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Progress, Yes, but Still Inconsistent Family Leave Policies in US Graduate Medical Education
How Neurology Residency Programs Respond

Article In Brief

An article in the New England Journal of Medicine proposes changes in family leave policies for medical residents and fellows. Neurology program directors noted that although policies at some institutions are more accommodating than others, the inconsistency itself continues to be a problem.

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Finding a balance between work and family life for physicians has never been easy—with some of the biggest challenges occurring early on in their medical education. As more data emerge on the growing rate of burnout in US medical professionals, researchers are focusing their attention on contributing factors and actionable strategies for improvement from the bottom up.

During residency, for instance, when hours are often especially long, the inconsistent or nonexistent policies regarding paid parental leave can lead to increasingly stressful situations for residents who are trying to start a family. Addressing this concern, a perspective article published in the September 12 online edition of the New England Journal of Medicine (NEJM), put forward a list of practical policy changes for the national, institutional, and program levels.

“Work–life integration is notoriously elusive for graduate medical trainees; residency and fellowship training have historically been all-encompassing. Parenting during clinical training involves particularly difficult challenges,” Debra F. Weinstein, MD, vice president for graduate medical education at Partners HealthCare System in Boston, and coauthors wrote.

In fact, a JAMA research letter, published last December by the authors of the NEJM paper and colleagues, reviewed childbearing and family leave policies for 15 graduate medical education programs within 12 top medical schools and found that only half of them had established institutional paid family leave or childbearing leave policies for residents. “Absent such policies, program directors must navigate the expectations of trainees, faculty members, and department chairs, as well as societal norms, to create their own program-wide policy or, worse, resort to negotiating parental leave on an individual basis,” Dr. Weinstein and colleagues wrote.

These policies should not be handled on a case-by-case basis as often happens, they continued, calling on “GME (graduate medical education) oversight organizations to develop a unified, 21st-century approach to parental leave.” The approach, they stated, should include a minimum paid leave of six weeks for all GME trainees with a future goal of 12 weeks; competency assessments instead of required make-up time or minimum numbers of cases or procedures; better data and reporting on the national level about parenting during GME; and institutional development of part-time training options for trainees.

Co-author Christina Mangurian, MD, professor of psychiatry and vice chair for diversity and health equity in the department of psychiatry at the University of California, San Francisco Weill Institute for Neurosciences, said she remembers having to use up all of her sick leave and vacation time when she had a baby, which “isn't good planning for institutions because it is known that babies get sick and need their parent to stay home with them from time to time.”

Since that time, she has seen improvement in family leave policies across the country, with some major academic medical centers having 12 weeks (or more) of fully paid family leave policies for faculty. “While there is still room to grow for residents and staff, I am also encouraged that top level administrators are working on this as well.”

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“One of my mentors once told me that residencies are largely staffed by young people of childbearing age and some are bound to start families...that simple fact has helped reframe once-difficult conversations.”—DR. SUMA SHAH

Still, significant barriers exist, she acknowledged, including “adequate patient coverage, financing, and making sure people taking leave meet residency training requirements upon graduation. As we mentioned in our NEJM piece, we believe competency-based measurement is the way to proceed—rather than time-based.”

Program directors and others can get involved in advocacy efforts “by continuing to make noise at their own institutions, professional societies, and/or on social media via #medtwitter to advocate for enhanced paid family leave. Creating uniform paid family leave policies for residents and fellows will reduce inequities across and within institutions and benefit our entire profession. This is the right thing to do; we just need to work together to figure it out,” she told Neurology Today.

Commentators from neurology programs around the country commended the NEJM authors for raising important questions about family leave, particularly on the national level. Although policies at some institutions are more accommodating than others, the inconsistency itself continues to be a problem, they told Neurology Today.

How to Address Missed Call

Elisabeth B. Marsh, MD, associate professor of neurology, director of the Bayview Comprehensive Stroke Center, and associate program director of the Johns Hopkins Health neurology residency program, said that at Hopkins, all programs have an eight-week leave for new parents in residency and fellowship through a policy called New Child Accommodation leave. “If needed for medical reasons, they may extend their paid leave for up to a cumulative total of 13 weeks. In addition, they have four weeks a year of vacation that may be added,” she said.

“The Johns Hopkins Graduate Medical Education Committee recently passed a policy,” she continued, “which mandates that residents and fellows who are out on parental leave do not have to make up missed call, but each certifying board has different expectations regarding how much time can be missed,” Dr. Marsh said

“Within neurology, we work hard both before and after their leave to ensure that there is a smooth transition and that, despite their leave, they are acquiring all the necessary skills and experiences that they'll need to become excellent, competent physicians,” she continued. “We routinely meet with them upon their return to ensure that they are getting the support they need. We strongly believe in supporting our new families, and that this is an important part of our mission to promote wellness among trainees.”

Dr. Marsh told Neurology Today the NEJM article is “on point” when it comes to the difficulties and pressures that come up for new parents during training and that she was happy to see the authors address this at the national level. Further, she added, “as important as the amount of time off, is the support offered during the transition period to ensure success for both the trainee and the program.”

“One of my mentors once told me that residencies are largely staffed by young people of childbearing age and some are bound to start families...that simple fact has helped reframe once-difficult conversations,” Suma Shah, MD, assistant professor of neurology, associate director of the residency program, and medical director at Duke Neurology, said in an e-mail to Neurology Today.

Handling on a Case-by-Case Basis

Dr. Shah agreed that there were many salient points in the NEJM paper, but what resonated with her most was the “attention to inconsistent policies not only across institutions but within institutions,” she said. She called the proposals “thoughtful,” particularly the ones addressing parental leave on a larger scale—“address parental leave at an institutional level, establish a minimum time off, abandon requirements for makeup time in favor of competency assessments.”

Some of the suggestions, she said, would be a bit more difficult to put into practice—specifically part-time training programs or shared residency positions. “Though some applicants may know their family planning wishes as a medical student applying for residency, many don't. This places an extra burden of planning on a student, soon-to-be-trainee regarding a topic that they may not yet have considered,” she said.

Duke University does address family leave requests on a case-by-case level in each department, Dr. Shah noted. “There have been residents who prefer to take the minimum leave granted by the department and save their vacation time for later with their families whilst others will take the leave and the vacation all together to maximize time at home with the new addition. As the authors noted, there is some built-in flexibility with elective time that can allow for adjusted work schedules to help trainees during this time of tremendous transition.”

In their paper, Dr. Weinstein and colleagues addressed additional concerns about staffing to cover absences by residents on leave by suggesting programs create “deliberate redundancy in resident staffing or funding short-term coverage by other clinicians or moonlighting trainees.” They also called for better data on the number of residents who become parents so that programs can more accurately anticipate these needs.

Paternal Leave at Rush University

At Rush University Medical Center, Jake Torrison, MD, a PGY-4 neurology resident who recently took paternity leave, said he had a largely positive experience at his program. “Rush as an institution and Dr. Amar Bhatt were incredibly supportive. I received four weeks paid paternity leave with no strings attached, which I think is really important. I still have my full four weeks of vacation at my disposal, and they were very flexible in letting me move around elective time to accommodate adding some vacation to my paternity leave.”

His wife, who is a nurse anesthetist in a different Chicago institution, had a less straightforward experience, he said. “They force them to use up their saved PTO first, then grant various forms of leave (short-term disability, etc.) after vacation time is dried up. I think the way Rush does it, where it is a completely separate leave policy from vacation, was terrific. The formalized adoption and expansion of this at other institutions would be a step in the right direction for resident wellness.”

Dr. Torrison said that residents at other institutions may “feel pressured to come back early or not take the full leave and that would be a shame.” He reflected on how helpful it was for his family when both parents were home during the first month—“to take turns staying up with the crying baby and letting [my wife] get some sleep was priceless for us. If I were to have had to return to a demanding resident schedule or be gone for in house call it would have been very difficult for her/us.”

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“The Johns Hopkins Graduate Medical Education Committee recently passed a policy, which mandates that residents and fellows who are out on parental leave do not have to make up missed call, but each certifying board has different expectations regarding how much time can be missed.”—DR. ELISABETH B. MARSH

An additional point that is often overlooked in this discussion, he continued, is that many residents do not live near their home or support systems. Dr. Torrison and his wife, for example, are far from their families in Minnesota who might otherwise be able to help with the baby. “Though many were able to come down to meet the baby, we don't have a lot of family to rely on at baseline to help out with our baby, making my leave much more valuable to both of us. We were in fact able to spend several weeks at home with family and have a baptism with extended family present as well, thanks to us both being able to be on leave together,” he said.

Dr. Torrison agreed with the NEJM article's proposal to expand parental leave to at least six weeks across the US in order to improve resident wellness. As a resident, “You are often far away from home working long hours, and I think the concept of resident wellness is a topic often discussed but rarely acted upon in terms of ACGME protections. As the American workforce as a whole continues to embrace longer paid maternity/paternity leave, so should ACGME/resident education. If we don't, our best and brightest might start choosing other career paths that offer superior flexibility and life balance.”

Recommendations for Supporting Parenting During GMD

The NEJM article recommended the following policies for national oversight organizations, sponsoring institutions, and individual residency and fellowship programs.

National oversight organizations:

  • Establish a minimum of six weeks of paid leave for all graduate medical education (GME) trainees, with an intent to move toward 12 weeks
  • Abandon requirements for making up time and for minimum numbers of cases or procedures in favor of competency assessments
  • Track and report national data related to parenting during GME
  • Facilitate institutional development of part-time training options

Sponsoring institutions:

  • Ensure that institution-level policies address parental leave
  • Extend 12 weeks of leave provided under the Family and Medical Leave Act to all trainees
  • Continue full salary for at least six weeks of family leave
  • Ensure sufficient staffing to protect trainees from negative effects when colleagues are on leave
  • Facilitate access to child care and lactation facilities
  • Cultivate cross-specialty trainee parenting collaboratives
  • Individual residency and fellowship programs
  • Clarify implications of parental leave for applicants and trainees
  • Develop creative pilots that will enhance flexibility for trainee-parents

Individual residency and fellowship programs:

  • Clarify implications of parental leave for applicants and trainees
  • Develop creative pilots that will enhance flexibility for trainee-parents

Link Up for More Information

• Magudia K, Bick A, Cohen J, et al. Childbearing and family leave policies for resident physicians at top training institutions https://jamanetwork.com/journals/jama/fullarticle/2718057. JAMA 2018; 320: 2372–2374.
• Weinstein DF, Mangurian C, Jagsi R. Parenting during graduate medical training —Practical policy solutions to promote change https://www.nejm.org/doi/full/10.1056/NEJMp1904721. N Engl J Med 2019; Epub 2019 Sep 12.