Despite increasing numbers joining the field, women remain a minority group in gastroenterology, where they constitute only 18% of these physicians.1 Additionally, women continue to be underrepresented among senior faculty and in leadership roles in both academic and private practice settings.2 While women now make up a majority of medical school matriculants3,4 women trainees are frequently dissuaded from pursuing specialty fellowships following residency, particularly in procedurally based fields like gastroenterology, because of perceived incompatibility with childbearing and child-rearing.5-8 For many who choose to enter the field despite these challenges, gastroenterology training and early practice often coincide with childbearing years.910 These structural impediments may contribute to the “leaky pipeline” and female physician attrition during the first decade of independent practice after fellowship.11-13 Urgent changes are needed in order to retain and support clinicians and physician-scientists through this period so that they, their offspring, their patients, and the field are able to thrive.
Fertility and pregnancy
The decision to have a child is a major milestone for many physicians and often occurs during gastroenterology training or early practice.10 Medical-training and early-career environments are not yet optimized to support women who become pregnant. At baseline, the formative years of a career are challenging ones, punctuated by long hours and both intellectually and emotionally demanding work. They are also often physically grueling, particularly while one is learning and becoming efficient in endoscopy. The ergonomics in the endoscopy suite (as in other areas of medicine) are not optimized for physicians of shorter stature, smaller hand sizes, and those who may have difficulty pushing a several-hundred-pound endoscopy cart bedside, all of which contribute to increased injury risk for female proceduralists.7,14-16 Methods to reduce endoscopic injuries in pregnant endoscopists have not yet been studied. Additionally, the existence of maternity and gender bias has been well-documented, in our field and beyond.17-20 Not surprisingly, women in gastroenterology commonly report delayed childbearing, with expected consequences, including increased infertility rates, compared with nonphysician peers.21 After 5 and 10 years as attendings, female gastroenterologists continue to report fewer children than male colleagues.22,23 Once pregnant, there are a number of field-specific challenges to navigate. These include decisions about the safety of performing procedures involving fluoroscopy or high infectious risk, particularly early in pregnancy when organogenesis occurs.7,24 Additionally, engaging in appropriate obstetric care can be challenging given the need for regular physician and ultrasound appointments.
Simple, cost-efficient interventions may be effective in decreasing infertility rates, pregnancy loss, and poor physician experiences during pregnancy. For one, all gastroenterology divisions could craft written policies that include a no-tolerance approach to expressions of maternity bias against pregnant or postpartum trainees and faculty.12,25 Additionally, ergonomic improvements, such as standing pads, dial extenders, and adjusted screen heights may decrease injury rates and increase comfort for female endoscopists.26,27 There should also be a no-penalty, no-questions-asked approach for any female endoscopist who defers performance of an obstetrically high-risk procedure to a nonpregnant colleague. Additionally, pregnant gastroenterologists should be supported in obtaining high-quality obstetric care. At an individual level, nonpregnant gastroenterologists, and particularly male allies, can support pregnant colleagues by agreeing to perform higher-risk procedures, stepping in if a fellow is unable to perform endoscopy because of pregnancy, and by offering to push the endoscopy cart on behalf of a pregnant colleague to bedside, if necessary.10,28