Pregnancy during graduate medical education (GME) has traditionally been seen as a “women’s issue,”1,2 and the female trainees, their pregnancies, and the subsequent parental leaves largely have been handled on a case-by-case basis. Few GME programs provide clear guidelines that address work hours, call schedules, or clinical rotations during pregnancy. The inadequacy of this ad hoc approach to training during pregnancy has been described in the literature.3–6 Many have called for the development of well-defined parental leave and education policies to improve working conditions for pregnant trainees, to mitigate the increased workload imposed on colleagues during parental leave, and to address breastfeeding and the maternal and family health issues that arise during GME. Pregnant trainees and those contemplating pregnancy often report stress related to faculty and coworker attitudes, rigid and intense educational requirements, long work hours, unpredictable work demands, altered schedules, guilt over colleagues’ increased workloads, and concern for maternal–fetal well-being.7,8 Despite these concerns, the GME years are a biologically compelling time for pregnancy and childbirth, and many trainees have children then.9 Contemporary studies have not identified substantial progress in adequately addressing these challenges,10,11 despite increasing numbers of female physicians.12 Additionally, program directors are faced with accommodating more pregnancies during training,13 achieving fair and equitable leaves and workloads, and advocating for the health and well-being of trainees while maintaining high-quality programs.
Recent changes in the culture of medicine, the introduction of GME work hours restrictions,14,15 and broad societal and generational trends have affected expectations of both male and female trainees regarding work–life integration. The issues that arise from having children during GME are increasingly pertinent not only for women but also for their male colleagues and for program directors. Yet, little is known about how these demographic, regulatory, and cultural shifts have influenced personal reproductive plans, academic endeavors, and quality of life among trainees.
Our study examined the experiences of trainees at a single academic medical center with multiple GME programs. We identified trainees who did or did not become pregnant during training to better understand their plans for pregnancy, the personal and career consequences of pregnancy, and the impact of recent duty hours restrictions on these plans. We also aimed to determine whether and how pregnant trainees used available institutional support.
The Mayo Clinic Institutional Review Board deemed this study exempt.
An Internet-based survey, created using Survey Tracker, was sent to all trainees (N = 1,516) enrolled in the 269 GME programs (residencies and subspecialty fellowships) that are part of the Mayo School of Graduate Medical Education (MSGME) across three academic sites (Arizona, Florida, and Minnesota). Before the survey was released, letters were sent to program directors to alert them to the study and to enlist their support. An e-mail was then sent to all trainees inviting them to complete the survey; the invitation emphasized that the study was designed to include all trainees, regardless of gender or parental status. Trainees were assured that participation was voluntary and that responses would be confidential. No incentives were provided for participation. The initial invitation was sent on May 1, 2013. Four reminders were sent at two-week intervals, and the survey closed on July 15, 2013.
Scaled and open-ended questions assessed a number of pregnancy-related issues, including awareness and use of relevant institutional policies, influence of changes in duty hours restrictions on childbearing decisions, changes in duties and work schedule due to pregnancy, career changes and activities during pregnancy and subsequent parental leave, and maternal and neonatal complications. Skip patterns were designed to ensure the relevancy of survey items. The number of survey items ranged from 66 core items for all respondents to more than 200 items, depending on the number of pregnancies reported.
The formatting and branching schematics of the survey were constructed with the assistance of the Mayo Clinic Survey Research Center. The survey was piloted using a diverse subset of trainees who agreed that the content was relevant and inclusive and the format easy to follow. Time stamps indicated that the survey took approximately 10 to 15 minutes to complete.
For the purposes of this analysis, the following were considered surgical programs: general surgery and general surgical specialties, neurosurgery, obstetrics–gynecology, oral and maxillofacial surgery, otorhinolaryngology, and urology. The remaining programs were considered nonsurgical programs.
The survey data were downloaded from Survey Tracker into SPSS Statistics 21 (IBM, Armonk, New York) for analysis. All identifiers were replaced with unique identity codes. Categorical thresholds for items such as years since attending medical school or children’s ages were determined by examining the distributions of raw data. Categorical variables were compared using the χ2 test, and dichotomous variables using the Fisher exact test. Continuous variables were compared using independent t tests; the Cochran–Armitage trend test for ordinal categories was used to compare age categories. P values < .05 were considered significant.
We invited 1,516 trainees (915 [60%] men and 601 [40%] women) to participate, and 644 (42%) responded during the survey period. Respondents included 314 (34%) men and 330 (55%) women.
The response rates for postgraduate year (PGY) 1 and 2, PGY 3 and 4, and PGY ≥ 5 trainees were 63% (100 of 197 men [51%], 143 of 186 women [77%]), 40% (126 of 347 men [36%], 99 of 209 women [47%]), and 31% (88 of 369 men [24%], 88 of 195 women [45%]), respectively. Across all years of training, men were underrepresented (314 of 915; 34% response rate), and women were overrepresented (330 of 601; 55% response rate) (P < .001). The response rate for all surgical programs was 32% (72 of 255 men [28%], 34 of 77 women [44%]) compared with 45% for nonsurgical programs (242 of 663 men [37%], 296 of 521 women [57%]) (P = .004). The percentages of respondents did not differ across geographic sites.
The first 66 items were relevant to all respondents, and the response rate for each question among the 644 respondents ranged from 94% to 100%. Twenty-four respondents answered less than 50% of the last 21 questions.
Table 1 summarizes respondents’ demographics, and Table 2 summarizes selected information from respondents who were already parents.
Trainees without children
Most respondents had no children (378 of 644; 59%). Among these respondents, approximately two-thirds planned to have children. Forty (of 135; 30%) women and 36 (of 111; 32%) men planned pregnancies during their current training program, and 25 (19%) women and 14 (13%) men planned pregnancies during their next training program (see Table 1).
Trainees with children
Less than half of respondents had children (264 of 644; 41%), but among parents, 45% had more than 1 child. Respondents reported having 426 children, and details of 398 (93%) pregnancies were provided by 253 respondents: 306 pregnancies occurred during GME, and 92 occurred before GME. An additional 46 (7%) respondents were currently pregnant. On average, men reported having more children than women. Most (85%) children were ≤ 5 years old. Women had younger families than men: 91 (of 116; 78%) of their first-born children were ≤ 5 years old compared with 91 (of 148; 61%) for men. Both female (64%) and male (56%) parents planned to have additional children, including 24 (of 73; 33%) women and 28 (of 81; 35%) men who planned to have their next child during their current training program, and 13 (18%) women and 14 (17%) men who planned to have their next child during their next training program.
Trainees with children versus trainees without children
Respondents with children were more likely to be married or in a committed relationship than those without children (247 of 252 [98%] versus 223 of 375 [59%]) (P < .001) and were more likely to be older (33 versus 30 years old) (P < .01). Overall, 123 (of 326; 38%) women and 64 (of 313; 20%) men (as a spouse or partner) reported delaying pregnancy until after training. Reasons for this deferral were provided by 182 respondents. Women were more likely than men to cite extension of training (85 of 119 [71%] versus 22 of 63 [35%]) (P < .001), interference with fellowship plans (67 of 119 [56%] versus 18 of 63 [29%]) (P < .001), and concerns about potential pregnancy complications (52 of 119 [44%] versus 11 of 63 [17%]) (P = .001). Men were more likely to cite financial hardship (64 of 119 [54%] versus 44 of 63 [70%]) (P = .03).
Pregnancy during GME
In total, 253 respondents reported 398 pregnancies; 306 (77%) occurred during GME. Pregnancy and childbirth altered respondents’ choice of GME program, date of completion, career plans, and/or pursuit of an additional degree more often for women than men (see Figure 1). Pregnant women reported working similar weekly hours as men whose partners were pregnant. More than half the pregnant women (89 of 174; 51%) worked > 60 hours per week (versus men who reported working > 60 hours per week: 122 of 212; 58%) (P = .22); both reported working a similar median weekly range of hours (40–59 hours).
Parental leave during GME was available to 101 men and 83 women. Of these, 89 (88%) men and 81 (98%) women used it. The median length of parental leave was five to eight weeks for mothers and less than one week for fathers (data not shown). The 13 respondents who did not use parental leave cited five main reasons: (1) the sense of being a burden to colleagues (10 of 13); (2) anticipation of a heavier workload later (8 of 13); (3) delayed program completion (9 of 10); (4) not needing the time (8 of 10); and (5) not being the primary caregiver (7 of 10).
Eighty-one women reported taking parental (medical) leave for 97 pregnancies during GME. Thirty-two (40%) engaged in career-related activities while on leave for 44 pregnancies. The most common activity was research (22 women, 27 pregnancy leaves); other activities included writing papers, pursuit of an advanced degree or other training, mentoring students, attending conferences, and/or studying for examinations. Men did not report similar activities while on parental leave.
Return to training after parental leave
Of the respondents who had children during GME, 217 described their “return from parental leave.” After giving birth, 89% (101 of 113 reported pregnancies) of women resumed working ≥ 40-hour workweeks compared with 99% (133 of 135 reported pregnancies) of men. In their first rotation back from parental leave, 68 (of 140; 49%) women worked 41 to 60 hours per week, and 47 (of 140; 34%) women worked 61 to 80 hours per week, compared with 86 (of 192; 45%) (P = .50) men and 84 (of 192; 44%) (P = .07) men, respectively.
Effect of changes in duty hours restrictions
Roughly two-thirds of the 413 respondents who answered each duty hours question indicated that duty hours restrictions did not greatly influence whether they tried to become pregnant during GME (see Table 3). No significant differences were found between the responses of men and women to these questions (data not shown).
Since the early 1980s, pregnancy and family building have been increasingly important issues for GME programs,1,3,16 as the number of trainees who have children during these years has increased.6,8,17 A 1983 survey indicated that approximately 13% of female trainees became pregnant during GME.1 More recently, the percentage of women who become pregnant during GME has surpassed 35%.13,17,18 Our study demonstrates that, for trainees at the MSGME, the GME years are routinely characterized by family building: 41% of respondents were already parents, and another 7% were pregnant at the time. As the overall proportion of female trainees increases, the absolute number of trainees having children will also increase. Training programs such as obstetrics–gynecology and primary care specialties that traditionally have a greater percentage of female trainees may be disproportionately affected by this change.
Recommendations for dealing with this “baby boom” have been presented and affirmed.19–22 Most institutions, including ours, have formalized parental leave policies as required by the Family and Medical Leave Act of 1993.23 However, leave policies alone may be insufficient in addressing the burden perceived by trainees when their colleagues take parental leave.24 Part-time options,20 flexible scheduling,19 sympathetic colleagues,19 and specific policies for pregnancy21 improve the situation for trainees returning to work after childbirth. The American Academy of Pediatrics also has recommended a host of other policies that address adoption, maternity and paternity leave (beyond the Family and Medical Leave Act), and policies that tailor work conditions to meet the medical and emotional needs of the pregnant resident.22 Although such policies may improve the support for trainees during or after pregnancy, they insufficiently address the issues that stem from a reduced workforce within programs during such times. The growth of training programs, flexible (nonteaching) attending staff physician services, and the increased incorporation of physician extenders may alleviate these workforce issues, but such options might not be available on demand and thus will require planning and resources to implement.
The MSGME has three geographically separate academic sites (Arizona, Florida, and Minnesota) that all offer the same package of benefits to trainees. All trainees receive personal, spouse/partner, and child health care benefits. Paid maternal medical leave after childbirth is generally six weeks, as determined by the mother’s health care provider. Paid parental leave for adoptive parents and new fathers was two days at the time of our survey in 2013. All fathers and mothers may take additional time away by using vacation days or by taking an unpaid parental leave of absence (or a combination of both). Part-time training is not generally offered to trainees, although many individual programs may have a rotation with fewer weekly work hours that can be scheduled immediately after a trainee returns from leave. Various child care benefit options exist across the sites, including backup child care, sick child care, limited on-site child care, and child care discounts. We do not know whether differences in available benefits or in the perceived culture around childbearing among MSGME trainees are influential factors for applicants in selecting a residency; if the demographic characteristics of our residents differ from those of other training programs, the results of our survey may not be generalizable.
One objective of our study was to survey male and female trainees about their parental status and reproductive plans. We found that both parents and nonparents planned to have children during their current or next training program. The most enlightening and potentially actionable finding was that nearly half of all trainees planned to have a first child or an additional child during their current or next training program. Most parents who were eligible had taken parental leaves following their previous pregnancies, likely predicting that they would do the same following their future pregnancies, which could have a sizable impact on the workforce across training programs. From our current cohort of trainees, the MSGME might anticipate receiving more than 450 (30% of 1,516 trainees) leave requests over the next few years.
Although parental leave may affect GME training, the full extent of its influence on the career paths of trainees has not been well defined. We found that pregnancy and parental leave altered GME training, date of training completion, career plans, and pursuit of an additional degree more often for women than for men (see Figure 1). Currently, individual specialty boards set leave policies with respect to the amount of time allowed for absences during each year of training and whether time away can accumulate over the course of the GME program.10,25 Such variability means that a six-week leave will affect trainees in different specialties in alternate ways, ranging from having no impact to delaying qualification for a board certification examination by one year. Of the trainees who did not use parental leave, most cited delayed program completion as a reason. Such a delay in graduation affects not only the individual trainee but also the training program; smaller programs may be disproportionately affected by a trainee’s delayed graduation, especially if opportunities for required rotations are limited.
Similar to the findings from another study,26 our study showed that some women worked toward career advancement during maternity leave by conducting research and writing papers, pursuing an advanced degree or other training, mentoring students, attending conferences, and/or studying for examinations. Given the substantially shorter parental leaves available for men, we did not observe similar activities among them.
With fathers playing a greater role in parenting,27–29 it is unsurprising that nearly 90% of new fathers in our study used parental leave. Nationally, 89% of fathers rated paternity leave as an important benefit, with a greater percentage of millennials (93%) than of baby boomers (77%) identifying the importance of paternity leave. New fathers in today’s workforce take approximately two weeks of parental leave,30 and the amount of time off fathers take is strongly correlated to the availability of paid leave.30 The MSGME has recently extended paternity leave to five days, with the option to use unpaid leave or vacation time to extend that period. As millennial fathers perceive paternity leave as a more important benefit than previous generations did, GME programs, depending on their individual policies, may need to prepare for an increasing number of male trainees taking parental leave and potentially adding to the scheduling strain of the increasing number of maternity leaves.13,26,31
Our findings add to a growing body of evidence that training programs are seeing an increase in the number of pregnancies and family-building activities among their trainees.6,13,16,17 With the potential for an even greater number of male and female trainees taking parental leaves in the future, residency programs currently accredited by the Accreditation Council for Graduate Medical Education (ACGME) may not be able to cope with this “numbers game.” Despite the fact that the number of U.S. medical school graduates is increasing and that these graduates could provide the workforce needed to give stretched GME training programs some relief,32 the number of GME training programs is growing at a slower rate. However, despite the clear evidence that growth in GME is needed to meet projected physician workforce numbers,33 gaining support for such growth in the current political climate will not be easy.34
Our study has several limitations. The survey was long (66–200 items, depending on skip patterns), and we observed varying response rates to questions, especially as the survey progressed beyond question 66, which resulted in differing denominators for many questions and demographics. In addition, the overrepresentation of female respondents and underrepresentation of respondents from surgical programs were not a true reflection of the entire GME program. However, in academic year 2012–2013, when we completed our study, 40% of the 1,516 trainees in the MSGME were women, whereas 46% of all trainees in ACGME-accredited training programs were women.1235 Voluntary survey participation and an overall response rate of 42% likely reflect a bias in respondents’ personal interest in the topic of childbearing during GME. Finally, recall bias may have affected respondents’ accurate reporting of events surrounding prior pregnancies.
In conclusion, although a substantial number of trainees defer pregnancy and childbearing until after postgraduate training, the GME years increasingly are including family-building activities, despite potential perceptions of adverse consequences to trainees’ careers. We found that a substantial proportion of trainees planned to have one or more children during their GME training. Program directors must address the challenges related to pregnancy and parental leave for this growing group of both male and female trainees. We recommend that future research continue to explore these issues and that institutions pursue policies and practices to minimize the effects of parental leaves on the workforce as trainees build their families.
Acknowledgments: The authors gratefully acknowledge the support, manuscript review, and helpful comments of Stephen Rose, MD, dean of the Mayo School of Graduate Medical Education.
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