Is the glass ceiling in gastroenterology gone?

Gastroenterology has historically been one of the slowest fields in medicine to attract women. In 2006, only 10 years ago, gastroenterology ranked 30th of 36 medical specialties in the proportion of active physicians who were women. Among internal medicine subspecialties, both cardiology and gastroenterology were slow to attract female internal medicine residents, although in the last several years it appears that gastroenterology has caught up somewhat. The American Board of Internal Medicine resident and fellow workforce survey reports that in 2013/2014, 45% of internal medicine residents were women, 38% of all first-year fellows in the various subspecialties were women, and 35% of first-year gastroenterology fellows are women. This is a significant increase compared with only 10 years ago when only 25% of first-year gastroenterology fellows were women. The reasons for this change have not been well studied but are likely multifactorial. First, it has been proposed that women did not seek a career in gastroenterology because it was not viewed as “lifestyle friendly.” These concerns have been mitigated somewhat with the decreased call frequency in gastroenterology because of increasing gastroenterology practice size; the increase in dual-career couples, which has changed the demands on male physicians; and the availability for part-time work for women with young children who desire it. Second, similar to surgical fields, under-representation of women has likely been because of the “training culture” in which women students and residents have felt undervalued and unwelcome.^,  This “behind the scenes” discrimination is hard to fight, although the growing numbers of women in gastroenterology who serve as role models will help.

Although true discrimination against women in gastroenterology has clearly existed historically, there appears to be much less evidence for that in our present climate. The current article by Calderwood et al is evidence of the lack of gender discrimination in the leadership of the American Society for Gastrointestinal Endoscopy (ASGE). Female applicants for coveted ASGE committee appointments from the years 2011 to 2014 had a better chance of being appointed than men, with an odds ratio of 2.6. Indeed, this raises the issue of “reverse discrimination,” which can stem from the desire of professional societies to increase their diversity. Similar to prominent businesses and academic medical centers, the low number of women in gastroenterology has historically helped promote some aspects of their careers. Although the reasons for favoring female candidates are understandable, we should be careful in the future to not substitute an historical injustice with a new one. The issue of “reverse discrimination” for under-represented minorities is a hot topic in college admissions in the United States at the present time.

The phrase “glass ceiling” is defined as the unseen, yet unbreakable barrier that keeps women from rising to the upper rungs of the corporate ladder, regardless of their qualifications or achievements. As Calderwood et al point out, despite the increased number of women in medicine in general and gastroenterology in particular, the percentage of women in leadership positions remains low. Both in academic medicine and in gastroenterology professional societies, women hold few leadership positions. Over the last 30 years the 3 major American gastroenterology professional societies have had few female presidents: 1 for the American Gastroenterology Association, 2 for the American College of Gastroenterology, and 3 for the ASGE, although all 3 societies currently have women in the presidential pipeline. In contrast to the view that women in gastroenterology hold few leadership positions, a review in 2007 found that women occupied 11% of top gastroenterology society leadership and editorial boards, which was similar to the proportion of women in gastroenterology at that time. Perhaps the inclusion of editorial board membership is what led to that result.

Another presumed contributor to the glass ceiling in gastroenterology has been cultural; women do not promote themselves as much as men. Self-promotion and drive is simply not part of the traditional female gender role. Perhaps that culture is also changing. Calderwood et al report that the proportion of requests for committee appointments from women remained stable at 16% to 21% in 2011 to 2014. They note that this is higher than the current proportion of female membership in the ASGE, which is 15%. This suggests that women are asking for committee assignments or “promoting” themselves. This is a “soft” conclusion from this article because the authors did not have access to demographic information on the committee applicants. It is likely that applicants for ASGE committees are younger than the overall ASGE membership, and there are likely more women in the 32 to 50 age range of ASGE members. The 21% of committee applicants who are women may well be similar, or somewhat lower, than the percentage of female age-matched ASGE members.

Perhaps one of the last bastions of male predominance in gastroenterology is in interventional endoscopy, although we do not have data on the gender of the approximately 100 applicants for these fourth-year fellowships. The only study capturing any gender data on advanced endoscopists was a survey by Granato et al of practicing gastroenterologists who completed advanced fellowships from 2009 to 2013. Of the 41 respondents, 4 were women (9.8%). With a 44% survey response rate, it is difficult to know if this finding is truly representative. However, personal observation suggests that women’s representation in advanced endoscopy remains lower than other “subspecialties” in gastroenterology such as hepatology or inflammatory bowel disease.

One serious concern is that gender discrimination still persists in gastroenterology when it comes to equal pay for equal work. Although this is not a glass ceiling effect, it is grossly unfair and likely will not change until greater transparency occurs around salaries. Female gastroenterologists have been paid less even when number of hours worked are accounted for. Burke et al performed a survey of gastroenterologists who were 3 and 5 years out of training and showed that academic female gastroenterologists made an average of 77% of their male colleagues’ salaries at 3 years and 76% at 5 years. A similar wage disparity occurs in nonacademic practices at 3 years post-training, although the differences improved at 5 years out of fellowship, whereas it did not for academic women. A follow-up survey of this prospective cohort at 10 years demonstrated persistent salary inequality, with women earning $82,000 less than their male counterparts (95% confidence interval, $34,000-$130,000; P = .001).

Is the glass ceiling in gastroenterology really gone? If not gone, it certainly has some major cracks in it. The article by Calderwood et al demonstrates that female applicants are favored over men when requesting ASGE committee appointments. Committee membership is the stepping stone for professional society leadership. It also helps to establish a national reputation. Calderwood et al’s important study points out that this first step in the professional society ladder is quite open to women. This finding is particularly important for promotion in academic institutions, where national reputation is one of the criteria for advancement. Although there are still areas for improvement among gender-related issues in gastroenterology, we certainly applaud the progress women have made.