The time for change is now: Call for action over “ageing and unbalanced” cardiothoracic surgery community

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Analysis of the global make-up of the four largest global societies for cardiothoracic surgery suggest that the field is currently dominated by an older and predominantly male workforce.

The future of the specialty depends on its ability to evolve and grow and efforts must be made to attract trainees that represent a diverse patient population, the author of the analysis, Barbara Hamilton (University of California, San Francisco, San Francisco, USA), writes in The Annals of Thoracic Surgery in August.

Hamilton and colleagues examined membership data from the directories of the Society of Thoracic Surgeons (STS), the American Association for Thoracic Surgery (AATS), the European Association for Cardio-Thoracic Surgery (EACTS), and the Asian Society for Cardiovascular and Thoracic Surgery (ASCVTS) to gain a better understanding of the global composition of the cardiothoracic surgery community. Previous attempts to map out the make-up of the specialism have relied on survey data, which are potentially biased or limited by low response rates, Hamilton noted.

The analysis looked at variables including gender, age, academic rank and practice area, which were categorised to include adult cardiac, general thoracic, cardiac and thoracic, congenital and other.

A total of 12,053 membership profiles were captured in the analysis, the bulk of which (6,365) belonged to STS, followed by EACTS (3,661), AATS (1,495), and ASCVTS (532). Most members were located in USA and Europe.

Age data were available for STS and EACTS, and reflected a median age in both societies of 57 (interquartile range [IQR] 45,61). When stratified by society, STS was older with a median age of 60 (IQR 50,71).

The largest area of practice was found to be adult cardiac surgery (31%), while more members practiced a combination of cardiac and thoracic surgery (20%), and over a quarter (26%) of members practiced combinations including vascular surgery and critical care.

Of note, the data paint a picture of an overwhelmingly male community, with a 93% male membership across the four societies. EACTS had the highest proportion of women (9%), with ASCVTS (3%) the lowest. For the STS and the EACTS, the median age of female members was 48 (IQR 41, 57), which was younger than males (median 58, IQR 48, 68). When stratified in five-year increments, female members were mostly in the younger categories (35‒39, 40‒44, 45‒49, and 50‒54).

Among the 788 female members, the most common practice area was adult cardiac surgery (27%), and when stratified by academic rank, 21% identified as assistant, 29% as associate, and 50% as full professor. Of all full professors, 5% (n = 141/2,569) are female. Most females practiced academic medicine (60%), and 45% of females (n = 160/358) were in their early career stage.

Additionally, most members were in the late stage of their careers (64%), with the AATS (94%) having the highest proportion of late-stage career members, and the STS (38%), the lowest.

Commenting on the findings in The Annals of Thoracic Surgery, Hamilton writes: “We are a global community representing a broad scope of practice and a variety of careers. However, our current society members are mostly male, of older age in their later career stage, and of high academic rank.”

The future of the specialty depends on the ability to evolve and grow, Hamilton comments, adding that to do so the field must be able to attract trainees that represent the patients that are served.

“We must work to balance our community, support, promote, and increase the visibility of female and other underrepresented trainees and surgeons,” Hamilton adds.

Although the results of the analysis point towards an overwhelmingly male community, Hamilton recognises that study gains have been made in female representation.

“We found that EACTS had the highest proportion of female members (9%) and that 25% of EACTS trainees were female,” the author writes, noting that most females were in the early stages of their career and more likely to be cardiac surgeons.

“The representation of women in the active cardiothoracic surgery workforce has consistently increased from 4% in 2007 to 8% in 2020,” Hamilton continues. “However, this progress is offset in comparison with the medical world at large, which consists of 46% female trainees and 36% active physicians (across all specialties), and by the lack of female representation in senior and leadership positions.”

Female visibility in leadership roles at national cardiothoracic surgery meetings has traditionally been poor, she adds, with 13% of session leaders between 2015 and 2019 being female, and most past sessions being led by all-male panels.

Hamilton notes that the study does have limitations, including that the data do not represent the true practicing cardiothoracic surgery workforce. In particular, due to data protection regulations, the study team were unable to cross-check data and remove duplicate or overlapping memberships within some societies, meaning some individuals may have been double counted.

“We are global with a diversity of careers but concerning factors that require immediate attention,” Hamilton writes in her concluding remarks. “We are ageing and unbalanced in terms of sex, and risk losing the ability of our specialty to achieve longevity and sustainability. We must attract young students and residents, as well as support and encourage talented female and other under-represented trainees and young faculty members. We have made some small strides in these areas, but plentiful opportunities exist for continued growth and development.

“It is crucial that we wake up to these issues and create action on both individual and leadership levels. This action can include changing the narrative we have with students and trainees to highlight the need for and joy of our specialty, and by consciously promoting under-represented and female members of our societies, academic institutions, and communities. Actively supporting these minority members for visible and high-ranking positions can create change from top to bottom through not just action but inspiration. The time for change is now.”

“The take-home message of this study is clear: we must make our specialty more attractive to female surgeons, and take active steps to increase the presence of female surgeons in leadership positions within the associations,” J Rafael Sádaba (Hospital Universitario de Navarra, Pamplona, Spain) a co-author on the study and EACTS secretary general told Cardiovascular News. “I was glad to see that EACTS leads the way, not only in the overall proportion of female surgeons among our members, but more importantly, in the percentage of female trainees. Nevertheless, there is plenty of room for improvement, and we continue to strive for a gender balance among membership and leadership positions, and in our daily activities as an association.”


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