The Path to Gastroenterology & Hepatology Leadership: Inadvertently Perpetuating the Glass Ceiling and Sticky Floor

Dear Editors,

We read with great interest the recent commentary on behalf of the AGA Division Chiefs Consortium on the “Path to Gastroenterology Leadership.”¹ This article provides important insights into the process of seeking and securing a major leadership role in Gastroenterology & Hepatology (GIH), a topic of great interest to early and mid-career faculty, ourselves included.

As the authors state, “although these are challenging times to lead, they also provide a tremendous impetus and opportunity to identify and train a new generation of high-performing leaders to define the future of our field.” Therefore, we believe that it is critical to acknowledge that the article, while well-intentioned, inadvertently reinforces the phenomena of the “glass ceiling” and “sticky floor” for women and underrepresented minority (URM)^* groups in achieving GIH leadership positions.^2–5

The “glass ceiling” is the invisible barrier to advancement beyond a certain level in hierarchy and the “sticky floor” describes how fewer women and URM are promoted or provided institutional resources at the beginning of their careers when compared to other colleagues.⁶ Both phenomena are well described in medicine and disproportionately impact the advancement of women and URM groups into leadership roles. This impact is even greater for those with intersecting identities – for example women of color – who experience additional barriers to leadership.^{7, 8}

The article reports findings from a mixed methods study in which the authors surveyed members of the AGA Chiefs Consortium and conducted semi-formal interviews of a sample of current GIH division chiefs. The survey and semi-formal interviews focused on competencies, processes and pearls of advice for becoming a leader in GIH. Table 1 of the article outlines the demographics for the qualitative portion of the study (n=14).¹ The methods state that the 14 individuals were chosen to participate “based on their experience, status, and reputation as key opinion leaders in the field of GIH.” However, only two of the 14 participants were women and race/ethnicity are not reported. Among the quantitative survey respondents (n=40 of 170 eligible), sex/gender and race/ethnicity are not reported. Additionally, there is also no discussion of whether or not attempts were made to increase sample size of women or URM groups and the lack of diversity among the sample population is not acknowledged as a study limitation. Consideration of sex/gender and race/ethnicity is critical to the interpretation, validation, and generalizability of the study findings.⁹

Lack of diversity in the study participants and authorship is not only reminiscent of the lack of diversity in GIH leadership but is also frequently encountered in medical education and medical research. Ultimately, these representations converge to reinforce disparate health outcomes for URM groups. In 2020, despite equal numbers of women and men matriculating into medical schools, there are far fewer women faculty and women in high academic ranks and leadership positions compared to men.^{10, 11} According to American Association of Medical Colleges, only 9.2% of full-time U.S. medical school faculty are from URM groups. In a 2015 analysis of the 163 GIH fellowship programs in the U.S., only 18% of GIH fellowship program directors and 7% of division chiefs were women.¹² This gender disparity in leadership in academic medicine is even more pronounced for URM women physicians.¹³ Importantly, these differences in rank and leadership position are not explained by gender or race differences in productivity or attrition from the workforce.⁴

The gender gap in leadership in GIH has been attributed to several barriers including lack of role models and gender bias.¹⁴ While the racial gap in leadership in GIH has been well-documented^{15, 16} with recently proposed solutions to address this gap,¹⁷ there is less discussion in the GIH literature about the barriers to leadership for URM groups. However, it is likely that barriers to URM leadership in other spheres apply to GIH, including isolation, minority tax, stereotype threat, and institutional racism.^{7, 18} Several solutions have been proposed to address these gaps.^17–19 In order to “identify and train a new generation of high-performing leaders to define the future of our field”, we must acknowledge gender and racial disparities in GIH leadership and then create solutions that lead to systemic change. Failure to so do will continue to reinforce the glass ceiling and the sticky floor for women and URM groups in GIH.