Women in Anesthesiology and the Mid-Career Stall: Why They Are Not Advancing Into Senior Leadership.

Women anesthesiologists face many challenges when trying to advance their careers and find balance in personal and professional endeavors. In this article, we introduce the reader to several concepts central to understanding the challenges faced by mid-career women anesthesiologists and highlight why these challenges become particularly pronounced when women enter the mid-career stage. We describe how lack of constructive actionable feedback combined with lack of mentorship and sponsorship negatively affects women in the workplace. We also outline barriers and bias that mid-career women anesthesiologists face in high-level leadership roles along with the disproportionally high burden of nonpromotable work. We present a discussion of mistreatment and burnout, which are compounded by concurrent demands of parenthood and a professional career. We conclude with the impact that these barriers have on mid-career women anesthesiologists and recommendations for mitigating these challenges. They include a systematic increase in mentorship and sponsorship, an individualized professional development strategy, and an improved and comprehensive approach to promotion.

The Women in Cardiothoracic Anesthesiology Special Interest Group: What Can the Lessons of One Anesthesiology Affinity Group Tell Us About How to Build Impactful Professional Communities?

The Women In Cardiothoracic Anesthesiology (WICTA), a special interest group of the Society of Cardiovascular Anesthesiologists, has been highly successful in mobilizing WICTA, a historically underrepresented and marginalized group in the subspecialty, and in supporting real and meaningful change in the professional community. The experience of WICTA as a professional affinity group in impacting a professional organization to diversify, evolve, and become more responsive to a wider professional audience has important lessons for other professional organizations. This article discusses the recent history of affinity organizations in anesthesiology, the benefits they offer professional organizations, and the strategies that have been used to effectively motivate change in professional communities. These strategies include engaging a strong advisory board, identifying the need of constituents, creating additional opportunities for networking and membership, addressing gaps in professional development, and aligning goals with those of the larger national organization. WICTA is just one example of the potential opportunities that affinity groups offer to professional societies and organizations for expanding their reach, enhancing their impact on physicians in their target audience, and achieving organizational missions.

Misconceptions about women in leadership in academic medicine.

Despite progress made over the past decade, women are under-represented in positions of leadership in academic medicine. Women physicians face numerous challenges throughout their careers. Despite achieving leadership positions, women in leadership continue to experience the impact of those challenges. In this review, we describe four misconceptions about women in leadership, along with their impact and recommendations. First, we describe differences between mentorship and sponsorship, as well as their impact on attaining leadership positions. Second, the gender pay gap persists throughout women's careers, regardless of leadership positions. Third, we explore the role of self-efficacy in leadership in the context of stereotype threats. Fourth, gendered expectations of leadership characteristics place an undue burden on women, detracting from their leadership effectiveness. Organizations can address the challenges women face by creating robust mentorship and sponsorship networks, establishing transparent and equitable pay policies, promoting and normalizing a broader range of leadership styles, and improving work flexibility and support structure. Ultimately, such changes serve all members of the organization through increased retention and engagement.

RéSUMé: Malgré les progrès réalisés au cours de la dernière décennie, les femmes demeurent sous-représentées dans les postes de direction en médecine universitaire. Les femmes médecins font face à de nombreux défis tout au long de leur carrière. Malgré leur accession à des postes de direction, les femmes occupant ces postes continuent de subir l'impact de ces défis. Dans ce compte-rendu, nous décrivons quatre idées fausses sur les femmes en position de leadership, ainsi que leur impact et quelques recommandations. Tout d'abord, nous décrivons les différences entre le mentorat et le parrainage, ainsi que leur impact sur l'accession à des postes de leadership. Deuxièmement, l'écart de rémunération entre les sexes persiste tout au long de la carrière des femmes, quels que soient les postes de leadership. Troisièmement, nous explorons le rôle de l'auto-efficacité dans le leadership dans le contexte des menaces stéréotypées. Quatrièmement, les attentes genrées à l'égard des caractéristiques recherchées dans le leadership imposent un fardeau indu aux femmes, ce qui nuit à l'efficacité de leur leadership. Les organisations peuvent relever les défis auxquels les femmes sont confrontées en créant de solides réseaux de mentorat et de parrainage, en établissant des politiques salariales transparentes et équitables, en promouvant et en normalisant un éventail plus varié de styles de leadership et en améliorant la flexibilité du travail et les structures de soutien. En fin de compte, de tels changements servent tous les membres de l'organisation grâce à une rétention et une implication accrues.

A Call for Diversity: Underrepresented Minorities and Cardiothoracic Anesthesiology Fellowship Education.

This paper is the first of a four-part series that details the current barriers to diversity in the field of adult cardiothoracic anesthesiology and outlines actionable programs that can be implemented to create change. Part I and Part II address the training experience of women and underrepresented minorities (URMs) in adult cardiothoracic anesthesiology (ACTA), respectively, and explore concrete opportunities to promote positive change. Part III and Part IV examine the professional experience of URMs and women in ACTA, respectively, and discuss interventions that can facilitate a more equitable and inclusive environment for both groups. Although these problems are complex, the authors here offer a detailed analysis of the challenges faced by each group both in the training phase and the professional practice phase of their careers. The authors also present meaningful and concrete actions that can be implemented to create a more diverse, equitable, and inclusive professional environment in cardiovascular and thoracic anesthesiology.

Perceptions of Gender Disparities Among Women in Cardiothoracic Anesthesiology.

OBJECTIVE: In this study of women in cardiothoracic anesthesiology, the authors aimed to characterize demographics, roles in leadership, and perceived professional challenges. DESIGN: A prospective cross-sectional survey of female cardiothoracic anesthesiologists in the United States. SETTING: An internet-based survey of 43 questions was sent to women in cardiothoracic anesthesiology. The survey included questions on demographics, leadership, and perceptions of professional challenges including career advancement, compensation, promotion, harassment, and intimidation. PARTICIPANTS: A database of women in cardiothoracic anesthesiology was created via personal contacts and snowball sampling. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A total of 153 responses were analyzed, for a response rate of 65.1%. Most respondents were at the Clinical Instructor or Assistant Professor rank. Many women perceived that compensation, promotion, authorship, and career advancement were affected by gender. Furthermore, 67% of respondents identified having children as having a negative impact on career advancement. Many women reported experiencing derogatory comments (55.6%), intimidation (57.8%), microaggression (69.6%), sexual harassment (25.2%), verbal harassment (45.2%), and unwanted physical or sexual advances (24.4%). These behaviors were most often from a surgical attending, anesthesia attending, or patient. CONCLUSION: This survey study of women in cardiothoracic anesthesiology found that many women perceived inequities in financial compensation, authorship opportunities, and promotion; in addition, many felt that their career advancement was impacted negatively by having children. A striking finding was that the majority of women have experienced intimidation, derogatory comments, and microaggressions in the workplace.

Gender of Abstract Presenters at the Annual Meetings of the Society of Cardiovascular Anesthesiologists and American Society of Anesthesiologists: 2016 to 2020.

OBJECTIVE: The purpose of this study was to assess gender in abstract poster presentations at the Society of Cardiovascular Anesthesiologists (SCA) and American Society of Anesthesiologists (ASA) Annual Meetings from 2016 through 2020 to determine possible gender disparities in anesthesia overall as compared to cardiothoracic anesthesia. DESIGN: A bibliometric study SETTING: Publicly available data from the SCA and ASA websites. PARTICIPANTS: Presenting and senior authors of abstracts at the SCA and ASA Annual Meetings. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Abstract data on presenting and senior authors were collected for the years 2016 through 2020 for both annual meetings. Observed gender of abstract authors was compared to expected gender based on the gender distribution of cardiac anesthesiologists for the SCA or of all anesthesiologists for the ASA. From 2016 to 2020, the proportion of women senior authors on abstracts was significantly underrepresented (2016-2019, p < 0.05). At the SCA meetings, there was no significant difference in the observed versus expected proportion of women presenting and senior authors. The percentage of woman physicians' abstract-presenting authors at the ASA was overrepresented compared to the expected proportion for each year (2016-2020, p < 0.001). CONCLUSION: At the SCA, women were appropriately represented as both presenting and senior abstract authors. At the ASA, there was significant overrepresentation of women as presenting authors and underrepresentation of women as senior authors. These results suggested that abstract presentation is not a barrier to academic advancement.

Congenital anomalies of the aortic arch in acute type-a aortic dissection: implications for monitoring, perfusion strategy, and surgical repair.

OBJECTIVE: To assess whether management of acute Stanford type-A aortic dissection differs in patients with congenital anomalies of the aortic arch compared with standard institutional practice. DESIGN: Retrospective analysis of all consecutive patients from 2001 through 2011. SETTING: Quaternary referral center for surgical management of thoracic aortic disease. PARTICIPANTS: All patients with arch anomalies who underwent surgery for acute Stanford type-A aortic dissection during the study period (n = 43). INTERVENTIONS: Surgical management, anesthetic monitoring, and perfusion strategy were analyzed in a retrospective fashion. No new interventions were undertaken as part of this study. MEASUREMENTS AND MAIN RESULTS: Management differed most in patients with an aberrant right subclavian artery (n = 5), because the institutional standard of right axillary artery cannulation with left upper extremity arterial pressure monitoring was not possible. In patients with one of two "bovine" arch patterns (n = 32), management differed in the conduct of selective antegrade cerebral perfusion, which could include clamping above or below the takeoff of the left common carotid artery (and, therefore, produced unilateral or bilateral antegrade cerebral perfusion). All patients with a connective tissue disorder exhibited a bovine arch pattern. Management of patients with a right arch (n = 3) reflected the opposite of management for normal anatomy (for patients with traditional mirror-image branching) or opposite that of the aberrant right subclavian group (for patients who had a corresponding aberrant left subclavian artery). CONCLUSIONS: Rational management reflected the anatomic variations observed. These results support the importance of interdisciplinary planning, especially in an emergency, to optimize outcome.

Factor VIII inhibitor bypass activity and recombinant activated factor VII in cardiac surgery.

OBJECTIVE: Postcardiopulmonary bypass hemorrhage remains a serious complication of cardiac surgery. Given concerns regarding adverse effects of blood product transfusion and limited efficacy of current antifibrinolytics, procoagulant medications, including recombinant factor VIIa (rFVIIa) and factor eight inhibitor bypass activity (FEIBA), increasingly have been used in managing refractory bleeding. While effective, these medications are associated with thromboembolic complications. This study compared the efficacy and risk of adverse events of rFVIIa and FEIBA in cardiac surgical patients with refractory bleeding. DESIGN: This retrospective study evaluated 168 patients who underwent cardiac surgery and received either FEIBA or rFVIIa to manage postbypass hemorrhage. Demographic, clinical, and outcomes data were collected and statistical analysis performed to compare thromboembolic event rates, relative efficacy, and 30-day mortality following administration of these medications. SETTING: Single university hospital. PARTICIPANTS: Patients undergoing cardiac surgery. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULT: Sixty-one patients received rFVIIa, and 107 received FEIBA. Demographics, surgical procedures, and preoperative anticoagulation were similar between the cohorts; however, the rFVIIa cohort had longer durations of cardiopulmonary bypass (305.1 v 243.8 min, p<0.01). There were no significant differences in the number of thromboembolic events, 30-day mortality, or rates of revision surgery. Neither group demonstrated a clear relationship between dosage and occurrence of thromboembolic events. The rFVIIa cohort received more platelets than the FEIBA cohort (3.13 v 1.67 units, p = 0.01), but transfusion rates of other blood products were similar. CONCLUSIONS: This study suggests that rFVIIa and FEIBA have similar efficacy and adverse event profiles in managing intractable postbypass hemorrhage in cardiac surgical patients. Further prospective studies are required.

The Heart of the Matter: Increasing Quality and Charge Capture from Intraoperative Transesophageal Echocardiography.

Although transesophageal echocardiography is routinely performed at our institution, there is no easy way to document the procedure in the electronic medical record and generate a bill compliant with reimbursement requirements. We present the results of a quality improvement project that used agile development methodology to incorporate intraoperative transesophageal echocardiography into the electronic medical record. We discuss improvements in the quality of clinical documentation, technical workflow challenges overcome, and cost and time to return on investment. Billing was increased from an average of 36% to 84.6% when compared with the same time period in the previous year. The expected recoupment of investment for this project is just 18 weeks.

Factors contributing to adverse perioperative events in adults with congenital heart disease: a structured analysis of cases from the closed claims project.

OBJECTIVE: Prior investigations have suggested that the rapidly growing population of adults with congenital heart disease is at increased risk of perioperative morbidity and mortality, but information is limited on the nature of those perioperative factors that may relate to adverse outcomes. We sought to use a national claims database to describe the contribution of perioperative factors to adverse outcomes and compare contributing factors in cardiac vs. noncardiac operations. DESIGN: The study is a retrospective in-depth structured analysis of cases from the Anesthesia Closed Claims Project database. SETTING: We examined the largest national anesthesia malpractice claims database. PATIENTS: We included all claims cases involving adult patients with congenital heart disease (CHD). INTERVENTIONS: Patients in this retrospective analysis were classified by type of surgery (cardiac or noncardiac). OUTCOME MEASURES: Perioperative factors contributing to an adverse event were assessed by an expert panel of cardiac anesthesiologists. RESULTS: Of 21 confirmed cases, 11 (52%) involved cardiac procedures and 10 (48%) noncardiac procedures. The most common factors contributing to the adverse event in cardiac cases were surgical technique (73% of cases) and intraoperative anesthetic care (55%), whereas in noncardiac cases, postoperative monitoring/care (50%), CHD (50%) and preoperative assessment or optimization (40%) were most common. The factors contributing to the patient injury differed similarly: in cardiac cases, the most common factors were intraoperative anesthetic care (55%) and surgical technique (45%) compared with postoperative monitoring/care (50%) and CHD (50%) in noncardiac cases. CONCLUSIONS: Within the limitations of a small number of events in a claims-based database, this study offers advantages of being a national, structured analysis of real cases to provide detailed information on phenomena that are otherwise abstract and hypothesized by expert opinion. These results should help affirm the role of anesthesiologists in acquiring and executing expertise as consultants in perioperative medicine for adults with congenital heart disease patients.

Perioperative management of combined carotid and coronary artery bypass grafting procedures.

The objective of this review is to provide a high level overview on current thinking for treatment of patients with combined carotid and coronary artery disease given that these patients are at higher risk of adverse cardiac events, stroke, and death. This review discusses (1) the current literature addressing perioperative stroke risk in the setting of coronary artery bypass graft, (2) the literature regarding different surgical approaches when both carotid and coronary revascularization are being considered, and (3) the data available to guide optimal management of this complex patient population to minimize complications regardless of the surgical approach taken.

Safety of transesophageal echocardiography.

Since its introduction into the operating room in the early 1980s, transesophageal echocardiography (TEE) has gained widespread use during cardiac, major vascular, and transplantation surgery, as well as in emergency and intensive care medicine. Moreover, TEE has become an invaluable diagnostic tool for the management of patients with cardiovascular disease in a nonoperative setting. In comparison with other diagnostic modalities, TEE is relatively safe and noninvasive. However, the insertion and manipulation of the ultrasound probe can cause oropharyngeal, esophageal, or gastric trauma. Here, the authors review the safety profile of TEE by identifying complications and propose a set of relative and absolute contraindications to probe placement. In addition, alternative echocardiographic modalities (e.g., epicardial echocardiography) that may be considered when TEE probe placement is contraindicated or not feasible are discussed.