Qualitative Exploration of the "Guilt Gap" Among Physician-Faculty with Caregiving Responsibilities.

Introduction: Differences in time commitments and resources contribute to the difficulties of work-life integration for many physician-scientists, particularly for women with family caregiving responsibilities. Understanding the challenges faced by this population is critical for the retention of these critical members of the workforce. Methods: We conducted semi-structured telephone interviews with recipients of the 2017 Doris Duke Charitable Foundation's Fund to Retain Clinical Scientists (FRCS) and reviewed application narratives from the 2020 award recipients. Award recipients were asked about their caregiving responsibilities and careers, particularly as they related to the impact of the FRCS award and the aftereffects of the COVID-19 pandemic. Analysts then iteratively revised the coding scheme and interpreted the data using qualitative thematic analysis. Results: Of the 14 interviewees and 19 narrative contributors, 25 (76%) were women. The main qualitative themes that emerged were as follows: (1) women experience unrealistically high caregiving burdens, (2) women are overburdened by disadvantageous and undervalued expectations at work, (3) work-life expectations increased during the COVID-19 pandemic, and (4) unrealistic work-life expectations led to guilt and burnout. Conclusions: These findings provide a rich understanding of the factors contributing to guilt and burnout among physician-scientists, particularly women, and how work duties that increase physician obligations exacerbated these challenges. Understanding these experiences is critical to supporting and retaining a diverse workforce in academic medicine.

Leadership Experiences and Perceptions of Mid-Career to Senior Clinician-Scientists: A Qualitative Exploration.

PURPOSE: This study aimed to elucidate the experiences and perceptions of mid-career to senior clinician-scientists in academic medicine regarding pursuing, attaining, or rejecting leadership roles as well as their conceptualization of the influence of leadership in their broader career trajectories. METHOD: The authors conducted a qualitative analysis of in-depth, semistructured interviews conducted in 2022 with a diverse sample of clinician-scientists who received new National Institutes of Health K08 or K23 Career Development Awards between 2006 and 2009. A total of 859 of the 915 survey respondents (94%) were eligible to be recruited for the qualitative study. Qualitative analysis was informed by thematic analysis and used a social constructionist approach to understanding participants' conceptualizations of their experiences. Interview transcripts were coded using an iterative, inductive coding process. Themes were generated by reviewing coded data and identifying common patterns in participant narratives, affording particular attention to participants' discussion of the effect of race and/or gender on their leadership experiences. RESULTS: Sixty clinician-scientists participated in individual interviews. Five themes were generated surrounding participants' conceptualizations of their leadership experiences. Themes were (1) feeling unprepared for leadership roles, (2) reluctance and lack of intention in attaining leadership positions, (3) influence of networks on leadership access and decision-making, (4) impact-related benefits and downsides of leadership, and (5) confining ideas of who leaders are. CONCLUSIONS: The study highlighted the need for formal leadership training in academic medicine and the importance of mentorship and sponsorship in attaining and succeeding in leadership positions. Individuals from communities underrepresented in leadership positions faced additional challenges internalizing a leadership identity. Efforts to encourage current leaders to engage in intentional succession planning and development of faculty towards leadership roles, including expansion of institutional leadership development programs, are needed to promote equitable distribution of leadership opportunities.

Professional Experiences and Career Trajectories of Mid- to Senior-Career Women Clinician-Scientists: A Qualitative Study.

Importance: Despite increasing evidence and recognition of persistent gender disparities in academic medicine, qualitative data detailing the association of gender-based experiences with career progression remain sparse, particularly at the mid- to senior-career stage. Objective: To investigate the role gender has played in everyday professional experiences of mid- to senior-career women clinician-scientists and their perceptions of gender-related barriers experienced across their careers. Design, Setting, and Participants: In this qualitative study, a total of 60 of 159 invited clinician-scientists who received National Institutes of Health K08 or K23 awards between 2006 and 2009 and responded to a survey in 2021 agreed to participate. Invitees were selected using random, purposive sampling to support sample heterogeneity. Semistructured in-depth interviews were conducted January to May 2022. For this study, interviews from 31 women were analyzed using the framework approach to thematic analysis. Data analyses were performed between August and October 2023. Main Outcomes and Measures: Descriptive themes of participant experiences of gender and gender-based barriers in academic medicine. Results: A total of 31 women clinician-scientists (8 identifying as Asian [25.8%], 14 identifying as White [45.2%], and 9 identifying as members of a minority group underrepresented in medicine [29.0%]; 14 aged 40-49 years [45.2%] and 14 aged 50-59 years [45.2%]) were included. Among them, 17 participants (54.8%) had children who required adult supervision or care, 7 participants (22.6%) had children who did not require supervision or care, and 6 participants (19.4%) did not have children. There were 4 dominant themes identified within participant experiences in academic medicine: the mental burden of gendered expectations at work and home, inequitable treatment of women in bureaucratic processes, subtle and less subtle professional exclusion of women, and value of communities built on shared identities, experiences, and solidarity. Conclusions and Relevance: This study found that women perceived the institution of academic medicine as a male-centric system misaligned with the needs of women, with associated feelings of exclusion, disillusionment, and loss of trust in their institutions. Findings suggest that the confluence of domestic obligations and unaccommodating institutional environments may make it difficult for women clinician-scientists to achieve established timelines of career progression and productivity; these findings may have long-term implications for the well-being and retention of women in academic medicine.

Strategies to Support Faculty Caregivers at U.S. Medical Schools.

PURPOSE: To describe the policies, processes, and programs at U.S. medical schools to support faculty caregivers before and in response to the COVID-19 pandemic. METHOD: In 2021, the Doris Duke Charitable Foundation and founding members of the COVID-19 Fund to Retain Clinical Scientists (FRCS) Collaborative launched and supported the COVID-19 FRCS program to recognize medical schools and their efforts to strengthen policies, processes, and programs supporting biomedical faculty with family caregiving responsibilities in the context of COVID-19-related impacts. The authors conducted a qualitative conceptual content analysis of the deidentified, open-ended responses submitted by institutions in their applications to the COVID-19 FRCS program and summarized the reported strategies using recurring patterns and common approaches. RESULTS: Fifty-four institutions applied to the COVID-19 FRCS program in 2021 and were included in this study. COVID-19-related impacts on biomedical faculty included stymied career progression and academic productivity, exacerbated career-caregiving time conflicts, adverse effects on family and personal well-being and mental health, increased financial hardships, and amplified faculty caregiver stigma. The described policies, processes, and programs to support faculty caregivers fell into 4 domains: support for dependent care, career and workplace flexibility, career development support, and institutional culture change to reduce stigma. COVID-19-related modifications spanned these domains with remote and flexible work manifesting as disruptive changes. Strategies to support women and underrepresented in medicine faculty, who bear a disproportionate burden of caregiving responsibilities, centered on career development support and institutional culture change. The projected durability of the enacted changes varied by institution and across strategies. CONCLUSIONS: The COVID-19 pandemic presents a disruptive opportunity to translate lessons learned into positive change to better support faculty caregivers, particularly women and underrepresented in medicine faculty. This study's findings provide a framework to guide sustainable change to support equity, diversity, and vitality in the academic biomedical workforce.

Insights from an Intervention to Support Early Career Faculty with Extraprofessional Caregiving Responsibilities.

Background: Insufficient support for balancing career and family responsibilities hinders retention of physician-scientists. Programs to improve retention of this important group of faculty are crucial. Understanding the experiences of program implementers is key to refining and improving program offerings. Methods: We conducted an interpretive, descriptive, and qualitative study as part of an ongoing evaluation of the Doris Duke Charitable Foundation's Fund to Retain Clinical Scientists (FRCS) awards. We conducted telephone interviews with 12 program directors representing all 10 US medical schools who received the Doris Duke funding in 2016. Results: Of the 12 participants, 10 were women (83.3%). Participating program directors perceived the FRCS award as capable of producing paradigmatic changes regarding how responsibilities at home and work in academic medicine are viewed and integrated by early-career faculty members. The main qualitative themes that captured directors' experiences implementing the program were as follows: (1) championing a new paradigm of support, (2) lessons learned while implementing the new paradigm, (3) results of the new paradigm, and (4) sustaining the paradigm. Conclusions: These findings may help to inform development of similar programs to retain and support the career progress of physician-scientists with extraprofessional caregiving responsibilities. The interviews illuminate ways in which the Doris Duke FRCS award has driven institutional culture change by normalizing discussion and prompted reassessment of extraprofessional challenges and how best to aid early-career faculty members in overcoming these challenges.

Financial Toxicity During Breast Cancer Treatment: A Qualitative Analysis to Inform Strategies for Mitigation.

PURPOSE: Financial toxicity from cancer treatment is a growing concern. Its impact on patients requires refining our understanding of this phenomenon. We sought to characterize patients' experiences of financial toxicity in the context of an established framework to identify knowledge gaps and strategies for mitigation. METHODS: Semistructured interviews with patients with breast cancer who received financial aid from a philanthropic organization during treatment were conducted from February to May 2020. Interviews were transcribed and coded until thematic saturation was reached, and findings were contextualized within an existing financial toxicity framework. RESULTS: Thirty-two patients were interviewed, of whom 58% were non-Hispanic White. The mean age was 46 years. Diagnoses ranged from ductal carcinoma in situ to metastatic breast cancer. Concordant with an established framework, we found that direct and indirect costs determined objective financial burden and subjective financial distress stemmed from psychosocial, behavioral, and material impact of diagnosis and treatment. We identified expectations as a novel theme affecting financial toxicity. We identified knowledge gaps in treatment expectations, provider conversations, identification of resources, and support-finding and offer strategies for mitigating financial toxicity on the basis of participant responses, such as leveraging support from decision aids and allied providers. CONCLUSION: This qualitative study confirms an existing framework for understanding financial toxicity and identifies treatment expectations as a novel theme affecting both objective financial burden and subjective financial distress. Four knowledge gaps are identified, and strategies for mitigating financial toxicity are offered. Mitigating patients' financial toxicity is an important unmet need in optimizing cancer treatment.

A qualitative study to evaluate physician attitudes regarding omission of surgery among exceptional responders to neoadjuvant systemic therapy for breast cancer (NRG-CC006).

PURPOSE: Accrual to clinical trials that challenge well-established treatment paradigms represents a unique challenge. Physician opinions on investigation of a novel approach to breast cancer treatment, in which patients with complete response to neoadjuvant chemotherapy are offered omission of lumpectomy, are unknown. NRG-CC006 sought to describe physician attitudes toward a novel approach to breast cancer treatment. METHODS: We recruited 18 participants in the fields of surgery, medical oncology, and radiation oncology to participate in the semi-structured telephone interviews. Main outcomes are qualitative themes associated with omission of surgery. RESULTS: Of 18 interview participants, specialty and gender were evenly represented across surgery, medical oncology, and radiation oncology. Qualitative themes included general attitudes toward treatment de-escalation, stakeholder considerations, and trial/protocol considerations. The vast majority of participants expressed interest in investigation of omission of surgery, with all participants endorsing need for further investigation into treatment de-escalation. Stakeholder considerations in opening such a trial emphasized need for multidisciplinary involvement and, particularly, the unique role of surgeons as gatekeepers in breast cancer treatment. Finally, participants endorsed a need for further foundational studies to develop ways to predict complete pathologic response to chemotherapy without surgical intervention. CONCLUSIONS: Physicians expressed interest in investigating a novel approach to breast cancer treatment that would omit surgery in complete responders to neoadjuvant chemotherapy. Multidisciplinary input, and specifically surgeon engagement, will be key to the success of future investigations. Ongoing work to develop approaches to predict pathologic complete response accurately is needed to achieve the promise of this idea. ClinTrials #: BR005: NCT03188393 June 13, 2017.