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DOI: 10.1161/CIRCULATIONAHA.107.187673 2007


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DOI: 10.1161/CIRCULATIONAHA.107.187673 2007

  1. 1. European Perspectives Circulation 2007;116;f121-f126 DOI: 10.1161/CIRCULATIONAHA.107.187673 Circulation is published by the American Heart Association. 7272 Greenville Avenue, Dallas, TX 72514 Copyright © 2007 American Heart Association. All rights reserved. Print ISSN: 0009-7322. Online ISSN: 1524-4539 The online version of this article, along with updated information and services, is located on the World Wide Web at: Subscriptions: Information about subscribing to Circulation is online at Permissions: Permissions & Rights Desk, Lippincott Williams & Wilkins, a division of Wolters Kluwer Health, 351 West Camden Street, Baltimore, MD 21202-2436. Phone: 410-528-4050. Fax: 410-528-8550. E-mail: Reprints: Information about reprints can be found online at Downloaded from by on July 22, 2010
  2. 2. Circulation November 20, 2007 f121 Circulation: European Perspectives Lo-res European Perspectives in Cardiology Viewpoint: Marie Elsya Speechly-Dick, MD, MRCP What Prospects Do Women in Cardiology Have in the United Kingdom? Dr Marie Elsya Speechly-Dick, one of the first women to train part-time in cardiology in the United Kingdom, now practises as a part-time consultant cardiologist at University College London Hospitals, London, England. She talks to Ingrid Torjesen, BSc, about her work and why the speciality remains predominantly male. r Marie Elsya Speechly-Dick joined University College the Royal College of Physicians1 found that although D London Hospitals (UCLH) in 1990 when she was appointed to a registrar’s post ahead of more than 8 male women entering UK medical schools outnumber men, women remain underrepresented in cardiology, making up applicants. She was the first woman ever to be appointed only 16.8% of trainees and 7.4% of consultants—all this above the grade of senior house officer at the hospital’s despite cardiology’s status as one of the most popular spe- cardiology unit. ciality preferences for women medical students, with Since then, the gender balance at UCLH London women accounting for 28% of those who envision a career Hospitals has changed markedly, and the Heart Hospital in cardiology.2 probably has more women cardiologists than any other These figures prompted the British Cardiac Society, now cardiac centre in the United Kingdom. There are 7 female renamed the British Cardiovascular Society (BCS), to estab- consultants in cardiology, with a wide range of subspeciali- lish a working group (which included Dr Speechly-Dick) to ties in intervenional cardiology, cardiomyopathy, and grown examine the underrepresentation of women consultants and up congenital heart disease, and some hold academic posts. to question whether a continuing male predominance in Dr Speechly-Dick suggests that women have been attracted cardiology represents a cause for concern. It discovered that to cardiology at UCLH because other women are already many women found themselves “turned off” from the spe- working there successfully. “After 1 or 2 female appointments, ciality early in their medical careers because they did not you start getting a critical mass,” she says. “Maybe women consider it flexible or family friendly.3 are attracted to the fact that it isn’t an all-male working From her working group experience, Dr Speechly-Dick environment; maybe it is that the attitude of the men here says she found that many women change their minds about suggests that it is okay to have female colleagues. It is prob- cardiology by the time they reach senior house officer level. ably a bit of both. I personally found senior coleagues at “It seems to be that women perceive cardiology as not family UCLH very supportive when I was a trainee.” friendly in terms of working practices and hours, and that But other cardiac centres within the United Kingdom other specialities, such as anaesthetics, appear more family do not show such a positive situation. A 2002 census by friendly in terms of a professional working environment On other pages... Postgraduate Cardiology Training in Turkey Spotlight: Gary McVeigh, MD, PhD, FRCP, FRCPI Oktay Ergene, MD, FESC, who sat on the European Society Dr Gary McVeigh, professor of cardiovascular medicine of Cardiology Education Committee between 2004 and 2006, in the Department of Therapeutics and Pharmacology at has been involved in Turkish government efforts to Queen’s University, Belfast, Northern Ireland, talks about standardise postgraduate cardiology training in his country. his difficult early years and the development of his career. Page f123 Page f125 Downloaded from by on July 22, 2010
  3. 3. f122 Circulation November 20, 2007 and the attitudes of peers and Kirsty Wigglesworth/PA Archive/PA Photos Circulation: European Perspectives seniors.” The working group found no evidence of gender discrimina- tion at selection for cardiology training programmes. Its report concluded that “a substantial proportion of the talent pool is being lost to other specialities” and that “if [the failure of cardi- ology to attract women] is not corrected it will prove increas- ingly difficult to maintain high standards of cardiological prac- tice and research.”4 Dr Speechly-Dick says the BCS working group tried to develop initiatives to encour- age women to enter cardiology. “We concluded that we needed to raise the profile of women in cardiology and needed to make Figure. The Heart Hospital, London, where Dr Speechly-Dick has responsibility for teaching first-year it clear that flexible training clinical students cardiology, a part of her work she regards as important and enjoyable. was an option. I don’t remember getting any information on that as a junior. I had to find out women. “We should also aim for a system that allows doctors about it myself.” to move betwen full and part-time working as their commit- She explains, “It was obvious at that time that very few ments outside of work change with time. poeple knew about how to apply for flexible training. I am The 2002 Royal College of Physicians census found that still grateful for the help, encouragement and mentoring I 9.2% of all consultants work part-time, almost half them received from Ilfra Goldberg, MRCP, who was postgrad- women.1 Thirty-eight of the 451 consultant cardiologists for uate dean for flexible training at the time.” whom data were available worked part-time, but only 4 were Dr Speechly-Dick, who has 3 children, ages 11, 9, and 6, women. Dr Speechly-Dick estimates that around 8 women had her first child just after completing her MD thesis, so now work as part-time cardiology consultants. she trained part-time and has worked part-time ever since. Change will come as “a very slow process, a trickle down “When I was training part-time, for most of this period I was in terms of attitude,” she admits.” Female role models will the only part-time female trainee in the country,” she says, hasten this change by encouraging more young women to “which gives you an idea of the lack of women in cardiology pursue cardiology, she argues, and as more women gain then. There are more now, but there still aren’t very many.” consultant’s posts and some work part-time, this will impact At that time, part-time trainees had to train proportionally on the perceptions of their peers. The appointment of Dr for exactly the same time as a full-time trainee, making the Jane Flint, BSc, MD, FRCP, as a female representative on the process much longer. But, Dr Speechly-Dick explains, “The council of the BCS, and the establishment of a national rules aren’t quite so punitive now. The regulations are grad- mentoring scheme for female cardiologists, as recommen- ually changing towards competency-based assessment, so, ded by the working group, all represent steps toward for example, you don’t have to train for exactly twice as long achieving this. if you are half-time.” Dr Speechly-Dick enjoys teaching, so she has taken on The BCS working group also wanted to make a career in more and more such responsibilities because she feels it is cardiology more attractive by encouraging trusts to create hugely important and because she enjoys it. She currently part-time consultants posts where possible, and to offer job has the responsibility of teaching first-year clinical students shares. But, Dr Speechly-Dick says, “This is not going to be in cardiology at the Heart Hospital in Bloomsbury (See realistic until there are a sufficient number of women in the Figure). In 2005, she was officially selected as an academic speciality to share jobs, or other part-timers who can job role model by the British Medical Association’s Health share. A lot of this isn’t going to happen until we get more Policy and Economic Research Unit for being an inspira- women coming through the trainee grades.” tional teacher and role model. She does not consider it possible to increase the number “One reason I do the teaching is so that the students have of women entering cardiology without a change of attitude a female role model. They can see that there is a female in the profession as a whole, and an acceptance of more cardiologist with a family and children who is able to work flexible training and working practices for both men and part-time at a teaching hospital,” she says. “I think it is Downloaded from by on July 22, 2010
  4. 4. f123 Circulation November 20, 2007 good for some of the female students to see that, and this is best that they are interested in their work. Cardiology is Circulation: European Perspectives may help to change their attitudes in the future.” challenging and very competitive, and you need to be In her current job, she divides her time equally between enthusiastic to succeed.” teaching and clinical work. She runs a rapid-access chest If she was ever given the choice, Dr Speechly-Dick would pain clinic, so her clinical work is not interventional, and, to choose cardiology again. “Cardiology is a very rewarding some extent, it is sessional, with no on-call requirements. “I speciality,” she says. have been lucky to be able to design my job to fit in with my Ingrid Torjesen is a freelance medical journalist. interests, my strengths, and my desire to work part-time References because of my needs outside of work,” she admits. “I have 1. Census of Consultant Physicians in the UK, 2002. The Federation of quite a good work/life balance.” the Royal Colleges of Physicians of the United Kingdom, 2002. Web site. Dr Speechly-Dick chose cardiology because she wanted to Available at college/mwu/mwu_02_home.htm. be a hospital doctor and it seemed an interesting speciality. “I Accessed October 8, 2007. 2. Lambert T, Goldacre M, Parkhouse J. Career preferences and their liked the idea of an interventional speciality: the excite- variation by medical school among newly qualified doctors. Health ment, new techniques, and being able to do things on the Trends. 1996;28:135–144. spot. And there is the sense of community that comes from 3. Timmis AD, English KM. Women in cardiology: a UK perspective. working in a hospital—the colleagues, the camaraderie, and Heart. 2005;91:273–274. 4. Timmis AD, Baker C, Banerjee S, Calver AL, Dornhorst A, English the multidisciplinary atmosphere.” KM, Flint J, Speechly-Dick ME, Turner D. Women in UK cardiology: She continues, “I always recommend trainees to choose report of a working group of the British Cardiac Society. Heart. what they are going to be most enthusiastic about, because it 2005;91:283–289. Postgraduate Cardiology Training in Turkey Postgraduate Cardiology Training Is Undergoing a Radical Review to Bring It Into Line With European Union Requirements Oktay Ergene, MD, FESC, is a professor of cardiology based at a state hospital in Izmir, on Turkey’s Aegean Coast. He sat on the European Society of Cardiology Education Committee between 2004 and 2006, and he has been involved in Turkish government efforts to standardise postgraduate cardiology training. He talks to Judy Ozkan, BSc, about the reforms. n Turkey, entrance to a faculty of medicine depends on a undergo oral and written examinations and an assessment I single selective examination administered by the National Selection and Placement Centre. Students receive of their thesis,” says Dr Ergene. “If they complete these successfully, the Turkish Ministry of Health approves the assignments to universities according to their results, and trainees as cardiology specialists. Most then can be many of them hope to gain admittance to the faculty of employed in state hospitals.” medicine, which has an annual acceptance of 5000 students, As part of an ongoing effort to improve the health 40% of them female.1 service in Turkey and bring it into line with European Undergraduates study in medical school for 6 years and Union (EU) requirements, postgraduate medical training can then qualify for admission to specialty training via the has been undergoing a radical review to establish a national twice-yearly Postgraduate Medical Education Entrance standard and a core curriculum and to achieve proper Examination, which tests medical knowledge and foreign staffing ratios in accordance with health policy and needs. language ability. Around 3000 candidates pass this exami- Dr Ergene believes training requires tailoring to take nation, but the country only has about 160 to 200 places for into account the geographical distribution of Turkey’s pop- cardiology residency training. ulation of 70 million. He says, “We have 1400 cardiologists, According to Dr Ergene, until 1990 cardiology training which means a ratio of 2 doctors per 100 000 people, and in Turkey came within internal medicine training, almost as most of them are concentrated in the big cities. But in geo- a discipline within a discipline. Since 1990, however, the graphic terms, our population is unevenly spread, and in country’s medical establishment has accepted cardiology as some areas, such as the Black Sea region, there may be no a separate branch in medicine; it now consists of a 4-year more than 5 cardiologists for a population of 400 000. And residency at a state or a university hospital endorsed by the although faculties giving postgraduate cardiology training Turkish Ministry of Health.2 “Trainees prepare a thesis dur- are increasing, this increase needs to keep pace with a ing the residency period, and at the end of this period, they growing population.” Downloaded from by on July 22, 2010
  5. 5. f 124 Circulation November 20, 2007 Further key developmental needs Circulation: European Perspectives include educating trainers in terms of delivering the core curriculum. Currently, institutions set their own standards, creating considerable varia- tion across the system. To standardise the training process, the Turkish Medical Association3 established a consultancy board and, between 1994 and 2004, carried out a review of the system. A regular congress of post- graduate training meets to work on a competency training syllabus and reg- ulation of cardiology training. In 2002, the Turkish Society of Cardiology accepted the consultancy board regula- tions and developed a competency- based postgraduate examination and a training programme called the Cardiology Syllabus. The board is cur- rently working on the development of Figure. Dr Ergene with some of his staff and trainees. The Turkish Medical Association is a logbook for use across the country working towards the introduction of regulations that will standardise medical training. for trainee accreditation. training program.” However, when the Turkish Society The Turkish Medical Association is one of the bodies of Cardiology4 applied to the Ministry of Health to have working with the Ministry of Health on regulations to stan- subspeciality training recognised, the ministry refused. dardise postgraduate medical training generally. Lack of “This was because the EU does not accept any subspecial- agreement between the bodies involved in the standard- ity training policy,” explains Dr Ergene. “However, in isation process is making it difficult to implement the Holland, postgraduates of cardiology will soon be able to changes. Although the Ministry of Health passed a law that select a subspeciality among invasive cardiology, electro- all agencies involved in the process have accepted in prin- physiology, cardiac imaging, and general cardiology, and ciple, the ministry has not yet implemented the law. other countries look destined to follow suit. In Turkey, our Dr Ergene says, “This is the main barrier to developing feeling is that at least invasive cardiology and arrhythmia/ cardiology training, because the established regulations electrophysiology should only be performed after a sub- cover many essential topics. We need agreement between specialty training program to address any skills gap. the agencies involved in the training on working together Currently, some cardiologists are practicing with no real and on which agency is going to be the main authority.” experience in these fields, and this does nothing to enhance The length of training is another aspect under review. the service we deliver.” The duration of residency training in Turkey was 4 years Dr Ergene concludes, “Since cardiology training until 2002. Although 6 years is normal in EU countries, 5 gained a speciality status, hospital departments providing years is currently considered appropriate for Turkey. Dr training have increased in number, and most of them Ergene considers this the right decision for Turkey, and he now have cardiac haemodynamic and invasive electro- suggests not reviewing this issue for at least 10 years. physiology labs, and they are very close to EU standards “Postgraduate cardiology training should be 5 years, in terms of facilities and equipment. Our greatest challenge including 1 year of rotation in internal medicine,” he says. now is to implement the standardisation of the post- “Increasing training duration to 6 years will lead to a short- graduate training model. I hope this will be complete in 5 age of cardiologists. At current rates, we need 10 to 12 to 10 years’ time.” years to make sure that the current ratio of 6 cardiologists Judy Ozkan is a freelance medical writer. per 100 000 people is achieved. While 5 years may still References seem to be short for postgraduate training, in the near future there will be the addition of a further 2 years of sub- 1. Sayek I, Kiper N, Odabasi O. Turkish Medical Association Undergraduate Medical Education Report 2006. Ankara, Turkey: speciality training.” Turkish Medical Association; 2006. Dr Ergene would like to see the EU clarify the issue of 2. Republic of Turkey Ministry of Health Web site. Available at: subspeciality training, because he currently perceives some disparity: “Cardiology is a high-tech branch of medicine 849816B2EF4376734BED947CDE#. Accessed October 15, 2007. 3. Turkish Medical Association Web site. Available at: that has grown naturally into subspecialities. Invasive Accessed October 15, 2007. cardiology, cardiac imaging, and electrophysiology sub- 4. Turkish Society of Cardiology Web site. Available at: specialities should have priority in the subspeciality Accessed October 15, 2007. Downloaded from by on July 22, 2010
  6. 6. f125 Circulation November 20, 2007 Spotlight: Gary McVeigh, MD, PhD, FRCP, FRCPI Circulation: European Perspectives A Journey From a Deprived Area of a Troubled Northern Ireland to the Heights of Cardiovascular Research and Clinical Practice Dr Gary McVeigh is professor of cardiovascular medicine in the Department of Therapeutics and Pharmacology at Queen’s University, Belfast, Northern Ireland, and a consultant physician at the Belfast Health and Social Care Trust. He talks to Jennifer Taylor, BSc, about his difficult early years and the development of his career. ducation provided a turning point in the life of Dr Gary his MD in 1987 and had his research published in the E McVeigh, and with his career firmly established, he now devotes a large amount of his time to aspiring doctors. British Medical Journal.1 “It was pretty topical at the time,” he says. “That piqued my interest in research.” He grew up in Lurgan, just outside Belfast, Ireland, and Dennis Johnston, MD, the Whitla Professor of Clinical when he was in secondary school, from 1968 and 1975, Pharmacology at Queen’s, served as Dr McVeigh’s first “the Troubles” were at their worst in Northern Ireland’s mentor. “He introduced me to the research environment history. This period of severe civil unrest in the country and the field of hypertension.” Having decided he wanted lasted from 1963 until 1985, with a cycle of violence to do more research, Dr McVeigh enrolled for his PhD at fomented mainly by 2 rival outlawed paramilitary organi- Queen’s. He won a Senior Fulbright Scholarship, a British- sations, the Catholic Irish Republican Army and the American Research Fellowship, and a Wellcome Travelling Protestant Ulster Volunteer Force. Rioting and disorder Fellowship that enabled him to spend the year 1988 at the were commonplace (Figure 1), and shootings and terrorist University of Minnesota, Minneapolis, Minn, working in bombings were frequent. It was a difficult time and a harsh cardiology under the mentorship of Jay Cohn, MD, head of environment in which to grow up. the cardiology division at the university. Dr Cohn introduced Dr McVeigh was the first person in his family to go to Dr McVeigh to the study of the structure and function of university. “I came from a deprived estate in the middle of arterial blood vessels. the Troubles in the 1970s, and I just wanted to get out,” he “That initial work was also in the field of hypertension,” he says. “I grew up in a staunchly working class Republican says. “But it was really viewing hypertension as a vascular estate. I saw education as an escape route from the disease assessed through the study of the structural and func- Troubles.” And get out he did, by studying medicine at tional properties of arterial blood vessels using waveform Queen’s University Belfast. He says, “For a working class analysis.” After this year in the United States, he returned to kid at the time, it seemed terribly exotic to study medicine.” Belfast to complete his PhD and his medical training. Medical rotations through the Belfast hospitals came Dr McVeigh eventually returned to the United States next, followed by passing the examinations for member- and worked there for 6 more years as an associate profes- ship of the Royal College of Physicians. He then enrolled sor of medicine at the University of Minnesota. He says, “I for an MD by thesis, also at Queen’s University. His continued to pursue my research work with Jay Cohn, and research, in the field of hypertension, investigated the case during that time I helped validate a noninvasive device for for low-dose diuretics as a treatment option. He obtained recording arterial pressure waveforms.” During his 6-year tenure in Minnesota, he also partici- Alex Bowie/Getty Images pated actively in clinical work in both the inpatient and outpatient settings whilst pursuing his research interests. “I really wanted to understand how risk factors alter the properties of arte- rial blood vessels to accelerate disease development and the early occurrence of cardiovascular events.” But Belfast would become his home again. He took up a consultant post— a joint appointment between Queen’s University and the United Kingdom’s Figure 1. Rioting and disorder were commonplace in Belfast during the Troubles, and this made National Health Service—and became it a harsh environment in which to grow up. Dr McVeigh found education was a way to escape. professor of cardiovascular medicine in Downloaded from by on July 22, 2010
  7. 7. f 126 Circulation November 20, 2007 2004. “My time is spent 50/50 between the National Health Circulation: European Perspectives Service and the university,” he says. His clinical work in the hospital involves care of the acute medical admissions and outpatient work specialising in diabetes mellitus, hyperten- sion, hypercholesterolaemia, and heart failure. His university work involves research in these areas, along with under- graduate teaching of medical students. Dr McVeigh enjoys the teaching aspects of his role, and he serves as the regional adviser for Ireland for the Royal College of Physicians of Edinburgh. He represents not only Northern Ireland (part of the United Kingdom) but also the interests of the college’s member physicians in the Republic of Ireland. The work for this professional body entails education, setting standards, and organising exami- nations. “In the present challenging environment, main- taining standards must remain a high priority for the profession,” he says. Committee work represents a big part of Dr McVeigh’s career. He sits on the executive committee of the British Hypertension Society, and he has received recognition as a clinical expert in hypertension by the European Society of Figure 2. The novel part of this generic ultrasound machine is the Hypertension. He currently serves as president of the Ulster software Dr McVeigh and colleages developed to enable clinicians to use existing machines to make physiological recordings. Medical Society, which fosters interdisciplinary education for specialists and generalists in all fields of medicine. Dr disease predictor, which facilitates the study of arterial McVeigh serves on an appraisal panel for the United blood vessel structure and function (Figure 2), won the best Kingdom’s National Institute for Health and Clinical diagnostic award in the cardiovascular category. “The Excellence. This work involves monthly meetings in majority of my research is clinically based,” he says. “Our London to examine the clinical and cost-effectiveness of new approach has a direct clinical application, and we are various technologies. “I view it as a kind of continuing med- currently studying patients from our cardiovascular risk ical education,” he says. “Reading the volumes of material clinics. In particular, we are focusing on damage to particu- on different technologies certainly keeps you up to date.” lar target organs like the eye and kidney.” He explains, “I Dr McVeigh’s research is going strong. He has approx- am continuing to automate the technique so it can be rolled imately 100 peer-reviewed publications relating to his out across Northern Ireland, with the aim of removing oper- specialist area. Since 2000, he has supervised 11 MD students ator dependency so that any healthcare worker could use it. and 4 PhD students, and he has secured £2.5 million in grant With our software development, clinicians will be able to use funding. He is particularly proud of the United Kingdom existing machines to make the physiological recordings.” Medical Futures Innovation Award he won this year, in the “The roll-out involves getting the agreement of clini- cardiovascular section (Figure 1). “Medical Futures invite cians,” he says. They would pool the data they collected, to applications from the United Kingdom for novel technolo- form 1 large study. “If it works in a few pilot centres, there gies, with commercial potential, designed to improve is no reason why we could not collaborate to collect United patient care,” he says. His ultrasound-based cardiovascular Kingdom–wide data,” he adds. He believes the information could enable them to stratify cardiovascular risk for an individual much more precisely than current methods allow. Jennifer Taylor is a freelance medical writer. Reference 1. McVeigh G, Galloway D, Johnston D. The case for low dose diuretics in hypertension: comparison of low and conventional doses of cyclopenthiazide. BMJ. 1988;297:95–98. The opinions expressed in Circulation: European Perspectives in Cardiology are not necessarily those of the editors or of the American Heart Association. Editor: Thomas F. Lüscher, MD, FRCP, FACC Managing Editor: Keith Barnard, MB, BS, MRCS, LRCP We welcome your comments. E-mail the managing editor at Figure 1. Dr McVeigh (2nd from right) was proud to receive the United Kingdom Medical Futures Innovation Award this year. Downloaded from by on July 22, 2010