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For peer review onlyFactors impacting on retention, success and equitable

participation in clinical academic careers: A scoping review and meta-thematic synthesis

Journal: BMJ Open

Manuscript ID bmjopen-2019-033480

Article Type: Research

Date Submitted by the Author: 07-Aug-2019

Complete List of Authors: Vassie, Claire; Imperial College London, Medical Education Research Unit, Faculty of MedicineSmith, Sue; Imperial College London, Medical Education Research Unit, Faculty of Medicine Leedham-Green, Kathleen; Imperial College London, Medical Education Research Unit, Faculty of Medicine

Keywords: MEDICAL EDUCATION & TRAINING, QUALITATIVE RESEARCH, Health policy < HEALTH SERVICES ADMINISTRATION & MANAGEMENT

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For peer review only

Factors impacting on retention, success and equitable participation in clinical academic careers: A scoping review and meta-thematic synthesis

Claire Vassie1, Sue Smith1, Kathleen Leedham-Green1

1 Medical Education Research Unit, Faculty of Medicine, Imperial College London, London, UK

Correspondence to: Dr Kathleen Leedham-Green [email protected]

Word count: 2776

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ABSTRACT

Objectives: To examine and synthesise current evidence on the factors that affect recruitment, retention, participation and progression within the clinical academic pathway, with a particular focus on equitable participation across protected characteristics including gender, ethnicity and sexual orientation.

Design: Scoping review and meta-thematic synthesis

Data Sources: Web of Science, Google Scholar

Article Selection: English language articles exploring factors affecting recruitment, retention, progression and equitable participation in clinical academic careers undertaken within North America, Australasia and Western Europe between Jan 2005 - April 2019. 39 relevant articles were identified using detailed inclusion/exclusion criteria.

Data Extraction: For the meta-thematic synthesis, papers were coded for factors relating to equitable participation facilitated by NVivo software. Domains and categories of research findings were derived through an iterative consensual process. 17 articles were thematically analysed. No new themes arose after 9 papers.

Results: 13 discrete themes of factors impacting on equitable participation were identified which were categorised into external (societal), personal, interpersonal and organisational domains. Within these 13 themes we present a range of detailed factors which have implications for institutions looking to improve the retention and success of a diverse clinical academic workforce.

Conclusions: Clinical academic careers play an essential role in the delivery of high-quality translational research and improvements in patient care and clinical training. Over recent years, there has been a decline in the number of clinical academics, with certain demographic groups being persistently underrepresented in the work force, particularly at the higher professional grades. This review identified the range of factors impacting on equitable participation in clinical academia. The broad and often interconnected nature of these factors suggests that there is no ‘silver bullet’ and that interventions will need to be multi-factorial, addressing structural and cultural factors as well as individual needs.

Keywords: Clinical Academia, Physician Researchers, Equality, Gender.

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Strengths and limitations of this study (5 points max) To our knowledge, this is the first review article to examine a full continuum of factors affecting

equitable participation in clinical academia at all stages of the pipeline, from the attractiveness of the career at an early stage (e.g. medical students) to retention during and after PhD and progression to professorship.

Our methodology allowed the use of broad search criteria including snowballing to establish the extent and range of literature on this topic. It allowed us to systematically identify papers for meta-thematic synthesis on the basis of quality, relevance and recency.

Our findings will have limited relevance to nursing, midwifery, allied health professions or other geographies where there may be divergent issues in relation to gender, sexuality and ethnicity or the nature of clinical academia. We did not identify any papers relating to disability and the clinical academic career pathway. Class was excluded from this review, as the clinical academic population belongs by definition to the upper professional occupations. However, this does not take account of the socioeconomic background of students at the stage of selection into medical school, which is likely to be a significant factor.

The majority of papers identified in the scoping review focused on gender, therefore the factors identified within each theme may not fully represent issues relating to other protected characteristics such as race, ethnicity and sexual orientation.

Funding statement: This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors

Competing Interests Statement: No competing interests to declare

Articles should list each author’s contribution individually; Our team comprised an early career clinical academic (CV), an established educational researcher (KLG) and a professor of medical education (SS), all trained qualitative researchers with professional insights into the subject of enquiry. The Faculty of Medicine at Imperial College has a strong research interest in widening participation. The Imperial College School of Medicine also has more graduates entering the clinical academic pathway than any other UK medical school. These factors combined led to our interest in identifying factors surrounding equitable participation in the clinical academic career pathway

All authors made substantial contributions to the conception, study design and data analysis and synthesis. KLG and CV screened for relevant articles. CV and KLG coded the selected articles. SS conducted auditing of the saturated coding structure. KLG, CV and SS drafted the initial manuscripts. All authors revised the drafts critically for important intellectual content, approved the final version to be published and agree to be accountable for all aspects of the work.

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1 BACKGROUNDClinical academics, also referred to as physician-researchers, physician-scientists or academic

physicians, combine clinical practice with academic research and teaching. Their clinical practice

informs their academic practice and vice versa, creating a powerful synergy that is critical to

healthcare innovation(1), the translation of research into tangible improvements in patient care(2), as

well as driving research questions that are relevant to patient populations(3), and supporting the

workforce of the future through medical education(4). As such, the declining number of clinical

academics, which has been observed internationally(5, 6) is concerning.

Issues with recruitment and retention within clinical academia affect certain demographic groups

disproportionately. For example in the UK, women have outnumbered men entering medical school

since 1996(7), however in 2016 the ratio of male to female clinical academics stood at 71.5% to

28.6%(8). The gender disparity is even greater at professorial level(3). Several studies have

demonstrated that females and minority ethic clinical academics are also underrepresented at senior

levels in North America, Australasia and across Western Europe(9-11). Concerningly, there is evidence

that representation of ethnic minorities actually declined in the US between 1990 and 2016(12).

A diverse clinical academic workforce is not only important from a values perspective, it also drives

innovation and excellence in research and teaching(13, 14), for example training doctors to practice

in culturally diverse environments(13), or researching health issues specific to underrepresented

communities(3, 15). From an economic perspective, the attrition of a highly trained elite workforce

due to potentially remediable factors warrants attention and investment.

The failure to achieve equitable participation in the clinical academic workforce has been discussed

extensively in the literature for decades, however much of the empirical research is observational

rather than explanatory, for example measuring promotion rates rather than exploring the underlying

reasons for underrepresentation. There is also a body of literature that evaluates interventional

programmes such as mentoring programmes or Athena Swan in the UK, including a recent review of

interventions(11). There is a gap in the literature for a review of explanatory factors.

2 REVIEW OBJECTIVESPast research in the area has often focussed on a particular stage of career development(16, 17), a

particular population(18, 19), or a particular factor that affects equitable participation(20-22). Our aim

is to examine this body of literature as a whole and to synthesise the full continuum of factors affecting

equitable participation, retention and success in clinical academia at all stages of the pipeline. In doing

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so, we hope to inform researchers and policy makers on the range of factors that need to be

considered, as well as supporting conversations about how some of these factors might be interlinked.

We have not researched interventions or synthesised evidence on the relative importance of factors

as we take the view that this type of knowledge is likely to be highly context dependent and needs to

be researched and addressed locally.

3 METHODOLOGY

Thematic analysis is a validated method for meta-synthesis of exploratory rather than interventional

research findings, bringing together and integrating findings of multiple studies(23). We utilised

Thomas et al’s 3-step framework for thematic synthesis.(23)

- Phase 1 (long list and short list of papers, demonstration of saturation)

- Phase 2 (coding tree, and descriptive analysis of main themes, quotes)

- Phase 3 (interpretive analysis tested against the underlying data)

Phase 1 began with a scoping review, to determine the extent, range and nature of research in this

area. Phase 2 involved a qualitative meta-thematic synthesis drawing together all the factors that

these papers had identified. In phase 3 the resulting framework was used to create an integrated

description and explanation of the subject under review.

Scoping review is a methodology that has an evolving literature base(24) and many definitions, some

involving more evidence synthesis than others. Our methods were guided by our purpose which was

to rapidly and systematically map the key areas of research and the main types and sources of

evidence available, so that we could identify appropriate papers for meta-thematic synthesis.

Munn et al identify that when a study is “interested in the identification of certain

characteristics/concepts in papers or studies, and in the mapping, reporting or discussion of these

characteristics/concepts” a scoping review the appropriate choice of methodology(25). As such, the

scoping review methodology was appropriate to address our aim.

3.1 Inclusion criteria

Inclusion criteria are listed and justified in table 1.

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Table 1 Inclusion criteria and justificationCriteria JustificationTypes of participantsExclusion of articles relating to nursing, midwifery and allied health professionals

Nursing, midwifery and allied health professions were excluded due to divergent issues relating to gender and equitable participation.

North American, Western European, Australasian, and available in the English language

Our geographical focus was chosen due to a) established clinical academic career pathways in these regions and b) the heavy influence of societal norms on attitudes to equitable participation which are relatively similar across these regions(26).

Relevance to phenomena of interest (clinical academic career pipeline) within the context of diversityIdentifies factors that impact on equitable participation in the career pipeline (attractiveness, retention, success)

Our aim was to synthesise the range of factors impacting on equitable participation. We therefore excluded research that

measured markers of equitable participation (e.g. publication or promotion rates),

evaluated interventions to address equitable participation (e.g. mentoring schemes),

assessed the impacts of attrition (e.g. on research quality) UNLESS they also empirically explored underlying reasons for unequal participation.

Conducted between 2005 and April 2019

2005 was the year Modernising Medical Careers was introduced in the UK and current recommendations for clinical academic training were established(27).

Types of publicationsExclusion of theoretical perspectives, commentaries, letters, opinion pieces.

Our aim was to identify robust conceptual categories and to explore their explanatory value. Our interest was in the concepts that had been identified by researchers, rather than the original raw data i.e. second order data(28). We therefore included empirical qualitative research, reviews grounded in robust empirical data, mixed methods studies with substantial qualitative elements, and quantitative papers that tested a broad range of factors across demographics. Theoretical perspectives, commentaries and opinion pieces were excluded.

Subject to peer review and published in a reputable (non-predatory) journal

Publication in a reputable journal following peer review was used as an initial surrogate for quality. Unpublished PhD theses, on-going unpublished studies on trial registers, letters, conference abstracts, grey literature and suspected predatory journals (29) were excluded.

Available in the English Language

The language criterion was partly pragmatic, and also to avoid the risk of misinterpreting constructs through translation.

3.2 Search Strategy

We used a PICo ‘population, phenomenon of interest, context’ strategy(30) to develop our question

and search terms (listed in Table 2) which is appropriate for exploratory rather than interventional

reviews. The terms were derived from an analysis of commonly used words in the titles of papers

relating to equitable participation in clinical academic careers, iteratively expanded and systematically

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re-applied as the range of terms relating to our subject of interest became apparent. We purposefully

included terms relating to protected characteristics including gender, race, disability and sexual

orientation. Social class was not included as the population is by definition classed within higher

professional occupations.

Table 2 Search termsPopulation – clinical academics

Context – diversity & equity Phenomenon of interest – retention and success

clinical academ* divers* success*academic medic* equit* participat* physician scientist* bias* promot*academic surg* under-represent* inclus* academic clinician* female* retainphysician researcher* gender retention

women career*minorit* attritionracial* leaders*ethnic* sexuality orientation LGBT* disab*

The literature in this area doesn’t have a defined MESH term, topic category or keyword and there is

a wide range to terms to describe clinical academia, including specialty specific terms such as academic

diabetology. We therefore began with a search on Web of Science combining terms relating to clinical

academia and participation and equity (see terms in table 1). We systematically expanded this search

using forward snowballing approach(31) using Google Scholar, to include relevant papers that had

cited the most commonly cited papers in both our original list and then again on the expanded list.

This snowballing approach allowed us to identify literature that did not use standard terminology in

the title or abstract and has been shown to be superior to searches based on fixed search terms if

seeded from suitably influential and relevant papers(32). Web of Science was chosen and not

expanded by Scopus as both have 100% coverage of PubMed which includes the core reputable

journals relevant to clinical academia. Google Scholar was chosen for the snowballing step as it has

superior citation coverage to both Web of Science and Scopus(33).

Our criteria were ordered so that the more labour intensive items were applied towards the end. As

we were planning a meta-thematic synthesis, coding articles until thematic saturation had been

achieved, we began by reapplying our criteria to the most recent five years of full text articles. Having

identified a manageable number of potential papers, our thematic synthesis began by purposefully

sampling these papers to ensure we had covered the spectrum of gender, ethnicity and sexuality, and

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the pipeline from entry to training posts, completion of PhD, post-doctoral engagement and career

progression to professorship.

3.3 Critical appraisal of research quality

In evidence synthesis through qualitative approaches, findings are not statistically weighted according

to strength of evidence. The aim is to develop robust categories of research findings that fit across the

full range of the relevant literature. Our appraisal of research quality was therefore not as detailed as

for an appraisal of evidence to support an intervention. A single researcher (KLG) who is an

experienced reviewer, appraised the quality of each paper, informed by the relevant CASP checklist,

across five grades (poor, moderate to poor, moderate, moderate to good or good). Methodologically

poor papers were excluded, and moderate to poor papers were included with provisos detailed in

table 2.

3.4 Textual data extraction

We used a consensual qualitative research approach(34) involving two independent coders (CV) and

(KLG) and an auditor (SS). We uploaded the selected papers to analytical software (NVivo 12, QSR

International) purposefully sampling papers that were potentially rich in factors and with diverse

perspectives on the topic. (CV) and (KLG) coded each paper’s research findings into core ideas (content

coding) each representing a discrete factor impacting on equitable participation. Each coder cross-

checked the other’s coding.

3.5 Textual data synthesis

Content codes were arranged into higher level domains (themes) through an inductive consensual

process, involving team discussions and iteratively testing the thematic structure against new papers.

Saturation of themes was demonstrated when no new themes had emerged for 5 consecutively coded

papers. Our content coding, thematic structure and data saturation were audited by (SS) who had not

been involved in the coding process. The structure was tested by (SS) against two further articles from

our sample which were selected to challenge our framework by looking at different underrepresented

groups, different geographies and stages in the pipeline. Finally these themes domains of findings

were categorised according to personal, interpersonal, organisational and societal factors, reflecting

the multiple layers of influence on the career development of clinical academics.

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3.6 Patient and Public Involvement

No Patient Involvement

4 RESULTSWe applied our search terms tightly (population AND phenomenal of interest AND context in the title)

to generate 73 papers that we were confident had relevance to this area of research. We then

searched for papers citing the 12 most frequently cited of these papers on Google Scholar which

expanded this list to 625. Titles were screened according to our inclusion criteria, leaving 258 potential

papers for inclusion since 2005. Note that the date range for the scoping review (2005-2019) was

broader than the range considered for meta-thematic synthesis (2014-2019) where only the most

recent five years were included. The initially broad approach supported the identification of highly

cited papers on this topic, which is necessary for effective forward snowballing (identification of

related papers through citation indexes). The subsequent contraction to the most recent five years

was a pragmatic way of reducing the large number of papers identified to a manageable number for

full text review and potential inclusion in the meta-thematic synthesis. As such, only full text papers

from the most recent five years were uploaded onto NVivo, which reduced the number or potential

papers for inclusion to 72. Our criteria were re-applied to the full-text papers, reducing this number

to 39.

Our search results are summarised in Figure 1.

Figure 1: PRISMA flow diagram

<INSERT FIGURE 1 HERE>

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4.1 Methodological quality

No new themes arose after 9 papers. Saturation was determined after a further 5 papers had been coded with no new themes arising, an additional paper

was coded to ensure adequate coverage of LGBT aspects. The thematic structure was tested on a further two papers. A total of 17 papers were fully coded.

Each paper that was included in the meta-thematic synthesis was subjected to a critical appraisal of quality.

Our critical appraisal of papers included in the meta-thematic synthesis is presented in Table 3.

Table 3 Methodological quality

Article citation Study design Population Comments on quality1. Ellinas EH, Fouad N, Byars-Winston A. Women and the Decision to Leave, Linger, or Lean In: Predictors of Intent to Leave and Aspirations to Leadership and Advancement in Academic Medicine. Journal of Womens Health. 2018;27(3):324-332.

Cross-sectional quantitative survey

614 current academic respondents (of 1456) at one US medical collegeFocus on equity: genderFocus on pipeline: attrition, retention and promotion

Pros: well designed, wide range of factors explored and some significant factors identifiedCons: lacks qualitative data (reported below separately)Appraisal: good

2. Huttner A, Cacace M, d'Andrea L, et al. Inequality dynamics in the workplace among microbiologists and infectious disease specialists: a qualitative study in five European countries. Clinical Microbiology and Infection. 2017;23(5):332.e331-332.e339.

Thematic analysis of interviews and focus groups

52 interviews and 5 focus groups across 5 European countriesFocus on equity: generalFocus on pipeline: general

Pros: broad range of themes, backed up by primary data Cons: unclear how the interviews were structured, and what questions/topics were/were not exploredAppraisal: moderate to good

3. Sánchez NF, Rankin S, Callahan E, et al. LGBT trainee and health professional perspectives on academic careers—facilitators and challenges. LGBT health 2015;2(4):346-56.

Mixed methods survey and focus groups

Recruited from two US LGBT academic health conferences, 252 surveys completed by HCPs and trainees and a subset of 41 participated in 8 focus groupsFocus on equity: LGBTFocus on pipeline: facilitators and challenges on academic careers

Pros: validated questionnaire, large number of focus groups analysed using CQR, important nicheCons: noneAppraisal: good

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4. Sanchez NF, Poll-Hunter N, Spencer DJ, et al. Attracting Diverse Talent to Academia: Perspectives of Medical Students and Residents. Journal of Career Development. 2018;45(5):440-457.


643 survey respondents, 121 focus group participants recruited from attendees at four US national conferences, two that focus on Hispanic/Latino traineesFocus on equity: race, ethnicity and genderFocus on pipeline: career interests, influencing factors including influential individuals, and career expectations

Pros: wide national US coverage; open focus group questions analysed using CQR; survey explores relative impacts across a wide range of factors Cons: extensive quantisation of qualitative results with few verbatim quotesAppraisal: moderate to good

5. Martinez LR, O'Brien KR, Hebl MR. Fleeing the Ivory Tower: Gender Differences in the Turnover Experiences of Women Faculty. Journal of Womens Health. 2017;26(5):580-586.

Cross-sectional mixed methods survey, snowballing recruitment

433 academics who had left 6 US medical schoolsFocus on equity: survey on how experiences with harassment/discrimination, family-related issues, and recruitment/retention offers impacted their decisions to leaveFocus on pipeline: people who had left tenured positions

Pros: good study design, rich qualitative dataCons: narrow focus on factors driving attritionAppraisal: good

6. Ellinas EH, Kaljo K, Patitucci TN, Novalija J, Byars-Winston A, Fouad NA. No Room to "Lean In": A Qualitative Study on Gendered Barriers to Promotion and Leadership. Journal of Womens Health. 2018.

Cross-sectional qualitative survey

491 current academic respondents (of 1456) at one US medical collegeFocus on equity: genderFocus on pipeline: promotion and leadership

Pros: well designed, rich qualitative dataCons: extensive quantisation of qualitative comments – how were outlying views included?Appraisal: moderate to good

7. Ranieri VF, Barratt H, Rees G, Fulop NJ. A Qualitative Study of the Influences on Clinical Academic Physicians' Postdoctoral Career Decision Making. Academic Medicine. 2018;93(11):1686-1693.

Thematic analysis of semi-structured interviews

35 interviews doctoral trainee physicians from University College LondonFocus on equity: moderateFocus on pipeline: post-doc

Pros: good study designCons: narrow geographical and pipeline focus, moderate focus on equityAppraisal: good

8. Rao SK, Kimball AB, Lehrhoff SR, et al. The impact of administrative burden on academic physicians: Results of a hospital-wide physician survey. Academic Medicine. 2017;92(2):237-243.


1,774 (96%) of academic physicians within a single US healthcare organisationFocus on equity: genderFocus on pipeline: workload, satisfaction, burnout

Pros: explores impacts of multiple factors across both gendersCons: moderate quality, heavy emphasis on administrative burden, no data on instrument development, no qualitative data, one relevant factor identifiedAppraisal: moderate to poor, limit to single factor

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9. Jagsi R, Griffith KA, Jones RD, et al. Factors Associated with Success of Clinician-Researchers Receiving Career Development Awards from the National Institutes of Health: A Longitudinal Cohort Study. Academic Medicine 2017;92(10):1429-39.

Longitudinal quantitative survey

1,066 (of 1,719) US national research awardees from 2006-2009, surveyed in 2010-11 and 2014Focus on equity: genderFocus on pipeline: continued engagement in research

Pros: wide range of factors explored and significant factors identifiedCons: lacks qualitative dataAppraisal: moderate

10. Lopes J, Ranieri V, Lambert T, et al. The clinical academic workforce of the future: A cross-sectional study of factors influencing career decision-making among clinical PhD students at two research-intensive UK universities. BMJ Open. 2017;7(8).


322 respondents (of 523) current PhD students at two UK universitiesFocus on equity: genderFocus on pipeline: reasons for staring PhD, experiences during PhD and post-PhD career intentions

Pros: well designed, wide range of factors explored and significant factors identifiedCons: lacks qualitative dataAppraisal: good

11. Edmunds LD, Ovseiko PV, Shepperd S, et al. Why do women choose or reject careers in academic medicine? A narrative review of empirical evidence. The Lancet. 2016;388(10062):2948-2958.

Narrative review of empirical evidence

52 empirical papers exploring reasons for choose/leaving academic medicineFocus on equity: genderFocus on pipeline: general

Pros: broad explanatory coverage across five themesCons: limited qualitative studies in reviewAppraisal: good

12. Ranieri V, Barratt H, Fulop N, Rees G. Factors that influence career progression among postdoctoral clinical academics: a scoping review of the literature. Bmj Open. 2016;6(10).

Scoping review All English language papers, all dates: 9 commentaries, 34 empirical papers, 6 reviews, 1 case study identifiedFocus on equity: gender included, but not main focusFocus on pipeline: post-doctoral career progression

Pros: multiple relevant factors in six themes identified Cons: narrow range of search terms, included opinion pieces; includes publications back to 1991Appraisal: good

13. Eley DS, Jensen C, Thomas R, et al. What will it take? Pathways, time and funding: Australian medical students' perspective on clinician-scientist training. Bmc Medical Education 2017;17 doi: 10.1186/s12909-017-1081-2

Cross-sectional mixed-methods survey

418 (of 2000) Australian medical students at one institution, all years Focus on equity: gender included, but not main focusFocus on pipeline: attractiveness, barriers, facilitators

Pros: explored a wide range a factors, rich qualitative data, good analysisCons: limited focus on equityAppraisal: good

14. Skinnider MA, Twa DDW, Squair JW, Rosenblum ND, Lukac CD, Canadian MDPPIG. Predictors of sustained research involvement among MD/PhD programme graduates. Medical Education. 2018;52(5):536-545.


70 Canadian MD PhD completers who had completed physician scientist trainingFocus on equity: genderFocus on pipeline: education, career trajectory, publication and funding records, debt, and career and lifestyle satisfaction

Pros: explored impacts of multiple factors across both gendersCons: moderate quality, no qualitative data, many of the outcomes measuring rather than exploring underlying reasons for differential participation

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Appraisal: moderate to poor, exclude statistically marginal results e.g. prior MA negatively associated with sustained involvement

15. Humberstone E. Women Deans' Perceptions of the Gender Gap in American Medical Deanships. Education for Health. 2017;30(3):248-253.


8 female deans of US medical schools (of 19)Focus on equity: genderFocus on pipeline: barriers facing women becoming deans

Pros: multiple relevant factors identified with strong reference to underlying raw data, strong emergent themesCons: small sample, purposeful sample of successful women Appraisal: moderate to good

16. Wingard D, Trejo J, Gudea M, Goodman S, Reznik V. Faculty Equity, Diversity, Culture and Climate Change in Academic Medicine: A Longitudinal Study. Journal of the National Medical Association. 2019;111(1):46-53.

Longitudinal action research project involving multiple surveys and interventions

Survey participants between 478 and 515 (of 1350) faculty at one US health sciences facilityFocus on equity: generalFocus on pipeline: equitable retention, salary, satisfaction and promotion

Pros: multiple factors explored in the discussion section, with reference to strong underlying dataCons: limited empirical qualitative dataAppraisal: moderate

17. Kaplan SE, Gunn CM, Kulukulualani AK, Raj A, Freund KM, Carr PL. Challenges in Recruiting, Retaining and Promoting Racially and Ethnically Diverse Faculty. Journal of the National Medical Association. 2018;110(1):58-64.


44 senior faculty with responsibility for diversity and inclusion at 24 randomly selected US medical schoolsFocus on equity: under-represented racial and ethnic minoritiesFocus on pipeline: climate, programs, and challenges with regard to recruitment, retention and promotion of minority faculty

Pros: good methodology; strong use of underlying quotes discussed with reference to the literatureCons: may be biased towards positive as faculty interviewed were responsible for promoting a positive climateAppraisal: moderate

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4.2 Findings of the review

Our thematic meta-synthesis is given in Table 4, and summarised in Figure 2.

Table 4 Thematic meta-synthesisCategories and themes No. of papers

referencing this category/ theme

Total no. of coded references to this category/ theme

Sub-topics within theme Example quotes coded to this theme

Personal factors 16 275

Social capital 4 5 Ability to garner support from a sponsor1

Knowledge of the factors that support progression, advancement and salary negotiation2

Collegiality and social integration into the academic community1 3

Inclusion in/exclusion from informal social networks1 4

Professional advancement, including promotion seeking, is tied to having informal networks and supports and to garnering sponsorship—someone in a position of power to advocate for one’s career advancement—and men are more likely to have more of these resources than are women.1

Confidence and ambition

9 26 Strategic planning towards promotion4

- Applying for other positions to leverage position5

- Ability to self-promote6 7

- Thriving on politics of advancement4 Negotiation skills2

Externalising rather than internalising barriers6

Status cost to consultants starting as a junior researcher7

Resilience to burnout8

Most notable is that senior leadership was a more frequently cited theme among the [represented males]. Represented males aspired to be deans, departmental chairs, and division chiefs. Promotion to departmental chair or division chief was viewed as being based on grant funding attained, number of publications, and quality mentorship.4

Competing demands and priorities

12 93 Role conflict1 6 8

- See separate sections on orientation to roles- Drives leadership as a means of addressing conflict1

- Drives attrition1

Work-life conflict1 2 4-7 9 10 Family-work conflict- Expectation to prioritise family11 (see section on

societal factors)- Partner with demanding career5 6 11

- Perception of clinical academia as barrier to raising a family1 2 4 11-13

- Lack of female role models that have managed both1 4 11 12

- Need for geographic stability (e.g. children at school, partner’s career)1 5 10

Barriers to returning after children (see also section on organisational factors)

Increased role conflict was a significant [association with] of leadership seeking in both models, indicating that role conflict is either a driver or a consequence of leadership, capturing the challenges of meeting family needs and career demands that may come with choosing to move up the academic ladder.1

For both genders, increased role conflict and decreased perceptions of organizational support were associated with intent to leave, contributing about 20% of the variance for both groups.1

“The impact that research would potentially have on delaying completion of training and thus reducing the already limited years available for having children seems small but is a big deal to me. I have talked to several male students about this and it has never been a consideration or issue for any of them”.13

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- Availability of part-time posts and flexible working11

12

- Flexibility of moving between teaching and research, both directions11

- Availability of support/incentives for returners11

- Stigma of part-time working2

- Tendency to expect full-time outputs within part-time hours2

Impacts of career break on career success- Age at which family started coinciding with

research training years11

- Delay to career path and outputs2 13

- Perception of need for stability affecting salary/promotion negotiations5

A former junior female faculty identified a number of factors that led them to leave academic medicine. Both a shortage of female role models that championed balancing work and family responsibilities (and inspired others to do the same) and low remuneration discouraged female physicians from pursuing an academic career.12

“I am not sure I can do this—clinics, teaching, research, babies, and all”11

Financial considerations

8 21 Variable inequalities between research vs clinical pay structures11 13

Need for financial stability7 12 13

- Attrition driven by temporary vs tenured working12

Attrition from academic pathway driven by- Lack of access to affordable child care2

- Level of debt11 12 14

- Cost of living e.g. in London7

- Starting a family7

- Desire for higher salary1 4 11 13

Another factor influencing the decision of women to shift from full-time to part-time work is the lack of affordable child care services….In fact, working part-time is an alternative strategy to manage child care duties, sometimes chosen to avoid spending most of one's salary on expensive services.2

For both genders, debt was associated with the consideration of students leaving… and loan repayment programmes were likely to encourage indebted students to enter careers in clinical research.11

Orientation to roles 12 130- Orientation

towards administrative role

4 4 Administrative burden and dislike for administrative duties linked to burnout and ‘no desire’ for leadership roles6-8 (see section on orientation to leadership)Interest in the organisational aspects of education/research linked to interest in academic medicine as a career4

For leadership, faculty in the No Desire code group shared their love of patient care and research, and conversely their dislike of administrative work.6

- Orientation towards clinical care

2 7 Return to full time clinical role driven by- Delay reaching consultant status due to academic

time commitment7 - Feeling deskilled as a clinician due to time spent on

research/education7

- Wanting more patient contact6 7 Interest in combining research/academia with clinical contact- Feeling full time clinical career unviable7

- Feeling research makes them a better clinician6 7

Feeling clinically “deskilled” (as they lost skills they once possessed with time spent out of the clinic), fed up, and too “old” to be a clinical trainee motivated other participants to return to the clinic fulltime.7

A career in clinical academia had the potential to shape these participants into better clinicians, as their ability to understand and conduct high-quality research, which they honed during their PhD training, could inform their clinical practice.7

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- Orientation to leadership

4 21 Attractiveness of leadership role driven by- Wanting visibility as a role-model for others3 15

Rejection of leadership roles driven by- Perception of significant administrative burden and

out-of-ours work6

- ‘Gendered landscape’ of administrative leadership1

6 - Tendency/expectation for leaders to have stay-at-

home partners1

- Leadership role seen as conflicting with research/clinical role1 6

- Perceptions of poor leadership practices and conflict6

- Leadership advantages seen as ‘not worth the time or stress’ (male view)6

- Promotion seen as linked to grant funding, research output and senior sponsorship (favouring males)4

- Perceived as unviable due to lack of recognition, over-load and need to self-promote (female view)6

- Not feeling ready to take on leadership responsibilities (see compensatory behaviours)6

- Conceptions of leadership (power vs influence)1

The deans recommended re-evaluating traditional views of leader qualifications because the current standards do not necessarily parse out strong leaders and are more likely to exclude women candidates.15

“I prefer and highly value my time and effort in research and I have observed that accepting leadership roles often adversely affects research.”6

Women may respond differently to leadership questions phrased as interest in moving one’s department in new directions or in improving department practices rather than statements invoking traditionally androcentric roles regarding leading.1

- Orientation to research and academia

10 94 Interest in research role driven by- Early research experiences (e.g. as undergraduate,

trainee etc.)3 10 11 14

- Early training in research methods11

- Training in a research intensive hospital/university11

14

- Mentorship and role modelling, promoting ‘you can do it’3 4

- Early research success (e.g. publication)6 11 14

- Intrinsic interest in doing research, or a particular research topic or community impact6 12 13

Interest in academic role driven by- Academic freedom12

- Perceived as less stressful than clinical work7

- Perceived as more interesting than clinical work7

- Clearly structured career path6 10 12 13

- Benefits seen as ‘outweighing’ the difficulties7

Attrition driven by- Feeling unable to ‘switch off’ due to pressures to

publish/apply for funding7

All of these individuals planned to continue in research, having completed their PhD, because of intrapersonal influences, such as continued enjoyment and interest in their area of research. These participants found academia rewarding because of its ability to provide what clinical medicine no longer could, such as intellectual stimulation, competition, and diversity in their work.7

[Under-represented minority] participants considered the pursuit of academia as a way to positively influence outcomes for underserved communities. Trainees expressed that an academic career facilitated these objectives through community-based research, mentorship of minority trainees, role modelling, and leadership.4

…women researchers begin their careers with less institutional support. This likely can have an impact… as early academic productivity predicts retention and advancement in academic careers.11

“What I’ve had over the last five, six years is every night there’s something different I could be doing on my laptop. I

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- Competing demands and priorities7 (see separate theme)

- Lack of awareness of clinical academic career structure10

- Gender climate for trainees in teaching hospitals11

- Clinical commitments impacting research time2

could be writing this. I could be writing that … there’s always the pressure and it’s not right. I haven’t got any more give at the moment. At the moment, I’m just burnt out. I don’t want to do any more.”7

- Orientation towards education

2 15 Interest in educational role driven by- Culture of continuous learning, staying up to date4

- Early educational involvement/experiences (e.g. as undergraduate, trainee)4 11

- Wanting to facilitate success of others4

- Wanting to act as a role model/mentor4

- Wanting to make a difference4

- Wanting to build a diverse workforce4

- Interest in teaching a particular topic (e.g. community medicine)4

Attrition driven by- Competing demands and priorities (see separate

theme)- Time away from clinical care/progression (see

orientation to clinical role)- Status of teaching vs research (see section on

academic culture)

Respondents also noted that serving as a mentor to medical students and trainees contributes to interest in [academic medicine]. One respondent explained, “as a mentor, you can reach out to thousands of people who can ... impact change” (African American male, medical student).4

In two qualitative studies, female physicians (53 from the USA, seven from elsewhere) reflecting on their career choices reported that they were attracted to academic medicine by opportunities to teach, but with experience they also came to appreciate research more.11

Interpersonal (behavioural) factors

14 149

Supportive behaviours

9 32 Sponsorship- Advocacy for advancement1 4 6

- Support for early publication6

Supportive mentoring behaviours (see also mentoring availability)- Altruistic guidance and clarity12

- Building self-efficacy4 12

- Encouraging continuation within academia4 15

- Encouraging successful publication4 13

- Guiding and critiquing academic work12 13

- Moral and institutional support12

- Supporting career planning4 15

Supporting resilience in the face of difficulty12

It is often the person who is ‘‘scooped up’’ by their mentor and placed in a position for promotion. These persons have advantage because they are drawn into the process. Many are male.6

Professional advancement, including promotion seeking, is tied to having informal networks and supports and to garnering sponsorship—someone in a position of power to advocate for one’s career advancement—and men are more likely to have more of these resources than are women.1

Discriminatory behaviours

12 97 Conscious- Disrespect2 7 11

- Disruptive behaviours5 16

- Micro-aggressions2 11

“… a senior colleague of clearly homosexual orientation. Despite being very prepared, he was marginalized by the group leader. . . . He was placed in the ward, kept out of any possibility to publish and teach.”2

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- Sponsorship and preferential treatment of men 2 5 7

15

- Sexual harassment2 5 11

- Social exclusion2 11 12 15

Unconscious- Attitudes towards women exhibiting ‘male’ traits

(ambition, aggression, assertiveness)11

- Being treated differently to colleagues2 7 11 12

- Value judgements and invisibility2 5 11 15

- Assumptions about status and role5 11 15

- Diversity burden15 17

Cultural exclusion2 11

“The exclusion of women can be done in so many ways. It has been all the time actually. Also in meetings. [When you talk] they start to play with the phone or whatever. . . . We had a meeting with the boss and I talked with him for 30 seconds; and then he said: ‘She is giving a monologue.’. . . . Yes, subtle means.”2

“According to my mentors (usually chairs), before going up for promotion I always need one more thing even though there are many criteria for promotion, of which I have more than fulfilled. I have observed that this is not the case for several of my colleagues who are male.”6

Compensatory behaviours

7 19 Enduring effects of mistreatment2 11

Equalising behaviour (opposite of asserting dominance)11

Stereotype threat (fear of being seen to conform to stereotype)1

- Fear of speaking up or asking for adjustments2 12

Felt (vs enacted) bias (assumption you are being judged)12

Feeling you need to be ‘twice as good’ / not good enough yet2 11

“But in time, I learned to be silent, not to talk about it. Although I faced the problems, I did not mention anything about them. Because if I talk about the problems, they dislike me more.”2

Organisational factors 17 345

Academic culture 14 57 Pressured and uncertain environment2 7 9 15

- Pressure to apply for research grants- Pressure to publish regularly- Out of hours culture- Anxieties caused by fixed term/temporary research

contractsHierarchical structures- Limited promotion prospects at senior level6- Criticisms of promotion criteria and process

favouring self-promoters6

- Low status of teaching and research into inclusivity3

11

- Women over-represented in teaching11

- Limited recognition of teaching contribution in promotion criteria12

- Perception of under-appreciation of women’s contributions6

Variable interpersonal academic culture

Female full professor: ‘‘the ‘loudest’ people who self-promote seem to get the position.’’6

The majority of [minority faculty] felt that they [were] respected for their differences… they felt valued for what they brought… they did not feel marginalized because of belonging to a particular group)17

One dean noted that academic medicine has a more “conservative culture” that views “women, especially young women, in a very specific way;” women leaders are “not the norm, and we stick with the norm” [another dean] suggested that unconscious bias and lack of accommodation of work‑life balance needs contributed to an institutional culture that may discourage women’s advancement.15

Those who left academic medicine described their research institution as unwelcoming and individualistically competitive.12

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- Respectful and inclusive4 5 9 12 15-17

- Competitive and unwelcoming12

Broad spectrum of academic roles and responsibilities (teaching, research, mentoring, administration, leadership)4

Junior faculty valued institutions that were committed to their career development. They were discouraged by institutional failure to formally recognise their dedication to teaching and ambiguity regarding their pathway to promotion.12

Clinical workplace culture

7 30 Gendered culture in teaching hospitals2 11

- Positive in a narrow range of specialties including neurology, pathology, internal medicine and paediatrics14

- Negative in the majority of specialties including surgery2 7 14

Nepotism and lack of transparency in promotion pathways2

Prioritisation of service provision over research or teaching2 6 12

Given that the greatest attrition in commitment to research seems to occur during residency, it is imperative that medical schools and teaching hospitals work in partnership to improve gender climate and culture at the interface between the medical school and teaching hospitals.11

When you have an outpatient clinic, you might be asked to go and fetch your own patients whereas the nurse might do that for the male intern, or you have to change your own paper on the examination bench…Just little things like that.2

All surgeons look at you. . . . ‘Well, you are a woman, you will never be a good surgeon.’ . . . When I was a student, there were not a lot of female students specializing in surgical specialties. They stopped sometimes their education to become general practitioners.2

White male: “[When I was in the other hospital] there was the head of internal medicine trumpeting the fact that he never wanted to have a woman in his ward. Firstly, because they get on his nerves; secondly, because he said that every time you have to discuss with them, they begin to cry and to view any remark as offending them personally; thirdly, because women become pregnant. Partially I found this attitude here too [in the hospital where I am presently working].”

Pressure to prioritise clinical duties over research and teaching was frequently cited as a negative aspect of early career clinical academics’ working environment.12

Organisational policies & practices

17 242

- On equity and discrimination, wellbeing and burnout

14 90 Authenticity of commitment to diversity- Commitment of senior leadership17

- Diversity Council or Diversity Champion17

- Feeling like the ‘Token Diversity’ candidate17

- Investment in unconscious bias training11 16

- No tolerance policy on discrimination5

- Monitoring16

Regardless of gender, faculty expressing [Role Overload] frequently worked part time (p = 0.001) and had a spouse working outside the home (93%, p = 0.043).6

“diversity exhaustion for our [minority] faculty members… when people are asked to do so much to help recruit, retain,

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- Diversity training that includes LGBTQ3

Family friendly policies- Flexible working beyond childcare e.g. for family

crises16

- Availability of flexible working1 2 5-7 10 12 15 16

- Culture of flexible working2 12

- Maternity Pay and funding for family support2 5 13

- Addressing out-of-hours culture7 10

Hiring and promotion practices- Representation on hiring and promotion panels15 17 - Disproportionate burden on minority staff e.g. to sit

on panels17

- Selection criteria that disadvantage women e.g. requirement to travel, status of education vs research5 10 11 15

promote, support, mentor other people who look like themselves.”17

Moreover,[]part-time working] may carry a stigma: “I think working part-time is a thing that hampers progression in your career, in general. . . . Apparently people think: ‘OK, part-time means no ambition.’ Which is not true.” 2

“They’re very good with cultural diversity training, but when it comes to LGBT concerns it’s kind of like they don’t talk about it. It’s like a brick wall.’’ 3… a series of policy and programmatic interventions (data collection and dissemination, family friendly policies, training, and faculty development programs) was associated with increases in faculty diversity, equity, respectful behavior and improved faculty climate.16

- On mentoring, social support, networking, role modelling

15 85 Role-modelling- Lack of critical mass of academics from diverse

backgrounds5 17

- Lack of female role models that have managed family and career1 2 4 5 11 12

- Role modelling work-life balance4

- Visibility of concordant role models2 4 6 10-12 15

Networking- Concordant networking opportunities3

Supervision- Variability of relationship with research supervisor- Suboptimal departmental leadership practices6

Mentoring (see also section on interpersonal factors)- Availability of concordant mentoring4 5 10 11 17 3- Cross gender mentoring requires understanding of

unique challenges1

- Formal mentorship supporting advancement of under-represented groups5 10 17

- Women choosing lower status but supportive mentors11

Poor quality or inconsistently available mentoring6 13

…significantly more women (p = 0.032) expressed the concern or frustration that they needed to self-promote or else were simply forgotten by their leaders.6

“I am shocked when I look around. Even if I think that things are going well, that people are not discriminated. ...When you look around, there are always more men than women in leadership positions.”2

Those who were based in an academic setting that nurtured supportive mentorship and positive role modelling tended to pursue academic medicine with greater career satisfaction and confidence.12

- On active support for career advancement

8 31 Career planning support1 4 6 7 10 12

Clear promotion pathway that includes education6 7 12

Faculty Development Programmes16

Leadership training4 6

- for women4

These gendered patterns of family–work dynamics, coupled with the association between organizational support and intent to leave, point to the organization’s responsibility and accountability in establishing practices that can facilitate embeddedness or a reason to stay, such as a positive

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Training for careers counsellors on gender in clinical academic careers4

Training on promotional pathways, policies and procedures7 12 16

promotion climate. It is worth noting that opportunities for advancement are necessary, but not sufficient to increase retention for all faculty members, as promotion climate was not a positive reason to stay for female respondents.1

- On remuneration, funding and resourcing

9 21 Academic vs clinical salary discrepancies11 12

Gendered allocation of office space or admin support2 9

Performance recognition schemes17

Opportunities for funding and credit (see also section on personal financial considerations)- Resources to protect time for research e.g. clinical

backfill5 9 12

- Availability of student loan repayment schemes11

- Competitiveness for limited sources of funding12

- Gendered allocation of research funding14

- Research funding for trainee doctors vs consultants7

- Tendency for women to apply for funded PhDsGender or ethnicity based pay gap2 5

The ongoing pay gap (both for women and for expatriates) is exacerbated by salary negotiations which tend to favour local male professionals, as they are often more assertive.2

“In my clinic there are two men and they have two separate rooms, the other four female doctors are in one room. So, males have more opportunities than me [to do research].”2

There is evidence that programs targeted at junior faculty can have successful outcome measures … Such programs, essential to retain and develop successfully recruited underrepresented faculty, require dedicated funds and institutional commitment over an extended period of time.17

External (societal) factors 8 25

National clinical structures and funding

2 5 Junior doctor contract – longer ‘core working hours’7

- Impact on parents without primary caregiver as partner

- Impact on research capacityVisibility of academic training pathway to clinicians7 13

Many participants… voiced their fears that the new junior doctor contract in the United Kingdom may financially penalize both female clinicians and those interested in pursuing an academic career, due to potential increases in working hours accompanied by a reduction in out-of-hours pay.7

… participants noted difficulty accessing information and guidance on training pathways and uncertainty about how to progress in a clinical academic career, particularly if they were ineligible for the integrated academic training pathway.7

Societal attitudes to diversity and equity

3 13 Expectation for women to be primary caregiver2 5 11

Women less likely to have a primary caregiver as partner11

Expectation for women to shoulder household chores2 5

Increasing acceptance of non-gendered household roles2

We suggest that such a pattern reflects a general gender norm within society whereby women are more likely to hinder their careers because of family responsibilities and ‘‘second shifts’’ than are men.5

“It seems that younger couples try to share much more equally. I don't know if that's true for every aspect of life. But also many of my male colleagues leave early one or two days a week to go pick up the kids at the day care centre.”2

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National research structures and funding

3 6 Small number of senior academic positions10

Potential for joint funding of senior CA positions10

Difficulty securing post-doctoral funding7 10

Decreased national funding for research/austerity12

Structures preventing consultants applying for clinical lectureships10

Respondents not planning a [clinical academic career]…are particularly worried about the small number of senior academic appointments available as well as the difficulty of obtaining research grants and work-life balance10

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5 DISCUSSION

The objective of this scoping review was to examine and synthesise current evidence on the factors

that affect recruitment, retention, participation and progression within the clinical academic pathway,

with a particular focus on equitable participation for under-represented groups. We identified 13

discrete domains of factors (figure 2), which we organised into personal, interpersonal, organisation

and societal categories using a socio-ecological approach to understand the interactive effects

between individuals and their wider environment. Each factor identified can be either a facilitator or

a barrier to equitable participation. Of note, of the 17 papers included in the meta-thematic synthesis,

only 1 focussed specifically on LGBT diversity and only 1 focussed exclusively on ethnic diversity. As

such, the synthesis presented below may be overly weighted towards gender specific issues.

Figure 2: summary of meta-thematic synthesis of factors relating to retention, success and equitable

participation in clinical academia

<Insert Figure 2 here>

Factors within the organisational realm (culture, practices and policies) were most frequently

discussed within the literature, and are a clear target for action given that organisational culture and

practices are to a degree within the control of institutional leaders and can be more easily and rapidly

transformed than wider external and societal factors.

Within the organisational realm, conscious discriminatory behaviours were discussed frequently,

particularly in the clinical context. This varied by specialty and institutions, with discriminatory

behaviours appearing to be driven by the pressurised and hierarchical clinical workplace culture and

being particularly prominent in specialties with a strong social identity, such as surgery. Institutions

should actively promote and enforce publicly policies that demonstrate a zero-tolerance approach to

active discrimination. Our findings suggest it may not be enough to address organisational culture on

a single side of the research vs clinical divide. Research institute policies on inclusive practices won’t

support this workforce, unless they are also adopted and monitored within clinical setting. The authors

also note that in the UK, the erosion of the traditional firm structure may have affected clinical culture.

Without the firm structure, trainees may lack consistent relationships with their seniors who are key

to their training and development(35, 36). The increased fluidity of the structure of clinical teams

could present a hinderance to a cohesive culture and the strong mentoring relationships key to a

successful clinical-academic career. Whilst this did not present itself as a specific theme in the

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literature examined, looking at this area of clinical culture and its effect on equitable participation in

clinical academia could represent an interesting area for future research.

We observed an interplay between organisational policies and practices, compensatory behaviours

and perceived competing demands and priorities, particularly in work-life matters. The overly

crowded lives of underrepresented groups were noted by several authors, whether this was secondary

to conflicts with care giving responsibilities, or a lack of critical mass of ‘diversity role models’ placing

more pressure on individuals to contribute to mentoring schemes and numerous committees and

panels, detracting from research time. Naturally, changes in organisational policies towards flexible

working, and mandating essential activities are kept within normal childcare hours, can make a

significant and immediate difference in minimising conflict and potential burnout. Senior leaders’

public support for such policies is critical; it was noted in some cases where there were flexible working

policies in place, making use of such policies was frowned upon. Compensatory behaviours in those

who are underrepresented may mean that those who would benefit most from such policies may not

utilise them due to concerns about being judged negatively or reinforcing an existing negative

stereotype. Publicly supportive senior leadership is key to overcoming these concerns. Previous

research has suggested that effective mentoring relationships do not necessitate matching on the

basis of gender or ethnicity(37, 38), and institutions should focus on developing effective and sensitive

mentorship programmes rather than placing additional pressures on particular individuals.

Another emerging interplay can be observed on a higher societal level. With attitudes towards

traditional caregiving roles evolving, work-life conflict issues will become a deterrent for an increasing

number of early clinical academics, regardless of gender, if organisational practices do not change.

Interventions to support research productivity and address burnout among parents might have wider

benefits, having significant implications for the future clinical academic pipeline as a whole.

We noted the importance of social capital to research productivity, early publication success and

career progression. However, it is harder to build social capital if one is unable to engage in out-of-

hours activities, has different sociocultural references, or is not accepted into a culture of

heteronormative ‘banter’ within a team. Supportive behaviours, such as sponsorship and inclusion in

a community of practice, can therefore themselves harm diversity if they are only offered to trainees

with high social capital that look and sound like incumbent senior academics. At a national policy level,

the creation of clear and transparent national pathways would make participation less dependent on

the support and guidance of a senior academic, which seems to favour the demographic of

incumbents.

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Past systematic reviews in the area have focussed on a particular stage of career decision making, a

particular population, or a particular factor that affects equitable participation. Our methodology

allowed us to examine and synthesise a broader range of literature. It also facilitated the creation of

an integrative analysis of the factors that influence equitable participation in clinical academia at all

stages of the pipeline, from recruitment to professorship.

Rigorous consensual qualitative research methods were employed. All coding was cross-checked by

two authors and the coding structure was audited, and saturation confirmed, by a third author.

The scoping review methodology introduced a breadth of literature types. Given this breadth, no

standardised quality assessment instrument was available, instead we undertook an individual

assessment for each paper. However, the flexibility of the scoping review methodology enabled us to

gauge the ‘bigger picture’ with more breadth than a traditional systematic review approach.

An additional limitation of our study was the limited literature on equitable participation for ethnic

minority and LGBTQ clinicians. Whilst we were able to test our coding structure against a few papers

focusing on these areas, the infancy of research in this area, compared to gender-based papers, is a

limitation of our findings. In addition, the geographical limitation to North America, Western Europe

and Australasia, limits wider applicability.

6 CONCLUSION

This review has identified thirteen themes of factors impacting on equitable participation in clinical

academia. The broad and often interconnected nature of these factors suggests that there is no ‘silver

bullet’ and that interventions will need to be multi-factorial, addressing structural and cultural factors

as well as individual needs. We suggest that organisations work to mitigate role conflict which drives

burnout and attrition, address the clinical workplace culture which appears divergent from academic

culture, and promote transparent national career pathways.

Figure Legends




REFERENCES (BODY OF TEXT) – references from tables listed at end of the document

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5. Windsor J, Garrod T, Tan L, Talley NJ, Churchill J, Farmer E, et al. Progress towards a sustainable clinical academic training pathway. ANZ Journal of Surgery. 2018 10/01; 2019/06;88(10):952-3.

6. Rimmer A. Clinical academic workforce continues to shrink. BMJ. 2017 British Medical Journal Publishing Group;358:j3352.

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15. Cohen JJ. The consequences of premature abandonment of affirmative action in medical school admissions. JAMA. 2003 Mar 5;289(9):1143-9.

16. Andriole DA, Jeffe DB. Predictors of full-time faculty appointment among MD-PhD program graduates: a national cohort study. Medical education online. 2016 05/13;21:30941-.

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17. Vetter MH, Carter M. Differences between first and fourth year medical students' interest in pursuing careers in academic medicine. Int J Med Educ. 2016 May 24;7:154-7.

18. Abu-Zaid A, Altinawi B, Eshaq AM, Alkhatib L, Hoilat J, Kadan S, et al. Interest and perceived barriers toward careers in academic medicine among medical students at Alfaisal University - College of Medicine: A Saudi Arabian perspective. Med Teach. 2018 Sep;40(sup1):S90-5.

19. Windsor J, Searle J, Hanney R, Chapman A, Grigg M, Choong P, et al. Building a sustainable clinical academic workforce to meet the future healthcare needs of Australia and New Zealand: report from the first summit meeting. Intern Med J. 2015 09/01; 2019/07;45(9):965-71.

20. McDermott M, Gelb DJ, Wilson K, Pawloski M, Burke JF, Shelgikar AV, et al. Sex Differences in Academic Rank and Publication Rate at Top-Ranked US Neurology Programs. JAMA Neurol. 2018 Aug 1;75(8):956-61.

21. Pololi LH, Civian JT, Brennan RT, Dottolo AL, Krupat E. Experiencing the culture of academic medicine: gender matters, a national study. J Gen Intern Med. 2013 Feb;28(2):201-7.

22. Farkas AH, Bonifacino E, Turner R, Tilstra SA, Corbelli JA. Mentorship of Women in Academic Medicine: a Systematic Review. J Gen Intern Med. 2019 Jul;34(7):1322-9.

23. Thomas J, Harden A. Methods for the thematic synthesis of qualitative research in systematic reviews. BMC Medical Research Methodology. 2008 07/10;8(1):45.

24. Peters MD, Godfrey CM, Khalil H, McInerney P, Parker D, Soares CB. Guidance for conducting systematic scoping reviews. Int J Evid Based Healthc. 2015 Sep;13(3):141-6.

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26. Ray J, Esipova N, Pugliese A, Maybud S. Towards a better future for women and work: voices of women and men. Geneva: International Labour Organization and Gallup; 2017. Report No.: p 219.

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28. Toye F, Seers K, Allcock N, Briggs M, Carr E, Barker K. Meta-ethnography 25 years on: challenges and insights for synthesising a large number of qualitative studies. BMC Med Res Methodol. 2014 Jun 21;14:80,2288-14-80.

29. List of Predatory Journals [Internet].; 2019 []. Available from: https://predatoryjournals.com/journals/.

30. Joanna Briggs Institute. JBI Reviewer's Manual. 2019.

31. Wohlin C. Guidelines for snowballing in systematic literature studies and a replication in software engineering. Proceedings of the 18th international conference on evaluation and assessment in software engineering; Citeseer; 2014.

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32. Badampudi D, Wohlin C, Petersen K. Experiences from using snowballing and database searches in systematic literature studies. Proceedings of the 19th International Conference on Evaluation and Assessment in Software Engineering; ACM; 2015.

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36. Abbasi K. Firm findings on doctors' wellbeing. J R Soc Med. 2017 05;110(5):175-.

37. DeCastro R, Griffith KA, Ubel PA, Stewart A, Jagsi R. Mentoring and the Career Satisfaction of Male and Female Academic Medical Faculty. Academic Medicine. 2014;89(2).

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REFERENCES (FROM TABLES)

1. Ellinas EH, Fouad N, Byars-Winston A. Women and the Decision to Leave, Linger, or Lean In: Predictors of Intent to Leave and Aspirations to Leadership and Advancement in Academic Medicine. Journal of Womens Health 2018;27(3):324-32. doi: 10.1089/jwh.2017.6457

2. Huttner A, Cacace M, d'Andrea L, et al. Inequality dynamics in the workplace among microbiologists and infectious disease specialists: a qualitative study in five European countries. Clinical Microbiology and Infection 2017;23(5):332.e1-32.e9. doi: 10.1016/j.cmi.2016.09.015

3. Sánchez NF, Rankin S, Callahan E, et al. LGBT trainee and health professional perspectives on academic careers—facilitators and challenges. LGBT health 2015;2(4):346-56.

4. Sanchez NF, Poll-Hunter N, Spencer DJ, et al. Attracting Diverse Talent to Academia: Perspectives of Medical Students and Residents. Journal of Career Development 2018;45(5):440-57. doi: 10.1177/0894845317709997

5. Martinez LR, O'Brien KR, Hebl MR. Fleeing the Ivory Tower: Gender Differences in the Turnover Experiences of Women Faculty. Journal of Womens Health 2017;26(5):580-86. doi: 10.1089/jwh.2016.6023

6. Ellinas EH, Kaljo K, Patitucci TN, et al. No Room to "Lean In": A Qualitative Study on Gendered Barriers to Promotion and Leadership. Journal of Womens Health 2018 doi: 10.1089/jwh.2018.7252

7. Ranieri VF, Barratt H, Rees G, et al. A Qualitative Study of the Influences on Clinical Academic Physicians' Postdoctoral Career Decision Making. Academic Medicine 2018;93(11):1686-93. doi: 10.1097/acm.0000000000002141

8. Rao SK, Kimball AB, Lehrhoff SR, et al. The impact of administrative burden on academic physicians: Results of a hospital-wide physician survey. Academic Medicine 2017;92(2):237-43. doi: 10.1097/ACM.0000000000001461

9. Jagsi R, Griffith KA, Jones RD, et al. Factors Associated with Success of Clinician-Researchers Receiving Career Development Awards from the National Institutes of Health: A Longitudinal

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Cohort Study. Academic Medicine 2017;92(10):1429-39. doi: 10.1097/ACM.0000000000001728

10. Lopes J, Ranieri V, Lambert T, et al. The clinical academic workforce of the future: A cross-sectional study of factors influencing career decision-making among clinical PhD students at two research-intensive UK universities. BMJ Open 2017;7(8) doi: 10.1136/bmjopen-2017-016823

11. Edmunds LD, Ovseiko PV, Shepperd S, et al. Why do women choose or reject careers in academic medicine? A narrative review of empirical evidence. The Lancet 2016;388(10062):2948-58.

12. Ranieri V, Barratt H, Fulop N, et al. Factors that influence career progression among postdoctoral clinical academics: a scoping review of the literature. Bmj Open 2016;6(10) doi: 10.1136/bmjopen-2016-013523

13. Eley DS, Jensen C, Thomas R, et al. What will it take? Pathways, time and funding: Australian medical students' perspective on clinician-scientist training. Bmc Medical Education 2017;17 doi: 10.1186/s12909-017-1081-2

14. Skinnider MA, Twa DDW, Squair JW, et al. Predictors of sustained research involvement among MD/PhD programme graduates. Medical Education 2018;52(5):536-45. doi: 10.1111/medu.13513

15. Humberstone E. Women Deans' Perceptions of the Gender Gap in American Medical Deanships. Education for Health 2017;30(3):248-53. doi: 10.4103/efh.EfH_291_16

16. Wingard D, Trejo J, Gudea M, et al. Faculty Equity, Diversity, Culture and Climate Change in Academic Medicine: A Longitudinal Study. Journal of the National Medical Association 2019;111(1):46-53. doi: 10.1016/j.jnma.2018.05.004

17. Kaplan SE, Gunn CM, Kulukulualani AK, et al. Challenges in Recruiting, Retaining and Promoting Racially and Ethnically Diverse Faculty. Journal of the National Medical Association 2018;110(1):58-64. doi: 10.1016/j.jnma.2017.02.001

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Incl

ud

ed

El

igib

ility

Records identified through database searching

(n = 73)

Scre

enin

g Id

en

tifi

cati

on

Additional records identified through forward snowballing

(n = 552)

Records after duplicates removed (n = 625)

Records screened (n = 624)

Records excluded (n = 366)

Full-text articles assessed for eligibility

(n = 72 most recent of 258)

Full-text articles excluded, (n = 33, relevance)

Studies eligible for qualitative synthesis

(n = 39)

Studies included in meta-thematic synthesis (n = 17, saturation)

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• Mentoring & sponsoring

• Emotional & practical support


• Conscious: micro-aggressions, bullying harassment, exclusion

• Unconscious: value judgements, invisibility, diversity burden, preferential sponsorship etc.


• On equity, discrimination, wellbeing, burnout

• On mentoring, social support, networking, role-modelling

• On career advancement

• On remuneration, funding, resourcing


• Gendered culture in surgery, variable across specialties

• Lack of transparency on advancement

• Prioritisation of clinical vs research/teaching roles

Academic culture

• Pressured and uncertain

• Hierarchical

• Status of research vs education

• Variable culture of inclusivity

National policies

• Clinical & research training structures

• Research and clinical priorities

Societal attitudes

• Attitudes to gender & diversity

• Expectations re family & household roles

Competing demands & priorities

• Role conflict e.g. research vs clinical

• Work-life/family conflict

• Ability to negotiate multiple roles

Orientation to role(s)

• Motivations, experiences, satisfaction with clinical, research, administrative, leadership, academic and educational roles


• Level of debt

• Need for financial security

• Desire for higher salary

Social capital

• Advantages based on social assets e.g. ability to garner support

Confidence & ambition

• Planning, negotiation, resilience


• Enduring effects of mistreatment

• Equalizing behaviours

• Feeling you need to be ‘twice as good’

• Fear of speaking up or asking for adjustments, stereotype threat

• Presumptions about being judged

Societal factors Organisational factors Interpersonal factors

Personal

factors

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1

Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) Checklist

SECTION ITEM PRISMA-ScR CHECKLIST ITEM REPORTED ON PAGE #

TITLETitle 1 Identify the report as a scoping review. 1

ABSTRACT

Structured summary 2

Provide a structured summary that includes (as applicable): background, objectives, eligibility criteria, sources of evidence, charting methods, results, and conclusions that relate to the review questions and objectives.

2

INTRODUCTION

Rationale 3

Describe the rationale for the review in the context of what is already known. Explain why the review questions/objectives lend themselves to a scoping review approach.

4

Objectives 4

Provide an explicit statement of the questions and objectives being addressed with reference to their key elements (e.g., population or participants, concepts, and context) or other relevant key elements used to conceptualize the review questions and/or objectives.

4

METHODS

Protocol and registration 5

Indicate whether a review protocol exists; state if and where it can be accessed (e.g., a Web address); and if available, provide registration information, including the registration number.

5

Eligibility criteria 6

Specify characteristics of the sources of evidence used as eligibility criteria (e.g., years considered, language, and publication status), and provide a rationale.

5-7

Information sources* 7

Describe all information sources in the search (e.g., databases with dates of coverage and contact with authors to identify additional sources), as well as the date the most recent search was executed.

5-7

Search 8Present the full electronic search strategy for at least 1 database, including any limits used, such that it could be repeated.

6-7

Selection of sources of evidence†

9State the process for selecting sources of evidence (i.e., screening and eligibility) included in the scoping review.

6-7

Data charting process‡ 10

Describe the methods of charting data from the included sources of evidence (e.g., calibrated forms or forms that have been tested by the team before their use, and whether data charting was done independently or in duplicate) and any processes for obtaining and confirming data from investigators.

8

Data items 11List and define all variables for which data were sought and any assumptions and simplifications made.

8

Critical appraisal of individual sources of evidence§

12

If done, provide a rationale for conducting a critical appraisal of included sources of evidence; describe the methods used and how this information was used in any data synthesis (if appropriate).

8

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2


Synthesis of results 13 Describe the methods of handling and summarizing

the data that were charted. 8

RESULTS

Selection of sources of evidence

14

Give numbers of sources of evidence screened, assessed for eligibility, and included in the review, with reasons for exclusions at each stage, ideally using a flow diagram.

Figure 1- PRISMA flow diagram

Characteristics of sources of evidence

15 For each source of evidence, present characteristics for which data were charted and provide the citations. 11-14

Critical appraisal within sources of evidence

16 If done, present data on critical appraisal of included sources of evidence (see item 12). 11-14

Results of individual sources of evidence

17For each included source of evidence, present the relevant data that were charted that relate to the review questions and objectives.

12-23

Synthesis of results 18 Summarize and/or present the charting results as

they relate to the review questions and objectives. 24

DISCUSSION

Summary of evidence 19

Summarize the main results (including an overview of concepts, themes, and types of evidence available), link to the review questions and objectives, and consider the relevance to key groups.

24-26

Limitations 20 Discuss the limitations of the scoping review process. 26

Conclusions 21Provide a general interpretation of the results with respect to the review questions and objectives, as well as potential implications and/or next steps.

26

FUNDING

Funding 22

Describe sources of funding for the included sources of evidence, as well as sources of funding for the scoping review. Describe the role of the funders of the scoping review.

3

JBI = Joanna Briggs Institute; PRISMA-ScR = Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews.* Where sources of evidence (see second footnote) are compiled from, such as bibliographic databases, social media platforms, and Web sites.† A more inclusive/heterogeneous term used to account for the different types of evidence or data sources (e.g., quantitative and/or qualitative research, expert opinion, and policy documents) that may be eligible in a scoping review as opposed to only studies. This is not to be confused with information sources (see first footnote).‡ The frameworks by Arksey and O’Malley (6) and Levac and colleagues (7) and the JBI guidance (4, 5) refer to the process of data extraction in a scoping review as data charting.§ The process of systematically examining research evidence to assess its validity, results, and relevance before using it to inform a decision. This term is used for items 12 and 19 instead of "risk of bias" (which is more applicable to systematic reviews of interventions) to include and acknowledge the various sources of evidence that may be used in a scoping review (e.g., quantitative and/or qualitative research, expert opinion, and policy document).

From: Tricco AC, Lillie E, Zarin W, O'Brien KK, Colquhoun H, Levac D, et al. PRISMA Extension for Scoping Reviews (PRISMA-ScR): Checklist and Explanation. Ann Intern Med. ;169:467–473. doi: 10.7326/M18-0850

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Journal: BMJ Open

Manuscript ID bmjopen-2019-033480.R1

Article Type: Original research

Date Submitted by the Author: 17-Jan-2020


<b>Primary Subject Heading</b>: Medical education and training

Secondary Subject Heading: Health services research

Keywords:

MEDICAL EDUCATION & TRAINING, QUALITATIVE RESEARCH, Health policy < HEALTH SERVICES ADMINISTRATION & MANAGEMENT, Organisational development < HEALTH SERVICES ADMINISTRATION & MANAGEMENT


BMJ Open on N



jopen.bmj.com

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arch 2020. Dow

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Word count: 2380 excluding tables

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ABSTRACT

Objectives: To examine and synthesise current evidence on the factors that affect recruitment, retention, participation and progression within the clinical academic pathway, with a particular focus on equitable participation across protected characteristics including gender, ethnicity and sexual orientation.



Article Selection: English language articles exploring factors affecting recruitment, retention, progression and equitable participation in clinical academic careers undertaken within North America, Australasia and Western Europe between Jan 2005 - April 2019. 39 relevant articles were identified using detailed inclusion/exclusion criteria.

Data Extraction: For the meta-thematic synthesis, papers were coded for factors relating to equitable participation facilitated by NVivo software. Themes and higher level categories were derived through an iterative consensual process. 17 articles were thematically analysed. No new themes arose after 9 papers.

Results: 13 discrete themes of factors impacting on equitable participation were identified which were categorised into external (societal), personal, interpersonal and organisational domains. Within these themes we present a range of detailed sub-themes and factors which have implications for institutions looking to improve the retention and success of a diverse clinical academic workforce.

Conclusions: Clinical academic careers play an essential role in the delivery of high-quality translational research and improvements in patient care and clinical training. Over recent years, there has been a decline in the number of clinical academics, with certain demographic groups being persistently underrepresented in the work force, particularly at the higher professional grades. This review identified the range of factors impacting on equitable participation in clinical academia. The broad and often interconnected nature of these factors suggests that there is no ‘silver bullet’ and that interventions will need to be multi-factorial, addressing structural and cultural factors as well as individual needs.

Keywords: Clinical Academia, Physician Researchers, Diversity, Gender.

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Strengths and limitations of this study This review examines a full continuum of factors affecting equitable participation in clinical

academia at all stages of the pipeline. Our methodology allowed the use of broad search criteria to establish the extent and range of

literature and to systematically select papers on the basis of quality, relevance and recency. Our findings will have limited relevance to nursing, midwifery, allied health professions or other

geographies where there may be divergent issues in relation to gender, sexuality and ethnicity or the nature of clinical academia.

The majority of papers identified in the scoping review focused on gender, therefore the factors identified within each theme may not fully represent issues relating to other protected characteristics such as race, ethnicity and sexual orientation.

Funding statement: This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors

Competing Interests Statement: No competing interests to declare

Contributorship StatementOur team comprised an early career clinical academic (CV), an established educational researcher (KLG) and a professor of medical education (SS), all trained qualitative researchers with professional insights into the subject of enquiry. The Faculty of Medicine at Imperial College has a strong research interest in widening participation. The Imperial College School of Medicine also has more graduates entering the clinical academic pathway than any other UK medical school. These factors combined led to our interest in identifying factors surrounding equitable participation in the clinical academic career pathway

All authors were involved in the conception and design of the study and in the acquisition, analysis, and interpretation of our findings. CV and KLG identified and coded the papers. SS audited the process and coding. All authors worked together to generate the themes and categories through a consensual process. CV drafted the work, KLG created the tables. All authors revised it critically for important intellectual content. All authors gave approval to the final version and agree to be accountable for all aspects of the work. All authors undertake to ensure that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

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BACKGROUND

Clinical academics, also referred to as physician-researchers, physician-scientists or academic


informs their academic practice and vice versa, creating a powerful synergy that is critical to

healthcare innovation[1], the translation of research into tangible improvements in patient care[2], as

well as driving research questions that are relevant to patient populations[3], and supporting the

workforce of the future through medical education[4]. As such, the declining number of clinical

academics, which has been observed internationally[5, 6] is concerning.



since 1996[7], however in 2017 the ratio of male to female clinical academics stood at 69% to 31%

with the gender disparity even greater at professorial level[8]. Several studies have demonstrated that

females and minority ethnic clinical academics are also underrepresented at senior levels in North

America, Australasia and across Western Europe[9-11]. Concerningly, there is evidence that

representation of ethnic minorities actually declined in the US between 1990 and 2016[12].


innovation and excellence in research and teaching[13, 14], for example training doctors to practice

in culturally diverse environments[13], or researching health issues specific to underrepresented

communities[3, 15]. From an economic perspective, the attrition of a highly trained elite workforce






programmes such as mentoring programmes or the Higher Education Equality Charters in the UK,

including a recent review of interventions[11]. There is a gap in the literature for a review of

explanatory factors.

REVIEW OBJECTIVES

Past research in the area has often focussed on a particular stage of career development[16, 17], a

particular population[4, 18], or a particular factor that affects equitable participation[19-21]. Our aim



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METHODOLOGY

Thematic analysis is a validated method for meta-synthesis of exploratory rather than interventional

research findings, bringing together and integrating findings of multiple studies[22]. We utilised

Thomas et al’s 3-step framework for thematic synthesis[22].








Scoping review is a methodology that has an evolving literature base[23] and many definitions, some

involving more evidence synthesis than others. Our methods were guided by our purpose which was



Munn et al identify that when a study is “interested in the identification of certain


characteristics/concepts” a scoping review is the appropriate choice of methodology[24]. As such, the

scoping review methodology was appropriate to address our aim.

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Inclusion criteria

Our inclusion criteria are listed and justified in Table 1.

Table 1 Inclusion criteria and justificationCriteria JustificationTypes of participantsExclusion of articles relating to nursing, midwifery and allied health professionals



Our geographical focus was chosen due to a) established clinical academic career pathways in these regions and b) the heavy influence of societal norms on attitudes to equitable participation which are relatively similar across these regions[25].







2005 was the year Modernising Medical Careers was introduced in the UK and current recommendations for clinical academic training were established[26].


Our aim was to identify robust conceptual categories and to explore their explanatory value. Our interest was in the concepts that had been identified by researchers, rather than the original raw data i.e. second order data[27]. We therefore included empirical qualitative research, reviews grounded in robust empirical data, mixed methods studies with substantial qualitative elements, and quantitative papers that tested a broad range of factors across demographics. Theoretical perspectives, commentaries and opinion pieces were excluded.


Publication in a reputable journal following peer review was used as an initial surrogate for quality. Unpublished PhD theses, on-going unpublished studies on trial registers, letters, conference abstracts, grey literature and suspected predatory journals[28] were excluded.



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Search Strategy

We used a PICo ‘population, phenomenon of interest, context’ strategy[29] to develop our question




re-applied as the range of terms relating to our subject of interest became apparent. We purposefully

included terms relating to protected characteristics including gender, race, disability and sexual



Table 2 Search termsPopulation – clinical academics




The literature in this area doesn’t have a defined MESH term, topic category or keyword and there is

a wide range to terms to describe clinical academia, including specialty specific terms such as academic


academia and participation and equity (see terms in Table 2). We systematically expanded this search

using forward snowballing approach[30] using Google Scholar, to include relevant papers that had

cited the most commonly cited papers in both our original list and then again on the expanded list.



seeded from suitably influential and relevant papers[31]. Web of Science was chosen and not



superior citation coverage to both Web of Science and Scopus[32].

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identified a manageable number of potential papers, our thematic synthesis began by purposefully




Critical appraisal of research quality








Table 3.

Textual data extraction

We used a consensual qualitative research approach[33] involving two independent coders (CV) and

(KLG) and an auditor (SS). We uploaded the selected papers to analytical software (NVivo 12, QSR

International) purposefully sampling papers that were potentially rich in factors and with diverse




Textual data synthesis

Content codes were arranged into higher level themes through an inductive consensual process,

involving team discussions and iteratively testing the thematic structure against new papers.





groups, different geographies and stages in the pipeline. Finally, these themes were categorised

according to personal, interpersonal, organisational and societal factors, reflecting the multiple layers

of influence on the career development of clinical academics.

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Patient and Public Involvement

No Patient Involvement

Research Ethics Approval

Research ethics committee approval was not required as this is a review paper.

RESULTS

We applied our search terms tightly (population AND phenomenal of interest AND context in the title)

to generate 73 papers that we were confident had relevance to this area of research. We then

searched for papers citing the 12 most frequently cited of these papers on Google Scholar, and the

most frequently cited relevant papers from the expanded list, which generated 625 papers. Titles were

screened according to our inclusion criteria, leaving 258 potential papers for inclusion since 2005.

Note that the date range for the scoping review (2005-2019) was broader than the range considered

for meta-thematic synthesis (2014-2019) where only the most recent five years were included. The

initially broad approach supported the identification of highly cited papers on this topic, which is

necessary for effective forward snowballing (identification of related papers through citation indexes).

The subsequent contraction to the most recent five years was a pragmatic way of reducing the large

number of papers identified to a manageable number for full text review and potential inclusion in

the meta-thematic synthesis. As such, only full text papers from the most recent five years were

uploaded onto NVivo, which reduced the number or potential papers for inclusion to 72. Our criteria

were re-applied to the full-text papers, reducing this number to 39. Our search results are summarised

in Figure 1.



Methodological quality


Findings of the review

The findings of the review are presented in Table 4.

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Table 3 Methodological quality

Article citation Study design Population Comments on qualityEllinas EH, Fouad N, Byars-Winston A. Women and the Decision to Leave, Linger, or Lean In: Predictors of Intent to Leave and Aspirations to Leadership and Advancement in Academic Medicine. Journal of Womens Health. 2018;27(3):324-332.[34]




Huttner A, Cacace M, d'Andrea L, et al. Inequality dynamics in the workplace among microbiologists and infectious disease specialists: a qualitative study in five European countries. Clinical Microbiology and Infection. 2017;23(5):332.e331-332.e339.[35]




Sánchez NF, Rankin S, Callahan E, et al. LGBT trainee and health professional perspectives on academic careers—facilitators and challenges. LGBT health 2015;2(4):346-56.[36]




Sanchez NF, Poll-Hunter N, Spencer DJ, et al. Attracting Diverse Talent to Academia: Perspectives of Medical Students and Residents. Journal of Career Development. 2018;45(5):440-457.[37]




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Martinez LR, O'Brien KR, Hebl MR. Fleeing the Ivory Tower: Gender Differences in the Turnover Experiences of Women Faculty. Journal of Womens Health. 2017;26(5):580-586.[38]




Ellinas EH, Kaljo K, Patitucci TN, Novalija J, Byars-Winston A, Fouad NA. No Room to "Lean In": A Qualitative Study on Gendered Barriers to Promotion and Leadership. Journal of Womens Health. 2018.[39]




Ranieri VF, Barratt H, Rees G, Fulop NJ. A Qualitative Study of the Influences on Clinical Academic Physicians' Postdoctoral Career Decision Making. Academic Medicine. 2018;93(11):1686-1693.[40]




Rao SK, Kimball AB, Lehrhoff SR, et al. The impact of administrative burden on academic physicians: Results of a hospital-wide physician survey. Academic Medicine. 2017;92(2):237-243.[41]




Jagsi R, Griffith KA, Jones RD, et al. Factors Associated with Success of Clinician-Researchers Receiving Career Development Awards from the National Institutes of Health: A Longitudinal Cohort Study. Academic Medicine 2017;92(10):1429-39.[42]




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Lopes J, Ranieri V, Lambert T, et al. The clinical academic workforce of the future: A cross-sectional study of factors influencing career decision-making among clinical PhD students at two research-intensive UK universities. BMJ Open. 2017;7(8).[43]




Edmunds LD, Ovseiko PV, Shepperd S, et al. Why do women choose or reject careers in academic medicine? A narrative review of empirical evidence. The Lancet. 2016;388(10062):2948-2958.[44]




Ranieri V, Barratt H, Fulop N, Rees G. Factors that influence career progression among postdoctoral clinical academics: a scoping review of the literature. BMJ Open. 2016;6(10).[45]



Eley DS, Jensen C, Thomas R, et al. What will it take? Pathways, time and funding: Australian medical students' perspective on clinician-scientist training. BMC Medical Education 2017;17 doi: 10.1186/s12909-017-1081-2.[46]



Pros: explored a wide range a factors, rich qualitative data, good analysisCons: limited focus on equityAppraisal: good

Skinnider MA, Twa DDW, Squair JW, Rosenblum ND, Lukac CD, Canadian MDPPIG. Predictors of sustained research involvement among MD/PhD programme graduates. Medical Education. 2018;52(5):536-545.[47]



Pros: explored impacts of multiple factors across both gendersCons: moderate quality, no qualitative data, many of the outcomes measuring rather than exploring underlying reasons for differential participationAppraisal: moderate to poor, exclude statistically marginal results e.g. prior MA negatively associated with sustained involvement

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Humberstone E. Women Deans' Perceptions of the Gender Gap in American Medical Deanships. Education for Health. 2017;30(3):248-253.[48]



Pros: multiple relevant factors identified with strong reference to underlying raw data, strong emergent themesCons: small sample, purposeful sample of successful women Appraisal: moderate to good

Wingard D, Trejo J, Gudea M, Goodman S, Reznik V. Faculty Equity, Diversity, Culture and Climate Change in Academic Medicine: A Longitudinal Study. Journal of the National Medical Association. 2019;111(1):46-53.[49]




Kaplan SE, Gunn CM, Kulukulualani AK, Raj A, Freund KM, Carr PL. Challenges in Recruiting, Retaining and Promoting Racially and Ethnically Diverse Faculty. Journal of the National Medical Association. 2018;110(1):58-64.[50]




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Table 4 Findings of the review: factors impacting on retention, success and equitable participation in clinical academic careers

Categories and themes

Papers Coding summary Examples of coding text

1. Personal factors 16

1.1 Social capital 4 Advancement in clinical academia was described as inherently competitive[45], favouring participants with higher social capital, who are more likely to be included within formal and informal academic networking[34, 36, 37], to garner support[34], and to be aware of the mechanisms of advancement[35]. Social capital was seen as related to tangible social assets such as gender and race which intersect to create multiple levels of disadvantage[34].

Professional advancement, including promotion seeking, is tied to having informal networks and supports and to garnering sponsorship—someone in a position of power to advocate for one’s career advancement—and men are more likely to have more of these resources than are women.[34]

1.2 Confidence and ambition

6 Confidence and ambition were described as driving career advancement, favouring those (usually men) who strategically plan towards promotion[37, 38], self-promote[39, 40], negotiate their position[35], and thrive on the politics of advancement[37]. Resilience and the ability to grow through difficulties also support advancement[39, 40].

Conversely, ambition deters some senior clinicians from starting as junior researchers[40].

Most notable is that senior leadership was a more frequently cited theme among the [represented males]. Represented males aspired to be deans, departmental chairs, and division chiefs. Promotion to departmental chair or division chief was viewed as being based on grant funding attained, number of publications, and quality mentorship.[37]

1.3 Competing demands and priorities

9 Competing demands and priorities included role conflict between competing clinical and research commitments; work-life conflict; and family-work conflict. These were mitigated by an ability to negotiate multiple roles.

Women were more likely to be affected by family-work conflict relating to sociocultural expectations to prioritise family[44], the likelihood of having a partner with an equally demanding career[38, 39, 44] and having to accommodate family geographical needs including their partner’s career decisions[34, 38, 43]. A lack of control over career moves due to family commitments was felt to impact on women’s promotion and salary negotiations[38]. They were discouraged by a lack of

Increased role conflict was a significant [association with] of leadership seeking in both models, indicating that role conflict is either a driver or a consequence of leadership, capturing the challenges of meeting family needs and career demands that may come with choosing to move up the academic ladder.[34]

For both genders, increased role conflict and decreased perceptions of organizational support were associated with intent to leave, contributing about 20% of the variance for both groups.[34]

“The impact that research would potentially have on delaying completion of training and thus reducing the already limited years

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female role models with both a family and a successful clinical academic career[34, 37, 44, 45].

Family-work conflict was compounded by multiple barriers to returning to work including a lack of part-time posts with flexible working or support/incentives for returners[44, 45], and difficulties in moving flexibly between research and teaching (in both directions)[44]. Clinical academia was perceived by many as a barrier to raising a family[34, 35, 37, 44-46]. Research training often coincided with child-rearing years leaving those that had taken a career break behind their peers on research outputs and career progression[35, 44, 46].

There was a tendency to expect full-time outputs from part-time workers[35], and a tendency to stigmatise part-time workers as disinterested or under-committed[35].

available for having children seems small but is a big deal to me. I have talked to several male students about this and it has never been a consideration or issue for any of them”.[46]

A former junior female faculty identified a number of factors that led them to leave academic medicine. Both a shortage of female role models that championed balancing work and family responsibilities (and inspired others to do the same) and low remuneration discouraged female physicians from pursuing an academic career.[45]

“I am not sure I can do this—clinics, teaching, research, babies, and all”[44]

1.4 Financial considerations

8 Financial considerations were a concern, exacerbated by levels of student debt[44, 45, 47] and the concentration of research institutions into areas of high living cost[40]. The cost of starting a family and lack of access to affordable childcare made this more acute for those with parenting responsibilities[35, 40].

There were pay inequalities between clinical and research pathways leaving some clinicians with research ambitions taking pay cuts for funded doctoral studentships or even self-funding, affecting those with either a desire for higher pay or a need for financial stability[34, 37, 40, 44-46].

Another factor influencing the decision of women to shift from full-time to part-time work is the lack of affordable child care services….In fact, working part-time is an alternative strategy to manage child care duties, sometimes chosen to avoid spending most of one's salary on expensive services.[35]

For both genders, debt was associated with the consideration of students leaving… and loan repayment programmes were likely to encourage indebted students to enter careers in clinical research.[44]

1.5 Orientation to roles

12

1.5.1 Orientation towards administrative role

4 A dislike for administration was linked to burnout and avoidance of leadership[39, 40].

Conversely an interest in the organisational aspects of research and education was linked to interest in academic medicine as a career[37].

For leadership, faculty in the No Desire code group shared their love of patient care and research, and conversely their dislike of administrative work.[39]

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1.5.2 Orientation towards clinical care

2 A return to full time clinical care was driven by wanting more patient contact, feeling deskilled by time away from patient care, and a delay in reaching consultant status due to academic time commitment[39, 40].

Retention was supported by feeling that research made them a better clinician, either through alignment of their research to clinical needs or because their academic activities provided respite from full-time clinical care[39, 40].

Feeling clinically “deskilled” (as they lost skills they once possessed with time spent out of the clinic), fed up, and too “old” to be a clinical trainee motivated other participants to return to the clinic fulltime.[40]

A career in clinical academia had the potential to shape these participants into better clinicians, as their ability to understand and conduct high-quality research, which they honed during their PhD training, could inform their clinical practice.[40]

1.5.3 Orientation to leadership

4 There were a large number of personal factors contributing to a rejection of leadership roles by women. These included distancing from androcentric conceptions of leadership as related to power and conflict, seeing leadership as a distraction from clinical or research work, as unviable due to a lack of recognition of women, work over-load and a perceived need to self-promote[34, 39]. A leadership culture of long hours and out-of-hours networking excludes many with parenting responsibilities[34]. Promotion was seen as linked to grant funding and publication frequency, favouring those engaged in research rather than education[37] not only excluding some women but not producing the most competent leaders[48].

There was a tendency for women to wait until they were over-qualified for promotion, while men applied without meeting all the criteria[39]. This was partly attributed to women feeling unready and partly to compensatory behaviours in response to discouragement[39]. Men also rejected leadership roles, which were perceived by some as not worth the time or stress[39].

Female and other minority clinical academics were attracted to leadership roles as a way of influencing research agendas, of resolving conflict, and of promoting diversity by becoming a visible role model[36, 48].

The deans recommended re-evaluating traditional views of leader qualifications because the current standards do not necessarily parse out strong leaders and are more likely to exclude women candidates.[48]

“I prefer and highly value my time and effort in research and I have observed that accepting leadership roles often adversely affects research.”[39]

Women may respond differently to leadership questions phrased as interest in moving one’s department in new directions or in improving department practices rather than statements invoking traditionally androcentric roles regarding leading.[34]

1.5.4 Orientation to research and academia

10 Orientation to research was supported by undergraduate research experiences, early training in research methods, and training in a research-intensive university or hospital[36, 43, 44,

All of these individuals planned to continue in research, having completed their PhD, because of intrapersonal influences, such as continued enjoyment and interest in their area of research. These

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47]. Clinicians from diverse backgrounds were sometimes attracted to research by its relevance to women’s health, LGBTQ+ health, or underserved community needs[39, 45, 46].

Early publication success was an important driving factor[39, 44, 47], favouring those who were more likely to benefit from mentoring, sponsorship and academic support[36, 37]. The benefits of academia were described as outweighing the difficulties: more interesting and less stressful than clinical service provision[40], offering academic freedom[45], and a clearly structured career path[39, 43, 45, 46], although not all were aware that the pathway existed[43]. Attrition was driven by feeling unable to ‘switch-off’ from one’s academic role due to pressures to publish or apply for funding[40], and by competing demands and priorities including clinical and personal commitments[35, 40].

participants found academia rewarding because of its ability to provide what clinical medicine no longer could, such as intellectual stimulation, competition, and diversity in their work.[40]

[Under-represented minority] participants considered the pursuit of academia as a way to positively influence outcomes for underserved communities. Trainees expressed that an academic career facilitated these objectives through community-based research, mentorship of minority trainees, role modelling, and leadership.[37]

…women researchers begin their careers with less institutional support. This likely can have an impact… as early academic productivity predicts retention and advancement in academic careers.[44]

“What I’ve had over the last five, six years is every night there’s something different I could be doing on my laptop. I could be writing this. I could be writing that … there’s always the pressure and it’s not right. I haven’t got any more give at the moment. At the moment, I’m just burnt out. I don’t want to do any more.”[40]

1.5.5 Orientation towards education

2 Women were described as more interested in opportunities to teach than conduct biomedical research, however gender differences were also linked to education’s flexibility, its historically lower status (deterring some men) and the competitiveness of the research pathway[44]. Education encourages women into academia, some discovering research after having begun as an educator[44].

An interest in education is partly driven by opportunity and experience, but it is also values driven: wanting to facilitate success in others, wanting to make a difference or stay up-to-date, wanting to build a diverse workforce or enact social change through teaching, attracting participants from diverse backgrounds[37, 44].

Respondents also noted that serving as a mentor to medical students and trainees contributes to interest in [academic medicine]. One respondent explained, “as a mentor, you can reach out to thousands of people who can ... impact change” (African American male, medical student).[37]

In two qualitative studies, female physicians (53 from the USA, seven from elsewhere) reflecting on their career choices reported that they were attracted to academic medicine by opportunities to teach, but with experience they also came to appreciate research more.[44]

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Attrition from educational activities was driven by limited scope for progression, as well as competing clinical and personal demands and priorities[44].

2. Interpersonal (behavioural) factors

14

2.1 Supportive behaviours

9 We classified supportive behaviours as either ‘sponsorship’ the preferential treatment of a protégé, or ‘mentorship’ regular support designed to build self-efficacy through advice or coaching.

Sponsorship included advocacy for advancement[34, 37, 39] and preferential support for early publication[39]. There was concern that sponsorship tended to be preferentially available to those within an informal network with characteristics that reflected incumbent clinical academics, disadvantaging minorities and women[34, 39].

Mentoring on the other hand tended to be formalised and more equitably available[38, 43, 50]. Supportive mentoring behaviours included altruistic guidance and clarity, building self-efficacy, encouraging continuity and supporting resilience in the face of difficulty, encouraging successful publication, guiding and critiquing academic work, supporting career planning, and providing moral and institutional guidance[37, 45, 46, 48].

It is often the person who is ‘‘scooped up’’ by their mentor and placed in a position for promotion. These persons have advantage because they are drawn into the process. Many are male.[39]

Professional advancement, including promotion seeking, is tied to having informal networks and supports and to garnering sponsorship—someone in a position of power to advocate for one’s career advancement—and men are more likely to have more of these resources than are women.[34]

2.2 Discriminatory behaviours

12 We classified discriminatory behaviours as either conscious or unconscious.

Conscious discrimination was expressed as overt disrespect[35, 40, 44], disruptive behaviours[38, 49], micro-aggressions[35, 44], sexual harassment[35, 38, 44], social[35, 44, 45, 48] or cultural exclusion[35, 44] and deliberate sponsorship or preferential treatment of people of a chosen characteristic[35, 38, 40, 48].

Unconscious discriminatory behaviours, sometimes by women themselves, included judgemental attitudes towards women exhibiting ‘male’ characteristics such as ambition, aggression or

“… a senior colleague of clearly homosexual orientation. Despite being very prepared, he was marginalized by the group leader. . . . He was placed in the ward, kept out of any possibility to publish and teach.”[35]

“The exclusion of women can be done in so many ways. It has been all the time actually. Also in meetings. [When you talk] they start to play with the phone or whatever. . . . We had a meeting with the boss and I talked with him for 30 seconds; and then he said: ‘She is giving a monologue.’. . . . Yes, subtle means.”[35]

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assertiveness[44], simply being treated differently to colleagues[35, 40, 44, 45], unconscious value judgements leading to academic invisibility or assumptions about status or role[35, 38, 44, 48]. This sometimes manifested as a diversity burden, where minority academics were disproportionately required to sit on selection panels, provide mentoring, or to appear in public, detracting from their clinical research activities[48, 50].

“According to my mentors (usually chairs), before going up for promotion I always need one more thing even though there are many criteria for promotion, of which I have more than fulfilled. I have observed that this is not the case for several of my colleagues who are male.”[39]

2.3 Compensatory behaviours

4 Compensatory behaviours by those affected by discrimination included equalising behaviours, such as submissive or self-deprecating talk[44]; a fear of being seen to conform stereotype[34]; fear of speaking up or asking for adjustments[35, 45]; and feeling that they needed to be twice as good to advance[35, 44].

Compensatory behaviours manifested even without active discriminatory behaviour due to the enduring effects of prior mistreatment[35, 44, 45].

“But in time, I learned to be silent, not to talk about it. Although I faced the problems, I did not mention anything about them. Because if I talk about the problems, they dislike me more.”[35]

3. Organisational factors

17

3.1 Academic culture 14 In comparison to the clinical workplace, the academic workplace culture was described as respectful and inclusive[37, 38, 42, 45, 48-50] however some found it competitive and unwelcoming[45]. The broad spectrum of academic roles and responsibilities (teaching, research, mentoring, administration and leadership) were seen as attractive[37].

It was frequently described as pressured and uncertain: pressure to apply for research grants, to publish regularly, with anxieties caused by fixed term or temporary research contracts, and an out-of-hours culture which effectively excludes those with parental responsibilities[35, 40, 42, 48]. The academic structure was described as hierarchical with limited prospects at senior levels, driving both excellence and exclusion[39].

There was a perception of under-appreciation of women’s contributions and criticism that promotion processes favoured

Female full professor: ‘‘the ‘loudest’ people who self-promote seem to get the position.’’[39]

The majority of [minority faculty] felt that they [were] respected for their differences… they felt valued for what they brought… they did not feel marginalized because of belonging to a particular group)[50]

One dean noted that academic medicine has a more “conservative culture” that views “women, especially young women, in a very specific way;” women leaders are “not the norm, and we stick with the norm” [another dean] suggested that unconscious bias and lack of accommodation of work-life balance needs contributed to an institutional culture that may discourage women’s advancement.[48]

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self-promoters[39]. Promotion criteria attributed low worth to teaching[45], disproportionately affecting women who are over-represented in education[44]. Research into inclusivity was also seen as lower status disproportionately affecting minority researchers[36, 44].

Those who left academic medicine described their research institution as unwelcoming and individualistically competitive.[45]

Junior faculty valued institutions that were committed to their career development. They were discouraged by institutional failure to formally recognise their dedication to teaching and ambiguity regarding their pathway to promotion.[45]

3.2 Clinical workplace culture

5 The clinical workplace culture generally prioritises clinical service provision over teaching or research[35, 39, 45]. The gender culture in teaching hospitals varied across specialties and institutions and was positive in a narrow range of specialties including neurology, pathology, internal medicine and paediatrics[47]; it was however perceived as negative in the majority of specialties including surgery[35, 40, 47].

Where the clinical promotion pathway lacked transparency, there were also concerns about nepotism[35].

Given that the greatest attrition in commitment to research seems to occur during residency, it is imperative that medical schools and teaching hospitals work in partnership to improve gender climate and culture at the interface between the medical school and teaching hospitals.[44]

“When you have an outpatient clinic, you might be asked to go and fetch your own patients whereas the nurse might do that for the male intern, or you have to change your own paper on the examination bench…Just little things like that.”[35]

“All surgeons look at you. . . . ‘Well, you are a woman, you will never be a good surgeon.’ . . . When I was a student, there were not a lot of female students specializing in surgical specialties. They stopped sometimes their education to become general practitioners.”[35]

White male: “[When I was in the other hospital] there was the head of internal medicine trumpeting the fact that he never wanted to have a woman in his ward. Firstly, because they get on his nerves; secondly, because he said that every time you have to discuss with them, they begin to cry and to view any remark as offending them personally; thirdly, because women become pregnant. Partially I found this attitude here too [in the hospital where I am presently working].”[35]

Pressure to prioritise clinical duties over research and teaching was frequently cited as a negative aspect of early career clinical academics’ working environment.[45]

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3.3 Organisational policies & practices

17

3.3.1 On equity and discrimination, wellbeing and burnout

14 The authenticity of leadership’s commitment to diversity was seen as crucial, helped by the involvement of a diversity council or diversity champion with both resources and power[50]. Rhetoric was converted to action through active monitoring, investment in unconscious bias training and zero tolerance on discrimination[44, 49, 50]. A lack of critical mass of academics from diverse backgrounds discouraged new applicants[38, 50]. Some characteristics were felt to be more protected than others such as LGBT[36].

Essential family friendly policies included the availability of flexible working[34, 35, 38-40, 43, 45, 48, 49] or maternity/carer pay[35, 38, 46]. Successful programmes enhanced this by actively addressing the out-of-hours culture bringing meetings and communication into working hours[40, 43], and creating a culture of flexible working for all [35, 45] which some extended beyond childcare to cover, for example, unexpected personal or family crises[49].

Hiring and promotion practices such as diverse representation on selection panels were helpful[48, 50], as long as they didn’t overly burden diverse individuals[50]. Some promotion criteria were seen as actively disadvantaging women, such as a requirement to travel, or the status of education compared to research[38, 43, 44, 48].

Regardless of gender, faculty expressing [Role Overload] frequently worked part time (p = 0.001) and had a spouse working outside the home (93%, p = 0.043).[39]

“diversity exhaustion for our [minority] faculty members… when people are asked to do so much to help recruit, retain, promote, support, mentor other people who look like themselves.”[50]

Moreover,[]part-time working] may carry a stigma: “I think working part-time is a thing that hampers progression in your career, in general. . . . Apparently people think: ‘OK, part-time means no ambition.’ Which is not true.” [35]

“They’re very good with cultural diversity training, but when it comes to LGBT concerns it’s kind of like they don’t talk about it. It’s like a brick wall.’’ [36]

… a series of policy and programmatic interventions (data collection and dissemination, family friendly policies, training, and faculty development programs) was associated with increases in faculty diversity, equity, respectful behavior and improved faculty climate.[49]

3.3.2 On mentoring, social support, networking, role modelling

15 The visibility of concordant role models was seen as important[35, 37, 39, 43-45, 48]. Females wanted role models that were based on more than gender, such as modelling a work-life balance, or balancing a successful career with family[34, 35, 37, 38, 44, 45].

Networking opportunities needed to feel inclusive, with sensitivity to culture and parental commitments[36].

…significantly more women (p = 0.032) expressed the concern or frustration that they needed to self-promote or else were simply forgotten by their leaders.[39]

“I am shocked when I look around. Even if I think that things are going well, that people are not discriminated. ...When you look around, there are always more men than women in leadership positions.”[35]

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The availability of concordant mentoring was seen as important[36-38, 43, 44, 50] but not always achievable. Cross-gender mentoring was successful where there was an understanding of the unique challenges faced by women[34]. Formal mentorship programmes to support the advancement of under-represented groups were described[38, 43, 50]. There may be issues with females prioritising lower status but supportive mentors and men benefiting from mentors with higher status[44], and poor quality or inconsistently available mentoring[39, 46].

Those who were based in an academic setting that nurtured supportive mentorship and positive role modelling tended to pursue academic medicine with greater career satisfaction and confidence.[45]

3.3.3 On active support for career advancement

8 Some institutions described active support for career planning aimed at promoting talent over ambition[34, 37, 39, 40, 43, 45]. Other measures included career pathways that include education[39, 40, 45], faculty development programmes[49], performance recognition schemes[50], leadership training[39] for women[37], training career counsellors on the issues facing women in clinical academia[37], and steps to increase the transparency of promotional pathways, policies and procedures[40, 45, 49].

These gendered patterns of family–work dynamics, coupled with the association between organizational support and intent to leave, point to the organization’s responsibility and accountability in establishing practices that can facilitate embeddedness or a reason to stay, such as a positive promotion climate. It is worth noting that opportunities for advancement are necessary, but not sufficient to increase retention for all faculty members, as promotion climate was not a positive reason to stay for female respondents.[34]

3.3.4 On remuneration, funding and resources

9 The allocation of funding and resources also impacted on retention and success. Return to full time clinical practice was driven by academic vs clinical salary discrepancies[44, 45] and the availability of funding, credit or loan repayment schemes[44]; see also the prior section on personal financial considerations. Clinicians needed protected research time and resources to back-fill their clinical duties[38, 42, 45].

There was a tendency for women to apply for funded PhDs which are a scarce resource and competitively allocated[44]. The allocation of research funding was also felt to be overly competitive[45] and gendered[47], as was the allocation of research space and administrative support[35, 42]. A gender and ethnicity-based pay gap was reported[35, 38].

The ongoing pay gap (both for women and for expatriates) is exacerbated by salary negotiations which tend to favour local male professionals, as they are often more assertive.[35]

“In my clinic there are two men and they have two separate rooms, the other four female doctors are in one room. So, males have more opportunities than me [to do research].”[35]

There is evidence that programs targeted at junior faculty can have successful outcome measures … Such programs, essential to retain and develop successfully recruited underrepresented faculty, require dedicated funds and institutional commitment over an extended period of time.[50]

4. External (societal) factors

6

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4.1 National clinical academic structures and funding

3 The availability of national and international research funding is impacted on by economic and political factors[45]. Funding of higher education impacts on the number of senior academic positions, and the availability of post-doctoral positions[40, 43].

National structures need to be studied locally as they are by definition situated in their time and context. We focus here on the current UK training pathway as a case example. National structures in the UK have led to discrepancies in research funding depending on whether the applicant is a trainee or consultant contributing to a disconnect at that transition[40], alongside structures preventing consultants applying for clinical lectureships[43]. There are calls for jointly funded positions to address this issue[43]. There was concern that the new trainee doctor contract with longer core hours will impact on research capacity, particularly for parents with care-giving responsibilities[40]. The visibility of national research training opportunities to clinicians was an issue, particularly for those not on an integrated run-through pathway[40, 46].

Many participants… voiced their fears that the new junior doctor contract in the United Kingdom may financially penalize both female clinicians and those interested in pursuing an academic career, due to potential increases in working hours accompanied by a reduction in out-of-hours pay.[40]

… participants noted difficulty accessing information and guidance on training pathways and uncertainty about how to progress in a clinical academic career, particularly if they were ineligible for the integrated academic training pathway.[40]

Respondents not planning a [clinical academic career]…are particularly worried about the small number of senior academic appointments available as well as the difficulty of obtaining research grants and work-life balance[43]

4.2 Societal attitudes to diversity and equity

3 Societal factors relating to diversity and equity also impacted on equitable participation in this demanding career[35, 38, 44].

There are ongoing expectations for women to shoulder household chores and to be the primary caregiver, effectively doing a second shift after work. This may be giving way to an increasing acceptance of non-gendered household roles. Fewer people of either gender have a stay-at-home partner[35].

We suggest that such a pattern reflects a general gender norm within society whereby women are more likely to hinder their careers because of family responsibilities and ‘‘second shifts’’ than are men.[38]

“It seems that younger couples try to share much more equally. I don't know if that's true for every aspect of life. But also many of my male colleagues leave early one or two days a week to go pick up the kids at the day care centre.”[35]

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DISCUSSION

The objective of this review was to scope and synthesise current evidence on the factors affecting

recruitment, retention, participation and progression within the clinical academic pathway, with a

focus on equitable participation for under-represented groups.

We identified 13 themes (Figure 2), which we organised into personal, interpersonal, organisation and

societal categories using a socio-ecological approach[51]. The structure aimed to illustrate the

dynamic interrelations between personal attributes and multiple levels of contextual factors.




We expect most interventions to target the organisational level as these are within the control of local

leadership and can therefore be more rapidly changed than wider external and societal factors.

Interventions at this level are more likely to be successful if they address the issues identified at the

personal and interpersonal levels, whilst acknowledging the wider national and societal landscape.

Both deliberate and unconscious discriminatory behaviours were frequently discussed, particularly in

the clinical context. This varied by specialty and institution, with discriminatory behaviours appearing

to be driven by pressurised and hierarchical clinical workplaces. Our findings suggest it may not be

enough to address organisational culture on a single side of the research vs clinical divide. Research

institute policies on equality and diversity won’t support this workforce unless they are also adopted

and monitored within the clinical setting. Policies to support gender equality will increasingly support

both men and women as societal norms shift towards more equal family and household

responsibilities.

Although limited papers were included on sexuality and race/ethnicity, we found that they sat well

within the 13 themes identified, particularly those relating to social capital, interest in personally-

congruent research, interpersonal factors (discriminatory, supportive and compensatory behaviours),

and policies and practices within organisations to address the workplace culture (supportive

mentoring and networking, and unconscious bias training).

National policy changes are needed to address transparency of the pathway, remuneration for

doctoral education that reflects the particular needs and contribution of this highly skilled and mature

workforce, the availability of post-doctoral posts, and transitions particularly at the trainee /

consultant level.

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Strengths and Limitations

Past systematic reviews in the area have focussed on a particular stage of career decision making, a

particular population, or a particular factor that affects equitable participation. Our scoping

methodology allowed us to examine and synthesise a broader range of literature. It also facilitated

the creation of an integrative analysis of the factors that influence equitable participation in clinical

academia at all stages of the pipeline, from recruitment to professorship.

All coding was cross-checked by two authors and the coding structure was audited, and saturation

confirmed, by a third author. The flexibility of the scoping methodology enabled us to gauge the

‘bigger picture’ with more breadth than a traditional systematic review approach.

A limitation of our study was the limited literature on equitable participation for ethnic minority and

LGBTQ+ clinicians. Whilst we were able to test our coding structure against a few papers focusing on

these areas, the infancy of research in this area, compared to gender-based papers, is a limitation of

our findings. The geographical limitation to North America, Western Europe and Australasia, limits

wider applicability. Policy is in constant transition and will need to be studied and addressed locally.

This paper focused on current UK policy as an illustrative case. We did not identify any papers relating

to disability and the clinical academic career pathway. Class was excluded from this review, as the

clinical academic population belongs by definition to the upper professional occupations. However,

this does not take account of the socioeconomic background of students at the stage of selection into

medical school, which is likely to be a significant factor. Further research is needed to explore factors

affecting equitable participation in the clinical academic pathway for LGBTQ+ clinicians, clinicians with

a disability and to track the progress of entrants from different socioeconomic backgrounds.

CONCLUSION


academia. The broad and often interconnected nature of these factors suggests that there is no ‘silver

bullet’ and that interventions will need to be multi-factorial, addressing structural and cultural factors

as well as individual needs. We suggest that organisations work to mitigate role conflict and

remuneration which drive burnout and attrition, address the clinical workplace culture which appears

divergent from academic culture, and promote coherent, transparent national career pathways.

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Figure Legends


Figure 2: Summary of meta-thematic synthesis of factors relating to retention, success and equitable


Data Sharing Agreement

Data are available upon reasonable request. Coding data is available from the corresponding author.

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Incl

ud

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• Gendered culture, variable across specialties e.g. surgery


• Prioritisation of clinical vs academic roles

Academic culture

• Pressured and uncertain

• Hierarchical



National policies


• Research and clinical funding & priorities

Societal attitudes








• Research

• Clinical

• Administrative

• Educational

• Leadership


• Level of debt



Social capital











Personal factors

Figure 2: Summary of meta-thematic synthesis of factors relating to retention, success and equitable participation in clinical academia Page 31 of 32


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1




ABSTRACT



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INTRODUCTION

Rationale 3


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Objectives 4


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METHODS



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RESULTS


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DISCUSSION



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FUNDING

Funding 22


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Journal: BMJ Open

Manuscript ID bmjopen-2019-033480.R2

Article Type: Original research

Date Submitted by the Author: 11-Feb-2020


<b>Primary Subject Heading</b>: Medical education and training

Secondary Subject Heading: Health services research

Keywords:

MEDICAL EDUCATION & TRAINING, QUALITATIVE RESEARCH, Health policy < HEALTH SERVICES ADMINISTRATION & MANAGEMENT, Organisational development < HEALTH SERVICES ADMINISTRATION & MANAGEMENT


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Word count: 5973 excluding tables

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ABSTRACT

Objectives: To examine and synthesise current evidence on the factors that affect recruitment, retention, participation and progression within the clinical academic pathway, focusing on equitable participation across protected characteristics including gender, ethnicity and sexual orientation.



Article Selection: We conducted a scoping review of English language articles on factors affecting recruitment, retention, progression and equitable participation in clinical academic careers published within North America, Australasia and Western Europe between Jan 2005 and April 2019. The most recent and relevant 39 articles were selected for meta-thematic synthesis using detailed inclusion/exclusion criteria.

Data Extraction: Articles were purposively sampled to cover protected characteristics and career stages and coded for factors relating to equitable participation. 17 articles were fully coded. No new themes arose after 9 papers. Themes and higher level categories were derived through an iterative consensual process.

Results: 13 discrete themes of factors impacting on equitable participation were identified including societal attitudes and expectations; national and organisational policies, priorities and resourcing; academic and clinical workplace cultures; supportive, discriminatory and compensatory interpersonal behaviours; and personal factors relating to social capital, finances, competing priorities, confidence and ambition, and orientation to clinical, academic and leadership roles.

Conclusions: The broad and often interconnected nature of these factors suggests that interventions will need to address structural and cultural factors as well as individual needs. In addition to standard good practice on equality and diversity, we suggest that organisations provide equitable support towards early publication success and targeted mentoring; address financial and role insecurity; address the clinical workplace culture; mitigate clinical-academic-personal role conflicts and overload; ensure that promotional structures and processes encourage diverse applicants; and promote family-friendly, coherent and transparent national career pathways.

Keywords: Clinical Academia, Physician Researchers, Diversity, Gender.

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Strengths and limitations of this study Our review consolidates the full continuum of factors affecting equitable participation in clinical

academia at all stages of the pipeline and across a range of protected characteristics. Our findings will have limited relevance to nursing, midwifery, allied health professions or other

geographies where there may be divergent issues in relation to gender, sexuality and ethnicity or the nature of clinical academia.

The majority of papers identified in the scoping review focused on gender, therefore the factors identified within each theme may not fully represent issues relating to ethnicity and sexual orientation. No studies relating to disability were identified.

Policy is in constant transition and will need to be studied and addressed locally. This paper focused on current UK policy as an illustrative case.

Funding statement: This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

Competing Interests Statement: No competing interests to declare.

Contributorship StatementOur team comprised an early career clinical academic (CV), an established educational researcher (KLG) and a professor of medical education (SS), all experienced qualitative researchers with professional insights into the subject of enquiry. The Faculty of Medicine at Imperial College has a strong research interest in widening participation and its School of Medicine has more graduates entering the clinical academic pathway than any other UK medical school. These factors combined to stimulate our interest in identifying factors surrounding equitable participation in the clinical academic career pathway.

All authors were involved in the conception and design of the study and in the acquisition, analysis, and interpretation of our findings. CV and KLG identified and coded the papers. SS audited the process and coding. All authors worked together to generate the themes and categories. CV and KLG drafted the work, KLG created the results section and tables. All authors revised it critically for intellectual content. All authors gave approval to the final version and agree to be accountable for all aspects of the work. All authors undertake to ensure that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

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BACKGROUND

Clinical academics, also referred to as physician-researchers, physician-scientists or academic


informs their academic practice and vice versa, creating a synergy: their expertise in both areas drives

innovation and supports the translation of research into clinical practice[1, 2]; conversely their clinical

expertise guides their research[3]. This breadth of skills is also important in training the next

generation of medical professionals[4]. The declining number of clinical academics, which has been

observed internationally[5, 6], is therefore concerning.



since 1996[7], however in 2017 the ratio of male to female clinical academics stood at 69% to 31%

with the gender disparity even greater at professorial level[8]. Several studies have demonstrated that

females and minority ethnic clinical academics are also underrepresented at senior levels in North

America, Australasia and across Western Europe[9-11]. Concerningly, there is evidence that

representation of ethnic minorities actually declined in the US between 1990 and 2016[12].


innovation and excellence in research and teaching[13, 14], for example training doctors to practice

in culturally diverse environments[13], or researching health issues specific to underrepresented

communities[2, 15]. From an economic perspective, the attrition of a highly trained elite workforce






programmes such as mentoring programmes or the Higher Education Equality Charters in the UK,

including a recent review of interventions[11]. There is a gap in the literature for a review of

explanatory factors.

REVIEW OBJECTIVES

Past research in the area has often focussed on a particular stage of career development[16, 17], a

particular population[4, 18], or a particular factor that affects equitable participation[19-21]. Our aim



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METHODOLOGY

Thematic analysis is an established method for meta-synthesis of exploratory rather than

interventional research findings, bringing together and integrating findings of multiple studies[22]. We

utilised Thomas et al’s 3-step framework for thematic synthesis[22].








The methodology of scoping reviews has an evolving literature base[23], with many definitions, some

involving more evidence synthesis than others. Our methods were guided by our purpose, which was



Munn et al state that when a study is “interested in the identification of certain


characteristics/concepts” a scoping review is the appropriate choice of methodology[24], and hence

was suited to our research.

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Inclusion criteria

Our inclusion criteria are listed and justified in Table 1.

Table 1: Inclusion criteria and justificationCriteria JustificationTypes of participantsExclusion of articles relating to nursing, midwifery and allied health professionals



Our geographical focus was chosen due to a) established clinical academic career pathways in these regions and b) the heavy influence of societal norms on attitudes to equitable participation which are relatively similar across these regions[25].







2005 was the year Modernising Medical Careers was introduced in the UK and current recommendations for clinical academic training were established[26].


Our aim was to identify robust conceptual categories and to explore their explanatory value. Our interest was in the concepts that had been identified by researchers, rather than the original raw data i.e. second order data[27]. We therefore included empirical qualitative research, reviews grounded in robust empirical data, mixed methods studies with substantial qualitative elements, and quantitative papers that tested a broad range of factors across demographics. Theoretical perspectives, commentaries and opinion pieces were excluded.


Publication in a reputable journal following peer review was used as an initial surrogate for quality. Unpublished PhD theses, on-going unpublished studies on trial registers, letters, conference abstracts, grey literature and suspected predatory journals[28] were excluded.



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Search strategy

We used a PICo ‘population, phenomenon of interest, context’ strategy[29] to develop our question




re-applied as the range of terms relating to our subject of interest became apparent. We included a

range of terms relating to protected characteristics including gender, race, disability and sexual



Table 2: Search termsPopulation – clinical academics




Web of Science search string: TITLE: ("clinical academ*" OR "academic medic*" OR "physician scientist" OR "academic surg*" OR "academic clinician" OR "physician scientist") AND TITLE: (divers* OR equit* OR bias* OR under-represent* OR female* OR gender OR women OR minorit* OR racial* OR ethnic* OR sexuality OR orientation OR LGBT* OR Disab*) AND TITLE: (success* OR participat* OR promot* OR inclus* OR retain OR retention OR career* OR attrition OR leaders*)

The literature in this area doesn’t have a defined MESH term, topic category or keyword and there are

many terms to describe clinical academia, including specialty specific terms such as academic


academia, participation and equity (see terms in Table 2). We systematically expanded this search

using a forward snowballing approach[30] using Google Scholar, to include relevant papers that had

cited the 12 most commonly cited papers in both our original list and then again on the expanded list.



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seeded from suitably influential and relevant papers[31]. Web of Science was chosen and not



superior citation coverage to both Web of Science and Scopus[32].




identified a manageable number of potential papers, our thematic synthesis began by purposively




Critical appraisal of research quality








Table 3.

Textual data extraction

We used a consensual qualitative research approach[33] involving two independent coders, (CV) and

(KLG), and an auditor (SS). We uploaded the selected papers to analytical software (NVivo 12, QSR

International) purposively sampling papers that were potentially rich in factors and with diverse




Textual data synthesis

Content codes were arranged into higher level themes through an inductive consensual process,

involving team discussions and iteratively testing the thematic structure against new papers.



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groups, different geographies and stages in the pipeline. Finally, these themes were categorised

according to personal, interpersonal, organisational and societal factors, reflecting the multiple layers

of influence on the career development of clinical academics.

Patient and public involvement

Patients were not involved in the design, planning and conception of this study

Research ethics approval

Research ethics committee approval was not required as this is a review paper.

RESULTS

We applied our search terms tightly (population AND phenomena of interest AND context in the title)

to identify 73 papers that we were confident had relevance to this area of research. The two-step

forward snowballing process on Google Scholar generated 625 papers. Titles were screened according

to our inclusion criteria, leaving 258 potential papers for inclusion since 2005. Note that the date range

for the scoping review (2005-2019) was broader than the range considered for meta-thematic

synthesis (2014-2019) where only the most recent five years were included. The initially wide time-

frame supported the identification of highly cited papers on this topic, which is necessary for effective

forward snowballing (identification of related papers through citation indexes). The subsequent

contraction to the most recent five years was a pragmatic way of reducing the large number of papers

identified to a manageable number for full text review and potential inclusion in the meta-thematic

synthesis. As such, only full text papers from the most recent five years were uploaded onto NVivo,

which reduced the number or potential papers for inclusion to 72. Our criteria were re-applied to the

full-text papers, reducing this number to 39. Our search results are summarised in Figure 1.



Methodological quality


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Table 3: Methodological quality

Article citation Study design Population Comments on qualityEllinas EH, Fouad N, Byars-Winston A. Women and the Decision to Leave, Linger, or Lean In: Predictors of Intent to Leave and Aspirations to Leadership and Advancement in Academic Medicine. Journal of Women’s Health. 2018;27(3):324-332.[34]




Huttner A, Cacace M, d'Andrea L, et al. Inequality dynamics in the workplace among microbiologists and infectious disease specialists: a qualitative study in five European countries. Clinical Microbiology and Infection. 2017;23(5):332.e331-332.e339.[35]




Sánchez NF, Rankin S, Callahan E, et al. LGBT trainee and health professional perspectives on academic careers—facilitators and challenges. LGBT health 2015;2(4):346-56.[36]




Sanchez NF, Poll-Hunter N, Spencer DJ, et al. Attracting Diverse Talent to Academia: Perspectives of Medical Students and Residents. Journal of Career Development. 2018;45(5):440-457.[37]




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Martinez LR, O'Brien KR, Hebl MR. Fleeing the Ivory Tower: Gender Differences in the Turnover Experiences of Women Faculty. Journal of Women’s Health. 2017;26(5):580-586.[38]




Ellinas EH, Kaljo K, Patitucci TN, Novalija J, Byars-Winston A, Fouad NA. No Room to "Lean In": A Qualitative Study on Gendered Barriers to Promotion and Leadership. Journal of Women’s Health. 2018.[39]




Ranieri VF, Barratt H, Rees G, Fulop NJ. A Qualitative Study of the Influences on Clinical Academic Physicians' Postdoctoral Career Decision Making. Academic Medicine. 2018;93(11):1686-1693.[40]




Rao SK, Kimball AB, Lehrhoff SR, et al. The impact of administrative burden on academic physicians: Results of a hospital-wide physician survey. Academic Medicine. 2017;92(2):237-243.[41]




Jagsi R, Griffith KA, Jones RD, et al. Factors Associated with Success of Clinician-Researchers Receiving Career Development Awards from the National Institutes of Health: A Longitudinal Cohort Study. Academic Medicine 2017;92(10):1429-39.[42]




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Lopes J, Ranieri V, Lambert T, et al. The clinical academic workforce of the future: A cross-sectional study of factors influencing career decision-making among clinical PhD students at two research-intensive UK universities. BMJ Open. 2017;7(8).[43]




Edmunds LD, Ovseiko PV, Shepperd S, et al. Why do women choose or reject careers in academic medicine? A narrative review of empirical evidence. The Lancet. 2016;388(10062):2948-2958.[44]




Ranieri V, Barratt H, Fulop N, Rees G. Factors that influence career progression among postdoctoral clinical academics: a scoping review of the literature. BMJ Open. 2016;6(10).[45]



Eley DS, Jensen C, Thomas R, et al. What will it take? Pathways, time and funding: Australian medical students' perspective on clinician-scientist training. BMC Medical Education 2017;17 doi: 10.1186/s12909-017-1081-2.[46]



Pros: explored a wide range of factors, rich qualitative data, good analysisCons: limited focus on equityAppraisal: good

Skinnider MA, Twa DDW, Squair JW, Rosenblum ND, Lukac CD, Canadian MDPPIG. Predictors of sustained research involvement among MD/PhD programme graduates. Medical Education. 2018;52(5):536-545.[47]



Pros: explored impacts of multiple factors across both gendersCons: moderate quality, no qualitative data, many of the outcomes measuring rather than exploring underlying reasons for differential participationAppraisal: moderate to poor, exclude statistically marginal results e.g. prior MA negatively associated with sustained involvement

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Humberstone E. Women Deans' Perceptions of the Gender Gap in American Medical Deanships. Education for Health. 2017;30(3):248-253.[48]



Pros: multiple relevant factors identified with strong reference to underlying raw data, strong emergent themesCons: small sample, purposive sample of successful women Appraisal: moderate to good

Wingard D, Trejo J, Gudea M, Goodman S, Reznik V. Faculty Equity, Diversity, Culture and Climate Change in Academic Medicine: A Longitudinal Study. Journal of the National Medical Association. 2019;111(1):46-53.[49]




Kaplan SE, Gunn CM, Kulukulualani AK, Raj A, Freund KM, Carr PL. Challenges in Recruiting, Retaining and Promoting Racially and Ethnically Diverse Faculty. Journal of the National Medical Association. 2018;110(1):58-64.[50]




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Findings of the review

We identified 13 themes (Figure 2), which we organised into personal, interpersonal, organisation and

societal categories using a socio-ecological approach[51]. The structure aimed to illustrate the

dynamic interrelations between personal attributes and multiple levels of contextual factors.

Figure 2: Factors relating to retention, success and equitable participation in clinical academia


1. Personal factors

1.1 Social capital

Advancement in clinical academia was described as inherently competitive[45], favouring participants with

higher social capital, who are more likely to be included within formal and informal academic networking[34,

36, 37], to garner support[34], and to be aware of the mechanisms of advancement[35]. Social capital was seen

as related to tangible social assets such as gender and race which intersect to create multiple levels of

disadvantage[34].

Professional advancement, including promotion seeking, is tied to having informal networks and

supports and to garnering sponsorship—someone in a position of power to advocate for one’s career

advancement—and men are more likely to have more of these resources than are women.[34]

1.2 Confidence and ambition

Confidence and ambition were described as driving career advancement, favouring those (usually men) who

strategically plan towards promotion[37, 38], self-promote[39, 40], negotiate their position[35], or thrive on the

politics of advancement[37]. Resilience and the ability to grow through difficulties also support advancement[39,

40]. Conversely, ambition deters some senior clinicians from starting as junior researchers[40].

…significantly more women (p = 0.032) expressed the concern or frustration that they needed to self-

promote or else were simply forgotten by their leaders.[39]

1.3 Competing demands and priorities

Competing demands and priorities included role conflict between competing clinical and research

commitments; work-life conflict; and family-work conflict. These were mitigated by an ability to negotiate

multiple roles. Women were more likely to be affected by family-work conflict relating to sociocultural

expectations to prioritise family[44], the likelihood of having a partner with an equally demanding career[38, 39,

44], and having to accommodate family geographical needs including their partner’s career decisions[34, 38,

43]. A lack of control over career moves due to family commitments was felt to impact on women’s promotion

and salary negotiations[38]. They were discouraged by a lack of female role models with both a family and a

successful clinical academic career[34, 37, 44, 45].

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Family-work conflict was compounded by multiple barriers to returning to work including a lack of part-time

posts with flexible working or support/incentives for returners[44, 45], and difficulties in moving flexibly

between research and teaching (in both directions)[44]. Clinical academia was perceived by many as a barrier

to raising a family[34, 35, 37, 44-46]. Research training often coincided with child-rearing years leaving those

that had taken a career break behind their peers on research outputs and career progression[35, 44, 46].

There was a tendency to expect full-time outputs from part-time workers[35], and a tendency to stigmatise part-

time workers as disinterested or under-committed[35].

“I think working part-time is a thing that hampers progression in your career, in general. . . . Apparently

people think: ‘OK, part-time means no ambition.’ Which is not true.” [35]

1.4 Financial considerations

Financial considerations were a concern, exacerbated by levels of student debt[44, 45, 47] and the concentration

of research institutions into areas of high living cost[40]. The cost of starting a family and lack of access to

affordable childcare made this more acute for those with parenting responsibilities[35, 40].

In fact, working part-time is an alternative strategy to manage child care duties, sometimes chosen to

avoid spending most of one's salary on expensive services.[35]

There were pay inequalities between clinical and research pathways, leaving some clinicians with research

ambitions taking pay cuts for funded doctoral studentships or even self-funding, affecting those with either a

desire for higher pay or a need for financial stability[34, 37, 40, 44-46].

For both genders, debt was associated with the consideration of students leaving…[44]

1.5 Orientation to roles

1.5.1 Orientation towards administrative role

A dislike for administration was linked to burnout and avoidance of leadership responsibilities[39, 40].

Conversely an interest in the organisational aspects of research and education was linked to interest in academic

medicine as a career[37].

1.5.2 Orientation towards clinical care

A return to full time clinical care was driven by wanting more patient contact, feeling deskilled by time away

from patient care, and a delay in reaching consultant status due to academic time commitment[39, 40].

Retention was supported by feeling that research made them a better clinician, either through alignment of

their research to clinical needs or because their academic activities provided respite from full-time clinical

care[39, 40].

1.5.3 Orientation to leadership

There were many personal factors contributing to a rejection of leadership roles by women. These included

distancing from androcentric conceptions of leadership as related to power and conflict; seeing leadership as a

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distraction from clinical or research work; or as unviable due to a lack of recognition of women, work over-load

and a perceived need to self-promote[34, 39]. A leadership culture of long hours and out-of-hours networking

excluded many with parenting responsibilities[34]. Promotion was seen as linked to grant funding and

publication frequency, favouring those engaged in research rather than education[37], not only excluding some

women but not producing the most competent leaders[48].

The deans recommended re-evaluating traditional views of leader qualifications because the current

standards do not necessarily parse out strong leaders and are more likely to exclude women

candidates.[48]

There was a tendency for women to wait until they were over-qualified for promotion, while men applied

without meeting all the criteria[39]. This was partly attributed to women feeling unready, and partly to

compensatory behaviours in response to discouragement[39]. Some men also rejected leadership roles, which

were described as not worth the time or stress[39].

“According to my mentors (usually chairs), before going up for promotion I always need one more thing

even though there are many criteria for promotion, of which I have more than fulfilled. I have observed

that this is not the case for several of my colleagues who are male.”[39]

Female and other minority clinical academics were attracted to leadership roles as a way of influencing research

agendas, of resolving conflict, and of promoting diversity by becoming a visible role model[36, 48].

1.5.4 Orientation to research and academia

Orientation to research was supported by undergraduate research experiences, early training in research

methods, and training in a research-intensive university or hospital[36, 43, 44, 47]. Clinicians from diverse

backgrounds were sometimes attracted to research by its relevance to women’s health, LGBTQ+ health, or

underserved community needs[39, 45, 46].

Early publication success was an important driving factor[39, 44, 47], favouring those who were more likely to

benefit from mentoring, sponsorship and academic support[36, 37]. The benefits of academia were described

as outweighing the difficulties: more interesting and less stressful than clinical service provision[40], offering

academic freedom[45], and a clearly structured career path[39, 43, 45, 46], although not all were aware that the

pathway existed[43]. Attrition was driven by feeling unable to ‘switch-off’ from one’s academic role due to

pressures to publish or apply for funding[40], and by competing demands and priorities including clinical and

personal commitments[35, 40].

1.5.5 Orientation towards education

Women were described as more interested in opportunities to teach than conduct biomedical research,

however gender differences were also linked to education’s flexibility, its historically lower status (deterring

some men) and the competitiveness of the research pathway[44]. Education encouraged women into academia,

some discovering research after having begun as an educator[44].

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In two qualitative studies, female physicians (53 from the USA, seven from elsewhere) reflecting on their

career choices reported that they were attracted to academic medicine by opportunities to teach, but

with experience they also came to appreciate research more.[44]

An interest in education was partly driven by opportunity and experience, but was also driven by values: wanting

to facilitate success in others, wanting to make a difference or stay up-to-date, wanting to build a diverse

workforce or enact social change through teaching, attracting participants from diverse backgrounds[37, 44].

“as a mentor, you can reach out to thousands of people who can ... impact change” (African American

male, medical student).[37]

Attrition from educational activities was driven by limited scope for progression, as well as competing clinical

and personal demands and priorities[44].

2. Interpersonal (behavioural) factors

2.1 Supportive behaviours

Supportive behaviours included mentorship, involving regular support designed to build self-efficacy through

advice or coaching. This was contrasted to sponsorship, or the preferential treatment of a protégé.

There was concern that sponsorship tended to be preferentially available to those with characteristics that

reflected incumbent clinical academics, disadvantaging minorities and women[34, 39]. Sponsorship included

advocacy for advancement[34, 37, 39] and preferential support for early publication[39].

Mentoring on the other hand tended to be formalised and more equitably available[38, 43, 50]. Supportive

mentoring behaviours included altruistic guidance and clarity, building self-efficacy, encouraging continuity and

supporting resilience in the face of difficulty, encouraging successful publication, guiding and critiquing academic

work, supporting career planning, and providing moral and institutional guidance[37, 45, 46, 48].

2.2 Discriminatory behaviours

Conscious discrimination was expressed as overt disrespect[35, 40, 44], disruptive behaviours[38, 49], micro-

aggressions[35, 44], sexual harassment[35, 38, 44], social[35, 44, 45, 48] or cultural exclusion[35, 44] and

deliberate sponsorship or preferential treatment of people of a chosen characteristic[35, 38, 40, 48].

“… a senior colleague of clearly homosexual orientation. Despite being very prepared, he was

marginalized by the group leader. . . . He was placed in the ward, kept out of any possibility to publish

and teach.”[35]

Unconscious discriminatory behaviours, sometimes by women themselves, included judgemental attitudes

towards women exhibiting ‘male’ characteristics such as ambition, aggression or assertiveness[44], simply being

treated differently to colleagues[35, 40, 44, 45], unconscious value judgements leading to academic invisibility

or assumptions about status or role[35, 38, 44, 48].

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“When you have an outpatient clinic, you might be asked to go and fetch your own patients whereas

the nurse might do that for the male intern, or you have to change your own paper on the examination

bench…Just little things like that.”[35]

“The exclusion of women can be done in so many ways. It has been all the time actually. Also in meetings.

[When you talk] they start to play with the phone or whatever. . . . We had a meeting with the boss and

I talked with him for 30 seconds; and then he said: ‘She is giving a monologue.’. . . . Yes, subtle

means.”[35]

Indirect discrimination sometimes manifested as a diversity burden, where minority academics were

disproportionately required to sit on selection panels, provide mentoring, or to appear in public, detracting from

their clinical research activities[48, 50].

“diversity exhaustion for our [minority] faculty members… when people are asked to do so much to help

recruit, retain, promote, support, mentor other people who look like themselves.”[50]

2.3 Compensatory behaviours

Compensatory behaviours by those affected by discrimination included equalising behaviours, such as

submissive or self-deprecating talk[44]; a fear of being seen to conform stereotype[34]; fear of speaking up or

asking for adjustments[35, 45]; and feeling that they needed to be twice as good to advance[35, 44].

Compensatory behaviours manifested even without active discriminatory behaviour due to the enduring effects

of prior mistreatment[35, 44, 45].

“But in time, I learned to be silent, not to talk about it. Although I faced the problems, I did not mention

anything about them. Because if I talk about the problems, they dislike me more.”[35]

3. Organisational factors

3.1 Academic culture

In comparison to the clinical workplace, the academic workplace culture was described as respectful and

inclusive[37, 38, 42, 45, 48-50], however some found it competitive and unwelcoming[45]. The broad spectrum

of academic roles and responsibilities (teaching, research, mentoring, administration and leadership) were seen

as attractive[37].

Academia was frequently described as pressured and uncertain: pressure to apply for research grants, to publish

regularly, with anxieties caused by fixed term or temporary research contracts, and an out-of-hours culture

which effectively excludes those with parental responsibilities[35, 40, 42, 48]. The academic structure was

described as hierarchical with limited prospects at senior levels, driving both excellence and exclusion[39].

There was a perception of under-appreciation of women’s contributions and criticism that promotion processes

favoured self-promoters[39]. Promotion criteria attributed low worth to teaching[45], disproportionately

affecting women who are over-represented in education[44]. Research into inclusivity was also seen as lower

status disproportionately affecting minority researchers[36, 44].

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Junior faculty valued institutions that were committed to their career development. They were

discouraged by institutional failure to formally recognise their dedication to teaching and ambiguity

regarding their pathway to promotion.[45]

3.2 Clinical workplace culture

The clinical workplace culture was described as pressuring clinicians to prioritise service provision over teaching

or research[35, 39, 45]. The gender culture in teaching hospitals varied across specialties and institutions and

one study found it positive in a narrow range of specialties including neurology, pathology, internal medicine

and paediatrics[47]; it was however perceived as negative in the majority of specialties including surgery[35, 40,

47]. Where the clinical promotion pathway lacked transparency, there were also concerns about nepotism[35].

“All surgeons look at you. . . . ‘Well, you are a woman, you will never be a good surgeon.’ . . . When I

was a student, there were not a lot of female students specializing in surgical specialties. They stopped

sometimes their education to become general practitioners.”[35]

White male: “[When I was in the other hospital] there was the head of internal medicine trumpeting the

fact that he never wanted to have a woman in his ward. Firstly, because they get on his nerves; secondly,

because he said that every time you have to discuss with them, they begin to cry and to view any remark

as offending them personally; thirdly, because women become pregnant. Partially I found this attitude

here too [in the hospital where I am presently working].”[35]

3.3 Organisational policies & practices

3.3.1 On equity and discrimination, wellbeing and burnout

The authenticity of leadership’s commitment to diversity was seen as crucial, helped by the involvement of a

diversity council or diversity champion with both resources and power[50]. Rhetoric was converted to action

through active monitoring, investment in unconscious bias training and zero tolerance on discrimination[44, 49,

50]. A lack of critical mass of academics from diverse backgrounds discouraged new applicants[38, 50]. Some

characteristics such as gender or race were felt to be more protected than others such as sexuality[36].

“They’re very good with cultural diversity training, but when it comes to LGBT concerns it’s kind of like

they don’t talk about it. It’s like a brick wall.’’ [36]

Essential family friendly policies included the availability of flexible working[34, 35, 38-40, 43, 45, 48, 49] or

maternity/carer pay[35, 38, 46]. Successful programmes enhanced this by actively addressing the out-of-hours

culture bringing meetings and communication into working hours[40, 43], and creating a culture of flexible

working for all [35, 45] which some extended beyond childcare to cover, for example, unexpected personal or

family crises[49].

Regardless of gender, faculty expressing [Role Overload] frequently worked part time (p = 0.001) and

had a spouse working outside the home (93%, p = 0.043).[39]

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Hiring and promotion practices such as diverse representation on selection panels were helpful[48, 50], as long

as they didn’t overly burden diverse individuals[50]. Some promotion criteria were seen as actively

disadvantaging women, such as a requirement to travel, or the status of education compared to research[38,

43, 44, 48].

3.3.2 On mentoring, social support, networking, role modelling

The visibility of concordant role models was seen as important[35, 37, 39, 43-45, 48]. Females wanted role

models that were based on more than gender, such as modelling a work-life balance, or balancing a successful

career with family[34, 35, 37, 38, 44, 45].

“I am shocked when I look around. Even if I think that things are going well, that people are not

discriminated. ...When you look around, there are always more men than women in leadership

positions.”[35]

Networking opportunities needed to feel inclusive, with sensitivity to culture and parental commitments[36].

The availability of concordant mentoring was seen as important[36-38, 43, 44, 50] but not always achievable.

Cross-gender mentoring was successful where there was an understanding of the unique challenges faced by

women[34]. Formal mentorship programmes to support the advancement of under-represented groups were

described[38, 43, 50]. There may be issues with females prioritising lower status but supportive mentors and

men benefiting from mentors with higher status[44], and poor quality or inconsistently available mentoring[39,

46].

3.3.3 On active support for career advancement

Some institutions described active support for career planning aimed at promoting talent over ambition[34, 37,

39, 40, 43, 45]. Other measures included career pathways that include education[39, 40, 45], faculty

development programmes[49], performance recognition schemes[50], leadership training[39] for women[37],

training career counsellors on the issues facing women in clinical academia[37], and steps to increase the

transparency of promotional pathways, policies and procedures[40, 45, 49].

These gendered patterns of family–work dynamics, coupled with the association between

organizational support and intent to leave, point to the organization’s responsibility and accountability

in establishing practices that can facilitate embeddedness or a reason to stay, such as a positive

promotion climate. It is worth noting that opportunities for advancement are necessary, but not

sufficient to increase retention for all faculty members, as promotion climate was not a positive reason

to stay for female respondents.[34]

3.3.4 On remuneration, funding and resources

The allocation of funding and resources also impacted on retention and success. Return to full time clinical

practice was driven by academic vs clinical salary discrepancies[44, 45] and the availability of funding, credit or

loan repayment schemes[44]; see also the prior section on personal financial considerations. Clinicians needed

protected research time and resources to back-fill their clinical duties[38, 42, 45].

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There was a tendency for women to apply for funded PhDs which are a scarce resource and competitively

allocated[44]. The allocation of research funding was also felt to be overly competitive[45] and gendered[47],

as was the allocation of research space and administrative support[35, 42]. A gender and ethnicity-based pay

gap was reported[35, 38].

“In my clinic there are two men and they have two separate rooms, the other four female doctors are in

one room. So, males have more opportunities than me [to do research].”[35]

The ongoing pay gap (both for women and for expatriates) is exacerbated by salary negotiations which

tend to favour local male professionals, as they are often more assertive.[35]

4. External (societal) factors

4.1 National clinical academic structures and funding

The availability of national and international research funding is affected by economic and political factors[45].

Funding of higher education impacts on the number of senior academic positions, and the availability of post-

doctoral positions[40, 43].

National structures need to be studied locally as they are by definition situated in their time and context. We

focus here on the current UK training pathway as a case example. National structures in the UK have led to

discrepancies in research funding depending on whether the applicant is a trainee or consultant, which

contributes to a disconnect at that transition[40], alongside structures preventing consultants from applying for

clinical lectureships[43]. There are calls for jointly funded positions to address this issue[43]. There was concern

that the new trainee doctor contract with longer core hours will reduce research capacity, particularly for

parents with care-giving responsibilities[40]. The visibility of national research training opportunities to clinicians

was an issue, particularly for those not on an integrated run-through pathway[40, 46].

Many participants… voiced their fears that the new junior doctor contract in the United Kingdom may

financially penalize both female clinicians and those interested in pursuing an academic career, due to

potential increases in working hours accompanied by a reduction in out-of-hours pay.[40]

… participants noted difficulty accessing information and guidance on training pathways and

uncertainty about how to progress in a clinical academic career, particularly if they were ineligible for

the integrated academic training pathway.[40]

Respondents [planning to leave clinical academia]…are particularly worried about the small number of

senior academic appointments available as well as the difficulty of obtaining research grants and work-

life balance[43]

4.2 Societal attitudes to diversity and equity

Societal factors relating to gender and diversity also impact on equitable participation in this demanding

career[35, 38, 44]. There are ongoing expectations for women to shoulder household chores and to be the

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primary caregiver, effectively doing a second shift after work. This may be giving way to an increasing acceptance

of non-gendered household roles. Fewer people of either gender have a stay-at-home partner[35].

We suggest that such a pattern reflects a general gender norm within society whereby women are more

likely to hinder their careers because of family responsibilities and ‘‘second shifts’’ than are men.[38]

“It seems that younger couples try to share much more equally. I don't know if that's true for every

aspect of life. But also many of my male colleagues leave early one or two days a week to go pick up the

kids at the day care centre.”[35]

DISCUSSION

The objective of this review was to scope and synthesise current evidence on the factors affecting

recruitment, retention, participation and progression within the clinical academic pathway, with a

focus on equitable participation for under-represented groups. These factors, summarised in figure 2,

reveal a multi-dimensional problem with individual, inter-personal and societal-institutional aspects,

and nuances at different stages of the career pipeline.

There are calls for interventions to target the organisational level rather than expecting individuals to

adapt[52]. Organisational changes are also within the control of local leadership and can therefore be

more rapidly changed than wider external and societal factors. Interventions at this level will need to

address the issues identified at the personal and interpersonal levels, whilst acknowledging the wider

national and societal landscape. For example, addressing the out-of-hours working culture; ensuring

that promotion pathways value education and rely less on self-promotion; and providing research

support for part-time workers and those with parenting responsibilities to mitigate role overload.

Policies to support gender equality may increasingly support both men and women as societal norms

shift towards more equal family and household responsibilities[53].

Many of these issues relate to work-family conflict or the advantages conferred by social capital, which

are well documented and generic to a range of careers[54, 55]. We will therefore focus our discussion

on the aspects that appear unique to clinical academia. Early publication success and research

mentoring during medical school and early training were associated with entering the pipeline and

opportunities need to be offered equitably, rather than through informal networking which may

disadvantage minorities. Financial pressures relating to debt accrued during extended medical training

and poorly funded PhD programmes need to be addressed. Both deliberate and unconscious

discriminatory behaviours were frequently discussed, particularly in the clinical context. This varied

by specialty and institution, with discriminatory behaviours appearing to be driven by pressurised and

hierarchical clinical workplaces, again suggesting an organisational approach is needed. Our findings

suggest it may not be enough to address organisational culture on a single side of the research v.

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clinical divide. Research institute policies on equality, diversity and family-friendly working are unlikely

to support this workforce unless they are also adopted and monitored within the clinical setting.

Interventions at the national policy level are needed to address transparency of the pathway,

remuneration for doctoral education that reflects the particular needs and contribution of this highly

skilled and mature workforce, the availability of post-doctoral posts, and transitions particularly at the

trainee / consultant level. These findings reflect and confirm policy recommendations from the UK’s

Medical Research Council[56].

Past reviews in the area have focussed on a particular stage of career decision making[57], a particular

population[44], or a particular factor that affects equitable participation[58]. Our methodology

allowed us to examine and synthesise a broader range of literature. It also facilitated the creation of

an integrated analysis of the factors that influence equitable participation in clinical academia at all

stages of the pipeline, from recruitment to professorship.

A limitation of our study was the limited literature on equitable participation for ethnic minority and

LGBTQ+ clinicians. Although relatively few papers on sexuality or on ethnicity were included, we found

that they sat well within the 13 themes identified, particularly those relating to social capital, interest

in personally-congruent research, interpersonal factors (discriminatory, supportive and compensatory

behaviours), and policies and practices within organisations to address the workplace culture

(supportive mentoring, networking and training). The infancy of research in this area, compared to

gender-based papers, is a limitation of our findings. We did not identify any papers relating to disability

within the clinical academic career pathway. Class was excluded from this review, as the clinical

academic population belongs by definition to the upper professional occupations. However, this does

not take account of the socioeconomic background of students at the stage of selection into medical

school which is likely to be a significant factor. Further research is needed to explore these gaps.

CONCLUSIONS


academia. Their broad and often interconnected nature suggests that interventions will need to

address structural and cultural factors as well as individual needs. In addition to standard good

practice on equality and diversity, we suggest that organisations provide equitable support towards

early publication success and targeted mentoring; address financial and role insecurity; address the

clinical workplace culture; mitigate clinical-academic-personal role conflicts and overload; ensure that

promotional structures and processes encourage diverse applicants; and promote family-friendly,

coherent and transparent national career pathways.

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Figure Legends


Figure 2: Factors relating to retention, success and equitable participation in clinical academia

Data Sharing Agreement

Coding data is available from the corresponding author upon reasonable request.

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38. Martinez LR, O'Brien KR, Hebl MR. Fleeing the Ivory Tower: Gender Differences in the Turnover Experiences of Women Faculty. Journal of Womens Health. 2017;26(5):580-6.39. Ellinas EH, Kaljo K, Patitucci TN, Novalija J, Byars-Winston A, Fouad NA. No Room to "Lean In": A Qualitative Study on Gendered Barriers to Promotion and Leadership. Journal of Womens Health. 2018.40. Ranieri VF, Barratt H, Rees G, Fulop NJ. A Qualitative Study of the Influences on Clinical Academic Physicians' Postdoctoral Career Decision Making. Academic Medicine. 2018;93(11):1686-93.41. Rao SK, Kimball AB, Lehrhoff SR, Hidrue MK, Colton DG, Ferris TG, et al. The impact of administrative burden on academic physicians: Results of a hospital-wide physician survey. Academic Medicine. 2017;92(2):237-43.42. Jagsi R, Griffith KA, Jones RD, Stewart A, Ubel PA. Factors Associated with Success of Clinician-Researchers Receiving Career Development Awards from the National Institutes of Health: A Longitudinal Cohort Study. Academic Medicine. 2017;92(10):1429-39.43. Lopes J, Ranieri V, Lambert T, Pugh C, Barratt H, Fulop NJ, et al. The clinical academic workforce of the future: A cross-sectional study of factors influencing career decision-making among clinical PhD students at two research-intensive UK universities. BMJ Open. 2017;7(8).44. Edmunds LD, Ovseiko PV, Shepperd S, Greenhalgh T, Frith P, Roberts NW, et al. Why do women choose or reject careers in academic medicine? A narrative review of empirical evidence. The Lancet. 2016;388(10062):2948-58.45. Ranieri V, Barratt H, Fulop N, Rees G. Factors that influence career progression among postdoctoral clinical academics: a scoping review of the literature. Bmj Open. 2016;6(10).46. Eley DS, Jensen C, Thomas R, Benham H. What will it take? Pathways, time and funding: Australian medical students' perspective on clinician-scientist training. Bmc Medical Education. 2017;17.47. Skinnider MA, Twa DDW, Squair JW, Rosenblum ND, Lukac CD, Canadian MDPPIG. Predictors of sustained research involvement among MD/PhD programme graduates. Medical Education. 2018;52(5):536-45.48. Humberstone E. Women Deans' Perceptions of the Gender Gap in American Medical Deanships. Education for Health. 2017;30(3):248-53.49. Wingard D, Trejo J, Gudea M, Goodman S, Reznik V. Faculty Equity, Diversity, Culture and Climate Change in Academic Medicine: A Longitudinal Study. Journal of the National Medical Association. 2019;111(1):46-53.50. Kaplan SE, Gunn CM, Kulukulualani AK, Raj A, Freund KM, Carr PL. Challenges in Recruiting, Retaining and Promoting Racially and Ethnically Diverse Faculty. Journal of the National Medical Association. 2018;110(1):58-64.51. Bronfenbrenner U. Ecological systems theory. Six theories of child development: Revised formulations and current issues. London, England: Jessica Kingsley Publishers; 1992. p. 187-249.52. Montgomery A, Panagopoulou E, Esmail A, Richards T, Maslach C. Burnout in healthcare: the case for organisational change. BMJ. 2019;366:l4774.53. Sallee M, Ward K, Wolf-Wendel L. Can Anyone Have it All? Gendered Views on Parenting and Academic Careers. Innovative Higher Education. 2016;41(3):187-202.54. Michel JS, Kotrba LM, Mitchelson JK, Clark MA, Baltes BB. Antecedents of work–family conflict: A meta-analytic review. Journal of Organizational Behavior. 2011;32(5):689-725.55. Seibert SE, Kraimer ML, Liden RC. A Social Capital Theory of Career Success. Academy of Management Journal. 2001;44(2):219-37.56. Oldfield K TC, Garnett E. A Cross-Funder Review of Early-Career Clinical Academics: Enablers and Barriers to Progression. Medical Research Council in collaboration with the Academy of Medical Sciences, British Heart Foundation, Cancer Research UK, National Institute for Health Research and Wellcome Trust; 2015.

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57. Straus SE, Straus C, Tzanetos K, Medicine UtaotICtRA. Career choice in academic medicine: systematic review. Journal of general internal medicine. 2006;21(12):1222-9.58. Kashiwagi DT, Varkey P, Cook DA. Mentoring Programs for Physicians in Academic Medicine: A Systematic Review. Academic Medicine. 2013;88(7):1029-37.

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Incl

ud

ed

El

igib

ility


(n = 73)

Scre

enin

g Id

en

tifi

cati

on


(n = 552)








(n = 39)


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• Gendered culture, variable across specialties e.g. surgery


• Prioritisation of clinical vs academic roles

Academic culture

• Pressured & uncertain

• Hierarchical



National policies


• Clinical & research funding & priorities

Societal attitudes








• Research

• Clinical

• Administrative

• Educational

• Leadership


• Level of debt



Social capital











Personal factors

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1




ABSTRACT



2

INTRODUCTION

Rationale 3


4

Objectives 4


4

METHODS



5



5-7



5-7


6-7



6-7



8


8


12


8

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2




RESULTS


14









12-23



DISCUSSION



24-26



26

FUNDING

Funding 22


3



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Documents

bmjopen.bmj.com€¦ · For peer review only 18. Abu-Zaid A, Altinawi B, Eshaq AM, Alkhatib L, Hoilat J, Kadan S, et al. Interest and perceived barriers toward careers in academic