Objective: To explore the attitudes of Australian medical students to the balance between work, family and other aspects of lifestyle, within a broader exploration of the issues that they regard as important to their decisions about future career.
Design: Qualitative study using semistructured focus groups and individual interviews.
Setting: The three medical schools in New South Wales and a national conference for students interested in rural practice.
Participants: First- and final-year medical students who volunteered for focus groups held between March and August 2002 (82 students in 10 groups) or for individual interviews held between July and December 2003 (48 students).
Main outcome measures: Emergent themes relating to the balance of work, family and other aspects of lifestyle.
Results: Most students referred to a balance of work, family and lifestyle as an important factor in their career decisions. While indicating they were committed to medicine, they were unwilling to work to the exclusion of all else. Most saw family commitments as a high priority, and many saw “time out” as important in maintaining their health. Female students spoke of part-time work as essential for future happiness, while some male students expressed a preference for working part-time. They would seek to achieve balance by choosing to work in disciplines, locations and structures where limited-hours work is available, and would negotiate support from their partners and parents in caring for children.
Conclusions: It is important that the medical profession continue to develop working and training structures that allow a balance of work, family and lifestyle.
For many years, most medical practitioners in Australia and overseas have worked more than 40 hours per week, often in response to the need to provide emergency services. 1-3 The willingness of doctors to work extended hours has been traditionally valued by the medical profession in Western society as an aspect of professionalism and a sign of a level of commitment of doctors to their profession. 4-8 However, extended working hours are a source of stress for many doctors. 9-13 Although female doctors tend to work fewer hours on average than male doctors,6,7 many find conflict between their roles as doctors, mothers and wives a significant source of stress. 6,13-18
Women now make up about fifty percent of medical students,19 and it is likely that balancing work and family commitments will be a significant issue for them in the future. There is also evidence that recent medical graduates of both sexes are concerned about the impact of vocational choice on family life and lifestyle. 20,21
We report qualitative data on medical students’ attitudes to the balance between work, family and other aspects of lifestyle and how they expect to achieve this balance in their lives. This was part of a broader exploration of the issues that Australian medical students regard as important to their decisions about future career.
We obtained data from 10 focus groups of medical students held between March and August 2002 and 48 interviews with individual medical students between July and December 2003. We used the two forms of data collection to provide methodological triangulation and ensure reliability of the data.
The study used the methods of grounded theory, a qualitative approach to analysing social processes. 22 Techniques used included constant expansion (ie, questions were added to interviews to pursue issues raised in earlier interviews), theoretical sampling (ie, particular types of participants were pursued to achieve a range of views and fill in gaps), and constant comparison (ie, data were compared to previous data as they were collected).
The focus groups were conducted at three universities in New South Wales and at a national conference for students interested in rural practice from all 11 Australian medical schools. Students were invited to participate in the focus groups by a notice posted on the medical faculty websites, a flyer distributed to tutorial groups and, at the conference, by an announcement by one of us (H M T) at a plenary session. Each focus group comprised 6 to 10 students in either the first or final year of their medical course. The universities, type of course and composition of the focus groups are shown in the Box.
The interviews were conducted with first- and final-year medical students from the three universities. Students were invited to participate by a notice posted on the medical faculty websites.
The invitations stated that the focus groups and interviews were part of a project investigating the influences on choice of rural practice, but were open to all students, not only those interested in a rural career. Focus groups and interviews were held at times convenient to the students. They were not paid to participate.
Maximum variation sampling was used, in that the researchers attempted to include students from a range of demographic backgrounds and from medical courses that differed in entry requirements and course structure.
Questions were developed specifically for this project based on a literature review. This included a Boolean search of Medline (1975–2001) and Sociological Abstracts, a sociological database published by Cambridge Scientific Abstracts (1963–2001), using the key words medical students, doctors, and career. We also searched the websites of the Australian Medical Association, the Australian Medical Workforce Advisory Committee, the NSW Rural Doctors Network and the Australian Department of Health and Ageing to identify studies of factors influencing the career choices of medical students and graduates. Relevant references cited in documents at these sites were followed up.
The questions asked about students’ attitudes and intentions in relation to the discipline of medicine; geographical location and practice environments in which they wished to work; and influences on their career intentions and the decision-making process. There were no specific questions about balancing work, family and lifestyle. While a theme list was used to structure the interviews, the approach was informant-led, and data collection was sensitive to the concerns of and issues raised by participants in the interviews. New questions were added as the study proceeded to pursue the issues raised.
The focus groups were semistructured and lasted 60 to 90 minutes. All but four groups were led by two facilitators (the authors); three were led by H M T and one by S M S alone, for logistical reasons. Facilitators posed set questions, giving all students the opportunity to provide individual answers to each question and encouraging discussion of any issues.
The interviews lasted 20 to 40 minutes and comprised the same questions as the focus groups. They were conducted by one of us (H M T) and were face to face, except five, which were by telephone because of difficulties organising a time to meet. During interviews, the researcher questioned students in depth about issues identified in the focus groups and in previous interviews.
The focus groups and interviews were audiotaped and transcribed. Transcriptions were analysed independently by the two authors for content and emergent themes, using the N6 computer package. 23 Themes and subthemes were coded, and the results discussed to reach consensus on the meaning of individual statements, ensuring researcher triangulation.
Codes developed for analysis of focus group data were also used in analysis of interview data, with new codes being added for interview data as needed. The data of the focus groups and interviews reached saturation by the completion of the study (ie, no new themes or subthemes were emerging from later interviews). Focus group data were compared with interview data, ensuring methodological triangulation.
General themes relating to all data were identified, including factors influencing discipline choice, such as role models, experience, personal interest and work availability at preferred locations. A detailed analysis was undertaken of issues relating to the balance of work, family and other aspects of lifestyle. We also analysed sex differences by considering comments in which participants referred directly to their sex as a factor influencing career intentions, as well as differences between issues raised by male and female participants.
Ethical approval was given before the project by the human research ethics committees of the University of Newcastle, the University of New South Wales and the University of Sydney. Potential participants were given a detailed information sheet on the project and signed a consent form before participating. Data were de-identified before analysis to protect confidentiality.
Eighty-two students participated in the focus groups (36 men and 46 women in first or final year in 2002), and another 48 in the interviews (18 men and 30 women in first or final year in 2003). Two interviews were not properly recorded because of equipment failure; for one, the interviewer’s notes were used as data, while the other was excluded as the notes were insufficient.
Participants were aged from 17 to 40 years and included both married and single people, with and without children. Some were graduate students, with many years of experience in the workforce in a variety of occupations, while others had entered university straight from school. They also included people from Aboriginal and non-English-speaking backgrounds. The focus groups at the rural conference included students from all 11 Australian medical schools.
Issues relating to the balance of work, family and other aspects of lifestyle were raised by students in all focus groups and by most of those interviewed, even though there were no specific questions about these issues. The few students interviewed who did not raise these issues were younger, mainly first-year students and recent school-leavers.
Most students discussed having a commitment to work and a desire to also have “time to spend with my family and time to pursue other interests”. One student said that a balanced life means “you have medicine and you have life as well, and medicine is part of your life, not the whole of it”.
Analysis identified five main themes relating to work–life balance: work, family, leisure, generational change and achieving work–life balance.
Some students saw “medicine as a bit of a calling”, with commitment to working in areas such as rural or remote communities or developing countries. They spoke of “wanting to help people”, because “we all know with statistics, there is such a need for it”. Few students saw medicine as “just a job in the end”. Most indicated their commitment to working in medicine, but resisted the tendency to be “workaholics”, rejecting “medical martyrdom” and being reluctant to be “a sacrificial lamb” or “slaughtered to medicine” by “working from 6.30 in the morning until midnight at hospital”. They saw enjoyment as an important aspect of work, to which adequate time out from work would contribute.
Most referred to family life, with some students of each sex indicating they would consider a career change to achieve a work–family balance.
Those without a partner or children discussed family issues as hypothetical, while those with family referred to “the commitments and responsibilities that I have already” limiting their options for postgraduate training because of concerns about demanding training programs.
Many saw “lifestyle” (social and leisure pursuits) as a high priority, and indicated unwillingness to work in a medical discipline or location where long hours would preclude other activities. Several spoke of needing to sustain themselves emotionally while working long term in medicine, seeing “time out” as a health issue.
Students perceived a difference between their attitudes to balancing work, family and lifestyle and those of older doctors. Many spoke of “recognising some of the down sides of people who have practised before us and learning from what they are telling us now”. They felt that “it’s all a bit tragic really . . . for the human profession” that many older doctors had been so focused on work that they had missed out on other aspects of life, with some having “a bitter twisted old man syndrome”.
Some students whose parents were doctors did not wish to emulate their long working hours. Some were concerned about pressures from senior colleagues on junior doctors to be there when “your consultant’s having ward rounds at 6 o’clock on Friday afternoon and on Sunday”. One student thought a professor who said “medicine is a full time thing and don’t expect that you can do it any other way” was “closed minded”. Another spoke of “reversing some of those . . . suicide statistics . . . alcoholism statistics etc by just looking after yourself”.
Some students discussed achieving a balance of work, family and lifestyle by “compromise” and by making specific career and family choices.
Career choice: Many spoke of choosing specialties and locations where work with flexible and limited hours would be available, seeing these as “more family friendly”.
Many referred to being “discouraged from doing O & G . . . because of the hours” and a perception that “it’s just not compatible with family life”. Some indicated being deterred from surgery or from working in rural or remote locations because of their perception of a heavy burden of work, describing surgical training as “punitive”.
Many spoke of preferring work environments perceived as more flexible. Most would prefer “not to be in a solo practice”, seeing “larger group practices” as “ideal”. While some thought “your own private practice could be a little bit more flexible around kids and family”, others thought a salaried position would be more flexible, as “you’re on a roster, do the work and you get your money in. When you’re off, you’re off, and someone else covers for you.” Those interested in obstetrics said they would prefer to work as a staff specialist rather than a private obstetrician because of working hours.
Family and relationship choices: Most students discussed negotiation and compromise with their partners to work out responsibilities for children and home life. Some spoke of having “a joint role, with neither person working completely full time”, while a few female students spoke of reversing traditional gender roles with their partners. Some students said they would “like to be near one of our parents when we have kids”, as they saw family support as important in helping them cope with being in dual-career families.
Female students of all ages were more likely than male students to identify family issues as important in career decisions and to speak about part-time work as essential for their future happiness. One female student said: “The fact that we want to have kids at some time will really influence what we do.”
Another female student said, “this brings the whole gender issue into it . . . the problem of being a female practitioner . . . is thinking about other issues in terms of part-time work . . . I . . can see that I will want to have kids at some stage”.
Female students were aware of facing a balancing act in the future, with concerns about where they would fit in the “biological demands of being a woman”. Many spoke of “fitting children in”, and most seemed “very well aware that your fertility goes down the older you get”, some having a sense of urgency about having children. First-year female students mostly saw family priorities as something for the future, but felt they could not “really picture how family and medicine are going to all fit together”.
Male students spoke about desiring to spend time with their families, and preferring work which would enable them to do so. For example, a male student said, “hours are very important to me. My poor suffering wife, because I work part time and . . . every weekend”.
Most participants indicated that the desire to balance work, family and other aspects of lifestyle would influence their career decisions, including discipline of medicine, work structures and locations. Students saw work–life balance as important for reasons such as family commitments and desire to follow social and leisure pursuits and have “time out”. Students expected to achieve balance through career and family choices.
The study also provided evidence of generational change in attitudes to work–life balance. The students spoke of having learned from the mistakes of previous generations. However, it is also likely that the high priority they give to balancing work and family reflects social changes, such as the feminisation of the medical workforce, the increase in dual-career families, the changing role of men in families, and the increasing age of medical graduates with the advent of graduate-entry medical courses.
In the past, many doctors worked extended hours with the support of a wife who was not employed outside the home. 24,25 Most study participants no longer expected that their partners would provide this level of support. Many expected their partners would participate in the paid workforce and share family responsibilities, as well as contributing to family income. Most indicated a preference for work structures, such as group practices, and, in some cases, salaried staff specialist hospital positions, that would provide shorter, more flexible working hours and shared after-hours rosters.
As the participants were self-selected, it might be argued that their views do not reflect those of the general medical student population. However, maximum variation sampling ensured that the sample included students from a range of backgrounds and ages, and the students expressed a range of opinions and ideas on the theme of work–life balance.
These results indicate a need for the continuing development of part-time postgraduate medical training and for work structures with the option of working limited hours. They also have implications for the medical workforce: if increasing numbers of doctors choose to limit their working hours then more doctors may be needed to provide the same levels of medical services.
The use of qualitative methods enabled the researchers to explore issues relating to career choice without predetermining issues to be investigated, as for a quantitative study. Earlier studies found work–family–lifestyle balance to be important for female medical students,26,27 but this study shows that many male students now see balance in their lives as a high priority. These results are consistent with the findings of recent studies that some young male doctors are interested in part-time work. 20,21
The challenge for health administrators and doctors of the future will be to develop structures that allow doctors to undertake hours of work which make it possible to maintain a healthy balance between work, family and lifestyle, and at the same time provide an appropriate level of healthcare to the Australian community with adequate emergency services.
Composition of focus groups
University of Newcastle (undergraduate course with mixed intake of school-leavers and graduates): two Year 1 and two Year 5 groups (one of each sex from each year).
University of New South Wales (undergraduate course with a mainly school-leaver intake): one Year 1 and one Year 6 group (both mixed sex).
University of Sydney (graduate-entry course): one Year 1 and one Year 4 group (both mixed sex).
Rural conference (attended by students interested in rural practice from all 11 Australian medical schools): one Year 1 and one final-year group (both mixed sex).
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