At the moment, different countries across Europe have different approaches to specialty postgraduate training (1, 2). Paediatric trainees’ pathways vary in:
- admission to residency procedures
- curricula (including patient exposure, assessment modalities, etc.)
- working and education hours
- concluding exam
This is in part due to historical reasons related to different national health service setups, and the variable connections existing between the health service and postgraduate education. At the same time, the equivalence of specialist titles in Europe is a crucial factor in reducing barriers to freedom of movement, and facilitating exchanges, whilst protecting and promoting patient safety. As a result, there is a considerable effort to harmonise training across Europe, so that doctors would be trained and assessed in a comparable manner (3).
As Young EAP, we aim to improve our specialty training, to share ideas and experiences and to advocate about European and national issues of residents and young Paediatrics specialists. Referring to the survey on the satisfaction of paediatric residents with their training, published in 2017 by the American Academy of Pediatrics (AAP), nearly all residents were satisfied (4). As we started our journey as YEAP in 2017, we felt this might not be the case across Europe.
METHODS AND LIMITATIONS
In 2018, we created a questionnaire that was distributed electronically among residents in 24 European countries. Answers in the survey were received from 430 Paediatric residents in 17 countries. Unfortunately, we received no answers from some large countries with many residents (eg. France, Italy) and can therefore only offer an estimate of working conditions throughout Europe.
The answers were analysed through Surveymonkey, and due to the importance of individual comments, reviewed individually as well.
The respondents were evenly distributed across different years of residency, with most of them (65 %) currently working in a university hospital.
Most residents work full time. Standard working hours in different countries range from 40-48 to 60 and more hours per week. There is a uniform and striking discrepancy between contracted and actual working hours, with nearly all participants claiming they work more than contracted – some even up to 85-100 hours per week.
In 10 countries, 30-50 % of official working hours are out-of-hours, further depending on the rotation, staffing and maternity status.
Extra hours due to sick colleagues, or unfilled shifts, are offered no extra compensation in 35 % of cases. The situation is even worse with extra hours due to unfinished work, which are not compensated at all in 80 %. If compensation in the form of time given back is offered, it is often impossible to use this due to understaffing. It has to be stressed, though, that there were considerable differences even within the same country, depending on the employer, employee and personal views. It seems that fear of negative consequences and strong, possibly culturally dependent work ethic also plays an important role in residents being hesitant to claim their rights.
Switzerland is a bright exception where all participating residents feel encouraged to record their extra hours. Estonia, Latvia, Lithuania and the Netherlands are on the opposite end of the spectrum. Residents in Switzerland and Norway are largely satisfied with the way working hours are organised in their hospital. In 10 countries (Spain, Portugal, the Netherlands, Lithuania, Latvia, Slovenia, Ireland, Germany, Belgium, Austria), the majority (ranging from 50 to 91 %) of residents are dissatisfied.
Among general comments regarding working hours, the problems exposed in many countries were too much work, shifts being too long and study time not being included in working hours.
The five countries in which residents are most dissatisfied with the organisation around pregnancy and parental leave are Ireland, Switzerland, Spain, Belgium, the Netherlands and Malta. This seems to be mostly due to little time for paternity and maternity leave and having to work night shifts until a late stage of pregnancy (between the 32nd-36th week or until delivery). Especially in Belgium, the Netherlands and Malta residents – both men and women – wish for more time for paternity leave.
The wish for more flexible working hours in order to take your child to their childcare facility was stressed. Residents expressed the need for greater availability of information on pregnancy and maternity leave before getting pregnant or having a child. Above all residents would wish for more support with obtaining information on how things are organised during pregnancy and parental leave. Many mothers noted they have no protected time for breastfeeding when getting back to work.
To summarize, discontent was mostly due to:
- short paternity/maternity leave
- wish for more support while obtaining information on pregnancy and parental time
- night shifts until late stage of pregnancy
- no dedicated time for breastfeeding
- inflexible working hours
The majority (58,8%) of residents claim that education hours are not included within the working week, their education is mainly gained on the job by taking care of patients. Only in three countries (Belgium, Norway and Ukraine), young medical doctors get to have at least half a day of education every week. Another recurring point was noticed in the comment section: young paediatricians can join educational activities, but only if their clinical work on the ward or ER is complete. A positive example is the Netherlands, where the residents have one day every month for obligatory, paid teaching. In Slovenia, residents educate themselves during their free time, but this depends on the hospital/ward worked in. The situation is most accurately defined in parts of the UK – one day teaching per month for 1st to 5th year trainees, three days per year for 6th to 8th year trainees – although, again, this was not uniform across the country, with some areas having no mandatory education programme. When asked if educational time is protected, with no duties on the ward, the answers were divided equally between options: yes, fully; yes, if I organise someone to cover me; no, not at all.
Conference time is organised differently across Europe. Trainees are allowed to attend conferences with an allowance from 1 to 14 days per year. Some countries limit attendance to a number of days, others to a certain sum of attendance fees. There is a common trend for conference costs of the resident to be paid by the employer if one has a presentation (poster or verbal). In Belgium, Croatia, Lithuania, Germany, Slovenia and the UK, trainees can get their travel and participation expenses covered as well.
68,75% of respondents said they were dissatisfied with their education hours and how they are organised in their hospital. It is of note that the distribution of satisfaction is uneven intra- and internationally.
Clearly, our study can offer only a narrow glimpse into the working conditions of European paediatric residents and is by no means representative of every resident in any of the participating countries. Undoubtedly, things have changed (for the worse?) in the last few years and in the face of an ongoing pandemic. But the study highlights the areas which should be addressed throughout Europe: more flexibility in the duration of shifts and working hours (especially in the view of parenthood) and dedicated educational time included in the working hours.
The formative years of future paediatricians are crucial in establishment of proper work-life balance and job satisfaction. We believe that simultaneously improving working conditions over time and establishing a high standard of specialty training conditions may prevent junior paediatricians from considering leaving clinical practice after residency training (6), and also prevent the cases of burnout, which was shown to affect nearly 50% of paediatric residents, adversely affecting their performance (7) and quality of life.
- Meric R, Stone RG, Lupu VV et al.: The Diversity of Pediatric Residency Programs across Europe: Admission Procedures, Curricula and Duration of Courses. J Pediatr. 2020 Jul;222:266-268.e1. doi: 10.1016/j.jpeds.2020.03.062.
- Pettoello-Mantovani M, Ehrich J, Romondia A et al.: Diversity and Differences of Postgraduate Training in General and Subspecialty Pediatrics in the European Union. J Pediatr. 2014 Aug;165(2):424-426.e2. doi: 10.1016/j.jpeds.2014.05.016.
- Ehrich JHH, Tenore A, et al.: Diversity of Pediatric Workforce and Education in 2012 in Europe: A Need for Unifying Concepts or Accepting Enjoyable Differences? J Pediatr. 2015 Aug;167(2):471-6.e4. doi: 10.1016/j.jpeds.2015.03.031.
- Degen C, Weigl M et al.: The impact of training and working conditions on junior doctors’ intention to leave clinical practice. BMC Med Educ. 2014 Jun 18;14:119. doi: 10.1186/1472-6920-14-119.
- McKinley TF, Boland KA, et al.: Burnout and interventions in pediatric residency: A literature review. Burnout Research 2017 Sept; p.9-17. https://doi.org/10.1016/j.burn.2017.02.003
About the authors:
Larisa Kragelj is the Slovenian representative within Young EAP and a 5th year paediatric resident.
Karolina Stasiukynaitė is the Lithuanian representative within Young EAP and a 3rd year paediatric resident.
Lena de Maizière is the German representative within Young EAP and a 5th year pediatric resident.
Special thanks to former Dutch YEAP representative, Renske van Vugt, for creating the “Working conditions” survey.
Sian Copley is the Young EAP Secretary and UK representative and a 7th year paediatric resident
Daniela Kolfhurst is the Austrian representative within Young EAP