Open access to part-time specialist training – the Swiss experience

Gender shift in the medical profession evokes an increasing demand for innovative work and training curricula. Faced with persistent differences between the sexes as regards practice patterns and speciality choice, some medical workforce planners call for easier access to part-time training and more flexible work arrangements [1]. In European Union countries, due to the rather restrictive EC Directive 93/16, part-time medical speciality training is only permitted when, “training on a full-time basis would not be practicable for well-founded individual reasons” [2]. Although England has pioneered so called flexible training schemes, the spread of part-time training is impaired in the EU despite its proven feasibility and a frequent call for it, especially from female physicians [3]. In recent years part-time training in some Western countries involves up to 7% of the total number of specialist intermediate grade trainees but comes as a consequence of new remuneration regulations, which are increasingly under threat [4]. As Switzerland is not a member of the European Union, the Swiss Medical Association (FMH) as responsible authority, was free in 1992 to issue a much more liberal regulation for medical speciality training [5]. Since than part-time training is permitted, without further eligibility restrictions, for at least half of the postgraduate training time for all applicants. Allocation of all part-time training posts is decentralised, occurring at the individual institutions accredited for postgraduate training. Additionally, the individual speciality societies are free to accredit the entire postgraduate training time as part-time, if they consider it practical for their speciality. The only restrictions are that the total time in training must be the same as for full-time trainees, and a minimum level of 50% employment must be met. By the year 2001 a total of 44 different medical specialisation diplomas (including a five-year training period in general medicine) could be obtained in Switzerland. Each applicant was free to shape his or her training framework of fulland Introduction: Gender shift in the medical profession evokes an increasing demand for innovative work and training curricula. In 1992 a regulation was introduced in Switzerland that permitted part-time specialist training without any eligibility restriction. This survey investigates the extent of part-time specialist training after 10 years. Methods: The anonymous data of all 776 physicians who applied for a specialisation diploma in 2001 were analysed with regard to periods of parttime training, gender and speciality. A questionnaire-based survey collected the available parttime training posts in 1503 accredited institutions (96%). Results: 115 (15%) of all applicants, 33% of the female and 6% of the male completed at least one period of part-time training in their curricula. 24% of the accredited institutions offered at least one part-time training position. The majority of these posts is restricted to specialities like psychiatry, paediatric psychiatry, internal medicine, gynaecology, anaesthesia and paediatrics, areas traditionally preferred by women, while other specialities do not offer part-time training positions to a comparable extent. Conclusions: Part-time speciality training is well established and more frequently used in Switzerland than in countries of the EU. However, as the distribution of part-time training positions develops very different among specialities, even a liberal access policy is not able to reduce the imbalance in gender distribution amongst the medical specialities.

Gender shift in the medical profession evokes an increasing demand for innovative work and training curricula.Faced with persistent differences between the sexes as regards practice patterns and speciality choice, some medical workforce planners call for easier access to part-time training and more flexible work arrangements [1].In European Union countries, due to the rather restrictive EC Directive 93/16, part-time medical speciality training is only permitted when, "training on a full-time basis would not be practicable for well-founded individual reasons" [2].Although England has pioneered so called flexible training schemes, the spread of part-time training is impaired in the EU despite its proven feasibility and a frequent call for it, especially from female physicians [3].In recent years part-time training in some Western countries involves up to 7% of the total number of specialist intermediate grade trainees but comes as a consequence of new remuneration regulations, which are increasingly under threat [4].
As Switzerland is not a member of the European Union, the Swiss Medical Association (FMH) as responsible authority, was free in 1992 to issue a much more liberal regulation for medical speciality training [5].Since than part-time training is permitted, without further eligibility restrictions, for at least half of the postgraduate training time for all applicants.Allocation of all part-time training posts is decentralised, occurring at the individual institutions accredited for postgraduate training.Additionally, the individual speciality societies are free to accredit the entire postgraduate training time as part-time, if they consider it practical for their speciality.The only restrictions are that the total time in training must be the same as for full-time trainees, and a minimum level of 50% employment must be met.
By the year 2001 a total of 44 different medical specialisation diplomas (including a five-year training period in general medicine) could be obtained in Switzerland.Each applicant was free to shape his or her training framework of full-and Introduction: Gender shift in the medical profession evokes an increasing demand for innovative work and training curricula.In 1992 a regulation was introduced in Switzerland that permitted part-time specialist training without any eligibility restriction.This survey investigates the extent of part-time specialist training after 10 years.
Methods: The anonymous data of all 776 physicians who applied for a specialisation diploma in 2001 were analysed with regard to periods of parttime training, gender and speciality.A questionnaire-based survey collected the available parttime training posts in 1503 accredited institutions (96%).
Results: 115 (15%) of all applicants, 33% of the female and 6% of the male completed at least one period of part-time training in their curricula.24% of the accredited institutions offered at least one part-time training position.The majority of these posts is restricted to specialities like psychiatry, paediatric psychiatry, internal medicine, gynaecology, anaesthesia and paediatrics, areas traditionally preferred by women, while other specialities do not offer part-time training positions to a comparable extent.
Conclusions: Part-time speciality training is well established and more frequently used in Switzerland than in countries of the EU.However, as the distribution of part-time training positions develops very different among specialities, even a liberal access policy is not able to reduce the imbalance in gender distribution amongst the medical specialities.

Key words: postgraduate training; part-time; physicians; women; Switzerland
part-time periods according to the postgraduate training regulation (WBO) of the FMH and the training programs of each speciality.In order to obtain a speciality diploma, certificates of each training period and of the passing of a final exam had to be submitted to the medical education department of FMH.
Our aim was to investigate the extent of parttime training in Switzerland and its distribution among the different specialities 10 years after the introduction of the new regulation.

Methods
By using the database of the department of medical education of FMH we prospectively investigated the curricula of all physicians who applied for a medical specialisation diploma in 2001.All information used was anonymously and only specified according to gender, duration of part-time periods and discipline.
Furthermore, in order to estimate the number of part-time positions available, specific questions were added to a questionnaire, which is sent to the programme directors of all 1565 institutions accredited for postgraduate training each year.Data were analysed using simple descriptive statistics, significance was ascertained by using the χ 2 -test.

Results
In 2001, a total of 776 speciality diplomas were conferred on 528 men (68%) and 248 women (32%).At least one accountable period of parttime training (minimal time: 6 months) was found in the curricula of 15% of all applicants.33% (81) of the female and 6% (34) of the male made use of this opportunity (p <0.001).The mean duration of the part-time employment was 30.1 (SD + 23.8) months for women and 16.3 (SD + 9.3) months for men (Table 1).All applicants with part-time employment fulfilled the requirements to obtain the speciality diploma and had passed the final exams successfully.
Ten (23%) of 44 specialities (allergology and clinical immunology, angiology, work medicine, medical genetics, general medicine, psychiatry and psychotherapy, paediatric psychiatry, pathology, preventive medicine and public health, and radiology), allow their trainees to perform all their training on a part-time basis without further restriction, all others demand that a minimum of 50% should be on full-time.An actualised list of specialities and available in Switzerland, some 771 or 9.8% were reserved for part-time trainees.More than 50% of them fall into three disciplines: psychiatry (28%), paediatric psychiatry (14%) and internal medicine (13%).Together with further four disciplines -gynaecology and obstetrics (7%), anaesthesiology (4%), paediatrics (4%) and rheumatology (3%) -they cover nearly three quarters of all part-time posts available.In paediatric psychiatry a majority of available posts are part-time.Three specialities (gastroenterology, cardiac surgery and urology) offered no parttime positions at all (Table 2).Table 3 shows the percentage of female physicians in different specialities and the change of this percentage during the last decade.There is an obvious imbalance with regard to the proportion of women in the medical workforce and the dynamic of their change.

Discussion
Part-time training has become well established in Switzerland and, with unrestricted access, one-third (33%) of all female physicians take advantage of the opportunity of having at least one period of their training in a part-time position.To our knowledge, this is the highest reported rate in Western countries and correlates well with the documented wish of most female medical students and physicians to work part-time at least for part of their career [6].The growing proportion of female physicians in Switzerland is comparable to other Western countries, as is the disparity in spe-ciality distribution [1].In recent years growing evidence has emerged, that among other motives, the possibility of "flexible" training represents a major reason for choosing a particular speciality for female physicians [7][8][9][10][11].Therefore, the distribution of applied diplomas and the availability of part-time training positions may be of interest, since they reflect, despite liberal regulation, that use of part-time training seems to be limited to a few specialities with a traditionally high -or rapidly growing -proportion of female physicians.In gynaecology 11% and in psychiatry 21% of the available training positions are already part-time positions, while in paediatric psychiatry, the only field with a female workforce majority, this figure is already 61%.The development of these huge differences is difficult to explain, especially as physician workforce planning is largely based on the assumption that "professional socialisation is a gender-neutral process that instils in physicians a common set of values, knowledge and norms" [1].It is possible that the climate of part-time training in certain specialities will in time also lead men to choose this type of training more often.However, the majority of specialities which are less often chosen by women, lack significant opportunity for flexible training for either sex and show an unchanged disparity in gender distribution over the last decade.On the one hand it is possible in the future, that part-time training positions in these fields will be established under the pressure of a growing proportion of female applicants, however, it is equally possible that the lack of flexible training will prove to be a barrier denying women access to these specialities and so increasing the existing disproportion.In the latter case this could lead to a significant shortage of applicants in particular specialities.
We conclude that part-time speciality training is practical, well established and more frequently used in Switzerland than in the countries of the European Union.However, as the distribution of part-time training positions has developed very differently between specialities, even a liberal access policy has not been able to reduce the imbalance in gender distribution amongst medical specialities.Whether this disparity is due to specific demands or to a cultural problem of the individual speciality remains unanswered.

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