INTRODUCTION

An early description of the hospital medicine career predicted potential for enhanced satisfaction, focused clinical competence, and a better-defined schedule than “traditional GIM practice.”1 Yet even early on, concerns existed regarding hospitalist susceptibility to burnout, which have since been demonstrated. In 2011, nearly a quarter of surveyed academic hospitalists reported burnout symptoms.2 Lack of personal and family time related to weekend and evening clinical responsibilities and lack of control over work schedule predicted burnout and low job satisfaction.2 More recent surveys demonstrate that burnout disproportionately impacts women physicians.3 Women physician-scientists assume more parenting and household responsibilities,4 struggling most with work-life integration.5

These challenges, compounding implicit and explicit biases and a lack of transparent equitable processes that mitigate bias, may contribute to medicine’s observed gender disparities.6,7 A small body of research has explored gender inequities among academic hospitalists within leadership, scholarly productivity,8 and income.9 Women may consider career redefinition an alternative to attrition,10 via nonlinear career paths.

Nonlinear career paths, defined as extended leave (EL) and flexible work arrangements,11 are increasingly common.12 Women physicians are more likely than men to reduce work hours to part time.10 Economist Sylvia Ann Hewlett wrote that more than 60% of highly qualified women have nonlinear careers,13 a finding that is consistent regardless of family status.14 Yet, Hewlett also theorized that nonlinear career paths could lead to decreased retention of women in the workforce and fewer women within leadership.11,15 No prior studies have evaluated nonlinear career paths in academic hospital medicine—a field characterized by a predominantly shift-based schedule. While there is evidence that women in academia pursuing nonlinear career paths experience negative impacts on career trajectory,14,16 no published studies have examined nonlinear career path utilization by gender and whether these may contribute to gender inequities within academic hospital medicine.

The primary goal of this pilot study was to compare the frequency with which academic hospitalist physicians pursue nonlinear career paths by gender and to identify gender differences in key determinants of these decisions. The secondary goal was to assess the perceived impact of two types of nonlinear career paths—ELand/ornon-traditional work arrangements (NTWA)—on hospitalists’ personal lives and careers, and whether these differ by gender.

METHODS

Study Design and Sites

This is a cross-sectional descriptive study of hospitalist physicians in three academic centers across the USA. Each site employs hospitalists with varying career concentrations including clinically focused faculty, clinician-educators, and physician-scientists. Each hospitalist group delivers care on teaching and non-teaching general medicine services, perioperative co-management, and specialty-based hospital medicine services. The sites were similar in size with 94 hospitalists employed at site 1, 103 at site 2, and 78 at site 3. Full-time pediatric hospitalists, full-time palliative care physicians, and advanced practice providers within hospitalist divisions were excluded.

Survey Development

The authors developed a survey based on data from Hewlett et al.’s research report “The Hidden Brain Drain.”11 A multidisciplinary team with experience in gender equity research (MB; JAB), academic hospital medicine (MVD; JAB; MB; KJO), qualitative methods (JAB; KAC), and survey design (KAC; KJO; AK) developed the survey within REDCap, which included closed- and open-ended items to assess utilization of and experiences with nonlinear career paths within academic hospital medicine. Survey items were categorized within four sections: (1) EL; (2) NTWA; (3) institutional culture;17 and (4) demographics. To mitigate stereotype threat in responses,18 participants provided demographics at the end of the survey.19 See Appendix A for the complete survey.

EL was defined as an absence from the respondent’s current employment for at least 30 days—a minimum duration inclusive of most maternity leaves.20 NTWA was defined as any choice a respondent may take that diverged from “traditional” schedules and/or responsibilities of the current hospitalist position, as institutionally stipulated. A “traditional” hospitalist schedule consists of alternating weeklong clinical and non-clinical blocks, though organizational schedules vary. Though Hewlett referenced “flexible work arrangements,”11 our survey substituted “non-traditional work arrangements” as a more inclusive characterization encompassing the many strategies hospitalists use to modify schedules and careers based on personal and professional priorities.

Survey Administration

A site champion emailed a survey link to eligible participants at each institution with language explaining the study’s purpose. The email explained that by continuing with the voluntary survey, participants inherently provided consent to study participation. The link launched on July 13, 2020, for 21 days. Participants received email reminders at 7 and 14 days. All sites’ institutional review boards (IRB) deemed this study exempt. Responses were anonymous and stored online via REDCap. Datasets are available from the corresponding author on reasonable request.

Site champions contacted program administrators of their respective hospitalist groups to obtain leave policies, gender distributions of eligible respondents, and de-identified group-level data regarding maternity/paternity, family, and personal leave lengths 3 years prior to survey administration (January 1, 2017, to July 1, 2020).

Analysis

Descriptive statistics were calculated for all variables of interest using Fisher’s exact test. Categorical variables were summarized with counts and percentages. We examine associations between EL and demographic variables and assess for differences in EL utilization by gender. We excluded respondents choosing “prefer not to answer” to describe gender. We examined the association between gender and experience with NTWA. Additionally, we categorized NTWA strategies into three groups based on the presumed likelihood of positive, negative, or neutral career impacts, examining the positive and negative groups’ association with gender also using Fisher’s exact test.

Our team employed grounded theory qualitative analysis21 to categorize and interpret responses to open-text questions. We derived codes inductively from respondent survey comments, avoiding a priori hypotheses, preconceived categories, or theoretical perspectives.

Three researchers, MVD (hospitalist, assistant professor—identifying as a woman; one EL for childbearing), JAU (hospitalist, instructor—identifying as a man; with one EL for childrearing), and JAB (hospitalist, associate professor—identifying as a woman, with one EL for childbearing) independently read all comments to contextualize the body of data. All initial coding was blinded to respondent gender. Each researcher open coded an overlapping subset of responses and subsequently discussed impressions with the coding group to triangulate preliminary initial descriptive codes. All comments were then coded independently by each member of the group, who refined the coding framework in an iterative fashion, using the constant comparative technique.22 In second level analysis, axial coding, codes that had been split during initial coding were strategically reassembled by the group into a smaller number of code categories identified to illustrate experiences of hospitalists with EL and NTWA. Modifications to the coding scheme were made after differences in the application of codes were identified and adjudicated to 100% consensus. Responses were then un-blinded to gender, and the coding team met two additional times for selective coding—reviewing axial codes to identify core themes and subthemes by gender. This process resulted in finalization of the coding scheme and codebook.

RESULTS

Participant Characteristics

Of eligible respondents receiving an emailed survey link (N = 272), 51.5% completed EL items, 47.4% completed NTWA items, and 41.5% completed demographic items. Respondents had a binary gender distribution (54.9% women; 39.8% men) that largely represented the sample population. No participants self-identified as non-binary; six respondents declined to answer. See Table 1 for respondent demographics.

Table 1 Demographic Variables in Relation to Extended Leave
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Quantitative Survey Findings

Of 141 participating hospitalists, 27.9% reported taking EL at least once during their current employment. Of respondents that completed gender demographic items (N = 113), more women reported taking EL compared with men (p = 0.035), and also reported taking longer ELs (p = 0.002); 29% of ELs lasted < 3 months for women compared to 83.3% for men. Both men and women cited “birth/adoption of a child” as the main reason for EL. Furthermore, respondent parents who had not taken leave (N = 26) were predominantly men (76.9%). Half of women (51.6%) reported at least one child compared with 62.2% of men. Bivariate analysis of EL and demographics confirmed that self-identification as a woman (p = 0.047) and having children (p < 0.001) were the two factors significantly associated with taking EL; findings persisted following exclusion of gender nonrespondents (p = 0.035; p < 0.001). Being married was also associated with taking EL (p = 0.034) but did not reach significance after removing gender nonrespondents.

As for NTWA, 74.3% of respondents described modifying “traditional” hospitalist schedules and/or roles. There was no significant difference between genders in who have experience with at least one NTWA (p = 0.114) Women and men shared “birth/adoption of a child” and “burnout” as the most common reasons for NTWA. The most frequently reported NTWA among genders was “change of career focus to a less clinical position (e.g., decreased clinical time in favor of academic or administrative pursuits).” Men and women respondents diverged in utilization of part-time work; women (27.4%) assumed a part-time schedule more than twice as often as men (11.4%). When grouping NTWA strategies into those that may negatively impact career trajectory (i.e., declined an offer for a leadership position)versus those that may positively impact career (i.e., decreased clinical time in favor of academic pursuits), men and women did not significantly differ in NTWA strategies chosen (p = 0.88). See Table 2 for quantitative analysis based on gender.

Table 2 Leave Status, Leave Length, and NTWA Strategy in Association with Gender
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Qualitative Findings

Within open-text comments describing impacts of EL and NTWA, we identified four overarching domains: personal, career, well-being, and work-life integration. Within each domain, positive and negative impacts were reported. Please see Tables 3 and 4 for a complete list of domains, themes, and subthemes, with representative responses.

Table 3 Domains, Themes, and Subthemes from Qualitative Analysis of 32 Responses to the Question “What impact, If Any, Has Your Decision to Take Extended Leave Had on Your Career and/or Personal Life?” from a Study of Academic Hospitalists (2020)
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Extended Leave

Within the personal domain, both genders described EL having a positive effect on the parenting relationship. Women expressed negative impacts across all four domains whereas men solely noted negative impact to career—a decrease in academic productivity. Within the career domain, women, unlike men, reported workplace bias and harassment related to EL and parenting, lack of academic productivity after return from EL, and within the well-being domain, difficulty balancing competing responsibilities. One woman speculated that parenting itself rather than EL is the primary barrier to maintaining career trajectory.

Non-traditional Work Arrangements

Within the work-life integration domain, both genders associated NTWA with increased schedule flexibility, predictability, and work-life satisfaction. Within the well-being domain, both genders reported burnout prevention. Within the personal domain, respondents of both genders noted that NTWA allowed careers to align with personal priorities. Both genders described positive impacts of NTWA on career advancement. Some women expressed a sense of agency in their decision to pursue a different direction. Several women, however, perceived negative impacts to career relating to academic advancement, promotion, and loss of opportunity and expressed self-doubt regarding clinical and non-clinical identities; similar impacts were not noted by men. Only women expressed secondary concerns about financial impacts of EL and NTWA (Table 4).

Table 4 Domains, Themes, and Subthemes from Qualitative Analysis of 88 Responses to the Question “What Impact, If Any, Has Your Decision to Take a Non-traditional Work Arrangement Had on Your Career and/or Personal Life?” From a Study of Academic Hospitalists (2020)
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DISCUSSION

Our pilot study of academic hospitalists demonstrated that women respondents took EL significantly more often than men and described a wider range of related negative impacts. Our results also suggest that men and women have similar primary drivers of EL and pursue similar NTWA strategies, with both groups most commonly choosing to decrease clinical time. Men and women described positive impacts of NTWA for all four identified domains, though only women noted negative impacts on their career trajectories.

The gender imbalance among those who take EL reflects institution-level policies and cultural norms emphasizing maternity rather than parental leave. Leave length taken for childbirth as reported by site-level hospitalist administrators was proportionate to the amount of paid leave offered. Participating institutions had vastly different family leave policies regarding whether leave was paid and for how long (see Appendix B for institutional leave policies). Anecdotally, the site with the most gender parity in leave policies also reported the longest average leaves for both genders. Broadening paid leave opportunities for both birthing and adoptive parents and their partners may be a key component of equity in the impacts of nonlinear career paths across genders.

Consistent with comments offered by a single respondent that parenting itself rather than EL may be the larger influencer of career trajectory, Riano et al. postulated that restricting family leave to the primary caregiver forces women to assume the brunt of childrearing responsibilities and could eventually lead to attrition of women from academic medicine.20 Though our study did not assess career attrition, the negative career, personal, work-life integration, and well-being impacts of EL disproportionately reported by women are a concerning signal that attrition might follow. In more egalitarian countries such as Sweden, a country that promotes paid paternity leave and encourages shared parenting responsibilities, longer paternity leaves have been associated with greater retention of women within the workforce.23 Interestingly, Pylkkänan et al. found equitable leave policies did not necessarily translate to men taking longer leaves, suggesting that specific encouragement of men to take parental leave is also necessary to promote gender equality within the workforce.

Our qualitative analysis highlights stark differences between genders in their experiences related to EL. Only women reported workplace bias and harassment after returning from leave, which contributed to loss of opportunity, previously described among women academic hospitalists.24 These observations support other accounts of pervasive bias and discrimination of women physicians not limited to EL.25,26 Gottenborg et al. suggested creating a flexible “ramp-up and ramp-down” period for clinical work surrounding leave to account for “the challenges of pregnancy and new motherhood.”24 However, some of our respondents felt that such a period (given the inability to “jump back into” non-clinical projects immediately) might widen the productivity gap in comparison with peers that have not taken leave.

Unlike prior descriptions of women in medicine utilizing flexible work arrangements more often than men,11 our study suggests that men and women pursue NTWA at similar rates. Both genders described benefit from the accompanying schedule flexibility that allows for more family time and the ability to mold a career better aligned with personal values. Women who pursued NTWA described weakened confidence regarding their clinical and non-clinical capabilities, which may be a driver or consequence of these schedule alterations. Our findings mirror those of Pololi et al. who observed that women physicians across all academic ranks perceived lower self-efficacy for career advancement.27 They also align with findings of personal doubt regarding professional identity previously described among part-time women hospitalists.28 Though the impacts of NTWA may be confounded in hospital medicine by a largely shift-based work structure perhaps viewed as in itself “non-traditional,”1 these findings are noteworthy. We do not wish to implicate women themselves in these difficulties. Rather, our observations direct us toward larger questions regarding the veracity of the so-called confidence gap between women and men29 and the culpability of institutions and society at large in perpetuating gender stereotypes.

Our study has several strengths. To our knowledge, this is the first study that describes and compares experiences of academic hospitalist physicians in regard to nonlinear career paths. Three academic centers across the USA participated; we believe that our results are generalizable to the academic hospitalist community at large. Although this work occurred during the COVID-19 pandemic, we had a strong response rate from a population disproportionately impacted by increases in clinical demand, perhaps reflecting the importance of this topic within our target population. The survey was also designed to capture academic hospitalist physician experience across the gender spectrum, distinguishing it from many publications on gender equity within hospital medicine and beyond.

This pilot study was limited by its relatively small sample of physicians. Moreover, while we included non-binary options for gender self-identification, the majority of respondents identified as a man or woman. This finding is not unexpected. Given that transgender and gender non-binary individuals are estimated to represent less than 2% of the overall population,30 they may perceive a risk to anonymity with self-identification. Demographics reflected the largest group of respondents at the assistant professor rank, despite relative parity across ranges of years of practice. We attribute these findings to differing institutional promotional requirements (i.e., a participating site with a non-binding timeline), but cannot exclude that nonlinear career paths directly impeded academic promotion where a strict timeline exists. Differing institutional response rates may have skewed results regarding EL utilization and impact, as institutions varied in their policies on paid leave. Though it is possible that family status and not gender is driving reported results, this is not true within our sample where a greater percentage of men than women reported at least one child. Furthermore, evidence supports that single compared to partnered women take leave for different reasons but at similar rates and often suffer even greater career and financial penalties.15 Finally, we could not specifically define NTWA within the context of hospital medicine, but allowed respondents to define this for us within the construct of our survey. Qualitative investigation with structured or unstructured interviews would be required to better understand how respondents define NTWA.

Pursuit of nonlinear career paths in hospital medicine may be a double-edged sword for women. It has been offered that “such norms perpetuate gender segregation at work as ‘part-time jobs remain predominantly female.’”31 However, some authors note that nonlinear career paths advance representation in the workforce by allowing women to participate who might otherwise be subject to attrition due to competing responsibilities.32 Given evidence of improved patient outcomes when women physicians deliver hospital care,33 institutional and national support for creating a culture in which nonlinear career paths do not threaten advancement in hospital medicine is a workforce imperative. Such support will include, at a minimum, inclusive recruitment processes, equitable allocation of career opportunities, reexamination of promotional criteria and timelines, holistic mentorship, and support for personal needs, including childcare and caregiving.

CONCLUSION

As might be expected, our study found that women academic hospitalists reported taking extended leave twice as often as men. More surprisingly, men addressed burnout and childbearing by utilizing non-traditional work arrangements at similar rates. Women, however, described disproportionately more adverse personal, career, work-life integration and well-being impacts, including bias and discrimination, career impediment, and identity uncertainty. Our findings lay the groundwork for additional exploration of cultural and policy interventions, particularly improved paid leave policies, which may minimize gender disparities in academic hospital medicine as the field continues to mature.