Gastroenterology Training and Career Choices: AProspective Longitudinal Study of the Impact ofGender and of Managed CareFreda L. Arlow, M.D., F.A.C.G., Patricia L. Raymond, M.D., F.A.C.G., Robyn G. Karlstadt, M.D., F.A.C.G.,Raquel Croitoru, M.D., F.A.C.G., Benjamin A. Rybicki, M.H.S., Ph.D., and Suriya V. Sastri, M.D.Department of Gastroenterology, Henry Ford Health System, Detroit, Michigan; Department of ClinicalInternal Medicine, Eastern Virginia Medical School, Norfolk, Virginia; Wyeth Ayerst Pharmaceuticals, St.David’s, Pennsylvania; Treasure Valley Gastroenterology, Nampa, Idaho; Department of Biostatistics andEpidemiology, Henry Ford Hospital, Detroit, Michigan; and Midwest Endoscopy Center, Willowbrook,Illinois

OBJECTIVE: We aimed to determine if gender differencesexist in the selection and training of female and male gas-troenterology fellows.

METHODS: One hundred seventy-six of 218 training pro-gram directors returned an 18-question survey about theirprograms, including leave policies, training, and prevalenceof female faculty. Two cohorts of graduating trainees from1993 and 1995 (N � 393) returned anonymous surveysregarding their training program experiences, demograph-ics, and business training.

RESULTS: Female gastroenterology trainees are more likelyto choose programs according to parental leave policies(p � 0.05), female faculty (0.2990 correlation coefficient),and “family reasons” (p � 0.04) than the male trainees.Female trainees were more likely to remain childless (p �0.001) or have fewer children at the end of training despitemarital status not unlike their male colleagues. Female train-ees altered their family planning because of training pro-gram restrictions (20% vs 7%, p � 0.001). They perceivedgender discrimination (39%) and sexual harassment (19%)during gastroenterology training. Trainees of both sexes hadmentorship during training (65% vs 71%, ns); female train-ees were more likely to have an opposite sex mentor (71%vs 3.4%) despite an almost 50% prevalence of female full-time and clinical faculty. Female trainees were apt to be lesstrained in advanced endoscopy (p � 0.005). Trainees ofboth sexes were influenced by the changing health careenvironment in career choice (49% vs 42%, ns); neithergender felt adequately prepared for the business aspects ofgastroenterology.

CONCLUSION: Alterations in gastroenterology training areneeded to attract qualified female applicants. New graduatesof both sexes lack practice management education. (Am JGastroenterol 2002;97:459–469. © 2002 by Am. Coll. ofGastroenterology)

INTRODUCTION

The new millennium offers novel challenges in supplyingadequate manpower for the field of gastroenterology. Onesuch test is the declining number of residents of both gen-ders who choose this field of specialization. Two factorsseem to be at work in this statistical decline and are thesubject of study in this article: the impact of managed careand the possible influence of gender-related social stresseson female residents considering gastroenterology as a careerchoice are two areas that may be affecting the supply of newtrainees entering our field. We have experienced increasingdemand for women gastroenterologists, although womenhave traditionally been a minority in this specialty. Thisstudy explores factors that may influence the demographicsand size of our professional gastroenterology workforce.

In 1992, the ACG Committee on Women in Gastroenter-ology proposed a 10-yr prospective study on trends in fel-lowship training and practice patterns with the intent ofdetermining whether gender-related barriers exist. The tim-ing of the study allowed the authors to enhance the designby assessing the professional development of both sexes andthe effect of managed care on this sampling of recent grad-uates as they completed their training and embarked on acareer in gastroenterology.

The profession of gastroenterology, with its prominentprocedural component, is exquisitely sensitive to the down-ward ratcheting of reimbursement due to managed care. Thepublicity over declining returns and oversupply of special-ists has likely acted to reduce the number of internal med-icine residents choosing gastroenterology subspecialty train-ing. In 1998 the lowest internal medicine subspecializationrate (40%) was recorded since data collection began in the1970s, with a 33% decrease in specialization in gastroen-terology (1).

The number of women in this male-dominated field hasalso slumped, despite a great demand for female gastroen-

THE AMERICAN JOURNAL OF GASTROENTEROLOGY Vol. 97, No. 2, 2002© 2002 by Am. Coll. of Gastroenterology ISSN 0002-9270/02/$22.00Published by Elsevier Science Inc. PII S0002-9270(01)04047-3

terologists in private practice. Women physicians continueto choose “traditional” areas of medicine such as pediatrics,obstetrics/gynecology, psychiatry, and family practice.Women are underrepresented in subspecialties (26%) rela-tive to their presence in internal medicine (34%). Amongwomen, gastroenterology (15%) and cardiology (17%) werethe least chosen subspecialties (2).

Increasing numbers of women are choosing medicine asa career (3). However, issues such as “flex time” or sharedpositions, options for career interruption, or child bearingand rearing have rarely been addressed in either medicaltraining or medical careers. In recent years, various trainingprograms in medicine have begun offering flexible sched-uling, innovative benefits, and leave policies, perhaps inresponse to increasing numbers of females entering theworkforce. The presence of such programs in gastroenter-ology training or in practice is unknown, as is whether thepresence of such policies ultimately influences the gendercomposition of the gastroenterology training programs andselection of employment.

Additionally, there is a perceived need for training in thebusiness of gastroenterology in fellowship programs forgastroenterologists of both sexes. As the art of treatmentcollides with the realities of business, our trainees need thetools to thrive in this new economy of medicine.

This longitudinal prospective study, initially proposed fora 10-yr period, observes recent gastroenterology graduatesas they establish their professional careers and respond tothe upheaval in medical care delivery. The authors seek toestablish means to attract and retain women in gastroenter-ology training, to establish policies to allow such training tobe gender equal, to encourage membership and advance-ment in the gastroenterology specialty societies, and toevaluate the apparent inadequacy of training related to thebusiness of gastroenterology in our training institutions.This work addresses only the training program director andbaseline postfellowship survey results.

MATERIALS AND METHODS

Questionnaires composed of 18 queries were mailed to 218United States gastroenterology adult and pediatric trainingprogram directors, as identified in Gastroenterology, Vol-ume 101, 1990. Questions concerned formal leave policiesand other characteristics of their programs, including lengthof training program, hazardous exposure policies, existenceof flexible scheduling and shared fellowship training oppor-tunities, faculty and trainee gender composition, and “oncall” schedule (Fig. 1). Three separate mailings and fol-low-up phone calls were performed to ensure a high re-sponse rate. Data were analyzed using Spearman correlationcoefficients or descriptive statistics, where appropriate.

The first cohort (1993 graduates) of 491 total UnitedStates gastroenterology trainees, whose names were pro-vided by the training program directors, received a mailed

questionnaire (Fig. 2). The responding 1993 graduates be-came our first cohort. One follow-up mailing and telephonecontact was made to reduce nonresponders. A second cohort(1995 graduates) received their questionnaires directly fromtheir training program directors—thus, the response rate isnot known. A second cohort was deemed necessary by ourstatistician to ensure significance in the findings over theextended study with the expected dropout rate.

The year 0 survey, administered to both fellow cohorts atthe end of their gastroenterology training, was an internallyvalidated survey of 32 questions relating to demographicinformation, fellowship program structure, choice of fellow-ship program, mentorship, exposure to advanced proce-dures, and use of leave policies. An additional 18-questionsupplement about the impact of managed care and the avail-ability of training in business matters was administered tothe 1995 cohort only (Fig. 3).

Both cohorts received anonymous study questionnaires atcompletion of fellowship training (year 0). These question-naires assigned unique identifiers to each respondent toassure anonymity and to facilitate longitudinal tracking ofthe subjects for later surveys at years 3, 5, and 10. Thesurveys obtained from the training program directors andthe initial surveys of graduating gastroenterologists are rep-resented in this article; abstracts of some of this data havepreviously been presented (4–8).

Data were analyzed using SAS (Cary, NC) software by �2

and Fisher’s exact test with data check for improperly codedvariables and outliers performed by the Biostatistics andEpidemiology Division of Henry Ford Health System. Theycontinue to store the data thus far obtained. Frequencydistributions and descriptive statistics were generated, andan adjusted mean was generated to compare trainee demo-graphics and characteristics of their fellowship and earlyposttraining experience. Spearman correlation coefficientswere used to determine significance of some multivariatequestions.

RESULTS

Training Program Directors SurveyOf the 218 training program directors contacted, 176 (81%)responded. Not all questions were answered by all programdirectors; therefore, data are presented as a percentage ofthose responding to each question.

LEAVE POLICIES OF TRAINING PROGRAMS. Al-though only 45% (76/168) of programs had formal leavepolicies, 67% (113/168) had granted sick leave, 42% (70/165) had granted maternity or parental leave, 18% (29/164)had granted psychiatric leave, and 16.5% (27/164) hadgranted military leave. Of those programs that did not iden-tify a formal leave policy, 26% (24/93) had plans for estab-lishing one in the future. The policies for ensuring boardeligibility after a leave varied greatly, with 48.5% (64/132)of programs requiring repetition of the same amount of time

460 Arlow et al. AJG – Vol. 97, No. 2, 2002

Figure 1. Survey of gastroenterology training program directors.

missed and 57% (73/128) demanding completion of proce-dural requirements for matriculation.

FEMALE GASTROENTEROLOGY TRAINEES. Al-though 53% of programs surveyed (93/176) had a femaletrainee, only 15.3% (162 female trainees/1062 total trainees)of all gastroenterology fellows were female. Female traineeswere more prevalent in the longer programs, with 11.6%female trainees in 2-yr programs (50 female fellows/430total fellows), 14.4% in 2.5-yr programs (21/146), and 18.7%in 3-yr training programs (91/486) (p � 0.020 overall).

Programs that offered parental leave had significantlymore female trainees (1.6- to 1.8-fold higher) than thosewithout (p � 0.05). Only 36% (58/160 responding) ofprograms had guidelines for hazardous exposure duringpregnancy. As few as 7% (12/171) had shared fellowship orflex time options. The amount of night call (�0.1712) andnumber of female faculty (0.2990) analyzed for correlationcoefficient correlated weakly with the percentage of femaletrainees. The amount of research time and exposure toradiation had no relationship to the percentage of femaletrainees.

1993 and 1995 Trainee Year 0 SurveyOf the 1993 trainees asked to participate initially, responseswere received from 244 of the 491, a 49.7% response rate.For the 1995 trainees, 149 responded, with response ratesnot defined, as the surveys were distributed by the programdirectors. Because each subject did not answer every ques-tion, data are presented as a percentage of those respondingto each question. The cohorts of matriculating gastroenter-ology fellows of 1993 and 1995 were compared to verifythat the cohorts were statistically comparable, then com-bined to achieve statistical significance. (Variations betweenthe 1993 and 1995 cohorts will be noted.)

The combined cohort comprised 19% female trainees;17.2% of the 1993 cohort (42/244) and 22.7% of the 1995cohort (33/149) were female.

SELECTION OF GASTROENTEROLOGY TRAININGPROGRAM. Male and female trainees chose gastroenter-ology programs within the match in 58–66% of cases, andthe participation in match did not differ between the sexes(males � 175/265, 66.0%; females � 37/64, 57.8%, ns).

Figure 2. Demographic survey: fellows in gastroenterology—initial.

462 Arlow et al. AJG – Vol. 97, No. 2, 2002

Figure 2. (continued)

463AJG – February, 2002 Gender, Managed Care, Training, and Career Choices

However, the overall percentage who participated in thematch declined from 69.1% (159/230) in the 1993 cohortto 53.5% (53/99) in the 1995 cohort (p � 0.007). Com-parable with the training director data, female traineeswere more likely to be in a 3-yr program than their malecounterparts, with distribution to 2-, 3-, and 4-yr pro-grams seen in Table 1.

During the interview process for gastroenterology fellow-ship, candidates faced questions that were gender specific.When asked, “Did you encounter any gender-related ques-tions when applying for a position in a training program?,”female applicants answered in the affirmative more oftenthan men (37.5% [27/72] vs 2.3% [7/311], p � 0.001).

When asked which factors determined the rank of aparticular program when selecting a training program, therespondents highly ranked clinical exposure, academic qual-ity, and geographical reasons (Table 2), although clinicalexposure was more important for male trainess (p � 0.001).Family reasons were more important for the female trainees

(p � 0.04). Of less importance to all fellows were salaries,the presence of a mentor, and benefits and leave policy.

FELLOWSHIP AND ADVANCED TECHNIQUE TRAIN-ING. In the year 0 survey of the 1993 and 1995 cohortsthere were no significant gender-related differences for ba-sic training issues, such as amount of research and on-calltime. There were no gender differences in amount of fluo-roscopy exposure. Both men and women were equally boardeligible or board certified at the completion of their training.

However, in the year 0 supplement survey of the 1995cohort (Table 3), women trainees were less likely to receivetraining in diagnostic and therapeutic ERCP or laser tech-niques. Only 38% of women, versus 65% of men (p �0.005), received training in therapeutic ERCP, and 12% ofwomen, versus 34% of men (p � 0.017), received trainingin laser therapy. Both genders received equal training inendoscopic ultrasound.

The perception of discriminatory practices or sexual ha-

Figure 3. Supplemental questionnaire for 1995 gastroenterology graduates.

464 Arlow et al. AJG – Vol. 97, No. 2, 2002

rassment among our trainees remains, with 39% of the 1995cohort women answering in the affirmative to “Did youperceive any discrimination in your training program?” and19% to “Did you encounter any sexual harassment in yourtraining program?” (p � 0.001).

MENTORSHIP IN GI TRAINING. Up to 70% of all fel-lows have a mentor, with no significant rate differences inmale or female trainees (Table 4). However, 84.4% of maletrainees had a same-sex mentor, compared with 5.8% offemale trainees. This statistic is interesting in light of datafrom the training directors survey indicating that 47.8%

(154/322) of clinical faculty and 48.0% (110/229) of full-time academic gastroenterologists are female.

MARITAL STATUS AND CHILDREN. As opposed totheir male colleagues, female trainees delayed starting orexpanding a family. Although female and male trainees hadsimilar marital status (Table 5), women were significantlymore likely to be childless (p � 0.001). Approximately

Figure 3. (continued)

Table 1. Trainee Response: Length of Gastroenterology Trainingby Gender

Male Female

2 yr 179/313 (57.2%) 29/74 (39.2%)3 yr 129/313 (41.2%) 43/74 (58.1%)4 yr 5/313 (1.2%) 2/74 (2.7%)

p � 0.020 overall.

Table 2. Trainee Response: Selection of Fellowship Program

Factors That Influenced Decision toChoose a Particular Program Male Female p

Clinical exposure 2.81 2.23 �0.001Academic quality 2.35 2.36 nsGeographical location 2.69 2.93 nsFamily reasons 4.26 4.99 �0.04Presence of a mentor 5.92 5.89 nsSalary 6.71 6.91 nsBenefits and leave policy 7.80 7.92 ns

Scale of 1–10: 1 � most important, 10 � least important.

465AJG – February, 2002 Gender, Managed Care, Training, and Career Choices

20.3% of female trainees altered their family plans duringtraining, compared with 7.1% of the male fellows (p �0.001). However, women did take advantage of existingleave policies as needed (Table 6), with 26.8% versus 4.9%taking maternity or parental leave (p � 0.001), and 9.5%versus 2.2% (p � 0.003) taking other available leave.

KNOWLEDGE OF FELLOWSHIP AND LEAVE POLI-CIES. Both male and female trainees were less aware ofimportant policies of their training programs regarding ma-ternity or parental leave (p � 0.001), hazardous exposurepolicies (p � 0.001), or policies on flex time or sharedfellowships (p � 0.006) or information on board eligibilityin the event of a leave (p � 0.001) than they were of otherpolicy issues of fellowship training. However, both maleand female fellows had similar knowledge of sick leave andmilitary leave policies. Despite more children among maletrainees, few took advantage of parental leave policies.

MEMBERSHIP IN GASTROENTEROLOGY ORGANI-ZATIONS. Male and female fellows completing their train-ing were similarly represented in the four main gastroenter-ology specialty organizations (Table 7).

BUSINESS TRAINING AND CAREER SELECTION.The second component of this study focused on the businessof health care and how the impact of such training for thisfacet might influence job selections. Graduating fellows ofthis era were concerned about the impact of managed careon their nascent careers, and felt unprepared to meet thechallenge. In the year 0 supplement survey of the 1995cohort, 45% of 1995 graduates reported that selection oftheir first job was influenced by health care changes, with32% of those choosing a salaried position over traditionalprivate practice. Nineteen percent of women graduates feltthey received education in business matters, compared with5% of men (p � 0.015). Few trainees were instructed onmanaged care, salary negotiations, or costs of procedures,labs, radiographs, or medications (Table 8).

Women entering the field of gastroenterology discovereda community desire for women gastroenterologists amongfemale patients. Women in gastroenterology training no-ticed gender-specific requests for their services while intraining. Seventy-four percent (55/74) of women traineeshad female patients overtly express a preference for a femalephysician, and 51.2% (162/316) of male trainees had pa-tients explicitly communicate an inclination for a femalephysician (p � 0.0001).

DISCUSSION

Recruitment of qualified female gastroenterology trainees isessential to meet the demands of academic and privatepractices and patients for female gastroenterologists. Somepatients seek out female gastroenterologists and might notcomply with required examinations if a female gastroenter-ologist is not available. A recent gastroenterology abstract(9) revealed that 61% of women and 37% of men (p �0.0001) would be more willing to have a flexible sigmoid-oscopy by a same-sex gastroenterologist. Similar specificrequests for same-gender gastroenterologists were seen inour survey, indicating a demand for more female gastroen-terologists to service the colorectal cancer screening of ouraging population. Perhaps if women completing their inter-nal medicine training were aware of this underserved pop-ulation, they would be more likely to choose gastroenterol-ogy as a career.

Our survey indicates that the number of female trainees ina gastroenterology training program correlates loosely withthe likelihood of having an established maternal or parentalleave policy. This suggests that programs with more women

Table 4. Trainee Response: Mentorship During Fellowship

Male Fellows Female Fellows

Had a mentor duringtraining

198/307 (64.5%)* 52/73 (71.2%)*

Same-gender mentor 173/205 (84.4%) 3/52 (5.8%)Opposite-gender mentor 7/205 (3.4%) 37/52 (71.2%)Mentors of both genders 25/205 (12.2%) 12/52 (23.1%)

* Nonsignificant.

Table 5. Trainee Response: Marital Status and Number ofChildren

Male Female p

Single 56/297 (18.9%) 18/68 (26.5%) nsMarried 236/297 (79.5%) 47/68 (69.1%) nsDivorced 5/297 (1.7%) 2/68 (2.9%) nsWidowed 0/297 (0%) 1/68 (1.5%) nsNo children 114/302 (37.8%) 45/70 (64.3%) �0.001One child 68/302 (22.5%) 13/70 (18.6%)Two children 82/302 (27.2%) 10/70 (14.3%)Three children 36/302 (11.9%) 10/70 (14.3%)Four children 2/302 (0.7%) 1/70 (1.4%)

Table 6. Trainee Response: Utilization of Leave

Male Female p

Took maternity/parentalleave during training

15/305 (4.9%) 19/71 (26.8%) �0.001

Took military/sick/psychiatric leaveduring training

7/312 (2.2%) 7/74 (9.5%) �0.003

Altered family planningbecause of trainingprogram restrictions

22/310 (7.1%) 15/74 (20.3%) �0.001

Table 3. Trainee Response: Advanced Training Exposure Varia-tion Between Male and Female Fellows, 1995 Cohort

Male Female p

Diagnostic ERCP 99/115 (86.1%) 20/32 (62.5%) �0.003Therapeutic ERCP 74/114 (64.9%) 12/32 (37.5%) �0.005Laser 39/114 (34.2%) 4/32 (12.5%) �0.017Endoscopic

Ultrasound17/113 (15.0%) 3/31 (9.7%) ns

466 Arlow et al. AJG – Vol. 97, No. 2, 2002

are more likely to have such policies, or perhaps women areattracted to programs that acknowledge these needs. Fur-thermore, because women physicians are in their peak re-productive years during training, tend to select programsbecause of “family reasons,” and alter family planning toaccommodate this training, programs that recognize specialrequirements may attract the best female candidates. Deci-sions regarding delay in expanding one’s family made bytrainees were based upon shaky knowledge of such leavepolicies already existing in their training programs. Deci-sions not to inquire may have been shaped by a desire not tobe regarded as looking for special privileges, or to curryfavor with the directors who assign specialized training.Neither male nor female trainees knew of the various leaveand safety policies of their institutions, and perhaps there isconcern that requesting such information might be miscon-strued as a lack of commitment on the part of the trainee.This conclusion is supported by male trainees’ nonpartici-pation in parental leave time, despite their having a largernumber of children than their female counterparts. Dissem-ination of formal leave and safety policies (and availabilityof flexible and shared fellowships) in the training programsby the individual training directors would promote greaterawareness of such programs by both candidates and ongoingtrainees and might encourage additional excellent candi-dates to choose training in gastroenterology.

The surveys reflected gender-related trends that are ofsome concern. Although nearly 50% of full-time and clin-ical faculty were female at many academic training centersat the time of the study, female trainees were still morelikely to have an opposite gender mentor. Same-sex mentors

may be important for the young female gastroenterologist asshe tries to balance her career and her home life. Mentorshipin training allows trainees guidance in both their careerchoices and advancement in academia. The lack of same-sexfemale mentorships is troubling. As for advanced technicalprocedures, women received less advanced endoscopictraining, although it remains speculative if this discrepancyis due to lack of opportunity or interest. However, it isimportant to point out that women with less advanced en-doscopic training may find that they are less marketable orreceive a lower income based on lack of participation inadvanced endoscopic training; thus, women trainees shouldbe encouraged to pursue equal levels of specialty endo-scopic training. Women were more likely to report discrim-ination and sexual harassment both in the interview processand during gastroenterology training itself. Discriminationby gender in gastroenterology training, perhaps with limi-tations in advanced endoscopic training, may be a contrib-uting factor to the lower incomes of private practice femalegastroenterologists seen in follow-up surveys of this samecohort (3-yr survey results).

Another potential factor in the recruitment, retention, andadvancement of women in the field of gastroenterology isthat women face more career interruptions than men. Tim-ing of pregnancy often affects training and early careerdevelopment, with 13% of pregnancies occurring duringfellowship training and 28% during the early years of prac-tice (10). As seen in this study, women gastroenterologytrainees had similar training interruption by leave, perhapsto the detriment of their careers. This disparity may belessened if male trainees are encouraged to take more of

Table 7. Trainee Response: Memberships in Gastroenterology Organizations at Completion of Fellowship

Male Female p

American College of Gastroenterology 205/315 (65.1%) 42/74 (56.8%) nsAmerican Gastroenterological Association 246/316 (77.9%) 60/74 (81.1%) nsAmerican Society for Gastrointestinal Endoscopy 192/316 (60.8%) 39/74 (52.7%) nsAmerican Association for the Study of Liver Diseases 23/315 (7.3%) 7/73 (9.6%) ns

Table 8. Trainee Response (1995 Cohort Only): Business Education and Impact of Managed Care

Male Female p

Changing health care climate influenced career choice 56/115 (48.7%) 13/31 (41.9%) nsSelected salaried position over private practice 23/72 (31.9%) 6/19 (31.6%) nsThought of leaving medicine 16/112 (14.3%) 2/30 (6.7%) nsWill be working in a clinical setting 109/112 (97.3%) 29/31 (93.5%) nsNeed to follow clinical practice guidelines at work 28/108 (25.9%) 3/25 (12.0%) nsNeed to perform a certain number of procedures each

month before profit2/106 (1.9%) 2/26 (7.7%) ns

Received business training in fellowship 6/113 (5.3%) 6/32 (18.8%) �0.015Prepared for contract negotiations 5/113 (4.4%) 2/32 (6.3%) nsEducated in types of managed care 14/112 (12.5%) 2/32 (6.25%) nsEducated regarding changes in insurance industry 21/112 (18.8%) 9/32 (28.1%) nsEducated regarding procedure costs 45/112 (40.2%) 11/31 (35.5%) nsEducated regarding laboratory costs 35/112 (31.3%) 9/31 (29.0%) nsEducated regarding radiology costs 31/112 (27.7%) 8/31 (25.8%) nsEducated regarding medication costs 47/111 (42.3%) 11/31 (35.5%) ns

467AJG – February, 2002 Gender, Managed Care, Training, and Career Choices

their allowed parental leave, thus also experiencing careerinterruptions. In addition, pregnant and nonpregnant gastro-enterologists alike face potential exposure to harmful infec-tious or physical agents, both in training and in practice,with few guidelines established. Hazardous materials train-ing during fellowship should be improved, and informationshould be distributed to both male and female fellows fortheir protection, regardless of fecund status.

Participation in gastroenterology specialty societies isimportant to both male and female gastroenterologists, forcareer and intellectual advancement as well as for continu-ing medical education requirements. Women and men par-ticipate equally in gastroenterology specialty societies at theend of their fellowship training. However, perhaps in re-sponse to the multiple roles and time demands, womenphysicians do not maintain their memberships in organizedmedicine, nor do they band together to make their concernsknown (11). In 1992, women accounted for only 4% of theAmerican College of Gastroenterology’s 4875 members,and only 3% of the American Society for GastrointestinalEndoscopy (12), despite gastroenterology female graduatesaccounting for 15% of the class. Lower historical values offemale gastroenterologists may account for a portion of thisdiscrepancy; however, additional efforts should be taken byall of the gastroenterology specialty societies to retain theirposttraining membership and to encourage active participa-tion of all members, regardless of gender.

This survey was also designed to be modified over thecourse of its 10-yr duration to anticipate changes in thedelivery of health care and its impact on gastroenterology.The current changes in health care delivery have revolu-tionized the way that physicians practice medicine. Gastro-enterologists and others who use expensive technology areamong the first to experience the impact of health carereform. Gastroenterology fellows are undereducated aboutthe costs of their medical decision making regarding proce-dures, labs, radiographs, and medication. They do not havebasic training in billing, accounting, collections, or contract-ing (13). More training in the business of medicine deliveredat the fellowship level needs to be provided to enable ourtrainees to compete successfully in the managed care arena.

The ongoing study seeks to follow these gastroenterologytrainees through their early career development. It will beinformative to determine if male and female gastroenterol-ogists experience similar careers in academia and privatepractice. As noted in this study, training requirements alterthe family planning of female gastroenterologists, and thedeferred childbearing of our cohort may well be made up inthe early formative years of establishing an academic rep-utation or practice. Women physicians tend to work insalaried positions or institutional practices and are lesslikely to be self-employed, and have a lower average netincome adjusted for hours of practice (14, 15). Similarfindings of lower average income for similar hours of workare emerging in this ongoing study (3-yr survey results).

The disparity between male and female gastroenterolo-gists in both career progression and income needs to becorrected to encourage women to participate fully in ourchosen profession.

ACKNOWLEDGMENTS

Funding for this research was provided by a grant from theAmerican College of Gastroenterology. Special thanks toMs. Amy Locklear for her assistance with editorial prepa-ration of the manuscript.

Reprint requests and correspondence: Patricia L. Raymond,M.D., F.A.C.G., 112 Gainsborough Square, Suite 200, Chesa-peake, VA 23320.

Received Dec. 3, 1999; accepted Oct. 8, 2001.

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469AJG – February, 2002 Gender, Managed Care, Training, and Career Choices