was noted among women.1Patel S Ngai J. Gender diversity in cardiothoracic anesthesiology fellowship: The influence of geographical region.J Cardiothorac Vasc Anesth. 2021; 35: 1725-1731Abstract Full Text Full Text PDF Scopus (2) Google Scholar This latter point may simply be a function of where most women apply. Acceptance rates were statistically similar for both genders with the exception of 2017, when the acceptance rate for men was nearly twice as great in the Southwest (85% v 44%; p = 0.02). It is worth noting that among the Southwestern states, Texas is the only state with ACTA fellowships (five programs, 19 positions presently). This observation was unlikely due to gender bias, and could just as easily have been due to other factors such as program withdrawal, exception agreements outside the match, and personal reasons such as health or family-related considerations. Most women matched into Northeast programs, with the fewest matching in the Southwest. This is no doubt a function of the numbers of programs and positions, with New York alone having the largest number of programs and positions overall in the country (there are presently nine programs with 35 positions), and the Northeast region having the largest number of fellowship positions (n = 78). Across numerous specialties and subspecialties, persistent trends in the representation of female residents and fellows continue to exist despite decades of comparable rates of matriculation and graduation from medical school. Unlike many surgical specialties, particularly with the introduction of integrated pathways, which have been attracting increasing numbers of women, there has been a longstanding plateau in the proportion of female anesthesiology residents.18Capdeville M. Gender disparities in cardiovascular fellowship training among 3 specialties from 2007 to 2017.J Cardiothorac Vasc Anesth. 2019; 33: 604-620Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar Give or take, for the last decade, women have made up approximately one-third of core anesthesiology residency classes. This is concerning when one considers that the number of integrated vascular surgery positions has increased, with a 170% increase in the number of women applicants,19Arous EJ Judelson DR Simons JP et al.Increasing the number of integrated vascular surgery residency positions is important to address the impending shortage of vascular surgeons in the United States.J Vasc Surg. 2018; 67: 1618-1625Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar and that presently 20% of cardiothoracic surgery residents are women.20Stephens EH Robich MP Walters DM et al.Gender and cardiothoracic surgery training: Specialty interests, satisfaction, and career pathways.Ann Thorac Surg. 2016; 102: 200-206Abstract Full Text Full Text PDF PubMed Scopus (43) Google Scholar The stagnant numbers in anesthesiology have limited the pool of viable candidates for ACTA. The most recent Accreditation Council Graduate for Medical Education (ACGME) Data Resource Book (2019-2020) identified 160 anesthesiology residency programs with 6,698 residents, of whom 2,199 (32.8%) were female. For ACTA, there were 71 fellowship programs with 220 fellows, including 72 women (32.7%).21Accreditation Council for Graduate Medical Education. Data resource book. Available at: https://www.acgme.org/About-Us/Publications-and-Resources/Graduate-Medical-Education-Data-Resource-Book. Accessed February 22, 2021.Google Scholar Presently, there are 73 ACTA programs in the United States with 253 positions. The number of positions per ACTA program ranges from one to 18, with five states across the country accounting for nearly half of all these positions (California, Massachusetts, New York, Ohio, and Texas), and there are 18 states that have no programs at all (eight are without an anesthesiology residency program, a requirement for fellowship accreditation), placing a good number of potential applicants at a “geographic disadvantage” regardless of gender.22Accreditation Council for Graduate Medical Education. Available at: https://apps.acgme.org/ads/public/. Accessed March 23, 2021.Google Scholar With these figures, and the increasingly competitive nature of ACTA (according to SFMatch.org, 20% failed to match into a program in 2020), geography will come into play for many who prioritize program location. For some, family and other personal reasons may take precedence over matching into a more prestigious program, and in many instances, fellows will endure commuter marriages/relationships to pursue fellowship training at all, or to attend a program of their choosing. It is not surprising that the acceptance rates for women into ACTA programs was comparable to that of men across the five US regions examined by Drs Patel and Ngai.1Patel S Ngai J. Gender diversity in cardiothoracic anesthesiology fellowship: The influence of geographical region.J Cardiothorac Vasc Anesth. 2021; 35: 1725-1731Abstract Full Text Full Text PDF Scopus (2) Google Scholar A similar trend was noted in a Canadian study of gender patterns among anesthesiology residency applicants, in which the greater number of men entering such programs was attributed to fewer women ranking anesthesiology as their first choice in the Canadian Residency Matching Service.23Baerlocher MO Hussain R Bradley J. Gender patterns amongst Canadian anesthesiologists.Can J Anesth. 2006; 53: 437-441Crossref PubMed Scopus (10) Google Scholar A previous Canadian study also found that from 1995 to 2004, women were no more likely than their male counterparts to be rejected for residency positions in their first ranked specialty, including anesthesiology.24Baerlocher MO Detsky AS. Are applicants to Canadian residency programs rejected because of their sex?.CMAJ. 2005; 173: 1439-1440Crossref PubMed Scopus (9) Google Scholar Had there been a sizeable difference favoring men over women, it would warrant seeking out other reasons for such a discrepancy, including program culture and leadership. Based on a listing of ACTA program directors across the country on the ACGME web site, and determination of gender from name or other identifying factors on department web sites, there are presently 43 men and 30 women serving in this role. So in essence, there is a greater proportion of female ACTA program directors (41%) than fellows (approximately 33%)—contrast this with surgery fellowship programs across 14 specialties, in which women represented only 18% of all fellowship program directors, with (not surprisingly) 65% in charge of breast surgery fellowships.25Filiberto AC Le CB Loftus TJ et al.Gender differences among surgical fellowship program directors.Surgery. 2019; 166: 735-737Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar This is a positive sign for ACTA, and may help to influence the gender disparities among fellows when female anesthesiology residents realize that ACTA is a viable option for women, and with leadership opportunities. As stated by Drs Patel and Ngai, there is a need to proactively make an effort to attract women to anesthesiology and narrow that gender gap.1Patel S Ngai J. Gender diversity in cardiothoracic anesthesiology fellowship: The influence of geographical region.J Cardiothorac Vasc Anesth. 2021; 35: 1725-1731Abstract Full Text Full Text PDF Scopus (2) Google Scholar Medical school is obviously a very important (likely the most important) starting point. Statistics published by the Association of American Medical Colleges showed at a first glance that in 2020 to 2021, there were 3,516 applicants (men, 2,364 [67.2%]; women, 1,152 [32.8%]) from US and Canadian MD-granting medical school graduates, US Doctor of Osteopathic medicine (DO)-granting medical school graduates, and international medical school graduates (IMGs), to ACGME-accredited anesthesiology programs.26Association of American Medical Colleges. Table C-1: Residency applicants to ACGME-accredited programs by specialty and sex, 2020-2021. Available at: https://www.aamc.org/media/6171/download. Accessed February 23, 2021.Google Scholar The average number of applications per individual was 47.0 and 44.3 for men and women, respectively.26Association of American Medical Colleges. Table C-1: Residency applicants to ACGME-accredited programs by specialty and sex, 2020-2021. Available at: https://www.aamc.org/media/6171/download. Accessed February 23, 2021.Google Scholar Therefore, there are approximately twice as many male applicants as female applicants, and men submit slightly more applications than women. Things get more interesting when one takes a closer look at applicants by type of medical school.27Association of American Medical Colleges. Table B3: Number of active residents by type of medical school, GME specialty, and sex, 2019-2020. Available at: https://www.aamc.org/data-reports/students-residents/interactive-data/report-residents/2020/table-b3-number-active-residents-type-medical-school-gme-specialty-and-sex. Accessed February 23, 2021.Google Scholar From 2019 to 2020, the breakdown of anesthesiology residents and ACTA fellows by gender and type of medical school was as follows: There were 6,220 active anesthesiology residents.•For IMGs, there were 841 active anesthesiology residents (men, 544 [8.7%]; women, 297 [4.8%])—male:female (M:F), 1.8•For US and Canadian MD graduates, there were 4,374 active anesthesiology residents (men, 2,879 [46.3%]; women, 1,495 [24.0%])—M:F, 1.9•For US DO graduates, there were 1,005 active anesthesiology residents (men, 743 [11.9%]; women, 262 [4.2%])—M:F, 2.8 There were 177 active ACTA fellows.•For IMGs, there were 19 active ACTA fellows (men, 12 [6.8%]); women, 7 [4.0%])—M:F, 1.7•For US and Canadian MD graduates, there were 139 active ACTA fellows (men, 95 [53.7%]; women, 44 [24.9%])—M:F, 2.2•For US DO graduates, there were 19 active ACTA fellows (men, 12 [6.8%]; women, 7 [4.0%])—M:F, 1.7 Whether type of US medical school is a consideration for program directors in the ranking process has not been investigated. Interestingly, according to the Association of American Medical Colleges, for the 2020- to-2021 cycle, the average number of applications to anesthesiology residency programs for US MD-granting medical schools was 42.8, compared with 56.1 for DO-granting schools.28Association of American Medical Colleges. Table C3: Residency applicants to ACGME-accredited programs by specialty and medical school type, 2020-2021. Available at: https://www.aamc.org/system/files/2020-12/2020_FACTS_Table_C-3.pdf. Accessed February 23, 2021.Google Scholar The difference between osteopathic medical schools and all allopathic medical schools in the proportions of female anesthesiology residents is equally noteworthy, and female students from the former group may be worth targeting. With the recent merger between the American Osteopathic Association and the American Association of Colleges of Osteopathic Medicine with the ACGME, it is conceivable that we could entice more female graduates from osteopathic medical schools into applying to anesthesiology programs, thereby increasing the pool of potential ACTA fellowship applicants.29Accreditation Council for Graduate Medical Education. Executive summary of the agreement among ACGME, AOA, and AACOM. Available at: https://acgme.org/Portals/0/PDFs/Nasca-Community/Executive_Summary_of_the_Agreement_between_ACGME_and_AOA.pdf. Accessed March 3, 2021.Google Scholar Drs Patel and Ngai have addressed an important question regarding the possibility of gender bias and geography in the acceptance rates of ACTA fellowship applicants.1Patel S Ngai J. Gender diversity in cardiothoracic anesthesiology fellowship: The influence of geographical region.J Cardiothorac Vasc Anesth. 2021; 35: 1725-1731Abstract Full Text Full Text PDF Scopus (2) Google Scholar Is it gender bias on the part of programs and their leadership (that may or may not be related to program location), or is it geographic bias on the part of applicants? Is geographic bias based on personal desires or personal obligations? There is no real way to answer these questions without detailed knowledge of rank list information, including how far down the list program directors went to match, and whether applicants matched in their top choices. One must also consider how the recruitment of internal candidates affects the competitiveness of applicants from outside institutions, and what proportion of candidates apply to and are accepted into geographically remote programs. Are men and women influenced by program location to the same degree? Why? Are women more influenced by the gender of the program director, or diversity within the program than men? Are the driving forces behind relocation the same for men as for women?

Background and Purpose— Prior annualized estimates of pediatric ischemic stroke incidence have ranged from 0.54 to 1.2 per 100 000 US children but relied purely on diagnostic code searches to identify cases. We sought to obtain a new estimate using both diagnostic code searches and searches of radiology reports and to assess the relative value of these 2 strategies. Methods— Using the population of 2.3 million children (<20 years old) enrolled in a Northern Californian managed care plan (1993 to 2003), we performed electronic searches of (1) inpatient and outpatient diagnoses for International Classification of Diseases, 9th Revision codes suggestive of stroke and cerebral palsy; and (2) radiology reports for key words suggestive of infarction. Cases were confirmed through chart review. We calculated sensitivities and positive predictive values for the 2 search strategies. Results— We identified 1307 potential cases from the International Classification of Diseases, 9th Revision code search and 510 from the radiology search. A total of 205 ischemic stroke cases were confirmed, yielding an ischemic stroke incidence of 2.4 per 100 000 person-years. The radiology search had a higher sensitivity (83%) than the International Classification of Diseases, 9th Revision code search (39%), although both had low positive predictive values. For perinatal stroke, the sensitivity of the stroke International Classification of Diseases, 9th Revision codes alone was 12% versus 57% for stroke and cerebral palsy codes combined; the radiology search was again the most sensitive (87%). Conclusions— Our incidence estimate doubles that of prior US reports, a difference at least partially explained by our use of radiology searches for case identification. Studies relying purely on International Classification of Diseases, 9th Revision code searches may underestimate childhood ischemic stroke rates, particularly for neonates.

AT NO TIME in modern-day history have institutions of higher learning and professional organizations been under more scrutiny to demonstrate team diversity, a battle cry for social justice, outrage at a flawed social system, care for all ranks of caregivers, and policing of those “dangerous liaisons” with “big pharma” and industry. The stakes have never been higher. Today, breathing the wrong word, and incomplete sound bites will land a person in the unemployment line. Between a global pandemic, civil unrest, political division, and a multigenerational society with divergent opinions, discord has become the norm. The end result, unfortunately, is that important messages get lost in the mire. Most would agree that the system is broken and in need of actionable solutions. So why is it taking so long? The American Heart Association (AHA) and the American College of Cardiology (ACC) have updated their Consensus Conference Report on Professionalism and Ethics after a 16-year hiatus. The document recently was published in both the Journal of the American College of Cardiology and Circulation.1Benjamin IJ Valentine CM Oetgen WJ et al.2020 American Heart Association and American College of Cardiology consensus conference on professionalism and ethics. A consensus conference report.J Am Coll Cardiol. 2021; 77: 3079-3133Crossref PubMed Scopus (3) Google Scholar,2Benjamin IJ Valentine CM Oetgen WJ et al.2020 American Heart Association and American College of Cardiology consensus conference on professionalism and ethics.A consensus conference report. Circulation. 2021; 143: e1035-e1087PubMed Google Scholar It is an exhaustive presentation of updated guidelines assembled by five individual task forces. The AHA/ACC conference took place on October 19-20, 2020, bringing together 61 individuals from more diverse backgrounds this time (41.2% women, 7.9% Black, 4.8% Hispanic) to address professionalism and ethics in cardiovascular medicine. As with the 2004 document, a series of five task forces came together; however, the current iteration looks nothing like its predecessor. The 2004 document was, broadly speaking, mostly about codes of conduct in research and other areas, conflicts of interest (COI), self-referral, and expert testimony.3Popp RJ Smith Jr, SC Adams RJ et al.ACCF/AHA consensus conference report on professionalism and ethics.Circulation. 2004; 110: 2506-2549Crossref PubMed Scopus (9) Google Scholar That same year, however, eight working groups from the 35th Bethesda Conference also came together to develop a series of recommendations to address the growing shortage of cardiologists.4Fye WB. 35th Bethesda Conference. Introduction: The origins and implications of a growing shortage of cardiologists.J Am Coll Cardiol. 2004; 44: 221-232Crossref PubMed Scopus (25) Google Scholar Working Groups 2 and 3 addressed how to encourage women and minorities to choose a career in cardiology.5Warnes CA Fedson SE Foster E et al.Working Group 2: How to encourage more women to choose a career in cardiology.J Am Coll Cardiol. 2004; 44: 238-241Crossref PubMed Scopus (20) Google Scholar,6Francis CK Alpert JS Clark LT et al.Working Group 3: How to encourage more minorities to choose a career in cardiology.J Am Coll Cardiol. 2004; 44: 241-245Crossref PubMed Scopus (10) Google Scholar More on that later. This time around, led by Dr. Ivor J. Benjamin, the topics broached are highly relevant to today's social climate. It is a commendable effort, brought to fruition by countless hours of deliberation by a dedicated and diverse group of individuals. So, how should one define professionalism? What about ethics and COI? Professionalism and ethics are terms that are rooted in beneficence, integrity, and the Golden Rule. The two concepts are inextricably linked since you really cannot have one without the other, most notably in medicine. According to the Institute of Medicine, a COI constitutes “circumstances that create a risk that professional judgments or actions regarding a primary interest will be unduly influenced by a secondary interest.”7Institute of Medicine (US) Committee on Conflict of Interest in Medical ResearchEducation, and Practice. Conflict of interest in medical research, education, and practice. National Academies Press (US), 2009Google Scholar Notwithstanding, we live in a world where most individuals have their own idea of what constitutes professional or ethical conduct, and, at times, it can be anything but what it was intended to be, even among doctors. The AHA/ACC conference has created a long to-do list, and within the confines of an editorial, the authors examine important elements from each of the five task forces’ summative recommendations. Scandals make headlines…and headlines can leave terrible lasting impressions. Unfortunately, negative press that screams out “egregious behavior!” on the part of high-profile individuals or organizations can destroy public trust and overshadow the majority of well-intentioned, honest parties. One such example is the fairly recent Abbott-sponsored EXCEL trial comparing coronary artery bypass graft (CABG) versus percutaneous coronary intervention in patients with left main coronary disease, which was published (and not retracted) in the New England Journal of Medicine.8Stone GW Sabik JF Simonton CA et al.Everolimus-eluting stents or bypass surgery for left main coronary artery disease.N Engl J Med. 2016; 375: 2223-2235Crossref PubMed Scopus (641) Google Scholar,9Stone GW Kappetein AP Sabik JF et al.Five-year outcomes after PCI or CABG for left main coronary disease.N Engl Med. 2019; 381: 1820-1830Crossref PubMed Scopus (273) Google Scholar The composite endpoints were death, stroke, and myocardial infarction (MI). Some of the trial outcomes drew scrutiny, most notably for mortality and MI. The controversy was significant enough that a coauthor (a cardiothoracic surgeon) removed his name from the manuscript, and red flags were raised with the Data and Safety Monitoring Board. To add fuel to the fire, a dataset with a three-year follow-up that included a universal definition of MI (including troponin, as opposed to CK-MB alone) was leaked to the British Broadcasting Corporation, who, in turn, worked with biostatisticians to confirm that there were more MIs in the percutaneous coronary intervention group versus CABG when the seemingly more appropriate definition of MI was applied—a contradiction to the published data. This revelation was monumental, as it reversed the original study findings in favor of CABG and led to more controversy when the 2018 European Society of Cardiology (ESC)/European Association of Cardiothoracic Surgeons (EACTS) guidelines on left main disease were being drafted. The EACTS withdrew its support for the final guidelines in December 2019, and it was not until October 2020 that ESC/EACTS announced new left main recommendations.10Cohen D, Brown E. Is the tide turning on the ‘grubby’ affair of EXCEL and the European guidelines? Available at: https://www.medscape.com/viewarticle/939944. Accessed June 19, 2021.Google Scholar This blight on the scientific community had far-reaching consequences, as it raised issues of integrity, COI, and oversight, leaving investigators, the industry, a world-renowned journal, and the European guideline writing committee with a bruised reputation. Events such as this sow seeds of doubt, and all the backpedaling in the world will never fully restore confidence. Cardiology is not alone in its less-proud moments in the spotlight, as anesthesiologists well know from the Joachim Boldt debacle that has had lasting repercussions.11Wiedermann CJ Joannidis M. The Boldt scandal still in need of action: The example of colloids 10 years after initial suspicion of fraud.Intensive Care Med. 2018; 44: 1735-1737Crossref PubMed Scopus (4) Google Scholar Over the years, increasing numbers of papers have been retracted from peer-reviewed journals.12Stern AM Casadevall A Steen RG et al.Financial costs and personal consequences of research misconduct resulting in retracted publications.Elife. 2014; 3: e02956Crossref PubMed Scopus (84) Google Scholar Most recently, the retraction of two high-profile studies that made the rounds in the daily news cycle on the use of hydroxychloroquine in coronavirus disease 2019 (COVID-19) patients, originally published in the Lancet and the New England Journal of Medicine, were stark examples of how politics can tarnish objectivity.13Funck-Brentano Salem JE Chloroquine or hydroxychloroquine for COVID-19: Why might they be hazardous?.Lancet. 2020; 22 (S0140-6736(20)31174-0Online ahead of print. PMID: 32450109. Retracted)https://doi.org/10.1016/S0140-6736(20)31174-0Crossref Scopus (31) Google Scholar,14Mehra MR Desai SS Henry TD et al.Cardiovascular disease, drug therapy, and mortality in Covid-19.N Engl J Med. 2020; 382 (Epub 2020 May 1. PMID: 32356626. Retracted): e102https://doi.org/10.1056/NEJMoa2007621Crossref PubMed Scopus (598) Google Scholar Many are asking themselves how two of the world's foremost high-impact journals allowed this to slip through the cracks. The answer to this question may never come to light, but this incident does raise questions about the peer review system. Does all of this imply that industry funding is “dirty money” and that other sources of financial support should be sought for large randomized controlled studies? If this were to occur, the reality would be that all meaningful large-scale research would come to a grinding halt. It is a slippery slope, and Dr. Lisa Rosenbaum addressed the good, the bad, and the ugly in an insightful three-part series on the subject of COIs.15Rosenbaum L. Conflicts of interest—Part 1. Reconnecting the dots—Reinterpreting industry-physician relations.N Engl J Med. 2015; 372: 1860-1864Crossref PubMed Scopus (84) Google Scholar, 16Rosenbaum L. Conflicts of interest—Part 2. Understanding bias—The case for careful study.N Engl J Med. 2015; 372: 1959-1963Crossref PubMed Scopus (65) Google Scholar, 17Rosenbaum L. Conflicts of interest—Part 3. Beyond moral outrage—Weighing the trade-offs of COI regulation.N Engl J Med. 2015; 372: 2064-2068Crossref PubMed Scopus (67) Google Scholar Research fraud is not all about dollars and cents, and COIs are not always financial in nature. The many faces of research fraud include: inventing data, not doing the study, altering data, plagiarism, duplicated publications, and journal bias toward publishing positive results.18Harvey L. Research fraud: A long-term problem exacerbated by the clamour for research grants.Quality in Higher Education. 2020; 26: 243-261Crossref Scopus (3) Google Scholar Pressure to “publish or perish” and the need to survive as an employed scientist also have been construed as COIs.19Gandevia S. Publication pressure and scientific misconduct: Why we need more open governance.Spinal Cord. 2018; 56: 821-822Crossref PubMed Scopus (5) Google Scholar Publication metrics, such as journal impact numbers, citation numbers, and numbers of publications, are necessary for promotion and obtaining research grants, and “gaming the metrics” has been identified as an “occupational requirement” for scientists, journal staff, and university administrators.19Gandevia S. Publication pressure and scientific misconduct: Why we need more open governance.Spinal Cord. 2018; 56: 821-822Crossref PubMed Scopus (5) Google Scholar There is variability among medical specialties in financial relationships with industry,20Campbell EG Gruen RL Mountford J et al.A national survey of physician-industry relationships.N Engl J Med. 2007; 356: 1742-1750Crossref PubMed Scopus (382) Google Scholar and cardiology is no stranger to industry. A study on the disclosure of industry payments to physicians, using data from the Open Payments Program, noted that among the medical specialties, cardiovascular medicine, followed by gastroenterology, had the highest proportion of physicians receiving industry payments.21Marshall DC Jackson ME Hattangadi-Gluth JA. Disclosure of industry payments to physicians: An epidemiologic analysis of early data from the open payments program.Mayo Clin Proc. 2016; 9: 84-96Abstract Full Text Full Text PDF Scopus (55) Google Scholar In fact, 78% of physicians specializing in cardiovascular disease received some sort of compensation from industry. Pathologists were at the lower end of the spectrum at 9%, which is not at all surprising. One need only consider the evolution of transcatheter aortic valve replacement, a billion-dollar industry that has led to significant advancements in the nonsurgical treatment of valvular heart disease. Despite some issues raised with the updated Valve Academic Research Consortium 3 guidelines,22Généreux P Piazza N Alu MC et al.Valve Academic Research Consortium 3: Updated endpoint definitions for aortic valve clinical research.Eur Heart J. 2021; 42: 1825-1857Crossref PubMed Scopus (35) Google Scholar the outcome of this industry relationship has been good. The Physician Payments Sunshine Act went into effect August 1, 2013, and requires that drug, medical device, and biologicals manufacturers involved in United States (US) healthcare programs monitor and report on certain payments and valuable gifts made to physicians and teaching hospitals. Reports are submitted annually to the Centers for Medicare and Medicaid Services and are available to the public. Reportable payments include cash, cash-equivalent, or in-kind items, stocks, or other services valued at a minimum of ten dollars or 100 dollars in a calendar year.23Health Policy Brief: The Physician Payments Sunshine ActHealth Affairs.2014https://www.healthaffairs.org/do/10.1377/hpb20141002.272302/full/healthpolicybrief_127.pdfGoogle Scholar Beyond consulting, speaker or lecturer fees, food, and beverages must be reported, along with travel, royalties, and licensing fees. The purpose of the Sunshine Act was to allow for greater transparency; however, the appropriateness of financial relationships is not included in the policy.24Kirschner NM Sulmasy LS Kesselheim AS. Health policy basics: The physician payment sunshine act and the open payments program.Ann Intern Med. 2014; 161: 519-521Crossref PubMed Scopus (55) Google Scholar This is problematic, as disclosures can create a “damned if you do, damned if you don't” dilemma. The argument against stringent reporting policies is that there surely will be unintended consequences. At what point should one draw the line? Keeping track of every insignificant “gift” valued at ten dollars is tantamount to counting grains of sand on the beach. After all, at some point in everyone's career, who has not enjoyed a sandwich or pocketed a cheap logo pen? One study matched the financial disclosures by authors of all 39 ACC and AHA guidelines from 2009 to 2012 to public disclosures made by 15 pharmaceutical companies over the same time period. The authors found an error rate of 71.6% when author disclosures were matched to what companies were reporting. Conversely, authors failed to match company disclosures 54.7% of the time. Although the differences are large, they are nevertheless disturbing. Modest and significant payments were defined by ACC/AHA guidelines as <$10,000 and ≥$10,000, respectively.25Alhamoud HA Dudum R Young HA et al.Author self-disclosure compared with pharmaceutical company reporting of physician payments.Am J Med. 2016; 129: 59-63Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar Whether these discrepancies were due to errors in reporting as opposed to undisclosed relationships is unclear. With the Centers for Medicare and Medicaid Services Open Payments Program disclosure requirements, physicians have the opportunity to dispute incorrect payment information prior to its public release. Unfortunately, doing so is a painful and very time-consuming exercise in government bureaucracy and red tape, which has led some to not bother with setting the record straight. Oberlin noted that in 2014, among 12,579 out of 4.45 million payments that were disputed, there were approximately 9,000 unresolved disputes at the end of the review period.26Oberlin DT Gonzalez CM. Industry ties in medicine: Insight from the open payments program.Mayo Clin Proc. 2016; 6: 685-686Abstract Full Text Full Text PDF Scopus (9) Google Scholar Cardiology has been scrutinized for its overwhelming ties to industry relative to many other specialties. The fact that the industry has shamelessly exploited the public to promote its products, whether they be pharmaceuticals or medical devices, does not help. Consider the number of pharmaceutical ads on the radio and television—is there really a point? Who even pays attention? Oh, and by the way, under current law, pharmaceutical manufacturers can legally deduct advertising expenses from federal taxes. So much for cost containment and the consumer… The inconvenient truth in all of this is that, like it or not, relationships with the industry are a “necessary evil.” Relationships between authors and industry have become essential, particularly with the limited amount of government-sponsored research funding. As it turns out, many of the most experienced clinicians and investigators have some sort of tie to industry, and disqualifying them from writing reviews, guidelines, or recommendations is not only unrealistic but could prevent the dissemination of important, and, yes, unbiased information. Furthermore, not everyone pockets the money, which often goes to the parent institution—not the individual—or to support education and other worthy causes. Unfortunately, it only takes one sensationalized faux pas to lead the public to believe that all scientists have the same morals as crooked politicians. The point of the earlier discussion has been to highlight the complexity of relationships in the medical profession. It is easy for the media to cherry-pick and sensationalize questionable ethics; but, in truth, these generally are inexcusable exceptions to honest practices. The AHA/ACC document has proposed an extensive process for addressing COIs and relationships with industry that includes educators, researchers, reviewers, and expert witnesses. These rely on mandatory disclosures, better scrutiny of relationships, setting strict requirements, and meticulous internal policing. It is a huge undertaking that will, hopefully, appease the critics. Overall, the ACC/AHA has done a pretty decent job over the years, and their desire to add further transparency to their efforts is a worthy endeavor. Out of all of the chaos in recent years, one important element has come to the surface, and that is the importance of diversity in the workforce. The US population never has been more diverse, yet the growth of ethnic and racially diverse populations has outpaced the modest gains observed in the diversification of the physician workforce. Increasingly, institutions are highlighting diversity in their marketing and strategic planning. Most, if not all, institutions have a diversity and inclusion officer, along with a mission statement pledging support of diversity initiatives. Despite these actions, a closer glimpse of staff physicians and trainees across all specialties helps illustrate the very long road ahead. Businesses have long recognized the value that diversity brings to productivity, innovation, and the bottom line. The often-cited 2015 McKinsey report, Why Diversity Matters, demonstrated that companies that employed a workforce in the top quartile for gender and racial and/or ethnic diversity were 30% more likely to have financial returns that exceeded national industry medians—they got it right.27Hunt V, Layton D, Prince S. Diversity matters. McKinsey & Company, London, 2015. Available at: https://www.mckinsey.com/∼/media/mckinsey/business%20functions/organization/our%20insights/why%20diversity%20matters/why%20diversity%20matters.pdf. Accessed July 15, 2021.Google Scholar Granted, medicine has additional obstacles not encountered in the business world. A successful entrepreneur does not have to go through eight or more years of undergraduate and graduate medical education, followed by up to a decade of postgraduate training on a resident and/or fellow salary and saddled with student loan debt. A large part of the ACC/AHA document is devoted to addressing the importance of diversity and racism (topics not included in the previous ACC/AHA conference on ethics and professionalism) and highlights many of the social injustices that exist in the world. Task Force 2 has taken a good hard look at current issues, including inadequate diversification within the ranks, historic injustices, racism, sexism, and biases and inequalities that impact members across the spectrum of the physician workforce, from trainees up into leadership. They identify challenges that still need to be met and offer a series of solutions that will, hopefully, initiate change that is desperately needed. An important recommendation is the establishment of diversity metrics to define best practices that address: team membership, citizenship, mutual respect, allyship, identifying personal privilege, relinquishing power, antiracism, antisexism, and supporting and promoting others. They also highlight the need for accountability when abuses of power occur, including harassment, discrimination, and bias, and advocate for research evaluating best practices. Monitoring successes and failures and proactively initiating appropriate measures where needed are indispensable, as the barriers that need to be surmounted are numerous and far-reaching and will require the creation of a “new normal,” in which the stakes and opportunities are more equitably defined and disseminated. This will not happen overnight. Racial disparities in the physician workforce are an age-old problem. For decades, organizations have made targeted efforts to ameliorate the presence of underrepresented minorities (URMs), from early on, across the educational spectrum, and through into professional life.28Nivet MA. Minorities in academic medicine: Review of the literature.J Vasc Surg. 2010; : 53S-58SAbstract Full Text Full Text PDF PubMed Scopus (65) Google Scholar The end result, unfortunately, has been inconsistent and inadequate—this is more than just a pipeline problem. As with most specialties, cardiology has struggled to increase its representation of women and URMs. According to Brotherton and Etzel's annual publication of graduate medical education statistics in the Journal of the American Medical Association, for cardiovascular medicine in 2007, the representation of Blacks, Hispanics, Asians, and Whites was 4.1%, 6.2%, 32.8%, and 51.1%, respectively.29Brotherton SE Etzel SI. Graduate medical education, 2007-2008.JAMA. 2008; 300: 1228-1243Crossref PubMed Scopus (61) Google Scholar In 2019, the statistics were 5.3%, 6.2%, 37.1%, and 45.1%, respectively.30Brotherton SE Etzel SI. Graduate Medical Education, 2019-2020.JAMA. 2020; 324: 1230-1250Crossref PubMed Scopus (21) Google Scholar Little has changed for Blacks and Hispanics, while other lesser-represented minorities, such as Native Americans and Alaska Natives, are scarcely on the radar. The statistics reported by the Accreditation Council for Graduate Medical Education (ACGME) show similar trends, with one major difference being that the ACGME only started publishing racial and ethnic data for trainees from the 2011 to 2012 cycle onward.31ACGME 2011-2012 Data Resource Book. Available at: https://www.acgme.org/About-Us/Publications-and-Resources/Graduate-Medical-Education-Data-Resource-Book/Accessed July 17, 2021.Google Scholar Along parallel lines, according to the 2018 National Sample Survey of Registered Nurses, the distribution of race and ethnicity by initial nursing program graduation year showed that graduates from 1977 and earlier were comprised of 6.2% Hispanic and 7.0% Black, while those from 2013 onward included 19.5% Hispanic and 10.3% Black.32U.S. Department of Health and Human Services, Health Resources and Services Administration, National Center for Health Workforce AnalysisBrief Summary Results from the 2018 National Sample Survey of Registered Nurses.2019https://bhw.hrsa.gov/sites/default/files/bureau-health-workforce/data-research/nssrn-summary-report.pdfGoogle Scholar The increase in minority groups was driven largely by Hispanics, whose representation is concordant with their representation in the general population in the United States, whereas that of Blacks is approaching their population demographic. This has been a success for nursing. With the discouraging figures in medicine, it is important to point out that cardiology is not alone. According to the 2019-to-2020 ACGME Data Resource Book, there were 144,988 trainees in all ACGME-accredited training programs.33ACGME 2019-2020 Data Resource Book. Available at: https://www.acgme.org/About-Us/Publications-and-Resources/Graduate-Medical-Education-Data-Resource-Book/. Accessed July 17, 2021.Google Scholar The breakdown was as follows: 7,376 Black (5%); 8,891 Hispanic (6%); and 428 Native American and/or Native Alaskan (0.3%). These numbers did not take into consideration attrition and dismissal, which tend to be higher among URMs.34Aryee JNA Bolarinwa SA Jr Montgomery SR et al.Race, gender, and residency: A survey of trainee experience.J Natl Med Assoc. 2021; 113: 199-207Crossref PubMed Scopus (3) Google Scholar, 35Nwokolo V Longoria K Loftis C et al.Examining the gap between medical school matriculation and graduation rates amongst self-identified minorities.J Natl Med Assoc. 2021; 113: 315-323Crossref PubMed Scopus (2) Google Scholar, 36Orom H Semalulu T Underwood III W. The social and learning environments experienced by underrepresented minority medical school students: A narrative review.Acad Med. 2013; 88: 1765-1767Crossref PubMed Scopus (72) Google Scholar A study on the diversity of US medical students over a four-decade period (1978-2019) found that the percentage of female matriculants doubled (there was a 12-fold increase in the enrollment of Asian women), while the percentages of underrepresented racial and ethnic groups remained well below their population demographic.37Morris DB Gruppuso PA McGee HA et al.Diversity of the national medical student body—Four decades of inequities.N Engl J Med. 2021; 384: 1661-1668Crossref PubMed Scopus (20) Google Scholar In 2019, African Americans and Hispanics accounted for 13.4% and 18.5% of the US population, respectively.38United States Census Bureau QuickFacts. Available at: https://www.census.gov/quickfacts/fact/table/US/PST045219. Accessed July 14, 2021.Google Scholar Program diversity has been shown to influence residency program selection, and diverse role models are essential for successful recruitment. Not surprisingly, women and URMs have differed in their assessments of training programs when compared to male and non-URM applicants, and program diversity has been influential in their residency selection.39Ku MC Li YE Prober C Valantine H. Decisions, decisions: How program diversity influences residency program choice.J Am Coll Surg. 2011; 213: 294-305Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar The underlying issues at the core of these disparities are beyond the scope of an editorial, but it is abundantly clear that with only small proportions of Blacks, Hispanics, and lesser represented minorities entering internal medicine programs (the pool from which cardiovascular medicine programs have to recruit ), there remains a significant amount of work to be done at both the undergraduate and graduate medical education levels. Something needs to happen early along the educational pipeline, or the stagnant numbers being reported year after year will remain unchanged centuries from now. Remember, it took women, who represent slightly more than half of the US demographic, many decades to achieve parity in medical school matriculation. Despite this nearly 20-year-old achievement, gender inclusion has not kept pace with gender diversity and is reflected in the experiences of women in predominantly male-dominated specialties. Active recruitment efforts, partnerships with various organizations, and the creation of pipeline programs have been successful at recruiting URMs, as have mentoring programs.40Vick AD Baugh A Lambert J et al.Levers of change: A review of contemporary interventions to enhance diversity in medical schools in the USA.Adv Med Educ Pract. 2018; 9: 53-61Crossref PubMed Scopus (17) Google Scholar, 41Carline JD Patterson DG Davis LA et al.Precollege programs intended to increase the representation of minorities in medicine.Acad Med. 1998; 73: 288-298Crossref PubMed Scopus (24) Google Scholar, 42Morgan HK Haggins A Lypson ML et al.The importance of the premedical experience in diversifying the health care workforce.Acad Med. 2016; 91: 1488-1491Crossref PubMed Scopus (7) Google Scholar, 43Rumala BB Cason Jr, FD Recruitment of underrepresented minority students to medical school: Minority medical student organizations, an untapped resource.J Natl Med Assoc. 2007; 99: 1000-1009PubMed Google Scholar For the latter, the paucity of faculty from URM groups makes it nearly impossible to achieve mentor-mentee concordance, and without the participation of nonminority faculty, mentoring will continue to be a problem. Faculty attrition is a known problem among URM and female faculty. Common themes reported by URM faculty have included isolation, difficulty with cross-cultural relationships, overt and covert bias and discrimination, a lack of mentors and role models, and different performance expectations. These experiences often compromise physician well-being (discussed below) and are associated with depression and a lack of job satisfaction. URMs also often are disproportionately tasked with shouldering the burden for diversity initiative

Many of us late baby boomers and members of the “Gen X” crowd still can remember as medical students spending countless nights in the medical library, poring through the stacks to find articles located amid thousands of files, housed within the hundreds of little drawers that held the Index Medicus, which was key to locating the needed references. This was followed by carrying the thick, heavy, bound journal volumes over to the copy machine to start copying one page at a time, holding each volume down firmly to avoid inadvertently excluding any part of the text. The time spent on such travails was tedious and took away from precious time needed to study, not to mention the cost of copy machine copy cards! When transesophageal echocardiography began to emerge as part of the cardiothoracic anesthesiologist’s diagnostic and monitoring armamentarium in the 1990s, VHS tape was the norm, and the Hewlett Packard HP1000 echocardiography machine, with its small CRT screen and mostly manual adjustments, was a technological phenomenon. Reviewing studies meant fast-forwarding and rewinding the tape to locate the desired frames. The first National Board of Echocardiography examination, administered in 1998, included Scantron fill-ins and a video component that included various examples of pathology displayed on an old glaring television screen, with a VHS video player that allowed for the opportunity to view each video segment only twice. Technology has come a long way since its seemingly humble beginnings, and for those of us who have experienced this evolution, it seems hard to imagine how we ever got by. For today’s generation of millennial learners (b. 1980–2000), however, sophisticated technology is the norm, and just as the acquisition of knowledge has evolved, so too have learning styles.1Boysen II, PG Daste L Northern T Multigenerational challenges and the future of graduate medical education.Ochsner J. 2016; 16: 101-107PubMed Google Scholar It doesn’t take the intelligence of a physician to see the appeal of condensing 250 pounds of medical textbooks into a fully searchable 8-ounce smartphone. In the current issue of the Journal of Cardiothoracic and Vascular Anesthesia, Linganna et al. leverage the smartphone’s power to enhance bedside training in echocardiography.2Linganna R. Patel S. Al Ghofaily L et al.Pilot study suggests smartphone application improves resident transesophageal echocardiography knowledge: A randomized controlled trial.J Cardiothorac Vasc Anesth. 2020; 16 ([Epub ahead of print])https://doi.org/10.1053/j.jcva.2019Crossref Google Scholar The study examined the use of “EchoEducator,” a smartphone-based application, with the primary goal of improving anesthesiology resident knowledge of transesophageal echocardiography. They enlisted 18 randomly assigned residents on their cardiac anesthesia rotation. Residents in the control arm of the study received standard intraoperative teaching, whereas the study group had access to the smartphone application, or “app.” Both preintervention and postintervention assessments were administered to each group. The authors found that the study group had a greater increase in scores (19.19%; p = 0.02) versus controls. Does this mean that today’s residents learn more efficiently through a smartphone or computer? Is it possible that residents, being aware of their participation in a study, changed their normal study habits? The “Hawthorne” effect has been described in numerous studies and relates to an individual’s participation in a research study and the possible effect on normal behavior as a result of the awareness of being observed.3McCambridge J Witton J Elbourne DR Systematic review of the Hawthorne effect: New concepts are needed to study research participation effects.J Clin Epidemiol. 2014; 67: 267-277Abstract Full Text Full Text PDF PubMed Scopus (982) Google Scholar Or was this simply because of the fact that the use of mobile applications is a stimulus for millennial learners to engage more?4Shaw CM Tan SA Integration of mobile technology in educational materials improves participation: Creation of a novel smartphone application for resident education.J Surg Educ. 2015; 72: 670-673Crossref PubMed Scopus (27) Google Scholar Each of these hypotheses is plausible. This brings us to the next question, “Besides the delivery method of printed paper versus tablet screen, is there a difference in brain learning?” An interesting study, “Your Brain on Google: Patterns of Cerebral Activation During Internet Searching,” included 24 participants ages 55 to 76, half of whom had never used the internet.5Small GW Moody TD Siddarth P et al.Your brain on Google: Patterns of cerebral activation during internet searching.Am J Geriatr Psychiatry. 2009; 17: 116-126Abstract Full Text Full Text PDF PubMed Scopus (140) Google Scholar The authors used functional magnetic resonance imaging to investigate the difference between performing a novel internet search task versus a control task of reading text on a computer screen. The group that performed only computer text reading demonstrated increased brain activity in regions controlling language, reading, memory, and visual abilities. The group that performed internet searches of the same information activated all these same regions in addition to neural networks controlling decision making and complex reasoning. That’s right, more areas of the brain were engaged by using a search engine—including complex reasoning. Even though this alone may not translate into improved learning, the authors concluded that internet searching appears to be much more stimulating than simple reading. We can visualize the classic literature buffs cringing in the background. So, who doesn’t love a good smartphone? With their increasing sleekness and functionality, smartphones have transitioned from niche technology to ubiquity. Today’s smartphones have overwhelming mass appeal and borderline addictive properties as attested by the countless individuals who have mastered walking, eyes fixated on their mobile devices, without so much as lifting their heads to guide their steps—a potentially hazardous mode of distraction as evidenced by the woman who infamously fell into a fountain at a shopping mall. Nevertheless, these devices serve as more than just a repository for phone numbers; they are an information superhighway and a guide to staying connected with the world. The potential for mobile learning (M-Learning) and the amount of information available at our fingertips truly are astonishing. M-learning is the concept of all learning being done on a mobile device, including smartphones, tablets, and eReaders. There is no question that today’s learner has more platforms available than ever before. In fact, a social learning “ecosystem” has been described, whereby graduate medical education will be faced with a generation that prefers social learning over traditional methods.1Boysen II, PG Daste L Northern T Multigenerational challenges and the future of graduate medical education.Ochsner J. 2016; 16: 101-107PubMed Google Scholar When once upon a time there was only the public library’s Dewey Decimal System, the smartphone has given us the ability to “Google” while relaxing on a commuter train. Most physicians own smartphones. At many institutions, smartphones are issued to staff physicians and residents/fellows, allowing for broader communication within the system, paging capabilities, access to medical records and imaging studies, and access to the internet and its many available educational tools. Smartphones hold textbooks, medical calculators, and drug formularies, and customized apps have been designed to fit specific educational needs. There has been an explosion of new electronic-based learning tools, from simulation to handheld tools holding gigabytes of current information. Today’s medical students prefer online resources as their “go-to” for information.6Gavali MY Khismatrao DS Gavali YV et al.Smartphone, the new learning aid amongst medical students.J Clin Diagn Res. 2017; 11: JC05-8PubMed Google Scholar Mobile device “M-learning” (ie, apps, and plug-ins via smartphone or tablet); simulation; and social media (wikis, blogs, YouTube, group networking) are the dominant forms of learning through technology.7Bullock A Webb K Technology in postgraduate medical education: A dynamic influence on learning?.Postgrad Med J. 2015; 91: 646-650Crossref PubMed Scopus (28) Google Scholar Social media, apps, podcasts, and collaborative learning (eg, WhatsApp) have enhanced learning for today’s students and perhaps even have increased the speed of learning and retention because of the visual content. Such uninterrupted access to these materials and portability beyond the classroom and conference hall truly has revolutionized medical education.8Short SS Lin AC Merianos DJ et al.Smartphones, trainees, and mobile education: Implications for graduate medical education.J Grad Med Educ. 2014; 6: 199-202Crossref PubMed Google Scholar A prospective e-mail survey of Accreditation Council for Graduate Medical Education training programs found that more than 85% of respondents used a smartphone and that apps were commonly used in clinical practice.9Franko OI Tirrell TF Smartphone app use among medical providers in ACGME training programs.J Med Syst. 2012; 36: 3135-3139Crossref PubMed Scopus (335) Google Scholar App use tended to decrease with increasing training level (residents 68.1%; fellows 55.4%; <5 y practice 52.1%; 5-15 y practice 49.1%; >15 y practice 39.2%), and 88.4% of residents reported using their smartphones for medical purposes compared with 78.2% of senior attending staff. The field of cardiology is not new to the application of modern technology, whether we are talking about mobile health and telemedicine or artificial intelligence.10Seetharam K Kagiyama N Sengupta PP Application of mobile health, telemedicine and artificial intelligence to echocardiography.Echo Res Pract. 2019; 6: R41-52Crossref PubMed Scopus (18) Google Scholar Just as handheld imaging devices in cardiovascular medicine have added to physical examination findings and enhanced diagnostic capabilities with speed and accuracy, so, too, have they become routine educational tools in medicine and countless other professions. For example, cardiovascular medicine has embraced smartphone technology in the clinical arena, with many uses including real-time, smartphone-enabled electrocardiography, handheld echocardiography (a simple phased-array probe can be connected directly to a smartphone), and digital stethoscopes that can record and share heart sounds via an accompanying app.10Seetharam K Kagiyama N Sengupta PP Application of mobile health, telemedicine and artificial intelligence to echocardiography.Echo Res Pract. 2019; 6: R41-52Crossref PubMed Scopus (18) Google Scholar11Nguyen HH Silva JNA Use of smartphone technology in cardiology.Trends Cardiovasc Med. 2016; 26: 376-386Crossref PubMed Scopus (35) Google Scholar Other specialties have embraced the use of mobile technology in resident education, including apps that have been demonstrated to engage residents4Shaw CM Tan SA Integration of mobile technology in educational materials improves participation: Creation of a novel smartphone application for resident education.J Surg Educ. 2015; 72: 670-673Crossref PubMed Scopus (27) Google Scholar and help improve in-training examination scores.12Hsueh WD Bent JP Moskowitz HS An app to enhance resident education in otolaryngology.Laryngoscope. 2018; 128: 1340-1345Crossref PubMed Scopus (11) Google Scholar A randomized controlled trial on the use of a smartphone application by anesthesiology residents who were tasked with dealing with 2 simulated crises found that use of this cognitive aid resulted in significantly better technical performance.13Lelaidier R Balanca B Boet S et al.Use of a hand-held digital cognitive aid in simulated crises: The MAX randomized controlled trial.Br J Anaesth. 2017; 119: 1015-1021Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar A systematic review on the effect of social media on resident education, recruitment, and professionalism found a mixed effect, largely because of a limited number of studies, and most importantly, because of a lack of good quality studies.14Sterling M Leung P Wright D et al.The use of social media in graduate medical education: A systematic review.Acad Med. 2017; 92: 1043-1056Crossref PubMed Scopus (98) Google Scholar These mixed results failed to offer any guidance on the optimal incorporation of social media platforms into graduate medical education. Frequent learning modalities used to engage and enhance learning and teach technical skills in that review included Twitter, podcasts, blogs, YouTube, and wikis. There are literally tens of thousands of downloadable medical apps available to health care professionals and the general lay public. This is an unregulated industry, with inadequate rating of quality and accuracy. On September 27, 2019, the US Food and Drug Administration (FDA) issued its “Policy for Device Software Functions and Mobile Medical Applications Guidance for Industry and Food and Drug Administration Staff.”15US Food and Drug Administration. Policy for device software functions and mobile medical applications: Guidance for industry and Food and Drug Administration staff. Available at: https://www.fda.gov/media/80958/download. Accessed February 11, 2020.Google Scholar This document clarifies a subset of software functions to which FDA authority is applied. Software functions that do not meet the definition of “medical device” (ie, section 201[h] of the Federal Food, Drug, and Cosmetic Act) are exempt from regulation as devices. Stated otherwise, FDA oversight applies when software functions perform medical device functions. For example, if a software function is to diagnose, treat, or cure a disease, it is considered a medical device and thereby subject to oversight. This implies that a large number of medical apps, including teaching aids, are not regulated. Concerns with app-based learning modules include a lack of high-quality and popular apps,9Franko OI Tirrell TF Smartphone app use among medical providers in ACGME training programs.J Med Syst. 2012; 36: 3135-3139Crossref PubMed Scopus (335) Google Scholar peer review oversight and validation, conflict of interest, and a lack of medical experts involved in their development.7Bullock A Webb K Technology in postgraduate medical education: A dynamic influence on learning?.Postgrad Med J. 2015; 91: 646-650Crossref PubMed Scopus (28) Google Scholar,16Windish D EBM apps that help you search for answers to your clinical questions.Evid Based Med. 2014; 19: 85-87Crossref PubMed Scopus (6) Google Scholar The rapid development of smartphone apps has outpaced what little quality control and oversight exist. One study searched iTunes and PlayStore for cardiothoracic surgery–themed apps.17Edlin JCE Deshpande RP Caveats of smartphone applications for the cardiothoracic trainee.J Thorac Cardiovasc Surg. 2013; 146: 1321-1326Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar Sixty-three percent of 379 apps had a user rating, 15% were associated with a publisher or medical society, and only 6% were linked to a named medical professional. A systematic review of available apps in neurosurgery examined their clinical use by Canadian residents and conducted a quality audit of the 3 most popular apps using the Healthcare Smartphone App Evaluation Tool.18Bergeron D Iorio-Morin C Bigder M et al.Mobile applications in neurosurgery: A systematic review, quality audit, and survey of Canadian neurosurgery residents.World Neurosurg. 2019; 127: e1026-38Abstract Full Text PDF PubMed Scopus (7) Google Scholar The audit found that all 3 apps received excellent Healthcare Smartphone App Evaluation Tool scores and information were estimated to be accurate. Conversely, a review of 60 published articles from 4 general categories (patient care/monitoring, health apps for laypersons, communication/education/research, physician or student reference apps) on the current and potential use of smartphones among internal medicine physicians and students, found a paucity of high-quality studies to better understand optimal use of this technology.19Ozdalga E Ozdalga A Ahuja N The smartphone in medicine: A review of current and potential use among physicians and students.J Med Internet Res. 2012; 14: e128Crossref PubMed Scopus (430) Google Scholar Smartphones have earned a prominent place in medical education despite a lack of robust evidence supporting their value.20Buijink AWG Visser BJ Marshall L Medical apps for smartphones: Lack of evidence undermines quality and safety.Evid Based Med. 2012; 18: 90-92Crossref PubMed Scopus (174) Google Scholar,21Visser BJ Buijink AWG Need to peer-review medical applications for smart phones.J Telemed Telecare. 2012; 18: 124Crossref PubMed Scopus (21) Google Scholar They are clearly sources of immediate answers to questions; however, they do not replace the need for a strong knowledge base, whose achievement is far from instantaneous, and it is doubtful they will eliminate the need for classroom didactics and conferences.22Wissman K Hogan L We need to be smarter than our smartphones (letter).Am J Pharm Educ. 2019; 83: 7350PubMed Google Scholar Proper use of these devices, keeping in mind that most apps are not properly vetted, will continue to afford a practical means of obtaining information efficiently and with the added benefit of active engagement of the user, particularly when group participation is involved. The current study by Linganna et al. pulls the sheets back on reality—that M-learning through smartphones is here to stay.2Linganna R. Patel S. Al Ghofaily L et al.Pilot study suggests smartphone application improves resident transesophageal echocardiography knowledge: A randomized controlled trial.J Cardiothorac Vasc Anesth. 2020; 16 ([Epub ahead of print])https://doi.org/10.1053/j.jcva.2019Crossref Google Scholar Their bold embrace of technology may very well be the best way to reach a new audience. Physician educators would be wise to embrace this new era through participation in mobile application development and quality assessment. Medical learning apps should be viewed as a force multiplier whereby teachers and students alike are no longer chained to the classroom. Whereas the classroom of today remains housed within the confines of brick and mortar, the classroom of the future ultimately may have no walls. Pilot Study Suggests Smartphone Application Knowledge Improves Resident Transesophageal Echocardiography Knowledge: A Randomized Controlled TrialJournal of Cardiothoracic and Vascular AnesthesiaVol. 34Issue 8PreviewThe objective of this study was to determine whether an asynchronous smartphone-based application with image-based questions would improve anesthesiology resident transesophageal echocardiography (TEE) knowledge compared with standard intraoperative teaching alone. Full-Text PDF

LIFE’S parallels are endless—and the presence of women on stage is no exception. Consider this: in Shakespeare’s London, men and adolescent boys played the role of female characters for literally decades. Paradoxically, they might even have found occasion to play the part of a woman pretending to be a man. Now there’s talent! It was not until 1642, at the start of the English Civil War when the Puritans gained control, that stage plays were banned, and theaters and playhouses were shuttered.1Manktelow H. Discovering literature: Shakespeare and renaissance. Available at: https://www.bl.uk/shakespeare/articles/women-playing-shakespeare-the-first-female-desdemona. Accessed February 21, 2020.Google Scholar With the restoration of the English monarchy (or should we call it “manarchy”?) in 1660, King Charles II, after having spent years in exile at the court of Louis XIV of France, had developed an appreciation for the theater arts. In addition to reinstituting the theater in England, Charles II allowed women to act professionally for the first time, having developed great enthusiasm for their talents on the French stage.2Thorpe V. Secret lives of women who broke taboo to act in Shakespeare. Available at: https://www.theguardian.com/culture/2016/apr/10/secret-lives-of-women-shakespeare. Accessed February 21, 2020.Google Scholar Most notably, Anne Marshall is credited with likely having been the first woman to play Desdemona in Othello in 1660, 44 years after Shakespeare’s death.1Manktelow H. Discovering literature: Shakespeare and renaissance. Available at: https://www.bl.uk/shakespeare/articles/women-playing-shakespeare-the-first-female-desdemona. Accessed February 21, 2020.Google Scholar Now, here we are in the 21st century’s modern scientific world where presumably we have made great strides and yet men continue to grace the podium in far greater numbers than women, paralleling history on multiple levels. In this issue of the Journal of Cardiothoracic and Vascular Anesthesia, Shilcutt et al. examined the representation of women as speakers at the Society of Cardiovascular Anesthesiologists (SCA) annual meetings’ scientific sessions over a 4-year period (2015-2018).3Shilcutt L. Lorenzen K.A. Whose voices are heard? Speaker gender representation at the Society of Cardiovascular Anesthesiologists Annual Meeting.J Cardiothorac Vasc Anesth. 2020; 34: 1805-1809Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar These sessions included the main program, problem-based learning discussions (PBLDs), workshops, and moderation of fellow sessions. SCA membership by gender was estimated using the recent 2019 SCA Diversity Survey, which yielded a female representation of 29.1%. The authors found that for all combined sessions, there was an overall significant difference in the expected versus observed proportion of women speakers, who accounted for 22% to 25% of all speakers. However, further breakdown demonstrated that these differences remained significant for the main sessions but not the PBLDs, workshops, and fellow sessions. So, is this good news that women are being equitably represented at PBLDs, workshops, and fellow sessions? When you begin to think about it, not really. The prestige lies with the main program, including keynote addresses, plenary sessions, etc. It then should come as no surprise that women are underrepresented in the more coveted and esteemed portions of the program. As will be discussed further in the following, this problem is not unique to the SCA and has been described repeatedly in various medical and surgical specialties, technology, business, and other unrelated professions. Each year new words enter the lexicon of the English language. Words such as “selfie,” “Googling,” “woke,” and “boomer” have become commonplace in today’s modern dialogue. So, too, has the term “manel,” which appeared in the Cambridge Dictionary as a newly coined word on October 30, 2017, and is cited as follows: manel noun [C]–/ˈmæn.əl/–a panel made up only of men.4cambridge Dictionary. About words: New words – 30 October 2017. Available at: https://dictionaryblog.cambridge.org/2017/10/30/new-words-30-october-2017/. Accessed February 25, 2020.Google Scholar The point of panels, as we all know, is to create a platform that brings a variety of divergent experiences, opinions, and perspectives to a topic of interest. The issue of “manels” has been raised in numerous contexts, yet the surplus of all-male panels at scientific conferences still exists despite efforts to curb the problem. The upward climb to professional success is steeper for women. Unfortunately, hard work and excellent credentials cannot always overcome some of the existing biases within the system, including unbalanced opportunities for advancement and promotion and less access to resources.5Nonemaker L Women physicians in academic medicine: New insights from cohort studies.N Engl J Med. 2000; 342: 399-405Crossref PubMed Scopus (371) Google Scholar Promotion is dependent on recognized achievements that open increasing numbers of doors. A key event in one’s academic career is the invitation to serve as a speaker at a professional society meeting. These speaking engagements offer numerous advantages, including public recognition of one’s achievements, networking opportunities, serving as an aid to academic advancement, potential for future collaboration, and external recognition as an expert in the field. Networking is a major means of expanding professional opportunities and can lead to future speaking engagements. Having women at the podium also has a positive effect on younger female peers who are seeking role models. To date, metrics used for academic promotion have been unfavorable toward women.5Nonemaker L Women physicians in academic medicine: New insights from cohort studies.N Engl J Med. 2000; 342: 399-405Crossref PubMed Scopus (371) Google Scholar These include first and senior author publications,6Jagsi R Guancial EA Worobey CC et al.The “gender gap” in authorship of academic medical literature—a 35-year perspective.N Engl J Med. 2006; 355: 281-287Crossref PubMed Scopus (531) Google Scholar grants and awards,7Pagel PS Hudetz JA Scholarly productivity and National Institutes of Health funding for Foundation for Anesthesia Education and Research grant recipients: Insights from a bibliometric analysis.Anesthesiology. 2015; 123: 683-691Crossref PubMed Scopus (36) Google Scholar membership on editorial boards,8Amrein K Langmann A Fahrleitner-Pammer A et al.Women underrepresented on editorial boards of 60 major medical journals.Gender Med. 2011; 8: 378-387Abstract Full Text Full Text PDF PubMed Scopus (152) Google Scholar department leadership positions,9Bissing MA Lange EMS Davila WF et al.Status of women in academic anesthesiology: A 10-year update.Anesth Analg. 2019; 128: 137-143Crossref PubMed Scopus (38) Google Scholar speaking engagements at regional and national conferences, professional society leadership positions,10Toledo P Duce L Adams J et al.Diversity in the American Society of Anesthesiologists leadership.Anesth Analg. 2017; 124: 1611-1616Crossref PubMed Scopus (38) Google Scholar and serving as an oral board examiner.11Fahy BG Culley DJ Sun H et al.Gender distribution of the American Board of Anesthesiology diplomates, examiners, and directors (1985-2015).Anesth Analg. 2018; 127: 564-568Crossref PubMed Scopus (15) Google Scholar It should come as no surprise then that women also are scarce at the podium, particularly as headliners and keynote speakers. Numerous reports have found that diversity improves decision making, quality, and financial performance and leads to improved outcomes by bringing new perspectives, experience, and ideas to the table.12Gomez LE Bernet P Diversity improves performance and outcomes.J Nat Med Assoc. 2019; 111: 383-392Crossref PubMed Scopus (81) Google Scholar This holds true for medicine and other professions, including business and technology.13Jayne MEA Dipboye RL Leveraging diversity to improve business performance: Research findings and recommendations for organizations.Human Resource Manage. 2004; 43: 409-424Crossref Scopus (273) Google Scholar,14National Center for Women and Information Technology. What is the impact of gender diversity on technology business performance: Research summary. Available at: https://www.ncwit.org/sites/default/files/resources/impactgenderdiversitytechbusinessperformance_print.pdf. Accessed February 26, 2020.Google Scholar Diversity also has had a positive effect at scientific meetings. At the American Society for Radiation Oncology Annual Meeting, for instance, panels with >50% female gender composition were associated with individual measures of audience satisfaction.15Rahimy E Jagsi R Park HS et al.Quality at the American Society for Radiation Oncology Annual Meeting: Gender balance among invited speakers and associations with panel success.Int J Rad Onc Biol Phys. 2019; 104: 987-996Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar Grand rounds are another speaking venue where gender representation has been unbalanced relative to audience demographic. Boiko et al. surveyed grand rounds speaker series among 9 specialties, including anesthesiology, in 2014.16Boiko JR Anderson AJM Gordon RA Representation of women among academic grand rounds speakers.JAMA Intern Med. 2017; 177: 722-724Crossref PubMed Scopus (68) Google Scholar They compared female speaker percentages with workforce demographics and found that, with the exception of obstetrics/gynecology and surgery, the percentages of nontrainee female speakers were significantly lower than the female composition of faculty workforces. For anesthesiology, there were 26.2% female nontrainee speakers relative to 34% faculty members who were women. There also was more intramural versus extramural participation by women. Another troubling observation that has been described frequently is that when women present at conferences, they are addressed less frequently by their professional title than are their male counterparts when introduced by a male colleague. The converse has not been the case.17Files JA Mayer AP Ko MG et al.Speaker introductions at internal medicine grand rounds: Forms of address reveal gender bias.J Womens Health (Larchmt). 2017; 26: 413-419Crossref PubMed Scopus (119) Google Scholar,18Davids JS Lyu HG Hoang CM et al.Female representation and implicit gender bias at the 2017 American Society of Colon and Rectal Surgeons’ Annual Scientific and Tripartite Meeting.Dis Colon Rectum. 2019; 62: 357-362Crossref PubMed Scopus (36) Google Scholar This unfortunate practice, even if unintentional, undermines the status of women within the society. A study that examined the gender makeup of speakers relative to the expected composition based on membership profiles at the American Society of Anesthesiologists (ASA) annual meetings from 2011 to 2016, found that gender breakdown was fairly consistent over the period under study, ranging from 22.3% to 27.7% female participation.19Moeschler SM Gali B Goyal S et al.Speaker gender representation at the American Society of Anesthesiology Annual Meeting.Anesth Analg. 2019; 129: 301-305Crossref PubMed Scopus (24) Google Scholar Although the overall number of women speakers was similar to what would be expected relative to ASA membership (25.0% v 25.9%; p = 0.153), the proportion of single speakers (as opposed to panelists) was more unfavorable toward women (20.2% v 25.9%; p < 0.001). In fact, among single speakers, women made up only 7% of plenary lectures (3/41). Furthermore, single- gender panels (2-5 participants) showed a significant predominance of all-male constituents. A retrospective analysis of the representation of women speakers at the Canadian Anesthesiologists’ Society annual meeting from 2007 to 2019 found that 28.5% of speaker slots included women, closely approximating their representation in Canadian clinical anesthesiology, with increasing trends over the study period.20Lorello GR Parmar A Flexman AM Representation of women amongst speakers at the Canadian Anesthesiologists’ Society annual meeting: A retrospective analysis from 2007 to 2019.Can J Anesth. 2020; 67: 430-436Crossref PubMed Scopus (7) Google Scholar A breakdown of anesthesiology subspecialties, however, found that women had the greatest representation in obstetric anesthesia, as opposed to cardiothoracic anesthesia, transplantation anesthesia, and critical care symposia. This is in alignment with trends in authorship in anesthesiology journals.21Miller J Chuba E Deiner S et al.Trends in authorship in anesthesiology journals.Anesth Analg. 2019; 129: 306-310Crossref PubMed Scopus (42) Google Scholar Furthermore, among the 311 symposia (defined as consisting of 2 or more speakers), 46% consisted of all-male speakers. Unlike the study by Shilcutt et al., this analysis excluded PBLDs and workshops.3Shilcutt L. Lorenzen K.A. Whose voices are heard? Speaker gender representation at the Society of Cardiovascular Anesthesiologists Annual Meeting.J Cardiothorac Vasc Anesth. 2020; 34: 1805-1809Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar A retrospective audit of annual scientific meetings (2012-2014) that included 6 Australasian specialty colleges, including anesthesiology, found that male speakers not only outnumbered women at every conference, but that they also were allocated greater speaking time in 7 of 17 of the annual scientific meetings.22Modra LJ Austin DE Young SA et al.Female representation at Australasian specialty conferences.Med J Aust. 2016; 204: 385-386Crossref PubMed Scopus (14) Google Scholar Clearly, we have a problem. A cross-sectional analysis of speaker gender at 181 US and Canadian medical conferences found that although the proportion of female speakers increased from 24.6% in 2007 to 34.1% in 2017, women still remained underrepresented as a whole.23Ruzycki SM Fletcher S Earp M et al.Trends in the proportion of female speakers at medical conferences un the United States and in Canada, 2007 to 2017.JAMA Netw Open. 2019; 2: e192103Crossref PubMed Scopus (67) Google Scholar A review of women’s participation as speakers at 5 critical care conferences from 2010 to 2016 found that men outnumbered women at all conferences over the 7-year period, with female physicians representing 5% to 26% of speakers.24Mehta S Rose L Cook D et al.The speaker gender gap at critical care conferences.Crit Care Med. 2018; 46: 991-996Crossref PubMed Scopus (56) Google Scholar Similar trends also have been noted in general surgery,25Wilcox AR Trooboff SW Lai CS et al.Trends in gender representation at the American College of Surgeons Clinical Congress and the Academic Surgical Congress: A mixed picture of progress.J Am Coll Surg. 2019; 229: 397-403Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar neurosurgery,26Silva N Cerasiello S Semonche A et al.Gender representation at neurological surgery conferences.World Neurosurg. 2019; 129: 453-459Abstract Full Text PDF PubMed Scopus (19) Google Scholar plastic surgery,27Santosa KB Larson EL Vannucci B et al.Gender imbalance at academic plastic surgery meetings.Plast Reconstr Surg. 2019; 143: 1798-1806Crossref PubMed Scopus (16) Google Scholar and dermatologic surgery,28Flaten HK, Goodman L, Wong E, et al. Analysis of speaking opportunities by gender at national dermatologic surgery conferences [e-pub ahead of print]. Dermatol Surg. doi: 10.1097/DSS.0000000000002275, AccessedGoogle Scholar among others. Subcategories of speaking topics considered “female friendly” tend to be where women predominate. These include obstetrics and gynecology, breast, pediatrics, and sessions geared specifically at women. For instance, greater female representation at the American Society for Radiation Oncology Annual Meeting was noted in the “female subspecialties” of breast, gynecology, and pediatrics,15Rahimy E Jagsi R Park HS et al.Quality at the American Society for Radiation Oncology Annual Meeting: Gender balance among invited speakers and associations with panel success.Int J Rad Onc Biol Phys. 2019; 104: 987-996Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar whereas at the American College of Surgeons Clinical Congress and Academic Surgical Congress, women-only panels predominated on the topics of breast surgery and women in surgery.25Wilcox AR Trooboff SW Lai CS et al.Trends in gender representation at the American College of Surgeons Clinical Congress and the Academic Surgical Congress: A mixed picture of progress.J Am Coll Surg. 2019; 229: 397-403Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar A number of reasons (or excuses) have been postulated for the lack of participation of women as invited speakers.29Nittrouer CL Hebl MR Ashburn-Nardo L et al.Gender disparities in colloquium speakers at top universities.Proc Natl Acad Sci USA. 2018; 115: 104-108Crossref PubMed Scopus (85) Google Scholar, 30Wennerås C Wold A Nepotism and sexism in peer review.Nature. 1997; 387: 341-343Crossref PubMed Scopus (797) Google Scholar, 31Guzman-Reyes S Pivalizza EG Gender distribution in professional anesthesiology activities.Anesth Analg. 2019; 129: e179-80Crossref PubMed Scopus (3) Google Scholar, 32Penfold R Knight K Al-Hadithy N et al.Women speakers in healthcare: Speaking up for balanced gender representation.Future Healthc J. 2019; 6: 167-171Crossref PubMed Google Scholar These include the following:•Women are offered invitations to speak but decline more often than men because of personal or professional obligations (this notion has been debunked)•Women are less career-oriented than men•Women are less assertive in their search for opportunities•Women are less productive than men, so their efforts have less merit•Personal choices•Greater part-time status•Need for patience with gaining appropriate experience necessary to become a speaker•Event organizers wanted more women to speak but could not find anyone suitable or invitees were unavailable The important question is whether the gender gap at the podium results from bias or is simply the result of gender differences within academic medicine itself. Trying to rationalize the facts will continue to prove fruitless unless real solutions with measurable outcomes are implemented. The bête noire that nobody speaks of—nepotism—unfortunately and unwittingly can result in a lack of change in the regular lineup of speakers at scientific conferences. Many qualified individuals have felt shut out of public speaking opportunities because they were not part of a well-connected network of peers. The concept of a “friendship bonus”30Wennerås C Wold A Nepotism and sexism in peer review.Nature. 1997; 387: 341-343Crossref PubMed Scopus (797) Google Scholar has been argued both ways, and despite ongoing efforts at the organizational level to promote qualified women, this element should not be dismissed. This notion has been suggested as a possible explanation for the over-representation of “all-male” panels and the lack of an open nomination process for ASA plenary speakers (as opposed to selection by committee alone).33Chandraprose RK, Hopf HW. Gender representation in speakers at ASA: It’s not a patience, part-time, or pipeline issue [e-pub ahead of print]. Anesth Analg doi: 10.1213/ANE.0000000000004645, AccessedGoogle Scholar Along parallel lines, a study by Wennerås et al. strongly suggested that peer reviewers for the Swedish Medical Research Council, a main funding agency for biomedical research in Sweden, were unable to judge scientific merit independent of gender.30Wennerås C Wold A Nepotism and sexism in peer review.Nature. 1997; 387: 341-343Crossref PubMed Scopus (797) Google Scholar Using multiple regression analyses of the relationship between defined parameters of scientific productivity and competence scores, the authors found that peer reviewers either overestimated the achievements of men or underestimated those of women. They found unequivocally that men and women with equal scientific productivity did not receive the same competence rating by the Medical Research Council reviewers. These authors also coined the term “friendship bonus” previously mentioned, supporting the observation that applicants who were affiliated with a committee member received higher competence scores than applicants of the same gender and productivity without such connections. The proportion of women invited to speak at conferences has been correlated to the number of women among event organizers and committees and a reduction in the number of infamous “manels” in a number of reports.24Mehta S Rose L Cook D et al.The speaker gender gap at critical care conferences.Crit Care Med. 2018; 46: 991-996Crossref PubMed Scopus (56) Google Scholar,34Débarre F Rode NO Ugelvig LV Gender equity at scientific events.Evol Lett. 2018; 2: 148-158Crossref PubMed Scopus (29) Google Scholar, 35Dumitra TC, Trepanier M, Lee L, et al. Gender distribution of speakers on panels at the Society of American Gastrointestinal and Endoscopic Surgeons annual meeting [e-pub ahead of print]. Surg Endosc. doi: 10.1007/s00464-019-07182-2, AccessedGoogle Scholar, 36Al-Lami H, Bingener J. Faculty diversity at academic surgical meetings—Opportunity for action [e-pub ahead of print]? J Gastrointest Surg. doi: 10.1007/s11605-019-04394-8, AccessedGoogle Scholar, 37Gerull KM, Wahba BM, Goldin LM, et al. Representation of women in speaking roles at surgical conferences [e-pub ahead of print]. Am J Surg. doi: 10.1016/j.amjsurg.2019.09.004, AccessedGoogle Scholar, 38Ghatan CE Altamirano J Fassiotto M et al.Achieving speaker gender equity at the SIR Annual Scientific Meeting: The effect of female session coordinators.J Vasc Interv Radiol. 2019; 30: 1870-1875Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar An often-cited study examined the relationship of women on a convening team with the proportion of female speakers at scientific symposia. In an analysis of 460 symposia involving 1,845 speakers at 2 large meetings sponsored by the American Society of Microbiology, the presence of at least 1 female member on the convening team was directly correlated to a greater proportion of invited female speakers and the decreased likelihood of an all-male symposium roster.39Casadevall A Handelsman J The presence of female conveners correlates with a higher proportion of female speakers at scientific symposia.Bio. 2014; 5: e00846-13Google Scholar These findings suggested that women make conscious efforts to be more inclusive of other women, although direct causation can only be inferred from the correlation. For each year under study, Shilcutt et al reported a female representation on the SCA scientific program committee of 29.6% (n = 8), 39.0% (n = 9), 30.7% (n = 8), and 29.6% (n = 8), respectively.3Shilcutt L. Lorenzen K.A. Whose voices are heard? Speaker gender representation at the Society of Cardiovascular Anesthesiologists Annual Meeting.J Cardiothorac Vasc Anesth. 2020; 34: 1805-1809Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar This breakdown mirrors SCA membership based on survey results with the exception of 2016 and is much higher than the proportion of women participating in the main sessions in each of the years (16.0%, 17.4%, 16.9%, and 16.9%, respectively). Fortunately, several organizations have taken a proactive stance to create a more balanced and inclusive speaker profile at conferences. These include the following:•On June 12, 2019, Dr. Francis Collins, Director of the National Institutes of Health, announced that he would no longer participate in scientific and medical forums that do not include women, stating: “Starting now, when I consider speaking invitations, I will expect a level playing field, where scientists of all backgrounds are evaluated fairly for speaking opportunities. If that attention to inclusiveness is not evident in the agenda, I will decline to take part. I challenge other scientific leaders across the biomedical enterprise to do the same.”4040. Collins FS. Time to end the manel tradition. Available at: https://www.nih.gov/about-nih/who-we-are/nih-director/statements/time-end-manel-tradition. Accessed February 25, 2020.Google Scholar•The Lancet has made a diversity pledge, posted on its web site (https://www.thelancet.com/diversity) and is committed to ending all-male panels; ending participation of its editors on public conference panels that do not include women; and for hosted events, setting a goal for the inclusion of at least 50% female speakers.41The Editors of the Lancet Group The Lancet Group’s commitments to gender equity and diversity.Lancet. 2019; 394: 452-453Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar•The National Academy of Sciences, National Academy of Engineering, and Institute of Medicine have published guidelines with the goal of maximizing opportunities for and the potential of women in science and engineering.42National Academy of Sciences, National Academy of Engineering, and Institute of Medicine Beyond bias and barriers: Fulfilling the potential of women in academic science and engineering. National Academies Press, Washington, DC2007Google Scholar•Springer’s Nature formalized its efforts to make conferences more inclusive by introducing a code of conduct and diversity policy applicable not only to Nature conferences, but to all Springer Nature scholarly events. This commitment includes putting an end to all-male organizing committees for all new Nature conferences; inviting equal percentages of men and women speakers, including keynote presentations; eliminating “manels”; and monitoring and reporting progress annually.43Skipper M, Inchcoombe S. Announcing a new diversity commitment for Springer Nature’s research publishing. Available at: https://www.springernature.com/gp/advancing-discovery/blog/blogposts/new-diversity-commitment/17485502. Accessed February 25, 2020.Google Scholar Determining the optimal proportion of female speakers without having to resort to quotas or tokenism will be a challenge, but not an insurmountable one. Most of us can agree that gender equity should be based on merit. Still, there is no consensus on whether the representation of women should mirror the proportion of practicing physicians, that of professional society members, or even that of trainees.35Dumitra TC, Trepanier M, Lee L, et al. Gender distribution of speakers on panels at the Society of American Gastrointestinal and Endoscopic Surgeons annual meeting [e-pub ahead of print]. Surg Endosc. doi: 10.1007/s00464-019-07182-2, AccessedGoogle Scholar The latter might actually help to accelerate a narrowing of the gender gap. Nevertheless, we will need to do a better job gathering critical data. The makeup of our professional societies will need to be better tracked for starters. Perhaps including stated gender as a voluntary part of membership renewal and creation of a database would be a way of improving accuracy over incomplete survey data. It also would be important to know more about speaking invitations, how often they are declined, and the number of individual orators versus those giving multiple talks (which often are counted individually, bloating the actual number of women). Finally, just as King Charles II opened the doors for women to perform on the stage in England, so, too, must male colleagues, who outnumber women in key decision-making positions, be agents of change by taking an active role in encouraging diversity.32Penfold R Knight K Al-Hadithy N et al.Women speakers in healthcare: Speaking up for balanced gender representation.Future Healthc J. 2019; 6: 167-171Crossref PubMed Google Scholar As previously stated, many organizations have taken pledges, and perhaps it is time we all did the same. There are no conflicts of interest to report. Whose Voices Are Heard? Speaker Gender Representation at the Society of Cardiovascular Anesthesiologists Annual MeetingJournal of Cardiothoracic and Vascular AnesthesiaVol. 34Issue 7PreviewGender disparities in academic medicine continue to be prevalent despite significant advances in the number of women entering medicine over the last decades. The purpose of the present study was to investigate gender representation of speakers at Society of Cardiovascular Anesthesiologists (SCA) Annual Scientific Sessions meetings from 2015 to 2018. Full-Text PDF

The fellowship in adult cardiothoracic anesthesiology has matured as an accredited program. This special article addresses current challenges in this educational milieu. The first challenge relates to serving as a program director in the contemporary era. The second challenge deals with the accreditation process, including the site visit. The third challenge discusses the integration of structural heart disease and interventional echocardiography into daily practice. The fourth challenge deals with the issues that face fellowship education in the near future. Taken together, these perspectives provide a review of the contemporary challenges facing fellowship education in adult cardiothoracic anesthesiology.

ABSTRACT Ivor Lewis described his approach to resection of carcinoma of the esophagus in 1946, and his operative technique remains a mainstay of surgical treatment nearly three quarters of a century later. The integration of regional anesthesia into the perioperative management of patients undergoing open esophagectomy has been recommended based on salutary effects on outcomes, most notably postoperative pulmonary complications. With the advent of newer minimally invasive approaches, the benefits of regional blockade have been ill-defined, leading us to question the value of our long held standard.

The Program Evaluation Committee has an essential role in the quality improvement process of the adult cardiothoracic anesthesiology fellowship. The annual program evaluation presents all stakeholders with an opportunity to evolve with the changing needs and opportunities of the fellowship milieu. The active engagement of the program in this process is a high-quality approach to successful planning, preparation and conduct of the self-study and site visit that are important extensions of the annual program evaluation and the program evaluation committee. (C) 2019 Elsevier Inc. All rights reserved.

THE FIRST issue of the Journal of Cardiothoracic and Vascular Anesthesia appeared in 1987. That same year Aretha Franklin became the first woman inducted into the Rock and Roll Hall of Fame, Margaret Thatcher was elected as Prime Minister of the United Kingdom for the third time, and first-year female residents in Obstetrics and Gynecology outnumbered men for the first time. Fast forward to 2019, and even though women now account for about half of all medical school graduates, significant disparities still exist across most aspects of their professional career development and advancement. For literally decades, studies have confirmed a disproportion in the gender composition of journal editorial boards across a large number of specialties. Despite an upward trend in the number of women holding a seat at the table, the rate of increase has been slow, and the proportions generally are not reflective of the representation of women in their respective specialties. Few studies have examined the editorial board composition of anesthesiology journals (Table 1),1Morton M.J. Sonnad S.S. Women on professional society and journal editorial boards.J Nat Med Assoc. 2007; 99: 764-771PubMed Google Scholar, 2Amrein K. Langmann A. Fahrleitner-Pammer A. et al.Women underrepresented on editorial boards of 60 major medical journals.Gender Med. 2011; 8: 378-387Abstract Full Text Full Text PDF PubMed Scopus (198) Google Scholar, 3Lorello G.R. Parmar A. Flexman A.M. Representation of women on the editorial board of the Canadian Journal of Anesthesia: A retrospective analysis from 1954 to 2018.Can J Anesth. 2019; 66: 989-990Crossref PubMed Scopus (22) Google Scholar, 4Miller J. Chuba E. Deiner S. et al.Trends in authorship in anesthesiology journals.Anesth Analg. 2019; 129: 306-310Crossref PubMed Scopus (59) Google Scholar, 5Pagel P.S. Freed J.K. Lien C.A. Gender composition and trends of Journal of Cardiothoracic and Vascular Anesthesia editorial board membership: A 33-year analysis, 1987-2019.J Cardiothoracic Vasc Anesth. 2019; 33: 3229-3234Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar and to date, none has specifically addressed the subspecialty of cardiothoracic anesthesia.Table 1Representation of Women on Anesthesiology Journal Editorial BoardsCitationJournal(s) ExaminedTimeline% Female Editorial Board MembersMorton et al.1Morton M.J. Sonnad S.S. Women on professional society and journal editorial boards.J Nat Med Assoc. 2007; 99: 764-771PubMed Google ScholarAnesthesiologyAnesthesia & AnalgesiaMarch 200410.9%4.8%Amrein et al.2Amrein K. Langmann A. Fahrleitner-Pammer A. et al.Women underrepresented on editorial boards of 60 major medical journals.Gender Med. 2011; 8: 378-387Abstract Full Text Full Text PDF PubMed Scopus (198) Google ScholarAnesthesiologyPain British Journal of AnaesthesiaEuropean Journal of PainAnesthesia & Analgesia201011.6%23.9%9.4%24.2%6.9%(overall 15%)Lorello et al.3Lorello G.R. Parmar A. Flexman A.M. Representation of women on the editorial board of the Canadian Journal of Anesthesia: A retrospective analysis from 1954 to 2018.Can J Anesth. 2019; 66: 989-990Crossref PubMed Scopus (22) Google ScholarCanadian Journal of Anesthesia1954–20181996*Year that first woman joined the editorial board.–2018201420172019†Data from 2019 described anecdotally in study but not part of analysis.6%11%0%19%25%†Data from 2019 described anecdotally in study but not part of analysis.Miller et al.4Miller J. Chuba E. Deiner S. et al.Trends in authorship in anesthesiology journals.Anesth Analg. 2019; 129: 306-310Crossref PubMed Scopus (59) Google ScholarAnesthesiologyAnesthesia & Analgesia(combined)20022007‡Unable to extract actual percentages from published graphic representation of trends for 2007 and 2012; however, the trend was upward after 2007.2012‡Unable to extract actual percentages from published graphic representation of trends for 2007 and 2012; however, the trend was upward after 2007.20179.5%––15.5%Pagel et al.5Pagel P.S. Freed J.K. Lien C.A. Gender composition and trends of Journal of Cardiothoracic and Vascular Anesthesia editorial board membership: A 33-year analysis, 1987-2019.J Cardiothoracic Vasc Anesth. 2019; 33: 3229-3234Abstract Full Text Full Text PDF PubMed Scopus (20) Google ScholarJournal of Cardiothoracic and Vascular Anesthesia1987–19951996–20032004–20112012–20192.9%7.2%9.8%16.2% Year that first woman joined the editorial board.† Data from 2019 described anecdotally in study but not part of analysis.‡ Unable to extract actual percentages from published graphic representation of trends for 2007 and 2012; however, the trend was upward after 2007. Open table in a new tab In this issue of the Journal of Cardiothoracic and Vascular Anesthesia, Pagel et al. followed-up on their recent publication on gender trends in authorship and publishing in the journal6Pagel P.S. Freed J.K. Lien C.A. Gender differences in authorship in the Journal of Cardiothoracic and Vascular Anesthesia: A 28-year analysis of publications originating from the United States, 1990-2017.J Cardiothorac Vasc Anesth. 2019; 33: 593-599Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar with a study on the journal's editorial board composition over a 33-year timespan, from the journal's inception in 1987 to the present.5Pagel P.S. Freed J.K. Lien C.A. Gender composition and trends of Journal of Cardiothoracic and Vascular Anesthesia editorial board membership: A 33-year analysis, 1987-2019.J Cardiothoracic Vasc Anesth. 2019; 33: 3229-3234Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar The study period was divided into quartiles (1987–1995, 1996–2003, 2004–2011, and 2012–2019), and among the 2,787 members who could be positively identified by gender, 11.1% were women (310/2,787). Further breakdown yielded that women represented the following: 13.0% associate and section editors (54/414) and 10.9% general editors (256/2,353). An upward trend in female board membership was noted at each quartile, with an overall increase from 2.5% to 15.8%, mostly because of an increase in general editors. As has been reported across numerous medical and surgical specialty/subspecialty journals, women also are underrepresented on the journal's editorial board relative to practicing female academic cardiothoracic anesthesiologists in the United States. Along similar lines, Pagel et al. noted gender gaps between first and senior authorship and board composition when data from their original study were correlated.6Pagel P.S. Freed J.K. Lien C.A. Gender differences in authorship in the Journal of Cardiothoracic and Vascular Anesthesia: A 28-year analysis of publications originating from the United States, 1990-2017.J Cardiothorac Vasc Anesth. 2019; 33: 593-599Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar How women in the other anesthesiology subspecialties fare is unknown at this point. The few studies that included editorial board membership data for both Anesthesiology and Anesthesia & Analgesia showed a wide gender gap between the 2 journals, with Anesthesiology being more favorable toward women. Both journals include members from various subspecialties, and published studies have examined only overall numbers without any breakdown. If one considers that adult cardiothoracic anesthesia is a predominantly male-dominated subspecialty, the number of women serving on the Journal of Cardiothoracic and Vascular Anesthesia board may be somewhat better compared with that of Anesthesiology and Anesthesia & Analgesia, although this has yet to be determined. It would be interesting to examine the breakdown of women on the latter journal's board relative to the subspecialties. For instance, are women better represented in the obstetric and pediatric anesthesia sections? Women in medicine have faced unique challenges since the achievement of equal representation in medical school. One would have hoped that the natural progression would be for them to find their place professionally across the spectrum of medical specialties, including research opportunities, grants and awards, academic advancement, speaking opportunities at society conferences, compensation, editorial board membership, and leadership opportunities. Based on what we already know, parity is nowhere in sight, so don't hold your breath, and despite things “getting better,” the pace has been sluggish and trends have not kept up with the changing demographic. The interrelationship among academic position, scholarly output, and leadership roles still contributes to the likelihood of being on an editorial board. The invitation or nomination to serve on a journal's editorial board can be based on a number of factors, including academic rank, number of peer reviewed publications, and research expertise.7Kennedy B.L. Lin Y. Dickstein L.J. Women on the editorial boards of major journals.Acad Med. 2001; 76: 849-851Crossref PubMed Scopus (58) Google Scholar Serving on an editorial board is an honor, but it also is a springboard to further career advancement for many. Benefits of being on a board include the development of relationships with other peers, formation of new professional networks, advancement of scholarship, and recognition as an expert in one's specialty. Gender disparities in the composition of journal editorial boards were brought to our attention in the 2008 study by Jagsi et al., which examined the gender composition of editors-in-chief and editorial board members from 16 high-impact medical journals from 1970–2005.8Jagsi R. Tarbell N.J. Henault L.E. et al.The representation of women on the editorial boards of major medical journals: A 35-year perspective.Arch Intern Med. 2008; 168: 544-548Crossref PubMed Scopus (93) Google Scholar The authors found that gender distribution increased from 1.4% in 1970 to 16.0% in 2005, with an overall 11.5% representation during the study period. Even though the trend was positive, is this really good enough? How should we define the appropriate proportion of women occupying editorial board seats? A common theme across studies is that there has been a small uptick in female editorial board membership, but that it is not representative of the overall proportion of faculty members in the various specialties, including radiology,9Piper C.L. Scheel J.R. Lee C.I. et al.Representation of women on radiology journal editorial boards: A 40-year analysis.Acad Radiol. 2018; 25: 1640-1645Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar anesthesiology,1Morton M.J. Sonnad S.S. Women on professional society and journal editorial boards.J Nat Med Assoc. 2007; 99: 764-771PubMed Google Scholar emergency medicine,10Miro O. Burillo-Putze G. Plunkett P.K. et al.Female representation on emergency medicine editorial teams.Emerg Med. 2010; 17: 84-88Google Scholar and dermatology.11Gollins C.E. Shipman A.R. Murrell D.F. A study of the number of female editors-in-chief of dermatology journals.Int J Womens Dermatol. 2017; 3: 185-188Crossref PubMed Scopus (19) Google Scholar Even in the traditionally female-dominated areas of pediatrics and obstetrics and gynecology, the proportion of female board members has been significantly less than the proportion of women in these specialties.1Morton M.J. Sonnad S.S. Women on professional society and journal editorial boards.J Nat Med Assoc. 2007; 99: 764-771PubMed Google Scholar, 7Kennedy B.L. Lin Y. Dickstein L.J. Women on the editorial boards of major journals.Acad Med. 2001; 76: 849-851Crossref PubMed Scopus (58) Google Scholar The presence of a female editor-in-chief, a rarity in itself, was not correlated with higher percentages of female editorial board members in a few studies that examined this relationship.2Amrein K. Langmann A. Fahrleitner-Pammer A. et al.Women underrepresented on editorial boards of 60 major medical journals.Gender Med. 2011; 8: 378-387Abstract Full Text Full Text PDF PubMed Scopus (198) Google Scholar, 8Jagsi R. Tarbell N.J. Henault L.E. et al.The representation of women on the editorial boards of major medical journals: A 35-year perspective.Arch Intern Med. 2008; 168: 544-548Crossref PubMed Scopus (93) Google Scholar The question of requisite qualifications and selection criteria for women to be appointed to society journal editorial boards was posed in a brief communication penned by a female cardiovascular surgeon from Japan, a country where the gender disparities are exceedingly high.12Tomizawa Y. What are the qualifications and selection criteria for women to be appointed to society journal editorial boards?.Gen Thorac Cardiovasc Surg. 2014; 62: 131-132Google Scholar For instance, in 2012 the first woman was appointed to the editorial board of an English journal by the Japanese Association for Thoracic Surgery, making it the first female appointment as editor of an English journal among all surgical member societies of the Japanese Association of Medical Science. This author recommended that editor appointments should be based on unbiased and objective selection criteria. Disparities in advancement across multiple categories have left women lagging behind their male peers for a number of reasons, including the following: opportunity; implicit and explicit biases; discrimination; disproportionate child parenting and household responsibilities; delays in early career advancement; lack of support at departmental, institutional, and professional society levels; career path choices within academic practice; lack of mentorship and female role models; rigid organizational structures; and the pipeline phenomenon.13Jolly S. Griffith K.A. DeCastro R. et al.Gender differences in time spent on parenting and domestic responsibilities by high-achieving young physician-researchers.Ann Intern Med. 2014; 160: 344-353Crossref PubMed Google Scholar, 14Dickersin K. Fredman L. Flegal K.M. et al.Is there a sex bias in choosing editors? Epidemiology journals as an example.JAMA. 1998; 280: 260-264Crossref PubMed Scopus (64) Google Scholar, 15Robinson S. Lecky F. Mason S. Editorial boards: Where are all the women?.Eur J Emerg Med. 2010; 17: 61-62Google Scholar The disparities in editorial board membership are not unique to US publications, as illustrated in a geographic glimpse of the largest international radiologic societies that included 6 journals (January 2018 issues) with an impact factor ≥1 in which 19.13% of editorial board members were women.16Abdellatif W. Shao M. Jalal S. et al.Novel geographic thematic study of the largest radiology societies globally: How is gender structure biased within editorial boards?.Am J Roentgenol. 2019; 213: 2-7Crossref PubMed Scopus (33) Google Scholar Female board members in the higher academic echelons were less represented than their male counterparts and less likely to hold departmental leadership titles. Subcategorization of all editorial board positions showed that men predominated in all listed associate editor positions (100% for cardiac imaging) with the exception of (not surprisingly) breast imaging associate editor (63.64% female). This same trend also has been observed in the STEM (science, technology, engineering, and math) disciplines; social sciences; and business.14Dickersin K. Fredman L. Flegal K.M. et al.Is there a sex bias in choosing editors? Epidemiology journals as an example.JAMA. 1998; 280: 260-264Crossref PubMed Scopus (64) Google Scholar, 17Cho A.H. Johnson S.A. Schuman C.E. et al.Women are underrepresented on the editorial boards of journals in environmental biology and natural resource management.Peer J. 2017; 2: e542Google Scholar All the studies to date have had similar limitations, including: being limited to specific journals in one or more specialties; many studies examined fixed time points (eg, one specific month's issue for the year) or incremental versus continuous time points; potential selection bias of journals sampled; same editors being counted during each period in multiyear studies (instead of providing an absolute total number of individual women); different numbers of board members among journals; and the lack of information concerning women who might have declined offers to join a board. So how do we tackle this problem, and why is this important? Women should be in a position to reach their full potential. There is no lack of talent among women in medicine; however, outdated institutional hierarchies have held many women back. Editorial board members play an important role in the dissemination of scientific information to the medical community. Women can bring gender-specific life experiences and perspectives to the board and address underrepresented aspects of women's health and gender-specific data analysis. They can generate new ideas and affect decisions made when the board convenes. Just as international representation on editorial boards is important, so, too, is gender diversity.18Carnes M. Morrissey C. Geller S.E. Women's health and women's leadership in academic medicine: Hitting the same glass ceiling?.J Womens Health (Larchmt). 2008; 17: 1453-1462Crossref PubMed Scopus (197) Google Scholar, 19Heidari S. Babor T.F. De Castro P. et al.Sex and gender equity in research: Rationale for the SAGER guidelines and recommended use.Res Integr Peer Rev. 2016; 1: 2Crossref PubMed Google Scholar After all, women are a significant part of a journal's readership. Some approaches and initiatives have been suggested to help tip the balance, including early career mentoring; ad hocreviewing opportunities to develop the requisite skills; support from higher institutional levels (eg, department chair, institutional faculty development programs); integration of family considerations in order to level the playing field; evaluating board turnover rates versus length of tenure of more senior members; review of qualification thresholds for board membership; and monitoring the process for editorial board appointments and nominations. We also need to take note of the advancement of women at regular intervals (not every 10 years!), set goals, and follow-up on outcomes. So has this just been all talk and no action? Not exactly. A number of organizations have been addressing this problem. In its 2007 executive summary entitled “Beyond Bias and Barriers: Fulfilling the Potential of Women in Academic Science and Engineering,” the National Academy of Sciences, National Academy of Engineering, and Institute of Medicine proposed a series of guidelines intended to ensure adequate representation of women in many areas, including editorial boards.20National Academy of Sciences, National Academy of Engineering, and Institute of MedicineBeyond bias and barriers: Fulfilling the potential of women in academic science and engineering. National Academies Press, Washington, DC2007Google Scholar The European Association of Science Editors, which was established in 2012, has a Gender Policy Committee, for which one of the stated missions is to “encourage gender balance among reviewers, on editorial boards, and in editorial offices.”21European Association of Science Editors. Gender policy committee. Available at: http://old.ease.org.uk/about-us/organisation-and-administration/gender-policy-committee. Accessed August 7, 2019.Google Scholar The journal The Lancet recognizes the underrepresentation of women as authors, reviewers, and in editorial positions across journals. In response to these inequities, The Lancet launched its #LancetWomen project in December 2017.22Clark J. Horton R. What is The Lancet doing about gender and diversity?.Lancet. 2019; 393: 508-510Abstract Full Text Full Text PDF PubMed Scopus (63) Google Scholar, 23Boylan J. Dacre J. Gordon H. Addressing women's under-representation in medical leadership.Lancet. 2019; 393: e14Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar, 24Editors of the Lancet GroupThe Lancet Group's commitments to gender equity and diversity.Lancet. 2019; 394: 452-453Google Scholar Lancet specialty journals (18 in all) made a commitment to reach gender parity on their editorial advisory boards by 2020. Eight of these journals already have met this goal. A diversity pledge has been posted on the journal's website (https://www.thelancet.com/diversity). The Lancet Group also has made a commitment to end all-male panels; stated that their editors would not serve on panels that did not include women at public conferences; and that for hosted events, the goal is for participation of at least 50% female speakers. Founded in 1823, The Lancet is one of the oldest and most well-recognized medical journals in the world, with an impact factor of 59. It is comforting to see that a journal as prestigious as The Lancet is leading the way, and hopefully other journals will follow suit. The American Society of Anesthesiologists in recent years has given rise to the first female anesthesia society, Women in Anesthesiology, Inc., whose mission is to support women anesthesiologists both professionally and personally by focusing on “techniques and tools that will help women physicians advance in their careers while addressing the specific challenges women physicians may face” (www.womeninanesthesiology.org). The Society of Cardiovascular Anesthesiologists similarly has introduced a Women in Cardiothoracic Anesthesia Special Interest Group. Along parallel lines, the corporate world has been gaining ground and even has set benchmarks with a timeline. In the corporate arena, women have faced challenges similar to those of physicians, for which a longstanding gender gap has been noted on boards of directors. A “2020 Women on Boards Gender Diversity Index (GDI)” was developed in 2011, representing a yearly review of the gender diversity in boards of directors of companies on the Russell 3000 Index and Fortune 1000 list. The stated goal is for all corporations to exceed a 20% threshold of women on boards by 2020.252020 Women on Boards. Gender diversity index: 2018 progress of women corporate directors by company size, state, and industry sector. Available at: https://www.2020wob.com/sites/default/files/2020WOB_GDI_Report_2018_FINAL.pdf. Accessed August 7, 2019.Google Scholar In this report, gender diversity is not construed as a social issue but rather as a strategic imperative. Pagel et al. have offered further insight into the problem of gender imbalance on journal editorial boards and for the first time have brought cardiothoracic anesthesia into the discussion. It is likely that over past decades, large numbers of talented female cardiothoracic anesthesiologists were overlooked when opportunities for professional advancement should have been at their disposal. Others simply grew weary of trying to prove themselves amid historically biased institutional hierarchies and succumbed to the norms of the day. The good news is that this topic is gaining widespread attention, with respected organizations across various disciplines setting realistic goals with timelines. Women are not looking for special concessions—they simply want access to the same opportunities that have been routinely afforded to their male counterparts. Now that we are abundantly aware of the problem, it is time for action. The authors do not have any conflicts of interest to declare. Gender Composition and Trends of Journal of Cardiothoracic and Vascular Anesthesia Editorial Board Membership: A 33-Year Analysis, 1987-2019Journal of Cardiothoracic and Vascular AnesthesiaVol. 33Issue 12PreviewGender disparities in editorial board composition exist in the vast majority of specialties including anesthesiology. If a similar lack of gender parity exists in cardiothoracic anesthesiology is unknown. The authors examined the gender composition and trends of the Journal of Cardiothoracic and Vascular Anesthesia (JCVA) editorial board from the initial year of its publication (1987) to 2019. The authors tested the hypothesis that the proportion of women serving on the JCVA editorial board has steadily increased over the journal's history, but women are underrepresented compared with the percentage of those currently practicing academic cardiothoracic anesthesia in the United States (US). Full-Text PDF

Gender disparities in writing are not unique to medicine. Over the centuries, many renowned female authors of all genres devised clever ways to get their works published. The reason for this is obvious – to overcome publisher bias and to reach a broader audience that included men who might otherwise consider female-penned works inferior. The list of such accomplished women is long – the Brontë sisters, Charlotte, Emily and Anne adopted the male pseudonyms Currer, Ellis, and Acton Bell; Mary Ann Evans published under the famous name of George Eliot; Nelle Harper Lee went by the more ambiguous Harper Lee. Some might still mistakenly believe that this strategy was a historical phenomenon born out of necessity and is no longer relevant in modern day society–think again. On the advice of her publisher, Joanne K. Rowling, one of today's most successful authors, used her initials instead of her first name to conceal her gender from the Harry Potter audience, a fact that might otherwise have discouraged boys and men from reading her works. And so it goes… So why all this talk of women and literature over the centuries? The answer is simple—whether we are discussing great literary works, science and technology, or medicine women have faced hurdles to get published. The reasons for this are complex and beyond the scope of an editorial, however, the statistics can neither be dismissed nor simply attributed to personal choice. Jagsi et al brought attention to this phenomenon in their 2006 study on the gender gap in authorship in 6 prominent medical journals over 35 years.1Jagsi R. Guancial E.A. Worobey C.C. et al.The “gender gap” in authorship of academic medical literature—A 35-year perspective.N Engl J Med. 2006; 355: 281-287Crossref PubMed Scopus (607) Google Scholar Since this landmark publication, the subject of gender-related bias in the medical literature has gained significant traction, with multiple reports addressing gender disparity in number of publications, grants and scholarships, time to academic promotion, hospital leadership positions, access to mentors, and other career resources.2Blumenthal D.M. Olenski A.R. Yeh R.W. et al.Sex differences in faculty rank among academic cardiologists in the United States.Circulation. 2017; 135: 506-517Crossref PubMed Scopus (86) Google Scholar, 3Thibault G.E. Women in academic medicine.Acad Med. 2016; 91: 1045-1046Crossref PubMed Scopus (42) Google Scholar, 4Rochon P.A. Davidoff F. Levinson W. Women in academic medicine leadership: Has anything changed in 25 years?.Acad Med. 2016; 91: 1053-1056Crossref PubMed Scopus (97) Google Scholar Although there are no clear and distinct barriers that impede a woman's professional growth in academia, she may not have equal access to important assets, including networking and mentorship. A key requirement for academic advancement is lead involvement in research and publications in high-impact peer-reviewed journals. In this issue of the Journal, Pagel et al have examined gender-based differences in authorship of manuscripts from the U.S. that were published between 1990-2017 in the Journal of Cardiothoracic and Vascular Anesthesia.5Pagel PS, Freed JK, Lien CA. Gender differences in authorship in the Journal of Cardiothoracic and Vascular Anesthesia: A 28-year analysis of publications originating from the United States, 1990-2017. J Cardiothorac Vasc Anesth (current issue).Google Scholar They included in their analysis peer-reviewed original research, review articles, case reports, and editorials. In order to examine the gender distribution of authorship over time, the authors selected four 3-year periods: 1990-1992, 1999-2001, 2008-2010, and 2015-2017. Their goal was to analyze changes in the percentage of women who published as first-, last- and corresponding authors over a 28-year time-span, and the results were not surprising. For the entire study period, women were significantly less likely to hold the position of first author (22.4%), last author (10.3%) and corresponding author (14.6%), than men. The paucity of women serving as senior authors is striking but has a logical explanation. Last authors are typically specialists holding the highest academic rank, are established researchers and experienced mentors. It is also a well-known fact that women physicians are better represented at mid-level career than in the higher academic ranks.2Blumenthal D.M. Olenski A.R. Yeh R.W. et al.Sex differences in faculty rank among academic cardiologists in the United States.Circulation. 2017; 135: 506-517Crossref PubMed Scopus (86) Google Scholar In the present study, the percentage of publications by women as first authors increased substantially over time (from 9.6% in 1990-92 to 26.2% in 2015-17), while there was a significantly smaller change when women served as project mentors and senior authors (7.0% in 1990-92 to 11.8% in 2015-17). This echoes the reality found in other medical specialties such as surgery, cardiology, and emergency medicine (to name only a few), and suggests that women are severely under-represented among physicians within the higher academic ranks.6Mueller C. Wright R. Girod S. The publication gender gap in US academic surgery.BMC Surg. 2017; 17: 16Crossref PubMed Scopus (84) Google Scholar, 7Asghar M. Usman M.S. Aibani R. et al.Sex differences in authorship of academic cardiology literature over the last 2 decades.J Am Coll Cardiol. 2018; 72: 681-685Crossref PubMed Scopus (31) Google Scholar, 8Zhuge Y. Kaufman J. Simeone D. et al.Is there still a glass ceiling for women in academic surgery?.Ann Surg. 2011; 253: 637-643Crossref PubMed Scopus (323) Google Scholar When examining the temporal changes in female authorship over the course of 28 years, Pagel et al made an interesting observation concerning all publication types. There was a notable increase in the number of publications by female authors from 1990-92 (12.1%) to 2015-17 (22.9%). This is a positive finding that correlates with the conclusions from other studies examining female authorship in medical journals with a high impact factor (Table 1). A closer look at this temporal dynamic, however, reveals that after the initial increase in women's publications from 1990-92 to 2008-10, there is a plateau among almost all publication types. As a result, the number of female authored publications in the Journal has remained fairly flat for the last decade. Jagsi et al also noted a similar loss of momentum over time, with the sharpest gains occurring in the female-dominated specialties of pediatrics and obstetrics & gynecology despite a plateau effect (Table 1).1Jagsi R. Guancial E.A. Worobey C.C. et al.The “gender gap” in authorship of academic medical literature—A 35-year perspective.N Engl J Med. 2006; 355: 281-287Crossref PubMed Scopus (607) Google Scholar The specific reasons behind this lack of any further increase in female authorship over the last 10 years are largely unknown, however, Filardo et al have demonstrated a similar trend in publications by female authors in 6 high-impact journals after the year 2010.9Filardo G. da Graca B.D. Sass D.M. et al.Trends and comparison of female first authorship in high impact medical journals: Observational study (1994-2014).BMJ. 2016; 352: i847Crossref PubMed Scopus (286) Google Scholar Their group even showed a trend toward decreased publications by female authors after 2010 in the British Journal of Medicine, The Lancet and the New England Journal of Medicine, findings similar to those in the present study. They noted that from 1994-2014 female first authorship increased from 27% to 37%, while first authorship eventually plateaued, showing no meaningful gains between 2009-2014. In a study of 6 peer-reviewed journals from the United Kingdom from 1970-2004, female representation increased on average from 10.5% to 36.5% and 12.3% to 16.5% for first- and senior authors, respectively, though there were significant differences based on specialty.10Sidhu R. Rajashekhar P. Lavin V.L. et al.The gender imbalance in academic medicine: A study of female authorship in the United Kingdom.J R Soc Med. 2009; 102: 337-342Crossref PubMed Scopus (134) Google ScholarTable 1Studies evaluating the percentage of female first authors in various peer-review journals over time. The last two columns represent the percentages at the beginning and end of each study period, respectivelyAuthor/YearStudy PeriodJournal% Female 1st Authors (Start)% Female 1st Authors (End)Filardo G et al9Filardo G. da Graca B.D. Sass D.M. et al.Trends and comparison of female first authorship in high impact medical journals: Observational study (1994-2014).BMJ. 2016; 352: i847Crossref PubMed Scopus (286) Google Scholar20161994-2014Annals of Internal Medicine26%51%Archives of Internal Medicine33%42%British Medical Journal35%36%Journal of American Medical Association33%46%The Lancet27%31%New England Journal of Medicine28%25%Asghar M et al7Asghar M. Usman M.S. Aibani R. et al.Sex differences in authorship of academic cardiology literature over the last 2 decades.J Am Coll Cardiol. 2018; 72: 681-685Crossref PubMed Scopus (31) Google Scholar20181996-2016American Journal of Cardiology10.5%21%Journal of American College of Cardiology11%16.1%British Medical Journal Heart13.7%27.8%European Heart Journal13.1%20.3%Clinical Cardiology6.5%21%Circulation11.5%23.8%Jagsi R et al1Jagsi R. Guancial E.A. Worobey C.C. et al.The “gender gap” in authorship of academic medical literature—A 35-year perspective.N Engl J Med. 2006; 355: 281-287Crossref PubMed Scopus (607) Google Scholar20061970-2004New England Journal of Medicine4.3%14.1%Journal of American Medical Association5.7%26.5%Annals of Internal Medicine4.7%31.5%Annals of Surgery2.3%16.7%Obstetrics & Gynecology6.7%40.7%Journal of Pediatrics15.0%38.9%Miller J et al11Miller J. Chuba E. Deiner S. et al.Trends in authorship in anesthesiology journals.Anesth Analg. 2018; (E-pub ahead of print)https://doi.org/10.1213/ANE.0000000000003949Crossref Scopus (59) Google Scholar20182002-2017Anesthesiology20.1%31.6%Anesthesia & Analgesia20.8%29.7%Pagel PS et al5Pagel PS, Freed JK, Lien CA. Gender differences in authorship in the Journal of Cardiothoracic and Vascular Anesthesia: A 28-year analysis of publications originating from the United States, 1990-2017. J Cardiothorac Vasc Anesth (current issue).Google Scholar20191990-2017Journal of Cardiothoracic and Vascular Anesthesia9.6%26.2% Open table in a new tab A recent publication examining trends in authorship over 4 time periods (2002, 2007, 2012, 2017) in two high-impact anesthesiology journals, Anesthesiology and Anesthesia & Analgesia, found that women saw overall increases in first- and senior-authorship, and editorial board membership of 10%, 9%, and 6%, respectively.11Miller J. Chuba E. Deiner S. et al.Trends in authorship in anesthesiology journals.Anesth Analg. 2018; (E-pub ahead of print)https://doi.org/10.1213/ANE.0000000000003949Crossref Scopus (59) Google Scholar Though these figures are encouraging, they are far from earth-shattering. The greatest female representation was in the subspecialties of neuroanesthesia, obstetric anesthesia, pain management, and pediatric anesthesia. Cardiac anesthesia had the lowest female first author representation in the clinical subspecialties, and the second lowest in senior authorship after critical care. One would like to believe that the review process is fair and unbiased, but this notion has been put into question by some.12Khan K. Is open peer review the fairest system?.No. Br Med J. 2010; 341: c6425Crossref PubMed Scopus (37) Google Scholar, 13Groves T. Is open peer review the fairest system?.Yes. Br Med J. 2010; 341: c6424Crossref PubMed Scopus (41) Google Scholar In a survey-based study of biomedical academics from high-ranking universities throughout the world on the subject of peer review systems of medical journals, less than half of respondents felt that the peer review system was fair, scientific, or transparent, with a majority favoring a double-blind peer review system.14Ho R.C. Mak K. Tao R. et al.Views on the peer review system of biomedical journals: An online survey of academics from high-ranking universities.BMC Med Res Methodol. 2013; 13: 74Crossref PubMed Scopus (47) Google Scholar Female gender was one factor that was independently and inversely associated with agreement that biomedical journal peer review is fair. Concerns about single blind review are that it may be associated with biases that include gender, nationality, language of authors, and prestige of the author's institution.15Snodgrass R. Single- versus double-blind reviewing: An analysis of the literature.SIGMOD Record. 2006; 35: 8-21Crossref Scopus (77) Google Scholar A study examining the impact of single blind review on the acceptance of manuscripts from “reputed scholars” compared to “newcomers” in computer science actually found that the latter group was at a disadvantage.16Seeber M. Bacchelli A. Does single blind peer review hinder newcomers?.Scientometrics. 2017; 113: 567-585Google Scholar It has been suggested that blinding of both authors and referees (double-blind review) might mitigate some of the bias problems that may occur in publication, though opinions still diverge on this matter.17West J.D. Jacquet J. King M.M. et al.The role of gender in scholarly authorship.PLoS One. 2013; 8: e66212Crossref PubMed Scopus (433) Google Scholar, 18Rexrode K.M. The gender gap in first authorship of research papers.BMJ. 2016; 352: i1130Crossref PubMed Scopus (18) Google Scholar Coming back to the subject of literature and gender disclosure, Catherine Nichols revealed a striking reality when, in 2015, she received 8 times more publishing requests when she used the male pseudonym George Leyer.19Nichols C. Homme de Plume: What I learned sending my novel out under a male name. https://jezebel.com/homme-de-plume-what-i-learned-sending-my-novel-out-und-1720637627? (accessed December 30, 2018)Google Scholar And this was just 3 years ago! Francine Prose posed the question “Are women writers really inferior?” in an often-referenced essay where she challenges readers to distinguish between male and female “sounding” writing.20Prose F. Scent of a woman's ink. Are women writers really inferior?. Harper's Magazine, June 1998: 61-70Google Scholar And of course, Virginia Wolff famously stated in A Room of One's Own, “I would venture to guess that Anon, who wrote so many poems without signing them, was often a woman.” The Journal of Cardiothoracic and Vascular Anesthesia employs a double-blind peer review process, eliminating the possibility of gender bias in manuscript acceptance. On the other hand, Anesthesiology and Anesthesia & Analgesia are single-blinded. In order to know whether the blinding process has had any impact on cardiothoracic anesthesia publications by women, one would need to conduct an in-depth review of specialty-specific publications between the journals, a daunting task. Noteworthy is the fact that the impact factors of Anesthesiology and Anesthesia & Analgesia are higher than the Journal of Cardiothoracic and Vascular Anesthesia, which might affect an author's choice of journal for submission. It is important to keep in mind, however, that the former 2 have had the advantage of being the designated journals for the American Society of Anesthesiologists (ASA) and the Society of Cardiovascular Anesthesiologists (SCA), respectively, although the Journal of Cardiothoracic and Vascular Anesthesia has very recently been added as an option for SCA members. With all this said, it is clear that the gender disparities in authorship are multifactorial, with numerous and complex elements implicated. The list is long, and may include: inadequate/disparate research funding; institutional and leadership failures to support and promote women; competitive disadvantage; gender bias (conscious and unconscious); greater confidence gap relative to men; full-time versus part time status and productivity; greater rejection of manuscripts; lack of mentoring; impact of traditional gender roles; choice of work hours and personal choices regarding work-life balance; uneven parenting responsibilities; family planning; different peaks in productivity compared to men; bias against women in the review process; and career duration.21Allen I. Women doctors and their careers: What now?.BMJ. 2005; 331: 569-572Crossref PubMed Scopus (105) Google Scholar, 22Lundine J. Bourgeault I.L. Clark J. et al.The gendered system of academic publishing (Comment).Lancet. 2018; 391: 1754-1756Abstract Full Text Full Text PDF PubMed Scopus (92) Google Scholar One must also not ignore the fact that the gender composition and hierarchy of academic departments, along with what has been described as a “leaking pipeline” are rate limiting steps in the process.23Arnett D. Plugging the leaking pipeline—Why men have a stake in the recruitment and retention of women in cardiovascular medicine and research.Circ Cardiovasc Qual Outcomes. 2015; 8: S63-S64Crossref PubMed Scopus (10) Google Scholar While some specialties such as surgery have seen a steady increase in the percentage of women entering their training programs, anesthesiology has remained stagnant with just over one-third female representation.24Accreditation Council for Graduate Medical Education. Data Resource Book. Available at: http://www.acgme.org/About-Us/Publications-and-Resources/Graduate-Medical-Education-Data-Resource-Book. Accessed December 30, 2018.Google Scholar Around one quarter to one third of cardiothoracic anesthesia fellows have been women over the last decade. This number correlates closely with the percentage of women practicing this specialty in departments with accredited fellowships, as noted by Pagel et al. Thus, data shows us that the percentage of women entering the specialty of cardiothoracic anesthesia, the percentage of women practicing their specialty in academic institutions, and ultimately the percentage of women publishing in the field of cardiothoracic anesthesia have followed similar trends in the last 10 years. These figures are encouraging but bring us back to the notion that greater recruitment of women into anesthesiology (and ultimately cardiothoracic sub-specialization) will be necessary before we can ever hope to approach parity. Whether we are talking about science or the arts, literature or medicine, one thing is inherently clear. Women over the years have been marginalized as writers, but the causes are multiple and cannot be solely attributed to bias and gender discrimination. The plateau effect seen in this study is pervasive among specialties and in need of further investigation. In the meantime, there are ample opportunities to improve the engagement of women anesthesiologists in clinical research, provide solid academic support and mentorship for grant application, and acknowledge their contributions as writers. Until we have objectively identified the obstacles faced by women in academic medicine and acted on them, women will continue to hit a wall when it comes to journal authorship. Gender Differences in Authorship in the Journal of Cardiothoracic and Vascular Anesthesia: A 28-Year Analysis of Publications Originating From the United States, 1990-2017Journal of Cardiothoracic and Vascular AnesthesiaVol. 33Issue 3PreviewGender-based differences in scholarship among cardiothoracic anesthesiologists have not been studied. The authors examined the gender distribution of authorship of original research articles, case reports, review articles, and editorials in the Journal of Cardiothoracic and Vascular Anesthesia (JCVA) originating from the United States during four 3-year intervals to determine temporal changes in productivity of women in cardiothoracic anesthesiology. The authors tested the hypothesis that scholarly output of women has increased progressively in JCVA over time concomitant with greater participation in first, last, and corresponding author roles. Full-Text PDF

The clinical competency committee offers a fellowship program a structured approach to assess the clinical performance of each trainee in a comprehensive fashion This special article examines the structure and function of this important committee in detail. Furthermore, the strategies for the optimal functioning of this committee are also discussed as a way to enhance the overall quality of the fellowship program.

Historically, in times of need, women always managed to step up to the plate to get a critical job done. Nowhere is this more striking than during World War II, when women made significant contributions to the war effort after the Japanese bombing of Pearl Harbor in 1941, performing jobs traditionally relegated to men. Even childcare and household duties were collectively organized by these women. At a time when the industrial labor force was left with inadequate numbers of workers, women filled that void, despite being paid approximately half a man's salary. In fact, trade unions worried that men's pay would be reduced as a result of women's participation in the wartime effort and needed to be reassured that their positions in these "men's jobs" would only be temporary.1Anitha S, Pearson R (2013) Striking Women. Lincoln: University of Lincoln. https://www.strikingwomen.org. Accessed October 4, 2019.Google Scholar,2Wikipedia. Rosie the riveter. Available at: https://en.wikipedia.org/wiki/Rosie_the_Riveter. Accessed October 4, 2019.Google Scholar Many worked in factories and shipyards, and on assembly lines building planes and ships, and producing munitions and other war supplies. Others drove buses, trains, and ambulances. If a woman could run a mixer, it was said that she could learn to use a drill. The largest increase in female workers was in the aviation industry where women accounted for 65% of the total workforce, having made up only 1% in pre-war times.3History.com. American women in World War II. Available at: https://www.history.com/topics/world-war-ii/american-women-in-world-war-ii-1. Accessed October 4, 2019.Google Scholar So, this begs the question: over three-quarters of a century later, why are so many specialties in medicine still considered men's jobs? For more than 2 decades, reports from all over the world have identified obstacles to women choosing a career in cardiology and its subspecialties. Some of the recurring themes have included concerns about a vexing or uncongenial work atmosphere, pay disparities, overt and covert discrimination, radiation exposure, long hours, maternity-leave policies (or lack thereof), and a lack of opportunities for advancement. The question is not whether women can do this job—we already know the answer to that. The real issue is why is it taking so long for women to be embraced by this specialty? In the October 2019 issue of the Journal of the American College of Cardiology, representatives of the American College of Cardiology (ACC) Women in Cardiology (WIC) Leadership Council and Diversity and Inclusion Task Force published 10 broad recommendations to increase the recruitment, retention, and career advancement of female cardiologists.4Sharma G. Sarma A.A. Walsh M.N. et al.10 recommendations to enhance recruitment, retention, and career advancement of women cardiologists.J Am Coll Cardiol. 2019; 74: 1839-1842Crossref PubMed Scopus (14) Google Scholar A wide array of problem areas are targeted for change, amid an interplay of personal-, institutional-, educational-, social-, organizational-, occupational exposure–, cultural-, and resource-based components. It is a bold and admirable goal, and we all can agree that a greater degree of equity has been long overdue. These 10 points are outlined in Table 1 and address commonly stated themes of gender inequity, most of which have been the subject of publications over the last 15 to 20 years and also apply to medicine as a whole. To address each of these would be beyond the scope of an editorial; however, herein we discuss specific areas from a historical and feasibility standpoint.Table 1Ten Recommendations to Enhance the Recruitment, Retention, and Career Advancement of Women Cardiologists.Target Areas for Recruitment, Retention, and AdvancementRecommendations1. Employers, institutions, practices• Career flexibility, work-life balance• Implicit bias and zero tolerance for harassment• Parental leave policies• Radiation safety• Lactation space2. Leadership—academic divisional, departmental• Establish mentoring programs• Increase number of women fellowship applicants3. Fellowship program directors, ACGME• Work with ACGME to ensure clear FMLA policies and flexibility in training4. Research funding agencies• Gender equity in review processes and committees5. Professional societies• Report data on gender inequities in funding, publication, promotion, compensation6. Scientific journals• Establish equity in the peer review process• Address gender disparities in authorship7. Senior women cardiologists• Work to improve climate for women• Mentor and sponsor future generations8. Fellows, early and mid-career cardiologists• Create supportive culture• Collaboration and mentorship9. Senior men and peer cardiologists• Learn to recognize harassment or bullying• Intervene when these occur10. Spouses and partners• Share in domestic responsibilities• Share in child and elder care• Work to change social normsAbbreviations: ACGME, Accreditation Council for Graduate Medical Education; FMLA, Family and Medical Leave Act of 1993.Adapted from Sharma et al.4Sharma G. Sarma A.A. Walsh M.N. et al.10 recommendations to enhance recruitment, retention, and career advancement of women cardiologists.J Am Coll Cardiol. 2019; 74: 1839-1842Crossref PubMed Scopus (14) Google Scholar Open table in a new tab Abbreviations: ACGME, Accreditation Council for Graduate Medical Education; FMLA, Family and Medical Leave Act of 1993. Adapted from Sharma et al.4Sharma G. Sarma A.A. Walsh M.N. et al.10 recommendations to enhance recruitment, retention, and career advancement of women cardiologists.J Am Coll Cardiol. 2019; 74: 1839-1842Crossref PubMed Scopus (14) Google Scholar In 2018 to 2019, US medical school enrollment comprised 49.5% women, proof that parity is achievable.5Association of American Medical Colleges. Total enrollment by US medical school and sex, 2014-2015 through 2018-2019. Available at: https://www.aamc.org/system/files/2019-11/2019_FACTS_Table_B-2.2.pdf. Accessed October 10, 2019.Google Scholar Currently, internal medicine residencies are composed of 47.2% women, with only 24.5% in cardiovascular medicine fellowships, and a mere 13.2% and 11.4% in the procedural subspecialties of electrophysiology and interventional cardiology, respectively (Table 2).6Brotherton S.E. Etzel S.I. Graduate medical education, 2017-2018.JAMA. 2018; 320: 1051-1070Crossref PubMed Scopus (41) Google Scholar,7Brotherton S.E. Etzel S.I. Graduate medical education, 2018-2019.JAMA. 2019; 322: 996-1016Crossref PubMed Scopus (36) Google Scholar Among practicing cardiologists, women represented only 10.3% of the workforce in 2018, mainly in general cardiology and advanced heart failure/transplantation.8MedAxiom. 2019 Cardiovascular provider compensation and production survey. Available at: https://go.medaxiom.com/2019CompSurvey. Accessed October 8, 2019.Google ScholarTable 2Data from the Association of American Medical Colleges for 2017-2018 and 2018-20196Brotherton S.E. Etzel S.I. Graduate medical education, 2017-2018.JAMA. 2018; 320: 1051-1070Crossref PubMed Scopus (41) Google Scholar,7Brotherton S.E. Etzel S.I. Graduate medical education, 2018-2019.JAMA. 2019; 322: 996-1016Crossref PubMed Scopus (36) Google ScholarPrograms (n)Positions (n)Women (n)Women (%)Anesthesiology 2017-20181145,9392,03534.3% 2018-20191526,1412,06533.6%Adult CTA 2017-2018661705029.4% 2018-2019671805228.9%Internal medicine 2017-201849726,22810,99541.9% 2018-201953327,17911,47447.2%Adult CHD 2017-20181114642.9% 2018-201920221254.5%ADV HF/TXP 2017-201872772329.9% 2018-201974992828.3%General CARD 2017-20182162,73162522.9% 2018-20192382,89971124.5%Cardiac EP 2017-20181081882111.2% 2018-20191082462811.4%Interventional 2017-20181502883010.4% 2018-20191603114113.2%Abbreviations: ADV HF/TXP, advanced heart failure/transplantation; CARD, cardiology; CHD, congenital heart disease; CTA, cardiothoracic anesthesia; EP, electrophysiology. Open table in a new tab Abbreviations: ADV HF/TXP, advanced heart failure/transplantation; CARD, cardiology; CHD, congenital heart disease; CTA, cardiothoracic anesthesia; EP, electrophysiology. So, is cardiology really a man's job? The statistics certainly suggest it is. One important consideration is the projected shortage of cardiologists in the midst of a growing and aging population. Add to this a growing population of much younger patients with cardiovascular disease amid high rates of diabetes, smoking, poor lifestyle choices, and an obesity epidemic, and you have a perfect storm. In addition, as surgical volume is increasingly being absorbed by transcatheter procedures, it becomes inherently clear that we are in for a major crisis if things do not change. So what will it take to attract more women? Now is a perfect time to capitalize on the value they can bring to a specialty in growing need of practitioners, just as women kept the production lines moving during World War II. In fact, women may be in a better position to negotiate more suitable conditions for themselves as the physician deficit grows. This will require that a deeply rooted system embraces change, including many of the recommendations outlined in Table 1.4Sharma G. Sarma A.A. Walsh M.N. et al.10 recommendations to enhance recruitment, retention, and career advancement of women cardiologists.J Am Coll Cardiol. 2019; 74: 1839-1842Crossref PubMed Scopus (14) Google Scholar Since 2015, the Association of American Medical Colleges has commissioned annual updates of national physician workforce projections.9IHS Markit Ltd. 2019 update: The complexities of physician supply and demand: Projections from 2017 to 2032. Available at:https://aamc-black.global.ssl.fastly.net/production/media/filer_public/31/13/3113ee5c-a038-4c16-89af-294a69826650/2019_update_-_the_complexities_of_physician_supply_and_demand_-_projections_from_2017-2032.pdf. Accessed October 12, 2019.Google Scholar The most recent report concluded that physician demand will outpace supply, resulting in a projected shortfall of between 46,900 and 121,900 physicians by 2032. Primary driving forces for these trends include both an aging and growing patient population. Between 2017 and 2032, a 10.3% US population growth is expected. Most striking is the 48.0% projected growth of seniors ≥65 years (75.3% for those ≥75 y) compared with 3.5% growth for individuals younger than 18 years. The ramifications are tremendous considering seniors are the group with the greatest per capita healthcare consumption in the United States. Importantly, more than 40% of active physicians will be ≥65 years old over the next decade, with prospects of retirement further affecting supply. Notably, physicians of all ages are working fewer hours overall, and today's millennial physicians have very different attitudes about work-life balance and work hours than do older generations. According to the Association of American Medical Colleges report, if the trend of reduced working hours continues, there could be a potential loss of 20,900 FTE (full-time equivalent) physicians by 2032 compared with unchanged work patterns. MedAxiom is a membership network and service provider for cardiology practices including hospitals and academic institutions. It has partnered with the ACC and conducts annual surveys of members representing more than one-third of all cardiology and cardiovascular groups in the United States. According to the 2019 MedAxiom Cardiovascular Provider Compensation and Production Survey, the distribution of cardiologists by age group in 2018 was as follows: age 30 to 40 (16%); 41 to 50 (28%); 51 to 60 (29%); and 61 and older (27% [the highest level on record]).8MedAxiom. 2019 Cardiovascular provider compensation and production survey. Available at: https://go.medaxiom.com/2019CompSurvey. Accessed October 8, 2019.Google Scholar For those older than 61 years, the proportion of general noninvasive cardiologists and interventional cardiologists was 31% and 29%, respectively. Some from the latter group will switch to a general practice as they get older. Interestingly, there was a decrease in the number of part-time cardiologists from 13% to 7% between 2012 and 2016.8MedAxiom. 2019 Cardiovascular provider compensation and production survey. Available at: https://go.medaxiom.com/2019CompSurvey. Accessed October 8, 2019.Google Scholar Many practices will not hire part-time physicians, resulting in more senior staff retiring earlier than planned, whereas others simply retire for reasons including burnout, long work hours, onerous call schedules, and disenchantment with the bureaucracy. Without the part-time option, women with young children can be shut out from potential jobs that would allow them the flexibility they need to care for their families. In 2004, ACC President Dr. Bruce Fye sounded the alarm over projected shortages and appointed a task force to study the cardiology workforce.10Fye W.B. Introduction: The origins and implications of a growing shortage of cardiologists.J Am Coll Cardiol. 2004; 44: 221-232Crossref PubMed Scopus (25) Google Scholar Earlier predictions that the supply of specialists would outstrip demand by more than 60% proved erroneous and contributed to the reduction in trainee positions, a difficult job market for specialists, and a greater push toward primary care.11Weiner J.P. Forecasting the effects of health reform on U.S. physician workforce requirement: Evidence from HMO staffing patterns.JAMA. 1994; 272: 222-230Crossref PubMed Scopus (430) Google Scholar The ACC effort resulted in the development of 8 working group documents addressing strategies to help balance the supply-demand problem.12Fye W.B. Cardiology's workforce shortage—implications for patient care and research.Circulation. 2004; 109: 813-816Crossref PubMed Scopus (19) Google Scholar "Working Group 2: How to Encourage More Women to Choose a Career in Cardiology" includes a number of recommendations, including increasing visibility of the specialty at early educational stages, during medical school, and during internal medicine residency; provision of mentors and role models; and emphasizing the broad spectrum of career opportunities beyond the catheterization laboratory that offer a more favorable work-life balance.13Warnes C.A. Fedson S.E. Foster E. et al.Working Group 2: How to encourage more women to choose a career in cardiology.J Am Coll Cardiol. 2004; 2004: 238-241Crossref Scopus (18) Google Scholar Increased enrollment in medical school cannot address the projected shortage of physicians without concomitant growth of Accredited Council for Graduate Medical Education (ACGME) residency and fellowship programs. A significant portion of residency funding comes from Medicare, and sadly some of this has been limited by budgetary constraints, leaving Graduate Medical Education with the need to find alternative sources of support (the Balanced Budget Act of 1997 placed a cap on the number of positions Medicare would subsidize).14Congressional Research Service. Federal support of graduate medical education: An overview—updated December 27, 2018. Available at: https://crsreports.congress.gov. Accessed October 21, 2019.Google Scholar Sharma et al. have addressed the challenges program directors and female trainees face with regard to the lack of funding for parental leave, workforce needs, the need to subsidize extended training, and meeting educational goals.4Sharma G. Sarma A.A. Walsh M.N. et al.10 recommendations to enhance recruitment, retention, and career advancement of women cardiologists.J Am Coll Cardiol. 2019; 74: 1839-1842Crossref PubMed Scopus (14) Google Scholar The authors suggest that program directors should provide more flexible training pathways with individualized and innovative learning plans. They also recommend that accreditation agencies provide parental leave policies across the medical education continuum and implore the possible need to extend training (the ACGME allows only 20 days off per year), suggesting that video-based methods could fulfill their educational requirements. These are interesting suggestions that potentially could offset some of the learning requirements but undoubtedly would be hampered by patient care and procedural aspects of training, unless remote training took place on a nonclinical rotation such as research or imaging.15Moe T.G. Pregnancy in fellowship—building a career and family.J Am Coll Cardiol. 2014; 64: 734-736Crossref PubMed Scopus (7) Google Scholar Rearranging a trainee's rotation schedule is a logical starting point and could curtail the need to prolong training to some degree, unless the ACGME extends the number of allowable days away for all, a doubtful proposition in light of existing duty hour restrictions. The real sticking point is the pressure most departments face to do more with less. With ongoing budget cuts, added funding would be difficult to come by; however, with the right program and the right program director, creative ways to meet the rigid ACGME requirements possibly could work. The need to balance work with parenting and household responsibilities is one of the primary reasons women are underrepresented in cardiology. Family planning decisions center around timing, with a woman's desire to start or grow a family taking place early in her career. Pregnancy and maternity leave have been recurring themes in the professional life surveys conducted by the WIC Section of the ACC16Lewis S.J. Mehta L.S. Douglas P.S. et al.Changes in the professional lives of cardiologists over 2 decades.J Am Coll Cardiol. 2017; 69: 452-462Crossref PubMed Scopus (68) Google Scholar and are addressed in detail by Sharma et al., along with advocation for paternity leave.4Sharma G. Sarma A.A. Walsh M.N. et al.10 recommendations to enhance recruitment, retention, and career advancement of women cardiologists.J Am Coll Cardiol. 2019; 74: 1839-1842Crossref PubMed Scopus (14) Google Scholar This latter point, if universally adopted for both trainees and staff, could change some of the negative attitudes, particularly in dual working couples and create a "new normal." The WIC Pregnancy Workforce Group conducted an anonymous survey addressing the effect of issues related to family planning on the choice of a cardiology career to better understand ways of improving the situation or to effect reform.17Sarma A.A. Nkonde-Price C. Gulati M. et al.Cardiovascular medicine and society—The pregnant cardiologist.J Am Coll Cardiol. 2017; 69: 92-101Crossref PubMed Scopus (32) Google Scholar The most recent survey showed that women were more likely to have interrupted their training or staff practice for greater than 1 month compared with men (28% v 13% and 44% v 15%, respectively). Similar themes have also been noted in Europe and Australia.18Capranzano P. Kunadian V. Mauri J. et al.Motivations for and barriers to choosing an interventional cardiology career path: Results from the EAPCI Women Committee worldwide survey.Eurointervention. 2016; 12: 53-59Crossref PubMed Scopus (32) Google Scholar,19Segan L. Vlachadis Castles A. Women in cardiology in Australia—are we making any progress?.Heart, Lung and Circulation. 2019; 28: 690-696Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar In Australia, there actually are no clear policies to accommodate pregnancy and maternity leave.19Segan L. Vlachadis Castles A. Women in cardiology in Australia—are we making any progress?.Heart, Lung and Circulation. 2019; 28: 690-696Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar Another issue that is seldom spoken of is the effect a physician's pregnancy has on her colleagues. When a woman takes maternity leave, the response from coworkers can range anywhere from joyful and supportive to outright resentment at the prospect of having to cover more call and clinical duties. Notably, female cardiologists tend to shorten their allowable maternity leave, with 51% in one survey feeling pressure to take a shorter leave than available.17Sarma A.A. Nkonde-Price C. Gulati M. et al.Cardiovascular medicine and society—The pregnant cardiologist.J Am Coll Cardiol. 2017; 69: 92-101Crossref PubMed Scopus (32) Google Scholar Radiation exposure and the potential ill effects on health and fertility, although frequently cited as deterrents to women entering the procedural subspecialties, may not be as important as initially believed.20Best P J.M. Skelding K.A. Mehran R. et al.SCAI consensus document on occupational radiation exposure to the pregnant cardiologist and technical personnel.EuroIntervention. 2011; 6: 866-874Crossref PubMed Scopus (30) Google Scholar What may be lacking is proper education about appropriate shielding methods. This information should be disseminated as early as medical school because radiation exposure is often a deterrent to many who rule out certain specialties without knowledge of accepted safety data. Breastfeeding, which is rarely discussed, is a need that often is left for a new mother to deal with on her own. Although a lactation space and breast milk storage area should be made available to all postpartum staff and trainees, this often is not the case, and women can be relegated to dealing with this in unpractical areas if they do not have the luxury of a private office. Sharma et al. address this problem, which is perhaps one of the easiest to remedy.4Sharma G. Sarma A.A. Walsh M.N. et al.10 recommendations to enhance recruitment, retention, and career advancement of women cardiologists.J Am Coll Cardiol. 2019; 74: 1839-1842Crossref PubMed Scopus (14) Google Scholar Most female cardiologists become pregnant during their fellowship or early in their career. During interviews for fellowship or staff positions, women often are asked about pregnancy and future family planning. This line of questioning, although considered inappropriate, has remained commonplace.17Sarma A.A. Nkonde-Price C. Gulati M. et al.Cardiovascular medicine and society—The pregnant cardiologist.J Am Coll Cardiol. 2017; 69: 92-101Crossref PubMed Scopus (32) Google Scholar A desire to start or grow a family should never be a liability in the interview process, and although this line of questioning persists, many fail to report it because of potential negative repercussions. It is doubtful that male candidates are subjected to this line of questioning as often as women are. Including female staff in the interview process might allow female candidates to pose questions relating to family planning in a more confidential and safe environment. Female physicians with children spend more time on childcare and household responsibilities than do their male partners, leaving less time for professional work activities and commitments.21Woodward C.A. Williams A.P. Ferrier B. Cohen M. Time spent on professional activities and unwaged domestic work.Can Fam Physician. 1996; 42: 1928-1935PubMed Google Scholar The discrepancy in time spent on parenting and other domestic activities has led to women physician researchers achieving career success at a much slower rate than their male counterparts. These women also are more likely to take time off when unplanned disruptions in childcare arrangements occur compared with their spouse/partner (42.6% v 12.4%). When a child is sick or unanticipated events keep them from school or daycare, in a dual working couple, it is generally the mother who takes the time off.22Jolly S. Griffith K.A. DeCastro R. et al.Gender differences in time spent on parenting and domestic responsibility by high-achieving young physician researchers.Ann Intern Med. 2014; 160: 344-353Crossref PubMed Google Scholar According to the WIC professional life survey, relative to men, women are less likely to have a spouse who provides daycare (13% v 57%) and are more likely to require additional overnight childcare (48% v 24%).16Lewis S.J. Mehta L.S. Douglas P.S. et al.Changes in the professional lives of cardiologists over 2 decades.J Am Coll Cardiol. 2017; 69: 452-462Crossref PubMed Scopus (68) Google Scholar Without a stay-at-home spouse, household responsibilities like cooking and laundry generally are left to the woman. Furthermore, the misguided public notion that physicians all "make a lot of money" and easily can hire a nanny and/or a housekeeper ignores the fact that the average medical student accrues between $31,905 and $55,310 of tuition debt per year alone, without counting other debt and expenses.23Tuition and student fees for first-year students. Summary of statistics for academic year 2012-2013 through 2018-2019. Available at: https://www.aamc.org/data-reports/reporting-tools/report/tuition-and-student-fees-reports. Accessed October 28, 2019.Google Scholar For dual-physician couples, the financial burden doubles. Sharma et al. suggest that spouses and partners more equitably share in the responsibilities of domestic, child, and elder care and work to change social norms.4Sharma G. Sarma A.A. Walsh M.N. et al.10 recommendations to enhance recruitment, retention, and career advancement of women cardiologists.J Am Coll Cardiol. 2019; 74: 1839-1842Crossref PubMed Scopus (14) Google Scholar Without a doubt, some couples are able to achieve this; however, cultural and stereotypical norms still exist. As our society continues to evolve, younger generations will perhaps have a more egalitarian view of shared responsibilities, but there will always be exceptions. Let us now pose a rhetorical question: If men bore the greater burden of childrearing, parenting, and household responsibilities, would they choose a career in cardiology? Compared with their male counterparts, at all stages of their careers, women in academic cardiovascular medicine and research leave at a higher rate. This phenomenon has been designated the "leaking pipeline."24Arnett D.K. Plugging the leaking pipeline—why men have a stake in the recruitment and retention of women in cardiovascular medicine and research.Circ Cardiovasc Qual Outcomes. 2015; 8: S63-S64Crossref PubMed Scopus (8) Google Scholar Tsukada et al. explored the issue of retention of female cardiologists in Japan and noted that more women were dissatisfied with their jobs compared with men.25Tsukada Y.T. Tokita M. Kato K. et al.Solutions for retention of female cardiologists—from the survey of gender differences in the work and life of cardiologists.Circ J. 2009; 73: 2076-2083Crossref PubMed Scopus (9) Google Scholar Not surprisingly, these women experienced greater career limitations because of family and household responsibilities. Sound familiar? Also, in Japan, women generally take on the responsibility of elder care. Proposed solutions to the retention problems included creating a more family friendly work environment in hospitals; providing positions that offer more flexibility and predictability (eg, shift work, work-sharing, reduced hours); establishing retraining systems after childcare leave (in Japan, the options for childcare are very costly and limited compared with the United States); and creating work and research opportunities that would appeal to women.25Tsukada Y.T. Tokita M. Kato K. et al.Solutions for retention of female cardiologists—from the survey of gender differences in the work and life of cardiologists.Circ J. 2009; 73: 2076-2083Crossref PubMed Scopus (9) Google Scholar Each of these points are in step with the recommendations proposed by Sharma et al.4Sharma G. Sarma A.A. Walsh M.N. et al.10 recommendations to enhance recruitment, retention, and career advancement of women cardiologists.J Am Coll Cardiol. 2019; 74: 1839-1842Crossref PubMed Scopus (14) Google Scholar Whether we are talking about professional societies, institutional and department leadership, grant awards, full professorships, or editorial board memberships, women are poorly represented. The American Heart Association (AHA) was founded in 1924, and in its 95 years has had 10 women presidents.26Walsh M.N. Women as leaders in cardiovascular medicine.Clin Cardiol. 2018; 41: 269-273Crossref PubMed Scopus (9) Google Scholar The ACC was founded in 1949 and has had 3 female presidents over 70 years, with a 4th elected to serve in 2020 to 2021.27American College of Cardiology. Harold on history—women leading ACC, cardiovascular medicine. Available at: https://www.acc.org/latest-in-cardiology/articles/2019/03/18/12/42/harold-on-history-women-leading-acc-cardiovascular-medicine. Accessed November 1, 2019.Google Scholar In comparison, the American Society of Anesthesiologists was founded in 1905 and has had 2 female past presidents in 114 years, with a 3rd elected to serve in 2020.28American Society of Anesthesiologists. Past presidents. Available at: https://www.asahq.org/about-asa/governance-and-committees/past-presidents. Accessed November 1, 2019.Google Scholar The Society of Cardiovascular Anesthesiologists was founded in 1974 and has had 2 female presidents in 45 years.29Society of Cardiovascular Anesthesiologists. Past presidents. Available at: https://www.scahq.org/about/SCA-leadership/Past-Presidents. Accessed November 1, 2019.Google Scholar Despite the dismal proportions of women in cardiology, many have risen in the ranks and have become visible in a number of prestigious leadership roles, including research, health systems administration, editorial boards, and professional societies.26Walsh M.N. Women as leaders in cardiovascular medicine.Clin Cardiol. 2018; 41: 269-273Crossref PubMed Scopus (9) Google Scholar Historically, discrimination has been a common experience for women in medicine. The most recent professional life survey of cardiologists found similar rates of gender discrimination over nearly a 20-year span (71% in 1996 and 65% in 2015), most centering around gender, maternity, and parenting.16Lewis S.J. Mehta L.S. Douglas P.S.

Despite women accounting for nearly half of all U.S. medical school graduates, this balanced representation is lacking in the cardiovascular specialties. To explore this question further, gender-based trends in the selection of cardiovascular subspecialty fellowship training were investigated among three core specialties: anesthesiology, medicine, and surgery. Using enrollment and workforce data from the Accreditation Council for Graduate Medical Education (ACGME), the Association of American Medical Colleges (AAMC), and the Journal of the American Medical Association Annual Report on Graduate Medical Education, trends in cardiovascular fellowship selection among women were examined over a 10-year period (2007-2017). An attempt was also made to better understand barriers that might contribute to any discrepancies, as well as factors that might influence women's choices of cardiovascular specialties over other fields.