JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY
8, 2020
ª 2020 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION
PUBLISHED BY ELSEVIER
FELLOWS-IN-TRAINING & EARLY CAREER SECTION
A Model for the Career Advancement of
Women Fellows and Cardiologists
Nosheen Reza, MD, Sheela Krishnan, MD, Srinath Adusumalli, MD, MSC
C ardiology has long been a male-dominated
field. The American College of Cardiology
(ACC) and other credentialing organizations
estimate that approximately 10% to 14% of board-
certified and/or active adult cardiologists in the United
States are women (1,2). Over the past 12 years, the pro-
portion of women in U.S. general cardiology fellow-
ship programs has languished at 20% (3). Although
the percentage of women in U.S. internal medicine
training programs has increased over the last 25 years,
with women now comprising more than one-half of all
matriculants, the proportion of women training in
subspecialty fellowships has decreased. From 1991 to
2016, cardiology attracted the fewest women of 9 med-
ical subspecialties and had the lowest rates of increase
in enrolled women over this period (4).
The ACC and other societies have taken meaning-
ful steps toward identifying sex disparities in cardi-
ology and encouraging diversity and inclusion (1).
Much has been written about barriers to the engage-
ment of women, including wage inequality (5,6); bias,
discrimination, and sexual harassment (7); lack of
institutional support, mentorship, and role modeling
(8); inadequate workplace support for pregnant and
nursing cardiologists (9); and negative perceptions of
the field (10–12). Fellows-in-training (FITs) and early
career cardiologists (ECs) are particularly affected by
From the Division of Cardiovascular Medicine, Department of Medicine,
Perelman School of Medicine at the University of Pennsylvania, Phila-
delphia, Pennsylvania. Dr. Reza is supported by the National Institutes of
Health National Human Genome Research Institute Ruth L. Kirschstein
Institutional National Research Service T32 Award in Genomic Medicine
(T32 HG009495). All other authors have reported that they have no re-
lationships relevant to the contents of this paper to disclose.
The authors attest they are in compliance with human studies commit-
tees and animal welfare regulations of the authors’ institutions and Food
and Drug Administration guidelines, including patient consent where
appropriate. For more information, visit the JACC author instructions
page.
ISSN 0735-1097/$36.00
VOL. 76, NO.
these barriers at: 1) major career transitions, when
cultivating mentorship and sponsorship relationships
becomes essential; 2) during childbearing and early
parenting years; and 3) because sex biases can
adversely influence professional advancement
(13,14). Specific action plans that individuals and in-
stitutions can implement to highlight and ameliorate
these disparities are lacking.
In 2017, we founded the Penn Women in Cardiol-
ogy (PWIC), an organization of female FITs and fac-
ulty established to promote the recruitment,
retention, and advancement of female cardiologists.
Over the last 3 years, PWIC has implemented goal-
oriented programming for all levels of trainees and
faculty to directly address barriers faced by women in
cardiovascular medicine (Figure 1).
SKILL DEVELOPMENT
We conducted a needs assessment, targeted to female
FITs and faculty, from which we identified de-
ficiencies in professional skills as the initial target for
intervention. Women from within and outside of our
institution subsequently led a dedicated curriculum
on these topics. In our Time, Email, and EHR Man-
agement workshop, women learned how to assign
value to professional projects and responsibilities. In
our Leadership Style practicum taught by an expert
from the Wharton School of Business, attendees
gained insight into their leadership preferences. In
our Identifying and Balancing Personal Values
seminar, an executive coach guided women through
skill building in conflict resolution and negotiation.
FITs learned about the fellow-to-faculty transition
through our Job Search, Contracts, and Promotions
didactic with the division business administrator.
LEADERSHIP AND SPONSORSHIP
We are creating a culture in which mentor and
sponsor FITs and ECs for leadership opportunities.
https://doi.org/10.1016/j.jacc.2020.07.011
JACC VOL. 76, NO. 8, 2020 Reza et al. 997
AUGUST 25, 2020:996–1000 Fellows-in-Training & Early Career Section

F I G U R E 1 Mission, Vision, and Framework for the Establishment of a Formal Program to Support Women in Cardiology

Mission Statement Vision Statement

To advance opportunities for female To promote the recruitment and retention of women
cardiologists throughout their careers cardiovascular physicians & achieve gender parity across
personal and professional career domains
PILLARS

SKILL LEADERSHIP &

DEVELOPMENT SPONSORSHIP NETWORKING MENTORSHIP ADVOCACY

Needs Assessment Leadership Positions Speed Mentoring High School Shadowing Pregnancy
Chief Fellowship
Faculty Recruitment Parental Leave
Grand Rounds Coffee with a Cardiologist
Speaker Sessions Re-entry to Training
INTERVENTIONS

National Training
ACC WIC Leadership
Skill-Based Workshops ACC Leadership Forum
Time, Email, EHR ACC 3T Program
Leadership Styles ACC Leadership Academy
Personal Values
Job Search Opportunities
Negotiation
ACC Section Councils
Presentation Skills
ACC Committees
Personal Finance
ACC State Chapter
One-on-One Resident Radiation Safety
Regional & National
Mentoring
Conferences Fertility Preservation
Quarterly Newsletter
Social Media Interventional Cardiology
& Electrophysiology Grand Rounds
Alumni Network
Collaboration with Fellowship Recruitment
Women in Medicine
Groups Social Events Community Service

Key pillars of this program include skill development, leadership and sponsorship, networking, mentorship, and advocacy. ACC ¼ American College of Cardiology;
EHR ¼ electronic health record.

Over the last 5 years, 60% of our chief fellows have
been women. FITs attend national
training conferences with support from the fellow-
ship and share new knowledge with PWIC through
formal presentations upon their
encourage and nominate FITs to apply for ACC op-
portunities and have had 3 women serve as FIT
Editorial Fellows, 5 on Pennsylvania ACC Chapter
task forces, 6 on national ACC leadership councils,
15 as speakers at national conferences, and many in
leadership positions in multiple other professional
societies.
NETWORKING
Women build, maintain, and utilize professional
networks less effectively than men (15). We coun-
teract this with programming focused on developing
networks and networking skills. In our Speed Men-
toring, FITs are paired with women faculty in a speed
dating-style session to hone their “elevator pitches”
and exchange perspectives on being good mentees
and mentors. Visiting female Grand Rounds speakers
regularly meet with PWIC for Special Speaker Ses-
sions; over the last 3 years, we have met with 13
eminent female faculty in cardiovascular medicine.
leadership Through these opportunities, FITs and ECs learn
about the careers of successful WIC and meet new
potential mentors, sponsors, employers, and
return. We collaborators.
MENTORSHIP
From PWIC’s inception, we have prioritized outreach
to students and residents. In Coffee with a Cardiolo-
gist, we pair individual medical students with PWIC
members to discuss careers in cardiology. After their
initial meetings, medical students shadow FITs and
ECs and remain in contact with them. Internal med-
icine interns considering cardiology have One-on-One
Mentoring Meetings in which PWIC members create
action plans for the second to third years of resi-
dency, outline the fellowship application process,
connect trainees with research mentors, and offer
experiences for clinical cardiology exposure. These
meetings also allow PWIC members to tackle
perceived myths about cardiology that may otherwise
deter trainees from the field. Three “undecided”
women residents have chosen cardiology as a result
of PWIC mentorship.
998 Reza et al.
Fellows-in-Training & Early Career Section
This year, we will launch our interventional car-
diology and clinical cardiac electrophysiology (CCEP)
Alumni Network. Last year, women comprised only
12% of CCEP and 10% of IC fellows (16). The lack of
female role models in interventional cardiology and
CCEP strongly deters women from pursuing these
careers (17,18). We will use Internet-based platforms
for remote mentoring sessions to strengthen the
quantity and quality of role modeling for women in
procedural specialties.
ADVOCACY
Many female cardiologists face significant work-
related barriers to pre-conception health, pregnancy,
and breastfeeding (9). We developed and dissemi-
nated Guidelines and Expectations for Breastfeeding
Mothers, which summarizes challenges faced by
nursing FITs, delineates how each barrier should be
addressed in the clinical environment, and offers re-
sources to FITs and supervisors (19). The fellowship
program offsets expenses related to childcare and
pumping supplies incurred by new trainee mothers
who attend national conferences. Radiation safety
education is provided throughout training, and rota-
tion schedules are modified to accommodate trainee
preferences regarding radiation exposure during and
after pregnancy.
Policies regarding parental leave for medical
trainees are widely disparate (20,21). Insufficient
length and lack of paid leave have been associated
with parental stress and shorter breastfeeding dura-
tions (22). In contrast, shared caregiving has been
associated with safer births and decreased risk of
postpartum depression (23). The fellowship pro-
gram’s approach to parental leave involves
personalized discussion with each expecting FIT
regarding her/his options for parental leave, incor-
porating paid and unpaid leave, vacation time, and
allowances through the Family and Medical Leave Act
and American Board of Internal Medicine (24). We
encourage new mothers to take 12 weeks leave and
have created flexibility in the rotation schedule to
accommodate longer leaves or unanticipated events.
We also strongly encourage new fathers to take
extended leave at intervals that are best for their
families. Since establishing this practice, new fathers
have each taken between 2 to 6 weeks leave, an
improvement from the previous average of 1 week. In
2017, PWIC successfully advocated for a change in the
health system’s House Staff Policy to allow for
12 weeks of parental leave for dual physician-trainee
JACC VOL. 76, NO. 8, 2020
AUGUST 25, 2020:996–1000
couples, instead of the previously permitted
6 weeks per household (25).
Finally, fertility preservation is a common and
important consideration for FITs and ECs embarking
on extended training pathways like cardiology (26).
PWIC members have led departmental workshops on
this topic and are creating a resource guide for FITs.
To address the known gender disparities in recog-
nizing women trainee and faculty scholarship (27),
PWIC publishes a quarterly newsletter and uses social
media to promote women’s accomplishments. The
newsletters are disseminated to deans, the division
chief, and the faculty. Both interventions have helped
us engage men and women from within and outside
our institution as allies.
After identifying a gender disparity in invited
Grand Rounds speakers, PWIC collectively nominated
over 20 women for Grand Rounds lectureships for the
2019-2020 year. This year, one-half of the invitations
were extended to women, as compared to 7% to 15%
in prior years, and 9 of 18 speakers have been women.
We also recruit women faculty to participate in fellow
didactics, resulting in an increased representation of
women at journal clubs and case conferences. We are
tracking metrics like the annual proportions of
women honorees of clinical, research, and teaching
awards.
From 2016 to 2019, women comprised 50% of the
general cardiology fellowship, making our program
one of the most gender-balanced in the country.
The PWIC program is presented to fellowship ap-
plicants on every interview day. Over the last 5
years, 36% of our new faculty recruits have been
women, a remarkable feat given the low numbers of
female cardiologists in training and in practice. To
a build on this success, the Women’s Faculty Devel-
opment Program, an official division-level initiative,
will focus on strategies for career advancement for
ECs and midcareer faculty. The Program’s initial
projects include an analysis of wage disparities by
gender with the Department of Medicine and edu-
cation on compensation for trainees entering the
market.
The ACC considers diversity and inclusion essen-
tial to its mission for cardiology and as a professional
society (1). Through the Penn Women in Cardiology,
we strive to serve as an example of how a dedicated
strategy and vision for culture change can engage and
promote existing FIT and EC talent, provide value for
under-represented populations in our field, and
attract and retain future diverse generations of
leaders in cardiovascular medicine.
JACC VOL. 76, NO. 8, 2020 Reza et al. 999
AUGUST 25, 2020:996–1000 Fellows-in-Training & Early Career Section

ACKNOWLEDGMENT The authors thank the Division

of Cardiovascular Medicine at the Perelman School of ADDRESS FOR CORRESPONDENCE: Dr. Nosheen

Medicine at the University of Pennsylvania, including
Drs. Thomas P. Cappola, Frank E. Silvestry, Monika
Sanghavi, Victor A. Ferrari, and the women fellows
and faculty for their inspiration and support in the
creation of this program.
Reza, Perelman Center for Advanced Medicine, South
Tower 11th Floor, Room 11-134, 3400 Civic Center
Boulevard, Philadelphia, Pennsylvania 19104. E-mail:
nosheen.reza@pennmedicine.upenn.edu. Twitter:
@noshreza.

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16. AAMC. Table B3: Number of active residents,
by type of medical school, GME specialty, and sex.
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RESPONSE: The Time for Action Is Now

Pamela S. Douglas, MD
Duke University Clinical Research Institute, Durham, North Carolina
E-mail: pamela.douglas@duke.edu
Twitter: @pamelasdouglas

The lack of gender diversity in cardiology has long demographics, inequities, and barriers to recruitment
been considered a workforce problem, yet data were (1–5), alongside a robust and growing general litera-
lacking. The past 5 years have seen the publication of ture on implicit bias, harassment, and gender dis-
a series of cardiology-specific papers on physician parities, leading to an increasing appreciation of the
1000 Reza et al. JACC VOL. 76, NO. 8, 2020

Fellows-in-Training & Early Career Section AUGUST 25, 2020:996–1000

full magnitude of the under-representation and its
potential adverse impact on health care, research,
and access to talent. Most cardiologists are now
convinced that something needs to be done (Amer-
ican College of Cardiology [ACC] survey data, per-
sonal communication, June 2020). Our challenge has
now become figuring out what to do and how.
Reza and colleagues provide a detailed description
of a robust, multidimensional, and successful model
supporting female fellows and early career faculty at
a large academic medical center. The program
described shows creativity in its design and breadth,
energy in its implementation, and—above all—a
practical, team-based, and problem-solving
approach. Notably absent is any self-indulgence
(a.k.a., whining; beyond a necessary recognition of
the problem in its many dimensions) or even a
reasonable begrudging of the considerable extra work
required of women who are already facing an uphill
battle for work-life balance and equity. Although such
attitudinal issues are less visible than a mentoring or
Grand Rounds program, they are equally important.
Several components are not mentioned,
reading between the lines, must be present and are
worth calling out. The first is strong leadership sup-
port, without which the culture change (values and
beliefs) and climate change (attitudes and behaviors)
required to create meaningful, measurable success
cannot happen. At Penn, although unstated, it is
likely that the division made clear its support and
committed significant human, operational,
financial resources. Also, likely present is significant
“allyship,” a commitment on the part of men to be
accountable for the progress of women through
listening, supporting, self-reflection, and creating
change. Finally, the emphasis is not on diversity per
se (i.e., counting heads), but rather on the success of
colleagues. Indeed, diversity is not even mentioned
in the report in relationship to their program.
Penn is a very large, forward-thinking academic
medical center with a long history of attention to
women in cardiology. (When I led the Penn cardiol-
ogy training program in the mid-late 1980s, female
faculty and fellows met regularly for potluck dinners.
Applicant interview decisions were gender-blind, but
no other changes were made in selection criteria; 1
notable year, 5 of 7 first-year fellows were women.)
Comprehensive programs such as Penn’s may not be
generalizable or even feasible in smaller, less well-
resourced medical centers. However, other centers
should not be deterred or discouraged. Among the
many activities described, each cardiology program is
sure to find several that are actionable in their envi-
ronment, including the focus on outcomes. The Penn
model and positive experience should inspire others
to commit to exploring what can be done in their own
environments and then doing it.
but Finally, in the current climate of heightened
awareness of disparities and antiracism, it would be
remiss not to note that similar efforts should apply to
other under-represented groups who face an even
more unlevel and sometimes hostile playing field.
Merely providing professional development programs
and access to opportunity may result in advancing
newly skilled and empowered individuals while
and requiring them to continue to work in structures,
supported by systems that disadvantage them. Such
“diversity” efforts are hollow and are doomed to
failure. Inclusion and equity are the goals. We can
and must do better. The time for action is now.

REFERENCES

1. Lewis SJ, Mehta LS, Douglas PS, et al., for the
American College of Cardiology Women
in Cardiology Leadership Council. Changes in the
professional lives of cardiologists over 2 decades.
J Am Coll Cardiol 2017;69:452–62.
2. Mehta LS, Fisher K, Rzeszut AK, et al. Current
demographic status of cardiologists in the United
States. JAMA Cardiol 2019;4:1029–33.
3. Douglas PS, Rzeszut AK, Bairey Merz N, et al.
Career preferences and perceptions of cardiology
among US internal medicine trainees: factors
influencing cardiology career choice. JAMA Cardiol
2018;3:682–91.
4. Mehta LS, Lewis SJ, Duvernoy CS, et al., for the
American College of Cardiology Women in Cardi-
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satisfaction among U.S. cardiologists. J Am Coll
Cardiol 2019;73:3345–8.
5. Jagsi RJ, Biga C, Poppas A, et al. Differences
in work activities and compensation of male
and female cardiologists in community
practice in 2013. J Am Coll Cardiol 2016;67:
529–41.