Each year, tens of thousands of medical students interview for residency training positions, a process wrought with anxiety and insecurity. As I (A.N.W.) prepared for the series of meetings that would decide the next step in my career, I was advised to present myself in the most favorable light possible while being open and honest as to what I sought in a program. But I feared that some of my priorities—a supportive culture for the promotion of women, professional advancement opportunities for my significant other, and access to resources for young families—would decrease the competitiveness of my application. I struggled to find a way to address these issues without negatively influencing selection committee members. As an internal medicine applicant at multiple large academic research institutions, I found that responses to my queries were highly variable. Some programs freely provided the information I was looking for, but many did not. I had moments when I was empowered to ask difficult questions, and others where my fear of disappointing interviewers discouraged me from doing so.
Fortunately, the topics that were so hard to incorporate into my interviews were surprisingly easy to discuss in more casual situations. I discovered that programs were searching for ways to better support current trainees and demonstrate their support to applicants. However, neither the Accreditation Council for Graduate Medical Education (ACGME) nor the National Resident Matching Program (NRMP) has policies addressing the distribution of information about wellness resources and family support to applicants. As the NRMP Match Communication Code of Conduct prohibits interviewers from addressing gender, marital status, and intent to bear children, the burden of introducing such topics falls on the interviewees. Without transparency about these topics, how can programs and applicants alike identify the best fit? One year and one Match cycle later, here are the questions that I should have asked and that programs need to answer.
How Much Time Is Available for Parental Leave?
Although physicians spend many of their prime childbearing years in residency and fellowship, trainees considering pregnancy may encounter substantial obstacles, including lack of support from colleagues or administration and difficulty identifying the optimal timing for childbirth.1,2 The ACGME requires institutions to provide leave of absence policies to trainees—look for this information on the program’s website and in printed interview materials.3 Most policies are based on the Family and Medical Leave Act of 1993 (FMLA), which allows 12 weeks of unpaid leave for all employees with a year of service, in conjunction with an institution-specific paid leave policy, which typically ranges from 2 to 6 weeks counted toward the 12 weeks of FMLA.4 An equally important place to search for information is the medical specialty’s board certification website, which details individual specialty requirements as to how much time a resident can spend away from work without extending his or her training period.5 For instance, the American Board of Internal Medicine allows 1 month per academic year,6 but the American Board of Obstetrics and Gynecology permits 8 weeks per year with the total not to exceed 20 weeks over 4 years.7 If the total parental, personal illness, and vacation leave exceeds the limit established by the specialty board, the resident is required to make up the excess time at the end of residency. Most specialties only offer board exams once per year in the late summer/early fall, so a training extension of a few weeks can easily turn into a 1-year delay in acquiring board certification and subsequent employment. Given these multiple layers of policy that limit flexibility,8 it is reasonable to ask residency programs how much time trainees typically take for parental leave and what the scheduling options are. One important point for couples who are both medical professionals to consider is whether the institution grants equal maternity and paternity leave. Such policies are still rare but may translate to equal sharing of childcare responsibilities, resulting in an easier return to the workplace for new mothers.9
Are Lactation Resources Easily Accessible?
As a population, physician mothers have high rates of breastfeeding initiation, but their 6-month continuation rates are consistently below the 60% goal established by the Healthy People initiative.10 Nearly half of resident mothers who stopped breastfeeding early cited work-related reasons, including time limitations, lack of appropriate space, and the perception of burdening fellow residents.11 In response to these concerns, the ACGME recently updated the common program requirements to include “clean and private facilities for lactation that have refrigeration capabilities, with proximity appropriate for safe patient care.”12 Larger institutions may have a list or map of lactation rooms on their human resources website, although assessing proximity to resident work rooms will be difficult for those unfamiliar with the campus. These directories often detail the types of equipment provided, which can vary from an empty space to a fully furnished suite with a pump, sink, and refrigerator. Some hospitals even have breastfeeding vending machines with spare parts and accessories.
Regardless of physical resources, time remains a significant and often unaddressed obstacle for resident mothers who are breastfeeding. For example, a pumping schedule of 30 minutes every 4 hours over a 16-hour workday equates to 2 hours away from work duties with additional time needed for transit and preparation. To accommodate pumping, residents may be required to step out of procedures or rounds, miss educational conferences, or ask their colleagues to take on extra patient care responsibilities. These absences interfere with learning and alter professional relationships, as demonstrated in a recent article reporting lower peer evaluation scores for postpartum female residents compared with their male counterparts.13
Formal lactation policies are rare and may be limited to nonspecific statements of support for flexible scheduling and open conversation with supervisors about lactation needs. Current trainees can provide insight into the program culture, but many applicants will not encounter a resident mother during their interview day and will have difficulty in assessing the available support. If this is an important consideration, applicants can ask for the name and contact information of a female resident who had a child during training.
Do Residents Have Access to On-Site Childcare?
Childcare is a frequently cited source of stress for young physicians who have long work hours, limited scheduling flexibility, and tight budgets. This is not a gender-specific issue, although obstacles may differ depending on which parent is a medical trainee. Female residents are less likely than males to have a stay-at-home partner, which is a common source of childcare during training.14 However, male residents are less likely than females to be offered resources for childcare.15 Studies of childcare arrangements made during residency consistently demonstrate infrequent access to on-site childcare, sick-child care, and childcare subsidies, as well as poor knowledge of available childcare programs.16 In addition, family assistance may be limited for those who relocate away from their social support system. The existence of on-site childcare can often be determined through an online search or hospital tour, but many of these facilities are not actually available because of wait times in excess of 12 to 18 months or policies limiting resident access. Current trainees are, again, a valuable source of information about childcare arrangements, although even those with children may have limited or incomplete knowledge about available childcare programs. This question can also be posed to program leadership or the institution’s GME office. It is important to note that applicants calling the GME office do not have to provide their name to obtain information about policies and benefits.
Are There Recruitment Services for My Partner?
Dual physician couples at the same stage of training can participate in the Match process as a pair, which allows for conditional ranking to obtain positions in close geographical proximity. For applicants with a professional partner outside of medicine, the relocation process is unstructured. Job opportunities may not be a concern in large cities like New York or Chicago but may present an obstacle in less urban locations. Some hospitals provide recruitment resources for the partners of new faculty and senior-level administrators, including interview preparation services, information on area employers, and local job listings. However, it is not typical for residency applicants to have access to the same programs as faculty. Applicants to unique residency pathways, such as integrated programs or research tracks, may be the exception, as these positions generally represent a longer duration of employment and greater investment on the part of the institution. If a partner’s professional opportunities are a barrier to ranking a program, it is reasonable to mention this to the program director. He or she may be able to offer resources or assistance on a case-by-case basis, especially for highly ranked candidates.
Is the Workplace Culture Conducive to Women’s Academic Success?
A “culture conducive to women’s academic success” (CCWAS) requires equal access to resources, support for work–life balance, freedom from gender bias, and support from leadership.17 Although a 45-question CCWAS survey tool developed by Westring and colleagues17 was calibrated for faculty to evaluate their home institution, it includes items that can be easily observed by a residency applicant over the course of the interview day. Are there female trainees and faculty in leadership roles? Are both genders represented at the preinterview dinner? Do women speak up during morning report or noon conference, and are their comments taken seriously? Does the program newsletter recognize achievements equitably? Positive answers suggest support for the professional advancement of female trainees in the program. Current trainees are another excellent source of information, as they may be able to describe gender-specific mentorship or leadership programs within the department. Finally, applicants should consider asking program leadership how they support female trainees. The answer, or nonanswer, to this question may be the best indicator of whether the program will advocate for residents’ continued career development.
The previous questions represent only a small portion of the issues facing applicants in the residency interview process, and the information presented in response was gathered primarily from academic institutions and departments of medicine. What, then, is the optimal way to universally address these and other important topics that may be left off the hospital tour or program slide show? We hope that this Invited Commentary will empower applicants to ask questions about opportunities and resources available to them while interviewing with a program. In turn, we hope that calling attention to these concerns will inform programs to adapt their interview materials to include resources and points of contact so that interviewees can easily access the information they need. Finally, policies are needed to standardize communication between residency programs and applicants. This will likely require regulation at the level of the ACGME and NRMP, as prior attempts by program directors to implement residency interview guidelines have been met with limited success.18 Improving communication between applicants and programs will not erase the stress of residency interviews, but it can help improve goodness of fit in the Match and subsequent resident satisfaction and wellness.
The authors wish to thank Jennifer Stanley, Stacey Watkins-Bahraini, Katherine Hunt, Kelly Roszczynialski, Jason Morris, Sonya Heath, and Robin Lorenz for their support and assistance in the preparation of this article.
1. Jagsi R, Tarbell NJ, Weinstein DF. Becoming a doctor, starting a family—Leaves of absence from graduate medical education. N Engl J Med. 2007;357:1889–1891.
2. Willett LL, Wellons MF, Hartig JR, et al. Do women residents delay childbearing due to perceived career threats? Acad Med. 2010;85:640–646.
3. Riano NS, Linos E, Accurso EC, et al. Paid family and childbearing leave policies at top US medical schools. JAMA. 2018;319:611–614.
4. University of Alabama at Birmingham. Paid parental leave policy. https://www.uab.edu/policies/content/Pages/UAB-HR-POL-0000776.aspx
. Accessed June 1, 2019.
5. Varda BK, Glover M 4th. Specialty board leave policies for resident physicians requesting parental leave. JAMA. 2018;320:2374–2377.
6. American Board of Internal Medicine. Special training policies for certification. https://www.abim.org/certification/policies/general/special-training-policies.aspx#leave
. Accessed May 28, 2019.
7. American Board of Obstetrics and Gynecology. Specialty qualifying exam, eligibility requirements. https://www.abog.org/specialty-certification/specialty-qe-gen-info-misc-tab-details#Content_C009_Col00
. Accessed May 28, 2019.
8. Greenfield NP. Maternity and medical leave during residency: Time to standardize? Int J Women’s Dermatol. 2015;1:55.
9. Heymann J, Sprague AR, Nandi A, et al. Paid parental leave and family wellbeing in the sustainable development era. Public Health Rev. 2017;38:21.
10. Sattari M, Levine D, Serwint JR. Physician mothers: An unlikely high risk group-call for action. Breastfeed Med. 2010;5:35–39.
11. Orth TA, Drachman D, Habak P. Breastfeeding in obstetrics residency: Exploring maternal and colleague resident perspectives. Breastfeed Med. 2013;8:394–400.
12. Accreditation Council for Graduate Medical Education. Common program requirements (residency). https://www.acgme.org/What-We-Do/Accreditation/Common-Program-Requirements
. Accessed May 28, 2019.
13. Krause ML, Elrashidi MY, Halvorsen AJ, McDonald FS, Oxentenko AS. Impact of pregnancy and gender on internal medicine resident evaluations: A retrospective cohort study. J Gen Intern Med. 2017;32:648–653.
14. Mayer KL, Ho HS, Goodnight JE Jr. Childbearing and child care in surgery. Arch Surg. 2001;136:649–655.
15. Berkowitz CD, Frintner MP, Cull WL. Pediatric resident perceptions of family-friendly benefits. Acad Pediatr. 2010;10:360–366.
16. Snyder RA, Tarpley MJ, Phillips SE, Terhune KP. The case for on-site child care in residency training and afterward. J Grad Med Educ. 2013;5:365–367.
17. Westring AF, Speck RM, Sammel MD, et al. A culture conducive to women’s academic success: Development of a measure. Acad Med. 2012;87:1622–1631.
18. Chacko KM, Reddy S, Kisielewski M, Call S, Willett LL, Chaudhry S. Postinterview communications: Two surveys of internal medicine residency program directors before and after guideline implementation. Acad Med. 2018;93:1367–1373.