A Randomized Controlled Trial, N=2

Author: Tanya M Wildes, MD, MSCI

Keywords: Gender bias, academic medicine, medical marriage, Great Resignation

For 20 years, I have been living in a randomized controlled trial (RCT) with a sample size of 2.

The independent variable by which my co-participant and I were randomized in the mid 1970s is the presence of a second X chromosome vs the privilege of a Y chromosome.* The dependent variables observed have included both qualitative and quantitative measures related to being physicians in academic medicine, ranging from leadership opportunities and academic promotion to salary. The primary outcome we will examine today was the seminal time-to-event outcome of academic promotion, which was the first time I fully appreciated the professional impact of our different treatment groups.

My husband and I met as undergraduates where we were both premed. We happened to sit next to each other in a statistics class senior year. We joke that he asked me on a date with the dad-joke forerunner, “What are the odds you’ll go out with me?”

Fast forward a decade, with a wedding squeezed in at the beginning of our 4th year of medical school, we strode through our chosen residency & fellowships, with my pausing momentarily to give birth to our son at the end of fellowship. Then began our faculty journeys at the same institution. We worked hard, taking care of hundreds of patients, writing papers and grants, juggling shared calendars and nannies and vying for book-reading time with our toddler.

Our paths differed somewhat, with mine more focused on research and his on institutional leadership and clinical program development. But we walked in parallel, both briefly instructors then moving up to assistant professors. The evident differences in our experiences, such as salary and leadership opportunities, seemed easily explained by our different chosen fields and focuses.

I never questioned that a meritocracy existed, having grown up hearing the praise of bootstraps and the payoffs of hard work. To me, it stood to reason that promotion would naturally follow working as hard as I could for long enough. Then, there would come an “Atta, girl!” and promotion would follow.

In the fall of 2016, my trial co-participant came home and informed me that he was being recommended for promotion and that he was to submit his portfolio. I thought “Cool, must be time for that!” I assumed I would now be promoted in a similar timeframe: I had 3 times the number of publications as he did and had been awarded several grants. I do not present this data is not to suggest my CV was superior to his or to degrade his promotion; we simply had different career capital, and I had accumulated lots of what is typically valued as the currency of academic medicine.

So I entered my annual review meeting confident that I too would hear that I had “made it.” I introduced the topic and was promptly shot down with “You’re not ready…”

I inquired as to why, and was told that maybe I would be… if I received a certain type of grant... I was baffled; I was being evaluated against criteria that were not actually written requirements.

On the outside, I kept myself steady, and gently advocated for myself, walking the ridiculous tightrope of a woman advocating for herself without being deemed “pushy”. But inside, I was decimated.

Everything I believed about achievement was collapsing. I numbly walked out of the office, the walls of everything I believed about merit crumbling around me. I couldn’t reconcile it. I objectively met all the written, published criteria for promotion, so how was I “not ready”?

The pieces started to drop into place… I was experiencing gender bias. This leader had a picture in their mind about what an associate professor looked like, and I was not it. But what kind of RCT uses different measures for the same outcome?

I reformatted my CV. I started with the promotion criteria and pasted my activities and accomplishments under the criteria each fulfilled. This did get the process moving forward and I was eventually promoted (two years after my husband’s promotion). However, this delay will continue to follow me for my career. Some institutions require or at least consider a certain number of years at current rank before promotion to the next rank. He will likely become a full professor before I do. With salary often tied to rank, I may ultimately make less money over my career than if I had been promoted when I initially met criteria, alongside my peers.

There are some limitations in interpretation of the primary outcome in this small RCT. Our appointments were in different academic departments, which may have different conventions and processes for proposing candidates for promotion. However, both are governed by the same written criteria. The use of unwritten rules allows unconscious bias to flourish and contributes to disparities in promotion. And though I report here on only one small trial, my experience is not unique, and my experience were similar to those detailed in a recent qualitative study published by Murphy et al of the experiences of women faculty in academic medicine. 2 In an analysis of almost 600,000 medical school graduates from the late 1970s to the 2010s, using time-to-event analyses, women physicians were 24% less likely to be promoted from assistant to associate professor; the trend was not improving over time.

Another limitation of this study is that I am nonHispanic white; I grieve that faculty members of color face even greater barriers. A recent study of Association of American Medical Colleges data through 2019 demonstrated the faculty members who are of minority race/ethnicity underrepresented in medicine (URM) continue to experience lower rates of promotion for the assistant to associate professor level compared to their white and Asian counterparts. 4

My awakening to the fallacy of meritocracies was an earthquake in my life. I underwent a massive shift in what drove me each day. While I had always been passionate about my area of research, I no longer worked with a dual purpose of advancing my career while advancing the science. I had seen behind the curtain and knew that the academic treadmill did not have finish line. There was no “arrived”. Achievements are not what would make me “enough”. Author David Brooks calls this first path of achievement “The First Mountain.” This RCT outcome helped move me onto the Second Mountain, one focused on contribution rather than achievement, still passionate about the science, but also focused on making sure others don’t suffer the same decimation I did.

This experience also impacted my family. My husband has become a committed #HeforShe. And that little boy born at the start of our faculty journey? He’s been watching too. And he is one amazing little budding feminist, willing to speak up when he sees injustice or lack of awareness of issues related to gender bias. In fact, a recent lunchroom conversation gave him the opportunity to help a middle school classmate understand the differences between sexual assault, sexual harassment, and gender bias.

Twenty-five years ago in a stats class, sitting beside a person who would become my life partner and co-participant in this RCT, I learned that scientific questions are framed with null and alternate hypotheses. My experience has led me to reject two interrelated null hypotheses: that a meritocracy exists in academic medicine and that academic promotion was not influenced by gender. I look forward to the day where we will reject the alternate hypothesis, where the risk of bias in subjective evaluation of “readiness” are recognized, that systems are put in place to minimize this risk, and each faculty member’s qualifications for promotion are evaluated equitably.

* In this essay, I conflate sex and gender for narrative purposes.

About the author: Tanya Wildes is a hematologist/oncologist/geriatrician. She attended Washington University School of Medicine where she also completed Internal Medicine residency and Hematology/Oncology and Geriatrics fellowship. She was on faculty there through 2020; she pioneered the Great Resignation and has been a stay-at-home-mom-doctor for the last year. She is passionate about improving the care of older adults with cancer and continues research collaborations and mentoring the next generation of clinical investigators during her “career pause”. She lives in St Louis MO with her husband and son. (Twitter: @tanyawildes).