Endoscopist gender preference: a closer look and a nuanced approach needed

Abstract

Patients’ preferences for their physicians’ gender have been studied and well documented in various specialties, most notably in the field of obstetrics and gynecology. These studies have demonstrated significant correlations between health-related outcomes and the gender preferences of patients such as improved compliance, satisfaction, and health-seeking behaviors. In gastroenterology. more specifically in the field of endoscopy, there are a limited number of published studies examining the prevalence of gender preference among patients, with the body of the medical literature almost exclusively in Western contexts.1Anglade P. Ibrahim H. Abdel-Razig S. Does provider gender matter in endoscopy? An international perspective.Gastrointest Endosc. 2021; 93: 1160-1168Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar On the aggregate, the data have shown a significant variance in the proportion of women studied who express a gender preference for their endoscopist (22% to 70%), with the vast majority of these women preferring same-gender endoscopists, embarrassment being the most common reason for those preferences, followed by character attributes ascribed to female endoscopists such as being “more caring,” “empathetic,” and “easier to talk to.”1Anglade P. Ibrahim H. Abdel-Razig S. Does provider gender matter in endoscopy? An international perspective.Gastrointest Endosc. 2021; 93: 1160-1168Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar It has been proposed that social factors such as faith or culture play a role in expressed gender preferences for endoscopists, particularly in the international space, where preference for gender-concordant endoscopists does not seem to be limited to female patients. In 2 of the few international studies, in Israel2Lahat A. Assouline-Dayan Y. Katz L.H. et al.The preference for an endoscopist specific sex: a link between ethnic origin, religious belief, socioeconomic status, and procedure type.Patient Prefer Adherence. 2013; 7: 897-903Crossref PubMed Scopus (14) Google Scholar and Brunei,3Chong V.H. Gender preference and implications for screening colonoscopy: impact of endoscopy nurses.World J Gastroenterol. 2012; 18: 3590-3594Crossref PubMed Scopus (10) Google Scholar large proportions of male patients also expressed a gender preference, overwhelmingly for male endoscopists (88% and 89%, respectively). However, studies from diverse cultures and settings are lacking, preventing any conclusive collective understanding of the critical constructs that may underpin the health behaviors of our endoscopy patients. The article by Kamani et al4Kamani L. Butt N. Taufiq F. et al.Unique perspective of Muslim patients on gender preference for GI endoscopists: a multicenter survey.Gastrointest Endosc. 2021; 94: 1110-1115Abstract Full Text Full Text PDF Scopus (1) Google Scholar in this issue of Gastrointestinal Endoscopy addresses this important gap in the current literature. This multicenter study in 3 tertiary care hospitals in Pakistan is one of the largest published studies examining the topic of gender preference in endoscopy and offers new insights in a previously unstudied population and setting. In their study of >1000 Pakistani Muslim patients, the authors report a significant preference for gender-concordant endoscopists in both female and male patients (69.5% and 62.2% of female and male patients expressed any preference, and 75.7% and 72.5%, respectively, expressed a same-gender preference). These findings are consistent with the only other published study in a predominantly Muslim patient population,3Chong V.H. Gender preference and implications for screening colonoscopy: impact of endoscopy nurses.World J Gastroenterol. 2012; 18: 3590-3594Crossref PubMed Scopus (10) Google Scholar seeming to suggest a significant influence of social and/or faith-based factors. Additionally, and as reported in other studies,5Shah D.K. Karasek V. Gerkin R.D. et al.Sex preferences for colonoscopists and GI physicians among patients and health care professionals.Gastrointest Endosc. 2011; 74: 122-127.e2Abstract Full Text Full Text PDF PubMed Scopus (31) Google Scholar,6Zapatier J.A. Kumar A.R. Perez A. et al.Preferences for ethnicity and sex of endoscopists in a Hispanic population in the United States.Gastrointest Endosc. 2011; 73 (97.e1-4): 89-97Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar the majority of patients with a gender preference reported their willingness to wait for their preferred-sex endoscopist, representing a potential for significant delays in care—a disconcerting phenomenon in light of the role of endoscopy in the detection and prevention of colorectal cancer. In the study by Kamani et al,4Kamani L. Butt N. Taufiq F. et al.Unique perspective of Muslim patients on gender preference for GI endoscopists: a multicenter survey.Gastrointest Endosc. 2021; 94: 1110-1115Abstract Full Text Full Text PDF Scopus (1) Google Scholar the most common reasons for expressed preference for gender-concordant endoscopists by both male and female patients were “perceived endoscopist competence” and “personal comfort.” Although “personal comfort” is likely to encompass similar constructs to “embarrassment” (as mentioned previously, a well-established reason for gender preferences in the literature), previous studies have reported “competence” as an attribute more often associated with preference for male endoscopists.6Zapatier J.A. Kumar A.R. Perez A. et al.Preferences for ethnicity and sex of endoscopists in a Hispanic population in the United States.Gastrointest Endosc. 2011; 73 (97.e1-4): 89-97Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar, 7Menees S.B. Inadomi J.M. Korsnes S. et al.Women patients' preference for women physicians is a barrier to colon cancer screening.Gastrointest Endosc. 2005; 62: 219-223Abstract Full Text Full Text PDF PubMed Scopus (105) Google Scholar, 8Schneider A. Kanagarajan N. Anjelly D. et al.Importance of gender, socioeconomic status, and history of abuse on patient preference for endoscopist.Am J Gastroenterol. 2009; 104: 340-348Crossref PubMed Scopus (31) Google Scholar, 9Farraye F.A. Wong M. Hurwitz S. et al.Barriers to endoscopic colorectal cancer screening: are women different from men?.Am J Gastroenterol. 2004; 99: 341-349Crossref PubMed Scopus (108) Google Scholar This is particularly intriguing, implying a significant departure in views of female endoscopist competence among female patients as compared with female populations previously studied. Additionally, when other factors were reviewed for observed gender preference, female patients were significantly more likely to choose religious values and family pressure as reasons for their preference than were male patients, emphasizing the weight of societal influences on the medical decision making by female patients compared with males. It is important to note that female patients in this study as a whole were significantly less educated and made less income than their male counterparts; this is particularly significant in light of univariate analysis that determined both factors to influence the likelihood of having a gender preference. A few firsts with the article by Kamani et al4Kamani L. Butt N. Taufiq F. et al.Unique perspective of Muslim patients on gender preference for GI endoscopists: a multicenter survey.Gastrointest Endosc. 2021; 94: 1110-1115Abstract Full Text Full Text PDF Scopus (1) Google Scholar are worth highlighting. It is the first study that specifically investigated the role of the family in influencing expressed gender preferences. As established in the literature, patients’ families often have a significant impact on health behaviors, particularly in collectivist cultures. The authors’ decision to study this construct represents a socially informed study design. Subsequent significant correlative findings between this variable and gender preference among women patients attest to the importance of ensuring the use of socially and culturally relevant survey instruments in studying gender preference (unfortunately, survey instrument design and administration represents an area of significant methodologic variance in the literature on this topic). Another first represented by this article is its examination of whether changes exist between preprocedural and postprocedural expressed preference. It is interesting that most patients stuck to their initial preference after undergoing their endoscopies. Last, it is notable that 84% of all procedures in this study were upper endoscopies, unlike most studies on gender preference in endoscopy, which focus more on colonoscopy, by nature of the more “private” anatomic areas exposed. One is left to assume that the significant gender preference observed in the study population would likely be even more exaggerated with colonoscopy. This study not only bolsters the growing recognition of the impact of patient gender preferences in the field of endoscopy but also serves to highlight the need to work toward a more gender-balanced global gastroenterology workforce. Despite advances in the proportion of women entering medical school and subsequently completing training in gastroenterology, GI endoscopy remains a male-dominated field. What studies like this one by Kamani et al4Kamani L. Butt N. Taufiq F. et al.Unique perspective of Muslim patients on gender preference for GI endoscopists: a multicenter survey.Gastrointest Endosc. 2021; 94: 1110-1115Abstract Full Text Full Text PDF Scopus (1) Google Scholar substantiate is the significant relationship between the provider gender preference of our female patients and its impact on consequential health outcomes such as delays in care and health-seeking behaviors. As more of these data become evident, it behooves the global gastroenterology community to ensure that enough female endoscopists are on the ground, delivering care to this significant portion of the population. Another important insight gained from Kamani et al4Kamani L. Butt N. Taufiq F. et al.Unique perspective of Muslim patients on gender preference for GI endoscopists: a multicenter survey.Gastrointest Endosc. 2021; 94: 1110-1115Abstract Full Text Full Text PDF Scopus (1) Google Scholar is that gender preferences are heavily socially and culturally influenced and hence will likely vary widely depending on the population studied. For example, a recent article looking at a predominantly white population in the United States found that only 10% of women and 12% of men had a gender preference for their endoscopist and that men had more same-gender preference than women.10Khara H.S. Suthar D. Bergenstock M. et al.Identifying gender barriers for colorectal cancer screening and assessing the need for a multigender endoscopy team: a prospective multicenter study.Am J Gastroenterol. 2021; 116: 1646-1656Crossref PubMed Scopus (2) Google Scholar These seemingly “contradictory” results likely reflect the diversity of social contexts and communities studied and should not be viewed as evidence “against” the notion or impact of endoscopist gender on patient health choices and experiences. Remarkably, in the study by Kamani et al,4Kamani L. Butt N. Taufiq F. et al.Unique perspective of Muslim patients on gender preference for GI endoscopists: a multicenter survey.Gastrointest Endosc. 2021; 94: 1110-1115Abstract Full Text Full Text PDF Scopus (1) Google Scholar patient preferences were accommodated on the same day of the procedure—a difficult feat for most health service providers. As additional research unfolds in more settings, we can expect to gain further insights to the unique characteristics of the communities that we serve and the role of provider gender. This information should be used to inform and align staffing and operations to adapt to the needs of those we serve. At the individual patient encounter level, however, it is important that providers remain cognizant of the nuances expressed within communities and social structures. We need to realize that most communities are not homogeneous. Although these types of studies should inform the management and operations of systems-level services, individual practice must always assimilate knowledge generated from the whole while keeping the patient at the center. In other words, perhaps the most consequential implication of these studies rests in a simple change in practice: routinely asking the question whether a specific endoscopist gender is preferred. Much like many clinicians and administrative personnel who have recognized the importance of assessing barriers to care, such as the ability of patients to pick up the prescribed bowel preparation or the availability of safe postprocedural transport, assessment of gender preference is a key factor in providing timely care and optimal patient experiences. Both authors disclosed no financial relationships. Unique perspective of Muslim patients on gender preference for GI endoscopists: a multicenter surveyGastrointestinal EndoscopyVol. 94Issue 6PreviewPatient preference for a healthcare professional is mediated by physician gender. The primary aim of this study was to assess gender preference for an endoscopist in a cohort of Muslim patients. The secondary aim was to identify factors that influence gender preference. Full-Text PDF