Keywords Pancreatobiliary (ERCP) - Quality and logistical aspects - Training - Quality management
Introduction
Despite steady growth in the number of women who have completed medical training since
the first women were allowed to enroll in medical school about 150 years ago, there
remains significant gender disparity across the profession. This is most visible in
senior leadership, in academia, and in procedural specialities. Surveys of surgical
specialities in the UK have shown that only 35% of surgical trainees and 14% of surgical
consultants are female [1 ]. Similar trends in female representation in medicine have been noted globally [2 ].
Interventional therapeutic endoscopy has evolved into a speciality that provides alternatives
to traditional surgery. As it has evolved, gender disparities similar to those in
surgery have been noted. Over the last 25 years, female medical students have outnumbered
men and 55% are currently female, yet women only account for 36% of the consultant
body [3 ]
[4 ]. The 2020 British Society of Gastroenterology (BSG) workforce survey reported that
only 22% of the 1607 consultants were female [5 ]. Within gastroenterology, the disparity is glaring in hepatobiliary endoscopy i.e.,
endoscopic retrograde cholangiopancreatography (ERCP), where a recent Joint Advisory
Group (JAG) survey into sedation practices demonstrated that 94% of ERCPists were
male [6 ]. A freedom of information request to acute trusts in England in 2019 revealed that
only 5% of the ERCP workforce in the UK is female [7 ].
Gender disparity in medicine is multifactorial and complex, with factors including
attitudes extending across medical schools, hospitals, and society as a whole. It
may also be influenced by the degree of physical demand, the likelihood of procedure
complications, and psychological impact of complications. Endoscopy-related injuries
are common in endoscopists and it is well documented that female endoscopists report
more upper limb injuries and have a weaker grip and smaller glove sizes [8 ]. Despite this, endoscopes and equipment have remained one-size-fits-all, contributing
to this issue. A recent survey in the United States demonstrated that 46.9% of female
trainees and 60% of pregnant trainees felt equipment was not ergonomically optimized,
and this included right-sized gloves, aprons, dial extenders, and lead protection
[9 ].
It is important to explore and address these factors and reduce gender disparity because
it has been shown that diversity improves patient care, innovation, performance, and
financial aspects [10 ]. The importance of diversity has also been demonstrated in other fields such as
finance, where a 2017 report by Morgan Stanley concluded that “more gender diversity,
particularly in corporate settings, can translate to increased productivity, greater
innovation, better decision-making.”
This study provided an opportunity to explore whether gender disparity exists in ERCP
practice by examining the current state of training and practice from the perspective
of gender, exploring underlying factors associated with poor engagement or commitment,
and identifying where changes can be made to improve diversity and quality of service.
Methods
Population
An electronic survey was distributed via email to gastroenterology trainees and independent
ERCP practitioners in the UK. The survey was advertised via the BSG trainee section,
BSG Supporting Women in Gastroenterology (SWIG), and personal social media accounts
between April and July 2023. Training program directors, ERCP networks leads, and
trainee representatives were asked to assist in dissemination and regional engagement.
Survey design
A cross-sectional survey consisting of 20 questions in five sections was developed
by the authors at St Thomas’ Hospital using a web-based survey tool (Google). Non-identifiable
demographic information was obtained including age, gender, and level of training.
It included questions to assess training levels, access to ERCP training, gender perceptions,
and factors influencing gender bias.
Data collection
An introductory email describing the study and including a web link to the online
survey instrument was sent. Multiple email reminders, social media advertisements,
individual contacts, and BSG Trainees Section regional representatives were used to
remind participants and enhance response rates.
Patient and public involvement
No patients were involved in study design.
Statistical analysis
Data were analyzed using Microsoft Excel. Categorical variables and ordinal data were
summarized using counts and percentages and analyzed using χ2 test. P < 0.05 was considered statistically significant.
Results
Demographic data
There were 214 respondents. Ninety-seven were female (45%) and 117 were male (55%).
Forty-five percent were consultants. All UK training deaneries were represented. Overall,
83% of respondents worked on a full-time basis. Of the 17% respondents working on
less than full time (LTFT) basis, 80% were female (P < 0.001). Demographic data are summarized in [Table 1 ].
Table 1 Demographic data.
Total
Female
Male
n (%)
n (%)
n (%)
LTFT, less than full time; ST, specialist trainee.
Gender
214 (100)
97 (45)
117 (55)
Level
213 (100)
Consultant
95 (45)
28 (29)
67 (71)
Clinical Fellow
20 (9)
10 (50)
10 (50)
ST4
21 (10)
12 (57)
9 (43)
ST5
24 (11)
15 (62)
9 (38)
ST6
27 (13)
15 (56)
12 (44)
ST7
26 (12)
16 (62)
10 (38)
Working pattern
208 (100)
Full time
173 (83)
67 (39)
106 (61)
LTFT
35 (17)
28 (80)
7 (20)
Scope of practice, access, and attitude toward training
Respondents were asked to confirm their involvement in upper and lower gastrointestinal
therapeutic procedures, endoscopic ultrasound (EUS), and ERCP. The proportion of female
trainees involved in upper and lower gastrointestinal therapeutic endoscopy was greater
(58% and 53%) than in hepatobiliary (HPB) endoscopy (EUS 41% and ERCP 29%; P = 0.014). The lowest female representation was in ERCP, where most trainees were
male (71%). Regarding independent practitioners in ERCP, the ratio was 17% female
to 83% male.
Respondents were asked about access to training in ERCP, on a scale of 1 to 5 with
1 meaning no access. 53% said that there was no or poor access (score 1 or 2). Only
6.6 % felt that there was very good access (score 5). Sixty-four percent of female
respondents felt that access to ERCP training was affected by their gender, whereas
71% of males felt that this was not the case (P < 0.001). This perception was mirrored in a question on discouragement about commencing
ERCP training. Twenty-five percent of females felt there had been active discouragement,
whereas 95% of males felt that there had been no such discouragement (P < 0.0005).
Role modelling
Seventy-two percent of all respondents (male and female) could not identify female
ERCP role models or mentors in the department or nationally. Sixty percent of female
respondents felt that this negatively affected their attitude toward ERCP training,
compared with 12% of male respondents (P < 0.001). Seventy-one percent of respondents overall felt that there was no visibility
of female role models in ERCP at a national level (e.g. at conferences). More female
respondents felt that this negatively affected career choices (59% female vs 23% male,
P < 0.0005).
Gender-based attitudes
The vast majority of male respondents (approximately 90%) felt that they were treated
similarly to female colleagues by endoscopy staff, fellow endoscopists, and patients.
In contrast, a significant proportion of female respondents felt that they were treated
differently by endoscopy staff (24%, P = 0.0036) and fellow endoscopists (37%, P < 0.001). Thirty-five percent of females felt that patients treated them with less
respect than male colleagues (P = 0.013).
Perception around LTFT training
Respondents were asked if LTFT training affected training in ERCP and their perceptions
about availability of fellowships during training. The majority felt that LTFT was
incompatible with ERCP training. The results are shown in [Fig. 1 ].
Fig. 1 Perceptions around LTFT training
Environmental factors
When asked about the effect of radiation exposure on family planning, most of the
male respondents felt that this made no impact on a decision to train in ERCP (78%),
whereas 50% of females felt that it did (P < 0.0005). The majority of respondents, both male and female, did not have concerns
about cancer risk ([Table 2 ]). The same attitudes pertained to ergonomics of endoscopic equipment; however, a
significant minority did have concerns about these two factors. Approximately 53%
of female respondents found that wearing lead jackets and aprons during long procedures
had a negative impact, whereas only 30% of males thought this was the case (P = 0.0012).
Table 2 Impact of environmental factors.
Total
Female
Male
n (%)
n (%)
n (%)
Impact of radiation on family planning
194 (100)
92(100)
102 (100)
No impact
126 (65)
46 (50)
80 (78)
Negative impact
68 (35)
46 (50)
22 (22)
Impact of radiation on cancer risk
192 (100)
88 (100)
104 (100)
No impact
130 (68)
52 (59)
78 (75)
Negative impact
62 (32)
36 (41)
26 (25)
Ergonomics of equipment
187 (100)
84 (100)
103 (100)
No impact
144 (77)
58 (69)
86 (83)
Negative impact
43 (23)
26 (31)
17 (17)
Heavy lead and long procedure
192 (100)
90 (100)
102 (100)
No impact
113 (59)
42 (47)
71 (70)
Negative impact
79 (41)
48 (53)
31 (30)
Attitudes toward higher-risk procedures
Respondents were presented with a list of factors that could impact their perceptions
of and attitudes toward ERCP training. Fewer people responded to this subsection.
Of the 71 who felt that they had a lack of confidence with high-risk procedures, 66%
were female. Regarding concern about the negative psychological consequences of being
involved in serious complications, 56% were female. Thirty-eight respondents identified
a lack of self-advocacy, of whom 68% were female. One hundred and four respondents
felt that a lack of exposure to complex endoscopy in early training influenced their
decision about ERCP training (54% female vs 46% male). Differences between genders
on this topic were consistent but less notable than other factors ([Fig. 2 ]).
Fig. 2 Attitude to high risk procedures
Trainer attitudes
These questions were presented to trainers only. Eighty-nine responded and 22% of
respondents were female. Fifty-eight of 89 (65%) had trained female trainees in ERCP.
Thirty-nine trainers had experience with less than full-time trainees, and there was
no significant difference in gender among these trainees. Fifty-seven percent of trainers
felt that less than full-time working had a significant effect on training in ERCP.
Twenty-five percent felt that it might have an effect and 18% felt that it had no
effect.
Trainers were asked if trainee behavior was influenced by gender. Fifty percent of
trainers felt that gender made no difference to trainee confidence; however, of those
who felt that the gender did make a difference, over 95% felt that male gender was
associated with increased confidence. The same pattern applied to self-advocacy. Regarding
enthusiasm and resilience, the majority of trainers felt that gender did not make
a difference. Approximately 50% of trainers felt that gender made no difference to
the tendency for self-reflection or to beneficial interpersonal skills. However, of
the other 50% who did think there was a gender difference, the vast majority associated
female gender with more self-reflection and better interpersonal skills. Very few
trainers admitted to discouraging a female trainee (3 of 88).
Personal experiences
Respondents were invited to describe personal experiences and to give opinions about
the previously mentioned subject areas. Selected responses are provided in Box Personal experience and comments . Box Factors to encourage female trainees in HPB endoscopy contains selected responses on ideas to encourage more women to train in ERCP. The
authors were not aware of the gender of individual respondents.
Personal experience and comments
ERCP experience and exposure
Started ERCP training – I became pregnant twice hence training was stopped. Felt
too much of a learning curve to make progress working less than full time
As a trainee had to actively seek out ERCP training opportunities, often staying
very late or starting early to ensure free to attend lists.
If I had met one (female role model) earlier in my training I may have been
encouraged to train in ERCP
I have never seen a female ERCPist
(As a woman) I attended an ERCP conference in the UK and was guided more than once
to the nursing symposium….
Was told I had “left it too late” to consider ERCP training by a male consultant
at the beginning of ST5
I have a young family and needed to CCT and get a consultant job straight away.
Hence, I did not have the freedom to pursue a post-CCT fellowship
The only way I got my training was to get extra lists between 2 hospitals and
working post nights etc which was exhausting
Role models and mentors
The only reason I knew I could do it is because my TPD during training [a female
ERCPist] was living proof you can
The lack of female representation at conferences/courses/social media can be
isolating
It would make me feel less able to contribute and silently question if I should be
there
Throughout my training majority of gastroenterologists are male and all ERCPists I
have worked directly with have been male
Very few visible female ERCPists. Those I have met are exceptional and great
ambassadors
Gender bias in the endoscopy unit
When I did my fellowship abroad I did not feel that I was treated better or worse
than male colleagues
Have encountered sexism among patients, however, I think patients often see women
who are at more junior levels or training (ie registrars) as less experienced than
male equivalent
My experience was the nursing team would often warn me about the other ERCPists
and how terribly tempered they could be. It was never my actual experience – my
trainers were all lovely and excellent and patient
I was discouraged from doing ERCP and was told that a male colleague would likely
be better
When I expressed interest in ERCP, I had to justify my aspirations with regard to
if I was emotionally suited to deal with complications as a female and what would
happen to training if I was pregnant
[I am a female but] I have an overseas name and often I am referred to as Mr in
emails. Despite addressing myself as Dr… in endoscopy, the patients ask after
consenting etc, when will I see the doctor.
I think this is subtle. In the room if you are a female who takes command of a
room, there are comments raised of bossiness. If you are a male who does similar,
you
are simply assertive
LTFT challenges
I had to come in on days off for opportunistic training lists as a full-time
trainee. I can only imagine how difficult it would be for a less than full time
trainee
I asked to do my fellowship LTFT but have been told this is not possible. Have
managed to negotiate 1 day of remote working as a compromise
I asked to work LTFT during an ERCP/EUS fellowship to help more with childcare and
this was actively discouraged
Physical and psychological challenges
Some leads have very big armholes – might that increase risk of breast cancer? I
do often wonder about this
Heavy leads caused back ache and were awkward to take on and off and usually
nowhere to sit so standing in them for 4–5 hours. The equipment could hurt my fingers,
used to sometimes find the wire very stiff to pass
Tendonitis in thumb and passing difficult stents or long procedures with repeated
recannulation and bridge/wheel work causes discomfort during the procedure
As someone with a disability I faced similar ergonomic and equipment challenges
that initially were dismissed by employing organisation, especially when I was still
a
trainee and not a permanent member of staff
The equipment is designed for men small size aprons are not available the aprons
are heavy…
Complications was a major factor [in discouraging me]
The major cause of complaints or legal issues in my career have been related to
complications of ERCP
It's bloody hard! It takes a long time to master and requires considerable
dedication. And ERCP takes a certain personality...
CCT: certificate of completion of training; ERCP: endoscopic retrograde cholangiopancreatography;
EUS: endoscopic ultrasound; LTFT: less than full time; ST: specialist trainee; TPD:
training program director.
Factors to encourage female trainees in HPB endoscopy
Encouragement in first 2 years of training to anyone
showing a passion for endoscopy in general and then nurturing interest in ERCP if
technical competence in endoscopy shown might help encourage further training in HPB
endoscopy
More prominent female role models. More representation at Endolive events. Maybe
an Endolive ERCP session carried out just by female physicians
I think that seeing other women in the field is crucial – and not superhuman
women, normal ones! Finding a way to provide child-friendly hours – both to women
and
men in training and removing the stigma of LTFT in ERCP training
Active promotion by the excellent younger female colleagues who have come through
training in recent years
Make it the norm, set the expectation from ST4 day one and support them in those
rotations to places that can offer that training. Set a high standard for equipment
like leads, clear guidance on cancer prevention, scoping in pregnancy, sharing
challenges and when things go wrong
ERCP: endoscopic retrograde cholangiopancreatography; ST: specialist trainee; CCT:
certificate of completion of training; TPD: training programme director; LTFT: less
than full time; EUS: endoscopic ultrasound.
Discussion
This large national survey has identified significant differences in access to training,
uptake of training, and experience of training between female and male endoscopists
who have an interest in hepatobiliary work. This is consistent with gender disparities
seen in both the BSG workforce survey and the JAG survey [5 ]
[6 ]
[7 ]. According to the National Endoscopy Database (NED) analysis in 2023, there were
491 ERCP practitioners in the UK [6 ]. In the BSG workforce report of 2023, it is stated there were 660 endoscopy trainees
in total [11 ], although what proportion aspired to train in ERCP is unknown. It is likely to be
less than 25%. Therefore, the 214 respondents (which include trainees and independent
practitioners) is likely to be a representative sample.
Most of the secondary questions in the survey were about ERCP practice specifically.
There were concerning messages regarding role modelling, encouragement versus discouragement,
and departmental attitude. In addition, there were significant differences in attitude
toward environmental factors and the potential for involvement in complex cases with
higher morbidity and mortality. The survey touched upon psychological factors, and
respondents (who were self-selected) indicated that there are differences in the psychology
of male and female trainees. The free-text responses give more vivid illustrations
of the opinions and emotions associated with this topic, although it must be noted
that they are not necessarily representative, being individual examples.
Workforce surveys indicate significant gaps in gastroenterology consultant posts in
the next 5 to 10 years [12 ] and the recent BSG ERCP workforce survey demonstrates that one-fifth of the ERCP
workforce is planning to retire in the next 5 years, potentially creating a large
gap in workforce [13 ]. This survey also showed that over 10% of ERCP practitioners perform less than 75
procedures per year, which is concerning from the point of view of quality. The recent
change in gastroenterology curriculum poses many challenges to endoscopy training
and studies show that colonoscopy certification had fallen by two-thirds from 2018
to 2022 [14 ]. This leaves very little scope for training in complex HPB endoscopy and almost
all training will need to be pursued in a post-Certificate of Completion of Training
setting. Over half the respondents in a recent training survey indicated that they
had no exposure to either ERCP or EUS during training, thus hindering informed career
decisions [15 ]. According to a BSG statement, LTFT working is increasing. The reasons are broad,
and include caring duties, academic interests, mental or physical illness, work-life
balance, or other exceptional opportunities such as representing their country for
sport or national leadership positions. Ninety percent of working LTFT are women,
but a growing number of male trainees are requesting this pattern of working [16 ]. With LTFT training come fewer opportunities to practice, and if there are any adverse
outcomes, they will tend to dominate the experience and possibly cause the trainee
to reconsider before subsequent procedures reassure them that morbidity/mortality
is infrequent. One approach to this would be to concentrate ERCP training during specific
phases of LTFT training. This would require coordination with the rest of the gastroenterology
service (and possibly general medicine).
In addition to this, we noted a small number of female trainees reported that they
were discouraged from engaging in ERCP training. This needs further exploration. Previous
studies have reported that various factors such as confidence, LTFT, reduced self-advocacy,
and patriarchy play a role in low female representation in advanced endoscopy [17 ]. With regard to active discouragement, free-text comments in the survey refer to
perceptions that females are less emotionally equipped to deal with higher complication
rates in ERCP and that training would not be continuous due to career breaks due to
pregnancy. The issue of self-confidence and self-advocacy is both difficult to measure
and a sensitive topic. The survey appears to confirm that it is an important barrier;
therefore, a supportive approach is required. We suggest that the relationship between
trainer and trainee is crucial here, and an ongoing, trusting relationship will help.
Trainees rotate frequently; therefore, a single-mentor arrangement may be the better
solution.
A significant number of trainees were concerned about radiation exposure. Numerous
surveys have demonstrated that concerns about radiation exposure may play a significant
role in the discrepancy in numbers of female ERCP practitioners, especially of childbearing
age [18 ]
[19 ]. Studies show that this concern is shared by male students [20 ]. Despite the need to improve diversity, information around radiation exposure, safety
during pregnancy, guidance, and education in practice during pregnancy is lacking
or relatively inaccessible. Clearly presented information during training would help
to improve this situation.
The limitations of the study relate to self-selection of respondents. Those with stronger
opinions were more likely to respond, and therefore, there may be some bias. However,
we know,
objectively, that there are far fewer female independent and trainee ERCPists in the
country;
therefore, the messages communicated through the survey are likely to be accurate
overall.
Other studies have identified similar themes [6 ]
[7 ].
Identification of these variations is the first stage in redressing the imbalance.
Addressing the issues identified in this survey may reduce gender disparity over time.
However, the solutions are not easy to implement, especially when related to long-held
or outdated attitudes. Appreciation of the factors identified in the survey could
be translated into more positive messaging earlier in training, together with a proactive
attitude toward factors such as LTFT and better clarity around radiation risks. Change
in this context may require more affirmative action, such as requirements for training
centers to take on a minimum proportion of female trainees, clear mentor-mentee arrangements,
and a proactive approach to discussing LTFT with appropriate accommodations made for
hepatobiliary endoscopy.
Fear of psychological harm following involvement in complications or deaths is universal,
but especially relevant to hepatobiliary work. This should be addressed for all trainees
within the curriculum. Generational differences and traditional attitudes persist.
It is for
national bodies and local clinical leaders to address these issues where they are
identified
in departments. This negative influence is likely to wane over time, but it is still
being
felt by individuals. A focus on individual competency and interest should be promoted,
together with personalized mentoring such that hurdles, anxieties, and setbacks are
managed as
they occur over time. There are strong female role models in the UK, and an effort
should be
made to increase visibility and access. An overview of recommendations to achieve
this is
highlighted in Box Recommendations to achieve gender equity in
ERCP .
Recommendations to achieve gender equity in ERCP
Streamline HPB endoscopy training
Change in culture and inclusive behavior within endoscopy units
Increase visibility of female mentors and role models
Curriculum-based training on the psychological effects of complications
Avoid describing ERCP as especially challenging, risky or “heroic”
ERCP: endoscopic retrograde cholangiopancreatography.
Conclusions
Gender disparity in HPB endoscopy exists and is stark. Although ERCP training is
challenging for all trainees due to various factors such as lack of early exposure,
poor
access, and fear of complications, it seems to be particularly challenging for female
trainees. With shortened training time and increasing general medicine commitments
in the new
curriculum, ERCP training may become less attractive or realistic. Underlying this
disparity
are attitudes, assumptions, and ergonomic/environmental factors that will require
systemic and
sustained correction. Ideas about how to address this challenge exist within the female
cohort
of endoscopy trainees, and engagement with them may lead to welcome changes over time.
This is
essential to preserve the future ERCP workforce.
Bibliographical Record
