Recent data report that approximately 50% of medical school students and an estimated 40-50% of third-year internal medicine residents are women.1,2 Despite the large number of women in the early stages of medical training, the percentage of female gastroenterology (GI) fellows has remained stable at 25-30% over the last several years.3 Moreover, only about 13% of the nation's approximately 13,000 gastroenterologists are women.4
There is data, both published and anecdotal, that suggests female patients prefer to see female gastroenterologists. Shah et al conducted a prospective survey of more than 1,000 patients and found that females had a stronger sex preference for an office visit with a female gastroenterologist and also for a female colonoscopist.5 In order to meet this need, there must be a push to train more female gastroenterologists.
Several factors have been proposed to explain the gender gap in GI, and concerns about work-life balance are most commonly cited. Most physicians, gastroenterologists included, work anywhere between 55 and 60 hours per week. This may not include time required to keep up to date with medical literature or to complete administrative responsibilities. This time commitment alone exceeds the work expectations of most non-medical professions. Thus, it is not surprising that balancing a full-time career in GI with the demands of raising a family can be difficult; particularly since the responsibility of caring for a family, especially young children, often falls disproportionately on women. In addition, the required 3-year GI training program frequently comes at a time when most women are mothers of young children, which may further deter them from entering the field. As a result, some women may choose to practice medicine in a setting that may better fit the demands of a healthy work-life balance.
One solution to these issues is part-time work. Historically, there has not been widespread acceptance of part-time GI positions due to difficulty with patient coverage and challenges in meeting the financial demands of office overhead and malpractice insurance. Recently, there has been a trend of female physicians in part-time GI roles; however, no data exist to attest to job satisfaction of these physicians.
Female gastroenterologists may also face specific challenges in endoscopy. Endoscope dials come in standard sizes and may not conceivably be as accessable to the generally smaller female hand size. Surgical literature has reported that women tend to experience more musculoskeletal and occupational injuries related to laparoscopy; ostensibly, a similar trend could be extrapolated to GI.6 Very few female fellows pursue careers in the male-dominated sub-specialty of advanced endoscopy, perhaps due to concerns about radiation exposure for women of child-bearing age. Further, there may also be a lack of mentorship encouraging female GI fellows to consider advanced endoscopy as a career option, and this is certainly an area deserves more attention and thought.
Although many female gastroenterologists begin their career with ambitions of leadership in academic medicine, this ambition can be eclipsed by the aforementioned competing priorities. In academic medicine in general, a surprisingly small number of women hold positions of significant leadership. Wehner et al reported that among the top 50 NIH-funded medical schools, only 13% of department leaders were women.7 This culture of predominantly male leadership in GI may be discouraging for women, and is one example of a possible glass ceiling that exists for women in academic medicine.
Salaries of female gastroenterologists are also less than those for their male counterparts. Singh et al collected data on male and female gastroenterologists who had been in practice for 10 years.8 After adjusting for practice setting, work hours, practice ownership, free endoscopy center practice, and vacation time, they found that female gastroenterologists earned $82,000 (22%) less per year than their male colleagues (95% CI $34,000-130,000; P=0.001). Additionally, they found that women were more frequently in academic practice (38% vs 17%), but were less likely to hold the most advanced academic positions.
The dearth of women in GI leadership extends to our national societies as well. The ACG has only had two female past presidents, Dr. Christina M. Surawicz (1998) and Dr. Amy Foxx-Orenstein (2007).9 A similar trend prevails for the AGA, where the first female president was Dr. Sara Jordan in 1942 and 1943, and the next was Dr. Gail Hecht in 2010. Dr. Sheila Crowe has been elected for a term beginning in 2017 (personal communication, April 2016). The ASGE has had four female presidents over an approximately 25-year period: Dr. Barbara Frank (1991), Dr. Grace Elta (2008), Dr. Colleen Schmitt (2014), and Dr. Karen Woods, whose term begins in 2017 (personal communication, April 2016). Finally, the AASLD has had three female presidents whose terms have been concentrated over the last decade: Dr. Teresa L. Wright (2005), Dr. Guadalupe Garcia-Tsao (2012), and Dr. Gyongyi Szabo (2015).10
If we are to adequately address the observed gender differences in GI we must start at the top. Our leadership, represented by the national societies, should prioritize promoting greater equality in GI leadership positions and address the gender gap of incoming GI fellows. On an individual practice level, family responsibilities should be respected. For example, conferences should not be scheduled in early morning or evening hours, and administrative time should be provided to allow for patient correspondence. Additionally, the salary disparities between men and women providing the same specialty care must be reduced. As women in GI, we must stand together, advocate for each other, and translate these proposed changes into reality.
Richa Shukla MD
Baylor College of Medicine Houston, TX
ACG Case Reports Journal
3. Elta GH. The challenges of being a female gastroenterologist. Gastroenterol Clin North Am
5. Shah DK, Karasek V, Gerkin RD, Ramirez FC, Young MA. Sex preferences for colonoscopists and GI physicians among patients and health care professionals. Gastrointest Endosc
6. Harvin G. Review of musculoskeletal injuries and prevention in the endoscopy practitioner. J Clin Gastroenterol
7. Wehner MR, Nead KT, Linos K, Linos E. Plenty of moustaches but not enough women: Cross sectional study of medical leaders. BMJ
8. Singh A, Burke CA, Larive B, Sastri SV; Women in Gastroenterology Committee of American College of Gastroenterology. Do gender disparities persist in gastroenterology after 10 years of practice? Am J Gastroenterol
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