Sex, Gender, and Equity in Cardiovascular Medicine, Surgery, and Science in Canada Challenges, Successes, and Opportunities for Change

The Canadian Women's Heart Health Alliance ATLAS on the Epidemiology, Diagnosis, and Management of Cardiovascular Disease in Women - Chapter 8: Knowledge Gaps and Status of Existing Research Programs in Canada

Despite significant progress in medical research and public health efforts, gaps in knowledge of women's heart health remain across epidemiology, presentation, management, outcomes, education, research, and publications. Historically, heart disease was viewed primarily as a condition in men and male individuals, leading to limited understanding of the unique risks and symptoms that women experience. These knowledge gaps are particularly problematic because globally heart disease is the leading cause of death for women. Until recently, sex and gender have not been addressed in cardiovascular research, including in preclinical and clinical research. Recruitment was often limited to male participants and individuals identifying as men, and data analysis according to sex or gender was not conducted, leading to a lack of data on how treatments and interventions might affect female patients and individuals who identify as women differently. This lack of data has led to suboptimal treatment and limitations in our understanding of the underlying mechanisms of heart disease in women, and is directly related to limited awareness and knowledge gaps in professional training and public education. Women are often unaware of their risk factors for heart disease or symptoms they might experience, leading to delays in diagnosis and treatments. Additionally, health care providers might not receive adequate training to diagnose and treat heart disease in women, leading to misdiagnosis or undertreatment. Addressing these knowledge gaps requires a multipronged approach, including education and policy change, built on evidence-based research. In this chapter we review the current state of existing cardiovascular research in Canada with a specific focus on women.

Understanding Current Demographics, Practice Patterns, and Concerns of Women in Urology: Analysis From the 2022 Society of Women in Urology Census Task Force

OBJECTIVE

To describe the current demographics, needs, and challenges of women in Urology throughout the United States, including active Urologists as well as urologic trainees.

METHODS

An electronic survey was distributed via email and social media sites to all members of the Society of Women in Urology, including residents, fellows, and female urologists practicing in the US and its territories, between February 2022 and May 2022. The survey collected information on demographics, practice type, workplace, personal, family issues, barriers, and career plans from all respondents.

RESULTS

Of the estimated 1375 women urologists and trainees based on AUA census data, 379 responses (27.6% response rate) were received. Almost all respondents (98%) are members of the AUA. The average age was 42.9years (SD 18.6). In terms of ethnicity, most self-reported as White 71.0%, followed by 16.4% Asian or Asian American, and 6.3% African American. The majority reported practicing in urban locations (63.5%) at an academic setting (55.7%), followed by similar distribution between private practice and hospital-employed settings (17.0% and 16.7%, respectively). The vast majority, 89.6%, reported working full-time, while only 10.4% worked part-time. The average hours of work per week were 56.7 (SD 14.5). In terms of personal demographics, 81.9% were married, 17.3% were single and 1% did not answer. 68.8% of responders had children, with the majority of these children being born during or after training.

CONCLUSION

Based on the findings, although female urologists have increased in numbers, certain ethnicities are under-represented. Additional surveys and engagement of current trainees and practitioners are needed to identify further areas of intervention for specific needs.

Impact of gender inequality on the educational and career development of young epileptologists in Italy: A survey of the Young Epilepsy Section - Italian chapter

OBJECTIVE

The Young Epilepsy Section-Italian chapter (YES-I) is the Italian section of the International League Against Epilepsy (ILAE)-YES. It was founded in 2019 with the aim of increasing the involvement of young epileptologists within scientific associations and facilitating their educational training. The Education and Career Task Force designed a survey on the impact of gender inequality on the educational and professional growth of young epileptologists.

METHODS

The survey was proposed via QR code during the 43rd National Congress of the Italian League Against Epilepsy (Padua, 8-10 June 2022), and subsequently distributed via email until 7th September 2022.

RESULTS

Of the respondents, 73.6% were female. Of note, 51% of the entire sample answered that they found "no impact" of gender on educational activities (64.3% male against 46.1% female). Only 10% of women stated they have seen very much gender-related inequality in their education or career. However, the majority of our cohort (66%) thought that gender had a negative impact on progression within a scientific society, as well as in female leadership roles in clinical practice (67.9%). Furthermore female medical staff received little work recognition (56.6%). Lastly, 83% of responders did not have children, and only 37.7% declared their colleagues to be empathic in relation to absences for family emergencies.

CONCLUSIONS

Lack of awareness of the gender inequality issue might explain inconsistencies in the findings of our survey. Despite the remarkable progress of women rights over the last century, our survey suggests that disparities in academic and decision-making roles exist also in the epileptology field.

Demographics of Current and Aspiring Integrated Six-year Cardiothoracic Surgery Trainees

BACKGROUND

The integrated 6-year thoracic surgery (I-6) residency model was developed in part to promote early interest in cardiothoracic surgery in diverse trainees. To determine gaps in and opportunities for recruitment of women and minority groups in the pipeline for I-6 residency, we quantified rates of progression at each training level and trends over time.

METHODS

We obtained 2015 to 2019 medical student, I-6 applicant, and I-6 resident gender and race/ethnicity demographic data from the American Association of Medical Colleges and Electronic Residency Application Service public databases and Accreditation Council for Graduate Medical Education Data Resource Books. We performed χ², Fisher exact, and Cochran-Armitage tests for trend to compare 2015 and 2019.

RESULTS

Our cross-sectional analysis found increased representation of women and all non-White races/ethnicities, except Native American, at each training level from 2015 to 2019 (P < .001 for all). The greatest trends in increases were seen in the proportions of women (28% vs 22%, P = .46) and Asian/Pacific Islander (25% vs 15%, P = .08) applicants. There was also an increase in the proportions of women (28% vs 24%, P = .024) and White (61% vs 58%, P = .007) I-6 residents, with a trend for Asian/Pacific Islanders (20% vs 17%, P = .08). The proportions of Hispanic (5%) and Black/African American (2%) I-6 residents in 2019 remained low.

CONCLUSIONS

I-6 residency matriculation is not representative of medical student demographics and spotlights a need to foster early interest in cardiothoracic surgery among all groups underrepresented in medicine while ensuring that we mitigate bias in residency recruitment.

How can pediatric surgeons address racism and become actively anti-racist?

BACKGROUND/PURPOSE

This is an article submitted on behalf of the Canadian Association of Pediatric Surgeons. We assert that Pediatric Surgeons must work to dismantle systemic racism. Pediatric Surgeons have expertise in both common and rare surgical diseases affecting patients ranging from premature neonates to adolescents. Thus, our professional obligation is to transform our health and social systems to prevent the harms of racism to our patients.

METHODS

Specific to the Canadian context, we describe a brief history, the ongoing impact on individuals and communities, and the harmful effect on the surgical community and trainees. Finally, we developed a series of practical recommendations to help surgeons become actively anti-racist.

RESULTS

Four primary recommendations are made: (1) Increasing and supporting anti-racism education; (2) Changing individual behaviours to combat racism; (3) Developing strategies for organizational change; and (4) Committing to diversity in leadership.

CONCLUSION

As surgeons, we are actors of change, and we can take meaningful steps to combat racism in our health systems.

LEVEL OF EVIDENCE

V.

Experiences and Impacts of Harassment and Discrimination Among Women in Cardiac Medicine and Surgery: A Single-Centre Qualitative Study

Background

Gender- and sex-based harassment and discrimination are consistently reported by about 50% of women physicians, and the prevalence may be even greater among women in cardiology. An exploration of these experiences and their impacts on women in healthcare is necessary to design interventions, create supports, and facilitate empathy, support, and allyship among leadership.

Methods

To understand and describe the experiences of harassment and discrimination among women working in cardiac sciences, to inform the design of interventions and supports, we performed one-on-one, semi-structured interviews with women in the Department of Cardiac Sciences in a single institute. Interviews were coded independently in parallel using thematic analysis and reconciled by trained qualitative researchers. Experiences were categorized as harassment using the Canadian Human Rights Act. Codes were grouped into themes by iterative discussion.

Results

There were 15 participants, including trainees, physicians in a variety of cardiac subdisciplines, and nurse practitioners. All participants had experienced sex- or gender-based discrimination at work, though the impact and perception of these experiences varied. Whereas some participants felt that these experiences had little influence on their careers or personal lives, others changed practice specialties or locations due to harassment. Several participants had been sexually assaulted at work. Interviews revealed modifiable barriers to reporting harassment.

Conclusions

This qualitative dataset enriches the prevalence data on sex- and gender-based harassment among women working in cardiology by describing the impacts and perceptions of this harassment. Organizations should address commonly described barriers to reporting harassment, including addressing retaliation, and create systems-level supports for those affected by harassment.

Trends in leadership at shoulder and elbow fellowships: a cross-sectional demographic review

OBJECTIVE

To determine educational characteristics, trends, and demographics among shoulder and elbow fellowship leaders (FLs).

BACKGROUND

Fellowship leaders in shoulder and elbow impart lasting impact on trainees and field development. Four previous studies have analyzed the characteristics and career path trends among orthopedic surgery subspecialty FLs (spine, adult reconstruction, trauma, and sports medicine). We characterized the educational backgrounds and demographic composition of all 40 FLs including fellowship directors (FD), fellowship co-directors (co-FD), and associate fellowship directors (associate FD) of 31 American Shoulder and Elbow Surgeons (ASES)-accredited shoulder and elbow fellowships in the United States. We additionally compiled the residency and fellowship institutions that trained FLs as framework for aspiring leaders in orthopedic surgery.

METHODS

Using the American Shoulder and Elbow Surgeons (ASES) directory website page "ASES-Recognized Shoulder and Elbow Fellowship Programs," we identified all active shoulder and elbow fellowships within the United States as well as associated FL identifiers. Compiled data points include age, sex, ethnicity, residency/fellowship training location, time since education completion until FL appointment, length in FL role, personal research Scopus H-index, and major society and journal leadership position history.

RESULTS

We analyzed data from all 40 active FLs across 31 ASES-accredited shoulder and elbow fellowships, encompassing 26 FDs, 13 co-FDs, and 1 associate FD. The majority of FLs (97.5%) were male whereas 2.5% were female, with racial/ethnic identification of 80.0% Caucasian, 10.0% Asian/Pacific Islander, and 10.0% Middle Eastern. The mean Scopus H-index of the FLs was 24.63 ± 16.43. The top residency programs for producing future FLs were the University of Pittsburgh, University of Pennsylvania, University of Nebraska/Creighton, Hospital for Special Surgery, and Brown University (all n = 2). The top fellowship programs for producing future FLs were Mayo Clinic (n = 6), Columbia University (n = 6), San Francisco/California Pacific (n = 4), and Washington University in St Louis (n = 4).

CONCLUSION

Shoulder and elbow fellowship leaders graduate with increased frequency from certain fellowship programs with lesser correlation to residency institutions. Programs demonstrate high retention of prior trainees as future FLs. All FLs are distinguished by high indices of research productivity; however, demographic diversity remains limited, which is comparable to prior orthopedic subspecialty FL investigations.

Gender Differences in International Cardiology Guideline Authorship: A Comparison of the US, Canadian, and European Cardiology Guidelines From 2006 to 2020

Background Women continue to be underrepresented in cardiology and even more so in leadership positions. We evaluated the trends and gender differences in the guideline writing groups of the American College of Cardiology/American Heart Association (ACC/AHA), Canadian Cardiovascular Society (CCS), and European Society of Cardiology (ESC) guidelines from 2006 to 2020. Methods and Results We extracted all guidelines authors from 2006 to 2020, assessed their gender from publicly available profiles, and compared differences based on subspecialties and specific societies. Stratified and trend analyses were performed using χ² and average annual percentage change/average 5 year percentage change. A total of 80 ACC/AHA (1288 authors [28% women]), 64 CCS (988 authors [26% women]), and 59 ESC (1157 authors [16% women]) guidelines were analyzed. A significant increase in inclusion of women was seen in ACC/AHA (12.6% [2006] to 42.6% [2020]; average annual percentage change, 6.6% [2.3% to 11.1%]; P=0.005) and ESC (7.1% [2006] to 25.8% [2020]; average annual percentage change, 6.6% [0.2% to 13.5%]; P=0.04), but the trend remained similar in CCS (20.6% [2006] to 36.3% [2020]; average annual percentage change, -0.1% (-3.7% to 3.5%); P=0.94), guideline authors. More women were coauthors in the ACC/AHA and ESC guidelines when women were chairs of guidelines. There was a persistent disparity of women among guideline authors for general cardiology and all subspecialties, except for pediatric cardiology and heart failure guidelines. The appointment of women authors as a chair was significantly low in all societies (22.4% [ACC/AHA], 16.9% [CCS], and 7.2% [ESC]; P=0.008). Conclusions There is a significant disparity in the inclusion of women on all national guideline committees, in addition to serving as a chair of cardiology guidelines. Further advocacy is required to promote equity, diversity, and inclusion in our cardiology guidelines globally.

National Trends of Gender Disparity in Canadian Cardiovascular Society Guideline Authors, 2001-2020

Background

The level of representation of women in cardiology remains low compared to that of men, particularly in leadership positions. We evaluated gender disparity in the authorship of Canadian Cardiovascular Society (CCS) guidelines.

Methods

All CCS guidelines from 2001-2020 were identified. Gender was assessed based on pronoun use in the biographies and social media of the authors. Only primary panel authors were included in our analysis. Stratified analyses were performed based on subspecialties.

Results

A total of 76 guidelines were identified, with 1172 authors (26% women, 74% men, P < 0.0001), with no significant change in percentage of women authors over 2 decades, (37.1% in 2001, 36.3% in 2020, P = 0.34). Inclusion of women as authors occurred less frequently than inclusion of men in general cardiology guidelines (20.1% vs 79.9%, P < 0.0001) and all subspecialties—heart failure (36.4% vs 63.6%, P < 0.0001), interventional cardiology (12.6% vs 87.4%, P < 0.0001), electrophysiology (20.2% vs 79.8%, P < 0.0001), and pediatric cardiology (41.7% vs 58.3%, P = 0.02). It was less likely for women to be a chair or cochair of a guideline writing committee, compared with men (20.1% vs 79.8%, P < 0.0001). There were 609 unique authors (25.6% women, 74.4% men, P < 0.0001), 542 unique medical doctorate (MD) authors (20.7% women, 79.3% men, P < 0.0001), and 67 unique non-MD authors (65.7% women, 34.3% men, P = 0.0003).

Conclusions

There is a persistent shortfall in the inclusion of women authors for CCS guidelines, which has not changed over time. Further efforts are required to promote women's inclusion in leadership roles, which may lead to authorship of the guidelines.

Cardiovascular Physicians, Scientists, and Trainees Balancing Work and Caregiving Responsibilities in the COVID-19 Era: Sex and Race-Based Inequities

Background

The ongoing COVID-19 pandemic has exposed a work-life (im)balance that has been present but not openly discussed in medicine, surgery, and science for decades. The pandemic has exposed inequities in existing institutional structure and policies concerning clinical workload, research productivity, and/or teaching excellence inadvertently privileging those who do not have significant caregiving responsibilities or those who have the resources to pay for their management.

Methods

We sought to identify the challenges facing multidisciplinary faculty and trainees with dependents, and highlight a number of possible strategies to address challenges in work-life (im)balance.

Results

To date, there are no Canadian-based data to quantify the physical and mental effect of COVID-19 on health care workers, multidisciplinary faculty, and trainees. As the pandemic evolves, formal strategies should be discussed with an intersectional lens to promote equity in the workforce, including (but not limited to): (1) the inclusion of broad representation (including equal representation of women and other marginalized persons) in institutional-based pandemic response and recovery planning and decision-making; (2) an evaluation (eg, institutional-led survey) of the effect of the pandemic on work-life balance; (3) the establishment of formal dialogue (eg, workshops, training, and media campaigns) to normalize coexistence of work and caregiving responsibilities and to remove stigma of gender roles; (4) a reevaluation of workload and promotion reviews; and (5) the development of formal mentorship programs to support faculty and trainees.

Conclusions

We believe that a multistrategy approach needs to be considered by stakeholders (including policy-makers, institutions, and individuals) to create sustainable working conditions during and beyond this pandemic.