Host Maureen A. Madden, DNP, RN, CPNC-AC, CCRN, FCCM, welcomes Kitman Wai, MD, and Sonali Basu, MD, to discuss the article, “Evolution of Pediatric Critical Care Medicine Physicians Clinical and Academic Profile by Gender,” published in the October 2024 issue of Pediatric Critical Care Medicine (Wai K, et al. Pediatr Crit Care Med. 2024;25:e376-e386). This is the first analysis of career and academic characteristics of practicing pediatric critical care medicine physicians. The authors also studied the association of gender and career trajectory. They will discuss the gender gap between male and female pediatric critical care physicians in academic metrics and rank, career trajectory factors such as burnout and academic versus nonacademic careers, and the study limitations.
Dr. Wai is a critical care specialist and director of critical care medicine fellowship at Children’s National Hospital in Washington, DC. Dr. Basu is a critical care specialist, associate chief of critical care medicine, and associate director of critical care fellowship at Children’s National Hospital in Washington, DC.
Find more expert-developed articles from Pediatric Critical Care Medicine at pccmjournal.org.
Transcript:
Dr. Madden: Hello and welcome to the Society of Critical Care Medicine podcast. I’m your host, Maureen Madden. Today I’ll be speaking with Drs. Kitman Wai and Sonali Basu about the article, “Evolution of Pediatric Critical Care Medicine Physicians Clinical and Academic Profile by Gender,” which was published in the October 2024 issue of Pediatric Critical Care Medicine. To access the full article, visit pccmjournal.org.
Dr. Kitty Wai is a critical care specialist and director of critical care medicine fellowship, and Dr. Sonali Basu is a critical care specialist, associate chief of critical care medicine, and associate director of critical care fellowship, both at the Children’s National Hospital in Washington, DC. Welcome to Dr. Wai and Dr. Basu. Before we start, do either of you have any disclosures to report?
Dr. Wai: I do not.
Dr. Basu: Nothing related to this study.
Dr. Madden: Excellent. I’m so very happy to have both of you here and to talk about your publication. Congratulations, first of all, on having that published. To really understand background interest in this topic, why did you choose the focus of this publication, and have either of you had had any prior research on it?
Dr. Basu: This, going back historically, all started with just a casual conversation with one of the other authors, Dr. Murray Pollack, on this paper about abstracts and how many of them end up getting published. These are abstracts submitted to major conferences. We saw that there’s about a 40% publication rate. Then that got us thinking to the whole point or intent of doing research during fellowship, and we had looked specifically about abstracts done by trainees.
Given the ABP requirements, we know that it is there, but we started to think about the research component of fellowship and really what the end game with that was, and what impact that has on what you end up doing for the rest of your career. We then looked at all the fellowship programs and graduates of different fellowship programs throughout the country to see if there are different patterns between different fellowship programs and what their graduates end up doing academically.
We used publication and h-index as a metric, we can talk a little bit more about the validity of that, so looked at different fellowship programs and used the fellows who graduated from those programs as a surrogate for what the program was, then compared different ones. We found there are more academic programs, graduates from more academic programs end up working in places that are academic, bigger ICUs, and end up having more publication output later in their careers.
Then again, casually talking about the cohort we had and expanding it, then looking specifically at different factors, Kitty brought up, what about women in critical care? Because there are so many other factors that may impact these metrics, and I’ll pass it on to her to how we frame our next study. But a lot of interesting thoughts came out of it.
Dr. Wai: I’m going to take over what Sonali was saying. I’ve been involved in medical education and fellowship education since my graduation time, and it’s always interesting to me to see where the fellows go after they graduate. Looking back at my own career trajectory, there’s a moment of time that I do feel that my focus is not on my academic productivity, right, it’s definitely on my young family and how to really balance work and family.
So, looking at gender is something that I’m interested in to see if other individuals who are in this field, which is demanding when it comes to clinical work, feel the same way, or does the career trajectory get impacted at certain time points of their life, when they feel like they have to take a step back from where they are right now, take a step back in taking care of things outside of academic productivity, and then later on continue to build a career.
Sonali and Murray have had this dataset for a while, so we just went back in and built on it a little bit more, then that allowed us to give us a glimpse at the gender difference of the academic profile in pediatric critical care.
Dr. Madden: Having looked at your publication, as you said, you’re looking at the gender differences, and you’re looking at the h-index, which is productivity and impact, so how many articles have been published and how many citations have come from that publication and also looking at academic rank on the basis of, you chose five-year increments for looking at the course of your career, early, mid, to late, and what academic rank had been achieved. I’d love for you to briefly give an overview of what you found for your research, and then we can dive into a little bit more about why these may be the right metrics or just a starting point.
Dr. Basu: I can talk a little bit about why we started, our first, again, going back to that last paper with h-index, and again, we continued using that same metric here. Historically, a lot of the surgical subspecialties, and that’s where most of the literature is using h-index, use that as a very objective cut point for a different rank. Again, the h-index in surgical specialties is often very different than in pediatrics and pediatric critical care, just given the nature of the publications, and that there are not often as many single case reports or single surgical experiences that get cited.
So we use that, again, in pulling people’s h-index, we realize that there are flaws in that system too because it doesn’t really take where authorship is, so middle authorship that gets cited gets a point or however the points go on, and commitment you had to that study may be variable based on whether you were first author, second author, or a middle author in a slew of authors. But that was one of the things we thought was at least published on and could at least be referenced when we were doing it. But again, lots of flaws that we discovered with that system, but it was one of those things, it was the best system we had that we would be able to find something for everyone.
Dr. Madden: I’m glad that you recognize that it may have its limitations and be flawed. Talking in the context of academics in general, not just medicine, but historically had been that publish-or-perish mindset, that’s how your rank was, you were able to achieve and move up in the academic rank. Now we know, over time, that there’s been some movement to change how you’re evaluated for productivity, and it’s not just publication, it’s not bench research or clinical research, but maybe people are now taking on the safety and quality roles, they’re taking on other QI pieces, they’re taking on education roles, they may take on other academic ranks. That would not be captured within the h-index, as you said.
Dr. Wai: Correct. I think the reason we use h-index for this particular publication is because it’s publicly available. We did a search on Scopus or ResearchGate, like you mentioned before, and it’s something that just goes with the data that is readily available on public websites.
We also use MPI, we confirm things on American Board of Pediatrics. These are just what are available to us right now. Again, I think for this particular paper, we want to raise awareness that there might be a difference but by no mean that this is the best metric we can find to define somebody’s career or tell the story of what is happening for a physician of a different gender who is going through their career as a pediatric critical care specialist.
Dr. Madden: Talking about women, there’ve been lots of conversation over the years. And it sometimes is a question about whether or not these are valid items to study, such as work-life balance, the recognition that females are the childbearing individuals. Looking at that, how does that impact full-time versus part-time or even, as you said, stepping and taking time away?
Dr. Basu: Yeah, I think there is this unrecognized public awareness that women who are finishing fellowship are at that childbearing age so they may have different work output than their male counterparts. Again, the landscape is changing with parental leave. There are fathers or other caregivers who are taking time away.
But historically, it was this kind of recognition that, at that point in life, women may not have the same output over that amount of years. Where I’ve really learned to appreciate that people recognize this is in taking and participation in our institution’s promotion committee and just listening to the discussions of different candidates and their productivity over time. And there is always this, and it’s not discussed, but there’s always this recognition that they have two young children or something like that, and not in a negative or pejorative way in that why didn’t they do more but in a recognition of they’ve been so successful and they have young children.
So I think over time it is being more recognized, and there’s more appreciation of the multiple pulls in different ways. The other thing I was going to mention from your last question is that I do also now fully believe that there are different scales or different metrics in different institutions. What may constitute promotion to associate professor in one institution may be drastically different than associate professor in another institution.
We really saw that, though it wasn’t reported because we’re not comparing institution to institution, we saw some individuals at one institution where their h-index was equivalent, as an assistant professor, to what a professor’s h-index at another institution is. So I think that’s another thing that is a, I don’t know if I would call it a flaw, but something to consider that there is not a universal, you have to have a number of 10 to go up to the next level. Again, not taking into any consideration all the other things that impact promotion, service to hospital, service to community, service to field, those aren’t really measurable by any index or by any number.
Dr. Madden: Absolutely. I love that you brought that up. I’ve been in critical care, pediatric critical care specifically, for many years, and I’m not going to tell you how many, but I did have the good fortune early on in my career to work with some of the individuals who really developed pediatric critical care. We were talking about Murray Pollack, who’s on this study with you, he’s identified as one of those individuals and he’s contributed a huge body of knowledge to this. Peter Holbrook, Alan Fields, we could name so many, but they’re all male.
Looking at the history and also looking at the data, I think it has to be taken also in the context of what the environment looked like at the time. Critical care as a discipline is really not that old, to start with, but many of them were men who started it and have built a very robust discipline. Now you looked at the data and, in 2022, many more females, so actually it was 72% in first year of fellowship were female versus 10 years prior it was only 47%. We are seeing that shift and to look at some of the data, your rank has time associated with it also. The conversation about how many achieve full professor versus more predominance of females as assistant and associate, there’s so many things to pull out of there.
As you were saying to the viewpoint now of recognizing that there are many other areas of contribution and not all academic institutions are uniform, there’s no consistency where you are. I’ve seen that in my own environments over time. So I’m so happy to talk to you because there are so many things in here that are rich that still need to be discussed and brought out. You’ve taken the method of traditional research to try and bring it to the forefront. I understand that you’re continuing or there are individuals you work with who are continuing on this journey of looking at gender diversity.
Dr. Wai: Yes. I think we wrote it in the limitation of the study, right? I think for a study such as this, which is sort of one glimpse into one time looking at everybody who we can get the publicly available data, there’s definitely a flaw in the study. In order to get a better understanding of career trajectory, one of our star fellows who I have gotten permission to talk about this, Dr. Prabhakar has started taking the initiative to start planning a qualitative study as a continuum of this study. Because we really want to understand the story, the trajectory of individuals at different career time points, what their story is like as a pediatric critical care female physician, what do they value, what are the factors that drive their career to be the way it is.
We’re hoping that that study will, in a few years, hopefully everybody will see it again at PCCM, we’ll see. But we’re hoping that we will get some more rich data to describe people’s career trajectories in a more granular fashion instead of just a number and an h-index and a rank.
Dr. Madden: That’s stuff that I’m going to look forward to seeing and hopefully it’s something that comes out pretty soon and then lots of other people build upon it. One item I also wanted to touch on, and you did mention it also in your limitations and your conclusions in this publication, was about burnout. Recognizing that this is a high-intensity environment, high stress, high expectations, long hours, and then, as we said, trying to balance your personal and professional lives over time. I just wanted to get your take on how you think burnout has affected some of the statistics and conclusions that you were able to draw in your study.
Dr. Basu: I think burnout is definitely real and is a focus of a lot of how we shape training and faculty mentorship and faculty development is to try to train the best critical care physicians who are doing cutting-edge things, excellent clinical work, but still protecting them from the burnout that comes from the high-stress environment that we work in and the demands of all the things that are required of an intensivist.
I would be very curious to see, and we didn’t do this, although I’m sure in some world this data would exist if it could be done, is a cross between what we found with individuals and the workforce study that I think it was Ettinger did it, it just came out recently looking at, and again, it was survey based, but looking at weeks of service and hours of clinical demands and seeing if there’s some associations there.
Again, what neither of them really represent is all the other things that don’t have a measurable metric, cost of living, how many other responsibilities you have outside of work. Are you working extra because the compensation is not what you need? Do you have a partner who is working certain hours? I think there are so many things that we’re hopeful that this interview-based study that Dr. Prabhakar is doing will be telling. People have been very, very enthusiastic about being interviewed because I think people want to tell the story. I think people want to share why they did what they did, why they do what they do, and why they choose different things and different lifestyles as far as shift work or hours or weeks. But I’d be curious to see what the overlap is because I’m sure there are associations between burnout, output, and how much one is working.
Dr. Madden: I think that you’re absolutely correct that that’s going to be some very enlightening data to come out and really demonstrate that it correlates to the conversation. And now we’re just providing you the evidence to show what we’ve been talking about is true and it has value and how we can address it. Because individuals who are so highly trained and have such experience, we need to figure out how to maintain them in the environment for long term.
Some of the things that you looked at that weren’t necessarily statistically significant were the size of the units. You looked at academic versus nonacademic, and the nonacademic tend to be smaller, in my own experience. And when people shift into that, is there a shift later in career? Maybe better pay is there, better schedule, less stress because it’s not the huge academic center and the population of patients that come in don’t necessarily have the same complexity and high acuity. Thoughts about that?
Dr. Wai: Yeah, we were looking at that. A surprisingly large number of individuals actually choose to stay in an academic center, right? So we thought we saw a small trend of maybe later in the career, there is a trend toward going to the nonacademic unit, but we thought the trend was only in male, not in female.
But I think now there’s also some protection of staying in an academic center too. Like you said earlier on, when you have worked for some period of time, you probably have earned your ability to maybe not do as many night calls and maybe take on other responsibilities in the hospital. So I would say that we don’t see a big drop-off in the people who are in the academic center. Surprisingly, a lot of the individual, even at the professor level and/or 30, 40 years out of critical care medicine, they still choose to stay in an academic center.
Dr. Basu: The other thing I would add is, again, this is my history as a program director, Kitty being a program director, if you go back to the very beginning, this is the only thing that they know, right? When fellows are coming in to train, they train in academic centers. Their mentors are clinicians in academic centers, so that is the life that they know. The way fellowship is structured, it’s structured with usually 50% research time, right? And 50% clinical. That is the structure of an academic intensivist. When you spend three years where that’s all you know, you end up finishing at the end of fellowship thinking, what’s your first job?
Your first job is typically going to be something that is familiar, what you know, what you’ve seen, and what you’ve modeled for three years. Whether it’s true or not true, I think there is a lack of desire to leave academics immediately out of fellowship, out of the fear, whether it’s valid or not, that I won’t ever be able to get back into it, you know, if I go nonacademic, if I go community, I’m not going to get back in, which is by no means true.
Actually, I would imagine size doesn’t really matter. A lot of smaller units have less extra levels, so your need to be functioning at the highest of your abilities is much more, you know, when you’re at a place that is smaller, maybe community center. And I just think the way training evolves, people are being trained to become academic. And I think that’s where they feel that they have to stay because that’s what they know.
Dr. Madden: Yeah, I think that’s a very true statement. The other piece that I’ve observed over the course of my career is, you’ve now been surrounded by a large number of people who are encouraging you and supporting you and mentoring you and to step out and say, okay, now I’m the only one here, or there’s just a few of us and that level of resources and support doesn’t exist anymore. I truly feel that everybody needs to have that mentorship to continue to grow and develop and the academic environment traditionally is where you’re going to find it.
Our time’s almost up, and I want to make sure that you have both had the opportunity to mention everything in the brief time that we’ve had together. Sonali, are there any final things you’d like to make sure we hear?
Dr. Basu: I think the biggest thing is I’m just very excited to hear the results of the interview-based study that our fellow is doing because it’s, I think, a way to get the story out there. And it would be lovely if it wasn’t just females, if it was both men and women. We used a Listserv that was a female pediatric intensivist Listserv. I haven’t found one that has both genders, but just to hear stories from people like, why did you go where you went and what were the things that made you successful and what were the things that were hurdles for you?
I think what that would help us do for fellows and junior faculty is to allow to provide them that mentorship and to help them navigate their careers and make them successful. Every way we function is only by what we think is the right way to do it, right? And what we think is the right path and what we think will be the things that will make them successful. But it’d be interesting to hear the stories. I’m looking forward to that.
Dr. Madden: Kitty?
Dr. Wai: I think I am humbled by the fact that this publication has generated a lot of discussion, like among, even within our group and people who I have worked with before. And this is a start for us to really study the academic profile and all the trajectory of career. This old metric is probably outdated. We need to really look at our career as a whole and rethink our value of what is considered a successful career, right? That combined with really looking at the study that is coming out, some of the other data about workforce, we’re hoping it will paint a better picture for future trainees about what a career in pediatric critical care can look like and will potentially look like.
Dr. Madden: I want to thank both of you first for taking the time to talk about your manuscript with me. I think it’s really important information, and clearly you have made it a springboard for other people to continue to work on this and bring it out into the community of pediatric critical care and open the dialogue. Hopefully it has some sweeping impact over time, but we’ll have to wait and see.
This concludes another episode of the Society of Critical Care Medicine podcast. If you’re listening on your favorite podcast app and you liked what you heard, consider rating and leaving a review for the Society of Critical Care Medicine podcast on Maureen Madden.
Announcer: Maureen A. Madden, DNP, RN, CPNC-AC, CCRN, FCCM, is a professor of pediatrics at Rutgers Robert Wood Johnson Medical School and a pediatric critical care nurse practitioner in the pediatric intensive care unit at Bristol-Myers Squibb Children’s Hospital in New Brunswick, New Jersey.
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