Perceptions of the Leadership Through Scholarship Fellowship Graduates: An Exploratory Qualitative Study of Leadership

Numerous medical schools and organizations have focused on increasing the number of faculty who identify as underrepresented in medicine (URiM) and on promoting their retention and advancement. ¹, ² For this study, URiM is defined as those who identify as Black or African American; Latinx, Hispanic, or Spanish Origin; American Indian/Alaska Native; Native Hawaiian/Other Pacific Islander; or Southeast Asian. Studies have reported that 7.1% of full-time medical faculty in the United States identify as URiM compared to 34.1% URiM in the general US population. ^{3, 4} Low representation of URiM faculty translates to low representation in academic leadership positions. ⁵

Faculty development programs with a multifaceted approach are needed to successfully increase the number of URiM academic medicine faculty holding leadership positions. Essential features of these programs include personalized learning, mentorship, understanding of one’s career trajectory, and creation of a safe space for URiM faculty. ^{2, 6} Producing scholarly work is a vital component of this approach to the professional advancement of academic family medicine faculty. For some URiM faculty, barriers to success in scholarly work are due to the minority tax—that is, uncompensated labor assigned to faculty members who identify as part of a minoritized group. ^7-9 This tax is evident in the following areas:

• Promotion. Minority faculty are promoted less often than their non-URiM peers;

• Clinical efforts. Minority faculty have more time assigned to clinical efforts;

• Diversity efforts. Minority faculty represent institutional diversity on multiple committees¹⁰ ;

• Mentorship. Fewer mentors are made available for this group;

• Isolation. Few share identity with this group; and

• Racism. Minority faculty experience racist actions against them.

Mitigating the minority tax for URiM faculty is the responsibility of institutional and system leaders. Individualized developmental and leadership training can help URiM faculty grow and thrive in academic medicine, especially when it is tailored to address areas unique to this faculty group. ⁶, ¹¹

Work to promote the advancement of scholarship and writing skills of URiM academic family medicine faculty has been pioneered through resources provided by the Society of Teachers of Family Medicine (STFM) Foundation ¹² and the American Board of Family Medicine. In 2019, we (K.M.C., J.E.R., and J.W.) received a foundation grant from STFM to create a minority faculty development curriculum to cultivate the writing skills of URiM academic family physicians; the curriculum was called the STFM Leadership Through Scholarship Fellowship (LTSF). ¹²

The yearlong LTSF fellowship offers training and mentorship for URiM minority faculty early in their career (5 years or less since completing residency or fellowship) with a focus on developing scholarly writing skills for academic advancement and leadership. ¹² Because leadership always has been an essential component of this fellowship, LTSF faculty survey fellows on their perceptions of leadership after each cohort year. Because URiM faculty are infrequently found in academic medicine leadership positions, ¹³ we explored how they view leadership. Specifically, we wanted to know the answer to the following question: How do early-career URiM faculty participating in a faculty development fellowship view leadership in academic medicine?

This qualitative study is included in an umbrella institutional review board (IRB) exemption for educational research through the University of Utah, IRB #00091384. The first two cohorts of family medicine scholars selected for the LTSF participated in the study. ¹² Details about the fellowship have been published previously. ⁶ The faculty mentors, in consultation with leaders from the Offices of Faculty Development, and Data Analysis and Strategy at the Brody School of Medicine in Greenville, North Carolina, developed the leadership survey questions. Others who reviewed and provided feedback on the survey included Amy Fulton, PhD, director of the New Leadership Academy at the University of Utah; and Elizabeth H. Naumburg, MD, associate dean for student advising and professor of family medicine at the University of Rochester.

The survey consisted of 13 questions, eight of which were open-ended (Table 1). We asked the participants questions directed at understanding leadership opportunities within each participant’s institution; plans for leadership, including factors that hinder or promote those plans; and the role of scholarship in creating leadership opportunities. Fellows anonymously completed surveys at the end of each fellowship year. Therefore, the qualitative researchers (J.L. and V.F.) could not link characteristics or other information to responses/quotations. All participants completed the LTSF, aspired for leadership roles, and may not have occupied a leadership position at the time of the survey.

We used a thematic analysis approach for the qualitative open-ended survey questions. Two experienced qualitative researchers (J.L. and V.F.) applied Braun and Clarke’s phases of thematic analysis to the data for emergent coding and analysis. ¹⁴ They independently read all responses and recorded initial codes for each question. The next phase involved the researcher’s discussion and review of codes to organize them by patterns of meaning, which emerged as themes and subthemes responding to the research objective.

To illustrate, participants were asked to respond to this prompt: “Describe your approach to transforming scholarship to create leadership opportunities in academic medicine.” The initial codes applied to the responses were collaboration, mentorship, motivation, strategic, time for scholarship, not having the right credentials, and lack of resources. Codes then were combined to create secondary codes or themes depending on the complexity of sentiments. For example, strategic, time for scholarship, not having the right credentials, and collaboration were combined into the theme collaborative scholarship. One of the fellowship faculty (J.R.) resolved disputes by discussing them with the qualitative researchers (J.L. and V.F.). Then exemplar quotes were selected based on how well they reflected the themes.

Nineteen fellows (100% of fellowship participants) completed the leadership survey. The analysis identified two major themes with five subthemes (Table 2).

Across responses, our findings made clear that participants were working toward occupying leadership positions. For example, among participants, career goals included becoming a program director or advancing in rank to associate professor. Another participant stated the desire to run the doctoring course, while another mentioned the goal of becoming senior vice president in the office of ambulatory care and population health. For our fellows, two distinct concepts emerged under the theme of leadership development to achieve the previously stated career goals: (a) collaborative scholarship, and (b) request for mentorship.

Subtheme 1. Collaborative Scholarship. When asked to describe their approach to transforming scholarship to create leadership opportunities, the importance of collaborative scholarship emerged. For many respondents, collaborative scholarship was a pathway to identify and enhance emerging leadership skills while uncovering new interests within safe relationships with others. Under this first subtheme, participants commented that scholarship is necessary for career advancement and suggested that a team can be more productive than an individual. For example, one participant stated that “collaborating with colleagues across institutions, based on shared areas of interest” and “leveraging scholarship as a transferable currency for promotion and advancement, while also using it as a tool to establish myself as an expert in my area” was necessary. Collaborative scholarship is also a way to develop leadership skills. Another participant stated, “I facilitate the participation of my students and mentees in scholarly work and encourage team building and collaboration.”

Subtheme 2. Request for Mentorship. Under the second subtheme, request for mentorship, participants articulated the need for ongoing career mentorship. Career mentorship was described as multifocused, including career trajectories. As one participant stated, “I would like to have more one-on-one sessions with the faculty to help me hone my vision for my career in academia and help to understand the different paths/opportunities that I should consider.” Participants also wanted guidance and encouragement for a mentorship relationship and mentorship toward skill development, such as research methods. Another participant stated, “The next step I want to take is doing some quantitative research, so helping me move more into the world of creating an actual study and gathering data to write up would be transformative to my career.”

Participants described multiple barriers related to leadership development and scholarship. Three subthemes emerged from the data analysis: (a) lack of time, (b) lack of support, and (c) diminished opportunities for advancement. Some participants noted that due to other responsibilities, focusing on scholarship was not a priority and was often done after work hours. Some participants found ways to engage in scholarship activities through membership in quality improvement committees or other responsibilities.

Subtheme 1. Lack of Time. Participants discussed having little time to complete scholarly work due to other career roles. Some delayed time for scholarship until late hours of the night or on weekends. Key quotes illustrated the lack of time. “Time. I need time to dedicate to my contributions to organizations to advance in them. But work is very demanding and limits that time.” Similarly, many participants felt that they had to carve out time for scholarship.

I try to carve out time for writing during my administrative time. This is difficult due to my other responsibilities and, ironically enough, being the point person for diversity and social determinants of health work. I try to turn the projects already being worked on into publications.

Subtheme 2. Lack of Support. Another area discussed by participants was the lack of support from colleagues and administration for leadership activities and scholarly work. Due to a lack of support for academic work, some participants delayed doing anything related to scholarship. Other participants noted that the lack of organizational support caused them to consider alternative employment. “Unfortunately, I feel I have gone as far as I can in my organization. I have been passed over for promotion opportunities. So, it’s time to seek advancement outside of the organization.”

Subtheme 3. Diminished Opportunities for Advancement. Several responses on this subtheme were related to the lack of opportunities for advancement as a leader through promotion or appointment. Most common was the sentiment that leadership positions were occupied, and vacancies in these positions were rare. For example, when asked about leadership plans, one participant stated, “I will be hindered in those plans by my current job position as the person is not going to retire anytime soon; it will help if I can move and continue to have mentors that believe in me.” Fellows noted that any succession planning was not mentioned and that they were not included in discussions on plans for their career advancement, “I sometimes worried that I could be perceived as too young for being in those leadership roles.”

In this STFM Leadership Through Scholarship Fellowship qualitative study, we identified several themes that reflect the attitudes and perceptions of URiM faculty about professional development and leadership. These findings suggest that early-career faculty struggle to progress and meet career goals due to lack of institutional infrastructure, support, and mentorship. Although the theme of clinical work was not elicited, clinical commitments are likely significant contributors to the lack of time and support for academic pursuits. As documented in the literature, these themes are consistent with gate blocking and the minority tax. ^{7, 15}

The need for collaborative scholarship, as identified by participants in the study, is a new addition to the literature. For early-career URiM faculty, this need is especially pronounced because few URiM faculty in the full professor rank have devoted time to their development. ⁵ Collaborative scholarship among peers can be an essential part of faculty success. The study participants, however, articulated an expectation that leaders (ie, chairs and senior faculty) would collaborate and coauthor with them; yet this is the first paper to address this expectation. Study participants identified a need to be engaged in hands-on writing and coauthorship with more experienced scholars. While this need was indicated by URiM faculty, it is likely a practice that can benefit faculty of all identities.

Study participants appreciated that the LTSF faculty also identified as URiM. ^{6, 16} LTSF faculty (K.M.C., J.E.R., J.C.W.) incorporate collaborative scholarship as a vital part of their institutional leadership. With primary care specialties having the largest gap in scholarship and research efforts, the collaborative deficit identified in the study is probably not limited to URiM family medicine faculty. The deficit is likely a near-universal problem among early-career primary care clinical faculty in academic medical centers. This trend is conceivably due to a lack of infrastructure built into most primary care residencies and fellowships.

While our findings identified a gap in the literature about the needs of early-career faculty, they also helped us see that senior leaders can do better in mentoring. At many institutions, early-career faculty are told what they need to do without being provided an opportunity to learn how to do it or given instruction on how to add an additional responsibility into their busy, chaotic professional lives. This study reveals the need for senior leaders to change their practice to support early-career faculty better and to grow the research and scholarship missions of their residency programs, departments, and institutions. Leaders can invest in the development of URiM’s early-career faculty talent. Faculty development programs are part of that solution. Still, leaders should move beyond them by creating a culture that favors faculty growth among the clinical contributions of their faculty. As a part of this investment, senior faculty can employ instrumental mentoring, which includes both instruction and participation with early-career faculty. In other words, those who know how to write can write with those who are learning; those who know how to conduct research can conduct research with those who are learning, and so forth. Chairs and deans can include investment in early-career faculty as part of their periodic evaluations, while promotion and tenure committees can assign value to these activities.

Faculty development programs that include collaborative scholarship as a major component give faculty mentorship, experience, and support in an apprenticeship model (eg, LTSF and the primary care research fellowships for postdoctoral students funded by the Health Resources and Services Administration), which can be of value to all new faculty and senior leaders. ¹⁶ These programs also strengthen communities of inquiry and professional networks. ⁶ Mentorship is critical for all faculty but particularly for URiM faculty who may not have existing collaborative research networks and who have limited network reach.^{17, 18} Our other findings are consistent with existing literature on minority faculty in that they speak almost exclusively to the promotion tax and the mentorship tax. ^{7, 8, 15}

This study was limited by selection bias because all fellows self-selected to be participants in a fellowship designed to address leadership and scholarship challenges pertaining to URiM faculty. The fellows likely experienced the minority tax and gate blocking before becoming part of the fellowship. Those experiences may have played a role in the fellows seeking the fellowship. Ideally, these data would have been collected at the time of application; and, in the future, applicants may be asked some of the questions from this survey as a part of their application for the fellowship as well as at the end of their fellowship year.

Leadership is increasingly discussed in the literature, with recent papers on family medicine leadership pathways and on negotiating for leadership positions in family medicine. ^{19, 20} However, the literature includes little about the attitudes and perceptions of early-career family medicine faculty and even less, if any, describes ideas about URiM faculty leadership. ¹⁹ Programming such as the STFM Leadership Through Scholarship Fellowship can provide the type of mentorship that helps to navigate the waters of scholarship and leadership development.