Understanding the Non-Professional Needs of Early Career Doctors: An Interview-Based Study

Specialty colleges and health services play a key role in supporting doctors in their early careers, fostering a highly skilled workforce to respond to the community’s healthcare needs. In doing so, they are often well attuned to professional factors, such as long or uncontrolled work hours, but non-professional factors are less acknowledged. This is partly because there is limited research about the non-professional needs of early career doctors, impeding the capacity to tailor a response through structured policy and programs. This study aims to describe the non-professional needs of doctors in their early postgraduate career, including how they intersect with career and training experiences. Semi-structured interviews were conducted with 32 male and female medical graduates working across all Australian states and territories, spanning a variety of specialty areas and early career stages (up to their 17 th postgraduate year). Participants were asked about their career journey to date including non-professional factors related to their experiences. The results identied important non-professional needs, that strongly interplayed with career and training experiences, including: children’s education; partner’s career needs; family stability; major life stages; proximity to the extended family; and spending time with immediate family. Results also suggested clear gender differences, with female doctor’s needs orientated to partner work and carer responsibilities, while male doctor’s needs were oriented to spending time with family and meeting the family’s needs. In our data, female equivalents did not use this option; instead, they trained in locations where their partner and family were based, as was further shown in the partner’s career needs theme. For some female doctors the ability to live near extended family and receive support in caring for their children was an enabler of working the hours required of them in their postgraduate training.


Background
Doctors are people with families, friends and social interests, often unrelated to medicine. To date major policies and programs supporting doctors focus on their professional domains (1-3), despite nonprofessional needs potentially being central to their job satisfaction and observed recruitment and retention patterns. The World Health Organisation (WHO) recognises the equal importance of personal and professional support, for retention, each being highly valued by health workers and potential determinants of where doctors work (4,5). There is, however, an absence of literature describing the breadth of non-professional needs encountered by doctors in the early stages of their career, whereby failing to describe the needs of the 'whole person', affecting the capacity to shape of policy solutions and program structures. The early career of a doctor is a time of rapid personal and professional transition that is critical for setting up future working patterns that t with their preferred work-life goals (6).
Postgraduate medical training is completed when most doctors are in the age group for consolidating long-term relationships, partners establishing their careers, having young children and purchasing a home (7)(8)(9)(10). Many countries have transitioned to basic medical training of 4-5 years using a postgraduate course structure, after a minimum 3-year Bachelor degree is achieved (thus minimum age of 25 when emerging into the medical workforce). Graduating doctors therefore have more established lives when they reach early careers in medicine. Due to bottlenecks to get onto vocational training programs, early career doctors may face substantial professional pressures (11). The erce professional competition and tension to ful l postgraduate selection and education requirements needs to be considered in light of the non-professional lives, running parallel to their emerging career.
The World Health Organisation, in relation to personal and professional support for doctors, recognises the importance of living conditions, the working environment, outreach activities, support programmes, networks and recognition measures (5). Few studies have adequately described the personal or nonprofessional needs of doctors in their early career.
Research in postgraduate medicine highlights non-professional needs interplaying with choice of specialist career (12,13) with some focus on the differences between male and females in their specialist choice due to non-professional needs. Female doctors target exibility and support of personal circumstances, more strongly than males (6,(13)(14)(15)(16)(17)(18). Lifestyle is also a key consideration, where female doctors associate this with compatibility of work with family obligations while male doctors may consider this with respect to leisure time and activities (7,19). Non-professional factors including children and partner employment needs are likely to be mediated by gender. One study, not limited to early career stage, showed that male and female GPs moved away from rural locations in order to raise children and foster their educational needs (females immediately, males when children hit secondary school) and in relation to their male partner seeking work (20). Understanding these differences in the needs between male and female doctors during early career is important due to the increasing proportion of females in medicine (21)(22)(23).
In summary, while the literature points to the importance of work-life balance issues in early medical careers, it fails to adequately describe what the non-professional needs are and how they relate to different types and genders of doctors. Yet recognising and supporting non-professional needs, has important implications for recruiting and retaining doctors within medical college training systems and hospitals. For policy makers and employers, it may also underpin the capacity to achieve a gender-balanced workforce. This study aims to describe the non-professional needs of doctors in their early career, including how they intersect with career and training experiences.

Context
This study uses data from Australian doctors, where all medical graduates work for at least two years as 'junior doctors' prior to specialist training. Many doctors spend longer as a junior doctor as it is challenging to access vocational training programs. Once a doctor has obtained a vocational training position in a specialty college, they then enter their postgraduate training period called fellowship training, typically of 3-6 years' duration, depending on the speciality pursued. As emerging fellows they are still considered early career compared to experienced colleagues. Therefore, we consider this period as 'early career' in this paper.

Design and implementation
A purposive sample of 32 graduates of The University of Queensland in Australia were invited to participate by email. Those invited spanned their 1st and 17th postgraduate year, in line with our de nition of 'early career' (see context). The purposive sampling attempted to achieve a balance of male and female doctors, locations, a breadth of specialties and career stages (covering junior doctors through to fellows), with the focus drawing on different non-professional factors and early career experiences. Online interviews occurred for up to 60 minutes led by two PhD-trained qualitative female researchers (TG, PM) based in a private o ce, with the doctors located in a place of choice. Both interviewers had broad experiences and interest in the topic based on their employment in a regional training hub, though there was no pre-existing relationship with participants. An interview guide was developed (Table 1), piloted and used, with emerging themes prompted by the interviewers until data saturation was reached. Interviews were recorded and transcribed verbatim and not returned to participants for comment or correction. Analytical approach Transcripts were read by the broader research team (addition of BOS, MM), in blocks of nine and key themes were identi ed through inductive coding (24). The main author then conducted an in-depth review and analysis of the data and led discussions with the research team, including discussing both major themes and diverse cases, until consensus was reached and the data narrative and thick description was achieved (25,26). In the process, subjective values and inclinations of the researchers were balanced out, including establishing the most homogeneous themes possible.
Given our interest in the non-professional experiences, we used a phenomenological approach to describe these by exploring them from the perspective of those who have experienced them (27), in this case, doctors who were re ecting on their current or recent experiences.
In the data analysis process we used subtext to quotations to denote the characteristics of the person as J 'junior doctor', T 'trainee', or F 'fellow'; work locations in a R 'rural' or M 'metropolitan' location; M 'male' or F 'female'; Spec 'chosen or completing/ed a specialty' or GP 'general practice' (described in Table 1).
This study had ethical approval from The University of Queensland ethics committee (Ref no 2012001171).

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Overall, 32 participants responded who were working across different states and territories of Australia, with representation across genders, early career stages, specialist type and location of work (Table 2). Our ndings indicated that six key themes represented the non-professional needs of early career doctors, shown in Fig. 1. These included: children's education; partner's career needs; family stability and support network; major life events; and spending time with immediate family (Table 3). These factors strongly interplayed with career and training experiences, with the potential to affect participation, satisfaction and completion  Children's Education Doctors prioritised their children's education and sought stability and high quality in the education received by their children. The geographical relocation often associated with postgraduate training requirements placed pressure on the early career doctors to regularly change their children's schools or be forced to endure extended periods of separation from their families to meet training requirements.
Partner's career needs Female doctors who had partners that were associated with a non-medical oriented profession, were well-educated or who held high-level leadership positions tried to obtain training in geographic locations that offered employment for their partners. This was sometimes to the detriment to their own career with missed opportunities in their postgraduate training and work.
Family stability and support network Male doctors indicated that they would move themselves, being apart from their partner and children, to undertake training and work, ensuring stability for their family.
Female doctors, showed a need to work in in locations where their partner and family were located, being near extended family. This family network enabled the female doctors to receive support in caring for their children allowing them to work the hours required of them in the postgraduate period.

Major life events
Life events such as buying a house, getting married, or illness were seen to in uence a doctor's early career. These events affected a doctor's ability to geographically relocate regularly, as is often required in the postgraduate training period, or work the full-time hours required of early career doctors. Interviewees tended to pursue employment opportunities based on where they perceive good schooling is available and this may shape their career in the postgraduate period. If based in smaller rural communities, boarding school or y-in, y-out work models were noted as possibilities to enable children to receive a stable education, but these can also be unattractive options. Family stability and support network Beyond maintaining educational stability for children, a broader focus was on stability of the family unit and its proximity to extended family support networks. Male doctors indicated that they would move by themselves in the postgraduate period, prioritising their own instability rather than relocating the whole family.
I was a rural-bonded scholarship holder, so, I had to work outside capital cities…I chose to travel for the six years every day…so that they [family] didn't move, but I did. …I then asked to go part-time because my dad was dying at that point. He had weeks to live. They said, "You can have two weeks' leave, but you won't be allowed any more than that, and when you come back, we expect you back full-time shift work."…I resigned and my dad took a bit longer to die than expected… (JM6_Fem_GP) … one friend was told by someone at a very large hospital, a tertiary hospital in [X], a head of a department, that she had to choose between being a mother or a doctor because they would not accommodate her as a mother…I've had two friends that have left because there's just been no exibility at all and they're both single mothers… (JM6_Fem_GP)

Discussion
This study has explored the non-professional needs of early career doctors, showing some strong gender differences. These needs have the potential to shape career participation, satisfaction and completion of postgraduate work and specialty training. The central non-professional aspects include needs of children, partner, major life events and lifestyle stability. Our data indicated that female doctors may be more likely to change their career course than males, to achieve an overall balance with other commitments and partner interests. Maintaining a course of employment and training, depended on having access to wider family support. In part, this is related to the long and unpredictable hours that doctors may need to work in order to complete the postgraduate stage of training. Female doctor's needs were orientated to partner work and carer responsibilities, while male doctor's needs were oriented to spending time with family and meeting the family's needs, highlighting for males, these may be preferences, but for females they are structural barriers.
As a source of tension, postgraduate training often requires regular geographical relocation and rigid work and training schedules with minimal exibility, all of which can be disruptive to doctors' priorities of children's education, partner's careers, and the family's lifestyle/social connections (7,28,29). Male and female doctors with medical partners may nd the requirement to change training locations easier as they have a sympathetic base of support; however, the capacity for two postgraduate pathways to align could also vary depending on the vocational pathway. Female doctors, whose partners work in nonmedical specialised elds, may place their partner's career advancement before their own (30,31). Females with partners of exible and non-specialised employment were more easily able to work rurally.
Notably, male doctors did not identify giving major consideration to their partner's career needs. This may be because they did not have medical partners. However, it is likely to be important for training programs and health services recruiting female doctors to acknowledge that females may need more support to participate and satisfactorily complete postgraduate work and training requirements. This is critical given that a growing proportion of medical graduates are women.
Our ndings suggest that the different life stages doctors will nd themselves in at various times should be accounted for in training or recruitment cycles within early medical careers. Despite the extensive planning required around major events like marriage, buying a home and/or having children, many doctors in early career are still required to relocate regularly. In particular, female doctors are planning for both children and partner's careers around postgraduate work and training, often to the detriment of their own career and potentially further impacted by in exible working conditions (18). The capacity for females to move was more complicated by prioritising being near extended family for the level of support they needed to juggle training/work roles. The capacity to negotiate ongoing training in speci c geographic locations is particularly challenging for training programs that randomly allocate positions, again sometimes to the detriment of those who have more personal constraints, including illness.
Our ndings showed that a key consideration for recruiting both male and female early career doctors is children's educational opportunities and family stability. This, and work for partners, may be particularly pronounced in rural work and training where training often involves moving locations and educational opportunities may be considered less than in cities (20). Failing to consider these issues within rural recruitment will be at the detriment of achieving early career doctors in rural areas, and it likely to explain the poorer uptake of rural medicine by contemporary female doctors (32).
Our study is not without its limitations. It is limited to a single cross-sectional interview of a university cohort of one country, Australia. The applicability of the ndings across different countries and cultures would be of value to explore in future research, especially given that our ndings about gender may vary by socio-cultural constructs and norms. Further, our ndings could vary depending on postgraduate work and training systems in medicine in different countries. It should also be recognised that these nonprofessional needs may change by evolving career stages, and also as the workforce and societal constructs change, such as the feminisation of the medical workforce (18,(21)(22)(23).
The strengths of our study are in the methodological robust design that included the recruitment of research participants who: were not institutionally a liated any longer; were from different Australian states and territories; and represented different specialties across the medical eld. The design also ensured male and female representation. The phenomenological approach used in describing the nonprofessional needs of doctors in their early career working lives also provided a basis for exploring these needs through the lens of those who have experienced them.

Conclusion
Our ndings have shown that early career doctors have speci c non-professional needs, linked to children, partners, life events and family connection that strongly interplay with career and training experiences. They appear to vary by gender, location and eld of work. The non-professional needs have the potential to affect participation, satisfaction and completion of postgraduate work and training, particularly for female doctors. Speciality colleges, employers (hospitals and other health services), recruiters and training systems should give consideration to 'whole of person' factors in postgraduate work and training policies and programs. In particular, current training and employment pathways could be more exible, individually tailored, and accountable to the non-professional dimensions of doctors. By recognising and supporting the non-professional needs of early career doctors, the true potential of a skilled, satis ed and distributed workforce can be realised, bene ting community well-being.

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