Tenure: A System Built on Coercion

Kate Hitchcock, MD, PhD


April 28, 2022

I'm a tenured professor. But I'd get rid of tenure.

Francis Fukuyama

The way the tenure system is billed:

  • New graduates compete for assistant professor jobs in medical departments.

  • They spend the first 5-7 years proving that they are worthy.

  • Tenure and a promotion to associate professor bring the security of a guaranteed salary and more income.

  • They use their early momentum to build a national or international reputation.

  • Promotion to full professorship brings further income and prestige.

The way the system exists in colleges of medicine today:

  • New graduates with $242,000 in debt compete for assistant professor jobs, some tenure-track and some not.

  • Tenure-track faculty work 80-100 hour weeks for those first 5-7 years, risking burnout to obtain grants that have by and large evaporated for junior faculty.

    • Recall that with traditional timing, you have to have an NIH grant by around age 35 years or you lose your job (but not the $242K debt). Then, on this linked graph, notice the slope of the age 35-39 years line vs the 55-59 and 60-64 lines.

  • If they manage to hang on, they are awarded tenure, but it may only cover the university-sponsored portion of their salary. The guaranteed income they have secured may be $20,000 per year or less — poverty wages.

  • They continue working long hours, in many cases for further reward that never comes: Only about 17% of us ever make it to full professor.

  • Women can expect to run this entire gauntlet making 82% as much as their male counterparts at each level. At the end of that gauntlet, 79 women are promoted from associate to full professor for every 100 men.

  • And the end reward is… Prestige?

Meanwhile, the system in which we strive is doing just fine. If you haven't seen this graph, you need to.

It's doing especially well because we volunteer to do a lot of work. Truly huge amounts. We are told that we need to demonstrate service and teaching hours in order to be promoted. So we serve on committees and spend many hours each week reviewing, organizing, communicating, writing PowerPoints and revising abstracts, teaching medical students, and guiding undergrad shadowers.

Then, the medical journals come along and ask us to review papers. We are given to understand that this is mandatory for advancement, so in goes more hours of reading and commenting. The societies and journals make money for this work. We do not.

During and since the pandemic, the expectation of these added hours of uncompensated labor has become a particular issue as the country has come to realize that the care of the next generation is actual work — work that has largely fallen on women through cultural habit, even as they are expected to be as productive as their male counterparts. This situation worsened as the demand for care hours abruptly shifted from childcare workers to parents with little change in expectations of productivity.

Meanwhile, faculty sizes are reduced (relative to patient volumes) and the RVU requirements quietly drift up in support of a better bottom line for the hospital. Said the president of the AAMC in 1995: "…tenure in medical schools represents a linkage to…traditional devotion to a free exchange of ideas without threat of economic penalty. Yet, medical schools, because of their increased involvement in the real world of health care delivery, are also linked to the corporate culture, with its brutal devotion to productivity without guarantees of economic security."

Medical faculties everywhere seem to be getting the worst of both worlds.

What if, and hear me out now, we all at once admitted that traditional tenure in colleges of medicine has become a myth. What if we just gave up on participating in the promotion rat race? What would happen?

Imagine how the system could be different if we negotiated with contracts that specified our responsibilities so that we could insist on more hires where there is more work to do. Imagine medical journals paying editors and reviewers for their investment of time and energy.

What if we did things that way?

Please join the discussion below, but if you need to communicate with me offline, you can reach me via

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About Dr Kate Hitchcock
Kate Hitchcock, MD, PhD, is a radiation oncologist, biomedical engineer, and retired aircraft carrier driver who grew up as a Wyoming cowgirl. When she is not at the hospital, you can find her with Carolyn, Mary, Tyler, Nick, Marlee, and Colby the barking dog, enjoying the natural splendor of the great state of Florida. She thinks you should visit sometime and try to solve the puzzle of why the natives have so carefully shunted all of the tourists toward the House of Mouse. Connect with her on Twitter: @hitchcock_kate


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