Predicting Engagement of Applicants in the Leadership Through Scholarship Fellowship: A Qualitative Analysis

Underrepresented in medicine (URiM) faculty continue to have low numbers compared to well-represented groups in academic medical centers across the United States.¹ URiM for this study is defined as those who come from American Indian or Alaska Native, Black or African American, Latino, Hispanic or of Spanish Origin, Native Hawaiian or Pacific Islander, Southeast Asian backgrounds, and women of any race. Despite diversity efforts through pipeline and pathway programs,² URiM faculty development programs,³ and strategies and science surrounding mitigation of the minority tax,^4,5 little change has occurred in URiM representation in most specialties over the last 20 years.^6-8 The Association of American Medical Colleges and multiple medical specialty organizations have stated that increasing URiM representation in academic medicine faculty and medical practice is a goal.^9-11 Also, increased representation from these groups is associated with increased health utilization, lower health care costs, and better health outcomes.^12-14

Family medicine has higher URiM representation in the academic and clinical environments than all other specialties, including in department leadership, such as department chairs.^15,16,17 Family medicine faces the same attrition problems from academic medicine as other specialties. Family medicine minoritized faculty are not exempt from the minority tax,^18,19 the extra, uncompensated responsibilities placed on minoritized faculty. Even minoritized students experience their version of the minority tax, with its potential impact on academic performance being a big concern.²⁰ The minority tax has been linked to attrition from academic medicine, and one of the solutions explored in the literature is URiM faculty development.^21,22 While faculty development is part of the solution, institutional change is also essential to mitigating this tax.⁵ The Society of Teachers of Family Medicine (STFM), along with authors (J.E.R., K.M.C., J.C.W., S.A.O.), developed the Leadership Through Scholarship Fellowship (LTSF), in part, to address the minority tax and help minoritized faculty navigate the complex academic environment and succeed and thrive in academic family medicine.³ LTSF is a year-long faculty development program focused on teaching writing skills to early-career minoritized faculty in family medicine.⁹ The fellows and faculty meet during biannual in-person workshops, monthly virtual meetings, and frequent mentoring sessions. From 2019 to 2024, STFM funded LTSF with a grant from the American Board of Family Medicine, which covered all expenses for fellows and faculty. Today, fellows are responsible for travel and a small tuition fee; however, STFM continues to heavily subsidize the program.

We continue to evolve and improve the fellowship, and part of these changes have included exploring what fellows value in their fellowship experience. LTSF fellows value (a) personalizing learning, (b) impacting career trajectories, (c) clarifying the writing process, and (d) creating a safe place in a faculty development program.²³ LTSF fellows also appreciate leadership development, collaborative scholarship, and mentoring. Fellows have identified a lack of time, support, and diminished opportunities for advancement as obstacles to scholarly achievement.⁹ Fellows also recognize the impact of committee work on their career progression, with timing, expectations, lack of voice, and consequences of not serving on committees impacting their faculty experience.²⁴ Since 2020, LTSF has served 67 fellows (average 12 per year) and is associated with more than 70 fellow and faculty publications.

Our objective was to identify what applicant characteristics are associated with higher scholarly output and engagement during the fellowship period. The existing literature indicates that URiM faculty experience scholarship delay²⁵ despite reporting higher motivation and ambition than their non-URiM peers. We hypothesized that the LTSF faculty could detect ambition and motivation in fellowship applications and that these may be associated with higher scholarly output and engagement during the fellowship period.²⁶ The fellowship directors (J.E.R., K.M.C., J.C.W., S.A.O.) and qualitative researchers (D.F.A., A.N.C.) worked together to address two questions: (1) Which fellows demonstrate high ambition and motivation for success? and (2) What factors in their application were associated with high ambition and motivation for success?

This study included 23 participants in the LTSF offered through STFM from 2021 to 2023. We included fellows who submitted a completed application and graduated from the fellowship during the study period. A completed application included a personal statement, curriculum vitae, and short answers to three open-ended application questions developed by founding LTSF faculty:

1. What are your top three career and scholarship goals in the next 3 to 5 years?

2. What are the resources and support mechanisms that you have in place to help you reach your goals?

3. What are the challenges that you are currently facing (or perceive facing in the future) while pursuing your goals?

Completed applications were requested from STFM and de-identified for analysis. This study was approved by the Institutional Review Board of the University of Texas Medical Branch at Galveston (protocol #23–0232).

Foong et al. have described five common characteristics for high achievers: goal setting, consistency, learning strategies, coping mechanisms, and self-evaluation.²⁷ To classify fellows’ level of scholarly output and engagement, fellowship faculty applied an assignment into one of two categories: hungry for success or very hungry for success (hungry vs very hungry) based on the Foong et al. model. We used the terms hungry and very hungry as representative terms for lower and higher scholarly output and engagement, respectively, based on this model. Further, faculty perceived a hunger for success, as demonstrated broadly among applicants to the LTSF. They determined hunger to be the most appropriate descriptive term, for example, using hungry versus very hungry categorization instead of low and high achievers. The categorization was conducted based on the faculty responses to three questions: (1) Was there increasing interest and level of engagement in writing throughout the fellowship? (2) How responsive was the fellow to emails and other communications? and (3) Has writing quality improved throughout the fellowship?.

Three LTSF faculty members (S.A.O., K.M.C., J.C.W.) evaluated fellows for interest and level of engagement, responsiveness, and writing quality, and used that data to assign hunger categories. Where disagreement existed, faculty discussed the issue until they reached a consensus. After the discussion, the LTSF faculty agreed on the assignments for each hunger category. Volunteering and leading author groups, initiating communication with fellowship faculty, and increasing scholarly output beyond the assignments of the fellowship qualified fellows for the very hungry category. Hungry fellows completed assignments with enthusiasm, were responsive to group texts and emails, and were active participants in writing groups.

A.N.C. and D.F.A. are public health trained and have experience in qualitative research. They analyzed the free responses from the open-ended questions on the fellows’ de-identified applications and personal statements. After separating qualitative documents by hunger designation, A.N.C. and D.F.A. thematically analyzed each personal statement and the three free responses using a constant-comparison approach.^28-31 A.N.C. and D.F.A. generated codes individually, reviewed them jointly, and created a consensus codebook. A.N.C. and D.F.A. reviewed and recoded according to the codebook, and reconciled discrepancies through consensus. A.N.C. and D.F.A. grouped codes into thematic categories and selected illustrative quotes, without the assistance of any qualitative analysis software.

Quantitative data collected included self-reported race/ethnicity, type of doctorate, academic rank, leadership position at the time of fellowship application, completion of another fellowship before application, number of publications, years at current academic rank, years since graduating from residency, and years at current academic institution. Descriptive statistics for the fellows’ quantitative data were computed, including percentages, medians, and interquartile ranges. Due to the small sample size, the authors did not conduct further statistical analysis.

Twenty-three fellows met the inclusion criteria, yielding 69 distinct responses to the open-ended questions listed earlier. The LTSF faculty classified 12 fellows as very hungry fellows (52.5%) and 11 as hungry fellows (47.8%). Most fellows self-identified as African American/Black (73.9%). MDs were the largest group in the study population (73.9%). More than half of the fellows reported a leadership role at the time of application (65.2%). Most fellows were at the assistant professor rank (60.9%) with a median of 1 (IQR: 0.3–2.1) year at current rank and 2.5 (IQR:1–5) years from graduating residency. Gender data were not available because they are not collected in the LTSF application (Table 1).

Very hungry fellows had more years at their current institution (1.5 years vs 1 year) and at their current rank (3.25 years vs 1 year) than hungry fellows. More very hungry fellows held leadership positions at the time of application to the fellowship compared to hungry fellows (75% vs 54.5%). We found no difference in median publication between the two groups. Still, very hungry fellows participated in fewer fellowships than their hungry peers (6 vs 9). Very hungry fellows surprisingly had fewer months since completing residency training (27 vs 36 months). Fewer very hungry fellows reported unknown rank than hungry fellows (2 vs 4).

The codebook is included as (Appendix 1). Table 2 lists the themes, subthemes, and illustrative quotes from very hungry fellows. Very hungry fellows had themes of advocacy, leadership, systemic issues, and self-starters. Under the advocacy theme, most very hungry fellows desired to give their patients, community, and physician colleagues a voice. We also found a significant focus on health equity and inclusivity.

Regarding leadership, current or future interest in becoming leaders was prevalent among very hungry fellows. Widespread change and improvements in leadership skill sets were subthemes. In the systemic issues theme, very hungry fellows identified systemic concerns within health care or their home institutions. The lack of diversity (ie, homogeneity) and the visible taxation of minoritized identities (ie, minority tax) were subthemes. In the self-starter theme, very hungry fellows spoke of creating opportunities for themselves, including taking the initiative to develop their own resources.

Hungry fellows reported having sound support systems. Avenues of support came from their community, such as committees, associations, and collaboratives (4 out of 11) or from faculty colleagues (5 out of 11): “My colleagues have published articles for a myriad of organizations and are open to assisting me.” Three hungry fellows reported having support systems specifically for research: “Our school of medicine’s research department is open to help brainstorm questions that could be investigated, and their team is willing to provide guidance on how to go about getting new projects off the ground.”

Table 3 presents themes and subthemes common to all fellows. Mentorship was a shared theme for all fellows. Various forms of mentorship were reported and captured in the subthemes of advisor, lacking or needing mentorship, mentee, and guidance. Fellows expressed a passion and desire to mentor others while also needing mentors. Some fellows had a current mentor or were part of a formal mentoring program and sought help and guidance as they struggled to navigate the world of academic medicine. Fellows starting their academic faculty careers were uncertain about the path ahead, but very hungry fellows sought focused guidance from the fellowship. All fellows expressed interest in scholarship, including grants and publications. Some fellows had specific, focused goals, while others had broader goals. Among the fellows, very hungry fellows had more focused goals than hungry fellows. Most fellows reported a lack of supported time (formerly called protected time) as a current challenge, which was more frequently reported by very hungry fellows. The demands of clinical care often prevented the production of scholarship, and fellows who had dedicated supported time struggled to have it honored.

This analysis revealed that very hungry (high output and engagement) fellows were further along in their careers and had some leadership experience. Very hungry fellows also had advocacy, leadership, self-starter, and systemic issues as common themes in their applications. These themes are consistent with the following characteristics of high achievers, as identified by Foong et al: goal setting, consistency, learning strategies, and self-evaluation.²⁷ Hungry fellows reported the theme of support systems in their applications. Themes common to all applications were mentorship, scholarship, and lack of supported time. These findings suggest that those who most benefit from the LTSF (very hungry) are more focused on their career needs and aspirations and are more aware of their surroundings and situation than their hungry peers.

STFM created LTSF for early-career faculty, and conventional wisdom suggests that the earlier the exposure to the skills, the better; but this was not the case with LTSF. There are times in everyone’s career when “you don’t know what you don’t know,”³² which explains why those further in their careers exhibited greater hunger for success in LTSF. In addition, faculty development is like other forms of development, with appropriate lessons and skills for each stage.³³ Finding the right time for these interventions is challenging. Still, our study has revealed some traits that could be useful to other faculty development programs as they select participants.

Our study had several limitations. First, it included only 2 years of fellows and completed applications. Because all fellowship applicants were hungry, the raters had difficultly distinguishing between very hungry and hungry fellows. In addition, when creating the rubric for the analysis, we used “hunger” rather than “achiever,” as defined in our reference article. This approach may have impacted how we viewed fellows and how we classified them as hungry versus very hungry. We could have taken a different approach to the analysis. Perhaps our paper would have been stronger if the qualitative researchers had received the anonymized applications as a single group and not classified as hungry or very hungry by our rubric. Moreover, we noted that the LTSF application could use additional questions on gender and geography to better define our cohorts. Lastly, applicants in a free, popular faculty development fellowship for minoritized faculty tend to be highly motivated and exceptionally interested in their career progression, which can skew the results.

In this study, classifying fellowship applicants into high- and low-engagement groups identified themes consistent with the characteristics of high achievers as defined by Foong et al’s model of self-regulated learning.²⁷ This pilot study revealed an opportunity for further research, including the development and validation of tools to support the evaluation of applicants to faculty development programs, ensuring effective selection processes that result in maximum alignment, impact, and engagement with the intended audience.