G&H What is the current state of diversity, equity, and inclusion in endoscopy?
JC When looking at gender diversity as well as racial or ethnic diversity, the gastroenterology (GI) community has made some strides; however, we still have quite a way to go. Currently, 18% to 19% of practicing gastroenterologists in the United States are women and only about 13% of fellows in advanced endoscopy fellowship programs are women. According to data on racial diversity of the physician workforce from the Association of American Medical Colleges (AAMC), only 9% of academic GI faculty in the United States identify as underrepresented in medicine (UIM). Per the AAMC, UIM refers to racial and ethnic populations that are underrepresented in the medical profession relative to their numbers in the general population. In recent years, a decline in the number of UIM GI fellowship applications has been noted. This shows that the current state of diversity, equity, and inclusion (DEI) in GI has significant gaps and leaves the GI community with an opportunity to close these gaps.
G&H Why does diversity in endoscopy matter?
JC Diversity in endoscopy, and in GI broadly, matters because, from a workplace perspective, business research shows that companies with greater gender diversity are 15% more likely to outperform their peers and ethnically diverse organizations are about 35% more likely to outperform their peers. The reason for this competitive advantage is that greater diversity allows the opportunity for varied perspectives in decision-making. For GI practices, this might involve making decisions about how to approach education in endoscopy, how to approach patient care, or how to interact and collaborate with staff who are engaged in endoscopy. Ultimately, having a diverse endoscopy unit helps the team function better to achieve the goal of optimizing patient outcomes. Benefits of diversity in patient care (when those who provide care are themselves a member of an underserved community) are improved trust and compliance by patients and better communication and understanding of cultural differences by practitioners. Therefore, it is critical that we in the GI community provide a platform for patients from diverse populations to obtain care from health care practitioners, staff, and leadership from diverse racial and ethnic groups as well as gender populations. Importantly, individuals in the GI community from diverse racial, ethnic, and gender populations should play a role in making decisions about DEI; however, all members of the team must be involved.
G&H What are some of the key GI society initiatives for enhancing diversity?
JC The 5 major GI societies have become much more engaged around DEI efforts. The American Society for Gastrointestinal Endoscopy (ASGE), the American College of Gastroenterology, the American Association for the Study of Liver Diseases, the American Gastroenterological Association, and the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition have programs that help support the professional development of women and individuals who identify as UIM. All 5 organizations support research for projects that focus on underrepresented groups and offer specific awards and research grants for underrepresented investigators, including women. Pathway programs are available to help our trainees and learners through medical school and internal medicine or GI training. There are also programs to assist high school students who may decide to choose a career in academic medicine or even in private practice. The programs are designed to give individuals the tools to become successful in whatever career path they choose and become leaders in their specific careers.
Additionally, many committees focus on DEI efforts. The ASGE, for example, has the LEAD (Leadership Education and Development) program, developed by Dr Colleen Schmitt, that helps provide professional development skills to women, and the ASGE is initiating a similar program called Elevate that will specifically target gastroenterologists who are UIM. Furthermore, the ASGE has a subcommittee focused on lesbian, gay, bisexual, transgender, queer or questioning, and intersex (LGBTQI) practitioners and patients to ensure that the society is engaging optimally with gastroenterologist members and their patients who identify as LGBTQI. The hope is that these efforts will also improve the engagement of LGBTQI individuals in the health care system and improve clinical outcomes in this population.
Many of these committees are focused on unconscious bias education, as well as upstander and bystander training, to help GI practitioners who do not identify as UIM learn how to support individuals who belong to a minority group. It is important that all members of the GI community get in the game and participate in any way they can to ensure that these efforts move forward.
G&H Could you describe the minority tax?
JC The minority tax refers to the tremendous burden that UIM individuals and women face when they are expected to represent the entire minoritized group and participate in retention activities, mentorship of UIM groups or other women, and education of colleagues who are members of a majority group. The burden of managing these activities often falls on the minority group. This is also true for faculty participating in committees for DEI, recruitment, and faculty development. The same individuals are often tapped for these committees repeatedly. Because so few gastroenterologists are women or UIM, the burden, or tax, becomes tremendously high and untenable.
The additional challenge is that many of these efforts are not valued as highly as other GI activities or are not compensated, yet they require a lot of time and effort. Besides the lack of a dollar value for this work, often
UIM individuals and women do not obtain credit toward academic promotion. Unfortunately, for these individuals, it can take longer to move through the promotion track.
G&H How can this tax on minorities be lifted?
JC In terms of lifting the minority tax, I think many things can be done. Most important is to make sure that GI practices and endoscopy organizations develop a diverse and inclusive leadership structure. Leadership must be accountable for DEI initiatives and outcomes. I would also encourage that GI leaders secure more allies and sponsors to reduce the burden for GI practitioners who are UIM. Allies could be anybody or all of us but are generally people who are in a position of power and privilege. Often the message of lifting the minority tax is better received in conjunction with someone who has more of the power or has more of a platform and a voice to move some of the DEI efforts forward and to support what individuals in the DEI space are doing. Allies for the UIM could help in that process. It is very difficult for a small group of individuals to carry DEI initiatives forward. Advancing these initiatives is important and may occur by making sure that all faculty are trained and educated about the benefits of advocating for women, for UIM, and for individuals who identify as LGBTQI.
It is also important to fund mentoring programs. As I mentioned, if underrepresented groups are taxed with mentoring more individuals from underrepresented groups, grants need to be provided to allow protected time for that work. Finally, to move the needle forward even faster, women and individuals who are underrepresented in GI and endoscopy need to have leadership roles that are outside of DEI.
G&H How have gender disparities impacted both GI mentees and mentors?
JC I mentioned earlier that less than a quarter of practicing gastroenterologists in the United States are women. This presents a problem for female mentees looking for other women to be mentors. According to a survey of gastroenterologists, more women than men prefer a mentor of the same gender. The reality is that female mentees looking for gender concordance at this time may be disappointed because there are simply not enough female mentors available. While efforts are being made to fill this gap, male mentors continue to learn to successfully mentor women. To be a good mentor, one must be able to exercise empathy. This is also true for allies. Although the mentor or ally may not have had the same experiences—whether it be sexism or racism—or the same challenges or burdens, at least he or she can try to understand how these experiences could impact the individual. It is important for the mentor to be an attentive listener, to ask questions, to provide an opportunity for open dialogue, and to seek feedback for self-evaluation. The mentor should expect to be uncomfortable at times when receiving feedback, especially when it relates to DEI. Both the mentor and the mentee need to understand the expectations of the other. Mentors can also sponsor women to participate in committees and take on directorships or larger leadership roles. Sponsorship, whether you are male or female, is key in addition to mentorship.
G&H How does unconscious bias impact career development and patient care?
JC Unconscious bias is something everyone possesses. What is important is that we acknowledge it and try to apply strategies to mitigate how our bias impacts how we move in the workplace and in society. As far as unconscious bias and the impact it has in career development, it is pervasive. It can be seen in how individuals are hired. For instance, there are data to support that resumes with male-sounding names receive more responses than resumes with female names. Unconscious bias also has an impact on patients. A GI practitioner’s preconceived notions about how a patient will comply with care may alter what treatment the practitioner suggests or does not suggest if the assumption is that the patient may not understand or may not comply. More importantly, when communicating with patients, if the GI practitioner communicates in a way that displays racially preconceived notions about the patient, then that will lead to mistrust and the patient more than likely will not comply or will not return for care. This will result in poor outcomes. In reverse, patients may have biases that impact GI practitioners and how they deliver care. These biases must be mitigated along the spectrum of the clinical care environment, and all practitioners and health systems have a responsibility to help overcome them.
G&H What strategies can the GI community use to move DEI initiatives forward?
JC GI practices, practitioners, and educators can move DEI initiatives forward in many ways. First is the need for a commitment from leadership. If leadership is not on board with these efforts and does not hold everyone accountable, it is very difficult to make any kind of change. Second, DEI efforts need to be intentional. The GI community needs to be intentional about broadening its reach to increase representation of women and underrepresented groups in various GI organizations and in the number of GI learners and leaders. In general, the GI community must be intentional about changing the culture, ensuring that everyone feels welcomed and valued in whatever space they are in. Everyone, all GI practitioners, including our colleagues in the LGBTQI community and patients, should be treated as part of a team, in which every player adds value, and the similarities and the differences are valued.
The path to greater diversity also requires GI practitioners to be better listeners. GI practitioners and educators must listen to the needs of GI colleagues, of GI learners and trainees, and most importantly of GI patients. Ultimately, having a diverse team that listens to the needs of others can help achieve better patient outcomes. Finally, GI practitioners should collaborate with key stakeholders (patients, nurses, administrative staff, learners, colleagues, and clinical/administrative leaders) and ensure that the workforce is inclusive.
G&H What do you wish for the GI endoscopists of tomorrow?
JC My wish for the GI endoscopists of tomorrow is simple. I wish that endoscopists have greater empowerment to express their professional needs and goals as well as the opportunity and support to pursue their goals as these are expressed. Having empowered practitioners can lead to a greater positive impact on the patients they serve.
Disclosures
Dr Christie has served on advisory boards for Neurogastrx, Evoke Pharma, Grail, and Takeda Pharmaceuticals.
Suggested Reading
Carethers JM, Quezada SM, Carr RM, Day LW. Diversity within U.S. gastroenterology physician practices: the pipeline, cultural competencies, and GI societies approaches. Gastroenterology. 2019;156(4):829-833.
Day LW, Gonzalez S, Ladd AM, et al; ASGE Membership and Diversity Committee. Diversity in gastroenterology in the United States: where are we now? Where should we go? Gastrointest Endosc. 2016;83(4):679-683.
Hunt V, Layton D, Prince S. Diversity matters. McKinsey & Company. 2015. https://www.professionalwargaming.co.uk/McKinseyDivmatters-201501.pdf. Accessed May 17, 2023.
Rabinowitz LG, Grinspan LT, Kim MK. Gender in the endoscopy suite. Lancet Gastroenterol Hepatol. 2020;5(12):1032-1034.
Rabinowitz LG, Grinspan LT, Zylberberg HM, et al. Survey finds gender disparities impact both women mentors and mentees in gastroenterology. Am J Gastroenterol. 2021;116(9):1876-1884.
Rotundo LC, Gaidos JKJ. Creating a pathway to leadership for women in gastroenterology. Dig Dis Sci. 2022;67(2):397-399.
Yu JX, Berzin TM, Enestvedt B, et al. Gender disparities in advanced endoscopy fellowship. Endosc Int Open. 2021;9(3):E338-E342.