Pamela S. Douglas, MD, MACC, is the Ursula Geller Professor of Research in Cardiovascular Diseases in the Department of Medicine at Duke University and Director of the Multimodality Imaging Program at Duke Clinical Research Institute. She completed her MD at Virginia Commonwealth University, after which she pursued her residency and fellowship in cardiology at the University of Pennsylvania. Over the course of her career, Douglas has led numerous multicenter government studies, clinical trials and outcomes research studies. She is also renowned for her policy work focusing on improving the quality and appropriateness of imaging in clinical care, clinical trials and registries by developing national standards for imaging utilization, informatics and analysis. She is a pioneer in the fields of heart disease in women, sports cardiology and cardio-oncology. Douglas has authored over 400 peer-reviewed manuscripts and 30 practice guidelines and has served as the president of both the ACC and the American Society of Echocardiography. She has served as the chief of cardiology at both the University of Wisconsin and Duke University and has also held faculty positions at the University of Pennsylvania and Harvard University. Douglas currently serves on the External Advisory Council of the National Heart, Lung and Blood Institute and the Scientific Advisory Board of the Patient Advocate Foundation.

How did you start considering cardiology as a potential specialty? What inspired your interest in the field?

I first considered cardiology in medical school and rejected it. It seemed like there wasn't much exciting going on in cardiology, and this was the mid 70s so there were very few CABGs, very few caths, no diagnostic imaging, etc. The only EP was the His bundle recording and single chamber pacemakers. What I really liked taking care of was really sick people, and I loved my ICU rotations in residency, so from there I considered what were the fields where I could continue to do ICU work. I also wanted to do academics, and cardiology hit that sweet spot between taking care of really sick people but also being able to do clinical research as an academic career path, which I think is still, even 40 years later, much more established in cardiology than in many other specialties. Back then, you were either a bench person or you weren't in academics.

What are your clinical and research interests in cardiology? How did you develop these areas of interest?

I got into imaging just because it was so cool! That sounds really superficial, but the ability to actually see the heart beat in real time just blew me away. I was coming through residency and fellowship at a time when 2D was really getting established. My third year of fellowship was the first time we had doppler and we could actually make a diagnosis of aortic stenosis without catheterizing the patient, which sounds ridiculous now but the idea that we could measure a gradient and see whether a valve was leaking or stenotic non-invasively was a huge, huge advance. The heart was right there in your hands, and it's still pretty cool. All the other imaging techniques certainly have significant strengths, but none of them are real time like echocardiography. It's you, the transducer, and the heart; that's it.

Can you discuss your involvement with the American College of Cardiology?

Back in the early 90s, ACC and the European Society of Cardiology had an exchange program for new career faculty, so I was selected for that and I went to Europe for three weeks with a delegation. We travelled around Europe and went to different medical centers. It was fabulous. I had travelled overseas, but I had never travelled medically overseas and seen how other institutions work. Eventually, I joined the selection committee for the exchange program as well as the Merck Fellowship Award, which ACC still endows. From there, two female colleagues and friends decided to nominate me for the board. I looked at one of my mentors who was a past president, who said, "That is not happening, you are way too young." It happened. I was appointed to the board for a one-year appointment, which was renewed and then I applied to be on the presidential track and did that in 2005 and 2006. I was 50 when I became president, much younger than past ACC presidents. Many ACC leaders assume the presidency when they are semi-retired because of the time commitment; it is a difficult thing to do in the height of a busy career. I was able to stay very involved in ACC, in part because I'm younger and still very active, but also in part because I've found things that I really was passionate about. One of those was the CV Summit and the whole concept of non-clinical education and professionalism, competencies that go beyond knowing which drug to pick for heart failure and more about how to be a good doctor and person.

How did you get more involved with diversity and inclusion in cardiology?

About 6 or 7 years ago, my eyes started opening. We had always said that women would do better when the pipeline filled out. The medical student pipeline filled out, the internal medicine residency pipeline filled out, and nothing happened in terms of including women in cardiology. What was worse, it became obvious that women were excluded from many leadership roles. One of the things that really caught my attention was that one year, at the annual meeting, the highest profile session had seven discussants, all males. From there, I did some work on compensation equity and really got the ear of others who were in the presidency. We really needed to fix this because we were losing too much raw talent. If there's so many women in internal medicine residencies and they're not looking at cardiology as a career, we're losing their expertise and their excellence. No business or enterprise can take 30% of their top talent and throw it away or close the door for whatever reason and survive at the level of excellence where we would hope to be. We were able to start a task force in 2017 on diversity and inclusion in the ACC. It was a task force for its first 4 years, and this past spring it became a committee. I think we've heightened the awareness among cardiologists and cardiology institutions of the importance of representation, equity, and inclusion, as well as the importance of eliminating harassment and discrimination, and really making everyone welcome and heard in our profession and workplaces.

What barriers do you see that need to be eliminated to encourage more female medical students and residents to pursue cardiology?

There's an emphasis on the positives and a removal of the negatives. Emphasizing the positives - the women that are in cardiology love it. The satisfaction among female cardiologists is above 90%, just like men. Women have very rewarding careers in cardiology. There's a lot of variety, you can be a proceduralist, a radiologist, a clinician, etc. Within cardiology, there's a lot of different ways to shape a career and often to do one or two or even three of those things at once. The biggest barriers are the ones that are very much out in public at this point. Unpredictable hours is a big issue. Family friendliness is a big issue for women and also increasingly for men. The importance of mentors and role models of the same race and sex is often missing for some folks. Those things are equally true now if not truer than they were 10 years ago, and we have to take this really seriously. OB-GYN and general surgery increased the proportion of women in part by addressing these issues - by having clear shift work. We have to get past this feeling that the harder your call is, the more successful you are, it's just not right and causes burnout and so on. We have to change within the profession. Family friendliness is very much related to that. There's a lot of work being done to clarify federal and local legislation about family leave and what needs to happen during family leave, but it's a lot better than it used to be. But it's slow, and it's going to take a lot of hard work and upward battles to make those things happen. We've really benefited from both the Me Too and the Black Lives Matter movements in the sense of heightening society's awareness of inequities and the way in which people are privileged and how power drives relationships. Some organizations have incredibly bold initiatives to eliminate sexual harassment; for example the NIH has removed more than 70 PIs in the last 6 months from funding due to sexual harassment and discrimination. People need to realize that these changes are coming soon to an institution that matters to them. It may not be there yet, but it's coming. Change is definitely happening.

How can students advocate for women in cardiology and medicine as a whole?

Understand that the playing field is not level and work yourself to mitigate that. That's nowhere near enough, and I hate the idea that women need to upscale themselves to account for the inequities that are out there and that it's women's responsibility to change. I don't think it is women's responsibility to change, but on the other hand, more pragmatically, you can change yourself a lot faster than you can change the outside world. Learning things about negotiation and how to present yourself and being the best possible candidate that you can be are really important. We want to be true to ourselves and authentic, but at the same time, the male cardiology world may be alien to us. We have to work where we can accommodate ourselves professionally in that world while still being authentic to ourselves.

The other thing is to be aware that you will experience bias, harassment and discrimination. You may experience bullying. And be prepared to experience these things. Be prepared to stand up for yourself and ask for bystander support and ally support, to find mentors and sponsors who can help you work through things. Being prepared to deal with it doesn't necessarily make it any easier, but I think it takes away the surprise element. The other thing to be prepared for is paternalism. Some people give every indication that they are looking out for you and that they're giving you advice that is in your best interest, but it's limiting. Those comments are generally trying to say things on your behalf, but they can be very discouraging of your own ambitions and inclinations. Just get rid of them if they don't align with what you want. What you want is more important than what somebody else thinks might be suitable for you.

Do you have any parting thoughts for medical students and trainees, especially female medical students and residents who may be considering a career in cardiology?

Loving it. We're all happy in cardiology. There are amazing women in cardiology. We want to get to the point where you don't have to be extraordinary to be a woman in cardiology, but I can tell you that the women who are in cardiology right now are amazing and extraordinary and wonderful to have as colleagues and friends. I hope you all will join us!

"It was a great honor to speak with Dr. Douglas about her experiences in the field. I am certain that her insights and advice will be valuable to many members of ACC's medical student community." – Anusha Gandhi

This article was authored by Anusha Gandhi, medical student at Baylor College of Medicine in Houston, TX, and member leader of the ACC Medical Student Leadership Group.

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