Equity, diversity and inclusion of pediatric clinician–scientists in Canada: a thematic analysis

The pervasiveness and invisibility of sexism

Regardless of gender, all participants commented on the challenges that most female pediatric clinician–scientists experience in their doctoral and postdoctoral training and while obtaining and securing academic and pediatric clinician–scientist positions. The participants in this study viewed and experienced sexism as prevailing because of tensions between their public and private lives, including family responsibilities.

Work–life balance

Numerous examples of sexism were related to pregnancy, scant information on parental leave policies and limited access to pediatric clinician–scientists to discuss the optimal timing of starting a family. Most female participants were reluctant to share experiences of sexism with other pediatric clinician– scientists, career and research mentors, and senior leaders within their organizations and training institutions because of fear of reprisals or their concerns being dismissed. Participants noted that few, if any, female pediatric clinician– scientists talked openly about their children or family life with academic colleagues, contributing to the concealment of wanting to have a child. Some participants felt that gender inequities were trivialized by men and women alike, with jokes about parenting and efforts to achieve work–life balance. As one participant poignantly said, “joking about it doesn’t make it okay, or at least it doesn’t for me. And I find a lot of our current research investigators still do that where they joke about not spending enough time with their kids” (P2). Perhaps the most insidious problem for women is the perceived expectation that they publish, secure grants and maintain their clinical duties all while caring for their children.

Participants shared “constant tensions” between biological and psychological drives to care for children and meet the demands of a career as a pediatric clinician–scientist. Some of our participants shared that, out of necessity, at various stages in their training and careers they could not take maternity leave. Some women gave up part of their work, slowed down their training or declined opportunities for career advancements to care for their children. They struggled to find ways to carve out time in their career, experiencing great tension between this need and their academic goals. Although male and female participants disclosed struggling to manage clinical and research responsibilities and family life, the burden of child care primarily fell on women in this sample of participants. Participants described the considerable clinical and research demands resulting in long days, and evening and weekend shifts, pressuring women to make difficult choices about what aspects of their personal life or clinical responsibilities need to be curtailed.

Compromises to career and family

Several interviewees described the compromises between their career and family life, acknowledging this may have reduced their output of publications and grants, and most were accepting of the choices made. Some participants were unable to travel during the latter part of their pregnancy and when their children were very young. In addition to being penalized for not attending a professional conference, interviewees noted decreased numbers of presentations and invited talks on their CV, and the loss of opportunities for networking, building collaborations and learning of emerging advancements in their fields.

The invisibility and visibility of racism

These interviews took place in 2020, during a time when issues of institutional racism had risen to the forefront of public consciousness in Canada.31 Participants noted that the focus on racism in the news was accelerating conversations in academia about implicit bias and underrepresentation of minority populations as participants in health research. Despite this elevated social consciousness, many participants shared that racism was insidious and difficult to name, even among academics identifying as racialized individuals. Some participants went further and commented that we needed to question our whole way of conducting science to make more room for alternative and a range of viewpoints.

Uneasiness challenging racism and bias

Participants noted that they experienced both overt and covert racism because of their skin colour, accents and the origin of their names. The participants in this study felt they were not being invited past the submission phase for trainee and academic positions because they were being screened out of the hiring process based on the origin of their name and their international training background. Another example of racism described by participants was experiencing microaggressions, such as being seen and treated differently by patients, and overt aggression, such as being spat on by a patient who refused to be treated by them. Participants perceived that some colleagues prioritized comfort and safety over the uneasiness, awkwardness and conflict that comes with challenging racism and implicit biases. Several participants commented that, because of this discomfort, they felt they did not have a voice or a safe space in which to discuss racial issues. Other participants shared that they often found it challenging to navigate difficult discussions about racism with their colleagues, especially those in leadership positions. Even in interactions with their peers, many reported being afraid to confront racism during their training seminars out of concern about being ostracized.

Questioned credibility

Some expressed concerns that their colleagues, mentors and even patients questioned their credibility because they were not white. The fear of lacking credibility with colleagues and patients was magnified for participants for whom English was a second language. The participants highlighted 2 competing ideas in their training and academic careers: the importance of intersectionality and compounded oppression; and heterogeneous experiences of oppression and, for others, privilege. Many of the participants identified barriers while simultaneously recognizing privilege in other aspects of their lives. One participant shared that women who are also visible minorities are confronted with numerous systemic barriers and a profound sense of isolation moving through the education and professional pipeline. This participant described that her female (and male) colleagues could relate to the experiences of sexism. However, few could understand what it might be like to simultaneously experience sexism and racism from both colleagues and patients. She described how, throughout her career, she received negative messages and shock from clients and students alike for being a Black, female scientist, who was a principal investigator on tricouncil grants and in a senior administrative position. Another female participant who was East Asian described experiencing racist and sexist comments from patients who refused to receive care from her for being a visible minority and a woman. Finally, 3 other female participants who identified as either Asian or Spanish described experiencing discrimination not only for their gender but also for their skin colour and having a strong accent. They were less likely to be called on to speak in class, and their examples of working with underrepresented groups in their communities received less attention and interest from their professors, mentors and supervisors. Participants who were people of colour and female further described incidents where they were erroneously identified as individuals holding service-level jobs within their institutions, or at national or international meetings rather than clinicians and scientists.

Proposed individual-level solutions to the pervasive problems of sexism and racism

Identifying diverse mentors with shared experiences Identifying mentors was particularly challenging for women, individuals identifying as racialized individuals and newcomers to Canada. Pediatric clinician–scientists from underrepresented groups commented that they had trouble relating with senior faculty who could not identify with their experiences of sexism and/or racism.

Participants elaborated on the need for a more diverse group of mentors with a greater breadth of lived experience as a woman or from a visible minority. Some participants commented on how they had been motivated by earlier challenges they had experienced with finding mentors to try to become better role models and mentors to junior colleagues and trainees. For example, women who experienced sexism early in their careers made a conscious decision to become strong and positive mentors to early-career researchers.

Proposed institutional and system-level solutions to the pervasive problems of sexism, racism and the leaky pipeline

Participants noted the need for institutional and system-level changes, including the need to create courses led by senior female and racialized scientists aimed at discussing pregnancy and parenting during doctoral, postdoctoral and pediatric clinician–scientist positions.

Individual efforts to create brave spaces and meaningful conversations

Many of the participants argued for the creation of brave spaces for pediatric clinician–scientists and trainees to discuss EDI issues. The development of these brave spaces in academic and clinical settings is a way to promote authentic and deliberate dialogues among clinician– scientists about their experiences of racism, sexism and other forms of oppression. Such brave dialogues must occur regardless of whether conversations elicit discomfort, strong emotions and fierce debates with those who hold power and privilege.32^–34 Several female scientists valued the opportunity to discuss maternity leaves, pregnancy and parenting. Many argued that transparent discussions about mothering will help bring to the forefront that it is feasible to start a family and choose a pediatric clinician–scientist career path. Some participants suggested that mentors invite trainees and early-career researchers to discuss the pros and cons of when to have children if they were contemplating this decision.

Other interviewees emphasized the need for safe spaces to discuss issues related to race and ethnicity. One participant commented that the discomfort created by uncomfortable conversations about race was critical and potentially pivotal in facilitating change. Other participants similarly emphasized the need for brave spaces to engage in discussions about implicit racial biases. One participant shared that she created a safe space for her trainees to talk about their daily challenges and experiences with discrimination that they and their patients experience. She and other participants noted the need for everyone, including senior leadership, to demonstrate their willingness to engage in conversations about racism and sexism to make it easier and safer for students to openly discuss these issues. A supervisor of one participant took interest in the cultural background of members of their laboratory and demonstrated cultural sensitivity, such as identifying a space where Muslim laboratory members could perform daily prayers. Another participant created a journal club that explored issues regarding equity and diversity. Additionally, participants argued for uncomfortable discussions with those who may be in positions where they have directly and indirectly benefited from power imbalances in our health and academic systems. Participants demonstrated efforts to challenge racism and sexism by creating opportunities to disrupt narratives and practices that reinforce and conceal inequities and discrimination.

The porous and leaky pipeline

Many prospective pediatric clinician–scientists reported they struggled to launch their career given many structural barriers in postsecondary education and earlier in their career. This was particularly true of racialized individuals and women, who often face disparities at every stage of their academic and professional training. Explicit, implicit and overt biases lead to racialized individuals and women being less likely to be invited for interviews, to be offered positions, to find a mentor or to advance in their career. Some participants pointed to critical career stages in which the “pipeline” to a pediatric clinician–scientist career is particularly porous. For example, many promising candidates do not even make it to the stage of writing their application for entry into specialized pediatric clinician–scientist programs for a variety of reasons. Some pointed to women starting their family as a frequent “drop-off” from graduate school. Others noted that at each stage, nonwhite applicants may fail to advance for a range of reasons. For example, implicit bias prevents them from making critical connections with senior faculty or mentors who could provide references. Some elaborated on how the diversity within academia is considerably less than the diversity in the general population. Others emphasized the importance of not just recruiting more scientists into the pipeline but ensuring continued support at all stages of the pipeline.

The need for institutional change

Many participants offered suggestions for institutional changes to address the porous and leaky pipeline that is fueled by sexism and racism. Others commented on the need for targeted recruitment to academic positions to rectify EDI issues. Some focused on changes to pediatric clinician–scientist training programs at the institutional level, as well as supporting individuals emotionally (fostering feelings of trust and being valued) and instrumentally (spending time with someone and providing them with resources) during their training. Participants emphasized the importance of providing education about why differential treatment might be necessary for those receiving training from underrepresented groups. In fact, individuals who were in leadership positions noted that underrepresented pediatric clinician–scientists might need additional support because they have been historically disadvantaged.

Training programs could work with graduate and residency programs to nurture future pediatric clinician–scientists and to address EDI issues. Concrete suggestions included incentives for department chairs to select residents from minority groups and alumni mentorship programs. Some participants focused even further “upstream” on undergraduate or professional programs before research training begins. One concrete suggestion for addressing diversity issues to retain pediatric clinician–scientists included targeted funding opportunities. From individualto systemand structural-level changes, participants identified ways to recruit equity-seeking individuals pursuing a career as a pediatric clinician–scientist and supporting those in such positions to thrive and not just barely survive.