gms | German Medical Science

It seems that the “typical student” no longer exists in the year 2010. Employment, family planning, practice orientation and staying abroad are the new life experiences and issues concerning young people in their studies. One group of students in particular has come into focus in the last few years, parents at university (amongst others [1], [2], [3], [4]). The current 19^th Social Survey of the German Student Federation [5] puts this group at 5% of the entire student body. The Hertie Foundation audit “Family Friendly University” [6], the newly structured family service units and active support of dual-career couples in Germany are but a few highlights of these developments. This group of students, with their special needs, pushes medical schools with their tightly organized administrative structures to their limit and offering them support take the curricula into new territory. In the following, insights into the lives of medical students with children will be given and an approach to a solution presented based on the new concept of advisory staff at the university.

The President of the Conference of Medical Faculties, Prof. Dieter Bitter-Suermann, said at the beginning of 2010 that the requirements for medical studies cannot be increased further and that instead, bureaucracy must be reduced and the environment improved [7].

In April 2010, an article appeared in the Deutsche Ärzteblatt on “Looking for ‘good’ doctors” in which Dr. Birgit Hibbeler emphasized that the reconciliation of family and work needs to be improved [8].

All of these topics in medical education - admission, bureaucracy, environment and the training of good doctors - come together in the issue of reconciling work and family. It is precisely this problem which parents studying at university are faced with on a daily basis in a search for a, naturally individual, way to complete their studies successfully and purposefully but not at the expense of their own family or an excellent education.

The conducted interviews aim for a differentiated collection of data at the individual and personal level using qualitative research. Because, similar to the individual biographies, study patterns are not linear and streamlined, but complex and with interruptions.

“[…] everything is about uni and the kid and that doesn’t leave much room for anything else”, we were told by a female student in the first 4-month section of her Practical Year while raising a 2-year old son together with her husband. Following secondary school, she spent some time abroad, helping projects in developing countries. The desire for a social career had always been present, so after her return, she completed training as a paramedic. But shortly afterwards she was offered the coveted place to study medicine and continued her education at the Goethe University Frankfurt.

Based on her experiences and her age a bit older, she consciously dealt with the wider issues of family and life planning. Together with her husband, she opted for combining studies with parenthood and deliberately planned her pregnancy to fall into the period after the first section of medical undergraduate studies (Physikum). The birth of their son then required clearly structured planning and organization of daily routines, with active support from her husband, who claimed paternity leave twice. Thus neither a semester off or an interruption of studies in the clinical section was necessary. “Better like this than any other way,” she responded when asked about the best time for giving birth. Since the age of 14 months their son has been in a nursery, enabling the mother to continue with her studies and the father to work full time again. She clearly separates the various aspects of her live - on campus and at the clinic she is a student, at home and on the playground she is Mum and the two spheres rarely meet, also thanks to good time management.

This was a clear decision for the child and the family, so the little time she has for herself she is happy to invest and is planning a second child for the time after her internship year. This time with a sabbatical but not because of the balance between studying and child-rearing but because of the incompatibility of exams and child-rearing. The internship year allows for 20 days absence, which are commonly used for exam preparation but which she would have to use when the nursery is closed or if her son is ill. In preparation for the final exam, she therefore requires additional time. The spheres cannot be separated completely but can be integrated with each other. It is precisely this sabbatical which is ideal for breastfeeding the newborn and studying at the same time, while the husband takes paternity leave to take over primary care. Following graduation, she will initially seek out one of the “less popular” places, perhaps half a GP position in surgery in order to care for the children at home. Once these are placed in a kindergarten and nursery respectively, she wants to concentrate on her specialisation.

In her closing statement she tells that “I actually feel that medical school with a child is a feasible route for planning life and family regarding my career [...]. Even regarding my specialisation and given you’re not done yet with studying... and that you will be rather old by then, [...] and there are many who miss right time, this is the right one."

It is still the case that about 25% of female academics do not have children [9]. The Medical Association of the State of Hessen examined the dramatic scenario of female doctors postponing children until their specialisation period, leading to a dropout rate of up to 60%, at least temporarily. A third does not graduate at all [10], [11], [12], [13]. The results in Table 1 [Tab. 1] show that in particular pregnancy and child-rearing can be serious factors for withdrawing from studies. Considering that women make up two thirds of first-years in medicine, the issue of reconciling career and family will become increasingly important in the future. Especially, if the aim is to stop qualified female physicians, whose education was expensive, from quitting at the start of their career when dedicating themselves to family planning and children.

Although it is commonly said that “when assuming an average female academic biography, there is no right time” [[14], p. 32], initial study results of the “Pilot Project Part-time Medical Studies” in Frankfurt show that the assumption is that giving birth while an in the clinical section is still the best option. Related to this, the majority of the population believes the ideal age for a first child is the early 20s, with negative attitudes towards early parenthood rather pronounced. The primary reasons given are the conflict between the time needed for education/training and the family, financial difficulties and the limitations of one’s personal freedom [15]. Especially in light of the fact that the “subjective time frame for parenting of 5-8 years” [[16], p. 33] is limited by objective facts. Even a young female medical student, once she has gained her first professional experience, is at least in her early 30s. So the classic stage model of training-career-family no longer applies. In the first full census of the students at the Department of Medicine at the Goethe University Frankfurt [17], 57 participants stated that they were studying and had children (about 4% of all medical students). This result from the full survey also corresponds to those from other studies [18] and national surveys [19], while the number of student parents is slightly below the average of all disciplines.

“[…] other than that everything goes normally. The fact that […] I have a family, hasn’t changed through starting at university,” as a married female student in her 3. semester puts it, looking back to the time when she started university when her daughter was about eight. She had graduated from her mid-tier secondary school (Realschule) in 1993, began training, worked for several years and gained her A-levels at night school. She gave birth to her daughter around this time as well, a difficult experience as no attention was paid to her individual situation by the training centre. She then followed her dream of studying medicine and successfully applied to the Goethe University Frankfurt. Students with children have to date received preferential treatment in the allocation of university places by “Hochschulstart – Stiftung für Hochschulzulassung” (Nationwide Foundation for University Admission) and thus were able to select universities based on their family-friendly policies.

Her daughter is well cared for locally between school, after school care, grandparents and other relatives in Frankfurt. She stresses that “Precisely, the family is very important, if I didn’t have their support, I sometimes wouldn’t know what to do with her.” Especially studying for exams takes time and a quiet environment. Even trips on the underground are put to use. She can’t attend a lot of elective events as she has to pick up her daughter from after school care, help her with her homework in the afternoon and spend time with her, and “then learning everything on her own.”

In addition, she still works two days a week, where she gets a lot of understanding and respect for her multiple responsibilities, something she would wish from the university too on many occasions. Most know nothing about her family situation, they only know her as a slightly older student. Especially the younger students seem unsettled by her: “These are 19-year-old people just say things like “What is she doing here?” A bit like that, perhaps dismissive but also many with respect, I don’t really know but ultimately it doesn’t matter to me.” But the most important thing she has learned in the last semesters and which she would like to share with others is that perseverance is worthwhile. There are many days at university which are very stressful but in her experience, no matter how difficult the situation appeared at the time, there was always a solution and it is worthwhile to continue the struggle. Clear structure and organization are of enormous importance because “you don’t have any room to just say, oh, I’ll sleep in tomorrow. Every day it starts all over with family stuff. There’s the household, you have the child and you must face up to that.”

Achieving an ideal balanced state between family and studying is difficult, especially for women, whose role in recent decades has experienced rapid change - “Standard Female Biographies - Patchwork, Rubble or Self-realization Today?” [[14], p. 14]. Describing it as a double burden no longer suffices as female students with children take on a number of roles as wife, mother, student, employee and sometimes even carer. A number of worlds bump into each other, often from opposing sides which can often be difficult to reconcile, with studying and family life in particular dichotomous to each other.

Within the family the role of the mother is still often characterised as that of a dedicated, social role. She is there for others, cares for others, educates and runs the household. It would appear that even today, with the advent of motherhood, the traditional roles return [20]. At university however, students must be self-reliant, confident and competitive. Especially studying medicine requires a lot of self-confidence, stamina and high motivation. But future careers and specialisation models in science are still largely geared towards male norm biographies [21], assuming continuous availability, extreme resilience to stress and unbounded time structures.

In contrast to these, the requirements and role expectations for mothers at university are diametrically opposed and must nonetheless be reconciled with each other. The problem issues are visible several levels:

• Macro level (structural disadvantages and lack of support for students with children)
• Meso level (negotiation issues regarding the household and care responsibilities within the partnership)
• Micro level (fear of failure, mental overload and strong guilt feelings)

At the same time, education (under-/postgraduate) seems attractive for mothers as it represents an alternative to domestic family life, somewhere where they not only assigned the role of mother [22]. Beyond that, such strong conviction, self-confidence and strict time-management also lead to a challenging, often critical, position towards teaching and the curriculum. Student mothers are more likely to analyse research findings they are presented with, take a position and would like to discuss this. They are therefore sometimes as a nuisance factor in education and science because they question the status quo and redefine scientific relationships [23]. In contrast to this rather problematic perspective, mothers in medical degrees and academic life are often characterized by the skills they have acquired in the process, such as stress management and organizational skills.

The situation of male students with children is equally difficult because they seem to break down social traditions even more and despite increasing numbers, they are still in the background and little researched to date [24].

This small group of student fathers is often contrasted with the so-called “new fathers” [25], men who no longer define themselves through their traditional role as sole providers and family breadwinners. This can reduce the enormous pressure to always prove one’s strength and endurance, allowing emotion and empathy to come to the fore. This is coupled with a personal refusal to sacrifice one’s own family and private life for a job or training. Young fathers want to enjoy and experience time with their children, as evidenced, for example, by the steadily increasing numbers of fathers taking parental leave beyond the statutory two months. Even men in leadership positions dare to exit their careers and devote themselves primarily to their family.

Especially “the modern man” puts store in equality in family and domestic commitments but also in the financial security of family and taking responsibility. His identity is no longer solely dependent on his job and career world but rather he tries to strike a balance between the worlds, the so-called work-life-balance [26], [24]. This means they are ready for self-reflection and re-negotiate domains and activity spheres.

But even in some university disciplines saddled with tradition, it is not uncommon for students to be confronted with patriarchal structures and traditional male roles. It is a common experience of fathers at universities that their problems, regarding time and personal resources, are ridiculed and not taken seriously.

In this sense it is becoming more and more clear that students in general, not only student fathers, can benefit from a reorientation in terms of the compatibility of studying and living.

Thus both student mothers and fathers need and desire targeted support from the university. Stephanie Ward highlighted the support needs of mothers in particular in her study (2009) and described these as being very homogeneous. But this hides the study and life needs of the individual. It seems that what is rather meant are the problem areas, which in relation student parents are congruent overall, such as childcare, financial situations, work/study-life balance, multiple stresses, and curricular constraints.

The expansion of childcare in particular appears to be essential for academic success, especially for female students, even six years after the report of the Scientific Advisory Council for Family Affairs “Parenting and Education” [15]. The inability to reconcile career and family can primarily be traced back to missing or unreliable childcare.

“Because in most families the compatibility of family and career is ensured by a division of tasks between men and women, the expansion of childcare infrastructure has been treated as secondary for decades.” [[16], p. 70].

However, Ward's study (2009) revealed that student mothers place great store on (under-/postgraduate) education, especially social learning and tutorials where they are able to discuss and share knowledge.

Indeed, physical strains should not be overlooked either as stress, depression, excessive workload down to burn-out syndrome are dangerous factors of multiple stress situations:

Particularly conflict of roles can lead to negative effects on mental and emotional health, in the worst case leading to physical symptoms [22]. Support measures must therefore be established precisely in these sensitive areas: personal relationships with adequate communication, constructive and positive feedback and an acceptable balance between the different spheres of life for students and staff.

In addition, inter-student support should also be promoted, for example through student networks or committees. This would allow the positive social effects of the peer group to be employed and used positively because this student-centred learning format in particular matches the learning style of mothers.

Considering and monitoring all these diverse factors, students should not be left alone today. Especially student parents need advice and support in their studies.

The material used in this report is based on the studies carried out in the context of accompanying research to the pilot project Part-time Medical Studies. As early as the initial period of the project, from November 2009 to January 2010, a full census was prepared to analyze the situation at the Department of Medicine at the Goethe University. With over 1500 returned questionnaires, a return rate of 69% could be achieved. This questionnaire was modelled on the CHE University Ranking student survey which is conducted regularly at all German universities. Overall, there were 152 items, with the majority (123 items) interval-scaled evaluation questions on the following study aspects:

1.

Overall evaluation (1 item)

2.

Learning offer (4 items)

3.

E-Learning (4 items)

4.

Relevance to research (3 items)

5.

Relevance to workplace (3 items)

6.

Study organisation (7 items)

7.

Interlinking of pre-clinical and clinical parts (2 items)

8.

Support (6 items)

9.

Support in teaching with exposure to patients (1 item)

10.

Student contacts (2 items)

11.

Relevance to job market (5 items)

12.

IT-infrastructure (7 items)

13.

Labs (3 items)

14.

Treatment rooms (4 items)

15.

Skills Labs (4 items)

16.

Rooms (6 items)

17.

Libraries (14 items)

18.

Study time abroad (8 items)

19.

Evaluations (3 items)

20.

Advice and service offers (5 items)

The questionnaires were scanned using Evasys and evaluated using SPSS 17.

In addition a total of four qualitative thematic interviews were conducted in April 2010, with a total length of 128 minutes. Two student mothers from the pre-clinical and clinical part, a top athlete and a female student with a chronic illness were selected for these. The interviews took place in the consultation rooms and were based on previously developed guidelines according to both life and study situations:

1.

Training and studies

2.

Living and life conditions + social network

3.

Time of birth + female student with child and high performance sport and illness

4.

Self-perception, time management, personal strategies for coping

In each interview, one incentive question was used, generating a response or detailed follow-up questions. The recorded interviews were then transcribed and analyzed using the Mayring qualitative content analysis [27] through summaries, explications and structuring.

A comprehensive online survey on the “reconciliation of family and medical school” was started in all Hessian universities and the Universities of Göttingen and Mainz during the summer semester 2010. The goal was a detailed survey of the socio-demographic data and based on this data, the conception of subject-specific but cross-site recommendations.

Medical departments should explore new models to find a competent and effective way of providing advice which addresses the individual situations of students. Although this certainly represents a time cost for the administration, students must be offered an appropriate degree of flexibility so obligatory course content can be integrated into everyday life.

In addition, given the often quoted “family-friendly university,” university regulation should be brought in line with the legislation on higher education in Hessen to create an appropriate environment for student parents, because only with legal backing they will be able to demand and if necessary enforce their rights.

Catering for student parents is often described as time-consuming, unnecessary and without future, mainly by administrative and bureaucratic departmental structures. Such concerns certainly have their justification in a degree which has an intake of about 500 first-years each year which must be divided into small groups, seminars and internships.

According to the Department of Medicine at the Goethe University these are individual, forward-looking, promising and with the position for “Individual Student Services” it faces the challenge with a new advice and service offer. Since November 2009, medical students facing special challenges have been supported in the “Pilot Project Part-time Medical Studies”. This group consists primarily of student parents (4%), high-performance athletes (0.3%), students from non-EU countries (8%) [28], students with disabilities and care duties (0.5%). The offer includes open hours' advice, individual study organization and long-term, continuous support studies, including study skills training. The concept of holistic counselling is implemented in all cases, so that students can be offered support in various areas of life. Of course, a counselling centre cannot meet all demands, such as financial and legal benefits, but it can help support the search for childcare facilities, mental health counselling, assistance with exam anxiety and time management. This also involves setting up a competent and effective cooperation network established, for example, with the family services’ office of the main university, charities, religious university communities, the Hessian State Medical Association and non-university organizations.

By embedding in the intramural and extramural cooperation network in the pilot project, the university advisory staff must time and again assume new roles. They are in the grey area between administration, teaching and social student guidance. This can and will lead to conflict with internal university departments but these must be always solved by positive and above all internal means so that the work benefits all students. Regular, open communication channels and collegial support within the department are important in this.

To complement the comprehensive counselling services, a student network “MediKids” was set up which organizes regular meetings and deal with various issues. The primary aim is the informal exchange between students who, due to time constraints and being from different semesters, rarely socialise closely. Such a network can also expand the horizon of knowledge and detect problem areas. In addition there is an intergenerational effect, by which older students can assist those in the early semesters, both with technical and content issues and personal issues.

The special feature of this pilot project is both the holistic counselling and the parallel, evidence-based scientific support.

The medical school is and will remain a full-time degree course and many reasons speak for its status as such, but technical and social conditions in education must be created which permit students to reconcile their studies and family life, so especially women will no longer be faced with the choice of ‘children or career’ [29] or to interrupt their specialisation training. To this day, about a quarter of female graduates (in West Germany between the ages of 40-75) remain childless despite a desire for children [30], [31]. Although these figures already represent an improvement over report by the Scientific Council for Family Affairs from 2004 (over 40%), this does not represent a solution. Male academics in education or a scientific career are only affected to a small extent by the challenges of starting a family but there is no doubt this will be felt more clearly in their career in the future:

“Quitting or at least staying back in your career for [women; KI] is still the dominant pattern, despite the often considerable financial loss, in spite of the risks of an interrupted career and the perceived or at least suspected loss of social prestige.” [[16], p. 61].

Studying medicine and specialisation are characterized primarily by a combination of academic training with practical job training which requires time, patience and a lot of self-commitment - “an indomitable will”. Studying with a child requires sacrifice, which should not go unmentioned, but it can also mean a lot of enrichment and additional qualifications. No easy task for both the student parents and the universities but, in the words of one student - “I think you grow with your challenges.”

Our special thanks to the Dean, Prof. Josef M. Pfeilschifter, the Hospital Director Prof. Jürgen Schölmerich and the Medical Federation of Hessen.

We received a lot of kind support from the deans at the university departments in Gießen, Marburg, Göttingen and Mainz.

We thank the project staff Katharina Kloidt and Michaela Müller for their constructive and inspiring discussions and especially the students at the Faculty of Medicine at the Goethe University Frankfurt am Main.

We note with gratitude that the “Pilot Project Part-time Medical Studies” is supported by the Hessian Ministry for Science and the Arts, the Executive Committee and the Department of Medicine at the Goethe University Frankfurt am Main.

The authors declare that they have no competing interests.