Flexible Training in Surgery

Abstract

Time-Variable Training (TVT), including flexible work arrangements and Less-Than-Full-Time (LTFT) roles, is increasingly recognised as a mechanism to improve sustainability, diversity, and wellbeing in surgical education. Despite known demand and policy support, uptake remains low. This thesis used a mixed-methods approach, guided by critical realist ontology, to explore the experiences, barriers, and enablers for TVT in the Australasian context, integrating findings from a literature synthesis, survey, and qualitative interviews. The critical realist review synthesised 9 studies into 14 context-mechanism-outcome configurations. Key enablers included supportive culture, competency-based frameworks, clear supervisory structures, financial support, and accessible administrative pathways. Barriers included stigma and longer training duration. Cross-sectional survey of 800 doctors-in-training (98 respondents, 12.2% response rate) found that while most were interested in flexible work within 12 months, and nearly all within 10 years, only 0.8% were currently in LTFT roles—highlighting misalignment between demand and access. Standalone 0.5–0.75 FTE positions were preferred. Key motivations were work-life balance (28%) and childcare (26%); main barriers were financial concerns (28%), prolonged training (24%), and career impacts (22%). Stigma translated into negative experiences among LTFT trainees. Semi-structured interviews analysed using Self-Determination Theory (SDT) highlighted the role of autonomy, relatedness, and competence in shaping TVT experiences. Trainees valued autonomy to balance clinical and personal demands but struggled with perceptions of reduced commitment. Supportive supervisors and peers were protective. TVT trainees acted as “trailblazers,” navigating informal pathways in the absence of policy.

This thesis underscores the need for proactive, evidence-based policies to integrate flexibility in surgical training and support a more adaptive workforce.