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From a female perspective
  1. Dorothea Altschul
  1. Neurosurgery, Neurosurgeons of New Jersey, Ridgewood, NJ 07450, USA
  1. Correspondence to Dr Dorothea Altschul, Neurosurgery, Neurosurgeons of New Jersey, Ridgewood, NJ 07450, USA; daltschul{at}neurosurgerynj.com

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I love my job. I am fascinated by the intricate network of brain arteries and veins appearing on high-resolution screens. I like feeling the whimsical wires, the delicacy of the devices, and the forces transmitted by telescoped catheters advanced faster and safer into the branching brain vessels with every year of my practice. I am devoted to designing a beautiful stent construct and delivering it into a diseased artery just as much as I am devoted to assessing quality and outcomes data on all my patients. Many of my patients are women, as the cerebrovascular pathology disproportionally affects more women than men. There is now emerging evidence that gender diversity among physicians can have a positive impact on patient outcomes.1 2

I am one of an estimated <8% female neurointerventionalists in the world, though the exact numbers are not known. There are even fewer females in academic and leadership positions. There are numerous reasons why women are underrepresented,3 and this is not entirely unique to our specialty.

When I became a neurointerventionalist, I did not seek or think about being a female leader or female role model. At that time, there were only few fellowships that would consider training a non-radiologist. I was lucky enough to have been exposed to interventional neuroradiology in my residency training, a privilege that to this date is not bestowed on all trainees in the neurosciences. My mentors at the time, many of whom were pioneers in their own right, recognized my enthusiasm for the field and pushed me forward to pursue a neurointerventional career. I was one of the first female neurointerventionalists they ever trained. As a result, I studied the male neurointerventionalists just as much as the diseases; how they communicated with each other and their patients, how they built their team, how they dealt with complications, industry, their own career aspirations, and quality of life issues.

For years I was so busy following the path created by men that I ended up as a really good ‘male’ neurointerventionalist. I tried to be decisive in my answers, dressed in black suits, and hid my pregnancy for as long as I could. I have learned how to find a place in a subspecialty that has not attracted many women.

When I became pregnant in 2009, a literature search on radiation safety for a pregnant neurointerventionalist returned zero articles. I was faced with having to fulfill my full duties while also worrying about the health of my unborn child. I extrapolated existing data from other interventional specialties and studied reports on direct fetal radiation exposure. I comforted myself by thinking I was farther away from the beam than an interventional radiologist. By the time I was pregnant with my third child, I was an expert childbearing neurointerventionalist. I rarely shared my experiences because there was no platform, venue, or interest for it. Data on this subject, however, would have been important to not only ease my fears but those of many other women. Fortunately, more research is available now. It has supported the proposition that radiation exposure from performing fluoroscopic interventions does not result in adverse outcomes for physicians or their offspring.4 Many women continue to work during pregnancy, with reported fetal radiation doses far below recommended guidelines.5 6 Robotic assisted interventions and other novel protective equipment may further reduce radiation exposures in the future.7–10 That being said, more data are needed on this subject to assure women entering this field.

Deciding to be a neurointerventionalist, for women as well as men, is a great challenge, and this is further complicated by three different pathways into the subspecialty (via the departments of radiology, neurology, and neurosurgery), many of them with slightly different job descriptions. On top of navigating the inherent biases associated with each specialty, women also have to navigate gender bias, and they have to do it largely by themselves. Women are facing challenges accessing a community of women practitioners facing similar issues. I have not seen a female neurointerventionalist during my training and I did not have any easy access to female role models in my field, but I did have excellent male mentors and sponsors. Interestingly, significantly fewer females than males have a mentor during their career.11

Studies show that successful mentoring is associated with increased job satisfaction, greater retention rates, more success in obtaining promotions and research grants, and increased research publications, and work–life satisfaction may increase as well.11–13 There is some evidence that mentoring may be most effective when female mentees are mentored by female mentors.14 15

This field is a resource-intense specialty that has seen strong technological growth and rapid expansion in case volumes. New standards of stroke diagnosis and care have resulted in a new demand for well-trained expertise in the field and that has led to an increased call burden, management, and organizational stress on already trained professionals. In addition, neurointerventionalists face, at times, a bewildering array of psychological stressors impacting the care they are providing for critically ill and remarkably complex patients. While this is difficult for all neurointerventionalists, it has an especially pronounced impact on women. Between intense call schedules, breastfeeding, child-rearing, domestic responsibilities, and sleep deprivation, my passion for this profession was tested to the absolute limits on multiple occasions.

Lifestyle considerations in general are a major concern for both genders when choosing a profession. Burnout has afflicted our specialty. In one survey ‘feeling underappreciated’ by hospital or department leadership was strongly associated with burnout; however, the relationship to gender was not studied.16 Data from other surgical specialties suggest increased risk of burnout in females.1 Interestingly, additional call pay was identified as a strong protective factor against burnout,16 and pay inequity affects women more than men. Women doctors earned on average $20 k less than men in one study,17 and over ~$70 k less as department chairs.18

Certainly, discriminatory practices, long work hours, and limited exposure to this field during training could deter females from pursuing this procedural, male-dominated subspecialty. Not all of us may have the same priorities, and we need to be open to careers that may be less likely to follow a linear trajectory. More data are needed to define the exact barriers and quality of life priorities which may vary by individuals, generations, and geographical regions.19

By virtue of being a woman, I now face a new generation of highly qualified women asking illuminating questions; most interestingly, I see my male colleagues looking at me, and asking me to speak up to help define the pain points for female neurointerventionalists in creating a more inclusive environment. Given the sparsity of women currently in the field there is a greater expectation that we lead this conversation. As more women are coming up through a male dominated field, we now lack the formal training to effectively lead and coach a new generation of women behind us. Formal leadership training is another responsibility we will need to add to our list. Easy access to such training and other skill sets is needed, that is, negotiation skills, resilience training and executive coaching. I wish such training would have been available to me much earlier in my career.

A more inclusive environment would undoubtedly entail work and training options that support family life and a healthy work–life balance, as well as flexible part-time employment options. Further, more exposure to neurointervention during medical school and residency is needed, as well as structured radiation protection training. Understanding that the lack of mentors and sponsors is often cited as an obstacle for women opting into our field, many societies have now created organized women groups (Society of NeuroInterventional Surgery (SNIS), Society of Vascular and Interventional Neurology (SVIN), and World Federation of Interventional and Therapeutic Neuroradiology (WFITN)). More work is needed to create mentorship programs, and to identify women who can share their expertise, as well as men who are supportive of diversity. In addition, raising the profile of female leaders at the national and international level, in academia, industry, and on editorial boards will elevate the perception that women’s diverse backgrounds, experiences, and voices are also assets to our community.

My love for neurointervention led me to forge into one of the most complex and demanding, male-dominated medical careers. I have worked assiduously to attain and maintain the highest technical skills, but it wasn’t until I made a deliberate choice to show up as myself and demonstrate how diversity is an asset that I became comfortable leading the gender gap discussion and becoming a mentor.

If we make a collective choice to make this profession more inviting, I can see a strong path forward for all women considering this field. I encourage you to intentionally mentor a woman. She will work hard, and she will make you proud. I repeat. She will make you proud.

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Footnotes

  • Twitter @daltschul

  • Contributors I am the sole contributor.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Commissioned; internally peer reviewed.