It’s all in the details: start-up packages and ongoing gender bias in academic medicine

Women in STEM professions have long been told that we’ll achieve gender equity as soon as enough of us join a particular field. That turns out to be false. There are already fields where half of the scientists are women and little has changed in them.

Why? I believe that specific decision-making behaviors cumulatively add up to put women at a disadvantage and hold them back from rising to the top.

Let’s use my field — academic medicine — as an example. It’s a branch of medicine encompassing physicians and scientists affiliated with medical schools, universities, or hospitals. The physicians often combine clinical care with research. It’s crucial for creating medical miracles, like the preliminary work that made possible the mRNA Covid-19 vaccines or prosthetic heart valves or new cancer drugs. It’s also a field entered by a consistently increasing number of women over the past couple of decades. At least half of individuals in academic medicine are now women.

Despite the rising numbers of women, my research shows that gender inequity remains stubbornly entrenched in academic medicine. The data go back decades, and still show that women are paid less, promoted less often, and rarely rise into leadership positions. Even when they become leaders, their power is often diluted compared with their male colleagues. It’s time to change our approach to gender equity.

The importance of the start-up package

One specific situation — the resources in a scientist’s start-up package — helps explain how gender bias can cumulatively disadvantage women.

A start-up package is the bundle of funds and other resources given to scientists when they’re hired into a faculty position or move to a new one. It covers lab and office space, equipment, salaries, and administrative support. The bigger the start-up package, the more a scientist can do, and generous ones can provide a springboard to an important career by leading to more discoveries, grants, publications, and recognition. A stingy package can stall a career before it even takes off.

Is it possible to know for sure if gender enters into decisions about start-up packages? No. The lack of transparency about these packages means there’s no comprehensive data: no one keeps records of them, and the people who make the decisions are not held accountable for giving their rationales for them.

Despite the lack of transparency, I have both firsthand knowledge of the power of start-up packages on a career in academic medicine and some unique empirical data on other people’s experiences of them. I’ve had a successful career as a physician scientist, partly launched by a substantial start-up package, and I have conducted a qualitative study on women’s and men’s experiences in academic medicine. In 2019, I interviewed 54 women and 54 men at 16 institutions across the United States, and heard the stories of their professional trials and triumphs in nuanced, intimate detail. The results were just published in the journal Academic Medicine.

The data I collected suggest some disturbing patterns.

Here’s one example. Researcher One was recruited in mid-career to an elite institution and asked for a $2 million start-up package. “Sure,” the chair said. “We’ll give you what you need.” And the institution did. Person Two received a job offer from the same institution and was offered a package. But when Researcher Two showed up to start their new job, they found that the promised resources did not exist. The chair had never received the funds for the package, yet he neither apologized nor remedied the situation.

As it happened, Researcher One was a man and Researcher Two was a woman. Could the differences in their experiences be attributed to their gender? Not conclusively, of course. But on the whole, the men in my study reported more stories along the lines of Researcher One’s experience, and more women in my study reported stories similar to what happened to Researcher Two.

Funding can change a career

My own experience in academic medicine underscores both the lack of transparency about these important decisions and their importance for boosting a career. My first faculty position was at the institution where I completed my residency. I was not given a start-up package and didn’t know enough to ask for one — I was so thrilled that my institution wanted me on the faculty that I gladly accepted the salary and resources it gave me. Many of the women I interviewed reported the same feeling of gratitude for whatever their institutions gave them and a lack of awareness that they could ask for more.

Three years later, when I’d come to realize how important research funds were, the chair of my department received funding from a local foundation. He planned to use the money to recruit his son to our department, but his son declined the offer. I persuaded the chair to give those funds to me, and so received a windfall of $400,000. It was a matter of being in the right place at the right time and knowing about the money: luck and pluck.

This infusion of funding changed my life. I was able to do high-risk/high-reward research, through which I developed an innovative cancer drug that would have been impossible to fund with traditional grants. This enabled me to publish important papers and get more research funding from the National Institutes of Health, which helped me establish my reputation and accrue additional professional advantages. It’s hard to imagine what my career would have been like without that funding.

This money was the equivalent of a generous start-up package for me, but there had been no formal decision-making process about giving me the funds. It wasn’t based on open criteria about professional merit — although I would certainly have been eligible, based on my measurable accomplishments by that point. The institution didn’t create a process for the fair or equitable distribution of resources. Yet seat-of-the-pants decisions like this one can stall a career or give it a measurable boost.

Transparency about awarding resources would tell us a lot about what role gender plays.

Is academic medicine really a meritocracy?

Academic medicine claims to be a meritocracy. Success is supposedly defined by recognized measures of productivity such as journal articles published, grants funded, awards received, and the like. These measures are ostensibly the criteria for advancement and rewards, and they are presumed to be a neutral and accurate reflection of individual merit. If someone gets more grants and publishes more often in prestigious journals, it’s because their research is better. And — so we presume — if their research is better, it’s because of their individual talent and effort.

Although these assumptions have been challenged by studies that demonstrate inequities in the distribution of rewards, even in studies that control for productivity, the belief that academic medicine functions as a meritocracy remains entrenched. Research continues to demonstrate it isn’t, but we still have a lot to learn about exactly how advantages and disadvantages are produced in this field.

Research requires funding. Yet as my own experiences indicate, as well as the experiences of those I interviewed, the distribution of key resources may be a matter not of merit but of luck and pluck. It may be haphazard. It may even be downright unfair. When the distribution of important resources such as start-up packages is hidden from view, it is impossible to ascertain if their allocation is equitable, or to see how these hidden advantages may influence the accomplishment of more visible markers of productivity that are considered the legitimate basis of professional recognition and rewards.

As academic medicine considers how to achieve gender equity, transparency will be a key factor. When there’s no oversight of the distribution of resources and no accountability required of those who make the decisions, there’s room for unconscious bias to creep in. A true meritocracy needs to be open about how it measures and rewards merit, and start-up packages are a place to start.

Jennifer Rubin Grandis is a surgeon scientist and distinguished professor of otolaryngology‑head and neck surgery at the University of California, San Francisco.