Juggling roles

Although the original aim was to interview female medical clinical associate/professors with caring responsibilities, some participants claimed not to have any because they did not have children. However, it emerged through the interviews that almost all the participants cared for either children, parents or other adults, or a combination. While participants agreed that they enjoyed the mix of clinical and academic work which meant that they were ‘never, ever bored’ (P12), even without caring responsibilities, their role was described as ‘trying to serve two masters…it’s extremely difficult’ (P6). Participants reported difficulties in making it clear what their role as a clinical academic entailed, which sometimes led to conflicts: ‘people expect the same as they would of a full-time person in each of these roles’ (P10).

The addition of ‘the third role, at home, that everyone knows about, but nobody talks about’ which was described as ‘near enough full-time in itself’ (P10) brought added challenges. Participants who shared parenting with their male partners described themselves as ‘the default parent; the dropper-offer/picker-upper, and sorter-outer’ (P10), bearing the brunt of childcare as well as managing the household.

Participants described additional caring responsibilities experienced as a result of the COVID-19 pandemic. Although children of key workers were allowed to attend nurseries and schools during lockdowns, one participant described how she needed to work from home when her child’s class had to isolate after one person tested positive for COVID-19. Others described supporting clinically vulnerable family members and doing shopping and other tasks for elderly relatives to enable them to shield during the pandemic.

Issues around juggling these roles were further compounded by societal expectations that women should put childcare before their career, with some participants reporting that they were made to feel guilty by other people. The naturalisation of gendered roles was revealed through frequent references to their male partners being praised for doing cooking and childcare which were apparently perceived as ‘women’s work’, even when both partners had full-time jobs.

Lack of self-confidence

Some participants reported difficulties in building sufficient confidence to apply for an associate professor role and, even when successful, they suffered from ‘imposter syndrome’. Relatedly, there were multiple mentions of ‘luck’, suggesting that some participants attribute their success to chance, rather than recognising their hard work and dedication as described by other participants in the study. It was suggested that this may be due to the way that girls are socialised to behave: ‘boys are praised for things that we aren’t praised for’ (P12).

Discouragement

There was a recurring theme of participants being overlooked for promotion or discouraged from applying for senior posts. Some participants described conversations with both male and female colleagues where doubts were expressed about women’s abilities to ‘have it all’. For example, being advised that the clinical academic role was ‘unsuitable for a woman with children’ (P1) and ‘I shouldn’t apply because I would be too busy with my child’ (P2). This view was echoed by a participant in this study who suggested that women needed to choose between pursuing a clinical academic career and having a family.

There were frequent references to being undermined, patronised and having achievements minimised; there were also reports of bullying. Participants felt that their complaints were sometimes dismissed: ‘well, you know what he’s like!’ (P10) and attributed to ‘a difficulty you are going through’ (P2), rather than institutional problems.

Shortage of suitable clinical academic posts

Often the only way to get a clinical academic job was to successfully apply for a fellowship: ‘without it, there was no guarantee of a job locally’ (P11). However, participants had to prepare applications in their own time, thus disadvantaging those with caring responsibilities.

Although acknowledging that a lack of job security is not gender specific, ‘in the clinical academic world, you’re constantly looking for the next role’ (P2), it was considered particularly challenging for women who were unable to move to another university because their partners could not, or would not, relocate. Anxiety over future career prospects was suggested as a possible reason why many women leave the clinical academic career route. Participants felt that positive action was needed to avoid attrition of talented female medical clinical academics such as additional fellowships, specifically for women. Other suggestions included alternative career paths to allow women to (re)join the clinical academic pathway later in their careers and reintroducing an intermediate grade between associate professor and professor, which ‘might be a useful steppingstone’ (P7).

Masculine culture

Participants became aware of the lack of women at senior clinical academic levels as they progressed in their careers, even in predominantly female clinical specialties. They described a competitive culture as: ‘survival of the cruellest’ where success depended on navigating ‘blocks and barriers’ (P2), rather than nurturing people. Within this environment, participants noted how men were encouraged to express their opinions, whereas for women: ‘if you speak too much, you’re aggressive, but if you’re shy you’re weak’ (P8).

Promotion processes

The masculine culture was also said to influence promotion practices. Although one senior clinical academic noted that promotion committees were more likely to include women since the implementation of Athena SWAN initiatives, recently promoted participants described facing all-male interview panels which were said to be ‘daunting’ (P5). In addition, interviews were described as ‘designed to intimidate the candidate, which particularly disadvantages women’ (P1). One participant believed that women often disadvantage themselves by crediting their team effort and avoiding self-promotion. Suggesting that: ‘it’s to do with how we’re socialised…boys are taught to think that they’re wonderful and we aren’t’, she recommended that female candidates prepare their applications ‘like a man’, present themselves ‘as confidently as possible’ and ‘prepare for the possibility that the interview panel may behave fairly aggressively’ (P12).

Participants felt that promotion criteria were biased against clinical academics when competing against full-time academics, and people with caring responsibilities. Comparisons were made with clinical progression which, although it might be delayed due to caring responsibilities, was not reliant on meeting academic criteria. In this respect, the H index was particularly concerning for women who had taken maternity leave and/or worked part-time, resulting in fewer publications, successful grant applications, etc, when compared with male candidates. It was suggested that ‘pro-rata comparisons between candidates’ (P12) would make it fairer for women who had worked part-time during their career. It was also pointed out that some specialties did not attract as much research funding, or have so many high-ranking journals, as other specialties. Therefore, it would be fairer to include different criteria such as research impact, for example, benefits for patient care.

Accessing family-friendly policies

Some participants with caring responsibilities reported feeling reluctant to access family-friendly policies. For example, one participant framed her request to work from home 1 day each week in terms of being more productive academically, rather than enabling her ‘to do the school run and interact with other mums’ (P4). It was felt that working part-time was accepted more readily in the clinical setting than in clinical academia where participants feared that working less than full time might adversely affect funding applications. Other participants felt that part-time working was not effective: ‘the difficulty is that the work doesn’t decrease, there’s the same amount of work in fewer hours, for less pay’ (P12). In addition, one participant recalled ‘paying for full-time childcare but getting paid 50% of my salary’ (P13) in case work meetings or conferences occurred on ‘non-work’ days.

Flexibility

Participants valued the flexibility of the clinical academic role, specifically the academic aspects which could be fitted around caring responsibilities much more easily than their strict clinical schedules would allow: ‘that flexibility has really been key for me’ (P1). This was particularly appreciated during the COVID-19 pandemic where participants were able to work from home: ‘I have a lot more flexibility and control over my time than friends who chose to be full-time NHS consultants’ (P3). Remote working became commonplace and ‘much more acceptable’ (P10) during the COVID-19 pandemic, with meetings held online described as ‘a revelation…I’m not having to travel and fight for a car parking space…I’m more productive’ (P6). It was hoped that these practices would continue after pandemic.

Athena SWAN initiatives

Both the universities from which the sample was drawn had achieved Silver Athena SWAN status by introducing initiatives such as increasing the presence of women in interview panels. However, one participant felt ‘irritated’ that she was often asked to be part of an interview panel as ‘the token woman’, and ‘not because they felt I could bring anything to the interview process’ (P4).

Other measures included having dedicated car parking spaces for people arriving after 09:00: ‘knowing you can arrive at 9.15 and you don’t have to park offsite somewhere’ was described as a ‘practical thing that really helps’ (P13). However, the parking provision was considered inadequate, ‘5 spaces in the medical school carpark doesn’t really cut it’ (P13). Also, it was sometimes abused, ‘people park there before 9 o’clock and just sit in the car until they’re allowed’ (P2).

Another facilitator was the directive to schedule meetings in core times: ‘this Athena Swan initiative of meetings only being between 10 and 3 is just so wonderful, but whether people stick to them is another matter. I always stick to them; I never send meeting requests outside those hours’ (P11). Although the idea was to enable people with caring responsibilities to attend meetings, another participant said: ‘People don’t stick to it. They say, “well 4 o’clock is the only time I can make”. Well, that’s my school pick up time and I’ve got nobody else that can help, so I don’t have a choice’ (P2).

Despite most participants welcoming these family-friendly policies, some were critical about the amount of support that was directed at parents: ‘sometimes we feel like if we don’t have kids…they’re not interested in [supporting] us’ (P6).

Leadership development courses

Although individual support was appreciated, it was felt insufficient to deal with a ‘male-heavy’ environment (P5), and that what was needed was ‘a change of culture’ (P2). In this respect, leadership development courses were described as valuable for realising personal strengths and ‘break[ing] down internal barriers that women are socially conditioned with’ (P13). Participants felt that developing alternative leadership styles based on nurturing talent would improve the culture and encourage more women to pursue the clinical academic pathway: ‘the biggest difference can be made by more representation’ (P13).

Attainable role models

Participants in this study were able to identify female role models within their universities, although there were concerns that some women may make success seem unattainable. It was therefore felt important that female leaders share their stories which include their failures and setbacks along the way, as well as their tips for overcoming challenges.

In turn, participants discussed using their position to demonstrate an alternative culture:

I think we need to role model to people that you will never get an email from me at 6.30pm because that’s dinnertime. It makes everybody else think it’s okay, whereas if only one person is doing it, you’re the odd one out. But if that’s the culture of what’s healthy to have a happy life, then that culture spreads. (P11)

They were also keen to encourage other female medical clinical academics following behind them: ‘Now that I’ve climbed the ladder, the most important thing I can do is hold it tight, so that other women can climb it more easily’ (P13).

Participants offered advice for aspiring female medical clinical academics, as summarised in table 1.