G&H Could you briefly review the history of diversity in the field of gastrointestinal endoscopy, with specific focus on gender diversity?
AF The field of gastroenterology has seen significant growth over the past 2 decades. Historically, there were fewer opportunities for gastroenterologists, and most training programs combined internal medicine with gastroenterology. However, the introduction of screening colonoscopy marked a turning point, leading to a greater demand for specialists. In 2001, female representation in gastroenterology and hepatology societies was between 5% and 10%. Today, women account for approximately 21% of practicing gastroenterologists. Although over 50% of medical students are women, only about 30% of gastroenterology fellows are female. The demographics are gradually changing, but there is still a notable disparity. A significant challenge women face when pursuing gastroenterology is the extensive training required. Becoming a gastroenterologist demands an additional 3 years of training after completing 3 years of internal medicine. This extended timeline often coincides with a woman’s prime childbearing years, which can be a major consideration. Furthermore, women who enter medical school later in life, after taking time to gain experience or pay off student loans, may find it especially difficult to commit to extra years of training. For many women, the prospect of pregnancy and starting a family while still in training can seem daunting.
G&H How diverse is the field of advanced endoscopy today, and why are few women entering the field?
AF There is a noticeable gender gap in advanced endoscopy, with far fewer women than men entering the field. In 2023, only 16% of advanced fellows who matched in the American Society for Gastrointestinal Endoscopy (ASGE) fellowship match were women. Several factors contribute to this underrepresentation. One reason could be the perception that the work hours in advanced endoscopy are less flexible and the time commitment is more demanding than that for general gastroenterology. Many gastroenterologists trained during the COVID-19 pandemic, which led to a rise in flexible work arrangements, including the ability to work from home. This shift in expectations may not align with the demands of advanced endoscopy, where there is often a need for urgent procedures and a limited number of specialists available to perform complex interventions like endoscopic retrograde cholangiopancreatography. Another concern, particularly among women of childbearing age, is the potential risk of ionizing radiation exposure during fluoroscopy. While the actual risks are low, the perception remains owing to insufficient education on the matter. Ergonomics also plays a role. The design of endoscopes and endoscopy suites, which historically has been more suited to male practitioners, can be uncomfortable for women, particularly during long hours of standing. Additionally, performing endoscopic procedures multiple times a week can be physically taxing. Finally, the lack of female role models in advanced endoscopy is a significant factor. With so few women in the field, women may feel less encouraged to pursue this specialty. Research has shown that gastroenterology programs with more female fellows and faculty tend to attract more women into the field, highlighting the importance of representation.
G&H Where are the gaps in female representation and barriers to gender diversity most significant?
AF The most significant gap is in top leadership positions, where there are few women. For example, there have been few female presidents of major societies, resulting in a lack of female role models. One of the primary challenges in increasing gender diversity in gastroenterology and advanced endoscopy is the lack of female role models and leaders. A lack of visible female leaders makes it more difficult to recruit women into the specialty because they may not see others like them who have succeeded or who can provide mentorship and guidance.
G&H What efforts are ongoing to help increase gender diversity in endoscopy?
AF The Women’s Committee of the ASGE has created programs aimed at increasing female representation in leadership roles, on podiums, and in society work. Other initiatives such as Women in Endoscopy, led by Dr Uzma Siddiqui and Dr Amrita Sethi, and Scrubs and Heels, led by Dr Anita Afzali and Dr Aline Charabaty, share similar goals of boosting the number of women leading courses and presenting at conferences. Additionally, the American College of Gastroenterology and other organizations have implemented strict guidelines to ensure a certain number of female speakers at their courses, increasing the visibility of women leaders and encouraging more women to join gastroenterology. There is also a growing recognition that many female patients prefer female gastroenterologists, which further highlights the need for more women in the field. Societies are aware of this demand and are working to increase diversity.
Networking opportunities for women are another key focus. While in-person networking has become more challenging post–COVID-19 owing to virtual meetings, it remains an important tool for career growth. These events provide women with opportunities to share experiences, find mentors and sponsors, and learn from others who have navigated similar challenges. Connecting with women who share similar economic and social backgrounds can also be particularly beneficial. Seeing other women in leadership roles or on stage helps build confidence and shows that achieving similar success is possible. Societies understand the importance of providing these opportunities to help women succeed, and they are actively working toward creating pathways to leadership for women in the field. Education specifically directed toward women about the realities vs misconceptions regarding a career in advanced endoscopy might also be helpful in recruiting women to the field.
G&H What else can be done to further improve current efforts to remove barriers/recruit more women to the field?
AF As I mentioned, there is a high level of awareness about the risks of fluoroscopy but not enough education on the subject, particularly when it comes to exposure during training. Currently, fellows are not typically educated about the risks of fluoroscopy or how to minimize radiation exposure. Providing more comprehensive training on this topic would help alleviate concerns, especially for women who may be worried about potential health risks. This could also help create a safer environment for all practitioners, regardless of gender.
Ergonomics is another crucial area that needs attention. Endoscopists, particularly those in advanced endoscopy, are prone to repetitive-use injuries owing to the physical demands of the job. To address this, improvements such as lighter-weight endoscopes, monitors with adjustable heights, and thicker, more supportive floor mats would make a significant difference. Advanced endoscopists, who tend to perform more procedures than general gastroenterologists, would especially benefit from these upgrades. Reducing the physical strain of the job could help make it more sustainable and accessible, particularly for women who may be concerned about the long-term physical toll of the work.
Additionally, increasing access to resources that promote work-life balance (eg, more flexible work hours and part-time opportunities) could help attract more women to the field. Offering more supportive workplace policies, like those that address parental leave and breastfeeding accommodations, would also be key to making the field more accessible and attractive for women, especially those with young children. Workplace accommodations, such as those granted by the Providing Urgent Maternal Protections for Nursing Mothers, or PUMP, Act, can make it easier for women to pursue and extend their training through childbearing years, recognizing that balancing family and career can be challenging. Finally, more efforts should be made to highlight successful female role models in advanced endoscopy. Having visible women in leadership positions and as mentors would inspire more women to enter and persist in the field.
G&H How do you envision female leadership in advanced endoscopy in the future?
AF I am optimistic about the future of female leadership in advanced endoscopy. More women are entering the field, and the trend is moving in the right direction. However, there is still much work to be done to ensure that women have equal opportunities for leadership roles. Continued education, mentorship, and intentional promotion of women into leadership positions will be essential for making lasting change. Having access to a supportive and inclusive workplace environment will allow women to thrive, both professionally and personally. Ideally, women will not only be mentored by leaders in gastroenterology but also have the opportunity to connect with women leaders in other related fields, such as surgery and interventional radiology. This cross-specialty mentorship can provide unique perspectives and broaden opportunities for growth.
Attaining leadership roles, whether in national societies or high-level positions at universities and hospitals, requires a collective effort. Support from both men and women is critical for women to succeed in these positions. One of the key elements of fostering female leadership is ensuring that women are supported as they rise through the ranks. The mentorship and encouragement women receive along the way should be reciprocated, with those who benefit from support paying it forward to the next generation. It is important to create a culture where the focus is not just on climbing the ladder to the top, but on making sure that ladder remains accessible for others. This means women—especially those who reach higher positions—should actively mentor and support those following in their footsteps, creating a cycle of giving back that benefits the entire field. This expanded version elaborates on the importance of mentorship and support for women, both within and outside the gastroenterology field, and highlights the need for a culture of reciprocal support in leadership development.
G&H How does diversity in gastroenterology and advanced endoscopy compare with that in other medical specialties?
AF In specialties like interventional cardiology and interventional radiology, there are fewer women compared with fields like obstetrics, pediatrics, and internal medicine, which traditionally attract more female practitioners. Advanced endoscopy faces similar challenges, with gender diversity lagging behind in part because of the high demands of the field and the traditionally male-dominated field of advanced endoscopy. However, interventional radiology has made strides by changing its fellowship structure. Now, fellows can start directly in interventional radiology, rather than first completing general radiology and then pursuing additional training in intervention. This streamlined pathway could help attract more women to the field, as it reduces the overall training burden and provides a clearer, more direct route to specialization. There is also a growing interest in interventional gastroenterology owing to the innovative procedures emerging in the field, such as endoscopic suturing, endoscopic bariatrics, and full-thickness resection. These advancements could potentially draw more women into the specialty, though whether this trend will significantly increase female representation remains to be seen.
With regard to surgery, there are still fewer female surgeons compared with their male counterparts. However, surgical societies have made intentional efforts to increase female participation, including offering more mentorship and leadership development programs for women, with great success. Interestingly, studies have shown that patients treated by female physicians, including surgeons, may experience better outcomes. For example, a recent systematic review and meta-analysis found that patients treated by female surgeons had lower mortality rates compared with those treated by male surgeons. This evidence highlights the importance of increasing diversity in specialties, not just for gender equity but also for potential improvements in patient care.
One significant issue faced by women across all specialties, including gastroenterology and advanced endoscopy, is the gender pay gap. The ASGE has recognized this and is working on a benchmarking salary survey to increase transparency around salary and benefits. By creating a database that compares compensation across regions and practice types, the ASGE aims to empower physicians to negotiate fairer salaries and benefits. Importantly, research shows that as more women enter a field, the overall salaries for all physicians in that specialty can decrease—likely owing to women’s historically lower pay. Increasing transparency in compensation can help address this issue, benefiting both men and women.
Disclosures
Dr Faulx serves on the ASGE Foundation Board of Trustees and as chair of the ASGE Women’s Committee.
Suggested Reading
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