Abstract
Background: Underrepresented voices and perspectives are missing from academic and clinical health sciences. We aimed to define the unique opportunities and challenges of pediatric clinician–scientists related to equity, diversity and inclusion; and to identify key components of training needed to support people from equity-seeking groups as emerging and early-career pediatric clinician–scientists to generate diverse health research leaders in knowledge generation, implementation and translation.
Methods: Using a qualitative descriptive approach, we examined the experiences of clinician stakeholders. Semistructured interviews were conducted with pediatric clinician–scientist stakeholders. Thematic analysis was performed.
Results: We interviewed a total of 39 individuals. Our analysis resulted in 4 interrelated themes: the pervasiveness and invisibility of sexism; the invisibility and visibility of racism; proposed individual-level solutions to the sexism and racism; and proposed institutional and system-level changes to address the porous and leaky pipeline. These themes acknowledged that, ultimately, system change is required for addressing equity, diversity and inclusion in clinical and academic training environments.
Interpretation: These findings highlight the importance of addressing systemic biases that limit the inclusion of women and racialized individuals in pediatric clinician–scientist careers. Further research is needed to explore the problem of exclusion, which will, in turn, inform education of pediatric clinician–scientists and inform better ways to promote equity, diversity and inclusivity; these steps are needed to foster systemic change in the cultures that perpetuate exclusivity in both academic and clinical communities.
Diversifying the clinician–scientist workforce is a critical step toward improving care for underserved populations and reducing existing disparities in a variety of health outcomes.1 The training in both health care and research enables clinician–scientists to be specialists in both biomedical research and translational bench-to-bedside medicine.2 Clinician–scientist training is nonlinear and cross-disciplinary in manner. Clinician–scientists are essential members of scientific teams addressing grand challenges in health care and bench-to-bedside medicine.3
Women and racialized individuals are underrepresented among pediatric clinician–scientists.4,5 The underrepresentation of women and racialized individuals in pediatric clinician–scientist roles may be due to notable biases against women and racially diverse individuals despite their having credentials comparable to those of their white male counterparts.6,7 Research demonstrates substantial challenges extending beyond the early career phase, including that women of colour are the least likely to secure research funding;8,9 that biases affect publishing and the grant evaluation processes;10 that women and racialized individuals entering the faculty rank are poorly compensated compared with males;11 and that mentorship and role models may be harder for women to secure than their male counterparts.12–14
Our recent scoping review found that research exploring the training and career paths of pediatric clinician–scientists from equity-seeking groups does not currently exist.15 The individualand system-level factors that will enhance equity, diversity and inclusion (EDI) among pediatric clinician– scientists are urgently needed to inform the evaluation frameworks and curricular content for pediatric clinician–scientist training programs.4,16 A lack of understanding of individual and systemic barriers to diversity is a critical gap in published literature and further perpetuates the inequity of women and racialized individuals. It is vital to improve knowledge regarding the factors limiting EDI among pediatric clinician–scientists to improve health outcomes for diverse populations. Race and gender concordance between pediatric clinician–scientists and patients has the potential to improve communication and trust, with higher rates of patients accessing preventive care and clinician–scientists who are more likely to work in communities of need, thus making their inclusion in public health important.17–21
Overall, racialized university professors increased from 17% in 2006 to 21% in 2016. Growth in the proportion of Black university professors increased from 1.8% to 2.0% during this same time frame. Women are becoming better represented among university professors, albeit more so in lower ranks, with women making up 48.5% of assistant professors and 27% of full professors. University professors who are racialized, Indigenous and women are less likely to have full-time positions. Racialized women are the most underrepresented among full-time employees. The wage gap is deepest for racialized women professors, who are earning an average of 68 cents on every dollar earned by their white male counterparts.22
The impetus for the current study was the innovation and reconfiguration of the Canadian Child Health Clinician Scientist Program (CCHCSP); identifying current gaps and strengths within the program was deemed a priority for this process. Based on the findings of this main study, there seemed to be a huge gap around EDI for women and ethnic minorities. The research team felt there was a need to write a separate paper focusing on these aspects.
The objective of this study was to explicate the barriers to and facilitators of EDI by exploring the perspectives of a variety of pediatric clinician–scientist stakeholders in child and mental health. The specific aims were to define the unique opportunities and challenges of pediatric clinician–scientists related to EDI, and identify key components of pediatric clinician–scientist training needs to support women and ethnic minorities as emerging and early career pediatric clinician–scientists to generate diverse health research leaders in knowledge generation, implementation and translation.
Methods
Employing a qualitative descriptive approach,23,24 we analyzed our data using a thematic analysis approach25–27 and followed the Consolidated Criteria for Reporting Qualitative Research.28 Guided by an interpretivist paradigm, the research team sought to explore clinician–scientists’ perspectives of the educational, institutional and relational factors that influence their experiences as clinician–scientists to pursue and remain in this field.29
Participant recruitment
We used purposive and snowball sampling procedures to recruit key pediatric clinician–scientist stakeholders, including early-career trainees, decision-makers, funders, leaders and department chairs in university settings and the health care system. Recruitment material was disseminated via email through pediatric clinician–scientist training programs in Canada, the United States and the Netherlands. We included countries with pediatric clinician–scientist programs “identical” to the CCHCSP to make sure the identified issues were not only related to Canada but universal. Although the distribution of interviews was heavily skewed to Canadian participants (as the main aim was to understand the Canadian landscape), the US and Dutch participants (who are familiar with the CCHCSP) were used to identify global issues and differentiate these potential local Canadian issues. A sampling frame was created to ensure maximum variation in our sample and to recruit participants from different geographical regions in Canada, and to recruit trainees and participants with career trajectories from early career to senior leadership and from diverse disciplines and settings.
Inclusion criteria
Individuals were invited to participate if they met the following inclusion criteria: they identified as trainee, early-career, midcareer or senior child health clinician–scientists, or were in administrative and leadership positions, supporting the training and retention of clinician scientists. We also included decisionmakers in health care and clinician–scientist training programs in Canada and internationally (US and the Netherlands).
Exclusion criteria
We excluded clinician–scientists working outside of child health or primarily in the adult population.
Data collection
A semistructured interview guide (Appendix 1, available at www.cmajopen.ca/content/10/4/E911/suppl/DC1) was established with input from pediatric clinician–scientist content experts and included open-ended questions about opportunities and challenges in training and in pursuing and sustaining a clinician–scientist role in different academic settings and contexts. Between July and December 2020, we, G.D., K.S.B. and L.P., all white female PhD-prepared researchers with experience in interviewing participants and qualitative analysis, and all trained clinicians (social work, nursing and physical therapy, respectively), individually conducted 45-minute to 1-hour interviews via Zoom, which were recorded and transcribed. Interviews were analyzed as they were conducted, which then informed subsequent interviews until theoretical saturation (i.e., no additional data were being found) occurred.
Analysis
Thematic analysis is a qualitative method used to identify, describe and interpret the meaning and importance of patterns in data26 and uses 6 phases: familiarization, initial coding, theme development, theme refinement, defining and naming themes, and writing up the themes with a preliminary report.27 After familiarization, coding and theme development, the core research team (L.P., G.D. and K.S.B.) met to share their preliminary impressions and observations of initial patterns across and within interviews. The research team used memoing and regular meetings to discuss the codes and, through consensus, agreed on the final themes. There were no conflicts or disagreements over the codes and themes established. The themes were further refined and named while simultaneously being written up with supportive quotations from the participant interviews. We followed the step-by-step approach for conducting a trustworthy thematic analysis outlined by Nowell and colleagues,30 including memoing decisions about the coding process and the process for establishing themes.
Ethics approval
Research ethics boards at the University of Calgary and University of Alberta approved this study.
Results
We interviewed 39 individuals, including 26 women (66.7%) and 9 (23.1%) racialized participants (Table 1). All 9 participants who identified as racialized met our inclusion criteria for being child health clinician–scientists.
This thematic analysis resulted in 4 interrelated themes: the pervasiveness and invisibility of sexism; the invisibility and visibility of racism; proposed individual-level solutions to the sexism and racism; and proposed institutional and system-level changes to address the porous and leaky pipeline (Table 2).
The pervasiveness and invisibility of sexism
Regardless of gender, all participants commented on the challenges that most female pediatric clinician–scientists experience in their doctoral and postdoctoral training and while obtaining and securing academic and pediatric clinician–scientist positions. The participants in this study viewed and experienced sexism as prevailing because of tensions between their public and private lives, including family responsibilities.
Work–life balance
Numerous examples of sexism were related to pregnancy, scant information on parental leave policies and limited access to pediatric clinician–scientists to discuss the optimal timing of starting a family. Most female participants were reluctant to share experiences of sexism with other pediatric clinician– scientists, career and research mentors, and senior leaders within their organizations and training institutions because of fear of reprisals or their concerns being dismissed. Participants noted that few, if any, female pediatric clinician– scientists talked openly about their children or family life with academic colleagues, contributing to the concealment of wanting to have a child. Some participants felt that gender inequities were trivialized by men and women alike, with jokes about parenting and efforts to achieve work–life balance. As one participant poignantly said, “joking about it doesn’t make it okay, or at least it doesn’t for me. And I find a lot of our current research investigators still do that where they joke about not spending enough time with their kids” (P2). Perhaps the most insidious problem for women is the perceived expectation that they publish, secure grants and maintain their clinical duties all while caring for their children.
Participants shared “constant tensions” between biological and psychological drives to care for children and meet the demands of a career as a pediatric clinician–scientist. Some of our participants shared that, out of necessity, at various stages in their training and careers they could not take maternity leave. Some women gave up part of their work, slowed down their training or declined opportunities for career advancements to care for their children. They struggled to find ways to carve out time in their career, experiencing great tension between this need and their academic goals. Although male and female participants disclosed struggling to manage clinical and research responsibilities and family life, the burden of child care primarily fell on women in this sample of participants. Participants described the considerable clinical and research demands resulting in long days, and evening and weekend shifts, pressuring women to make difficult choices about what aspects of their personal life or clinical responsibilities need to be curtailed.
Compromises to career and family
Several interviewees described the compromises between their career and family life, acknowledging this may have reduced their output of publications and grants, and most were accepting of the choices made. Some participants were unable to travel during the latter part of their pregnancy and when their children were very young. In addition to being penalized for not attending a professional conference, interviewees noted decreased numbers of presentations and invited talks on their CV, and the loss of opportunities for networking, building collaborations and learning of emerging advancements in their fields.
The invisibility and visibility of racism
These interviews took place in 2020, during a time when issues of institutional racism had risen to the forefront of public consciousness in Canada.31 Participants noted that the focus on racism in the news was accelerating conversations in academia about implicit bias and underrepresentation of minority populations as participants in health research. Despite this elevated social consciousness, many participants shared that racism was insidious and difficult to name, even among academics identifying as racialized individuals. Some participants went further and commented that we needed to question our whole way of conducting science to make more room for alternative and a range of viewpoints.
Uneasiness challenging racism and bias
Participants noted that they experienced both overt and covert racism because of their skin colour, accents and the origin of their names. The participants in this study felt they were not being invited past the submission phase for trainee and academic positions because they were being screened out of the hiring process based on the origin of their name and their international training background. Another example of racism described by participants was experiencing microaggressions, such as being seen and treated differently by patients, and overt aggression, such as being spat on by a patient who refused to be treated by them. Participants perceived that some colleagues prioritized comfort and safety over the uneasiness, awkwardness and conflict that comes with challenging racism and implicit biases. Several participants commented that, because of this discomfort, they felt they did not have a voice or a safe space in which to discuss racial issues. Other participants shared that they often found it challenging to navigate difficult discussions about racism with their colleagues, especially those in leadership positions. Even in interactions with their peers, many reported being afraid to confront racism during their training seminars out of concern about being ostracized.
Questioned credibility
Some expressed concerns that their colleagues, mentors and even patients questioned their credibility because they were not white. The fear of lacking credibility with colleagues and patients was magnified for participants for whom English was a second language. The participants highlighted 2 competing ideas in their training and academic careers: the importance of intersectionality and compounded oppression; and heterogeneous experiences of oppression and, for others, privilege. Many of the participants identified barriers while simultaneously recognizing privilege in other aspects of their lives. One participant shared that women who are also visible minorities are confronted with numerous systemic barriers and a profound sense of isolation moving through the education and professional pipeline. This participant described that her female (and male) colleagues could relate to the experiences of sexism. However, few could understand what it might be like to simultaneously experience sexism and racism from both colleagues and patients. She described how, throughout her career, she received negative messages and shock from clients and students alike for being a Black, female scientist, who was a principal investigator on tricouncil grants and in a senior administrative position. Another female participant who was East Asian described experiencing racist and sexist comments from patients who refused to receive care from her for being a visible minority and a woman. Finally, 3 other female participants who identified as either Asian or Spanish described experiencing discrimination not only for their gender but also for their skin colour and having a strong accent. They were less likely to be called on to speak in class, and their examples of working with underrepresented groups in their communities received less attention and interest from their professors, mentors and supervisors. Participants who were people of colour and female further described incidents where they were erroneously identified as individuals holding service-level jobs within their institutions, or at national or international meetings rather than clinicians and scientists.
Proposed individual-level solutions to the pervasive problems of sexism and racism
Identifying diverse mentors with shared experiences Identifying mentors was particularly challenging for women, individuals identifying as racialized individuals and newcomers to Canada. Pediatric clinician–scientists from underrepresented groups commented that they had trouble relating with senior faculty who could not identify with their experiences of sexism and/or racism.
Participants elaborated on the need for a more diverse group of mentors with a greater breadth of lived experience as a woman or from a visible minority. Some participants commented on how they had been motivated by earlier challenges they had experienced with finding mentors to try to become better role models and mentors to junior colleagues and trainees. For example, women who experienced sexism early in their careers made a conscious decision to become strong and positive mentors to early-career researchers.
Proposed institutional and system-level solutions to the pervasive problems of sexism, racism and the leaky pipeline
Participants noted the need for institutional and system-level changes, including the need to create courses led by senior female and racialized scientists aimed at discussing pregnancy and parenting during doctoral, postdoctoral and pediatric clinician–scientist positions.
Individual efforts to create brave spaces and meaningful conversations
Many of the participants argued for the creation of brave spaces for pediatric clinician–scientists and trainees to discuss EDI issues. The development of these brave spaces in academic and clinical settings is a way to promote authentic and deliberate dialogues among clinician– scientists about their experiences of racism, sexism and other forms of oppression. Such brave dialogues must occur regardless of whether conversations elicit discomfort, strong emotions and fierce debates with those who hold power and privilege.32–34 Several female scientists valued the opportunity to discuss maternity leaves, pregnancy and parenting. Many argued that transparent discussions about mothering will help bring to the forefront that it is feasible to start a family and choose a pediatric clinician–scientist career path. Some participants suggested that mentors invite trainees and early-career researchers to discuss the pros and cons of when to have children if they were contemplating this decision.
Other interviewees emphasized the need for safe spaces to discuss issues related to race and ethnicity. One participant commented that the discomfort created by uncomfortable conversations about race was critical and potentially pivotal in facilitating change. Other participants similarly emphasized the need for brave spaces to engage in discussions about implicit racial biases. One participant shared that she created a safe space for her trainees to talk about their daily challenges and experiences with discrimination that they and their patients experience. She and other participants noted the need for everyone, including senior leadership, to demonstrate their willingness to engage in conversations about racism and sexism to make it easier and safer for students to openly discuss these issues. A supervisor of one participant took interest in the cultural background of members of their laboratory and demonstrated cultural sensitivity, such as identifying a space where Muslim laboratory members could perform daily prayers. Another participant created a journal club that explored issues regarding equity and diversity. Additionally, participants argued for uncomfortable discussions with those who may be in positions where they have directly and indirectly benefited from power imbalances in our health and academic systems. Participants demonstrated efforts to challenge racism and sexism by creating opportunities to disrupt narratives and practices that reinforce and conceal inequities and discrimination.
The porous and leaky pipeline
Many prospective pediatric clinician–scientists reported they struggled to launch their career given many structural barriers in postsecondary education and earlier in their career. This was particularly true of racialized individuals and women, who often face disparities at every stage of their academic and professional training. Explicit, implicit and overt biases lead to racialized individuals and women being less likely to be invited for interviews, to be offered positions, to find a mentor or to advance in their career. Some participants pointed to critical career stages in which the “pipeline” to a pediatric clinician–scientist career is particularly porous. For example, many promising candidates do not even make it to the stage of writing their application for entry into specialized pediatric clinician–scientist programs for a variety of reasons. Some pointed to women starting their family as a frequent “drop-off” from graduate school. Others noted that at each stage, nonwhite applicants may fail to advance for a range of reasons. For example, implicit bias prevents them from making critical connections with senior faculty or mentors who could provide references. Some elaborated on how the diversity within academia is considerably less than the diversity in the general population. Others emphasized the importance of not just recruiting more scientists into the pipeline but ensuring continued support at all stages of the pipeline.
The need for institutional change
Many participants offered suggestions for institutional changes to address the porous and leaky pipeline that is fueled by sexism and racism. Others commented on the need for targeted recruitment to academic positions to rectify EDI issues. Some focused on changes to pediatric clinician–scientist training programs at the institutional level, as well as supporting individuals emotionally (fostering feelings of trust and being valued) and instrumentally (spending time with someone and providing them with resources) during their training. Participants emphasized the importance of providing education about why differential treatment might be necessary for those receiving training from underrepresented groups. In fact, individuals who were in leadership positions noted that underrepresented pediatric clinician–scientists might need additional support because they have been historically disadvantaged.
Training programs could work with graduate and residency programs to nurture future pediatric clinician–scientists and to address EDI issues. Concrete suggestions included incentives for department chairs to select residents from minority groups and alumni mentorship programs. Some participants focused even further “upstream” on undergraduate or professional programs before research training begins. One concrete suggestion for addressing diversity issues to retain pediatric clinician–scientists included targeted funding opportunities. From individualto systemand structural-level changes, participants identified ways to recruit equity-seeking individuals pursuing a career as a pediatric clinician–scientist and supporting those in such positions to thrive and not just barely survive.
Interpretation
Findings from this study highlighted various individualand system-level factors that impede and facilitate the training, career and academic development of pediatric clinician– scientists, especially those from equity-seeking groups.
Clinician–scientists are considered an “endangered species” because of inadequate resources, training and employment opportunities.35 The pipeline for pediatric clinician–scientists, including graduate students, is riddled with substantial biases against women and underrepresented minorities despite their having credentials comparable to those of their white male counterparts.36 These groups continue to face challenges as they proceed in their academic career with poorer funding and limited prospects for publishing.37–39
Our findings suggest that female academics often experience overt and covert sexism around family planning and caring for children that profoundly affects their career development and identity as pediatric clinician–scientists. This is consistent with previous research that describes women’s work in the private sphere as invisible and the inequities and structural barriers embedded within academic medicine and the pediatric clinician–scientist field as pervasive.9,13,14,40,41 Caring responsibilities remain highly gendered, regardless of the number of caregivers in the home,12 and women are expected to maintain the responsibility for household chores and to be the primary caregiver.42
Consistent with our findings, graduate students, trainees, academics and clinicians of ethnic minorities face racism, discrimination and ongoing racial microaggressions within academic departments at every stage of the path during their training and practice.43–45 Understandably, high levels of negative race-related experiences lead to increased emotional distress and reduced sense of belonging for ethnic minorities,46 often resulting in poor well-being and performance, lower academic engagement and reduced likelihood of program completion.43 The results of our research are congruent with research about clinician–scientists in other fields, such as radiation36 and kidney disease,47 that show that there are many personal and systemic barriers that hinder underrepresented minorities from pursuing the role of clinician/physician–scientist.
Women and racialized individuals experience difficulties publishing early in their career, a lack of mentorship from diverse role models and reduced access to social networking venues. Similar to the importance placed on individualor system-level mentorship strategies found in this study, other researchers have advocated for structured mentorship programs for trainees that boost networking and collaborations with more experienced clinician–scientists.48,49
The issue of a thin and porous pipeline, specifically the recruitment and retention of women and racialized individuals to pediatric clinician–scientist positions, requires the availability of women and ethnic minorities to be mentored and hired into these positions. Small increases in the representation of previously excluded groups in undergraduate and graduate programs may contribute to improved program recruitment and students’ tenacity.50 Although improved program recruitment and summer programs aimed at providing research experiences to students from a variety of backgrounds are important, they are not a substitute for addressing systemic institutional barriers and for creating a more inclusive academic culture. Changing academic cultures requires the examination of discriminatory recruitment, hiring practices and research evaluations as well as addressing the culture that influences the development of social identity, career choice and academic persistence. Longstanding institutional structures, practices and patterns of discrimination perpetuate inequalities and discrimination that limit opportunities for marginalized individuals and contribute to gaps in employment and wages. One way to better understand the problem and measure progress would be for postsecondary institutions to improve reporting on employment and pay equity as well as data on successful and unsuccessful applicants, retention, tenure and promotions. These data will assist in measuring change and determining whether institutions are living up to their principles of EDI policies and practices. Potential solutions for gender inequities and women’s departure from academia include recruiting diverse applicants and training search committees; mentoring, networking and professional development through women faculty networks; and improving the academic climate and environment.
Mentorship with someone of a shared diversity may be the most beneficial in early career stages, though it is also useful to have diverse mentors over the stretch of an individual’s career. We recommend future research examining the unique challenges of gender minorities in pursuing and securing pediatric clinician–scientist positions. Interventions aimed at creating a climate for change rather than aiming only at changing individual attitudes or values are imperative. Research into inclusivity and diversity of programs that capitalize on people’s need for autonomy, that increase contact between diverse groups, and that include all members of an organization rather than only those who are a part of the intervention group is warranted.
We suggest that future studies exploring EDI in underrepresented groups within the clinician–scientist community expand on the inclusion criteria to include any clinician–scientist. This may allow for increased diversity of the sample and might improve data saturation of underrepresented groups such as LGBTQ2S+ people, ethnic minorities and women.
Limitations
This study had limitations. First, the findings are limited to the experiences and perspectives of a group of primarily Canadian pediatric clinician–scientists, with fewer participants being recruited from eastern Canada. Second, given that we focused on clinician–scientists in pediatric health, the findings may not be transferable to all clinician–scientists. Finally, we did not purposefully recruit gender minorities.
Conclusion
Findings from this study highlighted various individualand system-level factors that impede and facilitate the training, career and academic development of pediatric clinician–scientists, especially those from equity-seeking groups. These findings strongly point to the importance of addressing systemic biases that limit the inclusion of women and ethnic minorities in pediatric clinician–scientist careers.
Footnotes
Competing interests: None declared.
This article has been peer reviewed.
Contributors: All authors provided substantial contributions to the conception and design of the study. The initial draft of the manuscript was done by Gina Dimitropoulos and Katherine Bright, and all authors contributed to revising it critically for important intellectual content. All authors provided final approval of the version to be published. All authors agreed to be accountable for ensuring the questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. Gina Dimitropoulos is responsible for the overall content as the guarantor.
Funding: This research did not receive financial support.
Data sharing: These data are not available for sharing. When participants consented to participating in this study, they did not consent to access to transcripts or data beyond the research team. Many complete qualitative transcripts may be identifiable. Readers are welcome to contact the corresponding author for further clarification.
Supplemental information: For reviewer comments and the original submission of this manuscript, please see www.cmajopen.ca/content/10/4/E911/suppl/DC1.
This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY-NC-ND 4.0) licence, which permits use, distribution and reproduction in any medium, provided that the original publication is properly cited, the use is noncommercial (i.e., research or educational use), and no modifications or adaptations are made. See: https://creativecommons.org/licenses/by-nc-nd/4.0/
References
- © 2022 CMA Impact Inc. or its licensors