Addressing Gender in Gastroenterology and Opportunities for Change

The gender gap in medicine is not a secret. From pay disparities, and overt sexual harassment to policies that disproportionately affect working or expecting mothers, women across the medical spectrum face challenges not seen by their male colleagues.^1-3

The top male-dominated specialties include orthopedic surgery, neurological surgery, interventional radiology, thoracic surgery, pain medicine, and radiology according to an article published by the American Medical Association.⁴ Gastroenterology, however, is not far behind: 82.4% of all gastroenterologists are men, and only 25% to 30% of trainees in the field are women.⁵

“Although the rate of women entering gastroenterology has increased, it will take time and a concerted effort for men and women to be represented more equally in mid and senior ranks,” wrote Loren G. Rabinowitz, MD, of the Department of Gastroenterology at the Icahn School of Medicine at Mount Sinai in New York City, and colleagues. As it stands, they added, “Female trainees have fewer female role models and fewer opportunities to be sponsored and mentored by senior women in their fields.”⁵

These limited opportunities are the result of unconscious bias, which — while subtle often and untended — does result in disparate opportunities for medical professionals.⁵ Furthermore, the perceived differences in mentoring, compensation and promotions have been shown to decreased job satisfaction among female gastroenterologists. To best address these concerns, and increase awareness, Dr Rabinowitz and colleagues highlighted the best ways to “combat unconscious bias, advocate for equality, and create a fair, productive, and comfortable work environment.” These highlights, accompanied by suggested best practices, were published in Gastrointestinal Endoscopy.⁵

Challenges in the Learning Environment

Unlike in nonprocedural fields, one of the hallmarks of endoscopy education is hands-on learning.⁵ Moreover, unlike surgery — where tactile and visual cues can both be utilized — an endoscopist must rely on feel for proper execution of technique. This, according to the authors, often results in a hands-on learning experience, during which both parties should strive to feel as comfortable as possible.⁵

“Trainees should be educated early in fellowship that a hands-on approach to learning endoscopy may be an effective method,” the authors wrote, adding that first-year fellows may not be aware of the benefits of hands-on learning. However, physical contact between attending physicians and trainees may be awkward, particularly in the face of gender differences. Several studies^6-8 found that among trainees in surgical subspecialties, gender discrimination and sexual harassment incidences may be higher “in male-dominated fields that necessitate close physical proximity.”⁵

It is likely, then, Dr Rabinowitz and colleagues note, that similar challenges may be present in gastroenterology and may impact learning in an endoscopy suite setting.⁵

Industry Relationships at Issue

In addition to patient care, endoscopy training involves learning how to influence the field at large.⁵ This, the authors note, includes positioning trainees as authorities who interact and negotiate with industry representatives.⁵

It is this aspect of medicine that, in a post-#MeToo world, has become especially fraught,⁵ particularly in terms of interactions between pharmaceutical industry representatives and health care providers.

In 2018, the pharmaceutical industry spent nearly $20 billion in direct-to-physician marketing.⁹ Within the past several years, national media outlets have documented sales strategies aimed largely at male physicians. Although public outcry has resulted in significant changes in these practices — both self-imposed and legislation directed¹⁰ — there is limited published, academic data about how physician perceptions of the pharmaceutical industry vary by gender.⁵

“The majority of industry representatives in the endoscopy space are men,” Dr Rabinowitz and colleagues wrote. “Representatives tend to seek out physicians [who] will ultimately be responsible for decision making…currently these endoscopy leaders tend to be more senior, male, interventional endoscopists” because there are few mid- or senior-level female interventional endoscopists and a concomitant dearth of women in leadership positions.⁵

Interpersonally, these dynamics often result in subtle differences in the tone and content of casual conversations between male representatives and female endoscopists.⁵ These differences, then, affect the ability of women in the field to provide necessary feedback. One such example of this necessary feedback is the higher rate of endoscopic injury among female gastroenterologists because instruments are not sized for smaller hands.¹¹ With women placed in positions where this feedback is neither able to be given nor heard, this dynamic is set to continue.⁵

The Gender Gap in Academic Medicine

The gender gap is particularly pronounced in academic medicine. Two studies published in JAMA demonstrate this fact. The first reported that between 2006 and 2017, women received an average of $40,000 less in National Institutes of Health funding per grant than men¹²; the second found that female junior faculty pursuing basic science careers receive “significantly less start-up support from their institutions than men.”^5,13 Gastroenterology is not exempt from these findings. Currently, there are fewer women than men in academic gastroenterology, especially in senior positions.⁵

There are challenges in conference inclusion as well. Generally, women who are invited to speak at conferences have more seniority and more high-impact publications compared with men.⁵ While this may seem like a positive, the authors suggest that this means that the bar is set much higher for inclusion of women.