Vision 2020: How Caregiving and Work Productivity Outlook Shifted for Academic Pediatric Faculty

Introduction

Academic medical centers and their faculty have been directly affected by the coronavirus disease 2019 (COVID-19) pandemic across research, educational, and clinical domains. The pandemic has strained both clinical and basic science research ^{1 –4} and has had dramatic effects on medical education through the necessary shift of medical curricula and clinical teaching to virtual and remote methods to ensure safety for faculty and learners. ⁵ Clinically, COVID-19 has affected many specialties, requiring changes in practice, limited bedside interaction, increased remote medicine, and for many has presented a new disease entity with uncertain treatments and significant morbidity, mortality, and infection risk to health care providers. ^{6 –9}

Societal inequities have been exposed and exacerbated by the pandemic and extended to academic faculty, whose productivity may have been adversely affected. ^{10 –12} Female and minority faculty may face higher hurdles to maintaining their academic productivity due to these existing inequities and increased caregiving responsibilities during the pandemic. ^{13 –15}

We sought to describe the effects of the COVID-19 pandemic on faculty work productivity and caregiving responsibilities to identify groups of faculty at risk for widening inequities from the pandemic and to better understand and prioritize actual or potential strategies to mitigate the adverse effects on faculty academic productivity.

Materials and Methods

A cross-sectional study design was conducted with a self-report survey of pediatric faculty at Baylor College of Medicine. The survey was designed by a subcommittee of nine faculty engaged in clinical, educational, and research efforts, representing both junior and senior faculty. Published recommendations for how to prevent widening inequities due to the pandemic, ^{16 –18} studies assessing the effect of COVID on researchers, ¹⁹ and an internal report conducted by Temple University's College of Public Health (shared and used with permission) informed the development of the survey.

It was designed to assess descriptors of the faculty, changes in caregiving needs due to the pandemic, changes in job productivity across clinical, teaching, and research domains, and perceived changes for the individual's likelihood of pursuing promotion as previously planned. The Department of Pediatrics has a large and diverse faculty and the survey was designed so that only those with any caregiving responsibilities received questions regarding changes in caregiving due to the pandemic. Similarly, only those with ≥10% effort in clinical, teaching, or research received questions specific to those duty areas.

A list of potential mitigations of the pandemic's effect on faculty productivity and well-being, derived from the published literature ^{16 –18} as well as the Temple University survey was adapted for our context. Faculty were asked to identify which solutions they would find least to most helpful (Likert scale of 1–4). They were also invited to offer write-in responses for additional mitigations they would find beneficial. Patients or the public were not involved in the design, or conduct, or reporting, or dissemination plans of our research; however, the target population, pediatric faculty were involved.

Once the survey was developed, it was reviewed by seven additional faculty, representing men, women, clinicians, researchers, educators, and leadership, to provide feedback before administration. The local Institutional Review Board approved the study protocol (protocol number H-48852).

The final survey (available on request) was distributed via the secure REDCap platform ^20,21 to all faculty in the Department of Pediatrics on December 1, 2020. The institutional email address was used to track survey completion. Three reminders were sent to those who had not yet completed the survey, and it closed on December 20, 2020. The survey took ∼15 minutes to complete, and all responses were kept anonymous without linkage to email addresses.

Results

Of the 1226 faculty reached, 498 (40.6%) opened the survey. Six refused to participate, and four did not respond; six agreed but did not continue into the survey. The remaining 482 (39.3%) are included in this analysis, of whom 423 (88%) had complete data. The majority (70.1%) of the respondents were women (Table 1), which is slightly more than the 65% of the distribution list for the department of pediatrics (p < 0.05). A slightly lower proportion were instructors compared with the department as a whole (11.8% vs. 16%, p < 0.05). Seventeen percent were URM, similar to the department.

The majority of respondents reported doing ≥50% of caregiving and household responsibilities (n = 398, 82.6%), with more women than men (p < 0.001), and more junior faculty compared with full professors (p = 0.01) carrying the majority of this responsibility (Table 1 and Appendix Figure A1). Of the faculty with caregiving responsibilities (66.6%), 55.1% of those had a child or children in grade school (5–12 years). Their primary caregiving support was a spouse/partner (81.6%), and 44% of faculty with preexisting caregiving responsibilities reported a substantial increase in caregiving during 2020.

This increase in responsibility was reported to be greater for women (p = 0.003) and junior faculty (p = 0.02) (data not shown). Only 38.6% reported that their caregiver needs were fully met in September 2020, compared with 76.9% pre-pandemic and 34% early pandemic (March to June 2020). An unplanned daycare/school closure would affect many, with 42.1% reporting it would affect both themselves and their spouse/partner directly (Table 1).

The frequency of faculty workplace and wellness outcome responses are provided in Table 2. Five of the 12 regression models of perceived career-related outcomes had covariates associated with the outcomes (Table 3). Compared with men, women were more likely to report increased teaching quality (aOR = 2.8; 95% CI 1.07–7.32; p = 0.04). Women also reported increased clinical productivity when compared with men (aOR = 2.4; 95% CI 1.06–5.74; p = 0.04). Faculty with ≥10% in clinical, research, or teaching effort reported different one-year outlooks in each of their work contexts, with a fair-to-poor outlook reported by 20.5% with clinical, 41.3% for research, and 22.0% for teaching.

Using multiple pairwise comparisons, there were significant differences between research versus teaching and research versus clinical outlooks (Bonferroni adjusted p ≤ 0.001) (Fig. 1). None of the covariates was significantly associated with the 1-year outlook for each context of work.

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FIG. 1.

Pediatric faculty 1-year outlook for their productivity in clinical, research, and teaching efforts. *The number of faculty were significantly higher than expected based on the standardized residual. **The number of faculty were significantly lower than expected based on the standardized residual.

Many faculty planning to apply for promotion in the next 10 years (n = 308) reported concerns that the pandemic would delay promotion, with 44.0% agreeing or strongly agreeing that their increased caregiving responsibility, 44.8% their reduced research productivity, and 35.0% their changed teaching efforts affected their ability to go up for promotion in the future (Table 2). Junior faculty and those with pandemic-related increased caregiver responsibilities had double (aOR = 2.20; 95% CI 1.05–4.62; p-value = 0.04) and nearly quadruple the odds (aOR = 3.85; 95% CI 1.44–10.29; p-value = 0.01), respectively, for delaying plans for promotion.

Junior faculty also were more likely to report concerns that changes in teaching effort may delay their plans for promotion (aOR = 2.43; 95% CI 1.17–5.05; p-value = 0.02; Table 3). More than one-third of faculty (37.4%) reported a moderate to significant effect on their ability to do their job to their best of their ability due to the impact of the pandemic on their own or loved ones' physical or mental wellness. Caregivers with an increased responsibility during the COVID-19 pandemic were more likely to report wellness concerns affecting their job performance when compared with caregivers with no change in responsibilities (aOR = 2.34; 95% 1.12–4.89; p-value = 0.02); junior faculty were more likely to report these concerns than senior faculty (aOR = 1.76; 95% 1.04–2.97; p = 0.03; Table 3).

Overall, faculty reported that their preferred mitigation strategies included clear communication of expectations by leadership and that direct leaders acknowledge the need for adjustments in overall expectations. Women and junior faculty were more likely to report flexible work hours being most helpful (Table 4). Men reported that the option of having an offline day would be helpful, whereas significantly more women rated this option favorably.

Of the three separate analyses for the mitigation factors, junior versus senior faculty had significantly different preferences than the other groups compared, including greater preference for flexible work hours, an offline day, flexibility in clinical schedules, adjusted promotion requirements, workload reduction opportunities, and broader dissemination of career development virtual opportunities (the last being least favored by all) (Table 4). Faculty with increased caregiver needs reported workload reductions and expanded childcare as being more helpful when compared with those without increased needs (Table 4).

The major themes and subthemes of the write-in suggestions by faculty for other possible solutions can be found in Appendix Table A1. The comments by faculty included some challenges and frustrations that they faced during 2020. The themes in a summative format centered largely on six main domains or themes indicating a need for: communication and system-wide messaging, adjusted expectations for promotion; flexibility and allowing to work from home; childcare, eldercare, and domestic support; increased availability of support services; and acknowledging the multiple effects of the pandemic.

Discussion

Our study explores the perceived adverse effects of the COVID-19 pandemic on the different academic missions in a large diverse department of pediatrics as well as the subgroups of faculty members who may have been disproportionately affected. The COVID-19 pandemic has had a profound effect on academic physicians, physician-scientists, and scientists. Even before the pandemic, as is well reported in the literature, female academic faculty members typically had to juggle a disproportionate burden of household responsibilities compared with their male colleagues. ^{15,23 –25}

The pandemic brought this problem to a more acute focus, and female faculty faced a greater increase in caregiving responsibilities compared with men, suggesting that the pandemic may have unintentionally widened preexisting gender-based inequities with women, and junior faculty projecting long-lasting effects on their ability to fully engage in academic pursuits. ^{26 –31} In terms of career stage, irrespective of gender, junior faculty and those with increased caregiving responsibilities were at the highest risk of perceiving the pandemic to have an adverse effect on their career.

Our study showed a worse 1-year outlook for research than for clinical and teaching responsibilities among the pediatric faculty, similar to other studies that also found careers of scientists, female scientists, those involved in bench science, and those with younger dependents to be most adversely affected by the pandemic. ¹⁹ Other studies have reported similar gender disparities with lower academic productivity among female faculty. ²⁶ A number of financial, productivity, and administrative factors in concert with personal stressors likely contributed to this response by the pediatric research faculty.

From late March to late May 2020, our institutional research laboratories ceased in-person non-therapeutic and/or non-COVID-19 research efforts. Later in the year, when research teams were able to resume in-person work, effort remained limited due to staggered schedules and lab supply shortages that impaired research capacity. Administrative professionals also faced work–life balance challenges, leading to secondary issues for researchers needing support for inventory management, protocol approvals, grant preparation, budget, and human resource management. Although similar to other institutions, ²⁷ our department of pediatrics had an increase in grant submissions and publications in 2020 (unpublished data); this survey suggests that the increase in productivity was not felt by all, and the differences were not explained by the covariates assessed in this study.

The context and barriers experienced by some faculty that affected their productivity during the past year should be recognized by institutions when reviewing productivity during the pandemic, and consideration should be given for how to support at-risk faculty to maintain a diverse biomedical research workforce.

Not all women faculty were affected equally by the pandemic, with women more likely than men to report an increase in their teaching quality and an increase in clinical productivity in the past year compared with men. This may be related to the subspecialties represented, the differing career stages of women who participated in the survey, or the division-specific virtual teaching resources made available. It could also have been due to individual-level factors beyond the scope of this study. Women's increased clinical productivity may also point toward their greater recruitment to the clinical workforce, thus decreasing their contribution to other academic missions.

The faculty as a whole reported long-range implications of the pandemic on their perceived academic advancement, with greater than one-third of the faculty—particularly junior faculty and those with increased pandemic-related caregiver responsibilities—projecting that their promotion would likely be delayed. This highlights the importance that stressors related to work–life balance play a role in career advancement. Although delays in promotion for many may be unavoidable, the “tenure clock” was extended by 1 year at Baylor College of Medicine to recognize the challenges that are beyond the control of most individuals. Interestingly, this was not reported to be helpful by faculty (Table 4).

More than one-third of our faculty reported that concerns for their own or their loved ones' well-being moderately or significantly affected their ability to work. The emotional toll on health care workers during this pandemic is well documented, with a higher prevalence of both depression and anxiety among health care workers than the general public. ²⁸ Frontline health care workers were at a higher risk of contracting the disease as well as experiencing adverse psychological outcomes in forms of burnout, anxiety, fear of transmitting infection, feeling of incompatibility, depression, increased substance dependence, and post-traumatic stress disorder. ²⁸

For all faculty, the need to return to in-person work, while potentially putting children or family members at risk by outsourcing care was likely another source of stress. Specifically, among our faculty, those with an increase in caregiving responsibilities had a 2.5 higher odds of having a moderate to significant negative effect on their work, suggesting that mitigations are particularly needed for this subgroup.

When asked about mitigations regarding these disparities, the faculty felt that the most important topics revolved around communication. There was universal agreement that clear communication among leaders and faculty, adjustment of expectations, and flexibility to work from home were key mitigating factors (Table 4). Our faculty found least helpful additional support and training activities such as webinars, wellness training, peer support groups, or the College's adjustment of promotions criteria/tenure clocks. Although the survey did not quantify burnout, it is likely that a proactive approach, with an increase in organization-wide efforts and creative and tailored solutions to mitigate this, will, undoubtedly, benefit faculty going forward.

Our study has some important limitations. Although our faculty is large and diverse, there were slightly more female respondents and fewer instructors compared with the overall department, which could have led to respondent bias. It is important to note the timing of the survey: This was during the ninth month after the start of the pandemic and this brings with it the consideration that recall bias may have affected the responses. Moreover, it was disseminated at a time when our city was experiencing a surge in COVID that followed the Thanksgiving holiday in the United States and before the availability of vaccines.

Further, we did not specifically ask about the current status of childcare or schooling, and in-person learning partially resumed in public schools in October 2020. Although the effect of the timing is hard to quantify, a repeat survey should be conducted after the widespread vaccination of pediatric faculty and the U.S. population and with an increased return to in-person school. Further, real-time monitoring of markers of productivity and promotion readiness should be tracked for at-risk groups and addressed by the institution. Of note, the survey set out to explore stressors and opportunities for improvement and did not specifically ask “what went well” in the department during the pandemic.

In addition, a number of the desired mitigations had been implemented. Future surveys should also query what interventions and mitigations were favorable. As a single institution study, departmental and organizational factors may be very different compared with other institutions. However, this study reflects one of the largest departments of pediatrics in the world and may be generalizable to other academic pediatric departments. A national survey including pediatric academic institutions would give greater insight on the broader effect of the pandemic on pediatric faculty.

Conclusion

Women experienced a greater change in their caregiving responsibilities compared with men due to the pandemic. Pediatric faculty with increased caregiving responsibilities, many of whom are women, and junior faculty are at highest risk for the pandemic, affecting their productivity and/or ability for promotion. Researchers reported a worse 1-year outlook than the other groups. These subgroups may warrant special attention to help support their career advancement and retention in academic pediatrics. Faculty identified clear communication, acknowledged need for adjustments in expectations, and flexible work hours, with women and junior faculty more likely to report flexible work hours to be most helpful in helping maintain productivity.