Let’s talk about part-time: Finding work-life balance in residency

Motherhood. I planned for it, prepared for it, yet it hit me like a ton of bricks.

Seven years ago, I was a newly graduated MD, about to embark on what was supposed to be a five-year residency journey through psychiatry. I had finished eight years of post-secondary education and wished to put my training and career on some form of autopilot (we get paid so it must be like a real job – right??) so I could dedicate some time and energy into other areas of my life.

I was a married woman ready for motherhood.

As it turns out, there is no “auto-pilot” in medical residency training, and this “real job” came with regular weeks of 50-60+ hours of work (recording 104 hours over an eight-day stretch), additional frequent evening shifts and overnight calls (which can turn into 24+ hours of continuous work with no break), and countless administrative and educational expectations outside of regular work hours (such as studying and learning).

Historically, medical residency training was known to be gruelling and inflexible, with minimal time for personal life or other obligations (as residents would “reside” in hospital-provided lodging). Some of this has changed, although high levels of burnout persist. Current protections such as parental leave, as well as increasing conversations about wellness and work-life balance have shifted the dialogue – such that during my own medical education, it was common to hear both staff and residents provide reassurances that “residency is the best time to have kids.”

Two years after starting residency, I was on maternity leave with my first child. I was thankful for the year of leave and felt reconnected to areas of my life that had been put on hold for many years. I returned to work gradually, until the day when my daughter was in daycare five days a week and I could return full time.

My child didn’t disappear at the end of my maternity leave, and motherhood is for life.

The dichotomy between being “off” for a year, disconnected from my work as a physician, followed by resuming a workload identical to the one I had before being a mother felt artificial – I was given time off to “be a mother,” then returned to work as if I had never become one. My child didn’t disappear at the end of my maternity leave, and motherhood is for life. Rather than compartmentalize my different roles, I wished for harmony – for the option to remain connected to some of my work as a physician; to continue to be more present for my child upon my return.

I pondered these thoughts as I was preparing for my second child a year later, wondering again how to “balance” life and be more present in my children’s early years. That was when I had the good fortune of speaking to a clinician who had done some of her residency training part-time because of an illness in her family. She encouraged me to consider it as an option “before I have a reason to need it.”

I was intrigued. I had a brief conversation with my program director, who quickly reassured me that what I was asking for was not unreasonable. Within less than a week, I had received approval to work four days per week upon my return from maternity leave.

At the time, I was unaware of the extent of “part time” in residency training in Canada. As it turns out, part-time residency training is not new. As early as 1981, physicians have been asking for flexibility; that same year, the Canadian Journal of Psychiatry examined the experience of six residents at Queen’s University who had been provided with the option of part-time residency training. The research article noted that part-time training was pioneered in Britain as early as 1966. Another paper reviewed the experience of part-time residents in internal medicine from 1983 to 1993 at a university-affiliated hospital and found no negative impact on clinical competence, teaching or leadership skills, with a noted possible advantage in “humanistic attributes.”

And in recent years, a variety of programs across Canada – including family medicine, pediatrics, psychiatry, anesthesia, emergency medicine, and various others – have offered and implemented part-time options for residents in both rural settings as well as large urban centres. While parenting is one reason residents may request part-time training, residents also make requests for mental health and wellness or to cope with a mental or physical illness. Part time can act as an alternative to taking a full break from residency and going on “leave without pay.” Policies exist to guide this, such as those posted by the Royal College of Physicians and Surgeons of Canada, as well as others like the council of Ontario Faculties of Medicine or individual universities.

And here, a clarification. The term “part time” is misleading in medicine as it only means a reduced workload relative to the average or expected workload. This “average workload” can vary greatly between specialties, sites of work or rotations in residency. For example, duty hour limitations in the U.S. limit residents to 80 hour weeks, yet even this limit is “hotly contested” with some residents continuing to work above this limit while remaining quiet about it. While I was technically “part time,” this reduction in workload allowed me to get closer to the 40 hours a week that the rest of society calls “full time.” A “part-time resident” recently told me she is continuing to work 35-80 hours/week – the equivalent of two full-time positions for most. Current part-time schedule options for residents have not replaced ongoing conversations about duty hours and reasonable and sustainable work conditions during training.

The process to obtain part-time training varies between universities – from some approving it based on a one-time verbal request to others requiring written requests and involvement of departments such as an office for advocacy and wellness, only approving the request based on it being an “accommodation.” Scheduling is also varied, with some programs allowing for reduced work weeks on both outpatient and inpatient rotations, and others offering block-based scheduling (working certain weeks full time while being off other weeks). But not every resident who has made a request has obtained approval.

Knowing that I could have a protected day each week to spend with my children after my maternity leave, I felt comfortable splitting my parental leave with my husband and returned to work after six months this time.

It allowed me to have added study time in exchange for a regular, worry-free day of rest and family time.

This day away from work has at times allowed me to keep both children home to spend a lovely, relaxed day with them. At other times, it has given me some semblance of a “weekend’ when my schedule didn’t include one and has helped me prevent or manage burnout. And during the final year when residents spend most of their free time studying, it allowed me to have added study time in exchange for a regular, worry-free day of rest and family time.

The common theme is it allowed me to be more present – more present at work while I was there, more present at home when needed, more present during studying. And while the stress of residency training did not disappear at any time, the breathing space in my schedule has given me time to consolidate my learning, to reflect on patients as well as on systemic issues, and to learn with enjoyment.

While my biggest worry was that I would lose competence or confidence, I felt like a stronger resident overall. Debbie Hall, program administrator, agrees, noting that from her experience, “residents on 80 per cent are more keenly aware of learning in those four days,” and that “most residents who feel they need the time are strong learners.”

Interestingly, I have heard from residents that they tend to feel more stigmatized switching to part time than having to go off completely. Hall talks about this “stigma”, explaining that “for some reason, a solid break seems to be more acceptable where you’re just gone and then you come back” than requesting an alternate schedule such as part time. One resident explained that some are still reluctant, perceiving that a switch to part-time should be an option of “last resort,” that it is better to push hard until a resident hits the wall and disappears from the program temporarily rather than slow down to prevent a complete break.

And while residency programs offer modified training schedules for reasons such as pursuing research as part of a “research stream,” requests for similar scheduling changes for personal reasons such as parenthood seems to bring up a different conversation.

I am grateful that my own path was smooth with minimal challenges. As Hall notes: “The goal of the program and admin is that you learn, learn well, and pass.”

For others, though, negotiating with programs was challenging, with one putting limitations on approvals or on schedules that would be allowed, citing concerns about “undue stress,” with fears that off-service rotations would not be accommodating. Residents interviewed for this article have been told by supervisors that part time could be harmful to their careers, or have had it noted in evaluations, leaving one resident grappling with the negative impact it had on career prospects, having become the scapegoat for issues common with full-time residents as well. Others have said that they felt they needed to prove to supervisors and peers that part time was not reflective of being less committed or competent.

In theory, with the introduction of competence-based medical education, the work required is what is needed to complete various tasks and learning, meaning part-timers may meet all necessary criteria of a rotation despite the reduced weekly workload.

So, if residency is temporary, why is a conversation about part-time residency still relevant?

The reality is that the lifestyle of residents today is much closer to staff than previously – in certain cases having the same age or number of children, for example. Many physicians complete their medical education at later ages (“the average age of resident doctors in Canada is just over 30”) and are unwilling to “bite the bullet” throughout medical education and residency training and put life on hold until both are completed.

Life doesn’t stop in residency – life happens. Marriage happens and babies happen. Grief and illness and losses happen. Burnout happens. Therapy happens. And with some flexibility, life can happen while we remain present – more present for life and more present for all the work that comes with it.