#48 – When they don’t bend, you break

Episode host: Lara Varpio

Dr. Lara Varpio, portrait.
Lara Varpio
Photo: Erik Cronberg.

This episode delves into the challenges faced by healthcare professionals within the UK’s National Health Service (NHS), focusing on the inflexibility of training pathways. The paper uncovers themes of rigid career advancement, limited work-life balance, and systemic barriers hindering diversity. By offering real-world perspectives, it sheds light on the urgent need for reform in medical education to foster inclusivity and adaptability. You will not only gain a deeper understanding of the complexities within the healthcare system and be inspired to advocate for change but also gotten a thorugh recap on Conceptual and Theoretical Framework.

Episode article

Chekar CK, Brewster L, Lambert M, Patel T. Gender, flexibility and workforce in the NHS: A qualitative study. Int J Health Plann Manage. 2024 Feb 7. doi: 10.1002/hpm.3784. Epub ahead of print. PMID: 38321952.

Episode notes

In their paper titled “Gender, Flexibility, and Workforce in the NHS,” Chikar, Brewster, Lambert, and Patel delve into the experiences of doctors within the National Health Service (NHS). The focus lies on understanding how medical training pathways influence the recruitment and retention of female physicians.

The text highlights three main premises:

  1. Persistent Staffing Challenges: Despite efforts to address staffing issues, little meaningful change has been achieved.
  2. Training pathways for physicians are highly controlled and highly regulated: Physician training programs in the UK are highly regulated and lack flexibility, particularly concerning part-time work options.
  3. Shifting Gender Dynamics: The increasing number of women entering the medical profession challenges traditional expectations around training and work patterns.

Conceptual Framework:

  • Justification for Research: The conceptual framework justifies the study by highlighting the importance of understanding how training pathways affect the recruitment and retention of female physicians within the NHS. It identifies the gaps in knowledge (staffing challenges, rigid training pathways, gender dynamics) and the need to address them.
  • Setting Expectations: This framework sets up expectations for the study, explaining why a specific research design is necessary to address the identified gaps. It clarifies what is known (persistent staffing challenges, rigid training pathways) and what is not known (the specific impact on female physicians).
  • Contextual Considerations: The conceptual framework also considers contextual factors such as societal and organizational influences on the research topic. This includes factors like cultural norms, institutional policies, and historical trends shaping the experiences of doctors within the NHS.

Theoretical Framework

The theoretical framework is a logically developed and connected set of concepts and premises that are developed from one or sometimes more than one theory, and that framework scaffolds the study. The researcher uses concepts and premises from the theory as a foundation. It’s, in other words, the theoretical framework is the work you do as a researcher to implement a theory in your study

  • Building on Theory: The theoretical framework builds on existing theories to provide a deeper understanding of the research topic. In this case, the authors draw on Pierre Bourdieu’s theory of social capital.
  • Conceptualizing Flexibility: Using Bourdieu’s concept of social capital, the authors conceptualize flexibility as a valuable resource for physicians. They explore how variations in flexibility across training pathways impact recruitment and retention decisions, especially concerning gender dynamics.
  • Applying Theory to Practice: The theoretical framework guides the study by providing a structured approach to analyzing and interpreting the data. It helps researchers understand the underlying mechanisms influencing the phenomena under investigation.

In summary, the conceptual framework provides the rationale for the study and sets expectations, while the theoretical framework builds on existing theory to deepen understanding and guide the research process. Together, they provide a comprehensive framework for investigating the complex interplay between training pathways, gender dynamics, and workforce challenges within the NHS.


This paper aims to explore how gender intersects with medical training pathways, using the concept of flexibility as an interpretive lens, to try to understand what impact it may have on the recruitment and retention of doctors in the UK.

Chekar, Brewster, Lambert & Patel, 2024


The authors opted for semi-structured interviews involving 50 participants. Yes, you heard it right – 50 individuals comprising an equal split of 25 men and 25 women, offering a diverse pool of perspectives.

The interviews were structured to explore participants’ career journeys, supplemented with targeted inquiries into recruitment practices. Following data collection, a meticulous analysis ensued, guided by the method of constant comparison. This involved scrutinizing responses to identify recurring themes and patterns.

Furthermore, the research team diligently formulated codes to categorize and interpret the data. Through collaborative efforts, overarching themes were distilled, ensuring consensus among team members.

It’s noteworthy that despite originating from a different field, the authors refrained from explicitly outlining their methodological stance. However, the emphasis on establishing consensus and employing multiple coders for objectivity suggests a post-positivist inclination.

In essence, this methodology provides a comprehensive understanding of the research approach without overwhelming technical jargon.


Now, let’s delve into the three major themes identified in the data, which offer intriguing insights into the experiences of the participants.

Theme 1: Rigidity in Training Pathways

The authors shed light on the inflexibility inherent in the UK’s training pathways, particularly when trainees require flexibility the most. Despite the potential for trainees to pursue their desired specialties, they quickly realized the constraints imposed by national training numbers. These numbers, regulated by national bodies, offer limited opportunities for specialization, often dispersed across various locations. Additionally, this inflexibility assumes a certain degree of mobility, overlooking familial responsibilities that may hinder relocation.

Theme 2: Professional Advancement Barriers

The second theme addresses how the lack of flexibility impedes the professional progress of individuals unable to meet assumed expectations. Participants, particularly women, expressed how familial commitments hindered career advancement. The pathway to stable employment was fraught with structural obstacles, such as the expectation of obtaining additional qualifications like a master’s degree, which many found unattainable due to time constraints.

Theme 3: Impact on Well-being and Burnout

The third theme highlights the adverse effects of limited flexibility on participants’ well-being, contributing to burnout and a desire to leave the profession. Participants shared poignant accounts of being told that childcare responsibilities were not valid reasons for work absence. Furthermore, the refusal of organizations to accommodate job sharing requests underscored the systemic rigidity within the healthcare sector. These structural constraints not only exacerbate burnout but also pose significant challenges to achieving work-life balance.

The narratives shared by participants underscore the profound impact of structural inflexibility on their professional and personal lives. These themes prompt reflection on the systemic barriers faced by healthcare professionals and invite discussion on potential avenues for change.


This paper emphasizes the crucial role of flexibility as a form of social capital within medical education. It underscores the imperative for us to acknowledge that flexibility is no longer a luxury but a necessity. These findings underscore the urgency for our training structures, processes, and expectations to adapt to the evolving needs of society. We can no longer afford to lag behind.

The call for change resonates beyond the UK; it reverberates internationally. Our training systems and work expectations must embrace flexibility if we genuinely aspire for our physician population to mirror the diversity of our society. The profession’s ranks should reflect the diversity of its populace.

To those leaders who deem flexibility too challenging, I urge you to reconsider. If your response is riddled with excuses, you are part of the problem. It’s time to step aside and make room for those with the passion, determination, and perhaps even lived experiences to lead the charge for change. Maintaining inflexibility only serves to hinder participants’ success and perpetuate inequality.

Yes, I recognize that my words may evoke strong reactions, but let’s confront this discomfort head-on. For every dissenting voice, there are countless others rallying behind the call for change. So, if you’re hesitating, it’s time to relinquish your seat at the leadership table. Let’s embrace change together.


Varpio, L., Paradis, E., Uijtdehaage, S., & Young, M. (2020). The Distinctions Between Theory, Theoretical Framework, and Conceptual Framework. Academic Medicine, 95(7), 989–994.

Varpio, L., & Albert, M. (2013). AM Last Page: How Pierre Bourdieu’s Theory and Concepts Can Apply to Medical Education. Academic Medicine, 88(8), 1189.


Alexander Tejera

Alexander Tejera

Thank you for another wonderful episode of the podcast! Listening on my way from work today and with a long day of discussing Evidence Based Medicine and the role of RCTs it was a nice breather to hear some reflections on qualitative research which is my home turf. So, to my question. I have a quiet shallow understanding of Bourdieu's work and do not know what paradigm his theory of social capital is grounded in. Regardless, as you were discussing the theoretical framework of this paper and not being sure which paradigm the study is situated within, I would be very interested in hearing your thoughts on alignment between the paradigm of a study and theories used within it. Is an alignment between paradigm and theories important or is it possible to use theories situated within a different paradigm than the study you are conducting?

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