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A Timely Problem: Parental Leave During Medical Training

Webb, Allison M.B. MD, MAT; Hasty, Brittany N. MD, MHPE; Andolsek, Kathryn M. MD, MPH; Mechaber, Hilit F. MD; Harris, Toi Blakley MD; Chatterjee, Archana MD, PhD; Lautenberger, Diana M. MA; Gottlieb, Amy S. MD

doi: 10.1097/ACM.0000000000002733
Invited Commentaries
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Shifting demographics and concerns about burnout prevention merit a reexamination of existing structures and policies related to leaves of absence that may be necessary during medical training. In this Invited Commentary, the authors address the issue of parental leave for medical students and residents. Discussion about parental leave for these trainees is not new. Despite decades of dialogue, leave policies throughout the undergraduate and graduate medical education continuum lack standardization and are currently ill defined and inadequate. There are a number of barriers to implementation. These include stigma, financial concerns, workforce and duty hours challenges, and the historically rigid timeline for progression from one stage of medical training to the next. Potential solutions include parent-friendly curricular innovations, competency-based medical education, and provision of short-term disability insurance. Most important, adopting more flexible approaches to graduation requirements and specialty board examination eligibility must be addressed at the national level. The authors identify cultural and practical challenges to standardizing parental leave options across the medical education continuum and issue a call to action for implementing potential solutions.

A.M.B. Webb is an internal medicine–psychiatry resident, Walter Reed National Military Medical Center, Bethesda, Maryland.

B.N. Hasty is a postdoctoral research fellow, Stanford University School of Medicine, Stanford, California.

K.M. Andolsek is assistant dean for premedical education and professor of family medicine and community health, Duke University School of Medicine, Durham, North Carolina.

H.F. Mechaber is associate dean for student services and associate professor of clinical medicine, University of Miami Miller School of Medicine, Miami, Florida.

T.B. Harris is associate provost for institutional diversity, inclusion, and equity, and student services, and professor of psychiatry, pediatrics, and family and community medicine, Baylor College of Medicine, Houston, Texas.

A. Chatterjee is chair, Department of Pediatrics, and senior associate dean for faculty development, University of South Dakota Sanford School of Medicine, and chief pediatric medical officer, Sanford Health, Sioux Falls, South Dakota.

D.M. Lautenberger is director, Faculty and Staff Studies and Services, Women in Medicine and Science, Association of American Medical Colleges, Washington, D.C.

A.S. Gottlieb is associate dean for faculty affairs and professor of medicine and obstetrics and gynecology, University of Massachusetts Medical School–Baystate, and chief faculty development officer, Baystate Health, Springfield, Massachusetts.

Funding/Support: None reported.

Other disclosures: K.M. Andolsek is a member of the Board of Directors of the Accreditation Council for Graduate Medical Education.

Ethical approval: Reported as not applicable.

Disclaimer: The views expressed in this manuscript are those of the authors and do not reflect the official policy of the Department of the Army, Department of Defense, or the U.S. Government.

Previous presentations: Parts of this work were presented in a session at Learn Serve Lead 2018: The Association of American Medical Colleges Annual Meeting in Austin, Texas, November 5, 2018.

Correspondence should be addressed to Amy S. Gottlieb, MD, Office of Faculty Affairs, Baystate Health, 3601 Main St., 3rd Floor, Springfield, MA 01199; telephone: (413) 794-9551; email: Amy.GottliebMD@baystatehealth.org.

As members of the medical community, we are keenly aware of the growing need to support physician wellness, which involves recognizing the professional and personal challenges faced by our workforce. Shifting demographics and concerns about burnout prevention merit a reexamination of existing structures and policies related to leaves of absence that may be necessary during medical training.1 In this Invited Commentary, we address the issue of parental leave for medical trainees, which includes medical students and residents. Although not discussed here, other types of leave, including family leave and sick leave, may share similar challenges and potential solutions.

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A History of Parental Leave Policies During Medical Training

National dialogue about parental leave policies is not a new phenomenon. In a survey of 474 female physicians published in 1988, 63% (n = 299) of respondents reported becoming pregnant with their first child during medical training.2 A year later, the American College of Physicians recommended that residency programs incorporate planned parental leave, including written policies, to avoid negative impact on residents and programs.3 In 1993, the federal Family and Medical Leave Act (FMLA) guaranteed certain U.S. employees up to 12 weeks of unpaid leave, including parental leave, without threat of job loss.4 Despite this seemingly forward momentum, in 1995 a survey of the Association of American Medical Colleges’ Council of Teaching Hospitals revealed that 23% (n = 183) of participating institutions did not have formal written parental leave policies for graduate medical education (GME) trainees.5 Currently, the Accreditation Council for Graduate Medical Education (ACGME) mandates that sponsoring institutions have policies for vacation and other leaves of absence, “compliant with applicable laws,” and that these policies provide “residents/fellows accurate information regarding the impact of an extended leave of absence upon the criteria for satisfactory completion of the program and upon a resident’s/fellow’s eligibility to participate in examinations by the relevant certifying board(s).”6 To our knowledge, there are no published data that capture the degree of compliance with this expectation; however, a 2017 systematic review on parental leave found many inconsistencies in how programs operationalize the ACGME mandate.1 Regarding undergraduate medical education, the Liaison Committee on Medical Education (LCME) does not specifically address leave policies.7

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A Complex Problem and Rationale for Identifying Potential Solutions

Although parental leave may be an important concern for individuals in many professions and at many career stages, it is particularly relevant to those in medical training. Women now constitute over half of all medical school matriculants and 44% (n = 59,362) of GME trainees.8,9 Moreover, women represent more than half of GME trainees in nine specialties, including obstetrics–gynecology, pediatrics, child neurology, medicine, and family medicine.9 The age at medical school matriculation has been gradually increasing, and both women and men are typically in medical school or residency during prime childbearing and child-rearing years.

The reality is that trainees are having children. In a single-institution survey of 194 medical students, 13% (n = 25) had become a parent or pregnant during medical school.10 In another survey involving 644 male and female residents in multiple programs at a single institution, 31% (n = 128) of the 408 residents who planned to have children intended to do so during their current training program.11 Moreover, three-quarters of existing or past pregnancies reported at the time of the survey had occurred during GME training. Although only 184 respondents reported that parental leave had been available during their training, an overwhelming majority of both men and women took advantage of this benefit when it existed.

Studies document a lack of clarity in parental leave policies for medical trainees, and many express a desire for these policies to be more uniform.1 Creating policy standards across medical schools and residency programs is particularly important because of the inflexibility of training programs and the impact that training disruption may have on early career trajectories, particularly for women. Trainees report concerns that extended leave will affect their graduation, length of training, successful transition from one stage of training to another, and finances. Financial concerns are particularly salient for parent–learners, who may need to assume more debt to support their young families.10 Additionally, residents worry about increased work demands, altered schedules, stress on peers, and judgment from peers and faculty members.12 These concerns are well founded: A survey of general surgery program directors revealed negative perceptions of female surgical trainees who were parents despite no objective evidence for diminished performance.12 More recently, a national survey of obstetrics–gynecology program directors showed that 83% (n = 147) believed that becoming a parent negatively impacted resident performance.13

Lastly, although some programs have formal parental leave policies, these policies may not be transparent or fully address the complexities faced by those who require extended leave.11 Trainees who must take leave may not have considered all of their options before finding themselves in need.

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Considerations and a Call to Action

A national conversation about leaves of absence during medical training must include an honest assessment of barriers to implementation and a discussion of innovative and realistic ways to overcome them. Below are some critical considerations.

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Parent-friendly curricular innovations

The rigid timeline for progression from one stage of medical training to the next creates many potential barriers for implementing standardized parental leave policies. The challenge is particularly relevant to the preclinical years during medical school when it may be difficult to make up planned curricula that occur only once per year or are sequential in nature. By adopting online learning platforms, asynchronous models of instruction, and video-based educational methods, individuals could connect remotely to fulfill their educational requirements. Given the mounting evidence of equivalent learner outcomes with online educational tools, medical schools and residency programs should enhance their use as viable means to support trainees who are new parents.14

Clinical electives that explicitly accommodate telecommuting offer another potential solution for both medical students and residents taking or just returning from parental leave. To that end, some family medicine and pediatric residency programs have designed parenting-friendly electives that integrate the professional and personal needs of parent–learners via readings, reflective writing, weekly meetings with mentors, and summative projects.15,16 These electives provide flexible schedules and the ability to transition to full-time training while simultaneously allowing residents to meet graduation requirements and receive salary and benefits.

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Competency-based medical education

Competency-based medical education (CBME) focuses on learner outcomes and de-emphasizes time-based training. Competencies are driven by an ongoing analysis of specialty-specific needs and are the foundation for trainee assessment.17 Under a fully adopted CBME system for GME, residents would graduate when deemed competent in their particular specialty instead of after completing a specified number of years in training. Thus, a CBME framework predicated on rigorous assessment with validity evidence could allow motivated learners who meet performance milestones to complete graduation requirements faster than in a traditional time-based program.18 Currently, pediatrics permits extended leave without the consequence of prolonging residency graduation if the trainee is “well qualified and has met all the training requirements.”19 Additionally, CBME may allow increased opportunity for part-time residency education. In 2017–2018, there were only 263 part-time residents of the 135,326 in training.9 A collaborative effort—among programs, institutions, the ACGME, and the relevant specialty boards—might make this option more viable and appealing.

For trainees who wish to start families, the flexibility that CBME affords could potentially expand parental leave options by weeks to months. We encourage the ACGME to consider this benefit when implementing CBME more broadly in the future.

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Graduation requirements and board eligibility

Two significant barriers to creating sound parental leave policies for medical trainees are inextricably linked: inflexible program completion requirements and specialty board examination eligibility. Fortunately, in undergraduate medical education, some flexibility exists around the timing of clinical requirements for graduation and eligibility to sit for the United States Medical Licensing Examination. Resident trainees do not have similar options. A 2006 study analyzed graduation requirements and leave policies for 26 medical specialties.20 Ten out of the 26 programs allowed only four weeks per year of time away from the program, including vacation time; longer leaves had the potential to extend graduation and/or postpone board eligibility by at least one year.20 The most generous specialty boards allowed a total of up to eight weeks of time away from the program in addition to a yearly vacation allotment without impacting board eligibility.

Since the 2006 study, the American Board of Surgery has introduced a more flexible leave policy such that the mandatory 48 weeks per year of training may now be averaged over the first three years of residency.21 Averaging time is akin to permitting vacation accrual and provides the potential to accommodate extended leaves by allowing a resident one 12-week period “off” during the first three years of residency. However, it seems suboptimal to require a trainee to do three years of a demanding residency with no other time off except one day each week. Nor does this schema provide for an additional 12-week leave in the case of a second birth. Nonetheless, because most specialty boards do not currently permit residents to accrue vacation time for future use, we encourage all specialty boards, as a first step, to consider allowing this option to accommodate parental leaves.

Lastly, fixed specialty board examination dates may limit advancement to fellowship or practice after extended leave and could have significant financial and professional implications for trainees, particularly women. Expanding the number of board testing dates for computer-based and oral examinations seems like a reasonable solution and should be strongly considered.

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Short-term disability insurance

Short-term disability insurance, typically available only to women who have given birth, can provide financial support during parental leave and has been shown to improve access to antenatal care, extend gestational age, and increase birth weights.22 Paid leave has also been associated with lower rates of maternal depression and improved physical well-being.23 Although federal law mandates unpaid leave for employees via the FMLA, only a few states provide or require employers to offer short-term disability insurance to qualified employees.24 We encourage institutions to offer this resource to residents as a benefit of employment to support their health and the health of their newborn children. The LCME standard states that medical schools must “ensure that health insurance and disability insurance are available to each medical student and that health insurance is also available to each medical student’s dependents.”7 Although medical students are not considered employees and thus do not qualify for short-term disability insurance through an employer, the American Medical Association offers a Student Disability Income Plan that will pay up to 12 months of benefits after a 30-day waiting period if a student is unable to attend classes because of a covered illness. However, no benefits will be payable for a disability that is due to a pregnancy or childbirth except for one that results from a medically classified complication of pregnancy.25

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Cultural and Practical Challenges

We cannot ignore the workforce challenges inherent in providing trainees with greater flexibility to support caregiving needs of young children.26 Currently, there are no “temporary service” options to bring in a replacement trainee for one who is on a leave of absence. Faculty may also be at their limit of absorbing additional tasks offloaded from trainees on leave. Moreover, duty hours requirements and educational priorities rightfully place limits on other trainees “covering,” and absences may make it difficult for trainees to obtain required procedural numbers.

As with the 2003 and 2011 ACGME duty hours restrictions, which required some trainees to decrease their workweek by 20% or more, institutions must take a careful look at how much of the current trainees’ work time is truly educational and what aspects of it could be replaced by other members of the patient care team. Such substitutions could benefit all trainees’ educational experience by improving the education/service balance and could provide programs expanded capacity to manage trainee absences.

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Conclusion

The historic lack of parental leave policies reflects a bygone era when single men who lived at the hospital were the predominant group among medical trainees. That is no longer the case, and our educational system has failed to keep up with the changing demographics. By addressing exigencies and complexities to develop robust parental leave policies, we inherently celebrate the gender diversity of our workforce today and acknowledge the negative impact inaction may have on our female trainees.

Consistent, transparent, and viable parental leave policies are needed across the medical education continuum. Medical students and residents are starting families. Existing structures and policies are not adequate, despite decades of dialogue. In this Invited Commentary, we have identified challenges to instituting uniform, transparent parental leave policies and proposed a number of potential solutions. At the institutional level, parent-friendly curricula and short-term disability insurance coverage should be considered. At the national level, specialty board requirements that affect timing of graduation and examination eligibility are the greatest barriers to implementing parental leave policies during GME. We strongly urge boards to introduce flexible scheduling into required examinations and consider modifying leave-of-absence policies to support vacation accrual and elements of CBME so that parent–learners may graduate on time and continue along their chosen professional trajectories without penalty.

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Acknowledgments:

The authors would like to acknowledge members of the Association of American Medical Colleges’ Group on Women in Medicine and Science and Organization of the Resident Representatives, in particular Dr. Marissa Pavlinich, for their early feedback on the concepts addressed in this manuscript.

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