Why Are Numbers of Women, Minorities So Low in Cardiac EP?

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

The first study showed that only 5% of EP operators of Medicare procedures are women, and this number has not increased over the past several years.

The second study found a very low rate of applications for EP training programs from female and ethnic minority cardiology fellows.

"Women remain underrepresented in EP," lead author of the first study, Stacey Howell, MD, University of California San Francisco, told theheart.org | Medscape Cardiology. "Even in areas of major clinical growth, like atrial fibrillation (AF) ablation, the numbers of women are not increasing."

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

"It is important to have diversity in all specialities. It has been shown that women have poorer outcomes from some procedures including AF ablation and also poorer access," Usha Tedrow, MD, Brigham & Women’s Hospital, Boston, senior author of the second study, commented.

"Female and underrepresented minority cardiologists are more likely to deliver equitable treatment and decision-making for patients," Tedrow added. "Some women and ethnic minority patients prefer to have conversations on whether to have a procedure 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 a paper in Heart Rhythm and the other as a letter to JACC: Clinical Electrophysiology.

Howell explained that her group wanted to look at this issue to better define the representation of women in EP and how it might have changed over recent years.

They examined data from the Medicare Provider Utilization and Payment Database from 2013-2019 using codes for the most common EP procedures — AF ablation, supraventricular tachycardia/atrial flutter (SVT/AFL) ablation, and cardiac device implantation. The database summarizes Medicare services in the US and also gives information on the gender of the operator and geographical location.

Results showed that, on average, annually between 2013 and 2019, 5% of the 3524 EP operators were women. Procedure-specific analyses demonstrated a similarly low proportion of women EP operators across each procedure type.

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 women 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 missed) and the database does not include operators who perform less than 10 procedures a year (so data on low volume operators were not captured).

"I think it is still a good general representation of women in the field," she said.

Other findings included:

10 US states had no women EP operators who performed more than 10 of any given EP procedure annually
20 states had no women who performed more than 10 of either AF or SVT/AFL ablation procedures annually
10 states had no women device operators who performed more than 10 of any given type of device implantation annually

Howell pointed out that there are challenges with both recruiting women into EP and retaining women in the specialty. "Data suggest that around 9% of board-certified EPs are women, but our study shows that only 5% of clinicians performing EP procedures are female. So there may be a transition of women out of the EP lab into industry, research, or more general cardiology duties."

The second study, presented at the HRS meeting by Tedrow and Uyanga Batnyam, MD, also from Brigham & Women's, examined data on applicants for cardiac EP fellowships from the electronic residency application service (ERAS) from 2018-2021.

Of the pool of applicants to cardiac EP, women accounted for just 13%-15%, and ethnic minorities for 7%-10%.

African Americans were particularly badly represented, accounting for only 3%-5% of applicants and the figures for Hispanic applicants were similar (4% -5%).

The Brigham group also looked at overall cardiology applicants and found that of all female cardiology applicants, 71% did not do any subspecialty beyond cardiology, 11% did interventional cardiology, 10% heart failure, and just 6% applied for an EP fellowship.

Attrition of Females at Every Stage of Training

"There is a concept of women leaking from the pipeline. There is a gradual numerical attrition of representation at every stage of training," Tedrow noted.

She reported that women accounted for 48% of medical school students and 42% of internal medicine trainees, but when it comes to cardiology fellowships, just 23% are women, and for cardiac EP fellowships, the figure falls even further to 14%.

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

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

Tedrow cited a survey published last year which found that female cardiology fellows gave reasons for not pursuing the EP specialty that included lack of female role models, risk for radiation exposure, and 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 various procedures and change the culture to make it more attractive to women. The speciality needs to do more to ensure the recruitment processes are fair and equitable and we need to look at how we can actively recruit for diversity," she said.

Howell added that the long duration of training may be putting women off. "EPs have one of the longest training paths in medicine, with a total of 12 years before they are fully qualified — 4 years of medical school, 3 years internal medicine training, 3 years general cardiology fellowship then another 2 years cardiac electrophysiology fellowship. Such a long training period can be unattractive to women."

While fluoroscopy exposure may also be a concern for women, Howell pointed out that many procedures are now being performed with less fluoroscopy, hopefully minimizing this issue.

"We need to improve female mentorship. As a cardiology trainee it can be hard to get exposure to the EP lab. We need to make stronger efforts to draw women cardiology fellows into the EP lab and to give them a better understanding of what a career in cardiac EP looks like. Perhaps the training period can be streamlined as well," Howell said.

"EP is the Best Kept Secret in Cardiology"

Tedrow believes cardiac EP is a good specialty for women. "Most procedures are elective, so you have a lot of a control over your schedule, and there is now minimal exposure to fluoroscopy. You also see a broad spectrum of patients. So this is a great discipline for women interested in a procedural speciality, but EP is the best kept secret in cardiology. We need to let cardiology fellows know more about this at an early stage in their training," she commented.

In an editorial accompanying the paper in Heart Rhythm, 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 Heart Rhythm Society presidents in the past decade having been women. A steady increase has also been noted in female physician speakers at major cardiovascular conferences.

The editorialists say that this, together with ongoing efforts toward identifying and addressing barriers, raise the hope of attracting more female cardiology fellows to pursue EP.

"The common goal must be to strive toward a diverse, inclusive, and supportive environment for both genders to thrive in," they conclude.

Heart Rhythm 2022 Meeting. Presented April 29 and 30, 2022.

Heart Rhythm. Published online April 29, 2022. Full text, Editorial

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

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