Intended for healthcare professionals

Career Focus

Attitudes to flexible training

BMJ 1999; 318 doi: (Published 13 March 1999) Cite this as: BMJ 1999;318:S2-7185
  1. Gail Norcliffe,
  2. Christine Finlan, job-sharing joint heads,BMA Junior Doctors Section,
  1. Tavistock House, Tavistock Square, London, WC1H 9JR

    How's life for those who are already in it? Gail Norcliffe and Christine Finlan have just completed Britain's biggest ever survey of flexible trainees

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    Over recent years, the Junior Doctors Committee (JDC) has made considerable efforts to improve the opportunities for flexible training in hospitals and the conditions applying to those in such training. Among the improvements the JDC has been seeking are flexible training being available for all those who want it; competency based assessment, rather than a time served approach; and standard rates of pay being payable to those undertaking flexible training for the first 40 contracted hours they work.

    To provide detailed evidence of the current position, the committee has worked with the BMA's health policy and economic research unit to undertake a detailed survey of flexible trainees in the United Kingdom. Flexible trainees were sent the questionnaire in the latter half of November last year and asked to return them by the middle of December. Postgraduate deans' offices, which held the most up to date lists of flexible trainees in their region or province, helped by mailing out the survey. No reminders were sent. The results of the survey will be announced at the junior doctors' forum on the future of flexible training on 25 February, organised by the Junior Doctors Committee.

    One of the most striking features of the results was the response rate. Generally, surveys of junior doctors do not get a good response, but in this case 70% (797) of flexible trainees responded. This level of interest has been echoed in the number of applications to attend the junior doctors' forum (170 for the 100 places). Clearly, this is a well motivated group of junior doctors, keen to make their voice heard.

    Characteristics of trainees

    Most of the 797 respondents were women (only 22 were men); almost 75% were higher specialist trainees (specialist registrar, senior registrar, or registrar), although a sizeable minority were senior house officers; and most were in their early to middle 30s (76 respondents were under 30, and 87 were aged 40 or more). By far the most common reason for applying for flexible training was responsibility for children (89%); other family responsibilities and ill health were the other main reasons. Most trainees (738) lived with a partner, and 26 were single parents. The profile of the “average” flexible trainee is thus probably as could have been predicted: a 34.6 year old woman with children and a partner and who is in the specialist registrar grade.

    Family life

    Many of the respondents observed that the flexible training scheme was the only way in which they could responsibly combine parenthood with medical training, and some considered that “full time training and examinations [are] incompatible with any form of family life.” Given that a higher proportion of doctors will be women in years to come, it will be essential for there to be more opportunities for flexible training if doctors are to be retained. Extending the scheme may also be popular with junior doctors of both sexes who wish to work less than full time but who do not have young children.

    Working patterns

    The most common number of contracted basic hours among the flexible trainees was 24 (52%), followed by 20 hours (17%) and 28 hours (15%). On top of the basic hours, the average contracted on call commitment was 15 additional duty hours. In addition, 65% of respondents said that they regularly worked more than their contracted hours, with an average of just over four hours a week. Thus over half “part time” junior doctors were working in excess of 40 hours a week. Furthermore, the intensity of on call work seems to be greater for flexible trainees than for their full time counterparts. According to the most recent (September 1998) regional task force returns, 16% of posts are outside the new deal arrangements. However, about a quarter of flexible trainees on on call rotas reported that they spent 25% or less time resting during their on call time. Such work intensity is considerably in excess of the new deal limits, which require a period of eight hours' rest during a 32 hour duty period, five hours of which should be continuous and between 10 pm and 8 am.

    In commenting on the main problems encountered as a flexible trainee, a number of respondents noted the difficulties with being on call, particularly in arranging child care. Typical comments included: “On call is a huge problem, as my husband is often away/works long hours” and “I find on call stressful only because it is always a juggling act with children.” In addition, the medical culture of early starts and late finishes cannot be reconciled with childcare arrangements: “Early starts for theatre and post op checks before clinics - daycare nursery doesn't start early enough. Also departmental in house teaching is at 8 am - same problem.” Another flexible trainee threatened to resign because she found that she could not leave on time to collect her children when she covered intensive care in the afternoons. Such problems are obviously not confined only to flexible trainees but affect all junior and many senior doctors with children, the vast majority of whom are not benefiting from a family friendly working environment.

    Operation of the scheme

    Most respondents said that they had found out about the scheme by word of mouth from colleagues, which is disappointing in view of the efforts to publicise the scheme formally. Twenty two per cent reported a delay between when they wanted to start training flexibly and when they actually started. Although some commented on the disadvantages of extending their training, 77% (616) intended to complete their training as a flexible trainee.

    From the educational point of view, there was a reasonable level of satisfaction regarding flexible training meeting trainees' needs (see table 1). Study and research stand out as the least satisfactory aspects; this was reflected in the general comments, in which several respondents reported difficulties in undertaking and completing research.

    Table 1

    Satisfaction with educational value of flexible training.

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    A number of respondents commented on problems of continuity and handing over duties. A further problem was the perception that they were regarded as “lesser” members of the department and not taken as seriously as full time colleagues. Respondents were specifically asked if they were aware of being treated any differently by their colleagues or others because of their status, and replies are detailed in table 2. Although about half felt that they were treated differently, the comments show that much depends on attitudes at local level and the extent to which consultants are supportive and accommodating to the needs of flexible trainees.

    Table 2

    Are flexible trainees aware of different treatment by colleagues because of their status?

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    Pay was identified as a particular problem by several of those who commented. Several made observations about the unfairness of not being paid for the number of hours that they routinely worked. Others noted the wider problem of low pay, particularly those without a wage earning partner. One commented that flexible training “enables a life outside of medicine - as long as you can be financially supported by someone else.”


    On a particularly positive note, respondents overwhelmingly said they could recommend flexible training to their colleagues: only 2% said they would not, and 7% were not sure. Despite the difficulties, there was a consensus that, for very many people, flexible training is the only satisfactory way of combining being a junior doctor with other major responsibilities. However, the scheme would clearly benefit from various improvements to make it fairer to those who opt for this way of training.

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