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Cybercrime targeting health care organizations is continuing its upward trend, and it is adversely affecting patient care and leading to a growing number of lawsuits.

In a 2023 survey of 653 health care IT and security specialists, 66% reported disruption to patient care, 57% reported poor outcomes due to delays in procedures and tests, and 50% reported an increase in medical procedure complications due to cyberattacks.

The findings are contained in a report titled Cyber Insecurity in Healthcare: The Cost and Impact on Patient Safety and Care 2023. The survey was conducted by Ponemon Institute, an IT security research organization, in partnership with Proofpoint, Inc., a cybersecurity and compliance company.

According to the report, 88% of health care organizations experienced an average of 40 attacks in the previous 12 months. The average total cost of a cyberattack was nearly $5 million, a 13% increase from the previous year.

These numbers suggest that health care organizations are making little progress in mitigating the risks of cyberattacks on patient safety and wellbeing. “Health care continues to be one of the most attacked industries” said Ryan Witt, vice president for industry solutions at Proofpoint, which is based in Sunnyvale, California. “The report also demonstrates that, in many cases, cyber events can adversely impact patient care by complicating procedures, extending hospital stays, and increasing the likelihood of patients having to be transferred to another facility. This is a material change for hospital executives who have frequently associated cybercrime with regulatory compliance, reputational harm, and financial harm.”

Supply chain attacks are the type of threat most likely to affect patient care, according to the report. Nearly two-thirds (64%) of surveyed organizations experienced a supply chain attack in the past 2 years. Among those, 77% experienced disruptions to patient care as a result, an increase from 70% in the previous year.

Non-compliance with HIPAA can lead to substantial civil monetary penalties (CMPs), which are designed to punish health care providers for not taking their responsibilities under HIPAA seriously. “The health care industry is experiencing a profound and unprecedented cybersecurity crisis,” said David Ting, founder and chief technology officer atTausight, a startup in Sudbury, Massachusetts, that focuses on reducing health care cyber incidents using a proactive, risk management philosophy. “I’m not surprised by the numbers. The reality is that the real numbers are probably higher because of smaller incidents being underreported.”

A business email compromise (BEC) is the type of attack most likely to result in poor outcomes due to delayed procedures (71%), followed by ransomware (59%), the Ponemon survey found. A BEC is also the most likely type of attack to result in increased medical procedure complications (56%) and longer hospital lengths of stay (55%).

“Breach activity within health care remains a significant concern,” Witt said. “Threat actors have become incredibly adept at attacking people on messaging platforms. These attacks are socially engineered meaning that the messages are often compelling, relevant, written in a style expected by the recipient, and often come from seemingly valid email addresses.”

Cyberattacks in 2023 put greater strain on resources compared with the previous year, costing on average 13% more overall and 58% more in the time required to ensure the impact on patient care was corrected, according to the report. Ransomware remains an ever-present threat to health care organizations: 54% of respondents said their organization suffered a ransomware attack, up from 41% in the previous year.

“Lately, we have been seeing patient-led class-action lawsuits becoming the norm, and unfortunately that seems to be the trend that is bringing more awareness that will lead to action,” Ting said. “Patients are now demanding health care institutions protect their privacy after feeling violated. We often see the most basic strategies being missed, and they are often the most important: cyber hygiene and data awareness.”

The number of surveyed organizations making a ransom payment dropped to 40% in 2023, down from 51% the previous year. However, the average total cost for the highest ransom payment jumped 29% to $995,450. Further, 68% said the ransomware attack resulted in a disruption to patient care, with most organizations (59%) citing delays in procedures and tests that resulted in worse outcomes.

All organizations surveyed had at least 1 data loss or exfiltration incident involving sensitive and confidential health care data within the past 2 years. “Patients and doctors should exercise caution when receiving unsolicited emails or text messages,” Witt said. “Be skeptical when it comes to identifying phishing in your email message. Obtaining user credentials is the nirvana state for would-be threat actors, and even an innocuous email can provide meaningful data that can be further exploited.”

Among organizations reporting data loss or an exfiltration incident, 46% experienced increased patient mortality rates and 38% had increased complications from medical procedures. Health care organizations feel most vulnerable to and most concerned about cloud compromise.

BEC/spoofing concerns increased significantly. The number of respondents concerned about BEC/spoofing jumped to 62% from the prior year’s 46%. More than half (54%) of organizations on average experienced 5 of these types of incidents. BEC/spoofing attacks are more likely than other type to result in poor outcomes due to delayed procedures (71%), increased complications from procedures (56%), and lengthier hospital stays (55%).

“As this year’s Ponemon report clearly shows, cyberattacks can have a direct impact on patient safety, and, in some cases, increase mortality rates,” Witt said. “As physicians still adhere to the Hippocratic Oath, and its core tenet of do no harm, it’s imperative that healthcare continues to focus on cybersecurity in support of healthcare’s mission and to protect patients.”

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Both recurrent and severe acute kidney injury (AKI) requiring continuous renal replacement therapy (CRRT) portend worse outcomes in children, according to 2 new studies published in JAMA Network Open. A new device might improve pediatric AKI outcomes.

Infants in neonatal ICUs with recurrent AKI had a significantly longer hospital stay than those with a single episode of AKI, Austin D. Rutledge, DO, of the Medical University of South Carolina in Charleston, and colleagues reported. Their finding is from the AWAKEN study of 2162 infants, of whom 605 developed AKI, including 133 (22%) with recurrent AKI. Risk factors for recurrent AKI included younger gestational age, lower birthweight, and higher stage of initial AKI. Infants with recurrent AKI had a median length of stay of 60 days compared with 18 and 17 days for infants with a single AKI episode or no AKI, respectively.

“These results support the paradigm that [recurrent] AKI is likely an important and distinct clinical entity meriting increased surveillance after an initial AKI episode,” Dr Rutledge’s team wrote. “The present study provides important information that will inform the development of evidence-based post-AKI care guidelines to prevent and diagnose [recurrent] AKI sooner to improve outcomes.”

The second study found that use of continuous kidney replacement therapy (CKRT) for AKI or fluid overload in children, adolescents, and young adults in the intensive care unit often leads to major adverse kidney outcomes (MAKE). Among 969 patients aged 0 to 25 years treated with CKRT for AKI or fluid overload from the 2015 to 2021 Worldwide Exploration of Renal Replacement Outcomes Collaborative in Kidney Disease (WE-ROCK) registry, 630 patients (65.0%) developed MAKE within 90 days, Dana Y. Fuhrman, DO, MS, of the University of Pittsburgh Medical Center Children’s Hospital of Pittsburgh in Pennsylvania, and colleagues reported. MAKE-90 comprised death or persistent kidney dysfunction, including new dialysis dependence or a 25% decline in estimated glomerular filtration rate (eGFR) from baseline. Patients admitted for congenital heart disease or cardiomyopathy had the highest rates of MAKE-90. Of the full cohort, 38% died within 90 days.

On multivariable analysis, cardiac comorbidity, longer duration of intensive care unit admission before CKRT initiation (day 6 vs day 1) were significantly associated with 60% and 7% increased odds of MAKE-90, the investigators reported.

Patients who were successfully weaned from CKRT within 28 days had significant 68% and 98% decreased odds of MAKE-90 in adjusted analyses compared with patients for whom attempts at removal from CKRT failed or for whom no attempt was made, respectively.

“Our study highlights the need for a shift in the paradigm of how we study CKRT in youths, from focusing on CKRT initiation to a more wholistic approach systematically evaluating liberation,” Dr Fuhrman’s team wrote.

In February 2024, the FDA granted a humanitarian device exemption approval to SeaStar Medical’s selective cytopheretic device for pediatric AKI due to sepsis or a septic condition requiring CKRT.3 The device selectively targets proinflammatory neutrophils and monocytes during CKRT to reduce hyperinflammation and cytokine storm. In a pooled analysis from the SCD-PED-01 and SCD-PED-02 studies, published in Kidney Medicine, 22 pediatric patients treated with the immunomodulatory extracorporeal device had a 77.3% survival rate to day 60 after discharge.4

In these studies, no device-related serious adverse events or device-related infections occurred and no dialysis dependency at day 60. A post-market registry study will be established to collect additional data regarding safety and efficacy.

To receive the therapy, patients must weigh at least 10 kg (approximately 22 pounds). Efforts are underway to create a device for children weighing less than 10 kg.

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The American Academy of Orthopaedic Surgeons (AAOS) recently released updated guidelines for the management of hip osteoarthritis (OA). The full report has been published on the organization’s official website.1

The updated guidelines are a revision of the 2017 edition, introducing modifications to 14 of the 23 evidence-based recommendations for the nonoperative treatment of hip OA in adults. These revisions yielded 3 strong recommendations, 5 moderate recommendations, and the remaining were of limited nature. 2 The guidelines covered various recommendations supported by substantial evidence and options for treatment supported by lower quality evidence.

Recommendations for the Management of Hip OA

Tranexamic Acid (TXA) in Individuals Undergoing Total Hip Arthroplasty (THA):

  • For the pharmacological management of individuals with symptomatic hip OA who are undergoing THA, the use of both intravenous and topical TXA is strongly recommended.
  • TXA is effective for reducing the chances of blood loss and the necessity for blood transfusions in these patients, while potentially improving outcomes and maintaining a low risk for adverse events.

Intra-Articular Hyaluronic Acid:

  • For the pharmacological management of individuals with hip OA, the use of intra-articular hyaluronic acid is strongly not recommended.
  • The use of intra-articular hyaluronic acid does not demonstrate superior efficacy for improving function or alleviating pain when compared with a placebo.

Nonsteroidal Anti-Inflammatory Drug (NSAID) Use for Pharmacological Pain Management:

  • For the pharmacological management of individuals with hip OA, the use of oral NSAIDs is strongly recommended for the treatment of pain and enhancing functionality, provided there are no contraindications.
  • The use of oral NSAIDs for nonoperative treatment in symptomatic hip OA can be easily incorporated into treatment regimens, emphasizing the pivotal role of nonopioid medications in reducing reliance on opioids.

Postoperative Physical Therapy:

  • For the postoperative management of individuals with hip OA following THA, the use of both formal physical therapy or unsupervised home exercise is moderately recommended.
  • Regular exercise is crucial for a successful postoperative recovery; however, suggesting home exercise without proper guidance may impede outcomes for individuals who require structured rehabilitation.
  • Currently, there is a lack of identification of appropriate candidates for home exercise vs supervised therapy, potentially resulting in delayed recognition of negative outcomes.
  • The strength of this recommendation was lowered to moderate due to difficulty comparing studies with variations in physical therapy interventions — including duration and frequency — and a lack of studies directly comparing progressive outpatient physical therapy with an active placebo group during the critical 3-month postsurgery period.

Physical Therapy as Conservative Treatment:

  • For the treatment of mild to moderate symptomatic hip OA, physical therapy is moderately recommended.
  • Individuals who qualify for conservative treatment may find advantages in pursuing physical therapy to optimize range of motion, alleviate pain, and enhance overall functionality.
  • The strength of this recommendation was lowered to moderate due to variations in modalities, interventions, and significant heterogeneity in the frequency, duration, and intensity within intervention groups.

 Intra-Articular Corticosteroids:

  • For the pharmacological management of individuals with hip OA, the use of intra-articular corticosteroids is moderately recommended.
  • The use of intra-articular corticosteroids may enhance short-term function and alleviate pain for patients experiencing symptomatic OA of the hip.
  • The strength of this recommendation was lowered to moderate due to differences in study design, corticosteroid dosage, and inadequate reporting of adverse events.

Cemented Femoral Fixation:  

  • For the management of older individuals with symptomatic hip OA who are undergoing THA, the potential use of cemented femoral stems is moderately recommended and its use should be implemented with an individualized approach.
  • The use of cemented femoral stems in older individuals may be associated with a decreased risk for subsequent periprosthetic fracture; however, there is a possibility for bone cement implantation syndrome among certain decompensated patient populations.
  • The strength of this recommendation has been elevated to moderate, emphasizing the importance of addressing the risk for periprosthetic fractures in THA. This is in response to the widespread adoption of cementless femoral stems, driven by factors such as the effectiveness of biologic ingrowth fixation, shorter operation times, reduced risk for embolic debris, and a lack of training in the cement technique.

Individualized Exposure Approach:

  • §  For the management of individuals with symptomatic hip OA undergoing THA, an individualized surgical approach is moderately recommended. Considering there are specific risks and benefits for each, no preferred surgical approach can be identified based on the current evidence.
  • The strength of this recommendation has been decreased to moderate due to data heterogeneity, the indirectness of comparative studies, and the potential for future research to impact the recommendation.

Options for the Management of Hip OA

Impact of Body Mass Index (BMI) on Adverse Events:

  • For the management of individuals with symptomatic hip OA who are undergoing THA, limited evidence suggests that an increased BMI may heighten the risk for adverse events.
  • Assuming elevated BMI is a modifiable risk factor, it is valuable to explore any link between BMI and adverse events post-THA.

Impact of BMI on Clinical Outcomes:

  • For the management of individuals with symptomatic hip OA who have received THA, limited evidence indicates that individuals with increased BMI may achieve lower absolute patient-reported outcome scores. However, these individuals still experience a comparable level of improvement in patient satisfaction, pain, function, and quality of life.

Impact of Diabetes on Adverse Events:

  • For the management of individuals with symptomatic hip OA who have received THA, there islimited evidence indicating that individuals with uncontrolled diabetes may be at a higher risk for adverse events.
  • There is currently no consensus regarding a safe HbA1c level for surgery, and uncontrolled diabetes amplifies the risks associated with THA.
  • The decision to proceed with surgical treatment should be collaborative, weighing individual risks and benefits, as infection and renal injury pose significant morbidity and potential mortality.

Impact of Social Determinants of Health on Outcomes:

  • For the management of individuals with symptomatic hip OA undergoing THA, there is limited evidence indicating that factors such as education, income level, and insurance type impact the length of stay, total cost of care, and mortality among these patients.
  • Low-quality studies suggest that social determinants of health influence THA outcomes, underscoring the significant importance of addressing equity in the context of prevalent negative social determinants.

Impact of Neuraxial Anesthesia on Adverse Events:

  • For the management of individuals with symptomatic hip OA undergoing THA, limited evidence indicates that neuraxial anesthesia may be employed to decrease adverse events in these patients.
  • While neuraxial anesthesia has been associated with a reduction in adverse events, the choice of anesthesia should be tailored to each patient, taking into account their medical conditions and weighing the potential risks vs benefits.

Impact of Tobacco on Adverse Events:

  • For the management of individuals with symptomatic hip OA who have received THA, limited evidence suggests an elevated risk for adverse events in patients who use tobacco products.

Prescription Opioids as Conservative Treatment:

  • For the management of individuals with symptomatic hip OA, there is insufficient evidence on the use of prescription opioids as nonoperative treatment.
  • The guideline authors do not advise the use of oral opioids for nonoperative management.
  • Opioids provide minimal clinical benefit and carry significant adverse effects, while also increasing complications post-THA.

Pharmacological Management With Acetaminophen:

  • For the management of individuals with symptomatic hip OA, due to insufficient evidence, the guideline authorssuggest considering oral acetaminophen when not contraindicated for pain management.
  • The use of acetaminophen for nonoperative treatment may alleviate pain and enhance functionality in eligible individuals.
  • Nonopioid medications like acetaminophen are key for the nonoperative treatment of symptomatic hip OA and for reducing opioid usage. However, caution should be exercised due to contraindications when using oral acetaminophen, including pre-existing liver disease.

Impact of the Hip-Spine Relationship on Outcomes:

  • For the management of individuals with symptomatic hip OA, there is insufficient evidence on the relationship between hip OA and stiff spine syndrome.
  • The guideline authors believe individuals with hip OA and stiff spine syndrome may face an increased risk for dislocation following THA, compared against patients without this syndrome.
  • Dislocation, a significant complication in THA, may be influenced by the hip-spine relationship, but substantial data is lacking.
  • Despite potential complications, patients with stiff spines should not be precluded from surgery, emphasizing the need for individualized approaches and open discussion between surgeons and patients.
  • The strength of this recommendation has been decreased due to the heterogeneity of data and reported timepoints, with future research expected to significantly impact this recommendation.

This comprehensive guideline update offers evidence-based recommendations for managing symptomatic hip OA. Individualized approaches are emphasized, considering factors such as pharmacological interventions, physical therapy, surgical choices, and patient-specific conditions. This update aims to enhance patient outcomes, minimize complications, and guide healthcare professionals in delivering optimal care for patients with symptomatic hip osteoarthritis.

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February is American Heart Month, a time when physicians and patients alike are asked to reflect on cardiovascular health. At the beginning of American Heart Month is National Women Physicians Day (or Women in Medicine Day), which takes place on February 3, and is held to honor the achievements and contributions of women physicians.1

In observation of this day, Cardiology Advisor reached out to Payal Kohli, MD, FACC, founder and medical director, Cherry Creek Heart; associate clinical professor of medicine, University of Colorado Anschutz; and associate adjunct professor, Cardiology Division, Duke University; Nieca Goldberg, MD, medical director, Atria New York City and clinical associate professor of medicine, NYU Grossman School of Medicine; and Roxana Mehran, MD, director of interventional cardiovascular research and clinical trials, Icahn School of Medicine, Mount Sinai to learn more about their experiences as women in cardiology.

Dr Nieca Goldberg
Dr Payal Kohli

What obstacles have you encountered during your training in cardiology that you feel are different from what your male colleagues may have encountered?

Dr Kohli: It’s difficult to be a female cardiologist in 2024, there are so many challenges that you have to face along the way. One of the biggest challenges is pay disparity between male and female cardiologists. An article was recently published in JAMA2 that outlined an unexplained nearly 40% pay gap between women and men in the cardiology field despite recent pushes toward equal pay.

A secondary challenge to consider is that there is still a noticeable gender difference when it comes to who is being considered for promotions and leadership opportunities. There have been multiple times when a male colleague with fewer qualifications has been offered an opportunity that I would have liked to have had a chance to pursue. It’s hard to speak up when this happens, because I worry about seeming too demanding or too aggressive or not being perceived as a team player. This has also been demonstrated in the literature.3

This worry can also occur when staff and patients treat female and male physicians differently. For example, during an early part of my career, when I was just 2 years out of training, I was the only female provider at the clinic I was employed with and staff decided to have a Christmas potluck. I was signed up for this without my knowledge and then asked to bring gifts for everyone. My male colleagues were not asked to do the same. I felt pigeonholed into a gender role (women cook, they take care of others, etc.). I don’t like to cook, but felt pressured to comply, so I asked my mom for help and brought the requested gifts. I felt bad afterward for complying, but I was fearful of being considered unkind or not generous to my female staff members. I was afraid of those labels that people often apply to women who speak up and even more afraid that these labels would come from my female subordinates. I was asked to keep my door open during my lunch hour when I did my charting and called patients so I would appear more “approachable” to my staff. I was asked by my supervisor to park in the front of the office and enter the clinic through the front door (rather than using the back entrance, which was closer and used by my male colleagues). That way, I could stop at the receptionists and MA desks to say “Good morning.” The list of female-specific expectations went on…

Dr Goldberg: I remember my first day of medical school sitting in a lecture hall and introducing myself to my classmate sitting next to me and he said, “My friend had to go to school in Mexico so you could get a place in this class.” Implying that I was let in because of a quota to admit more women to medical school. I looked at him and said, “I am here because I belong here.”

As a cardiology fellow, it was a challenge being in an environment when inappropriate statements were made about women. My male colleagues were not collaborative. I recall being on the cardiac catheterization rotation and the cardiology fellow rotating with me assigned himself to all the patients. I asked why he didn’t divide up the cases and he said, “You are not going to be an interventional cardiologist; you do not need to assist on the cases.” He went on to say, “Women should be noninvasive cardiologists.”

The attending cardiologist heard this exchange. He looked at me and said, “Nieca, you will assist me with the next case.”

Dr Mehran: I trained in the early years of percutaneous coronary intervention inception, and was one of the few women in both clinical cardiology and interventional cardiology. I was often the only woman in the lab, in conferences, and on panels. I also felt that often my voice would not be heard; that could have also been from my own imposter syndrome, but I somehow managed to put it all behind me and persevere.

"
The one piece of advice I would give women who choose to be cardiologists is to think of yourself as a cardiologist who happens to be a woman, and not a woman who happens to be a cardiologist.

What initiatives are you seeing in your network that are making strides to support women or promote gender diversity and inclusivity in this space? How have they impacted you?

Dr Kohli: There are still a lot of things that need to be worked on. What’s positive is we have been working on them. We’ve been having these conversations. We’ve been creating initiatives. The American College of Cardiology (ACC) recently made its first statement on workplace equality and having a plan to address these issues. There have been grassroots efforts, work groups, and workshops on the issues women face in cardiology. Pregnancy and childrearing help is starting to be addressed and women are being empowered to speak up about unfair workplace conditions.

However, there is still this feeling that women need to be mindful about “crying wolf,” that if we raise too many issues at once they may be ignored. So, prioritizing certain issues has been helpful for focusing these efforts. Some specific changes I’ve seen that are encouraging more women to join the field are more part-time and remote roles that allow for flexibility. This gives women cardiologists who have children and who handle most of their family’s childcare more opportunities to continue their career path while maintaining their home life.

Dr Goldberg: The ACC has programming that promotes gender diversity and inclusivity. Early on in my career, I attended the Women in Cardiology luncheon at the ACC, and they had guest speakers to talk about various topics that addressed challenges that women in cardiology face, such as balancing their family and work life, and challenges to promotion and pay equity. This type of programming has grown, to have seminars and programming for women in cardiology on multiple days and allow for networking.

Dr Mehran: I have had the privilege and opportunity to network with my colleagues through my volunteer work with great organizations in cardiology. Both the American Heart Association (AHA) and ACC have been committed to women in cardiology and have provided important venues for networking, as well as recognition and career development to me personally and to so many women like me. AHA has been providing important mentorship networking opportunities for many women, and I have been lucky enough to be part of this. This past year, I was recognized by AHA as the recipient of the Women in Cardiology Mentoring Award. This recognition was paramount for my own development, and has helped me and many who have received it. It is a pleasure to work with organizations that are devoted in promoting women similar to men and closing the gender gaps in representation and promotion.

What resources or support systems did you tap into during your cardiology training and journey? What external resources would you recommend to other women physicians?

Dr Kohli: My journey has been full of many different things I’ve leaned on. During my fellowship, I started a writing column with my other fellows to try to address these kinds of issues and to give us a place to talk about the challenges we were experiencing. This column eventually evolved into the podcast I currently work on where I continue to discuss these challenges with my colleagues. Writing about the difficulties I face has helped me build a community where I feel safe talking with others about my own experiences. It’s been a hobby that has been helpful for getting through that stress. I’ve also found comfort in speaking to my male mentors and looking to them for advice, as they are sometimes able to provide an objective angle to a problem that I might not be able to see.

Other support systems I’ve found helpful are the Women in Cardiology Facebook group and the Women in Cardiology Work Group on the ACC website, as well as other social media groups where women physicians are able to vent about issues facing them and talk about their own experiences and the challenges they’ve dealt with in the medical field. Another valuable resource women physicians can lean on are their loved ones, because medicine is a difficult profession that challenges us on every level (emotionally, physically, financially) and having a strong support network can help ease that burden.

Attending conferences is a great way to expand your network and meet other women practicing cardiology. Conferences also give you the opportunity to meet health or wellness couches, including those specifically focused on women’s health, which can be a valuable resource for getting through tough points in life. I recommend the Cardiometabolic Health Congress Women’s Masterclass, which is a conference put on by women for women that offers panels on resiliency and professional guidance.

Dr Goldberg: I tapped into many different support systems. In addition to the ACC, I am also a member of the AHA and the American Medical Women’s Association. [I recommend being] inclusive when seeking mentorship. I have had male and female mentors, and it is good to have different perspectives as it helps you to grow and diversify your point of view to lead to better patient and professional interactions.

Reach out to women in other professions to learn about their experience. My friends outside of medicine have given me great career advice. Finally, [another source of support has been] my husband, who is a radiologist and has been the foundation of my support network throughout my career.

The one piece of advice I would give women who choose to be cardiologists is to think of yourself as a cardiologist who happens to be a woman and not a woman who happens to be a cardiologist.

Dr Mehran: Early in my career, during those hardships of watching the gaps in pay, recognition, promotion, I felt compelled to join organizations such as AHA that understand this and are there to close these gaps. Every cardiologist, especially women, should reach out. Surely, they will enjoy the benefits, as I have.

During your career, what are some palpable advancements in gender equity within cardiology that you’ve seen or experienced?

Dr Kohli: There’s been a bit of progress. Nationally, more women are getting into medicine and cardiology specifically because they realize there’s a niche being carved out for them within the field. Women are able to have a career in cardiology and have a personal life. They’re being represented more in academia and in leadership roles in national organizations. Women are heading departments of medicine, they’re appearing more on billboards for medical facilities, and are being viewed as key opinion leaders in their field.

Another positive change has been a push for more representation of women in clinical trials. We’re seeing more female specific data in research, including data on pregnancy, menopause, and hormones that shed more light on cardiovascular health in women.

Dr Goldberg: There are more women in medical school, yet we need to increase the number of women in the cardiology workforce. More women are leaning in and speaking up about the challenges we have as cardiologists.

Dr Mehran: We have made huge progress in closing gender gaps in cardiology over the last recent years, but I will also say that this is just the tip of the iceberg. There is so much more to do, as we know that while on the surface and statistically the numbers are improving, in reality the depth and breadth of real change has not yet occurred. I look forward to that day, when we are seen as one and no longer need to answer these important questions regarding equity and diversity in our field.

What is the most valuable advice or mentorship guidance you received during your training? How have you implemented this during your career?

Dr Kohli: The most valuable advice I’ve ever received was actually the worst advice I’ve ever received. I was told twice to “just put your head down and do the work.” It made me want to do the opposite, which is how I learned what works. You don’t want to lose your momentum. Don’t fake it ‘til you make it. Don’t change who you are to make a career. Make a career that follows your path and don’t lie to yourself. If something is wrong, try to figure out what it is and how to solve it and change the trajectory so you can keep going.

Dr Goldberg: Early in my career my mentor said to me that, as a woman, training and practicing cardiology would be different and more difficult for me compared to my male colleagues. I asked, “Should I quit?” and he said no. Instead, he said I should look at it as an opportunity to make a difference. I continue to use my “opportunity” to make a difference for my patients and my colleagues. 

Dr Mehran: My most usual answer to this difficult question is to follow your heart, work hard, and let go of the small stuff. Seek your inner talent, and be confident that you are deserving and able to conquer your dreams and goals. Never give up, and find strength within yourself when others doubt you or question your talent and brilliance. I was never good at this early in my career, and this is why I am giving this advice to everyone who is listening. Be sure that your voice is heard loud and clear, because your opinion and input matters and can actually improve our environment. Do not allow others to treat you poorly, and leave any toxic environment behind, because the truth is that they do not deserve you.

Dr Kohli: As a female physician, I get asked about my marital status and comments about how I look. I try to toe the line and look the part of a physician, but it’s a challenge and one my male colleagues tend not to have to face. Women physicians have their social media and personal lives scrutinized more than male physicians, and patients can change their perspective of female physicians when they learn about their personal lives. It is hard not to have patients view us as objects, which can be more difficult in the age of social media. Patients will ask me if I’m married or have children and I’ve learned that I have to divert these kinds of questions by trying to focus the discussion back on the patient by saying “this visit is about your health,” or something similar.

Dr Goldberg: I have been in work situations where colleagues think I should take care of women because I am a woman and have said that publicly. Although I have focused on equity in cardiovascular care in women, I have cared for people of all genders.

Dr Mehran: With regard to patients who are biased, when a woman shows up as the caretaker at the bedside, I would only say that you must remain strong, confident, and empowered to be yourself, and correct the patient’s view in the brilliant ways that you know how. This shall pass…

Editor’s Note – Some responses have been revised for clarity and brevity.

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