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It's no wonder that fewer women opt to go into cardiology, given the work-life balance issues and gender discrimination problems that plague the field. The question is: will the community do something about it?

A survey of internal medicine resident physicians revealed that the top perceptions of cardiology were that, as a field, it is associated with adverse job conditions, interference with family life, and lack of diversity. Women and future non-cardiologists valued work-life balance more highly than did men or those committed to cardiology.

In turn, women and future non-cardiologists also had worse perceptions of cardiology as a whole, according to the survey results published online in by Pamela Douglas, MD, of Duke University School of Medicine in Durham, North Carolina, and colleagues on the American College of Cardiology (ACC) Task Force on Diversity and Inclusion and the ACC Women in Cardiology Council.

"Little is known about factors influencing the selection of cardiology as a career. Our survey data suggest that internal medicine trainees' most valued aspects of professional development related to work-life balance and mentorship, while their strongest perceptions of cardiology were of a negative culture and job description at odds with their perceived needs," the authors concluded.

"Given the slight majority of female medical-school matriculants and internal medicine resident physicians, identifying and addressing cultural and societal barriers in women's perceptions of cardiology is crucial for the field to access the full range of talent in internal medicine."

The questionnaire had an overall response rate of 23.1%. Survey participants -- totaling 1,123 individuals, or approximately 5% of all internal medicine trainees in the U.S. at the time -- were contacted in 2009 and 2010 and came from 198 residency programs.

Poor Work-Life Balance

Coming in at the top of the list of professional development factors that were cited as being important to trainees were stable hours and positions that were family- and female-friendly.

And it is exactly these and other components of work-life balance -- or perceived lack thereof in cardiology -- that drives the underrepresentation of women in this field, suggested Anne Curtis, MD, of the University at Buffalo, State University of New York, and Fatima Rodriguez, MD, of Stanford University in California: "Why is our specialty losing so much talent?" they asked in an , citing the fact that even though approximately half of those in medical school classes are female, women constitute only 21% of general cardiology trainees, 7.2% of interventional fellows, and 6% of electrophysiology fellows. In practice, women account for 13.2% of cardiologists and 4% of interventional cardiologists.

It seems that work-life balance is just not there in cardiology -- making it a field especially undesirable among women.

"Having this factor be so important to career decisions today means that one needs to consider these issues in structuring positions in order to attract the best people," Curtis and Rodriguez said. They explained that to reverse the "staggering problem" of the underrepresentation of women in cardiology, it will take, among other strategies, professional societies drawing attention to this problem and structured programs created to provide female role models and mentors to medical students and residents.

If cardiology has one thing going for it in the meantime, it's the shift from a mainly private practice model to one of hospital or system employment," the commentary states. "While there is some loss of autonomy with this model, it also creates opportunities for more structured and predictable work schedules."

Sexual Harassment, Gender Discrimination

Last fall's Transcatheter Cardiovascular Therapeutics (TCT) conference was dedicated to the theme of diversity and was supposed to be a call to attention and action for interventional cardiology. Instead, it was more of the same-old, said Roxana Mehran, MD, of Icahn School of Medicine at Mount Sinai in New York City, writing in a in the same issue of JAMA Cardiology.

"The intention was great; the reality, somewhat deflating. The sessions dedicated to diversity were bare. I watched many men in business suits waiting by the doors to get into the mitral and transcatheter aortic valve replacement sessions, while there were echoes in our empty rooms. Simply put, there was no interest.

"The attendees, men and women, had come to TCT to learn about improving their techniques, hear cutting-edge technology updates and results of late-breaking clinical trials, and enhance their practice and knowledge. Who wants to hear negative news about women and minorities? I guess I do not blame them."

One session stood out however, and not in a good way, as Mehran shared the experience of a woman who described being asked about her "biological clock" several times during interviews for a fellowship in interventional cardiology: "I do not know of a single woman who has trained in cardiology and chosen interventional cardiology as her career who has not faced some level of sexual harassment or misconduct. This is not hyperbole," Mehran wrote. "Nearly half of all female cardiologists report that they have been asked about their intention to have children during interviews, and more than 60% have experienced sex-based discrimination."

It's time for medicine to have its own #MeToo moment, she suggested, urging women to speak up about the injustices they have faced to force change -- and leaders in the field to take solid action. "We all must act."

The $2.5M Wage Gap

"We have arrived at moment when change is within arm's reach; women and men must rally together to make the workplace fair, more productive, and better for everyone," agreed Rashmee Shah, MD, MS, of the University of Utah School of Medicine in Salt Lake City, writing in another in the issue.

Her focus, however, was on the wage gap between male and female cardiologists: Given that women cardiologists earn 7.3% less than male peers on average, one can estimate that they end up with $2.5 million less over a 35-year career, she estimated. And the problem actually manages to be even worse for those in academia, Shah said, where salary increases are often tied to promotion between ranks, and women are less likely than men to get those promotions, thereby being "stuck to the floor."

"Rather than place the burden solely on women to change the status quo, the predominantly male leadership needs to assume responsibility by creating a system that measures the value provided to the organization in a uniform, transparent way," Shah urged.

To understand why these patterns exist in the first place, it is imperative to look at the less obvious factors that prevent female advancement, she suggested: "Women, for example, receive less money for research start-up compared with men, a clear and measurable disadvantage that can propagate over time. Other factors that contribute to career success, such as a lack of sponsorship and opportunity, fewer networking options, and less effective negotiations, are more difficult to measure and not accounted for in studies of pay inequity."

All these mechanisms not only put considerable female talent at a financial disadvantage, but also hurt employers and businesses.

"Prior research demonstrates that diverse groups, such as those that include women, have a higher collective intelligence and better performance rate," Shah said. "The effect of collective intelligence is visible in the bottom line: organizations and companies with women in leadership positions have better financial performance rates and returns on investments. Investing in women's salaries is not only socially and legally just, but also a financially smart investment."