‘You Can't Be A Person And A Doctor’: The Work–Life Balance Of Doctors In Training—A Study

‘You can't be a person and a doctor’: the work–life balance of doctors in training—a qualitative study


Abstract

Objectives Investigate the work–life balance of doctors in training in the UK from the perspectives of trainers and trainees.

Design Qualitative semistructured focus groups and interviews with trainees and trainers.

Setting Postgraduate medical training in London, Yorkshire and Humber, Kent, Surrey and Sussex, and Wales during the junior doctor contract dispute at the end of 2015. Part of a larger General Medical Council study about the fairness of postgraduate medical training.

Participants 96 trainees and 41 trainers. Trainees comprised UK graduates and International Medical Graduates, across all stages of training in 6 specialties (General Practice, Medicine, Obstetrics and Gynaecology, Psychiatry, Radiology, Surgery) and Foundation.

Results

Analysis revealed five themes, described in detail below. In summary, the first two themes illustrate key contributors to work–life imbalance: trainees felt they had to prioritise work over home life to cope with a difficult job while also completing their training requirements; and frequent transitions at work and home could disrupt personal relationships. This caused stress which impacted on learning and also deprived trainees of support to cope with work difficulties. The next two themes explain the consequences of a lack of work–life balance. Trainees felt they lacked time to cope with personal pressures outside of work which they perceived as significantly affecting their learning and performance. Low morale and a feeling of exploitation was exacerbated by the proposed junior doctor contract, and was demotivating. The fifth theme describes the perceived greater negative impact on women due to structural barriers and discriminatory attitudes.

Expectation that trainees prioritise work over home life

Trainees expected to have to work hard and many felt medicine was a vocation. Many also felt they were expected to prioritise their work over their home life. As well as long hours and high volumes of patients to care for, trainees reported having to work in their evenings and holidays to fulfil all their training obligations such as examination revision—including finding suitable patients to practice for clinical examinations—and working on e-portfolios. This resulted in a loss of time for activities outside work, already restricted by long hours and for some, long commutes.

"Having to use leave to revise for the Royal College exams, and I guess that comes with a sacrifice of the social element or having a proper holiday or seeing your friends and using your holiday instead to revise."(White, UK graduate, male, Foundation)

Lack of work–life balance did not just result from work taking up a lot of time, but also from its stressful and difficult nature. Many trainees had worked in chaotic, poorly organised training environments in which service delivery was prioritised over learning needs and supervision was lacking. If trainees were lacking in confidence, these experiences could knock their confidence even further, impeding their ability and motivation to learn, sometimes with long-lasting effects. Similar negative effects resulted from working with trainers perceived as unsupportive or even bullying.

"The night shifts and the twelve days in a row and seventy hour weeks, I don't think they're very good for learning from the point of view that I'm too tired to learn, I'm just existing for long periods of time."
(White, UK graduate, female, GP, ST1–3)

"We didn't have SHOs, we didn't have registrars, we had staff grades and a consultant who was never around. I was constantly feeling like I wasn't sure if I was missing something, and I felt like that all the time. And no amount of sort of soul searching or reading books was helping me. What I took away from that, I wouldn't really call learning in the sense of being a junior doctor."
(Asian Indian, UK graduate, female, GP ST1–3)

A few trainers recognised that managing high volumes of work with training requirements and commitments outside work could be a significant problem for many trainees:

"You basically have a full-time job or a time-and-a-half job as a trainee, and then trying to do exams on top of that, or trying to look after a family on top of that, it's really-that's an ongoing problem that I think is the biggest problem for most trainees."
(Trainer Asian Indian, UK graduate, male, Obstetrics and Gynaecology)

Frequent transitions at work and at home and separation from family and friends

Trainees frequently changed workplaces, which could mean long commutes to work and could make it difficult to plan major life events such as buying a house or having a family:

"I'm looking forward to finishing my ST3. That's the point in my life where I'm going to start to have a life and get more of a balance. Not work full-time and start thinking about family. Because I feel like personally I've put everything on hold until I've got to the end of my training."
(White, UK graduate, female, GP ST3)

Having to spend time apart from family and friends due to work could put a huge strain on relationships; as one trainee put it, ‘it destroys families’ (White International Medical Graduate, Male ST4+ Surgery). Being separated from family and friends could also mean trainees lacked support outside work, which many found vital to enable them to cope with the demands of training.

These strains could be more likely for trainees who did poorly in assessments and so had less choice about where they worked, and whose partners who were also trainees and might be placed in another part of the country. International Medical Graduates and UK graduates from Black and Minority Ethnic backgrounds talked more frequently about ending up moving somewhere they had not wanted to be, being separated from their family and social support, and this causing stress and impeding their ability to learn and progress.

"If I don't get transferred over [to another region], I think I will be at the point where I will have to think of resigning from the job, because, I, we, me and my husband, we have lived apart, my daughter, my eldest daughter, now she's going to be six in January, she will be eighteen months old and we've lived apart for two years just because I had started my training and he was doing LATs [locum appointment for training jobs]. And it was a three hour commute, well one-way every weekend for him. But then again, it was hard for me as well, with the younger child and then, living apart in a country where literally this is just us as a family, we don't have much relatives around, so. I don't want to go through that again."
(Asian Pakistani, international medical graduate, female, Medicine ST4+)

These issues were recognised as a significant problem by several trainers:

"We've got 40% movement of trainees away from their medical school's localities now. […] There are a group obviously that's scored so low [in recruitment] they don't get the choice of where they want to be […and] don't have peer support. So that is an issue. I'm not sure what the answer is because real life is, you know, the top score gets the job."(Trainer, White, Irish, UK graduate, male, GP)

"The geography and the lack of autonomy [are the biggest problem for trainees. […] Having to move and not having control over where and when you move is difficult."
(Trainer, Black, UK graduate, female, Medicine)

Difficulty coping with commitments outside work

Trainees felt they lacked time and energy to deal with personal and family commitments outside work. Trainers and trainees identified pressures from outside work as being a major cause of trainees not engaging with training properly.

"To go home after a nightshift or whatever and then have difficulties that you have to deal with, like fielding one parent or another or, you know. So dealing with all the emotional stuff that comes with that and then having to switch off of that and then go into work and then still having to do your portfolio and do your exams and do your, you know, and switch back and forth. Plus it's so key to try and get on with your relationships so, me, I'm married and you want to make sure that, that all goes well, and my family live abroad."
(Asian Other, UK graduate, female, Medicine ST1–3)

"Needing fertility treatment was something. I couldn't conceive of rocking up to hospital every day for two weeks trying to get there and explain to people why I needed to leave the ward for two hours to go and get a scan every day for two weeks. And feeling like then have to take a year out of training to achieve that, it's bonkers."
(Asian Indian, UK graduate, female, ST4+ Medicine)

Many trainers felt the system did not allow them to support trainees with problems outside work, but some also believed that the more they know about trainees' personal lives, the more help and support they could provide.

"I've had one trainee go through divorce on the job, I've had another trainee on the brink of divorce based on domestic violence. And it's very hard to say to them “Well actually you need to prioritise your learning”.(Trainer, Asian Other, international medical graduate, female, Psychiatry)

"It's like we know the world around the patient, you need to know the world around the trainee."
(Trainer, White, UK graduate, female, GP)

Low morale and harm to well-being

Morale was generally low, and this was often because trainees felt that their propensity for hard work was exploited by employers and the government who put more and more demands on them without regard for their need for a personal life, and without providing good training environments or remuneration in return. The junior doctor contract dispute and the changes introduced with the Shape of Training review were perceived as exacerbating existing problems. The uncertainty regarding the outcome of the contract dispute and the proposed potential negative impact on work–life balance was distressing, and some trainees were considering alternative options, such as taking time out for research or seeking employment overseas.

F1: Personally I'm not even sure medicine is where my career is heading, to be honest with you. That's not just recent. That has been something over the last few years that's been niggling away. […] For me some of the constant denigration of morale and things like that, and working environment.

F2: I'm seriously thinking of quitting. […] Surely there are better ways that I can live my life. Surely there's more I can get out of my £36 000 a year that I'm earning from doing these nights, weekends. There's got to be more to it than that. […]

F3: I think morale. Junior doctors are- already before all this [contract] stuff happened, everyone was feeling a little bit, very demoralised. Morale has never been lower in the NHS. […] A lot of people are going “Why am I putting myself through this?”

(F1 White, UK graduate, female, GP ST1–3)

(F2 Asian Pakistani, UK graduate, female, GP ST1–3)

(F3 White British, UK graduate, female, GP ST1–3)

At its most extreme, a few trainees talked about being a doctor being a dehumanising experience that prevented participation in activities outside of work, such as having a family and being involved in the wider community.

"You can't be a person and a doctor." (Mixed, UK graduate, male, Psychiatry ST1–3)

"You're almost not viewed as a human being who has the right to have a family, to be involved in society, you know, involved with church or local charities or whatever."(White, UK graduate, female, GP ST1–3)

Low morale was only mentioned by one trainer.

Greater impact on women

The lack of work–life balance was felt to have a larger effect on the learning, performance and career progression of trainees with children or who wanted children, and women in particular. Some female trainees said having children would mean taking a ‘step back’ (White, UK graduate, female, ST1–3 GP) from their career and the only way possible to combine a family and work was to work less than full time; however, there was also a perceived lack of less-than-full-time positions during training and in consultant posts.

My current plan is that I will drop to part-time and I've come to that point because […] I don't think I can work full time, and have a family, and pass my exams.(White, UK graduate, female, GP ST1–3)

While not mentioned as frequently by trainers, several did mention the challenge of bringing up a family with a career in medicine:

"My current trainee has just come off maternity leave so her priority is her child and there are current episodes of sick leave, her child goes to nursery and bringing everything back to her and giving it to her. So it is quite the juggle for trainees."(Trainer, Asian Other, International Medical graduate, female, Psychiatry)

Although much fewer in number, some trainees described positive experiences of a training role which allowed them to have a work–life balance, which was particularly important at certain periods of life, such as after having children:

"It could be time of life as well. One of the rotations that I did with a hospice… we only had a consultant there once a week…. I actually really loved the job, but it was my first job back after maternity leave. I got to leave on time every day. For me coming from acute specialties it was really community-based, so it was great as my first insight to GP."
(White, UK graduate, female, GP ST1–3)

In addition to structural barriers, trainees described negative attitudes from seniors towards pregnancy and maternity/paternity leave, and towards trainees—especially women—who wanted to work less than full time. It was felt that these negative attitudes could impede learning for trainees who were having or had had children. Negative attitudes were most often reported to be from senior male doctors and/or in surgical specialties.

"I needed to learn how to do laparoscopic sterilisation and the consultant before we went in to do the case was very hostile towards me […] “How come I've got to that stage in my training and I've got children already? Was that appropriate to have children when I was at that level? How come I haven't been signed off for this particular procedure already?” […] I was in such a kind of emotional wreck by that point that I was completely incapable of learning anything. I couldn't even function at a basic level."
(White, UK graduate, female, Obstetrics and Gynaecology, ST4+)

"The surgical environment is a male bastion, whether or not we like to acknowledge it. If it's changed, it's slowly but it's still very, very male dominated. So maternity leave is a dirty word. […] I've had one very negative Annual Review of Competence Progression (ARCP) […] I was only 10 weeks pregnant and I felt that I was under pressure to be forthcoming with the pregnancy and as soon as I came out with that, that completely changed the dynamic of the ARCP and not in my favour. […] It was my first and I hope my only outcome that was not an outcome 1 […] Not to mention this very negative reaction I had from my consultant at the time in the unit when I told them I was pregnant. Very negative. He chastised me for it. […] It was soul destroying."
(Asian, UK graduate, female, Surgery, ST4+)

There were also reported instances of overt sexism, some of which were related to the perception that women would be less likely to prioritise work over their families:

"I hear [consultants] who come out with remarks that amount to- and I think I'm pretty much quoting verbatim, “I would never hire a female registrar if I could help it”.(Asian UK graduate, female, ST4+ Surgery)

"I've had people say to me, so “You're either a woman or a neurosurgeon, you can't be both” […] It made me lose the passion for my specialty and for my job."
(Asian Pakistani UK graduate, female ST4+ Surgery)

To manage these difficulties, some trainees altered their career paths. Several female trainees said they chose GP because it was the only specialty where they could see having family and being a doctor as feasible, because it allowed part-time working and greater control of their hours, and had shorter training. In contrast, a female GP trainer said that it was incredibly difficult bringing up a child while working as a GP as there is not the flexibility that exists in other careers to manage your workload, and a Medicine trainer said that work–life balance improved considerably once training ended.


Conclusions A lack of work–life balance in postgraduate medical training negatively impacted on trainees' learning and well-being. Women with children were particularly affected, suggesting this group would benefit the greatest from changes to improve the work–life balance of trainees




Source