STRENGTHS AND LIMITATIONS OF THIS STUDY

The study is novel in exploring less than full-time training from a male perspective.

Conducting interviews using Microsoft Teams allowed participation from a broad geographical area and from a diverse group of specialties.

Differences in the healthcare workforce and postgraduate medical training within the UK may limit the generalisability of findings outside of the Scottish context.

The reliance on voluntary participation may introduce selection bias, thereby influencing the emphasis of findings in this study.

Introduction

The COVID-19 SARS pandemic brought into sharp focus the need for the UK National Health Service (NHS) to prioritise the development of an organisational culture and working climate that supports the well-being of its workforce.1 2 Unsustainable workloads and workplace stress impact negatively on doctor well-being, engagement, retention and on patient care.3–5 Doctors in training have been given particular attention with increasing numbers at high risk of burnout.6

Less than full-time (LTFT) training allows postgraduate medical trainees (PMTs) to work reduced hours if they are unable or do not wish to continue on a full-time basis. LTFT trainees report less burnout, improved job satisfaction and a greater intention to remain working in the NHS.7 8 In addition, LTFT training may enhance workforce diversity by enabling doctors with additional requirements for flexible arrangements to remain within the workforce.8 9

The NHS has traditionally been slow to accommodate flexible working patterns,10 11 despite these being increasingly desired by trainees.8 12 Health Education England improved flexibility for PMTs through access to LTFT training for ‘category 3’ reasons; reasons of well-being and personal choice.13 Although Scotland also accepts LTFT applications for ‘category 3’ reasons, this has not been publicised or promoted in the same way, highlighting a significant variation in the approach to LTFT training within the UK.

Both male and female employees value flexible working,14 15 although the uptake among men has traditionally been lower.16 Similarly, despite an increasing number of male LTFT trainees in the UK, they remain a minority, with 18% of LTFT trainees in Scotland currently identifying as men.17

Workforce culture within the UK may still view flexible working in a negative light18 and traditional gender role stereotypes have been slow to change, especially for men.19 20 As a result, men who choose to work flexibly may face a greater challenge to their identity and status, reducing their inclination to apply for flexible working.15 21

At the time of study concept, only 9.9% of the LTFT trainees in Scotland self-identified as men.22 The reasons for low uptake of LTFT training among male PMTs in Scotland, however, remained unknown. To ensure equity of access across all genders, there was an imperative to understand this phenomenon more fully. It was also hoped that a better understanding could inform initiatives to enable those who might benefit from LTFT in the future. Our study was designed to begin to address these gaps in the literature.

Research question

Our study aimed to explore the perception and experience of LTFT training within Scottish male PMTs and to identify any enabling factors or barriers to LTFT training perceived by this group. In doing so, we aimed to provide insights that would point to ways of improving the experience of LTFTs in men.

MethodsMethodological approach

We undertook a prospective, qualitative explanatory study using semistructured individual interviews with PMTs in Scotland who identified as men. The study was based on a socioconstructivist theoretical framework and aimed to explore the diversity of participant experience and the social dimension to ‘meaning-making’ within the group.19

Data collection

Semistructured one-on-one interviews were chosen to allow a greater depth of insight into participants’ perspectives and experience and to facilitate an environment within which participants felt able to explore more sensitive and personal issues. This method of data collection was favoured over focus group discussions, which may have been more susceptible to social desirability bias.23

Interview schedules guided the conduct of interviews (see online supplemental materials). Interview schedule design was informed by the research literature and qualitative data obtained from the NHS Education for Scotland (NES) National LTFT training survey24 and refined iteratively following a pilot study with male LTFT PMTs in Scotland (Stone SL, Miller JJ, Johnston PW. Flexible training for male Postgraduate Medical Trainees in Scotland, an equal bite at the cherry? unpublished 2020). The interview schedule provided a framework for consistency; however, interviews followed an iterative approach, and participants were encouraged to speak about themes that were important to them. Most interviews lasted 50–60 min, although flexibility was permitted to allow participants to share their views and experience sufficiently.

All interviews were conducted from January to March 2021 by the lead researcher (SS) using Microsoft Teams. An individual ‘team’ was created by the researcher for each participant interview to preserve anonymity. Microsoft Teams became widely used in the NHS during the COVID-19 SARS pandemic and facilitated interviews during a time when travel and contact restrictions were in place.25 Participants were familiar with Microsoft Teams and its convenience allowed participation across a wide geographical area.

Researcher characteristics and reflexivity

All researchers are practising medical doctors in the UK. The lead researcher (SS) is a white cisgender woman with training and experience in qualitative research. SS undertook the study while working as an LTFT PMT in Scotland. In our opinion, a gender discordance between participant and interviewer (SS) was beneficial in allowing participants to be vulnerable and to disclose without concerns about compromising their masculinity.26

PJ is a cisgender man with a research interest in Postgraduate Medical Education and at the time was Deputy Postgraduate Dean (Scotland Deanery, North Region). JM is a cisgender woman, and at the time of the study worked as the Associate Postgraduate Dean for LTFT training in the North of Scotland. SLS conducted the study as part of an MA in Clinical Education, and as such the interview schedule design, data collection, transcription and initial analysis were done independently.

Patient and public involvement

Patients and the public were not involved in the design, conduct or dissemination of the research.

Participant sampling and recruitment

Homogeneous purposive sampling was chosen for participant recruitment to explore the perceptions and experience within the specific group of interest. All PMTs in Scotland were emailed on our behalf by NES, the organisation that oversees postgraduate medical training in NHS Scotland, with information about the study and an invitation to participate. It was necessary to email all trainees in Scotland, as not all trainees had disclosed information to NES regarding their gender identity. PMTs of all grades (Foundation (Internship) through to Specialty Training (Residency)) who self-identified as men and had personal experience (past or present) of training on an LTFT basis were eligible to participate. Participants who registered interest in the study were contacted via email to arrange an interview. Written consent was obtained from all participants, and participants were also invited to complete a table of information to capture demographic information. Initially 12–16 interviews were planned; however, due to the diversity of trainee experience particularly in relation to trainee specialty and reason for LTFT application, further interviews (a total of 26) were required to ensure that data saturation had been reached.27

Data analysis

Interviews were audio recorded and transcribed verbatim by SS. Transcripts were then anonymised and uploaded into NVivo V.12 (QSR International, Doncaster, Victoria, Australia) to facilitate data management and further analysis. Anonymised transcripts were analysed inductively and iteratively by SS, JM and PJ using Braun and Clarke’s approach to thematic analysis28 alongside notes taken during and after the interview. Triangulation of results was enhanced through discussion between researchers and by ‘member checking’ with participants29

Results

All 6148 PMTs in Scotland were emailed information about the study. At the time of the study, 736 of all trainees were currently training on an LTFT basis and 73 (9.9%) of LTFT trainees had identified themselves as men to NES.22 32 trainees expressed an interest in participation, of whom 26 were eligible: 20 with current and 6 with previous experience of LTFT training in Scotland. All participants described being in a committed relationship with a female (22) or male (4) partner and 13 (50%) had a partner who was also working in the NHS as a medical doctor. Only one participant had previous experience of training LTFT during their foundation training. At the time of study, only 30 LTFT trainees (4% of all LTFT trainees) were in core or specialty surgical training and none of these had identified as men to NES. Table 1 reports further participant characteristics.

Table 1

Participant characteristics

Four key themes were identified during data analysis of transcripts following data saturation: (1) the culture of work in medicine, (2) traditional gender norms and the feminisation of LTFT training, (3) the lived experience of male LTFT trainees and (4) the ‘push and pull’ factors influencing male LTFT trainees. Verbatim quotes are reported in italics, and participants are identified using their anonymised participant (P) number. Table 2 summaries the key themes.

Table 2

Summary of key themes

The culture of work in medicineThe importance of work for identity formation

Participants took pride in their work, describing it as a ‘vocation’ (P12) in which they felt ‘emotionally involved’ (P11). Having a reputation as a hard worker was valued by trainees and described an early awareness of ‘ideal worker’ norms within medicine; “from day one of medical school…there’s this pressure that’s put on to you…a culture of working as hard as you possibly can…” (P12).

The impact of full-time training

Participants described full-time work as leaving them ‘exhausted’ (P2) and ‘drained’ (P13). Additional training requirements such as quality improvement projects, studying for professional exams and completing training portfolios were felt to require a significant time investment and were usually completed within their own time. Participants accepted the need for personal sacrifice to prioritise their work; however, they felt that the extent to which this was demanded could be excessive.

Changing attitudes towards work in medicine

While participants were committed to their work, participants described the importance of other personal roles and identities within their lives and most felt that the working environment within medicine was unsustainable and needed to change.

Traditional gender norms and the feminisation of LTFT trainingMasculinity and expected gender role norms

Participants universally described the persistence of traditional gender norms within medical culture. Over-working was seen to enhance masculine identity, and participants felt that male trainees would tend to define their identity and success through their professional work. By contrast, taking on a role as a male caregiver was viewed as feminine and ‘frivolous’ (P18) and therefore less desirable for male trainees.

Changing gender role expectations

Although participants felt that gender role norms were changing within society, this was not reflected in their lived experience in medicine where it was still ‘more accepted’ (P17) for female trainees to be LTFT. As a result, they described an expectation on them as male trainees to remain full time. In addition, some had experienced resistance to their LTFT application due to these expectations; “I was [initially] denied [LTFT] because my wife should be doing the childcare. That’s what my bosses actually said to me” (P14).

The lived experience of male LTFT traineesPersonal and professional benefits

Participants described feeling ‘less exhausted, (and) less burnt-out’ (P2) as an LTFT trainee with time to ‘decompress’ (P26). Participants appreciated the time to pursue other interests, roles and relationships. Those fathering children were positive about the impact they felt this had on child development and supporting their partners’ career ambitions.

In addition, many felt that working LTFT renewed their motivation for working as a doctor and their ability to contribute at work, for example, by allowing them greater capability for empathy and reflection; “I was more empathetic. I wasn't knackered from five days, but when I was there, I wanted to hear…that…professional interest in their lives, which then makes you make really good decisions” (P26).

Impact on training and finance

For some participants, LTFT training gave longer placements, allowing greater integration into a team. By contrast, those at a more junior level described feeling more isolated, and as it took longer to be known within a department, they felt that this impacted negatively on training. Participants described missing teaching and clinical opportunities if they occurred on their day away from work, and some noted the impact of lost continuity in patient care. Participants also felt that working LTFT had the potential to negatively impact on being offered academic opportunities, particularly within competitive training specialties.

Many trainees described needing to adjust the way they worked after becoming an LTFT trainee. This including learning to work more efficiently and ‘collegiately’ (P26), accepting the need to handover work, and recognising their own limitations; “I don't pretend I've got more time than I’ve got, because I really do have to leave at the end of the day otherwise no one’s going to be at home to greet the children” (P8). It was common, however, for trainees to increase their work intensity and duration on days when they were present at work to avoid handing work over to colleagues.

Participants acknowledged the financial impact of working LTFT especially if less than 80% WTE, although most felt the benefits gained outweighed the financial implications.

Changes to personal and professional identity

For many participants, working LTFT and the life events that surrounded this change resulted in a shift in their personal and professional identity. For some, the changes to their personal identity were positive, and they were pleased to find their identity was no longer wholly defined by their profession.

Some described feelings of ‘guilt’ (P5) for the perceived impact that their LTFT working had on colleagues and the clinical service. To remain a good team player, some chose to increase their work intensity or took on additional work to compensate. One trainee who found the change to their professional identity difficult returned to full-time training; “feeling like I had that hard barrier… [saying] ‘no this is the time that I'm away and that’s me’ was difficult. I felt a sense of letting the rest of the team down or leaving them to deal with things that really, I kind of felt were my responsibility” (P1).

Experience of discrimination and conflict

Participants described feeling a ‘novelty’ (P6) as a male LTFT trainee and found other colleagues ‘bemused’ (P17) by their counter-cultural decision. Participants felt that being LTFT was associated with ‘not pulling your weight’ (P10), ‘weakness’ (P21) or sometimes being ‘a failure’ (P7).

Only a few participants could think of a male LTFT role model within medicine, and some felt that their decision to train on an LTFT basis was under greater scrutiny as a men. As a result, they felt there was a greater chance of stigma for male doctors; “for the males working LTFT, I think, people might think there’s something wrong with you” (P8). In addition, participants felt that trainees of any gender who were LTFT due to ill-health and disability could be more at risk of stigma than those who chose to train on an LTFT basis for other reasons.

Most participants had experienced ‘little comments here and there’ (P21) re-enforcing stereotypes regarding LTFT workers and gender norms and were mindful of the cumulative effect of such comments. Less commonly, participants described situations where their LTFT status had caused direct ‘friction’ (P20) with their department, or when their application for LTFT training had led to overt conflict.

While all participants felt that negative perceptions surrounding LTFT training still existed, many felt supported by their departments, and participants largely found their peers supportive of LTFT training; “I was really supported in going into it [LTFT training] and have remained supported in doing it” (P2).

The ‘push and pull’ factors influencing male LTFT traineesCapacity for LTFT working

Participants felt overwhelmingly that the pressures on the NHS and its workforce were the biggest barrier to greater opportunities for LTFT working within Scotland. Participants felt that this reinforced the reluctance of departments to accept and encourage LTFT trainees. In addition, some trainees highlighted the funding structure of LTFT training within many specialties, which does not compensate departments directly for whole-time equivalent time lost to the rota, thereby disincentivising departments from accommodate LTFT working. Trainees believed that if working hours were better for all junior doctors, this would support staff retention in the future.

The perception of LTFT training

Many participants felt that the negative perception of LTFT training might prevent other men from applying. They felt the Deanery could play an important role in changing the perception of LTFT by widening the application criteria and helping to dissociate LTFT training from caring responsibilities. They were also keen for the Postgraduate Deanery to explicitly advertise LTFT as a valid opportunity and career choice for men; “You can't go anywhere without ‘women in surgery leaflets’; they’re about all the time, but there’s never anything about guys going LTFT” (P20).

The perception of LTFT training was described differently within different specialties. This was influenced by the extent to which LTFT training was normalised within the department, and the ease with which LTFT working patterns could be accommodated. Within some specialties, working LTFT was viewed ‘as an inevitability’ (P15) and ‘the done thing’ (P5); however, other participants received more conditional support, dependent on capacity within the department. Participants felt that more ‘competitive’ specialties and busier rotas tended to be less supportive of LTFT training. Some participants felt that LTFT trainees were considered a ‘nuisance’ and a ‘faff’” (P14) by their department, which could influence how willing a trainee might be to request LTFT training: “sometimes you find even if you want to go LTFT, the pressure that you get from the department itself makes you less comfortable and less willing [to go] LTFT” (P24).

The LTFT application process

Participants tended to describe their decision to apply for LTFT training as a process. Many appreciated the opportunity to talk through LTFT training with a respected other and felt that this enabled them to navigate some of the practical or perceptual challenges before applying. The majority felt that the application process itself could act as a deterrent for male applicants, as LTFT training was often perceived as inaccessible, and participants felt that male trainees would be more likely to assume they were ineligible. Many participants noted the financial impact of working LTFT and recognised that this would act as a barrier, especially for those who remained the ‘breadwinner’ in a partnership.

For some, the need to justify their application on grounds of ill-health brought anxiety and frustration; “[LTFT] shouldn’t need to be justified, it should just be a tick box exercise” (P12).

Supporting diversity and well-being

Participants felt that removing the criteria-based application process for LTFT would help to normalise LTFT working. Participants desired a greater focus on workforce planning and the acceptance of diversity in order to support the well-being of all trainees.

Discussion

The findings of this research study highlight the influence of medical culture in shaping the professional identity and work expectations of male trainees within postgraduate medical training in Scotland. This culture in turn was seen to influence participants willingness and perceived ability to request LTFT training, as well as their lived experience of LTFT training.

Consistent with the existing literature, participants felt that LTFT training improved their own health and impacted positively on their work efficiency, agency and performance.30–32 Although participants were proud of the strong ‘ideal worker’ culture in medicine, they felt that this also reinforced an ideal of invulnerability,33 as well as traditional perceptions of status and masculinity.18,34;35 In keeping with the literature, participants described the persistence of traditional gender role expectations and felt that LTFT training was perceived as more ‘acceptable’ and accessible for female trainees because of the implicit association with child-care responsibilities.21 30 Interestingly, LTFT training has not always been perceived in this way by female trainees themselves31 36 and therefore may be more of a reflection of the training environment, rather than trainee gender. In keeping with the literature, LTFT was perceived as a sign of weakness or femininity37–39; however, in contrast to other work, a proportion of participants did not feel they avoided the stigma associated with this as a man.32

In similarity with the other studies, we found that participants rejected some traditional views of masculinity and fatherhood, while also being keen to emphasising their strength in being distinctive despite opposition.30,40 Many participants were keen to act as a positive alternative male role model for other male trainees.41

Participants’ experience of LTFT training was influenced by the extent to which they internalised the surrounding culture of medicine and the extent to which they felt supported by others. In keeping with findings from other studies,42 participants felt that support for LTFT training varied between departments and felt that this was largely influenced by the perceived ability of a rota to accommodate LTFT working patterns as well as attitudes towards LTFT working.36

Participants described the barriers to LTFT training for male PMTs in Scotland as both perceptual and practical. Participants supported changes to widen access to LTFT training in Scotland and felt that this could help to normalise LTFT working among men and improve the perception of LTFT training.35 43 The similarity of these suggestions with previous work highlights the slow progress to date in this area, and trainees recognised that support for LTFT was unlikely to change significantly without an increase in workforce capacity.35 36

Participants overwhelmingly felt that greater access to LTFT training would positively impact on trainee well-being, diversity and retention.12 Although participants understood the Deanery’s reluctance to creating a climate of entitlement among trainees, they felt that this was counterproductive and would risk losing more trainees from the workforce.44 It has been argued that a sense of entitlement is necessary to achieve such a significant change in culture and behaviour among men.41

Strengths and limitations of the study

This study is novel in its attempt to explore the perception and experience of LTFT training from a male perspective and adds to our understanding of the perceived barriers to flexible working arrangements among male employees. The ability to capture interviews via Microsoft Teams enabled participation from a diverse group of trainees, generating a rich understanding of LTFT training from a male perspective across Scotland. There were no LTFT male trainees working within a general surgical specialty in Scotland at the time of the study, and so it was not possible to obtain the perspective of trainees working within this context. Inherent with any voluntary research participation is the possibility of selection bias, which may have influenced the emphasis and findings of our study. In addition, given the devolved nature of healthcare and the cultural and workforce differences across the UK, there are likely to be limitations to the generalisability of the data to other nations within the UK and further afield.

Conclusion

Participants perceived the culture of postgraduate medical training in Scotland as a hard-working environment that venerated adherence to ‘ideal worker’ norms and traditional gender role stereotypes. There was, however, an appreciation of changing attitudes and expectations, particularly among trainees. Given the perceived negative connotations of training LTFT within medicine, the Deanery needs to be explicit in naming and challenging the stereotypes in communication with trainees and trainers, and in promoting role models for male trainees. In addition, it will be necessary to adopt a strategic approach to workforce development that recognises the growth in demand for LTFT. This strategy will need to provide support to enable departments to balance rota cover with innovative ways to promote flexibility, and shared learning across the UK is likely to facilitate this.

In acknowledging that LTFT can support trainee well-being and retention, this study has shown the need to drive change in the approach to LTFT in those who identify as men. Doing so is likely to benefit inclusivity, diversity and the sustainability of the workforce.

Data availability statement

Data are available on reasonable request. All data relevant to the study are included in the article or uploaded as online supplemental information.

Ethics statementsPatient consent for publication

Not applicable.

Ethics approval

This study involves human participants and was approved by the Committee for Research Ethics and Governance in Medicine, Medical Science and Nutrition at the University of Aberdeen. Participants gave informed consent to participate in the study before taking part.

Acknowledgments

The authors express their gratitude to Dianne Morrison for her help in providing descriptive trainee data for the study, in addition to Dr Andrea Caldwell, Dr Alistair Leckie and Professor Alan Denison for their support and advice during the study.