Week 5 ACGVGR Long Diversity

2/3/2023
American College of Gastroenterology

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Participating in the Webinar
All attendees will be muted and

will remain in Listen Only Mode.
Type your questions here so

that the moderator can see
them. Not all questions will
be answered but we will get
to as many as possible.
How to Receive CME and MOC Points
LIVE VIRTUAL GRAND ROUNDS WEBINAR

ACG will send a link to a CME & MOC evaluation to all
attendees on the live webinar.
ABIM Board Certified physicians need to complete their MOC activities by December 31,
2023 in order for the MOC points to count toward any MOC requirements that are due by
the end of the year. No MOC credit may be awarded after March 1, 2024 for this activity.

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MOC QUESTION
If you plan to claim MOC Points for this

activity, you will be asked to: Please list
specific changes you will make in your practice
as a result of the information you received
from this activity.
Include specific strategies or changes that you plan to implement.
THESE ANSWERS WILL BE REVIEWED.
ACG Virtual Grand Rounds

Join us for upcoming Virtual Grand Rounds!
Week 6 – Thursday, February 9, 2023

Liver Cancer Update and Review for the Gastroenterologist
Faculty: Ayse Aytaman, MD, FACG
Moderator: Janice Jou, MD
At Noon and 8pm Eastern
Week 7 –Thursday, February 16, 2023

Post-COVID-19 Disorders of Gut-Brain Interaction/Functional
Gastrointestinal Disorders
Faculty: Max L. Schmulson, MD
Moderator: Sarah K. McGill, MD, MSc, FACG
At Noon and 8pm Eastern
Visit gi.org/ACGVGR to Register

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Disclosures
Asmeen Bhatt, MD, PhD, FACG
Dr. Bhatt has no relevant financial relationships with ineligible companies.
Millie D. Long, MD, MPH, FACG

AbbVie: Consultant; BMS: Consultant; Calibr: Consultant; Janssen: Consultant;
Lilly: Consultant; Pfizer: Consultant, Grant/Research Support; Prometheus:
Consultant; Takeda: Consultant, Grant/Research Support; Target
PharmaSolutions: Consultant; Theravance: Consultant
Allison R. Schulman, MD, MPH

Apollo Endosurgery: Consultant; Boston Scientific: Consultant; GI Dynamics:
Grant/Research Support; MicroTech: Consultant; Olympus America, Inc.:
Consultant
*All of the relevant financial relationships listed for these individuals have been mitigated
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Promoting Gender Diversity in Non-Clinical

Realms: Engaging Women in Research and
Authorships
Millie D. Long, MD, MPH, FACG

Professor of Medicine
Director, Gastroenterology and Hepatology Fellowship
University of North Carolina at Chapel Hill
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Outline: Engaging Women in Research and Authorships
Describe current state of women in GI

Identify challenges for women in GI
Identify methods to overcome challenges for women in GI
Review the current state of publishing for women in academic gastroenterology journals
Example of prominent female physician scientists in GI
Review high impact publications led by female physician scientists
What can we do to enhance the position of women in clinical research in GI?
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Women in Gastroenterology and Hepatology

As of 2019, only 18.9% of gastroenterologists are women
More recently 40-50% of new GI fellows have been women; which may lessen the
gender gap over the next decade
Women comprise 37% of full-time associate professors and 25% of full professors
Women comprise 19% of fellowship PDs
Only 29% of division or section chief positions are held by women, 18.9% of
department chairs and 18% of medical school deans
JAMA Intern Med 2021 Jul 12.

Pallardy C. Beckers GI & Endoscopy 2015
Colleges AoAM. 2018-2019
Jamorabo DS, et al. Ann Gastroenterol. 2021; 34(3): 316-322.
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Challenges for Women in Gastroenterology and Hepatology
Many women (up to 40%) will reduce their commitment to part time or leave
medicine within 6 years
Competing interests between work and home life
Bias, unequal wage, pregnancy and motherhood related discrimination
“Third shift” work at home
Lack of formal leadership training for women
Rabinowitz LG, et al. Am J Gastro 2021L10.14309

Frank E, et al. JAMA network open. 2019;2:e198340-e198340
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Overcoming the Gap for Women in GI
Become involved at local institution or GI society

Gain leadership experience and document on CV
Build a national reputation (committee work, research output, presentations)
Establish relationships, network, collaborate
Communicate your goals and interests to enhance opportunities for sponsorship
Rotundo LC, Gaidos JK. Dis Dis Sci. 67, 397-399.
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Female authorship in major academic journals over 20 years

Of 5 major GI and Hepatology journals published in U.S., 5-year intervals were evaluated between 1992-
2012
Gender of first and last author were determined by first name and confirmation strategies (web searches,
institutional websites, etc.)
AMA data were used to determine proportion of women among active gastroenterologists for
corresponding years
A total of 2275 articles were included
18% of first authors and 10.1% of senior authors were women
Over 20 years, proportion of female first authors increased from 9.1% to 29.3% (p for trend <0.001) over 20
years
Long M, et al. Gastrointest Endosc. 2015;81(6):1440-1447.
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Female authorship in major academic journals over 20 years
Long M, et al. Gastrointest Endosc. 2015;81(6):1440-1447.
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Female editorial board membership and editorial

authorship in major academic GI journals
Determined the sex of editorial board members (n=2282) and
authors of editorials (n=1705) across 6 journals from 1985-2020 at
5-year intervals
Proportion of women editorial board members increased from 2.9%
in 1985 to 19.8% in 2020 (p<0.001)
Women authors of editorials increased from 0% in 1985 to 22.2%
in 2020 (p<0.0001)
Currently, the editorial board of AJG is 25% female
Long M, et al. Am. J Gastroenterol. 2021 Mar 1; 116(3):613-616
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Prominent Female Physician Scientists in GI
Fasiha Kanwal MD, MSHS Norah Terrault MD, MPH Uma Mahadevan MD Maria Abreu MD Linda Nguyen MD
Professor, Section Chief, Baylor Professor, Chief GI and Liver Professor, IBD Center Director, Professor, IBD Center Professor, Director GI Motility
Editor in Chief, CGH USC UCSF Director, U. Miami and Neurogastroenterology,
HCC, Patient Reported Viral Hepatitis Pregnancy and IBD Immunology, IBD Stanford
Outcomes in Cirrhosis Motility, IBS, Gastroparesis
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Prominent Female Physician Scientists in GI
Fasiha Kanwal MD, MSHS Norah Terrault MD, MPH Uma Mahadevan MD Maria Abreu MD Linda Nguyen MD
Professor, Section Chief, Baylor Professor, Chief GI and Liver Professor, IBD Center Director, Professor, IBD Center Professor, Director GI Motility
Editor in Chief, CGH USC UCSF Director, U. Miami and Neurogastroenterology,
HCC, Patient Reported Viral Hepatitis Pregnancy and IBD Immunology, IBD Stanford
Outcomes in Cirrhosis Motility, IBS, Gastroparesis
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Risk Factors for HCC in contemporary

cohorts of patients with cirrhosis
Prospective cohorts from the Texas HCC consortium and Houston Veterans Administration Cirrhosis
Surveillance Cohort
Patients w/cirrhosis enrolled from 7 centers and followed until HCC, transplant, death or June 30, 2021
2733 patients with cirrhosis included
Etiology of Cirrhosis
7406 person-years of follow up
16.1 19
Annual incidence rate of HCC: 1.71% cured HCV, 1.32% ETOH, 1.24%
NAFLD
Risks include: cured HCC [HR 2.04], smoking [HE 1.63] and
obesity [HR 1.79]
30.1 23.3
Kanwal F, et al. Hepatology. 2022 Mar 1. [epub] Active HCV Cured HCC NAFLD ETOH
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AASLD Practice Guidance: Palliative care and symptom-

based management in decompensated cirrhosis
Palliative care can be provided to patients with DC at any
stage
Palliative care can be delivered by any member of the care
team
Palliative care does not preclude the delivery of disease-
directed or even curative treatments
Hospice is different than palliative care in that it focuses
exclusively on comfort, rather than disease-directed curative
treatment, including only those with life expectancy
measured in months
Rogal S, et al. Hepatology. 2022 Sep; 76(3):819-853.
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AGA Clinical Care Pathway for the Risk Stratification

and Management of Patients with NAFLD
Kanwal F, et al. Gastroenterology. 2021 Nov; 161(5):1657-1669.
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Pregnancy In IBD and Neonatal Outcomes (PIANO)

Prospective Cohort
Mahadevan U, et al. Gastroenterology. 2021 Mar; 160(4):1131-1139.
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Exposure to Corticosteroids in Pregnancy is Associated

with Adverse Perinatal Outcomes (PIANO)
1490 mothers with IBD enrolled, 1431 live births

Steroid use was associated with preterm birth (OR 1.79), LBW (OR 1.76), and NICU admission (OR
1.54)
Late corticosteroid use (2nd and/or 3rd trimester) was associated with serious infections at 9 and 12 months
Emphasizes the importance of controlling disease activity before and during pregnancy with steroid-sparing
therapy
Odufalu D, et al. Gut. 2022 Sep; 71(9):1766-1772.
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IBD Parenthood Clinical Care Pathway
Includes care pathways from preconception to

post-partum
Evidence based assessment of medication
utilization and optimization of disease state
during pregnancy
One of the first care pathways that also
included patient advocates in the planning
and distribution
Mahadevan U, et al. Am J Obstet Gynecol. 2019 Apr;220(4):308-323.
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GI/Hepatology Female Physician Scientists
Areas of interest across the GI/Hepatology spectrum

Many are experts in women’s health issues in GI/Hepatology
ALL are also experts in other content “niches”
ALL have moved the needle for women in GI/Hepatology through their publications, mentorship of
trainees and junior faculty, patient care, leadership (journals, societies)
ALL have continued to give back to the GI community and are role models for the next generation
of female physician scientists
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What can WE do to enhance the position

of women in clinical research in GI?
Sponsor women in GI for roles in committees, leadership, and collaborative
publications
Encourage female trainees to complete research training pathways (T-32) for
formal training in epidemiology, biostatistics, grant writing
Mentor women in GI; provide career advice, opportunities, invitations for review
papers
Invite women as reviewers for our top journals (including as a co-reviewer if you
receive an invite)
Invite women to write invited reviews, participate in published conference
proceedings
Sponsor female junior faculty/fellows for leadership training programs
Be an ally: advocate for change on behalf of patients and peers
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Words of Advice for Trainees and Junior Faculty in GI

on Developing a Research Career
Networking is really critical, and women generally don’t do as good a
job of this as men. There should be opportunities on a regular basis
throughout the year that you interact with people within your
university and your field on a casual as well as more formal level.You
Uma Mahadevan MD
can be the smartest person in the room, but if no one knows who you
are, you will struggle to get recognized for your work.
Choose your mentor wisely! If you pick someone very junior, you
may be seen as a competitor or a hindrance in their own
advancement. If you pick someone too senior with too many people,
you will only get the rubber stamp mentorship. Pick someone you
admire and connect with. Someone with a track record of mentoring
people who have developed independent careers.
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Words of Advice for Trainees and Junior Faculty in GI

on Developing a Research Career
Write every day. Set aside 30 min with no texts, IG,

twitter and write without looking anything up.
Sending a manuscript doesn’t have a deadline so you
must create your own discipline. Maria Abreu MD
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What does the future hold for women in GI?

Percentage of women will continue to in specialties including GI
will increase
Diversity will enhance all aspects of clinical care and research
Women will continue to gain leadership skills and leadership
positions
In 2017, all 4 GI societies were led by women, this will occur
with more frequency as deserving women are recognized
• Anna Lok (AASLD), Carol Burke (ACG), Sheila Crowe (AGA), and
Karen Woods (ASGE)
The future is bright!
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October 21-26, Charlotte, NC
It's Time to Break Another Glass Ceiling:

Women and Interventional Endoscopy
Allison R. Schulman, MD MPH

Associate Professor of Medicine & Surgery
Director of Bariatric Endoscopy
Interventional Endoscopy
Michigan Medicine
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• Background
• Despite an increasing number of women matriculating into

medical school, many challenges persist
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• Status of diversity in leadership
Nat Rev Gastro Hep 2020
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<0.7% of U.S. medical school faculty

full professors are Black women
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• Interventional endoscopy training
• Advanced endoscopy (AE) has

become a popular career
choice with a growing number
of applicants
• Dedicated AE fellowships (AEF)
originated in the 1980s,
focused on ERCP
• Field has grown tremendously
• Technically demanding, require
a special skill set
• Dedicated year in AE has
become apparent
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• The allure of an ever-evolving and innovative field is demonstrated by a

substantial increase in the number of AEFs in the country
• In the year 2000, there were about 10 AEFs, and currently there are >100
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• Despite its increasing popularity, women interventionalists

have been a glaring absence in this phenomenon
• For the 2018-2019 academic year, women represented only
12% of incoming AE fellows
• The percentage of female trainees interested in AE diminishes
as general GI fellowship progresses
• A greater proportion of men (78%) than women (59%) were
interested in AE as they began their GI fellowships
• Interest declined significantly among women as compared
with men for ERCP (22% vs 77%)
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51% Entering medical school
48% Graduating medical school
37% Entering GI fellowship
Percent of women
in 2019… 25% Graduating GI fellowship
18% Practicing GI
12% Matched into AE fellowship
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• What are the barriers?
• Underrepresentation of • Gender-based bias in

women workplace
• Leadership • Discrimination
• Lack of visible mentors • Implicit bias
• Lack of safe and comfortable • Imposter syndrome
environment • Work-life balance
• Ergonomics • Schedules
• Concerns for radiation • Family planning/pregnancy
exposure
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• Survey of AEF program directors participating in the ASGE match
• Aims:
• Describe program characteristics
• Identify contributors to gender disparity including barriers and
facilitators influencing women pursuing AEF training
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• 59.3% response rate (38/64)

• Women represented
• 15.8% (6/38) of AEF PDs
• 13.2% (5/38) of endoscopy chiefs
• 14.8 ± 17.0% of AEF faculty
• 12.0 ± 11.1% of AEF trainees over the past 10 years
• 47.4 % (18/38) programs reported no female AE faculty (!)
• 31.6 % (12/38) of programs have never had a female fellow (!)
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• Percentage of female fellows was strongly associated with percentage

of female AEF faculty (ß = 0.43, P < 0.001)
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• Percentage of female fellows was strongly associated with percentage

of female AEF faculty (ß = 0.43, P < 0.001)
• Most important cited barriers to recruitment:

• Inflexible hours and call (mean rank 3.3 ± 1.1)
• Exposure to fluoroscopy (2.9 ± 1.1)
• Lack of women endoscopists at national conferences/courses (2.9 ± 1.1)
• Lack of female mentorship (2.9 ± 1.0)
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• Why does this matter?
• 22-70% women with gender preference for endoscopists

• Patient gender single most predictive factor for same-sex preference
• 34.1-90% delay care until same-gender provider
• Study of 1078 Muslim patients

• 66% indicated gender preference
• 72% would delay care by 7 days for same gender
Anglade P et al. GIE 2021

Kamani L et al. GIE 2021
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• In survey, 24.7% women vs 37.5% men (no diff) wanted career in advanced
endoscopy
• Major motivating factors (men and women):
• Strong personal interest
• Preference for procedures
• Encouragement from a mentor
• Wider skill sets for jobs
• No gender difference in career satisfaction for those who went into AE
David Y et al. Am J Gastro 2021

Courtesy of Amrita Sethi
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• Academic faculty workforce should reflect female medical school

matriculants
• Increasing women in advanced endoscopy brings diversity of thought
• Serves valuable need for our patients (women prefer women)
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• How do we achieve this?
• System based factors:
• Evaluation of hiring practices • Avoid pipeline “leaks”

• Zero-tolerance policies for • Ensure advancement opportunity,
harassment parental support, an environment
• Ensuring equitable representation without harassment, sponsorship
• Transparency surrounding • Avoid pipeline “plugs”
parental leave policies • Term limits
• Breast pumping time, childcare • Fair selection processes for leadership
access, schedule flexibility
• Salary compensation and equity
Bilal et al, Am J Gastro 2021
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• System based factors:
• Diversify leadership • Provide opportunities

• Change the environment • Elevate and amplify perspectives
• Create networks and increase and voices of diversity
visibility of mentors/role models • Practice allyship
• Seek guidance
Bilal et al. Am J Gastro 2021
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• Individual factors:
• Self advocacy
• Support team of coaches,
sponsors, and mentors
• Combat the “third shift”
(household tasks)
• Allyship
Bilal et al. Am J Gastro 2021
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• Paradigm shift
• Recruitment of new endoscopists

Diversity and
• Retention of existing providers
gender equity in
• Sustainability
endoscopy
• Innovation
Adams MA, GIE 2021

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GIE 2020
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• Change at a local level (endoscopy unit / division)
• Increase presence at the table: chief of endo, meetings with unit

players (nursing, anesthesia, hospital supply)
• Amplify thoughts and ideas of others, prevent being overlooked
• Nominate others for opportunities, help overcome imposter syndrome
• Recognize good work and elevate to the level that will make a
difference (ex. email a supervisor/chief)
• Embrace failure/complications learning opportunities
• Address policies that cause barriers (pregnancy, work hours, meeting
times, etc.)
Adams MA, GIE 2021
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• Changing the environment

• Set the mission and core values
• Change the dialogue - definitions of success, qualifications
• Enhance the skillset - leadership training, professional coaching
• Bias training - without awareness there can be no change
• Provide atmosphere of safety (psychologically and physically)
• Expect excellence but reward the effort
Adams MA, GIE 2021

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• New platforms
WIE is the global organization that champions

the advancement of women through education,
professional growth and leadership development.
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• Societal involvement
• ASGE Women in Endoscopy SIG • Women in Endoscopy (WIE)

• ACG Women in GI Circle • Women in GI Network Asia
• UEG Diversity Committee Pacific Society (WIGNAPS)
• Society for Women in • Association of Black
Gastroenterology (SWiG) Gastroenterologists and
Hepatologists of America (ABGH)
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If you can’t see it, you can’t be it
Dusseldorf Live 2019

Adapted from slide courtesy of Amrita Sethi
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• Increasing visibility
If you can see it, you can do it
Adapted from slide courtesy of Amrita Sethi
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• Conclusion
• Despite an increasing number of women matriculating into medical

school, many challenges persist
• Gender disparities evident throughout medicine, with few women filling
leadership roles and being promoted
• These disparities are exacerbated in procedural fields including
interventional endoscopy
• Need to recruit and retain in order to sustain
• Need an inclusive, innovative environment
• Increase mentorship to inspire others, overcome obstructive perceptions
• Diversify leadership to enhance innovation, elevation, & promotion
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Thank you
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E RG O N O M I C S I N
ENDOSCOPY –
W H AT D O WO M E N
D O D I F F E R E N T LY ?
Asmeen Bhatt MD PhD

Assistant Professor
Department of Gastroenterology, Hepatology and Nutrition
The University of Texas Health Science Center at Houston
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E RG O N O M I C S
• Ergonomics- Greek words Ergon (work) and Nomos (laws). Term was coined by a
Polish scholar in 1857.
• Definition: an applied science concerned with designing and arranging things people
use so that the people and things interact most efficiently and safely (Merriam-
Webster Dictionary)
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W H Y I S I T I M P O RTA N T I N E N D O S C O P Y ?
Male : Female Gastroenterologists

Endoscopy related injury
• Prevalence of musculoskeletal injury ranging • Association of American Medical Colleges
from 29%-89% in physicians from performing (AAMC) data shows that only 17.6% of all
endoscopy, as summarized in several review practicing gastroenterologists are women.
articles.
• A 2016 survey revealed that 47% of • American Board of Internal Medicine (ABIM)
gastroenterology fellows reported a new statistics from academic year 2018-19 shows that
musculoskeletal injury related to endoscopy, 39% of first year gastroenterology trainees are
mostly in the first year of training. Only 25% now women!
had ergonomic training and 83% desired such
training. • Women have smaller hand sizes that do not fit
the endoscopes, have smaller muscle mass and
Shergill A et al. Gastrointest Endosc. 2009;70:145–153.
Yung D et al. Expert Rev Gastroenterol Hepatol. 2017;11(10):939-947. high levels of progesterone during pregnancy
Harvin G. J Clinical Gastroenterol 2014; 48 (7): 590-594.
Edward V et al. Endosc Int Open. 2019; 7(6): E808–E812. cause laxity of joints and ligaments, which can
Cohen D et al. Dig Dis Sci. 2008 ; 53(7):1902-1909.
Janssen I et al. J Appl Physiol (1985) 2000;89(1):81–88
all potentially lead to musculoskeletal injury.
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ENDOSCOPY
R E L AT E D I N J U RY
(ERI)
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E N D O S C O P Y R E L AT E D I N J U RY
Mechanisms
Overuse Injuries (high pinch force)
Prevalence
Repetitive Motions
29%-89% Awkward and Fixed Positions

Standing for long periods of time
Use of lead aprons
Lack of breaks and less recovery time
Sites
• Thumb, Hand, Wrist, Elbow, Shoulder
and Carpel Tunnel Syndrome
Shergill A et al. Gastrointest Endosc. 2009;70:145–153.
Harvin G. J Clinical Gastroenterol 2014; 48 (7): 590-594.
• Neck and Upper Back
Yung D et al. Expert Rev Gastroenterol Hepatol. 2017;11(10):939-947.
Ridtitid W et al. Gastrointest Endosc. 2015;81 (2):294–302.
• Lower Back
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ENDOSCOPY
R E L AT E D I N J U RY
IN FEMALES
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E N D O S C O P Y R E L AT E D I N J U RY I N F E M A L E S
• A 2004 survey of 726 laparoscopic surgeons studied the relationship between hand size and difficulty using
surgical instruments: found that the percentage of time subjects reported having difficulty using all
laparoscopic instruments was greater for the Small glove size group compared to both the Medium and Large
groups ( p < 0.001)
• A 2008 survey of U.S. gastroenterology fellows showed that respondents felt like hand size affected the ability
to learn endoscopy and a significant number of trainees, especially females, perceive that their hands are too
small for standard endoscopes
• Korean Study, n=55, Female participants (33%), Severe pain was seen in 47% (26/55), more women than men
reported severe pain (61% vs 40%, respectively, p=0.15)
• A study of 171 endoscopists from Portugal with 55% females, found that female gender was related to higher
number of musculoskeletal injury (P= 0.03) and severe pain (P=0.02)
Berguer R et al, Surg Endosc. 2004 Mar;18(3):508-12

Cohen D et al. Dig Dis Sci. 2008 ; 53(7):1902-1909
Byun Y et al., World J Gastroenterol, 2008; 14:4359-64 .
Morais R et al., Endosc Int Open. 2020; 8(4): E470–E480.
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E N D O S C O P Y R E L AT E D I N J U RY I N F E M A L E S
• Survey study of 1698 participants: Rates of Injury-75%. Male Participants – 65.7%; Thumb, neck,
hand/finger, lower back, shoulder, and wrist
• No significant difference in the prevalence of ERI between male and female gastroenterologists
• Females reported upper extremity ERI while males reported lower-back pain-related ERI
• Significant gender differences were noted in the reported mechanisms attributed to ERI
• Most respondents did not discuss ergonomic strategies in their current practice (63%)
• ERI was less likely to be reported in GI physicians who took breaks during endoscopy (P = 0.002)
• Approximately 79% of the female participants reported new-onset ERI related to pregnancy
Pawa S et al., Am J Gastroenterol 2021 Mar; 115 (3): 530-538
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P R E V E N T I O N A N D M I T I G AT I O N
Shergill A and McQuaid K. Gastrointest Endosc. 2019 Dec;90 (6):966–970.
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E N G I N E E R I N G C O N T RO L S
Colonoscope
control
Distal Auxiliary angle (left/right support device
Attachment Cap dial) assist knob/adaptor
Endoscope Related Controls

Endoscopy Unit
• Adjustable Beds
• Adjustable Monitors
Pathfinder
endoscope
overtube
Tan G and Rao S. Tech Gastrointest Endosc 2019; 21:133-139
Aer-O-Scope
Shergill A et al. Gastrointest Endosc. 2021;93 (3):704–970 Colonoscope system Invendo
Wei M et al. Gastrointest Endosc 2021 Mar;93(3):740-749
Colonoscope system
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Cushioned Or Insole
Shoes
Anti-Fatigue
Floor Mats
Compression
Stockings
Two-Piece
Lead Aprons
OTHERS….
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A D M I N I S T R AT I V E C O N T RO L S
Ergonomics training/ Safety culture:

• A 2021 Core Curriculum article for “Ergonomics in Endoscopy” addresses the training environment, goals of
training (cognitive, technical and non-technical skills) and training processes and assessment of training
• A 2020 study showed that simulation-based Endoscopy Training Curriculum (ETC) is associated with reduced
risk of Musculoskeletal Injury during endoscopy.
Walsh C et al. Gastrointest Endosc. 2021 June; 93 (6): 1222-1227

Khan R et al. Gastrointest Endosc. 2020 Nov;92(5):1070-1080
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A D M I N I S T R AT I V E C O N T RO L S
• Ergonomics “Time Out”:
A 2019 Quality Improvement Project aimed at GI faculty, fellows, nurses and technicians used an
“Ergonomic Checklist” among other measures to educate and improve Endoscopy Ergonomics.
• Endoscopy Schedule:
Incorporating non procedure days for recuperation
• Endoscope Maintenance
Ali MF et al. Tech Gastrointest Endosc. 2019, 21(3): 159-161
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P E R S O NA L P RO T E C T I V E E Q U I P M E N T
• Endoscopist’s Technique: “Pinkie Maneuver”, Place Shaft on the Bed
• Microbreaks/Stretches: A 2016 study of 56 surgeons showed that incorporating microbreaks with exercises
during surgery resulted in self-reported improvement or no change in their mental focus (88%) and physical
performance (100%) and significantly reduced discomfort in the shoulders. 87%of the surgeons wanted to
incorporate the microbreaks with exercises into their OR routine
• Maintain Physical Fitness: One 2019 article from the Am J Gastroenterol called on endoscopists to train as
“endo-athletes” and adopt the Ergonomic Pentathlon- Equipment (adjusting to appropriate heights), Preparation
(optimizing layout), Teamwork (teaching team best ergonomic practices), Recovery (regular exercising and
stretching between cases) and Reflection (contemplating how to improve ergonomics), as principles to help reduce
risk of injury
Ali MF et al. Tech Gastrointest Endosc. 2019, 21(3): 159-161

Hallbeck M et al. Appl Ergon. 2017 Apr;60:334-341
Zibert K et al. Am J Gastroenterol. 2019 Apr;114(4):541-543.
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E RG O N O M I C S
IN ENDOSCOPY
- W H AT D O WO M E N D O
D I F F E R E N T LY ?
79
METHODS
• A survey instrument was designed in REDCap.

• The survey was distributed as a REDCap link via Demographic
email to participants (practicing gastroenterologists) in Data
2020 and responses to the survey were stored within
REDCap.
• Equipment
•Endoscopy room
• The study protocol was approved by the IRB at the orientation
University of Texas Health Science Center at •Use of specific parts of the
endoscope
Personal
Houston. Preferences •Styles of performing
various techniques
• Statistical data analysis was done using the Stata

software version 14.2. Majority of the overall data •Sites of injury
contained categorical variables which were •If time was taken off from
work?
summarized as frequency for analysis and the Injury from •Use of corrective lenses
statistical significance between females and males performing •Preferences to improve
ergonomics
were determined. endoscopy
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40
2/3/2023
Yes Female Male p-value

(n=107) (n=41) (n=66)
Age
<40 years 45 (42.1%) 21 (46.7%) 24 (36.4%)
40-60 years 45 (42.1%) 18 (40%) 27 (40.9%) 0.04*
> 60 years 17 (15.8%) 2 (11.7%) 15 (22.7%)
Years in practice
<5 years 31 (29%) 13 (31.7%) 18 (27.3%)
5-10 years 32 (30%) 16 (39%) 16 (24.2%) 0.12
>10 years 44 (41.1%) 12 (29.3%) 32 (48.5%)
Practice setting
Academic/University 81 (75.7%) 34 (82.9%) 47 (71.2%)
Private 17 (15.9%) 5 (12.2%) 12 (18.2%) 0.37
Hospital employed 9 (8.4%) 2 (4.9%) 7 (10.6%)
S U RV E Y Gender distribution of practice

Solo practice
<25% female
1 (0.93%)
46 (43%)
0
18 (43.9%)
1 (1.5%)
28 (42.4%) 0.85
25-50% female 51 (47.6%) 19 (46.3%) 32 (48.5%)
PA RT I C I PA N T >50% female 9 (8.4%) 4 (9.8%) 5 (7.6%)
CHARACTE RI STI CS Weekly case volumes

<20 cases
20-40 cases
38 (35.5%)
49 (45.8%)
18 (43.9%)
20 (48.8%)
20 (30.3%)
29 (43.9%) 0.04*
>40 cases 20 (18.7%) 3 (7.3%) 17 (25.8%)
Perform advanced endoscopy 38 (35.5%) 8 (19.5%) 30 (45.5%) 0.00*
Work with GI Fellows 77 (71.9%) 31 (76.6%) 46 (69.7%) 0.50

Height
<5’2” 9 (8.4%) 9 (21.9%) 0
5’2” – 5’8” 43 (40.2%) 28 (68.3%) 15 (22.7%) 0.00*
>5’8” 55 (51.4%) 4 (9.8%) 51 (77.3%)
Glove/Hand Size
X-Small 1 (0.9%) 1 (2.4%) 0
Small 21 (19.6%) 20 (48.8%) 1 (1.5%)
Medium 45 (42.1%) 20 (48.8%) 25 (37.9%) 0.00*
Large 30 (28 %) 0 30 (45.4%)
X-Large 10 (9.4%) 0 10 (15.2%)
Simulation device training 36 (33.6%) 13 (31.7%) 23 (34.8%) 0.73

during fellowship
81

(n=107) (n=41) (n=66)
Physician position
Predominantly standing 103 (96.3%) 41 (100%) 62 (93.9%) 0.27
Predominantly sitting 4 (3.7%) 0 4 (6.1%)

Patient Bed Level
ENDOSCOPY
At physician hip level 70 (65.4%) 28 (68.3%) 42 (63.6%)
0.79
Above physician hip level 30 (28%) 10 (24.4%) 20 (30.3%)
Below physician hip level 7 (6.6%) 3 (7.3%) 4 (6.1%)
Monitor Height
At physician eye level 63 (58.9%) 22 (53.7%) 41 (62.1%)
0.42
STYLES
Above physician eye level 34 (31.8%) 16 (39%) 18 (27.3%)
Below physician eye level 10 (9.3%) 3 (7.3%) 7 (10.6%)
Endoscope tower location Endoscope control hold technique
Behind physician 94 (87.8%) 36 (87.8%) 58 (87.9%)
0.73
In front of physician 6 (5.6%) 3 (7.3%) 3 (4.5%)
To the left of physician 7 (6.6%) 2 (4.9%) 5 (7.6%)
Endoscope wheel locks used frequently?
0.65
Yes 26 (24.3%) 9 (21.9%) 17 (25.8%)
No 81 (75.7%) 32 (78.1%) 49 (74.2%)
Hand predominantly used to turn small wheel on
endoscope
0.03*
Left 68 (63.5%) 21 (51.2%) 47 (71.2%)
Right 39 (36.5%) 20 (48.8%) 19 (28.8%)
Endoscope control hold technique
Umbilical cord inside the forearm 37 (34.6%) 4 (9.8%) 33 (50%) 0.00*
Umbilical cord outside the forearm 70 (65.4%) 37 (90.2%) 33 (50%)

Feedback asked from colleagues regarding endoscopy
posture
0.85
Yes 3 (2.8%) 1 (2.4%) 2 (3%)
No 104 (97.2%) 40 (97.6%) 64 (97%)
Colonoscope used in petite or low BMI patients
0.01*
Pediatric colonoscope 79 (73.8%) 36 (87.8%) 43 (65.1%)
Regular colonoscope 28 (26.2%) 5 (12.2%) 23 (34.9%)
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Preferred method for turning the endoscope shaft during procedure

(n=107) (n=41) (n=66)
Using the small (left/right deflection) wheel 49 (45.8%) 23 (56.1%) 26 (39.4%) 0.09
Torqueing or twisting the shaft 101 (94.4%) 40 (97.6%) 61 (92.4%) 0.26
Turning your left forearm (that is holding the endoscope 51 (47.7%) 17 (41.5%) 34 (51.5%) 0.31
control)
TECHNIQUE Turning your body 44 (41.1%) 16 (39%) 28 (42.4%) 0.72
Preferred method for stabilizing the endoscope shaft during procedure
PREFERENCES Yes Female Male p-value

(n=107) (n=41) (n=66)
Stabilize with your body 70 (65.4%) 28 (68.3%) 42 (63.6%) 0.62
Place shaft on the bed 72 (67.3%) 27 (65.8%) 45 (68.2%) 0.80
Hold the shaft with your fingers of left hand 53 (49.5%) 23 (56.1%) 30 (45.5%) 0.28
Ask for assistance from tech/nurse 30 (28%) 11 (26.8%) 19 (28.8%) 0.82
83
I N J U RY F RO M P E R F O R M I N G E N D O S C O P Y
Injury from performing endoscopy
(n=107) (n=41) (n=66)
Experienced any pain or tingling numbness associated with 53 (49.5%) 26 (63.4%) 27(40.9%) 0.02*
performing endoscopy
Pain in wrist 18 (16.8%) 11 (26.8%) 7 (10.6%) 0.02*
Pain in hand, thumb or fingers 43 (40.2%) 20 (48.8%) 23 (34.8%) 0.15
Pain in elbow 8 (7.5%) 3 (7.3%) 5 (7.6%) 0.96
Pain in neck 15 (14%) 8 (19.5%) 7 (10.6%) 0.19
Pain in shoulder 18 (16.8%) 7 (17.1%) 11 (16.7%) 0.95
Pain in upper back 11 (10.3%) 5 (12.2%) 6 (9.1%) 0.60
Pain in lower back 15 (14%) 9 (22%) 6 (9.1%) 0.06
Pain in hip 3 (2.8%) 1 (2.4%) 2 (3%) 0.85
Pain in knee 5 (4.7%) 0 5 (7.6%) 0.07
Pain in ankle 1 (0.9%) 0 1 (1.5%) 0.42
Pain in foot 3 (3.7%) 3 (7.3%) 1 (1.5%) 0.12
Taken time off from work to treat pain, tingling or numbness 9 (8.4%) 1 (2.4%) 8 (12.1%) 0.07
Needed corrective lenses or a change in prescription of lenses 10 (9.3%) 3 (7.3%) 7 (10.6%) 0.57
due to performing endoscopy
84

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U N I VA R I AT E A N D M U LT I VA R I AT E A NA LY S I S
Have you experienced any Factor Coefficie Standard p-

pain or numbness associated p-value nt error value
with the procedure? Weekly endoscopy case volume 0.137 0.313 0.66
(n=107) Yes No Gender 1.355 0.503 0.00*
Gender Female 26 (63.4%) 15 (36.6%) 0.02* Performing fluoroscopic or advanced 0.859 0.489 0.07
Male 27 (40.9%) 39 (59.1%) endoscopic procedures
Do you work with GI Yes 33 (42.9%) 44 (57.1%) 0.03* Endoscope hold control 0.029 0.492 0.95
fellows in training? No 20 (66.7%) 10 (33.3%) Monitor height location -0.031 0.360 0.93
Weekly endoscopy case < 20 cases 16 (42.1%) 22 (57.9%) Working with fellows in training -1.102 0.488 0.02*
volume 20 – 40 cases 28 (57.1%) 21 (42.9%) 0.34
> 40 cases 9 (45%) 11 (55%) Endoscope control hold technique
Performing fluoroscopic Yes 22 (57.9%) 16 (42.1%)
or Advanced endoscopic 0.19
No 31 (44.9%) 38 (55.1%)
procedures
How do you prefer to hold Outside the 36 (51.4%) 34 (48.6%) 0.59
the endoscope? forearm
Inside the 17 (45.9%) 20 (54.1%)
forearm
At what height is the Above eye level 18 (52.9%) 16 (47.1%)
monitor set for your At eye level 31 (49.2%) 32 (50.8%) 0.77
procedures? Below eye level 4 (40%) 6 (60%)
85
P R E F E R E N C E S T O I M P ROV E E N D O S C O P Y
E RG O N O M I C S
Preferences to improve ergonomics
(n=107) (n=41) (n=66)
Pre-procedure posture safety check list 70 (65.4%) 32 (78%) 38 (57.6%) 0.03*

Wear a posture sensor on your back which signals you to stand up 35 (32.7%) 20 (48.8%) 15 (22.7%) 0.00*
straight
Use braces at the site of pain to provide stability 35 (32.7%) 19 (46.3%) 16 (24.2%) 0.01*
Task colleagues (techs, nurses) to remind physician of correct 41 (38.3%) 18 (43.9%) 23 (34.8%) 0.34
posture
External items to help with position (chair, anti-fatigue mat, 43 (40.2%) 19 (46.3%) 24 (36.4%) 0.30
Christmas tree to hold shaft etc.)
Change working posture and use pauses during long procedures 49 (45.8%) 20 (48.8%) 29 (43.9%) 0.62
Re-design endoscopy room (remove unnecessary equipment, install 51 (47.7%) 20 (48.8%) 31 (47%) 0.85
adjustable monitors etc.)
Willing to try new re-designed lighter endoscopes 58 (54.2%) 24 (58.5%) 34 (51.5%) 0.47
Educate oneself about endoscopy ergonomics (attend conferences, 83 (77.6%) 31 (75.6%) 52 (78.8%) 0.70
read journal articles etc.)
86

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2/3/2023
P R E G NA N C Y A N D E N D O S C O P Y E RG O N O M I C S
• Of the 41 total female participants, 30 performed endoscopy during pregnancy (73.2%)

• Of those 30 participants, 7 (23.3%) performed advanced endoscopy with fluoroscopy during pregnancy.
These 30 participants stated that they did not use any special modifications to perform endoscopy or use
any special precautions to perform advanced endoscopy with fluoroscopy during pregnancy
• The two most common comments received from females who performed endoscopy during pregnancy
1) Procedure was preferably done sitting and
2) Fewer/lesser cases were performed each day
87
C O N C LU S I O N S
Survey Participant Characteristics- Females were shorter in height, had smaller hand sizes, performed
fewer weekly case volumes and more males than females performed advanced endoscopic procedures.
Endoscopy Styles- Females preferred holding the endoscope with the umbilical cord outside the forearm,
using the right hand to turn the small wheel and using a pediatric colonoscope to perform colonoscopy in a
petite or low BMI patient.
Technique Preferences- The preferred methods for turning the endoscope shaft and for stabilizing the
endoscope shaft during the procedure were not statistically different between the genders.
Our study is the first to highlight these subtle gender differences in endoscopy styles
88

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2/3/2023
C O N C LU S I O N S
Injury from performing endoscopy- Overwhelming percentage of gastroenterologists suffer work related
injury, especially females. Most common site on injury is hand, thumb and fingers. Females suffer from
more wrist pain than males.
Univariate and Multivariate Analysis of injury with variables- Gender is an independent risk factor for
injury. Working with a GI fellow decreases injury, while higher weekly case volumes and performing
advanced endoscopy procedures do not.
Preferences to improve endoscopy ergonomics- Our study proved a willingness to adopt options to
improve endoscopy ergonomics; will guide our future studies .
These findings provide insight into the needs for techniques to improve endoscopy ergonomics which will
likely prevent future injuries, enhance work efficiency and satisfaction.
We propose that there is a strong need for ergonomic focused specific training for female and male trainees
in gastroenterology
89
T H A N K YO U
90

45
2/3/2023
Questions
Asmeen Bhatt, MD, PhD, FACG
Millie D. Long, MD, MPH, FACG (will not be able to join for Q&A)
Allison R. Schulman, MD, MPH
91
92

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American College of Gastroenterology

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American College of Gastroenterology

Millie D. Long, MD, MPH, FACG

Allison R. Schulman, MD, MPH

American College of Gastroenterology

Promoting Gender Diversity in Non-Clinical

Millie D. Long, MD, MPH, FACG

Outline: Engaging Women in Research and Authorships

Describe current state of women in GI

American College of Gastroenterology

Women in Gastroenterology and Hepatology

JAMA Intern Med 2021 Jul 12.

Challenges for Women in Gastroenterology and Hepatology

Rabinowitz LG, et al. Am J Gastro 2021L10.14309

American College of Gastroenterology

Overcoming the Gap for Women in GI

Become involved at local institution or GI society

Rotundo LC, Gaidos JK. Dis Dis Sci. 67, 397-399.

Female authorship in major academic journals over 20 years

Long M, et al. Gastrointest Endosc. 2015;81(6):1440-1447.

American College of Gastroenterology

Female authorship in major academic journals over 20 years

Long M, et al. Gastrointest Endosc. 2015;81(6):1440-1447.

Female editorial board membership and editorial

Currently, the editorial board of AJG is 25% female

Long M, et al. Am. J Gastroenterol. 2021 Mar 1; 116(3):613-616

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Prominent Female Physician Scientists in GI

Prominent Female Physician Scientists in GI

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Risk Factors for HCC in contemporary

AASLD Practice Guidance: Palliative care and symptom-

Rogal S, et al. Hepatology. 2022 Sep; 76(3):819-853.

American College of Gastroenterology

AGA Clinical Care Pathway for the Risk Stratification

Kanwal F, et al. Gastroenterology. 2021 Nov; 161(5):1657-1669.

Pregnancy In IBD and Neonatal Outcomes (PIANO)

Mahadevan U, et al. Gastroenterology. 2021 Mar; 160(4):1131-1139.

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Exposure to Corticosteroids in Pregnancy is Associated

1490 mothers with IBD enrolled, 1431 live births

Odufalu D, et al. Gut. 2022 Sep; 71(9):1766-1772.

IBD Parenthood Clinical Care Pathway

Includes care pathways from preconception to

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