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Medicine is the same as ever — isn't it? The same hierarchical structure, with men dominating at senior levels; the same culture of heroic individualism; the same male-female inequalities with selection/promotion/retention procedures; the same difficulties for women to reach their professional potential. Women are clustered in the lower-status areas of medicine, earn less money on average, make less contribution to the profession outside direct medical care, experience higher levels of stress, have many more family responsibilities, and are much more likely to modify their careers to accommodate the needs of their partners and families.¹

One very important structural and organisational issue is the availability of part-time training during the long and demanding medical vocational pathway. Two articles^2,3 in this issue of the Journal discuss job-sharing, which is one way of achieving part-time training.

Job-sharing often involves more than one sharing arrangement — for example, alternating periods of a week or a fortnight, or splitting the week. Whitelaw and Nash² note that job-sharers in paediatric training are more likely to share work on a weekly basis while raising children, but to share in longer blocks if preparing for exams. Gun³ found a job-sharing colleague with similar needs that meshed over some, but not all, of her training years. Whitelaw and Nash note that the perceptions of hospital managers and doctors-in-training differ on the availability of particular units for job-sharing; they also note that there are different eligibility requirements between hospitals, implying judgement about what are "acceptable" and "unacceptable" reasons for job-sharing.² Whether a reason is "acceptable" may depend on the sex of the trainee, but, increasingly, men as well as women are beginning to request part-time training to give them the opportunity to combine training with care of children, study, and hobbies.

There has been a gradual increase in the number of part-time trainees in recent years (especially in emergency medicine, paediatrics and psychiatry) — in 1999, part-time trainees made up 6.5% of the total.⁴ Interestingly, in general practice, traditionally considered a very flexible training area, there was a 50% drop in part-time training over the period 1995-2000. The specialties with minimal numbers of part-time trainees include anaesthetics, dermatology, obstetrics and gynaecology, radiology and surgery.

The two articles illustrate a major difficulty in assessing part-time training: while Gun states that there were 17 part-time paediatric trainees in 1998 (a figure quoted from a report of the Medical Training Review Panel),³ Whitelaw and Nash's survey identified 34 such trainees in the same year.² The true proportion of trainees working part-time remains unclear, with differing periods of time per year spent in part-time training, and differing information provided by institutions and Colleges. More accurate collection of data and a clear definition of "part-time" training that differentiates it from "interrupted" training (eg, three months on and three off) are required.

Perceived problems continue to be canvassed: Whom do you share with? Will the College agree (in practice as well as in principle)? Is your reason "good enough"? Are your colleagues resentful ("Why should s(he) have 'time off'? "What if I have to do extra to cover?")? Are your consultants cautious ("What about continuity of care?" "What about continuity of meeting the needs of my busy lifestyle?")? Will the hospital bear potential extra costs? Can you and your childcare arrangements cope with converting to full-time work to cover your partner's leave or sickness? Can you get to the 7 am ward round or journal club? Will you miss that special clinic or unit meeting that is always on your day off? Should you refuse secondment? What will happen next year?

One outcome is very clear — part-time trainees report satisfaction with their job and lifestyle.^2,3 Less clear is the training outcome. There is no intrinsic reason why part-time training, if appropriately balanced, should be less effective than full-time training. However, institutional satisfaction with part-time training is hard to measure given the barriers to implementation, the variable number of trainees from year to year, the different specialties and consultants involved, and the rapid, concurrent changes to service delivery and the organisation of the junior medical workforce (including changes associated with implementing "safe hours" policies). Obvious benefits to the hospital of part-time work include having a potential pool of trainees to cover each other for illness or holidays, and improving the work contribution of trainees.²

There is a clear demand from many levels of the profession that part-time training be available, viable and valuable. The reality is that availability is highly variable, viability often still depends on the trainees "proving themselves", but value is clear.

The need for part-time training is part of a much wider debate about vocational medical training. We continue to grapple with the traditional needs of training organisations versus the personal and professional needs of trainees, the conflict between education and service in a tight fiscal environment, and the overall size, setting, distribution and safety of the junior medical workforce.

Cultural change is required; a change of core values and norms "from within" to achieve commitment to new organisational structures⁵ so that the medical profession better meets the needs of, and thus reaps the most benefit from, its entire medical workforce.

Jillian R Sewell
President, Paediatrics and Child Health Division, Royal Australasian College of Physicians
Member, Australian Medical Workforce Advisory Committee Working Party —
Career Choice and Workforce Participation

1. Dennerstein L. Roles and achievements: a survey of medical graduates. Melbourne: Key Centre for Women's Health in Society, 1989.
2. Whitelaw CM, Nash MC. Job-sharing in paediatric training in Australia: availability and trainee perception. Med J Aust 2001; 174: 407-409.
3. Gun MT. Part-time specialty training — my experience. Med J Aust 2001; 174: 410-412.
4. Medical Training Review Panel. Fourth report. Canberra : MTRP and Commonwealth Department of Health and Aged Care, August 2000.
5. Sinclair A. Doing leadership differently: gender power and sexuality in a changing business culture. Melbourne: Melbourne University Press, 1998.

©MJA 2001
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