‘Having women at the top’ drives structural change, advances gender equity in GI
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More women than ever have joined gastroenterology in the past 20 years — a staggering 219% increase according to the Association of American Medical Colleges — yet they continue to make up only 21% of active physicians in the specialty.
While the steady expansion of women physicians is evident in the field of gastroenterology and medicine overall, data have shown that marked disparities in pay policies, career advancement and leadership continue to widen the gap in representation and gender equity.
“These are structural issues in academic medicine that have been in place for decades that are really hard to navigate,” Nancy D. Spector, MD, executive director of the Executive Leadership and Academic Medicine and Executive Leadership in Health Care programs and executive director of the Lynn Yeakel Institute for Women’s Health and Leadership at Drexel University, told Healio Gastroenterology. “We won’t be able to make really big change in academic medicine until we change some of the structural issues.”
Research from the 2023 Association of American Medical Colleges Faculty Salary Report underscored these inequities, revealing a compensation difference of nearly $40,000 between male and female assistant professors in the U.S. A separate report published in The Lancet Gastroenterology & Hepatology in 2019 showed women made up only 7% of division chiefs and 18% of program directors. Further, an additional report published by Amy S. Oxentenko, MD, FACP, AGAF, FACG, and colleagues in 2022 showed national society organizations such as the AGA, ACG, ASGE and AASLD have each had only five or fewer women serve as presidents since their founding more than 70 years ago.
According to Oxentenko, ACG president and professor of medicine and vice dean of practice at the Mayo Clinic, the first step in making these changes lies in data transparency.
“Seeing objective data allows you to respond or react,” she said. “When you see that things are totally discordant and not representative of the demographics of your society, you’re going to make adjustments. It’s hard to argue with data.”
In a Healio Gastroenterology exclusive, champions of gender equity shed light on the existing data and factors inhibiting gender equity in gastroenterology and propose ways in which the individual and the system as a whole can work toward shattering the gender glass ceiling.
How Can We Bring About Change?
For many years, it has been a common misconception that the underrepresentation of women in academic leadership positions has been driven by the career pipeline. However, the increased proportion of women faculty in U.S. medical schools — from 37% in 1980 to 50% in 2022 — proves that solely increasing representation in the pipeline is “not sufficient on its own” to close the gender gap in leadership, Oxentenko and colleagues wrote in The Lancet Gastroenterology & Hepatology.
One solution that institutions may consider to fill this gap and promote the diversification of leadership is to endorse term limits.
“The idea that we would have term limits is controversial because it is not our norm,” Spector said. “But, oftentimes, the people who are in those [leadership] roles stay for a very long time, so there is no pathway to evolve the system and there is no pathway for women.”
Aside from the stagnation in new perspectives and ideas, the lack of women in leadership also plays a huge part in the structural policies that impact future generations, Rinarani Sanghavi, MD, MBA, a pediatric gastroenterologist and professor of pediatrics at UT Southwestern Medical Center, said.
“Division chiefs and department chairs not only control, influence and inspire the future generation, but they also control the money,” she said. “One of the ways we can achieve equity is when women are sitting at the table where decisions are made.
“Women should continue to advocate for themselves to be at the table and, when invited, sit at the table and not at the back of the room.”
In preparation for taking those next steps in career advancement, Oxentenko said her most important piece of advice to women is to think broadly about the type of leadership role they are striving for, rather than narrowing oneself into one specific box, and cultivate skills applicable to any position. These “key fundamental leadership skills” include effective written and verbal communication, active listening, authenticity, team building, efficiency and organizational excellence, crucial conversations and strategic thinking, among others. She also noted it may be helpful to get an outside point of view.
“It is always tough to get feedback on your leadership, but feedback is a gift,” Oxentenko said. “If you get feedback on things that other people see as growth opportunities, you can move the needle based on that feedback and become a stronger leader.
“That is going to be useful when applying for leadership roles. Also, having allies who know what your interests and strengths are can be key to opening doors of opportunity.”
Oxentenko’s final piece of advice to women is to be more proactive and vulnerable in putting oneself out there for roles — even if they feel they lack a few qualifications.
“Traditionally, women are less likely to apply for something unless they are clearly qualified, if not overqualified, whereas men often feel more comfortable applying for leadership roles, even if they are clearly missing a few of the requirements,” she said. “We need to encourage women to go ahead and apply. It’s OK if you don’t check all of the boxes; no one does.”
Beware the ‘Glass Cliff’
While the phrase “breaking the glass ceiling” has become synonymous with women rising above the barriers that keep them down, a lesser-known phrase — the “glass cliff” — describes the phenomenon in which attempts to diversify leadership or promote career advancement have fallen flat.
According to Oxentenko, this scenario occurs when women are placed in positions of leadership that have not been resourced properly to be successful or when they have been moved into leadership prematurely and without the necessary support. This phenomenon threatens diversity, equity and inclusion efforts because it may hinder the future advancement of gastroenterologists who are women or from underrepresented populations.
“We need to make sure that when we’re putting women and those from underrepresented backgrounds in leadership positions, we are making sure that we are supporting them, resourcing them appropriately and not elevating them so fast where we are setting them up for failure,” Oxentenko said. “We should be setting them up for success because if they fail, it erodes all of the progress made in DEI efforts.”
She continued, “We have to be mindful of the glass cliff.”
‘If You Don’t Ask, You’re Never Going to Get It’
Among the many barriers women face, Keerthana Kesavarapu, DO, and colleagues reported that one of the most striking relates to compensation. According to their research published in The Lancet Gastroenterology & Hepatology, the average yearly wage gap between men and women in the U.S. ranges from $50,000 to $82,000 when adjusted for types of practice and training, as well as the number of calls and hours worked.
Additionally, they noted that annual gross income was $110,000 and $96,000 lower for women in academic and nonacademic settings, respectively, compared with their male counterparts.
“You want to be paid equally for equal work,” Sanghavi said. “In fact, the Equal Pay Act of 1963 does say that you should be paid equally for equal work.”
However, even with this law, Spector noted that pay equity issues are complicated due to different reimbursement policies for patient care as well as a phenomenon called occupational gender segregation.
“It basically demonstrates that the more women in a field, the pay of the whole field drops,” she said. “For instance, if you look at the field of pediatrics over time, our salaries have dropped because more women are in the field.
“The same is true for other fields, which presents a problem because people who are knowledgeable about this will question why we should have more women in medicine.”
While equitable pay policies fall into the category of structural challenges that may take many years to mitigate, Sanghavi said understanding salary structure is a critical first step.
“I always tell everybody that you should know what your salary is made of,” she said. “You should understand your base salary, what your productivity is based on, as well as your incentive and bonus structure.”
Sanghavi also advised preparing for annual evaluations and pay negotiation.
“Being prepared is understanding what value you’re bringing to the practice or the institution,” she said. “Look into baseline salary data, know what others are being paid, and go ahead and negotiate for that.
“Everything is on the table — if you don’t ask, you’re never going to get it.”
Bolster Your Network With Allies
The representation of women in gastroenterology, particularly in leadership roles, is crucial to inspiring and guiding the next generation.
“In academic medicine, the work of improving opportunity and diversity within systems has historically been on the people who are underrepresented,” Spector said. “Currently, the work I’m doing with others is really focusing our attention on allyship.”
Women who currently hold leadership roles in the field are in a unique position to provide intentional and effective support. Additional support and organized allyship from women’s groups, societies, initiatives and leadership programs may also assist in providing the tools young career women need to thrive.
According to Sanghavi, three keys to success for woman as they start their careers are mentorship, sponsorship and coaching.
“Get multiple mentors,” she said. “I think you need a mentor specific to your specialty or field of study, a mentor who emulates what you think you want to be like in the next 10 or 20 years and a mentor who is of a different gender than you are. These different mentors provide a robust learning experience and different perspectives.”
Sponsors differ from mentors in that these are people who always keep you in mind for new opportunities. Conversely, a coach is somebody who can help you gain clarity on long-term goals, assist in tackling challenges such as impostor syndrome and microaggressions, and elucidate how strengths you already possess can be leveraged toward achieving your goals.
“To me, the key differentiator between those who succeed and those who don’t is having regular time with a really good coach who helps you keep your thoughts clear as to where you want to go,” Sanghavi said. “But having a combination of these three — mentorship, sponsorship and coaching — is vital.”
Though it is a common assumption that women will always support other women, Spector noted that the “scary” side to allyship in medicine is that this is sometimes not the case.
“Sometimes women don’t support other women behind them,” she said. “That’s the part we haven’t been talking about: It pops up and it is not comfortable to talk about. Women could have gone through amazing leadership training and still not be supportive of other women.
“It will be crucial to address that if we want to see meaningful change.”
The Minority Within the Minority
It’s no secret that women physicians are outnumbered in the male-dominated field of gastroenterology. Less recognized, however, is that within that minority are women of color, who face amplified inequities.
Although Black individuals comprise about 13% of the U.S. population, according to data published in The Lancet, they make up just over 5% of the physician workforce — and less than 3% are Black women. Even fewer Black women are in academic leadership roles, with only 0.8% serving as full-time professors at medical schools in 2020.
“There’s this tension with how much burden should be on the person vs. the system,” Spector said. “The burden of professional advancement should not be placed on women and women of intersectionality but rather on systems change and allyship to support the advancement of women and women of intersectionality.”
She added, “Another burden for women with intersectionality is that they also carry increased visibility, where every misstep is very public.”
Many of the microaggressions women of color face in medicine directly relate to historic systemic issues, which will likely take years to dismantle. In the meantime, Spector advises underrepresented women in her leadership program to focus their energy on empowerment.
“The empowerment piece goes back to being responsible for connecting with people, to participate in strategic career planning and leadership training, and to invest in your network,” she said. “This builds social capital, which can then help you overcome barriers.”
Spector added that women should not only use their network to help solve problems, but also to leverage connections for career advancement.
Women in Power Can Patch the ‘Leaky Pipeline’
According to Sanghavi, there are many studies which report women have to provide more evidence of their competence compared with men, have to work less hours or are suggested to do so after they have children and are often mistaken for custodial staff or nurses.
“The result is that we have a huge brain drain,” she said. “Within 6 years of completing training, about 25% of women are not working full time. We have what I call a ‘leaky pipeline’ — women are not progressing to some of the highest levels of leadership because they are leaving medicine.”
To patch these so-called leaks, women currently holding leadership positions must inspire the next generation and advocate for more equitable policies for the women coming up behind them.
“Having women at the top is so inspirational,” Spector said. “There are studies that demonstrate if you have a woman leader in, say, a surgical residency training program, you’ll get more women into that training program. Women like to see other women in that space; people want to see people like them ahead of them.”
She added, “It’s a very powerful thing to have women at the top.”
- References:
- Bajaj SS, et al. Lancet. 2021;doi:10.1016/S0140-6736(21)02217-0.
- Kesavarapu K, et al. Lancet Gastroenterol Hepatol. 2019;doi:10.1016/S2468-1253(19)30331-0.
- Oxentenko A, et al. Lancet Gastroenterol Hepatol. 2022;doi:10.1016/S2468-1253(22)00345-4.
- Women are changing the face of medicine in America. https://www.aamc.org/news/women-are-changing-face-medicine-america. Published May 28, 2024. Accessed Aug. 1, 2024.
- For more information:
- Amy S. Oxentenko, MD, FACP, AGAF, FACG, is ACG president and professor of medicine and vice dean of practice at the Mayo Clinic. She can be reached at oxentenko.amy@mayo.edu.
- Rinarani Sanghavi, MD, MBA, is a pediatric gastroenterologist and professor of pediatrics at UT Southwestern Medical Center. She can be reached at rinarani.sanghavi@utsouthwestern.edu.
- Nancy D. Spector, MD, is executive director of the Executive Leadership and Academic Medicine and Executive Leadership in Health Care programs and executive director of the Lynn Yeakel Institute for Women’s Health and Leadership at Drexel University. She can be reached at nancy.spector@drexel.edu.
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