From the sticky floor to the glass ceiling and everything in between: A systematic review and qualitative study focusing on inequalities in Clinical Academic careers

Gabrielle Finn, Eleanora P Uphoff, Gary Raine, John Buchanan, Connor Evans, Abisola Balogun, Millie Kehoe, Lesley Stewart, Jessica E Morgan, Jennifer Valeska Elli Brown, Gabrielle Maria Finn, Paul Alexander Tiffin

Research output: Book/ReportCommissioned reportpeer-review


The advancement of excellent healthcare requires a strategic funder approach to develop and retain talented, research-focused healthcare professionals who can balance clinical and academic activities effectively for the benefit of patient care. Unfortunately, there are many inequalities in clinical academia, often based upon protected characteristics such as gender, ethnicity and race. This inequality is well-recognised, yet there remain many barriers and facilitators associated with this career pathway that are poorly understood. Although funders
are keen to support healthcare professionals to become Clinical Academics (CAs), there are currently gaps at certain levels with a drop-off from lack of support and progression. Thus, the aim of this study was to (a) conduct a systematic review to explore barriers, facilitators, and existing interventions within CA careers and, (b) collect qualitative data to explore the lived experiences of CAs across the career trajectory. This study considered medical and dental CAs within the UK.

Five databases were searched in October 2019. Studies were eligible for inclusion if they included doctors or dentists, with or without CA careers. Outcomes were study-defined but related to success rates of joining or continuing within a CA career. Studies reporting quantitative and/or qualitative data were included. Title and abstract screening was performed using a novel two-staged search and screening process, making use of a machine learning algorithm. Full text screening was performed in duplicate. Risk of bias was
assessed using standardised tools selected based on study design. Given the heterogenous nature of the studies identified, narrative synthesis of quantitative data was performed. Qualitative data were thematically analysed.
The qualitative phase of this study utilised multiple methods of data collection: (a) semi structured interviews with 104 CAs, and (b) audio-diary and written diary data recorded by participants over an 8-month period, which coincided with the global COVID-19 pandemic. Participants were doctors and dentists who had various experiences of CA pathways including those who had successfully navigated clinical academia, those who had attempted to pursue a CA career but had been unsuccessful, or those who had given up research.
Interviews explored their motivation to pursue, barriers, facilitators and possible interventions that could potentially improve the experiences of CAs. Audio-diary data were collected using voice recordings and enabled 30 participants to report on issues impacting their CA experience in the moment. Interview and audio-diary data were transcribed and thematically analysed. Data were subjected to (c) an additional text-mining stage to look for patterns in word frequencies. Data were (d) triangulated through the observation of funding panels and seeking expert opinion and consensus on the issues raised.

The systematic review initially identified 34,230 records. After screening, 239 studies were included in the review of barriers and facilitators, 141 included in the review of interventions and seven in both reviews. Of the 148 studies included in the interventions review, 28 were included in the quantitative synthesis, 17 included in the qualitative synthesis and two included in both. Notably, the literature lacked high quality, well-reported research studies.
6 The majority of included studies were from North America. Both quantitative and qualitative studies lacked methodological rigour and/or were hindered by incomplete outcome reporting.
Most quantitative evidence was available for multi-faceted academic training programmes. There is evidence to suggest that such programmes may increase recruitment to academia among clinicians, but findings are less clear for retention and for other outcomes such as participation in research and obtaining research funding. Studies reported benefits of supportive relationships for CAs, including peers and senior mentors. Across studies, having committed, supportive, and experienced programme staff was seen as a key facilitator of programme success. Respondents identified several other factors at a programme, organisational or national level which acted as a facilitator or barrier to success. Few studies reported on the effects of interventions for women or minority groups.
Interview data broadly pertained to eight major themes: identity; motivation to pursue; barriers; enablers; myths and the hidden curriculum; interventions; advice and top tips; and prescriptive and descriptive biases. The audio-diary data were predominantly related to the impact of the pandemic with themes of: barriers; enablers; fears and uncertainty; identity and protected characteristics. Across the data, discrimination based upon protected characteristics was rife; this led to many CAs leaving the research environment. The narratives of CAs revealed common issues such as isolation, exhaustion and crises of confidence. The COVID-19 pandemic presented additional complexity for women who needed to juggle their work and family commitments; many reported wanting to relinquish their research. Participants proposed interventions including formal mentorship, making funding accessible and funders more approachable. A toxic culture of discriminatory behaviours and attitudes was described which led to many talented individuals being lost from the CA career pathway.

Existing literature is limited by rigour and reporting, but there are significant lessons to be learned. Our primary qualitative data provide comprehensive evidence that CAs struggle to navigate the CA pathway and balance clinical duties with conducting research. Research funders should commit to evaluating any future interventions they put into place which aim to address inequalities in the CA workforce. Successful interventions are likely to be comprehensive multi-faceted programmes of training, in which relational and support aspects are key. Interventions focused on individuals are felt to be less helpful than structural/environmental changes.
Original languageEnglish
Commissioning bodyNational Institute for Health and Care Research (NIHR)
Number of pages365
Publication statusPublished - 2021


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