There are several possible explanations for the gender disparity in clinical awards. For example, certain disciplines, especially fields known to have a large number of women, might be less represented in the total of 273 award recipients. However, we found that while 24 of the total 28 departments had one or more faculty members who received an award, the departments with the greatest number of award winners were medicine (69), pediatrics (47) and psychiatry (29), accounting for 56% of all the award recipients. These same three departments were the three with the greatest number of women faculty accounting for between 45 and 49 percent of the total number of women faculty in the SOM between 1999 (the first year we have reliable gender data by department) and 2007.

Part-time faculty appointments might also account for under-representation of women for clinical awards, especially if women were more likely to have part-time appointments. We used data from our Faculty Affairs office to determine how many faculty members had taken advantage of the SOM’s “reduction in duties” policy that allows faculty, with the approval of the chair of the department, to work part-time for up to 6 years. From 1999 to 2007, there were a total of 30 faculty members on the two clinically oriented tracks who took advantage of this policy and, of these, 17 were women and 13 were men. It seems unlikely that this difference would explain the smaller number of clinical awards given to women. In addition, we might expect this and other confounders to be equally likely to result in a lower proportion of women recipients of research and teaching awards, which was not the case.

Additionally, it is possible that some awards are given based on years of service. We were unable to determine if this was the case, but given that there were several awards given to junior faculty and these were also given more often to men than women, it appears unlikely to be a major determinant of award distribution by gender. As mentioned above, it would also seem that if years of service were a significant confounder, it would have similarly caused a decreased proportion of women receiving the research and teaching awards, which we did not find. Regardless, the barrier to recognition in the clinical awards may be related to barriers affecting the rank distribution of women faculty in the two standing faculty tracks at the SOM: In 2006–7, 33% of all women in the tenure track were full professors, while in the clinician–educator track only 16% had achieved that rank; for men the percentages were 52% and 30% respectively.¹⁵ At our institution both men and women are less represented at the full professor rank in the more clinically oriented track, but women are disproportionately more affected.

Finally, there exists the possibility that men are over-represented in clinical awards because of greater contributions. If this is the case, then assuming the culture supports equal contribution, gender equity in award receipt should not be forced. However, it is important to be certain that the culture allows women to make equal contributions. For example, there is research indicating that women face both constraints on their decision making and leadership styles²⁵ and potentially differing support from nurses,²⁶ both of which could contribute to lesser clinical contributions.

We speculate that an important contributing factor to the observed award discrepancies by gender may be the difficulty in defining objective measures of clinical excellence. In research careers, publications and grant awards provide reasonably objective criteria of success. For educational excellence, teaching evaluations, curricular development, and quality of syllabi are moderately objective standards for judging talent. For clinical distinction, however, the lack of easily quantifiable measures of excellence may result in a greater impact from unconscious bias in the process of determining these awards.³ When we reviewed the clinical award descriptions, they were based on criteria that reflected excellence but were either vague or difficult to objectively measure such as: “strives for highest quality of practice”, “maintains a commitment to patients that goes beyond the norm”, “provides cutting edge services to patients and colleagues”. Carnes et al. have pointed out that whenever there are ambiguity of performance criteria in a selection process for a position that is held primarily by men, the stage is set for evaluators to engage in stereotypic assumptions that may subconsciously favor men as leaders.³ Multiple studies in the social psychology literature provide evidence for this phenomenon and suggest that explicit and predetermined criteria can mitigate the activation of unconscious bias.^16–19 The difficulty of defining excellence in clinical patient care and in clinician-educator careers has been acknowledged by many and continues to be a challenge.^20–23 In one study of 114 department of medicine chairs in the United States and Canada, the four measures felt to be most important in assessing clinical skills were also reported as not being of high quality. The need for improved quality measures was emphasized as critical for the timely promotion and academic success of clinician-educators.^20,24

In reviewing the descriptions of the University of Pennsylvania SOM awards, we found only one that used language associated with the talents that have been emphasized more recently by many as key leadership skills of the 21st century.⁹ Similar to many other awards conferred in academic medicine today, the University of Pennsylvania SOM awards tend to emphasize individual achievement and the rigorously independent and competitive approach to academic excellence that have characterized the culture of academic medicine over the past 40 years.²⁵ Career recognition in the biosciences generally has been identified as following a “tournament model” where rewards accrue through intense competition²⁷. Recently there has been significant discussion about the need to foster a more collaborative culture where high performance team building and mutual accountability are the newly appreciated skills to recognize. In his remarks made at the AAMC 2007 national meeting and also discussed in an interview with Academic Physician & Scientist, Darryl Kirch, President and CEO of the AAMC, spoke of his view that “many of our misalignments have grown out of our highly individualistic, competitive culture and it will require us to move into a culture that is much more oriented toward collaboration and group problem solving to really deal with the challenges we face today.”^9,28

In a similar point of view, Carr et al. argue that while academic medicine has been quite effective at hiring and promoting the best “soloists” available, this culture has not always been effective at turning them into teams.²⁹ They state that academic medicine must move beyond “intellectual Darwinism” where intense competition amplifies small differences in productivity into large differences in rewards, into a greater community orientation where information-sharing and team-building are rewarded.²⁹ It is likely that we need to foster and reward both traditional and newer leadership skills for academic medicine to succeed in the future. The NIH Pioneer Award Program and the NIH focus on “Research Teams of the Future” both reflect the national emphasis on newer skills and achievements.³⁰ The awards process is another avenue to foster a culture shift and should entail the creation of new awards highlighting the language and talents valued by this “new” culture.

There are limitations to our study that should be noted. Our review of faculty awards was conducted at a single institution where a specific culture and value system exists. This culture will not be identical to that of other institutions. It is possible that other institutions with their own unique histories, mission priorities, promotion criteria, probationary policies, and leadership, might find different outcomes after examining their awards. Yet, we suggest that the process of review would be beneficial, and could help to clarify the incentives that contribute to the organizational value system. In addition, we acknowledge the subjective process of determining if awards reflected the “new” versus the “traditional” cultural values of academic medicine. It is possible that others reading the same award descriptions might come to a different conclusion about the talents and skills being recognized.