Dr. Miriam L. Cohen juggled six patients in her practice one recent morning at MedStar Union Memorial Hospital in Baltimore, which is not unusual when you're a cardiologist working to manage emergencies and prevent them.
What's unusual is that Cohen was there at all.
It's not that at 75 she's beyond traditional retirement age, but that nearly a half-century after she became the state's first female cardiologist patients are still far more likely to have their hearts treated by a man.
"We knew we had to do it perfectly or they wouldn't take more women," said Cohen as she updated patient records, allowing a cup of chicken noodle soup to grow cold.
Only about 11 percent of the approximately 24,600 U.S. cardiologists are women, according to the American College of Cardiology. Even fewer enter newer sub-specialties.
Other fields like surgery, radiology and emergency medicine also remain dominated by men. But the number of women entering cardiology remains the most stubbornly low, even though they now make up half the students in medical schools.
Becoming a cardiologist often takes more training than other specialities because it requires both a multiyear residency and a separate fellowship after medical school. The workdays are long too, since heart attacks don't respect office hours. This fuels the belief that women who intend to have children are put off by the lack of "work-life balance."
Cohen said she had a supportive husband, who was also a doctor, and help from in-laws when her two children were little. She became pregnant with her first child during the last leg of her training, a cardiology fellowship at the University of Maryland School of Medicine.
Most women don't make it to such fellowships, though many go through the prerequsite internal medicine residencies, according to data from the Association of American Medical Colleges. They are more likely to go directly to residencies in family medicine, dermatology, or obstetrics and gynecology.
Dr. Claire Duvernoy, chair of the American College of Cardiology's women-in-cardiology section, said work-life-balance demands are very real. One time her husband called as she was starting a surgical procedure to ask what was for dinner.
Duvernoy's not sure it's much different for OB-GYNs, however, who have similar training and unpredictable work hours delivering babies. Radiation exposure from diagnostic or therapeutic equipment is another oft-cited reason that women avoid cardiology, but that can be managed, she said.
There's also the culture of the profession.
"I think it's sometimes a little bit of macho testosterone-driven atmosphere," Duvernoy said. "This is life or death and you can't be timid. But that shouldn't exclude women."
The association is seeking a female cardiologist in each state to serve as a "champion" — or role model — to coordinate formal and informal events and provide mentoring so women not only enter the profession but catch up to male counterparts.
Studies show female cardiologists are less likely to be married and have children, hold top academic positions or earn equal pay.
"It can make a big difference, seeing another woman cardiologist," said Duvernoy, also an associate professor in the University of Michigan School of Medicine and an interventional cardiologist in the affiliated health system.
In Cohen's office at Union Memorial, one of her two partners is a woman who considers Cohen a mentor. Dr. Momina Mastoor said Cohen helped her understand how to present herself confidently.
Mastoor was reminded recently at conference on a cadiology subspecialty that not everyone expects women in the field.
"If I didn't have a badge saying I was a doctor, I'm sure people would have assumed I was a research coordinator," she said. "It blew my mind that I was the only woman there."
Mastoor and Duvernoy, like Cohen, said they were lured to cardiology by the thrill of saving lives.
"It's where all the action is," Cohen said.
The women hope to see heart disease fall below cancer as the leading cause of death among Americans. The U.S. Centers for Disease Control and Prevention attributes one in four deaths to cardiovascular disease.
Cohen, trim and high energy, said that goal will require hard work, which is something she's well acquainted with given her 12-hour work days.
"I set all the balls in motion" and then "I go home and collapse everyday," she said with a smile.
Sometimes she lectures her patients about their lifestyles, but mainly she says she's fighting genetics.
That was the case with Joshua Williams, a 30-year-old Baltimore man who was walking on a treadmill to test how well his heart was managing. He shrugged when asked if he minded a woman doctor.
"I've had plenty of women doctors," he said.
Some patients do want a doctor who looks like them, said Diana Lautenberger, who leads the Association of American Medical Colleges' group on women in medicine and science. But a larger issue is "attracting the best and the brightest" to the cardiology workforce no matter their gender or race.
Women doctors at Johns Hopkins School of Medicine have begun a mentoring program. Dr. Erin D. Michos, an associate professor and associate director of preventive cardiology, said the effort has boosted the pipeline of women.
Michos was the only female among nine fellows at Hopkins in 2003, but this year's class has five women. About 30 percent of the faculty in cardiology are now women, she said, showing: "Times are changing from Dr. Cohen's era."
Michos said mentors can help women navigate professional and family matters — like the time she was paged for an emergency while breastfeeding her baby.
"Having adequate role models is so important for young trainees who are deciding to choose their specialties," she said. "I was fortunate to have been introduced to role models ... which was highly influential in ultimately my choice of careers and my career trajectory."
Cohen has not just mentored women along the way. Mark M. Applefeld, director of the heart center at Mercy Medical Center in Baltimore, said Cohen helped train him. As a new doctor about five years behind Cohen, he sought her guidance while she was working in a University of Maryland clinic and he was at the nearby university hospital.
"She was a very well known clinician, and if I had a tough case I'd run it by her," he said. "She always had a large practice and I don't think she was taking much time off."
Applefeld said some chauvinism likely still remains in the field affecting women, and he's not sure what that and other barriers mean for gender statistics down the road. But he's certain the trail has been blazed.
Not long after Cohen entered the field, he noted, the late Dr. Bernadine Healy became Hopkins' first full-time female faculty member in cardiology and went on to lead the American Red Cross and become the first female head of the National Institutes of Health.
"If you step back and ask yourself over the last three or four decades who were the prominent cardiologists, Miriam's name will certainly be high on that list," Applefeld said.
Cohen said she plans to keep seeing patients — with breaks every month or two at her Florida home.
"I'll keep going as long as I'm physically and mentally able," she said as she headed out to check on a patient.