Internal medicine specialists' attitudes towards working part-time: a comparison between 1996 and 2004

Traditionally, medicine was a male dominated profession where working part-time was not possible. High standards for quality and continuity of care were translated in long working hours [1, 2]. In addition, the traditional ethos of medicine values single minded commitment with obligations to sacrifice personal and family needs for patient welfare and professional demands. Working part-time does not seem to fit those standards and can lead to problems regarding continuity of care, communication, and transfer of information.

However, during the last two decades the centrality of work in people's lives is perceived to be declining [1, 3]. Women combine work with family roles and there is an increase in men's participation in domestic work, although gender inequity still exists [4–7]. To be able to combine both work and family duties, part-time practice has become a useful strategy in medicine [8, 9]. In The Netherlands, for instance, 26% of the medical specialists worked part-time in 1996 [8] and this number has increased since then [10]. Although the prevalence of part-time workers in The Netherlands is high in comparison to other countries, increasing numbers of part-time working physicians can be found worldwide [11–13]. Moreover, since even more specialists, both male and female, are preferring to work part-time [8, 10, 14, 15] it can be expected that part-time work will only gain more importance in the future.

As more and more specialists work or prefer to work part-time, research has focussed on the consequences of this development for the quality of care. Several studies showed that patients of part-time doctors are just as satisfied with the quality of care as patients of full-time doctors [16–20]. However, one of these studies also demonstrated that patients of physicians who worked 'overtime', i.e. more than 65 hours a week, were more satisfied with visit-based continuity of care than were patients of full-time physicians [19]. With respect to the division of time, De Jong et al. [21] showed that part-time medical specialists spend proportionally as much time on direct patient care as full-time medical specialists. In addition, students who engage in part-time training appear to be just as motivated as their full-time peers [22].

Given that part-time work is becoming more common, and that there is no evidence that part-time work compromises quality of care, one may expect that the attitudes towards working part-time among medical specialists have changed as well. In a Dutch study from 1996 it was found that the attitudes towards working part-time within a speciality were related to the number of part-time workers and that female specialists had a more positive attitude than their male counterparts [2]. Also, specialists who had flexible working times were believed to lack commitment and to be less devoted to work [23–25]. A more recent study of Evans et al. [14] demonstrated that doctors in the UK still felt that one of the perceived disadvantages of working part-time was a negative attitude from others. Similar findings were found in a recent study in Australia [22]. However, Peters et al. [26] showed that perceptions of negative attitudes from others among trainees working part-time, may not always be accurate. Although many flexible trainees experienced negative attitudes from their full-time colleagues, the majority of them appeared to have quite positive views towards flexible training.

Although some studies have focussed on the attitudes towards working part-time, little is known about the possible attitude changes and specific aspects of attitude changes in time. Moreover, research has not considered whether differences in attitudes are related to other factors such as the time invested in work or the partnership an individual participates in. Studying attitudes is important because a negative attitude towards part-time work may prevent specialists preferring to work part-time from choosing their preferred career by serving as a closure mechanism. It is known that women tend to complete specialist training in specialities where part-time work is more accepted [27]. Besides individual preferences, the constraints associated with different specialities, such as opportunities to work part-time and prevailing social norms seem to play a role [9, 28]. According to Gjerberg [9] the attitudes of colleagues will have a great effect on the number of specialists who will go ahead with training as hospital specialists in part-time jobs. A more positive attitude can help part-timers achieve their ambitions and retain them within the profession. Finally, by studying attitude changes we can see which aspects have changed and which aspects are still considered to be problematic, thereby pointing to recommendations for policy.

The present study aimed to explore to what extent and in what way internal medicine specialists' attitudes towards part-time work changed between 1996 and 2004. Moreover, we wanted to find out which individual characteristics were associated with these attitudes and whether the attitudes of specialists within a partnership showed more resemblance to each other than the attitudes of specialists from different partnerships. Overall, the results of this study illustrate that the attitude towards working part-time changed to a small extent between 1996 and 2004: specialists in internal medicine in 2004 viewed part-time work slightly more positively than specialists in internal medicine in 1996. The largest changes in a positive direction were found with respect to part-time workers' autonomy, their ability to build up a network and the consequences of part-time work for continuity of care. However, on most aspects no change or a change in negative direction was found. These findings imply that, in spite of the increasing number of part-time workers and specialists preferring to work part-time in the last decade, part-time practice among specialists in internal medicine seems not to be fully accepted.

Full-time working specialists in internal medicine in 2004 still expressed concerns about the investments of part-timers in overhead tasks and the flexibility of task division with the increasing number of doctors working part-time. However, De Jong et al. [21] showed that part-time specialists do not allocate their time differently between their tasks than full-time specialists. Moreover, although their score had increased since 1996, full-timers in 2004 still viewed part-time work as threatening for the continuity and quality of care. As mentioned before, however, there is no evidence that part-time work compromises continuity and quality of care [e.g. [17, 18]]. Why negative ideas about the consequences of working part-time still exist among specialists in internal medicine needs to be further examined. On one aspect both full-timers and part-timers had strong reservations: having a small-part-time job (less than 0,3 FTE) at the start of a career. This is consistent with the study of Heiligers et al. [2] who found that the majority of medical specialists felt that part-timers had to work at least 20 to 24 hours per week.

As expected, part-time working specialists in internal medicine, both in 1996 and in 2004, had a more positive attitude towards working part-time than full-timers. With respect to gender, female specialists viewed part-time work more positively than their male counterparts. This finding is supported by several other studies [2, 32]. Remarkably, we found no differences in attitudes between female and male specialists in 2004. Whereas female specialists showed about the same attitude in 1996 as in 2004, male specialists became more positive, thereby ending the gender differences in attitudes. These findings suggest that the increasing number of male specialists working or preferring to work part-time, are reflected in a more positive attitude from male specialists. The evaluation of part-time work, thus, no longer seems to be a gender based issue.

In this study the attitudes of specialists in internal medicine in 2004 were found to be associated with different factors than the attitudes of specialists in internal medicine in 1996. In 1996 gender was the only significant predictor of internal medicine specialists' attitudes towards part-time work, with females being more positive than male specialists. In 2004 gender was no longer a significant predictor. Being a part-timer, younger and working less hours a week were positively related to their attitudes in 2004. When examining full- and part-timers separately, both age and the actual time invested in work appeared to be related only to the attitudes of full-time working specialists: the more hours they work and the older they are, the less positive their attitude. This finding supports our notion that it can indeed be relevant to go beyond the division of part-timers and full-timers in two groups, by taking the actual time invested into account. It also suggests that especially specialists in internal medicine working 'over-time' have a more negative attitude towards part-time work. The finding that younger specialists in internal medicine have a more positive attitude towards part-time work is consistent with ideas about the youngest generation, the so called Generation X'ers. Among other characteristics, they are described as having a desire for flexible schedules and an emphasis on having time for family and friends [33–35]. However, a recent study of Jovic et al. [36] demonstrated that regardless of differences in perceptions about generations, the actual work hours and attitudes regarding patient care and life balance behaviours do not vary much between the generations. Moreover, it is important to realize that 'working part-time' for medical specialists being self-employed in The Netherlands still means working on average fourty hours a week [37].

Although the results of this study may suggest there have been small attitude changes with respect to part-time work among medical specialists in the last decade, one cannot extrapolate these results to other groups of medical specialists. Previous research has shown marked variation in attitudes between different medical specialities [2]. Compared to other groups of medical specialists, specialists in internal medicine in 1996 appeared to have the least positive attitude towards part-time work, aside from the orthopaedic surgeons. In 2004, however, the attitudes of specialists in internal medicine were more positive compared to these of surgeons and radiologists [37]. To be able to draw conclusions about the attitude changes of medical specialists on the whole, more studies which include several specialities are needed.

Another important finding of this study is that specialists' attitudes towards part-time work were not found to cluster much within partnerships. The low level of clustering of specialists' attitudes indicates that the attitudes towards part-time work are mostly individually based and suggests only a small effect of social influences and shared circumstances within a partnership beyond individual characteristics. This finding seems inconsistent with other studies reporting a considerable extent of similarity in attitudes within partnerships [e.g. [38, 39]]. An explanation for our finding is that part-time work – though on the increase – is still relatively uncommon for specialists in internal medicine. As a result a fair number of partnerships may not have had any experience with part-time workers or specialists in internal medicine preferring to work part-time. The attitudes towards this subject may therefore predominantly reflect private opinions, since part-time work may not be an issue in these partnerships. This explanation is in line with a recent study which found that whether or not medical specialists are willing to work part-time is purely individual [40]. Presumably, the type of partnership (all full-timers, all part-timers or mixed) also plays a role with respect to the similarity of attitudes. Unfortunately however, we did not have information as to the type of partnerships specialists in internal medicine participated in.

In terms of limitations of the results, the number of part-timers was quite small for the 1996 sample. As a consequence, possibly not every association became apparent since it was more difficult to detect significant differences. Secondly, the variance in attitudes between partnerships in both analyses could not be estimated significantly. As a result we were not able to give reliable estimations as to the extent of attitude clustering within partnerships. Although the number of partnerships in our sample was not small (n = 110) and the results indicate that there is only a small extent of clustering of attitudes within partnerships, to give reliable figures a greater sample of partnerships is needed. However, since all partnerships of specialists in internal medicine in general hospitals in The Netherlands participated in this study, this was not possible. Furthermore, as there were no previously validated questionnaires about the attitude towards working part-time, a new scale was devised for the study of 1996. Although the scale had a good internal consistency, more research is needed on this subject. A further limitation of the study is that it is not longitudinal but involves two cohorts of specialists in internal medicine. In studies with a longitudinal design one can monitor the attitudes of medical specialists and the factors that influence them for several years, thereby contributing to our understanding of attitudes and attitude change.

The main strength of this study lies in the examination of the general climate for part-time work as well as the changes in the specific aspects of attitudes during the years. Moreover, it provides a picture about which individual characteristics contribute to a more positive or negative attitude. Whereas the individual characteristics that are associated with the attitudes are mainly descriptive and cannot be changed, the evaluation of the specific aspects of the attitudes can serve as useful indicators for policy. In general, the attitudes of specialists in internal medicine towards working part-time became slightly more positive over the past eight years. These findings may suggest that the time period was not long enough to produce major changes. In earlier studies it was stated that informal rules and cultural norms within the medical professions are very hard to overcome [1, 24]. Male specialists in internal medicine already view part-time work as positively as female specialists and the more positive attitude of younger specialists may point towards a change in a positive direction in the future. However, since the attitude change is only apparent for some groups, e.g. female specialists show no difference in attitude over the years, getting a more positive attitude does not seem to be just a matter of time. Full-time working specialists in internal medicine still express concerns with respect to the consequences of working part-time for investments in overhead tasks, flexibility of task division, efficiency, communication and continuity of care. Policy should be aimed at creating part-time arrangements and removing the organisational difficulties related to part-time work. Moreover, it is important that all specialists, both full-timers and part-timers, have a realistic view as to the consequences of working part-time. With the increasing number of specialists opting for part-time careers it is beneficial for hospitals and other health organizations to create a system in which part-time practice is fully integrated and accepted.

In spite of the increasing number of specialists seeking part-time careers, part-time practice among specialists in internal medicine seems not to be fully accepted. Gender no longer seems to be a significant predictor of the attitude towards part-time work. Rather, age and work aspects such as the number of hours worked were found to be associated with this attitude. Although there is little evidence to support them, full-time specialists in internal medicine in 2004 still expressed concerns about the consequences of part-time work for different aspects of the quality and continuity of care. Recognising and addressing these concerns is important, when integrating part-time practice within organisations. Besides removing the organisational difficulties related to part-time work, policy should be aimed at creating a realistic view as to the consequences of part-time practice, thereby contributing to more positive attitudes towards part-time work.