Welcome, everybody. I know that this session is competing with a few other sessions, so I really appreciate you coming to join us, and it is my pleasure to welcome you to San Diego and the Heart Rhythm 2025, 46th Annual Meeting of Heart Rhythm Society. If you haven't done so, please download the HRS 2025 mobile app from your preferred app store. All right. Okay. So, our first speaker, well, I'm Christina Miyake, I'm sorry, I'm from, I'm the Director of the Cardiovascular Genetics Arrhythmia Program at Texas Children's Hospital. I'm a pediatric electrophysiologist, and I, what you're going to see today is a combination of some peds and adult, a rhythm of equity, and we're talking about an important topic in terms of women in EP and advancement. And my, on behalf of my co-chair. I'm Prash Sanders from the University of Adelaide in Australia, and this is an important topic, and we have an amazing lineup of speakers to bring different aspects of this, and it's an issue that faces all of us in EP, so looking forward to the talks. All right. Our first speaker today is Dr. Molly Shaw. She's currently the Chief of Electrophysiology at Children's Hospital of Philadelphia, and her topic is Women in EP, Current Data and Workforce Trends. Thank you, Christina and Prash. I want to say ladies and gentlemen, but should I just leave it at ladies? Thank you, sir. Thank you so much, ladies and gentlemen. All right. So my charge is to present current data and workforce trends for women in electrophysiology, and I really look forward to hearing from the other speakers about barriers, strategies, and solutions. So for the next 10 minutes, I'm going to share some of the data we have regarding gender equity or disparity in EP fellowship, workforce, academic leadership, compensation, reimbursements, conferences, panels, clinical trials. So let's start with the adult electrophysiology field. In the current era, 52% women enter medical school, at the end of which approximately 45% enter internal medicine, and then there is what we call the residency to cardiology fellowship cliff. And a significant number of women deselect cardiology as a profession and then subsequently deselect electrophysiology. And then you're left with about 6% to 10% women who choose to pursue electrophysiology training. So to understand this deep drop, Nashua Abdul-Solem and colleagues conducted the first study of its kind to focus on factors that influence the choice of cardiology fellows to pursue EP training and the factors that deter them. So in this large survey, there was a relatively overall low interest in EP, men or women. And I think that's fine. If you don't like EP, don't enter our field. This is a very special field. Overall, only 14% of fellows in training reported an interest in EP, but among those interested, only 8% were women. In other words, only 10 women of all the respondents over a three-year general cardiology program from North America expressed an interest in EP. Now when looking at the reasons for selecting EP, men and women generally shared the same top factors, a strong interest in the field, an opportunity to perform hands-on procedures, and an analytic clinical decision-making process. But the only factor that influenced trainees differently by gender was the presence of a female role model. So women are more likely to pursue a career in EP if they had a female mentor when compared to men. And to investigate this even further, Baikiner and colleagues studied the association between women electrophysiology fellowship applicants and EP training programs with or without women EP faculty. The study identified 769 EP faculty and 351 EP fellows across 111 EP training programs nationwide. 12% of EP faculty were women, and 56% of the programs had at least one woman faculty. The presence of any woman faculty in a training program was associated with a higher presence of women EP trainees. There you can see the trend of female EPs is approximately 10 to 15% per year. But the data also showed that 60% of programs had no female trainees. And also if you look at the level of EP program directors and section chiefs, they were predominantly men. Now let's see how this transfers to trends in women operators. So you're out of fellowship now. Recent analysis of the Medicare provider utilization and payment database revealed that on an average only 5% of the 3,500 practicing EP operators were women. And I would love to actually hear from our adult colleagues if this data is true. But this is what's published. Despite a huge increase in the total number of AF ablations, the proportion of women remain the same. And this was true not just for AF ablations, but for SVT and flutter ablations, as well as device implantation. And then when analyzed geographically, 10 states had no women EP operators who performed more than 10 any given EP procedures, 20 states had no women who performed either atrial fibrillation or SVT ablations, and 10 had no women device operators who performed more than 10 device procedures annually. Based on the analysis of physician membership of the Heart Rhythm Society, 13% of its physician members are women. And this number increases slightly to 16% for women under the age of 40. So my question is then why are only 5% doing procedures? Is there a leak in the pipeline or is it a choice that women make? So looking further, 13% of women reported working in an academic center and 7% at a non-academic hospital or in private practice. Now I am a pediatric electrophysiologist, so let's compare some of this data to pediatric EP fellowship and workforce. Looking at women representation in different stages of training from pediatrics to pediatric cardiology to EP, we're fortunate to start out with a pretty robust pipeline because 70% of women in the first year of pediatric residency are women and 53% of categorical pediatric cardiology fellows at the current time are women. Data show that 60% of our cardiology fellows choose a subspecialty fellowship and most women actually choose a non-invasive branch. 9% go into electrophysiology and almost a third of them are women. So very different denominators, but approximately 30% of our trainees are women. Looking specifically at pediatric EP fellowship in the United States, of the 65 fellows trained in the recent seven fiscal years, 34% were women and the trend seems to be holding if not getting better. Looking at EP faculty at training programs, 9 of 12 programs had at least one female EP faculty and three programs had none. Now this also reflects in the current workforce because 35% of pediatric electrophysiologists are women. So once we train a woman EP fellow, we're not seeing them leave the field and I think this is a really positive trend that there isn't a pipeline leakage after fellowship. So when we talk about workforce, we also have to talk about compensation. There are an abundance of data and data sources that show that there are no medical specialties in which women earn the same or more than men. Looking at data compensation for almost 300 adult cardiologists, 8% of which were females, and this is data sent to MedAxium, in a fully adjusted model for clinical activities, professional and job characteristics. Sex remained the only independent factor for salary gaps and women in this sample would make $32,000 more per year if they had been male. Now as a pediatric electrophysiology society, we surveyed our physician members and generated a salary data for only full-time working electrophysiologists and 95% of the membership is full-time and works at an academic center. And here too we found that there was a significant difference in the median annual salaries of females versus males. Female EPs were less likely to be in the top 45% of earners and this difference persisted after adjustment for academic rank and years in practice. On average, women electrophysiologists earned 78 cents on the dollar compared to male pediatric electrophysiologists of equal rank and experience for doing the same work. And then I learned that there are actually gender differences in Medicare reimbursements and men tend to earn or get reimbursed at a higher rate for both inpatient and outpatient care. And if you look at this map state-wise, look at the darkest red color. This is the state of Louisiana. Men here have a 238% higher reimbursement rate than women. There's gender disparity in the promotion process at academic centers as well. Women are less likely to get promoted to associate and full professor and when they do, it takes longer than men. Specifically in pediatrics, only 27% of women were full professors and they're less likely to be appointed as department chairs. Let's look at society leadership, HRS, eight female presidents, PACES, the Pediatric and Congenital EP Society, eight presidents who are women since 1988. A recent systematic analysis of gender balance of speakers from six large conferences and you can see they are the conferences we all go to, found that less than 30% of all speakers were women and although this trend was improving, women remain the least represented as moderator, panelist, speaker, and abstract presenter in the invasive fields. In the heart rhythm, there is a trend, there's an upward trend for women speakers. This is my own hand count so please forgive me. I hand counted all the HRS speakers including faculty, abstract presenters, poster presenters and came up with 25% women. Cardiovascular clinical trials face the same issue and very, very happy to hear that HRS women leaders are taking huge strides to change this. What I worry the most about are the gender disparities that we don't hear about around the globe. While factors affecting gender disparity in EP are complex and diverse in the U.S., the impact of fewer female electrophysiologists all around the world is catastrophic, especially in low and middle income countries where the burden of disease in women is great and where there's actually a cultural reticence for female patients to seek care from male providers, leaving women untreated. And I hope that we'll hear more about this from our next speakers. In conclusion, I'm going to quote a very dynamic panelist and speaker, the EP field has been struck or stuck, maybe struck, in the same rhythm for decades. It is time for a reset and a rhythm change. Let us all leverage all of the analytical thinking and hands-on work that makes EP so attractive to us and harness those same talents into fixing this dysrhythmia of gender imbalance in our profession. Very elegantly said, Kamala. Thank you so much for your attention. We're going to save the questions until the end. So our next speaker is Dr. Jennifer Silva. She is chief of EP at Washington University and she's going to speak to us about why women representation matters when it comes to patient outcomes. Thank you. Thank you. Good morning. It's tough following Molly. It is. But it's a testament to the fact that there's three female pediatric EPs on this panel, similar to what the data are that she showed. I've been tasked with talking about why women representation matters when it comes to patient outcomes. I do have a bunch of disclosures, none of which are relevant to this talk, but I am going to tie a couple things in towards the end. As I was thinking about this, I really wanted to crystallize to myself why women representation matters and I came up with four discrete areas. One, I think we provide diverse perspectives. Two, I think there's a level of patient comfort. Three, there are communication differences. And four, and Molly did touch on this and I thank her for doing that, advocacy and research in clinical trials. So let's talk about the diverse perspectives. There's a lot of data on this. I didn't really want to go through this part study by study, but we know that women bring different perspectives and life experiences to that decision making process. It can generally lead to more comprehensive care strategies that addresses a broader range of patient needs. All of these things bulleted here have been shown and demonstrated and quantified in studies. There's an increased time listening to patient, increased time reviewing and reading the EMR. I feel like I spend one full day preparing for eight patients in clinic by just reviewing the EMR. I don't think I'm the only one who feels that way. Increased caution when prescribing medications, including and especially painkillers. Careful weighing of clinical hazards and risks. I thought this one was interesting. More extensive testing. This is true. It's been shown time and time again that female physicians tend to order more tests, particularly imaging testing than our male counterparts. And I think that's something to keep in mind as we look at the economic assessments of what reimbursement looks like. It can't be seen in isolation. We have to understand the context around it. Generally we request additional references that are more inclined to seek advice from our peers. How about patient comfort? Well, patients might feel more comfortable discussing certain issues, and Molly already alluded to this, related to reproductive health or gender-specific conditions with female health care providers. And we know that when you take a more accurate and more detailed history, you can generally impact your patient outcome for the better. There's also variations in nonverbal cues. I want to talk about, I thought this study was particularly interesting. This was a study, it's an older study. It's 2002, looking at physician gender effects on medical communications. And in this study, they binned medical communications into four large groups. Information giving, question asking, partnership behaviors, and socio-emotional behaviors. And what they found was that female physicians engaged in more active partnerships with their patients, more positive talk, psychosocial counseling, and question asking that focused on emotional talk. I thought that was interesting. Now, what was really interesting is there was no difference, no gender difference, in the amount or quality of manner of the biomedical information that was being given. Males and female physicians were giving the same information, medical information, but the way the information was being delivered and received was different from female providers. They also found that medical visits lasted, on average, two minutes or 10% longer. They must be using my clinic template of 20-minute patient visits than their male physicians. Now, there was a notable exception, and I'm always interested in looking at the edge case because sometimes we can find answers in those edge cases. And it was an OB-GYN where they thought that there was a different care pattern that was seen in OB-GYN than primary care and that that might explain some of these differences. These data looked at general medicine hospitalized patients and variations in processes between male and female patients, and this was a Canadian study over seven hospitals in Ontario with over 170,000 patients and 172 attending physicians. Here they once again demonstrated that female physicians were more likely to order imaging testing, CTs, MRIs, ultrasounds, but that patients being treated by a female physician had lower in-hospital mortality by 0.5% if you were being treated by a female physician. Now, I also really like this. That difference persisted after adjustment for patient characteristics, importantly, but was no longer significant after adjusting for other physician characteristics, particularly length of practice in our male practitioners. Turns out the longer they had been practicing, they were able to adjust for this. It's something to keep in mind as we think about this pipeline issue and a whole bolus of young physicians entering our workforce. These data are probably the data that everybody thinks about when you think about this given topic published in PNAS in 2018, looking at patient-physician gender concordance and increased mortality amongst female MI patients. Female patients being treated by male physicians were the least likely to survive after an MI. Patients treated by a female physician were the most likely to survive, regardless of patient gender, interestingly. The asymmetry, however, was most notable in female patients. Now, again, male physicians were more effective at treating female MI patients when they had worked with more female colleagues and when they had treated more female patients in the past. Once again, I'm a big believer in once you've identified your problem, try to find what things are working around so we can try to start finding solutions. This seems to be a theme that's repeating itself in the data. This is a sort of side data set that I wanted to include. It comes out of a nursing journal that specifically looked at integrating social determinants of health, health disparities, and healthcare workforce diversity and seeing the impacts. And what they were able to very clearly demonstrate was that minority patients are more likely to report lower quality in their overall interactions with their providers. And they measured that by looking at what patients felt was reduced consult time, diminished trust, less respect, and poor communication. So it's not just gender. It's also race. So race-concordant visits were longer and had higher ratings of patient-positive survey results than race-discordant visits. So it's both sex and race that we need to be thinking about as we're talking through this very complex topic. There was a call to action from this group. I'm not going to go through it because I have a feeling that much smarter people than me are going to do that later today. But there was nothing here that didn't intuitively make sense. I want to spend a little time talking more about research and clinical trials. So historically, we know that clinical trials have often underrepresented women, leading to gaps in understanding how treatment affects them. We know that increased female representation in research roles and as subjects in clinical trials can help ensure that the guidelines that everybody in this room is busy writing are actually impactful for our women patients. So I'd like to share some data, and some of this is in cardiology. Some of this is not. This is looking at gender gap in leadership of clinical trials. This was a study published in 23 that was a cross-sectional study using the clinicaltrials.gov database, looking at trials between 05 and 23, and looking at the number of PIs. So of the PIs, 32% were women, 64% were men. And while I love charts, and I love seeing cardiology at the top of the list, it is disappointing to see that cardiology had the lowest proportion of women as PIs, followed only by hepatology. That was a little strange to me. They also found that women were more likely to lead non-industry trials than industry trials. I hadn't expected that. And there was a lower rate of women PIs in interventional versus observational trials. These data, I think everybody in this room probably knows very well, but we can't talk about this topic without talking about this. This was the Women in Procedural Leadership Roles in Cardiology, the WILL observational study. This was looking at Watchman implants over two years to identify characteristics and prevalence of women, one, as early implanters, and two, in related leadership. Men composed 97% of the implanters, very reminiscent of the data that Molly just showed us. There was no difference in subspecialty, so these were done by both EPs and ICs. No difference in subspecialty or implant by gender. Only just sub 5% of hospitals had women in selected leadership roles. Women represented less than 1% of directors of cath labs. EP did slightly better, but only slightly, with being represented in 2.6% of directors of EP labs or chiefs of cardiology. Notably, hospitals that had women in leadership had a four time greater odds of having a woman implanter. Again, the role of the role model. So women are underrepresented in key subspecialties, but really particularly in the use of novel technology and key leadership roles. And increasing women leadership may improve gender diversity through the visibility of these role models. I just want to say, as a side note, as a person who has started companies, who approaches people to be PIs on studies, every woman I have ever approached has said no to me. Every woman I have ever approached has said no to me. I want to say that again. It is hard for me to pull women up if you don't say yes. Please say yes. Don't say yes to everything, but you really must consider these things when these opportunities come to you. I pulled this for Prash. This is a data set out of Australia, and it looked at gender profiles of PIs in a large academic clinical trials group. Not cardiology, it is an Australian GI clinical trials group and these are their data from 94 to 22. There was 69 clinical trials published by this trials group in that time. There were 89 PIs, and 18 trials were led by females. That's 20%. Interestingly, that was only nine unique females that led those trials. So what we're seeing is that, yes, there were females that were leading trials, but it was the same women doing it over and over again. And none were from invasive specialties. The good news is not just EP. The bad news, this problem is ubiquitous. From the Will Observational Study, I pulled this quote. I know people are gonna talk about the pipeline, so this addresses it. In 20 years of gender parity in medical school, with such paucity of women in leadership, probably represents something other than a simple pipeline issue. I think it's a role model issue. And I think part of it is that we think the pipeline starts at medical school. I'm a pediatrician. The pipeline starts here. The pipeline starts in elementary school. And I think that's really where we need to focus our efforts in elementary, middle, and high school education. And I would like to end by sharing this story. As I alluded to, I have a company, one of my companies did a clinical trial at my hospital. This was a young woman who was having an EP study. After she had consented to be in the study, we put the headset on her. One of the things we were looking at is consenting processes. Was it different when you saw what a procedure looked like versus me just telling you what a procedure looked like? And this young girl who I had known for a while, who was having a very straightforward EP study for SVT, said to me, Dr. Silva, you have to see this. And I said, oh, I've seen it. She said, no, no, no, no. I need to show you what I'm seeing in this headset. And I said, sweet girl, I know what's happening in that headset. I invented it, I designed it, I live and breathe this thing. And she took it off her head. She said, I didn't think women could do that. And I said, oh, okay. We're gonna be 30 minutes late for your start time, but tell me why you thought women couldn't do that. And she just hadn't ever really considered that a role of a woman could be in engineering or as an inventor. I'm really proud to say she has graduated from university with a degree in engineering. And this is how change happens. One gesture, one person, and one moment in time. So female clinician representation is vital for our patients. Improvements in communication, care, confidence, nonverbal cues, all very important. And it's not just sex. It is also race concordance that we need to be mindful of. We need to think about ways to change our workforce to reflect this, because this is not just a current issue, it is a future issue as well. I do think there's a role for societies. I don't totally understand and have crystallized what that is, but I do think there's an important role. And so I leave you with a call to action. Be a positive role model for one young female. You get to choose the timeline. You can do it once a day, you can do it once a week, you can do it once a month. But please, if you leave with nothing else, leave with that. I have all of these people to acknowledge. I'm very grateful for them. And I leave you with this last thing. There is a group, Women as One. They are doing an event today in association with Boston Scientific, specifically focused on women in clinical science, bridging the gap with industry. And that's happening later today at 4 p.m., where we'll be addressing a lot of the parts about women PIs in industry-funded trials. Thank you. We'll move to the next speaker, who's Dr. Kamala Tamirisar. She's going to talk about barriers to advancement for women in EP. Thanks, Kamala. Thank you so much for the invitation, and thank you, everyone, for staying here through this important discussion. So the barriers to advancing women in EP, some of the slides will overlap with Molly, because those are the barriers, but I'll try to... So this is the gender equity. We talked about the pipeline or the pathways, what I like to use. And just one point on this slide, we have to look at intersectionality. So for women who are colored women, we have this here, black, Hispanic, American Indians, and Native Hawaiian, very zero percent. For those women, it's not a leaky pathway, it's a plugged pathway, so they don't enter. So the role, going back to Jen's point, the role models, that has to start in elementary schools and very young. And we know the operators, so somewhere, not only it's a plugged pathway for some women, and it's a leaky pathway because we're not able to retain women. And we talked about the procedures, and we talked about why do we need more women physicians, and Jen really did a great job covering everything. Now I will go to the barriers. Well, we go back to that Sentinel paper by Nashua. This has really opened the door for us to look at. First things are radiation concerns, and I don't have a slide, but I will talk, spend a little time on that, and lack of female role models, which we talked about, and perceived old boys club culture, and discrimination, harassment, and other thing is the greater interest in another field. So as far as the greater interest in another field, how are the program directors doing when they rate, when they look at what are the priorities when you recruit a candidate to come and train in your program? I have this graph, and I summarize this. 31% of cardiology fellowship program director, survey respondents, are uncertain or do not believe that physician diversity enhances quality of care. 63% of fellowship directors do not think that diversity needs to be increased in their program, and only 6% of the fellowship directors ranked diversity or ability to enhance cultural competency as a top three priority. So program directors is, the barrier is right there. The program directors need to open the door, and I'm hoping in the next maybe few years we start to see these numbers change, more doors are open to recruit more women. And we did not even talk about intersectional issues. What about the black women, or the Hispanic women? We don't know the data. Maybe it's worse for them. Bottom line is, it's, if the field is plugged from those who recruit fellows, then we won't see the changes. So changing that mindset. Then we say, okay, the program director opened the door, let's go ahead and hire someone. And then we say, yeah, EP is a great field, I'm a wonderful role model, so is everyone else who's trying to do their best. What about the pay gaps? So they go into the market, and we talk about retention, we are not able to retain, because the pay gaps are, I know Molly showed several slides, but cardiology, if you look at the faculty position, instructor to the chief, as the promotion keeps happening, the pay scale goes down, and the gender gap between men and women as they become the chiefs is more transparent, and I have that shown here. So median salary for men and women salary. As you can see, the higher you climb up the ladder, the wider the gap when compared to the men in the same field. And the second part of the graph over there is the median annual salary for women versus men based on specialties, and cardiology has a very wide gap, and that is statistically significant. So one take-home point here is, yes, program directors is an issue, opening the doors. Second thing is, we won't be able to retain unless we narrow these gaps. Women can't do the same amount of work and get paid less. Medicare payment gaps, and Molly covered this very good slide, but I will stress a point here. We know that women make lower RVUs. That's a known fact. Women make lower RVUs. Why do they make the lower RVUs? The reason they make lower RVUs is what was shown by the previous two speakers, is they spend more time communicating with patients. They take more time focusing on the prevention, their social aspects, and other aspects, which are equally important as the procedural. So we need to create, I think I mentioned this yesterday, there has to be a timed value unit, not just pure RVU-based models, because we do change outcomes as shown in acute MI data, diabetes, and other data that was shown before. So men receive higher payments from and submit more charges to CMS compared to women. So that's one thing we have to do better. And I will ask anyone who, you know, how many times have you even looked into getting an audit, and how are you coding, and how are you billing for the charges? How many of you have done that? So men are very intentional about it. They reach out to the audit team, and they go to the coders and say, hey, every six months, I want to see if I'm billing at the highest level possible. So please do that. Please. It's OK to advocate, yes, we are excellent at patient care, but we are not very good about knowing the money. We have to start speaking in the financial language. So it is something from us that we need to charge and bill at the level we are providing the care. And the clinical trial gender gap, so someone in academia, we talk about retention. If these women are not able to climb up from instructor to the professor because they're not able to get into the high-impact journals, as no more than 10% of the publications from the major trials were led by a woman investigator. So the barrier is communication with industry and also applying. So we need to train more women how to write a grant, what it takes. We need more mentors and sponsors and the support from the industry. Leadership positions, this is a cross-sectional survey of 500 cardiology fellowship programs, and division chiefs were 5% were women versus 95% men. Program directors, 14% women versus 86% men. So we do not have enough. These numbers are changing for the latest paper, but we still have long ways to go. So we need to put forth one paper I did not put here is please do not wait for a perfect CV before you apply. And there is a paper from Harriet Manspell. Women wait for a perfect CV before they apply for these positions. Don't wait for a perfect CV. Just apply. If it means that three times, four times you get a no, then you keep pushing and say no. And one fine day, we'll all succeed. But involvement of women and men in cardiovascular guideline writing committees, and you can see the trend in the green bar is electrophysiology, 77% are men, 22% women. So we need to create more room from within ourselves about asking, applying, and the system to help us. And the solutions, I already put that in there. This is one of the editorials we wrote for Jack on Nashua's paper, basically everything that I covered. So two other points I will mention, and just here, let me see. We talked about those. Give me one second. Okay. So a few things I will mention is radiation is something I did not touch on. Work life, I don't like the word balance or harmony or integration, however we want to use it. Nothing related to this slide, but I wanted to touch on those two. We have a global survey paper process with me on it. It's going to come out. Two messages that are going to come out is the two parts to the radiation, if any follows. Radiation and fetal toxicity most of the time is a myth if you protect yourself and everything. But because of that, do not delay your pregnancies, because carrier is so important that we have noticed that women are advanced age, and that leads to more complications, and systems needs to invest so we don't double lead, triple lead, and then break our backs and have a gravid uterus, and we need to make a policy for flexibility. If there is a female who wants to be pregnant, she needs to be, and she says, I don't want to be in the procedure lab. We need to have flexibility documents supporting those women, otherwise nothing is going to change there. And this is going back to Van Spalt's paper in the trial list and the solutions, but the next speakers are going to talk. Last thing I will talk about, you know, the culture, old boys culture or the culture, environment. Environment needs to be conducive. Few things we need from the systems are the transparency. We don't know the paid transparency. We don't know what the neighbor makes. We just don't know, because we never ask, but it's something we need to ask. And please negotiate and ask for the contract, and there is policies, you know, for those who are employed and in systems, there are Title IX. How many of you know about Title IX? Good. So Title IX policies are there. We had a bunch of papers on that. Sexual harassment, and this I authored with Jack. You know, no, and I think in the systems that one barrier is the anonymous complaints are not encouraged. There's always a fear for retaliation. So that is something we need help from the policy makers and professional organization to get the support. Now, this is the last slide. Yes, we talked about barriers, but I'm very proud to say, and Kevin is here with me, and diversity equity inclusion initiatives as a council, one of them was women faculty inclusion, and we have made that benchmark, and I'm so proud to say that we are beyond 25%, and thank you for Ricky and, you know, for making that happen. GLOW program that Ricky spearheaded with Jen is now taken off. Any early career, please apply, and industry-sponsored women in EP is where my life started. The doors were opened, and we have plenty of role models, just, you know, and Heart Rhythm O2 is a great example, and we already talked about the luminaries, the women presidents of Heart Rhythm Society. Thank you so much. Thanks, Camilla. So our next speaker is Kevin Thomas, and he's going to do a difficult task, strategies for closing the gap, practical solutions for building an inclusive workforce. Well, good morning, everyone, good to see you all, and thank you so much for your attention. Thank you to our wonderful moderators and to my fellow co-speakers, just terrific, phenomenal talks. And so I appreciate the opportunity that was provided to me by the Scientific Session Committee, and I absolutely leapt at the opportunity to give this talk and be a part of this incredibly important topic, and that's very dear and personal to me. And just as this event is largely about really cultivating and developing the workforce for women, we need men to be strong supporters of that effort, for sure. And as a black man raised in this country by a single mother, women have always been something incredibly important to me. And as I reflect that my own household, I'm the vice dean at Duke and lead thousands of people, but in my household, my wife is a CEO and my 11-year-old daughter is a COO, and I'm very clear about that. So I'm going to talk about strategies, and you've heard some really wonderful data shown to you today talking about the inequities and the disparities that exist. You heard some very actionable and pragmatic approaches for individual things that can be done to try to, again, mitigate some of these disparities and equities that we see. I'm going to talk a little bit more about what institutional responsibilities are. And as someone who has been in the equity, diversity, and inclusion space for a long time, I like to focus on equity and what do I mean by equity, and I think it's important to name that given some of the weaponization that is occurring nationally toward these type of fields and initiatives. And when I talk about equity, I'm really talking about structural issues, practices, and policies of organizations and institutions, and so I think there is an opportunity and an unmet need to really shine a light on the responsibility for these individuals and these organizations collectively to really own the environment and the cultures that we have and why there have been challenges that lead to the inequitable numbers that we see in terms of women representation as well as underrepresented racial and ethnic groups. We're going to talk about the importance of inclusion. You've heard some of that, so I won't spend too much time with that. We'll talk about the current state. But I want to really spend my time focusing on how do you promote an inclusive workplace culture for women and underrepresented racial and ethnic groups? Then the really critical aspect of accountability, and that's monitoring and ensuring that the initiatives that we have are met, and that everyone is doing their part to advance the work. So understanding the importance, I'll briefly go through this. So again, you've heard over and over again, and I'm not going to spend too much time on this, but it is really important to understand what diversity and inclusive experiences where everyone feels like they have a voice and everyone has the opportunity to thrive, is incredibly important for our field, particularly a field like arrhythmia care and electrophysiology. We're going to talk about the importance in healthcare settings and the fact that, and we heard beautifully articulated how patients feel more comfortable if there is concordance. Now that isn't for everyone, and the data is interesting, if you really take a look at the data. We saw some compelling data that shows the importance of outcomes for congruence or concordance between clinicians and patients, but that data is mixed. And so, but even if there are a small proportion of people who that makes a difference for, then we need to recognize the importance of that. We also need to be conducting inclusive research that provide results that are generalizable to everyone. There's many different outcomes we've seen from clinical trials that suggest that all therapies aren't implemented and have the same effects on people by their gender. And so those things are really incredibly important so that our trials are representative. We also know that an inclusive workforce improves team dynamics, fosters innovation, and leads to better, more patient-centered and healthier outcomes. So there is enhanced creativity when we have diverse perspectives, particularly as it relates to sex and gender. We have improved problem solving. I'm a personal testimony to that. I have an office of 16 individuals, 14 of which are women. And people are like, Kevin, you need more men in your office, like, no, I don't. We wanna get stuff done, the women get stuff done. Also, let's talk about attracting top talent. Inclusivity in the workplace shows that organizations and institutions are welcoming. And so when there are opportunities for employment, individuals look at that. And so if we have more diverse and inclusive workforces, then there's the opportunity to recruit more top talent. It also reduces attrition. Studies have shown, and some of the things and the strategies I'm gonna bring forward today are rooted in data and science. Some of them are empirical. And then others, just a common sense. And so we're gonna cover that entire gamut about strategies that I think are incredibly important. And so we know that when people are in healthy workforce places, and there's civility, and there's appreciation, and there's respect, and there's value, that people are less likely to leave. So you've heard about the data. Another study that was published in JAC in 2023 looked at clinicaltrials.org, was able to discern using complex algorithms to extract the women who were actually the PIs for different trials. And in that particular study, they showed on average, although they represented a much smaller percentage of the clinical trial PIs, when they were the PIs, they were 7% absolute numbers more likely to enroll women patients than male PIs. So similar things have been shown for underrepresented racial and ethnic investigators. So I led a trial of shared decision making in primary prevention implantable cardioverter defibrillators. The trial was focused specifically on a high-risk population that we know has been underserved for that particular sudden cardiac arrest mitigation strategy. And using specific strategies, I was able to enroll 407 black patients over the course of a year. We used several techniques that I think are important that I think as the trial leader, I was able to bring to bear to allow us to be successful. One of those was geospatial mapping to determine the areas in the country where the highest density of eligible patients who self-identified as black were located, and to leverage enrolling and using sites in those areas to allow us to be successful in our enrollment goals. We also partnered with Rochester, who's led many of the primary prevention and secondary prevention ICD trials, to look at their logs to determine the sites that were most successful in enrolling diverse patients. I also was very intentional about identifying black site PIs and we used innovative technologies like iPads that has been shown to be impactful in terms of recruiting diverse populations. So what are the current challenges that we see? And this shows up in academic medical centers in particular, but also in other healthcare practices and systems throughout the country. And these individuals struggle with impacting diversity in workplace. And some of it has to do with just the lack of awareness of what are the effective policies and practices that allow for successful recruitment. So that can be gleaned by looking at institutions and practices that are incredibly diverse as it relates to having women as clinicians in their systems. We also know that practices are ill-equipped to recruit these populations, not knowing where specifically to search for these individuals. And so really hiring search firms or partnering with entities that have a track record of being successful in recruiting diverse populations is really essential to achieving some of that balance and equity that we are seeking. So the current state. So it's important that we do audits and we take again, accountability for how we're doing. And so annually we should be surveying and creating dashboards that provide us with updates on how we're doing with balancing our workforce as it relates to sex gender. We also need to ensure that we're engaging our constituents as well. So for the individuals we have within our units and organizations, we need to be doing surveys and qualitative assessments to help us understand what the experiences are. And that gives us then actionable steps to pursue to ensure our spaces are inclusive and they also are serving the needs of all of our individuals. Also, we have to look at things about how are people getting paid in our systems. That's incredibly important. We've heard about the pay disparities that exist and we have to be intentional about how to discover those. Similarly, we have to look at promotion practices. So if it's a private practice, what is the road to partnership? And is that being achieved at the same rate for women as it is for men? You have to be inclusive in your job descriptions and postings as well. Using language that talks about your values and your commitments to having inclusive environments and diverse workforces is incredibly important when you're trying to again, attract candidates. And it also serves to foster a welcoming environment. We also have to have outreach to underrepresented communities as well because we know that that's where clinicians tend to cluster when you're looking for recruitment. And then some of the practices, again, as I mentioned, it has to be very intentional. This is not gonna happen holistically. And not that you have to have quotas, but again, you have to be very intentional again in sharing your values and what things are most important for your organization. So we also have to, again, do and foster and our actions speak louder than our words about what our environments look like. And so we seek to have a culture that is respectful in where people feel like they belong and everyone has an opportunity for achieving at the highest level. And that's done by having open communication, transparency, and again, accountability, asking for feedback, sharing of ideas, engaging everyone's voice. We also have to understand that we're not alone. We have to recognize contributions and that can't just be for the men in the practice or in the organization. It has to be for women as well. Valuing diversity. Again, through experiences, teamwork, engagement, those things are important to developing a healthy workplace culture. So key areas for improvement, retention strategies. Again, they keep valuable employees and reduce turnover rates, but they also allow for entities and organizations to be more profitable. Having events that promote wellbeing and mindfulness is incredibly important. Again, ensuring that the culture is welcoming and is meeting the needs of everyone. And then having specific initiatives that foster a workplace culture and improves overall morale and looking at your policies and practices. So we heard a little bit about radiation exposure and what are the entities and the programs that are put in place to try to decrease radiation exposure for women. On-site daycare facilities. Is that an opportunity? These we know are barriers to women working in certain environments. Lactation facilities. Now again, that's an obvious thing that needs to be addressed, but you have to be intentional about it as well. Flexible work options. Shorter training experiences. I think we can be innovative as an organization to suggest pathways that will allow shorter training experiences for women, given the unique circumstances that women have to experience in employment. And then maternity leave. Making sure that those policies reflect the needs of women and newborn children, I think can be incredibly impactful as well. Support programs and mentorship programs. We've heard quite a bit about that, which is important for community building and also pathways to success and opportunities. You heard about both GLOW and GLOBE. GLOBE is for black electrophysiologists. And again, as one of the charter members of the Health Equity Council that was initially a task force, one of the first things I said was, we actually need to look at what the women in electrophysiology are doing, because they've made incredible gains and have really established a great template for other groups to be successful as well. I'm sorry, we're running out of time. Yep, I'll wrap up. So the last piece I wanna share is really about accountability. And so we can put forth these initiatives and action items and goals, but we have to be accountable for them and that requires regular review and engagement. So thank you for your time. So we now have our last speaker, Rikki Green, who's going to bring us home with the future of EP, building a sustainable, diverse and inclusive specialty. Okay, well, you'll be happy to hear that I will be quick. Let me get my slides up here. So we have heard from this fantastic panel about the barriers and that we recognize them and we are very aware of what's going on. We have also heard about very excellent strategies that we can take to overcome these barriers. So I was tasked with talking about the future. And there are no charts to show because the future is almost here. So I'm gonna forego the charts. You will not see a diagram, you won't see a chart, you will only see pictures. Because I figured I'm gonna take this kind of from a personal perspective and talk about what I think the future of EP is going to be like. The title is building a sustainable, diverse and inclusive specialty. And the first thing I would like to say is that I do recognize that we live in uncertain times. And perhaps it is difficult to talk about diversity and inclusive activities. But I may be naive, but I have chosen to be very optimistic and be positive because I think we need to move into the future with an optimistic outlook. Otherwise, life will be sad. My disclosures. I'm gonna start with a picture from a recent Women in EP meeting. And I'm gonna say to that, I think that the future of electrophysiology overall is bright. And I think that that's true for men and women. I think we're gonna continue to be needed as a specialty. I don't see AI replacing us anytime soon. I think we can integrate it, but we're still gonna be loved and appreciated by our patients. I see job offers coming to my fellows, men and women equally. And we definitely see more women out there. I mean, look at these pictures. This was just from last year. I think that new tools and technology is going to help, again, men and women. But I do think that it's gonna help us women perhaps even a little bit more. Why is that? Technology, we talked about radiation already, but there's an example of where we have come a long way from the terrible heavy lead that I wore during my three pregnancies, during my three fellowship. And I had three layers of incredibly heavy lead on. I think we're moving away from that. We have shorter procedures, less radiation exposure. We do more mapping. We're, you know, that foot on the floor of pedal is not as heavy as it used to be. It's not as heavy as it used to be anymore. You know, quicker procedures. Men and women, we both like that. But there's something to be said for being able to go in and do a leadless pacemaker instead of, you know, a two-hour standard pacemaker. So tools and technology here to help men and women, but us women, I really do think we benefit from it. Okay, this is me with my fellow faculty at UCSD. And to that, I'd like to think that we can continue to build from a supportive environment. My guys, I call them my guys. They are very supportive. They have been supportive all these years that I've been there. We just hired a young woman out of our fellowship to join the faculties for next year's picture. We will have two women in there. And I will also like to think that I think that the younger generation, my children's generation, they come from a mindset of support. So having that, it's gonna be a different dynamic in the workplace. I firmly believe that there may be some leftovers from the old boys' network, but I think it's gonna be gone. And I just think it's gonna be a good network. And women network well. And this is an example there of the women in EP listserv that we have actively ongoing with well over 200 women. A recent Zoom meeting and our WhatsApp network where we also connect. I think women network well. This is one of our strengths. So we should harness that and continue to network in many different ways. You know, there's more networking to be done than on the golf course. So let's keep that going where we're good. And this is my team in the EP lab. And I wanna point out here, these are all women. My rep here is a woman. My clinical specialist is a woman. The techs are women. The nurses are women. The overall environment in electrophysiology is changing to be more inclusive. There are days now when I'm in the EP lab and the room is there, we're only women in the room. The anesthesiologist is a woman. My fellow is a woman. The techs are women. The nurses are women. I can assure you that when I started many years ago, and we're talking decades here, I was the only woman. Every single time in every single room, I was the only woman. That doesn't happen anymore. And we're never gonna go back to that. It's interesting that I'm gonna tie right back into our first speaker about global commitment because that is an area where we do need to do more work. And this is from an APHRS many years ago in Melbourne and I loved that meeting because that was fantastic. We need to continue to build on a global commitment to support inclusivity and diversity around the globe. Very, very important. We had a fantastic women in EP luncheon session yesterday. For those of you who couldn't be there, the panel was with representatives from five women from everywhere in the world. And my last slide. This is the most important slide. EP, it will continue to be fun and it will continue to build friendships. So that's why we're all in this and it's gonna only get better. So thank you. All right, thank you for this. It was a great session. So many, the speakers, I actually learned a lot. I know we're running a little bit late but I did wanna open it up to any questions, conversations that we can bring up. Hi, Deborah Lockwood here. I'm so sorry this room isn't full because there was so much provocative, indeed some shocking data presented here that really needs to be generally known. I want to, if I may, play devil's advocate a little bit and then rebuff myself because I know that we try to point this out to the people who are actually in a position to make a difference. And quite often they come back with remarks that are actually quite stupid but they sound reasonable at the time. So one of the thing that comes up is that if only 10% of people are EPs, then the fact that we're getting 20% of people as PIs or near 20% of people as PIs or in leadership positions, then actually maybe we're over-represented. But of course, you have to go back to the 10% of people and know that those are already quite extraordinary people who have gone against people telling them that they can't and they shouldn't and so on. So they are actually the very top of the EP people. They're people who are really passionate about EP and they do, all 10% of them deserve to be in those leadership positions. And I think that's important. And then on a similar vein, we were talking about we should be reimbursing people for their time rather than these RVUs. And I think if you say that to an institution, they'll say, yes, but we get reimbursed by Medicare and Medicaid on the basis of RVUs. So we can't pay you more just because you take more time. But then one of the things that really didn't come up at all here is that not only does it result in better outcome to take more time, but it also results in much less litigation, which costs these institutions a lot of money. And I, for example, know that in 20 years of being an invasive electrophysiologist, and I'm one of those few who did the ablations and all the procedures, I was only sued once. It was dismissed, but just the once. And that was for a patient who came through the fellows clinic and really only met me fairly briefly. All the people that I actually saw myself and communicated with, I can't tell you, I'd love to say I never had any bad outcomes, but of course I did in that time, but never suing. So I think that's something really important that we can tell the people when they're thinking about employing women and they're saying that they're actually less productive. They're not less productive. That extra time communicating is really, really important. So thank you for that. Oh, and sorry, if I may, one more thing. This is really directed at Dr. Silver, is it? So your young girl who said that she didn't know that women could do that, I think that's really important. That's somewhere where we need to start. We can start with the children, but also it's not too late in medical school to rewrite the beliefs that they've been given as children and throughout their teenage years and so on. And we can tell them that they really can do it and we can make our female role models much more visible. Agreed. Hi, I'm Anja Schell. I'm a medical student from Sweden. So I wanted to thank you for the session first and foremost, but I wanted to ask you, because this data was quite America-centric, what's the situation in Europe or Asia or Australia? It's worse. It's worse. And why are they worse? Do you have any reasons or what do you think? I can maybe speak to Australia and Asia Pacific. So look, the Australian situation is changing dramatically, OK? So we are having increasing number of women who want to do cardiology, which is good. And we've instigated a lot of programs to encourage women into EP service. We haven't been as... It's just starting to happen. But, for example, we've had now four or five fellows come through our program and we're hoping to recruit back to kind of increase that opportunity. That didn't happen 10 years ago. So that's starting to change. Asia Pacific, we've got a big way to go, OK? Because it's a question of recognising there's a problem. And unless you recognise there's a problem, you're not going to try to fix it. And that's a major issue that we are facing. We're working on it, but it's going to take some time. Thank you. Well, on a positive note, you're here. And that's wonderful. I know. Look, thank you very much. I learned a heap in this session. And there's so much to unpack in this session and the contents. And there's so much for us to work together in terms of how we improve programs and improve this area. So well done to everyone who's speaking. And thank you for all the audience.

Heart Rhythm Society

electrophysiology

women in EP

gender disparities

female role models

inclusive work environments

diversity

workforce trends

systemic changes

mentorship