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The Most Valuable Resource Is Time: Insights From a Novel National Program to Improve Retention of Physician–Scientists With Caregiving Responsibilities

Jones, Rochelle D. MS; Miller, Jacquelyn MA; Vitous, C. Ann MA, MPH; Krenz, Chris; Brady, Kathleen T. MD; Brown, Ann J. MD, MHS; Daumit, Gail L. MD, MHS; Drake, Amelia F. MD; Fraser, Victoria J. MD; Hartmann, Katherine E. MD, PhD; Hochman, Judith S. MD; Girdler, Susan PhD; Libby, Anne M. PhD; Mangurian, Christina MD, MAS; Regensteiner, Judith G. PhD; Yonkers, Kimberly MD; Jagsi, Reshma MD

Author Information
doi: 10.1097/ACM.0000000000002903

Abstract

A robust workforce of physician–scientists is essential to advancing medicine and population health. Yet over 40% of early-career physicians with full-time faculty appointments at U.S. medical schools leave academia within 10 years of their first faculty appointments.1 Many promising physician–scientists fail to secure independent funding as principal investigators; for example, fewer than half of the recipients of prestigious K08 and K23 career development awards from the National Institutes of Health (NIH) go on to achieve independent R01 funding.2 Even after controlling for relevant characteristics (e.g., specialty, K-award type, and institutional affiliation), women in this highly able and motivated population are less likely than their male peers to receive independent funding, produce publications, or achieve leadership positions.3 In an era in which the number of women exceeds that of men amongst medical school matriculants in the United States,4 these observations are worrisome and should motivate investigation into mechanisms that drive gender differences in attrition and success.

One factor that may encumber the productivity, advancement, and retention of women (as well as some men) could be inadequate support for combining career and family responsibilities.5–9 Previous research has suggested that the traditional pathway to physician–scientist career advancement may be unsuitable for the retention of more recent generations of physician–scientists, particularly women, who may value temporal flexibility in work hours and promotion timelines.10–13 Evidence suggests that the pursuit of an academic medical career often involves struggling to integrate competing demands of clinical care, research, and family responsibilities.5,14–16 Compared with their male colleagues, women physician–scientists often spend more time on parenting and domestic responsibilities.5,15,16 Additionally, women physician–scientists may fear stigma when choosing to take advantage of institutional policies and practices allowing for time off or flexibility in scheduling.14 Recently, media reports have focused on the tremendous loss of talented women from the workforce due to work environments that are not supportive of the needs of caregivers, despite a rise in both parenting and eldercare demands.17,18 This attrition is concerning for physician–scientists, given observations that gender diversity may boost collective intelligence, improve scientific teamwork, and lead to superior scientific discoveries.19,20

Program evaluation research focusing on ways to address these challenges can inform and advance evidence-based interventions both to promote gender equity and to increase the vitality of the physician–scientist workforce in academic medicine. One such endeavor is a multicenter initiative launched by the Doris Duke Charitable Foundation in 2015; its goal is to promote the general vitality of the physician–scientist pipeline by facilitating the success and retention of early-career or junior physician–scientists facing substantial caregiving challenges. As described more fully elsewhere, the Fund to Retain Clinical Scientists (FRCS)21 has provided grants to 10 U.S. medical schools accredited by the Liaison Committee on Medical Education that, in turn, implement programs to provide financial and other support to both male and female physicians whose clinical research careers are at risk due to extraprofessional caregiving demands. Individual physician–scientists at each of the 10 institutions were competitively selected by institution-based selection committees in 2016 based on criteria requiring them to be junior faculty physician–scientists who show academic promise but face a substantial extraprofessional caregiving burden. Awardees received grant funding, typically $30,000 to $50,000 per year, to cover research support or to enable buyout of clinical duties. They were not permitted to use the funds to cover childcare or eldercare costs. Some institutions also provided access to other forms of support, such as leadership development training, training in academic and career development skills, and/or networking. Although both women and men could be selected for funding, the vast majority of awardees (28 out of 33; 85%) were women.

As part of a formal, prospectively designed evaluation of the FRCS, we conducted a qualitative analysis of data from semistructured interviews with physician–scientists who received program support. We sought to understand both the ways that pursuit of an academic medical career can be complicated by extraprofessional caregiving demands and recipients’ early impressions of the effects of receiving FRCS support. Our goals were (1) to build upon existing research related to work–life integration in academic medicine by providing vivid data from the lived experiences of a unique sample and (2) to inform both the ongoing implementation of the FRCS and the development of other interventions seeking to promote gender equity and success of physician–scientists.

Method

We invited all 33 physician–scientists (5 men and 28 women) who received FRCS support in the first year of the program to participate in semistructured, audio-recorded telephone interviews. We invited them by email in late 2017/early 2018 and conducted the interviews in early 2018. We assured the physician–scientists that the information they provided would be deidentified before we analyzed data or reported results, and we offered those who completed the interviews a $100 honorarium. The University of Michigan Institutional Review Board approved this study.

A single nonphysician interviewer (R.D.J.), who was formally trained in qualitative analysis through coursework at the University of Michigan and had led multiple prior qualitative investigations regarding physician–scientists’ career development,22,23 conducted all of the phone interviews. We developed an in-depth, semistructured interview guide with the input of those with expertise in the subject (work–life integration and career development of physician–scientists) and/or in qualitative research methods. Program site directors, leaders, and experts revised the guide extensively through multiple iterations, and it was not further adapted during the course of the interviews.

We used the interpretive description approach24–26 to applied qualitative research, seeking primarily to gather rich, contextualized data to interpret and describe physician–scientists’ lived experiences in terms of 2 associated phenomena: (1) navigating simultaneous professional and extraprofessional demands and (2) benefiting from the FRCS, an intervention specifically designed to support the careers of physician–scientists with caregiving responsibilities. The interview questions, thus, focused on assessing career and caregiving experiences along with participants’ early impressions of the FRCS (see Supplemental Digital Appendix 1 at http://links.lww.com/ACADMED/A718). Interview participants were asked to describe, first, the challenges they faced integrating all of their responsibilities and, second, the nature of their caregiving need when they applied for the FRCS award. They were asked to discuss how they used their program funds; their experiences with any additional services offered as part of the FRCS at their institution; and how the program has affected them, their career, and their home life. They were also asked to discuss the barriers faced by early-career physician–scientists and to offer their thoughts on how institutions and leaders in academic medicine might promote the success and retention of junior faculty.

Audio-recorded interviews were transcribed by a professional transcription service, and transcripts were deidentified prior to analysis. Four analysts (J.M., C.A.V., C.K., and the interviewer, R.D.J.) independently reviewed and coded each deidentified transcript. They used Dedoose version 8.0.35 (SocioCultural Research Consultants, LLC, Los Angeles, California), a web-based application for managing, organizing, and presenting qualitative research data. Each interview transcript was reviewed by at least 2 of these analysts. Collectively, the analysts represented diverse professional fields (sociology, psychology, medical anthropology, and public health) and personal backgrounds (gender, age, and race). We intentionally sought diversity in expertise and demographics to mitigate systemic bias and to increase validity. In keeping with an interpretive description approach,27 the 4 analysts iteratively revised the coding scheme, which was reviewed by the senior investigator (R.J.). The coding team regularly met to review the data and arbitrate differences in interpretations. The initial coding manual was developed based on the interviewer’s knowledge of the literature in this area, in combination with her impressions from the interviews and initial reviews of the transcripts. Other codes were generated inductively during the course of the iterative coding process. Overarching themes were then ascertained and refined using thematic analysis, as described by Braun and Clarke.28 In line with the interpretive description approach to qualitative research, the analysts sought to develop “a coherent conceptual description that taps thematic patterns and commonalities believed to characterize the phenomenon that is being studied and also accounts for the inevitable individual variations within them.”25

Results

Of the 33 FRCS awardees invited, 28 (23 women and 5 men) consented and participated in an interview (85% participation). Table 1 details the characteristics of the participants. The average interview duration was 42 minutes.

Table 1
Table 1:
Characteristics of Participants Included in a Qualitative Study of Physician–Scientists Receiving Awards in the First Year of the Doris Duke Charitable Foundation’s Fund to Retain Clinical Scientists, 2018

Through qualitative analysis of narratives provided by participants—men and women alike—we identified 3 prominent overarching thematic clusters, one of which (time) is the focus of this report. The 2 other overarching thematic clusters (stigma and validation) will be reported separately (contact authors for data). We have organized the overarching thematic cluster of time into 5 crosscutting themes: (1) time is a critical and limited resource, (2) timing is key, (3) the combination of limited time resources and timing conflicts has a particularly adverse effect on women’s career advancement, (4) flexible funds enable reclamation and repurposing of time resources, and (5) FRCS leaders should be cognizant of time and timing conflicts when developing program-related activities and services. We have explained each theme and its subthemes below. The more complex subthemes are further organized into multiple categories. Below, for each subtheme category, we provide an exemplary quotation (along with the gender and an age range of the participant source), and we have presented additional quotations to illustrate each of the first 4 themes in Tables 2 through 5.

Table 2
Table 2:
Representative Quotations Regarding Time as a Critical Resource, From a Qualitative Study of Physician–Scientists Receiving Awards in the First Year of the Doris Duke Charitable Foundation’s Fund to Retain Clinical Scientists, 2018

Theme 1: Time is a critical and limited resource

A major theme we identified is the idea that time is a critical and limited resource. One participant’s comment summarized the general sentiment expressed by men and women alike: “There just aren’t enough hours in the day” (Female, 40s). Participants generally commented that they often do not have the bandwidth to fully attend to the numerous daily demands on their time as physician–scientists, especially when combined with family responsibilities:

There’s never really enough time in the day . . . the challenge of having a family and a demanding work life is that you never leave anything that’s completely done. (Male, 30s)

Some specifically alluded to having to engage in administrative tasks that consume significant amounts of time, ultimately hindering their scholarly productivity, and they noted that activities necessary for meeting important family, domestic, or caregiving needs require a great deal of time as well (see also Table 2). Participants discussed the time and effort required simply to be physically present to care for one’s own children.

There are only so many hours in a working day . . . to interface with patients and be a presence at work . . . and also be present physically and emotionally for your child. (Female, 40s)

Several participants described challenges associated with caring for elderly parents and/or dealing with a family member’s health issues, which can be especially time-consuming and burdensome if combined with parenting responsibilities (see Table 2).

Another issue raised by participants is that nominally protected time for research is often left more or less unprotected in practice. Some participants pointed out that early-career physician–scientists are frequently pressed to cover administrative tasks or clinical duties that encroach upon what should be protected time for research. Others observed that expectations for productivity in clinical work frequently exceed the allocated percentage of work effort and impede clinician–researchers’ ability to complete funded research and develop new grant proposals. To illustrate, 1 participant commented:

My department had me doing more clinical work than I should have been doing, based on the percent effort I was supposed to dedicate to my [funded career development grant] . . . I was doing more clinical work than I should have, and I think the same is true for a lot of clinician researchers. (Female, 30s)

Ironically, the lack of time dedicated expressly to research leads to further erosion of protected time as grant support wanes (see Table 2).

Theme 2: Timing is key

Another key theme is the importance of timing. Physician–scientist participants (both men and women) noted that timing is crucial to their career progress. Some participants referred to challenges associated with short-term timing issues (see also Table 3) and the need for greater flexibility when integrating daily caregiving and career schedules:

Table 3
Table 3:
Representative Quotations About How Timing Is Key, From a Qualitative Study of Physician–Scientists Receiving Awards in the First Year of the Doris Duke Charitable Foundation’s Fund to Retain Clinical Scientists, 2018

This idea that you’re supposed to be in and around 9:00 to 5:00 or 7:30 to 5:00, whatever it is, it’s not realistic for a lot of people who have significant caregiving responsibilities during the week. (Male, 30s)

Others described challenges related to long-term timing issues, specifically critical time points along the physician–scientist career trajectory during which attaining important milestones necessary for advancement and retention is most pressing (see also Table 3). Some participants pointed out that these time constraints and expectations for early-career physician–scientists’ career advancement generally conflict with family-planning goals and timelines, especially during the crucial years of childbearing and rearing young children:

The most crucial years of your professional development are at the exact same time as your most crucial years for [reproduction] . . . having children . . . and your caregiving needs. . . . It is a lot. It is a lot on any one person. (Female, 40s)

Theme 3: Adverse effects on women’s career advancement

Although men and women alike described challenges related to time and timing, participants perceived the combination of limited time resources and timing conflicts as having a particularly adverse effect on women’s career advancement (see also Table 4). Several physician–scientists noted how caregiving often falls to women, especially mothers of young children. Participants recognized that societal expectations regarding gender roles and norms in the home contribute to this disparity:

Table 4
Table 4:
Representative Quotations Regarding How the Combination of Limited Time Resources and Timing Affects Women’s Career Advancement Particularly Adversely, From a Qualitative Study of Physician–Scientists Receiving Awards in the First Year of the Doris Duke Charitable Foundation’s Fund to Retain Clinical Scientists, 2018

I look at our male junior faculty and his wife cooks all the dinners for him and takes care of the household and he does nothing but write grants and do what he needs to do for work. . . . [but the female junior faculty] . . . we’re always talking about how are we going to balance practice and pickups and sick daycares. (Female, 40s)

Of note, participants acknowledged a number of other challenges that can impede or alter the progression of women’s academic career paths. For example, a woman’s career development might be delayed if she has difficulty finding a mentor or if she does not qualify for certain grants because of strict requirements regarding submission within a finite time after completing training. Additionally, some participants observed that pregnancy and the realities of a woman’s biological clock often conflict with career-related time requirements, which may lead to gaps in productivity and slower career progress:

[A]pplications [where] eligibility [is limited to] 3 years within starting your faculty position or 8 years within graduating [should] have this prorated. . . . so that the eligibility is based on time worked, not just a chronologic year, which may have a 3-month maternity leave . . . in it. (Female, 40s)

Participants’ comments suggest that some physician–scientists perceived the challenges related to limited time resources and timing conflicts as compounded for women who are first-generation academics and/or members of minority groups traditionally underrepresented in medicine:

[Caregiving burden] kills people who are the first-generation professionals in their family. It kills their career disproportionately. (Female, 40s)

It takes women and minorities a longer time to identify a mentor. And then, separate from identifying that mentor, it also takes us a longer period of time to identify research funding (Female, 30s).

Theme 4: The reclamation and repurposing of time resources

Participants consistently noted that the flexible funds provided by the FRCS effectively supported their capaRy to reclaim and repurpose time resources to benefit their careers:

I think the most valuable resource is time, and while institutions can’t give time, if they can give us more money, then we can use that to buy more time to do the work we want to do. (Male, 30s)

Some physician–scientists described how having flexible funds to buy more protected time for themselves allowed them more freedom to choose and to control how they spend their time (see Table 5). Participants described spending their newfound protected time on important scholarly activities, such as grant writing and publishing manuscripts:

Table 5
Table 5:
Representative Quotations Regarding How Flexible Funds Enable the Reclamation and Repurposing of Time, From a Qualitative Study of Physician–Scientists Receiving Awards in the First Year of the Doris Duke Charitable Foundation’s Fund to Retain Clinical Scientists, 2018

So, I use the fund to support 20% of my time for grant writing and so, it bought me out of a day of clinic which is equal to, like, 2 days [laughs] so that I could work on grants. (Female, 40s)

Other participants explained how having flexible funds (or program offerings) to support the outsourcing of time-consuming delegable tasks frees valuable time, which ultimately leads to increased productivity in other important areas:

I brought in . . . a second research assistant . . . Before [receiving the Doris Duke award], I had to come in and be the second person, because you have one person that’s spinning all the blood [while] the other person is sitting in the room with the patient. . . . Every time I had a research patient in, I had to be in that patient room for 6 hours. By having a second person, that freed up 6 hours’ worth of time for every study patient and my current study enrollment is at 92 so that’s 6 times 92 . . . that saved me. (Female, 40s)

Further, physician–scientists observed that securing time resources often mitigated both short-term and long-term timing issues. Some participants described experiencing improved balance and flexibility in scheduling and timing of daily activities.

It’s given me more flexibility in deciding where my energy needs to be concentrated on any given day. Because I have more people helping me, there are still days when I’m doing what my lab technician is doing alongside her. There are days when I’m helping recruit patients alongside the research coordinator, and then there are days when I’m just thinking, or there are days when I’m just being a mom. . . . If I have the flexibility, if I have the extra hands and the extra help, then it’s not so much of a sacrifice. I can still have the other part of my life going on in the background. (Female, 40s)

Others reported more steady workflow, boosts in productivity, and/or acceleration of their career progress. Participants recounted the immense value of being able to take time to attend to caregiving demands or to focus on scholarly pursuits while still feeling confident that important research activities were continuing thanks to vital research personnel (e.g., study coordinators, lab technicians, biostatisticians) who were supported in part by FRCS funds.

I was able to pay for an advanced data analyst . . . so that, while I was on maternity leave, he was working on my project, and so I came back after 12 weeks this time, and it wasn’t like I was just picking up where I left off. Things had continued to move forward while I was gone. (Female, 30s)

In addition, participants acknowledged that increased time resources were instrumental in ensuring their continued success and retention during critical time points in their career trajectories:

When I think about your early career, I think it’s a trajectory, and there’s sort of a learning curve and there’s a really steep part where most people fall off. And I think [the Doris Duke award] has kind of pushed all of us so that we have been able to kind of get past the really difficult part. (Female, 40s)

Theme 5: FRCS leaders should be cognizant of time and timing conflicts

A final theme focused on the time needed to access services or participate in activities that are supplemental to the FRCS. Some participants pointed out the need to minimize unnecessary time demands related to program participation.

Part of the point of why we all need this award is that we are all super busy and so I have actually appreciated that our institution . . . hasn’t put a whole bunch of other demands or expectations around [the grant funding]. (Female, 30s)

One of the things that I did complain about is that there was a scheduling kind of pressure, because I can’t attend some of these things, the lunches or the seminars. (Male, 40s)

Others suggested that program leaders consider offering career-advancing opportunities that fit into busy schedules and/or resources that support practical, time-saving solutions.

I would say that the workshops and stuff like that and kind of networking things are nice, though . . . it’s hard to take advantage of them because the biggest commodity that we all have is time and so to be physically present there and to do that is kind of eating some of the resource that I need the most. (Female, 30s)

The participating physician–scientists noted that networking and mentoring programs were helpful if they provided practical caregiving tips and/or offered camaraderie with those who share similar experiences—as long as the offerings themselves did not require too many time commitments:

Time is so tight. Every minute is absolutely planned and so, I think there’s a careful balance between having too many functions and obligations to attend and having a few meaningful ones, and you know I would err on the latter, but absolutely I think it’s important to create a community and to kind of build on this energy that Doris Duke has started in making those people like myself who are balancing a lot feel supported and like this is an issue that the institution recognizes. (Female, 30s)

Summary of findings

In sum, qualitative analysis revealed that time spent on caregiving poses an added challenge for physician–scientists who must, to achieve career success, already manage numerous demands on their time. We noted strong consensus that the flexible funds provided by the FRCS play a crucial role in promoting the success of early-career physician–scientists by alleviating time-related challenges and by helping to ameliorate timing conflicts. Generally, the participants described using FRCS funds to cover more protected time and/or to outsource research-related tasks. As a result, the physician–scientists could focus their valuable time on bolstering their productivity and achieving success in important career and personal arenas (e.g., preparing grant applications, doing clinical work, spending time with family), especially during critical time points along their career trajectory.

This program gives me the opportunity to not have to make any permanent decisions to cut different uses of my skill out. I don’t have to cut out research. I don’t have to cut out clinical work. I don’t have to spend less time with my kids. I can just make use of a broader set of resources. That’s what it means to me. (Female, 40s)

Physician–scientist participants observed that the pivotal time to attain important career milestones necessary for advancement often overlaps with the critical years of childbearing and rearing young children. Participants perceived the challenge of this timing conflict to be particularly acute for women because of a variety of factors, including those related to traditional gender roles in the home and the realities of biology. These observations suggest that programs such as the FRCS may be especially instrumental in supporting the career advancement of women:

A lot of the caregiving responsibilities still do fall to women so I think [the FRCS is] a way for institutions to show they are serious about women advancing in their careers. (Female, 30s)

Discussion and Conclusions

Situated within a unique national intervention specifically aimed at promoting the success of physician–scientists, this study yields important insights regarding the mechanisms by which gender differences in career outcomes develop and how they can effectively be addressed and mitigated. Our findings highlight the critical importance of time and timing for individuals pursuing careers in academic medicine, particularly women. Through qualitative analysis, we gained a nuanced understanding of (1) the numerous demands on early-career physician–scientists’ time, (2) the role that the FRCS has played in alleviating these time-related challenges and ameliorating timing conflicts, and (3) the importance of the FRCS in promoting the success of early-career physician–scientists, particularly women. We are aware of no other intervention of this scale and believe that these preliminary findings are important to disseminate to others who seek to deploy limited resources to effect meaningful change.

Our findings support prior observations that new generations of physician–scientists in academic medicine need and desire work–life integration as well as temporal flexibility in their work hours and career trajectories.10–12 While the participants in this study—the men and women alike—discussed the adverse effects of limited time and timing conflicts, they also recognized that women likely face additional challenges because of gendered expectations related to caregiving and/or due to the realities of the biological clock. These findings are consistent with prior observations that outdated systems of fixed tenure clocks, rigid promotion policies, and inflexible work hours are prohibitive of satisfactory work–life integration and detrimental to the career advancement of women.10–13

Authors of prior qualitative studies in academic medicine have revealed compelling findings regarding the disproportionate burden of caregiving demands shouldered by women and the associated challenges surrounding limited time and timing conflicts. In their study, Carr and colleagues interviewed senior medical school faculty members who commented that certain departments and some chairs viewed women as the main family caregiver.6 Interviewees also discussed pressure to establish “face time” during work hours, which may make career advancement especially difficult for women who need more flexibility because of family responsibilities.6 Similarly, in prior work, we analyzed data from interviews of NIH-funded career development award recipients and their mentors, and we noted both the perception that women are likely to be stigmatized for taking time off from work to care for their family and a general desire for institutions to offer support for flexible work scheduling.14 The current study extends these insights by revealing ways in which an intervention addressing the interrelated challenges of time and timing can, especially for women, provide support.

Our rich qualitative accounts regarding work–life integration and gender disparities in time-related challenges also complement previous large-scale survey studies, which suggest an association between gender differences in career outcomes and time spent on caregiving and domestic responsibilities. In a 1995 survey of academic faculty at U.S. medical schools, women with children published less and perceived their career progress as slower compared with their male counterparts with children.5 They also spent more weekday hours caring for children, were less able to work on weekends because of such responsibilities, and were more likely to be burdened by after-hours meetings, limited family leave policies, and lack of part-time tenure-track options.5 A more recent survey demonstrated substantial gender differences in time spent on work- and home-related activities among Generation X physician–scientists with children. Compared with their male counterparts, women spent over 8 hours more per week on parenting or domestic activities and were more likely to take time off work to attend to disruptions in childcare.15 That study further revealed that time spent on domestic labor competes with research time, suggesting that this conflict may contribute to gender disparities in success and career advancement.

Given these findings, several institutions have developed programs that provide practical support to new generations of physician–scientists as these early-career academics manage the important demands of both work and home. Stanford Medicine’s Academic Biomedical Career Customization pilot29,30 reimbursed teaching, service, and clinical activities that usually go unacknowledged: Earned credits could be redeemed for administrative and research assistance at work or for domestic services at home (e.g., housecleaning, laundry, or meal delivery). Several other institutions have reported positive results from providing funding support to early-career physician–scientists facing competing role obligations at work and at home. To illustrate, a retrospective evaluation of the Claflin Distinguished Scholar program at Massachusetts General Hospital,31 which specifically supports female investigators with child-rearing demands, demonstrated compelling returns on investment. Collectively, 31 recipients of this 2-year award realized a remarkable $51 million in direct funding for projects on which they were the principal investigators. Other articles have reported the positive influence of small programs—all inspired by this model—at the University of Pittsburgh and University of Massachusetts.32

Our study builds on this prior work by providing a formal, prospectively designed analysis of the effects of a similar program in a multicenter setting. Our findings reveal how such a program can be instrumental in allowing individual faculty members to reclaim and repurpose time resources, facilitating choice and control over how they spend their valuable time by supporting the outsourcing of time-consuming delegable tasks. Particularly compelling are physician–scientist participants’ vivid descriptions of how such support has been crucial to maintaining their career progress, enhancing their research productivity, and ensuring flexibility in their work–life integration, especially during critical time points along their career trajectory.

Given that a key mechanism by which funding programs can ameliorate the time-related challenges faced by physician–researchers is by allowing awardees to “buy out” their own time from clinical duties, we are concerned that some respondents perceived that specified effort allocations do not always match actual practice. Further research is warranted to evaluate whether clinical expectations for productivity may exceed the allocated percentage of work effort and encroach on physician–scientists’ ability to complete funded research and develop new grant proposals. If effort reporting is indeed vulnerable to inaccuracy, then institutions and funders should consider ways to promote greater concordance between formal expectations and actual practice, including increased monitoring, auditing, and provision of confidential systems for reporting when clinical demands cause actual time allocations to deviate from those that are expected and required.

Further research is also warranted to examine how intersectionality between gender and other social identities might complicate the challenges faced by awardees who are first-generation academics and/or who identify as minorities traditionally underrepresented in medicine. Comments about the compounded effects of certain demographic factors were particularly telling, given that the interview guide was not designed to evaluate or probe the complex subject of intersectionality. Although the first year of the program included too few awardees from groups underrepresented in medicine to allow for specific subgroup analyses, as data from additional years of the program accumulate, we will soon reach a sufficient population size to allow such a targeted investigation.

One strength of this study is that the participants represented settings that are diverse in many ways: institution size, NIH funding, overall faculty and leadership demographics, culture, and geographic location. Additional strengths are our rich dataset of narrative comments and our robust analytic approach. Triangulation among the analysts who independently coded and iteratively analyzed the data ensured that findings emerged through consensus.33 The analysts represented diverse professional and personal backgrounds, which further served to mitigate bias and increase validity.33 The trade-off, as in any qualitative study that involves extensive review of narrative transcripts, is that the increased depth of insights afforded by this approach requires some degree of sacrifice in terms of sample size; however, data collection and analysis continued until we reached thematic saturation and had gathered enough data to support well-developed, emergent themes.33,34 Another limitation is that a representative of each of the 10 medical schools participating in the FRCS invited their award recipients to participate in the interview study on behalf of the University of Michigan research team, and this direct contact may have affected the respondents’ comments during the interview if they feared that officials from their institutions, specifically those providing them with support, might learn of their responses. However, the medical school representatives were involved only in sending the invitation letter to their award recipients, and respondents were instructed in the letter to contact the University of Michigan research team directly if they were willing to participate in an interview. Moreover, the letter ensured confidentiality and explained that individual names would not be associated with any interview comments and that transcripts would be deidentified. Another limitation is our focus on recipients of the FRCS award, which was specifically targeted toward early-career physician–scientists working on clinical research projects while facing demands of caregiving. The results, therefore, may not be generalizable to those who did not apply or were not eligible to receive the funding. Nevertheless, a solid body of evidence suggests that issues relating to work-time flexibility, work–life integration, and gender inequality are fast becoming relevant to new generations of physician–scientists,10–12 others who are embarking upon faculty careers more generally,35 and the contemporary U.S. workforce at large.36 We believe that the insights gained from this select population have broad relevance and face validity.

This study provides a rich, nuanced understanding of the need for interventions that target what appears to be the central challenge for all physician–scientists: having too few hours in the day. This challenge is especially relevant for those early in their academic careers who are simultaneously building families—and for women in particular. By providing resources that can alleviate time-related challenges and mitigate timing conflicts, initiatives such as the FRCS have the potential to transform the working environment to maximize the retention of promising early-career faculty and promote equity in academic medicine.

Acknowledgments:

The authors wish to thank the recipients of the Fund to Retain Clinical Scientists award who took the time to participate in this study.

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