Women make up roughly 14% of practicing cardiologists in the United States¹. Heart disease is the number one killer of American women of all ages and races^{2, 5}. A lack of female providers is a quality improvement and patient safety issue in improving cardiovascular outcomes for female patients. When looking at systemic issues that have long prevented women from entering cardiology, similarly, systemic issues have led to fewer women receiving appropriate cardiac care.

What factors keep women out of the field of cardiology? There is no singular answer for this question. Research surveys show a variety of reasons including perception as a male dominated field, lack of female role models and women in leadership, concern for childbearing and family time, and gender discrimination by both providers and patients are but a few reasons for the wide gender gap amongst practicing providers ^{1, 3, 8}. The most common concern however lies with poor work life balance ^{1, 8}. Little improvement has been made in the last 20 years to narrow the gender gap in cardiology, and concern that if changes are not addressed, that women will continue to be underrepresented in the field, which will continue to impact patient care¹.

So where is the commonality between lack of gender diversity in cardiology providers and lack of cardiac care for female patients? Studies indicate that female physicians provide more of a partnered and counseling-based approach to patient care and are more likely to focus on prevention of disease, something that is often lacking for female patients⁷. Studies show that women are less likely to receive recommended treatment for coronary vascular disease, blood pressure control, and diabetes compared to men^{5, 7}. In part this may be because data on heart disease and symptoms are largely extrapolated from studies in men^4,5,7. As symptoms are often less classic or specific in women, providers are less aggressive in prevention due to lack of recognizing symptoms^4,5. Further, surveys indicate that providers lack of familiarity with discussing cardiovascular disease in women and lack of emphasis on the importance of cardiovascular risks in women, leave female patients disadvantaged in understanding or seeking care for symptoms themselves^5,6. Gender specific biology may also contribute to increased or altered risks for cardiovascular disease, including increased risks that develop during pregnancy, change in estrogen levels with menopause, and higher rates of diabetes and metabolic syndrome, which again are not well recognized by all providers and may not be inclusion criterion in cardiac studies^4,5. Many women do not know that cardiac disease is the number one cause of death for women in the United States^4,6. Interestingly, a Journal of Women's Health study indicates that concordant gender in patients and providers (female patients seen by female providers) may result in modest improvement in screening of preventative disease⁷. Though the results are not large, one cannot help but argue that female representation as cardiology providers is already a patient safety issue in that female patients may have a better chance of receiving equal care⁷. Further, one may argue that female representation in patients amongst all ages, including pregnancy in research studies, would help better shape provider understanding of care and prevention for female patients⁵.

Improving female representation in the field of cardiology for both physicians and patients will require a large systemic change with a focus on improving factors that are barriers to females. For providers, improved focus on work life balance within training programs and jobs, partnered leadership with current female faculty, and acknowledging and treating gender based microaggression in the workplace are steps to improve representation of women in cardiology ^1,3. Each of these steps is within our own ability to improve upon. Recognizing our own implicit bias, calling out discriminative behavior when we see it, setting up mentorship opportunities, encouraging talented female trainees to pursue male dominated fields, and advocating for the importance of representation in our workspace are important factors in improving the quality of care that we provide our patients^3,8. Likewise, changing study criterion, familiarizing ourselves with female cardiac care including cardiovascular risks with pregnancy or post-menopause, and spending more active time on prevention and cardiac education with our female patients is all within our grasps as providers^5,6. Acknowledging the need for change in our systems is our best chance to care for our patients. 

References:

1. Burgess, S. et al., "Women in Cardiology: Underwhelming Rate of Change." Circulation. 2019; 139: 1001-1002. https://www.ahajournals.org/doi/full/10.1161/CIRCULATIONAHA.118.037835.
2. "Leading Causes of Death-Females-All races and origins- United States, 2017." CDC Web Page. Last reviewed June 21, 2021. https://www.cdc.gov/women/lcod/2017/all-races-origins/index.htm.
3. Khan, M.S., et al., "Women Training in Cardiology and Its Subspecialties in the United States: A Decade of Little Progress in Representation." Circulation. 2020; 141: 609-611. https://www.ahajournals.org/doi/full/10.1161/CIRCULATIONAHA.119.044693.
4. "Gender Matters: Heart disease risk in women." Harvard Health Publishing Web Page. Published March 25, 2017, https://www.health.harvard.edu/heart-health/gender-matters-heart-disease-risk-in-women.
5. Garcia, M. MD., et al., "Cardiovascular Disease in Women: Clinical Perspectives." Circ Res. Apr 15; 118(8): 1273-1293. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4834856/
6. "Women and Heart Disease: New Data Reaffirm Lack of Awareness by Women and Physicians." ACC News Story. June 22, 2017. https://www.acc.org/latest-in-cardiology/articles/2017/06/22/10/01/women-and-heart-disease-new-data-reaffirm-lack-of-awareness-by-women-and-physicians.
7. Schmittdiel, J. Ph.D., et al., "The Associate of Patient-Physician Gender Concordance with Cardiovascular Disease Risk Factor Control and Treatments in Diabetes." J Womens Health. 2009 Dec; 18(12): 2065-2070. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2828159/.
8. Neal, T. "Women in Cardiology: Underrepresented, Underestimated, and Undervalued." TCTMD Web Page. May 31, 2018. https://www.tctmd.com/news/women-cardiology-underrepresented-underestimated-and-undervalued.

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