A vast body of literature critiques academia’s social structure and embedded field norms (Albert, Hodges, & Regehr, 2007; Becher, 1987; Boyer, 1990; Hermanowicz, 2009; Hoff & Pohl, 2016; Jenkins, 2020; Parsons & Platt, 1973). Specific to academic medicine, sociologists in the late 20th century (Freidson, 1985; Hafferty & Light, 1995) proposed that stratification heightened the authority of physician investigators and left “rank-and-file practitioners” with considerably less “freedom of action” than in the past. Fast forward 30–40 years. Today, physician educators typically have high clinical work expectations (akin to rank-and-file practitioners). Nonetheless, they are held to research expectations for career advancement, not clinical work expectations or even consensus-based criteria for educational excellence (Atasoylu et al., 2003; Baldwin, Chandran, & Gusic, 2011; Chang et al., 2021; Fantaye et al., 2022; Levinson & Rubenstein, 1999; Ryan et al., 2019; Sheffield, Wipf, & Buchwald, 1998). Disparities in career advancement of physician investigators versus physician educators have been reported; for example, there are longer times to promotion for physician educators (Beasley, Simon, & Wright, 2006; Beasley & Wright, 2003). Perceptions of disparities are also reported, with physician educators feeling undervalued in academic medicine’s social structure compared to their physician investigator peers (Bartle & Thistlethwaite, 2014; Browne, Webb, & Bullock, 2018; Hu et al., 2015; Kumar, Roberts, & Thistlethwaite, 2011; Sabel & Archer, 2014; Sethi, Ajjawi, McAleer, & Schofield, 2017; van Lankveld et al., 2017). Taken together, the dominant narrative for physician educators in academic medicine is one of constraint around career advancement. Thus, a study of agency is especially important for physician educators who feel undervalued and constrained by limited “freedom of action” to pursue the careers they want.
Theoretical Frame
Agency in careers of physician educators has been described using related concepts such as self-direction, initiative, and pro-activity (Bartle & Thistlethwaite, 2014; Browne et al., 2018; Sethi et al., 2017; Thomas et al., 2020). For example, Thomas et al (2020) reported that “proactivity led directly to new roles and opportunities” (pg 660). An exception is the work of Jauregui, O’Sullivan, Kalishman, Nishimura, and Robins (2019) who reported a push-pull influence of agency and context on the maintenance of physician educator identity among graduates of longitudinal faculty development programs. However, these authors also describe agency as “taking initiative to mentor” and “actively seeking ways to create projects” (Jauregui, O’Sullivan et al., 2019, pg 125). The focus on actions minimizes the significance of agentic perspectives, i.e., the internal process of making meaning of situations in ways that advance career goals without more external enactment and reflects a larger problem: agency is infrequently theorized in medical education (Varpio, Aschenbrener, & Bates, 2017).
Seeking a fuller understanding of agency in this paper, we relate the advancement of alternate career paths to the concept of faculty agency. O’Meara (Campbell & O'Meara, 2014; O'Meara, 2015; O'Meara & Campbell, 2011) purports that faculty agency is both assuming strategic perspectives (i.e., self-beliefs, self-talk, internal deliberations) and taking strategic actions toward career goals (i.e., taking on agentic behavior, taking strategic steps in action). In higher education, faculty agency has been used to explore career-family balance (O'Meara, 2015; O'Meara & Campbell, 2011), barriers to career advancement (Terosky, O'Meara, & Campbell, 2014), and measures of resistance enact toward cultural norms of higher education (Baez, 2000; Gonzales, 2015). Thus, our understanding of faculty agency considers two expressions of agency: a) strategic perspectives, what they believed was possible in their careers and b) strategic actions, what participants did to advance their career. Building from an extensive review of social science literature ― sociology (Archer, 2000; Emirbayer & Mische, 1998), psychology (Bandura, 1994), social psychology (Elder, 1994) ― O’Meara’s faculty agency also considers where (context) and when (time) agency happens. The latter is particularly important given our longitudinal approach to research described below. Drawing on work by Emirbayer and Mische (1998), O’Meara considers agency as informed by the past, oriented toward the future, and responsive to contingencies of the present. Simply put, understanding agency in the flow of time is critical to understanding agency at all.
The purpose of this paper is to describe and analyze how physician educators assumed strategic perspectives and took strategic actions over the course of five years to advance their careers. What we add to the literature are counternarratives, constructed from longitudinal qualitative data, that illuminate faculty agency and provide intimate, individual stories of what happens when physician educators push back on field norms for career advancement in academic medicine.
Research Approach And Orientation
We took a longitudinal qualitative approach to research (LQR), meaning we followed the same individuals through time (Balmer & Richards, 2017; Balmer, Varpio, Bennett, & Teunissen, 2021; Neale, 2019) This approach is particularly well-suited for research that explores phenomenon such as agency within the flow of time (Balmer & Richards, 2022; Neal, 2019). LQR is prospective inquiry: it follows the same people in real time, capturing stories of change (or continuity) as change happens and as it is anticipated. LQR is also retrospective inquiry: it explores change (or continuity) in hindsight, asking participants to respond to their former selves.
Our LQR is grounded in an interpretivist tradition, a tradition that elevates storied experiences as valuable and legitimate sources of knowledge (Lincoln & Guba, 1985). As such, reflexivity is central to understanding our work. D.F.B. is a white female, clinician-turned-researcher at the AMC where the participants were employed. Her experience with LQR helped her recognize that by exploring participants’ experiences in the context of a long-term research relationship, they were co-constructing a new way to make sense of those experiences. D.F.B. partnered with A.E.B., a biracial (AAPI/white) female with expertise in narrative analysis. A.E.B. is an educator-turned-researcher whose critical research lens helped frame how individuals navigate social structures and field norms. S.A.R. is a white male, physician educator with a master’s degree in medical education from AMC and experience with LQR.
Sample And Context
We derived data for this study from a larger LQR that traced the storied experiences of a cohort of eleven US physician educators who started the same graduate program in medical education in 2016 and completed the program in 2018. More information about the program, the cohort, and their experiences in and after the program can be found elsewhere (Balmer, Rosenblatt, & Boyer, 2021). Three participants from the original cohort offered significant insights into how physician educators acted in ways that run counter to field norms for their career advancement. Our decision to focus on these three participants reflects our research orientations: participants’ lives are storied experiences, and when analyzed through a temporal and narrative lens, lead to deeper understandings about structural traditions that are often taken for granted, such as legitimate ways to advance careers in academic medicine. Given our rich, prospective data, our targeted aim, and our expertise in LQR and narrative analysis, we were confident that our sample could yield sufficient qualitative findings (LaDonna, Artino, & Balmer, 2021; Malterud, Siersma, & Guassora, 2016).
At the start of the study, all three participants were employed by a large, research-intensive, academic medical center (AMC) in the United States. All three completed medical school and residency in the US; two completed fellowships at AMC. Their main areas of expertise were anesthesia, surgery, and internal medicine. All three participants were assistant professors at AMC at the start of the study. One was on a standing faculty track where promotion rested largely on scholarly productivity; two were on the associated clinical faculty track where scholarly productivity was not required for promotion. Regardless of track, all three were working full time and acting primarily as clinicians and clinical teachers for fellows, residents, and medical students.
Data Collection
D.F.B. led six annual interviews, starting in 2016; from 2018–2021, she was assisted by S.A.R. In these interviews, D.F.B. and S.A.R. asked several main questions to elicit information about things like peak learning experiences within a specific timeframe and career goals. In recursive interview style (Balmer, Varpio, et al., 2021)d shared with each participant’s their prior responses to main questions and asked participants to reflect on those responses. None of the interview questions asked specifically about personal/social identities.
In-person interviews were conducted in 2016–2019; subsequent interviews were conducted via video conferencing due to COVID-19 restrictions. Interviews lasted an average of 32 minutes (range 20–56 minutes). All interviews were audio-taped and transcribed by D.F.B., S.A. R., or a professional transcription company. The Institutional Review Board at Children’s Hospital of Philadelphia approved the study (IRB 16-012984) in 2016.
Data analysis
Our analysis was an iterative process. Recognizing the important insights into alternate career paths in medical education offered by our three participants and tapping into our own experience with stories derived from LQR (Balmer, Devlin, & Richards, 2017; Balmer, Rosenblatt, & Boyer, 2021; Balmer, Teunissen, Devlin, & Richards, 2020; Blalock & Leal, 2022), we proceeded with narrative analysis. Narrative analysis entails relating events and actions to one another to produce a temporally organized whole (Clandinin & Connelly, 2000; Konopasky, Varpio, & Stalmeijer, 2021; Polkinghorne, 1995). We drew upon a holistic lens from narrative analysis, a lens that “preserves the status of a story as a complex and integrated unit” (Konopasky et al, 2021, p 1370). By honoring the entirety of each participant’s stored experience (Konopasky et al., 2021; Polkinghorne, 1995), this holistic lens also privileged the longitudinal nature of our data.
Our dataset for this study consisted of 18 interviews (six interviews per participant) conducted from 2016 to 2021. Field texts were comprised of 150 pages of single-spaced interview transcripts. Data were managed in Atlas.ti v 9 (Scientific Software Development, Germany).
We analyzed data in three phases. In the first phase (Fall 2021), D.F.B. reviewed all field texts. As the primary investigator for the larger LQR, she had an existing, intimate knowledge of the field texts. To start narrative analysis for this study, she proceeded with a reading that was sensitized by her understanding of agency as unfolding through time. She wrote analytic memos about salient concepts like directing imagining one’s future career and what counts as legitimate career advancement in academic medicine. Then she created a time-ordered display where portions of field texts that illustrated agentic actions, what triggered those actions, and deliberations about those actions were displayed chronologically for each participant.
In the second phase of data analysis (Winter 2021), D.F.B. wove portions of field text from time-ordered displays into two-page, interim counternarratives for each participant. Agentic actions served as plot points in the counternarratives and formed a narrative arc for each participant’s story. D.F.B. shared interim counternarratives in final interviews with the three participants. She asked them to edit their counternarrative to better reflect their nuanced and evolving experience. (Clandinin, Cave, & Berendonk, 2017; Clandinin & Connelly, 2000) Two participants added details which highlighted the intentionality behind their agentic actions.
In the third phase of data analysis (2022), D.F.B. shared analytic memos and near complete counternarratives with A.E.B. In an initial reading, A.E.B. applied the theoretical lens of agency from O’Meara’s conceptualization, making notations of strategic actions and perspectives throughout the counternarratives. With these notations in hand, D.F.B. turned back to original transcripts to check credibility and added detail to the counternarratives. In this iterative process of transitioning from interim counternarratives to final counternarratives, our presentation of findings began to take shape. Clandinin and Connelly (2000) describe this process as one where researchers both follow the thread of a story as well as construct the story, sometimes as a reflection of theoretical underpinnings. Hence, D.F.B. and A.E.B. discussed their application of O’Meara’s lens, adding more detail about how agency was deliberated (strategic perspective) and enacted (strategic action) in the counternarratives. Together, they highlighted what happened when participants’ internal sense of what it means to be an educator did not align with field norms and the actions provoked by that misalignment. These revisions of the counternarratives formed the final presentation of findings.