The American Board of Medical Specialties (ABMS) announced in July 2020 the adoption of a parental leave policy for residents and fellows (1). The policy allows for a minimum of 6 weeks of leave, starting July 2021, and applies to all new parents, including birthing and nonbirthing parents, adoptive/foster parents, and surrogates. This policy allows that vacation and/or sick leave can be used in creating these 6 weeks of parental leave but that vacation/and or sick leave should not be fully depleted by the parental leave; therefore, a trainee can be mandated to use all but 1 day of their vacation and sick leave toward their 6 weeks of parental leave (1). There are several other caveats: this leave is only required to be available once during training (whether for parental, caregiver, or medical leave), and this leave policy only applies to training programs of 2 or more years' duration—it would therefore not apply to a fellow in their Transplant Hepatology or Inflammatory Bowel Disease fellowship. This policy applies only to board eligibility requirements and does not supersede institution or program policies. ABMS announced this as a “progressive” policy that will “offer trainees more flexibility, reduce stress, and increase autonomy in making life decisions.” (1) Although the new existence of a parental leave policy is a step in the right direction, trainees are in need of a more robust and evidence-based policy. This is particularly important in the field of gastroenterology, in which women are underrepresented and female gastroenterology trainees are more likely to have career decisions limited around the availability of parental leave (2). This article will highlight the importance of parental leave for trainees in medicine and in gastroenterology specifically and future directions for parental leave within gastroenterology.
Parents taking leave after the birth or adoption of a child has wide ranging benefits that are supported by an extensive evidence base, both in the general population and for trainee physicians specifically (3,4). These benefits include lower infant and child mortality rates, higher breastfeeding rates and longer breastfeeding duration, and improved maternal mental health (3–6). In addition to benefits to the individual physician and child, adequate parental leave and a supportive environment for new parents is essential for reducing gender disparities that are prevalent throughout medicine (7,8). However, although almost 40% of resident and fellow physicians planned to have children during their Graduate Medical Education training, and many training programs either do not have defined parental leave policies or those that do have a mean paid leave of 3.9 weeks (9,10). This is shorter than the time needed for physical recovery alone for many people who give birth (11–14).
The lack of a universal, standardized policy has forced trainees to make childbearing decisions without clear knowledge about the impact of that decision on their training or the time they would have to care for their newborn (7,15). In lieu of standardized parental leave, there has been an inconsistent conglomeration of time meant for other activities. Most parental leave for residents included vacation (81%) or sick leave (64%) (16). Policies that force trainees to choose between taking time for sick leave and maintaining the potential for future parental leave create perverse incentives against taking sick days when a trainee is symptomatic. As the current pandemic highlights, we must change the culture in medicine that encourages physicians to work despite symptoms of illness (17). Additionally and importantly within gastroenterology, inconsistent leave policies have created gender disparities that disadvantage the careers of those who are required to use research or elective time for parental leave, who are disproportionately female physicians (8,18). Furthermore, the lack of a consistent and standardized parental leave policy frequently excluded parents who are in same-sex partnerships, adoptive parents, or nonbirthing partners (15,19). Finally, if parental leave is cobbled together on a case-by-case basis, then programs and institutions must rely on increased work from colleagues to cover clinical duties, thus perpetuating bias and leading to guilt about taking leave (18).
Trainees are further limited by leave disqualifying them to sit for board examinations (20). In internal medicine specialties such as gastroenterology, before this new policy, trainees were permitted to take 1 month off per year to use as either vacation, parental leave, sick leave, or family leave, and taking more could have rendered them ineligible to take the board certification examination (21). Although there was a potential to extend leave for another month and remain board eligible if assessed by their clinical competency committee as being competent, a survey of program directors found that this was widely misunderstood and underutilized (18,22). Indeed, only 6.5% of program directors correctly chose not to extend training in the survey question about a resident requesting 8 weeks of maternity leave (22). Therefore, the problem with trainee parental leave includes both a misinterpretation of specialty board policies and a lack of policies in individual residency and fellowship programs, with no national standardized policy (2,22). Within gastroenterology specifically, this has resulted in fellows reporting widespread lack of awareness of their programs' parental leave policies (2).
Gastroenterology in particular is in need of a parental leave policy designed around evidence-based practices for parental and infant well-being. As a procedural and male-dominated specialty, women face additional barriers (23–25). Among subspecialties, gastroenterology has one of the lowest rates of female physicians, despite the demand for female gastroenterologists (2,26,27). Although the reasons behind gastroenterology remaining male-dominated are multifactorial, concerns about training interfering with childbearing were listed as the most important reason why female trainees did not choose advanced endoscopy fellowships in a recent study (28). Indeed, a study of gastroenterology fellowship program directors found that programs that offered parental leave had significantly more female trainees (1.6- to 1.8-fold higher) than those without leave policies (P < 0.05) (2). Many female physicians may be dissuaded from pursuing a career in gastroenterology because of a perceived forced choice between starting a family and pursuing subspecialty training, opting instead for fields with shorter or more family-friendly training programs (29–31). Along with increasing the number of women in gastroenterology, the availability of a standard parental leave policy may support retention and advancement for women in gastroenterology through reduced burnout, with associated positive economic impact for their employer since employees who take leave are more likely to return to work after leave (32–35).
In addition to impacting career paths, insufficient parental leave policies have also disproportionately affected female physicians' family planning. Female trainees are more likely than male trainees to delay childrearing, both during their internal medicine residency and gastroenterology fellowship, despite similar marital status (2,36). In a large study of gastroenterology fellowship graduates, 20.3% of female trainees altered their family plans during training, compared with 7.1% of the male fellows (P < 0.001) (2). There are well-documented consequences, including pregnancy complications, associated with advanced maternal age (37). Nearly a quarter of female physicians who attempted conception report infertility (38). In gastroenterology, after 5 and 10 years as an attending, female gastroenterologists still had fewer children than their male colleagues (39,40).
Robust parental leave is only the first step in creating a family-friendly environment in gastroenterology (7,18,41). We additionally need work environments that are designed to accommodate pregnancy and parenthood (42). Overall, residents have higher rates of miscarriage, hypertension in pregnancy, placental abruption, and intrauterine growth restriction than women in the general population (43). In response to this, several training programs in internal medicine and emergency medicine have created flexible scheduling options for new parents returning from leave, such as the ability to opt out of 24 hours calls or unscheduled calls, as well as lactation support (18,41). In addition, a novel program at one institution offers exemption from overnight calls in the third trimester of pregnancy (18). To date, there are no published policies within gastroenterology fellowships that provide alternate scheduling in fellowship. However, this is of particular relevance in our procedural field, with fellows frequently fielding overnight calls. A recent study found that 49.3% of residents who had more than 6 nights on call per month had obstetrical complications, significantly higher than those who had 6 or fewer nights on call per month (P < 0.001) (43). Among surgical residents, over 8 hours in the operating room per week was associated with significantly higher obstetrical complications (41.7%, P < 0.001) than those with less time in the operating room (43). Therefore, the amount of night call and procedural time during gastroenterology fellowship should be examined for the pregnant fellow, with the option for fellows to choose appropriate accommodations.
There are barriers that must be addressed to successfully and equitably implement standardized parental leave policies and a family-friendly environment for gastroenterology trainees. During training, there is typically a set amount of clinical obligations that are shared among a fixed pool of fellows, which raises the concern that the creation of parental leave policies will unfairly burden the already rigorous workload of fellowship colleagues. However, this is indeed why it is so important to create standard, universal leave policies. Implementing standard family leave means addressing these challenges without relying on unsustainable and inequitable policies. Currently, leave taken in a haphazard and makeshift fashion not only forces trainees taking leave to struggle with logistical hurdles and stigma but also harms their colleagues who are asked to balance additional clinical responsibilities (19). If each program could plan for standardized, universal leave that was the expectation for trainees, then programs would need to build in a structure to support this leave. In fact, legislation mandating paid leave is increasing, with 9 states and Washington D.C. now offering paid family leave (44). It would be prudent to keep pace with these laws. We would need to reform systems that frequently involve only a minimally sufficient number of providers toward systems with sufficient coverage to allow greater flexibility for leave accommodations. This would not only apply to parental leave but also to leave because of personal illness or family emergencies (1). This could be accomplished by increasing the number of fellows per class or by the availability of advanced practice providers to improve resilience in our clinical systems. By advocating for humane treatment of parents, systems will be built for a more flexible environment for all trainees. Indeed, the current COVID-19 pandemic sheds light on the benefits of a system with sufficient provider coverage to allow for adequate parental, caregiver, or medical leave, including for those who do not desire children.
Importantly, we must also address implicit and explicit bias against pregnancy, parenthood, and parental leave in medicine (42,45–47). It is well documented that female trainees in the postpartum period receive lower evaluations than male trainees whose female partners had recently given birth (48). When coverage of clinical duties is solicited by an individual trainee rather than being a part of a systemic policy, this can contribute to bias from peers and faculty (7). This gender and maternity bias perpetuates beyond training, as it has been documented that physician mothers faced workplace discrimination after training as well (42,45). Bias and harassment are present for Black physicians and other races underrepresented in medicine throughout medical education, and although we did not find published data on racial disparities around maternity leave for physicians, it is certainly possible that anti-Black bias intersects with gender bias to create further disparities (49,50). Maternity leave bias can also manifest in being selected less often for research or procedural opportunities. In surgical literature, female surgery residents reported that faculty performed fewer operations with them after their pregnancy and/or maternity leave (51). Although offering trainees the opportunity to choose reduced activity to maintain health is important, this is different than decreasing choice in educational procedural opportunities.
Part of reducing bias includes ensuring that parental leave is taken routinely, regardless of gender. Female gastroenterology trainees are significantly more likely to take parental leave than male fellows (2). If parental leave is routinely not taken by male fellows, this could perpetuate a bias against women in medicine due to concerns about impacting training and the coverage pool. However, if it becomes the cultural expectation that physicians take leave after the birth of a child, this will help to minimize the gender gap. The availability of standardized, universal leave for all parents will help change the cultural expectation that only birthing parents take leave (6). Furthermore, as fellowship programs expect and plan ahead for parental leave and therefore reduce the burden that parental leave places on colleagues, more nonbirthing parents will be able to take leave. In addition to reducing gender disparities, this will benefit nonbirthing partners and same-sex couples who have previously been excluded, either explicitly or through cultural pressure, from the benefits of parental leave (2,15,52,53).
The creation of an evidence-based leave policy and family-friendly culture in gastroenterology is critical to promote gender equity and reduce burnout. Now that ABMS has cleared the restriction of board eligibility if leave is taken, the field of gastroenterology has an opportunity to create a standardized, robust parental leave for all gastroenterology fellows that is separate from vacation and sick leave. This would not only benefit our field, but also serve as an example for other specialties. Although it is important for fellows to gain procedural and knowledge-based competence during their fellowship, a well-designed training program should be able to achieve this while providing adequate parental leave (7). We must ask ourselves whether equity, diversity, and inclusion in our workforce are attributes that we truly value and are willing to work to support. If so, we have much work to do.
CONFLICTS OF INTEREST
Guarantor of the article: Lauren Deborah Feld, MD.
Specific author contributions: Drafting and editing the manuscript. She has approved the final draft submitted.
Financial support: None to report.
Potential competing interests: None to report.
The author thanks Dominic J. Gibson, PhD, for feedback on drafts.
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