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BMJ Open BMJ Open: first published as 10.1136/bmjopen-2016-013897 on 2 December 2016. Downloaded from “You can’t be a person and a doctor”. The work-life balance of doctors in training: a national qualitative study ForJournal: peerBMJ Open review only Manuscript ID bmjopen-2016-013897 Article Type: Research Date Submitted by the Author: 15-Aug-2016 Complete List of Authors: Rich, Antonia; University College London Medical School, Research Department of Medical Education Viney, Rowena; University College London Medical School, Research Department of Medical Education Needleman, Sarah; University College London Medical School, Research Department of Medical Education Griffin, Ann; University College London, Medical School Woolf, Katherine; University College London, Academic Centre for Medical Education <b>Primary Subject Medical education and training Heading</b>: Secondary Subject Heading: Qualitative research QUALITATIVE RESEARCH, work-life balance, MEDICAL EDUCATION & http://bmjopen.bmj.com/ Keywords: TRAINING, women, gender, medical training on September 24, 2021 by guest. Protected copyright. For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 1 of 86 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2016-013897 on 2 December 2016. Downloaded from 1 2 3 4 “You can’t be a person and a doctor”. The work-life balance of 5 6 doctors in training: a national qualitative study 7 8 9 Dr Antonia Rich, Research Associate1 10 Dr Rowena Viney, Research Associate1 11 Dr Sarah Needleman, Clinical Teaching Fellow1 12 Dr Ann Griffin, Senior Lecturer in Medical Education2 13 Dr Katherine Woolf, Senior Lecturer in Medical Education1 [email protected] 14 15 1 For peer review only 16 Research Department of Medical Education 17 UCL Medical School 18 Room GF/664, Royal Free Hospital 19 London NW3 2PF 20 21 2Research Department of Medical Education 22 UCL Medical School 23 74 Huntley Street 24 London WC1E 6AU 25 26 27 28 Corresponding author: [email protected] 29 30 31 32 33 34 http://bmjopen.bmj.com/ 35 36 37 38 39 40 41 42 on September 24, 2021 by guest. Protected copyright. 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 1 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 2 of 86 BMJ Open: first published as 10.1136/bmjopen-2016-013897 on 2 December 2016. Downloaded from 1 2 3 4 5 6 7 8 9 Structured abstract 10 11 Objectives: Investigate the work-life balance of doctors in training in the United Kingdom (UK) from 12 the perspectives of trainers and trainees. 13 14 Design: Qualitative semi-structured focus groups and interviews with trainees and trainers. 15 Setting: PostgraduateFor medical peer training in London,review Yorkshire and Humber,only Kent Surrey and Sussex, 16 17 and Wales during the junior doctor contract dispute at the end of 2015. Part of a larger General 18 Medical Council study about the fairness of postgraduate medical training. 19 20 Participants: 96 trainees and 41 trainers. Trainees comprised both UK graduates and International 21 Medical Graduates, across all stages of training in six specialties (General Practice, Medicine, 22 Obstetrics & Gynaecology, Psychiatry, Radiology, Surgery) and Foundation. 23 24 Results: Postgraduate training was characterised by work-life imbalance. Long hours at work were 25 typically supplemented with revision and completion of the e-portfolio. Trainees regularly moved 26 workplaces which could disrupt their personal lives and sometimes led to separation from friends 27 and family. This made it challenging to cope with personal pressures, the stresses of which could 28 then impinge on learning and training, while also leaving trainees with a lack of social support 29 30 outside work to buffer against the considerable stresses of training. Low morale and harm to 31 wellbeing resulted in some trainees feeling dehumanised. Work-life imbalance was particularly 32 severe for those with children and especially women who faced a lack of less-than-full-time positions 33 and discriminatory attitudes. Female trainees frequently talked about having to choose a speciality 34 that was more conducive to a work-life balance such as general practice. The proposed junior doctor http://bmjopen.bmj.com/ 35 contract was felt to exacerbate existing problems. 36 37 Conclusions: A lack of work-life balance in postgraduate medical training negative impacted on 38 trainees’ learning and wellbeing. Women with children were particularly affected, suggesting they 39 40 would benefit the greatest from changes to improve the work life balance of trainees. 41 Key words: Qualitative, work-life balance, medical education, women, gender, medical training, 42 on September 24, 2021 by guest. Protected copyright. wellbeing. 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 2 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 3 of 86 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2016-013897 on 2 December 2016. Downloaded from 1 2 3 Strengths and Limitations 4 5 • There are increasing concerns about incidence of burnout and the lack of work-life balance in 6 7 doctors in the United Kingdom (UK); this study provides a timely account of junior doctors 8 experiences given fears that this may deteriorate further as a result of changes to junior 9 10 doctors’ contracts introduced in 2016. 11 12 • This qualitative study has a large and diverse population with 137 participants including 96 13 trainees from all grades, UK and international graduates from White and Black and Minority 14 15 EthnicFor backgrounds, peer six medical specialities review and four geographical only areas in England and 16 17 Wales. It also includes 41 trainers including course directors and postgraduate deans. 18 • Not all specialities and locations in the UK were represented, meaning potential differences 19 20 could not be fully explored. 21 22 • There is the possibility of response bias; those most dissatisfied may have been more likely to 23 volunteer, however trainees mostly described both positive as well as negative experiences. 24 25 26 27 28 29 30 31 32 33 34 http://bmjopen.bmj.com/ 35 36 37 38 39 40 41 42 on September 24, 2021 by guest. Protected copyright. 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 3 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 4 of 86 BMJ Open: first published as 10.1136/bmjopen-2016-013897 on 2 December 2016. Downloaded from 1 2 3 Introduction 4 5 Medicine is a prestigious and valued career, but it can be arduous: doctors are required to work long 6 hours, make difficult decisions in the face of uncertainty, and cope with death and distress while 7 maintaining compassion (1, 2). Doctors in training have to undertake competitive job applications 8 and numerous assessments and examinations, while managing frequent job, role, team and hospital 9 10 changes (3). It is unsurprising that medical training is associated with mental health problems (4-7) 11 with a recent review concluding that lack of work-life balance, long hours, lack of job satisfaction, 12 female sex, and younger age are important predictors of burnout in doctors (8). Doctors’ wellbeing 13 has a significant impact on healthcare provision and directly influences patient care, including 14 patient satisfaction, adherence to treatment, and interpersonal aspects of care (9-11). Recently 15 there have beenFor significant peer concerns that alreadyreview high levels of emotional only exhaustion and burnout in 16 17 doctors will increase as a result of changes to the junior doctor contract in the UK and this will cause 18 trainee doctors to leave the UK to work in other countries (1, 12) causing significant problems for a 19 health system already suffering a recruitment and retention crisis, particularly in specialities like 20 general practice and psychiatry (13-15). 21 22 As a group, female doctors have been found to be vulnerable to burnout (8) and two studies have 23 highlighted lack of work-life balance as the single most important precipitant of burnout in female 24 doctors. One UK study surveyed 716 doctors across six different NHS trusts in London and the South 25 East of England, finding that female doctors and doctors working full time had significantly increased 26 27 levels of stress and burnout compared to male doctors and those working less-than-full-time (16). A 28 study from the US found burnout rates among female doctors increased by 12% to 15% with each 29 additional 5 hours they worked over the contracted weekly 40 hours and this correlated with 30 women feeling less control of their working environment (17). The strain of juggling caring 31 responsibilities with challenging job demands impinges more on women because domestic 32 responsibilities more often fall to them; (18) although some studies have found the strain of 33 34 parenthood was related to stress for male as well as female doctors (19, 20). http://bmjopen.bmj.com/ 35 Previous research has examined the impact of work-life balance on doctors’ and medical students’ 36 37 psychological health, but there is little evidence about how it might affect their experiences of 38 training, learning, and career progression. This study will examine how trainee doctors and their 39 trainers perceive work-life balance during postgraduate medical training and its impact on learning 40 and career progression. This study formed part of a larger General Medical Council funded study 41 about the fairness of postgraduate medical training, and was conducted during the junior doctor 42 on September 24, 2021 by guest.