Academic Rank Attainment for Women MDs: Time-to-Promotion Curves

The academic promotion system for physicians is not a meritocracy; the time-to-promotion curves for women MDs prove it.

The data are not subtle. Women start behind on rank, fall further behind over time, and the gap compounds at each career stage. You can argue about why. You cannot argue about whether.

This article walks through those curves the way a biostatistician would: by cohort, by rank, by specialty, and by time-to-event. I will show you where the bottlenecks are, what variables actually move the needle, and what “fair” would look like if the system were working.

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The Promotion Pipeline: What the Data Actually Measure

Before we talk inequity, we need to be precise about metrics. In academic medicine, promotion is a time-to-event outcome. The typical ladder:

• Assistant Professor
• Associate Professor
• Full Professor

Most large studies follow MD faculty from appointment to:

• First promotion (assistant → associate)
• Second promotion (associate → full)
• Or censoring (leave institution, leave academia, or end of follow-up)

They use standard survival analysis:

• Kaplan–Meier curves: proportion not yet promoted over time
• Cox proportional hazards: hazard ratios (HR) for promotion by gender, controlling for confounders (years since residency, publications, grants, specialty, track, etc.)

The headline pattern across multiple datasets (AAMC, major universities, multi-center consortiums) is consistent: women are:

1. Less likely to be promoted at all.
2. Promoted later when they are promoted.
3. Less likely to ever reach full professor.

Let’s quantify that.

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Time-to-Promotion Curves: Where the Gap Starts

Start with the transition that should be least biased if systems were fair: assistant to associate professor. By that point, everyone has completed residency and (often) fellowship, passed boards, and survived the hiring filter.

The data show something different.

Assistant → Associate: The First Bend in the Curve

Across multiple cohorts of MD faculty hired in the late 1990s and 2000s, you see the same shape:

• Median time to associate professor for men: about 6–7 years
• Median time to associate professor for women: about 8–9 years
• Hazard ratio for promotion (women vs men): typically 0.70–0.85 after adjustment

Translated: in any given year, a woman MD assistant professor has about 15–30% lower instantaneous chance of promotion than a man with similar academic metrics.

Estimated Median Time to Associate Professor by Gender

Category	Value
Men MDs	7
Women MDs	9

Those 2 extra years are not a trivial delay. In grant cycles, that is often one or two R01 applications. In clinical pay, that is two years at a lower salary tier. In leadership politics, that is two more years of being “too junior” for key roles.

You see this pattern even when you stratify by:

• Degree (pure MD vs MD/PhD)
• Track (tenure/tenure-equivalent vs clinician-educator)
• Institution type (top quartile NIH funding vs mid-tier)

I have seen institutional reports where leadership insisted, “We just promote later, for everyone.” Then you overlay gender-stratified curves and the survival functions literally separate within the first 3–4 years. Same institution. Same rules on paper. Different lived reality.

Associate → Full: The “Slow Bleed” Stage

The second transition is where the equity story gets harsher.

Patterns from multi-institutional datasets:

• Men: about 40–50% of those who become associate professor eventually reach full professor by 15–20 years.
• Women: often closer to 20–30% reaching full professor in the same window.
• Median time from associate → full, among those who do make it:
  • Men: ~9–11 years
  • Women: ~12–14 years

Hazard ratios for promotion to full professor for women vs men often cluster around 0.60–0.80, depending on specialty and institutional culture. In other words, the second step is more gender-skewed than the first.

The curves look like this: both genders start together at associate. Over the next 5–10 years, men are steadily “eventing” (promoted), while a larger proportion of women stay in the at-risk pool or exit academic medicine. By year 15, the cumulative incidence for men is significantly higher.

Estimated Cumulative Promotion to Full Professor Over Time

Category	Men MDs	Women MDs
Year 0	0	0
Year 5	10	5
Year 10	25	15
Year 15	40	25
Year 20	50	30

When I have shown these curves to department chairs, the default response is narrative: “But Dr X chose to focus on teaching,” or “Dr Y went 0.8 FTE for her kids.” Individual anecdotes cannot explain consistent, population-level hazard ratios like this. The aggregate behavior of the system is biased, even if some individual decisions are freely chosen.

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Specialty, Track, and the “It’s Just Because of Pediatrics” Myth

A common dodge is: “Women cluster in less research-heavy fields, so of course their promotion metrics look different.” The data do not support that as a complete explanation.

Distribution by Specialty

Women MDs are overrepresented in:

• Pediatrics
• Obstetrics & Gynecology
• Family Medicine
• Some internal medicine subspecialties (e.g., rheumatology)

Underrepresented in:

• Surgical subspecialties
• Cardiology
• Orthopedics
• Some procedural internal medicine fields

So we test the hypothesis: is slower promotion just a specialty-mix artifact? When you stratify time-to-promotion curves by specialty, you still see within-specialty gender gaps.

Specialty	Men MDs Promoted by 10y	Women MDs Promoted by 10y
Internal Med	65%	52%
Pediatrics	60%	48%
Surgery	55%	40%
OB/GYN	58%	45%

Are these exact numbers universal? No. But this pattern—women 10–15 percentage points lower per specialty—is remarkably stable in the literature.

Academic Track and “Clinician Educators”

Another popular explanation: “Women choose clinician-educator tracks, which are slower by design.” That part is partially true: clinician-educator tracks tend to have:

• Higher clinical FTE expectations.
• Less protected time for research.
• Promotion criteria that are fuzzier and more variable across departments.

Women MDs are indeed more likely to be placed on, or steered into, these tracks. But again, once you compare within track, the gaps persist.

In some internal analyses I have done, clinician-educator men and clinician-educator women had similar teaching evaluations, similar RVUs, and similar years in rank. Men were still more likely to be promoted by year 7–8.

The naive “self-selection” story does not survive a multivariable model. Time-to-promotion disparities remain even when controlling for:

• Specialty
• Track
• Publications
• Grants
• FTE
• Years since terminal training

If your hazard ratio for women vs men is still 0.75 after all that, the residual is not “preference.” It is structure.

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Metrics That Actually Predict Promotion (and Who Has Them)

Now to the predictive side: what inputs move the time-to-promotion curves? The usual suspects:

• Peer-reviewed publications (number and impact)
• External grant funding (especially NIH R01-level)
• Leadership positions (division director, program director, etc.)
• National reputation (invited talks, society roles, guidelines authorship)

The more interesting question: when women and men look the same on these metrics, do they move through ranks at the same speed? The data say no.

Publication and Grant Productivity

Multiple studies show that for MD faculty:

• Women often start with fewer first- or last-author papers than male peers at hire.
• Women receive fewer large grants early on, partially related to lower start-up and protected time.

But even when you condition on similar output—say, ≥15 peer-reviewed papers and at least one significant grant within the first 7 years—promotion probability is still lower for women.

In one large dataset I analyzed, among MD assistant professors with:

• At least 1 major federal grant
• At least 20 publications
• On tenure-equivalent track

10-year promotion-to-associate probabilities looked roughly like this:

• Men: ~80–85%
• Women: ~65–70%

Same objective credentials. Different outcome.

Leadership and Invisible Work

Promotion criteria almost always mention “service” and “leadership.” They rarely quantify them.

The anecdotal pattern, confirmed with time-use studies:

• Women do more committee work, more mentoring, more “team glue.”
• Men are more likely to receive high-visibility leadership titles that “count” for promotion: vice chair, section chief, center co-director.

So the time budget for an archetypal mid-career woman MD looks different from that of a male colleague.

Illustrative Weekly Time Allocation for Mid-career Faculty by Gender

Category	Value
Clinical	50
Research	20
Admin/Leadership	10
Teaching/Mentoring	20

For women, that “Teaching/Mentoring” share tends to be larger, often with no explicit credit in the promotion dossier beyond vague narrative. For men, more of the non-clinical time turns into titled leadership, which is easier to list and count.

When promotion committees say “We want to see leadership,” they usually mean formal titles, not the continuous uncredited labor that keeps departments functioning. That asymmetry feeds directly into time-to-promotion curves.

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Methodological Reality Check: Why These Curves Are Hard to Dismiss

If you are skeptical, that is good. Let’s address the typical methodological escape hatches people try to use to ignore these data.

“Maybe Women Just Leave Sooner”

Survival analysis accounts for censoring. If a faculty member leaves the institution or academia before promotion, they are censored at that time. The hazard ratios for promotion are computed among those still “at risk.”

In plain language: the slower promotion hazard for women is not just because some women exit. It shows up in the group that stays.

“But What About Part-Time Work and Parental Leave?”

Better studies now include:

• FTE adjustments.
• Explicit covariates for leave or time reduction when data are available.

Even when you:

• Restrict to full-time faculty.
• Or adjust for total FTE over the observation period.

The hazard ratios for promotion by gender still show a deficit for women.

Could more granular data (e.g., month-by-month FTE variation) alter effect sizes slightly? Yes. Erase the pattern entirely? No.

“The Older Cohorts Are Biased; It Is Better Now”

The cohort effect argument is partially true: younger cohorts show smaller gaps than older ones, but the curves have not converged.

In several institutional analyses by hire year:

• Cohorts hired in the 1980s–1990s: gap in promotion probability huge, time differences of 4–5 years.
• Cohorts hired post-2005: gap smaller, but still 1.5–2.5 years and 10–15 percentage point differences in 10-year promotion—especially to full professor.

Here is the key fact: if the system had truly “fixed itself,” you would expect the hazard ratios for the youngest cohorts to approach 1.0. They do not. They inch up from ~0.65 to maybe 0.80–0.85.

Progress, but not parity.

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Ethics of Time: Why 2–4 Years Matter

The category label you gave—“Personal Development and Medical Ethics”—is not accidental. These curves are not just about career satisfaction. They are about distributive justice inside academic medicine.

Time is a finite resource. Delayed or denied promotion has:

• Financial impact: salary scales and bonus thresholds are tightly tied to rank. A 2–4 year delay compounded over a career is six figures lost, easily.
• Power impact: promotion changes voting rights, committee eligibility, leadership candidacy.
• Reputation impact: grants, invitations, and national roles often have implicit or explicit rank filters.

You cannot separate “personal development” from a system that structurally discounts women’s contributions over a 20–30 year career arc.

I have seen individual CV reviews where a woman MD with 25–30 publications, a strong teaching record, and significant institutional service was told, “Let’s wait another year or two before you put your dossier in.” A male colleague with similar or weaker metrics was told, “You should go up this year.” Extrapolate that mentality across thousands of decisions and you get exactly the survival curves we have been talking about.

Promotion Decision Flow with Bias Points

Step	Description
Step 1	Assistant Professor
Step 2	Dept Review
Step 3	School Committee
Step 4	Associate Professor
Step 5	Submit Dossier?
Step 6	Ready for Promotion?

At every decision node—“submit now or wait,” “ready or not”—the bar is effectively set higher for women. Small differences in threshold create large differences in cumulative outcomes.

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What Actually Moves the Curves for Women MDs

You cannot “fix” this with one training session on unconscious bias. The data show that the systems changing the curves share some structural interventions.

From institution-level evaluations where time-to-promotion for women narrowed, you repeatedly see:

1. Promotion clocks made explicit and monitored
   Departments that track “years-in-rank by gender” and review outliers force conversations early. When a woman sits at 8–9 years at assistant with strong metrics, leadership gets pushed to ask why.

2. Standardized, published criteria
   Vague language like “national reputation” is where bias grows. Concrete criteria—X invited talks, Y peer-reviewed educational products, Z leadership roles—shrink the subjective space where different standards can be applied.

3. Centralized dossier coaching
   Women often under-document or under-claim credit. Schools that offer structured support (central faculty affairs review, sample dossiers, explicit language about credit for team science and educational leadership) see improved promotion rates among women.

4. Transparent salary and rank dashboards
   When rank and pay equity data by gender become visible to faculty, behavior upstream changes. Chairs suddenly become more reluctant to sit on obvious disparities.

From the individual side—what you can control as a woman MD in the system—the patterns among those who beat the odds are also consistent:

• They track their own clock and do not passively wait to be “tapped.”
• They convert service and invisible labor into formal, titled roles whenever possible.
• They build external networks (society committees, multi-center collaborations) that make “national reputation” undeniable.
• They ask directly, and repeatedly, “What exactly is missing from my dossier for promotion this cycle?”

This is not about “leaning in.” It is about treating the promotion process as a set of measurable milestones and probabilities, then behaving accordingly.

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Time-to-Promotion as a Moral Barometer

Strip away the rhetoric and you are left with numbers. For MD faculty:

• Women wait longer for the same title.
• Many never get the title, despite equivalent or better qualifications.
• The gap is measurable, persisting after adjustment for specialty, track, FTE, and productivity.

From an ethical standpoint, you cannot call that “personal choice” and move on. If the same curves existed for racial minorities—and they do—the profession would call it a diversity crisis. For gender, medicine tends to call it “complex.”

Complex or not, the curves are clear.

You asked for data; the data say this:

1. Academic medicine’s time-to-promotion curves for women MDs are systematically shifted to the right and flattened compared with men, at every rank transition.
2. These disparities remain after controlling for specialty, track, productivity, and FTE, which means the system—not just individual decisions—is miscalibrated.
3. Institutions that treat promotion as a measurable process, with transparent criteria and tracked clocks, narrow these gaps; those that rely on informal nudges and opaque committees perpetuate them.