Sustaining Clinical Academic Leadership and Excellence (SCALE): protocol for a mixed‑methods international consensus

A shrinking clinical-academic workforce: international trends

Despite their recognised value, the clinical-academic workforce is in sustained decline across high-income countries. In the United Kingdom, clinical lecturer posts—crucial to the academic pipeline—fell by nearly one-third between 2010 and 2023, with community-based disciplines experiencing the steepest losses (Lander et al., 2010; Yin et al., 2017). Similar trends are evident in Canada, where the proportion of grant-funded clinician-scientists decreased by 28% between 2015 and 2022 (Lander et al., 2010; Yin et al., 2017). In Australia, the absence of a structured clinical-academic training pathway has created comparable vulnerabilities. Surveys of medical students in Australia and the United States consistently cite time pressures, insecure funding, and poorly defined career routes as major deterrents to pursuing academic careers (Eley et al., 2017; Eley, 2018; Eley & Benham, 2016). In low- and middle-income countries, fragile research infrastructure, chronic underfunding, and brain drain further exacerbate the problem (Franzen et al., 2017; Pillai et al., 2018).

Disproportionate impacts on primary care and community disciplines

The effects of this contraction are not evenly distributed across specialties. Primary care, family medicine, and community-oriented disciplines—fields central to early diagnosis, prevention, and health equity—are disproportionately affected (Gray, 2015). In the United Kingdom, academic general practitioners account for only 6.5% of clinical academics, with just one full-time equivalent GP academic for every 159 practising GPs (Gray, 2015). Engagement in formal academic training pathways among GP trainees remains exceedingly low, with fewer than 2% in the UK and under 1% in Canada pursuing this route (Haumann et al., 2016; Howe et al., 2024a; McDonald et al., 2016). This under-representation has consequential implications for research agendas and healthcare delivery models, particularly in areas where population health demands a strong primary care foundation.

Structural inequities further entrench these challenges. Racially minoritised doctors comprise only 17% of the UK academic general practice workforce (Howe et al., 2024b), and broader data suggest that women and physicians from underrepresented racial and ethnic groups experience slower career progression across all specialties (Daga et al., 2020; Lett et al., 2018; Yu et al., 2013). Such disparities threaten the diversity, representativeness, and ultimately the societal relevance of the clinical-academic community.

Barriers to entering and sustaining a clinical-academic career

Several interrelated barriers impede the entry and retention of clinician-scientists. Chief among these is funding instability. Hyper-competitive grant environments, short-term salary awards, and limited bridge funding opportunities collectively delay research independence and create precarious career trajectories (Lauer & Lauer, 2017; Rusakevich et al., 2021). For many early-career clinician-scientists, these structural challenges drive attraction towards purely clinical roles.

Clinical service demands increasingly erode protected research time, particularly within publicly funded health systems facing workforce shortages and rising care demands (Husain, 2021). This erosion of research capacity often occurs during critical early-career stages, when time and mentorship are most needed.

Inconsistent mentorship and training infrastructure further hinder academic progression. Many clinical academics report inadequate access to senior mentors capable of guiding them through the complexities of dual clinical and research careers, particularly outside large AMCs (Mirali et al., 2020; Yoon et al., 2018). Compounding these challenges are structural inequities linked to gender, ethnicity, and international graduate status, which create additional barriers to progression, lengthen time-to-first-grant, and exacerbate professional isolation (Fang et al., 2000; Lett et al., 2018).

Fragmented solutions: lessons from existing initiatives

A range of initiatives has sought to address these challenges, including protected research time schemes, integrated MD-PhD training pathways, and leadership development fellowships. Some have demonstrated promising results. Mentoring-focused programmes such as the Faculty Mentoring (FAME) scheme and the Mayo Clinic Kern Scholars programme have led to increased publication rates and greater research funding success among participants compared with controls (Barreto et al., 2021; Dovat et al., 2022). Protected-time initiatives have similarly been associated with enhanced academic productivity and improvements in clinical service delivery (Ognibene, 2018; Hilder et al., 2020).

However, most interventions remain fragmented, often institution-specific, and variably evaluated. Studies typically focus on short-term outputs rather than long-term career trajectories, limiting their generalisability (Kramer et al., 2015; Rosenblum et al., 2009). Calls for national oversight mechanisms, harmonised outcome tracking, and coordinated investment strategies have been made repeatedly but largely remain unmet (Weggemans et al., 2019; Yin et al., 2017).

Building consensus: a structured approach

Given the multifactorial nature of the problem and jurisdictional variations in healthcare and academic systems, a single prescriptive solution is unlikely to succeed. Nevertheless, policymakers, funders, and training institutions urgently require clear, prioritised, and context-sensitive strategies to support clinical-academic careers.

Structured consensus methods offer a transparent and rigorous means of addressing such complex challenges. Techniques such as the Nominal Group Technique (NGT) facilitate equitable participation, minimise dominance effects, and enable the generation of prioritised action statements in real-time (Cantrill et al., 2011). A subsequent single-round electronic Delphi process can validate and refine these outputs with broader stakeholder engagement, ensuring rigour, transparency, and feasibility (Cantrill et al., 2011). Adhering to established reporting standards such as ACCORD and CREDES will further enhance the credibility, replicability, and impact of the findings (Gattrell et al., 2024).

Against this backdrop, the SCALE (Sustaining Clinical Academic Leadership and Excellence) study aims to identify and prioritise actionable strategies to attract, retain, and advance clinical academics across disciplines, with particular attention to strengthening primary care and other under-represented fields. It further seeks to validate these strategies through a transparent, multi-stakeholder consensus process and to disseminate a concise, evidence-based roadmap that policymakers, funders, and training bodies can adapt to their specific contexts.

An opportunity for global collaboration at ICRE

The 2025 International Conference on Residency Education (ICRE) provides a timely and strategic platform for initiating this structured consensus-building process. Bringing together more than 2,000 clinicians, educators, and policymakers from over 30 countries, ICRE offers a rare opportunity for cross-disciplinary, cross-jurisdictional collaboration. Embedding a NGT session within the conference programme, preceded by a targeted pre-conference REDCap survey and followed by a single-round electronic Delphi, enables real-time knowledge synthesis at scale.

The presence of stakeholders from high-, middle-, and low-income settings will ensure the resulting consensus reflects a diversity of perspectives, increasing its relevance and potential for adaptation across healthcare systems. By generating a prioritised, actionable roadmap, the SCALE study aims to inform national and international strategies to sustain and strengthen the clinical-academic workforce, ensuring its capacity to meet future healthcare challenges.

Aims and objectives

The SCALE (Sustaining Clinical Academic Leadership and Excellence) study aims to identify and prioritise actionable strategies that attract, retain, and advance clinical academics across disciplines, with particular attention to primary care and other under-represented fields. It further seeks to validate these strategies through a transparent, stakeholder-driven consensus process and to disseminate a concise, evidence-based roadmap that policymakers, funders, and training bodies can adapt to their local contexts.

Study design

The SCALE study is a four-stage, mixed-methods, international consensus study comprising:

The protocol’s appendices, such as the pre-workshop survey and the search strategy for the rapid scoping review, will be prospectively registered on the Open Science Framework (OSF) and reported in accordance with the ACCORD guideline for consensus studies and the CREDES standards for Delphi work (Gattrell et al., 2024). The scoping review follows JBI methodology and PRISMA-ScR reporting principles (Page et al., 2021; Peters et al., 2020).

Stage 1: Rapid scoping review

Objective

To map existing evidence on strategies that recruit, retain, or advance clinical academics, with a specific focus on primary care and community-oriented disciplines.

Eligibility criteria

Eligible sources include empirical studies and opinion pieces published between 2015 and 2025, in any language and from any country, that describe interventions, programmes, or policies relevant to the clinician-scientist pipeline.

Information sources and search strategy

Searches will be conducted across MEDLINE, EMBASE, CINAHL, Scopus, and Web of Science, covering the period 1 January 2015 to 1 July 2025. Search terms will combine concepts related to clinician-scientists, workforce or career development, and interventions or strategies. Grey literature from funding agencies and policy organisations (e.g., CIHR, NIHR, NIH, OECD, WHO) will be included.

Selection and data charting

Two reviewers will independently screen titles/abstracts and full texts using Covidence software, resolving disagreements through consensus or arbitration by a third reviewer. A piloted charting form will capture study characteristics, intervention components, and reported outcomes.

Analysis and reporting

Findings will be summarised narratively and mapped against predefined domains (funding, workload, mentorship, equity). Reporting will follow the PRISMA-ScR checklist, and outputs will feed directly into survey-item generation, which will be uploaded to OSF.

Stage 2: Pre-workshop survey

Instrument development

Approximately 20 draft priority statements will be derived from the scoping review findings and framed as actionable recommendations (e.g., "Guarantee 20% protected time for early-career clinician-scientists"). Each statement will be rated for importance and feasibility on two 9-point Likert scales. Demographic items, a forced-choice ranking of the top five priorities, and a free-text field for additional suggestions will be included.

Platform and data security

The survey will be administered using REDCap, a secure, metadata-driven electronic data capture system hosted on encrypted servers at the Royal College of Surgeons in Ireland (RCSI). Access will be restricted to the study team via two-factor authentication.

Sampling and recruitment

The study team will distribute email invitations via institutional mailing lists (e.g., the College of Family Physicians of Canada and the NIHR Academy) and the advisory panel’s outreach channels. Targeted snowball sampling will be used to achieve ≥30% respondents from low- and middle-income countries (LMICs) and ≥40% early-career clinicians. Response rate targets (≥35%) will be monitored weekly; if unmet after two reminders, the steering group will broaden recruitment strategies. Assuming a conservative standard deviation of 2 on the 9-point scale, a minimum of 100 responses will yield 95% confidence intervals of ±0.4 on item medians—sufficient for NGT agenda-setting.

Analysis

Survey ratings will be summarised using descriptive statistics (medians, interquartile ranges [IQR]) for each item. Heat maps will be generated to visualise rating distributions and inform prioritisation at the NGT session. Free-text responses will undergo reflexive thematic analysis using NVivo, following Braun and Clarke’s six-phase approach (Braun & Clarke, 2008).

Stage 3: Nominal group technique workshop

Setting and participants

The NGT session will be conducted in person at ICRE (Québec City, 31 October 2025). Eighteen to twenty-two participants will be purposively selected to ensure diversity in geography, discipline, career stage, and equity groups. Simulation studies indicate this range achieves rating stability with diminishing returns beyond 20 participants.

Procedure

Following standard NGT protocols, the workshop will comprise:

Consensus definition

Consensus will be defined as a median score ≥7 with IQR ≤2, or ≥75% of participants rating an item 7–9 on the importance scale. Use of electronic anonymous voting, equal-time timers, and neutral facilitators will help prevent domination by senior voices.

Data handling

Workshop discussions were manually transcribed. Field notes and photographs of flip charts will supplement data capture. Quantitative and qualitative data will be integrated with survey findings to refine final statements.

Stage 4: Electronic Delphi validation (conditional)

If ≥20% of statements fail to meet consensus thresholds at the NGT workshop, or if under-represented stakeholder groups are insufficiently captured, a single-round electronic Delphi survey will be administered within two weeks. Participants will include all original survey respondents and NGT participants.

The Delphi instrument will present each statement alongside NGT median and IQR feedback and request re-rating using the same 9-point scale. Consensus thresholds will mirror those applied in the NGT. Any remaining non-consensus items will be reported transparently as research uncertainties. Delphi methods and reporting will adhere to CREDES guidance.

Patient and public involvement

Patients were not involved in the study design. However, lay representatives will be invited to review the plain-language summary.

Ethical considerations

The study is classified as minimal risk, and ethical approval has been granted (REC202506032) from the RCSI Research Ethics Committee in Dublin, Ireland. Study procedures will follow the Declaration of Helsinki regarding ethical standards for studies involving human participants. Informed electronic consent will be obtained before survey completion, and written informed consent will be obtained at the NGT workshop.

Summary

This protocol describes the design of the SCALE study—an international, mixed-methods consensus process to identify and prioritise strategies that support clinical academic careers across disciplines and stages. The study responds to global concerns about the declining number of clinician-scientists and the limited visibility and support for clinical academics in primary care and other underrepresented fields (Husain, 2021; Windsor et al., 2017). By combining a scoping review, an international survey, an NGT session, and a conditional Delphi round, SCALE aims to generate actionable guidance for decision-makers, grounded in stakeholder consensus.

Strengths of the study

SCALE incorporates several design strengths. First, its methodology adheres to recognised reporting standards for consensus research, including ACCORD and CREDES, which promote transparency and reproducibility (Gattrell et al., 2024; Jünger et al., 2017). Second, it combines wide engagement through survey distribution with in-depth deliberation via a facilitated NGT session. The latter has been used effectively in diverse fields—including healthcare, education, and conservation—as a structured, inclusive method for reaching consensus on complex issues (Fallon & O’Connell 2024; McMillan et al., 2016).

Embedding the NGT within the ICRE offers a cost-efficient and carbon-efficient approach to stakeholder engagement. This setting also facilitates real-time prioritisation among a geographically and professionally diverse group. Free-text survey data will be analysed using reflexive thematic analysis, enabling deeper exploration of underlying rationales and contextual differences across regions and career stages.

Limitations

This study also has limitations. While purposive and snowball sampling will support representation across geography, discipline, and career stage, self-selection bias may persist—particularly among respondents from LMICs. Language barriers and the requirement for in-person workshop attendance may further limit participation, despite mitigation efforts. These challenges reflect broader issues in global workforce research, including structural biases in access, authorship, and evidence generation (Harris et al., 2017).

The Delphi validation stage is limited to a single round, which may not fully resolve all areas of disagreement. However, this decision balances feasibility with rigour and aligns with recommended practice for structured consensus processes (Diamond et al., 2014). Any items that do not reach consensus will be transparently reported as research uncertainties.

Finally, while patient and public involvement is not embedded in this protocol, lay reviewers will be invited to co-develop a plain-language summary of findings. Future research could expand on this work by incorporating service user perspectives on the value and visibility of academic roles in clinical care.

Implications for research, policy and practice

The outputs of SCALE are intended to inform national and institutional strategies for academic workforce development. Prior research has emphasised the need for structured, integrated pathways to support clinical academic training and retention (Windsor et al., 2017). Mentorship, protected time for research, and a supportive institutional culture have all been associated with improved academic productivity and retention (Dovat et al., 2022; Raine et al., 2022). By identifying stakeholder-endorsed priorities, SCALE provides a roadmap to align with these efforts and inform investment decisions by funders, health systems, and universities.

The planned open dissemination of ranked strategies and thematic findings will also provide a resource for implementation research. Importantly, the study will highlight areas where further evidence or targeted intervention may be needed—particularly in relation to equity, interdisciplinarity, and the inclusion of generalist disciplines such as family medicine.