A 12-Year North American Longitudinal Study of Gender Equity and Equality in Gastroenterology

Abstract

Gender parity has yet to be achieved in gastroenterology (GI).1Association of American Medical CollegesPhysician Specialty Data Report. Association of American Medical Colleges, 2021Google Scholar,2Davids J.S. Scully R.E. Melnitchouk N. Impact of procedural training on pregnancy outcomes and career satisfaction in female postgraduate medical trainees in the United States.J Am Coll Surg. 2017; 225: 411-418.e2Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar In 2019, fewer than 1 in 5 (19%) practicing gastroenterologists were women, fewer than in general surgery (22%), sports medicine (27%), and critical care medicine (27%).1Association of American Medical CollegesPhysician Specialty Data Report. Association of American Medical Colleges, 2021Google Scholar Compared with nonprocedural medical fields, procedural specialties often have longer training, less flexible work schedules, and more physically demanding responsibilities.2Davids J.S. Scully R.E. Melnitchouk N. Impact of procedural training on pregnancy outcomes and career satisfaction in female postgraduate medical trainees in the United States.J Am Coll Surg. 2017; 225: 411-418.e2Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar However, biases (or genderism) can impair the ability of women to be represented equally and fairly across the training, advancement, and leadership continuum. In this study, we aimed to portray the landscape of gender equity and parity in GI. We analyzed the national trends of women’s representation in GI (ie, applicants, fellows, practicing gastroenterologists, and leadership) in a longitudinal analysis of 397,634 applications from 7672 applicants to 158 GI fellowship programs in North America from 2009 through 2018 (from the Association of American Medical Colleges)3Association of American Medical CollegesFACTS: Applicants, Matriculants, Enrollment, Graduates, MD-PhD, and Residency Applicants Data. Association of American Medical Colleges, 2021Google Scholar; 6184 first-year GI fellows in the United States from 2008 through 2020 (from the Association of American Medical Colleges)4American Board of Internal MedicineABIM Resident & Fellow Workforce Data. American Board of Internal Medicine, 2021Google Scholar; 82,809 practicing gastroenterologists from 2008 through 2019 (from the Association of American Medical Colleges)1Association of American Medical CollegesPhysician Specialty Data Report. Association of American Medical Colleges, 2021Google Scholar; and 189 GI fellowship program’s leadership and affiliated diversity offices from institutional websites in 2018 and 2021.5Tse C.S. Nguyen H. Hinds S.K. et al.885 Diversity offices' impact on gender parity in gastroenterology training: a decade-long analysis of gastroenterology fellowships' leadership, trainees, and applicants in North America from 2009-2018.Gastrointestinal Endoscopy. 2020; 91: AB75Abstract Full Text Full Text PDF Google Scholar We used χ2 and t test to analyze factors associated with gender distribution, and logistic regression to obtain odds ratios, using JMP statistical software (version 14, SAS Institute), with P < .05 considered statistically significant. Lifespan Health System’s Institutional Review Board exempted the study. Stepwise attrition of women in the pipeline to become gastroenterologists was observed through medical school, internal medicine (IM) residency, and GI fellowship (Figure 1). One-half of the medical school applicants (mean, 54%; range, 46%–54%), matriculants (mean, 49%; range, 46%–53%), and graduates (mean, 48%; range, 46%–50%) were women, although fewer than one-half (mean, 44%; range, 42%–46%) of the IM residents were women.4American Board of Internal MedicineABIM Resident & Fellow Workforce Data. American Board of Internal Medicine, 2021Google Scholar Only 1 in 3 GI fellowship applicants (mean, 33%; range, 31%–33%) and first-year GI fellows (mean, 33%; range, 29%–39%) were women. Discouragingly, these figures remained stagnant throughout the decade-long study period. Encouragingly, the proportion of women as actively practicing gastroenterologists increased steadily from 11% to 19% (Figure 1; 13% in 2010, 15% in 2014, 16% in 2015, and 18% in 2017). This might reflect higher rates of retention of women in GI through national, local, and institutional efforts (Table 1).Table 1Challenges, and Solutions for Gender Equity, Equality, and Parity in GastroenterologyBarriers and challengesProposed solutionExample of processes and initiativesUnderrepresentation Underrepresentation of women in procedural specialties as trainees, practicing physicians, and leadership (eg, academic medicine, health care organizations)1Association of American Medical CollegesPhysician Specialty Data Report. Association of American Medical Colleges, 2021Google Scholar,13Woodward Z. Rodriguez Z. Jou J.H. et al.Gender disparities in gastroenterology fellowship director positions in the United States.Gastrointest Endosc. 2017; 86: 595-599Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar,14Lautenberger D.M. Dandar Valerie M. The State of Women in Academic Medicine. Association of American Medical Colleges, 2020Google ScholarCreate diverse, inclusive, and respectful organization climate that prioritize gender and racial equity in hiring and promotions, with clear, accessible, and consistent policies7Association of American Medical CollegesGroup on Women in Medicine and Science (GWIMS) Toolkit: Diversity and Inclusion. Association of American Medical Colleges, 2021Google Scholar,8DeAro J. Bird S. Ryan S.M. NSF ADVANCE and gender equity: past, present and future of systemic institutional transformation strategies.Equal Divers Incl. 2019; 8: 131-139Crossref Scopus (17) Google ScholarProvide all faculty and graduate students with access to the National Center for Faculty Diversity and Development, an independent community for mentorship and training in academic professional development, through an institutional membership12National Science FoundationNSF Award # 1209235 - UC Davis ADVANCE: Institutional Transformation to Build and Sustain a Diverse Community of Innovative STEM Scholars. Division of Human Resource Development, National Science Foundation, 2019Google ScholarInclude qualified women physicians as job candidates, such as the inclusion of Diversity Statements in faculty job applications,8DeAro J. Bird S. Ryan S.M. NSF ADVANCE and gender equity: past, present and future of systemic institutional transformation strategies.Equal Divers Incl. 2019; 8: 131-139Crossref Scopus (17) Google Scholar and as members and leaders of search committees9Butkus R. Serchen J. Moyer D.V. et al.Achieving gender equity in physician compensation and career advancement: a position paper of the American College of Physicians.Ann Intern Med. 2018; 168: 721-723Crossref PubMed Scopus (196) Google ScholarA multipronged approach to support the success of junior women medical faculty was implemented at the University of Pennsylvania: 1) a Total Leadership Program and a Manuscript Writing Program for women junior faculty, 2) appreciative inquiry sessions on academic cultural change for senior leadership, and 3) interventional task forces for work practices, policies, recruitment, mentorship, and cultural attitudes. Over 3 years, widespread institutional change conducive to women's academic success were reported with statistically more grants and total peer-reviewed publications from women junior faculty, while decreasing the number of hours worked per week11Grisso J.A. Sammel M.D. Rubenstein A.H. et al.A randomized controlled trial to improve the success of women assistant professors.J Womens Health (Larchmt). 2017; 26: 571-579Crossref PubMed Scopus (26) Google ScholarA faculty diversity and inclusion program in the otolaryngology department at Johns Hopkins University increased the representation of women, and achieved rank-salary parity over 10 y15Lin S.Y. Francis H.W. Minor L.B. et al.Faculty diversity and inclusion program outcomes at an academic otolaryngology department.Laryngoscope. 2016; 126: 352-356Crossref PubMed Scopus (24) Google ScholarMentorship imbalances Women mentees experience challenges in procuring mentorship and sponsorship and women mentors express insufficient time and resources to guide mentees9Butkus R. Serchen J. Moyer D.V. et al.Achieving gender equity in physician compensation and career advancement: a position paper of the American College of Physicians.Ann Intern Med. 2018; 168: 721-723Crossref PubMed Scopus (196) Google Scholar,16Rabinowitz L.G. Grinspan L.T. Zylberberg H.M. et al.Survey finds gender disparities impact both women mentors and mentees in gastroenterology.Am J Gastroenterol. 2021; 116: 1876-1884Crossref PubMed Scopus (6) Google ScholarInstitute formal mentorship, coaching, and sponsorship programs and opportunities as deliberate career-advancement strategies for women in medicine16Rabinowitz L.G. Grinspan L.T. Zylberberg H.M. et al.Survey finds gender disparities impact both women mentors and mentees in gastroenterology.Am J Gastroenterol. 2021; 116: 1876-1884Crossref PubMed Scopus (6) Google Scholar,17Farkas A.H. Bonifacino E. Turner R. et al.Mentorship of women in academic medicine: a systematic review.J Gen Intern Med. 2019; 34: 1322-1329Crossref PubMed Scopus (96) Google ScholarA 10-y Women in Medicine and Health Science program provided opportunities for networking, sponsorship, mentorship, and career development that was associated with notable increases in women faculty (18% to 36%) and department chairs (5% to 23%)18Bauman M.D. Howell L.P. Villablanca A.C. The Women in Medicine and Health Science program: an innovative initiative to support female faculty at the University of California Davis School of Medicine.Acad Med. 2014; 89: 1462-1466Crossref PubMed Scopus (76) Google ScholarFormalized committees and programs from professional societies for career development and networking for women to address opportunity gaps,19Lin M.P. Lall M.D. Samuels-Kalow M. et al.Impact of a women-focused professional organization on academic retention and advancement: perceptions from a qualitative study.Acad Emerg Med. 2019; 26: 303-316Crossref PubMed Scopus (29) Google Scholar such as the American Gastroenterological Association’s Women’s Leadership Conference, Women’s Committee, annual Women in GI luncheon at Digestive Diseases Week20Lok A. Burke C.A. Crowe S.E. et al.Society leadership and diversity: hail to the women.Gastroenterology. 2017; 153: 618-620Abstract Full Text Full Text PDF PubMed Scopus (6) Google ScholarImplicit biases Structural biases, unconscious biases, and stereotypes that influence policies, procedures, and practices that may unfairly appraise contributions based on gender10Jagsi R. Spector N.D. Leading by design: lessons for the future from 25 years of the Executive Leadership in Academic Medicine (ELAM) program for women.Acad Med. 2020; 95: 1479-1482Crossref PubMed Scopus (18) Google ScholarProvision of regular and recurring implicit bias training, as well as organizational policies and procedures to address implicit bias that stem from characters of personal identity (eg, gender)9Butkus R. Serchen J. Moyer D.V. et al.Achieving gender equity in physician compensation and career advancement: a position paper of the American College of Physicians.Ann Intern Med. 2018; 168: 721-723Crossref PubMed Scopus (196) Google Scholar,12National Science FoundationNSF Award # 1209235 - UC Davis ADVANCE: Institutional Transformation to Build and Sustain a Diverse Community of Innovative STEM Scholars. Division of Human Resource Development, National Science Foundation, 2019Google Scholar1450 faculty and graduate students serving on search committees were trained in a mandatory implicit bias and best practices for new faculty recruitment in the University of California-Davis ADVANCE program. Outcomes include the establishment of the Center for the Advancement of Multicultural Perspectives on Science, with 25 new faculty recruited (including 15 Latina), and the implementation of the Inclusive Campus Climate Initiative that mentored 43 new faculty (including 19 women)12National Science FoundationNSF Award # 1209235 - UC Davis ADVANCE: Institutional Transformation to Build and Sustain a Diverse Community of Innovative STEM Scholars. Division of Human Resource Development, National Science Foundation, 2019Google ScholarAt the University of Pennsylvania, 133 women assistant professors identified 4 themes for a work environment and culture conducive to women’s academic success in medicine: support for work–life balance, equal access to opportunities, supportive leadership (eg, chair or chief), and freedom from gender biases21Westring A.F. Speck R.M. Sammel M.D. et al.A culture conducive to women's academic success: development of a measure.Acad Med. 2012; 87: 1622-1631Crossref PubMed Scopus (64) Google ScholarGender tax Undue burden and time commitments placed on women to engage in additional professional responsibilities that can impede productivity and hinder career progression (eg, token members on numerous committees, advise large number of students)22Hirshfield L.E. Joseph T.D. ‘We need a woman, we need a black woman’: gender, race, and identity taxation in the academy.Gender Educ. 2012; 24: 213-227Crossref Scopus (115) Google Scholar,23Gewin V. The time tax put on scientists of colour.Nature. 2020; 583: 479-481Crossref PubMed Scopus (43) Google ScholarEquity initiatives that systematically entails investment of resources into recruitment, promotion, and hiring policies, and requirements for inclusivity7Association of American Medical CollegesGroup on Women in Medicine and Science (GWIMS) Toolkit: Diversity and Inclusion. Association of American Medical Colleges, 2021Google Scholar,9Butkus R. Serchen J. Moyer D.V. et al.Achieving gender equity in physician compensation and career advancement: a position paper of the American College of Physicians.Ann Intern Med. 2018; 168: 721-723Crossref PubMed Scopus (196) Google ScholarInstitutional validation for diversity and inclusivity roles (as opposed to pro bono contributions),23Gewin V. The time tax put on scientists of colour.Nature. 2020; 583: 479-481Crossref PubMed Scopus (43) Google Scholar including metrics such as grants funding, presentations, awards, promotions, national recognition, and leadership roles (eg, Founder and Director, Mentoring Program for Women, Women’s Health Center of Excellence for Research)7Association of American Medical CollegesGroup on Women in Medicine and Science (GWIMS) Toolkit: Diversity and Inclusion. Association of American Medical Colleges, 2021Google ScholarSet time boundaries and negotiate counterbalances for time spent in department/institutional diversity, equity, and inclusivity activities (eg, reduced teaching commitments)23Gewin V. The time tax put on scientists of colour.Nature. 2020; 583: 479-481Crossref PubMed Scopus (43) Google ScholarGendered division of domestic labor Work–family conflicts stemming from unequal gender roles and norms for childbearing, parenting, and domestic responsibilities,2Davids J.S. Scully R.E. Melnitchouk N. Impact of procedural training on pregnancy outcomes and career satisfaction in female postgraduate medical trainees in the United States.J Am Coll Surg. 2017; 225: 411-418.e2Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar,10Jagsi R. Spector N.D. Leading by design: lessons for the future from 25 years of the Executive Leadership in Academic Medicine (ELAM) program for women.Acad Med. 2020; 95: 1479-1482Crossref PubMed Scopus (18) Google Scholar,16Rabinowitz L.G. Grinspan L.T. Zylberberg H.M. et al.Survey finds gender disparities impact both women mentors and mentees in gastroenterology.Am J Gastroenterol. 2021; 116: 1876-1884Crossref PubMed Scopus (6) Google Scholar especially for dual-professional and dual-physician couples.24Snyder R.A. Tarpley M.J. Phillips S.E. et al.The case for on-site child care in residency training and afterward.J Grad Med Educ. 2013; 5: 365-367Crossref PubMed Google ScholarFlexibility in structuring career paths, including tenure clock extensions and re-entry into faculty positions, that are supportive for the retention and advancement of women physicians9Butkus R. Serchen J. Moyer D.V. et al.Achieving gender equity in physician compensation and career advancement: a position paper of the American College of Physicians.Ann Intern Med. 2018; 168: 721-723Crossref PubMed Scopus (196) Google ScholarLegislature or local regulatory action to implement medical leave policies that provide a minimum of 6 wk of paid leave and calls9Butkus R. Serchen J. Moyer D.V. et al.Achieving gender equity in physician compensation and career advancement: a position paper of the American College of Physicians.Ann Intern Med. 2018; 168: 721-723Crossref PubMed Scopus (196) Google ScholarFair and transparent family leave policies and opportunities for work–life integration2Davids J.S. Scully R.E. Melnitchouk N. Impact of procedural training on pregnancy outcomes and career satisfaction in female postgraduate medical trainees in the United States.J Am Coll Surg. 2017; 225: 411-418.e2Abstract Full Text Full Text PDF PubMed Scopus (24) Google ScholarParental leave policies that provide adequate support for trainee in procedural specialties2Davids J.S. Scully R.E. Melnitchouk N. Impact of procedural training on pregnancy outcomes and career satisfaction in female postgraduate medical trainees in the United States.J Am Coll Surg. 2017; 225: 411-418.e2Abstract Full Text Full Text PDF PubMed Scopus (24) Google ScholarOn/near-site child care at medical centers with extended-hours (eg, 24-h child care open for on-call emergencies)24Snyder R.A. Tarpley M.J. Phillips S.E. et al.The case for on-site child care in residency training and afterward.J Grad Med Educ. 2013; 5: 365-367Crossref PubMed Google ScholarThe University of California-Davis ADVANCE program founded the Policy and Practice Recruitment Initiative and a Capital Resource Network to develop family-friendly policies and recruitment and retention strategies for dual-career faculty.12National Science FoundationNSF Award # 1209235 - UC Davis ADVANCE: Institutional Transformation to Build and Sustain a Diverse Community of Innovative STEM Scholars. Division of Human Resource Development, National Science Foundation, 2019Google Scholar More than 139 employment referrals for new faculty, staff, and their families were provided12National Science FoundationNSF Award # 1209235 - UC Davis ADVANCE: Institutional Transformation to Build and Sustain a Diverse Community of Innovative STEM Scholars. Division of Human Resource Development, National Science Foundation, 2019Google Scholar Open table in a new tab Men continue to hold the vast majority of leadership positions in graduate medical education, especially the most senior ranks of IM department and GI division chairs (Figure 1). Encouragingly, women IM department chairs doubled from 17% to 33% (P = .0003) and women GI associate fellowship program directors increased from 31% to 39% (P = .17). However, the proportion of women GI division chiefs (12%–13%) and GI fellowship program directors (24%) did not change. Institutions with women IM department chairs had higher odds of having a woman GI division chair (odds ratio, 3.5; 95% confidence interval, 1.4–8.9; P = .009), which, in turn, has higher odds of having women GI fellowship program directors (odds ratio, 2.9; 95% confidence interval, 1.2–6.9; P = .02). Although the majority (87% [n = 165 of 189]) of GI fellowship programs were affiliated with hospitals or institutions that had diversity offices and programs, fewer than one-half (46% [n = 87 of 189]) have missions or initiatives focused on women in medicine (as opposed to racial and ethnic diversity, for example). The presence of diversity programs was not associated with gender parity in GI fellowship training or leadership (P > .1). “Change is fast, transitions are slow” is an idiom often used in organizational behavioral models.6Arun K. Meenakshi N. Organizational Behaviour: A Modern Approach. Vikas Publishing House, 2009Google Scholar Changes are events or practices that differ from the status quo. Transitions are changes that cumulate to shifts in processes and interpersonal networks. Transformations are fundamental structural and adaptive changes in complex systems resultant from sustained transitions.6Arun K. Meenakshi N. Organizational Behaviour: A Modern Approach. Vikas Publishing House, 2009Google Scholar Gender parity has yet to be achieved in GI, and gender inequity is among the leading culprits. Equitable treatment of women and men according to their needs, where benefits, opportunities, rights, and obligations are delineated without genderism, can set the stage for gender parity in GI. First, in this decade-long analysis, we noted the attrition of women from the earliest stages of training to leadership, reminiscent of a leaky pipeline (see Figure 1). Second, the proportion of women applicants and GI fellows has remained unchanged over the past decade. Third, there has been a steady increase of women as actively practicing gastroenterologists in the workforce, which may reflect national, societal, and institutional efforts for gender diversity.7Association of American Medical CollegesGroup on Women in Medicine and Science (GWIMS) Toolkit: Diversity and Inclusion. Association of American Medical Colleges, 2021Google Scholar, 8DeAro J. Bird S. Ryan S.M. NSF ADVANCE and gender equity: past, present and future of systemic institutional transformation strategies.Equal Divers Incl. 2019; 8: 131-139Crossref Scopus (17) Google Scholar, 9Butkus R. Serchen J. Moyer D.V. et al.Achieving gender equity in physician compensation and career advancement: a position paper of the American College of Physicians.Ann Intern Med. 2018; 168: 721-723Crossref PubMed Scopus (196) Google Scholar, 10Jagsi R. Spector N.D. Leading by design: lessons for the future from 25 years of the Executive Leadership in Academic Medicine (ELAM) program for women.Acad Med. 2020; 95: 1479-1482Crossref PubMed Scopus (18) Google Scholar, 11Grisso J.A. Sammel M.D. Rubenstein A.H. et al.A randomized controlled trial to improve the success of women assistant professors.J Womens Health (Larchmt). 2017; 26: 571-579Crossref PubMed Scopus (26) Google Scholar, 12National Science FoundationNSF Award # 1209235 - UC Davis ADVANCE: Institutional Transformation to Build and Sustain a Diverse Community of Innovative STEM Scholars. Division of Human Resource Development, National Science Foundation, 2019Google Scholar Fourth, more gender parity among graduate medical education leadership was associated with more equal gender distribution within the GI leadership,13Woodward Z. Rodriguez Z. Jou J.H. et al.Gender disparities in gastroenterology fellowship director positions in the United States.Gastrointest Endosc. 2017; 86: 595-599Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar although the presence of a diversity office was not associated with gender parity among the trainees or leadership. An institutional climate and leadership prioritization of a diverse, inclusive, and respectful organization that prioritize gender equity are necessary to prevent attrition and promote advancement of women in GI.9Butkus R. Serchen J. Moyer D.V. et al.Achieving gender equity in physician compensation and career advancement: a position paper of the American College of Physicians.Ann Intern Med. 2018; 168: 721-723Crossref PubMed Scopus (196) Google Scholar,10Jagsi R. Spector N.D. Leading by design: lessons for the future from 25 years of the Executive Leadership in Academic Medicine (ELAM) program for women.Acad Med. 2020; 95: 1479-1482Crossref PubMed Scopus (18) Google Scholar Establishing and maintaining gender diversity and equity in GI is necessary to cultivate the full range of talents to improve the quality and impact of this field. Although gender disparity and inequity continue to exist in GI, there has been recognizable efforts and funding at the national, societal, and institutional level towards a cultural shift for gender equality and equity in GI, even though gender parity nationally may take decades to be fully realized.