Promoting Leadership by Women in Gastroenterology—Lessons Learned and Future Directions

Abstract

Historically, women have been underrepresented in most fields of medicine, especially in procedure-heavy fields such as gastroenterology. The gender gap has been gradually decreasing over the past few decades, but significant disparities continue to exist. In 2015, women comprised 46% of trainees across all specialties, 34.4% of gastroenterology (GI) fellows, and 16.4% of practicing gastroenterologists.1American Association of Medical Colleges (AAMC)ACGME residents and fellows by sex and specialty, 2015.www.aamc.org/data/workforce/reports/458766/2-2-chart.htmlGoogle Scholar, 2American Association of Medical Colleges (AAMC)Active physicians by sex and specialty, 2015.www.aamc.org/data/workforce/reports/458712/1-3-chart.htmlGoogle Scholar This represents a 4.8% increase in the number of female first-year fellows since 20103American Association of Medical Colleges (AAMC)Percentage change in the number of first-year ACGME residents and fellows by specialty, 2010–2015.www.aamc.org/data/workforce/reports/458780/2-6-chart.htmlGoogle Scholar and an even greater increase compared with 10 years ago when only one-quarter of first-year GI fellows were women.4Menees S.B. Elta G.H. Is the glass ceiling in gastroenterology gone?.Gastrointest Endosc. 2016; 83: 734-735Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar, 5American Board of Internal MedicineResident & fellow workforce data, 2016.www.abim.org/about/statistics-data/resident-fellow-workforce-data.aspxDate accessed: April 17, 2016Google Scholar Despite the increase in gender parity in those entering medical training, a significant difference continues to persist as women enter practice, widening further with higher academic rank and in leadership positions. In 2015, <20% of GI fellowship program directors and <10% of division chiefs were female.6American Board of Internal Medicine (ABIM).www.ABIM.org/statisticsGoogle Scholar, 7Woodward 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 The only academic rank where women outnumbered men was that of clinical instructor, the lowest academic rank (57% vs only 22% for full professor).8American Association of Medical Colleges (AAMC)Table 3: distribution of full-time faculty by department, rank, and gender, 2015.www.aamc.org/download/481182/data/2015table3.pdfGoogle Scholar This gender disparity in leadership across medicine is even more pronounced in women of racial minorities.9Albert M.A. #Me_Who: Anatomy of scholastic, leadership, and social isolation of underrepresented minority women in academic medicine.Circulation. 2018; 138: 451-454Crossref PubMed Scopus (18) Google Scholar The gender gap in leadership positions has been postulated to be a result of personal choices made by women who desire work–life balance; however, a survey of >3000 female physicians in 2015 found that 88% felt that it is important for women to be in positions of leadership and ≥50% reported it as an important personal goal.10MedscapeWomen as physician leaders.www.medscape.com/features/slideshow/public/femaleleadershipreport2015Google Scholar Furthermore, a study by Burke et al11Burke C.A. Sastri S.V. Jacobsen G. et al.Gender disparity in the practice of gastroenterology: the first 5 years of a career.Am J Gastroenterol. 2005; 100: 259-264Crossref PubMed Scopus (35) Google Scholar surveying GI fellows 3, 5, and 10 years after graduation showed women tended to have fewer children later than did men at a similar career stage. Women also reported altering family planning more so than men to accommodate their career goals.11Burke C.A. Sastri S.V. Jacobsen G. et al.Gender disparity in the practice of gastroenterology: the first 5 years of a career.Am J Gastroenterol. 2005; 100: 259-264Crossref PubMed Scopus (35) Google Scholar, 12Singh A. Burke C.A. Larive B. et al.Do gender disparities persist in gastroenterology after 10 years of practice?.Am J Gastroenterol. 2008; 103: 1589-1595Crossref PubMed Scopus (41) Google Scholar Thus, women often delay personal life goals in favor of developing their professional lives. To effectively eliminate the gender disparity in leadership positions within medicine, especially in previously male-dominated specialties such as gastroenterology, it is important to promote awareness of the current status of women in medical leadership roles, explore barriers to women aspiring leadership, and to promote strategies to allow for greater female representation in leadership positions within medicine and gastroenterology. Institutions and businesses can benefit from the diversity in ideas and unique traits which women leaders bring. They may more often possess the interpersonal skills and relational style associated with high emotional intelligence (EQ), which is widely considered a key driver of outstanding leadership.13Goleman D. Emotional intelligence. New York, NY: Bantam Dell, 1995.Google Scholar A recent study of >50,000 professionals globally and across all levels of management found that successful women leaders more effectively used the core competencies associated with EQ compared with men. Although some of these competencies are closely related to a stereotypically female personality—nurturing and collaborative—those in which these women scored highest compared with their male counterparts included being driven and taking initiative, which traditionally are viewed as “male” attributes. Women also viewed their leadership positions as highly vulnerable and tended to work longer and harder to prove their worth.14Zenger J. Folkman J. Are women leaders better than men.Harvard Business Review. 2012 March 15; (Available from:)https://hbr.org/2012/03/a-study-in-leadership-women-doGoogle Scholar The importance of EQ in health care leadership is less recognized compared with other businesses, but can significantly impact medical staff performance and patient outcomes. The common traits of high EQ in women physician leaders may better connect them with individuals and allow them to recognize and address the psychological and emotional state of their staff, which is important in reducing burnout and delivering unbiased patient care. Recent current events, including the #MeToo movement, have put a spotlight on sexual harassment and discrimination in the workplace, which has also affected women in medicine owing to existing gender inequality in positions of power. Women physician leaders are potentially more likely to recognize and be empowered to proactively address these issues. Likewise, women may be more willing to confide their concerns to female leaders. Studies have shown that a significantly disproportionate percentage of female medical students and academic faculty report sexual harassment from their superiors.15Jagsi R. Griffith K.A. Jones R. et al.Sexual harassment and discrimination experiences of academic medical faculty.JAMA. 2016; 315: 2120-2121Crossref PubMed Scopus (250) Google Scholar, 16Nora L.M. McLaughlin M.A. Fosson S.E. et al.Gender discrimination and sexual harassment in medical education: perspectives gained by a 14-school study.Acad Med. 2002; 77: 1226-1234Crossref PubMed Scopus (123) Google Scholar Women physicians also report higher rates of sexual harassment and discrimination from their patients.17Komaromy M. Bindman A.B. Haber R.J. et al.Sexual harassment in medical training.N Engl J Med. 1993; 328: 322-326Crossref PubMed Scopus (190) Google Scholar, 18Phillips S. Sexual harassment of female physicians by patients. What is to be done?.Can Fam Physician. 1996; 42: 73-78PubMed Google Scholar Furthermore, medical professionals, particularly in subspecialties such as GI, need to be cognizant of the past experiences of affected female patients because they may be less inclined to discuss symptoms or have invasive procedures performed involving bowel and sexual function with male providers. There are valuable benefits in improving female leadership in gastroenterology that can potentially refine the field by increasing academic research, improving health care delivery, and advance the management of GI diseases in women. A prime example includes the finding that a barrier to colonoscopy for female patients has been gender preference. In a 2005 survey, 45% of female patients expressed preference for a female endoscopist, 80% were willing to wait >1 month, and 14% were willing to pay more.19Menees 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 (108) Google Scholar As role models, women leaders can increase the recruitment and retention of female GI physicians to better meet this demand. Female GI leaders may also be more inclined to promote gender-based medicine by encouraging specialized approaches and clinics as well as conducting academic investigation into models of care delivery for certain female-related GI diseases such as pregnancy-related management of inflammatory bowel disease, pregnancy-specific and autoimmune liver diseases, irritable bowel syndrome, and pelvic floor disorders. The presence or absence of role models significantly impacts the desire for women physicians to pursue certain specialty fields and career positions (Figure 1).20Edmunds L.D. Ovseiko P.V. Shepperd S. et al.Why do women choose or reject careers in academic medicine? A narrative review of empirical evidence.Lancet. 2016; 388: 2948-2958Abstract Full Text Full Text PDF PubMed Scopus (184) Google Scholar Women GI physicians start their careers in fellowship seeing less female representation in academic leadership. In private practice, fewer women than men physicians are business owners.21Kane et al.Updated arrangements of physician practice arrangement.AMA policy research perspectives. 2016; (Available from:)https://www.ama-assn.org/sites/ama-assn.org/files/corp/media-browser/public/health-policy/PRP-2016-physician-benchmark-survey.pdfGoogle Scholar, 22A Comparison of the career attainments of men and women healthcare executives.ACHE. 2012; (Available from:)https://www.ache.org/pubs/research/genderstudy_execsummary.cfmGoogle Scholar Less than 20% of women are hospital chief executive officers and women achieve chief executive officer status at one-half the rate of men with a similar number of years of experience.21Kane et al.Updated arrangements of physician practice arrangement.AMA policy research perspectives. 2016; (Available from:)https://www.ama-assn.org/sites/ama-assn.org/files/corp/media-browser/public/health-policy/PRP-2016-physician-benchmark-survey.pdfGoogle Scholar In society leadership, there have only been 3 female presidents of the AGA since its inception in 1897. The future, however, does seem to be changing; in 2017, all 4 major GI societies—AASLD, ACG, AGA, and ASGE—had female presidents simultaneously. Among the AGA Committee Chairs, one-half are now occupied by a woman.23American Gastroenterological AssociationAbout AGA.www.gastro.org/about-aga/about-usGoogle Scholar Sheryl Sandberg, in her book, Lean In, suggests that gender bias is the central reason why women are not able to break the “glass ceiling” into leadership positions.24Sandberg S. Lean in: women, work, and the will to lead. Knopf, New York2013Google Scholar The impact of implicit bias on women has contributed to the inequality of compensation, number of first author publications in high-impact journals, and rate of academic promotions.25Shen Y.A. Webster J.M. Persistent underrepresentation of women’s science in high profile journals. 2018.www.biorxiv.org/content/10.1101/275362v2Google Scholar, 26Mangurian C. Linos E. Sarkar U. What's holding women in medicine back from leadership.Harvard Business Review. 2018 June; (Available from:)https://hbr.org/2018/06/whats-holding-women-in-medicine-back-from-leadershipGoogle Scholar Studies have found that women physicians are less formally addressed, given less autonomy, and underrecognized compared with their male counterparts.27Abbuhl S. Bristol M.N. Ashfaq H. et al.Examining faculty awards for gender equity and evolving values.J Gen Intern Med. 2010; 25: 57-60Crossref PubMed Scopus (24) Google Scholar, 28Files J.A. Mayer A. Ko A.P. et al.Speaker introductions at internal medicine grand rounds: forms of address reveal gender bias.J Womens Health. 2017; 25: 413-419Crossref Scopus (157) Google Scholar Patients also tended to judge female physicians more harshly than males when the information is presented in a similar style.29Hall J.A. Blanch-Hartigan D. Roter D. Patients' satisfaction with male versus female physicians: a meta-analysis.Med Care. 2011; 49: 611-617Crossref PubMed Scopus (72) Google Scholar Once in leadership positions, women then find themselves at a disadvantage by gender stereotypes, that is, pervasive assumptions that certain traits are or should be attached to a particular gender and are better for leadership. Studies have shown that, when female and male leaders of the same caliber and style are compared, women leaders are viewed less favorably and considered less suitable for leadership.24Sandberg S. Lean in: women, work, and the will to lead. Knopf, New York2013Google Scholar, 30Heilman M.E. Wallen A.S. Fuchs D. et al.Penalties for success: reactions to women who succeed at male gender-typed tasks.J Appl Psychol. 2004; 89: 416-427Crossref PubMed Scopus (783) Google Scholar When a woman does take charge or speaks up, she is often negatively labeled as “bossy” and treated more harshly by subordinates compared with men with similar characteristics, because she no longer fits the stereotype of a caring and communal female.31Heilman M.E. Okimoto T.G. Why are women penalized for success at male tasks? The implied communality deficit.J Appl Psychol. 2007; 92: 81-92Crossref PubMed Scopus (541) Google Scholar Time management and work–life balance are potential factors which contribute to the reduction in women advancing to leadership positions. Surgical careers, with the exception of obstetrics and gynecology, are often avoided by female physicians partly owing to concern regarding work–life balance.32Kerr H.L. Armstrong L.A. Cade L.E. Barriers to becoming a female surgeon and the influence of surgical role models.Postgrad Med J. 2016; 92: 56-80Crossref Scopus (45) Google Scholar Flexible or reduced work hours can prove challenging when trying to increase and maintain surgical skills. This trend seems to be mirrored in gastroenterology, especially for those practicing advanced endoscopy, where procedural volume is important. Women physician-researchers are at particular risk because the time lines of increased career and family demands intersect early on, which has resulted in fewer women submitting application grants, obtaining career development awards, and more women abandoning research compared with men.33Jolly S. Griffith K.A. DeCastro R. et al.Gender differences in time spent on parenting and domestic responsibilities by high-achieving young physician-researchers.Ann Intern Med. 2014; 160: 344-353Crossref PubMed Google Scholar, 34Mayes L.M. Wong C.A. Zimmer S. et al.Gender differences in career development awards in United States' anesthesiology and surgery departments, 2006-2016.BMC Anesthesiol. 2018; 18: 95Crossref PubMed Scopus (12) Google Scholar Women in private practice whose billing is directly tied to face-to-face time with patients are also negatively impacted through pay or job opportunities because of the need for parental leave or flexibility in schedules.35Desai T. Ali S. Fang X. et al.Equal work for unequal pay: the gender reimbursement gap for healthcare providers in the United States.Postgrad Med J. 2016; 92: 571-575Crossref PubMed Scopus (46) Google Scholar The professional competence of working mothers can also be questioned when pregnancy occurs or the request for maternity leave and flexible work schedules arise.36Williams J.C. The maternal wall.Human Resources Management. 2004; (Available from:)https://hbr.org/2004/10/the-maternal-wallGoogle Scholar A large survey of physician mothers reported feeling maternal discrimination more commonly in the form of being left out of administrative decisions and unequal pay and benefits.37Adesoye T. Mangurian C. Choo E.K. et al.Perceived discrimination experienced by physician mothers and desired workplace changes: a cross-sectional survey.JAMA Intern Med. 2017; 177: 1033-1036Crossref PubMed Scopus (131) Google Scholar Parental leave is often at the discretion of practices and institutions and, when unpaid, inadvertently places pressure on women to shorten their leave, contributing to emotional burn-out and dissatisfaction. Women often overcompensate owing to the guilt of placing career above family or fear of being perceived as less committed to their work because of home responsibilities, which then leads to increasing burn-out and further recoil from career advancement. Dual-doctor marriages are increasingly common, and, in these situations, female physicians are more often responsible for childcare, earn less, and feel that their spouse’s career took precedence over their own.38Sobecks N.W. Justice A.C. Hinze S. et al.When doctors marry doctors: a survey exploring the professional and family lives of young physicians.Ann Intern Med. 1999; 130: 312-319Crossref PubMed Scopus (71) Google Scholar Finally, women may feel that, by openly discussing priorities related to marriage and family, they could jeopardize their positions by making themselves seem unprofessional or disruptive. Women and men are known to differ in their approach to recognition. Women are less likely to advocate for themselves and assume that the quality of their work will speak for themselves.39Babcock L. Laschever S. Women don’t ask. Princeton University Press, Princeton, NJ2006Google Scholar The failure to ask for a promotion or negotiate compared with men has resulted in decreased career advancement as well as gender pay inequity.35Desai T. Ali S. Fang X. et al.Equal work for unequal pay: the gender reimbursement gap for healthcare providers in the United States.Postgrad Med J. 2016; 92: 571-575Crossref PubMed Scopus (46) Google Scholar Women’s hesitancy to self-promote can also be perceived as lacking in self-confidence and, therefore, potentially less capable as a leader. High-achieving women, such as physicians, are also more likely to be afflicted by the “imposter syndrome” or continual underestimation and doubt in one’s abilities.21Kane et al.Updated arrangements of physician practice arrangement.AMA policy research perspectives. 2016; (Available from:)https://www.ama-assn.org/sites/ama-assn.org/files/corp/media-browser/public/health-policy/PRP-2016-physician-benchmark-survey.pdfGoogle Scholar Although both women and men can be self-critical, women often judge themselves more harshly and hold each other to higher standards.40Parks-Stamm E.J. Heilman M.E. Hearns K.A. Motivated to penalize: women's strategic rejection of successful women.Pers Soc Psychol Bull. 2008; 34 (237-234)Crossref PubMed Scopus (128) Google Scholar The development of committees, task forces and initiatives with the goals of fostering leadership goals in women, initiating mentorship for women and increasing award recognition as well as promoting gender-directed research are valuable ways to reduce gender inequity (Figure 2). These programs should be accessible in institutions and organizations and encouraged for women physicians of all career levels and backgrounds, as a means for promotion, leadership education and female protection in the field. The AGA and sister GI societies have recognized the importance of such platforms through the creation of women’s committees and leadership conferences with strict commitments towards gender equality and female recognition within the field.41Schmitt C.M. Allen J.I. View from the top: perspectives on women in gastroenterology from society leaders.Gastroenterol Clin North Am. 2016; 45: 371-388Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar Symposia sponsored by the AGA and collectively by the GI societies such as Gastroenterology Women’s Council address women’s issues annually and are highly attended during national meetings. A number of leadership development seminars and workshops, often targeted to women physicians, focus on developing administrative skills, resilience in medicine and provide networking opportunities. Examples of these include programs sponsored by major universities such as Harvard and organizations such as The American Association of Medical Colleges, the Executive Leadership in Academic Leadership, and the American Association of Physician Leadership. For physicians in private practice who are also business owners, financial and managerial skills are useful and can similarly be learned through hospital or health care executive management conferences, personal coaching, informal mentoring, and business classes. Serving on local hospital committees and boards are opportunities for engagement with hospital executives, business professionals, and local political leaders while providing name recognition in the community. Institutions can improve workplace relationships and increase the retention of women physicians through staff education on gender discrimination and ongoing bias training. A continual review of gender equality in an organization’s leadership and management can encourage the growth of female participation and recognition. Mentorship in formal and informal settings is critically important to women aspiring to leadership positions and managing themselves as health care professionals. Obtaining a mentor is a task that should be shared by both the mentee and the mentor. Women looking for a mentor should seek out individuals, female or male, who they feel can educate and support them to their goals, either through modeling of their paths or championing their development. In academic medicine, it is particularly useful to identify a department or institutional mentor who can provide guidance on the promotions process and recommend them for opportunities to enhance leadership potential, such as giving lectures or serving on committees. Mentors identified through society membership or at other institutions can also provide a more objective viewpoint and wider exposure. Informal mentoring for women often comes in the form of finding others with similar expectations, such as physician mothers. Existing physician leaders should be encouraged to reach out to junior female colleagues with leadership potential and formally “sponsor” them into these positions. Furthermore, although it is important for women leaders to provide female peer support, it is just as beneficial for women leaders to mentor equally deserving men as a way to cultivate a culture of gender egalitarianism that will survive generations. Women still bear the majority of the household duties and child and elder care responsibilities.42Gjerdingen D. McGovern P. Bekker M. et al.Women's work roles and their impact on health, well-being, and career: comparisons between United States, Sweden, and The Netherlands.Womens Health. 2000; 31: 1-20Crossref Scopus (132) Google Scholar The America College of Physicians in a recent position paper on gender equity recommends the development of policies that allow for adequate and paid parental leave, flexible work schedules, and flexible career tracks.43Hingle S.T. Kane G.C. Butkus R. et al.Achieving gender equity in physician compensation and career advancement.Ann Intern Med. 2018; 169: 591Crossref PubMed Scopus (2) Google Scholar Insufficient on-site daycare facilities at medical centers is often a major barrier to physician mothers and efforts should be made to decrease long waiting lists for these spots and/or subsidize childcare. Women also need to advocate for themselves both at work and at home to breakdown existing stereotypes, promote work–life balance, and reduce unequal pay from their male counterparts. Making peers and bosses aware of their career aspirations can prove advantageous to being considered for leadership positions. Women should be encouraged to negotiate salary and ask for promotions rather than wait for their hard work to be recognized. It is also important for women to be the change they seek by recognizing and promoting the accomplishments of other females within their department. In the home, women ought to openly discuss their top priorities and concerns, work responsibilities, and career aspirations with their families and advocate for a partnership, seek compromise, or allow outside assistance in household duties and childcare responsibilities. Women now make up one-half of the physician workforce and it is essential that they are able to remain, thrive and excel within all aspects of medicine. As the field of gastroenterology ushers in a wave of more women physicians, we can serve as a model for increasing female career advancement. An integral part of this is increasing female representation in leadership both in academic medicine, health care administration and business practice. Breaking down obstacles that have previously prevented gender equality include eliminating gender bias, developing policies to improve work–life balance, encouraging mentorship, and promoting recognition and leadership education. The impact of these efforts will hopefully be to fulfill the life goals of women physicians, increase overall career satisfaction, improve patient care, and elevate the status of women everywhere.