60 Years After the First Woman Cardiac Surgeon: We Still Need More Women in Cardiac Surgery

Sex-Associated Disparities in Surgical and Percutaneous Management of Aortic Stenosis With Severe Features: Retrospective Analysis From the National Readmission Database

BACKGROUND

Referral for valve intervention for severe aortic stenosis (AS) may exhibit sex-associated disparities independent of the growth of transcatheter interventions. This study aimed to determine whether there were sex-associated differences in the use of aortic valve replacement (AVR), either surgical or transcatheter, in patients with aortic stenosis and severe features from a national cohort of patients.

METHODS

Using the National Readmission Database, all patients with an index diagnosis of AS between January 2015 and December 2019 were included and stratified by their 90-day readmission status and sex. AS with severe features was defined as the combination of primary- or secondary-coded diagnosis of AS in combination with heart failure, syncope, angina pectoris, cardiac arrest, or cardiogenic shock. A 1:1 nested case-control matching was performed to account for competing risk. The main investigated outcome was the sex-associated rate of AVR in the 90 days after index hospitalization.

RESULTS

A total of 31 712 matched weighted discharges were included in the analysis, 16 597 men (52.3%) and 15 116 women (47.7%). At 90 days, the rate of AVR was significantly lower in women (45.7% versus 53.6%, P<0.001) with significant difference for both surgical (P<0.001) and transcatheter (P=0.010) interventions. After multivariable adjustment, these differences persisted with women significantly less likely to receive AVR (adjusted odds ratio [aOR], 0.67 [95% CI, 0.63-0.71], P<0.001), either surgical AVR (aOR, 0.48 [95% CI, 0.43-0.54], P<0.001) or transcatheter aortic valve implantation (aOR, 0.79 [95% CI, 0.75-0.84], P<0.001).

CONCLUSIONS

The use of surgical AVR and transcatheter aortic valve implantation was significantly lower in female patients with AS and severe features independent from patient- and hospital-level characteristics.

An environmental scan of current mentorship: fostering the next generations in cardiothoracic surgery in the UK

OBJECTIVES

Mentorship is critical to the professional development of junior colleagues in cardiothoracic surgery. Despite its presumed importance and frequent discussion, its impact within cardiothoracic surgery training remains uncharacterised within the UK. We aimed to evaluate mentorship experience and identify gaps in the system of mentorship education. The differences between men and women's views on mentorship are also considered.

METHODS

We prospectively collected of 92 responses [50 M:42 F] over 18 weeks. 'Society for Cardiothoracic Surgery in Great Britain and Ireland (SCTS) Critically Appraising mentorship' survey was formulated using electronic questionnaire system and distributed via emails to health professionals and medical students by using SCTS membership directory. The survey domains explore respondents' demographics, current or previous academic appointments, leadership roles, experience of mentorship, and opinions regarding ideal implementation of mentorship model, including the views on necessity for racial and gender concordance between mentor and mentee.

RESULTS

43% of respondents (40/92) had less than 5 years of experience in practice, but in general men were more experienced than women with over 15 years of practice (40% versus 9.52%) (p = 0.01). Women are more likely to change their practice due to favourable work-life balance (40%, 4/10) or due to financial incentives (40%, 4/10). On the other hand, men were mostly likely to transit due to career specialisation (38.1%, 8/21) (p = 0.014). 48% of respondents (45/92) have a system of mentorship in the current practice, but 66.67% (30/92) did not have formal evaluations. All male participants did not think gender of mentor/mentee was important, but 21.43% (9/42) of women did (p = 0.002).

CONCLUSION

The need for mentorship programme is widely recognised and is imperative to achieve maximum career potential, both professionally and personally. The key will be to establish more structured mentoring programme, finding apposite mentor-mentee dyad, predefining mentorship need, and recognising the unique needs associated with the mentee's identity. Women face unique challenges as a minority, and this must be considered when forming mentorship relationship.

Global gender representation among presidents of cardiothoracic surgery societies

OBJECTIVE

Females continue to be underrepresented in academia. An analysis of gender representation among presidents of cardiothoracic surgery societies worldwide was performed.

METHODS

A comprehensive search was performed to identify cardiothoracic surgical societies present worldwide and divided by regions. Respective Society's official webpage was searched to extract data on past and present presidents. Gender was determined and verified via publicly available online profiles. Proportions and respective 95 ​% confidence interval(CI) were calculated using Binomial exact calculation.

RESULTS

A total of 34 cardiothoracic surgery societies were identified globally, of which only 16 provided information on past presidents in the public domain. A total of 563 past and current society presidents were identified. Women constituted only 16 [2.84 ​%; 95 ​% confidence interval: 1.63 ​%; 4.57 ​%] presidents. The first-ever women president was appointed in the year 2007 by the STSA during the 54th Annual meeting.

CONCLUSION

Stark lag persists in gender representation of presidential roles among the cardiothoracic societies globally.

Promoting gender diversity and ergonomic equity in the cardiac surgery operating room

PURPOSE OF REVIEW

The operating room (OR) infrastructure and equipment such as gloves, were historically designed at a time when most surgeons were male. Today, there are increasing numbers of females in the OR and we should ensure that there is not a disproportionate risk of ergonomic stress and risk of work-related injuries. This review provides a perspective on the representation of female cardiac surgeons globally and examines the unique ergonomic challenges they may face.

RECENT FINDINGS

Female cardiac surgeons represent approximately 17% of practitioners in our sample of cardiac surgery centers, underscoring significant underrepresentation. Female cardiac surgeons report higher incidences of work-related musculoskeletal injuries and ergonomic challenges compared to their male colleagues. This could negatively impact their physical health and performance. Studies further highlight the inadequacy of standardized surgical tools and workstations in accommodating sex-specific anthropometry, contributing to the disproportionate strain experienced by female surgeons.

SUMMARY

To mitigate gender disparities in cardiac surgery, there is a need to optimize OR infrastructure and surgical instrumentation to accommodate sex-based anatomical differences. Implementing ergonomic solutions, such as adjustable workstations and gender-specific surgical tools, could reduce musculoskeletal injuries and improve overall surgeon performance. Addressing these disparities represents a critical step toward fostering an equitable and inclusive surgical workforce, enhancing both the health and career longevity of female cardiac surgeons.

Diversity Recruitment in Cardiovascular Specialties: Barriers and Opportunities in Postgraduate Training Programs

Background

Diversity in postgraduate training programs can be increased through program-based recruitment strategies. Prospective applicants often examine website content to determine if training programs are inclusive and offer a good fit. Poor overlap between program director recruitment goals and program website content as a barrier to recruiting a diverse physician workforce has not extensively been studied.

Objectives

The aim of this study was to characterize barriers to recruiting a diverse physician workforce in cardiovascular specialties in the United States.

Methods

Cross-sectional survey of program directors and evaluation of website content for training programs in adult general cardiology, cardiothoracic surgery, vascular surgery, and adult cardiothoracic anesthesiology.

Results

A total of 68 surveys were completed (response rates of 10% to 13% across specialties), and 626 websites in cardiovascular specialties were analyzed. A majority (63%) of program directors prioritized increasing diversity, although 40% of these respondents did not have a plan or resources. Program culture was cited as a barrier to recruiting a diverse workforce. The median website score for inclusion and health equity content was 4.0 out of 18.0, with a health disparities curriculum offered in <10% of websites for most specialties.

Conclusions

To advance diversity in cardiovascular specialties, training programs must have inclusive learning environments perceived by prospective applicants. Barriers to recruiting a diverse physician workforce may be decreased by addressing training program culture with an emphasis on modifying training program website content to attract more diverse applicant pools. Health disparities curricula are underutilized resources in cardiovascular specialties that may support recruitment of a more diverse physician workforce.

The Gender Disparity in Operative Opportunities for Trainee Surgeons: A Review

INTRODUCTION

Assessing gender disparity in surgical trainees' operative opportunities and experience quantifies implicit gender bias and reflects a summation of many smaller biased interactions within the operating room environment. Highlighting gender disparity in surgery informs a platform for advocacy.

METHODS

A systematic literature search was performed using Medline, Web of Science, OpenMD and Science Direct consistent with the Preferred Reporting Items for Systematic Reviews and Metanalysis guidelines. A Boolean search strategy was used to identify articles relevant to gender in operative surgery. Only English language studies that assessed the gender of surgical trainees with regards to operative cases for total and/or autonomously performed case numbers were included.

RESULTS

Fifteen papers assessing the influence of gender on operative opportunities for trainee surgeons were identified. A discrepancy between the operative experiences of men and women trainee surgeons was found. Of eight studies assessing gender differences in total case numbers, four reported women undertaking fewer total cases than men; a similar trend was demonstrated in two studies that failed to reach statistical significance. Eight of eleven studies examining surgical autonomy reported more surgical autonomy afforded to men trainee surgeons than women.

CONCLUSIONS

A gendered bias in the operative opportunities afforded to trainee surgeons is suggested in the literature, reflecting implicit bias that underlies surgical culture worldwide. Although surgical specialties continue to have vast gender inequity, we fail to leverage talent and the benefits of diverse skills and experience, to the detriment of ourselves and our patients. Quantifying this issue will inform change.

Women in cardiac surgery: a global workforce analysis

OBJECTIVES

Cardiac surgery remains one of the most gender-imbalanced surgical specialties. Women constitute 6-11% of the North American workforce, while other regional data are scarce. Despite the acknowledged under-representation of women in cardiac surgery globally and evidence that surgeon-patient gender concordance enhances postoperative outcomes, precise figures remain poorly defined. Herein, we provide the 1st global quantification of women cardiac surgeons (WCS) and explore correlates of workforce diversity.

METHODS

The Cardiothoracic Surgery Network database was queried for cardiac surgeons within each country and cross-validated with external sources. Profile pronouns and the genderize.io application determined surgeon sex. Data were stratified by country, geographical region and national income group, and correlation analyses with socioeconomic and gender parity metrics were performed.

RESULTS

Women constitute 8.0% (1178/14 651) of the international cardiac surgical workforce, with a median of 0.00 WCS per million women (interquartile range: 0.00-0.09). North America (11.4%) and Europe (10.3%) lead regional representation, while East Asia (2.9%) and the Middle East (1.7%) rank lowest. High-income countries (9.9%) have double the proportion of WCS as low- and middle-income countries (4.8%), with a notable absence among low-income countries. Female representation correlates with Gross National Income per capita (τ = 0.39), the Global Gender Gap Index (τ = 0.26) and health expenditure (τ = 0.26).

CONCLUSIONS

Improving female representation in cardiac surgery is essential to advancing social justice and overall patient care. Yet, WCS remain a minority worldwide, with the most pronounced disparities in low- and middle-income countries and regions with low Gross National Income, Global Gender Gap Index and health expenditure. Confronting these inequities will require targeted mentorship efforts and addressing country-specific entry barriers, necessitating further research into the unique factors influencing women in low- and middle-income countries.

Risk Factors for Major Pregnancy Complications in Female Cardiothoracic Surgeons

OBJECTIVE

To describe the incidence of and risk factors for pregnancy complications in female cardiothoracic surgeons compared with women of similar sociodemographic profiles.

BACKGROUND

Female cardiothoracic surgeons often postpone childbearing, but little is known about their pregnancy outcomes.

METHODS

In 2023, a self-administered survey was distributed to US cardiothoracic surgeons/trainees. Surgeons with ≥1 live birth were queried on maternal work hours during pregnancy and major antenatal pregnancy complications. Male surgeons answered on behalf of non-surgeon childbearing partners (female non-surgeons).

RESULTS

The study included 255 surgeons (63.53% male; 36.47% female). Compared with female surgeons, male surgeons more often had partners who were not employed outside the home (25.64% vs 13.33%, P <0.001). Female surgeons were older than female non-surgeons at first live birth (34.49±4.41 vs 31.45±4.16, P <0.001), more often worked >60 h/wk during pregnancy (70.33% vs 14.08%, P <0.001), and more often had pregnancy complications (45.16% vs 27.16%, P =0.003; operating room (OR): 1.78, 95% CI: 1.01-3.13). Among female surgeons, 18.28% reduced work hours during pregnancy. During their third trimester, 54.84% worked >6 overnight calls/mo, and 72.04% operated >12 h/wk. Age ≥35 years (OR: 3.28, 95% CI: 1.27-8.45) and operating >12 h/wk during the third trimester (OR: 3.72, 95% CI: 1.04-13.30) were associated with pregnancy complications.

CONCLUSIONS

Female cardiothoracic surgeons are more likely to experience major pregnancy complications than non-surgeon partners of their male peers. Long operative hours during pregnancy and older maternal age are significant risk factors for pregnancy complications. To advance gender equity, policies to protect maternal-fetal health and facilitate childbearing during training and early career are needed.

Gender disparities in cardiothoracic surgery: a comparative study in India

Background

This study aimed to examine the prevalence of gender bias in the field of cardiothoracic vascular surgery in India and compared women surgeons and trainees in India and abroad.

Methods

This was a comparative, cross-sectional analytical study using an online questionnaire. The survey included questions about demographics, career choice, training, academic and leadership opportunities, and the impact of choosing cardiothoracic-vascular surgery as a career on personal life.

Results

A total of 203 practicing surgeons and trainees participated in the study and included 121 (59.6%) men and 82 (40.3%) women. Out of the 82 women, 48 (58.5%) were from India, and 34 (41.5%) were from other countries. Satisfaction with the specialty was similar among men and women (105 (86.7%) vs. 68 (82.9%), p = 0.44 respectively). Majority (n = 30, 62.5%) of the female surgeons in India reported being discriminated against, as well as receiving favored treatment 11 (22.9%). Compared to men, women surgeons in India were more frequently advised against pursuing a career in cardiothoracic and vascular surgery (p < 0.001) and were more frequently subjected to gender-related references (p < 0.001). In addition, they had fewer presentation opportunities (p = 0.016) at national or regional meetings during their training compared to men. Additionally, 50% (24) of the women in India reported being single, in contrast to 7% (6) of men, and only 15 (31.3%) women reported having a child, compared to 57 (66.3%) of the men.

Conclusion

The study revealed significant gender disparities within the field of cardiothoracic vascular surgery in India and highlights the urgent need to address gender disparities and bias in cardiothoracic vascular surgery.

Barriers to Access to Cardiac Surgery: Canadian Situation and Global Context

Cardiovascular disease is the leading cause of morbidity and mortality worldwide. Cardiovascular care spans primary, secondary, and tertiary prevention and care, whereby tertiary care is particularly prone to disparities in care. Challenges in access to care especially affect low- and middle-income countries (LMICs), however, multiple barriers also exist and persist across high-income countries. Canada is lauded for its universal health coverage but is faced with health care system challenges and substantial geographic barriers. Canada possesses 203 active cardiac surgeons, or 5.02 per million population, ranging from 3.70 per million in Newfoundland and Labrador to 7.48 in Nova Scotia. As such, Canada possesses fewer cardiac surgeons per million population than the average among high-income countries (7.15 per million), albeit more than the global average (1.64 per million) and far higher than the low-income country average (0.04 per million). In Canada, adult cardiac surgeons are active across 32 cardiac centres, representing 0.79 cardiac centres per million population, which is just above the global average (0.73 per million). In addition to centre and workforce variations, barriers to care exist in the form of waiting times, sociodemographic characteristics, insufficient virtual care infrastructure and electronic health record interoperability, and health care governance fragmentation. Meanwhile, Canada has highly favourable surgical outcomes, well established postacute cardiac care infrastructure, considerable spending on health, robust health administrative data, and effective health technology assessment agencies, which provides a foundation for continued improvements in care. In this narrative review, we describe successes and challenges surrounding access to cardiac surgery in Canada and globally.

Redefining global cardiac surgery through an intersectionality lens

Although cardiovascular diseases are the leading cause of morbidity and mortality worldwide, six billion people lack access to safe, timely and affordable cardiac surgical care when needed. The burden of cardiovascular disease and disparities in access to care vary widely based on sociodemographic characteristics, including but not limited to geography, sex, gender, race, ethnicity, indigeneity, socioeconomic status and age. To date, the majority of cardiovascular, global health and global surgical research has lacked intersectionality lenses and methodologies to better understand access to care at the intersection of multiple identities and traditions. As such, global (cardiac) surgical definitions and health system interventions have been rooted in reductionism, focusing, at most, on singular sociodemographic characteristics. In this article, we evaluate barriers in global access to cardiac surgery based on existing intersectionality themes and literature. We further examine intersectionality methodologies to study access to cardiovascular care and cardiac surgery and seek to redefine the definition of 'global cardiac surgery' through an intersectionality lens.

Global Access to Comprehensive Care for Paediatric and Congenital Heart Disease

Paediatric and congenital heart disease (PCHD) is common but remains forgotten on the global health agenda. Congenital heart disease is the most frequent major congenital anomaly, affecting approximately 1 in every 100 live births. In high-income countries, most children now live into adulthood, whereas in low- and middle-income countries, over 90% of patients do not get the care they need. Rheumatic heart disease is the most common acquired cardiovascular disease in children and adolescents. While almost completely eradicated in high-income countries, over 30-40 million people live with rheumatic heart disease in low- and middle-income countries. Challenges exist in the care for PCHD and, increasingly, adult congenital heart disease (ACHD) worldwide. In this review, we summarize the current status of PCHD and ACHD care through the health systems lens of workforce, infrastructure, financing, service delivery, information management and technology, and governance. We further highlight gaps in knowledge and opportunities moving forward to improve access to care for all those living with PCHD or ACHD worldwide.

Women in mechanical circulatory support: She persisted!

Many women physicians have blazed trails and played instrumental roles in advancing the field of Advanced Heart Failure (AHF), Mechanical Circulatory Support (MCS), and cardiac transplantation to its current recognition and glory. In contrast to other areas of cardiology, women have played an integral role in the evolution and emergence of this sub-specialty. Although the ceiling had been broken much later for women cardiothoracic (CT) surgeons in the field of AHF, the ingress of women into surgical fields particularly CT surgery was stonewalled due to pervasive stereotyping. The constancy, commitment, and contributions of women to the field of AHF and MCS cannot be minimized in bringing this field to the forefront of innovation both from technological aspect as well as in redesigning of healthcare delivery models. Integrated team-based approach is a necessity for the optimal care of MCS patients and forced institutions to develop this approach when patients with durable left ventricular assist devices (LVAD) began discharging from the hospitals to local communities. Women in various roles in this field played a pivotal role in developing and designing patient centered care and coordination of care in a multidisciplinary manner. While embracing the challenges and turning them to opportunities, establishing partnerships and finding solutions with expectations to egalitarianism, women in this field continue to push boundaries and subscribe to the continued evolution of the field of AHF and advanced cardiac therapies.