- Email: [email protected]
Fellowship or Family? A Comparison of Residency Leave Policies With the Family and Medical Leave Act
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ScienceDirect journal homepage: www.JournalofSurgicalResearch.com
Association for Academic Surgery
Fellowship or Family? A Comparison of Residency Leave Policies With the Family and Medical Leave Act Stephanie Treffert Lumpkin, MD,a,* Mia K. Klein, MD,a Ashley N. Battarbee, MD,b Paula D. Strassle, MSPH,c Sara Scarlet, MD, MPH,a and Meredith C. Duke, MD, MBAd a
Department of Surgery, University of North Carolina, Chapel Hill, North Carolina Department of Obstetrics and Gynecology, Maternal-Fetal Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina c Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina d Department of Surgery, Vanderbilt University, Nashville, Tennessee b
article info
abstract
Article history:
Background: In 1993, the Family and Medical Leave Act (FMLA) mandated 12 weeks of un-
Received 5 December 2018
paid, job-protected leave. The current impact of taking 12 weeks of leave during residency
Received in revised form
has not been evaluated.
5 February 2019
Methods: We examined the 2018 Accreditation Council for Graduate Medical Education
Accepted 6 March 2019
(n ¼ 24) specialty leave policies to determine the impact of 6- and 12-week leave on
Available online 29 April 2019
residency training, board eligibility, and fellowship training. We compared our findings with a 2006 study.
Keywords:
Results: In 2018, five (21%) specialties had policy language regarding parental leave during
Gender bias
residency, and four (16%) had language regarding medical leave. Median leave allowed was
FMLA
4 weeks (IQR 4-6). Six specialties (25%) decreased the number of weeks allowed for leave
Leave
from 2006 to 2018. In 2006, a 6-week leave would cause a 1-year delay in board eligibility in
GME
six specialties; in 2018, it would not cause delayed board eligibility in any specialty. In 2018,
Maternity
a 12-week (FMLA) leave would extend training by a median of 6 weeks (mean 4.1, range 0-
Paternity
8), would delay board eligibility by 6-12 months in three programs (mean 2.25, range 0-12), and would delay fellowship training by at least 1 year in 17 specialties (71%). The impact of a 12-week leave was similar between medical and surgical specialties. Conclusions: While leave policies have improved since 2006, most specialties allow for 6 weeks of leave, less than half of what is mandated by the FMLA. Moreover, a 12-week, FMLA-mandated leave would cause significant delays in board certification and entry into fellowship for most residency programs. ª 2019 Elsevier Inc. All rights reserved.
* Corresponding author. Department of Surgery, University of North Carolina, 4001 Burnett-Womack Building CB #7050, Chapel Hill, NC 27599-7050. Tel.: þ919 590-9184; fax: þ919 966-8806. E-mail address: [email protected] (S.T. Lumpkin). 0022-4804/$ e see front matter ª 2019 Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.jss.2019.03.004
lumpkin et al a comparison of residency leave policies
303
Introduction
Methods
In 1993, the Family and Medical Leave Act (FMLA) mandated 12 weeks of unpaid, job-protected leave, for all public-sector employers and all private-sector employers with at least 50 employees. FMLA is granted to employees in times of personal illness, the care of loved ones, and the birth of a child.1 Allowing employees to hold their jobs while allowing them to attend to personal and family needs is not only compassionate but also supports a larger and more diverse workforce. Inadequate parental leave duration has been linked to poor parental-child bonding and even higher infant mortality.2,3 In addition, family leave may be required for the increasing population of men and women who are becoming temporary and permanent caregivers for elderly parents, which accounts for a significant portion of the US economy.4,5 Even though 40% of all residents anticipate becoming a parent during training, taking leave to care for personal and family needs may delay residency graduation, board certification, and fellowship initiation.6,7 The American Academy of Pediatrics recommends, “regardless of gender, residents. should be guaranteed 6 to 8 weeks, at a minimum, of parental leave with pay . (and) in conformance with federal law, the resident should be allowed to extend the leave time (up to 12 weeks) when necessary by using paid vacation time or leave without pay.”2 These recommendations have not been universally adopted, and in a 2018 survey of surgical residents who are parents, 39% of respondents strongly considered leaving surgical residency and 30% would discourage female medical students from a surgical career because of the lack of support and inadequate duration of parental leave allowed during training.8 Residency training is inherently demanding and inflexible. Working approximately 80 hour per week, residents frequently cite issues beyond work hours, such as lack of time for self-care and conflicting responsibilities between work and home as significant drivers of burnout.9,10 Inadequate leave policies force residents to choose between family and career and have severe consequences, including burnout, poor patient care, lost lifetime wages, and magnified gender pay discrepancy. For example, according to the Center for American Progress, if a 27-year-old resident is required to delay their first year as a staff physician, assuming a $200,000 annual starting salary, they are subject to over $700,000 in lost income over their lifetime.11 Moreover, the sacrifice of taking time off for family goes beyond lost wages. Physicians who perceive work-life balance conflicts in the workplace are less likely to pursue promotions or leadership opportunities.12 These conflicts may even be associated with the growing unrest associated with gender inequity in academic medicine.13 In 2006, Rose et al. published a specialty-based comparison of parental leave policies and the subsequent impact of a 6week leave on extending training and board eligibility.7 However, it has been 12 years since the impact of family leave has been evaluated across all specialties, and the career impact of a 12-week leave during residency has not been assessed.
This was a cross-sectional, observational study. We included all primary specialties recognized by the Accreditation Council for Graduate Medical Education (ACGME) in the United States. Secondary specialties and those with fewer than 100 active residents nationwide were excluded. Two trained reviewers (S.T.L. and S.S.) examined each policy published by specialties in 2018; one reviewer (S.S.) received specific training in ethics review and policy analysis. The data collection and analysis methodology was modeled using the Rose et al. 2006 study.7 Briefly, based on a multidisciplinary review of the data abstracted from the governing bodies of each specialty (e.g., the American Board of Surgery), we determined whether or not a 6 or 12 week leave taken during a single year of residency would delay training duration, fellowship initiation, or board certification (Fig. 1). In addition, the presence of specific policy language regarding maternity leave, paternity leave, and sick leave was recorded. We also noted the presence of any flexible policies. Fisher’s exact and Wilcoxon tests were used to compare leave policies between 2006 and 2018, as well as between medical and surgical specialty programs. All analyses were
Fig. 1 e Primary ACGME specialty board policy analysis algorithm for determining impact of residency leave. This methodology was repeated to assess the impact of a 12week leave. Where X is equal to 6 or 12 week of leave taken by resident in graduate medical education. Each level represents a decision point in the policy analysis. For each level, if yes, the resident is not considered to be impacted at that level by X weeks of leave.
304 performed using Station, TX).
j o u r n a l o f s u r g i c a l r e s e a r c h s e p t e m b e r 2 0 1 9 ( 2 4 1 ) 3 0 2 e3 0 7
Stata
15.1
(StataCorp
2017,
College
Results We identified 24 primary board specialties (14 medical, 10 surgical) that met inclusion criteria (Table 1). The median leave time allowed in 2018 was 4 weeks (IQR 4-6). No difference was seen between medical and surgical specialty programs (median 4 versus 5 weeks, P ¼ 0.426). Medical specialties were more likely to have specific language regarding maternity, as well as paternity, leave (58% versus 42%, P ¼ 0.03). There was no difference in the mention of medical leave between specialty types (14% versus 30%, P ¼ 0.350). Notably, six specialties (25%) decreased the number of weeks allowed for
leave from 2006 to 2018 (3 medical, 3 surgical). Most of the programs that restricted their leave policies went from flexible to nonflexible leave policies (e.g., neurology went from discretionary to 4 week allowed leave). In 2006, six programs (25%) required a 6- to 12-months delay in board certification after a 6-week leave (Table 2). As of 2018, a 6-week leave would not delay board certification in any specialty because of both an increase in the duration of allowable leave and/or the addition of flexible policies. However, a 12-week leavedthe FMLA-mandated time alloweddtaken in 2018 would result in a 1-y delay in board certification in five specialties (21%) (2 medical, 3 surgical). In 2018, a 6-week leave would extend the duration of training in four specialties (17%) by 2 weeks (4 medical, 0 surgical). In 2018, a 12-week (FMLA) leave during residency would extend training by a median of 6 weeks (mean 4.2, range 0-8) and five
Table 1 e 2018 specialty-based characteristics of residency programs and maximum duration of leave allowed during residency in 2006 and 2018. Specialty name
Female residents 2016-2017*, %
Training duration (years)*
2006 max leave (weeks)
2018 max leave (weeks)
Change between 2006 and 2018
Allergy/immunology
58.9
2
4
4
e
Anesthesiology
31.6
4
4
4
e
Dermatology
62.1
4
6
6
e
Emergency medicine
32.9
4
6
6
e
Family medicine
39.4
3
4
4
e
Internal medicine
26.7
3
4
4
e
Neurology
29
4
Discretiony
4
Y
5.8
4
6
6
e
Pathology
28.5
4
5
4
Y
Pediatrics
60.4
3
4
4
e
PM&R
34.8
4
6
6
e
Preventive medicine
40.8
2
4
4
e
Psychiatry
37.2
4
Discretiony
4
Medical
Nuclear medicine
Radiology diagnostic
Y y
[
22
5
6
Discretion
Neurological surgery
16.5
7
Discretiony
4
Y
Obstetrics/gynecology
75.3
4
8
8
e
Ophthalmology
39.8
4
Discretiony
4
Y
Orthopedic surgery
14.7
5
6
6
e
Otolaryngology
34.3
5
6
6
e
Plastic surgery
40.3
6
4
4
e
Surgery (general)
34.4
5
4
4
Surgical
y
e y
Thoracic surgery
25.0
6
Discretion
Urologyz
25.3
5
Otherc
6
Y
Vascular surgery
35.2
6
N/Ax
4
N/Ax
Discretion
e
PM&R ¼ Preventative Medicine and Rehabilitation. * This information was obtained from publically and electronically available data published by the Association of American Medical Colleges and the Accreditation Council of Graduate Medical Education. y Discretion refers to residency specialties that explicitly allow for program director or intuitional discretion without setting a specific amount of leave in weeks. z Urology leave maximum in 2006 was based on a percentage of time missed from various clinical requirements. x Vascular Surgery was not recognized as a primary specialty in 2006.
305
lumpkin et al a comparison of residency leave policies
Table 2 e Specialty-based comparison of impact of 2006 and 2018 residency leave policies on training duration and board eligibility. Specialty name
Impact of 6-week leave 2016
Impact of 12-week (FMLA approved) leave
2018
2018
Delayed board eligibility?*
Delayed board eligibility?
Training extension, weeks
Delayed board eligibility?
Training extension, week
Discretiony
No
2
No
8
Anesthesiology
No
No
0
No
0
Dermatology
No
No
0
No
6
Emergency medicine
No
No
0
No
6
Family medicine
Yes
No
2
No
8
Internal medicine
No
No
0
No
8
Indeterminatez
No
0
No
0
Medical Allergy/immunology
Neurology Nuclear medicine
Yes
No
0
Yes
6
Pathology
Yes
No
0
No
0
Pediatrics
No
No
2
Yes
8
PM&R
No
No
0
No
6
Preventive medicine
No
No
2
No
8
Psychiatry Radiology diagnostic
z
No
0
No
0
No
No
0
No
0
Discretiony
No
0
No
8
Indeterminate
Surgical Neurological surgery Obstetrics/gynecology Ophthalmology
No
No
0
Yes
4
Discretiony
No
0
Yes
8
Orthopedic surgery
Yes
No
0
No
6
Otolaryngology
No
No
0
Yes
6
Plastic surgery
Yes
No
0
No
0
Surgery (general)
Yes
No
0
No
4
Thoracic surgery
Discretiony
No
0
No
0
Petitionx
No
0
No
6
N/Ak
No
0
No
4
Urology Vascular surgery
PM&R ¼ Preventative Medicine and Rehabilitation. * Data from 2006 is from Rose et al.7 y Discretion refers to residency specialties that explicitly allow for program director or intuitional discretion without setting a specific amount of leave in weeks. z Indeterminate based on 2006 study. x Resident must petition the credentialing committee to be considered for board eligibility after 6 weeks leave. k Vascular Surgery was not recognized as a primary specialty in 2006.
programs (2 medical, 3 surgical) would require a 6- to 12months delay in board eligibility (median 0 mo, mean 2.25, range 0-12). A 12-week leave in 17 specialties (71%) would delay fellowship training by at least 1 y. There was no difference between medical and surgical specialties in whether or not a 12-week leave would delay entry into fellowship (64% versus 80%, P ¼ 0.653) or the extension in the duration of training (6 versus 5-weeks median delay, P ¼ 0.414). A number of programs utilized identified seven unique flexible solutions in residency leave policies (Fig. 2). Notably, no programs explicitly mentioned all of the flexible policy solutions and four programs offered no flexible alternatives.
Discussion Overall, leave policies have largely improved since 2006, and programs now allow for a 6-week leave without affecting board eligibility. Unfortunately, in 2018, a 12-wk, FMLAmandated leave could delay completion of training by 6 weeks, which could delay fellowship by up to 1 y. In addition, this FMLA-mandated leave would result in delayed board eligibility in over two-thirds of specialties. Although several flexible policy solutions exist that could be used to mitigate these problems, currently no program has implemented all of them, and a few programs still offer no alternatives. Medical
306
j o u r n a l o f s u r g i c a l r e s e a r c h s e p t e m b e r 2 0 1 9 ( 2 4 1 ) 3 0 2 e3 0 7
Fig. 2 e Number of ACGME specialties with explicitly flexibly policies for residency leave. Data abstracted from publicly available, electronically published specialty board residency leave policies. Averaging refers to policies that allow for a certain number of weeks per year averaged over a certain period, for example, some specialties allow 12 weeks of leave averaged over 3 year. Other flexible policies included those policies that were specialty-specific and could not be reasonably grouped with the aforementioned categories, for example, neurology recommends a minimum amount of leave instead of a maximum.
and surgical specialties tended to be similar in terms of impact of policies, despite historical beliefs that surgical programs may be less family-friendly.14,15 Based purely on the duration of training alone, surgical specialties may allow for more flexible policy alternatives. Residents often feel like they have to choose between their family and career, but there should be alternative solutions. This problem is complex; while residency programs want to provide options, there is an inherent lack of redundancy in residency training. When even one resident is absent for a prolonged period, the workload increase can be a significant burden on their colleagues. Individual residents may feel the pressure to minimize the impact their absences cause to others, as well as its effect on their own education. Many residents have responded to these policies and attitudes by deferring child-bearing until after training is complete, but there can be negative effects of advancing parental age, including increased rates of infertility, birth defects, and pregnancy complications.16 In addition, many family or health-related leaves arise unexpectedly, making leave during residency inevitable. One potential solution is competency-based medical education (CBME) in place of the more traditional time-dependent model. CBME implementation models vary, but ultimately, this approach is based off of regular assessments of a learner’s achievement of milestones within their field.17 In Canada, for example, orthopedic surgery has moved to a primarily
competency-based training, which has allowed numerous residents to complete training in 4 years compared with the traditional 5-year track. This flexibility was shown to accelerate acquisition of operative skills and also allowed for flexibility in training duration for a plethora of reasons (e.g., professional development, family emergencies, difficulty obtaining the necessary skills to practice independently).18 This progressive CBME example can serve as a feasibility pilot for ACGME. It is difficult to make further comparisons between the United States and Canada, given that Canada’s Employment Insurance affords at least 17 weeks of paid parental leave.19 Currently, in the United States, ACGME continues to investigate and implement CBME, which could enhance capacity for additional leave policy flexibility. Future work will need to address potential and unforeseen downsides to CBME, such as extensively prolonged training and the vulnerability of trainees. Programs have multiple and sometimes competing aims including excellent patient care, stellar resident education, and promoting the health and well-being of all residents.20 These aims are not necessarily mutually exclusive, and it may be possible to allow for 12-weeks FMLA-mandated leave while still achieving these aims. Future studies and board organizations should determine if any of the flexible strategies could be adopted to allow for 12-weeks FMLA-mandated leave without sacrificing valuable learning time or creating
lumpkin et al a comparison of residency leave policies
significant delays in board eligibility. Placing emphasis on competency-based advancement, instead of requiring a specific number of weeks may be a potential solution. This study is not without limitations. These results are comprehensive of the primary specialty board policies, but may not be generalizable to non-ACGME programs, and must be considered on a case-by-case basis. With data limited to 2006 and 2018, no true longitudinal assessment was able to be conducted on an annual basis. In conclusion, although leave policies have improved since 2006, residency leave programs are still not meeting the requirements laid out by FMLA, and a 12-week, FMLA-mandated leave could have substantial and detrimental impacts on training. Programs should consider incorporating flexible policies.
3.
4.
5.
6.
7.
8.
Acknowledgment 9.
All authors listed attest to meeting the guidelines for authorship. Substantial contributions from Michael Williford, MD, and Katherine Cools, MD, MSCR, included data collection. Authors’ contributions: L.S.T. was responsible for study design, data collection, data analysis, and manuscript preparation. K.M. and S.S. were responsible for study design, data collection, data analysis, and manuscript preparation. In addition, S.S. has completed ethics and policy interpretation training. B.A.N. was responsible for significant portions of data analysis and manuscript preparation. S.P.D. was responsible for significant portions of the study design, data analysis, and manuscript preparation. D.M.C. was the senior author on this article, and thus oversaw and contributed to the overall study design and conceptualization and manuscript preparation.
Disclosure L.S.T. is also a postdoctoral fellowship, and at the time of submission, is currently funded through the Agency of Healthcare Quality and Research F32 and the American Society of Colon and Rectal Surgeons General Surgery Resident Research Initiation. This article is not directly associated with her postdoctoral research activities. The authors report no proprietary or commercial interest in any product mentioned or concept discussed in this article.
references
1. Family and Medical Leave Act - Wage and Hour Division. (WHD) - U.S. Department of labor. Available at: https://www. dol.gov/whd/fmla/ [accessed September 19, 2018]. 2. Section on medical students, residents, and fellowship trainees, committee on early childhood. Parental leave for
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20.
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residents and pediatric training programs. Pediatrics. 2013;131:387e390. Rossin M. The effects of maternity leave on children’s birth and infant health outcomes in the United States. J Health Econ. 2011;30:221e239. Chen M-L. The growing costs and burden of family caregiving of older adults: a review of paid sick leave and family leave policies. Gerontologist. 2016;56:391e396. Millennials. The emerging generation of family caregivers. Available at: https://www.aarp.org/ppi/info-2018/millennialfamily-caregiving.html [accessed September 4, 2018]. Blair JE, Mayer AP, Caubet SL, Norby SM, O’Connor MI, Hayes SN. Pregnancy and parental leave during graduate medical education. Acad Med. 2016;91:972e978. Rose SH, Burkle CM, Elliott BA, Koenig LF. The impact of parental leave on extending training and entering the board certification examination process: a specialty-based comparison. Mayo Clin Proc. 2006;81:1449e1453. Rangel EL, Smink DS, Castillo-Angeles M, et al. Pregnancy and motherhood during surgical training. JAMA Surg. 2018;153:644e652. Williford ML, Scarlet S, Meyers MO, et al. Multiple-institution comparison of resident and faculty perceptions of burnout and depression during surgical training. JAMA Surg. 2018;153:705e711. Gopal R, Glasheen JJ, Miyoshi TJ, Prochazka AV. Burnout and internal medicine resident work-hour restrictions. Arch Intern Med. 2005;165:2595e2600. Doerer K. How much does it cost to leave the workforce to care for a child? A lot more than you think. jPBS NewsHour. Available at: https://www.pbs.org/newshour/economy/how-much-doesit-cost-to-leave-the-workforce-to-care-for-a-child-a-lot-morethan-you-think [accessed September 19, 2018]. Ellinas EH, Fouad N, Byars-Winston A. Women and the decision to leave, linger, or lean in: predictors of intent to leave and aspirations to leadership and advancement in academic medicine. J Womens Health (Larchmt). 2018;27:324e332. Bates C, Gordon L, Travis E, et al. Striving for gender equity in academic medicine careers: a call to action. Acad Med. 2016;91:1050e1052. Aboshady O, Zenhom M, Nasr A. What should medical students do to choose their medical specialty? Pan Afr Med J. 2015;22:282. https://doi.org/10.11604/pamj.2015.22.282.7955. Katz J, Lamperti A, Gaughan JP. MBTI types, gender, and residency selection. J Psychol Type. 2007;67:51e58. Cleary-Goldman J, Malone FD, Vidaver J, et al. Impact of maternal age on obstetric outcome. Obstet Gynecol. 2005; 105(5 Pt 1):983e990. Carraccio C, Englander R, Van Melle E, et al. Advancing competency-based medical education: a charter for clinicianeducators. Acad Med. 2016;91:645e649. Having a family during residency j resident doctors of Canada. Available at: https://residentdoctors.ca/resources/ family-residency-canada/ [accessed January 8, 2019]. Nousiainen MT, Mironova P, Hynes M, et al. Eight-year outcomes of a competency-based residency training program in orthopedic surgery. Med Teach. 2018;18:1e13. Hariton E, Matthews B, Burns A, Akileswaran C, Berkowitz LR. Pregnancy and parental leave among obstetrics and gynecology residents: results of a nationwide survey of program directors. Am J Obstet Gynecol. 2018;219:199.e1e199.e8.
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.JournalofSurgicalResearch.com
Association for Academic Surgery
Fellowship or Family? A Comparison of Residency Leave Policies With the Family and Medical Leave Act Stephanie Treffert Lumpkin, MD,a,* Mia K. Klein, MD,a Ashley N. Battarbee, MD,b Paula D. Strassle, MSPH,c Sara Scarlet, MD, MPH,a and Meredith C. Duke, MD, MBAd a
Department of Surgery, University of North Carolina, Chapel Hill, North Carolina Department of Obstetrics and Gynecology, Maternal-Fetal Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina c Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina d Department of Surgery, Vanderbilt University, Nashville, Tennessee b
article info
abstract
Article history:
Background: In 1993, the Family and Medical Leave Act (FMLA) mandated 12 weeks of un-
Received 5 December 2018
paid, job-protected leave. The current impact of taking 12 weeks of leave during residency
Received in revised form
has not been evaluated.
5 February 2019
Methods: We examined the 2018 Accreditation Council for Graduate Medical Education
Accepted 6 March 2019
(n ¼ 24) specialty leave policies to determine the impact of 6- and 12-week leave on
Available online 29 April 2019
residency training, board eligibility, and fellowship training. We compared our findings with a 2006 study.
Keywords:
Results: In 2018, five (21%) specialties had policy language regarding parental leave during
Gender bias
residency, and four (16%) had language regarding medical leave. Median leave allowed was
FMLA
4 weeks (IQR 4-6). Six specialties (25%) decreased the number of weeks allowed for leave
Leave
from 2006 to 2018. In 2006, a 6-week leave would cause a 1-year delay in board eligibility in
GME
six specialties; in 2018, it would not cause delayed board eligibility in any specialty. In 2018,
Maternity
a 12-week (FMLA) leave would extend training by a median of 6 weeks (mean 4.1, range 0-
Paternity
8), would delay board eligibility by 6-12 months in three programs (mean 2.25, range 0-12), and would delay fellowship training by at least 1 year in 17 specialties (71%). The impact of a 12-week leave was similar between medical and surgical specialties. Conclusions: While leave policies have improved since 2006, most specialties allow for 6 weeks of leave, less than half of what is mandated by the FMLA. Moreover, a 12-week, FMLA-mandated leave would cause significant delays in board certification and entry into fellowship for most residency programs. ª 2019 Elsevier Inc. All rights reserved.
* Corresponding author. Department of Surgery, University of North Carolina, 4001 Burnett-Womack Building CB #7050, Chapel Hill, NC 27599-7050. Tel.: þ919 590-9184; fax: þ919 966-8806. E-mail address: [email protected] (S.T. Lumpkin). 0022-4804/$ e see front matter ª 2019 Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.jss.2019.03.004
lumpkin et al a comparison of residency leave policies
303
Introduction
Methods
In 1993, the Family and Medical Leave Act (FMLA) mandated 12 weeks of unpaid, job-protected leave, for all public-sector employers and all private-sector employers with at least 50 employees. FMLA is granted to employees in times of personal illness, the care of loved ones, and the birth of a child.1 Allowing employees to hold their jobs while allowing them to attend to personal and family needs is not only compassionate but also supports a larger and more diverse workforce. Inadequate parental leave duration has been linked to poor parental-child bonding and even higher infant mortality.2,3 In addition, family leave may be required for the increasing population of men and women who are becoming temporary and permanent caregivers for elderly parents, which accounts for a significant portion of the US economy.4,5 Even though 40% of all residents anticipate becoming a parent during training, taking leave to care for personal and family needs may delay residency graduation, board certification, and fellowship initiation.6,7 The American Academy of Pediatrics recommends, “regardless of gender, residents. should be guaranteed 6 to 8 weeks, at a minimum, of parental leave with pay . (and) in conformance with federal law, the resident should be allowed to extend the leave time (up to 12 weeks) when necessary by using paid vacation time or leave without pay.”2 These recommendations have not been universally adopted, and in a 2018 survey of surgical residents who are parents, 39% of respondents strongly considered leaving surgical residency and 30% would discourage female medical students from a surgical career because of the lack of support and inadequate duration of parental leave allowed during training.8 Residency training is inherently demanding and inflexible. Working approximately 80 hour per week, residents frequently cite issues beyond work hours, such as lack of time for self-care and conflicting responsibilities between work and home as significant drivers of burnout.9,10 Inadequate leave policies force residents to choose between family and career and have severe consequences, including burnout, poor patient care, lost lifetime wages, and magnified gender pay discrepancy. For example, according to the Center for American Progress, if a 27-year-old resident is required to delay their first year as a staff physician, assuming a $200,000 annual starting salary, they are subject to over $700,000 in lost income over their lifetime.11 Moreover, the sacrifice of taking time off for family goes beyond lost wages. Physicians who perceive work-life balance conflicts in the workplace are less likely to pursue promotions or leadership opportunities.12 These conflicts may even be associated with the growing unrest associated with gender inequity in academic medicine.13 In 2006, Rose et al. published a specialty-based comparison of parental leave policies and the subsequent impact of a 6week leave on extending training and board eligibility.7 However, it has been 12 years since the impact of family leave has been evaluated across all specialties, and the career impact of a 12-week leave during residency has not been assessed.
This was a cross-sectional, observational study. We included all primary specialties recognized by the Accreditation Council for Graduate Medical Education (ACGME) in the United States. Secondary specialties and those with fewer than 100 active residents nationwide were excluded. Two trained reviewers (S.T.L. and S.S.) examined each policy published by specialties in 2018; one reviewer (S.S.) received specific training in ethics review and policy analysis. The data collection and analysis methodology was modeled using the Rose et al. 2006 study.7 Briefly, based on a multidisciplinary review of the data abstracted from the governing bodies of each specialty (e.g., the American Board of Surgery), we determined whether or not a 6 or 12 week leave taken during a single year of residency would delay training duration, fellowship initiation, or board certification (Fig. 1). In addition, the presence of specific policy language regarding maternity leave, paternity leave, and sick leave was recorded. We also noted the presence of any flexible policies. Fisher’s exact and Wilcoxon tests were used to compare leave policies between 2006 and 2018, as well as between medical and surgical specialty programs. All analyses were
Fig. 1 e Primary ACGME specialty board policy analysis algorithm for determining impact of residency leave. This methodology was repeated to assess the impact of a 12week leave. Where X is equal to 6 or 12 week of leave taken by resident in graduate medical education. Each level represents a decision point in the policy analysis. For each level, if yes, the resident is not considered to be impacted at that level by X weeks of leave.
304 performed using Station, TX).
j o u r n a l o f s u r g i c a l r e s e a r c h s e p t e m b e r 2 0 1 9 ( 2 4 1 ) 3 0 2 e3 0 7
Stata
15.1
(StataCorp
2017,
College
Results We identified 24 primary board specialties (14 medical, 10 surgical) that met inclusion criteria (Table 1). The median leave time allowed in 2018 was 4 weeks (IQR 4-6). No difference was seen between medical and surgical specialty programs (median 4 versus 5 weeks, P ¼ 0.426). Medical specialties were more likely to have specific language regarding maternity, as well as paternity, leave (58% versus 42%, P ¼ 0.03). There was no difference in the mention of medical leave between specialty types (14% versus 30%, P ¼ 0.350). Notably, six specialties (25%) decreased the number of weeks allowed for
leave from 2006 to 2018 (3 medical, 3 surgical). Most of the programs that restricted their leave policies went from flexible to nonflexible leave policies (e.g., neurology went from discretionary to 4 week allowed leave). In 2006, six programs (25%) required a 6- to 12-months delay in board certification after a 6-week leave (Table 2). As of 2018, a 6-week leave would not delay board certification in any specialty because of both an increase in the duration of allowable leave and/or the addition of flexible policies. However, a 12-week leavedthe FMLA-mandated time alloweddtaken in 2018 would result in a 1-y delay in board certification in five specialties (21%) (2 medical, 3 surgical). In 2018, a 6-week leave would extend the duration of training in four specialties (17%) by 2 weeks (4 medical, 0 surgical). In 2018, a 12-week (FMLA) leave during residency would extend training by a median of 6 weeks (mean 4.2, range 0-8) and five
Table 1 e 2018 specialty-based characteristics of residency programs and maximum duration of leave allowed during residency in 2006 and 2018. Specialty name
Female residents 2016-2017*, %
Training duration (years)*
2006 max leave (weeks)
2018 max leave (weeks)
Change between 2006 and 2018
Allergy/immunology
58.9
2
4
4
e
Anesthesiology
31.6
4
4
4
e
Dermatology
62.1
4
6
6
e
Emergency medicine
32.9
4
6
6
e
Family medicine
39.4
3
4
4
e
Internal medicine
26.7
3
4
4
e
Neurology
29
4
Discretiony
4
Y
5.8
4
6
6
e
Pathology
28.5
4
5
4
Y
Pediatrics
60.4
3
4
4
e
PM&R
34.8
4
6
6
e
Preventive medicine
40.8
2
4
4
e
Psychiatry
37.2
4
Discretiony
4
Medical
Nuclear medicine
Radiology diagnostic
Y y
[
22
5
6
Discretion
Neurological surgery
16.5
7
Discretiony
4
Y
Obstetrics/gynecology
75.3
4
8
8
e
Ophthalmology
39.8
4
Discretiony
4
Y
Orthopedic surgery
14.7
5
6
6
e
Otolaryngology
34.3
5
6
6
e
Plastic surgery
40.3
6
4
4
e
Surgery (general)
34.4
5
4
4
Surgical
y
e y
Thoracic surgery
25.0
6
Discretion
Urologyz
25.3
5
Otherc
6
Y
Vascular surgery
35.2
6
N/Ax
4
N/Ax
Discretion
e
PM&R ¼ Preventative Medicine and Rehabilitation. * This information was obtained from publically and electronically available data published by the Association of American Medical Colleges and the Accreditation Council of Graduate Medical Education. y Discretion refers to residency specialties that explicitly allow for program director or intuitional discretion without setting a specific amount of leave in weeks. z Urology leave maximum in 2006 was based on a percentage of time missed from various clinical requirements. x Vascular Surgery was not recognized as a primary specialty in 2006.
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lumpkin et al a comparison of residency leave policies
Table 2 e Specialty-based comparison of impact of 2006 and 2018 residency leave policies on training duration and board eligibility. Specialty name
Impact of 6-week leave 2016
Impact of 12-week (FMLA approved) leave
2018
2018
Delayed board eligibility?*
Delayed board eligibility?
Training extension, weeks
Delayed board eligibility?
Training extension, week
Discretiony
No
2
No
8
Anesthesiology
No
No
0
No
0
Dermatology
No
No
0
No
6
Emergency medicine
No
No
0
No
6
Family medicine
Yes
No
2
No
8
Internal medicine
No
No
0
No
8
Indeterminatez
No
0
No
0
Medical Allergy/immunology
Neurology Nuclear medicine
Yes
No
0
Yes
6
Pathology
Yes
No
0
No
0
Pediatrics
No
No
2
Yes
8
PM&R
No
No
0
No
6
Preventive medicine
No
No
2
No
8
Psychiatry Radiology diagnostic
z
No
0
No
0
No
No
0
No
0
Discretiony
No
0
No
8
Indeterminate
Surgical Neurological surgery Obstetrics/gynecology Ophthalmology
No
No
0
Yes
4
Discretiony
No
0
Yes
8
Orthopedic surgery
Yes
No
0
No
6
Otolaryngology
No
No
0
Yes
6
Plastic surgery
Yes
No
0
No
0
Surgery (general)
Yes
No
0
No
4
Thoracic surgery
Discretiony
No
0
No
0
Petitionx
No
0
No
6
N/Ak
No
0
No
4
Urology Vascular surgery
PM&R ¼ Preventative Medicine and Rehabilitation. * Data from 2006 is from Rose et al.7 y Discretion refers to residency specialties that explicitly allow for program director or intuitional discretion without setting a specific amount of leave in weeks. z Indeterminate based on 2006 study. x Resident must petition the credentialing committee to be considered for board eligibility after 6 weeks leave. k Vascular Surgery was not recognized as a primary specialty in 2006.
programs (2 medical, 3 surgical) would require a 6- to 12months delay in board eligibility (median 0 mo, mean 2.25, range 0-12). A 12-week leave in 17 specialties (71%) would delay fellowship training by at least 1 y. There was no difference between medical and surgical specialties in whether or not a 12-week leave would delay entry into fellowship (64% versus 80%, P ¼ 0.653) or the extension in the duration of training (6 versus 5-weeks median delay, P ¼ 0.414). A number of programs utilized identified seven unique flexible solutions in residency leave policies (Fig. 2). Notably, no programs explicitly mentioned all of the flexible policy solutions and four programs offered no flexible alternatives.
Discussion Overall, leave policies have largely improved since 2006, and programs now allow for a 6-week leave without affecting board eligibility. Unfortunately, in 2018, a 12-wk, FMLAmandated leave could delay completion of training by 6 weeks, which could delay fellowship by up to 1 y. In addition, this FMLA-mandated leave would result in delayed board eligibility in over two-thirds of specialties. Although several flexible policy solutions exist that could be used to mitigate these problems, currently no program has implemented all of them, and a few programs still offer no alternatives. Medical
306
j o u r n a l o f s u r g i c a l r e s e a r c h s e p t e m b e r 2 0 1 9 ( 2 4 1 ) 3 0 2 e3 0 7
Fig. 2 e Number of ACGME specialties with explicitly flexibly policies for residency leave. Data abstracted from publicly available, electronically published specialty board residency leave policies. Averaging refers to policies that allow for a certain number of weeks per year averaged over a certain period, for example, some specialties allow 12 weeks of leave averaged over 3 year. Other flexible policies included those policies that were specialty-specific and could not be reasonably grouped with the aforementioned categories, for example, neurology recommends a minimum amount of leave instead of a maximum.
and surgical specialties tended to be similar in terms of impact of policies, despite historical beliefs that surgical programs may be less family-friendly.14,15 Based purely on the duration of training alone, surgical specialties may allow for more flexible policy alternatives. Residents often feel like they have to choose between their family and career, but there should be alternative solutions. This problem is complex; while residency programs want to provide options, there is an inherent lack of redundancy in residency training. When even one resident is absent for a prolonged period, the workload increase can be a significant burden on their colleagues. Individual residents may feel the pressure to minimize the impact their absences cause to others, as well as its effect on their own education. Many residents have responded to these policies and attitudes by deferring child-bearing until after training is complete, but there can be negative effects of advancing parental age, including increased rates of infertility, birth defects, and pregnancy complications.16 In addition, many family or health-related leaves arise unexpectedly, making leave during residency inevitable. One potential solution is competency-based medical education (CBME) in place of the more traditional time-dependent model. CBME implementation models vary, but ultimately, this approach is based off of regular assessments of a learner’s achievement of milestones within their field.17 In Canada, for example, orthopedic surgery has moved to a primarily
competency-based training, which has allowed numerous residents to complete training in 4 years compared with the traditional 5-year track. This flexibility was shown to accelerate acquisition of operative skills and also allowed for flexibility in training duration for a plethora of reasons (e.g., professional development, family emergencies, difficulty obtaining the necessary skills to practice independently).18 This progressive CBME example can serve as a feasibility pilot for ACGME. It is difficult to make further comparisons between the United States and Canada, given that Canada’s Employment Insurance affords at least 17 weeks of paid parental leave.19 Currently, in the United States, ACGME continues to investigate and implement CBME, which could enhance capacity for additional leave policy flexibility. Future work will need to address potential and unforeseen downsides to CBME, such as extensively prolonged training and the vulnerability of trainees. Programs have multiple and sometimes competing aims including excellent patient care, stellar resident education, and promoting the health and well-being of all residents.20 These aims are not necessarily mutually exclusive, and it may be possible to allow for 12-weeks FMLA-mandated leave while still achieving these aims. Future studies and board organizations should determine if any of the flexible strategies could be adopted to allow for 12-weeks FMLA-mandated leave without sacrificing valuable learning time or creating
lumpkin et al a comparison of residency leave policies
significant delays in board eligibility. Placing emphasis on competency-based advancement, instead of requiring a specific number of weeks may be a potential solution. This study is not without limitations. These results are comprehensive of the primary specialty board policies, but may not be generalizable to non-ACGME programs, and must be considered on a case-by-case basis. With data limited to 2006 and 2018, no true longitudinal assessment was able to be conducted on an annual basis. In conclusion, although leave policies have improved since 2006, residency leave programs are still not meeting the requirements laid out by FMLA, and a 12-week, FMLA-mandated leave could have substantial and detrimental impacts on training. Programs should consider incorporating flexible policies.
3.
4.
5.
6.
7.
8.
Acknowledgment 9.
All authors listed attest to meeting the guidelines for authorship. Substantial contributions from Michael Williford, MD, and Katherine Cools, MD, MSCR, included data collection. Authors’ contributions: L.S.T. was responsible for study design, data collection, data analysis, and manuscript preparation. K.M. and S.S. were responsible for study design, data collection, data analysis, and manuscript preparation. In addition, S.S. has completed ethics and policy interpretation training. B.A.N. was responsible for significant portions of data analysis and manuscript preparation. S.P.D. was responsible for significant portions of the study design, data analysis, and manuscript preparation. D.M.C. was the senior author on this article, and thus oversaw and contributed to the overall study design and conceptualization and manuscript preparation.
Disclosure L.S.T. is also a postdoctoral fellowship, and at the time of submission, is currently funded through the Agency of Healthcare Quality and Research F32 and the American Society of Colon and Rectal Surgeons General Surgery Resident Research Initiation. This article is not directly associated with her postdoctoral research activities. The authors report no proprietary or commercial interest in any product mentioned or concept discussed in this article.
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