Pathology Grand Rounds: March 23, 2023 – Jennifer Grandis, MD

March 23, 2023

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Building and Sustaining Careers in Academic Medicine: A Gender Equity Lens – by Jennifer Grandis, MD

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00:00So on behalf of the pathology department,
00:03Grand Rounds Committee and also the swim
00:06liaison to status of women in medicine
00:09liaisons including Joanna Gibson,
00:11Rita Aviraj and myself,
00:13it's really my honor to introduce
00:16Doctor Jennifer Grandes. Dr.
00:18Grandis is the Robert K whereby
00:21we're forby distinguished professor
00:23and head and neck cancer and the
00:26Department of Otolaryngology and had
00:28neck surgery at UCSF she's received.
00:31Um numerous awards for her mentoring
00:33and teaching as well as her research
00:36into basic and basic and translational
00:39research into the genomics of
00:41squamous cell and other head,
00:42neck cancers and also the role
00:44of stat mediated EGFR signaling
00:46and head and neck cancers.
00:48And for her research,
00:49she's received the prestigious
00:51R35 Outstanding Investigator award
00:53from National Cancer Institute.
00:56She currently actually serves on the
00:59Board of Scientific Advisors for NCI.
01:01And she's also been an editor of The Who
01:04Blue Book for head and neck cancers.
01:07And in addition to all of that
01:09amazing work and all of those
01:12contributions as position scientists,
01:13throughout her career,
01:15Doctor Grandis has also been
01:16an advocate for diversity,
01:18equity and inclusion.
01:19And in her role as the director
01:22of the Clinical and Translational
01:24Science Institute at UCSF,
01:26she developed and implemented programs
01:29to enhance professional development.
01:31Training and mentorship of women
01:33and junior faculty,
01:34as well as trainees from underrepresented
01:37backgrounds in medicine and research.
01:40And she's also published on on that work.
01:43And so today we're really extremely
01:45lucky to have Doctor Grandis
01:47as our grand round speaker.
01:49So please join me in welcoming her.
01:57So much it is so wonderful to be
02:00here with the connections from
02:02college and from my prior work in
02:05Pittsburgh and old friends and new.
02:07And this is a topic that is
02:10especially dear to my heart.
02:11I've done a lot of work and had neck
02:14cancer when a very dear friend of
02:16mine developed HPV positive head
02:18neck cancer about a decade ago.
02:19I understood the difference between
02:22research and me search because it
02:24suddenly became really important for
02:26me to save the life of my friend.
02:29And my work on gender equity has really
02:31evolved from research to research,
02:34and I'm happy to share that
02:35story with you today.
02:37So we all are little CEO's.
02:40At least it used to feel like
02:42we were little mini CEO's when
02:44we began our academic career,
02:46and it was almost passed on to us
02:48without explicit instructions.
02:50But I understood early on that the
02:53way to be successful that was to be
02:56promoted to secure tenure, was to.
02:59Respect and adhere to the meritocracy,
03:03whether it be grant funding or peer
03:06reviewed publications or service
03:07or invitations to speak.
03:09I understood what was expected
03:10of me and I did it.
03:12And in 2004 I I climbed to the top
03:15of the mountain and I thought,
03:17oh what do I see from here?
03:21And what I saw is I was done with me.
03:23I was so uninterested in in building
03:24me up as a business anymore.
03:26I had no interest in in franchising.
03:29But I really felt like I learned a
03:31lot and it was my opportunity to
03:33really give back in a fully authentic way.
03:36And so at around this time,
03:37I was given a lot of opportunities
03:39to learn about leadership in science
03:41and medicine at the University of Pittsburgh,
03:44whereas Dr. Dasik and I were reminiscing.
03:47It was really an extraordinary time
03:49to be there because we went from
03:52really an average medical school
03:53to a top tier research institution
03:55and we came along for the ride and
03:58we really believed in the mission.
04:00Which was discovery brings patients
04:02and if the patient mission is efficient,
04:05it will then be reinforced into
04:07the discovery mission,
04:08which was absolutely true.
04:09And so I had had leadership roles
04:12in the Cancer Center where I ran
04:14a program back when we had Oregon
04:16site programs.
04:16I became the vice chair for
04:18research and my department,
04:19which is otolaryngology and then
04:21Art Levine who came from NIH is our
04:24Dean and Senior Vice Chancellor,
04:26Health Sciences.
04:27Kind of plucked me out and said,
04:30let me teach you what it's like to
04:32be a leader in academic medicine.
04:33And it was really an effort to retain me.
04:35But I really appreciated the effort
04:37because it wasn't the right time
04:38for me and my family to move.
04:40And so for about five years,
04:42I went to every Dean meeting,
04:43every chancellor meeting,
04:45every chair meeting,
04:47and I watched and I listened and I learned,
04:50and I worked on some projects
04:52that were potentially important
04:53to me that helped the university.
04:55And I also, you know,
04:56was elected to all the societies
04:58we're supposed to get.
04:59Elected to but one thing I became
05:00aware of after so many years
05:02of being one of the very few,
05:04if not the only women in the room
05:06is I couldn't really rely on my
05:09experiences alone to guide others.
05:11This is particularly true in my clinical
05:14field of head neck surgery where
05:16when I started I I was only woman.
05:20It was me and 18 men in internship,
05:23and then I was the only woman resident.
05:25And now I'm very happy to say that half
05:27of our trainees are women, half of our.
05:29Junior faculty or women.
05:30But it was a very different
05:32experience back then.
05:33And as more medical students were
05:35interested in going into ENT and
05:37they would come to me for mentorship
05:39because I had a successful career.
05:41I was a mother, I had a happy marriage.
05:43I I did.
05:44I was concerned that my experience
05:46couldn't be replicated because I
05:48was so research focused and like
05:50we could talk about why I decided
05:52to spend so much time on research,
05:54but I decided that I really needed
05:56to understand what the women in ENT.
05:59What the world looked like to them.
06:01And so I took a validated statistical
06:04survey developed by Susan McKinnon,
06:06who is a plastic surgeon at Washu,
06:09and I modified it for otolaryngology.
06:13And I sent it to all the women
06:16otolaryngologist in the country,
06:17which was 504.
06:19And I matched each woman with two
06:22men who were practicing ENT in the
06:24same region of the country who
06:25were the same age because all the
06:28surveys previously in other fields.
06:29Medicine had concluded that women
06:31were underpaid compared to men,
06:33but people minimized those findings
06:35because it was like they were
06:37comparing older men and younger women.
06:39And of course those weren't comparable.
06:41And I decided I would try to eliminate
06:44that bias by doing it this way.
06:46And it was very eye opening to me.
06:48This is before we had, you know,
06:50electronic surveys of the 121 questions,
06:53like almost 70% of the people
06:56returned the questionnaire,
06:57which was exceptionally rewarding.
06:59But I learned that women were less
07:04successful and less satisfied.
07:06And this is despite having tried
07:08to put in controls for all these
07:11different variables personally.
07:12They were more likely to be diverse,
07:14divorced or childless,
07:15and regret their choice of career
07:18and experience higher instance
07:20of discrimination and harassment
07:22on the basis of gender and.
07:25I felt like in my naive and we can talk
07:28about my awakening as I've gotten older.
07:32I thought,
07:33OK now this is information.
07:34Two things.
07:35I'll publish this because we also earned
07:3720% less money for doing the same work.
07:39I'll publish this and that
07:41will change everything right.
07:42Because we're we're data-driven
07:43and here's the data and people
07:45are going to change their habits
07:47and everybody wake up
07:48and and and and be mindful of
07:49your own career development.
07:50And these are the pitfalls.
07:52And lo and behold,
07:54it was so disappointing.
07:562019 where and when Aaron O'Brien from
07:58Mayo Clinic wrote this piece and she said,
08:00you know, Jennifer Grant has published
08:02this I'll really long time ago
08:04and newsflash nothing's changed.
08:05And in 2020 the DOXIMITY
08:08data to look at a pay,
08:10a compensation and medicine across all
08:14fields found that older Laryngology had
08:17the highest degree of gender pay inequity.
08:20So here I am.
08:22We're still here and so the question is why?
08:26And that's going to be a theme
08:27for the rest of the talk.
08:28Why? When we know a problem,
08:31and we all overtly admit that it's a problem,
08:34why doesn't it get better?
08:38So it's called and NIH.
08:40So this is a work by Tim Lay at Washu,
08:43wonderful Guy, also an R35 ALDI.
08:46And what Tim did he he directed the MD,
08:49PhD program. Maybe still does at Washu.
08:51He asked.
08:52The really important question
08:53is is there any evidence that
08:55women are discriminated against
08:56at the time of peer review?
08:58And the answer is no.
09:00But here's the bottom line is that.
09:03Women stop applying for grants.
09:06They're equal numbers of women and men
09:09at the F level and at the K level.
09:11By the time you get to the ER level and
09:14beyond the the gap starts widening,
09:17but the gap is in
09:19proportionate to application.
09:20It's not proportionate,
09:21it has nothing it,
09:22it seems to be independent of peer review.
09:24And so for the last couple of years
09:26I was working as a consultant for
09:28the intramural program at NIH and
09:29some extramural stuff as well.
09:31And I said, wait, you guys have data.
09:33You know, let's say from Yale,
09:36you know how many of the applications
09:38to the NIH come from women and
09:41other individuals who are
09:43underrepresented in medicine?
09:45Yes, you do. Does Yale know?
09:48And they're like,
09:48we don't know.
09:49I said I'll bet you they don't
09:51because I went to UCSF and I said,
09:52do you have,
09:53does anybody here have any
09:55idea how well represented are
09:57women and minority populations
09:59are in the application pool?
10:02And the answer was nobody knew because.
10:04And and so I am really pushing
10:05hard at the NIH to give us our
10:08scorecards even if they give it
10:10to us privately because they're I
10:11I've seen the data and there are
10:14institutions where close to half of
10:15the applications come from women.
10:17And the only reason I'm using
10:19women as a proxy because we make
10:22up enough of the pool of potential
10:24applicants that it's actually the
10:26numbers are worth looking at it's.
10:29Dismal when it comes to other
10:30groups who are underrepresented
10:32in medicine with no evidence of
10:34any improvement overtime.
10:35So I'm I'm hopeful that we can
10:37get that information back to
10:39institution so that the Deans and
10:41the chairs know who is putting
10:43in grants and and those and
10:45I would say that the application.
10:49Discordance is reflective of a lot of things,
10:53but most importantly,
10:54resource allocation, discordance and
10:55we'll get to a little bit of that.
10:57So this is back in 2810.
11:00Years later, Tim looked at the data
11:02again and it was exactly the same.
11:04So once again, you know,
11:05science publication, here we have an issue.
11:0810 years later, nothing's changed.
11:11Now, what we've all held on to sort of
11:14as a beacon of hope is when, let's say,
11:17a woman gets a leadership position like
11:19you're Dean of the School of Medicine.
11:21The rest of us are like,
11:22you go girl and ohh progress.
11:24Things are changing,
11:26but the challenges is that the
11:28denominator has not been considered.
11:30So what I want to share with you,
11:33if you saw this,
11:34is that a few years ago they
11:36did a very smart thing.
11:38They they instead of looking
11:40at the numbers of women.
11:42Who were advancing along
11:44the academic trajectory.
11:46They took into consideration the denominator,
11:49how many women proportionally
11:51were eligible for advancement?
11:53And the sad news is that over 35 years,
11:59there's no evidence that
12:01the slopes are changing.
12:03There's no evidence that there's any
12:05significant change in advancement
12:07or narrowing of the gap over time.
12:09So that's the background to
12:10what I want to talk about.
12:12Today.
12:13Now, I mentioned to you that gender
12:16in my own career was an awakening.
12:19So when doctor Mcniff and I were
12:21students at Swarthmore College,
12:23it was Coed.
12:24It had been co-ed since its inception,
12:26and I never once Jen got
12:28the feeling that I was.
12:30Inhibited from doing anything I wanted
12:32to in life because I was a woman.
12:34It it was not part of the vocabulary,
12:36although I did learn later
12:38on this Jenny may recall,
12:39I got an award when we graduated and
12:41there was a comparable war to a man and
12:43we called them best girl and Best Boy.
12:45And I found out later on that the best
12:47boy got more money than the best girl.
12:50So even good old Quaker Swarthmore
12:53College has an opportunity for growth.
12:55Trust me,
12:56when when the Provost discovered
12:57that there was more money being
12:58given to the male who won the prize
13:00and the female won the prize,
13:01they changed the rules.
13:02But it's just endemic, you know,
13:04that's my feeling is I don't want,
13:05I don't think I want to.
13:06I want to.
13:07It probably are our villains
13:08and there probably are heroes,
13:10but most of us are just people,
13:11and most of us just come to work
13:13with the same sort of assumptions
13:15about ourselves and other human
13:17beings that we live in the
13:18life outside of work and it.
13:20Ends up contributing to this intractability.
13:23So I realized when I became a surgical
13:25intern that being a woman was
13:27different because I was the only one.
13:29And there's no doubt that I was treated
13:33differently from everybody else.
13:34But whether it was grit or
13:36resilience or my personality
13:38type or the simple awareness that there was
13:40no one to complain to, I mean, you know,
13:43my daughter's now an intern in Pediatrics.
13:45They're much nicer than surgeons.
13:46But the truth is,
13:47is that there's mechanisms now.
13:49So if, if, if.
13:50What had happened to me was happening today.
13:52There would have been an
13:54institutional mechanism or or Ave.
13:56for it to be reported it.
13:58It didn't exist.
13:58And I realized I had to learn
14:00how to be a surgeon.
14:01I had to learn the trade.
14:03So I just dealt with it.
14:05And I think one of the reasons
14:08that I became so connected to
14:10research is that it was,
14:13it seemed, less.
14:17Vulnerable to these biases.
14:19I felt like I understood the metrics.
14:21I understood how to write
14:23grants and get grants.
14:23Swarthmore taught us how to write,
14:25and I could publish papers and and it
14:28felt somehow protected from the swirl
14:31of is she a good surgeon kind of thing,
14:34you know, or or or something like that.
14:36On the other hand, there's lots of other
14:38reasons why I became a researcher,
14:39mostly because it was a way to help
14:41a whole lot more people beyond my
14:43own clinical practice.
14:44I got kind of.
14:45Used to being the only woman in the room.
14:48And I want to say this now because
14:50at the time I wasn't aware that
14:52it kind of felt good. Sometimes.
14:54I didn't process that at first.
14:56It was deeply uncomfortable and then
14:58I quote UN quote, got used to it.
15:00And, and I'll never forget,
15:02I was at a meeting in Europe and
15:04I was the only woman speaker.
15:06And I actually found the words
15:07to say to the meeting organizer,
15:09I can't believe that there aren't
15:11any other women in the world,
15:13you know, who would be able to
15:15speak on the topic of this meeting.
15:17And that he said something
15:18along the lines of, well,
15:19you, you know,
15:20you are at the same caliber as
15:22all of the other speakers here
15:24and you wouldn't want us to,
15:26you know,
15:26have to go down into like the
15:28second rank and and party was
15:30deeply offended by what he said.
15:31But I was also a little flattered.
15:34So what I would have liked to
15:35say is that what happens to you,
15:37it's kind of like Stockholm syndrome.
15:38You become used to feeling exceptional.
15:41You know,
15:42Doctor **** and I were talking about that.
15:43So in Pittsburgh, you know,
15:44by the time I was on like the 20th.
15:47You know a chair search committee
15:48is the only woman.
15:49I finally went to the Dean and
15:50said you gotta find another woman.
15:51Like there has to be more than
15:53me but but you need that.
15:54They're interesting.
15:55It's interesting, it's fun work.
15:56You get to meet people.
15:57So but it's a double edged sword
15:58and and it's something that I'm.
16:00I'm.
16:00I'm pleased I realized now.
16:02But I wasn't always a realized in
16:04that and I had this belief and I
16:06think it was naive that if I was
16:09great at what I did I would pave
16:11the way for others and I would
16:12make the world a better place.
16:14And then I kept looking behind
16:15me and like they weren't.
16:17Air like where where was the
16:19second string coming from where.
16:21And so it was a it was it was
16:24not necessarily a good solution.
16:27Now I was vulnerable to powerful
16:32men who for reasons that we can only
16:35speculate about wanted to harm me.
16:37And but by training and staying at
16:39the same institution for a long
16:41time I had even more powerful
16:43men who protected me.
16:44So when my postdoc mentor you know,
16:47stole my. Stuff and applied.
16:49And for an NIH grant with my
16:52data that didn't belong to him.
16:53The Cancer Center director
16:55fought that battle.
16:56I had to meet with the committee,
16:58but I didn't have to take it on myself.
17:00And I won't go through all the details,
17:02but I had other experiences where the
17:04CEO of the health system protected me,
17:06or my team protected me,
17:08or my chair protected me.
17:10And at the time, I didn't understand
17:12how important their protection was.
17:14It just felt like this was
17:16this was what mentors did.
17:18This is part of, you know.
17:19Living in a full throated world.
17:20And so I moved to a new institution in 2015,
17:23to a very top leadership position.
17:26I was and and I couldn't
17:29be protected anymore.
17:30There was no one there to protect me.
17:31So when the person who was became
17:34my boss started harassing me,
17:37I couldn't solve it, I couldn't fix it.
17:40And that was really the
17:42motivation to take on this work.
17:44And I realized with my accomplishments,
17:46if it could happen to me, it could happen.
17:50Absolutely anyone.
17:50And at this point,
17:52my daughter was about to start medical
17:54school and I just felt this powerful need,
17:57one,
17:57to heal and two,
17:58to use whatever voice I
18:00had to make a difference.
18:02But now it's a really important time for
18:04me to acknowledge that I am privileged.
18:07I am a cisgender,
18:09white rich woman,
18:11and even though bad things
18:13happen to me and I see bad things
18:16happening to people like me.
18:18I I need to acknowledge that
18:21the experiences of people who
18:23are even more different from
18:24the status quo than I am can be
18:27really amplified in this context.
18:29And I learned a lot in the study
18:31that I'll tell you about by
18:33interviewing people from really
18:34underrepresented backgrounds,
18:35people who are not necessarily cisgendered.
18:38And I understand that
18:39intersectionality is powerful,
18:41and we won't really understand each other's
18:44experiences until we ask and we listen.
18:47So right around the time
18:49that I was struggling,
18:50this report came out from the
18:52National Academies of Medicine.
18:54Well, it was medicine,
18:56sciences, and engineering was
18:57all the national academies.
18:59And surprise,
19:01surprise,
19:01the most pervasive harassment and
19:04discrimination on the basis of
19:06gender took place in medicine,
19:08even though the others had
19:10their challenges as well.
19:11There were five factors that
19:13they concluded in the report
19:15that created the conditions for.
19:17Harassment and discrimination
19:18in science and medicine,
19:20a perceived tolerance in the workplace.
19:23Male dominated work settings
19:25with men in positions of power.
19:28Hierarchical power structure.
19:29So there really is a chain of
19:32command and no real way to
19:34escape that chain of command,
19:36particularly if the perpetrator
19:37is in that chain of command.
19:40Title 7 and Title 9,
19:41but only symbolic compliance with it.
19:43We could talk a little bit more about
19:45that and maybe what's most important
19:47since the messages come from the
19:49top, if leadership doesn't get it,
19:52doesn't understand what's happening,
19:53it just has a trickle down impact.
19:56There may be very enlightened individuals and
19:58we can talk about the heroes and heroines,
20:00and I met many of them and I know
20:02many of them. But if we don't
20:05have systemic factors in place,
20:08we will continue to be vulnerable.
20:10To people who happen to be wonderful and then
20:13people who happen to be not so wonderful.
20:15What happens to women is that they are less
20:18satisfied with their job and their career,
20:20and they tend to withdraw.
20:22Maybe part of the dropping out from
20:25the NIH application workforce.
20:28And what I also encountered in my study
20:30that I'll share with you is when women
20:33report that they're being harassed,
20:34people either minimize the experience.
20:36My favorite response always was him.
20:40He seems so nice.
20:41And what are you supposed to do with that?
20:45Um, you know, because we're all complicated.
20:48And of course the people who harm
20:50us are loved by other people.
20:52They have families,
20:53they are decent people in some
20:55realms of their life.
20:56It doesn't mean,
20:56though,
20:57that what they're doing to you or
20:58what's happening to you doesn't count.
21:02I want to make sure that we all remember
21:05that women are just as biased as men.
21:09This was a brilliant study from Yale,
21:12and for those of you who don't remember it,
21:13I love this study was so eye opening.
21:16There was a CV and the CV was identical
21:19and the CD was either Jennifer or John.
21:22And they sent the CV to science professors
21:25at Ivy League institutions and they
21:28asked the professors, men and women,
21:31would you be more likely to hire?
21:33John or Jennifer and what
21:35would you likely pay them?
21:37And women and men,
21:38science professors in the Ivy League
21:41were more likely to want to hire
21:43John and to pay him more money.
21:45So all this means is we bring our
21:49sense of self, our impostor phenomenon,
21:51whatever we want to call it,
21:53to the workplace and we are all biased.
21:56It's just a matter of being human
21:58and it's something we just need to
22:00talk about a little bit more often,
22:01especially when it's gets gets
22:03manifested has.
22:04Consequences for other people.
22:05So my study that I'm going to
22:07tell you about is really trying to
22:10understand how gender shapes career
22:12paths in science and medicine.
22:14I hope I've now convinced you that
22:15the problem is that women physicians
22:18and scientists are underrepresented
22:20in leadership position,
22:21particularly in proportion to
22:22our presence in the field.
22:24We experience more discrimination
22:26and harassment,
22:27and we're paid less than
22:28our male counterparts.
22:29By the way,
22:30the doximity data that I told
22:32you about where my field is,
22:33like the worst offender, there was no field.
22:36In medicine,
22:37where women made as much as men zero.
22:40So every single there were
22:41better and they were worse,
22:42but there was no one where it was equal.
22:45So the reality is,
22:46I think I've said already is we
22:49recognize as this is not news.
22:51What's news is that it isn't changing.
22:54And So what I realized is that I
22:56needed to develop the research skills
22:59to understand why it wasn't changing.
23:01So I learned how to be a
23:04qualitative researcher,
23:05which is really different from doing.
23:07You know,
23:07high touch clinical investigation and
23:09cancer or molecular biology and cancer.
23:11But I was mentored by some
23:14wonderful sociologists at UCSF,
23:15and then Arlie Russell Hackshield,
23:17who's one of my heroes,
23:18also went to Swarthmore.
23:19But she's a sociologist at Berkeley and
23:22had written a lot about women's experiences.
23:23And I went out there a few times and
23:26really got some very good advice from her.
23:28So my objective and I was,
23:30I got IRB approval,
23:31I used my endowed chair to pay for it,
23:33and I wanted to listen and.
23:37Understand lots of voices in the in
23:40the all across the United States,
23:44men and women.
23:45Really importantly men too,
23:47to understand where we were.
23:49And I've always thought this,
23:51but I think Albert Einstein said it best.
23:53If I had an hour to solve a problem,
23:55I'd spend 55 minutes thinking
23:57about the problem in 5
23:58minutes about the solutions.
24:00We don't do that.
24:02We especially don't do it when
24:04it comes to these really thorny,
24:06complicated social problems.
24:07We immediately come up with solutions,
24:10and we don't fully understand the problem.
24:13So we're all surprised when
24:14the solutions don't work.
24:15So here's an example.
24:1720 years ago or so it became.
24:20Popular to often offer women an
24:22opportunity to lengthen the 10
24:24year clock so they could have
24:26children and they could get tenure
24:28and they wouldn't be punished.
24:30But because we are equitable institutions,
24:33anyone who was having a child had the
24:36opportunity to use the 10 year clock
24:39lengthening process 20 years later.
24:41When we look back at the data,
24:43men were advantaged,
24:44women were not,
24:46and the same thing seems to be
24:48likely to have happened with COVID.
24:49You know, because in most families,
24:52women are the primary
24:53caretakers of the children.
24:55Men took advantage of the COVID policies,
24:58dug deep, wrote more grants,
25:00wrote more papers,
25:01and my guess is this is going to be a
25:05space where we see an amplification of
25:07whatever inequities existed before.
25:10So I in 2019,
25:11it's important because I did
25:12this all before the pandemic.
25:14I traveled around the country and
25:17I and I sat down with 52 men and
25:2152 women at 16 different academic
25:23medical centers and I got their
25:27IRB approved consent and I recorded
25:29the interviews.
25:30I tried very hard to have a
25:32real diversity of institutions,
25:34both geographic location and you know
25:37top tier versus middle tier versus.
25:39Not so middle tier using NIH
25:42and use news rankings.
25:43The question was,
25:45was it any evidence that it
25:46was better at one than another?
25:47Newsflash?
25:48No.
25:48It's the same everywhere,
25:49but it's just,
25:50you know,
25:50different versions of social language.
25:53But it's really the same everywhere.
25:54Half by population.
25:55We're full professors or leaders.
25:57Because I really wanted people
25:59who had a Longview,
26:00and I also kind of wanted people who
26:01are in positions of accountability.
26:03I wanted to hear from their point of view,
26:04what they thought about it.
26:06All the interviews lasted about 60
26:08minutes and they were transcribed.
26:10And and and then coded and so
26:13this was new for me,
26:14but this is how we developed the code.
26:16So I had a team of sociologists
26:18and we developed our codes for the
26:21interviews based on the literature
26:22and also the salient features the 1st
26:2510 interviews trying to right size it.
26:27So we had two sets of codes.
26:29The first set of codes was all
26:30the features of academic medicine
26:32ecosystem and you can read them
26:33here and all this information is
26:35in the papers that we published,
26:37but they're pretty standard
26:39mentorship recruitment negotiations.
26:40Resources, etcetera.
26:41The second set of codes was So what
26:44we call gender related bad stuff.
26:46And it was really what are your experiences,
26:48what is your awareness,
26:50what is your observations,
26:51what is your perceived lack of awareness,
26:53et cetera.
26:53And then we analyze the data
26:55by looking
26:56for the intersections between gender
26:58related bad stuff and the features
27:01of the academic medicine ecosystem.
27:04So here are the interviewees.
27:06It was 52 men and 52
27:09women about the same age.
27:11The men were more likely to be MD's,
27:15the women more likely to be PHD's.
27:16And this is because I really tried
27:18to enrich for senior people,
27:19and there are very few women
27:21MD's who who were leaders.
27:23There were more likely to be women
27:25who were chairs of basic science
27:26departments than there were MD's who
27:28are chairs of clinical departments, 25%,
27:31assistant professors 25%, associate 50%.
27:34Um of full for the women,
27:37even more for the men.
27:38Men were more likely to
27:40have leadership positions.
27:41I tried very hard to find women
27:43with leadership positions,
27:44and men were significantly more
27:45likely to hold endowed chairs.
27:47And I think that's pretty
27:48much true everywhere.
27:50So we have published 3 papers to
27:52date in the peer reviewed literature
27:54and I'll tell you a little bit
27:56about each of those papers now.
27:59So the 1st paper we published
28:01had to do with mentorship now.
28:04Only the women reported to me that they
28:07had been sexually harassed by their mentor.
28:11Now,
28:11I'm sure that there are men in this world who
28:14have been sexually harassed by their mentor,
28:17but I didn't meet them,
28:18so I can only conclude that
28:20it's probably less common.
28:21But imagine that when this happens,
28:24mentorship is such a private place,
28:26it's so difficult to know what to do.
28:29The one woman who I met who had a
28:32postdoc mentor who sexually harassed.
28:35Who was encouraged to go to the
28:38Title 9 Office and report it,
28:41went through a formal adjudication
28:45process where his he he basically
28:48just had his hand slapped.
28:50She had to stay in his lab and she
28:53was geographically constrained
28:55by her family situation.
28:57And his argument was she misinterpreted
29:00my embrace and I'm thinking the
29:03word embrace is the problematic.
29:05Were there, however,
29:06she did what we think people should do,
29:10and it didn't help her at all.
29:12In fact, I would say from my point of view,
29:15it probably hurt her career because
29:17now she's officially labeled as a
29:19troublemaker and she wasn't able to
29:21get herself out of that situation.
29:23So that's what happens when a
29:26mentor harasses a mentee.
29:27The good news, though,
29:29about mentorship is both women
29:31and men became aware of gender
29:34inequities in academia.
29:36Because of their relationships with
29:38women mentors and women mentees.
29:40I heard from men who happened to train
29:43with women that their their mentors
29:45taught them about the world that
29:48existed for them as opposed to these men.
29:50And you know I can tell you I'm
29:52married to a man who's 6 foot four.
29:54And what he has learned probably
29:57by being married to little old me,
29:59is that by being a man who's tall,
30:02he is awarded so much respect and and.
30:06And um.
30:09Accolades simply by walking into a room.
30:12And I can tell you the number of times I
30:14walked into a room with my male resident
30:16where everybody assumed that I was the
30:18nurse and that male resident was the doctor.
30:20It's too numerous to count.
30:21It was just standard and it's kind
30:23of funny and we would joke about it,
30:25but it's not so funny after a while,
30:27you know. So, but so the point is,
30:29is that my husband has become
30:31aware of these inequities.
30:32But through through being married to me now,
30:34our daughter who's a physician and and
30:36it's just an awareness problem, both women.
30:39And men mentors recognize challenges
30:41that they're women mentees faced,
30:43and they really went out of their
30:44way to try to help them. Now,
30:46I would say sometimes they felt powerless.
30:49So I'm recalling an interview with
30:51a man who ran a graduate program.
30:53And one of the graduate students,
30:55a woman in the graduate program,
30:56was being harassed by a senior
30:58faculty member,
30:59and he saw it.
31:00But because the senior faculty member
31:02had so much power in the institution,
31:04and this man was more junior,
31:06he didn't know what to do except
31:08help her move her desk.
31:09So he made an effort to help her.
31:12But I would call that a hero action
31:14and not a systemic action.
31:16And what we need are systemic actions with
31:20systemic recognition that these things are,
31:22are really odious and they
31:24really bring all of us down.
31:26And both women and men modeled
31:28family work balance and tried to
31:31create family-friendly environments,
31:33but sometimes it backfired.
31:34So I heard from women who were Graduate
31:36School or medical school or training,
31:39and they saw that.
31:40And their, their male mentor took off
31:42in the middle of the day, you know,
31:44to go to their sons baseball game.
31:46That really inspired them that
31:47they could do the same thing,
31:49but the price that they paid
31:51for taking advantage of the same
31:54flexibility was so different.
31:56And so again,
31:57it helps to have your mentor
31:59understand you and respect you,
32:01but if your mentor can't address the
32:03challenges in the room, it's difficult.
32:06But let me now point out the real.
32:10Issue.
32:13In 2018, at the end of the annual
32:16INSERVICE exam for surgery,
32:18so every surgical resident in
32:20the country takes this exam,
32:22they had the opportunity to participate
32:24in a survey to assess discrimination,
32:28abuse, harassment and burnout.
32:3197% took part.
32:32And what this article found was that
32:36the attending surgeons the mentors.
32:39They were the most frequent sources
32:42of sexual harassment and abuse.
32:44The next month I'm sitting in a chair
32:46of surgery's office and he is agreed
32:48to be part of my study, and I asked
32:50him what he thought about this paper.
32:52Oh, that was awful.
32:54I cannot believe that's still happening.
32:57I said I agree with you,
32:59So what are you doing about it here?
33:01And he looked at me and I said,
33:03you realize your residents
33:05were part of this study.
33:08And it was.
33:09The ability to connect those
33:11dots is not trivial.
33:13It's really,
33:14really hard when people are in positions
33:17of accountability and leadership.
33:19To not be frightened to learn about
33:21what might be happening because
33:23it means they'll be responsible,
33:25then they'll have to do something about it.
33:27So it's just so much easier to believe
33:29that the people who took part of this
33:31study are training somewhere else,
33:33and that your faculty members aren't the
33:35ones doing the abuse or the harassment.
33:38So I mostly had wonderful
33:40mentoring experiences.
33:41They almost were always men by definition.
33:44And I mentioned that my postdoc
33:46mentor did something awful to me,
33:47but all I had to do was discover it,
33:50report it to the Cancer Center director,
33:52and then he took care of it.
33:54I've now been a mentor for longer than I
33:58have been a mentee and it is hard work.
34:01Frequent communication is key.
34:02And being able to admit when you're wrong,
34:05I can tell you a story.
34:07I had a woman graduate student,
34:09and this was about 15 years ago when there
34:11was a lot of cell line misidentification.
34:13And she came to me and she said,
34:15you know, we published this
34:16paper and it wasn't her paper.
34:17She was a middle author.
34:18And she said we used these cell lines,
34:20but we didn't, you know, a genotype
34:22because we weren't genotyping back then.
34:25I'm worried that they might
34:26have been misidentified.
34:27And I said, well,
34:29I guess that's theoretically possible,
34:30but, you know, the results were.
34:32Producible and like,
34:32you know, 5 or 10 cell lines.
34:34I don't know how we would ever find those
34:36cell lines and go back in genotyping now.
34:37And I think that's something
34:39we need to do going forward.
34:40Basically, I dismissed her.
34:42She wasn't happy with my answer.
34:44So she went to the chair of her department,
34:45which is pharmacology,
34:46and he reached out to me.
34:48My first reaction was I was mortified.
34:50I was so embarrassed.
34:52And then I realized she was right
34:54and I didn't realize that she was.
34:58My answer was inadequate.
34:59And so we went back and we repeated
35:01all the experiments and genotype.
35:02The lines and the results were validated.
35:05And today she and I have
35:06a wonderful relationship.
35:07She's now chair of her department.
35:08I'm really proud of her,
35:10but all I can say is none
35:11of us are perfect mentors.
35:12None of us are perfect parents.
35:13We make mistakes, and recognizing those
35:15mistakes is really an important thing.
35:18Choosing mentors and mentees is
35:20both strategic but also organic,
35:22and we are all people.
35:24We're both exceptional and we're complicated.
35:27The next paper was on promotion and tenure,
35:31and I wanted to analyze the data from
35:34the women and the data from the men,
35:36but I couldn't because only two men
35:39reported any problems with promotion
35:42and tenure and they were both gay.
35:45Could have been a coincidence,
35:47but I realized I just didn't
35:49have that data in my study,
35:51so it was only about the
35:53experiences of women.
35:53So take it for what it's worth
35:55and what the women reported to me.
35:58Even if they had sailed through,
36:00the process was that they spelled
36:02that the the criteria for promotion
36:04and tenure were either ambiguous or
36:07seem to be inconsistently applied.
36:10The most common story I heard was I
36:12went to my chair or my division chief.
36:14I said I was ready and he said no, no,
36:16you're not. You need another year.
36:18And then I saw this guy over
36:19there who was hired after me,
36:21who doesn't have many publications
36:22and grants. He was put forward.
36:24So it was basically trying to
36:26reconcile their own experience.
36:28With the experience of a colleague
36:30and trying to make sense of
36:32that in their own institution,
36:34there appeared to be a lack of
36:36standard processes for reviewing the
36:37applications and making decisions.
36:39I could tell you one of my own stories,
36:40and at UCSF throughout the
36:43University of California,
36:45we have an opportunity
36:46for accelerated promotion.
36:47We have these very Byzantine step levels,
36:49but the more the higher you are,
36:51the more you make in retirement.
36:52So it's not trivial.
36:53So if you have some big accomplishment,
36:55you can apply to jump a step level.
36:58So something big had happened
36:59to me and I went to my chair,
37:00who is wonderful, who supports me?
37:03And I said, you know,
37:04do you think this year I can go
37:06for an accelerated promotion?
37:08He said, oh, Jennifer,
37:09you're already ahead of me.
37:11And this would make it even more ahead of me.
37:13And that would be really
37:15uncomfortable for me.
37:15And in the moment, I thought,
37:18thank you for being honest,
37:19but what a wacky thing to think, right?
37:21But this is what people think.
37:23I was just grateful that
37:24he was so honest with me.
37:26So this is what I mean.
37:28But it's it's seemingly ambiguous now.
37:31Some women were so vulnerable to
37:34malicious behavior of senior faculty,
37:36division chiefs and department chairs.
37:38The most awful story was a person who
37:41was hired, basic scientist, you know,
37:43moved her family, all her children.
37:45The chair discovered the
37:46resources that he'd
37:48counted on to support her
37:49were not his to give out.
37:50And he essentially,
37:52from that day forward,
37:54tried to destroy her.
37:56And it was extraordinary that.
37:58She was able to survive and
38:00go to another institution,
38:02but listening to her experiences
38:03was harrowing and when she went to
38:05the Provost office to complain,
38:07she was told to suck it up.
38:08This guy and the Provost were really good
38:10friends and nothing was going to happen.
38:12And as I said, women see the men having
38:14a different experiences of advancement.
38:16So I sailed through,
38:17and part of it is I was really good.
38:20But I also had a friend on the
38:22promotion and tenure committee,
38:24and she came to me when I
38:25was going up for promotion.
38:26And she said, OK, here's the truth.
38:29The truth is you're going to be asked to give
38:31us a list of people to write you letters,
38:33and then we're going to come
38:34up with a list on our own.
38:35And the letters from our list are going
38:37to matter more than the letters on your list.
38:39And so why don't you let me know
38:42who should be on our list and.
38:45I don't know that this was right or wrong,
38:48but all I can say is that it was
38:50standard knowledge in circles,
38:53but not usually circles of women.
38:55So I would just want to say that
38:56if we're going to play a game,
38:58we all need to play by the same rules.
39:00If we're not going to play a game,
39:01let's not play a game.
39:02But I was really Privy.
39:04I I thought,
39:05to some inside baseball knowledge
39:06that I would have been otherwise.
39:08So I was hired right after residency.
39:10I just had a baby.
39:12I got my key award when I was a resident,
39:14and I had no startup package.
39:16I was just, I was like so grateful
39:18that they hired me again,
39:20something more to talk about.
39:21But I realized after a time
39:23that I needed startup package,
39:25even though I had my key award,
39:26and then we got an R1.
39:27I still need some resources
39:29to really take risks.
39:30My chairman bless his heart.
39:33Raised money to recruit his son.
39:38His son wisely chose not to come.
39:40But I knew my chairman had this money,
39:41so I don't know how I had the
39:43courage to do this, but I walked
39:44into his office and said, you know,
39:46that money that you raised to support,
39:48blah, blah, blah, can I have it?
39:50I could really use it and that's
39:51that's how I got my start up package.
39:53It's like three years later.
39:55But it was only because his son had the
39:57decency not to come and work for his dad.
40:00Every time I've learned that I was underpaid,
40:02it was an accident the first time and
40:04now is working for a chair who I adored,
40:07who adored me.
40:07And he was trying to retain
40:09a junior faculty member.
40:10And I was his key award mentor.
40:12That's how much older I am.
40:14And he told me the salary
40:16that he offered him to stay.
40:17And I went speechless,
40:19which is really an unusual thing.
40:21And he said. I don't pay you that much.
40:23Do I like?
40:24No, you don't.
40:27And he corrected it.
40:28But it was, it was just accidental.
40:31Now, one of the things that I appreciate
40:33is I now work at a public institution
40:35and all of our salaries are public.
40:37And it has really made this
40:40conversation so much easier.
40:41And I see no good reason for
40:45compensation not to be public.
40:47You know, I grew up in an
40:48era where it was unseemly.
40:49We didn't talk about it.
40:50But if we have a problem called pay equity,
40:54which we do in science and medicine.
40:56And I don't know how we're going to get
40:58better if we don't actually look at the data.
41:01I was lucky too, in that I received
41:03endowed chairs without asking for them.
41:05You know, my chair at UCSF.
41:07My chair and ENT wanted to retain me.
41:10But my message to all of us is be mindful of
41:13the advancement criteria and ask for help.
41:17There are people to help.
41:18I can't tell you how many women I
41:20interviewed when they were being
41:21recruited someplace got like a
41:22super secret private phone call
41:24from another woman there say,
41:26OK, here's how it works.
41:27This is what you need to ask for.
41:28I mean, and this is not written down and.
41:31We have to be mindful that what
41:34is secretive is not going to
41:36get to the people who need it.
41:38But maybe the most important paper
41:40that we wrote was about networking
41:43and professional relationships.
41:47The conclusions were that women are
41:50routinely excluded from networking
41:52activities dominated by men.
41:54Almost everybody I interviewed
41:55talked about the boys club,
41:57whether it be the Medicine Boys
41:59Club or the Science Boys Club,
42:01and they understood that being in
42:03this club was really beneficial.
42:06And if you were not in the club,
42:08you did not have those benefits.
42:10One of my favorite stories was a
42:11guy whose wife is also in medicine.
42:13He golfed, and so he got to meet
42:15all these really powerful men
42:16who golfed at these meetings.
42:18And when it came time for him to be
42:20nominated for a prize or go promotion,
42:22he just reached out to his golf
42:24buddies and they all wrote letters.
42:25And he knew that his wife did
42:28not have the same opportunity
42:30to find people like this.
42:33Women make efforts to counteract exclusion,
42:37but I have to say that the
42:40limitations are real, that until,
42:43you know, women have.
42:45Equal power, equal accountability.
42:47These were much more like support groups.
42:52So women getting together and
42:54and talking about childcare or
42:56how to navigate this environment,
42:58then there's there's nothing wrong
43:00with it but it's not the same as the
43:03mail networks and one thing I want
43:05to say is and and then there were
43:08other patterns of gender related
43:09exclusion that were unrelated
43:11to the boys Club and maybe the
43:13most common one was alcohol.
43:16So alcohol shows up in professional
43:19environments and people become disinhibited
43:22when they drink alcohol and when the.
43:28Senior. People present are men
43:31and they're just inhibiting the
43:33younger people present are women.
43:34It becomes a fairly challenging
43:37environment to navigate. This is true.
43:40And I could say it happened at UCSF.
43:42I'm, I'm able to disclose this,
43:43my institution,
43:44I was interviewing someone for the book,
43:47another institution, and she said to me,
43:49oh, you've heard about the Wilbur
43:51Hot Springs resorts, haven't you?
43:53I'm like, no, what's that?
43:55Just Oh my God.
43:56So not that long ago,
43:58let's say 15 years ago.
44:00The basic science departments would
44:03have their departmental retreat
44:05at this venue in the Bay Area.
44:07And this woman and the only graduate
44:10students at the time were women,
44:12and they show up.
44:13They're so excited to present
44:14their research to these,
44:15you know, famous senior people.
44:17And the talks go well during the day.
44:19And then they're supposed to
44:20all go into the Hot Springs,
44:22and she describes going down to the
44:25water and seeing all of her male
44:28professors naked and realizes that
44:30she's expected to take off her clothes.
44:33And so she did.
44:35And she's describing this is 15 years later,
44:37she's now married with three children.
44:39She's describing what it
44:40felt like to have to do that.
44:43And I said. How did the,
44:45how did you experience that with your cohort?
44:47Because the other PhD students for women,
44:50she said we couldn't talk about it.
44:52We were so ashamed,
44:53you know, that we did this,
44:55that it took us years before we
44:57were actually able to talk about it.
44:59So I'm thinking, this is crazy, right?
45:01This can't happen.
45:02So I go back to UCSF and I find some
45:04senior faculty and I go to them.
45:06I said, tell me about the Wilbur Hot Springs.
45:08Oh man, that was awful.
45:09Yeah.
45:10And, and, and I said to the men,
45:12because the men were telling me this.
45:13I said, why didn't you do anything?
45:15I mean, why didn't you?
45:16I mean, even 15 years ago,
45:18it was not cool to get naked
45:20with your trainees.
45:21I mean,
45:21I can't imagine a time in this country
45:23where we thought that was good,
45:25a good mentoring policy,
45:26and they felt powerless.
45:27So they knew it was bad.
45:29They stopped showing up.
45:31They didn't feel like their voice was
45:33powerful enough to challenge the status quo.
45:36So.
45:37That's my appalling story.
45:40So my network experience is surprise,
45:42surprise.
45:42I'm an extrovert and I can say
45:44that it's helpful.
45:45So I'm married to an introvert.
45:47I have a child who's an introvert,
45:49and I really appreciate half
45:51of us are introverts.
45:52It can be really hard when you're
45:54the only one who looks like you
45:55in a room and you don't feel like
45:57you have a voice that you can use.
45:59It's hard to network in venues.
46:00As I just illustrated.
46:02We are not comfortable.
46:04Most power networks in science and
46:06medicine are still male dominated.
46:08But I can tell you that if you
46:10can show
46:10up and you can speak up,
46:11you can make a real difference.
46:13I think that in this era of at
46:15least an awareness of diversity,
46:17equity, inclusion, we are beginning
46:19to have a language that we can use.
46:22And I want to say I was wrong about Elam.
46:25So I don't know if anyone here has done Elam
46:27executive leadership in academic medicine.
46:29Every year my Dean, my chair would say,
46:31oh, do you want to go do this?
46:33And I thought it sounded like a really good.
46:35Idea. But my kids were young.
46:37I always already felt stretched
46:39going to science meetings,
46:40doing my surgical work and my research.
46:42And I just didn't see how spending,
46:44you know, a month away was going to help me.
46:47And I naively thought and by the
46:50way everybody empowers a man.
46:51How would a bunch of women getting together
46:53and training each other how to do leadership.
46:55How would this help?
46:56But I think I was wrong because many,
46:58many women including your Dean
47:00went through in the Elam program.
47:02And I think it,
47:03at least my understanding is giving them an.
47:06Network to support them.
47:07People that can go to for advice
47:09outside their institution,
47:11and I wish that I had taken advantage
47:13of it back then, but I'm way too old.
47:16So what keeps me here?
47:18Well, I get to come here and talk with you,
47:20which is really a joy.
47:21But I love discovering things in our
47:24research that can really change the world,
47:27that can help so many people
47:30beyond our clinical practice.
47:31I love interacting with
47:33colleagues and trainees,
47:35and I keep hoping that I
47:37can make a difference.
47:38So what am I take home points?
47:41Consolidation of power in places
47:43otherwise known as people without
47:46transparency or accountability,
47:49facilitates and perpetuates the
47:51inequities that we all realize exist.
47:55After admissions to medical
47:57school and Graduate School.
47:59The deal is off.
48:01We are persistently disadvantaged.
48:03Women are and individuals who
48:05are underrepresented after
48:06the admissions process.
48:08Policies are necessary,
48:10but they're not sufficient,
48:12as illustrated by the
48:1410 year clock extension.
48:16When something bad happens to you,
48:19please know that you're not alone.
48:21Find somebody you can talk to.
48:24And when you see something bad
48:26happening to someone else,
48:28if you can find your voice,
48:30say something, do something.
48:32At the very least,
48:34let that person know that you
48:37saw what was happening to them.
48:39A few years ago,
48:40I was still in my leadership position.
48:42We were.
48:43We were brainstorming about
48:45the capital campaign themes,
48:47and a woman offered a theme radio silence.
48:50About 5 minutes later, a man spoke up.
48:54And essentially said the same thing.
48:56Ohh, that's a wonderful idea.
48:59And I'm looking at them and I'm
49:00looking at her and she's looking at me.
49:02I didn't have the courage then to say,
49:05you know,
49:05so and so just said that and that
49:07is great that you both have the
49:08same idea and it's a good idea.
49:09I think I would do that now.
49:11But afterwards I went up to her and
49:12said I am so sorry that happened to you.
49:14I saw that you know what happened?
49:16And and so we see it. We feel it.
49:18And and at least if you can't speak
49:20out in the moment to give her the
49:21credit that she needs or them the
49:23credit that they need at least.
49:25That's something, no about it afterwards.
49:27But at the end of the day,
49:29there's no quick fixes.
49:31This is hard stuff.
49:34Just like a great marriage is hard stuff.
49:37Being a great parent is hard stuff.
49:39Being a lifelong friend is hard stuff.
49:41We need a language and a culture free from
49:44retaliation to talk about what we experience.
49:47We need to get comfortable
49:49feeling uncomfortable.
49:50These are hard things to talk about,
49:52but we have to do it because
49:54at the end of the day.
49:55Right now what we have is a
49:57winner takes all mentality.
49:58Someone's either a villain or they're a hero.
50:00What about their a good person who stumble,
50:02who made a mistake,
50:04who said something disrespectful,
50:05who it doesn't mean that they go to jail,
50:07it just means there's an opportunity
50:09to educate each other in the world that
50:11we spend an enormous amount of time.
50:13And so I'd really like to take
50:15ratchet the stakes down,
50:16ratchet the noise down and just create
50:19communities where we work so that we
50:22can really be our best selves. So.
50:25Advice to my younger self and to you,
50:28of course.
50:28I wish I'd written down my experiences
50:30and how they made me feel before
50:32I got to such a crisis mode.
50:34One of my really wise mentors,
50:36when he saw me going into surgery,
50:37he said,
50:38oh,
50:38you should really keep a journal
50:39because what you're going to go through,
50:41other people going to want to know about.
50:42I was too overwhelmed and I don't
50:44think I could have handled being
50:47honest about what was happening.
50:49I really dismissed and minimized what was
50:52happening because it was too hard to manage.
50:56Your bosses, our bosses,
50:58are not our parents.
50:59We don't have to spend so much
51:01time trying to please them.
51:03Embrace Team science and hold on to
51:06your true research partners and friends.
51:08They will be with you forever.
51:10And find communities places to work where
51:13you can bring your full self and be accepted.
51:16If someone is uncomfortable with you,
51:19it's their problem,
51:20not yours.
51:21Family and friends are everything.
51:24Your children will love you for who
51:25you are and forgive your missteps.
51:27I can't tell you how many times
51:29I threatened to quit and stay
51:30home with my children.
51:31Luckily,
51:31they had the good sense to talk me out of it.
51:34Take the bad stuff seriously,
51:36but not personally.
51:36If you can realize it's bad
51:38but it's not your fault,
51:39there's nothing wrong with you.
51:41And if you can find a way,
51:42we were talking this point,
51:43if you can lean into those hard times,
51:45you will grow. So when I think back
51:47about what happened to me, I say,
51:49I used to say, well, if I'd known it,
51:51I'm not sure I would have moved,
51:53but now I know I would have,
51:55because I wouldn't be here today and I
51:56wouldn't be talking to you about this.
51:58And as much as it was hard at the time,
52:02I'm fine.
52:02And now I can actually help the world.
52:06And this is just to acknowledge,
52:07no, I'm not standing in a hole.
52:09I'm just that much shorter than
52:10everybody else in my family.
52:12Thank you very much and good luck.
52:21We have time for questions.
52:23Yes. That was amazing.
52:30You've done so much.
52:36Now that the new way is. Awareness.
52:43Hmm. How do you think this
52:46is this affecting all?
52:49This is it, you know,
52:52doesn't have any effect yet.
52:53I think the jury's still out,
52:55but I think it's a double edged sword.
52:56I wrote a piece in stat news
52:58about a month ago to another piece
52:59coming out in the conversation.
53:01I think the good news is we now
53:02have a vocabulary and I don't think
53:05there's a single institutional
53:07leader who is against it.
53:08It would be they would be unable to continue.
53:11There's nobody who's in a position.
53:13Um, of leadership in science and medicine?
53:16Who who doesn't overtly embrace DEI?
53:20So that's the good news.
53:21The bad news is they don't
53:23understand it or mean it.
53:25And.
53:28And that's where the hard
53:30conversations come in.
53:31And we also run the risk of assuming that
53:34the policies are going to change everything.
53:37So let me give you an example.
53:38We now, anytime you're part of
53:40a important search committee,
53:41you have to get training on unconscious bias.
53:44And someone from HR comes to talk
53:45to you're like, OK, game on,
53:47we're on the same page.
53:49I can't tell you how many times in a
53:51search committee setting I have heard
53:53and other save reported to me that
53:56women candidates are judged by gendered.
53:58Language for example.
53:59Ohh, she's just not warm and fuzzy enough.
54:02And the woman sitting there saying thanks.
54:06I just she.
54:09Yeah, have to be more of a department,
54:11and we certainly didn't talk about that.
54:13Male candidates, warmth and fuzziness.
54:16So, you know, things still happen.
54:20And,
54:21and but I'm hoping that rather than
54:23us believing that the policies and
54:26the mission are limitations that their
54:28opportunities and what it's going to
54:31take is we all have to find her voice.
54:33And I promise you that when
54:36you say something respectfully
54:38the backlash is so minimal.
54:40I'll give you an example.
54:41I was at a meeting we were trying to
54:43identify people for an individual role
54:45was an opportunity woman's name came
54:47up and the chair of the department
54:49and man said, oh, no, no, no, no.
54:51She can't do it.
54:51She has three young children.
54:53And I don't know how I found the words.
54:54I said so and so I'm so grateful
54:56that you want to protect her.
54:58But I was a woman with young children once,
55:01too. And I would have wanted the opportunity.
55:03I would have wanted to be my
55:05decision whether I took it or not.
55:07I wouldn't have wanted my
55:08chair to protect me from it.
55:10You can always be there as a resource
55:11if she wants to talk to you about.
55:13I saw the women, all the women there.
55:14But, but, but, but, you know,
55:18it's a chance that we can speak out.
55:19You have to find the voice
55:20that has to be respected.
55:22And it's hard.
55:22I was telling,
55:23you know,
55:24the folks at dinner last night,
55:25I was on a I won't board the details,
55:27but an investor call, so trying to
55:29raise millions of dollars to get a
55:31drug that I invented into the clinic.
55:33And umm, a woman asked another
55:36woman a question before she
55:37had a chance to answer it.
55:39A senior man said,
55:40I'll answer that and he just shuts her down.
55:42And I saw the women recoil and immediately,
55:48you know, I called the man and said.
55:51Didn't know yet we're doing this but
55:53this is what's happening and and it
55:55was OK and then I reached out to her
55:57and said I saw that and I'm so sorry
55:59and and it meant so much to her.
56:01It took her a while to come back.
56:02She's you know in her late 50s early 60s
56:04and it just we call these microaggressions.
56:07So I would like to say they're neither
56:08micro nor necessarily aggressive.
56:10I don't like the term because it
56:12kind of makes it sound like it's
56:15trivial but repeatedly you know
56:16your your voice isn't heard one
56:18of the IT can really destroy you.
56:21And one of the my male interviews,
56:23he's told me about a culture in in where
56:27he trained and this was in cardiology and
56:30he described it as a really sexist culture.
56:32I said what do you mean?
56:33He said, Oh yeah, in the Cath lab, you know,
56:36they wouldn't even talk to the women fellows,
56:40so.
56:42What does that mean?
56:43If you're in a fellowship and you
56:44want to learn how to do something,
56:46but your your professors choose
56:48to pretend you don't exist,
56:50that's a pretty big problem.
56:51Hard to call it out.
56:53He was a trainee as well.
56:54There was nothing he can say.
56:55But I'd like to say that you accumulate
56:57this over a lifetime and you hang in there.
56:59I'm not even thinking about
57:00the people who leave,
57:01and it's really gut wrenching.
57:03And we're a field dedicated to healing,
57:06and I'd like us to remember that,
57:08you know, when we think about the
57:10impact we have on each other and.
57:12If you're talking about a
57:14person who's an investigator,
57:15you don't know if they're going to cure.
57:18The disease that's going
57:19to kill your loved one.
57:20And then when we force people out,
57:21he'll have the same amount of talent.
57:23You know we were just talking last night.
57:25I'm doing a study now on MD PHD's and.
57:2930 years, MD, PhD, trainees, women and men.
57:33Equal number of F awards equal
57:35number of K awards at the ER level.
57:37It starts going like this.
57:38Today there are 100 program project
57:40grants in the country led by an MD, PhD.
57:43Three are women.
57:45So what you see is that this.
57:48Silencing now,
57:49maybe all these women chose to be clinician.
57:52Educators chose going to private practice,
57:53but the point is they started in the
57:56same place with the same ambitions.
57:58And I would argue there were myriad
58:00of things that happened to them.
58:01What I heard most often from the men
58:04is that the reason the women
58:06dropped out is they had families.
58:08Not a single woman told me that
58:10the reason that she was held
58:12back was because of her family.
58:14So there are people who choose to pull
58:16back and go part time, and that's fine.
58:19But there's this perception disconnect.
58:21I would say the one last
58:22answer to your question,
58:23I'm sorry I've gone on so long,
58:25is I think when you're working in an
58:28environment that is overtly committed to
58:30DIY and you're not feeling very included
58:33or that you're treated equitably,
58:36it can be very painful because it feels
58:38like maybe there's something wrong with you.
58:40Maybe you're misinterpreting,
58:41maybe you're not getting it,
58:43maybe you don't belong there.
58:44So I think it's a double edged sword.
58:45I'd like to see it as an opportunity,
58:47but I'd love to hear you know,
58:48what other people think. Yes.
58:52Thank you so much. Bing.
58:54Stop. So my question.
59:01This problem. This.
59:05Questions. Otherwise, yeah.
59:15How do we encourage open discussion?
59:21Yeah. Something, yeah.
59:26Become a problem with safety.
59:28And it's not like people know
59:31because they don't pop over, right?
59:34Right. Right. Right. Yeah.
59:44Some, some. Yeah, yeah, yeah.
59:46Oh, that's such a thank you
59:49so much for for asking that.
59:51Which means you're, you're,
59:52you're a wonderful chair.
59:54So I would start with you.
59:56I would start by saying I'm new here.
59:59I wasn't born in this country.
01:00:02I need to understand.
01:00:04Where I'm missing things and so I'm human.
01:00:09I bring unconscious bias
01:00:10every day to my world,
01:00:12and I'm unconscious.
01:00:13I don't even know it.
01:00:14So I would really like to invite you
01:00:17all to give me feedback when I misstep,
01:00:20when I misstate, when I stumble.
01:00:22I would really like to learn from all of you,
01:00:25and if you can create an environment where
01:00:28they can give you feedback and you can
01:00:30listen and not be destroyed by that feedback,
01:00:34it will be such a wonderful.
01:00:36Model for everybody else.
01:00:38So first be willing to listen.
01:00:41The other thing is listening really,
01:00:43really matters that so many of
01:00:44the men that I interviewed,
01:00:46you know,
01:00:46at the end of the interview is like
01:00:48all these light bulbs had gone off
01:00:49in their head and they'd say to me,
01:00:51what can I do?
01:00:52And I said, well,
01:00:53when was the last time you reached
01:00:56out to a woman colleague or woman
01:00:58trainee and asked her about her
01:01:01experiences and they had never done it.
01:01:03It's so simple and what
01:01:05you can do as a leader.
01:01:07You can invite small groups.
01:01:10It's probably too hard in in large groups.
01:01:12Small groups of people have a monthly lunch,
01:01:14and the monthly lunch is just let's
01:01:16talk about how did we get here?
01:01:17What are our joint values,
01:01:19what do we want to accomplish?
01:01:20What's holding you back?
01:01:21What can I do to eliminate those barriers
01:01:23to holding you back? And listen.
01:01:26So one of my favorite interviews.
01:01:29I love this guy.
01:01:30He's so the men.
01:01:32And Peter,
01:01:32you'll appreciate this.
01:01:33The men who are most clued in were
01:01:35the men who are married to women.
01:01:38Who are also in the field
01:01:39because they'd heard it,
01:01:40you know, like my husband,
01:01:41they'd come home every day and they'd
01:01:42heard their wife talk about what their
01:01:44experiences were in the workplace.
01:01:46And so he's describing in the beginning of
01:01:48you how his wife is Mansplain Mantera opted,
01:01:51you know, frustrated all these meetings.
01:01:53And I said to him so, and he ran a center.
01:01:56How do you mitigate against that
01:01:58happening in the meetings that you run?
01:02:00He said.
01:02:02I don't think it's ever happened.
01:02:05Oh, it must have happened.
01:02:07Oh, I just didn't see it.
01:02:09So, but, but it but that's it.
01:02:12I mean I I honestly, when I you know,
01:02:14the man who who you know Mantra
01:02:15opted the woman last week,
01:02:17he didn't realize he was doing it.
01:02:18I mean, when it was pointed out he did.
01:02:21But we have to find ways to give
01:02:24feedback without it feeling crushing,
01:02:26without it feeling like career.
01:02:27And we have to be able to judge high crimes
01:02:31and misdemeanors from
01:02:32day-to-day human foibles.
01:02:34But I would say that the
01:02:36cumulation of the day-to-day human
01:02:37foibles is so powerfully toxic.
01:02:39So create an environment,
01:02:41be open to feedback,
01:02:43and walk the walk.
01:02:47Thank you, Peter.
01:02:51Salary. You know, there's been a
01:02:54lot of pressure around here, but.
01:03:00Business basic type, yeah.
01:03:05Yeah. But one of the biggest
01:03:09challenge. Hmm, huge problem.
01:03:14Prosperity.
01:03:17Absolutely. OK.
01:03:18So this is the Wild West.
01:03:21So what I and I hope that we're moving.
01:03:23So bottom line, thank you for recognizing
01:03:26because here's the typical scenario.
01:03:28It costs a lot more to hire a new
01:03:29person than their retainer person.
01:03:31That's the bottom line.
01:03:32So it's really economically to
01:03:33everybody's advantage to retain
01:03:34the person who's already there.
01:03:36Women tend not to job search so much,
01:03:40and whether it's because we don't
01:03:42think we're worthy or whether
01:03:43because we have a partners who are
01:03:46geographically constrained or whatnot,
01:03:47that's a different conversation.
01:03:48But it's far more common for a man
01:03:51to come in and say I've got this
01:03:53other offer and to be retained.
01:03:54And when they're retained
01:03:56they get more resources.
01:03:57So every time they interviewed
01:03:58a chair I said,
01:03:59So what do you do under those circumstances?
01:04:02Only two chairs recognized it and solved it.
01:04:06Well, recognized it to solve it.
01:04:08And one of them was happened to be an
01:04:10institution where the Dean had been
01:04:12publicly humiliated for salary and equity.
01:04:14So every time that a man was retained,
01:04:17this guy went to the Dean and said, OK,
01:04:18we need to raise everybody's salary.
01:04:20You know,
01:04:20this is what I'm giving him.
01:04:21And the guy did it because his job
01:04:23was on the line and I'm trying to
01:04:25remember the other institution.
01:04:27There was more of a mechanism there to do it.
01:04:29But most people just throw up their
01:04:30hands and say I I can't afford it,
01:04:32I just can't do it.
01:04:33And it's huge and and and guess what?
01:04:36There's no institutional records.
01:04:38So here's what we and also it's kind of like,
01:04:42you know, Woody Allen, you know,
01:04:44how many times a week do you have sex?
01:04:45Ohh, we have it all the time.
01:04:46Three times a week. We never have.
01:04:48We have a three times a week.
01:04:49So someone's impression of retaining some
01:04:51like thinking of our conversation, really.
01:04:54You didn't feel retained.
01:04:56Right.
01:04:57You know,
01:04:57because it was too little,
01:04:58too late.
01:04:59But I promise the people who sat her
01:05:01down and tried to keep her thought
01:05:03they were trying to retain her,
01:05:04but they had missed the boat,
01:05:06you know, so many years before.
01:05:08So what I think we need to do
01:05:09as an institution,
01:05:10I'd love CEO ahead of the curve on this.
01:05:13Let's collect the data.
01:05:14You know we can't.
01:05:16Again, you can't solve a problem you
01:05:18don't understand. We need metrics.
01:05:20These are emotional things.
01:05:21So bottom line is when someone leaves,
01:05:25there needs to be a rigorous.
01:05:27Exit interview and it can't be by the person.
01:05:30They're leaving.
01:05:31And we need to deeply understand
01:05:33what didn't they get?
01:05:34Why couldn't they stay?
01:05:36Yes, maybe it was. So shiny out there.
01:05:39There was no way they're going to stay.
01:05:41But maybe there's a lot
01:05:42to be learned from that.
01:05:42And the question is,
01:05:43did did you feel like there was
01:05:45a sincere retention effort?
01:05:47I think we'd be stunned at what we hear.
01:05:50And the other thing is,
01:05:51when someone retains someone,
01:05:52they have to look at the big picture.
01:05:55Even if you don't know how to fix it,
01:05:56you have to say, OK, now I've given
01:05:59him these additional resources.
01:06:01So we looked at the you have to say,
01:06:03this has happened.
01:06:04I have a problem.
01:06:06What are we gonna do about this is
01:06:07something probably exists everywhere,
01:06:08but at least you can collect the
01:06:10data and know what to do about it.
01:06:12So I'm thank you for turning on the lights,
01:06:14but I think retention is the Wild
01:06:16West and I'm hopeful that UCSF
01:06:19neck right now because they're
01:06:21really tired of me nagging.
01:06:23But I think we're going to start collecting
01:06:24the data because it's important.
01:06:28Yes. You mentioned the beginning
01:06:30that there is a dramatic NIH
01:06:33transfer submitted by women.
01:06:37Spitting ohh let me start the ways OK.
01:06:44I think I I call it the protege phenomenon,
01:06:47and I've seen it up close too
01:06:50many times to be able to recount.
01:06:53If they're being hired by a man.
01:06:55They see in a young man a younger
01:06:58version of themselves and they
01:07:00want to invest in that protege and
01:07:03whether that be discretionary funds,
01:07:05space, administrative support,
01:07:07we'll call it the startup package.
01:07:11When a woman comes along with the same
01:07:13ambitions, if they're not so inclined,
01:07:17they may not see her the same way.
01:07:19They may have a very different impression,
01:07:21you know, if she comes in
01:07:22with the same qualifications,
01:07:22with the same ambition.
01:07:24And so I think that.
01:07:27It starts early on with differential
01:07:31support and resource allocation
01:07:33and mentorship rich funding.
01:07:36I mean, there's, I mean.
01:07:38So many women I interviewed who dropped
01:07:40out of the investigator track and gone
01:07:43into the mostly the educator track
01:07:46talked about not having the resources
01:07:48that they needed in order to stay
01:07:52competitive and submit the grants.
01:07:54Now, sometimes it's probably a genuine
01:07:56interest in doing something else,
01:07:57but I don't see any gender biological
01:08:00basis for why a woman would choose
01:08:03a different track than a man,
01:08:05and especially the MD PHD's.
01:08:06To me, that's.
01:08:08So blatantly a cohort of
01:08:11homogeneous individuals, you know,
01:08:13most people go into MDP's.
01:08:14Don't do it to be clinician educators.
01:08:16You know,
01:08:17there's a much quicker route to become
01:08:19a clinician educator than to get a PhD.
01:08:21So I think it's an accumulation
01:08:23of a lot of different facts,
01:08:26not the least of which is sometimes
01:08:28not seeing anybody who looks
01:08:29like you in that track.
01:08:30I'll tell you a story.
01:08:32We had in our department a woman
01:08:35who came mostly do clinical work,
01:08:38but she had research.
01:08:39Training.
01:08:39And she had researched ambitions
01:08:41and she got research grants.
01:08:42And every time she asked the chair
01:08:45to give her some protected time
01:08:47so she could do the research,
01:08:48the answer was no, no, no.
01:08:49You were hired to do this,
01:08:51OK.
01:08:52At the same time,
01:08:54the chair is recruiting a former
01:08:55male resident back to the program who
01:08:57hasn't done a lick of research than
01:08:59has since his PhD, like 10 years ago.
01:09:01And it's throwing the moon at
01:09:03him in terms of a package.
01:09:05And I'm like, there's a real disconnect here,
01:09:08but it really has to do with, you know,
01:09:10probably gendered assumptions,
01:09:12impressions of who people are
01:09:13and what they're meant to be.
01:09:14We are terrible at picking winners.
01:09:16I would just like us all to acknowledge
01:09:18that we think we can pick the winners,
01:09:20but we really can't because
01:09:21at the end of the day.
01:09:23What matters most is the
01:09:25individuals commitment and passion.
01:09:28And,
01:09:28and I can tell you lots of stories offline,
01:09:31but if you have a person who's
01:09:33equally committed and passionate,
01:09:34but they happen to look a certain way,
01:09:36they may not get what they
01:09:37need in order to
01:09:38be successful. But it's it's
01:09:39a profoundly big difference.
01:09:41And I think such a waste of talent.
01:09:43Not that the women physician educators
01:09:46aren't doing wonderful work,
01:09:48but that's not why they
01:09:50became physician scientists.
01:09:54I have a question.
01:09:57Well, First off, I'm a winner.
01:09:58Thank you so much Doctor
01:10:01Granese for your talk.
01:10:03So first just to illustrate how how?
01:10:07You know, maybe innocuous.
01:10:08Some of these examples are like for
01:10:11example when I was doing sign out with.
01:10:13An attending, a male attending,
01:10:15and I had a male senior resident with him.
01:10:18With me, I was a, I think a PG Y two.
01:10:22They would talk about fishing and
01:10:24golf and these are activities that
01:10:26I personally have not engaged in.
01:10:28So being the extrovert that I am,
01:10:32I felt like, you know,
01:10:34there wasn't really like much
01:10:36of an impression that they could
01:10:38make of me because I could not
01:10:39participate in that discussion.
01:10:41So actually my my question
01:10:43is how do we safeguard?
01:10:44Um, from repeating exhibiting traits
01:10:47and behaviors that are stereotypically,
01:10:49say, sexist, racist, ableist.
01:10:51All that is because even within
01:10:53women organizations and groups
01:10:55or even other minority groups,
01:10:57there are still implicit biases
01:11:00and behaviors that we have sort of
01:11:03been ingrained and umm, you know,
01:11:05we, we're pretty much,
01:11:06we're nurtured with it, right?
01:11:08In surgery, we have, you know,
01:11:11women or residents who would be very,
01:11:13you know, brash and cussing.
01:11:15Just like our male attendings,
01:11:16you know, like, you know,
01:11:18copying these behaviors,
01:11:20these gendered behaviors to sort of
01:11:23elevate themselves or that perception of,
01:11:26OK, I'm,
01:11:26I want to be just like them so
01:11:28that they can see themselves in me.
01:11:31But they may be detrimental to,
01:11:34you know,
01:11:35people who are not going to try
01:11:37to do those types of behaviors
01:11:39because they're honestly not savory.
01:11:42You said thank you so much for.
01:11:46Your observations, they're spot on.
01:11:49I call it the aggressive, assertive dilemma.
01:11:52You know,
01:11:53somebody wants in Pittsburgh said to me,
01:11:55you know, you're a little aggressive.
01:11:57And I said, well, tell me what you mean.
01:11:58And they describe the behavior.
01:11:59I said that sounds assertive.
01:12:01And if I was a man,
01:12:02you'd probably compliment me.
01:12:03And they're like, oh, yeah.
01:12:05So,
01:12:05but it took me a long time to
01:12:07be able to say that.
01:12:08So what I would suggest is that
01:12:11we all decide we're going to
01:12:14talk about these things.
01:12:16And we're going to give each other feedback.
01:12:18And we're going to acknowledge
01:12:19that we're going to bring our own,
01:12:22you know,
01:12:23biases and ableist and gendered
01:12:25expectations into the workplace
01:12:26through no fault of her own.
01:12:29But we work hard, we work evenings,
01:12:31we work weekends,
01:12:32and give permission to the people that
01:12:34we work with to give us feedback.
01:12:37So start by asking for feedback and
01:12:39then asking permission to give them feedback,
01:12:41too.
01:12:42It's interesting.
01:12:42I wrote a piece that got that went viral.
01:12:46On I think it was like fishing,
01:12:49hunting and strip clubs because
01:12:50those were the places that,
01:12:52you know,
01:12:52that the men went to hang out and
01:12:54I had a woman reach out to me from
01:12:56the business world, she says.
01:12:57You know,
01:12:58my daughter's in medicine and I
01:12:59wish she had learned how to
01:13:00golf because I think golfing is
01:13:02so important for the career.
01:13:03And I'm thinking, well, that is one solution.
01:13:07But it doesn't really address
01:13:08the nugget of the problem.
01:13:10And so you're right, when you were PG Y2,
01:13:12you probably had no ability to say,
01:13:15I'm so glad you guys liked to hunt and fish,
01:13:17but how about did you see this movie?
01:13:20I mean, I'm not a hunter Fisher,
01:13:22but it's hard because when you're
01:13:24in that position of vulnerability,
01:13:26it's really hard to find the language.
01:13:27But that's where going to your chair,
01:13:29your program director, and say,
01:13:31how do I navigate this?
01:13:32And then maybe in a different environment
01:13:34where it's safe for them to get feedback.
01:13:37They can get feedback.
01:13:38There is no easy answer except to
01:13:41recognize how pervasive these issues
01:13:44are and to find a creative environment
01:13:47and a climate at work where we can be
01:13:51ourselves and talk about these things.
01:13:53But it's hard.
01:13:54Thank you.
01:14:07Thank you so much. Ohh. Ohh my pleasure.