Why are the numbers of women and minorities so low in cardiac PE?

The very low number of women and ethnic minority individuals in the cardiac electrophysiology (EP) specialty in the United States has been highlighted in two new studies.

The first study showed that only 5% of EP operators in Medicare procedures are women, and that number hasn’t increased in recent years.

The second study found a very low rate of application to PE training programs from female and ethnic minority cardiology fellows.

“Women remain underrepresented in PE,” said lead author of the first study, Stacey Howell, MD, University of California, San Francisco. lecoeur.org | Medscape Cardiology. “Even in areas of major clinical growth, such as atrial fibrillation (AF) ablation, the number of women does not increase.”

Both groups stress that more needs to be done to attract women and ethnic minorities into the field of EP.

“It’s important to have diversity across all specialties. Women have been shown to have poorer outcomes with certain procedures, including AF ablation, and also more limited access,” said Usha Tedrow, MD, Brigham & Women’s Hospital, Boston, lead author of the second study. , commented.

“Female and underrepresented minority cardiologists are more likely to provide equitable treatment and decision-making to patients,” Tedrow added. “Some ethnic minority women and patients prefer to have conversations about whether to have surgery or have a defibrillator fitted with a doctor who shares their background.”

Both studies are being presented at the Heart Rhythm 2022 meeting in San Francisco this weekend. The studies are also published online to coincide with their presentation at the meeting – one as paper in Heartbeat and the other as letter to JACC: Clinical Electrophysiology.

Howell explained that his group wanted to look into this issue in order to better define the representation of women in the EP and how it has changed over the past few years.

They looked at data from the Medicare Provider Utilization and Payment Database from 2013 to 2019 using codes for the most common EP procedures – AF ablation, supraventricular tachycardia/atrial flutter (SVT/AFL) ablation and implantation of cardiac devices. The database summarizes Medicare services in the United States and also provides information on the operator’s gender and geographic location.

The results showed that on an annual average between 2013 and 2019, 5% of the 3524 EP operators were women. Procedure-specific analyzes demonstrated an equally low proportion of PE operators for each type of procedure.

Despite a 137% increase in the total number of operators performing AF ablation over the 7-year period, the proportion of women remained unchanged at 4%. The number of operators performing SVT/AFL ablations and device operators remained constant over time, as did the proportion of female operators at 5%.

Howell acknowledged some limitations of the Medicare database – that it does not include all EP procedures in the US (so some operators will have been overlooked) and that the database does not include operators who perform less of 10 procedures per year (so data on low operator volumes was not captured).

“I think it’s still a good overall representation of women in the field,” she said.

Other findings included:

  • 10 US states had no PE operator performing more than 10 given PE procedures per year

  • 20 states had no women who performed more than 10 AF or SVT/AFL ablation procedures per year

  • 10 states had no device operators performing more than 10 device implantations of any type per year

Howell pointed out that there are challenges both in recruiting women into PE and in retaining women in the specialty. “The data suggests that approximately 9% of board-certified EPs are women, but our study shows that only 5% of clinicians performing EP procedures are women. So there may be a transition of women from EP laboratory to industry, research or more general cardiology tasks.”

The second study, presented at the HRS meeting by Tedrow and Uyanga Batnyam, MD, also of Brigham & Women’s, examined data on Electronic Residency Application Service (ERAS) cardiac EP scholarship applicants from 2018 to 2021.

Among the pool of candidates for cardiac PE, women made up only 13% to 15% and ethnic minorities 7% to 10%.

African Americans were particularly poorly represented, making up only 3% to 5% of applicants, and the numbers for Hispanic applicants were similar (4% to 5%).

The Brigham Group also reviewed all cardiology candidates and found that of all cardiology candidates, 71% had done no subspecialties beyond cardiology, 11% had done interventional cardiology, 10% cardiac arrestand only 6% applied for an EP scholarship.

Attrition of women at each stage of training

“There’s a concept of women leaking from the pipeline. There’s a gradual numerical attrition of representation at every stage of formation,” Tedrow noted.

She said women make up 48% of medical students and 42% of internal medicine trainees, but when it comes to cardiology fellowships, only 23% are women, and for cardiac EP fellowships, the figure drops even further. more at 14%.

“The trajectory of ethnic minorities does not show the same attrition but rather starts low and stays low,” she added, with ethnic minorities accounting for 10% of medical students, 13% of internal medicine trainees, 9% of cardiology fellows, and 7% of cardiac EP fellows.

Howell and Tedrow both suggested issues that could explain the low percentage of women in the PE field.

Tedrow cited a survey published last year that found female cardiology fellows gave reasons for not pursuing the EP specialty, including lack of female role models, risk of radiation exposureand a perception of an “old boys’ club”.

“We need to give cardiology fellows early exposure to EP training, so they are all aware of the different procedures and change the culture to make it more appealing to women. The specialty needs to do more to ensure that recruitment processes are fair and equitable and we need to consider how we can actively recruit for diversity,” she said.

Howell added that the long duration of training can discourage women. “EPs have one of the longest training paths in medicine, taking a total of 12 years before they are fully qualified – 4 years of medical school, 3 years of internal medicine training, 3 years of scholarship in general cardiology and then another 2 years of fellowship in cardiac electrophysiology. a long period of training can be unattractive for women.”

While exposure to fluoroscopy can also be a concern for women, Howell pointed out that many procedures are now performed with less fluoroscopy, which hopefully minimizes this issue.

“We need to improve female mentorship. As a cardiology trainee, it can be difficult to get exposure to the EP lab. We need to work harder to attract female cardiology fellows to the EP lab and give them a better understanding of what a career in cardiac EP looks like. Maybe the training period can be streamlined as well,” Howell said.

“EP is the best kept secret in cardiology”

Tedrow thinks cardiac PE is a good specialty for women. “Most of the procedures are elective, so you have a lot of control over your schedule, and exposure to fluoroscopy is now minimal. You also see a wide range of patients, so it’s a great discipline for women interested in a procedural specialty, but PE is the best kept secret in Cardiology, and we need to make Cardiology Fellows aware of this at an early stage in their training,” she commented.

In a editorial support the paper in Heartbeat, Kavisha Patel, MD, and Ulrika Birgersdotter-Green, MD, University of California San Diego Health, note that there has recently been an improvement in terms of female representation in leadership roles, with three presidents of the Heart Rhythm Society over the past decade. women. A steady increase has also been noted in female physician speakers at major cardiovascular conferences.

Columnists say this, combined with ongoing efforts to identify and overcome barriers, raises hopes of attracting more female cardiology fellows to pursue PE.

“The common goal must be to strive for a diverse, inclusive and supportive environment in which both genders can thrive,” they conclude.

Heartbeat 2022 Meeting. Presented April 29-30, 2022.

Heartbeat. Published online April 29, 2022. Full Text, Editorial

JACC: Clinical Electrophysiology. Published online April 28, 2022. Letter


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