Women remain underrepresented in pediatric cardiology leadership despite entry-level parity
North American pediatric cardiology has reached gender parity among physicians entering the field, yet leadership has not caught up. A multicenter survey published in JACC: Advances mapped women’s representation across 16 prespecified leadership positions at pediatric cardiology programs with more than five cardiologists, and the gap was still visible across most levels of command.
Across 99 centers, a median of 13 leadership roles per center were identified, with women occupying 36.8% of all posts and 35.1% of cardiology-specific roles. Those numbers sit well below parity in a specialty where the pipeline no longer appears to be the main constraint. The finding points instead to a structural problem deeper in the academic and administrative ladder: physicians may be entering pediatric cardiology in roughly equal numbers, but the distribution of authority remains uneven when it comes time to appoint chiefs, subsection leaders, and other decision-makers.
Only 13% of pediatric cardiology chiefs were women.
Leadership gaps widened above the subsection level
The survey’s most striking signal came from the top of the divisional hierarchy. Women were substantially more common in subsection leadership roles at centers led by women division chiefs than at male-led centers, 47% versus 36% with a P value of 0.028. In practical terms, leadership culture appears to matter. When a woman holds the chief role, the surrounding leadership structure seems more likely to distribute responsibility more evenly among women physicians.
That pattern is consistent with the way academic advancement often works in medicine. Appointments are rarely made in a vacuum; they are shaped by sponsorship, visibility, prior leadership exposure, and the informal expectations that determine who is seen as “ready” for the next role. A woman-led division may not only alter the roster at the top, but also broaden who gets selected for subsection oversight, programmatic stewardship, and shared administrative authority. Even in a specialty with a strong female workforce pipeline, those selection dynamics can preserve or widen inequity if left unexamined.
Shared posts and dual roles revealed a second layer of imbalance
The study also exposed an important asymmetry in how leadership is packaged. A minority of leadership posts were shared by two physicians, but women were more likely than men to share a role, 5.4% versus 2.5%, with a P value of 0.010. At the same time, men were more likely to hold more than one leadership position concurrently, 15.1% versus 9.9%, P = 0.012.
Those two findings matter because they suggest women are not only less likely to reach leadership; when they do, the role may be structured differently. Shared appointments can reflect collaboration, but they can also signal diluted authority, reduced visibility, or a tendency to distribute responsibility in ways that do not carry the same institutional weight as a singular post. Dual leadership roles, by contrast, often concentrate influence, expand networking reach, and create compounding opportunities for future promotion. The imbalance therefore extends beyond headcount. It touches the architecture of power itself.
In a hospital system, these distinctions influence hiring decisions, committee access, mentorship pipelines, and the pace at which an individual physician becomes embedded in institutional governance. A leader who holds multiple posts is often better positioned to shape agendas, control resources, and build a record that opens doors to regional or national leadership. The survey suggests men are more likely to accumulate that kind of accumulated authority, while women are more often placed in shared arrangements that may not generate the same upward momentum.
Center size, region, and fellowship structure did not explain the disparity
The analysis did not find an association between the percentage of women in leadership and center size, geographic region, the presence of a categorical fellowship program, or the gender of the department chair. That absence of association is informative. It argues against a simple explanation based on geography, institutional scale, or whether a program trains fellows in a categorical track. The gender imbalance appears widespread rather than confined to one part of the continent or one type of institution.
Because no single structural variable explained the pattern, the more plausible drivers lie in leadership selection processes that operate similarly across settings. Appointment committees, nomination traditions, and informal sponsor networks may all favor repetition of the same leadership profile unless institutions deliberately interrupt that cycle. Pediatric cardiology may have achieved parity at the front door, but the internal promotion machinery still seems to favor men for top-line and multiple concurrent roles.
The bedside consequence is less visible but still real
Leadership composition is not a cosmetic issue. Division chiefs, subsection heads, and program directors influence staffing, trainee culture, research priorities, and the clinical environment in which children with congenital and acquired heart disease are treated. When women physicians are less visible in those roles, the downstream effect reaches recruitment, mentorship, and retention. It also shapes which questions are asked in departmental planning, which careers are normalized for junior faculty, and which physicians are seen as the default holders of authority.
For a specialty that depends on long training pathways and close professional networks, those signals are consequential. A trainee deciding whether to pursue academic pediatric cardiology is not only watching technical excellence; she is also watching who gets promoted, who leads conferences, and who is trusted with multiple institutional responsibilities. Unequal leadership representation can quietly narrow the perceived horizon for advancement even when the entering workforce is balanced.
A clearer picture of where equity efforts need to focus
The study does not argue that women are absent from pediatric cardiology leadership. They are present, and in a substantial share of roles. But presence is not parity, and representation below 40% across leadership positions still falls short of the workforce balance that now exists at the entry level. The most actionable signal in the survey is the improved distribution of women’s leadership roles in centers led by women chiefs. That finding suggests change is possible within existing structures, not only through broad policy statements but through who is placed in visible, decision-making positions.
For hospitals and training programs, the relevant question is no longer whether women are joining the specialty. They are. The sharper issue is whether the selection process for leadership is reproducing older patterns even after the pipeline has changed. This survey indicates it is, and in ways that reach from chief positions to the allocation of shared and concurrent leadership posts.
Any effort to close the gap will need to examine promotion pathways, nomination practices, and succession planning, because the disparity persists across nearly every subgroup examined here.