Eligible participants included female IC fellows and attendings currently practicing in the U.S. Exclusion criteria included retired physicians or those unable to practice due to health limitations, and ICs employed at the Minneapolis Heart Institute.

Potential participants were identified through professional networks, institutional contacts, and peer referrals, and were invited via email. Interested individuals received an information sheet detailing the study’s purpose and confidentiality procedures. Verbal informed consent was obtained before each interview. Participation was voluntary and uncompensated. The study protocol was approved by the Allina Health Institutional Review Board.

A purposive and snowball sampling strategy was used to achieve diversity. Recruitment and data collection continued until thematic saturation, the point at which no new concepts emerged, was achieved. Eighteen women ICs participated in the study. Two additional invitees initially accepted but later withdrew due to scheduling conflicts.

Data were collected between February and April 2025 through semistructured interviews conducted via a secure online platform (Zoom; 12 interviews) or in-person when feasible (6 interviews). The interview guide was developed based on prior literature and pilot testing within the research team ( Supplemental Methods ). It covered 5 thematic domains: (1) career trajectory and advancement; (2) workplace culture and mentorship; (3) work–life balance and family considerations; (4) pregnancy and radiation safety; and (5) recommendations for improving gender equity. Each interview lasted approximately 30–60 minutes and was recorded and transcribed verbatim. No one other than the researchers and participants was present during any interview. Transcripts were deidentified and stored on secure, encrypted MHIF servers in compliance with institutional data-security protocols. Transcripts were not returned to participants for comment or correction, and participants did not provide feedback on the study findings. No repeat interviews were carried out.

The study was conceived by Michaella Alexandrou, MD, a research fellow affiliated with the MHIF, who served as the interviewer. Dr. Alexandrou (M) identifies as a woman and has research experience on sex differences in IC and physician wellbeing. Dr. Alexandrou (D), who holds a PhD in qualitative analysis, contributed expertise in study design and analysis. The research team included cardiologists, fellows, burnout experts and qualitative research collaborators. All team members declared no relevant financial conflicts. No power dynamic existed that could influence responses. Participants were informed that the interviewer’s goal was to understand their lived experiences rather than evaluate performance or institutional policy. Reflexivity (the practice through which researchers self-consciously examine and evaluate their own subjectivity) was maintained through reflexive journaling and team discussions to monitor bias, particularly concerning shared professional identities.

A thematic content analysis approach was used to interpret the data. Two investigators independently reviewed the transcripts in full and performed manual coding by hand using Microsoft Word and Excel. Initial codes were generated inductively from the data, compared across transcripts, and grouped into categories reflecting shared meanings and experiences. The research team then met iteratively to discuss coding discrepancies, refine category definitions, and reach consensus on the final set of themes and subthemes.

Themes were derived inductively from the data rather than predetermined. Although the interview guide was informed by prior literature and study objectives, the themes that emerged during analysis were slightly different from those outlined in the original guide. Major themes were clearly defined and systematically presented in the Results section. Minor themes were also discussed to highlight the diversity of experiences among participants. There was consistency between the data and the findings. Participant quotations were included in the Results section to illustrate each major theme and subtheme.

Many participants described initial discouragement when expressing interest in IC. Early in training, women often encountered implicit and explicit messages that the field was “too demanding,” “not family-friendly,” or “not for women.” These conversations frequently came from mentors or senior colleagues, shaping a perception of exclusion even before fellowship. While most participants ultimately received encouragement from peers or immediate colleagues, many recalled the cumulative effect of early bias and skepticism.

“One of my mentors tried to persuade me to do something else, said it’s not a good lifestyle for a woman. But another mentor was very supportive. Since then, I’ve just encountered support and no adversity.”

“As a female being deterred from the field was not an uncommon conversation. People I looked up to told me this field’s not meant for a little white girl like myself—it’s meant for aggressive, angry, blunt personalities. I don’t think it’s always intentional, but it happens.”

A senior attending noted that while early-career support was often generous, this support sometimes diminished as they advanced professionally. They perceived that once they became peers or potential competitors within male-dominated environments, collegiality could shift to guardedness or exclusion.

“Early challenges were pivotal, but later barriers became more solid. People are less willing to help when you’re a threat.”

Women also reported needing to “work harder to prove themselves” compared with male colleagues, particularly early in their careers. They described how professional credibility was earned slowly and how perceptions of competence evolved only after years of performance.

“Women have to work harder. Men are given the benefit of the doubt. My career was slower because of it.

“I had to prove interest to get cath room assignments, while male colleagues often got them automatically. Once proven, I was well-treated.”

Beyond entry into the specialty, negotiation for career advancement, resources, and compensation was repeatedly described as difficult, opaque, and intimidating, requiring self-advocacy or institutional escalation. Salary transparency, or its absence, was a common source of frustration. Participants’ experiences with salary negotiation illustrated both clear perceptions of gender disparity and broader concerns about institutional transparency. While some women believed their compensation differences reflected gender bias, many others viewed pay inequity as a systemic issue affecting all physicians, regardless of gender, driven by the absence of standardized benchmarks or open discussion about salaries. Compensation disparities were also noted in industry settings, where participants described wide variability in honoraria and consulting payments.

“Salary transparency changes showed I was underpaid. I had a large bump, but I still don’t trust chairs to be fair.”

Motherhood and parenting emerged as some of the most complex and emotionally charged professional challenges described by participants. Women recalled navigating pregnancy, maternity leave, and childcare within systems that were rarely designed with their needs in mind. Across interviews, uncertainty about radiation safety, eligibility for leave, and schedule flexibility created anxiety, forcing many to negotiate solutions on a case-by-case basis.

Several participants described relying on informal goodwill rather than formal policies. Some were able to negotiate supportive arrangements through personal advocacy and collegial understanding. A few reported positive institutional cultures where supervisors proactively accommodated pregnancy and early motherhood, offering flexibility without judgment. Other participants had to advocate to create their own solutions through persistence and negotiation, underscoring the lack of standardized maternity provisions.

“They had no maternity-leave policy. I forced them to pay 10 weeks by presenting options and negotiated reduced hours.”

Many described this evolution as a personal and institutional learning process. Early resistance often gave way to greater understanding as departments gained experience managing parental leave, and as women themselves grew more assertive in articulating needs.

“First pregnancy was during general fellowship; planned 8 weeks but took ten with pushback. Now taking 3 months; there’s more support this time.”

Feelings of guilt, pressure to return early, and the absence of coverage policies were recurring themes. Many women internalized the message that maternity leave carried professional risk. Returning to work was frequently physically and emotionally taxing, especially in high-volume catheterization labs lacking structured re-entry plans. Several women sensed subtle skepticism from colleagues regarding their commitment after childbirth. These perceptions reinforced the pressure to overperform immediately upon return, fueling exhaustion and, in some cases, burnout.

“I had her in my second year of cardiology fellowship. I took 6 weeks, which included my 4 weeks of vacation. I felt so guilty for taking it and was made to feel I really had no choice.”

“You could feel the shift after maternity leave. Suddenly there’s this quiet assumption that you’re less available, less ambitious.”

Perspectives of single participants

Not all participants were mothers, and single participants provided equally insightful perspectives on how demanding training timelines intersect with personal life. Several expressed optimisms about maintaining future balance. Others cited pragmatic or relational reasons for postponing parenthood, noting that their institutions were generally supportive but that structural barriers, such as late training completion, still limited choice.

“No children. (…) Training finishes so late. This has big implications.”

Both mothers and single participants emphasized that the ability to integrate family life into a career in IC depends heavily on individual negotiation rather than standardized support. Several participants emphasized that there is no “perfect” or convenient time to have children in IC. They described family planning as an inherently imperfect decision, advising that one must proceed when personally ready rather than waiting for the “right” career stage.

“Regarding having a baby during fellowship…it’s challenging but worth it…Maybe my only regret is we should have started earlier. There’s no right time, you just have to make time.”

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