Are part time doctors better doctors?BMJ 1997; 315 doi: https://doi.org/10.1136/bmj.315.7113.2 (Published 10 October 1997) Cite this as: BMJ 1997;315:S2-7113
Working part time brings more humanity and a greater understanding of patients and the real world, argues Helen Gibson
Part time work has an ambivalent position in medicine. The high drop out rate of doctors has provided a major economic incentive to allow more flexible working1 - one survey found that a quarter of a 10 year cohort of medical graduates in the north west of England had no contact with the NHS.2 Yet the traditional ethos of medicine values single minded commitment, continuity of care, and success linked to age. This has led to part time workers being undervalued.
There has been a great interest in flexible working among doctors with supply outstripping demand.3 Looking at this more closely, however, a paradox becomes apparent. The lower status applies almost exclusively to women, particularly those with domestic responsibilities, doctors in training grades, and those in non-training career posts. Part time NHS contracts for consultants, especially those who work elsewhere in medicine for remuneration, are not thought of in the same way. The difference is that consultants are regarded as showing self determination, whereas flexible working in others is considered an option to allow those who cannot cope with the existing system to do less. This rather paternalistic view does not consider that part timers may bring badly needed qualities to a profession that is beset with low morale, stress, and communication problems.
A sign of the times
Although most doctors continue to work long hours, it is not because they want to. Most feel that although medicine is a major commitment they also deserve a decent family life and leisure time. Many younger doctors and women doctors feel more strongly that medicine should be organised to balance careers with family and other interests.4 This is in keeping with current trends elsewhere in the job market. Less than half of the workforce in the industrialised world will be in proper full time jobs in organisations by the beginning of the next century.5 In this atmosphere, Handy's concept of portfolio careers, which consist of several different jobs, combine paid and unpaid work, and change according to circumstances makes increasing sense.
Debunking the myths
Part time working has low status because, compared with traditional values, doctors who work flexibly may seem to lack commitment, underachieve when compared with the rest of their cohort, and lack the mental and emotional strength to make it. This is not the case. Although some doctors do become ill from stress and are unable to work, the overall prevalence of stress in the profession is too high to claim that this is because some weaker individuals cannot cope with normal demands.6 Overall job stress is mostly related to work overload and the effect on home life and this affects both men and women. Although the types of problems affecting the careers of both sexes are similar, women's careers are particularly affected by the demands of working in a traditionally male profession and child rearing.
Qualities that part time workers can bring to medicine
Wider experience of life
Humanity and caring
More liberally educated doctors
There is no evidence that the women who change specialties or go part time because of demands of child care are any less talented than those who continue, but women suffer from the lack of enough female role models in some specialties to prove to sceptics that they are as competent and motivated as men. The overriding problem is of the continued lack of status afforded to child care. Time out of clinical work to do research on narrow and sometimes obscure topics is acceptable, but maternity leave is less so. In fact, having and caring for children, as well as providing greater maturity and responsibility, enhances paediatric, management, and communication skills. More importantly, although caring is one of the qualities most valued in a doctor, looking after your own family is often the only practical experience of caring that most doctors have.
E M Forster called those who had only one dimension to their lives “flat people.” Candidates for medical school are selected, particularly in those schools that hold interviews, not just on high science A level results but on the ability to show that they are well rounded individuals with many talents. The irony is that these great all rounders often end up consumed by the system that they seek to enter with no time for other pursuits. Although the moulding of multifaceted people into single faceted people can be thought of simply as a waste of talent and be a source of regret later in life, it has more profound implications for medicine. Medicine has to be practised in the real world. Doctors are taught to think of life, illness, and death in a specifically medical way and as medicine becomes more specialised and more technical, the similarities between the lives of doctors and those of the majority of their patients become fewer.
Downie and Charlton suggest that to counterbalance this, doctors should have at least one other way of thinking than that of medicine.7 Since medicine is not a postgraduate degree and most courses are full of almost exclusively scientific information, the most amenable way for this to occur is by combining the practice of medicine with something else. Not only would this bring wider experience into medicine, it would also stimulate more interest and creativity. Doctors who already have successes in other fields are praised, but given the quality of entrants into medical school, this could become the norm and not the exception.
Humanity in medicine
Humanity is a longed for and often elusive quality in medicine. Charlton defines the humane doctor as one who is wise, compassionate, and liberally educated and who recognises that there is more to life than medicine-both for doctors and their patients.8 Humanity cannot be put on the medical curriculum. As Weatherall said, “No medical school can teach a young person how to be understanding and caring. This can come only from experience of life.”9 When life consists only of medicine and especially of the type of medicine where technical skills and scientific diagnosis is prized, this experience is limited. Humanity and its comprising qualities are promoted by a broad education in the widest sense of the word. Sir Kenneth Calman, the chief medical officer, talks of wanting doctors who optimally are clinicians, scientists, and scholars, with wisdom promoted by scholarship.10 Neither hum- anity nor wisdom are promoted by excessive busyness and pressurised conditions of work. To quote Weatherall again, “From the time that they [doctors] decide on a career in medicine until they retire, many of them live in such an overcharged atmosphere, and one in which the demands on them are so great, that sometimes the central reason for what they are doing- that is the wellbeing of their patients-is forgotten.”9
Threatening the status quo
Increased acceptance of part time working into all fields of medicine will alter the traditional norms. It will allow more women to fulfill their potential in medicine and will threaten the old fashioned sexist attitudes and practices that have limited them in the past. A well worn argument against part time working is that it adversely effects continuity of care. But in medical practice with the increasing subspecialisation of medicine and the introduction of partial shifts, this is an ideal which no longer exists to any great extent. The movement is increasingly towards team collaboration and as most doctors think that women have a more collaborative style of practice,4 this situation will improve only as women become more equal in medical practice.
Life in perspective
Part timers can bring many well needed qualities to medicine, most importantly the ability to put life and medicine into perspective. Tired, stressed, and unfulfilled doctors cannot be good communicators,11 and they find it hard to be sympathetic and caring. Recent discussion about how to select medical students who will be caring doctors and good communicators misses a vital point. The understanding and caring doctors are in medicine right now. What is needed is more space and flexibility to allow them to develop and maximise these qualities and at a time when they are developing, not at the end of their careers. This is something that part time working can address.
Although it may seem that increased part time working would reduce manpower levels, a more flexible approach could also attract back those doctors who refuse to work in the system-doctors with a wider life experience and possibly a more creative approach to life. The idea of portfolio careers is a good one and an idea that would make medicine a more fulfilling career for many. But it is important to remember, as Handy points out, that free work is as serious as paid work. A career portfolio that includes being a doctor, mother, and aspiring pianist is just as relevant as one where the person is a doctor, medical politician, and MD student and may be more valuable in terms of understanding what is important in life and in communicating with the majority of patients.