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Don’t fix the women, fix the system: recognizing and addressing implicit gender bias in gastroenterology training and practice

  • Megan A. Adams
    Affiliations
    VA Ann Arbor Center for Clinical Management Research, Ann Arbor, Michigan, USA
    Division of Gastroenterology, Department of Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
    Institute for Healthcare Policy and Innovation, Ann Arbor, Michigan, USA
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Published:March 05, 2021DOI:https://doi.org/10.1016/j.gie.2020.10.022

      Abbreviations:

      ASGE (American Society for Gastrointestinal Endoscopy)
      Amidst the collective national reckoning on sexual harassment, assault, and discrimination inspired by the #MeToo and #Times Up movements, there has been increased scrutiny of the role of unconscious bias, gendered societal expectations, and harassment in creating and perpetuating gender inequity in medicine. Strikingly, in one of the first surveys exploring gender harassment at a major academic medical center, >92% of female physicians and faculty reported having experienced gender harassment (including feeling mistreated, slighted, or ignored because of their gender, being the recipient of sexist remarks, or being put down or treated with condescension because of their gender) during their training or practice.
      • Vargas E.A.
      • Brassel S.T.
      • Cortina L.M.
      • et al.
      #MedToo: A large-scale examination of the incidence and impact of sexual harassment of physicians and other faculty at an academic medical center.
      However, it is important to recognize that overt harassment and discrimination constitute only a small part of a female physician’s gendered experiences during training and practice, which often involve “microaggressions” or subtle, often unconscious, practices of gender-related inclusion and exclusion.
      Gender inequity in the medical profession is manifested in areas that have important consequences in shaping female physicians’ careers and compensation, including attaining leadership positions, journal authorship, speaker invitations, and competitive salaries.
      • Spector N.D.
      • Oversholser B.
      Examining gender disparity in medicine and setting a course forward.
      It may also contribute to higher rates of burnout and depression among female physicians at all levels of training, and to higher rates of workplace attrition. This differential treatment has been shown to start as early as medical school and extend throughout postgraduate medical training and practice. Despite the gender bias that female physicians face in their clinical practice, they have been shown to perform at least as well as men and to achieve better patient outcomes in some studies.
      Since the enactment of Title IX in the 1970s, enrollment of women in medical schools in the United States has steadily increased. Indeed, women have constituted >40% of medical school enrollment for >25 years. Yet, representation of female physicians among tenured faculty and senior leadership at academic medical centers lags significantly behind. There also remains a striking gender divide in specialty choice, with female representation in procedural subspecialties, including gastroenterology and surgery, remaining low. According to recent data, women represent <20% of practicing gastroenterologists and 25% to 30% of gastroenterology trainees, with wide variation across programs.
      • Rabinowitz L.G.
      • Anandasabapathy S.
      • Sethi A.
      • et al.
      Addressing gender in gastroenterology: opportunities for change.
      Gender disparities are even more pronounced in interventional endoscopy and surgery, in which female medical students are often actively encouraged to pursue nonprocedural specialties, are less likely to be considered exceptional candidates compared with men of equal caliber, and may be given less autonomy in training.
      • Myerson S.L.
      • Sternbach J.M.
      • Zwischenberg J.B.
      • et al.
      The effect of gender on resident autonomy in the operating room.
      But the problem is not merely the number of women in gastroenterology—it is also their lived experiences and opportunity to succeed once in training and practice.
      • Kang S.K.
      • Kaplan S.
      Working toward gender diversity and inclusion in medicine: myths and solutions.
      The study by Rabinowitz et al
      • Rabinowitz L.G.
      • Grinspan L.T.
      • Williams K.
      • et al.
      Gender dynamics in education and practice of gastroenterology.
      provides an important window into gender dynamics in gastroenterology fellowships that may negatively affect the careers of aspiring female gastroenterologists and accompany them into clinical practice. The authors report the results of a web survey aimed at exploring differences in the experiences of male and female trainees in gastroenterology and practicing gastroenterologists from 12 geographically diverse academic gastroenterology programs and 3 large gastroenterology private practices. Among survey respondents, female gastroenterologists and trainees reported significant differences in endoscopy educational instruction compared with their male colleagues (specifically, decreased tactile instruction, which has been shown to be beneficial in teaching endoscopic skills but also may raise concerns regarding unwanted touching when opposite genders are involved). They also reported increased perceived gender bias both during and after training, including differential treatment by endoscopy staff. Notably, male respondents largely perceived no gender bias against their female peers.
      These results are consistent with prior studies evaluating the experiences of female trainees in other procedural fields. For instance, female surgical trainees have been found to receive less formative feedback and less procedural autonomy than male trainees during residency.
      • Myerson S.L.
      • Sternbach J.M.
      • Zwischenberg J.B.
      • et al.
      The effect of gender on resident autonomy in the operating room.
      A recent study of implicit bias in emergency medicine and obstetrics and gynecology residencies suggests that programs that have been predominantly male may have higher rates of implicit bias against female trainees.
      • Hansen M.
      • Schoonover A.
      • Skarica B.
      • et al.
      Implicit gender bias among US resident physicians.

      Gastroenterology professional society efforts to achieve gender equity

      Heightened awareness of gender inequity in gastroenterology education, training, and practice is but the first step in tackling the problem. However, implementing effective interventions to achieve gender equity has proved challenging because of the entrenched nature of gender bias in organizational and institutional structures, processes, and cultural norms.
      Existing efforts to achieve gender equity in gastroenterology have largely occurred at the national level. Gastroenterology professional societies have been proactive in developing initiatives and programs intended to teach women career advancement skills and facilitate the path to leadership positions. Programs such as the Leadership Education and Development Program of the American Society for Gastrointestinal Endoscopy (ASGE) and the Women’s Leadership Conference of the American Gastroenterological Association have provided superb resources and mentorship to an accomplished field of female gastroenterologists and have created a strong sense of community among current and former participants. Other initiatives such as the ASGE’s Women in Endoscopy aim to support female gastroenterologists’ career development during their first 5 years in practice by offering role models, critical resources, and skills development. Still, however valuable and well intentioned, efforts to teach women how to negotiate better, project confidence, vocalize more in meetings, and be more assertive often fall short of inducing systemic change because they implicitly assume that the source of the problem is the women themselves (“fixing the women, not the system”).
      Other society initiatives that have proved successful involve intentional efforts to promote gender diversity in committee and leadership appointments. For instance, Calderwood et al
      • Calderwood A.H.
      • Enestvedt B.K.
      • DeVivo R.
      • et al.
      Impact of gender on requests for ASGE leadership positions.
      found that, although only 20% of applicants for ASGE committee appointments from 2010 to 2014 were women, female applicants had a higher rate of appointment to committee positions than did their male counterparts. In addition, 2017 was the first year in which all 4 major gastroenterology societies (ASGE, American Gastroenterological Association, American Association for the Study of Liver Diseases, and American College of Gastroenterology) were simultaneously led by accomplished women presidents, shattering decades of precedent. These efforts to cultivate and promote accomplished women leaders are critical to breaking down gender barriers, changing entrenched culture, providing role models that inspire and empower younger generations, and raising issues critical to our female patients. Women leaders also are essential to bringing workplace issues, such as gender-based optimization of endoscopy ergonomics, to the forefront.

      The path forward for gastroenterology: fix the system, not the women

      The study by Rabinowitz et al
      • Rabinowitz L.G.
      • Grinspan L.T.
      • Williams K.
      • et al.
      Gender dynamics in education and practice of gastroenterology.
      highlights that we must do more to improve the experience of female gastroenterologists from the earliest stages of fellowship, and that efforts to address gender inequity in gastroenterology must occur not only at the national (professional society) level but also at the institutional level. Indeed, gender inequity is due to a complex web of systemic, institutional, and cultural barriers that must each be targeted to fully address the problem.
      Many institutions have responded to this call to action by developing comprehensive diversity, equity, and inclusion strategies and by mandating implicit bias training for physicians and staff at all levels. This approach stems from a recognition that, owing to the pervasive nature of gender bias and discrimination, institutions must be intentional in identifying and dismantling policies and practices that perpetuate inequities, developing concrete and multifaceted strategies to eliminate inequities, and transforming aspects of institutional culture that serve as barriers to equity and inclusion. Large academic gastroenterology programs such as that at the University of Michigan have formed “women in gastroenterology” committees to promote work-life balance, foster the professional advancement of women institutionally and nationally, and ensure that institutional policies and recommendations take into account the interests of female gastroenterologists and trainees. Developing buy-in for such initiatives requires a recognition that gender equity and inclusion are essential for the health of the medical community and our patients.
      But few existing programs at the institutional level are directed at addressing implicit bias in gastroenterology education. Indeed, there is a pressing need to better understand factors contributing to gender bias in fellowship training and its short- and long-term impacts on gastroenterology trainees, and to develop interventions to address this bias in training and practice. At an institutional level, it is vital to create opportunities for open dialogue regarding gender and bias among trainees and faculty, proactively examine institutional policies to uncover structural and systemic biases, and train attending gastroenterologists to recognize and mitigate unconscious bias in teaching techniques, assessment, and feedback. The latter intervention is particularly critical, given our recent transition to competency-based assessment in gastroenterology fellowships. Probing for gender bias in narrative evaluations of female faculty by trainees is also warranted, given recent studies demonstrating quantifiable linguistic differences in narrative comments about male and female faculty, even after adjustment for the gender of the evaluator.
      • Heath J.K.
      • Weissman G.E.
      • Clancy C.B.
      • et al.
      Assessment of gender-based linguistic differences in physician trainee evaluations of medical faculty using automated text mining.
      This is consistent with similar studies showing the presence of bias in narrative evaluation of trainees.

      Conclusion

      In the words of prominent civil rights attorney Kimberlé Crenshaw, to fix the system we must move away from “see[ing] inequality as a ‘them’ problem or ‘unfortunate other’ problem”
      • Steinmetz K.
      Interview with Kimberlé Crenshaw.
      and understand that persistent gender inequities in our specialty (whether in the form of unfair exclusion or of unearned inclusion) impede our ability to deliver high-quality care to our patients and rob us of the collective strength that diversity and inclusion bring to our profession. The authors should be applauded for both shining a light on persistent gender-based inequity in gastroenterology and providing actionable recommendations to guide our path forward.

      Disclosure

      The author disclosed no financial relationships.

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      Linked Article

      • Gender dynamics in education and practice of gastroenterology
        Gastrointestinal EndoscopyVol. 93Issue 5
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          With an increasing number of women joining procedural fields, including gastroenterology, optimizing the work environment for learning, teaching, and clinical practice is essential to the well-being of both physicians and their patients. We queried female and male gastroenterologists on their beliefs toward the endoscopy suite environment, as well as their experiences in learning and teaching endoscopic skills.
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